Oh My…What’s This?

Let’s be honest, health care teams are busier than ever these days. Throughout our Trimesters we have given you lots of great info to help you have the empowered pregnancy you have always dreamed of. Here’s a recap of the important conditions that your health care team may not have time to tell you about ~ but we will! You need to be in the driver’s seat keeping your pregnancy healthy and safe from day one…

Amniocentesis

An amniocentesis, usually done between Weeks 15-20, is a test to check for fetal abnormalities such as Down syndrome, a genetic disorder, or spinal bifida, a neural tube defect, and has been a valuable tool in assessing fetal well-being since the 1970s. If you are at a particular risk for either one of these conditions, you can postpone having an amniocentesis until after you’ve seen the results of your second trimester screenings. An amniocentesis removes about 2 Tbsp. (30 ml.) of the amniotic fluid surrounding your baby for testing. This analysis may be a better choice over CVS if the results of other blood tests (such as the alpha-fetoprotein test) taken during your pregnancy have been abnormal. An amniocentesis may also be ordered during the third trimester of your pregnancy to confirm fetal lung maturity if your doctor is considering an early delivery.

Amniotic Fluid, Polyhydramnios and Oligohydramnios

Amniotic Fluid (AF)

It is the watery fluid surrounding your baby inside the amniotic membrane (sac) and is an essential part of pregnancy and fetal development. This fluid helps shield and guard your baby while performing a significant part in the maturity of many of your baby’s organs such as the lungs, kidneys, and gastrointestinal track.

AF is mainly produced by the excretion of your baby’s urine and the secretion of oral, nasal, tracheal, and pulmonary fluids that move across the placenta and into the mother’s circulatory system. AF rates can vary, usually 500-1000 ml of fluid is present during a normal pregnancy. Did you know that amniotic fluid volume (AFV) increases from about 25 ml at 10 weeks to about 400 ml at 20 weeks and continues to replicate until you have reached 32-33 weeks? Around 28 weeks gestation, the AFV reaches a volume in the region of 800 ml and that level should remain constant until 40 weeks. After 40 weeks, the level usually declines and is around 400 ml by 42 weeks. An Amniotic Fluid Index (AFI) of 5-25 centimeters is considered normal and is also a part of the BPP. Too much or too little amniotic fluid may be related to abnormalities in growth and other pregnancy problems.
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Polyhydramnios

(also known as hydramnios) occurs when there is too much amniotic fluid around the baby. This condition is present in approximately one percent of all pregnancies. Although there are both maternal and fetal causes of polyhydramnios such as a multiple pregnancy, maternal diabetes, twin-to-twin transfusion syndrome or a birth defect, the cause of polyhydramnios is unknown in approximately 65% of those diagnosed. This condition and its possible causes are usually diagnosed with an ultrasound and if detected, your health care provider will recommend a specific treatment plan.

When too much amniotic fluid is present, the mother’s uterus becomes over distended. With close monitoring that includes repeated ultrasounds calculating growth, BPPs, and fetal assessments, many cases of polyhydramnios are easily treated. If polyhydramnios is more serious, your team may use different treatments. Treatments may include administering medications up to Week 32 reducing the fluid production, performing an amnioreduction via amniocentesis that removes excess fluid, or scheduling an early delivery. Close monitoring and the treatment of polyhydramnios may avoid complications such as intrauterine growth restriction (IUGR), preterm labor, the premature rupture of membranes, which may increase the risk of placental abruption, umbilical cord prolapse with possible compression, and stillbirth.
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Oligohydramnios

It is where there is too little amniotic fluid surrounding your baby. It affects about four percent of women and is usually diagnosed during the third trimester. The causes of oligohydramnios may include birth defects, placental problems, leaking or the rupture of membranes, post date pregnancy or maternal complications such as hypertension, diabetes, dehydration, or preeclampsia. If diagnosed during the first half of your pregnancy, more serious complications may result such as birth defects or a greater likelihood of miscarriage or stillbirth. One complication of prolonged deprivation of amniotic fluid is pulmonary hypoplasia, which results in an abnormal or incomplete development of the baby’s lungs.

During the second half of your pregnancy, the complications of oligohydramnios may include IUGR, preterm birth and labor complications such as an increased risk for compression of the umbilical cord and aspiration of thick meconium (your baby’s first bowel movement).

Your baby’s gestational age is important when oligohydramnios is diagnosed because complications such as maternal hypertension, diabetes, or fetal genitourinary tract problems may occur. If diagnosed with oligohydramnios, both you and your baby will be closely monitored. Rigorous fetal biophysical surveillance including NST’s and frequent ultrasound evaluations will examine your baby’s level of mobility.

The treatment for oligohydramnios may be as simple as advising mom to hydrate with fluids orally or intravenously (IV), which may help to ensure that amniotic fluid levels will rise. For more severe cases of oligohydramnios during the antenatal period, an amnio-infusion is now an option. This procedure adds fluid via an intrauterine catheter into the amniotic cavity (however low amniotic fluids levels usually return within 7 days). Ultrasound visualization, made possible by this addition of fluid, may enable your health care team to determine the cause of oligohydramnios, thereby increasing the potential for a favorable outcome at delivery.

If you are near to full term and oligohydramnios endangers your baby’s well being, then an early delivery may be necessary. An amnio-infusion may be performed during labor to help cushion the umbilical cord and reduce the chances of a cesarean section.

Oligohydramnios may cause complications in approximately 12% of pregnancies which go beyond 41 weeks. Pregnancies beyond 42 weeks may suffer from the amniotic fluid level dropping by 50%. For more information on polyhydramnios and oligohydramnios, please visit Medline Plus and the University of Rochester Medical Center.

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Anterior and Posterior Placenta Previa

Moms either have an anterior or posterior placenta, which means that some have their placentas towards the front of the uterus (anterior) and others towards the back (posterior). If your placenta is towards the front (anterior), don’t be alarmed if you are not experiencing or feeling your baby’s movements early in your pregnancy. In fact with this placental position you may not feel as much movement from your baby even in the third trimester. This is because the placenta serves as a cushion between your tummy and your baby, making it more difficult for you to feel movement.  Your health care team may also have more trouble hearing your baby’s heartbeat with this placental position especially earlier in your pregnancy. An anterior placental position towards the front of the uterus can also make an amniocentesis more challenging as the needle inserted to remove the fluid will need to avoid the placenta. An anterior placenta in and of itself poses no risk to the health of you and your baby.

Chorionic Villus Sampling (CVS) and Amniocentesis

If you are over 35, have a family history of a genetic disorder, or have had a chromosomal abnormality in a previous pregnancy, you may want to consider having a Chorionic Villus Sampling (CVS). This is an invasive diagnostic test performed by sampling the chorionic villus from the placenta. These villi, which actually form the placenta and share the baby’s genetics, were first seen developing in Week 6.

This testing will reveal genetic disorders such as Tay-Sachs disease, Cystic Fibrosis or a chromosomal abnormality such as Down syndrome. It will not test for neural tube defects such as spina bifida. You should discuss with your health care team the decision of whether or not to have this test done. Although this sampling will provide important information regarding your baby’s health, its risks must be clearly explained and disclosed. CVS can be performed earlier than an amniocentesis and the results will be available sooner. This early test usually performed during Weeks 11-13 will put your fears to rest sooner, and provide more time to plan and prepare for your child’s condition.

An amniocentesis, usually done between Weeks 15-20, is a test to check for fetal abnormalities such as Down syndrome, a genetic disorder, or spinal bifida, a neural tube defect, and has been a valuable tool in assessing fetal well-being since the 1970s.  If you are at a particular risk for either one of these conditions, you can postpone having an amniocentesis until after you’ve seen the results of your second trimester screenings. An amniocentesis removes about 2 Tbsp. (30 ml.) of the amniotic fluid surrounding your baby for testing. This analysis may be a better choice over CVS if the results of other blood tests (such as the alpha-fetoprotein test) taken during your pregnancy have been abnormal. An amniocentesis may also be ordered during the third trimester of your pregnancy to confirm fetal lung maturity if your doctor is considering an early delivery.

Both tests, when performed before Week 20, carry the following risk of miscarriage: one in 200. CVS could introduce GBS into the uterine cavity and amniocentesis could make a point of entry into the placenta for GBS. Please discuss the risks with your care provider before undergoing either of these procedures. For more information on CVS or amniocentesis, visit MedlinePlus, a service of the U.S. National Library of Medicine, National Institutes of Health.

There is a new genetic maternity blood test, the MaterniT21™PLUS, which can be performed earlier than a CVS or an amniocentesis. With no threat of miscarriage, this test may be drawn as early as Week 10. The results will determine if your baby is at risk for various genetic anomalies such as Down syndrome or Trisomy 18. Although it doesn’t rule out all genetic abnormalities, it is noninvasive, carries a high accuracy rate (99.1%), a low false positive rate (0.2%), and lets you know the sex of your baby. Early testing allows extra time to ask questions, schedule further tests, make an appointment with a maternal fetal specialist or perinatologist, and most importantly, more time to prepare and plan if a genetic abnormality is found. Speak with your health care team about this new approach if genetic testing is recommended.

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Cord Insertion Site to the Placenta: Central, Marginal or Velamentous

Your medical team will also be able to determine where your baby’s umbilical cord is attached to the placenta. An ideal location is called a central insertion site. This is where the umbilical cord is attached to the very center of the placenta.  It provides the healthiest attachment and allows your baby to easily receive oxygen and nutrients when compared to the other two types. The cord can have a marginal insertion site or be velamentous. Both of these conditions are considered abnormal and can cause other complications. It is important to know this attachment early in your pregnancy. If you are diagnosed with a marginal or a velamentous insertion site, your pregnancy will be and should be closely monitored. Your medical team will want to check on your baby often and most likely, you will have more prenatal visits, ultrasounds, Fetal Non Stress Tests (NSTs), and Biophysical Profiles (BPPs). These abnormal attachments can cause problems, and do create enough of a concern for more frequent monitoring.

Decreased Fetal Movements (DFM)

“Most women who notice a decrease in movement will still have a healthy outcome,” says Obstetrician-Gynecologist Ruth Fretts, M.D., MPH, Assistant Professor at Harvard Medical School and Chair of the Stillbirth Review Committee at the Brigham and Women’s Hospital in Boston. “The biggest concern is when it happens repeatedly.” Dr. Fretts reminds every mom that as her pregnancy advances and her expected baby has less space, the movements won’t be as strong and obvious. But if it takes you more than two hours to count 10 movements, your health care team should be called. She says a Fetal Non-Stress Test (NST) is necessary to confirm your baby’s heart rate, “This rules out a life-threatening emergency, but it doesn’t address the underlying reason for decreased movement.”

Dr. Fretts says an ultrasound may add additional clarification. Unfortunately in the United States ultrasounds will be performed only about 20% of the time in these situations, so mom will need to assert her proactive skillfulness requesting one is done. With a normal NST, movement counting should be completed and charted every day. Mom should never hesitate to be evaluated every time a problem is perceived.

If the thought of counting and charting your baby’s movements makes you nervous, remember that movement counting is the safest and easiest course of action that every mom can take to monitor her baby’s movements on a daily basis. This simple concept is also free and non-invasive. Studies inform us that being attentive to your baby’s movements and informing your health care team of any changes such as speeding up or slowing down, or changes in sleep-wake cycles will decrease the likelihood of having a stillbirth. Ask your health care team about the signs that your baby may not be well and their protocol for such signs.

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Depression

Antenatal (or Prenatal) Depression is depression during pregnancy. Not only is it common, it may also continue or newly manifest as Perinatal Mood And Anxiety Disorder (PMAD) which encompasses a wide range of mood disorders after delivery and up to year after your baby is born. You may have signs of depression but not even be aware that you are depressed. It’s estimated that approximately 13 percent of pregnant women and new mothers experience depression. Every woman may have a few days where she feels sad, blue or down in the dumps. However with depression, the sad, anxious or empty feelings do not go away and your day-to-day routine and lifestyle changes because of these emotions. Your depression may present simply as feelings of unhappiness and gloom, or possibly spiral to feelings of overwhelming guilt, uncontainable hysteria or thoughts of inflicting harm on yourself or your baby.

Depression is a mental illness that does tend to run in families. If you or your family has a history of depression or other mental illness, you may be more likely to experience depression during or after pregnancy. There is no single cause for depression. Your depression may be triggered by a combination of factors including the stressful events of everyday life.

Maybe you are young, single and pregnant, experiencing a lack of support from your family and friends, a victim of physical abuse, or facing marriage or money difficulties. Perhaps there is substance abuse or a problematic pregnancy and birth in your past. Do you have anxious or negative feelings about your present condition? Are you caring for an aging family member or have you just lost a loved one? Unfortunately, any of these variables may become a trigger for your depression during or following pregnancy.

Women are at a greater risk of depression at certain times in their lives than men, and with some women hormonal factors may contribute to their depression. Research tells us that hormonal changes occurring within the brain chemistry that controls our emotions and mood may play a large role in depression.

Prenatal Depression

Growing up you may have experienced depressive symptoms right before menstruation. Some women experience depression during and following pregnancy because when pregnant, levels of the female hormones estrogen and progesterone surge. Then, in the first 24 hours after childbirth, hormone levels quickly return to normal levels leading researchers to believe that these extreme changes in hormone levels may lead to depression. Women may also experience hormonal and mood fluctuations during perimenopause.

It is normal to feel symptoms of mild depression-like feelings during and after pregnancy, but if your baby blues don’t go away after two weeks or you have any of the following symptoms for more than two weeks, you should speak to your health care team. Sadly, some women don’t tell anyone about their symptoms, worrying that they will be viewed as unfit parents. They feel embarrassed, ashamed, or guilty about feeling depressed when they are supposed to feel overjoyed at this time in their lives.

Symptoms of Prenatal and Postnatal Depression

 You may experience:

  • Feelings of restlessness, moodiness, sadness, hopelessness or being overwhelmed that may intensify.
  • Crying a lot.
  • Having no energy or motivation.
  • Eating too little or too much.
  • Sleeping too little or too much.
  • Having trouble focusing, remembering, making decisions or performing tasks at work or home.
  • Feeling worthless and guilty.
  • Losing interest or pleasure in activities you used to enjoy.
  • Withdrawing from friends and family.
  • Having headaches, aches and pains, or stomach problems that don’t go away.
  • Having trouble caring for yourself or your baby.
  • Having thoughts of harming yourself or your baby.

Your symptoms will provide the basis for an accurate diagnosis from your health care team. Your doctor will ask the necessary questions to test for depression and may also refer you to a mental health professional that specializes in treating depression. Please know that depression does improve with treatment.

If you are already on medication for depression, stopping your medicine when you become pregnant or are breastfeeding could cause your depression to come back. You must be open and honest with your health care team regarding your depression and pregnancy. Do not stop any prescribed medicine without first talking to your doctor as not taking it could be harmful to you or your baby.

Untreated depression during pregnancy can hurt you and your developing baby, as you will have a difficult time caring for yourself. Depression may cause you to eat poorly, not gain adequate weight and suffer from insomnia. You may miss vital prenatal visits, become incapable of following medical instruction and even begin using harmful substance such as tobacco, alcohol or illegal drugs. Your baby may be small for his or her gestational age (SGA) and be born prematurely. Receiving professional treatment is important for both you and your baby.

Depression Treatment

In a recent study in the May issue of Obstetrics & Gynecology, researchers found that women with the symptoms of depression were associated with a 27 percent increased risk of delivering their babies before 37 weeks gestation, an 82 percent increased risk of delivering their babies before 32 weeks gestation, and a 28 percent increased risk of having a SGA baby. But they also discovered that approximately one fifth of the expectant women that were treated with antidepressants for depression had no association with the increased risks for any of these problems with their babies.

Dr. Kartik K. Venkatesh M.D., Ph.D., the study’s lead author and Clinical Fellow in Obstetrics, Gynecology and Reproductive Biology at Harvard states, “By screening early in pregnancy, you could identify those at higher risk and counsel them about the importance of treatment. Treating these women for depression may have real benefits.” Screening mothers early for depression is the key to not only their health but also that of their expected babies.

Following a diagnosis of depression, your may be treated with Talk Therapy that involves visiting a therapist, psychologist, or social worker to learn to change how depression makes you think, feel, and act. Or an Antidepressant Medication may be prescribed to relieve the symptoms of your depression. These treatment methods can be used alone or together. Talk with your doctor about the benefits and risks of taking medication while you are pregnant or breastfeeding. Other therapies such as exercise, acupuncture and support groups may be helpful. 

Perinatal Mood And Anxiety Disorder (PMAD) 

Did you realize that 1 in 5 women are diagnosed with mood disorders in the postpartum setting? Melissa Whippo, L.C.S.W. a Clinical Social Worker at the University of California, San Francisco’s (UCSF) Pregnancy and Postpartum Mood Assessment Clinic works with pregnant and postpartum women. She meets with women not only during pregnancy and after delivery, but also at any stage of their fertility process. Ms. Whippo emphasizes the single term “postpartum depression” fails to encompass the range of mood disorders women commonly experience in the postpartum setting, and although PMAD doesn’t roll off the tongue so easily, it is a more accurate description of depression in the postpartum period according to Ms. Whippo.

Untreated PMAD limits the ability of a new mom to parent. The symptoms of PMAD last longer and are more severe than depression during pregnancy. You may experience decreased energy, the inability to focus, moodiness and be incapable or disinterested in meeting your baby’s needs. You may also experience thoughts of hurting your baby or hurting yourself. Your feelings of guilt and losing confidence in yourself as a new mother will exacerbate your depression.

Researchers believe PMAD also affects your baby in numerous ways. It can cause your baby to have developmental language delays, difficulties with mother-child bonding, behavior problems and increased crying.

It’s not a well-known fact that low levels of thyroid hormones might mimic PMAD after you give birth as these levels may drop. Thyroid hormones regulate how your body uses and stores energy from food. Low levels of your body’s thyroid hormones may cause symptoms of depression. A simple blood test can tell if this condition is causing your symptoms. If so, your doctor can prescribe thyroid medicine.

Kristin Sample, writer, teacher, dancer and blogger immediately began her postpartum journey with extreme anxiousness and a quick weight loss of 25 pounds within the first two weeks of delivering her son Jackson. She wondered if this amazing feat was the result of breast-feeding, pumping and healthy eating? In her heart, she realized something did not seem right.

Just two months later Kristen’s symptoms were reversed and she began experiencing relentless fatigue and effortless weight gain. Like many women in her situation, Kristin’s internist dismissed her new concerns of exceptionally low energy and unusually easy weight gain offering her Xanax and a consultation with a therapist for postpartum depression instead.

A simple blood test with her OB six months later revealed thyroid levels so low that Kristen’s doctor wondered how she could get herself out of bed in the morning and keep moving throughout the day. She learned that her initial extreme anxiousness and immediate weight loss occurring in the days following the birth of her son was the result of Postpartum Thyroiditis, a condition causing mild hyperthyroidism (overactive thyroid) symptoms.

The undiagnosed postpartum thyroiditis Kristen initially experienced gave way to Hashimoto’s Disease, a potentially more serious and chronic thyroid condition in which the thyroid becomes underactive (hypothyroid).

Medication was prescribed that enabled her to loose weight and increase her energy levels. An endocrinologist closely monitored Kristen’s second pregnancy adjusting her medication monthly as the thyroid is vital in helping the body stay pregnant. A mismanaged thyroid condition may result in miscarriage and stillbirth and is often undiagnosed until surrounding a pregnancy.

Every mom throughout her pregnancy journey must listen to her body and take care of herself. This will ensure that she stays in good health. The early days with a newborn can be draining for every new parent. Once your baby’s sleep schedule begins to normalize and you still do not feel like yourself before your pregnancy, speak with your doctor about PMAD or a possible thyroid problem. A simple blood test may just make all the difference!

Postpartum Anxiety Disorder

When you are a new mom, a certain level of anxiety is normal. However, when your anxiety starts to affect your ability to take care of yourself or your baby, it is time to see a medical professional for treatment. It’s estimated that about ten percent of new moms develop a significant anxiety disorder following delivery day. Postpartum Anxiety Disorder is manifested by an inability to relax and be still, racing thoughts, nonstop worrying, nausea, vertigo and faintness, and changes in sleep and appetite.

Postpartum Psychosis 

Postpartum Psychosis for a new mom is rare but does exist. It occurs in about 1 to 4 out of every 1,000 births beginning in the first two weeks following delivery. Women who have bipolar disorder or another mental health problem called schizoaffective disorder have a higher risk for postpartum psychosis. Symptoms may include seeing things that aren’t there, confusion, rapid mood swings and trying to hurt yourself or your new baby.

Other PMAD Disorders 

Postpartum Obsessive Compulsive Disorder (OCD) manifests as having unreasonable thoughts and fears that lead to a repetitive type of behavior. Developing OCD during or after pregnancy can be terrifying for women for many reasons but mainly because of the intrusive nature of repetitive thoughts. About three to five percent of new moms will experience OCD during their pregnancy or following delivery day. Intrusive thoughts such as, “What if I drop the baby, What if I forget the baby? or What if I stab the baby?” may plague an expectant or new mother.

Although a blessed event, childbirth can be traumatic for some moms. Postpartum Post-Traumatic Stress Disorder (PTSD) is more common in women who have had a problematic childbirth (including miscarriage, stillbirth, unplanned C-section, prolapsed cord, forceps deliver, or transfer of the newborn to the NICU), and in women who worry about childbirth, have experienced prior childbirth trauma, or have a history of PTSD. Symptoms may include constant anxiety, nightmares, avoiding people and places, and flashbacks to the traumatic experience.

Support During Depression

To be proactive, alleviate or help relieve the symptoms of depression during and after pregnancy, you may want to consider these helpful tips:

  • Rest and get as much sleep as you can. If you have young children who are not sleeping though the night on a regular sleeping schedule, you may want to consider sleep training. Expecting another baby is a great motivator to have everyone sleeping at night on the same schedule.
  • Don’t try to do too much or push yourself.
  • Ask your partner, family, and friends for help, even for something as simple as a periodic nap.
  • Make time to go out, visit friends, or spend time alone with your partner.
  • Discuss your feelings with your partner, family and friends.
  • Talk with other mothers so you can learn from their experiences.
  • Join a support group. Ask your doctor about groups in your area.
  • Don’t make any major life changes during pregnancy or right after giving birth. Major changes can cause unnecessary stress. Sometimes big changes can’t be avoided. When that happens, try to arrange support and help in your new situation ahead of time.
  • Once your baby arrives, sleep when your baby sleeps. If you are breastfeeding, you may decide to “pump and sleep.” Meaning you will pump breast milk before you go to bed at night and your baby can be fed by the other parent, partner or family member while you get some sleep!
  • After delivery day, consider finding outside support. If you want to manage your new life on your own, start figuring out how you can streamline your new responsibilities so caring for your new baby will receive your full attention making your life more manageable and enjoyable.

If you are diagnosed with PMAD following your baby’s arrival, please realize that you are not alone and you are not to blame and with help you will feel like yourself again. It is vital to recognize your symptoms and seek the help of a qualified professional before your condition intensifies.

If you are feeling depressed before, during pregnancy or after having your baby, don’t suffer alone. Please tell a loved one and call your health care team right away!

To learn more about depression before, during and after pregnancy, or for a list of organizations ready to assist you, please visit Womenshealth.gov or call them at 800-994-9662 (TDD: 888-220-5446).

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Estimated Placental Volume (EPV)

Estimated Placental Volume (EPV) should be incorporated into prenatal care” explains Yale Researcher, Harvey J. Kliman, MD, PhD. Dr. Kliman is the Director of the Reproductive and Placental Research Unit Department of Obstetrics and Gynecology, Yale University School of Medicine. EPV is calculated using a simple 2-dimensional ultrasound to assess the ratio of baby to placenta. Kliman states, “Docs should know about abnormal placentas. Not knowing anything about a placenta is like driving a car without a gas gauge!”

The EPV method is a screening tool performed by your health care team and is simply done while you are having your baby’s ultrasounds around 10 and 18 weeks. Normative curves for EPV between 10 and 40 weeks are available from Dr. Kliman.

A significantly small placenta determined by EPV may be associated with IUGR of the fetus and should alert your doctor to follow your pregnancy more closely. The complications from a small placenta do not occur suddenly and the results can be devastating. The most severe outcome of a very small placenta is an intrauterine fetal demise. Using the EPV may help warn doctors of this complication before it’s too late. Your health care team can learn more about EPV by visiting the Yale School of Medicine.

You are invited to join Dr. Kliman’s pregnancy study to monitor your expected baby’s placenta, the organ that develops in your uterus during pregnancy to provide your baby nutrients and oxygen. You may download the EPV ResearchKit app, designed by Dr. Kliman and available from the iTunes Store to your iPhone or iPad. This EPV app allows you and your health care team to track the link between the placental volume, the amount of nourishment supplied to your baby, and a healthy pregnancy. By participating in this study you will help researchers to understand normal and abnormal placental growth. Once you are found to be eligible to join, you will sign a consent form; the EPV will be recorded at each ultrasound. At the completion of your pregnancy, your health care team will be asked to report your pregnancy outcome (the researchers have no access to your personal information).

Speak with your health care team about becoming part of this exciting new study to ensure the wellbeing of your baby while proactively helping to secure your baby’s health on delivery day.

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Fetal Hiccups

Babies love to hiccup! Light, recurring and sequential patterns are what you will notice at first. Later in your pregnancy, your baby’s hiccups will become robust and recognizable. Although most babies have hiccups and they are harmless, some fetal hiccups may be a reason for concern. According to Obstetrician-Gynecologist Dr. Jason Collins, MD, MSCR, of The Pregnancy Institute, even though your baby’s hiccups can be recurrent, once the Week 32 gestational marker is reached, your baby’s hiccups should lessen and not be present on a daily basis. So, when your baby continues to hiccup every day with hiccups lasting longer than 15 minutes or a series of hiccups 3–4 times with 24 hours, alert your health care team and have your baby evaluated for possible umbilical cord concerns.

Fetal Non-Stress Test (NST), Biophysical Profile (BPP) and Cord Blood Flow Doppler Test

Three tests to check on your baby’s well-being in utero are: a NST, a BPP, and a Cord Blood Flow Doppler Test. The first test, an NST, will monitor and evaluate your baby’s heartbeat. This test usually starts in the third trimester (for high risk moms as early as the Week 28) for moms and expected babies who need special care and monitoring with conditions such as diabetes or hypertension, blood clotting disorders, follow up for an amniocentesis, IUGR, a baby who is small or not growing properly, a less active baby, if you have passed your due date or if you hae had a previous loss.  A NST usually takes 20-40 minutes to complete. Your baby’s heartbeat will be heard and recorded while your baby is inactive and active. The NST is a reactive test meaning your baby’s heart beats faster when moving. To be reactive, this must happen at least two times in 20 minutes. If your baby is sleeping or inactive, you may be given juice or water to drink to encourage your baby to move! The NST will be considered nonreactive if your baby’s heart does not beat faster when your baby is active, or quiet and not moving. Don’t panic if this happens! They will consider this a false NST, but it merely means the NST did not provide enough information and additional tests such as a BPP may be necessary.

A BPP combines both fetal heart rate monitoring (NST) and a fetal ultrasound. Your baby’s breathing, heart rate, movements, muscle tone and amniotic fluid level are calculated and scored. The ideal goal is to get 10 out of 10. This simple combination of testing does not cause any physical danger to you or your baby. A BPP is normally performed as early as the 28th to 32nd week of pregnancy. It may, however, be considered when your doctor is planning an early delivery, typically after the 24th to 26th week of your pregnancy. A low score on a BPP might indicate that you and your baby need further monitoring or special care. In some cases, early or immediate delivery might be necessary.

A Cord Blood Doppler Test is given to check the blood flow within the umbilical cord. A healthy umbilical cord will have two arteries, one vein, be the proper length and contain adequate Wharton’s Jelly. Wharton’s Jelly is a specialized tissue which serves many purposes for the developing fetus. Its specialized cells contain gelatin-like mucus that encase fibers. These properties give it an elastic and cushiony effect, which can tolerate the vibration, bending, stretching and twisting of an active fetus. In addition, it holds the vessels together, may regulate blood flow, plays a role in providing nutrition to the fetus, stores chemistry for the onset of labor, and protects the supply line. The Cord Doppler test may be more pivotal for umbilical cords that have only one artery, but it can also alert your health care team to other umbilical cord issues such as a knot, a kink, twisting or torsion, a nuchal cord and a short or long cord. This simple procedure tests the velocity and direction of the blood flow.

If you’ve had a previous stillbirth due to a UCA, your health care team can assign a perinatologist or maternal fetal specialist who can schedule a NST and BPP anywhere from one to three times a week depending on moms comfort level to monitor the health of her baby. Remember that if you’ve had a pervious loss or complication, your doctor should absolutely label your next pregnancy as high risk!

In the presence of a nuchal cord, movement counting is especially important now and for the duration of your pregnancy if the nuchal cord remains or if your health care team considers the cord tight with or without kinks. Remember, changes in your baby’s movements, such as speeding up or slowing down, or changes in sleep-wake cycles could be a sign that your baby is not well. Know when your baby is awake and when he or she is asleep. Becoming your expected baby’s guardian through awareness, a proactive attitude and vigilance will empower you.

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Fundal Height

As the end of your second trimester approaches, keep a check on your baby’s growth measurements. Fundal height measurements, EPV, or estimated weight with ultrasound performed monthly will let you and your team know if the placenta is supplying adequate nourishment for your baby.

Mayo Clinic Obstetrician and Medical Editor-in-Chief, Dr. Roger W. Harms, explains that fundal height is measured from the top of the uterus down to the pubic bone. Once you have entered the second trimester, your fundal height measurement will usually equal your gestational week. So, if you are in your 28th week, your health care team will anticipate your fundal height to measure approximately 28 centimeters.

Keep in mind, although fundal height is a means for estimating your baby’s fetal development, as well as gestational age, it is not a precise measurement and it is not uncommon to gauge your baby’s fundal height smaller or larger than anticipated. Depending on your height, stature or frame, if your bladder is empty or full, or if you are pregnant with twins or multiples, you may see differences in your fundal height. However, also keep in mind that a faster or slower rate may also be due to growth restriction which is rapid or slow, his or her amniotic fluid, fibroids of the uterus, baby’s descent into the pelvis before time, or baby’s unusual positioning such as a breech presentation.

Usually, fundal height measurements reassure your health care team of your baby’s growth. If you’re concerned about your fundal height measurements, ask your health care provider for specific details. Your health care team may recommend an ultrasound or other tests to determine the cause of an atypical measurement.

Professor Jason Gardosi, MD, FRCSED, FRCOG, Director of the Perinatal Institute, Birmingham, England, has developed the Growth Assisted Protocol (GAP) program based on the motivating principle that many instances of adverse perinatal outcomes of pregnancy are potentially avoidable.

Every mom using this program has a Gestation Related Optimal Weight (GROW) chart for her baby calculated by combining mom’s height, weight, ethnic origin and previous pregnancies at the beginning of her pregnancy.

This chart will predict the growth of mom’s expected baby week by week. By measuring the fundal height, if the baby’s growth falls outside the anticipated “norm” for mom’s predicted growth chart, additional ultrasounds will be ordered to insure that the baby is thriving. Professor Gardosi’s protocol includes 4.5 ultrasounds from Week 28 onwards.

If the ultrasound results indicate the baby needs help, he or she can be treated in the womb. However when careful monitoring shows the baby is still stressed, an early delivery will be performed. To learn more about Professor Gardosi’s GAP program and the importance of fundal height, visit the Perinatal Institute.

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Glucose Challenge Screening

By 26 weeks, make sure your health care team has scheduled you for a Glucose Challenge Screening (an adaptation of the Glucose Tolerance Test which tests for Type 2 Diabetes). This screening is for Gestational Diabetes, a type of diabetes present only when you are pregnant. This test is done between 26-28 weeks and will accurately measure the response of your body to glucose (sugar). If the test is positive, you will need to undergo further testing to confirm this pregnancy diagnosis.

Your health care team will help you decide on a wholesome eating plan and exercise regime to maintain a healthy pregnancy with gestational diabetes. If you are having trouble achieving your targeted pregnancy glucose levels, a medication called insulin, given by injection, may be needed, which will not harm your baby.

If you are diagnosed with gestational diabetes, your blood sugar will need to be monitored closely and kept under control. This condition can lead to extremely serious complications if not managed well. When your blood sugar is not controlled and allowed to run high, there is an increased risk of miscarriage, stillbirth, preeclampsia, preterm delivery (before 37 weeks), and the possibility of a Caesarean section due to a large baby weighing 9 pounds or more

For more information on gestational diabetes, how it can be managed and how it may impact your pregnancy, or to proactively pass this vital information via the CDC’s Health-e-Cards to other pregnant moms, please visit the CDC and the National Diabetes Information Clearinghouse (NDIC).

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Incompetent Cervix (CI)

An Incompetent Cervix, also called cervical insufficiency, or CI, is a condition of pregnancy that occurs when the expectant mother’s cervical tissue is weakened to such a degree that it may lead to an unexpected pregnancy loss. This may be due to a previous childbirth, cervical trauma such as a broad cervical conization (cervical biopsy), various abnormalities and irregularities of the uterus, the possible exposure to the synthetic estrogen Diethylstilbestrol (DES), or there may be no defining cause. CI can cause or contribute to premature birth, and in many cases, the loss of an otherwise robust pregnancy. While CI occurs in only one out of 100 pregnancies, the condition is responsible for approximately 25 percent of losses in the second trimester.

Before you become pregnant, your cervix is normally closed and firm. As your pregnancy advances and you prepare for delivery day, the cervix gradually relaxes, shortens in length (effaces) and opens (dilates). If your cervix is incompetent, it might begin to open ahead of time and you may deliver your baby too early without even feeling any contractions. CI usually manifests between Weeks 16-24, with most instances taking place between Weeks 18-22.

It is difficult to diagnose CI and because of this, it is difficult to treat. A manual pelvic examination may detect CI. For a diagnosis of CI to be made, the cervical opening must be greater than 2.5 cm, or the cervical length must have shortened to less than 20mm. Funneling, a shortening of the cervix and dilatation of the internal cervical canal, can also be a sign of CI.

A transvaginal ultrasound is the best technique to examine the cervix according to Dr. James E. Sumners, M.D., of St. Vincent Women’s Center for Prenatal Diagnosis in Indianapolis. This specialized ultrasound helps monitor cervical length and can check to see if the cervix is opening. This method visualizes the entire cervix and the complete cervical canal. Once diagnosed, preventative medication, repeated ultrasounds, or various techniques for closing the cervix may be implemented such as a cervical cerclage, a purse-string stitch that acts as an cinch to keep the cervix from dilating. This is usually performed in an outpatient setting between Weeks 12-15.

Unfortunately, during pregnancy you may not experience or feel any signs or symptoms that your cervix is beginning to open too early. You could possibly notice some minor discomfort or vaginal spotting over several days or perhaps weeks. You should alert your health care team if you notice any of the following between Weeks 14-20: pelvic pressure, a backache, mild abdominal cramping and a variation in your vaginal discharge such as mucous or blood.

Women who have already had a miscarriage because of incompetent cervix will likely have the same outcome in future pregnancies if they do not seek treatment. Not seeking treatment can lead to great stress and emotional suffering for women and couples hoping to become parents.

To find out more information on diagnosis, treatment or understanding how CI may impact your pregnancy, please visit the March of Dimes and The University of Chicago Hospitals.

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Infection: Cytomegalovirus (CMV)

Cytomegalovirus (CMV) is a common virus that poses a major risk to pregnant women who are around babies and young children. Moms who are child care providers, daycare workers, preschool teachers, therapists, and nurses need to take extra precautions as preschoolers are the majority of carriers. CMV is present in saliva, urine, feces, tears, blood, mucus and other bodily fluids. You cannot catch CMV by simply being in the same room with someone, unless bodily fluids are exchanged. Additionally, there is no information to indicate CMV is transmitted in the air (airborne).

The American College of Obstetricians and Gynecologists (ACOG) and the CDC recommend that OB/GYNs counsel women on basic prevention measures to guard against CMV.

CMV is very prevalent among healthy children 1 to 3 years of age as they are at high risk for contracting CMV. Since CMV can be transmitted to an unborn child from a pregnant mother experiencing a primary or recurrent CMV infection, how can you minimize your risk? Here are a few simple preventative steps you can proactively incorporate into your daily routine from Stop CMV – The CMV Action Network:

  • Wash your hands often with soap and water for 15-20 seconds, especially after changing diapers, feeding a young child, wiping a young child’s nose or drool, and handling children’s toys.
  • Do not share food, drinks, or eating utensils used by young children.
  • Do not put a child’s pacifier in your mouth.
  • Do not share a toothbrush with a young child.
  • Avoid contact with saliva when kissing a child.
  • Clean toys, countertops, and other surfaces that come into contact with children’s urine or saliva.

Some babies born with congenital CMV are symptomatic at birth, others are asymptomatic. Children born with congenital CMV may develop permanent medical conditions and disabilities, such as deafness, blindness, cerebral palsy, mental and physical disabilities, seizures, and death.

Become your expected baby’s guardian today by taking an active role in your personal hygiene and healthcare decisions and prevent CMV. Consult your health care team if you are concerned about the CMV infection during pregnancy, you develop a mononucleosis or flu-like illness during pregnancy, or you feel you may be a candidate for CMV screening or treatment.

If you would like further information on CMV and how it may affect your pregnancy and your baby’s future, please visit Stop CMV. If you would like to proactively pass this vital information via the CDC’s Health-e-Cards to other pregnant moms, please visit the CDC.

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Infection: Genital Herpes

Genital Herpes is a chronic permanent viral infection. One in five pregnant women has herpes, either Herpes Simplex Virus (HSV-1) which is responsible for cold sores on the mouth and lips or Herpes Simplex Virus-2 (HSV-2), which is responsible for genital herpes. Although genital herpes can be caused by HSV-1 or HSV-2, most mothers of infants who acquire neonatal herpes are asymptomatic, meaning they have never had an outbreak of genital herpes!

Women with recurrent genital herpes have antibodies which protect the baby from neonatal herpes infections. However, if a mother acquires genital herpes during the last trimester of her pregnancy there is a 30–50 per cent chance of transmitting this infection to her baby. Acyclovir, an anti-viral medication used to treat genital herpes, if taken during the last trimester, may help prevent a neonatal infection.

It is recommended that any woman with an outbreak of genital herpes at the time of delivery should have a Caesarean section. For more information on genital herpes and how it may impact your pregnancy, please visit the CDC and the March of Dimes.

In preventing infections which may prove harmful to you and your baby, Dr. McGregor advises you to see your health care team for any symptoms of a bladder (urinary tract) infection, vaginitis symptoms and an unexplained fever. He also advocates good dental hygiene and care, reporting any vaginal bleeding, discharge or fluid leakage to your health care team, and avoiding membrane stripping to induce labor. Dr. McGregor also encourages moms to be vaccinated for Influenza (Inactivated) and Tdap (Tetanus, Diphtheria and Pertussis) at 28 Weeks if their adult vaccinations are not up to date.

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Infection: Group B Strep

Your urine will be cultured for Group B Strep (GBS). If your results are positive for GBS or for an asymptomatic bacteriuria, the U.S. Centers for Disease Control and Prevention (CDC) recommends appropriate antibiotic treatment if your urine culture shows over 100,000 colonies per cc. Once you finish your antibiotics, have a test of cure (TOC) to ensure that the infection has cleared completely. Make sure you ask for the results of your urine culture on your next visit.

If your urine is negative for GBS, you will have a rectovaginal swab taken at 35 – 37 weeks gestation and cultured to ensure that you are still GBS negative. If you are positive for GBS at this initial visit or at a later date, discuss with your health care team how GBS will impact your birth plan and the intravenous antibiotics that will be required during labor and delivery.

According to Researcher, James A. McGregor, MDCM, Retired Professor of OB-GYN, Division of Perinatology, University of Southern California, Keck School of Medicine, any infection can be potentially life threatening to your baby. Approximately 1 in 4 pregnant women carry GBS, the most common cause of life-threatening infections in newborns according to the CDC. GBS can not only infect babies during pregnancy, but also during the first few days and weeks of life.

“Women should have accurate information to know how to best protect their babies”, states Group B Strep International’s co-founder, Marti Perhach. For awareness materials and further information, please visit GBS today. If you would like to proactively pass along Health-e-Cards containing vital GBS information to other pregnant moms, please visit the CDC. Your health care team can now download the free “Prevent Group B Strep” App for iOS and Android devices by simply visiting the CDC.

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Infection: Listeria

According to the CDC, Listeria (listeriosis) is bacteria found in soil, water, dust, plants, raw meats, processed foods, some prepared vegetables, and in the feces of animals and humans. Most listeria infections affecting pregnant women come from eating contaminated foods. This infection may be passed to an expectant mother’s baby through the placenta, and the mother may not even show any signs of illness. Listeria can lead to miscarriage, stillbirth and premature delivery. In a newborn the presence of listeria may result in blood stream infections, meningitis and possible death. A late neonatal infection may even appear more than 5 to 7 days following delivery. Because of the potentially severe consequences of listeria, it’s important that you, as well as your health care team, are familiar with the prevention, symptoms, diagnosis and treatment of this infection.

The chance of contracting listeria is ten times higher for pregnant women than that of the overall population, and twenty-four times higher for Hispanic women. Symptoms can be as mild as fever, chill, muscle aches, diarrhea and upset stomach, and can take a few days or possibly weeks to emerge. A pregnant mom may not even be aware that she has it. The more serious symptoms of a listeria infection for the pregnant mom may range from headache, stiff neck and confusion to a loss of balance and even convulsions. This is why prevention is vital and that you take appropriate food safety precautions during pregnancy.

The USDA’s Food Safety and Inspection Service (FSIS) and the U.S. Food and Drug Administration (FDA) provide the following guidelines for pregnant women:

  • Do not eat hot dogs, luncheon meats, or deli meats unless they are reheated until steaming hot.
  • Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats.
  • Do not eat soft cheeses such as feta, Brie, Camembert, blue- veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, and Panela, unless they have labels that clearly state they are made from pasteurized milk. It is safe to eat hard cheeses, semi-soft cheeses such as mozzarella, pasteurized processed cheese slices and spreads, cream cheese and cottage cheese.
  • Do not eat refrigerated pate and meat spreads. It is safe to eat canned or shelf-stable pate and meat spreads.
  • Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish such as a casserole. Examples of refrigerated smoked seafood include salmon, trout, whitefish, cod, tuna, and mackerel which are most often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” This fish is found in the refrigerated section or sold at the deli counters of grocery stores and delicatessens. It is safe to eat canned fish such as salmon and tuna or shelf-stable smoked seafood.
  • Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk.
  • Use all refrigerated perishable items that are precooked or ready-to-eat as soon as possible.
  • Clean your refrigerator regularly to avoid cross-contamination.
  • Use a refrigerator thermometer to make sure that the refrigerator always stays at 40 °F or below.

It’s important to note that if you have eaten food contaminated with listeria and are asymptomatic, most professionals believe you don’t need any tests or treatment, even if you are pregnant. Although you should inform your health care team if you are pregnant and have eaten the contaminated food, and within 2 months experience flu-like symptoms.

If a pregnant mom does contract listeria, antibiotics are given to treat it. In most cases, the antibiotics also prevent infection of the fetus or newborn. Antibiotics are also given to babies who are born with listeria.

If you experience any symptoms of listeria, consult your health care team immediately. A blood test can be performed to find out if listeria is the cause of your symptoms.

For more information on listeria prevention and how listeria infection can impact both you and your baby during and after pregnancy, please visit the CDC and the NIH.

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Infection: Toxoplasmosis

Toxoplasmosis, considered one of the neglected parasitic infections, is an infection that a mom may pick up from something as simple as cleaning a cat litter box or making a hamburger patty. Toxoplasma Gondi is a parasite so small it is invisible to the human eye and, fortunately, most healthy immune systems will not allow the parasite to trigger an infection. It is estimated that 22.5% of Americans 12 years and older have been infected with toxoplasma. Although usually asymptomatic, symptoms accompanying toxoplasmosis may be similar to those of the flu with swollen lymph glands or muscle aches and pains that last for a month or more.

If you have been recently infected, speak with your health care team. It is advised you wait six months before becoming pregnant. Usually, if you have been infected with toxoplasma before you became pregnant, your unborn child is protected by your immunity. Your health care team may advise a blood test be drawn to check for antibodies to toxoplasma if you are pregnant. If you become infected during pregnancy, medication is available. You and your baby should be closely monitored during your pregnancy and after your baby is born.

Unfortunately, this infection may possibly result in miscarriage prior to 20 weeks or a stillbirth after 20 weeks. Although on occasion infected newborns may exhibit serious eye or brain damage at birth, the majorities of infected infants do not have symptoms present at birth but may develop serious signs later in life, such as blindness or mental disability.

The March of Dimes suggests the following simple steps in avoiding contamination:

  • Don’t eat raw or undercooked meat, especially lamb or pork. Cooked meat should not look pink, and the juices should be clear.
  • Wash your hands with soap and water after handling fruits, vegetables or raw meat.
  • Don’t touch your eyes, nose or mouth when handling raw meat.
  • Clean cutting boards, work surfaces and utensils with hot, soapy water after using them with fruits, vegetables or raw meat.
  • Peel or thoroughly wash all raw fruits and vegetables before eating.
  • Use work gloves when you’re gardening. Wash your hands afterwards.
  • Don’t let your cat go outside your home where it may come in contact with the parasite.
  • Ask someone else to clean your cat’s litter box. If you have to do it yourself, wear gloves. Wash your hands thoroughly when you’re done emptying the litter.
  • Stay away from children’s sandboxes. Cats like to use them as litter boxes.

For further information on toxoplasmosis and how it can impact you and your baby during pregnancy and after birth, please visit the CDC and the March of Dimes.

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Infertility

It’s a proactive step towards conception and pregnancy for you and you partner to make an appointment and meet with your health care team when you are considering starting a family. They can help you prepare your body for a healthy baby, answer your questions on fertility and give you both tips on conceiving.

Did you know that it is estimated that ten to fifteen percent of couples have trouble getting pregnant or reaching a successful delivery day? Or that female infertility, male infertility or a combination of the two affects millions of couples worldwide? So what exactly is infertility? Infertility means that with frequent intercourse for at least a year of actively trying, a couple cannot conceive.

The onus of infertility rests equally between the female and male factoring about one-third of the time for each. The remaining one-third causation is either not known or a combination of both male and female factors. With age, there is a natural decrease in fertility spurring the investigation and management of infertility to be started sooner by some specialists in certain couples.

Identifying the cause of female infertility can be challenging but there are several treatments available once the cause is realized. Your possible treatment will depend on the primary problem. Treatment may not always be warranted as numerous infertile couples do go on to conceive a child naturally. It is estimated that approximately six percent of married women (15-44) are not able to become pregnant after one year of unprotected sex, and that roughly twelve percent of women (15-44) struggle with infertility or carrying a pregnancy forty weeks regardless of their marital status.

Male infertility data from the National Survey of Family Growth in 2002 that was analyzed by the CDC showed that 7.5% of all sexually experienced men younger than age 45 reported seeing a fertility doctor during their lifetime. This means that 3.3–4.7 million men sought help for infertility and of the men who wanted help, 18% were diagnosed with a male-related infertility problem, including sperm or semen problems (14%) and varicocele (6%).

Symptoms

The foremost symptom of infertility is the inability of a couple to become pregnant. Female infertility may be associated with a lack of ovulation arising from a menstrual cycle that is excessively long (35 days or more) or short (less than 21 days). An irregular or absent period can signal a lack of ovulation as being the cause of infertility. However, there may also be no other apparent signs or symptoms.

When you decide to see a doctor and seek medical help depends, to some extent, on your age, as a woman’s age is probably the most significant factor related to her ability to conceive. According to the Mayo Clinic:

  • If you’re in your early 30s or younger, most doctors recommend trying to get pregnant for at least a year before having any testing or treatment.
  • If you’re between 35 and 40, discuss your concerns with your doctor after six months of trying.
  • If you’re older than 40, your doctor may want to begin testing or treatment right away.

Your doctor will most likely recommend a member of the American Society of Reproductive Medicine in your area to help you with your infertility.

Causes

Today, the trend of delayed marriage and childbirth are the main social causes of infertility. Physically, in order for you to become pregnant ovulation, sperm, regular intercourse, open fallopian tubes and a normal uterus must all co-exist working simultaneously together. However, there are several factors that can prevent this process from taking place and causing female infertility. Genetic testing will also help determine whether there’s a genetic defect may also be a source of infertility prompting the need for genetic testing.

Ovulation disorders

Ovulation disorders are responsible for roughly 25 percent of couples remaining infertile. This condition causes you to ovulate irregularly or perhaps not at all. Inconsistency in the reproductive hormonal regulation by either the hypothalamus or pituitary gland, or by difficulties within the ovary itself may be to blame for this problem. The Mayo Clinic defines ovulation disorders as:

Polycystic ovary syndrome (PCOS). In PCOS, complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone     imbalance, which affects ovulation. PCOS is associated with insulin     resistance and obesity, abnormal hair growth on the face or body, and  acne. It’s the most common cause of female infertility.

Hypothalamic dysfunction. The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing

hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods.

Premature ovarian insufficiency. This disorder is usually caused by an autoimmune response where your body mistakenly attacks ovarian tissues or by premature loss of eggs from your ovary due to genetic problems or environmental insults such as chemotherapy. It results in the loss of the ability to produce eggs by the ovary, as well as a decreased estrogen production under the age of 40.

Too much prolactin. Less commonly, the pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Most commonly this is due to a problem in the pituitary gland, but it can also be related to medications you’re taking for another disease.

Damaged fallopian tubes (tubal infertility)

The inability of sperm to reach the egg or the failure of the fertilized egg to reach and implant in the uterus may be due to damaged or blocked fallopian tubes. The Mayo Clinic states tubal damage or blockage may be a result of:

Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections.

Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of the uterus.

Pelvic tuberculosis, a major cause of tubal infertility worldwide, although uncommon in the United States.

Endometriosis

Uterine tissue that implants and grows elsewhere is called endometriosis. This additional growth of uterine tissue when removed surgically may cause scarring obstructing the narrow fallopian tube. If this occurs, the egg and sperm will not unite. Equally, endometriosis may also affect the lining of the uterus jeopardizing the implantation of the fertilized egg. This condition may also be indirectly responsible for upsetting fertility by causing injury to the sperm or egg. It is estimated that 25-50 percent of women have this condition.

Uterine or cervical causes

There are a number of uterine or cervical conditions that may interfere with your egg becoming implanted in the uterus. This increases the risk of a miscarriage. The Mayo Clinic defines these conditions as:

Benign polyps or tumors (fibroids or myomas) are common in the uterus, and some types can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids or polyps can become pregnant.

Endometriosis scarring or inflammation within the uterus can disrupt implantation.

Uterine abnormalities present from birth, such as an abnormally shaped uterus, can cause problems becoming or remaining pregnant.

Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.

Sometimes the cervix can’t produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.

Male infertility

This may be caused by various factors. It is usually diagnosed by two semen analyses taken at least one month apart. A specialist evaluates the number of sperm (concentration), motility (movement), and morphology (shape). If the result is slightly abnormal, a diagnosis of infertility is not necessary made. However, if the abnormal result is due to an illness such as a viral infection, it will take roughly two to three months before the sperm parameters change and the test can be repeated. This analysis will aid in deciding how male factors are possibly contributing to the couple’s infertility.

According to the CDC, the conditions that can contribute to an atypical semen analyses include:

  • Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
  • Medical conditions or exposures such as diabetes, cystic fibrosis, trauma, infection, testicular failure, or treatment with chemotherapy or radiation.
  • Unhealthy habits such as heavy alcohol use, testosterone supplementation, smoking, anabolic steroid use, and illicit drug use.
  • Environmental toxins including exposure to pesticides and lead.

The National Institute of Health (NIH) state that other causes of male infertility may include:

  • Physical problems with the testicles.
  • Blockages in the ducts that carry sperm.
  • Hormone problems.
  • A history of high fevers or mumps.
  • Genetic disorders.
  • Lifestyle or environmental factors.

An incompetent cervix, also called cervical insufficiency, or CI, is a condition of pregnancy that occurs when the expectant mother’s cervical tissue is weakened to such a degree that it may lead to an unexpected pregnancy loss. This may be due to a previous childbirth, cervical trauma such as a broad cervical conization (cervical biopsy), various abnormalities and irregularities of the uterus, the possible exposure to the synthetic estrogen Diethylstilbestrol (DES), or there may be no defining cause. CI can cause or contribute to premature birth, and in many cases, the loss of an otherwise robust pregnancy. While CI occurs in only one out of 100 pregnancies, the condition is responsible for approximately 25 percent of losses in the second trimester.

Before you become pregnant, your cervix is normally closed and firm. As your pregnancy advances and you prepare for delivery day, the cervix gradually relaxes, shortens in length (effaces) and opens (dilates). If your cervix is incompetent, it might begin to open ahead of time and you may deliver your baby too early without even feeling any contractions. CI usually manifests between Weeks 16-24, with most instances taking place between Weeks 18-22.

It is difficult to diagnose CI and because of this, it is difficult to treat. A manual pelvic examination may detect CI. For a diagnosis of CI to be made, the cervical opening must be greater than 2.5 cm, or the cervical length must have shortened to less than 20mm. Funneling, a shortening of the cervix and dilatation of the internal cervical canal, can also be a sign of CI.

A transvaginal ultrasound is the best technique to examine the cervix according to Dr. James E. Sumners, M.D., of St. Vincent Women’s Center for Prenatal Diagnosis in Indianapolis. This specialized ultrasound helps monitor cervical length and can check to see if the cervix is opening. This method visualizes the entire cervix and the complete cervical canal. Once diagnosed, preventative medication, repeated ultrasounds, or various techniques for closing the cervix may be implemented such as a cervical cerclage, a purse-string stitch that acts as an cinch to keep the cervix from dilating. This is usually performed in an outpatient setting between Weeks 12-15.

Unfortunately, during pregnancy you may not experience or feel any signs or symptoms that your cervix is beginning to open too early. You could possibly notice some minor discomfort or vaginal spotting over several days or perhaps weeks. You should alert your health care team if you notice any of the following between Weeks 14-20: pelvic pressure, a backache, mild abdominal cramping and a variation in your vaginal discharge such as mucous or blood.

Women who have already had a miscarriage because of incompetent cervix will likely have the same outcome in future pregnancies if they do not seek treatment. Not seeking treatment can lead to great stress and emotional suffering for women and couples hoping to become parents.

To find out more information on diagnosis, treatment or understanding how CI may impact your pregnancy, please visit the March of Dimes and The University of Chicago Hospitals.

Unexplained infertility

Unfortunately, a source for your infertility may never be discovered. Unresolved fertility issues may result from a combination of various minor causes affecting the couple as a whole. It can be devastating to not know the reason for your infertility but the good news is that infertility can possibly be reversed in time.

Risk factors

According to the Mayo Clinic, there are definite risk factors that may increase your chances of infertility. They are:

  • With increasing age, the quality and quantity of a woman’s eggs begin to decline. In the mid-30s, the rate of follicle loss accelerates, resulting in fewer and poorer quality eggs, making conception more challenging and increasing the risk of miscarriage.
  • Besides damaging your cervix and fallopian tubes, smoking increases your risk of miscarriage and ectopic pregnancy. It’s also thought to age your ovaries and deplete your eggs prematurely, reducing your ability to get pregnant. Stop smoking before beginning fertility treatment.
  • If you’re overweight or significantly underweight, it may hinder normal ovulation. Getting to a healthy body mass index (BMI) has been shown to increase the frequency of ovulation and likelihood of pregnancy.
  • Sexual history. Sexually transmitted infections such as chlamydia and gonorrhea can cause fallopian tube damage. Having unprotected intercourse with multiple partners increases your chances of contracting a sexually transmitted disease (STD) that may cause fertility problems later.
  • Heavy drinking is associated with an increased risk of ovulation disorders and endometriosis.

It must also be noted that passive smoking has also been established to have an effect on fertility and the heavy use of marijuana decreases fertility in both men and women.

Preparing for your appointment

If you decide to have your infertility evaluated, it’s important that you begin tracking your periods, your symptoms and dates of intercourse before your first visit. You will also want to make a list of medications and supplements — either vitamins or herbal remedies — with doses and frequency for your specialist. Any pertinent medical records with previous tests or treatments should accompany you.

Both you and your partner will have a medical and sexual history taken; any previous pregnancies with your current partner will be discussed. You will both be assessed for possible causes as well as potential treatments to correct this condition.

Don’t forget to bring a notebook or iPad with you for two reasons. First, beforehand you can prepare any questions that you would like answered, and second, you will be able to jot down any essential information given to you at this time.

Tests, diagnosis, treatments and drugs

Your specialist may possibly order any number of tests that he or she feels will help to evaluate, diagnose and treat your condition. Testing may range from a simple over-the-counter ovulation prediction kit to a laparoscopy which is a minimally invasive procedure visualizing your fallopian tubes, ovaries and uterus to genetic testing which will indicate if a genetic problem is responsible for your infertility. It is important to remember that no one test is a perfect predictor of fertility.

Nearly 85-90 percent of infertility cases are treated conservatively with drugs or the surgical repair of reproductive organs. Although numerous surgical procedures can correct difficulties or increase female fertility, the surgical interventions for fertility are rare these days as fertility treatments such as laparoscopic surgery, microscopic tubal ligation reversal surgery and tubal surgeries have high success rates.

Endometriosis may be diagnosed by using ultrasonography and endometrial biopsy that are not considered part of the basic infertility investigation. Neither blood tests nor imaging studies alone can correctly diagnose endometriosis. Although ultrasound might identify an ovarian cyst that includes an endometrioma, a laparoscopy is still required to make the diagnosis.

The fertility drugs used today may increase a woman’s chance of becoming pregnant with twins, triplets, or other multiples. If you are pregnant with multiples, additional problems, monitoring and health care visits may be increased. Multiple fetuses have an increased risk of being born prematurely and are also at a higher risk of health and developmental problems.

Male factor infertility, depending on the primary cause, may be approached either medically, surgically, or helped with reproductive therapies. Medical and surgical treatments will normally be handled by a urologist specializing in infertility. A reproductive endocrinologist may also be needed. This specialist may offer intrauterine inseminations (IUIs) or assisted reproductive technology (ART). ART includes all fertility treatments in which both eggs and sperm are handled outside of the body. These procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. The main type of ART to overcome male infertility is in vitro fertilization (IVF), which currently accounts for more than 99 percent of ART procedures; tens of thousands of babies have been born around the world with this procedure. Severe male factor infertility is associated with genetic disorders such as mutations in the cystic fibrosis genes and is treated effectively only with IVF. ART accounts for approximately 10-15 percent of the remaining infertility treatment options.

Overall, many factors will determine how your specialist will treat your infertility. The complexity of infertility requires a substantial fiscal, physical, emotional and time commitment on your and your partner’s part. It may only take a couple of treatments to correct your infertility. However, some couples require numerous appointments and therapies before conception is possible. As mentioned above, medication or even surgery may be necessary to assist with conception, or complex procedures may also be warranted or introduced.

Coping and support

The quest for finding a cause for your infertility may be a strenuous and demanding one both physically and emotionally. Did you know that studies indicate that couples experiencing psychological stress have poorer results with infertility treatments? It will help to relieve any unnecessary anxiety by making sure you that you are aware, informed and understand the success rates, risks, and benefits of the potential therapies that are being offered. After consulting with your doctor, you and your partner will select the option that you feel is most advantageous to create a successful conception.

Don’t forget to keep your close friends and family informed of your progress. Many couples find comfort and support through the anonymity of online groups via social media. Professional help is always available to you both so never hesitate to reach out to your health care team for advice or a reference.

Continue your healthy lifestyle entertaining a moderate level of activity and exercise, and a well-balanced diet. This combination can boost your spirits as your tackle your infertility. Remember, that you always have alternatives to infertility. Adoption, surrogacy, gestational carriers or even deciding on not having any children may be choices you will want to consider. You should discuss these possibilities or another course of action that may appeal to you early in your infertility process as this can lower stress during treatments and disappointment if conception does not take place.

Prevention

It’s important that you try to improve your chances of normal fertility if you are considering becoming pregnant now or in the future. Simply incorporating the basics of good health is paramount. By maintaining a normal weight, eliminating smoking, alcohol and limiting your caffeine level to less than 200 to 300 milligrams a day, and reducing your stress level will improve your chances of normal fertility and the hope for conception to ensue.

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Intrahepatic Cholestasis Of Pregnancy (ICP)

Although some itching in pregnancy is normal, if you notice itching, primarily at night on the palms of hands, arms, legs, soles of feet or all-over itching which typically increases in severity, speak with your health care team. Intrahepatic Cholestasis of Pregnancy (ICP), a liver disorder occurring during pregnancy, affects 1 – 2 women per 1000 with itching being the most common symptom. While ICP has been reported early on in pregnancy by some individuals, it commonly begins in the third trimester when hormone concentrations peak.

Two simple blood tests will determine if you could possibly have ICP. ICPcare.org: For women and families that experience Intrahepatic Cholestasis of Pregnancy, provides pertinent educational information, the risks of the disorder ranging from fetal distress to an increased risk of intrauterine fetal demise (stillbirth) and a letter explaining ICP to your health care provider. For additional information on ICP and how it could possibly impact your pregnancy, please visit ICPcare.org.

Meconium

Your baby could possibly pass meconium, a solid greenish-brown waste, in utero prior to delivery. Meconium-stained amniotic fluid (AF) occurs in about 13% of live deliveries. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health (NIH):

“Meconium is the early feces (stool) passed by a newborn soon after birth, before the baby has started to digest breast milk (or formula). In some cases, the baby passes meconium while still inside the uterus. This usually happens when babies are “under stress” because their supply of blood and oxygen decreases, often due to problems with the placenta.

Risk factors that may cause stress on the baby before birth include:

  • “Aging” of the placenta if the pregnancy goes far past the due date.
  • Decreased oxygen to the infant while in the uterus.
  • Diabetes in the pregnant mother.
  • Difficult delivery or long labor.
  • High blood pressure in the pregnant mother.

Prevention

Risk factors for this condition should be identified as early as possible. If the mother’s water broke at home, she should tell the health care provider whether the fluid was clear or stained with a greenish or brown substance.

Fetal monitoring is started so that any signs of fetal distress can be found early. Immediate intervention in the delivery room can sometimes help prevent this condition (meconium aspiration). Health care providers who are trained in newborn resuscitation should be present.”

If your water breaks or you notice a leakage which is greenish-brown in color, indicating the presence of meconium in your amniotic fluid, call your health care team immediately and go to L&D.

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Miscarriage

Pregnancy is such an exciting time in your life. However, we have come to realize that it is beneficial for you to be aware of miscarriage in the event that you or someone you knows faces one. Learning about early fetal development in your first trimester enables you to have a better understanding of what is happening inside of your body as your pregnancy progresses, and what your health care team may be looking for in the case of a possible miscarriage.

Miscarriage is the spontaneous loss of a pregnancy from natural causes within the first 20 weeks of gestation. Women usually miscarry before Week 14. Anyone can have a miscarriage. Approximately ten to twenty-five percent of known pregnancies will end in miscarriage. In fact this number is most likely much greater as miscarriages occurring very early in the first trimester are perhaps not yet even detected as a pregnancy. These are called Chemical Pregnancies and occur shortly after implantation. At this point, you may not have realized that you have conceived. Chemical pregnancies are responsible for 50-75 percent of all miscarriages. The bleeding that occurs with a chemical pregnancy is around the time of the bleeding of your normal menstrual cycle.

Sadly, miscarriage is a relatively common experience and yet its frequency does not make it any easier to undergo or accept. The emotional turmoil inflicted on you and your family can be heartbreaking. Understanding the possible symptoms, types, causes, and risks involved in a miscarriage, and the medical care needed when confronting it may allow your emotional healing to begin sooner.

Symptoms

Miscarriage is often a process and not a single event. It may be hallmarked by an abrupt decrease in the signs of pregnancy such as breast sensitivity or morning sickness. You may also experience lightheadedness, dizziness or feeling faint and weight loss. Vaginal spotting with white-pink mucous, or brown or bright red bleeding may be noticed. A gush of clear or pink fluid or tissue may also be passed vaginally. Cramping, often more intense than normal menstrual cramps, may or may not be present. True contractions that might be extremely painful occurring every 5-20 minutes may be experienced, and mild to acute pain in the lower abdomen or back may be observed. If fetal tissue passes from your vagina, it should be placed in a clean container and taken to your health care team’s office or to the hospital for analysis.

If you experience any or all of the above symptoms, it is important that your health care team be notified immediately, or that you visit the nearest Emergency Room (ER) for an evaluation. Please remember that some bleeding may be experienced in 20 to 30 percent of all pregnancies, and approximately 50 percent of the women who experience vaginal spotting or bleeding in the first trimester do go on to have successful pregnancies.

Types

Although there are several types of miscarriages, usually it is simply referred to as miscarriage without specifying the kind. However, your health care team may also use the following terminology to define miscarriage as provided by American Pregnancy Association:

  • Threatened Miscarriage:
    Some degree of early pregnancy uterine bleeding accompanied by cramping or lower backache. The cervix remains closed. This bleeding is often the result of implantation.
  • Ectopic Pregnancy:
    A fertilized egg implants itself in places other than     the uterus, most commonly the fallopian tube. Treatment is needed immediately to stop the development of the implanted egg. If not treated rapidly, this could end in serious maternal complications.
  • Inevitable or Incomplete Miscarriage:
    Abdominal or back pain accompanied by bleeding with an open cervix. Miscarriage is inevitable when there is a dilation or effacement of the cervix and/or there is rupture of the membranes. Bleeding and cramps may persist if the miscarriage is not complete.
  • Complete Miscarriage:
    A completed miscarriage is when the embryo or products of conception have emptied out of the uterus. Bleeding should subside quickly, as should any pain or cramping. A completed miscarriage can be confirmed by an ultrasound or by having a surgical curettage (D&C) performed.
  • Missed Miscarriage:
    Women can experience a miscarriage without knowing it. A missed miscarriage is when embryonic death has occurred but there is not any expulsion of the embryo. It is not known why this occurs. Signs of this would be a loss of pregnancy symptoms and the absence of fetal heart tones found on an ultrasound.
  • Recurrent Miscarriage (RM):
    Defined as 3 or more consecutive first trimester miscarriages. This can affect 1% of couples trying to conceive.

Causes

There are many different causes for a miscarriage, however, the major cause of miscarriage during the first trimester is genetic or chromosomal, meaning the fetus isn’t developing normally. Most chromosomal abnormalities are the cause of a damaged egg or sperm cell, or are due to a problem at the time that the zygote goes through the division process. Typically in this situation, the embryo divides and grows abnormally for an unknown reason, and not a problem inherited from the mother and father. According to the Mayo Clinic, examples of this particular abnormality are:

Blighted ovum

Blighted ovum occurs when no embryo forms.

Intrauterine fetal demise

In this situation the embryo is present but has stopped developing and died before any symptoms of pregnancy loss have occurred.

Molar pregnancy

A molar pregnancy is a noncancerous (benign) tumor that develops in the uterus. A molar pregnancy occurs when there is an extra set of paternal chromosomes in a fertilized egg. This error at the time of conception transforms what would normally become the placenta into a growing mass of cysts. This is a rare cause of pregnancy loss.

There are also various maternal health conditions that may lead to miscarriage such as uncontrolled diabetes, infections including bacterial, viral, parasitic and fungal or sexually transmitted diseases (STD’s), hormonal problems for instance Polycystic Ovary Syndrome, cervical or uterine disorders, thyroid disease or maternal trauma. Environmental toxins such as excessive exposure to lead, mercury or organic solvents, low levels of folic acid and taking certain antibiotics such as clarithromycin are linked to the possibility of causing a miscarriage. Never take any herb, supplement or medication during pregnancy without the consent of a medical professional.

Your routine day-to-day activities such as moderate exercise, sexual intercourse or work (as long as you are not subjected to unsafe chemicals or radiation) will NOT cause a miscarriage! Equally, neither nausea nor vomiting, not even morning sickness, will cause a miscarriage.

The Mayo Clinic states that there are several maternal factors that may increase the risk of miscarriage:

  • Age
    Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it’s about 80 percent. Paternal age also might play a role. Some research also suggests that women who become pregnant by older men are at a slightly higher risk of miscarriage.
  • Previous miscarriages
    Women who have had two or more consecutive miscarriages are at higher risk of miscarriage.
  • Chronic conditions
    Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage.
  • Uterine or cervical problems
    Certain uterine abnormalities or weak cervical tissues (incompetent cervix) might increase the risk of miscarriage.
  • Smoking, alcohol and illicit drugs
    Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage.
  • Weight
    Being underweight or being overweight has been linked with an increased risk of miscarriage.

Prenatal genetic tests such as Chorionic Villus Sampling (CVS) and Amniocentesis that are described in Week 12 are invasive procedures and do carry a slight risk of miscarriage.

Medical Intervention

The diagnosis of miscarriage is a sensitive one. If bleeding or pain is noticed, you must contact your health care team immediately as you may be experiencing a Threatened Miscarriage. Rest will most likely be advised until your symptoms subside; exercise and sexual activity will probably need to be avoided. Although these suggestions have not been proven to reduce the risk of miscarriage, they might improve your comfort and overall wellbeing during this time. Avoid travel right after your diagnosis as prompt medical attention may be necessary.

If your symptoms do not subside, an examination will follow. Your health care provider will perform a pelvic exam to determine if there are any problems with your uterus and if dilatation has begun. An ultrasound will allow your baby’s development and heartbeat to be assessed and visualized. If it is determined that the embryo has died or was never formed, a miscarriage will occur.

Your health care team will follow a specific protocol for the treatment of miscarriage. Their primary goal is to prevent hemorrhaging or infection at this time.

The Mayo Clinic explains three possible protocols:

Expectant management

If you have no signs of infection, you might choose to let the miscarriage progress naturally. Usually this happens within a couple of weeks of determining that the embryo has died. Unfortunately it might take up to three or four weeks. This can be an emotionally difficult time. If expulsion doesn’t happen on its own, medical or surgical treatment will be.

Medical treatment. If, after a diagnosis of certain pregnancy loss, you’d prefer to speed the process, medication can cause your body to expel the pregnancy tissue and placenta. Although you can take the medication by mouth, your health care provider might recommend inserting the medication vaginally to increase its effectiveness and minimize side effects such as nausea and diarrhea. For about 70 to 90 percent of women, this treatment works within 24 hours.

Surgical treatment. Another option is a minor surgical procedure called suction dilation and curettage (D&C). During this procedure, your health care provider dilates your cervix and removes tissue from the inside of your uterus. Complications are rare, but they might include damage to the connective tissue of your cervix or the uterine wall. Surgical treatment is needed if you have a miscarriage accompanied by heavy bleeding or signs of an infection.

Once your health care team has implemented the appropriate protocol and care for your miscarriage, you will need to pay close attention to the possibility of bleeding over the next few days. In the event of increased bleeding or the start of chills or fever, your health care team must be called immediately.

Moving Forward

Following a miscarriage, you will often have many questions about your physical and emotional recover, and when you can begin to try and conceive again.

Physically, your journey back to day-to-day life after a miscarriage is a relatively speedy one. It may take a mere few hours to a couple of days depending on your baby’s gestational age and the protocol chosen, and may take longer if anything unusual is experienced such as excessive bleeding, a fever or abdominal pain that would cause your health care team to be notified. It will take about 4-6 weeks for your period to return to normal. Any type of contraception should be started immediately after a miscarriage. However, it is important that two weeks following your miscarriage sexual activity should be avoided in addition to inserting anything into the vagina, such as a tampon.

Your emotional healing after a miscarriage may be a slow process and may take much longer than your physical healing. Miscarriage can be an immense loss that your colleagues, friends and family might not fully understand. Your emotions might run the gamut from rage and blame to utter hopelessness. Time is needed to grieve the loss of your pregnancy, together with the hopes and dreams that come with your pregnancy. Seeking help from loved ones is vital as well as from professionals, especially if you are experiencing profound sadness or hopelessness.

Miscarriage is usually a one-time occurrence and will follow with a healthy pregnancy. Statistics tell us that less than five percent of women have two consecutive miscarriages, and only one percent have three or more consecutive miscarriages.

If you experience multiple miscarriages, typically greater than three in a row, you should consider scheduling an in-depth consultation and an intense prenatal workup with your health care team. This includes being tested to identify a possible underlying cause such as uterine abnormalities, coagulation problems or chromosomal abnormalities. Your health care team may encourage this testing after two losses. Following testing, if the reason for your miscarriage cannot be discovered, please don’t despair as approximately 60 to 70 percent of women with unexplained repeated miscarriages do go on to have healthy pregnancies. You may want to consider in vitro fertilization, embryo transfer, or artificial insemination to achieve a successful pregnancy if you have a history of unexplained miscarriages.

Following a miscarriage, you should discuss getting pregnant again with your health care team, and seek guidance about the right time to conceive. Being physically and emotionally prepared is vital while waiting for conception to occur and that includes maintaining a healthy diet. Saying no to caffeine, alcohol and tobacco, which are known to raise the risk of miscarriage, is paramount. Indulge in calcium-rich foods, low-fat dairy products, almonds, beans, and nutritious green vegetable such as kale and spinach. Organic free-range protein sources are essential such as eggs and poultry. Olive oil is also a wonderful healthy option. Together diet and exercise will benefit you in maintaining a normal weight.

A daily dose of folic acid is recommended and can be found in a prenatal supplement. Low levels of folic acid have been associated with miscarriage. If you have been diagnosed as a high-risk pregnancy, bed rest may be advised. A low-stress lifestyle is always beneficial.

Although there have been no studies showing that homeopathy prevents miscarriage, the literature on homeopathy does report women who have had successful pregnancies after miscarriage when being treated with this type of alternative medicine.

Did you know that after a miscarriage it is possible to become pregnant during the first menstrual cycle? If a pregnancy occurs immediately following your miscarriage, your health care team should be notified. They may also advise bed rest and progesterone if there is a history of previous miscarriages, along with the close monitoring of any chronic medical condition in safeguarding your pregnancy.

For the most part, there is nothing you can do to prevent a miscarriage. What you can do is work closely with your health care team and be extremely prudent and watchful for known pregnancy risks. With regular prenatal care, good-quality sleep, abstinence from contact sports, and implementing the pregnancy strategies mentioned above, you can reassure yourself that you are taking the best care of both yourself and your developing baby.

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Movement Counting

Since prenatal appointments are not on a daily basis, it is up to you to pay close attention each day to your baby’s movements. By simply counting your baby’s movements, this non-invasive, easy, and free method allows you to get to know your baby’s movements patterns and will alert you to the possibility of a potential problem.

We believe in tracking your baby’s movements and not relying on hand-held monitors, Dopplers or phone apps to check your baby’s heartbeat.

Movement Counting Directions: You can count your movements at any point during the day. Ideally, we recommend first thing in the morning, once in the afternoon, and once in the evening before bed.

Whenever you want to count your baby’s movements, lie on your left side if possible and count every kick, punch, roll, twist, twirl, jab and swoosh – but not hiccups. You should be able to get 10 movements in one hour or less. Then, jot down the number. This information will be important for you and your health care team.

You may wonder, “How will I know if something isn’t right?” You are looking for anything different or out of the ordinary. For example: Let’s say you always do your movement counts at 7am, immediately following breakfast, and it usually takes about 5 minutes to count your 10 movements. If one morning, at the same time, it suddenly took you 45 minutes to get 10 movements, that would be considered out of the ordinary. You might want to wait a little and do another movement counting session just to be sure. But if you are truly concerned, call your health care team.

Another example: You may count 4 or 5 movements in an hour instead of the usual 10 movements. Count your movements again. If, for any reason, you are still not able to obtain the usual 10 movements in your normal amount of time, you detect an unusual amount of activity level for your baby (an increase or decrease in fetal movement), or you notice any sudden changes in movement, call your health care team to make sure your baby is well. If you are unable to contact or visit your health care team, go to Labor and Delivery (L&D) as most L&D units will see you immediately for Decreased Fetal Movements (DFM), or go to the nearest Emergency Room (ER).

Don’t ever hesitate to call your health care team about any questions or concerns you may have or comments you don’t understand. They are there to educate and inform you. That’s their job! You know your baby best, so always trust your instincts.

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Nuchal Cords

Through scientific research, we know that umbilical cord abnormalities are seen in one-third of all live births. Cerebral palsy and quadriplegic cerebral palsy are a direct result of such umbilical cord abnormalities.

There are two types of nuchal cords, A & B. Type A encircles the neck in an unlocked pattern. Type B encircles the neck in a locked pattern, and this second type is responsible for 1 in 50 stillbirths according to Dr. Collins.

Nuchal cords are extremely common and most babies can wriggle their way out of them prior to settling into the head down position. Still, all nuchal cords have the potential to be extremely problematic. Dr. Collins also stresses that the problem may not be where the cord is or how it may be tangled but how much “slack” (defined as not tight or stretched taut, but hanging loosely or having a good deal of give) the baby has in the cord. For instance, in a tight cord with little slack, blood flow may be compromised through the cord. In this case, a nuchal cord can become a serious condition. The amount of cord slack can be assessed during Cord Doppler tests. A baby can have a nuchal cord during the entire pregnancy, up until delivery, but the cord needs to remain slack. The most important aspect of dealing with any type of umbilical cord concern is to be aware of its presence, so if the baby starts having changes in patterns of movement and heart decelerations when monitored, you may know now that a cord issue may be the cause.

If your baby does not wriggle out of his or her nuchal cord and it remains, discuss with your health care team the need for closer monitoring solutions such as frequent office visits, ultrasounds (ultrasounds are the only way your baby’s umbilical cord can be seen in utero), BPP, NST, Cord Doppler tests to show blood flow, very diligent movement counting and daily home fetal heart rate monitoring.

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Nuchal Translucency Screening (NST)

Ask your health care team if a Nuchal Translucency Screening (NTS) should be performed, as this test is not routinely performed in many states. This screening consists of a blood test and an ultrasound. Administered between Weeks 11-13, this screening for chromosomal abnormalities gives families important information on potential outcomes as early as possible. First trimester screening results can be combined with second trimester screen results to detect Down syndrome and Trisomy 18. This testing provides an estimate of risk only. A positive result, which indicates an increased risk, does not mean your baby has a problem.

During this screening, an ultrasound will measure the fluid accumulation behind the neck of the baby, called the nuchal translucency (NT). Extra fluid, (an increased NT) can be a sign of Down syndrome, Trisomy 18 or Trisomy 13.

Increased nuchal translucency has also been associated with other fetal anomalies such as cardiac defects. A second trimester fetal anatomy ultrasound and echocardiogram are recommended if the NT is increased.

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Preeclampsia

One condition to watch for is Preeclampsia which affects about five percent of pregnant women. Preeclampsia has risen by twenty-five percent over the last twenty years and is a major source of maternal and infant illness and death. Preeclampsia may occur during the last half of pregnancy and also during the postpartum period. This condition affects thousands of women and babies every year and is typically hallmarked by an increase in blood pressure. Although additional protein may be present in the urine (proteinuria), it is no longer a criterion for diagnosing preeclampsia, as many women do not have significant levels of protein present in their urine, which ultimately can delay diagnosis and treatment. Once you reach Week 20, your health care team will be evaluating you at every visit to make sure you are symptom free and not exhibiting any signs of preeclampsia.

One early warning sign of preeclampsia may be a minimal increase in blood pressure. Symptoms may include, but are not limited to, rapid weight gain, edema, with swelling in the face, hands and feet, nausea, vomiting, headache, visual disturbances, low back pain and abdominal or shoulder pain.

A woman may be at risk for developing preeclampsia if she has chronic hypertension, a previous pregnancy with a diagnosis of preeclampsia, is aged 35 or beyond, pregnant with multiples, has kidney disease or diabetes, is obese, African American, or has an immune disorder.

If this is your first pregnancy, the symptoms of nausea, vomiting and lower backache may be present. How do you distinguish these symptoms from the onset of preeclampsia? Every pregnant mom should call her health care team if she experiences any of these symptoms for the first time.

If left untreated, preeclampsia can be dangerous and even fatal for both you and your baby. If you develop blurred vision, severe abdominal pain or severe headaches, call you health care team immediately.

According to the Preeclampsia Foundation:

“When we urge women to trust themselves, we are referring to the intuitive feeling that preeclamptic women often have that “something is not right.” While these feelings may be nothing, it is important for women to report any concerns and for care providers to be diligent, particularly if accompanied by other signs or symptoms.”

For further information regarding the signs, symptoms, care and treatment of preeclampsia and HELLP Syndrome, a life-threatening situation which is considered a variant of preeclampsia, please visit the Preeclampsia Foundation and the Mayo Clinic.

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Pre-pregnancy Caffeine

A study conducted by the NIH and Ohio State University recently published in the journal Fertility and Sterility found a worrisome link between caffeine consumption and miscarriage. Quite simply, the data proves that couples who drank more than two caffeinated drinks a day during the weeks prior to conception had a greater risk that the woman would miscarry.

That’s correct — the research found that both Mom’s caffeine and Dad’s caffeine consumption could play a role in miscarriage! This study also confirms previous research showing that women who drink more than two caffeinated beverages each day during the first seven weeks of pregnancy are also more likely to miscarry. On the bright side, this study did show that women who took a daily multivitamin before and after conception appeared to greatly reduce miscarriage risk!

Preterm Labor

Ask your health care team to explain the signs and signals of preterm labor. Always inform your health care team of any contractions that you experience.

“What is preterm labor, when does it begin and how will you know if you are having it?” Preterm labor occurs before your 37th gestational week. You are probably familiar with Braxton-Hicks Contractions which are erratic, feeble contractions varying in duration and strength and usually end when you relax, drink water, change your level of activity or alter your position. Braxton-Hicks contractions are considered “false” labor contractions.

You will need to be concerned about contractions which are different from Braxton-Hicks. A few indications that you may be experiencing preterm labor are contractions occurring at recurring intervals that are regular, contractions that may or may not become stronger, contractions including low backache, spasms, twinges or any other discomfort and contractions altering your vaginal secretions, for example, bleeding or spotting or water being emitted or oozing from your vagina.

According to the Mayo Clinic:

“While some uterine activity before 37 weeks of pregnancy is normal, contact your health care provider if you have four contractions every 20 minutes or eight contractions in an hour…If you’re concerned about what you’re feeling — especially if you have vaginal bleeding accompanied by abdominal cramps or pain — contact your health care provider right away. Don’t worry about mistaking false labor for the real thing. Everyone will be pleased if it’s a false alarm.”

If you experience any of these symptoms, call your health care team and go to Labor and Delivery (L&D) for further evaluation. For further information on the signs, symptoms and management of preterm labor please visit the Mayo Clinic or the March of Dimes.

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Quad Marker Screen

The Quad Marker Screen is a blood test that is performed between Weeks 15-20 of your pregnancy. This screen determines if you are at a higher or lower risk of carrying a baby with a birth defect such as Down syndrome, Open Neural Tube Defects (NTDs) including spina bifida, or Trisomy 18. This test predicts the likelihood of several potential problems with your baby and/or carrying your baby; it does not diagnose the problem.

The Quad Marker Screen measures multiple biochemical markers in the mother’s blood that are produced by the fetus and placenta during the early second trimester. A positive screen does not provide a diagnosis, but indicates the increased risk and the need for further evaluation. It is followed by an ultrasound, which may be your Week 20 ultrasound. Speak with your health care team to decide if you should consider having the Quad Marker Screen performed.

Sleep Position and Sleep

Why not begin sleeping on your left side now? According to BabyCenter Sleep Expert, Donna Arand, Ph.D., Clinical Director of the Kettering Sleep Disorders Center and Associate Research Professor in neurology at the Boonshoft School of Medicine at Wright State University explains:

  • “Sleeping on your side is best while you’re pregnant. In particular, sleeping on your left side may benefit your baby by improving blood flow – and therefore nutrients – to the placenta. It also helps your which in turn reduces swelling in your ankles, feet, and hands.
  • It’s a good idea to start training yourself early in pregnancy to sleep on your left side whenever you can. Of course, staying in one position all night isn’t likely to be comfortable, so turning from side to side while favoring your left side is probably the best strategy.
  • As for sleeping on your back, avoid that position throughout pregnancy, especially in the later months. Here’s why:
  • When you’re sleeping on your back, the weight of your uterus lies on the spine, back muscles, intestines, and major blood vessels. This can lead to muscle aches and pains, hemorrhoids, and impaired circulation, which is uncomfortable for you and can reduce circulation to your baby.
  • Back sleeping can make blood pressure drop, causing some expectant moms to experience dizziness. On the other hand, in some moms-to-be it can make blood pressure go up.
  • Finally, back sleeping can cause snoring and, with increased weight, could lead to sleep apnea.”

Did you know some pregnant women prefer an air bed for comfort? Air beds provide an adjustable technology creating a desired firmness or softness that accommodates a mom’s changing weight, dimensions and comfort levels. For more information on pregnancy and sleep, please visit BabyCenter and the National Sleep Foundation.

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Stillbirth

In the United States Stillbirth refers to the loss of a baby of twenty or more weeks gestation. Stillbirth is not a cause of death but rather a term indicating a baby has died in utero. The universal definition of when a loss is a stillbirth varies internationally making it difficult to gather and compare data and ultimately determine how frequently stillbirth occurs.

A stillbirth is the death of a baby before or during delivery. Approximately, one out of 160 pregnancies tragically end in stillbirth in the USA. Although the cause of many stillbirths is unknown, many are attributed to any of the following: birth defects and genetic problems, complications with the placenta or the umbilical cord, or possibly maternal diabetes, high blood pressure or obesity.

According to the CDC, a stillbirth is additionally categorized as either early, late, or term:

  • An early stillbirth is a fetal death occurring between 20 and 27 completed pregnancy weeks.
  • A late stillbirth occurs between 28 and 36 completed pregnancy weeks.
  • A term stillbirth occurs between 37 or more completed pregnancy weeks.

No race, income level, age group or ethnicity is immune to stillbirth. However, there are risk factors that may increase the likelihood of stillbirth. There is a higher incidence of stillbirth if you are of the black race, 35 years or older, overweight, a smoker, have endured an earlier loss, or have a medical condition such as diabetes or high blood pressure. These issues may put an expectant mother at risk for stillbirth or preterm birth.

A gradual decrease in fetal movement was noticed by fifty percent of mothers a few days prior to the death of their babies. A recent study in Norway noted a thirty percent reduction in stillbirth when pregnant women were encouraged to track fetal movement by their healthcare provider, and were told to immediately seek medical attention when they noticed any decline in their baby’s movements.

If you have had a previous stillbirth, your next pregnancy will be considered a High Risk pregnancy by your health care team and you will be referred to a Maternal Fetal Specialist for exceptional care. This necessary attention will be given to all aspects of your pregnancy. It may include more frequent medical visits, additional ultrasounds or specialized testing, and increased monitoring to be sure you and your baby are both doing well. If your health care team does not consider your subsequent pregnancy to be a high risk pregnancy, you should discuss your concerns with them including the option of transferring your care to another health care team.

Beginning at Week 20 every mom is encouraged to begin keeping a journal tracking her baby’s movements. Getting to know your baby’s movements and taking note of when your baby is stirring or slumbering is fundamental. Daily journaling will enable you to become familiar with the movements of your little one so your baby’s daily routine will become second nature to you. Knowing your baby’s patterns of movement will enable you move easily into Kick Counting, which will begin around Week 28.

PAK encourages all pregnant moms to use our Mom & Baby Tracking Chart from Week 13 onwards. If for any reason you detect an unusual level of activity for your baby (an increase or decrease in fetal movement), you notice any sudden changes in movement, or once movement counting has commenced you are unable to obtain the usual 10 movements in your normal amount of time, call and visit your health care team to make sure that your baby is well. If you are unable to contact or visit your health care team, go to Labor and Delivery (L&D) as most L&D units will see you immediately for Decreased Fetal Movements (DFM), or go to the nearest Emergency Room (ER).

Discuss any changes to your Mom & Baby Tracking Chart with your health care team and don’t ever hesitate to call them about any questions or concerns that you may have, or comments that they may have made to you that you don’t understand. Your team is there to educate and inform you, that’s their job! You know your baby best, so always trust your instincts.

For more information on stillbirth and movement counting please visit the CDC,  babyMed, PAK’s Third Trimester, Week 28 and PAK’s Operation Due Date Mom & Baby Tracking Charts on our website.

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Stripping Membranes

Dr. McGregor advises that pregnant women avoid unnecessary, frequent or forceful cervical exams that may push bacteria closer to your baby; both vaginal or perineal ultrasounds in place of cervical exams are less invasive.

It is important that you discuss the benefits and risks of possible methods of induction with your health care team well before your due date. You may not be asked before “stripping” or “sweeping” of your membranes is performed.

Stripping or sweeping of your amniotic membranes is a technique performed by your health care team to try to jump start labor. During a regular office pelvic exam, the practitioner inserts a finger into the cervix (the mouth of the uterus) separating the amniotic fluid sac from the side of the uterus near the cervix. Hormones are then released which may soften the cervix preparing the uterus to contract. This approach will not put you into labor right away and may not put you into labor at all but it may start contractions and help the cervix open.

If you have tested positive for GBS tell your health care team not to strip your membranes. Be aware that although you may have tested negative for GBS initially in your pregnancy, you may test positive before your due date. GBS can cross membranes that are intact so stripping membranes or using cervical ripening gel to induce labor may push bacteria closer to your baby.

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Tocophobia

Some form of anxiety is normal for pregnancy, a time of high emotions, excitement, as well as nervousness. But did you know some women are absolutely terrified of pregnancy and anything related to it? Tocophobia, from the Greek tokos, meaning childbirth and phobos, meaning fear, is a pathological dread of pregnancy. Primary tocophobia affects roughly 13 percent of women who have never been pregnant. Though these women are desperate to have a baby, many will postpone or totally avoid pregnancy due to this pathological and irrational fear. Some will even terminate a pregnancy. Secondary tocophobia may be seen in women who have experienced a traumatic obstetric event, a termination of pregnancy, miscarriage, stillbirth, a normal healthy delivery (and for some very distressing reason, she will not consider having another baby) or a depressive illness in pregnancy.

If you believe your fears of pregnancy are irrational, speak openly with your family doctor or health care team. Management of this condition is available through appropriate childbirth education, psychological counseling and support. As with any phobia, it can be treated. For more information on tocophobia, please contact your health care team.

Vaccinations Before Pregnancy

The best time to receive vaccinations is before you become pregnant according to the U.S. Department of Health and Human Services (DHHS) so discuss this possibility with your health care team if this pertains to you. Vaccinations will help safeguard your body from infection and this protection passes to your baby during pregnancy. You are encouraged to have a preconception exam to make sure you are up to date with your “adult” vaccines; bring a copy of your vaccination record with you. If you don’t have this record, a simple blood test will let your health care team know what vaccinations you need. If you aren’t current, ask your doctor for the requisite vaccines. Women are generally advised to wait one month following any vaccinations to become pregnant. Your health care team may or may not advocate vaccinations during pregnancy.

According to the Centers for Disease Control (CDC), the “risk to a developing fetus from vaccination of the mother during pregnancy is theoretical. No evidence exists of risk to the fetus from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Live vaccines administered to a pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and live bacterial vaccines generally are contraindicated during pregnancy.”

There are a few vaccines that are usually recommended before pregnancy. You may be familiar with three of the most common ones. The first is Influenza IIV (Inactivated). “Inactivated” means the vaccine does not contain a “live” virus. Vaccinations containing “live” viruses are contraindicated and not given to pregnant women per the CDC. The second recommended vaccine is Tdap (tetanus, diphtheria and pertussis). This vaccine is not only recommended for you, but also relatives, close friends and caregivers who will spend time with your baby. The third is MMR (measles, mumps and rubella). Measles contracted during pregnancy may be dangerous to pregnant women and result in miscarriage.

Several vaccinations are given “if indicated” before or after pregnancy. One reason a vaccine may be indicated is because you have the potential for exposure to an infection. For example, your health care team may suggest you be vaccinated for rabies if you are a technician working in a veterinarian’s office and may possibly come in contact with a rabid animal. Another reason a vaccine may be indicated is that you have a medical condition that increases your risk for contracting an infection. One example is that you may have had your spleen removed (splenectomy). Your spleen helps your body fight infections so your health care team may recommend that you receive the Pneumococcal vaccine to prevent pneumonia. Some other vaccinations which may be given “if indicated” before or after pregnancy are Hepatitis A, Hepatitis B, Meningococcal Polysaccharide/Conjugate, HPV (human papillomanvirus), Varicella (chicken pox) and Tetanus/Diphtheria (TD). Tdap is the preferred vaccination of choice over TD as it also contains pertussis (whooping cough).

The CDC states that if you are pregnant and not up to date on your flu vaccine, you may be at a higher risk for developing flu and flu-related complications. They recommend that all women who are or will be pregnant during the influenza season be vaccinated with the Influenza (Inactivated) vaccine.

The National Institute of Health (NIH) acknowledges the concern among pregnant women receiving Influenza (Inactivated) in a “multi-dose” form as it contains a small amount of mercury (thimerosal), a preservative. Although this vaccine has not been shown to cause attention deficit hyperactivity disorder or autism, the fear among expecting moms still exists. Routine vaccinations are available without the preservative thimerosal added. It is important that all pregnant women know that they may request their vaccination be free of this preservative if they so wish.

Every woman must thoroughly research any medication or vaccination recommended to her during pregnancy. Any concerns or the possible side effects of any medication or vaccination should be discussed with her health care team. Please refer to the March of Dimes and the CDC for more information on vaccinations before, during and after pregnancy, Guidelines for Vaccinating Pregnant Women, and breastfeeding and vaccinations.

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Vaccinations During Pregnancy

If you are not current with your vaccinations, you have discussed being vaccinated with your health care team and you would like to be vaccinated, Dr. McGregor advocates being immunized around Week 28 for Influenza (Inactivated) and Tdap (Tetanus, Diphtheria and Pertussis). The Tdap vaccination is also recommended for relatives, friends and caregivers who will spend time with your baby.

Week 40 & Still Pregnant

If your baby has not arrived on time, please don’t be surprised or upset. Many moms have babies past Week 40; this is a crucial time during pregnancy as the amniotic fluid surrounding your baby is beginning to decrease and the placental function needed to sustain your baby’s life may be beginning to slow. You will need to discuss with your health care team the probability of when to expect your baby’s arrival or the possibility of planning your baby’s delivery day.

Ask, specifically, how long beyond your expected due date you will be allowed to wait if labor does not begin spontaneously? What additional monitoring will be implemented? Will special tests such as NSTs’ be performed on a daily basis? Will you have weekly or more frequent BPPs’? Is an induction necessary and if so, when? What exactly is involved in an induction? What about scheduling a C-Section? What is your health care team’s overall plan? What is their protocol?

Sometimes the birth plan doesn’t go exactly as planned or even desired. If your plan becomes altered, you should be educated and familiar with your options ahead of time. This will help ensure that you are comfortable making the very best decisions for you and your baby with your team.

A healthy outcome for you and your baby is paramount after the 40-week gestational marker has elapsed. Pay extremely close attention to any changes in your or your baby’s health; this is key. Contact your health care team at any time with any questions or concerns you have until your baby is safely in your arms. Don’t forget to do your movement counting three times a day!

A proactive, vigilant mom will feel empowered to ask the simple, yet important questions that can make a difference in her baby’s health. Operation Due Date empowers expectant moms by educating them about healthy pregnancies, fostering an awareness of their babies daily fetal moments, and the actions they can take to help ensure that their babies come into the world safe and healthy.

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Your Baby’s Movements And Heart Rate

Your baby’s movements and heart rate will basically stay the same during the last trimester of your pregnancy. All moms need to continue being their baby’s guardian up until delivery day. Make sure you continue with movement counting ideally three times a day. Remember, a change in your baby’s movements such as speeding up or slowing down, or changes in sleep-wake cycles could be the sign that your baby is not well. Call your doctor, midwife, or health care team with any questions or concerns. If you are unable to reach them go to L&D or the nearest ER to check on your baby. Always trust your instincts.

Your Baby’s 20-Week Ultrasound

This amazing week will be one of your baby’s most important. After completing your 20-week ultrasound, you will be equipped with vital information. This ultrasound closely examines both your baby’s anatomy and the environment within the uterus.

All of your baby’s structures will be studied, focusing on your baby’s organs and skeletal system. Congenital Cardiac Heart Disease (CCHD) is the most common congenital disorder in newborns. During this ultrasound, nearly half of the babies with CCHD will be diagnosed. Once your baby’s is delivered, make sure you request a simple 5 minute pulse oximetry test to ensure that your baby’s heart is beating flawlessly and oxygenating maximally with no signs of CCHD. The latest research advises waiting for this screening until your baby is 24 hours old or waiting until as close to discharge as possible. Your baby’s right hand or right foot is used during this screening. For further information on CCHD, please go to The National Institute of Health and Wolters Kluwer Health, UpToDate®, a clinical decision support system.

The umbilical cord and placenta should be carefully assessed for normal development and position, according to Dr. Collins, and EPV rechecked. Dr. Collins encourages every mom to begin a journal at this time blueprinting her baby’s movements. Get to know your baby and start taking the time to jot down when your baby is stirring or slumbering. Daily journaling will enable you to become familiar with the movements of your little one so your baby’s daily routine will become second nature to you. Knowing your baby’s patterns of movement will enable you move easily into Movment Counting, which will begin around Week 28.

The amniotic fluid volume is evaluated as part of your antepartum fetal surveillance and the sex of your baby is determined at this time. Remember, have fun counting your baby’s ten fingers and ten toes!

Discuss all the results of your ultrasound thoroughly with your health care team, addressing any findings or questions you may have. If there is a concern with any aspect of your 20-week ultrasound, they will schedule a more advanced ultrasound and further testing.

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Your Baby’s 28-Week Ultrasound

Request an ultrasound around this time to examine the umbilical cord and placenta for normal development and position. If your ultrasound is not covered by your insurance, use your Pregnancy PUR$E to help fund this test.

According to Dr. Collins, who has been researching Umbilical Cord Accidents (UCA) for over 25 years, it is typically during Weeks 28–30 when a problem could arise with your baby’s umbilical cord. He also believes an ultrasound at this time could detect a potential problem, making it a useful tool. The umbilical cord is a definite risk factor during the later part of your pregnancy and could compromise your baby.

Both Drs. Kliman and Uma Reddy, MD, MPH, Medical Officer Pregnancy & Perinatology Branch, Eunice Schriver National Institute of Child and Human Development, concur that UCAs, including nuchal cords, true knots, twists, torsion, kinks and long or short cords, account for 16 percent of the 26,000 yearly deaths in utero in the USA. That is at least 71 untimely deaths each and every day in our country. Dr. Collins states a UCA is not a rare condition or event and should be watched for especially in the last trimester of pregnancy.

After your ultrasound

If a problem is seen on your baby’s ultrasound with the umbilical cord or placenta, a plan of action needs to be decided upon with your health care team. Examples of close monitoring include repeat office visits, ultrasounds, Fetal Non-Stress Tests (NST), Biophysical Profiles (BPP), Cord (blood flow) Doppler tests, very diligent movement counting and daily home fetal heart rate monitoring offered by companies such as Genesis Obstetrical Home Health Care Services.

If you and your health care team determines your baby should have further monitoring following your 28-week ultrasound, or you are considered high risk, don’t panic! It is comforting and reassuring to know your baby is healthy and stable thanks to the frequent monitoring. The four main reasons for monitoring your baby are to ensure that your baby is comfortable in utero, to ensure that your baby’s heart rate is normal and steady with no significant decelerations (decels) present, the placenta is working efficiently and not appearing to be aged, and to ensure that there are no signs of preterm or premature labor present.

“Most women who notice a decrease in movement will still have a healthy outcome,” says Obstetrician-Gynecologist Ruth Fretts, M.D., MPH, Assistant Professor at Harvard Medical School and Chair of the Stillbirth Review Committee at the Brigham and Women’s Hospital in Boston. “The biggest concern is when it happens repeatedly.” Dr. Fretts reminds every mom that as her pregnancy advances and her expected baby has less space, the kicks won’t be as strong and obvious. But if it takes you more than two hours to count 10 movements, your health care team should be called. She says a Fetal Non-Stress Test (NST) is necessary to confirm your baby’s heart rate, “This rules out a life-threatening emergency, but it doesn’t address the underlying reason for decreased movement.”

Dr. Fretts says an ultrasound may add additional clarification.

Unfortunately in the United States ultrasounds will be performed only about 20% of the time in these situations, so mom will need to assert her proactive skillfulness requesting one is done. With a normal NST, movement counting should be completed and kept track of every day. Mom should never hesitate to be evaluated every time a problem is perceived.

If the thought of counting and charting your baby’s movements makes you nervous, remember that movement counting is the safest and easiest course of action that every mom can take to monitor her baby’s movements on a daily basis. This simple concept is also free and non-invasive. Studies inform us that being attentive to your baby’s movements and informing your health care team of any changes such as speeding up or slowing down, or changes in sleep-wake cycles will decrease the likelihood of having a stillbirth. Ask your health care team for the signs that your baby may not well and their protocol for such signs.

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Your Baby’s 36-Week Ultrasound

Request an additional ultrasound now to examine the umbilical cord and placenta for normal development and position. If your ultrasound is not covered by your insurance, use your Pregnancy PUR$E to help fund this test.

Dr. Collins believes an ultrasound at this time could detect a potential problem, making it a useful proactive pregnancy tool. The umbilical cord is a definite risk factor during the later part of your pregnancy and could compromise your baby. As mentioned in Week 28, UCAs, including nuchal cords, true knots, twists, torsion, kinks and long or short cords, account for 16 percent of the 26,000 yearly deaths in utero in the USA. That is at least 71 untimely deaths each and every day in our country. Dr. Collins states a UCA is not a “rare condition or event” and should be watched for especially in the last trimester of pregnancy.

After your ultrasound

If a problem is seen on your baby’s ultrasound with the umbilical cord or placenta, a plan of action needs to be decided upon with your health care team. Examples of close monitoring include repeat office visits, ultrasounds, Fetal Non-Stress Tests (NST), Biophysical Profiles (BPP), Cord (blood flow) Doppler tests, very diligent movement counting and daily home fetal heart rate monitoring offered by companies such as Genesis Obstetrical Home Health Care Services.

If you and your health care team determine your baby should have further monitoring following your 36-week ultrasound, or you are considered high risk, don’t panic! Remember, it is comforting and reassuring to know your baby is healthy and stable thanks to the frequent monitoring. The four main reasons for monitoring your baby are to ensure that your baby is comfortable in utero, to ensure that your baby’s heart rate is normal and steady with no significant decelerations (decels) present, the placenta is working efficiently and not appearing to be aged, and to ensure that there are no signs of preterm or premature labor present. And continue movement counting ideally three times a day until your baby arrives.

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Zika Virus

All women considering becoming pregnant must be aware of the Zika Virus. Current research on Zika is in its infancy globally. There is a correlation with pregnant women infected with Zika and microcephaly; babies born with abnormally small heads.

How does it spread?

It is spread by Aedes mosquitoes. They are found throughout the Americas except for Canada and Chile where it is too cold for them to survive. The World Health Organization (WHO) expects Zika to spread throughout the Americas, but other scientists have warned that countries in Asia could face large outbreaks too.

The CDC updated its Zika virus guidance for pregnant women, advising them to protect themselves if their male sexual partner has traveled to or lives in an area where Zika virus is circulating as sexual transmission has been confirmed.

What are the symptoms?

Deaths are rare and only one in five people infected is thought to develop symptoms. These include:

  • Mild fever
  • Conjunctivitis (red, sore eyes)
  • Headache
  • Joint pain
  • A rash

What is microcephaly?

The link between Zika virus, pregnancy and microcephaly has been confirmed. Microcephaly is when a baby is born with an abnormally small head, as their brain has not developed properly in utero. The severity varies, but it can be deadly if the brain is so underdeveloped that it cannot regulate the functions vital to life. Children that do survive face intellectual disability and developmental delays.

What can people do?

As there is no treatment, the only option is to reduce the risk of being bitten. Health officials advise people to: 

  • Use insect repellents.
  • Cover up with long-sleeved clothes.
  • Keep windows and doors closed.

The mosquitoes lay their eggs in standing water, so people are also being told to empty buckets and flower pots. The US Centers for Disease Control (CDC) has advised pregnant women not to travel to affected areas including Latin America and the Caribbean.

What is being done?

WHO Director General Dr. Margaret Chan states that the priorities are to protect pregnant women and their babies from harm and to control the mosquitoes that are spreading the virus. Dr. Chan reaffirms that pregnant women should not travel to countries affected by Zika and to seek advice from their doctors if they are living in areas affected by Zika as well as protect themselves against mosquito bites by wearing repellent.

Currently, there is a concerted global effort to develop a vaccine for the Zika virus that will protect the general population against its adverse effects.

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