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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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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.
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.
Signs of a miscarriage include vaginal spotting, abdominal pain or cramping, and fluid or tissue passing from the vagina. Bleeding can be a symptom of miscarriage, but many women also have bleeding in early pregnancy and don't miscarry. Bleeding during pregnancy may be referred to as a threatened miscarriage. Of those who seek clinical treatment for bleeding during pregnancy, about half will miscarry. Miscarriage may be detected during an ultrasound exam, or through serial human chorionic gonadotropin (HCG) testing.
Each year, ill health as a result of pregnancy is experienced (sometimes permanently) by more than 20 million women around the world. In 2013 complications of pregnancy resulted in 293,000 deaths down from 377,000 deaths in 1990. Common causes include maternal bleeding (44,000), complications of abortion (44,000), high blood pressure of pregnancy (29,000), maternal sepsis (24,000), and obstructed labor (19,000).
The following are some examples of pregnancy complications:
- Pregnancy induced hypertension
- Anemia
- Postpartum depression
- Postpartum psychosis
- Thromboembolic disorders. These are the leading cause of death in pregnant women in the US.
- PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy), a skin disease that develops around the 32nd week. Signs are red plaques, papules, and itchiness around the belly button that then spreads all over the body except for the inside of hands and face.
- Ectopic pregnancy, implantation of the embryo outside the uterus.
- Hyperemesis gravidarum, excessive nausea and vomiting that is more severe than normal morning sickness.
- Pulmonary embolism, blood clots that form in the legs that can migrate to the lungs.
There is also an increased susceptibility and severity of certain infections in pregnancy.
Generally it is preferable to describe specific signs in lieu of declaring "fetal distress" that include:
- Decreased movement felt by the mother
- Meconium in the amniotic fluid ("meconium stained fluid")
- Non-reassuring patterns seen on cardiotocography:
- increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction
- decreased variability in the fetal heart rate
- late decelerations
- Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp prick through the open cervix in labor
- fetal metabolic acidosis
- elevated fetal blood lactate levels (from fetal scalp blood testing) indicating the baby has a lactic acidosis
Some of these signs are more reliable predictors of fetal compromise than others. For example, cardiotocography can give high false positive rates, even when interpreted by highly experienced medical personnel. Metabolic acidosis is a more reliable predictor, but is not always available.
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.
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.
Miscarriage, also known as spontaneous abortion and pregnancy loss, is the natural death of an embryo or fetus before it is able to survive independently. Some use the cutoff of 20 weeks of gestation, after which fetal death is known as a stillbirth. The most common symptom of a miscarriage is vaginal bleeding with or without pain. Sadness, anxiety and guilt often occur afterwards. Tissue and clot-like material may leave the uterus and pass through and out of the vagina. When a woman keeps having miscarriages, infertility is present.
Risk factors for miscarriage include an older parent, previous miscarriage, exposure to tobacco smoke, obesity, diabetes, thyroid problems, and drug or alcohol use. About 80% of miscarriages occur in the first 12 weeks of pregnancy (the first trimester). The underlying cause in about half of cases involves chromosomal abnormalities. Diagnosis of a miscarriage may involve checking to see if the cervix is open or closed, testing blood levels of human chorionic gonadotropin (hCG), and an ultrasound. Other conditions that can produce similar symptoms include an ectopic pregnancy and implantation bleeding.
Prevention is occasionally possible with good prenatal care. Avoiding drugs, alcohol, infectious diseases, and radiation may prevent miscarriage. No specific treatment is usually needed during the first 7 to 14 days. Most miscarriages will complete without additional interventions. Occasionally the medication misoprostol or a procedure such as vacuum aspiration is used to remove the remaining tissue. Women who have a blood type of rhesus negative (Rh negative) may require Rho(D) immune globulin. Pain medication may be beneficial. Emotional support may help with negative emotions.
Miscarriage is the most common complication of early pregnancy. Among women who know they are pregnant, the miscarriage rate is roughly 10% to 20%, while rates among all fertilisation is around 30% to 50%. 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. About 5% of women have two miscarriages in a row. Some recommend not using the term "abortion" in discussions with those experiencing a miscarriage in an effort to decrease distress.
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.
Symptoms of a rupture may be initially quite subtle. An old cesarean scar may undergo dehiscence; but with further labor the woman may experience abdominal pain and vaginal bleeding, though these signs are difficult to distinguish from normal labor. Often a deterioration of the fetal heart rate is a leading sign, but the cardinal sign of uterine rupture is loss of fetal station on manual vaginal exam. Intra-abdominal bleeding can lead to hypovolemic shock and death. Although the associated maternal mortality is now less than one percent, the fetal mortality rate is between two and six percent when rupture occurs in the hospital.
In pregnancy uterine rupture may cause a viable abdominal pregnancy. This is what accounts for most abdominal pregnancy births.
- Abdominal pain and tenderness. The pain may not be severe; it may occur suddenly at the peak of a contraction. The woman may describe a feeling that something "gave way" or "ripped."
- Chest pain, pain between the scapulae, or pain on inspiration—Pain occurs because of the irritation of blood below the woman's diaphragm
- Hypovolemic shock caused by haemorrhage— Falling blood pressure, tachycardia, tachypnea, pallor, cool and clammy skin, and anxiety. The fall in blood pressure is often a late sign of haemorrhage
- Signs associated with fetal oxygenation, such as late deceleration, reduced variability, tachycardia, and bradycardia
- Absent fetal heart sounds with a large disruption of the placenta; absent fetal heart activity by ultrasound examination
- Cessation of uterine contractions
- Palpation of the fetus outside the uterus (usually occurs only with a large, complete rupture). The fetus is likely to be dead at this point.
- Signs of an abdominal pregnancy
- Post-term pregnancy
Swelling (especially in the hands and face) was originally considered an important sign for a diagnosis of pre-eclampsia. However, because swelling is a common occurrence in pregnancy, its utility as a distinguishing factor in pre-eclampsia is not high. Pitting edema (unusual swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed on) can be significant, and should be reported to a health care provider.
In general, none of the signs of pre-eclampsia are specific, and even convulsions in pregnancy are more likely to have causes other than eclampsia in modern practice. Further, a symptom such as epigastric pain may be misinterpreted as heartburn. Diagnosis, therefore, depends on finding a coincidence of several pre-eclamptic features, the final proof being their regression after delivery.
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.
A heterotopic pregnancy is a rare complication of pregnancy in which both extra-uterine (ectopic pregnancy) and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.
A possible pregnancy must be considered in any woman who has abdominal pain or abnormal vaginal bleeding. A heterotopic pregnancy may have similar signs and symptoms as a normal intrauterine pregnancy, a normal intrauterine pregnancy and a ruptured ovarian cyst, a corpus luteum, or appendicitis. Blood tests and ultrasound can be used to differentiate these conditions.
HELLP syndrome is defined as hemolysis (microangiopathic), elevated liver enzymes (liver dysfunction), and low platelets (thrombocytopenia). This condition may occur in 10–20% of patients with severe pre-eclampsia and eclampsia and is associated with increased maternal and fetal morbidity and mortality. In 50% of instances, HELLP syndrome develops preterm, while 20% of cases develop in late gestation and 30% during the post-partum period.
It is common to have bleeding in early pregnancy, this is associated with implantation bleeding and can be mistaken for a regular period. However implantation bleeding is usually much lighter and in many cases sanitary napkins aren't necessary. Although excessive bleeding in the first trimester can also be associated with miscarriage.
Morning sickness occurs in about seventy percent of all pregnant women, and typically improves after the first trimester. Although described as "morning sickness", women can experience this nausea during the afternoon, evening, and throughout the entire day. Unfortunately there is no strong evidence showing one treatment that works for all women. Ginger may help some women but the results change from study to study.
Uterine rupture is a serious event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad ligament. A uterine rupture is a life-threatening event for mother and baby.
A uterine rupture typically occurs during active labor, but may also develop during late pregnancy.
Uterine dehiscence is a similar condition, but involves fewer layers, less bleeding, and less risk.
Twin-to-twin transfusion syndrome (TTTS), also known as feto-fetal transfusion syndrome (FFTS) and twin oligohydramnios-polyhydramnios sequence (TOPS) is a complication of disproportionate blood supply, resulting in high morbidity and mortality. It can affect monochorionic multiples, that is, multiple pregnancies where two or more fetuses share a chorion and hence a single placenta. Severe TTTS has a 60–100% mortality rate.
An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.
A staging system proposed by fetal surgeon Dr. Ruben Quintero is commonly used to classify the severity of TTTS.
Stage I: A small amount of amniotic fluid (oligohydramnios) is found around the donor twin and a large amount of amniotic fluid (polyhydramnios) is found around the recipient twin.
Stage II: In addition to the description above, the ultrasound is not able to identify the bladder in the donor twin.
Stage III: In addition to the characteristics of Stages I and II, there is abnormal blood flow in the umbilical cords of the twins.
Stage IV: In addition to all of the above findings, the recipient twin has swelling under the skin and appears to be experiencing heart failure (fetal hydrops).
Stage V: In addition to all of the above findings, one of the twins has died. This can happen to either twin. The risk to either the donor or the recipient is roughly equal & is quite high in Stage II or higher TTTS.
The Quintero staging does not provide information about prognosis, and other staging systems have been proposed.
Placental insufficiency can be induced experimentally by bilateral uterine artery ligation of the pregnant rat.
The following characteristics of placentas have been said to be associated with placental insufficiency, however all of them occur in normal healthy placentas and full term healthy births, so none of them can be used to accurately diagnose placental insufficiency:
- Abnormally thin placenta (less than 1 cm)
- Circumvallate placenta (1% of normal placentas)
- Amnion cell metaplasia, (amnion nodosum) (present in 65% of normal placentas)
- Increased syncytial knots
- Calcifications
- Infarcts due to focal or diffuse thickening of blood vessels
- Villi capillaries occupying about 50% of the villi volume or when <40% of capillaries are on the villous periphery
Placental insufficiency should not be confused with complete placental abruption, in which the placenta separates off the uterine wall, which immediately results in no blood flow to the placenta, which leads to immediate fetal demise. In the case of a marginal, incomplete placental abruption of less than 50%, usually weeks of hospitalization precedes delivery and outcomes are not necessarily affected by the partial abruption.
Early diagnosis is important and today facilitated by the use of sonography and the quantitative human chorionic gonadotropin (hCG) assay. As in other cases of ectopic pregnancy, risk factors are: previous tubal pregnancy, IVF therapy, tubal surgery, and a history of sexual infection.
Typical symptoms of an interstitial pregnancy are the classic signs of ectopic pregnancy, namely abdominal pain and vaginal bleeding. Hemorrhagic shock is found in almost a quarter of patients.; this explains the relatively high mortality rate.
In pregnant patients, sonography is the primary method to make the diagnosis, even when patients have no symptoms. The paucity of myometrium around the gestational sac is diagnostic, while, in contrast, the angular pregnancy has at least 5 mm of myometrium on all of its sides. Ultrasonic criteria for the diagnosis include an empty uterine cavity, a gestational sac separate from the uterine cavity, and a myometrial thinning of less than 5 mm around the gestational sac; typically the "interstitial line sign"—an echogenic line from the endometrial cavity to the corner next to the gestational mass—is seen. MRI can be used particularly when it is important to distinguish between an interstitial and angular pregnancy.
On average, the gestational age at presentation is about 7–8 weeks. In a 2007 series, 22% of patients presented with rupture and hemorrhagic shock, while a third of the patients were asymptomatic; the remainder had abdominal pain and/or vaginal bleeding. Cases that are not diagnosed until surgery show an asymmetrical bulge in the upper corner of the uterus.
The seizures of eclampsia typically present during pregnancy and prior to delivery (the antepartum period), but may also occur during labor and delivery (the intrapartum period) or after the baby has been delivered (the postpartum period). If postpartum seizures develop, it is most likely to occur within the first 48 hours after delivery. However, late postpartum seizures of eclampsia may occur as late as 4 weeks after delivery.