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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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Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly occurs around 32 weeks of gestation, but can be as early as late mid-trimester. 51.6% of women with placenta previa have antepartum haemorrhage. This bleeding often starts mildly and may increase as the area of placental separation increases. Previa should be suspected if there is bleeding after 24 weeks of gestation. Bleeding after delivery occurs in about 22% of those affected.
Women may also present as a case of failure of engagement of fetal head.
In the early stages of placental abruption, there may be no symptoms. When symptoms develop, they tend to develop suddenly. Common symptoms include sudden-onset abdominal pain, contractions that seem continuous and do not stop, vaginal bleeding, enlarged uterus disproportionate to the gestational age of the fetus, decreased fetal movement, and decreased fetal heart rate.
Vaginal bleeding, if it occurs, may be bright red or dark.
A placental abruption caused by arterial bleeding at the center of the placenta leads to sudden development of severe symptoms and life-threatening conditions including fetal heart rate abnormalities, severe maternal hemorrhage, and disseminated intravascular coagulation (DIC). Those abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause small amounts of bleeding, intrauterine growth restriction, and oligohydramnios (low levels of amniotic fluid).
Placenta praevia is when the placenta attaches inside the uterus but near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.
Risk factors include pregnancy at an older age and smoking as well as prior cesarean section, labor induction, or termination of pregnancy. Diagnosis is by ultrasound. It is classified as a complication of pregnancy.
For those who are less than 36 weeks pregnant with only a small amount of bleeding recommendations may include bed rest and avoiding sexual intercourse. For those after 36 weeks of pregnancy or with a significant amount of bleeding, cesarean section is generally recommended. In those less than 36 weeks pregnant, corticosteroids may be given to speed development of the babies lungs. Cases that occur in early pregnancy may resolve on their own.
It affects approximately 0.5% of pregnancies. After four cesarean section it, however, effects 10% of pregnancies. Rates of disease have increased over the late 20th century and early 21st century. The condition was first described in 1685 by Paul Portal.
Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.
The cause of placental abruption is not entirely clear. Risk factors include smoking, preeclampsia, prior abruption, trauma during pregnancy, cocaine use, and previous cesarean section. Diagnosis is based on symptoms and supported by ultrasound. It is classified as a complication of pregnancy.
For small abruption bed rest may be recommended while for more significant abruptions or those that occur near term, delivery may be recommended. If everything is stable vaginal delivery may be tried, otherwise cesarean section is recommended. In those less than 36 weeks pregnant, corticosteroids may be given to speed development of the babies lungs. Treatment may require blood transfusion or emergency hysterectomy.
Placental abruption occurs in about 1 in 200 pregnancies. Along with placenta previa and uterine rupture it is one of the most common cause of vaginal bleeding in the later part of pregnancy. Placental abruption is the reason for about 15% of infant deaths around the time of birth. The condition was described at least as early as 1664.
Hyperemesis gravidarum is the presence of severe and persistent vomiting, causing dehydration and weight loss. It is more severe than the more common morning sickness and is estimated to affect 0.5–2.0% of pregnant women.
Gestational diabetes is when a woman without diabetes develops high blood sugar levels during pregnancy.
The symptoms and discomforts of pregnancy are those presentations and conditions that result from pregnancy but do not significantly interfere with activities of daily living or pose a threat to the health of the mother or baby. This is in contrast to pregnancy complications. Sometimes a symptom that is considered a discomfort can be considered a complication when it is more severe. For example, nausea (morning sickness) can be a discomfort, but if, in combination with significant vomiting it causes a water-electrolyte imbalance, it is a complication known as hyperemesis gravidarum.
Common symptoms and discomforts of pregnancy include:
- Tiredness.
- Constipation
- Pelvic girdle pain
- Back pain
- Braxton Hicks contractions. Occasional, irregular, and often painless contractions that occur several times per day.
- Edema (swelling). Common complaint in advancing pregnancy. Caused by compression of the inferior vena cava and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities.
- Increased urinary frequency. A common complaint, caused by increased intravascular volume, elevated glomerular filtration rate, and compression of the bladder by the expanding uterus.
- Urinary tract infection
- Varicose veins. Common complaint caused by relaxation of the venous smooth muscle and increased intravascular pressure.
- Haemorrhoids (piles). Swollen veins at or inside the anal area. Caused by impaired venous return, straining associated with constipation, or increased intra-abdominal pressure in later pregnancy.
- Regurgitation, heartburn, and nausea.
- Stretch marks
- Breast tenderness is common during the first trimester, and is more common in women who are pregnant at a young age.
In addition, pregnancy may result in pregnancy complication such as deep vein thrombosis or worsening of an intercurrent disease in pregnancy.
Associated terms for pregnancy are "gravid" and "parous". "Gravidus" and "gravid" come from the Latin for "heavy" and a pregnant female is sometimes referred to as a "gravida". Gravidity is a term used to describe the number of times that a female has been pregnant. Similarly, the term "parity" is used for the number of times that a female carries a pregnancy to a viable stage. Twins and other multiple births are counted as one pregnancy and birth. A woman who has never been pregnant is referred to as a "nulligravida." A woman who is (or has been only) pregnant for the first time is referred to as a "primigravida", and a woman in subsequent pregnancies as a "multigravida" or as "multiparous." Therefore, during a second pregnancy a woman would be described as "gravida 2, para 1" and upon live delivery as "gravida 2, para 2." In-progress pregnancies, abortions, miscarriages and/ or stillbirths account for parity values being less than the gravida number. In the case of a multiple birth the gravida number and parity value are increased by one only. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as "nulliparous."
The terms "preterm" and "postterm" have largely replaced earlier terms of "premature" and "postmature." "Preterm" and "postterm" are defined above, whereas "premature" and "postmature" have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy.
Locked twins is a rare complication of multiple pregnancy where two fetuses become interlocked during presentation before birth. It occurs in roughly 1 in 1,000 twin deliveries and 1 in 90,000 deliveries overall. Most often, locked twins are delivered via Caesarean section, given that the condition has been diagnosed early enough. The fetal mortality rate is high for the twin that presents first, with over 50% being stillborn.
There are two types of locked twins: breech/vertex and vertex/vertex. In breech/vertex presentations, which are much more common, the first twin is in the breech position, presenting feet-first, and the second is in the cephalic (vertex) position, presenting in the normal head-first manner. In these cases, the chin of the first twin locks behind the chin of the second twin while in the uterus or birth canal, preventing vaginal delivery. In vertex/vertex presentations, where both twins are positioned for head-first delivery, the two heads become locked at the pelvic brim, preventing either fetus from passing through the pelvic inlet in a vaginal delivery.
Contributing factors to the interlocking of twins include uterine hypertonicity, small fetal size, and reduced levels of amniotic fluid following rupture of the membranes. It is more likely to occur in women with large pelvises, young primigravidae (young women in their first pregnancy), and pregnancies with monoamniotic twins.
Shoulder presentations are uncommon (about 0.5% of births) as usually towards the end of gestation either the head or the buttocks start to enter the upper part of the pelvis anchoring the fetus in a longitudinal lie. It is not known in all cases of shoulder presentation why the longitudinal lie is not reached, but possible causes include bony abnormalities of the pelvis, uterine abnormalities such as malformations or tumors (fibroids), and other tumors in the pelvis or abdomen can also lead to a shoulder presentation. Other factors are a lax abdominal musculature, uterine overdistension (i.e. polyhydramnios), multiple gestation, placenta previa, a small fetus, or a fetus with some abnormality. Further, if the amniotic fluid sac ruptures the shoulder or arm may become wedged as a shoulder presentation.
Inspection of the abdomen may already give a clue as it is wide from side to side. Usually performing the Leopold's maneuvers will demonstrate the transverse lie of the fetus. Ultrasound examination delivers the diagnosis and may indicate possible causes such as multiple gestation or a tumor. On vaginal examination, the absence of a head or feet/breech is apparent.
Shoulder presentations are classified into four types, based on the location of the scapula:
- Left scapula-anterior (LSA)
- Right scapula-anterior (RSA)
- Left scapula-posterior (LSP)
- Right scapula-posterior (RSP)
Types of breech depend on how the baby’s legs are lying.
- A frank breech (otherwise known as an extended breech) is where the baby’s legs are up next to its abdomen, with its knees straight and its feet next to its ears. This is the most common type of breech.
- A complete breech (flexed) breech is when the baby appears as though it is sitting crossed-legged with its legs bent at the hips and knees.
- A footling breech is when one or both of the baby’s feet are born first instead of the pelvis. This is more common in babies born prematurely or before their due date.
In addition to the above, breech births in which the sacrum is the fetal denominator can be classified by the position of a fetus. Thus sacro-anterior, sacro-transverse and sacro-posterior positions all exist, but left sacro-anterior is the most common presentation. Sacro-anterior indicates an easier delivery compared to other forms.
Fetal entities: First twin 17-30%; Second twin 28-39%; Stillborn 26%; Prader-Willi syndrome 50%, Werdnig-Hoffman syndrome 10%; Smith-Lemli-Opitz syndrome 40%; Fetal alcohol syndrome 40%; Potter anomaly 36%; Zellweger syndrome 27%; Myotonic dystrophy 21%, 13 trisomy syndrome 12%; 18 trisomy syndrome 43%; 21 trisomy syndrome 5%; de Lange syndrome 10%; Anencephalus 6-18%, Spina bifida 20-30%; Congenital Hydrocephalus 24-37%; Osteogenesis imperfecta 33.3%; Amyoplasia 33.3%; Achondrogenesis 33.3%; Amelia 50%; Craniosynostosis 8%; Sacral agenesis 30.4%; Arthrogriposis multiplex congenita 33.3; Congenital dislocation of the hip 33.3%; Hereditary sensory neuropathy type III 25%; Centronuclear myoptathy 16.7%; Multiple pituitary hormone deficiency 50%; Isolated pituitary hormone deficiency 20%; Ectopic posterior pituitary gland 33.3%; Congenital bilateral perisilvian syndrome 33.3; Symmetric fetal growth restriction 40%; Asymmetric fetal growth restriction 40%; Nonimmune hydrops fetalis 15%; Atresio ani 18.2%; Microcephalus 15.4%; Omphalocele 12.5%; Prematurity 40%
Placental and amniotic fluid entities: Amniotic sheet perpendicular to the placenta 50%; Cornual-fundal implantation of the placenta 30%; Placenta previa 12.5%; Oligohydramnios 17%; Polyhydramnios 15.8%; MATERNAL ENTITIES: Uterus arcuatus 22.6%; Uterus unicornuatus 33.3%; Uterus bicornuatus 34.8%; Uterus didelphys 30-41%; Uterus septus 45.8%; Leimyoma uteri 9-20%; Spinal cord injury 10%; Carriers of Duchenne muscular dystrophy 17%
Combination of two medical entities: First twin in uterus with two bodies 14.29%; Second twin in uterus with two bodies 18.52%.
Also, women with previous Caesarean deliveries have a risk of breech presentation at term twice that of women with previous vaginal deliveries.
The highest possible probability of breech presentation of 50% indicates that breech presentation is a consequence of random filling of the intrauterine space, with the same probability of breech and cephalic presentation in a longitudinally elongated uterus.
An intercurrent (or concurrent, concomitant or, in most cases, pre-existing) disease in pregnancy is a disease that is not directly caused by the pregnancy (in contrast to a complication of pregnancy), but which may become worse or be a potential risk to the pregnancy (such as "causing" pregnancy complications). A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.
In such circumstances, women who wish to continue with a pregnancy require extra medical care, often from an interdisciplinary team. Such a team might include (besides an obstetrician) a specialist in the disorder and other practitioners (for example, maternal-fetal specialists or obstetric physicians, dieticians, etc.).
The major concern of shoulder dystocia is damage to the upper brachial plexus nerves. These supply the sensory and motor components of the shoulder, arm and hands. The ventral roots (motor pathway) are most prone to injury. The cause of injury to the baby is debated, but a probable mechanism is manual stretching of the nerves, which in itself can cause injury. Excess tension may physically tear the nerve roots out from the neonatal spinal column, resulting in total dysfunction.
- Klumpke paralysis
- Erb's Palsy
- Fetal hypoxia
- Fetal death
- Cerebral palsy
- Maternal post partum hemorrhage (11%)
- Vaginal lacerations and 3rd/4th degree tears, extended episiotomies
- uterine rupture
In pregnancy, there is an increased susceptibility and/or severity of several infectious diseases.
Large for gestational age (LGA) is an indication of high prenatal growth rate.
LGA is often defined as a weight, length, or head circumference that lies above the 90th percentile for that gestational age. However, it has been suggested that the definition be restricted to infants with birth weights greater than the 97th percentile (2 standard deviations above the mean) as this more accurately describes infants who are at greatest risk for perinatal morbidity and mortality.
Macrosomia, which literally means "long body", is sometimes confused with LGA. Some experts consider a baby to be big when it weighs more than at birth, and others say a baby is big if it weighs more than . A baby is also called “large for gestational age” if its weight is greater than the 90th percentile at birth.
Infertility is the major symptom of TFI and is generally defined as a woman under 35 who has not become pregnant after 12 months without the use of contraception. Twelve months is the lower reference limit for "Time to Pregnancy" (TTP) by the World Health Organization. When the inability to conceive is accompanied by signs and symptoms of pelvic inflammatory disease such as lower abdominal pain, TFI may be present. A history of pelvic inflammatory disease, the laproscopic evidence of scarring and a diagnosis of salpingitis supports the diagnosis.
Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus (not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage, growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects.
LGA and macrosomia cannot be diagnosed until after birth, as it is impossible to accurately estimate the size and weight of a child in the womb. Babies that are large for gestational age throughout the pregnancy may be suspected because of an ultrasound, but fetal weight estimations in pregnancy are quite imprecise. For non-diabetic women, ultrasounds and care providers are equally inaccurate at predicting whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby, they will be wrong half the time.
Although big babies are born to only 1 out of 10 women, the 2013 Listening to Mothers Survey found that 1 out of 3 American women were told that their babies were too big. In the end, the average birth weight of these suspected “big babies” was only . In the end, care provider concerns about a suspected big baby were the fourth-most common reason for an induction (16% of all inductions), and the fifth-most common reason for a C-section (9% of all C-sections). This treatment is not based on current best evidence.
Research has consistently shown that, as far as birth complications are concerned, the care provider’s perception that a baby is big is more harmful than an actual big baby by itself. In a 2008 study, researchers compared what happened to women who were suspected of having a big baby to what happened to women who were not suspected of having a big baby—but who ended up having one. In the end, women who were suspected of having a big baby (and actually had one) had a triple in the induction rate, more than triple the C-section rate, and a quadrupling of the maternal complication rate, compared to women who were not suspected of having a big baby but who had one anyway.
Complications were most often due to C-sections and included bleeding (hemorrhage), wound infection, wound separation, fever, and need for antibiotics. There were no differences in shoulder dystocia between the two groups. In other words, when a care provider “suspected” a big baby (as compared to not knowing the baby was going to be big), this tripled the C-section rates and made mothers more likely to experience complications, without improving the health of babies.
Tubal factor infertility can be due to Chlamydia infection and testing for Chlamydia antibodies is one diagnostic tool. Women have difficulty getting pregnant or carrying a baby to term due to the buildup of scar tissue in the Fallopian tubes causing damage to the cilia on the epithelial cells. TFI can also be due to endometriosis.
There are several potential risk factors or causes to this increased risk:
- An increased immune tolerance in pregnancy to prevent an immune reaction against the fetus
- Maternal physiological changes including a decrease in respiratory volumes and urinary stasis due to an enlarging uterus.
- The presence of a placenta for pathogens to use as a habitat, such as by "L. monocytogenes" and "P. falciparum".
Arterial occlusion may be due to thrombi, amniotic fragments or air embolism. Postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. Subarachnoid haemorrhage can occur after miscarriage or childbirth. Epidural anaesthesia can, if the dura is punctured, lead to leakage of Cerebrospinal fluid and subdural haematoma. All these can occasionally present with psychiatric symptoms.
Shoulder dystocia is a specific case of obstructed labour whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below, or requires significant manipulation to pass below, the pubic symphysis. It is diagnosed when the shoulders fail to deliver shortly after the fetal head. Shoulder dystocia is an obstetric emergency, and fetal demise can occur if the infant is not delivered, due to compression of the umbilical cord within the birth canal. It occurs in approximately 0.3-1% of vaginal births.