Pregnancy Concerns & Special Circumstances
Note: The information on this website should not be interpreted as medical advice. All of the information compiled here has been referenced where possible, and as with any information obtained from the internet you should verify the information for yourself. If you have questions please consult your health care provider.
Pregnancy-Induced Hypertension (PIH, Pre-eclampsia,
Toxemia)
The terms Pregnancy-induced hypertension, Pre-eclampsia, and Toxemia are often used
interchangeably, but they actually describe different hypertensive
disorders that occur during pregnancy. The common symptom in all three is
elevated blood pressure— considered by most care providers to be over
140/90. The blood pressure measurement should be confirmed at least 4-6 hours
after the first reading. It is also extremely important that a
properly-sized blood pressure cuff is used in order to obtain an accurate
reading.
When high blood pressure is the only symptom present, the term Pregnancy-induced hypertension is accurate. PIH by itself has not been shown to have a negative effect on the mother or fetus. The blood pressure returns to normal levels by 6 weeks postpartum, and there are no other symptoms associated with this condition.
When elevated blood pressure is coupled with other symptoms such as protein in the urine (proteinuria), increased reflex response, headaches and visual changes, or abnormal swelling of the face and extremities, it is referred to as pre-eclampsia. Protein may also be present in the urine due to other factors such as dehydration, so it is important to verify the presence and amount of protein, as well as identifying the combination of proteinuria and hypertension in order to accurately diagnose pre-eclampsia. Pre-eclampsia is diagnosed in about 5-10% of pregnancies. Several risk factors have been identified and many theories have been proposed. Meanwhile, a large body of research is ongoing, as no single factor or combination of factors has been consistently related to the development of this disorder. The most promising research centers around two major theories. Many of these theories surround nutritional deficiencies in the mother— especially protein deficiency. The other theories center around immune response in the mother to the growing fetus. This is supported by research that demonstrates a higher risk of pre-eclampsia in women who have been exposed to their partners sperm for less than 4 months, either due to a recent change in partners or due to barrier contraception (condom) use. For more information about these issues, please see the resources at the right.
Pre-eclampsia in and of itself has been associated with slower growth in the fetus, and, because delivery of the baby is the only "cure" for pre-eclampsia, the risk of premature delivery is higher in pregnancies complicated by pre-eclampsia.
When seizures or convulsions occur in concert with hypertension and proteinuria, the diagnosis of toxemia or eclampsia is made. This condition carries a high risk of death for the mother and fetus. The only cure is delivery of the infant. Many women who present with high blood pressure and protein in the urine receive a medication called Magnesium Sulfate (MgSO4). This drug is also used to stop pre-term contractions of the uterus, so when it is given during labor, it is important to remember that it will slow (and possibly stop) the uterine contractions, leading to an increased use of Pitocin. Pitocin is also known to elevate the blood pressure.1
HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets)
HELLP Syndrome is another hypertensive disorder of
pregnancy. It is a unique form of pre-eclampsia with
specific diagnostic criteria including the abnormal breakdown of red blood
cells (hemolysis), elevated liver enzymes (SGOT and LDH, specifically), and
low platelets. The most serious complication of HELLP Syndrome is rupture of
the liver. If you are experiencing pain in your right, upper abdomen, or
severe headaches, you should be sure to discuss this with your care provider
since these symptoms may present before elevated blood pressure or protein
is present in your urine.
Gestational Diabetes
There is a great deal of
controversy surrounding the diagnosis and treatment of Gestational Diabetes.
Identified in the 1960s, various screening protocols have been tested and different treatments have been suggested for GD, including dietary management and insulin injections. Regardless of treatment, the incidence of stillbirth, miscarriage, and complications associated with large (macrosomic) babies has not been shown to decrease. This is worth repeating: testing and treatment have not been shown to improve outcomes.2
If you have been diagnosed with Gestational Diabetes you will likely be placed on a special diet and you may be encouraged to have your labor induced early to avoid having a big baby. There is evidence that induction of labor for suspected macrosomia increases the rate of cesarean section when compared to allowing labor to start spontaneously.3 For more information on Gestational Diabetes, see the resources at the left.
Anemia (Low Iron, Low Hemoglobin,
Anaemia)
Anemia is a condition in which there is not a high enough
concentration of oxygen-carrying hemoglobin in the blood. It is most
commonly caused by a deficiency of dietary iron, and commonly affects
pregnant women as their blood volume increases beginning in the 2nd month
of pregnancy. This increase in blood volume normally dilutes the
concentration of hemoglobin and can cause symptoms of anemia including
fatigue and weakness, and even shortness of breath and decreased blood
pressure. Less commonly, folic acid deficiency or conditions such as
thalassemia or sickle cell disease can cause anemia.
You will most likely be tested for anemia at your first prenatal visit and again at approximately 26-28 weeks or if you exhibit symptoms of anemia at any time during the pregnancy. Many care providers routinely prescribe prenatal iron supplements, however these are poorly absorbed when compared to most food sources. Iron absorption is enhanced by Vitamin C if taken simultaneously. Iron absorption is decreased by large consumption of dairy products, so these supplements should be taken several hours before or after ingesting milk products. To get the most out of an iron supplement, try taking it on an empty stomach with a glass of orange juice. As with any nutrient, the best source for iron is a healthy diet rich in lean red meat, tuna, salmon, whole grains, and dark green leafy vegetables. Supplements should not serve as the primary source for any nutrient. If supplementation is necessary there are options other than iron tablets such as chlorophyll, yellow dock, alfalfa, and an herbal supplement called Floradix.
Some evidence suggests that a hemoglobin level of 9.5gm/dl is optimum during pregnancy. This is in contrast to the level of 10.5-11.5gm/dl which is commonly used to diagnose anemia in pregnancy. Great efforts are often made to maintain the higher level of hemoglobin during pregnancy despite the fact that the decreased concentration is actually the result of the optimum blood volume increase that normally occurs during pregnancy. There is no doubt that if a woman is experiencing negative effects of lowered concentration of hemoglobin, especially in the first trimester, she and her growing baby may benefit from treatment, however, routine iron supplementation in women with hemoglobin values above 9.5gm/dl beyond the first trimester of pregnancy has failed to show any positive effect on mother or baby. There is no decrease in maternal hemorrhage, infection, preterm birth, low birthweight, stillbirth, or newborn illness with routine iron supplementation to maintain hemoglobin levels above 9.5gm/dl.4
Preterm Labor (Pramature Labor)
Preterm labor
refers to uterine contractions that cause cervical changes before 37 weeks
gestation. Throughout pregnancy the uterine muscles contract in preparation
for labor and delivery. The contractions are called "Braxton-Hicks"
contractions and they do not normally cause cervical dilation (opening) or
effacement (thinning). Usually Braxton-Hicks contractions are painless,
lasting less than 30 seconds, and occur at irregular intervals. These
contractions often increase in frequency and intensity toward the end of
pregnancy and can often be mistaken for preterm labor.
Staying well-hydrated throughout your pregnancy can help to prevent excess uterine activity. Another way to determine if the contractions you are experiencing are abnormal is to change your activity level; if you've been very active, try lying down with some water and resting quietly for 30 minutes. If you have been sitting down all day at a desk, try getting up and walking around. If the contractions continue or increase in frequency, length or strength, contact your care provider. A full bladder can also cause the uterus to contract more frequently, so be sure that you are going to the bathroom regularly. Other factors such as undiagnosed bladder or kidney infections or vaginal infections can also contribute to preterm labor.
True preterm labor may be suspected if contractions are occurring more frequently than 6 per hour, or if they are lasting longer than 30 seconds each, accompanied by backache, cramping, vaginal bleeding, or fluid leaking from the vagina. If you suspect that you are experiencing pre-term labor it is always a good idea to contact your care provider and report your symptoms. Your midwife or doctor may want to see you and perform an exam to determine if the contractions are causing your cervix to dilate. You may also be offered a Fetal Fibronectin test, where vaginal secretions are tested for the presence of a specific protein that may predict your risk of spontaneous preterm birth within the following 7-10 days.
Preterm labor is managed differently depending on how far along your pregnancy has progressed and depending on your individual doctor or midwife. It will also be managed differently if your water has broken. There are medications such as magnesium sulfate (MgSO4), ritodrine, or terbutaline that may be administered to stop contractions. These are smooth-muscle relaxants called "tocolytics" and they do have known side-effects that you should carefully discuss with your provider. You may also be placed on strict bed-rest or even hospitalized for the remainder of your pregnancy. You may be given steroids such as betamethasone or dexamethasone in order to prevent respiratory distress syndrome if your baby is between 26-34 weeks gestation. You may also be offered an ultrasound to assess fetal lung maturity and determine if your baby might benefit from these medications if you are at 34-36 weeks. There are also non-pharmaceutical treatments for preterm contractions used by traditional midwives such as small amounts of wine (alcohol is also a muscle relaxant) or herbs such as lobelia or wild yam. For more information about preterm labor and its management, see the resources at the right.
Breech Presentation
While the vast majority of
babies are head-down by around 34 weeks, your care provider may have
informed you that your baby is still in a breech presentation. There are
several variations of breech presentation. You may have an ultrasound to
determine exactly how your baby is lying in your womb. Frank breech,
where the baby has his legs straightened and up near his face is the most
common. This is also considered the safest position for a vaginal birth if
you can find a care provider who still attends breech births.
Complete breech is when the baby has his legs crossed. This position
is less common than frank breech, and vaginal delivery may still be an
option. Footling breech means that the baby has one or both feet
presenting before the buttocks. This is considered the most risky
presentation for a vaginal delivery by most doctors and midwives due to the
increased risk of cord prolapse and the increased chance that the baby's
body may pass through the cervix before it is fully dilated making delivery
of the head difficult or impossible. It is also the least common breech
presentation.
The good news is that by 37 weeks, nearly 97% of babies will have turned to a head-down position. There are also documented cases of babies turning from breech to vertex even during spontaneous labor, so a scheduled cesarean is not your only option. There are also several ways to encourage a baby to turn from breech to head-down during the last weeks of labor. I have a client handout, So Your Baby is Still Breech? available for download. It covers many different options for correcting breech presentation before labor.
The most common procedure used by most doctors and nurse midwives is called an External Cephalic Version (ECV). Usually your baby is carefully monitored at the hospital or doctor's office via ultrasound during the procedure. You may be given medication to relax the uterine muscles. The care provider then gently manipulates the baby and attempts to turn the baby into a head-down position. Some women report that this is very painful, although others have had successful ECV with no pain at all, so the experience and expertise of the care provider is key. The success rates also vary widely from one care provider to the next, so be sure to ask your own doctor or midwife about their personal level of experience.
Many women are told to prepare for immediate labor induction if the ECV procedure is successful, to prevent the baby from turning himself around again before spontaneous labor, which may be weeks in the future. This is despite the fact that many women were told prior to ECV that 'there isn't enough room' for the baby to turn himself around after 36 weeks. Induction of labor before the cervix is ripe and the baby is ready to be born has a very high failure rate, meaning that many women end up with a surgical delivery despite a successful ECV. Discuss your care provider's feelings about allowing spontaneous labor to begin following a successful ECV.
For more information, please see the resources at the left.
More information coming soon.1. Pitocin® (Synthetic Oxytocin) Pharmaceutical Information Insert.
2. Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy (Cochrane Review). Cochrane Library, Issue 4, 2003.
3. Luis Sanchez-Ramos, MD, Sara Bernstein, MD, and Andrew M. Kaunitz, MD. Expectant Management Versus Labor Induction for Suspected Fetal Macrosomia: A Systematic Review. Obstet Gynecol. 2002 Nov;100(5 Pt 1):997-1002.
4. Scholl TO, Reilly T. Anemia, Iron and Pregnancy Outcome J Nutr. 2000 Feb;130(2S Suppl):443S-447S.
