Headaches in pregnancy

Headaches are common during pregnancy and are often triggered by a change in hormones during pregnancy, but they usually improve or stop in the second and third trimester. You can take acetaminophen (paracetamol) if you need to for a mild headache, but get advice from a pharmacist or your doctor about how much to take and for how long. And make sure you follow the instructions on the packet for how much you can take. Try to take the lowest dose of paracetamol that works and for the shortest amount of time. Your doctor or pharmacist can give you more advice if the pain is ongoing and doesn’t go away with acetaminophen (paracetamol).

There are some painkillers you should NOT take while you’re pregnant. These include tablets or capsules that:

• contain added caffeine (sometimes sold with ‘extra’ on the label)
• contain codeine
• are anti-inflammatory, like ibuprofen or aspirin.

Some women may be advised to take a low dose of aspirin as a treatment if they have had miscarriages before or they are at risk of pre-eclampsia. This will be prescribed by a doctor. Aspirin should not be taken as treatment for a headache.

To help prevent more headaches:

• drink plenty of fluids
• get enough sleep
• rest and relax.

Although most pregnancy headaches are innocent, unexplained, frequent headaches later in your pregnancy could be a sign of a more serious condition called pre-eclampsia, so tell your doctor if this is the case.

What causes headaches during pregnancy?

Many women experience headaches during pregnancy and may occur at any time during your pregnancy, but headaches tend to be most common during the first and third trimesters. If you’re pregnant, you may notice an increase in the number of headaches you have at around week 9 of your pregnancy.

As well as hormonal changes, headaches in the early stages of pregnancy can be caused by an increase in the volume of blood your body is producing.

During the first trimester, your body experiences a surge of hormones and an increase in blood volume. These two changes can cause more frequent headaches. These headaches may be further aggravated by stress, poor posture or changes in your vision.

Women who have regular migraine headaches may discover that they experience fewer migraines during pregnancy; however, some women may encounter the same number or even more migraine headaches. If you are pregnant, it is important to talk to your health care provider about any medications that you may be taking for headaches.

Headaches during the third trimester tend to be related more often to poor posture and tension from carrying extra weight. Headaches during the third trimester may also be caused by a condition called pre-eclampsia, which is high blood pressure during pregnancy.

Other causes of headaches during pregnancy can include:

• not getting enough sleep
• withdrawal from caffeine (e.g. in coffee, tea or cola drinks)
• low blood sugar
• dehydration
• feeling stressed
• poor posture, particularly as your baby gets bigger
• having depression or anxiety

Migraines and pregnancy

Migraine is a particular type of headache that mostly occurs on one side of the head – it can be either moderate or very painful. People who experience migraine can also feel sick or vomit, and be sensitive to light or sound.

Many people who have migraines may have:

• severe pain, which feels like a throbbing, pounding or pulsating pain
• nausea (feeling sick)
• pain brought on by bright lights
• an ‘aura’, such as flashing lights before the migraine starts.

In pregnancy, migraine may get worse for the first few months, but for many women it can improve in the later stages of their pregnancy when the level of the hormone estrogen stabilizes. Other women may experience no change or a decrease in the number of migraine headaches while pregnant. Some women may experience differences in migraine during different pregnancies.

If you have always had migraines, you may find that they get better during your pregnancy. But pregnancy can also change the nature of migraines, so if you have a migraine that feels different to what you’ve had before, see your doctor or hospital maternity unit.

Will a migraine hurt my baby?

Women with migraines are at slightly higher risk of developing high blood pressure and pre-eclampsia. This risk is very small and most women with migraines will not have high blood pressure.

If you have any worries at any time, talk to your doctor.

Secondary headaches

Pregnancy is a risk factor for a secondary headache disorder. Hypercoagulability, hormonal changes and anaesthesia for labour are just some of the multiple factors contributing to the high incidence of secondary headaches during pregnancy ²⁾.

A recent study by Robbins et al ³⁾ found 35% of secondary headaches among 140 pregnant women presenting with acute headache: hypertensive disorders of pregnancy covered 51% of these cases (about 18% of total), with preeclampsia as the major cause, followed by reversible posterior leukoencephalopathy syndrome (PRES, eclampsia), reversible cerebral vasoconstriction syndrome and acute arterial hypertension. These data place between two previous studies that reported percentages of secondary headaches ranging from 14.3% to 52.6% ⁴⁾. In particular, among patients with a primary headache history, longer attack duration is the most common feature suggesting a secondary headache, reaching the statistical significance ⁵⁾ or just approaching it ⁶⁾.

The authors show how lack of headache history, elevated blood pressure and abnormalities at neurologic examination are the main red flags for a secondary origin of an acute headache during pregnancy ⁷⁾. In the second trimester, a new onset of headache may signal the presence of a pseudotumor cerebri ⁸⁾, while in case of a severe postural headache a spontaneous intracranial hypotension must be ruled out ⁹⁾. In front of the well-known red flags (see the list above) brain MRI or CT scan are often required ¹⁰⁾. Use of contrast agents such as gadolinium is not recommended, given the lack of data regarding safety to the fetus and its ability to cross the placenta and remain in the amniotic fluid ¹¹⁾.

Iodinated contrast should be avoided as well as it may suppress fetal thyroid function ¹²⁾.

Recently the European Headache Federation published a consensus statement on technical investigation for primary headache disorders ¹³⁾.

Secondary headache features may not differ from those of primary headaches; furthermore, migraine is as an independent risk factor for the development of secondary headaches (e.g., the risk of gestational hypertension increased by 1.42-fold) ¹⁴⁾, so that recognizing these conditions in pregnant women may be a true diagnostic challenge.

Cerebral venous thrombosis, pre-eclampsia, hamorrhagic or ischemic stroke, subarachnoid haemorrhage (SAH), reversible cerebral vasoconstriction syndrome, reversible posterior leukoencephalopathy syndrome (reversible posterior leukoencephalopathy syndrome), idiopathic intracranial hypertension or pituitary apoplexy must be ruled out as soon as possible (Table 1) ¹⁵⁾.

Table 1. Main causes of secondary headache in pregnant women

Secondary headaches during pregnancy
Arterial dissection	Intracranial hypotension
Arteriovenous malformation	Ischemic stroke
Brain tumors	Meningitis/encephalitis
Cerebral venous thrombosis (CVT)	Pituitary adenoma
Choriocarcinoma	Pituitary apoplexy
Cranial neuralgias	Pituitary meningioma
Dehydration	Reversible posterior leukoencephalopathy syndrome (PRES)
Eclampsia and pre-eclampsia	Reversible vasoconstriction syndrome (RCVS)
Head trauma	Sinusitis
Idiopathic intracranial hypertension (IIH)	Subarachnoid haemorrhage (SAH)
Intracranial haemorrhage (ICH)	Vasculitis

Cerebral venous thrombosis

Headache caused by cerebral venous thrombosis has no specific characteristics: it is most often diffuse, progressive and severe, but can be unilateral and sudden (even thunderclap), or mild, and sometimes is migraine-like ¹⁶⁾. Headache is present in 80–90% of cases of cerebral venous thrombosis and it is often associated with focal signs (neurological deficits or seizures) and/or signs of intracranial hypertension (nausea and papilledema), subacute encephalopathy or cavernous sinus syndrome, carrying a mortality rate of up to 30% ¹⁷⁾.

Pre-eclampsia and eclampsia

Pre-eclampsia occurs in 5% of pregnancies ¹⁸⁾: a progressive bilateral (temporal, frontal, occipital or diffuse) pulsating headache in a woman who is pregnant or in the puerperium (up to 4 weeks postpartum), often aggravated by physical activity, failing to respond to the over-the-counter remedies, may be the herald symptom of this condition, which can associate with visual changes similar to the typical visual aura. It must resolve within a week after blood pressure adjustment ¹⁹⁾. According to the International Classification of Headache Disorders 3rd edition (ICHD-3 beta) headache should have at least two of the following three characteristics: a) bilateral location, b) pulsating quality, and c) aggravated by physical activity ²⁰⁾.

Ischemic stroke

Headache accompanies ischemic stroke especially within the posterior circulation, in up to one-third of cases and is usually overshadowed by focal signs and/or alterations of consciousness, which in most cases allows easy differentiation from the primary headaches. The risk of ischemic stroke in migraineurs was evaluated using the United States Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality and found to be elevated ²¹⁾.

Headache has a self-limited course, and is very rarely the presenting or a prominent feature of ischemic stroke ²²⁾. It is usually of moderate intensity, and has no specific characteristics. It can be bilateral or unilateral ipsilateral to the stroke. Rarely, an acute ischemic stroke can present with an isolated sudden (even thunderclap) headache ²³⁾.

The diagnosis of headache and its causal link with ischemic stroke is easy because the headache presents both acutely and with neurological signs and because it often remits rapidly.

Subarachnoid hemorrhage

In subarachnoid hemorrhage headache is usually the prominent symptom. The pain is typically severe and sudden, peaking in seconds (thunderclap headache) or minutes, often followed by vomiting and loss of consciousness ²⁴⁾. Subarachnoid hemorrhage is a serious condition with mortality rate of 40–50% and with 10–20% of patients dying before arriving at hospital. The abrupt onset is the key feature and can help to distinguish from primary headaches with thunderclap features (e.g., associated with exercise or sexual activity). Subarachnoid hemorrhage presents a 20-fold increased risk in the puerperium and it gives a thunderclap headache ²⁵⁾.

Arterial dissection

Arterial dissection is a rare complication of pregnancy and puerperium. There have been reports of cervical carotid, vertebral and intracranial artery dissection in association with preeclampsia ²⁶⁾. Headache is the most frequent inaugural symptom, described as severe, unilateral (ipsilateral to the dissected vessel), with a sudden (even thunderclap) onset. Pain is persistent for days and can remain isolated or be a warning symptom preceding ischaemic infarcts.

Reversible cerebral vasoconstriction syndrome

Headache caused by reversible cerebral vasoconstriction syndrome is severe and diffuse and typically of the thunderclap type, recurring over 1–2 weeks, often triggered by sexual activity, exertion, Valsalva manoeuvres and/or emotion ²⁷⁾. Headache is often the only symptom of reversible cerebral vasoconstriction syndrome, but the condition can be associated with fluctuating focal neurological deficits and sometimes seizures.

Reversible cerebral vasoconstriction syndrome is commonly associated with the post-partum period, usually within a week after delivery: its severe thunderclap headache usually relapses within a few days, resolving by approximately twelve weeks after clinical onset ²⁸⁾. The typical differential diagnosis is cerebral vasculitis, which needs to be ruled out due to the course of the disease and different treatment options.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiological clinical entity characterized by insidious onset of headache, impaired consciousness, visual changes or blindness, seizures, nausea, and vomiting, and focal neurological signs. In nearly 2/3 of patients with posterior reversible encephalopathy syndrome, headache is the most common symptom and is usually described as occipital and bilateral and dull in nature ²⁹⁾. Symptoms develop without prodrome, and progress over 12–48 hours.

Posterior reversible encephalopathy syndrome is often associated with hypertensive encephalopathy, preeclampsia, eclampsia, reversible cerebral vasoconstriction syndrome, renal failure, immunosuppressive therapy or chemotherapy. posterior reversible encephalopathy syndrome is more common in women and the development of this condition after delivery is unusual. The condition is usually reversible when early diagnosis is established and appropriate treatment is started without delay; symptoms generally resolve within a period of days or weeks while recovery of the MRI abnormalities takes longer ³⁰⁾.

Idiopathic intracranial hypertension

Usually during the first trimester, obese women can suffer from a progressive, daily headache, aggravated by Valsalva and position change, associated with papilledema and severe visual deficits, together with tinnitus or sixth-nerve palsies, defining the clinical pattern of idiopathic intracranial hypertension ³¹⁾. The headache is frequently described as frontal, retro-orbital, ‘pressure like’ or explosive; migraine-like headache may also occur.

Pituitary apoplexy

Pituitary apoplexy is a rare cause of sudden and severe headache during pregnancy ³²⁾. The sudden rise of a severe headache, with nausea, vomiting, ophtalmoplegia, altered consciousness and accompanied from onset or later by visual symptoms and/or hypopituitarism must raise the clinical suspicion of a pituitary apoplexy ³³⁾. The rare clinical syndrome of pituitary apoplexy is an acute, life-threatening condition. It is important to distinguish from the other causes of thunderclap headache ³⁴⁾. Most cases occur as the first presentation of rapid enlargement of non-functioning pituitary macroadenomas as a result of hemorrhage and/or infarction.

What can I do to prevent headaches in pregnancy?

There are some things you can do to prevent headaches. Try to:

• figure out what causes your headache also called a headache trigger. Common headache triggers are cigarette smoke, certain foods and eye strain. Once you know your triggers, try to limit or get rid of them.
• drink at least eight glasses of fluid a day to avoid dehydration
• do something active every day
• get enough sleep every night. Rest during the day when you can.
• eat a healthy, balanced diet
• rest and relax as much as possible. You could try things like mindfulness or yoga
• try to reduce your stress. Stress is worry, strain or pressure that you feel in response to things that happen in your life. Tell your health care provider if you need help to reduce your stress.

Talk to your health care provider before you take any medicine, supplement or herbal product to relieve your headache. Some may be harmful to your baby.

Headaches in pregnancy treatment

It’s not advisable for pregnant women with migraine to use migraine medicine. For other headaches it’s also recommended that you try to treat your headache without medicine, however your health care provider may recommend acetaminophen.

You may want to try to relieve your headache with one or more of the following natural remedies:

• getting more sleep or rest and relaxation
• pregnancy yoga classes or other exercise
• practising good posture, particularly later in your pregnancy
• eating regular, well-balanced meals
• putting a warm facecloth on your eye and nose area, if it is a sinus headache
• putting a cold pack on the back of your neck, taking a bath or using a heat pack, if it is a tension headache
• neck and shoulders massage
• if you have a sinus headache, apply a warm compress around your eyes and nose
• if you have a tension headache, apply a cold compress or ice pack at the base of your neck
• maintain your blood sugar by eating smaller, more frequent meals – this may also help prevent future headaches
• get a massage – massaging your shoulders and neck is an effective way to relieve pain
• rest in a dark room and practice deep breathing
• take a warm shower or bath
• practice good posture (especially during the third trimester).

Pregnant women who experience migraine should avoid things that may trigger their migraine headaches. This may include:

• chocolate
• alcohol
• yogurt
• peanuts
• bread
• sour cream
• preserved meats
• aged cheese
• bread with fresh yeast
• monosodium glutamate (MSG)
• caffeine (withdrawal from)
• bright or flickering lights
• strong smells
• loud sounds
• computer or movie screens
• sudden or excessive exercise
• emotional triggers such as arguments or stress

If you do take medicine for your headache or migraine you should check with your doctor, pharmacist or midwife first. Acetaminophen (paracetamol) with or without codeine, is generally considered safe for pregnant women to use but you should avoid using other pain medicine such as aspirin or ibuprofen.

Diarrhea in pregnancy

Diarrhea literally means “flowing through” and is defined as having three or more loose or liquid bowel movements in a 24 hour period. If you are experiencing three runny, watery bowel movements in one day, the main concern is to stay hydrated. You can lose a significant amount of fluids when experiencing diarrhea during pregnancy. Dehydration can be serious, even deadly. You will need to make sure you are re-hydrating yourself. Diarrhea is rarely life-threatening, but it shouldn’t be taken too lightly, especially while pregnant.

When it lasts just a few days, diarrhea typically is related to an infection (usually gastroenteritis) or eating something that upsets your stomach.

Diarrhea that develops without an identifiable trigger or in combination with low back pain and increased vaginal discharge or mucus can be symptoms of preterm labor. Call your doctor immediately if you experience this combination of symptoms.

Diarrhea in pregnancy third trimester

Diarrhea during the third trimester is not uncommon and is more likely to happen as you approach your due date. It could be a sign that labor is near, and it can occur right before labor or a couple of weeks before labor. If it is a couple of weeks before your due date, a premature birth should not be expected.

If you are experiencing diarrhea during your third trimester, it does not mean your baby is coming right now, so you should not be alarmed. This is just a way some women’s bodies prepare for the labor that is going to start at some point. You may want to be aware of other labor signs as well.

What causes diarrhea during pregnancy?

Don’t be surprised if you experience diarrhea during pregnancy. When you first find out you are pregnant, you may make sudden changes in your diet to make sure your baby is getting the nutrients they need. If you change the food you eat, that can sometimes cause an upset stomach or diarrhea.

Another reason diarrhea occurs is because some pregnant women become sensitive to particular foods. These could be foods you have eaten often before, but eating them while pregnant can give you an upset stomach or diarrhea. Another cause of diarrhea during pregnancy is hormonal changes.

Sometimes hormones can cause your digestive process to slow down, and at times that can lead to diarrhea. Every pregnant woman has these hormonal changes, but some will experience diarrhea early in their pregnancy from those changes. If you are experiencing diarrhea, it could also be due to a bacterial or viral infection.

Diarrhea in pregnancy treatment

Most cases of diarrhea will clear up on its own within a couple of days. The main concern of diarrhea is staying hydrated. Make sure you drink plenty of water, juice, and broth to rehydrate yourself and replace the electrolytes your body has lost. The water will help replenish your lost fluids, the juice will help replenish your potassium levels and the broth will help replenish your sodium.

If your diarrhea doesn’t clear up on its own you may need to consult your doctor. If diarrhea during your pregnancy is caused by bacteria or parasites, you may need antibiotics. If a virus is causing your diarrhea, antibiotics will not help. To determine the cause, you will need to speak with your health care provider.

Pregnancy discharge

All women, whether they’re pregnant or not, have some vaginal discharge starting a year or two before puberty and ending after the menopause. How much discharge you have changes from time to time and it usually gets heavier just before your period.

Almost all women have more vaginal discharge in pregnancy. Normal vaginal discharge during pregnancy is called leukorrhea and is thin, white, milky, and mild smelling. This is quite normal and happens for a few reasons. During pregnancy the cervix (neck of the womb) and vaginal walls get softer and discharge increases to help prevent any infections traveling up from the vagina to the womb. Towards the end of pregnancy, the amount of discharge increases and can be confused with urine.

In the last week or so of pregnancy, your discharge may contain streaks of thick mucus and some blood. This is called a ‘show’ and happens when the mucus that has been present in your cervix during pregnancy comes away. It’s a sign that the body is starting to prepare for birth, and you may have a few small ‘shows’ in the days before you go into labor.

Increased discharge is a normal part of pregnancy, but it’s important to keep an eye on it and tell your doctor or midwife if it changes in any way.

You should notify your health care provider any time there is a change in normal pregnancy discharge. NEVER try to diagnose and treat yourself. Spotting during pregnancy can be normal but should be mentioned to your health care provider.

Notify your doctor immediately if you experience spotting or bleeding that is enough to fill a pad or tampon, lasts longer than a day, and is accompanied by cramping or pain.

During pregnancy DO NOT:

• Use tampons-they can introduce new germs into the vagina.
• Douche – this can interrupt the normal balance of healthy bacteria in the vagina and lead to infection.
• Assume that it is a vaginal infection and treat it yourself.

During pregnancy DO:

• Use panty liners if it makes you more comfortable.
• Notify your health care provider at your appointment of any changes.

Is it normal to have vaginal discharge in pregnancy?

Yes. Almost all women have more vaginal discharge in pregnancy. This is normal, and helps prevent any infections traveling up from the vagina to the womb.

Towards the end of pregnancy, the amount of discharge increases further. In the last week or so of pregnancy, it may contain streaks of sticky, jelly-like pink mucus.

This is called a “show”, and happens when the mucus that’s been present in your cervix during pregnancy comes away.

It’s a sign that the body is starting to prepare for birth. You may have a few small “shows” in the days before you go into labor.

What does normal vaginal discharge in pregnancy look like?

The discharge during pregnancy should be clear or milky white. This extra vaginal discharge in pregnancy is nothing to worry about.

Check if your vaginal discharge is normal:

• Vaginal discharge doesn’t have a strong or unpleasant smell
• Vaginal discharge is clear or white
• Vaginal discharge is thick and sticky
• Vaginal discharge is slippery and wet

The amount of discharge varies. You usually get heavier discharge during pregnancy, if you’re sexually active or if you’re using birth control. It’s often slippery and wet for a few days between your periods (when you ovulate).

How do I know if it’s normal vaginal discharge or the mucus plug?

The amount of vaginal discharge increases even more towards the end of your pregnancy and during the last week. It might also contain streaks of sticky, jelly-like pink mucus. This is called a ‘show’ and happens when the mucus plug that’s in your cervix during pregnancy comes away.

If you get a ‘show’, your body might be preparing for birth. Don’t get too excited or panicked though. You could have a few shows before you go into labor. If you’re worried about anything, speak to your doctor.

What is abnormal vaginal discharge?

If your vaginal discharge is green or yellowish, has strong-smell and/or accompanied by redness or itching, you may have a vaginal infection. One of the most common vaginal infections during pregnancy is candidiasis, also known as a yeast infection. Another cause of abnormal discharge could also be an sexually transmitted infection (also called STI, sexually transmitted disease or STD). A sexually transmitted infection (STI) is an infection you can get from having unprotected sex or intimate physical contact with someone who is infected. You can get an STI from having unprotected vaginal, anal or oral sex. You can get a sexually transmitted disease even if you’re pregnant—being pregnant doesn’t protect you from getting infected.

Sexually transmitted diseases can be cause by bacteria, viruses or parasites. Many people with sexually transmitted diseases don’t know they’re infected because they often have no signs or symptoms. Nearly 20 million new sexually transmitted infections happen each year in the United States.

Some sexually transmitted infections can spread in ways other than sex. For example, you can get some sexually transmitted infections, like HIV, syphilis and herpes, by having direct contact with body fluids from an infected person. This can happen by genital touching, touching or kissing an infected sore (in the case of syphilis) or by sharing drug needles or other items that come in contact with body fluids from an infected person.

You can pass some sexually transmitted infections to your baby during pregnancy, labor, birth and breastfeeding. Sexually transmitted infections can cause serious problems for babies. Early testing and treatment can help protect your baby from infection.

Bacterial vaginosis also called BV or vaginitis, is an infection caused when there’s too much of certain bacteria in the vagina. It’s not an sexually transmitted infection, but you’re more likely to get it if you have a new sex partner or more than one sex partner. If you have bacterial vaginosis, you’re at increased risk of getting an sexually transmitted infection.

Table 1. Vaginal discharge that can be a sign of an infection

Discharge	Possible cause
Smells fishy	Bacterial vaginosis
Thick and white, like cottage cheese	Thrush (yeast infection)
Green, yellow or frothy	Trichomoniasis
With pelvic pain or bleeding	Chlamydia or gonorrhea
With blisters or sores	Genital herpes

How can you protect yourself and your baby from sexually transmitted infections?

The best way to protect your baby from sexually transmitted infections is to protect yourself from sexually transmitted infections. If you have an sexually transmitted infection, the best way to protect your baby is to get early and regular treatment during pregnancy.

Here’s what you can do to reduce your risk and your baby’s risk for infection:

• Don’t have sex. Sex includes vaginal, oral and anal sex.
• Limit the number of sex partners you have. Have sex with only one person who doesn’t have other sex partners.
• Use a condom every time you have sex. Condoms are barrier methods of birth control. Barrier methods help prevent pregnancy and sexually transmitted infections by blocking or killing your partner’s sperm. Male latex condoms work best to prevent sexually transmitted infections; other kinds of condoms don’t work as well. Other kinds of birth control, like the pill and implants, don’t protect you from sexually transmitted infections.
• Don’t share needles, syringes, razors or other things that may come in contact with another person’s blood or body fluid.
• Get tested and treated. Early testing and treatment can help reduce the risk of passing an sexually transmitted infection to your baby. Ask your partner to get tested and treated, too. Even if you get treated for an sexually transmitted infection, you can get re-infected (get the infection again) if your partner is infected.
• Go to all your prenatal care checkups, even if you’re feeling fine. You may have an sexually transmitted infection and not know it. If you think you may have an sexually transmitted infection, tell your provider so you can get tested and treated right away.
• Get vaccinated. Vaccinations can help protect you from some sexually transmitted infections, like hepatitis B and some types of human papillomavirus (also called HPV). Vaccinations are shots that contain a vaccine that helps make you immune to certain diseases. If you’re immune to a disease, you can’t get the disease.

What problems can sexually transmitted infections cause during pregnancy?

Having an sexually transmitted infection during pregnancy can cause serious problems for you and your baby, including:

• Premature birth. This is birth that happens too soon, before 37 weeks of pregnancy. Premature babies can have serious health problems at birth and later in life.
• Low birthweight. This is when a baby is born weighing less than 5 pounds, 8 ounces.
• Premature rupture of the membranes also called PROM. This is when the sac around your baby breaks (your water breaks) before you go into labor.
• Pelvic inflammatory disease also called PID. Pelvic inflammatory disease is an infection of a woman’s reproductive organs, including the uterus (also called womb), fallopian tubes, ovaries and cervix. These organs all play a part in pregnancy. PID can make it hard for you to get pregnant. During pregnancy, it can lead to problems like ectopic pregnancy. An ectopic pregnancy can cause serious problems for you and always ends in pregnancy loss. Reproductive organs include the uterus (also called womb), ovaries, fallopian tubes and cervix. All of these organs play a part in a woman’s getting pregnant.
• Miscarriage. This is when a baby dies in the womb before 20 weeks of pregnancy.
• Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.

Having an sexually transmitted infection can cause problems for your baby after birth, too, like problems with the eyes, lungs and liver. Some of these problems can affect your baby’s entire life, and some can even cause death. This is why it’s important to get tested and treated for sexually transmitted infections. Treatment before and during pregnancy can help protect your baby from infection.

How do I know if you have an sexually transmitted infection?

Sexually transmitted infections often have no signs or symptoms, so you may not know you’re infected. Signs of a condition are things someone else can see or know about you, like you have a rash or you’re coughing. Symptoms are things you feel yourself that others can’t see, like having a sore throat or feeling dizzy.

Common signs and symptoms of sexually transmitted infections include:

• Flu-like symptoms, including headache and fatigue (feeling very tired)
• Vaginal discharge or burning, itching, redness or swelling in the vaginal area
• Pain, itching or burning when you go to the bathroom; pain, discharge or bleeding in the rectum (where bowel movements leave the body); or painful bowel movements
• Belly pain
• Pain during sex or bleeding after sex or between periods
• Eye infections
• Sores on the mouth or the vaginal, genital or anal areas

As part of your prenatal care (medical care you get during pregnancy), your health care provider tests you for certain sexually transmitted infections, including:

• Chlamydia and gonorrhea. These sexually transmitted infections are most common in women younger than 25. Most infected women have no signs or symptoms. You’re tested for these sexually transmitted infections with a Pap test (when your provider collects cells from your cervix).
• Genital herpes. You can get genital herpes from unprotected sex or through direct contact with an infected person’s herpes sore or fluid from a herpes sore. Having genital herpes during pregnancy can cause serious health problems for your baby, including brain infection (also called herpes encephalitis); eye diseases; infection of the liver, lungs, kidneys, skin and mouth; and even death. You’re most likely to pass herpes to your baby if you have genital herpes sores and blisters (called an outbreak) for the first time late in pregnancy. You get tested for genital herpes with a blood test.
• Hepatitis B also called hep B. You can get hep B from unprotected sex or through direct contact with infected body fluids, like blood, saliva, semen and vaginal fluid. It spreads easily through breaks in the skin or in soft body tissues in the nose, mouth and eyes. If untreated, hep B can damage your liver. Many infected women have no signs or symptoms, but some may have jaundice. This is when your liver isn’t working properly so your eyes and skin look yellow. The Centers for Disease Control and Prevention (also called CDC) recommends that all pregnant women get a blood test for hep B and that any adult, including pregnant women, at risk for hep B gets vaccinated. You can get vaccinated even if you’re not at risk for hep B. If you’re pregnant and you test positive for hep B, you get another test that can help your provider know if your baby’s at risk for infection. Babies with hep B can have life-long health problems, including liver problems. CDC recommends that all babies get vaccinated for hep B at birth and later as part of their regular vaccination schedule, and that all babies born to women with hep B get vaccinated and treated for hep B at birth.
• Human papillomavirus (HPV). HPV is the most common sexually transmitted infection in the United States. In most cases, HPV goes away on its own. But if it doesn’t, it can cause genital warts (small bumps in the genital area) and cancer of the cervix (also called cervical cancer). The Centers for Disease Control and Prevention (also called CDC) recommends women up to age 26 get the HPV vaccination to protect them from HPV. If you’re pregnant and have an HPV infection with genital warts, you may get more warts during pregnancy. They may grow large enough to block the vagina. If this happens, you may need to have a cesarean birth (also called c-section). A c-section is surgery in which your baby is born through a cut your doctor makes in your belly and uterus (womb). It’s rare for HPV to pass from mother to baby during pregnancy. If it does happen, it can cause warts to grow on the baby’s voice box (also called larynx). You get tested for HPV with a Pap test.
• Human immunodeficiency virus (HIV). HIV is a virus that attacks the body’s immune system. The immune system protects the body from infections, cancers and some diseases. If untreated, HIV can lead to AIDS. In the United States, HIV is most commonly spread through unprotected sex with or by sharing drug needles with an infected person. Having HIV can make it easier for you to get infected with other sexually transmitted infections. If you have HIV, early and regular treatment during pregnancy can help protect your baby from infection. You get tested for HIV with a blood test.
• Syphilis. You can get syphilis from unprotected sex or through direct contact with (touching or kissing) an infected person’s syphilis sore. If not treated, syphilis can damage your eyes, heart, brain and spinal cord. If you have syphilis, early and regular treatment during pregnancy can help protect your baby from infection. When a baby is born with syphilis, it’s called congenital syphilis. Congenital syphilis is completely preventable, but many babies born to moms with untreated syphilis die from the infection. The best way to protect your baby from congenital syphilis is to prevent infection before and during pregnancy. You get tested for syphilis with a blood test.
• Zika. Your provider may test you for Zika if you have signs or symptoms of infection or if you or your partner has been in an area where Zika is spreading. Zika is a virus that spreads mainly through mosquito bites and unprotected sex with an infected person. Zika often has no signs or symptoms so you may not know you’re infected. If you have Zika during pregnancy, it causes a birth defect called microcephaly (a condition where the head is smaller than normal) that’s part of a condition called congenital Zika syndrome. If you’re pregnant and you think you’ve been exposed to Zika before or during pregnancy, tell your doctor right away.

Ask your doctor about getting tested for sexually transmitted infections during pregnancy. Find out which tests you get and when you get them. If you think you may have an sexually transmitted infection, tell your doctor. Early testing and treatment can help protect your baby.

How are sexually transmitted infections treated?

Early testing and treatment can help protect you and your baby from most sexually transmitted infections.

If you have an sexually transmitted infection that’s caused by bacteria, your doctor prescribes antibiotics to treat it. Bacteria are tiny organisms that live in and around your body. Some bacteria are good for your body, and others can make you sick. Antibiotics are medicines that kill infections caused by bacteria.

Sexually transmitted infections that are caused by a virus (like HIV, HPV, herpes or hepatitis) can’t be cured with treatment. But treatment can help you manage signs and symptoms.

Should vaginal discharge smell different in pregnancy?

Talk to your doctor if your discharge has an unpleasant smell, you feel itchy or sore, or you have pain when you urinate. If your discharge changes, for example in smell, color or texture, it might be a sign of infection.

Do I have normal pregnancy discharge or a yeast infection?

Yeast infections, which are also known as thrush, are more common than any other time in a woman’s life, especially during the second trimester of pregnancy. Thrush makes vaginal discharge thick, white and cottage cheese like. This is common and a normal symptom in the second trimester.

A fungus called candida, which is normally harmless, causes thrush. It tends to grow in warm, moist conditions. Thrush develops if the normal balance of bacteria in the vagina changes, which happens in pregnancy. Yeast infection occurs when the normal levels of acid and yeast in the vagina are out of balance, which allows the yeast to overgrow causing an uncomfortable, but not serious a condition.

Higher levels of estrogen are another part of pregnancy that can make thrush more likely. Thrush during pregnancy can be treated easily, so speak to your doctor or midwife to find out what help is available.

If you have never been diagnosed or treated by a doctor for a yeast infection and have some of the symptoms, you should see your doctor first for accurate diagnosis and treatment. Other infections have similar symptoms, so you want to make sure that you are treating the infection correctly. There are also treatments that are not appropriate during pregnancy.

Furthermore, if you are experiencing symptoms similar to a yeast infection, but a doctor has not made the diagnosis, you may have one of the following:

• Sexually Transmitted Diseases (STDs) like Chlamydia, Gonorrhea and Trichomoniasis
• A vaginal infection called bacterial vaginosis

What causes yeast infections during pregnancy?

A yeast infection can be caused by one or more of the following:

• Hormonal changes that come with pregnancy or before your period
• Taking hormones or birth control pills
• Taking antibiotics or steroids
• High blood sugar, as in diabetes
• Vaginal intercourse
• Douching
• Blood or semen.

What are the symptoms of yeast infections?

The symptoms of a yeast infection may include one or more of the following:

• Vaginal discharge that is usually white/tan in color, similar to cottage cheese and may smell like yeast/bread
• Other discharge may be greenish or yellowish, also similar to cottage cheese and may smell like yeast/bread
• An increase in discharge
• Redness, itching, or irritation of the lips of the vagina
• Burning sensation during urination or intercourse.

How do I know for sure if I have a yeast infection?

At your doctor’s office or medical clinic, a clinician will use a simple, painless swab to remove the discharge or vaginal secretions and examine it through a microscope. Usually, upon a simple examination of the vagina, a physician can diagnose a yeast infection. In rare cases, the culture may be sent to a lab.

How are yeast infections treated during pregnancy?

During pregnancy, doctors recommend vaginal creams and suppositories only. The oral medication, Diflucan (a single-dose medication), has not been proven safe during pregnancy and lactation. Not all vaginal creams and suppositories are okay to use during pregnancy, so it is best to consult your doctor or pharmacist to get the right one. If left untreated, yeast infections can pass to your baby’s mouth during delivery. This is called “thrush” and is effectively treated with Nystatin.

It may take 10-14 days to find relief or completely clear up the infection while you are pregnant. After the infection has cleared up and any sores have healed, it may be helpful to use a starch-free drying powder, or Nystatin powder to prevent a recurring infection.

How can I stop my yeast infection coming back?

Thrush can keep coming back but most yeast infections can usually be avoided by doing the following:

• Avoid washing down there with soap or shower gels, wipes or feminine hygiene products.
• Use a soap substitute for washing and just wash once a day.
• After regular, thorough washing (using unscented, hypoallergenic or gentle soap), use your blow dryer on a low, cool setting to help dry the outside of your genital area.
• Avoid vaginal douching, which is when people flush water up inside the vagina to wash it.
• Avoid wearing tight-fitting clothes.
• Wear loose, breathable cotton clothing and cotton underwear.
• Always wipe from front to back after using the restroom.
• Shower immediately after you swim. Change out of your swimsuit, workout clothes, or other damp clothes as soon as possible.
• Include yogurt with “lactobacillus acidophilus” in your diet.
• Consider using probiotics like live yogurts directly where you’re feeling the symptoms of thrush. You can also eat and drink probiotics.
• Limit sugar intake, as sugar promotes the growth of yeast.
• Get plenty of rest to make it easier for your body to fight infections.

DO NOT:

• use feminine hygiene sprays
• use sanitary pads and tampons that contain deodorant
• take a bubble bath/use scented soaps
• use colored or perfumed toilet paper.

Pregnancy discharge causes

Vaginal discharge is a fluid or mucus that keeps your vagina clean and moist and prevents infection. Vaginal discharge gets heavier during pregnancy, especially towards the end, as it helps to stop bacteria going up to the womb from the vagina. You’re also likely to get more discharge when you’re pregnant because more blood is flowing to the area.

Pregnancy discharge treatment

Discharge during pregnancy is just one of the seemingly endless but normal and temporary changes that pregnancy brings. You don’t need to do anything about it.

If you’re finding thrush (yeast infection) a real nuisance, you could try unscented panty liners or change your pants more often during the day. Also see above for preventive measures.

Pregnancy gingivitis

Gingivitis is an inflammation of the gums that is caused when plaque that contains bacteria slowly backs up on your teeth and gums accumulates in the spaces between the gums and the teeth. The accumulation of bacteria release toxins that can lead to the loss of bone around the teeth and can eventually lead to tooth decay and tooth loss. During pregnancy, about half of all women (60 to 70 percent) experience a condition called pregnancy gingivitis or swollen gums during pregnancy. Prolonging gingivitis can lead to much more serious conditions like periodontitis—a much more dangerous form of gum disease. Periodontal disease can cause an infection that destroys the bone supporting your teeth which may lead to tooth loss, bleeding gums and bad breath.

Pregnant women are at increased risk for periodontal disease because the increased levels of progesterone hormone that come with pregnancy cause an increased response to plaque bacteria in the mouth.

Your dentist will be able to help with your swollen and bleeding gums during pregnancy. If you’re pregnant, your dental professional needs to know about the first signs of gingivitis symptoms. Gingivitis is most common during months two to eight of pregnancy. Tell your dental professional when you are pregnant—he or she may recommend more frequent dental cleanings during the second trimester or early in the third trimester to help combat the effects of increased progesterone and help you avoid gingivitis. This extra plaque may cause swelling, bleeding, redness and/or tenderness in the gums. As a result, pregnant women are more likely to develop gingivitis even if they follow a consistent oral health care routine.

When you want to treat gum disease, especially gingivitis, try these simple but effective methods:

• Brush twice a day, every day
• Floss twice a day, every day
• Rinse thoroughly with an anti-gingivitis mouthwash. Avoid mouthwashes that contain alcohol.
• Mouthwashes cannot remove existing plaque. Only regular toothbrushing and flossing can do this.
• A daily salt rinse (1 teaspoon of salt added to a cup of warm water) can help reduce gum inflammation. Swirl the wash around your mouth a few times before spitting it out (do not swallow).
• Visit your dentist regularly

Pregnancy gingivitis causes

Pregnant women are at increased risk for periodontal disease because the increased levels of progesterone hormone that come with pregnancy cause an increased response to plaque bacteria in the mouth.

Plaque

Your mouth is full of bacteria that combine with saliva to form a sticky film known as plaque, which builds up on your teeth. When you consume food and drink high in carbohydrates (sugary or starchy foods), bacteria in plaque turn carbohydrates into the energy they need, producing acid at the same time. Over time, acid in plaque begins to break down your tooth’s surface and causes tooth decay.

Other bacteria in plaque can also irritate your gums, making them inflamed and sore.

Plaque is usually easy to remove by brushing and flossing your teeth, but it can harden and form a substance called tartar if it’s not removed.

Tartar sticks much more firmly to teeth than plaque and can usually only be removed by a dentist or dental hygienist.

Conditions related to gum disease

As well as poor oral hygiene, a number of things can increase your risk of developing problems with your gums. Conditions like diabetes and heart disease can also be impacted by gum disease. In fact, 95% of people who suffer from diabetes will experience some form of gum disease. Gum disease also impacts heart health, and could even lead to cardiovascular disease if not treated.

• Diabetes: Several types of health conditions contribute to poor healing of oral tissues. But people with diabetes should always be aware that they are at risk for poor healing from any type of dental problem. Diabetes is one of the most common endocrine disorders. People with diabetes are at greater risk for infections and often suffer from dry mouth, which can promote tooth decay and gingivitis. And because people with diabetes are also prone to poor healing of oral tissues, gingivitis can be more difficult to treat if it does occur. This is why a regular oral care routine is especially important. If you have sensitive teeth or gums, choose a toothbrush with soft bristles and a soft floss to minimize discomfort. If you have diabetes, be sure to tell your dental professional. He or she may want results from a blood test to show how well you control your condition.
• Vitamin C deficiency: Gum tissue conditions can have many causes, but don’t forget to consider poor nutrition. Inadequate vitamin C can promote bleeding gums that can develop into gingivitis if left untreated. Vitamin C also helps the body perform maintenance and repair on bones, teeth, and cartilage, and it also helps wounds heal.
• Malnutrition: A condition that occurs when a person’s diet does not contain the right amount of nutrients.
• Smoking
• Stress
• Weakened immune system – for example, because of conditions like HIV and AIDS or certain treatments, such as chemotherapy.

You may also be more likely to have gum disease if you’re taking medicines that cause a dry mouth. These medicines include antidepressants and antihistamines.

Pregnancy gingivitis prevention

It’s very important to keep your teeth and gums clean and healthy while you’re pregnant. The best way to prevent or deal with gum problems is to practise good oral hygiene.

To control the amount of plaque in your mouth and to prevent pregnancy gingivitis, follow these steps to reduce the bacteria that can lead to pregnancy gingivitis.

Steps to prevent pregnancy gingivitis and look after your teeth and gums:

• Remember to floss twice daily to remove small bits of food from between your teeth, which will help to prevent the build-up of plaque and avoid the build-up of bacteria.
• Brush thoroughly at least twice a day for 2 minutes with a fluoride toothpaste, preferably in the morning and at night. Ask your dentist to show you a good brushing method to remove plaque.
• Take your time; you should spend at least two minutes brushing your teeth
• Be sure to use anti-plaque toothpaste to help protect your teeth from decay and gingivitis
• Rinse thoroughly after brushing to get rid of bacteria in hard-to-reach places. Avoid mouthwashes that contain alcohol.
• A daily salt rinse (1 teaspoon of salt added to a cup of warm water) can help reduce gum inflammation. Swirl the wash around your mouth a few times before spitting it out (do not swallow).
• Eat a healthy, balanced diet; be sure that you are getting enough calcium, vitamins D, C and A, phosphorous and protein.
• Avoid sugary snacks, drinks (such as fizzy drinks or sweet tea) and sugary foods too often – try to keep them to meal times.
• If you’re hungry between meals, snack on foods such as vegetables, fresh fruit or plain yogurt, and avoid sugary or acidic foods.
• Stop smoking, as it can make gum disease worse.
• Continue to visit your dentist regularly.

If you have morning sickness (nausea and vomiting), rinse your mouth with plain water after each time you are sick. This will help prevent the acid in your vomit from damaging your teeth.

Do not brush your teeth straight away as they will be softened by the acid from your stomach. Wait about an hour before brushing.

Pregnancy gingivitis signs and symptoms

Healthy gums should be pink, firm and keep your teeth securely in place. Your gums should not bleed when you touch or brush them.

Gum disease is not always painful and you may be unaware you have it. Pregnancy gingivitis and its later form, periodontitis—are formed by plaque buildup along the gum line. Though you may not notice anything in mild cases of gum disease, sensitive teeth, bleeding or swollen gums are the most common warning signs that something needs to be addressed.

Bleeding after brushing your teeth is due to early stages of pregnancy gingivitis. Now, if you just started to floss again, you will likely see some blood due to the irritation it causes in the gums initially. However, this should only last a short amount of time and even so, your gums should not bleed just from brushing.

Other symptoms include swollen gums, the persistence of bad breath (or having a bad taste in your mouth), shifting teeth and the formation of pockets between your teeth and your gums. On top of this, it is possible you actually have gum disease but just can’t see the conditions, depending on the area of the gums suffering from periodontitis. Seeing your dental professional every six months allows you to stay on top of this potential condition.

If gingivitis goes without treatment, it develops into periodontitis or gum disease. Eventually, the inner layers of the gum begin to pull away from the teeth. This forms pockets on either side of the teeth. The spaces collect debris brushing your teeth will not always remove, causing infection in the gums and the gum line to shrink. As the gum line shrinks, the pockets enlarge, and you run the risk of teeth falling out and suffering from other serious oral conditions.

Early symptoms of gum disease

This stage of gum disease is called gingivitis. Gum disease is not always painful and you may be unaware you have it.

The initial symptoms of gum disease can include:

• red and swollen gums
• bleeding gums after brushing or flossing your teeth

Advanced symptoms

If gingivitis is untreated, the tissues and bone that support the teeth can also become affected. This is known as periodontitis, or periodontal disease.

Symptoms of periodontitis can include:

• bad breath (halitosis)
• an unpleasant taste in your mouth
• loose teeth that can make eating difficult
• collections of pus that develop under your gums or teeth (gum abscesses)

Acute necrotizing ulcerative gingivitis

In rare cases, a condition called acute necrotizing ulcerative gingivitis (ANUG) can develop suddenly.

The symptoms of acute necrotising ulcerative gingivitis are usually more severe than those of gum disease and can include:

• bleeding, painful gums
• painful ulcers
• receding gums in between your teeth
• bad breath
• a metallic taste in your mouth
• excess saliva in your mouth
• difficulty swallowing or talking
• a high temperature (fever).

Pregnancy gingivitis complications

If you develop pregnancy gingivitis and do not have the plaque or tartar (hardened plaque) removed from your teeth, the condition may get worse and lead to periodontitis.

You may develop further complications if you do not treat periodontitis, where the tissue that supports teeth is affected.

These include:

• recurrent gum abscesses (painful collections of pus)
• increasing damage to the periodontal ligament (the tissue that connects the tooth to the socket)
• increasing damage to and loss of the alveolar bone (the bone in the jaw that contains the sockets of the teeth)
• receding gums
• loose teeth
• loss of teeth

Acute necrotizing ulcerative gingivitis

If you have acute necrotizing ulcerative gingivitis (ANUG) and it’s not treated, it can cause more severe complications. The infection can spread to all areas of your gums and the alveolar bone surrounding your teeth.

This can lead to:

• the gums between your teeth being completely destroyed
• large ulcers (open sores) leaving permanent holes in your gums
• loose and unstable teeth

If acute necrotizing ulcerative gingivitis is not properly treated the first time you have it, you’re more likely to have recurring cases in the future. This can cause persistent bad breath (halitosis) and bleeding gums, as well as gradually receding gums.

In rare cases, acute necrotizing ulcerative gingivitis can lead to gangrene affecting the lips and cheeks. This occurs when tissue starts to die and waste away. If you develop gangrene, you may need to have the dead tissue removed.

Other complications

Gum disease has also been associated with an increased risk for a number of other health conditions, including:

• cardiovascular disease
• lung infections
• premature labor and having a baby with a low birth weight if you’re affected during pregnancy

But while people with gum disease may have an increased risk of these problems, there’s not currently any clear evidence that gum disease directly causes them.

Pregnancy gingivitis treatment

Go to the dentist so they can give your teeth a thorough clean and show you how to keep your teeth clean at home. There are ways in which you can treat or severely limit gum disease. First and foremost, follow your dentist’s instructions for regular oral care at home in order to get the most benefit out of your treatment. That means twice-daily tooth brushing and flossing, plus regular visits to the dentist for follow-ups and professional cleanings. If you experience any new problems following a regular oral care routine, ask your dental hygienist or dentist to recommend products that can make your routine easier.

Oral hygiene

Good oral hygiene involves:

• Brushing your teeth for about 2 minutes last thing at night before you go to bed and on 1 other occasion every day – it does not matter if you use an electric or manual toothbrush, but some people find it easier to clean their teeth thoroughly with an electric toothbrush
• Using toothpaste that contains the right amount of fluoride, a natural mineral that helps protect against tooth decay
• Flossing your teeth or using interdental brushes regularly – preferably daily, before brushing your teeth
• Not smoking
• Regularly visiting your dentist – at least once every 1 to 2 years, but more frequently if necessary

Mouthwash

Antiseptic mouthwashes containing chlorhexidine or hexetidine are available over the counter from pharmacies. But there’s some debate about whether using mouthwash is necessary for people with healthy gums.

Mouthwashes cannot remove existing plaque. Only regular toothbrushing and flossing can do this.

Your dentist may recommend using mouthwash if it helps control the build-up of plaque, the sticky substance that forms when bacteria collects on the surface of your teeth.

Your dentist will be able to advise you about which type of mouthwash is most suitable and how to use it.

Chlorhexidine mouthwash can stain your teeth brown if you use it regularly.

Rinse your mouth thoroughly between brushing your teeth and using a chlorhexidine mouthwash as some ingredients in toothpaste can prevent the mouthwash working.

You should not use a chlorhexidine mouthwash for longer than 4 weeks.

Dental treatments

Some of the dental treatments described here may also be recommended if you have gum disease.

Scale and polish

To remove plaque and tartar (hardened plaque) that can build up on your teeth, your dentist may suggest that you have your teeth scaled and polished. This is a “professional clean” usually carried out at your dental surgery by a dental hygienist. The dental hygienist will scrape away plaque and tartar from your teeth using special instruments, then polish your teeth to remove marks or stains.

If a lot of plaque or tartar has built up, you may need to have more than 1 scale and polish.

Root planing

In some cases of gum disease, root planing (debridement) may be required. This is a deep clean under the gums that gets rid of bacteria from the roots of your teeth.

Before having the treatment, you may need to have a local anesthetic (painkilling medication) to numb the area. You may experience some pain and discomfort for up to 48 hours after having root planing.

Further treatment

If you have severe gum disease, you may need further treatment, such as periodontal surgery.

In some cases, it’s necessary to remove the affected tooth.

Your dentist will be able to tell you about the procedure needed and how it’s carried out. If necessary, they can refer you to a specialist.

If you’re having surgery or root planing, you may be given antibiotics (medication to treat infections). Your dentist will tell you whether this is necessary.

Stopping smoking

Smoking is one of the most significant risk factors for gum disease.

Acute necrotizing ulcerative gingivitis

Acute necrotizing ulcerative gingivitis should always be treated by a dentist. But if you see your doctor before visiting a dentist, they may provide you with some treatment while you wait to see your dentist.

As well as the oral hygiene advice and dental treatments mentioned above, treatments for acute necrotizing ulcerative gingivitis may also include antibiotics, painkillers and different types of mouthwash.

Antibiotics

Treatment with antibiotics, such as metronidazole or amoxicillin, may be recommended if you have acute necrotizing ulcerative gingivitis. You’ll usually have to take these for 3 days.

Amoxicillin is not suitable for people allergic to penicillin.

Metronidazole can react with alcohol, causing you to feel very unwell. You should not drink alcohol while you’re taking metronidazole and for 48 hours after you finish the course of treatment.

Other side effects of metronidazole and amoxicillin can include feeling sick, vomiting and diarrhea.

Painkillers

Acetaminophen (paracetamol) and ibuprofen are the most commonly prescribed painkillers.

They’re also available over the counter from pharmacies. They may help reduce pain and discomfort.

But paracetamol and ibuprofen are not suitable for everyone, so read the manufacturer’s instructions before taking them.

Mouthwash

Mouthwash containing chlorhexidine or hydrogen peroxide may be prescribed to treat acute necrotising ulcerative gingivitis. Some chlorhexidine mouthwashes are also available over the counter, though they may not be as effective as a hydrogen peroxide mouthwash.

You should always read the instructions before using mouthwash. Some types may need to be diluted in water before they’re used.

Nosebleeds in pregnancy

Nosebleeds during pregnancy also called epistaxis, are fairly common. Nosebleeds are quite common in pregnancy because of hormonal changes. Although nosebleeds can be frightening, in most cases there’s no need to worry about as long as you don’t lose a lot of blood and you should be able to treat a bleeding nose yourself at home. However, see your doctor if you’re worried about your nosebleeds. During pregnancy, you may also find that your nose gets more blocked up than usual.

Nosebleeds can give you a fright or be a nuisance, but as long as you don’t lose a lot of blood, they are generally nothing to be worried about. In most cases, a nosebleed won’t harm you or your baby.

While the odd nosebleed may be annoying, serious nosebleeds in otherwise healthy pregnant women are very rare.

During a nosebleed, blood flows from one or both nostrils. Nosebleed can be heavy or light and last from a few seconds to more than 10 minutes. The blood flow can be light or quite heavy.

Nosebleeds can happen at night, while you’re sleeping. You might feel liquid in the back of your throat before blood comes out of your nose if you’re lying down. You may wake up feeling the blood going down the back of your throat before you sit up. It will then come out of your nose.

But if your nosebleeds are heavy, recurrent or occur alongside other symptoms, speak to your doctor. Nosebleeds in pregnancy are sometimes associated with:

• a higher incidence of postpartum hemorrhage
• hypertension and pre-eclampsia
• nasal aemangioma (a small harmless growth in the nose)
• pregnancy-related coagulopathies (blood-clotting disorders)
• taking aspirin or other anti-coagulant treatments.

If nosebleed are serious, your doctor may use various treatments and will check whether any underlying issues are causing your nosebleeds. The doctor may offer cauterization, which is a burning treatment that seals bleeding blood vessels, or nasal packing, where gauze is packed into the nose .

Figure 1. Nose external anatomy

Figure 2. Nasal septum

Figure 3. Arteries involve in nose bleeds (nasal septum)

Figure 4. Arterial supply of the nasal cavity

Footnote: The different territories supplied by the internal carotid artery (green) and the external carotid artery (yellow) are indicated in a). The Kiesselbach area (blue) is supplied by branches of both the main arteries (red).

a) Arteries supplying the nasal septum and b) the lateral walls of the nasal cavity.

[Source ¹⁾ ]

Are nosebleeds in pregnancy common?

Yes, absolutely. Around one in five pregnant women get nosebleeds, so you aren’t alone if you’re suffering from nosebleeds while pregnant.

Nosebleeds in pregnancy causes

During your first trimester the amount of blood circulating in your body increases and your heart works harder. This means that the lining of your nasal passage (inside your nose) also receives more blood. You have tiny blood vessels inside your nose so the increased blood volume can sometimes damage those blood vessels and cause them to burst, resulting in a nosebleed.

Changes in your hormones during pregnancy can also contribute to nosebleeds.

These changes can make your nose feel congested (stuffy) and it might get more blocked up than usual. Your gums may also feel swollen and may bleed.

Nose bleeds can often occur if you:

• Have allergies, infections, or dryness that cause itching and lead to picking of the nose.
• Pick your nose
• Blow your nose too hard that ruptures superficial blood vessels
• Strain too hard on the toilet
• Have an infection in the nose, throat or sinuses
• Low humidity or irritating fumes: If your house is very dry, or if you live in a dry climate, the lining of your child’s nose may dry out, making it more likely to bleed. If he is frequently exposed to toxic fumes (fortunately, an unusual occurrence), they may cause nosebleeds, too.
• Receive a bump, knock or blow to the head or face
• Have a cold
• Have a bunged-up or stuffy nose from an allergy.
• Anatomical problems: Any abnormal structure inside the nose can lead to crusting and bleeding (e.g., deviated septum)
• Are taking some types of medicines, such as anticoagulants (e.g., warfarin) or anti-inflammatories (e.g., aspirin) or nose sprays
• Clotting disorders that run in families or are due to medications.
• •Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously.
• •Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.
• Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.

In general, nose bleeds are not a symptom or result of high blood pressure. It is possible, but rare, that severe high blood pressure may worsen or prolong bleeding if you have a nosebleed.

How can you prevent a nose bleed?

Your nose contains many small blood vessels. Due to the increase in blood circulation during your pregnancy, these blood vessels are more prone to burst, causing a nosebleed. If you are blowing your nose, do so gently and try to avoid large sneezes. This will help reduce your possibility of having a nosebleed during pregnancy.

You should also avoid picking your nose. You could be more likely to get nosebleeds in winter months when the air is drier, so you may like to use a dehumidifier in your home to moisten the air. The moistened air will help decrease your chances of a nosebleed while pregnant.

If you’ve recently had a nosebleed:

• Sneeze with your mouth open.
• Try to avoid bending down or vigorously exercising for at least 12 hours afterwards.
• Avoid hitting your nose on anything.

Nosebleeds in pregnancy treatment

How to stop a nosebleed:

1. Sit down and keep your head upright. This reduces the pressure in the blood vessels inside your nose and will help to slow down the bleeding.
2. Firmly pinch the soft part of your nose, just above your nostrils (underneath the bony ridge), for 10 to 15 minutes without releasing the pressure.
3. Lean forward and breathe through your mouth. This will drain blood down your nose instead of down the back of your throat.
4. Sit or stand upright, rather than lying down, as this reduces the blood pressure in the veins of your nose and will discourage further bleeding.
5. Spit out any blood that is in your mouth.
6. Place a covered ice pack, or a packet of frozen peas wrapped in a tea towel, on the bridge of your nose. You may also want to suck an ice cube.
7. After 10 to 15 minutes, gently release your pinch to see if the bleeding has stopped.

If the bleeding doesn’t stop, try this procedure again for another 10 minutes or seek medical advice – see your doctor urgently.

For the next 24 hours, you should try to avoid:

• Avoid blowing or picking your nose your nose, bending down and strenuous activity for at least 12 hours after a nosebleed.
• Avoid heavy lifting
• Avoid strenuous exercise
• Avoid drinking alcohol or hot drinks.

It’s a good idea to swallow lots of water, as dryness in your nose can make nosebleeds worse. Other ideas to reduce dryness include using a humidifier in your house or dabbing some petroleum jelly in each nostril.

Vulvar varicosities during pregnancy

Vulvar varicosities are varicose veins (dilated veins) at the vulva or outer surface of the female genitalia (in the labia majora and labia minora) ¹⁾. Vulvar varicosities occur most often during pregnancy. This is due to the increase in blood volume to the pelvic region during pregnancy and the associated decrease in how quickly your blood flows from your lower body to your heart. As a result, blood pools in the veins of your lower extremities as well as your vulvar region, causing vulvar varicosities. Vulvar varicosities can occur alone or along with varicose veins of the legs.

The anatomical basis for the development of vulvar varicosities relates to the connections between the veins of the pelvis and external genitals ²⁾. Vulvar veins drain into the external and internal pudendal veins, which deliver blood to the great saphenous vein and internal iliac vein. The veins of the labia majora and labia minora anastomose with the uterovaginal plexus. In addition, the connection to the pelvic veins is provided via the obturator vein and superficial circumflex iliac vein, as well as the groin, clitoral, and perineal perforant veins.

It is estimated that between 4 percent and 22 percent of women and 22–34 percent of women with varicose veins of the pelvis will develop vulvar varicose veins during pregnancy, although the actual figure is most likely to be much higher with many women not developing any symptoms, or being too embarrassed to discuss the symptoms with their doctor ³⁾. In some patients, vulvar varicosities may be associated with a chronic pelvic pain syndrome called pelvic congestion syndrome ⁴⁾. Vulvar varicosities are rare during a first pregnancy and generally develop during month 5 of a second pregnancy and occurred most often in women with a history of two or more full-term pregnancies (91%). The risk increases with the number of pregnancies ⁵⁾.

Vulvar varicosities don’t always cause signs and symptoms. If they occur, they might include a feeling of fullness or pressure in the vulvar area, vulvar swelling and discomfort. In extreme cases, the dilated vessels can bulge. They might look bluish and feel bumpy. Long periods of standing, exercise and sex can aggravate the condition.

During the postpartum period, perineal veins may persist and enlarge with time in 4%–8% of patients ⁶⁾. Vulvar varicosities are associated with venous thromboembolic events, both during pregnancy and in the nonpregnant state, superficial dyspareunia (painful intercourse), and vulvar pain (vulvodynia) ⁷⁾. Vulvar varicosities may also cause psychoemotional and family problems. It is difficult to estimate reliably the prevalence of this pathological condition, as vulvar varicosities often remain undiagnosed because of the atypical localization of the varicose veins, women’s reluctance to consult, and in some cases the absence of any discomfort.

In most cases, vulvar varicosities can be diagnosed at clinical examination, and do not require any special investigation methods. Their diagnosis requires an assessment of the state of the intrapelvic veins, and in cases of pregnancy further observation and examination in the postpartum period.

Vulvar varicosities treatment varies from purely conservative measures during pregnancy to various surgical procedures on the ovarian and vulvar veins. A diagnostic and treatment algorithm for vulvar varicosities in various clinical situations is presented in Figure 4. An individualized approach to diagnostic methods and treatment for this disorder can significantly improve the quality of care of patients with chronic venous diseases.

To feel relief:

• Get a support garment. Look for one specifically designed for vulvar varicosities. Some designs also provide support for the lower abdomen and lower back.
• Change position. Avoid standing or sitting for long periods of time.
• Elevate your legs. This can help promote circulation.
• Apply cold compresses to your vulva. This might ease your discomfort.

Vulvar varicosities likely won’t affect your mode of delivery. These veins tend to have a low blood flow. As a result, even if bleeding occurred, it could easily be controlled.

Typically, vulvar varicosities related to pregnancy go away within about six weeks after delivery.

Figure 1. The vulva

Figure 2. Vulvar varicose veins

Footnotes: A 33-year-old woman was admitted for induction of labor at 41 weeks 3 days of gestation. This was her third full-term pregnancy, and she had received regular antenatal care. Before induction, the physical examination revealed venous varicosities on the right labia majora and minora and the right vaginal wall (Panel A). Varicose veins in both legs were also noted. The patient reported that the varicosities had developed several months earlier and caused increasing discomfort and pruritus, but she had been embarrassed to mention them. She had had smaller varicosities during her previous pregnancies, with normal vaginal delivery. Vulvovaginal varicosities are common in pregnancy and usually appear in the second trimester. Possible mechanisms include compression of the inferior vena cava by the gravid uterus and hormonal changes. The presence of vulvar varicosities is not a contraindication for vaginal delivery, but clinical discretion regarding the route of delivery is required, depending on the size and location of the varicosities. In this instance, the patient underwent caesarean delivery without complications. The vulvar varicosities were substantially smaller after delivery (Panel B).

[Source ⁸⁾ ]

Figure 3. Thrombophlebitis of the vulvar veins. Hyperemia and edema in the area of thrombosed veins (arrow).

Figure 4. Vulvar varicosities diagnostic and treatment algorithm

Abbreviations: DUS = duplex ultrasound; VTE = venous thromboembolic event; UV = uterine vein; PV = parametrial vein; GV = gonadal (ovarian) vein; PVC = pelvic venous congestion; VAD = venoactive drug; MSCT = multislice computed tomography; SOPP = selective ovariography with pelvic phlebography; PhE = phlebectomy; ST = sclerotherapy; VCI = vena cava inferior; VCFI = vena cava-filter implantation; ACT = anticoagulant therapy.

[Source ⁹⁾ ]

Will the vulvar varicose veins rupture during childbirth?

It’s highly unlikely that damaged vein will rupture during childbirth. There have been a few cases of the varicose vein rupturing during pregnancy, however following the above tips, and seeking professional advice, will help prevent this from happening.

The good news is for most women is the varicose veins will resolve on their own after several months post-partum. In some cases, it can take up to a year. For a small percentage of women, however, varicose veins will not shrink or disappear after pregnancy and may require medical treatment.

Varicose veins and swelling in your legs, ankles and feet

If you look down and can’t see your ankles, you’re not alone. Many women have swelling in their legs, ankles and feet during pregnancy. Swelling may be caused by pregnancy hormones, having more fluid in your body during pregnancy, and pressure from your growing baby on the veins that carry blood to your heart.

Pressure on a vein called the inferior vena cava may cause sore, itchy, blue bulges on your legs. These are called varicose veins. They usually don’t cause problems, but they’re not pretty. You’re more likely to have them if it’s your first pregnancy or if other people in your family have them.

Here’s what you can do to help relieve varicose veins and swelling in your legs, ankles and feet:

• Don’t stand for long periods of time.
• When you’re sitting down, put your feet up. Don’t cross your legs when you sit.
• When you’re lying down, put your legs up on a pillow.
• Sleep on your left side. This takes pressure off the vein that returns blood from the lower parts of your body to your heart.
• Wear support hose or compression stockings or leggings. These fit tight all over and can help control swelling. Don’t wear socks or stockings that have a tight band of elastic around the leg.
• Do something active every day. Talk to your provider about activities that are safe during pregnancy.
• Put an ice pack on swollen areas.

If you have extreme or sudden swelling, call your doctor right away. These may be signs of a serious condition called preeclampsia. This condition can happen after the 20th week of pregnancy. It’s when a woman has high blood pressure and signs like a severe headache that mean that some of her organs aren’t working properly.

Vulvar varicosities causes

Varicose veins can develop in your vulva during pregnancy due to normal changes that occur to your body at this time, such as:

• increased blood volume
• hormonal softening of the walls of your veins
• increasing pressure on the large veins in the abdomen and pelvis as your baby grows.

Vulvar varicosities symptoms

Not all women with vulvar varicosities will be able to see them and most often they are asymptomatic. Some women will have visible veins around the vulva or inner thigh. Yet others will not show any visible signs but they will experience pain.

If you don’t have any physical side-effects, here are a few symptoms you can look out for:

• Pain around the pelvis or lower back, usually described as a dull ache.
• A feeling of heaviness or fullness of the vulva.
• Any pain in the vulva that gets worse after standing, sexual activity, or physical activity.
• Swelling or itchiness around the vulva.
• An increase in urination.

In rare cases, they cause anxiety, pain, and manifest as heaviness, discomfort during walking, painful intercourse (dyspareunia) and pruritus (itch).

Vulvar varicosities complicationa

Complications such as thrombosis or bleeding are rare. A superficial thrombosis presents as a painful, red (inflammatory) swelling, and is firm to the touch. It requires examination to look for an underlying deep venous thrombosis. Spontaneous bleeding appears to be of academic interest, and in practice is not observed. Bleeding during childbirth is associated with vaginal tears or an episiotomy; internal bleeding results in formation of a hematoma, primarily affecting the labia. Vulvar varices are not an indication for a cesarean section delivery.

Vulvar varicosities diagnosis

Clinical examination of the patient standing and then supine reveals the following: soft, bluish dilatations, depressible by digital examination, with no painful point (sign of thrombosis). Often, this varicose network extends downwards to the medial aspect of the thigh, towards the long saphenous trunk, and sometimes posteriorly to the anal margin. The perfectly bilateral nature and the fact that they are associated with a varicose network in both lower limbs are reassuring.

The diagnostic test of pregnant women with vulvar varicosities is limited to duplex ultrasound of the veins of the perineum and lower extremities. This diagnostic test is required not only to verify the diagnosis but also to exclude latent thrombosis in the inferior vena cava in the presence of subjective symptoms. Dilation of the external pudendal vein and associated reflux, which represents an obvious reason for formation of vulvar varicosities, was found in 56% of patients.

Vulvar varicosities treatment

Vulvar varicosities treatment is symptomatic during pregnancy and curative afterward if the vulvar varicosities persist. The good news about vulvar varicose veins during pregnancy is that they are likely to disappear spontaneously within a few days of giving birth and rarely persist one month later.

Follow-up of 25 patients who developed vulvar varicosities during pregnancy for at least 1 year after childbirth revealed that dilated vulvar veins persisted in only 20% of patients ¹⁰⁾. A reduction in vulvar varicosity was observed from the first days after birth, and most patients reported their complete disappearance within 2–8 months (5.8±1.04 months on average).

An association was found between the end of lactation period or a reduction in breastfeeding and the rate of vulvar varicosity disappearance: the shorter the lactation period, the earlier the varicose veins of the perineum disappeared, and vice versa. This once again indicates that hormonal changes play an important role in the development of varicose veins of the lower extremities, in the perineum, and in the small pelvis during pregnancy.

During pregnancy

Here are few safe ways you can treat the symptoms and prevent further damage to the varicose veins:

• Avoid standing still for any length of time—move, walk, change positions.
• Strictly avoid any squatting (kneel or sit on a stool). This is very important.
• Avoid constipation (this increases the strain pressure on your veins). Make sure your bowel motions are soft and easy to pass and sit in the emptying position using hand support under your perineum. Remember:
  • maintain curve in lower back
  • lean forward from the hips
  • allow abdomen to relax forward
  • always keep breathing
  • no straining
  • a small footstool may enhance position.
• Avoid any other activities that cause straining such as lifting, pushing, pulling, sneezing or coughing. When you cannot avoid any of these activities, use your hands or a rolled towel to help support your perineum.
• Lie down to rest–often. Sitting does not relieve the pressure on this area. Lying on your side is best.
• Ice fingers – cold compresses may give temporary relief. A trick some women use after giving birth is filling a rubber glove with cold water and ice. Using the glove as an ice-pack can help reduce swelling and relieve pain. Please note: ice should not be held on the area for longer than 30 minutes to 1 hour. Ice can reduce the blood flow needed for your body to heal.
• Practise your pelvic floor exercises regularly this will help blood to circulate better in the area and strengthen the supporting tissues around the veins.
• Supportive underwear – using support garments to assist in reducing the symptoms of vulval varicosities. Many women also find that full leg support stockings can some provide relief. You can also try supportive underwear (with a gusset) or bike pants with double sanitary pads inside. You will get the best results if you apply garments and support hosiery before getting out of bed in the morning (i.e. before gravity has taken effect).
• Pruritus (itch) is treated by bathing with a foaming solution without soap, and then a water-based zinc oxide paste. Pain and heaviness are treated with high-dose phlebotonic agents ¹¹⁾.
• Aromatherapy – some aromatherapists suggest using diluted geranium oil in a bath or soaked into a gauze pad as a direct compress to the area.

It should be remembered that pregnancy is a risk factor for venous thrombosis.

• Bleeding requires compression therapy.
• Sclerotherapy is always possible during pregnancy. It does not carry any particular risks either for the woman or the fetus. It is rarely performed because its beneficial results are uncertain in an unfavorable hormonal context.

After pregnancy

A month after delivery, vulvar varices most often have disappeared. Small, asymptomatic residual vulvar varicose veins are seen again after 1 year. Large or symptomatic varices are managed with curative therapy. Sclerotherapy is the preferred method because it is very effective on these thin-walled varices. It is administered most often in a very superficial varicose vein blister under visual control using a very fine gauge needle (30G) and a liquid sclerosing product. Sclerosing foamy products are more thrombogenic and are not indicated here. The dose used is 1 cc of 0.5% or 1% Aetoxisclerol; or 0.33% or 0.5%.Trombovar.

Varices in the groin or the mons veneris can be treated with echosclerosis. Care should be taken to avoid the external pudendal artery for which an accidental injection produces disastrous lesions in the vascular area downstream. Identification with the duplex color technique, by greatly increasing gains in the future area of injection, is essential to keeping in mind that “what is not seen exists” ¹²⁾.

Phlebectomy remains possible for perineal varices ¹³⁾, but is little performed because of the good results obtained with sclerotherapy. The same holds true for ligation of the labial or marginal perforating veins with the patient in the lithotomy position after identification by sonography.

Pregnancy hemorrhoids

Hemorrhoids also called piles, are a normal part of your anatomy. You have both internal and external hemorrhoids, located inside the anal canal and around the anal opening, respectively. The internal hemorrhoids are a part of the blood supply to the anus and are made up of small arterial branches. External hemorrhoids are veins. You are not aware of your hemorrhoids when they are in their normal state. Hemorrhoids cause no symptoms. Pregnancy predisposes women to symptomatic hemorrhoids that usually resolve after delivery. During pregnancy, hemorrhoids are caused by increased blood flow in the pelvic area and the pressure on veins there from your growing uterus. Constipation can make your hemorrhoids worse. Constipation is when you don’t have bowel movements or they don’t happen often, or your stools (poop) are hard to pass. Adding fiber and fluids to your diet can help prevent constipation and hemorrhoids.

If you have a hemorrhoid, you may feel a tender lump on the edge of your anus. You may also see blood on the toilet paper or in the toilet after a bowel movement. Hemorrhoids may also be itchy and painful.

The symptoms of hemorrhoids can be relieved with ice packs to reduce swelling. Sitting in a bath of warm water may relieve symptoms. You also may use a hemorrhoid cream or suppositories.

Surgical intervention is contraindicated because of the risk of inducing labor ¹⁾. Conservative treatment is recommended, with excision of thrombosed external hemorrhoids if necessary.

Hemorrhoids are very common in both men and women. Nearly half of Americans have hemorrhoids by age 50 ²⁾. If you have bleeding or severe pain, see your doctor right away.

Figure 1. Pregnancy hemorrhoids

Types of hemorrhoids

The type of hemorrhoid you have depends on where it occurs.

• Internal hemorrhoids involve the veins inside your rectum. Internal hemorrhoids usually don’t hurt but they may bleed painlessly.
• Prolapsed hemorrhoids may stretch down until they bulge outside your anus. A prolapsed hemorrhoid may go back inside your rectum on its own, or you can gently push it back inside.
• External hemorrhoids involve the veins outside the anus. They can be itchy or painful and can sometimes crack and bleed.

Internal hemorrhoids

Painless rectal bleeding or prolapse of anal tissue is often associated with symptomatic internal hemorrhoids. Prolapse is hemorrhoidal tissue coming from the inside that can often be felt on the outside of the anus when wiping or having a bowel movement. This tissue often goes back inside spontaneously or can be pushed back internally by the patient. The symptoms tend to progress slowly over a long time and are often intermittent.

Internal hemorrhoids are classified by their degree of prolapse ³⁾, which helps determine management:

• Grade One: No prolapse
• Grade Two: Prolapse that goes back in on its own
• Grade Three: Prolapse that must be pushed back in by the patient
• Grade Four: Prolapse that cannot be pushed back in by the patient (often very painful)

Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk. It may be found on the wipe, dripping into the toilet bowl, or streaked on the bowel movement itself. Not all people with symptomatic internal hemorrhoids will have significant bleeding. Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus. People with internal hemorrhoids may also complain of mucus discharge, difficulty with cleaning themselves after a bowel movement or a sense that their stool is “stuck” at the anus with bowel movements. People without significant symptoms from internal hemorrhoids do not require treatment based on their appearance alone.

Most patients with grade 1 or 2 hemorrhoids, and many with grade 3 hemorrhoids, can be treated in primary care offices. Patients in whom office-based treatment is ineffective (see below under Treatment) and those with mixed hemorrhoids may require treatment in surgical suites with facilities for anesthesia. The most common surgical treatments are ligation or tissue destruction, fixation techniques (i.e., hemorrhoidopexy – hemorrhoid stapling), and excision (i.e., hemorrhoidectomy).

External hemorrhoids

Symptomatic external hemorrhoids often present as a bluish-colored painful lump just outside the anus and they tend to occur spontaneously and may have been preceded by an unusual amount of straining. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood clot or thrombosis develops in this tightly held area, the pressure goes up rapidly in these tissues often causing pain. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. Patients may also complain of intermittent swelling, pressure and discomfort, related to external hemorrhoids which are not thrombosed.

Thrombosed external hemorrhoids

Thrombosed external hemorrhoids cause acute, severe pain. Without intervention, the pain typically improves over two to three days, with continued improvement as the thrombus gradually absorbs over several weeks. Analgesics and stool softeners may be beneficial. Topical therapy with nifedipine and lidocaine cream is more effective for pain relief than lidocaine (Xylocaine) alone ⁴⁾.

In patients with severe pain from thrombosed hemorrhoids, excision or incision and evacuation of the thrombus within 72 hours of symptom onset provide more rapid pain relief than conservative treatment ⁵⁾. Both procedures can be performed under local anesthesia, and the resulting wound can be left open or sutured ⁶⁾.

Pregnancy hemorrhoids causes

Hemorrhoids are caused by increased pressure in the veins of your anus or rectum. One of the main causes is straining when you’re trying to have a bowel movement. This may happen if you’re constipated or if you have diarrhea. It may also happen if you sit on the toilet too long. Hemorrhoids can also be caused by obesity, heavy lifting or any other activity that caused you to strain.

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from increased pressure in the lower rectum due to:

• Straining during bowel movements or heavy lifting or vigorous activity.
• Pregnancy and vaginal deliveries. Straining during physical labor
• Hard or watery bowel movements.
• Sitting on the toilet for a long time (for example, while reading or playing video games).
• A low-fiber diet.
• Aging.
• Being overweight or obesity
• Constipation
• Anal intercourse

Pregnancy hemorrhoids prevention

Here’s what you can do to help prevent hemorrhoids during pregnancy:

• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
• Drink plenty of water. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
• Consider fiber supplements. Most people don’t get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
• Do something active every day. Talk to your doctor about activities that are safe during pregnancy.
• Gain the right amount of weight during pregnancy. Talk to your doctor about how much you should gain.
• Don’t strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
• Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
• Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
• Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

Pregnancy hemorrhoids symptoms

Signs and symptoms of hemorrhoids may include:

• Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet
• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• A lump near your anus, which may be sensitive or painful (may be a thrombosed hemorrhoid)

Hemorrhoid symptoms usually depend on the location.

Internal hemorrhoids. These lie inside the rectum. You usually can’t see or feel these hemorrhoids, and they rarely cause discomfort. But straining or irritation when passing stool can damage a hemorrhoid’s surface and cause it to bleed. When they cause symptoms, the most common are painless rectal bleeding, which usually is seen as bright red blood on the toilet paper or in the toilet bowl. It is important to know that just a few drops of blood in toilet water can change the color of the water dramatically.

Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids. These are under the skin around your anus and cause no symptoms. When they cause symptoms, the most common are pain, itching, pressure and bleeding; they can often be felt as a bulge in the skin near the anal opening.

Thrombosed hemorrhoids. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus) that can result in severe pain, swelling, inflammation and a hard lump near your anus.

Pregnancy hemorrhoids complications

Complications of hemorrhoids are very rare but include:

• Anemia. Rarely, chronic blood loss from hemorrhoids may cause anemia, in which you don’t have enough healthy red blood cells to carry oxygen to your cells.
• Strangulated hemorrhoid. If the blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be “strangulated,” another cause of extreme pain.

Pregnancy hemorrhoids diagnosis

Your doctor may be able to see if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include examination of your anal canal and rectum:

• Digital examination. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths. The exam can suggest to your doctor whether further testing is needed.
• Visual inspection. Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope.

Your doctor may want to examine your entire colon using colonoscopy if:

• Your signs and symptoms suggest you might have another digestive system disease
• You have risk factors for colorectal cancer
• You’re middle-aged and haven’t had a recent colonoscopy.

The American Society of Colon and Rectal Surgeons recommends taking the patient history and performing a physical examination with anoscopy and further endoscopic evaluation if there is concern for inflammatory bowel disease or cancer ⁷⁾. A complete evaluation of the colon is warranted in the following groups ⁸⁾:

• Patients who are 50 years or older and have not had a complete examination of the colon within the past 10 years
• Patients who are 40 years or older and have not had a complete examination of the colon within the past 10 years, and who have one first-degree relative in whom colorectal cancer or adenoma was diagnosed at age 60 years or younger
• Patients who are 40 years or older and have not had a complete examination of the colon within the past five years, and who have more than one first-degree relative in whom colorectal cancer or adenoma was diagnosed at age 60 years or younger
• Patients with iron deficiency anemia
• Patients who have a positive fecal occult blood test.

Pregnancy hemorrhoids treatment

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

Eat high-fiber foods. Eat more fruits, vegetables and whole grains – it is usually recommended you eat 20-35 grams of fiber per day. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.

Don’t sit for a long time. Get up and move around to help move the weight of your uterus off of the pelvic veins.

Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.

Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. Make sure the water’s not hot. A sitz bath fits over the toilet.

Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.

Don’t use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn’t contain perfume or alcohol.

Apply cold patch or witch hazel pads. Apply ice packs or cold compresses on your anus to relieve swelling.

Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

Ask your doctor about over-the-counter medicine (creams or wipes) that are safe to use during pregnancy. Also ask about fiber supplements and stool (poop) softeners. Don’t take any medicine, supplement or herbal product without talking to your doctor first. Over-the-counter medicine is medicine you can buy without a prescription from your doctor. A supplement is a product you take to make up for certain nutrients that you don’t get enough of in the foods you eat. An herbal product, like a pill or tea, is made from herbs (plants) that are used in cooking.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don’t get relief in a week, or sooner if you have severe pain or bleeding.

What is oligohydramnios

Oligohydramnios is a condition when you have too little amniotic fluid. Amniotic fluid is the fluid that is contained in the amniotic sac and it surrounds your baby in your uterus (womb). Amniotic fluid is very important for your baby’s development. Oligohydramnios may occur with late pregnancies, ruptured membranes, placental dysfunction, or fetal abnormalities.

While in the womb, your baby floats in the amniotic fluid. The amount of amniotic fluid is greatest at about 34 weeks (gestation) into the pregnancy, when it averages 800 mL. About 600 mL of amniotic fluid surrounds the baby at full term (40 weeks gestation).

The amniotic fluid constantly moves (circulates) as the baby swallows and “inhales” the fluid, and then releases it.

During pregnancy, amniotic fluid provides a cushion that protects the baby from injury and allows room for growth, movement and development. Amniotic fluid also keeps the umbilical cord from being compressed between the baby and the uterine wall. In addition, the amount of amniotic fluid reflects the baby’s urine output — a measure of a baby’s well-being.

The amniotic fluid helps:

• The developing baby to move in the womb, which allows for proper bone growth
• The lungs to develop properly
• Prevents pressure on the umbilical cord
• Keep a constant temperature around the baby, protecting from heat loss
• Protect the baby from outside injury by cushioning sudden blows or movements

If you have oligohydramnios (low amniotic fluid), what happens next will depend on the cause, severity, your baby’s gestational age, your health and your baby’s health.

Various factors can contribute to oligohydramnios in pregnancy, including:

• Your water breaking
• The placenta peeling away from the inner wall of the uterus — either partially or completely — before delivery (placental abruption)
• Certain health conditions in the mother, such as chronic high blood pressure
• Use of certain medications, such as angiotensin-converting enzyme (ACE) inhibitors
• Certain health conditions in the baby, such as restricted growth or a genetic disorder

If you have oligohydramnios (low amniotic fluid) and you’re 36 to 37 weeks pregnant, the safest treatment might be delivery. If you’re less than 36 weeks pregnant, your doctor will review your baby’s health, discuss why you might have oligohydramnios (low amniotic fluid) and recommend monitoring your pregnancy with fetal ultrasounds. He or she also might recommend drinking more fluids — especially if you’re dehydrated.

If you have oligohydramnios (low amniotic fluid) during labor, your doctor might consider a procedure in which fluid is placed in the amniotic sac (amnioinfusion). This is typically done during labor if there are fetal heart rate abnormalities. Amnioinfusion is done by introducing saline into the amniotic sac through a catheter placed in the cervix during labor.

Oligohydramnios (low amniotic fluid) during pregnancy is a serious condition. If you have any concerns about the amount of fluid around your baby, talk with your health care provider.

Figure 1. Amniotic fluid

How do you know if you have oligohydramnios?

If you notice that you are leaking fluid from your vagina, tell your health care provider. It may be a sign of oligohydramnios. Your provider watches out for other signs, such as if you’re not gaining enough weight or if the baby isn’t growing as fast as he should.

Your health care provider uses ultrasound to measure the amount of amniotic fluid. There are two ways to measure the fluid: amniotic fluid index (AFI) and maximum vertical pocket (MPV).

The amniotic fluid index (AFI) checks how deep the amniotic fluid is in four areas of your uterus. The amniotic fluid index (AFI) is an estimate of the amniotic fluid volume in a pregnant uterus. It is part of the fetal biophysical profile. These amounts are then added up. If your amniotic fluid index (AFI) is less than 5 centimeters, you have oligohydramnios.

The maximum vertical pocket (MPV) measures the deepest area of your uterus to check the amniotic fluid level. If your maximum vertical pocket (MPV) is less than 2 centimeters, you have oligohydramnios.

The deepest (maximal) vertical pocket (MPV) depth is considered a reliable method for assessing amniotic fluid volume on ultrasound ¹⁾. It is performed by assessing a pocket of a maximal depth of amniotic fluid which is free of an umbilical cord and fetal parts.

The usually accepted MPV values are:

• MPV <2 cm: indicative of oligohydramnios
• MPV 2-8 cm: normal but should be taken in the context of subjective volume
• MPV >8 cm: indicative of polyhydramnios (although some centers, particularly in Australia, New Zealand and the United Kingdom, use a cut off of >10 cm)

Ask your health provider if you have questions about these measurements.

Figure 2. Oligohydramnios ultrasound

Footnote: Gestation 23+6/40, transverse lie. Estimation of fetal weight <5th percentile and abdominal circumference (AC) on 15th percentile. Amniotic fluid index (AFI) is reduced at 2.5. An AFI < 5-8 is indicative of oligohydramnios. In this case there is also reduced amniotic fluid volume subjectively. The cause in this case was preterm premature rupture of membranes (PPROM).

What causes oligohydramnios

Sometimes the causes of oligohydramnios are not known. Some known causes are:

• Health problems, such as high blood pressure or preexisting diabetes (having too much sugar in the blood before pregnancy)
• Certain medications, like those used to treat high blood pressure – If you have high blood pressure, talk to your provider before getting pregnant to make sure your blood pressure is under control.
• Post-term pregnancy – A pregnancy that goes 2 or more weeks past the due date. A full-term pregnancy is one that lasts 39 to 41 weeks.
• Birth defects, especially ones that affect the baby’s kidneys and urinary tract.
• Premature rupture of the membranes (PROM) – When the amniotic sac breaks after 37 weeks of pregnancy but before labor starts.

A helpful mnemonic for remembering some causes of oligohydramnios is DRIPPC ²⁾:

• D: Demise and drugs (e.g. prostaglandin inhibitors [indomethacin])
• R: Renal abnormalities (decreased urine output)
  • renal agenesis
  • renal dysplasia
  • posterior urethral valves
  • polycystic kidneys
  • multicystic dysplastic kidney
  • urethral atresia
• I: Intrauterine Growth Restriction (IUGR), 80% may occur from decreased renal perfusion due to sparing effect
• P: Premature rupture of membranes
  • premature rupture of membranes (PROM)
  • preterm premature rupture of membranes (PPROM)
• P: Post-dates. Post dates fetus is when there is prolonged gestation when the fetus remains in-utero beyond 2 weeks beyond expected date of delivery (>42 weeks gestation).
• C: Chromosomal anomalies (especially if other anomalies are found)
  • Trisomy 18. Edwards syndrome, also known as trisomy 18 fetuses can have multiple anomalies in multiple systems
  • Trisomy 13. Patau syndrome (also known as trisomy 13) is considered the 3rd commonest autosomal trisomy.
  • Triploidy. Triploidy is a rare lethal chromosomal (aneupliodic) abnormality caused by the presence of an entire extra chromosomal set.

Associations

• Potter sequence
• Underlying fetal hypoxia and fetal cardiovascular compromise: from preferential flow to the fetal brain at the expense of diminished renal blood flow
• Twin pregnancy-related complications: twin to twin transfusion syndrome: in pump twin
• Maternal dehydration

About 4 out of 100 (4 percent) pregnant women have oligohydramnios. It can happen at any time during pregnancy, but it’s most common in the last trimester (last 3 months). It happens in about 12 out of 100 (12 percent) women whose pregnancies last about 2 weeks past their due dates. This is because the amount of amniotic fluid usually decreases by that time.

Oligohydramnios symptoms

Some of oligohydramnios symptoms may include:

• Fluid leaking from your vagina.
• Your uterus not growing as expected.
• Your baby’s movements slowing down.

Oligohydramnios complications

If oligohydramnios happens in the first 2 trimesters (first 6 months) of pregnancy, it is more likely to cause serious problems than if it happens in the last trimester. These problems can be:

• Birth defects – Problems with a baby’s body that are present at birth
• Miscarriage – When a baby dies in the womb before 20 weeks of pregnancy
• Premature birth – Birth before 37 weeks of pregnancy
• Stillbirth – When a baby dies in the womb after 20 weeks of pregnancy

If oligohydramnios happens in the third trimester of pregnancy, it can cause:

• The baby to grow slowly
• Problems during labor and birth, such as the umbilical cord being squeezed. The umbilical cord carries food and oxygen from the placenta to the baby. If it’s squeezed, the baby doesn’t get enough food and oxygen.
• A greater chance of needing a cesarean section (when your baby is born through a cut the doctor makes in your belly and uterus)

Oligohydramnios diagnosis

Oligohydramnios may be discovered incidentally during routine ultrasonography and noted during antepartum surveillance for other conditions. The diagnosis may be prompted by a lag in sequential fundal height measurements (size less than that expected for the dates) or by fetal parts that are easily palpated through the maternal abdomen ³⁾.

During ultrasonography of the fetal anatomy, normal-appearing fetal kidneys and fluid-filled bladder may be observed to rule out renal agenesis, cystic dysplasia, and ureteral obstruction. Check fetal growth to rule out intrauterine growth restriction (IUGR) leading to oliguria.

Other examinations

MRI and 3-dimensional (3D) ultrasonography are newer (and more expensive) modalities for accurately assessing the amniotic fluid volume ⁴⁾.

Fetal MRI can complement ultrasonography by providing better visualization in the fetus when ultrasound may be limited, in cases such as severe maternal obesity. Although MRI may offer a larger field of view and better tissue contrast and not be limited by shadowing from osseous structures, it has a limited resolution when compared with ultrasonography and is less readily available and is more expensive ⁵⁾.

In 35 women with healthy singleton pregnancies, rapid MRI-based projection hydrography measurement was found to be a better predictor of amniotic fluid volume than ultrasonography (in utero at 28-32 weeks’ gestation). For the ultrasound measurements, single deepest vertical pocket (SDVP) measurement related most closely to amniotic fluid volume, with amniotic fluid index (AFI) demonstrating a weaker relationship. Manual multisection planimetry (MSP)-based measurement of amniotic fluid volume was used as a proxy reference standard ⁶⁾.

Oligohydramnios treatment

If you have a healthy pregnancy and get oligohydramnios near the end of your pregnancy, you probably don’t need treatment. Your provider may want to see you more often. She may want to do ultrasounds weekly or more often to check the amount of amniotic fluid.

Sometimes amnioinfusion can help prevent problems in the baby. Amnioinfusion is when the provider puts a saline solution (salty water) into the uterus through your cervix (the opening to the uterus that sits at the top of your vagina). This treatment can help prevent some problems, such as the umbilical cord being squeezed. If the umbilical cord is squeezed, the baby doesn’t get enough food and oxygen.

If the fluid gets too low or if your baby is having trouble staying healthy, your provider may recommend starting labor early to help prevent problems during labor and birth. However, with regular prenatal care, chances are that your baby will be born healthy.

Drinking lots of water may help increase the amount of amniotic fluid. Your doctor may recommend less physical activity or going on bed rest.

What is polyhydramnios

Polyhydramnios is when you have too much amniotic fluid in the amniotic sac. The amniotic sac (or amnios) is the membranous sac surrounding the developing baby within the uterus (womb). The amniotic fluid within the sac is nourishing, and protects the baby while it is growing.

About 1 out of 100 (1 percent) pregnant women have polyhydramnios. It usually happens when amniotic fluid builds up slowly in the second half of pregnancy. In a small number of women, amniotic fluid builds up quickly. This can happen as early as 16 weeks of pregnancy and it usually causes very early birth.

Polyhydramnios isn’t usually a sign of anything serious, but you’ll probably have some extra check-ups and will be advised to give birth in hospital.

Many women with polyhydramnios don’t have symptoms. If you have a lot of extra amniotic fluid you may have belly pain and trouble breathing. This is because the uterus presses on your organs and lungs. Most cases of polyhydramnios are mild and result from a gradual buildup of amniotic fluid during the second half of pregnancy. Severe polyhydramnios may cause shortness of breath, preterm labor, or other signs and symptoms.

Your health care provider uses ultrasound to measure the amount of amniotic fluid in the later stages of pregnancy. There are two ways to measure the fluid: amniotic fluid index and maximum vertical pocket.

The amniotic fluid index checks how deep the amniotic fluid is in four areas of your uterus. These amounts are then added up. If your amniotic fluid index is more than 24 centimeters, you have polyhdramnios.

The maximum vertical pocket measures the deepest area of your uterus to check the amniotic fluid level. If your maximum vertical pocket is more than 8 centimeters, you have polyhdramnios.

Ask your healthcare provider if you have questions about these measurements.

If you’re diagnosed with polyhydramnios, your health care provider will carefully monitor your pregnancy to help prevent complications. Treatment depends on the severity of the condition. Mild polyhydramnios may go away on its own. Severe polyhydramnios may require closer monitoring.

Will I have a healthy pregnancy and baby?

Most women with polyhydramnios won’t have any significant problems during their pregnancy and will have a healthy baby.

But there is a slightly increased risk of:

• Pregnancy and birth complications, such as giving birth prematurely (before 37 weeks), problems with the baby’s position, or a problem with the position of the umbilical cord (prolapsed umbilical cord)
• A problem with your baby

You’ll need extra check-ups to look for these problems, and you’ll normally be advised to give birth in hospital.

If you’ve been told you have polyhydramnios:

• try not to worry – remember polyhydramnios isn’t usually a sign of something serious
• get plenty of rest – if you work, you might consider starting your maternity leave early
• speak to your doctor about your birth plan – including what to do if your waters break or labor starts earlier than expected
• talk to your doctor if you have any concerns about yourself or your baby, get any new symptoms, feel very uncomfortable, or your tummy gets bigger suddenly

Amniotic fluid

Amniotic fluid is the fluid that surrounds your baby in your uterus (womb) (Figure 1). It’s very important for your baby’s development.

During pregnancy, your uterus is filled with amniotic fluid.

Here’s what the amniotic fluid does:

• Cushions and protects your baby
• Keeps a steady temperature around your baby
• Helps your baby’s lungs grow and develop because your baby breathes in the fluid
• Helps your baby’s digestive system develop because your baby swallows the fluid
• Helps your baby’s muscles and bones develop because your baby can move around in the fluid
• Keeps the umbilical cord (the cord that carries food and oxygen from the placenta to your baby) from being squeezed

The amniotic sac (bag) inside the uterus holds your growing baby. It is filled with amniotic fluid. This sac forms about 12 days after getting pregnant.

In the early weeks of pregnancy, the amniotic fluid is mostly water that comes from your body. After about 20 weeks of pregnancy, your baby’s urine makes up most of the fluid. Amniotic fluid also contains nutrients, hormones (chemicals made by the body) and antibodies (cells in the body that fight off infection).

How much amniotic fluid should there be?

The amount of amniotic fluid increases until about 36 weeks of pregnancy. At that time, it makes up about 1 quart (946 ml). After that, the amount of amniotic fluid usually begins to decrease.

Sometimes you can have too little or too much amniotic fluid. Too little fluid is called oligohydramnios. Too much fluid is called polyhydramnios. Either one can cause problems for a pregnant woman and her baby. Even with these conditions, though, most babies are born healthy.

Does the color of amniotic fluid mean anything?

Normal amniotic fluid is clear or tinted yellow. Fluid that looks green or brown usually means that the baby has passed his first bowel movement (meconium) while in the womb. Usually, the baby has his first bowel movement after birth.

If the baby passes meconium in the womb, it can get into his lungs through the amniotic fluid. This can cause serious breathing problems, called meconium aspiration syndrome, especially if the fluid is thick.

Some babies with meconium in the amniotic fluid may need treatment right away after birth to prevent breathing problems. Babies who appear healthy at birth may not need treatment, even if the amniotic fluid has meconium.

Figure 1. Amniotic fluid and sac

Polyhydramnios complications

The earlier that polyhydramnios occurs in pregnancy and the greater the amount of excess amniotic fluid, the higher the risk of complications.

Polyhydramnios may increase the risk of these problems during pregnancy:

• Premature birth – Birth before 37 weeks of pregnancy
• Premature rupture of the membranes (PROM) – When the amniotic sac breaks after 37 weeks of pregnancy but before labor starts
• Placental abruption – When the placenta partially or completely peels away from the wall of the uterus before birth
• Umbilical cord prolapse — when the umbilical cord drops into the vagina ahead of the baby
• Stillbirth – When a baby dies in the womb after 20 weeks of pregnancy
• Postpartum hemorrhage – Severe bleeding after birth due to lack of uterine muscle tone after delivery
• Fetal malposition – When a baby is not in a head-down position and may need to be born by cesarean section
• Caesarean section delivery

Polyhydramnios causes

In about half of cases, doctors don’t know what causes polyhydramnios. In other cases, they can identify a cause.

Some known causes are:

• Birth defects, especially those that affect the baby’s swallowing or a blockage in the baby’s gut (gut atresia). A baby’s swallowing keeps the fluid in the womb at a steady level.
• Diabetes in the mother– Having too much sugar in your blood, including diabetes caused by pregnancy (gestational diabetes)
• Mismatch between your blood and your baby’s blood, such as Rh (Rhesus disease) and Kell diseases causing the baby’s blood cells being attacked by the mother’s blood cells
• A lack of red blood cells in the baby (fetal anemia)
• Twin-to-twin transfusion syndrome – If you’re carrying identical twins, this is when one twin gets too much blood flow and the other gets too little.
• Problems with the baby’s heart rate
• An infection in the baby
• A problem with the placenta
• a build-up of fluid in the baby (hydrops fetalis)
• A genetic problem in the baby

Most babies whose mothers have polyhydramnios will be healthy. Speak to your doctor or midwife if you’re concerned or have any questions.

Polyhydramnios symptoms

Polyhydramnios tends to develop gradually and there may not be noticeable symptoms.

Polyhydramnios symptoms result from pressure being exerted within the uterus and on nearby organs.

Mild polyhydramnios may cause few — if any — signs or symptoms.

Severe polyhydramnios may cause:

• breathlessness or shortness of breath or the inability to breathe
• Swelling in the lower extremities – swollen feet and abdominal wall
• Heartburn
• Constipation
• Feeling your bump is very big and heavy
• Uterine discomfort or contractions

But these are common problems for pregnant women and aren’t necessarily caused by polyhydramnios. Talk to your doctor if you have these symptoms and you’re worried.

Your health care provider may also suspect polyhydramnios if your uterus is excessively enlarged and he or she has trouble feeling the baby.

In rare cases, fluid can build up around the baby quickly. Contact your doctor if your tummy gets bigger suddenly.

Polyhydramnios diagnosis

If your health care provider suspects polyhydramnios, he or she will do a fetal ultrasound. This test uses high-frequency sound waves to produce images of your baby on a monitor.

If the initial ultrasound shows evidence of polyhydramnios, your health care provider may do a more detailed ultrasound. He or she will estimate the amniotic fluid volume by measuring the single largest, deepest pocket of fluid around your baby. An amniotic fluid volume value of 8 centimeters or more suggests polyhydramnios.

An alternative way of measuring amniotic fluid is measuring the largest pocket in four specific parts of your uterus. The sum of these measurements is the amniotic fluid index (AFI). An AFI of 25 centimeters or more indicates polyhydramnios. Your health care provider will also use a detailed ultrasound to diagnose or rule out birth defects and other complications.

Your health care provider may offer additional testing if you have a diagnosis of polyhydramnios. Testing will be based on your risk factors, exposure to infections and prior evaluations of your baby.

Additional tests may include:

• Blood tests. Blood tests for infectious diseases associated with polyhydramnios may be offered.
• Amniocentesis. Amniocentesis is a procedure in which a sample of amniotic fluid — which contains fetal cells and various chemicals produced by the baby — is removed from the uterus for testing. Testing may include a karyotype analysis, used to screen the baby’s chromosomes for abnormalities.

If you’re diagnosed with polyhydramnios, your health care provider will closely monitor your pregnancy. Monitoring may include the following:

• Nonstress test. This test checks how your baby’s heart rate reacts when your baby moves. During the test, you’ll wear a special device on your abdomen to measure the baby’s heart rate. You may be asked to eat or drink something to make the baby active. A buzzer-like device also may be used to wake the baby and encourage movement.
• Biophysical profile. This test uses an ultrasound to provide more information about your baby’s breathing, tone and movement, as well as the volume of amniotic fluid in your uterus. It may be combined with a nonstress test.

Polyhydramnios treatment

When an ultrasound shows you have too much amniotic fluid, your provider does a more detailed ultrasound to check for birth defects and twin-to-twin transfusion syndrome.

Your provider also may recommend a blood test for diabetes and an amniocentesis. Amniocentesis is a test that takes some amniotic fluid from around the baby to check for problems, like birth defects.

In many cases, mild polyhydramnios goes away by itself. Other times, it may go away when the problem causing it is fixed. For example, if your baby’s heart rate is causing the problem, sometimes your provider can give you medicine to fix it.

In other cases, treatment for an underlying condition — such as diabetes — may help resolve polyhydramnios.

If you have mild to moderate polyhydramnios, you’ll likely be able to carry your baby to term, delivering at 39 or 40 weeks. If you have severe polyhydramnios, your health care provider will discuss the appropriate timing of delivery, to avoid complications for you and your baby.

If you have polyhydramnios, you usually have ultrasounds weekly or more often to check amniotic fluid levels. You may also have tests to check your baby’s health.

Having too much amniotic fluid may make you uncomfortable. Your provider may give you medicine called indomethacin. This medicine helps lower the amount of urine that your baby makes, so it lowers the amount of amniotic fluid. Indomethacin isn’t recommended beyond 31 weeks of pregnancy. Due to the risk of fetal heart problems, your baby’s heart may need to be monitored with a fetal echocardiogram and Doppler ultrasound. Other side effects may include nausea, vomiting, acid reflux and inflammation of the lining of the stomach (gastritis).

Amniocentesis also can remove extra fluid. Your health care provider may use amniocentesis to drain excess amniotic fluid from your uterus. This procedure carries a small risk of complications, including preterm labor, placental abruption and premature rupture of the membranes.

After treatment, your doctor will still want to monitor your amniotic fluid level approximately every one to three weeks.

If you have slight polyhdramnios near the end of your pregnancy but tests show that you and your baby are healthy, you usually don’t need any treatment.

During the rest of your pregnancy, you’ll probably have:

• extra antenatal appointments and ultrasound scans to check for problems with you and your baby
• tests to look for causes of polyhydramnios, such as a blood test for diabetes in pregnancy or amniocentesis (where some amniotic fluid is removed and tested)
• treatment for the underlying cause, if one is found – for example, changes to your diet or possibly medication if you have diabetes

Your doctor may also talk to you about any changes to your birth plan.

You’ll normally be advised to give birth in hospital. This is so any equipment or treatment needed for you or your baby is easily available.

You can usually wait for labor to start naturally. Sometimes induction (starting labor with medication) or a caesarean section (an operation to deliver your baby) may be needed if there’s a risk to you or your baby.

You’ll probably pass a lot of fluid when you give birth – this is normal and nothing to worry about. Your baby’s heartbeat may also need to be monitored during labor.

After giving birth, your baby will have an examination to check they’re healthy and they may have some tests – for example, a tube may be passed down their throat to check for a problem with their gut.

What is preterm labor

Preterm labor is labor that happens before the 37th week of pregnancy. About 8 out of 100 babies will be born prematurely. Labor is when regular contractions lead to opening up of the cervix (neck of the womb). This normally occurs at between 37 and 42 weeks of pregnancy. If it occurs before 37 weeks, it is known as premature labor. Very premature birth is much less common, with fewer than one in 100 babies being born at between 22 and 28 weeks of pregnancy.

Preterm and premature mean the same thing — early. Preterm labor is labor that begins early, before 37 weeks of pregnancy. Labor is the process your body goes through to give birth to your baby. Preterm labor can lead to premature birth. Premature birth is when your baby is born early, before 37 weeks of pregnancy. Your baby needs about 40 weeks in the womb to grow and develop before birth.

Babies born before 37 weeks of pregnancy are called premature. Premature babies can have serious health problems at birth and later in life. About 1 in 10 babies is born prematurely each year in the United States.

• If you believe you are having preterm labor, get medical help right away. If in doubt, get checked early.
• Don’t worry about mistaking false labor for the real thing. Everyone will be pleased if it’s a false alarm.

If your preterm contractions result in preterm labor, your baby will be born early. The earlier premature birth happens, the greater the health risks for your baby. Many premature babies (preemies) need special care in the neonatal intensive care unit. Preemies can also have long-term mental and physical disabilities.

While the specific cause of preterm labor often isn’t clear, certain risk factors may up the odds of early labor. But, preterm labor can also occur in pregnant women with no known risk factors. Still, it’s a good idea to know if you’re at risk of preterm labor and how you might help prevent it.

Signs of preterm labor

The signs of preterm labor can be similar to the signs of labor that starts at full term, and may include:

• Regular or frequent contractions that make your belly tighten like a fist. The contractions may or may not be painful.
• Period-type pains
• A “show” (when the plug of mucus that has sealed the cervix during pregnancy comes away and out of the vagina)
• Change in your vaginal discharge (watery, mucus or bloody) or more vaginal discharge than usual
• Breaking of the waters (rupture of membranes) – this can be a gush or a trickle
• Constant low, dull backache
• Pressure in your pelvis or lower belly, like your baby is pushing down
• Belly cramps with or without diarrhea

If you think your labor (you are having regular, painful tightenings or you think your waters have broken) might be starting and you’re less than 37 weeks pregnant, it is important that you call your doctor or hospital maternity unit straight away. You are likely to be asked to come in. They’ll need to check you and your baby to find out whether you’re in labor, and discuss your care choices with you.

Your doctor or midwife will ask whether you have had a premature birth in a previous pregnancy. You will also be asked about your general health, whether you have had any abdominal pain, tightenings or bleeding, and whether you think your waters have broken.

They’ll offer checks, tests and monitoring to find out whether:

• your waters have broken
• you’re in labor
• you have an infection

You will have a check-up that may include:

• a general examination and a check of your temperature, pulse and blood pressure
• a vaginal examination, blood test, urine test and cardiotocography to record contractions and your baby’s heartbeat
• an examination of your abdomen
• blood sample to check for signs of infection
• urine sample to test for signs of infection

You may also be offered an ultrasound scan to check your baby’s wellbeing and which way round he or she is lying.

The start of labor is usually diagnosed by vaginal examination:

• Your doctor or midwife will use a speculum (an instrument used to separate the walls of the vagina) to see whether the cervix is changing in preparation for labor or has already opened up.
• Your doctor or midwife will also be able to see whether there is fluid leaking, which may indicate that your waters have broken. Sometimes the waters break before 37 weeks but labor doesn’t start.
• A vaginal swab may be taken to check for infection.
• Another type of swab called fetal fibronectin may be taken from the top of the vagina, if you are at between 24 and 34 weeks of pregnancy. This test helps to see whether you are likely to go into labor soon or not:
  • Most women who are suspected of being in premature labor have a negative swab. This is very reassuring because fewer than one in 100 women with a negative test will go into labor within the next 2 weeks.
  • A positive swab means that there is an increased chance you may go into labor. One in five women who have a positive swab go into labor within 10 days.

The swab will be less accurate if you have any bleeding, if your waters have broken or if you have had sexual intercourse in the previous 24 hours.

If labor is not confirmed or if you have a negative fetal fibronectin swab, you should be able to go home if you are well and there are no concerns for you or your baby.

If labor is suspected, you will be advised to stay in hospital. You may be offered:

• A course of two to four corticosteroids injections usually over a 24–48 hour period to help with your baby’s development and reduce the chance of problems caused by being born early (unless you have already received steroids in this pregnancy).
• A course of antibiotics if it is confirmed that your waters have broken, to reduce the risk of an infection getting into the womb.
• An opportunity to talk to one of the neonatal team about the care that your baby is likely to receive, if born early. You and your partner may also wish to visit the neonatal unit.
• Medication (tablets or through a drip) to try to stop labor, if your waters have not broken and there are no concerns about you or your baby. This is only advised in the following circumstances:
  • while you are having your course of corticosteroids
  • if you need to be transferred to a hospital where there is a neonatal intensive care unit, which could be some distance away; this is particularly the case if you are less than 32 weeks pregnant.
• These medications are not routinely recommended for women having twins or triplets because it is not clear that they are beneficial in that situation.
• Treatment with magnesium sulfate, through a drip in your arm. This would be considered if you are less than 30 weeks pregnant and likely to give birth within the next 24 hours. This treatment reduces the chance of complications for your baby, in particular cerebral palsy. You may experience minor side effects such as flushing and nausea. If you are advised to have this treatment, your doctor will discuss it fully with you.

Planned premature labor

In some cases, preterm labor is planned and induced because it’s safer for the baby to be born sooner rather than later.

This could be because of a health condition in the mother, such as pre-eclampsia, or in the baby. Your midwife and doctor will discuss with you the benefits and risks of continuing with the pregnancy versus your baby being born premature.

You can still make a birth plan, and discuss your wishes with your birth partner, midwife and doctor.

What are the risks of preterm birth?

Babies born before full term (before 37 weeks) are vulnerable to problems associated with premature birth. The earlier in the pregnancy a baby is born, the more vulnerable they are. Premature babies have an increased risk of health problems, particularly with breathing, feeding and infection. The earlier your baby is born, the more likely he or she is to have these problems and your baby may need to be looked after in a neonatal unit. However, more than eight out of ten premature babies born after 28 weeks survive and only a small number will have serious long-term disability. Many survivors (as children) who have long-term health problems still rate their quality of life as being good.

Your goal is to get as close to term (40 weeks) as you can before giving birth. The closer you get to term, the greater your chances of having a healthy baby. Work with your doctor or obstetrician. Together you can take steps to keep you from giving birth too early.

Babies are considered ‘viable’ at 24 weeks of pregnancy – this means it’s possible for them to survive being born at this stage. If you give birth before 24 weeks of pregnancy, it is sadly much less likely that your baby will survive. Babies who do survive after such a premature birth often have serious health problems. The possible treatment and outcomes for your baby in your individual situation will be discussed with you.

Premature baby is at risk of a variety of problems, such as:

• not breastfeeding well;
• having immature lungs, and not being able to breathe on their own;
• bleeding in the brain;
• life-threatening infections;
• jaundice;
• inflammation of the bowel;
• long-term health problems, such as cerebral palsy; or
• dying.

Babies born this early need special care in a hospital with specialist facilities for premature babies. This is called a neonatal unit. They may have health and development problems because they haven’t fully developed in the womb.

If your baby is likely to be delivered early, you should be admitted to a hospital with a neonatal unit.

Not all hospitals have facilities for the care of very premature babies, so it may be necessary to transfer you and your baby to another unit, ideally before delivery (if time permits) or immediately afterwards.

Twins and multiples

Twins and triplets are often born prematurely. The average delivery date for twins is 37 weeks, and 33 weeks for triplets.

If you have any reason to think that your labor may be starting early, contact your hospital straight away.

What causes preterm labor

For most women, the cause of preterm labor is not found. It is thought that a number of factors, sometimes involving infection, can bring about a change in the cervix that causes labor to start.

However, there are certain factors that increase the risk.

These include if:

• your waters have broken early
• you have had a premature birth or your waters broke before 37 weeks, in a previous pregnancy
• you have had a previous late miscarriage (after 14 weeks of pregnancy)
• you have had vaginal bleeding after 14 weeks in this pregnancy
• you have an abnormality in the shape of your womb
• you are carrying twins or triplets
• you have excess fluid around your baby
• you have a short cervix
• you are a smoker
• you have had fertility treatment.

Having your baby early means that you are at an increased risk of having a premature birth in a future pregnancy. However, you are still likely to have a baby born at more than 37 weeks next time.

You will be advised to be under the care of a consultant obstetrician who will discuss with you a plan for your pregnancy. This will depend on your individual situation and on whether a cause for your early delivery, such as infection, was found.

Can preterm labor be prevented?

In some circumstances, particularly if you have had a baby born prematurely or a late miscarriage in the past, you may be offered vaginal scans in pregnancy to measure the length of your cervix or you may be advised to have a suture (stitch) put around it to prevent it opening early.

A cervical suture is an operation where a suture (stitch) is placed around the cervix (neck of the womb). It is also sometimes known as cervical cerclage. It is usually done at between 12 and 24 weeks of pregnancy.

A cervical suture is sometimes recommended for women who are thought to have a high chance of a late miscarriage or of going into preterm labor. The purpose of the suture is to reduce the risk of your baby being born early. Premature babies have an increased risk of short- and long-term health problems.

The exact cause of preterm labor or late miscarriages is not clear, but they may be caused by changes in the cervix such as shortening and opening. A cervical suture helps to keep the cervix long and closed, thereby reducing the risk of premature birth or late miscarriage.

Insertion of the suture takes place in an operating theater. You may have a spinal anesthetic where you will stay awake but will be numb from the waist down or you may be given a general anesthetic where you will be asleep. Your team will advise which would be the best option for you.

You will be advised not to eat or drink for 4–6 hours before the operation. In the operating theater, your legs will be put in supports and sterile covers will be used to keep the operating area clean. The doctor will then insert a speculum (a plastic or metal instrument used to separate the walls of the vagina to show or reach the cervix) into the vagina and put the suture around the cervix. The operation should take less than 30 minute.

Afterwards, you may be given antibiotics to help prevent infection and you will be offered medication to ease any discomfort. You may also have a tube (catheter) inserted into your bladder that will be removed once the anesthetic has worn off.

You are likely to be able to go home the same day although you may be advised to stay in hospital longer.

After the operation, you will usually have some bleeding from the vagina, which should change to brown in color after a day or two. You may have a rise in temperature that should settle without treatment.

Once you recover from the operation, you can carry on as normal for the rest of your pregnancy. Resting in bed is not normally recommended. Sexual intercourse may be continued when you feel comfortable to do so. Your doctor can advise you about the activities you can do and those best avoided during the first few days after the procedure.

Are cervical sutures sometimes inserted through the abdomen?

Yes, if a vaginal cervical suture has not worked in the past or it is not possible to insert a vaginal suture. This would involve an operation through your abdomen and is called a ‘transabdominal cerclage’. It is done either before you become pregnant again or in early pregnancy. Such a suture is not removed and your baby would be born by caesarean section.

When might a cervical suture be advised?

You may be in one of the following situations:

• If you have had one or two late miscarriages or premature births (before 34 weeks), you may be offered ultrasound scans between 14 and 24 weeks of pregnancy to measure the length of your cervix. If the scans show that it has shortened to less than 25 mm, you may be advised to have a cervical suture.
• If you have suffered three or more late miscarriages or three or more premature births you may be advised to have a cervical suture inserted at about 12–14 weeks of pregnancy.

During pregnancy it is sometimes noticed during a vaginal examination or a routine scan that the cervix has started to open up. Depending on your circumstances, you may be offered a suture called a rescue suture. If you are in this situation, a senior obstetrician will discuss with you the risks and benefits of having a rescue suture.

Are there situations when a cervical suture would not be advised?

Sometimes a cervical suture is not advised. It would not normally improve the outcome for your baby/babies and may carry risks to you in the following circumstances:

• you are more than 24 weeks pregnant
• you are carrying twins or triplets
• your womb is an abnormal shape
• an ultrasound scan done for another reason happens to show that you have a short cervix
• you have had treatment to the cervix for an abnormal smear.

If a suture is not the right option for you, you will still be closely monitored. This may include regular vaginal ultrasound scans to measure the length of your cervix until 24 weeks of pregnancy. If the cervix is shortened, you may be offered corticosteroid injections after 23 weeks to increase the chance of your baby surviving if born early.

Are there situations when a cervical suture would not be put in?

Yes. A cervical suture would not be put in if:

• you are already in labor or your waters have broken
• you have signs of infection in your womb
• you have vaginal bleeding
• there are concerns about your baby’s wellbeing.

Are there any risks in having a cervical suture?

There is a small risk that your bladder or cervix may be damaged at the time of the operation. Rarely, your membranes may be ruptured. The risk of complications is higher if you have a rescue suture and this will be discussed with you before the operation.

A planned cervical suture does not increase your risk of infection, miscarriage, or premature labor. It does not increase your risk of having to be started off in labor (be induced) or needing a caesarean section.

Is there anything I should look out for?

If you experience any of the following symptoms, you should contact your maternity unit:

• contractions or cramping
• vaginal bleeding
• your waters breaking
• smelly vaginal discharge.

How and when will the suture be taken out?

Your suture will be taken out at the hospital. This will normally happen at around 36–37 weeks of pregnancy, unless you go into labor before then.

You will not normally need an anesthetic. A speculum is inserted into your vagina and the suture is cut and removed. It usually takes just a few minutes.

You may have a small amount of bleeding afterwards. Any red bleeding should settle within 24 hours but you may have a brown discharge for longer. If you have any concerns, tell your midwife or doctor.

If you go into labor with the cervical suture in place, it is very important to have it removed promptly to prevent damage to your cervix. If you think you are in labor, contact your maternity unit straight away.

If your waters break early but you are not in labor, the stitch will usually be removed because of the increased risk of infection. The timing of this will be decided by the team looking after you.

Preterm labor complications

Many women diagnosed with preterm labor deliver at or near term. However, there are no medications or surgical procedures to stop preterm labor, once it has started. In some cases, preterm labor associated with problems such as an infection or smoking can be managed by treating the infection or quitting smoking.

Preterm labor could lead to premature birth. This can pose a number of health concerns, such as low birth weight, breathing difficulties, underdeveloped organs and vision problems. Children who are born prematurely also have a higher risk of learning disabilities and behavioral problems.

Causes of premature birth

There are many causes of premature birth. Most occur spontaneously, however on occasions a mother or baby may necessitate an early induction of labor or caesarean birth. This can occur for medical or non-medical reasons.

Common reasons for preterm birth can be associated with different factors including medical and pregnancy; social, personal and economic; and behavioral.

Medical and Pregnancy

Cervical incompetence: This occurs when a weak cervix cannot support the weight of the uterus and begins to dilate (widen) and efface (thin) before pregnancy has reached term. Occasionally women diagnosed with an incompetent cervix may undergo a procedure in early stages of pregnancy called a cerclage. This involves placing a stitch in the cervix to prevent it opening up too soon and removing the stitch when nearing term.

Multiple births: Occurs when more than one fetus is carried in a single pregnancy. Twins and other multiple births are often induced early if labor is not spontaneous. Around 50% of twin pregnancies will be born before 37 weeks and a very high percentage of higher order multiples will be born prematurely.

Placental Accreta: Placenta accreta is a general term to describe a serious complication of pregnancy when part of the placenta, or entire placenta invades and is inseparable from the uterine wall causing severe blood loss after delivery. After giving birth the placenta should separate completely from the uterus. If part or all of the placenta remains attached it is called placenta accreta. It’s also possible for the placenta to invade the muscles of the uterus (placenta increta) or grow through the uterine wall, sometimes extending to nearby organs (placenta percreta).

Placenta Previa: A complication of pregnancy where the placenta has attached to the uterine wall close to or over the opening of the cervix. The most common complication of placenta Previa is bleeding leading to an increased risk of slow foetal growth and premature birth. Almost all babies are delivered via caesarean birth as the increased risk of severe bleeding associated with a vaginal birth can be life threatening. A woman is also at increased risk of having further premature births if this has occurred in previous pregnancies.

Placental abruption: A complication of pregnancy, where the placenta separates from the wall of the uterus. It is the most common cause of late pregnancy bleeding and if the separation is severe can contribute to fetal and maternal death. Direct trauma to the uterus is a known cause, and risk factors may be multiple pregnancies, smoking and high blood pressure including preeclampsia.

Placental insufficiency: This condition can prevent the baby from gaining essential nourishment. Symptoms may include below average weight gain, below average fetal development, or slow growth of the uterus. It can also lead to foetal distress decreasing their heart rate and in serious cases an inability to tolerate a vaginal birth, thus requiring a caesarean delivery. An ultrasound examination will determine if growth of the foetus is adequate and doctors may advise preterm delivery if necessary. Placental insufficiency can be caused by conditions such as diabetes, high blood pressure or preeclampsia, maternal blood clotting disorders, smoking or taking drugs such as cocaine.

Preeclampsia: A complication of pregnancy where hypertension, high blood pressure, occurs in conjunction with high levels of protein in the urine and oedema. The increases in blood pressure can prevent adequate oxygen reaching the foetus and possibly lead to health problems for the baby. It is most common after the 20th week of pregnancy. Risk is increased if the mother already has high blood pressure, diabetes or kidney disease. Preeclampsia is the most common of the dangerous pregnancy complications and can affect both mother and baby. A variation of preeclampsia is HELLP syndrome, a life threatening liver disorder, also related to hypertension in pregnancy. It is usually diagnosed as a direct result of being evaluated for preeclampsia. HELLP is an abbreviation of Hemolytic anemia, Elevated Liver enzymes and Low Platelet count. Approximately 10% to 20% of women who have severe preeclampsia develop HELLP and the only way to reverse this syndrome is the birth of the baby to prevent the potential death of both mother and fetus.

Preterm premature rupture of membranes (PPROM): A condition which occurs in pregnancy when the amniotic sac spontaneously ruptures before the onset of labor. This can lead to spontaneous delivery of the baby within hours or can take weeks until birth. The mother is usually confined to hospital to monitor the pregnancy and prevent complications. There may be no known cause or it could be related to risk factors such as an infection, lower socioeconomic conditions where it is more common adequate antenatal care has not been received, vaginal bleeding from conditions such as placental abruption and smoking.

Previous premature birth: Women who have had a premature delivery previously have an increased chance of having another pre-term delivery.

Having a family history of premature birth. This means someone in your family (like your mother, grandmother or sister) has had a premature baby. If you were born prematurely, you’re more likely than others to give birth early.

Serious or an existing medical condition and other reasons: Conditions such as rhesus negative blood group, gestational diabetes, diabetes, kidney disease and high blood pressure can all affect a developing baby. In some cases, the decision to deliver a baby prematurely is because either they or the mother are medically unwell due to a health problem, congenital abnormality or surgical need.

Twin to twin transfusion syndrome (TTTS): A complication where two or more fetuses share a common placenta and associated with high morbidity and mortality.

Urine infection: Sometimes during the middle to later months of a pregnancy a serious uterine infection can trigger preterm labor. It is important that any possible urine infection be brought to the attention of your health care professional.

Uterine abnormalities: Women with an abnormally shaped uterus such as a bicornuate uterus could be at risk of preterm labor. The baby may have less room to grow and when there isn’t enough room for the baby, the stretching of the uterus can cause labor to begin.

Connective tissue disorders, like Ehlers-Danlos syndromes (also called EDS) and vascular Ehlers-Danlos syndrome (also called vEDS). Connective tissue is tissue that surrounds and supports other tissues and organs. Ehlers-Danlos syndromes can cause joints to be loose and easy to dislocate; skin to be thin and easily stretched and bruised; and blood vessels to be fragile and small. It also can affect your uterus and intestines. Vascular Ehlers-Danlos syndrome is the most serious kind of Ehlers-Danlos syndromes because it can cause arteries and organs (like the uterus) to rupture (burst). Ehlers-Danlos syndromes and vascular Ehlers-Danlos syndrome are genetic conditions that can be passed from parent to child through genes.

Being pregnant with a baby who has certain birth defects, like heart defects or spina bifida. Birth defects are health conditions that are present at birth. They change the shape or function of one or more parts of the body. Birth defects can cause problems in overall health, how the body develops or how the body works. Spina bifida is a birth defect of the spine.

Thrombophilias. These are conditions that increase your risk of making abnormal blood clots.

Getting pregnant again too soon after having a baby. For most women it’s best to wait at least 18 months before getting pregnant again. Talk to your provider about the right amount of time for you.

Social, personal and economic

Mother’s Age: Younger than 17 years or over 35 years

Lower socioeconomic situations: even after assessing other variables such as maternal age, race, behavioral issues and medical situations, low income and social disadvantages lead to higher rates of premature birth. Studies continue to determine optimal means to address this issue.

Race: there is a greater risk of women of African descent to have premature births. This risk is seen to be as much as five times more than Caucasian women despite similar health care provision.

Behavioral

Substance use and abuse: This includes smoking, drinking alcohol or using illicit drugs. The use of some substances can lead to decreased oxygenation to the fetus and small for gestational age babies, birth defects and sadly fetal death if a baby is not delivered in time to prevent irreversible complications.

Late antenatal care: Situations that can potentially lead to premature birth can be better treated if early antenatal care is sought.

Stress: Certain hormones and proteins in the blood that help control the contraction of the uterus and the production of infection fighting cells are increased in times of stress. These can lead to increased risk of infections, uterine irritability and thereby increasing the risk of premature birth.

Risk factors for preterm labor

Preterm labor can affect any pregnancy and many women who have preterm labor have no known risk factors. Many factors have been associated with an increased risk of preterm labor, however, including:

• Previous preterm labor or premature birth, particularly in the most recent pregnancy or in more than one previous pregnancy
• Pregnancy with twins, triplets or other multiples
• Certain problems with the uterus, cervix or placenta
• A lack of prenatal medical care
• Smoking cigarettes or using illicit drugs during pregnancy
• Certain infections, particularly of the genital tract, such as urinary tract infections or vaginal infections (e.g. bacterial vaginosis)
• Some chronic conditions, such as high blood pressure, diabetes or clotting disorders
• Being underweight or overweight before pregnancy, or gaining too little or too much weight during pregnancy
• Stressful life events, such as the death of a loved one
• Red blood cell deficiency (anemia), particularly during early pregnancy
• Too much amniotic fluid (polyhydramnios)
• Pregnancy complications, such as preeclampsia
• Vaginal bleeding during pregnancy
• Presence of a fetal birth defect
• Little or no prenatal care
• An interval of less than six months since the last pregnancy
• Stress
• Being under 17 or over 35 years old

Also, having a short cervical length or the presence of fetal fibronectin — a substance that acts like a glue between the fetal sac and the lining of the uterus — in your vaginal discharge has been linked to an increased risk of preterm labor.

While some past research suggested that gum disease might be linked with premature birth, treatment of periodontal disease during pregnancy hasn’t been proved to reduce the risk of premature birth.

Preterm labor prevention

You might not be able to prevent preterm labor — but there’s much you can do to promote a healthy, full-term pregnancy. For example:

• Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby’s health. Mention any signs or symptoms that concern you, even if you think they’re silly or unimportant. If you have a history of preterm labor or develop signs or symptoms of preterm labor, you might need to see your health care provider more often during pregnancy for exams and tests.
• Eat a healthy diet. During pregnancy, you’ll need more folic acid, calcium, iron and other essential nutrients. A daily prenatal vitamin — ideally starting a few months before conception — can help fill any gaps.
• Avoid risky substances. If you smoke, quit. Smoking might trigger preterm labor. Illicit drugs are off-limits, too. In addition, medications of any type — even those available over-the-counter — deserve caution. Get your health care provider’s OK before taking any medications or supplements.
• Protect yourself from infections. Talk to your provider about vaccinations that can help protect you from certain infections. Wash your hands with soap and water after using the bathroom or blowing your nose. Don’t eat raw meat, fish or eggs. Have safe sex. Don’t touch cat poop.
• Be cautious when using assisted reproductive technology (ART). If you’re planning to use ART to get pregnant, consider how many embryos will be implanted. Multiple pregnancies carry a higher risk of preterm labor.
• Wait at least 18 months between giving birth and getting pregnant again. Use birth control until you’re ready to get pregnant again. If you’re older than 35 or you’ve had a miscarriage or stillbirth, talk to your provider about how long to wait between pregnancies. Miscarriage is the death of a baby in the womb before 20 weeks of pregnancy. Stillbirth is the death of a baby in the womb after 20 weeks of pregnancy.

If your health care provider determines that you’re at increased risk of preterm labor, he or she might recommend taking additional steps to reduce your risk, such as:

• Taking preventive medications. If you have a history of premature birth, your health care provider might suggest weekly shots of a form of the hormone progesterone called hydroxyprogesterone caproate (Makena) during your second trimester. In additional, your doctor might offer progesterone, which is inserted in the vagina, as a preventive measure against preterm birth.
• Limiting certain physical activities. If you’re at risk of preterm labor or develop signs or symptoms of preterm labor, your health care provider might suggest avoiding heavy lifting or spending too much time on your feet.
• Managing chronic conditions. Certain conditions, such as diabetes and high blood pressure, increase the risk of preterm labor. Work with your health care provider to keep any chronic conditions under control.

If you have a history of preterm labor or premature birth, you’re at risk of a subsequent preterm labor. Work with your health care provider to manage any risk factors and respond to early warning signs and symptoms.

Preterm labor signs and symptoms

For some women, the signs and symptoms of preterm labor are unmistakable. For others, they’re more subtle.

If you have any of the following symptoms, contact your doctor or midwife straight away, as you could be in labor:

• either a slow trickle or a gush of clear or pinkish fluid from your vagina or any increase in vaginal discharge
• constant low, dull backache
• cramps like strong period pains
• regular or frequent painful contractions — a tightening sensation in the abdomen
• mild abdominal cramps
• a frequent need to urinate
• a feeling of pressure in your pelvis or lower abdomen (feeling that the baby is pushing down)
• vaginal spotting or bleeding
• a change in vaginal discharge – watery, mucous, or bloody vaginal discharge
• nausea, vomiting or diarrhea
• 4 or more contractions per hour
• bleeding or blood spotting after 3 months into your pregnancy

Don’t delay if you have strong pain, a smelly discharge or bleeding from your vagina, or if you are feeling feverish, sick or have a temperature, call immediately as you may need urgent medical attention.

• Don’t worry about mistaking false labor for the real thing. Everyone will be pleased if it’s a false alarm.

You may have some of the symptoms but not others. For example, your waters may have broken but with no contractions, or vice versa. Contractions don’t always indicate that you’re in labor, so your healthcare team will carry out checks to find out.

Many women experience Braxton Hicks, sometimes known as practice contractions. These can become quite strong and painful during the third trimester, and it’s easy to mistake them for the real thing.

The healthcare team will check

• whether you are actually in labor
• if labor hasn’t started, whether your symptoms are due to some other cause that needs treating
• if you are definitely in labor, whether this has been caused by something (such as an infection) that needs treating, and how far the labor is progressing, so they can line up the facilities you need, either to delay the birth or to deliver the baby.

Preterm labor diagnosis

To help diagnose preterm labor, your health care provider will document your signs and symptoms. If you’re experiencing regular, painful contractions and your cervix has begun to soften, thin and open before 37 weeks of pregnancy, you’ll likely be diagnosed with preterm labor.

Tests and procedures to diagnose preterm labor include:

• Pelvic exam. Your health care provider might evaluate the firmness and tenderness of your uterus and the baby’s size and position. He or she might also do a pelvic exam to determine if your cervix has begun to open — if your water hasn’t broken and the placenta isn’t covering your cervix (placenta previa).
• Ultrasound. An ultrasound might be used to measure the length of your cervix and determine your baby’s size, age, weight and position in your uterus. You might need to be monitored for a period of time and then have another ultrasound to measure any changes in your cervix, including cervical length.
• Uterine monitoring. Your health care provider might use a uterine monitor to measure the duration and spacing of your contractions.
• Lab tests. Your health care provider might take a swab of your vaginal secretions to check for the presence of certain infections and fetal fibronectin — a substance that acts like a glue between the fetal sac and the lining of the uterus and is discharged during labor. However, this test isn’t reliable enough to be used on its own to assess the risk of preterm labor.
• Maturity amniocentesis. Your health care provider might recommend a procedure in which amniotic fluid is removed from the uterus (amniocentesis) to determine your baby’s lung maturity. The technique can also be used to detect an infection in the amniotic fluid.

If you’re in preterm labor, your health care provider will explain the risks and benefits of trying to stop your labor. Keep in mind that preterm labor sometimes stops on its own.

Preterm labor treatment

If your waters have broken

Your unborn baby lies in an amniotic sac of fluid or ‘waters’. ‘Waters breaking’ means that the sac has ruptured or broken. Your waters normally break around the time labor is due but in around 2% of pregnancies they break early for various reasons.

If your waters break before your baby has reached full term (37 weeks), the medical name for it is preterm prelabour rupture of the membranes, or PPROM. If this happens early, before the contractions start, it can (but does not always) trigger early labor.

If your waters have broken early, you will experience it as a trickle or a gush of water from your vagina. It is likely to continue leaking once it has started. If it isn’t too heavy you can use a sanitary towel to catch it. This will also allow you to see what color it is, which will be helpful information for health professionals. It may be pinkish if it contains some blood, or it may be clear. If it greenish or brown go to the maternity unit as soon as possible. If it is heavy, you may need to use a towel.

Does it hurt when my waters break?

No it shouldn’t hurt when your waters break or when they are broken for you. The amniotic sac, which is the part that ‘breaks’ doesn’t have pain receptors, which are the things that cause you to feel pain when you get a cut for example.

You are likely to have an internal examination. This will allow the doctor to look at your cervix and check:

• if the leaking fluid is amniotic fluid
• if it is changing in preparation for labor
• to check for infection by taking a swab.

You might have an ultrasound scan to estimate the amount of fluid left around your baby.

If only a very small amount of amniotic fluid leaks, it is not always easy to be sure whether your waters have broken.

• You may be advised to wear a pad and stay in hospital for a few hours to monitor the situation.
• If you go home but continue to leak fluid at home, you should return to the hospital again.

If your waters are shown to have broken, you will be advised to come into hospital for at least 48 hours. You and your unborn baby will be closely monitored for signs of infection. This will include having your temperature and pulse taken regularly, and your baby’s heart rate will also be monitored.

What are the risks if my waters break early (PPROM)?

If your waters break early the risks and treatment are dependent on the stage of pregnancy you are at.

1. You are at risk of going into preterm labor – the health risks for the baby of early birth are greater the younger they are.
2. If you do not go into labor, you and the baby are at risk of infection.

The doctors have to balance these two considerations. If the waters have broken because of infection, you and the baby have a high risk of getting the infection and you may need to deliver sooner to prevent this.

If the waters have broken but there is no infection currently present, you and the baby are still at risk but the immediate risk is lesser and your treatment will depend on your stage of pregnancy.

• If you are under 24 weeks of pregnancy and the baby is born, sadly, it is unlikely the baby will survive.
• If you are over 30 weeks and the baby is born, the likelihood of your baby surviving is much higher – over 95%.

If your waters have broken there’s an increased risk of infection for you and your baby. You’ll be offered:

• antibiotics to take for a maximum of 10 days, or until labor starts – whichever is sooner
• tests for infection, which may include blood and urine tests

Figure 1. Preterm labor – pre-labor rupture of membranes (P-PROM)

Preterm pre-labor rupture of membranes (P-PROM) doesn’t definitely mean you’re going into labor. You may be able to go home if there’s no infection and you don’t go into labor within 48 hours.

If you go home, you’ll be advised to tell your midwife immediately if:

• your temperature is raised (a raised temperature is usually over 99.5 °F (37.5 °C) but check with your midwife – they may need you to call before it gets to 99.5 °F (37.5 °C). You should take your temperature every four hours when you’re awake
• any fluid coming from your vagina (called vaginal loss) is colored or smelly
• you bleed from your vagina
• your baby’s movements slow down or stop.

You should avoid having sexual intercourse.

Contact your doctor or midwife and return to the hospital immediately if you have:

• a raised temperature (more than 98.6 °F or 37 °C)
• flu-like symptoms (feeling hot and shivery)
• vaginal bleeding
• if the leaking fluid becomes greenish or smelly
• contractions
• abdominal pain
• if you are worried that the baby is not moving as normal.

Inducing labor or preterm labor with PPROM

If you are past 34 weeks the doctor will weigh up the benefits of inducing labor before the due date to avoid the risk of infection with the disadvantages of being born premature, and may make a recommendation for early delivery.

You may need to stay in a hospital that has a neonatal unit and be monitored carefully for any sign of infection. You may also be treated with antibiotics, corticosteroids and magnesium sulfate (if you are less than 30 weeks) to help prepare your baby in case the are born prematurely.

Over 80% of women who have pre-labor rupture of membranes (PPROM) deliver their baby within seven days of their waters breaking.

Causes of waters breaking early (PPROM)

Intrauterine infection is present in around a third of women with pre-labor rupture of membranes (PPROM). In many cases however it happens without any infection being present. The reason for these cases is unclear, however it has been linked to heavy smoking (more than 10 cigarettes a day) in pregnancy.

What if there are no waters left in my womb?

Your baby’s amniotic sac has to have the right amount of amniotic fluid for the pregnancy to continue normally. If there is a break in the waters your baby will continue to produce amniotic fluid.

Before 23 weeks, the baby needs ‘waters’ to be present for their lungs to develop normally. Loss of water before this can lead to severe problems with lung development that can be critical after birth. After 23 weeks your baby does not need the amniotic fluid so much, so low levels of fluid may not be a problem in itself, but if the low levels are due to your waters breaking then there is a risk of infection.

If your waters haven’t broken

Your midwife or doctor should discuss with you the symptoms of preterm labor and offer checks to see if you’re in labor. These checks can include asking you about your medical and pregnancy history, and about possible labor signs, such as:

• contractions – how long, how strong and how far apart they are
• any pain
• vaginal loss, such as waters or a show

You may be offered a vaginal examination, and your pulse, blood pressure and temperature may also be checked.

Your midwife or doctor will also check your baby. They’ll probably feel your bump to find out the baby’s position and how far into your pelvis the baby’s head is.

They should also ask about your baby’s movements in the last 24 hours. If they don’t ask, tell them about the baby’s movements.

If you’re in preterm labor

The midwife or doctor may offer:

• medicine to try to slow down or stop your labor (tocolytic). Examples of this are magnesium sulphate, terbutaline and nifedipine.
• corticosteroid injections, which can help your baby’s lungs

Tocolytics

Your health care provider might give you a medication called a tocolytic to temporarily stop your contractions. These medications won’t halt preterm labor for longer than two days because they don’t address the underlying cause of preterm labor. However, they might delay preterm labor long enough for corticosteroids to provide the maximum benefit or, if necessary, for you to be transported to a facility that can provide specialized care for your premature baby.

Your health care provider can help you weigh the risks and benefits of using a tocolytic. In addition, your health care provider won’t recommend a tocolytic if you have certain conditions, such as pregnancy-induced high blood pressure.

What side effects can tocolytics cause?

Several kinds of tocolytics may be used during preterm labor, each with different side effects.

Beta-adrenergic receptor agonists, like terbutaline. Possible side effects for your baby may include having a fast heartbeat. Possible side effects for you may include:

• Chest pain; fast or irregular heartbeat
• Breathing trouble; fluid in the lungs
• Diarrhea, nausea (feeling sick to your stomach), throwing up
• Feeling dizzy; shaking or feeling nervous; seizures
• Fever, headache
• High blood sugar
• Low blood pressure; low blood potassium

Calcium channel blockers, like nifedipine. There are no side effects for your baby. Possible side effects for you may include:

• Constipation, diarrhea, nausea
• Feeling dizzy or faint
• Headache
• Low blood pressure
• Redness of the skin

Magnesium sulfate. Side effects for your baby may include:

• Being tired and drowsy
• Slowed breathing
• Weak muscles
• Low levels of calcium and bone problems, if the drug is used for more than 5 to 7 days.

Side effects for you may include:

• Breathing problems, fluid in the lungs
• Dry mouth
• Fatigue (being very tired), weak muscle
• Headache, double vision, slurred speech
• Heart attack
• Nausea or throwing up
• Redness of the skin, heavy sweating

Nonsteroidal anti-inflammatory drugs (also called NSAIDs), like indomethacin. Side effects for your baby may include:

• Bleeding in the brain or heart
• Patent ductus arteriosis, also called PDA. This is a heart problem that’s common in premature babies.
• Jaundice. This is a common condition caused by the build-up of a substance called bilirubin in the blood that makes a baby’s skin and the white parts of his eyes look yellow.
• Kidney problems, like making too little urine
• Necrotizing enterocolitis (also called NEC). This is a problem in a baby’s intestines.
• Rising blood pressure in the lungs

Side effects for you include:

• Feeling dizzy
• Heartburn
• Nausea or throwing up
• Oligohydramnios. This is when you have too little amniotic fluid. Amniotic fluid is the fluid that surrounds your baby in the womb.
• Swollen stomach lining
• Vaginal bleeding

Slowing down labor or stopping it isn’t appropriate in all circumstances – your midwife or doctor can discuss your situation with you. They will consider:

• how many weeks pregnant you are
• whether it might be safer for the baby to be born – for example, if you have an infection or you’re bleeding
• local neonatal (newborn) care facilities and whether you might need to be moved to another hospital
• your wishes

Corticosteroid injections can help your baby’s lungs get ready for breathing if they’re born prematurely. There are two injections, given 12 hours apart – your midwife or doctor will discuss the benefits and risks with you. A single course of corticosteroids has been shown to help with a baby’s development and therefore will increase the chance of your baby surviving, once born. Corticosteroid injection also lessens the chance of your baby having serious complications after birth such as breathing problems owing to the lungs not being fully developed, bleeding into the brain, serious infection or bowel inflammation.

Corticosteroids probably won’t be offered after 36 weeks as your baby’s lungs are likely to be ready for breathing on their own.

If you’re in premature labor and you’re between 24 and 29 weeks pregnant you should be offered magnesium sulfate. This can help protect your baby’s brain development. You may also be offered it if you’re in labor between 30 and 34 weeks. This is to protect your baby against problems linked to being born too soon, such as cerebral palsy.

Can corticosteroids harm me or my baby?

A single course of two to four injections is considered to be safe for you and your baby. More evidence is needed to say whether two or more courses of corticosteroids during pregnancy are safe for your baby.

At what stage of pregnancy should corticosteroids be given?

Corticosteroids help most if they are given to you between 24 weeks and 34 weeks plus 6 days of pregnancy. If you are having a planned caesarean section between 35 and 38 weeks plus 6 days, corticosteroids are usually recommended. Corticosteroids may be given earlier than 24 weeks, but the evidence that they will be helpful for your baby in that situation is less clear; your obstetrician doctor will discuss this with you.

How long are corticosteroids effective for?

Corticosteroids are of most help if the last dose is given to you between 24 hours and 1 week before you have your baby. There may still be benefit even if your baby is born within 24 hours of the first dose.

Who should be given corticosteroids in pregnancy?

You may be advised to have corticosteroids if there is an increased chance that your baby will be born before 35 weeks of pregnancy.

This includes:

• if you are in preterm labor
• if you are suspected to be in preterm labor but this has not been confirmed yet
• if your waters break even if you are not having contractions
• if it may benefit your baby to be delivered early, for example if your baby is not growing
• if it may benefit you to have your baby early, for example if you are seriously unwell, are bleeding heavily or have severe pre-eclampsia.

If you are having a planned caesarean section before 39 weeks of pregnancy, corticosteroids are recommended to lessen the chance of breathing problems for your baby. If you have diabetes or gestational diabetes, you may need to be in hospital since corticosteroids increase the blood sugar level.

When are corticosteroids not necessary?

Giving treatment just in case an event occurs is known as prophylactic treatment. If you have previously had a baby born early, have a multiple pregnancy or have had treatment to your cervix (entrance to the womb), prophylactic treatment with corticosteroids early in pregnancy is not recommended because there is no evidence that it will help your baby.

Are there any circumstances where you wouldn’t be able to have corticosteroids?

Corticosteroids can suppress the mother’s immune system, but there is no evidence that a single course of corticosteroids will cause harm even if you have a severe infection. If you or your baby are unwell, corticosteroids will usually be started but delivery of your baby will not be delayed to allow you to complete the course.