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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Ionizing radiation levels given to a woman during cancer treatment cause miscarriage. Exposure can also impact fertility. The use of chemotherapeutic drugs used to treat childhood cancer increases the risk of miscarriage.
Immunizations have not been found to cause miscarriage. There is no significant association between antidepressant medication exposure and spontaneous abortion. The risk of miscarriage is not likely decrease by discontinuing SSRI prior to pregnancy. Some available data suggest that there is a small increased risk of miscarriage for women taking any antidepressant, though this risk becomes less statistically significant when excluding studies of poor quality.
Medicines that increase the risk of miscarriage include:
- retinoids
- nonsteroidal anti-inflammatory drugs (NSAIDs) , such as ibuprofen
- misoprostol
- methotrexate
Nutrition during pregnancy is important to ensure healthy growth of the fetus. Nutrition during pregnancy is different from the non-pregnant state. There are increased energy requirements and specific micronutrient requirements. Women benefit from education to encourage a balanced energy and protein intake during pregnancy. Some women may need professional medical advice if their diet is affected by medical conditions, food allergies, or specific religious/ ethical beliefs.
Adequate periconceptional (time before and right after conception) folic acid (also called folate or Vitamin B) intake has been shown to decrease the risk of fetal neural tube defects, such as spina bifida. The neural tube develops during the first 28 days of pregnancy, a urine pregnancy test is not usually positive until 14 days post-conception, explaining the necessity to guarantee adequate folate intake before conception. Folate is abundant in green leafy vegetables, legumes, and citrus. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.
DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for the woman to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the woman through the placenta during pregnancy and in breast milk after birth.
Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is common. Women living in low and middle income countries are suggested to take multiple micronutrient supplements containing iron and folic acid. These supplements have been shown to improve birth outcomes in developing countries, but do not have an effect on perinatal mortality. Adequate intake of folic acid, and iron is often recommended. In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may also require supplementation. Vitamin E supplementation has not been shown to improve birth outcomes. Zinc supplementation has been associated with a decrease in preterm birth, but it is unclear whether it is causative. Daily iron supplementation reduces the risk of maternal anemia. Studies of routine daily iron supplementation for pregnant women found improvement in blood iron levels, without a clear clinical benefit. The nutritional needs for women carrying twins or triplets. are higher than those of women carrying one baby.
Women are counseled to avoid certain foods, because of the possibility of contamination with bacteria or parasites that can cause illness. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Unpasteurized dairy and deli meats may contain "Listeria," which can cause neonatal meningitis, stillbirth and miscarriage. Pregnant women are also more prone to "Salmonella" infections, can be in eggs and poultry, which should be thoroughly cooked. Cat feces and undercooked meats may contain the parasite Toxoplasma gondii and can cause toxoplasmosis. Practicing good hygiene in the kitchen can reduce these risks.
Women are also counseled to eat seafood in moderation and to eliminate seafood known to be high in mercury because of the risk of birth defects. Pregnant women are counseled to consume caffeine in moderation, because large amounts of caffeine are associated with miscarriage. However, the relationship between caffeine, birthweight, and preterm birth is unclear.
The use of recreational drugs in pregnancy can cause various pregnancy complications.
- Ethanol during pregnancy can cause fetal alcohol syndrome and fetal alcohol spectrum disorder. Studies have shown that light to moderate drinking during pregnancy might not pose a risk to the fetus, although no amount of alcohol during pregnancy can be guaranteed to be absolutely safe.
- Tobacco smoking during pregnancy can cause a wide range of behavioral, neurological, and physical difficulties. Smoking during pregnancy causes twice the risk of premature rupture of membranes, placental abruption and placenta previa. Smoking is associated with 30% higher odds of preterm birth.
- Prenatal cocaine exposure is associated with premature birth, birth defects and attention deficit disorder.
- Prenatal methamphetamine exposure can cause premature birth and congenital abnormalities. Short-term neonatal outcomes show small deficits in infant neurobehavioral function and growth restriction. Long-term effects in terms of impaired brain development may also be caused by methamphetamine use.
- Cannabis in pregnancy has been shown to be teratogenic in large doses in animals, but has not shown any teratogenic effects in humans.
Since locked twins are often diagnosed in the late stages of delivery, it is often too late to intervene to save the life of the first twin and thus there is a high rate of stillbirth, estimated to be over 50%.
Instead of referring to "fetal distress" current recommendations hold to look for more specific signs and symptoms, assess them, and take the appropriate steps to remedy the situationthrough the implementation of intrauterine resuscitation. Traditionally the diagnosis of "fetal distress" led the obstetrician to recommend rapid delivery by instrumental delivery or by caesarean section if vaginal delivery is not advised.
An initial assessment to determine the status of the mother and fetus is required. Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta previa on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.
Corticosteroids are indicated at 24–34 weeks gestation, given the higher risk of premature birth.
Exact cause of placenta previa is unknown. It is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. These factors may reduce differential growth of lower segment, resulting in less upward shift in placental position as pregnancy advances.
If locked twins are diagnosed in early delivery, before either twin is born, both fetuses can be delivered by Caesarean section. If one fetus has been partially born, attempts can be made to disimpact the twins manually, such as by the Zavanelli maneuver, with a view to performing an assisted delivery with ventouse or forceps. If the diagnosis is made only after the first locked twin has died in the birth canal, or if it is not expected to survive, the first twin may be decapitated and its head pushed up to allow safe delivery of the second twin.
At least one case has been reported where hexoprenaline was used to relax the uterine smooth muscle and thereby temporarily inhibit labour so that the fetal heads could be disimpacted.
Taking aspirin is associated with a 1% to 5% reduction in pre-eclampsia and a 1% to 5% reduction in premature births in women at high risk. The World Health Organization recommends low-dose aspirin for the prevention of pre-eclampsia in women at high risk and recommends it be started before 20 weeks of pregnancy. The United States Preventive Services Task Force recommends a low-dose regimen for women at high risk beginning in the 12th week. Benefits are less if started after 16 weeks.
Extrauterine pregnancies are non-viable and can be fatal to the mother if left untreated. The mortality rate for the extrauterine pregnancy is approximately 35%.
In low-risk pregnancies, the association between cigarette smoking and a reduced risk of pre-eclampsia has been consistent and reproducible across epidemiologic studies. High-risk pregnancies (those with pregestational diabetes, chronic hypertension, history of pre-eclampsia in a previous pregnancy, or multifetal gestation) showed no significant protective effect. The reason for this discrepancy is not definitively known; research supports speculation that the underlying pathology increases the risk of preeclampsia to such a degree that any measurable reduction of risk due to smoking is masked. However, the damaging effects of smoking on overall health and pregnancy outcomes outweighs the benefits in decreasing the incidence of preeclampsia. It is recommended that smoking be stopped prior to, during and after pregnancy.
Studies suggest that marijuana use in the months prior to or during the early stages of pregnancy may interfere with normal placental development and consequently increase the risk of preeclampsia.
Emergency exploratory laparotomy with cesarean delivery accompanied by fluid and blood transfusion are indicated for the management of uterine rupture. Depending on the nature of the rupture and the condition of the patient, the uterus may be either repaired or removed (cesarean hysterectomy). Delay in management places both mother and child at significant risk.
Heterotopic pregnancy is treated with surgical removal of the ectopic gestation by salpingectomy or salpingostomy. Expectant management has been successfully applied in select cases. Successful salpingocentesis has also been reported.
The risk of pregnancy complications increases as the mother's age increases. Risks associated with childbearing over the age of 50 include an increased incidence of gestational diabetes, hypertension, delivery by caesarean section, miscarriage, preeclampsia, and placenta previa. In comparison to mothers between 20 and 29 years of age, mothers over 50 are at almost three times the risk of low birth weight, premature birth, and extremely premature birth; their risk of extremely low birth weight, small size for gestational age, and fetal mortality was almost double.
In medicine (obstetrics), the term fetal distress refers to the presence of signs in a pregnant woman—before or during childbirth—that suggest that the fetus may not be well. Because of its lack of precision, the term is eschewed in modern American obstetrics.
Striae gravidarum (pregnancy-related stretch marks) occur in 50% to 90% of women, and are caused both by the skin stretching and by the effects of hormonal changes on fibers in the skin. They are more common in younger women, women of color, women having larger babies and women who are overweight or obese, and they sometimes run in families. Stretch marks generally begin as red or purple stripes (striae rubra), fading to pale or flesh-color (striae alba) after pregnancy that will generally be permanent. They appear most commonly on the abdomen, breasts, buttocks, thighs, and arms, and may cause itching and discomfort. Although several kinds of multi-component creams are marketed and used, along with vitamin E cream, cocoa butter, almond oil and olive oil, none have been shown to prevent or reduce stretch marks in pregnancy. The safety for use in pregnancy of one herbal ingredient used in some products, Centella asiatica, has been questioned. Some treatments used to reduce scarring, such as topical tretinoin lasers, are sometimes used on stretch marks, but evidence on them is limited. Topical tretinoin has been shown to cause malformations in animals, without adequate human studies on safety in human pregnancies.
Pregnancy over age 50 has, over recent years, become more possible for women, due to recent advances in assisted reproductive technology, in particular egg donation. Typically, a woman's fecundity ends with menopause, which by definition is 12 consecutive months without having had any menstrual flow at all. During perimenopause, the menstrual cycle and the periods become irregular and eventually stop altogether, but even when periods are still regular, the egg quality of women in their forties is lower than in younger women, making the likelihood of conceiving a healthy baby also reduced, particularly after age 42. It is important to note, that the female biological clock can vary greatly from woman to woman. A woman's individual level of fertility can be tested through a variety of methods.
Men also experience a decline in fertility as they age, for example, the average time to pregnancy if a man is under 25 is just over 4.5 months but nearly two years if a man is over 40 (if the woman is under 25). The risk of genetic defects is greatly increased due to the paternal age effect. Children with fathers aged 40 or older are more than five times as likely to have an autism spectrum disorder than children fathered by men aged under 30. Researchers estimate that compared to a male fathering a child in his early 20's - there is double the chance of the child getting schizophrenia when the father is age 40, and triple the risk of schizophrenia when the father is age 50 (though, for most people this means the risk goes from approximately 1 in 121 when a man is 29, to 1 in 47 when a man is age 50 to 54). Men's fertility declines throughout the lifespan, with the volume of a man’s semen and sperm motility (the ability of sperm to move towards an egg) decrease continually between the ages of 20 and 80. The risk of dwarfism and miscarriage also increases as men age
In the United States, between 1997 and 1999, 539 births were reported among mothers over age 50 (four per 100,000 births), with 194 being over 55.
The oldest mother to date to conceive, was 71 years, and the youngest mother, 5 years old. According to statistics from the Human Fertilisation and Embryology Authority, in the UK more than 20 babies are born to women over age 50 per year through in-vitro fertilization with the use of donor oocytes (eggs).
Maria del Carmen Bousada de Lara is the oldest verified mother; she was aged 66 years 358 days when she gave birth to twins; she was 130 days older than Adriana Iliescu, who gave birth in 2005 to a baby girl. In both cases the children were conceived through IVF with donor eggs. The oldest verified mother to conceive naturally (listed currently in the Guinness Records) is Dawn Brooke (UK); she conceived a son at the age of 59 years in 1997 while taking oestrogen.
Some doctors recommend complete bed-rest for the mother coupled with massive intakes of protein as a therapy to try to counteract the syndrome. Research completed shows these nutritional supplements do work. Diet supplementation was associated with lower overall incidence of TTTS (20/52 versus 8/51, P = 0.02) and with lower prevalence of TTTS at delivery (18/52 versus 6/51, P = 0.012) when compared with no supplementation. Nutritional intervention also significantly prolonged the time between the diagnosis of TTTS and delivery (9.4 ± 3.7 weeks versus 4.6 ± 6.5 weeks; P = 0.014). The earlier nutritional regimen was introduced, the lesser chance of detecting TTTS ( P = 0.001). Although not statistically significant, dietary intervention was also associated with lower Quintero stage, fewer invasive treatments, and lower twin birth weight discordance. Diet supplementation appears to counter maternal metabolic abnormalities in monochorionic twin pregnancies and improve perinatal outcomes in TTTS when combined with the standard therapeutic options. Nutritional therapy appears to be most effective in mitigating cases that are caught in Quintero Stage I, little effect has been observed in those that are beyond Stage I.
Patients with an ectopic pregnancy are generally at higher risk for a recurrence, however, there are no specific data for patients with an interstitial pregnancy. When a new pregnancy is diagnosed it is important to monitor the pregnancy by transvaginal sonography to assure that is it properly located, and that the surgically repaired area remains intact. Cesarean delivery is recommended to avoid uterine rupture during labor.
Pica is a craving for nonedible items such as dirt or clay. It is caused by iron deficiency which is normal during pregnancy and can be overcome with iron in prenatal vitamins or, if severe, parenteral iron
This procedure involves removal of amniotic fluid periodically throughout the pregnancy under the assumption that the extra fluid in the recipient twin can cause preterm labor, perinatal mortality, or tissue damage. In the case that the fluid does not reaccumulate, the reduction of amniotic fluid stabilizes the pregnancy. Otherwise the treatment is repeated as necessary. There is no standard procedure for how much fluid is removed each time. There is a danger that if too much fluid is removed, the recipient twin could die. This procedure is associated with a 66% survival rate of at least one fetus, with a 15% risk of cerebral palsy and average delivery occurring at 29 weeks gestation.
Because the black cherry tree is the preferred host tree for the eastern tent caterpillar, one approach to prevention is to simply remove the trees from the vicinity of horse farms, which was one of the very first recommendations made concerning MRLS. Next, because the brief time for which the full-grown ETCs are on the ground in the vicinity of pregnant mares, simply keeping pregnant mares out of contact with them is also an effective preventative mechanism. In this regard, one Kentucky horse farm took the approach of simply muzzling mares during an ETC exposure period, an approach which was reportedly effective.
No effective treatment for MRLS is apparent. Mares which aborted are treated with broad-spectrum antibiotics to avoid bacterial infections. The foals born from mares infected with MRLS are given supportive care and supplied with medication to reduce inflammatory response and improve blood flow, but none of the treatments appears to be effective, as the majority of the foals do not survive. Unilateral uveitis is treated symptomatically with antibiotics and anti-inflammatory drugs.
Choice of treatment is largely dictated by the clinical situation. A ruptured interstitial pregnancy is a medical emergency that requires an immediate surgical intervention either by laparoscopy or laparotomy to stop the bleeding and remove the pregnancy.
Surgical methods to remove the pregnancy include cornual evacuation, incision of the cornua with removal of the pregnancy (cornuostomy), resection of the cornual area or a cornual wedge resection, typically combined with an ipsilateral salpingectomy, and hysterectomy. Because of the vascularity of the interstitial region particularly during pregnancy, blood loss during surgery may be substantial. Postoperatively, patients with conservative surgical therapy are at risk for development of a persistent ectopic pregnancy due to the presence of deeply embedded surviving trophoblastic tissue; thus, monitoring of hCG levels is indicated until they become undetectable.
In patients with an asymptomatic interstitial pregnancy methotrexate has been successfully used, however, this approach may fail and result in cornual rupture of the pregnancy. Selective uterine artery embolization has been successfully performed to treat interstial pregnancies.
A uterine scar from a previous cesarean section is the most common risk factor. (In one review, 52% had previous cesarean scars.) Other forms of uterine surgery that result in full-thickness incisions (such as a myomectomy), dysfunctional labor, labor augmentation by oxytocin or prostaglandins, and high parity may also set the stage for uterine rupture. In 2006, an extremely rare case of uterine rupture in a first pregnancy with no risk factors was reported.