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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)
          Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
          
        
Medical imaging may be indicated in pregnancy because of pregnancy complications, intercurrent diseases or routine prenatal care. Magnetic resonance imaging (MRI) without MRI contrast agents as well as obstetric ultrasonography are not associated with any risk for the mother or the fetus, and are the imaging techniques of choice for pregnant women. Projectional radiography, X-ray computed tomography and nuclear medicine imaging result in some degree of ionizing radiation exposure, but in most cases the absorbed doses are not associated with harm to the baby. At higher dosages, effects can include miscarriage, birth defects and intellectual disability.
Obstetric ultrasonography can detect fetal abnormalities, detect multiple pregnancies, and improve gestational dating at 24 weeks. The resultant estimated gestational age and due date of the fetus are slightly more accurate than methods based on last menstrual period. Ultrasound is used to measure the nuchal fold in order to screen for Downs syndrome.
Some disorders and conditions can mean that pregnancy is considered high-risk (about 6-8% of pregnancies in the USA) and in extreme cases may be contraindicated. High-risk pregnancies are the main focus of doctors specialising in maternal-fetal medicine.
Serious pre-existing disorders which can reduce a woman's physical ability to survive pregnancy include a range of congenital defects (that is, conditions with which the woman herself was born, for example, those of the heart or , some of which are listed above) and diseases acquired at any time during the woman's life.
Factors increasing the risk (to either the woman, the fetus/es, or both) of pregnancy complications beyond the normal level of risk may be present in a woman's medical profile either before she becomes pregnant or during the pregnancy. These pre-existing factors may relate to physical and/or mental health, and/or to social issues, or a combination.
Some common risk factors include:
- Age of either parent
- Adolescent parents
- Older parents
- Exposure to environmental toxins in pregnancy
- Exposure to recreational drugs in pregnancy:
- Ethanol during pregnancy can cause fetal alcohol syndrome and fetal alcohol spectrum disorder.
- Tobacco smoking and pregnancy, when combined, causes twice the risk of premature rupture of membranes, placental abruption and placenta previa. Also, it causes 30% higher odds of the baby being born prematurely.
- Prenatal cocaine exposure is associated with, for example, premature birth, birth defects and attention deficit disorder.
- Prenatal methamphetamine exposure can cause premature birth and congenital abnormalities. Other investigations have revealed short-term neonatal outcomes to include small deficits in infant neurobehavioral function and growth restriction when compared to control infants. Also, prenatal methamphetamine use is believed to have long-term effects in terms of brain development, which may last for many years.
- Cannabis in pregnancy is possibly associated with adverse effects on the child later in life.
- Exposure to Pharmaceutical drugs in pregnancy. Anti-depressants, for example, may increase risks of such outcomes as preterm delivery.
- Ionizing radiation
- Risks arising from previous pregnancies:
- Complications experienced during a previous pregnancy are more likely to recur.
- Many previous pregnancies. Women who have had five previous pregnancies face increased risks of very rapid labor and excessive bleeding after delivery.
- Multiple previous fetuses. Women who have had more than one fetus in a previous pregnancy face increased risk of mislocated placenta.
- Multiple pregnancy, that is, having more than one fetus in a single pregnancy.
- Social and socioeconomic factors. Generally speaking, unmarried women and those in lower socioeconomic groups experience an increased level of risk in pregnancy, due at least in part to lack of access to appropriate prenatal care.
- Unintended pregnancy. Unintended pregnancies preclude preconception care and delays prenatal care. They preclude other preventive care, may disrupt life plans and on average have worse health and psychological outcomes for the mother and, if birth occurs, the child.
- Height. Pregnancy in women whose height is less than 1.5 meters (5 feet) correlates with higher incidences of preterm birth and underweight babies. Also, these women are more likely to have a small pelvis, which can result in such complications during childbirth as shoulder dystocia.
- Weight
- Low weight: Women whose pre-pregnancy weight is less than 45.5 kilograms (100 pounds) are more likely to have underweight babies.
- Obese women are more likely to have very large babies, potentially increasing difficulties in childbirth. Obesity also increases the chances of developing gestational diabetes, high blood pressure, preeclampsia, experiencing postterm pregnancy and/or requiring a cesarean delivery.
- Intercurrent disease in pregnancy, that is, a disease and condition not necessarily directly caused by the pregnancy, such as diabetes mellitus in pregnancy, SLE in pregnancy or thyroid disease in pregnancy.
Pregnancy does not have an adverse effect on the course of Behçet's disease and may possibly ameliorate its course. Still, there is a substantial variability in clinical course between patients and even for different pregnancies in the same patient. Also, the other way around, Behçet's disease confers an increased risk of pregnancy complications, miscarriage and Cesarean section.
Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen. The most effective way of screening for thyroid dysfunction is not known. A review found that more women were diagnosed with thyroid dysfunction when all pregnant women were tested instead of just testing those at ‘high-risk’ of thyroid problems (those with family history, signs or symptoms). Finding more women with thyroid dysfunction meant that the women could have treatment and management through their pregnancies. However the outcomes of the pregnancies were surprisingly similar so more research is needed to look at the effects of screening all women for thyroid problems.
Oxytocin is typically used right after the delivery of the baby to prevent PPH. Misoprostol may be used in areas where oxytocin is not available. Early clamping of the umbilical cord does not decrease risks and may cause anemia in the baby, thus is usually not recommended.
Active management of the third stage is a method of shortening the stage between when the baby is born and when the placenta is delivered. This stage is when the mother is at risk of having a PPH. Active management involves giving a drug which helps the uterus contract before delivering the placenta by a gentle but sustained pull on the umbilical cord whilst exerting upward pressure on the lower abdomen to support the uterus.
Another method of active management which is not recommended now is fundal pressure. A review into this method found no research and advises controlled cord traction because fundal pressure can cause the mother unnecessary pain. Allowing the cord to drain appears to shorten the third stage and reduce blood loss but evidence around this subject is not strong enough to draw solid conclusions.
Nipple stimulation and breastfeeding triggers the release of natural oxytocin in the body, therefore it is thought that encouraging the baby to suckle soon after birth may reduce the risk of PPH for the mother. A review looking into this did not find enough good research to say whether or not nipple stimulation did reduce PPH. More research is needed to answer this question.
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.
The condition can be diagnosed based on inspection of the vulva. In patients with labial fusion, a flat plane of tissue with a dense central line of tissue is usually seen when the labia majora are retracted, while an anterior opening is usually present below the clitoris.
Obstructed labour may be diagnosed based on physical examination.
Treatment is not usually necessary in asymptomatic cases, since most fusions will separate naturally over time, but may be required when symptoms are present. The standard method of treatment for labial fusion is the application of topical estrogen cream onto the areas of adhesion, which is effective in 90% of patients. In severe cases where the labia minora are entirely fused, causing urinary outflow obstruction or vaginal obstruction, the labia should be separated surgically. Recurrence after treatment is common but is thought to be prevented by good hygiene practices. One study has shown that betamethasone may be more effective than estrogen cream in preventing recurrence, with fewer side effects.
The World Health Organization recommends the use of a device called the non-pneumatic anti-shock garment (NASG) for use in delivery activities outside of a hospital setting, the aim being to improve shock in a mother with obstetrical bleeding long enough to reach a hospital.
The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis. Other measures include: keeping the women hydrated and antibiotics if the membranes have been ruptured for more than 18 hours.
The uterus should be evacuated and contractions should be stimulated using intravenous oxytocin; hysterectomy (the removal of the uterus) may be needed in some cases.
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.
The fetus may be compromised if there is prolonged delivery because of the non-contractile uterus; severe bleeding may cause hypovolemic shock in the mother.
Hematometra is usually treated by surgical cervical dilation to drain the blood from the uterus. Other treatments target the underlying cause of the hematometra; for example, a hysteroscopy may be required to resect adhesions that have developed following a previous surgery. If the cause of the hematometra is unclear, a biopsy of endometrial tissue can be taken to test for the presence of a neoplasm (cancer). Antibiotics may be given as prophylaxis against the possibility of infection.
Although hematometra can often be diagnosed based purely on the patient's history of amenorrhea and cyclic abdominal pain, as well as a palpable pelvic mass on examination, the diagnosis can be confirmed by ultrasound, which will show blood pooled in the uterus and an enlargement of the uterine cavity. A pyelogram or laparoscopy may assist in diagnosing any congenital disorder that is suspected to be the underlying cause of the hematometra.
1. The uterine height is greater than the normal for the particular day of puerperium. Normal puerperal uterus may be displaced by a full bladder or a loaded rectum. It feels boggy and softer upon palpation.
2. Presence of features responsible for subinvolution may be evident.
Several techniques are used to reduce the risk of tearing, but with little evidence for efficacy. Antenatal digital perineal massage is often advocated, and may reduce the risk of trauma only in nulliparous women. ‘Hands on’ techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated, but their efficacy is unclear. Waterbirth and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing. However, this effect has never been clearly demonstrated.
Subinvolution is a medical condition in which after childbirth, the uterus does not return to its normal size.
A 2008 study found that over 85% of women having a vaginal birth sustain some form of perineal trauma, and 60-70% receive stitches. A retrospective study of 8,603 vaginal deliveries in 1994 found a third degree tear had been clinically diagnosed in only 50 women (0.6%). However, when the same authors used anal endosonography in a consecutive group of 202 deliveries, there was evidence of third degree tears in 35% of first-time mothers and 44% of mothers with previous children. These numbers are confirmed by other researchers in 1999.
A study by the Agency for Healthcare Research and Quality (AHRQ) found that in 2011, first- and second-degree perineal tear was the most common complicating condition for vaginal deliveries in the U.S. among women covered by either private insurance or Medicaid.
Second-degree perineal laceration rates were higher for women covered by private insurance than for women covered by Medicaid.
If a pregnant mother is identified as being infected with syphilis, treatment can effectively prevent congenital syphilis from developing in the fetus, especially if he or she is treated before the sixteenth week of pregnancy. The fetus is at greatest risk of contracting syphilis when the mother is in the early stages of infection, but the disease can be passed at any point during pregnancy, even during delivery (if the child had not already contracted it). A woman in the secondary stage of syphilis decreases her fetus's risk of developing congenital syphilis by 98% if she receives treatment before the last month of pregnancy. An afflicted child can be treated using antibiotics much like an adult; however, any developmental symptoms are likely to be permanent.
Kassowitz’s law is an empirical observation used in context of congenital syphilis stating that the greater the duration between the infection of the mother and conception, the better is the outcome for the infant. Features of a better outcome include less chance of stillbirth and of developing congenital syphilis.
The Centers for Disease Control and Prevention recommends treating symptomatic or babies born to infected mother with unknown treatment status with procaine penicillin G, 50,000 U/kg dose IM a day in a single dose for 10 days. Treatment for these babies can vary on a case by case basis. Treatment cannot reverse any deformities, brain, or permanent tissue damage that has already occurred.
Usually no treatment is indicated for clinically asymptomatic cervical ectropions. Hormonal therapy may be indicated for symptomatic erosion. If it becomes troublesome to the patient, it can be treated by discontinuing oral contraceptives, cryotherapy treatment, or by using ablation treatment under local anaesthetic. Ablation involves using a preheated probe (100 °C) to destroy 3–4 mm of the epithelium. In post-partum erosion, observation and re-examination are necessary for 3 months after labour.
The appearance of tuberous breasts can potentially be changed through surgical procedures, including the tissue expansion method and breast implants.
The procedure to change the appearance of tuberous breasts can be more complicated than a regular breast augmentation, and some plastic surgeons have specialist training in tuberous breast correction. As tuberous breasts are a congenital deformity, referral for treatment under the National Health Service may be possible in the United Kingdom. A starting point for those seeking such a referral may be a visit to their local General Practitioner. For those seeking non-surgical solutions, counseling may be recommended as a way of coming to terms with body image.