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Although most pregnancies proceed normally, we are constantly alert to possible complications. Emphasis is on prevention and early detection of complications. The following information discusses some of the commonly observed conditions.

Miscarriage
Approximately 30% of pregnant women will experience some bleeding during the first trimester of pregnancy. Many of the causes of this bleeding are entirely harmless.

Bleeding usually only lasts for a few days and then disappears. Sometimes the bleeding will occur at the time of the expected period. Occasionally, sexual intercourse may break a few of the small blood vessels on the cervix and cause light bleeding. Another common cause of bleeding is that as the placenta grows into the wall of the uterus, small blood vessels break.

These benign causes of bleeding in early pregnancy usually last only a few days, and this bleeding is not heavy or accompanied by cramping. If such bleeding occurs, you should confine yourself to bed for 24 hours. You should also refrain from intercourse until you have had no bleeding at all for two weeks. Please notify us at that time so we can arrange an examination.

Miscarriage may be heralded by heavier bleeding and severe lower abdominal cramping. Again, you should initially place yourself at rest, but if the bleeding and cramping persist, call the office. If bleeding is heavy enough to saturate a pad per hour, cramping is severe, or there is a passage of tissue, you will need to be seen immediately to find out if you are having a miscarriage.

Miscarriages usually occur because the developing placenta or fetus is abnormal in some way. The most common cause is a genetic abnormality of either the egg or sperm involved in the pregnancy. Other causes include abnormal implantation of the placenta into the uterine wall, abnormalities of the uterine lining, or uterine infections.

It is important to realize that none of these are caused by your actions. You should not think that something you did or failed to do caused this process to begin.

Likewise, you must understand that once the process has started, there is no medical treatment that will prevent it from happening. This is nature’s way of correcting an abnormal pregnancy. If a miscarriage occurs, it may be best to scrape the uterine lining to remove any remaining tissue. This procedure, referred to as a D & C, lessens the risk of continued bleeding and possible infection. In addition, it allows an exploration of the uterine cavity to see if any abnormalities such as a malformation of the uterus or a fibroid tumor may have caused the miscarriage. If these conditions exist, they can be corrected surgically before you attempt another pregnancy.

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Toxemia
Toxemia is a condition that occurs only during pregnancy and resolves when the pregnancy is terminated. It is characterized by

• high blood pressure,
• excessive accumulation of fluid within the mother’s body (edema), especially in the hands and face, and
• the presence of protein in the urine.

A rise in blood pressure is usually the first sign that toxemia is developing. Swelling in the hands and face and protein in the urine usually come later.

The pregnant woman does not initially notice any sign of feeling ill as this condition develops. If these signs are present, you will be asked to confine yourself to bed, positioned on your side. This seems to slow the development of toxemia, but it does not go away until the baby has been delivered. If you have been told that you have high blood pressure and experience a sudden gain of weight, severe persistent headaches, disturbances of vision, severe upper abdominal pain, vomiting or retching, or feel emotional, tense, or jittery, you should be examined immediately.

The causes of toxemia are not completely known. It is suspected that the placenta may produce a substance that causes blood vessels to contract. This causes blood pressure to rise and decreases blood flow to the placenta and the mother’s kidneys. If the condition is not controlled, the pregnant woman may develop severe complications including convulsions, coma, or death. The decreased blood flow to the placenta may result in the baby’s failure to grow while in the uterus and, occasionally, stillbirth. Avoidance and control of the toxemia involve the following:

• Resting on one’s left side periodically throughout the day
• A diet adequate in protein
• Avoidance of excessive salt
• Adequate intake of fluids

If these measures cannot be maintained at home, it is occasionally necessary to place the patient in the hospital to ensure complete rest and to monitor the mother and baby. If toxemia develops, it is necessary to monitor the baby’s well-being by non-stress testing or contraction stress testing.

The serious nature of toxemia is often underestimated, because initially there are so few symptoms noted. Although toxemia can sometimes be controlled with the measures mentioned above, delivery is the only way to eliminate the disease.

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Intrauterine Growth Restriction (IUGR)
Throughout your pregnancy, we will carefully measure the growth and size of your uterus. From the 18th to the 36th week of pregnancy, the expected size of the uterus in centimeters equals the number of weeks of gestation.

Measurements of three centimeters above or below this number are considered to be within the normal range. If the size of the uterus registers outside this range, or if there has been no growth of the uterus over successive visits, the baby may not be growing properly. The usual cause for this condition is that the placenta is either too small or is not functioning well enough to supply the baby with the necessary nutrients.

Women at higher risk of developing intrauterine growth restriction include women with previous “small-for-dates” babies, women with high blood pressure, and women who have had infants with birth defects. It is most common, however, that none of these predisposing factors is present.
Intrauterine growth restriction is a difficult diagnosis to make since when a small baby is expected, the baby’s size is often normal at birth and, conversely, babies who seem to be of normal size in the uterus may be smaller than expected at birth.

If growth restriction of the fetus is suspected, serial ultrasound studies are helpful to determine the size and the growth of the baby. If the diagnosis is confirmed by ultrasound, studies to assure well-being of the fetus are often started in the last few weeks of pregnancy. The most common tests are the non-stress and contraction stress tests discussed earlier.

Treatment consists of trying to improve circulation to the placenta by having you rest, lying on your left side for several hours every day. Special attention to good nutrition also helps.
Since these babies tolerate labor less well than normal sized babies, careful monitoring during labor is required.

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Prolonged Pregnancy
When a pregnancy extends more than two weeks beyond the due date, the aging placenta will occasionally fail to supply the baby with proper amounts of food and oxygen. The result is a decrease in the amniotic fluid, staining of the amniotic fluid due to the baby’s bowel movements, loss of the baby’s subcutaneous fat, a decreased tolerance of contractions during labor, and occasionally death of the baby while still in the uterus.

Although 13% of all pregnancies extend 42 weeks beyond the last menstrual period, many of these pregnancies are not actually overdue. For some reason, the conception was delayed. This is why we pay such careful attention to determining the first day of the last menstrual period, conception date if known, and the date of the onset of fetal heart tones with both the Doppler and stethoscope. If there are any questions, we may use ultrasound to confirm or adjust the dates.

When a pregnancy extends beyond 42 weeks, we consider inducing labor. If the cervix is not favorable for induction, tests for fetal well-being are performed.

If there is evidence of fetal well-being, it is generally considered safe to wait until the cervix does become favorable for induction. If appropriate, we may perform procedures to ripen the cervix so induction can be done.

Careful monitoring of the baby’s heart rate during labor is essential when the pregnancy is overdue.

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Twins
Twin pregnancies occur once in every 90 pregnancies. Twinning is more common if the mother has a history of fraternal (two-egg) twins in her family or if she conceived while taking fertility drugs. The diagnosis is usually made early in the second trimester when the uterus is found to be larger than expected for dates. Diagnosis is usually confirmed by ultrasound examination.

Two major risks of a twin pregnancy are premature labor and intrauterine growth restriction. Both risks can be improved if the mother rests while lying on her side.

As soon as the diagnosis is made, you should make an effort to lie on your side when sleeping at night as well as to spend two to four hours each day lying on your side. This increases blood flow to the placenta, giving more nutrients and oxygen to the babies. In addition, it may take some of the pressure off the cervix, preventing premature labor.

The need for rest increases as the pregnancy advances. It is usually necessary to stop working and also to find extra help if you have small children at home. Lying on your side most of the time is difficult, but the results are worthwhile.

Twin pregnancies also have a greater risk during labor. The risks and complications that they pose will be discussed in the “Variations of Labor” chapter later in this book.

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Herpes
Herpes virus infections of the genital tract have become more common in recent years. Herpes is somewhat complicated. If you have had herpetic sores or lesions in the past, then any sores in the future are considered recurrences. Babies born to a mother with recurrent herpetic infections (active sores with itching, or irritation) have approximately a 4% chance of becoming infected.

Your very first outbreak of herpetic sores is considered to be the “primary infection.” Having your very first herpes outbreak during pregnancy can be much more serious to you and your baby. Women with a primary infection at the time of delivery have a 50% chance that their baby will be infected with herpes. If a baby is infected with a herpes virus, it causes a severe illness with risk of encephalitis, mental retardation, and death.

The herpes virus infects the skin and mucous membranes of the lips and mouth as well as the vulva and vagina in the female. The characteristic lesion is a cluster of small blisters, which break and form multiple, shallow ulcers.

These ulcerations may cause no symptoms at all. More commonly, they cause a sense of itching or irritation, referred to as prodromal symptoms. Occasionally, they may be extremely painful. The virus is usually transmitted by sexual contact. The condition tends to flare up during times of stress.
There is no known cure for this condition. If you have or suspect that you have a history of herpes infection of the genital tract, please let us know. If you have an outbreak during pregnancy that you suspect may be herpes, you should notify us immediately so that we can obtain cultures to determine if your suspicion is correct.

If you have active lesions or prodromal symptoms of an outbreak at the time you are ready to deliver, you should be delivered by cesarean section. If you have a history of herpes and the membranes rupture, you should notify us immediately so that you can be closely examined for any visible lesions.

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Preterm Birth
Preterm birth refers to births from the 20th week through the 36th week of pregnancy. Babies born during this period require special care to help the baby eat, breathe, and maintain a normal body temperature. Preventing premature birth is one of the important goals of your care during pregnancy.
Though the cause of preterm birth is not known, the following conditions may be associated with an increased likelihood of preterm birth:

1. Previous preterm labor or delivery
2. Current pregnancy with twins, triplets, etc.
3. Abnormally shaped uterus or DES exposure
4. Incompetent cervix, previous cone biopsy of cervix, or large fibroid tumor
5. Severe urinary tract or kidney infections
6. Excessive uterine activity before 37 weeks
7. Bleeding during pregnancy
8. Too little or too much amniotic fluid
9. Smoking

A uterine contraction is the tightening of the uterine muscle. By placing your fingertips over the uterus, you should be able to indent the uterus when it is relaxed. During a contraction, the uterus becomes hard over its entire surface and may seem to rise up in your abdomen.

Contractions are normal throughout pregnancy and often occur with changes in position or having a full bladder. They are usually painless and without pattern. Contractions of preterm labor may be painless as well, but they often have a pattern. They may last from 20–120 seconds. If contractions occur every 15 minutes or closer, you need to be examined to see if changes in the cervix such as effacement (thinning) and dilation (opening) have occurred.

Warning signs of preterm labor may be difficult to distinguish from signs that occur normally during pregnancy. The following signs may occur normally in your pregnancy, but if they do occur, you should monitor them closely for uterine contractions:

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1. Menstrual-like Cramps— Cramping in the lower abdomen just above the pubic bone, which may be rhythmic, wave-like, or constant
2. Dull Lower Backache—Low backache that radiates to the side or front of the abdomen and may be rhythmic or constant; it is often not relieved by position changes
3. Pelvic Pressure—There is a feeling of fullness or pressure in the pelvic area, back, or thigh; it may feel as though the baby is going to fall ou
4. Intestinal Cramps—These may occur with or without diarrhea and may resemble gas pains
5. Increase or Change in Vaginal Discharge—The vaginal secretions may increase in amount, change to a thinner consistency, or develop a pinkish or brownish color

If these signs occur, you should lie down with a pillow behind your back so you are tilted slightly to your left side. Place your fingertips on your uterus. If your uterus becomes tight and feels hard, you are having a contraction. Use your watch and record the length of each contraction as well as the frequency (the time from the beginning of one contraction until the beginning of the next). After one hour, if you have had four or more contractions (one contraction every 15 minutes), call your physician or nurse midwife and go to the office or to the Birthing Center at PVH. You will be monitored for contractions (manually or electronically), and your cervix will be checked for effacement and/or dilation.

If preterm labor occurs, it can usually be slowed or stopped if detected early enough. Treatment may be as simple as drinking a good amount of fluids or emptying your bladder. At other times, medications may be required.

Women at high risk for preterm labor or women with excessive uterine contractions may be referred to a service that provides electronic monitoring of contractions at home. A device is placed on the abdomen for one hour each morning and night. The information is recorded and transmitted by phone to the service, whose nurses then interpret the information. If four or more contractions per hour occur, your physician or nurse midwife will be notified so that appropriate steps can be taken to prevent premature birth.

What Is Normal?

• Three or fewer contractions per hour
• Backaches caused by your growing baby and changing posture
• Pressure caused by your growing baby pressing on your pubic bone and legs
• Pulling and stretching of muscles that may cause localized pain

What Is Not Normal?

• Four or more regular contractions per hour
• Rhythmic, lower abdominal cramps
• A low, dull backache that feels different than what you normally experience
• Persistent diarrhea or intestinal cramps
• An unusual rhythmic or persistent pelvic pressure
• A large amount of mucus or water leaking from the vagina
• A change in color of vaginal discharge to pink or brown

Remember, it is important to be aware of what is typical or normal for you, as this awareness will enable you to identify what is not normal.