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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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Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. The treatment choice does not play a major role; A randomized study in 2013 concluded that the rates of intrauterine pregnancy 2 years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery. In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over 2 years is over 90%.
When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, but most fetuses die or are aborted. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died).
In the developing world, however, especially in Africa, the death rate is very high, and ectopic pregnancies are a major cause of death among women of childbearing age.
Not only is obesity associated with miscarriage, it can result in sub-fertility and other adverse pregnancy outcomes. Recurrent miscarriage is also related to obesity. Women with bulimia nervosa and anorexia nervosa may have a greater risk for miscarriage. Nutrient deficiencies have not been found to impact miscarriage rates but hyperemesis gravidarum sometimes precedes a miscarriage.
Caffeine consumption also has been correlated to miscarriage rates, at least at higher levels of intake. However, such higher rates have been found to be statistically significant only in certain circumstances.
Vitamin supplementation has generally not shown to be effective in preventing miscarriage. Chinese traditional medicine has not been found to prevent miscarriage.
The age of the pregnant woman is a significant risk factor. Miscarriage rates increase steadily with age, with more substantial increases after age 35. In those under the age of 35 the risk is about 10% while it is about 45% in those over the age of 40. Risk begins to increase around the age of 30. Paternal age is associated with increased risk.
The following have been identified as risk factors for placenta previa:
- Previous placenta previa (recurrence rate 4–8%), caesarean delivery, myomectomy or endometrium damage caused by D&C.
- Women who are younger than 20 are at higher risk and women older than 35 are at increasing risk as they get older.
- Alcohol use during pregnancy was previous listed as a risk factor, but is discredited by this article.
- Women who have had previous pregnancies ( multiparity ), especially a large number of closely spaced pregnancies, are at higher risk due to uterine damage.
- Smoking during pregnancy; cocaine use during pregnancy
- Women with a large placentae from twins or erythroblastosis are at higher risk.
- Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference.
- Placental pathology (Vellamentous insertion, succinturiate lobes, bipartite i.e. bilobed placenta etc.)
- Baby is in an unusual position: breech (buttocks first) or transverse (lying horizontally across the womb).
Placenta previa is itself a risk factor of placenta accreta.
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.
Because pregnancy is outside the uterus, abdominal pregnancy serves as a model of human male pregnancy or for females who lack a uterus, although such pregnancy would be dangerous.
Cases of combined simultaneous abdominal and intrauterine pregnancy have been reported.
The prevalence of heterotopic pregnancy is estimated at 0.6‑2.5:10,000 pregnancies. There is a significant increase in the incidence of heterotopic pregnancy in women undergoing ovulation induction. An even greater incidence of heterotopic pregnancy is reported in pregnancies following assisted reproduction techniques such as In Vitro Fertilization (IVF) and Gamete intrafallopian transfer (GIFT), with an estimated incidence at between 1 and 3 in 100 pregnancies. If there is embryo transfer of more than 4 embryos, the risk has been quoted as 1 in 45. In natural conceptions, the incidence of heterotopic pregnancy has been estimated to be 1 in 30 000 pregnancies.
About 1.4% of ectopic pregnancies are abdominal, or about 1 out of every 8,000 pregnancies. A report from Nigeria places the frequency in that country at 34 per 100,000 deliveries and a report from Zimbabwe, 11 per 100,000 deliveries. The maternal mortality rate is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a "normal" delivery (1987 US data).
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.
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.
In rare cases, inherited bleeding disorders, like hemophilia, von Willebrand disease (vWD), or factor IX or XI deficiency, may cause severe postpartum hemorrhage, with an increased risk of death particularly in the postpartum period. The risk of postpartum hemorrhage in patients with vWD and carriers of hemophilia has been found to be 18.5% and 22% respectively. This pathology occurs due to the normal physiological drop in maternal clotting factors after delivery which greatly increases the risk of secondary postpartum hemorrhage.
Another bleeding risk factor is thrombocytopenia, or decreased platelet levels, which is the most common hematological change associated with pregnancy induced hypertension. If platelet counts drop less than 100,000 per microliter the patient will be at a severe risk for inability to clot during and after delivery.
Interstitial pregnancies account for 2–4% of all tubal pregnancies, or for 1 in 2,500 to 5,000 live births. About one in fifty women with an interstitial pregnancy dies. Patients with an interstitial pregnancies have a 7-times higher mortality than those with ectopics in general. With the growing use of assisted reproductive technologies, the incidence of interstitial pregnancy is rising.
Although the risk of placental abruption cannot be eliminated, it can be reduced. Avoiding tobacco, alcohol and cocaine during pregnancy decreases the risk. Staying away from activities which have a high risk of physical trauma is also important. Women who have high blood pressure or who have had a previous placental abruption and want to conceive must be closely supervised by a doctor.
The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.
It is crucial for women to be made aware of the signs of placental abruption, such as vaginal bleeding, and that if they experience such symptoms they must get into contact with their health care provider/the hospital "without any delay".
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%.
The prognosis of this complication depends on whether treatment is received by the patient, on the quality of treatment, and on the severity of the abruption. Outcomes for the baby also depend on the gestational age.
In the Western world, maternal deaths due to placental abruption are rare. The fetal prognosis is worse than the maternal prognosis; approximately 12% of fetuses affected by placental abruption die. 77% of fetuses that die from placental abruption die before birth; the remainder die due to complications of preterm birth.
Without any form of medical intervention, as often happens in many parts of the world, placental abruption has a high maternal mortality rate.
An important risk factor for placenta accreta is placenta previa in the presence of a uterine scar. Placenta previa is an independent risk factor for placenta accreta. Additional reported risk factors for placenta accreta include maternal age and multiparity, other prior uterine surgery, prior uterine curettage, uterine irradiation, endometrial ablation, Asherman syndrome, uterine leiomyomata, uterine anomalies, hypertensive disorders of pregnancy, and smoking.
The condition is increased in incidence by the presence of scar tissue i.e. Asherman's syndrome usually from past uterine surgery, especially from a past dilation and curettage, (which is used for many indications including miscarriage, termination, and postpartum hemorrhage), myomectomy, or caesarean section. A thin decidua can also be a contributing factor to such trophoblastic invasion. Some studies suggest that the rate of incidence is higher when the fetus is female. Other risk factors include low-lying placenta, anterior placenta, congenital or acquired uterine defects (such as uterine septa), leiomyoma, ectopic implantation of placenta (including cornual pregnancy).
Pregnant women above 35 years of age who have had a Caesarian section and now have a placenta previa overlying the uterine scar have a 40% chance of placenta accreta.
Antepartum bleeding (APH), also prepartum hemorrhage, is bleeding during pregnancy from the 24th week (sometimes defined as from the 20th week) gestational age to full term (40th week). The primary consideration is the presence of a placenta previa which is a low lying placenta at or very near to the internal cervical os. This condition occurs in roughly 4 out of 1000 pregnancies and usually needs to be resolved by delivering the baby via cesarean section. Also a placental abruption (in which there is premature separation of the placenta) can lead to obstetrical hemorrhage, sometimes concealed. This pathology is of important consideration after maternal trauma such as a motor vehicle accident or fall.
Other considerations to include when assessing antepartum bleeding are: sterile vaginal exams that are performed in order to assess dilation of the patient when the 40th week is approaching. As well as cervical insufficiency defined as a midtrimester (14th-26th week) dilation of the cervix which may need medical intervention to assist in keeping the pregnancy sustainable.
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.
The reported incidence of placenta accreta has increased from approximately 0.8 per 1000 deliveries in the 1980s to 3 per 1000 deliveries in the past decade.
Incidence has been increasing with increased rates of Caesarean deliveries, with rates of 1 in 4,027 pregnancies in the 1970s, 1 in 2,510 in the 1980s, and 1 in 533 for 1982–2002. In 2002, ACOG estimated that incidence has increased 10-fold over the past 50 years. The risk of placenta accreta in future deliveries after Caesarian section is 0.4-0.8%. For patients with placenta previa, risk increases with number of previous Caesarean sections, with rates of 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater number of Caesarean sections.
The presence of subchorionic bleeding around the gestational sac does not have a significant association with miscarriage overall. However, the case of intrauterine hematoma observed before 9 weeks of gestational age has been associated with an increased risk of miscarriage. In one study women who complied with instructions for bed rest for the duration of bleeding had a lower rate of miscarriage and a higher rate of term pregnancy than non-compliant women. The study had several limitations; results were severely confounded by inherent differences between compliant and non-compliant women.
Ovarian pregnancies are rare: the vast majority of ectopic pregnancies occur in the fallopian tube; only about 0.15-3% of ectopics occur in the ovary. The incidence has been reported to be about 1:3,000 to 1:7,000 deliveries.
There are various explanations, none of which is universally accepted because of the complex involvement of cortical, hypothalamic, endocrine, and psychogenic factors. Proposed mechanisms include the effect of stress on the hypothalamo-pituitary-adrenal axis, constipation, weight gain, and the movement of intestinal gas.
Sudden infant death syndrome (SIDS) is the sudden death of an infant that is unexplainable by the infant's history. The death also remains unexplainable upon autopsy. Infants exposed to smoke, both during pregnancy and after birth, are found to be more at risk of SIDS due to the increased levels of nicotine often found in SIDS cases. Infants exposed to smoke during pregnancy are up to three times more likely to die of SIDS that children born to non-smoking mothers.
There is limited evidence that smoking reduces the incidence of pregnancy-induced hypertension, but not when the pregnancy is with more than one baby (i.e. it has no effect on twins etc.).