Diagnoses
Pregnancy induced hypertension (PIH)
Pregnancy induced hypertension is defined as elevated blood pressure during pregnancy. It includes preeclampsia, eclampsia, and transient hypertension (high blood pressure that occurs only during the pregnancy). Hypertension is usually defined as blood pressure readings of over 140/90, although this may vary depending on your baseline (normal) blood pressure. With preeclampsia, you may also have edema (swelling in the tissues, especially the hands and feet), and protein in the urine. Preeclampsia occurs in 3-6% of pregnancies in the U.S.
The causes of preeclampsia are not known. There may be genetic, immunologic (related to your immune system), hormonal, nutritional or infectious influences that produce the disease. Preeclampsia is also associated with the following:
Signs and symptoms include unusual or rapid weight gain and edema (swelling from increased fluids in your body), protein in the urine, increased blood pressure (especially the diastolic, or bottom number). There may also be changes in kidney and liver function, blurred vision, and increased reflexes. Your doctor may do several tests to see if you have this condition. These might include taking blood, checking your urine, or getting an EKG (an electrical reading of your heart). Your doctor may also do an ultrasound or other tests to see how the baby is doing.
The treatment you will receive depends on the severity of your preeclampsia. Delivery of the baby can cause blood pressure to return to normal. If the baby is immature, it may not be a good idea to induce delivery. You may be asked to rest in bed more often, possibly on your left side to prevent compression of the major blood vessel (vena cava) which brings blood back to the heart and improves blood flow. Your doctor may suggest that you do not add salt to your foods. There are medicines to help decrease your blood pressure. You may be treated as an outpatient and can stay at home, or your doctor may want to admit you to the hospital to better monitor your condition. If you are at 37 weeks or more, your doctor may choose to induce labor (starting labor before you start labor on your own). If your condition becomes severe, you may be treated with a medicine to prevent seizures (see "Medications"). If you do have a seizure, your diagnosis will be called eclampsia, and it is highly likely that labor will be induced or a Cesarean Section will be done once your condition is stabilized.
Placenta Previa and Abruptio Placenta
Placenta previa occurs when the placenta implants (grows) either completely or partially over the cervical opening (os). It is considered a "complete" or "total" previa when the internal os of the cervix is entirely covered by the placenta. It is called a "partial" previa if the opening is only partly covered, and a "marginal" previa when only the edge of the placenta reaches the internal os.
The cause of a placenta previa is unknown. Some possible factors are:
If you have a placenta previa, you may experience painless bleeding, especially during the late 2nd or early 3rd trimester. The blood will be bright red, and can occur in gushes, at intervals, or may be continuous. Your doctor usually needs an ultrasound to see where the placenta is placed in order to make this diagnosis. Placentas that appear on ultrasound to be covering the cervical os at earlier than 30 weeks may recede and may not cover the opening at the time of delivery.
How you are treated will depend on the age of the fetus and the amount of bleeding you are having. If the fetus is not mature (is less than 36 weeks) and there is no active bleeding, you will probably not have to stay in the hospital. Your doctor will probably monitor the fetus by ultrasound, or with a nonstress test or biophysical profile (see "Tests"). If the fetus is mature, and you are in labor, you will need to deliver the baby by cesarean section. Cesarean section is the safest way to deliver the baby in order to prevent excessive blood loss.
Abruptio placenta (an abruption) occurs when the placenta partially separates from the wall of the uterus before the delivery of the fetus. The bleeding that results may come out of the cervix or it may stay between the placenta and the uterus. This can be a dangerous situation for the mother and the baby since the mother may be losing blood and the blood flow to the fetus may be decreased.
The cause of abruptio placenta is unknown. Some conditions that are associated with it include:
Signs and symptoms of abruptio placenta can vary. The major symptom is bleeding. You may also experience uterine tenderness, back pain, or frequent contractions.
Treatment will depend on the baby's age and the amount of blood loss. If there is a lot of bleeding, delivery of the fetus and treatment of hemorrhage (excessive bleeding) will be done. If there is not much blood loss, treatment may depend on the status and the age of the fetus. The mother and baby will have to be monitored closely, but the goal is to prolong the pregnancy to increase fetal growth and development. In most cases, tocolytic drugs (to stop contractions) are not used, but your doctor will discuss this with you if it is an option. A vaginal delivery may be an option, but if there is prolonged bleeding or a total separation of the placenta, delivery of the baby is by means of an immediate cesarean section.
An incompetent cervix is defined as a painless dilation or stretching of the cervical opening without labor or contractions of the uterus. This may occur in the 2nd trimester or early in the 3rd trimester. Your cervix is the lower part of the uterus that opens into the vagina. During pregnancy, the cervix usually remains closed until labor begins. At that time, contractions work to thin the muscle and widen the opening for the baby to pass through. However, if your cervix opens early, a spontaneous abortion (miscarriage) or pre-term birth may result.
The cause of an incompetent cervix is not known. Some of the factors associated with this condition are:
Since the early dilation of the cervix is often painless, you may not notice any symptoms. Sometimes the amniotic sac will break and your doctor will determine how dilated your cervix is through a sterile speculum exam.
The treatments for an incompetent cervix usually include bed rest, hydration (drink plenty of fluids or get fluids through an IV), tocolytic drugs (to stop contractions if you are having them), or a cerclage (pronounced sair-klazhe). This may mean that your doctor will "tie" the cervix closed (like a purse string) until the baby is old enough to be born. A cerclage is usually performed between 14 and 26 weeks, although with advancing pregnancy the risk of rupture of your membranes or stimulation of preterm labor increases. If you and your doctor decide a cerclage is best, an ultrasound of the baby should be performed before the surgery. You should also be treated for cervical infection if one is present. It is also recommended that you do not have sexual intercourse for a week before and after surgery. If you decide not to have a cerclage, you will probably be put on activity restriction, and your doctor will monitor your cervical effacement and dilation frequently. Be familiar with the signs and symptoms of labor (see "Preterm labor") and let your doctor know if you experience any of these symptoms. The cerclage sutures (or stitches) will be removed if you go into labor.
PPROM: Premature pre-term rupture of membranes
PPROM, premature preterm rupture of membranes, is the breaking of the amniotic sac (sac filled with fluid that surrounds the fetus) before the onset of labor and before the fetus is at term. The amniotic sac is important for the fetus as it cushions the baby's body in the uterus and protects the fetus from infection. PPROM may involve the loss of all or some of this fluid. If the rupture involves a small tear, the leak may seal on its own.
The cause of PPROM is not known. Although the following factors have not been established to cause PPROM, they are associated with an increased risk of PPROM:
You may notice fluid leaking from the vagina or even experience a "gush" of fluid if your membranes rupture. If there is an infection present, you may have a fever, rapid heart rate, and feel some uterine tenderness. Your doctor may do several tests to tell if your membranes have broken. One is a nitrazine test. The health care provider (doctor, nurse midwife) will place some fluid taken from your vagina on litmus paper. If the paper turns blue, this is a positive test, indicating that your membranes have broken. The other test is the ferning test. This involves putting some of this fluid on a microscope slide and letting it dry. The doctor then looks at it under the microscope and if it is amniotic fluid, a certain "ferning" pattern shows up. Your doctor may also do a sterile speculum exam to look at your cervix to see if the membranes are intact, and if your cervix has changed or dilated.
Management of PPROM is aimed at giving the fetus as much time as possible to mature in the uterus. You may be given antibiotics to prevent an infection from developing. Depending on how old the baby is, you may be given injections of corticosteroids (betamethasone) to help the fetal lungs develop (usually if your pregnancy is between 24 and 34 weeks). If you are having contractions, tocolytic drugs may be started (see "Medications"). If you are being treated at home, you may be asked to check your temperature, blood pressure, pulse and breathing rate every day. You should also watch yourself for any tenderness in your uterus and note any changes in the color, odor and amount of vaginal discharge. You may be asked not to take baths, and to avoid sexual intercourse, breast stimulation or other sexual stimulation (this may cause labor to start). It is important for you to know the signs and symptoms of pre-term labor (see "Preterm labor"). If you think you have any of these signs or symptoms, you should call your doctor. Finally, your health care provider may also monitor the baby's heart rate, and/or amniotic fluid index (see "Tests"). If you are very near term (almost 37 weeks) or have a serious infection, your doctor may induce labor (start labor before you go in to labor on your own).
Multiple gestation (twins, triplets, etc.)
Multiple gestation is when there are two or more fetuses in the uterus at the same time. This occurs when more than one egg is fertilized by more than one sperm (making dizygotic or fraternal twins, triplets etc.), or when a fertilized egg divides (making monozygotic or identical twins), or a combination of these processes. The fetuses may or may not share placentas and an amniotic sac. The number of fetuses is usually visualized by ultrasound.
Carrying more than one fetus at a time can make pregnancy more complicated for the mother. Doctors usually see patients with a multiple gestation more often. Your cervix may be checked more often because multiple gestation may lead to early effacement and dilation (thinning and opening of the cervix). You will also have your urine and blood pressure monitored because pregnancy induced hypertension can happen more often and may be noticed earlier in the pregnancy.
Preterm delivery is more common in multiple gestation than in singleton pregnancies, so the goal of prenatal (before labor and delivery) treatment is to prolong the pregnancy as much as possible. Different therapies have been used, including bed rest, home uterine activity monitoring, hospitalization, tocolytic medicines, and cervical cerclage ("sewing" the cervix closed, see "Treatments"). The doctor may also do more frequent ultrasounds and tests to monitor the fetuses. If you experience preterm labor before 35 weeks, your doctor will probably try to stop the contractions. This could involve the use of tocolytic drugs (see "Medications"). Your doctor may also want to do tests to check the development of the baby's lungs, and you may be given corticosteroids (betamethasone) to help the fetal lungs develop.
For more information on these diagnoses, see Chism, D. (1997). The high-risk pregnancy sourcebook. Lowell House.
References:
Cunningham, F., MacDonald, P., Gant, N., Leveno, K., Gilstrap, L., Hankins, G., & Clark, S. (1997). Williams Obstetrics (20th Ed.). Stamford, CT: Appleton & Lange.
Wong, D., & Perry, S. (1998). Maternal child nursing care. St. Louis: Mosby.
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© 2004 Professor Judy Maloni, Case Western Reserve University.
This page last updated 11/05/04.