HEALTH EDUCATION:

Good pre-pregnancy nutrition not only helps prevent anemia, but also helps build other nutritional stores in the mother's
body. Eating a healthy and balanced diet before and during pregnancy helps keep up your levels of iron and other
important nutrients needed for your health and that of your growing baby.
Good food sources of iron include the following:

Meats. Beef, pork, lamb, liver, and other organ meats.

Poultry. Chicken, duck, turkey, liver (especially dark meat).

Fish. Shellfish, including (fully-cooked) clams, mussels, and oysters are good. So are sardines and anchovies. The
FDA recommends that pregnant women eat 8 to 12 ounces per week of fish that are lower in mercury. These
include salmon, shrimp, pollock, cod, tilapia, and catfish. Don't eat the following fish because they are highest in
mercury: tilefish from the Gulf of Mexico, shark, swordfish, and king mackerel. Limit white (albacore) tuna to
only 6 ounces per week.

Leafy greens of the cabbage family. These include broccoli, kale, turnip greens, and collards.

Legumes. Lima beans and green peas; dry beans and peas, such as pinto beans, black-eyed peas, and canned
baked beans.

Yeast-leavened whole-wheat bread and rolls

Iron-enriched white bread, pasta, rice, and cereals

Vitamin supplements containing at least 400 micrograms of folic acid are recommended for all women of childbearing age
and during pregnancy. Food sources of folate include the following:

Leafy, dark green vegetables

Dried beans and peas

Citrus fruits and juices and most berries

Fortified breakfast cereals

Enriched grain products

Management of FGR depends on the severity of growth restriction, and how early the problem began in the pregnancy.
Generally, the earlier and more severe the growth restriction, the greater the risks to the fetus. Careful monitoring of a
fetus with FGR and ongoing testing may be needed.
Treatments may include:

Nutrition. Some studies have shown that increasing maternal nutrition may increase gestational weight gain and
fetal growth.

Bedrest. Bedrest in the hospital or at home may help improve circulation to the fetus.

Delivery. If FGR endangers the health of the fetus, then an early delivery may be needed.

Fetal growth restriction may occur, even when the mother is in good health. However, some factors may increase the risks
of FGR, such as cigarette smoking and poor maternal nutrition. Avoiding harmful lifestyles, eating a healthy diet, and
getting prenatal care may help decrease the risks for FGR. Early detection may also help with FGR treatment and
outcome.
Treatment for preterm labor may include:

Bedrest (either at home or in the hospital may be recommended)

Hospitalization (as specialized personnel and equipment may be necessary)

Tocolytic medications--medications to help slow or stop contractions. These may be given in an injection under
the skin or intravenously (IV). Tocolytic medications often used include indomethacin or nifedipine.

Corticosteroid medications--medications that may help mature the lungs of the fetus. Lung immaturity is a major
problem of premature babies.

Cervical cerclage--a procedure used to suture the cervical opening. Cerclage is used for women with an
incompetent cervix. This is a condition in which the cervix is physically weak and unable to stay closed during
pregnancy.

Antibiotics (to treat infection)

Delivery--if treatments do not stop preterm labor or if the fetus or mother is in danger, delivery of the baby may
occur. Cesarean delivery may be recommended in certain cases

Because of the tremendous advances in the care of sick and premature babies, more and more babies are surviving despite
being born early and being very small. However, prevention of early birth is the best way of promoting good health for
babies.
Prenatal care is a key factor in preventing preterm births and low birthweight babies. At prenatal visits, the health of both
mother and fetus can be checked. Because maternal nutrition and weight gain are linked with fetal weight gain and
birthweight, eating a healthy diet and gaining weight in pregnancy are essential. Prenatal care is also important in
identifying problems and lifestyles that can increase the risks for preterm labor and birth. Some ways to help prevent
prematurity and to provide the best care for premature babies may include the following:

Identifying mothers at risk for preterm labor

Prenatal education of the symptoms of preterm labor

Avoiding heavy or repetitive work or standing for long periods of time which may increase the risk of preterm
labor

Early identification and treatment of preterm labor

Some women at high risk for preterm birth may be candidates for treatment with the hormone progesterone. This hormone
and its derivative, 17-alpha hydroxyprogesterone, are naturally produced by the placenta during pregnancy. Recent studies
have shown that progesterone supplements help reduce the risk for preterm birth in women who had a previous
spontaneous preterm birth. More research is needed for this and other ways to help reduce the incidence of prematurity.
Treatment for preterm premature rupture of membranes may include:

Hospitalization

Expectant management (in very few cases of PPROM, the membranes may seal over and the fluid may stop
leaking without treatment, although this is uncommon unless PROM was from a procedure, such as
amniocentesis, early in gestation)

Monitoring for signs of infection, such as fever, pain, increased fetal heart rate, and/or lab tests.

Giving the mother medications called corticosteroids that may help mature the lungs of the fetus (lung immaturity
is a major problem of premature babies). However, corticosteroids may mask an infection in the uterus.

Antibiotics (to prevent or treat infections) and to prolong the time to delivery

Tocolytics. Medications used to stop preterm labor.

Women with PPROM usually are induced to deliver at 34 weeks if stable. If there are signs of abruption,
chorioamnionitis, or fetal compromise, then early delivery would be necessary.)

Unfortunately, there is no way to actively prevent PROM. However, this condition does have a strong link with cigarette
smoking and mothers should stop smoking as soon as possible.
The following are the most common symptoms of high blood pressure in pregnancy:

Increased blood pressure

Absence or presence of protein in the urine (to diagnose gestational hypertension or preeclampsia)

Edema (swelling)

Sudden weight gain

Visual changes such as blurred or double vision

Nausea, vomiting

Right-sided upper abdominal pain or pain around the stomach

Urinating small amounts

Changes in liver or kidney function tests

A woman with gestational hypertension may not have any symptoms.

Diagnosis is often based on the increase in blood pressure levels, but other symptoms may help establish gestational
hypertension as the diagnosis. Tests for gestational hypertension may include the following:

Blood pressure measurement

Urine testing to rule out preeclampsia

Assessment of edema

Frequent weight measurements

Liver and kidney function tests to rule out preeclampsia

Blood clotting tests to rule out preeclampsia

The goal of treatment is to prevent the condition from becoming worse and to prevent it from causing other complications.
Treatment for gestational hypertension may include:

Bedrest, either at home or in the hospital, may be recommended

Hospitalization (as specialized personnel and equipment may be necessary)

Magnesium sulfate (or other antihypertensive medications for gestational hypertension if blood pressure readings
are in the severe range)

Fetal monitoring (to check the health of the fetus) which may include:
o

Fetal movement counting. Keeping track of fetal kicks and movements. A change in the number or
frequency may mean the fetus is under stress.

Nonstress testing. A test that measures the fetal heart rate in response to the fetus's movements.

Biophysical profile. A test that combines nonstress test with ultrasound to observe the fetus.

Doppler flow studies. A type of ultrasound that uses sound waves to measure the flow of blood through a
blood vessel.

Continued laboratory testing of urine and blood (for changes that may signal worsening of gestational
hypertension or progression to preeclampsia)

Medications, called corticosteroids, that may help to mature the lungs of the fetus if early delivery is likely (lung
immaturity is a major problem of premature babies).

Early identification of women at risk for gestational hypertension may help prevent some complications of the disease.
Education about the warning symptoms is also important because early recognition may help women receive treatment
and prevent worsening of the disease.

HELLP Syndrome HELLP syndrome is a disorder related to preeclampsia and eclampsia (high blood pressure problems
of pregnancy). The actual incidence is not known, but it appears to develop in 1 to 2 out of 1,000 pregnancies, and in 10%
to 20% of pregnant women with severe preeclampsia or eclampsia. It usually develops before delivery but may occur after
delivery as well. HELLP syndrome consists of the following problems:

Hemolysis--red blood cells break down.

Elevated liver enzymes--damage to liver cells cause changes in liver function lab tests.

Low platelets--cells found in the blood that are needed to help the blood to clot in order to control bleeding.

The cause of HELLP syndrome is unknown. Some conditions may increase the risk of developing HELLP syndrome,
including the following:

Preeclampsia or eclampsia during pregnancy

Previous pregnancy with HELLP syndrome

In addition to the risks of high blood pressure during pregnancy, which include poor blood flow to organs and possible
seizures, HELLP syndrome can cause other problems. The breakdown of red blood cells may cause anemia, and blood
clotting problems may occur.
A serious blood clotting complication called disseminated intravascular coagulation (DIC) may lead to severe bleeding.
Placental abruption (early detachment of the placenta) may also occur. HELLP syndrome can also cause rupture or
bleeding of the liver, or a blockage of blood to the liver. Another possible serious complication is pulmonary edema (fluid
buildup in the lungs). .
Severe disease may place the mother and fetus in danger and it may be necessary to deliver the baby early to prevent
further complications. Recovery from HELLP syndrome may take several days after delivery. HELLP syndrome is a
serious condition that can be life threatening for both mother and her baby.
The following are the most common symptoms of HELLP syndrome:

Right-sided upper abdominal pain or pain around the stomach

Nausea, vomiting

Headache

Increased blood pressure

Protein in the urine

Edema (swelling)

The symptoms of HELLP syndrome may look like other medical conditions, including hypertensive disorders of
pregnancy such as gestational hypertension, preeclampsia, and eclampsia. Always consult your doctor for a diagnosis.

In addition to a complete medical history and physical exam, other tests for HELLP syndrome may include:

Blood pressure measurement

Red blood cell count

Blood levels of lactate dehydrogenase (LDH)

Bilirubin level--a substance produced by the breakdown of red blood cells.

Liver function tests

Platelet count--cells found in the blood that are needed to help the blood clot to control bleeding.

Urine tests for protein

Treatment may include:

Bedrest (either at home or in the hospital may be recommended)

Blood transfusions (for severe anemia and low platelets)

Magnesium sulfate (to prevent seizures)

Antihypertensive medications (to reduce blood pressure)

Hospitalization and continuous fetal monitoring (to check the health of the fetus) may include:
o

Nonstress testing--a test that measures the fetal heart rate in response to the fetus' movements.

Biophysical profile--a test that combines nonstress test with ultrasound to observe the fetus.

Doppler flow studies--a type of ultrasound that uses sound waves to measure the flow of blood through a
blood vessel.

Lab testing of liver, urine, and blood (for changes that may signal worsening of HELLP syndrome)

Medications, called corticosteroids, that may help mature the lungs of the preterm fetus (lung immaturity is a
major problem of premature babies)

Delivery (if HELLP syndrome worsens and endangers the well-being of the mother or fetus, then an early
delivery may be necessary). Delivery is the only cure for HELLP syndrome.

Early identification of women at risk for HELLP syndrome may help prevent some complications of the disease.
Education about the warning signs is also important because early recognition may help women receive treatment and
prevent worsening of the disease.
Amniotic Fluid Problems: Hydramnios and Oligohydramnios

Amniotic fluid is an important part of pregnancy and fetal development. This watery fluid is inside a casing called the
amniotic membrane (or sac) and fluid surrounds the fetus throughout pregnancy. Normal amounts may vary, but,
generally, women carry about 500 to 1000 ml of amniotic fluid. Amniotic fluid helps protect and cushion the fetus and
plays an important role in the development of many of the fetal organs including the lungs, kidneys, and gastrointestinal
tract. Fluid is produced by the fetal lungs and kidneys. It is taken up with fetal swallowing and sent across the placenta to
the mother's circulation. Too much or too little amniotic fluid is linked to problems in development and pregnancy
complications. Differences in the amount of fluid may be the cause or the result of the problem.
Hydramnios is a condition in which there is too much amniotic fluid around the fetus. It occurs in about 1% of all
pregnancies. It is also called polyhydramnios.
There are several causes of hydramnios. Generally, either too much fluid is being produced or there is a problem with the
fluid being taken up, or both. Factors that are associated with hydramnios include the following:

Maternal factors:
o

Diabetes

Fetal factors:
o

Gastrointestinal abnormalities that block the passage of fluid

Abnormal swallowing due to problems with the central nervous system or chromosomal abnormalities

Twin-to-twin transfusion syndrome

Heart failure

Congenital infection (acquired in pregnancy)

Too much amniotic fluid can cause the mother's uterus to become overdistended and may lead to preterm labor or
premature rupture of membranes (the amniotic sac). Hydramnios is also associated with birth defects in the fetus. When
the amniotic sac ruptures, large amounts of fluid leaving the uterus may increase the risk of placental abruption (early
detachment of the placenta) or umbilical cord prolapse (when the cord falls down through the cervical opening) where it
may be compressed.
The following are the most common symptoms of hydramnios:

Rapid growth of uterus

Discomfort in the abdomen

Uterine size (fundal height) greater than expected for gestational age

Uterine contractions

The symptoms of hydramnios may look like other medical conditions. Always consult your health care provider for a
diagnosis.

In addition to a complete medical history and a physical exam, hydramnios is usually diagnosed with ultrasound (a test
using sound waves to create a picture of internal structures) by measuring pockets of fluid to estimate the total volume. In
some cases, ultrasound is also helpful in finding a cause of hydramnios, such as multiple pregnancy or a birth defect.
Specific treatment for hydramnios will be determined by your health care provider based on:

Your pregnancy, overall health, and medical history

Extent of the condition

How well you can handle specific medications, procedures, or therapies

Expectations for the course of the condition

Your opinion or preference

Treatment for hydramnios may include:

Closely monitoring the amount of amniotic fluid and frequent follow-up visits with the health care provider

Medication (to decrease fetal urine production)

Amnioreduction--amniocentesis (inserting a needle through the uterus and into the amniotic sac) to remove some
of the amniotic fluid; this procedure may need to be repeated.

Delivery (if complications endanger the well-being of the fetus or mother, then an early delivery may be
necessary)

The goal of treatment is to relieve the mother's discomfort and continue the pregnancy.
Oligohydramnios is a condition in which there is too little amniotic fluid around the fetus. It occurs in about 4% of all
pregnancies.
There are several causes of oligohydramnios. Generally, it is caused by conditions that prevent or reduce amniotic fluid
production including:

Premature rupture of membranes (before labor)

Intrauterine growth restriction (poor fetal growth)

Post-term pregnancy

Birth defects, especially kidney and urinary tract malformations

Twin-to-twin transfusion syndrome

Amniotic fluid is important in the development of fetal organs, especially the lungs. Too little fluid for long periods may
cause abnormal or incomplete development of the lungs called pulmonary hypoplasia. Intrauterine growth restriction

(poor fetal growth) is also associated with decreased amounts of amniotic fluid. Oligohydramnios may be a complication
at delivery, increasing the risk for compression of the umbilical cord and aspiration of thick meconium (baby's first bowel
movement).
The following are the most common symptoms of oligohydramnios. However, each woman may experience symptoms
differently. Symptoms may include:

Leaking of amniotic fluid when the cause is rupture of the amniotic sac

Decreased amount of amniotic fluid on ultrasound

Uterine size (fundal height) smaller than expected for gestational age

The symptoms of the oligohydramnios may resemble other medical conditions. Always consult your health care provider
for a diagnosis.
In addition to a complete medical history and physical exam, a diagnosis is usually made using ultrasound. Pockets of
amniotic fluid can be measured and the total amount estimated. Ultrasound can also show fetal growth, the structure of the
kidneys and urinary tract, and detect urine in the fetal bladder. Doppler flow studies (a type of ultrasound used to measure
blood flow) may be used to check the arteries in the kidneys, and the blood flow through the placenta.
Treatment for oligohydramnios may include:

Closely monitoring the amount of amniotic fluid and frequent follow-up visits with the health care provider

Amnioinfusion--instilling a special fluid into the amniotic sac to replace lost or low levels of amniotic fluid.
Amnioinfusion may be given in a woman in labor whose membranes have ruptured. Amnioinfusion will not be
given if the woman is not in labor.

Delivery (if oligohydramnios endangers the well-being of the fetus, then an early delivery may be necessary)

Bleeding in Pregnancy: Placenta Previa and Placental Abruption

Bleeding may occur at various times in pregnancy. Although bleeding is alarming, it may or may not be a serious
complication. The time of bleeding in the pregnancy, the amount, and whether or not there is pain may vary depending on
the cause.
Bleeding in the first trimester of pregnancy is quite common and may be due to the following:

Miscarriage (pregnancy loss)

Ectopic pregnancy (pregnancy outside the uterus, usually in the fallopian tube)

Gestational trophoblastic disease (a rare condition that may be cancerous in which a grape-like mass of fetal and
placental tissues develops)

Implantation of the embryo in the uterus

Infection

Bleeding between the uterine wall and placental membrane (subchorionic hemorrhage or hematoma)

Normal changes in the cells of the cervix due to pregnancy

Bleeding in late pregnancy (after about 20 weeks) may be due to the following:

Placenta previa (placenta is near or covers the cervical opening)

Placental abruption (placenta detaches prematurely from the uterus)

Preterm labor

Unknown cause

Placenta previa is a condition in which the placenta is attached close to or covering the cervix (opening of the uterus).
Placenta previa occurs in about one in every 200 live births. There are three types of placenta previa:

Total placenta previa. The placenta completely covers the cervix.

Partial placenta previa. The placenta is partially over the cervix.

Marginal placenta previa. The placenta is near the edge of the cervix.

The cause of placenta previa is unknown, but it is associated with certain conditions including the following:

Women who have scarring of the uterine wall from previous pregnancies

Women who have fibroids or other abnormalities of the uterus

Women who have had previous uterine surgeries or cesarean deliveries

Older mothers (over age 35)

African-American or other minority race mothers

Cigarette smoking

Placenta previa in a previous pregnancy

Being pregnant with a male fetus

The greatest risk of placenta previa is bleeding (or hemorrhage). Bleeding often occurs as the lower part of the uterus thins
during the third trimester of pregnancy in preparation for labor. This causes the area of the placenta over the cervix to
bleed. The more of the placenta that covers the cervical os (the opening of the cervix), the greater the risk for bleeding.
Other risks include the following:

Abnormal implantation of the placenta

Slowed fetal growth

Preterm birth

Birth defects

The most common symptom of placenta previa is vaginal bleeding that is bright red and not associated with abdominal
tenderness or pain, especially in the third trimester of pregnancy. However, each woman may exhibit different symptoms
of the condition or symptoms may resemble other conditions or medical problems. Always consult your doctor for a
diagnosis.
In addition to a complete medical history and physical examination, an ultrasound (a test using sound waves to create a
picture of internal structures) may be used to diagnose placenta previa. An ultrasound can show the location of the
placenta and how much is covering the cervix. A vaginal ultrasound may be more accurate in diagnosis.
Although ultrasound may show a low-lying placenta in early pregnancy, only a few women will develop true placenta
previa. It is common for the placenta to move upwards and away from the cervix as the uterus grows, called placental
migration.
There is no treatment to change the position of the placenta. Once placenta previa is diagnosed, additional ultrasound
examinations are often performed to track its location. Bed rest or hospital admission may be necessary. It may be
necessary to deliver the baby, depending on the amount of bleeding, the gestational age, and condition of the fetus.
Cesarean delivery is necessary for most cases of placenta previa. Severe blood loss may require a blood transfusion.
Placental abruption is the premature separation of a placenta from its implantation site in the uterus. Within the placenta
are many blood vessels that allow the transfer of nutrients to the fetus from the mother. If the placenta begins to detach
during pregnancy, there is bleeding from these vessels. The larger the area that detaches, the greater the amount of
bleeding. Placental abruption occurs about once in every 100 births. It is also called abruptio placenta.
Other than direct trauma to the uterus such as in a motor vehicle accident, the cause of placental abruption is unknown. It
is, however, associated with certain conditions, including the following:

Previous pregnancy with placental abruption

Hypertension (high blood pressure)

Cigarette smoking

Multiple pregnancy

Sickle cell anemia

Placental abruption is dangerous because of the risk of uncontrolled bleeding (hemorrhage), with less oxygen and
nutrients going to the baby. Although severe placental abruption is rare, other complications may include the following:

Hemorrhage and shock

Disseminated vascular coagulation (DIC)--a serious blood clotting complication.

Poor blood flow and damage to kidneys or brain

Stillbirth

Hemorrhage during labor

The most common symptom of placental abruption is dark red vaginal bleeding with pain during the third trimester of
pregnancy. It also can occur during labor. However, each woman may experience symptoms differently. Some women
may not have vaginal bleeding that is detectable, but there may be bleeding inside the uterus. Symptoms may include:

Vaginal bleeding

Abdominal pain

Uterine contractions that do not relax

Blood in amniotic fluid

Nausea

Thirst

Faint feeling

Decreased fetal movements

The symptoms of placental abruption may resemble other medical conditions. Always consult your doctor for a diagnosis.
The diagnosis of placental abruption is usually made by the symptoms, and the amount of bleeding and pain. Ultrasound
may also be used to show the location of the bleeding and to check the fetus. There are three grades of placental abruption,
including the following:

Grade 1. Small amount of vaginal bleeding and some uterine contractions, no signs of fetal distress or low blood
pressure in the mother.

Grade 2. Mild to moderate amount of bleeding, uterine contractions, the fetal heart rate may shows signs of
distress.

Grade 3. Moderate to severe bleeding or concealed (hidden) bleeding, uterine contractions that do not relax
(called tetany), abdominal pain, low blood pressure, fetal death.

Sometimes placental abruption is not diagnosed until after delivery, when an area of clotted blood is found behind the
placenta.
There is no treatment to stop placental abruption or reattach the placenta. Once placental abruption is diagnosed, a
woman's care depends on the amount of bleeding, the gestational age, and condition of the fetus. Vaginal delivery may be
possible if the fetus is tolerating labor. If placental abruption is affecting the fetus, then cesarean delivery may be
necessary. Severe blood loss may require a blood transfusion.
h Disease
Rh disease occurs during pregnancy when there is an incompatibility between the blood types of the mother and baby.
Every person has a blood type (O, A, B, or AB) and an Rh factor, either positive or negative. The blood type and the Rh
factor simply mean that a person's blood has certain specific characteristics. The blood type is found as proteins on red
blood cells and in body fluids. The Rh factor is a protein that is found on the covering of the red blood cells. If the Rh
factor protein is present on the cells, the person is Rh positive. If there is no Rh factor protein, the person is Rh negative.
Rh factors are genetically determined. A baby may have the blood type and Rh factor of either parent, or a combination of
both parents. Rh factors follow a common pattern of genetic inheritance. The Rh positive gene is dominant (stronger), and
even when paired with an Rh negative gene, the positive gene takes over. For example:

If a person has the genes + +, the Rh factor in the blood will be positive.

If a person has the genes + -, the Rh factor will be positive.

If a person has the genes - -, the Rh factor will be negative.

A baby receives one gene from the father and one from the mother.

If a father's Rh factor genes are + +, and the mother's are + +, the baby will have one + from the father
and one + gene from the mother. The baby will be + + Rh positive.

If a father's Rh factor genes are + +, and the mother's are - -, the baby will have one + from the father
and one - gene from the mother. The baby will be + - Rh positive.

If the father's genes are + - Rh positive, and the mother's are + - Rh positive, the baby can be:

+ + Rh positive

+ - Rh positive

- - Rh negative

If the father's genes are - -, and the mother's are + -, the baby can be:

+ - Rh positive

- - Rh negative

If the father's genes are - -, and the mother's are - -, the baby will be:

- - Rh negative

Problems with the Rh factor occur only when the mother's Rh factor is negative and the baby's is positive.
When an Rh negative mother has a baby that is Rh positive, problems can develop if the baby's red blood cells cross to the
Rh negative mother. This usually happens at delivery when the placenta detaches. It may also happen, however, anytime
blood cells of the two circulations mix such as during a miscarriage or abortion, with a fall, or during an invasive prenatal
testing procedure such as an amniocentesis or chorionic villus sampling.
The mother's immune system sees the baby's Rh positive red blood cells as foreign. Just as when bacteria invade the body,
the immune system responds by developing antibodies to fight and destroy these foreign cells. The mother's immune
system keeps the antibodies in case the foreign cells appear again, even in a future pregnancy. The mother is now Rh
sensitized.
Although it is not as common, a similar problem of incompatibility may happen between the blood types (A, B, O, AB) of
the mother and baby in the following situations:

Mother's Blood Type

Baby's Blood Type

A or B

In a first pregnancy, Rh sensitization is not likely. Usually it only becomes a problem in a future pregnancy with another
Rh positive baby. During that pregnancy, the mother's antibodies cross the placenta to fight the Rh positive cells in the
baby's body. As the antibodies destroy the red blood cells, the baby can become anemic. The anemia can lead to other
complications including jaundice, heart failure, and organ enlargement.
Rh disease is also called erythroblastosis fetalis during pregnancy. In the newborn, the resulting condition is called
hemolytic disease of the newborn (HDN).
Some of the more common complications of Rh disease for the fetus and newborn baby include the following:

Anemia (in some cases, the anemia is severe with enlargement of the liver and spleen)

Jaundice. This is a yellowing of the skin, eyes, and mucous membranes.

Severe anemia with enlargement of the liver and spleen

Hydrops fetalis. This occurs as the fetal organs are unable to handle the anemia. The heart begins to fail and large
amounts of fluid build up in the fetal tissues and organs. A fetus with hydrops fetalis is at great risk of being
stillborn.

After birth, the red blood cell destruction may continue. Problems may include the following:

Severe jaundice. The baby's liver is unable to handle the large amount of a substance called bilirubin that results
from red blood cell breakdown. The baby's liver is enlarged and anemia continues.

Kernicterus. The most severe form of too much bilirubin and results from the build up of bilirubin in the brain.
This can cause seizures, brain damage, deafness, and death.

A mother has no physical signs of Rh disease, but her Rh positive baby can have problems if the mother has developed
antibodies. The following are the most common symptoms of Rh disease in the fetus. However, each pregnancy may have
different symptoms of the condition. Symptoms may include:

With amniocentesis, the amniotic fluid may have a yellow coloring and contain bilirubin.

Ultrasound of the fetus shows enlarged liver, spleen, or heart and fluid build up in the fetus' abdomen.

The symptoms of Rh disease may resemble other conditions or medical problems. Always consult your doctor for a
diagnosis.
Early identification of the Rh negative mother is very important. Then, the risks for the baby can be determined by blood
testing of both parents (Rh negative mother, Rh positive father). The disease may be diagnosed if a previous pregnancy
resulted in an Rh positive baby. In addition to a complete medical history and physical examination, diagnostic procedures
for Rh disease may include:

Testing the presence of Rh positive antibodies in the mother's blood

Ultrasound to detect organ enlargement or fluid build up in the fetus. Ultrasound is a diagnostic imaging
technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and
organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various
vessels.

Amniocentesis. A test performed to determine chromosomal and genetic disorders and certain birth defects. The
test involves inserting a needle through the abdominal and uterine wall into the amniotic sac to retrieve a sample
of amniotic fluid.

Sampling of some of the blood from the fetal umbilical cord, such as percutaneous umbilical blood
sampling, during pregnancy to check for antibodies, bilirubin, and anemia in the fetus.

Your health care provider will figure out the best treatment for you and your baby based on:

How old you are

Your overall health and medical history

How well you and your baby can handle specific medications, procedures, or therapies

Your opinion or preference

Treatments for Rh disease may include:

Intrauterine blood transfusion of red blood cells into the baby's circulation. A procedure that is done by placing a
needle through the mother's uterus and into the abdominal cavity of the fetus or directly into the vein in the
umbilical cord. It may be necessary to give a sedative medication to keep the baby from moving. Intrauterine
transfusions may need to be repeated.

Early delivery, if the fetus develops complications (if the fetus has mature lungs, labor and delivery may be
induced to prevent worsening of the disease)

Fortunately, HDN is a very preventable disease. Because of the advances in prenatal care, nearly all women with Rh
negative blood are identified in early pregnancy by blood testing. If a mother is Rh negative, she will be tested for Rh
antibody titers. If she has not been sensitized, she is usually given a drug called Rh immunoglobulin (RhIg), also known
as RhoGAM. This is a specially-developed blood product that can prevent an Rh negative mother's antibodies from being
able to react to Rh positive cells. Many women are also given RhIg around the 28th week of pregnancy, unless the mother
has vaginal bleeding, trauma, or an amniocentesis before 28 weeks. After the baby is born, a woman should receive a
second dose of the drug within 72 hours if the baby is Rh positive.

RhIg destroys any anti-Rh antibodies that enter in the mother's circulation before her immune system becomes sensitized.
This helps protect a future Rh positive baby.
Acquired Immune Deficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV)
Human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS). The virus destroys
or weakens the cells of the immune system. A weak immune system reduces the body's ability to fight infections and
certain cancers over time. The term "AIDS" means the HIV infection is in its most advanced stages.
Adults and teens most commonly get HIV through sexual activity with someone who already has the virus. Nearly all
children under the age of 13 are infected with HIV by their mothers. This happens in the womb or as they pass through the
birth canal during labor. The virus can also be passed to children through breastfeeding.
Not every child born to a mother with HIV will get the virus. Without treatment, a woman with HIV has a one in four
chance of infecting her fetus. But, early testing and treatment can reduce the number of mother-to-child HIV infections. If
a test shows a woman has HIV, she can take antiretroviral medications during pregnancy and labor. These medications can
also be used to treat the infant for a short time after birth.
These are the ways the HIV virus can be passed to another person:

Vertical transmission. This is when HIV is spread to babies who are born to, or breastfed by, mothers infected
with the virus.

Sexual contact. HIV is spread in adults and adolescents most commonly by sexual contact with an infected
partner. The virus enters the body through the lining of the vagina, vulva, penis, rectum, or mouth through sexual
activity.

Blood contamination. HIV may also be spread through contact with infected blood. However, due to the
screening of blood for the HIV virus, the risk of getting HIV from blood transfusions is extremely low.

Needles. HIV is often spread by sharing needles, syringes, or drug use equipment with someone who is infected
with the virus. It is rare for patients to infect healthcare workers, or vice-versa, through accidental sticks with
contaminated needles or other medical instruments.

No known cases of HIV/AIDS have been spread by the following:

Saliva

Sweat

Tears

Casual contact, such as sharing food utensils, towels, and bedding

Swimming pools

Telephones

Toilet seats

Biting insects, such as mosquitoes

Some people may get a flu-like illness within a month or two after exposure to the HIV virus. This flu-like illness is often
thought to be something else. Many people don't have any symptoms at all when they first become infected. Continued or
severe symptoms may show up within 2 years in babies born with an HIV infection. Continued or severe symptoms may
not surface for 10 years or more, after HIV first enters the body in adults, or within 2 years in children born with an HIV
infection.
The symptoms of HIV may seem like other conditions or medical problems. Always see your baby's health care
provider for a diagnosis.
Doctors and HIV experts agree that all pregnant women should get an HIV test. A blood test is the most common way to
diagnose HIV in children over 18 months, teens, and adults.
Care that includes HIV counseling, testing, and treatment of infected mothers during pregnancy saves lives. It
is recommended that HIV-positive women take specific medications during pregnancy and during labor. Blood tests are
also done to check the amount of virus. HIV-positive women should see a specialist during pregnancy.
Newborn babies of HIV-positive mothers may also receive medication to lower the chances of passing HIV on to the
baby.
Cesarean delivery may be recommended for HIV-positive women. This also helps reduce the risk of transmission of the
virus to the baby, especially when the mother receives medications. HIV may also be transmitted through breast milk.
Because breast milk contains the virus, HIV-positive mothers should not breastfeed their babies.
Post-Term Pregnancy
A pregnancy that lasts more than 42 weeks (294 days since the first day of the last menstrual period) is considered postterm. The vast majority of women deliver between 37 and 42 weeks of pregnancy. Other terms often used for this include
prolonged pregnancy, post-dates pregnancy (after the due date), and postmaturity.
It is not known why some women carry a pregnancy longer than others. It is often due to a miscalculation of pregnancy
conception dates. A woman is much more likely to have a post-term pregnancy if previous pregnancies went beyond 42
weeks.
Post-term pregnancy is associated with longer labors and operative delivery (forceps or vacuum-assisted birth). Mothers
are at increased risk for vaginal birth trauma due to a large baby. Cesarean delivery is twice as likely in a post-term
pregnancy because of the size of the baby. Mothers are also at increased risk for infection and wound complications, and
postpartum (after birth) hemorrhage.
There are also risks for the fetus and newborn in a post-term pregnancy, including stillbirth and newborn death. Toward
the end of pregnancy, the placenta, which supplies the fetus with the nutrients and oxygen from the mother's circulation,
begins to age and may not function as efficiently as before. Amniotic fluid volume may decrease and the fetus may stop
gaining weight, or may even lose weight. Risks can increase during labor and birth for a fetus with poor oxygen supply.
Birth injury may also occur if the baby is large. Babies born after 42 weeks may be at risk for meconium aspiration, when
a baby breathes in fluid containing the first stool. Hypoglycemia (low blood sugar) can also occur because the baby has
too little glucose-producing stores.
Correct pregnancy dating is important in accurately diagnosing and managing post-term pregnancy. The size of the uterus
at various points in early pregnancy, the date the fetal heartbeat was first heard, and when a mother first feels fetal

movement all help confirm pregnancy dates. Ultrasound (a diagnostic imaging technique that uses high-frequency sound
waves and a computer to create images of blood vessels, tissues, and organs) is often used in early pregnancy to establish
or confirm a due date.
In a post-term pregnancy, testing may be done to check fetal well-being and identify problems. Tests often include
ultrasound, nonstress testing (how the fetal heart rate responds to fetal activity), and estimation of the amniotic fluid
volume.
The goal of management of post-term pregnancy is to prevent complications and deliver a healthy baby. Specific
management for post-term pregnancy will be determined by your doctor based on:

Your pregnancy, overall health, and medical history

Extent of the condition

Your tolerance for specific medications, procedures, or therapies

Expectations for the course of the condition

Your opinion or preferences

Maternal and fetal testing are often performed for a post-term pregnancy to monitor for signs of problems. Some of the
ways to detect potential problems include the following:

Fetal movement counting. Keeping track of fetal kicks and movements. A change in the number or frequency
may mean the fetus is under stress.

Nonstress testing. A test that watches the fetal heart rate for increases with fetal movements, a sign of fetal wellbeing.

Biophysical profile. A test that combines the nonstress test with an ultrasound to evaluate fetal well-being.

Ultrasound. A diagnostic imaging technique that uses high-frequency sound waves and a computer to create
images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to
assess blood flow through various vessels. Ultrasounds are used to follow fetal growth.

Doppler flow studies. A type of ultrasound that uses sound waves to measure blood flow, commonly used in
intrauterine growth restriction (IUGR) babies.

If tests determine that it is no longer healthy for the fetus to stay in the mother's uterus, labor may be induced, to deliver
the baby.
The decision to induce labor for post-term pregnancy depends on many factors. During labor, the fetal heart rate may be
monitored with an electronic monitor to help identify changes in the heart rate due to low oxygenation. Changes in a
baby's condition may require a cesarean delivery.
During labor, continuous fetal heart rate monitoring is often used to help detect changes in the fetal heart rate. Because a
post-term fetus is more likely to pass meconium (the first stool) during labor, the risk of meconium aspiration is increased.
The baby may need suctioning and special care after delivery.

Amnioinfusion is sometimes used during labor if there is very little amniotic fluid or the fetus is compressing the
umbilical cord. In amnioinfusion, a sterile fluid is instilled with a catheter (hollow tube) into the broken amniotic sac to
help replace the low levels of fluid and cushion the fetus and cord.
If labor does not progress or there is fetal distress, cesarean delivery may be needed. Very large babies may have difficulty
at delivery, and may have a greater risk of injury during forceps or vacuum-assisted delivery. Clinicians must proceed
with caution to prevent any harm to the baby.
Postpartum Hemorrhage
Postpartum hemorrhage is excessive bleeding following the birth of a baby. About 1% to 5% of women have postpartum
hemorrhage and it is more likely with a cesarean birth. Hemorrhage most commonly occurs after the placenta is delivered.
The average amount of blood loss after the birth of a single baby in vaginal delivery is about 500 ml (or about a half of a
quart). The average amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart). Most postpartum
hemorrhage occurs right after delivery, but it can occur later as well.
Once a baby is delivered, the uterus normally continues to contract (tightening of uterine muscles) and expels the
placenta. After the placenta is delivered, these contractions help compress the bleeding vessels in the area where the
placenta was attached. If the uterus does not contract strongly enough, called uterine atony, these blood vessels bleed
freely and hemorrhage occurs. This is the most common cause of postpartum hemorrhage. If small pieces of the placenta
remain attached, bleeding is also likely.
Some women are at greater risk for postpartum hemorrhage than others. Conditions that may increase the risk for
postpartum hemorrhage include the following:

Placental abruption. The early detachment of the placenta from the uterus.

Placenta previa. The placenta covers or is near the cervical opening.

Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid or a large baby,
especially with birthweight over 4,000 grams (8.8 pounds).

Multiple pregnancy. More than one placenta and overdistention of the uterus.

Gestational hypertension or preeclampsia. High blood pressure of pregnancy.

Having many previous births

Prolonged labor

Infection

Obesity

Medications to induce labor

Medications to stop contractions (for preterm labor)

Use of forceps or vacuum-assisted delivery

General anesthesia

Postpartum hemorrhage may also be due to other factors including the following:

Tear in the cervix or vaginal tissues

Tear in a uterine blood vessel

Bleeding into a concealed tissue area or space in the pelvis which develops into a hematoma, usually in the vulva
or vaginal area

Blood clotting disorders, such as disseminated intravascular coagulation

Placenta accreta. The placenta is abnormally attached to the inside of the uterus (a condition that occurs in one in
2,500 births and is more common if the placenta is attached over a prior cesarean scar).

Placenta increta. The placental tissues invade the muscle of the uterus.

Placenta percreta. The placental tissues extend all the way through the uterine muscle.

Although an uncommon event, uterine rupture can be life-threatening for the mother. Conditions that may increase the risk
of uterine rupture include surgery to remove fibroid (benign) tumors and a prior cesarean scar. A prior scar on the uterus in
the upper part of the fundus has a higher risk of uterine rupture compared with a horizontal scar in the lower uterine
segment called a lower transverse incision. It can also occur before delivery and place the fetus at risk as well.
Excessive and rapid blood loss can cause a severe drop in the mother's blood pressure and may lead to shock and death if
not treated.
The following are the most common symptoms of postpartum hemorrhage:

Uncontrolled bleeding

Decreased blood pressure

Increased heart rate

Decrease in the red blood cell count (hematocrit)

Swelling and pain in tissues in the vaginal and perineal area, if bleeding is due to a hematoma

The symptoms of postpartum hemorrhage may look like other conditions or medical problems. Always consult
your doctor for a diagnosis.
In addition to a complete medical history and physical exam, diagnosis is usually based on symptoms, with lab tests often
helping with the diagnosis. Tests used to diagnose postpartum hemorrhage may include:

Estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of packs and
sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram)

Pulse rate and blood pressure measurement

Hematocrit (red blood cell count)

Clotting factors in the blood

The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible.
Treatment for postpartum hemorrhage may include:

Medication (to stimulate uterine contractions)

Manual massage of the uterus (to stimulate contractions)

Removal of placental pieces that remain in the uterus

Examination of the uterus and other pelvic tissues, and examination of the vagina and vulva to look for areas that
may need repair.

Bakri balloon or a Foley catheter to compress the bleeding inside the uterus. Packing the uterus with sponges and
sterile materials may be used if a Bakri balloon or Foley catheter is not available.

Laparotomy. Surgery to open the abdomen to find the cause of bleeding.

Tying-off of bleeding blood vessels using uterine compression sutures. This is done during a laparotomy.

Hysterectomy. Surgical removal of the uterus; in most cases, this is a last resort.

Replacing lost blood and fluids is important in treating postpartum hemorrhage. Intravenous (IV) fluids, blood, and blood
products may be given rapidly to prevent shock. The mother may also receive oxygen by mask.
Postpartum hemorrhage can be quite serious. However, quickly detecting and treating the cause of bleeding can often lead
to a full recovery.
Care and Management of Multiple Pregnancy
Management of multiple pregnancy may include the following:

Increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher
weight gain is also recommended for multiple pregnancy. The Institute of Medicine recommends that women
carrying twins who have a normal body mass index should gain between 37 and 54 pounds. Those who are
overweight should gain 31-50 pounds; and obese women should gain 25-42 pounds.

More frequent prenatal visits

Multiple pregnancy increases the risk for complications. More frequent visits may help detect complications early

enough for effective treatment or management. The mother's nutritional status and weight should also be
monitored more closely.

Referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound
evaluations, and to coordinate care of complications, may be necessary.

Increased rest
Some women may also need bedrest--either at home or in the hospital depending on pregnancy complications or
the number of fetuses. Higher-order multiple pregnancies often require bedrest starting in the middle of the
second trimester. Preventive bed rest has not been shown to prevent preterm birth in multiple pregnancy.

Maternal and fetal testing

Testing may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.

Tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or stop contractions of the uterus. These
may be given orally, in an injection, or intravenously. Tocolytic medications often used include magnesium
sulfate.

Corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the fetuses. Lung immaturity is a major
problem of premature babies.

Cervical cerclage
Cerclage (a procedure used to suture shut the cervical opening) is used for women with an incompetent cervix.
This is a condition in which the cervix is physically weak and unable to stay closed during pregnancy. Some
women with higher-order multiples may require cerclage in early pregnancy.

Delivery of multiples depends on many factors including the fetal positions, gestational age, and health of mother and
fetuses. Generally, in twins, if both fetuses are in the vertex (head-down) position and there are no other complications, a
vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally, then
the second is either turned to the vertex position or delivered breech (buttocks are presented first). These procedures can
increase the risk for problems such as prolapsed cord (when the cord slips down through the cervical opening).
Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are
delivered by cesarean. Most triplets and other higher-order multiples are born by cesarean.

Vaginal delivery may take place in an operating room because of the greater risks for complications during birth and the

potential need for cesarean delivery. Cesarean delivery is usually needed for fetuses that are in abnormal positions, for
certain medical conditions of the mother, and for fetal distress.