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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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Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become unconscious.
Depending on the definition in question, postpartum hemorrhage is defined as more than 500ml following vaginal delivery or 1000ml of blood loss following caesarean section in the first 24 hours following delivery.
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).
Obstetrical bleeding also known as obstetrical hemorrhage and maternal hemorrhage, refers to heavy bleeding during pregnancy, labor, or the postpartum period. Bleeding may be vaginal or less commonly but more dangerously, internal, into the abdominal cavity. Typically bleeding is related to the pregnancy itself, but some forms of bleeding are caused by other events.
The most frequent cause of maternal mortality worldwide is severe hemorrhage with 8.7 million cases occurring in 2015 and 83,000 of those events resulting in maternal death. Between 2003 and 2009, hemorrhage accounted for 27.1% of all maternal deaths globally
Abnormal bleeding after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. Other definitions of excessive postpartum bleeding are hemodynamic instability, drop of hemoglobin of more than 10%, or requiring blood transfusion. In the literature, primary postpartum hemorrhage is defined as uncontrolled bleeding that occurs in the first 24 hours after delivery while secondary hemorrhage occurs between 24 hours and six weeks.
Based on severity:
- Class 0: Asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
- Class 1: Mild and represents approximately 48% of all cases. Characteristics include the following:
- No vaginal bleeding to mild vaginal bleeding
- Slightly tender uterus
- Normal maternal blood pressure and heart rate
- No coagulopathy
- No fetal distress
- Class 2: Moderate and represents approximately 27% of all cases. Characteristics include the following:
- No vaginal bleeding to moderate vaginal bleeding
- Moderate-to-severe uterine tenderness with possible tetanic contractions
- Maternal tachycardia with orthostatic changes in blood pressure and heart rate
- Fetal distress
- Hypofibrinogenemia (i.e., 50–250 mg/dL)
- Class 3: Severe and represents approximately 24% of all cases. Characteristics include the following:
- No vaginal bleeding to heavy vaginal bleeding
- Very painful tetanic uterus
- Maternal shock
- Hypofibrinogenemia (i.e., <150 mg/dL)
- Coagulopathy
- Fetal death
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.
Retained placenta is a condition in which all or part of the placenta or membranes remain in the uterus during the third stage of labour. Retained placenta can be broadly divided into:
- failed separation of the placenta from the uterine lining
- placenta separated from the uterine lining but retained within the uterus
A retained placenta is commonly a cause of postpartum haemorrhage, both primary and secondary.
Gestational diabetes is when a woman without diabetes develops high blood sugar levels during pregnancy.
In humans, retained placenta is generally defined as a placenta that has not undergone placental expulsion within 30 minutes of the baby’s birth where the third stage of labor has been managed actively.
Risks of retained placenta include hemorrhage and infection. After the placenta is delivered, the uterus should contract down to close off all the blood vessels inside the uterus. If the placenta only partially separates, the uterus cannot contract properly, so the blood vessels inside will continue to bleed. A retained placenta thereby leads to hemorrhage.
Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscles during labor compresses the blood vessels and reduces flow, thereby increasing the likelihood of coagulation and preventing hemorrhage. A lack of uterine muscle contraction, however, can lead to an acute hemorrhage, as the uterine blood vessels are not sufficiently compressed. Clinically, 75-80% of postpartum hemorrhages are due to uterine atony.
Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall). Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:
- Accreta – chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis.
- Increta – chorionic villi invade into the myometrium.
- Percreta – chorionic villi invade through the perimetrium (uterine serosa).
Because of abnormal attachment to the myometrium, placenta accreta is associated with an increased risk of heavy bleeding at the time of attempted vaginal delivery. The need for transfusion of blood products is frequent, and hysterectomy is sometimes required to control life-threatening hemorrhage.
Menstruation occurs typically monthly, lasts 3–7 days, and involves up to 80 ml blood. Bleeding in excess of this norm in a nonpregnant woman constitutes gynecologic hemorrhage. In addition, early pregnancy bleeding has sometimes been included as gynecologic hemorrhage, namely bleeding from a miscarriage or an ectopic pregnancy, while it actually represents obstetrical bleeding. However, from a practical view, early pregnancy bleeding is usually handled like a gynecological hemorrhage.
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.
Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis (blood clots). Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability), as a physiologically adaptive mechanism to prevent "post partum" bleeding. However, when combined with an additional underlying hypercoagulable states, the risk of thrombosis or embolism may become substantial.
Gynecologic hemorrhage represents excessive bleeding of the female reproductive system. Such bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma. Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical hemorrhage.
When the antepartum diagnosis of placenta accreta is made, it is usually based on ultrasound findings in the second or third trimester. Sonographic findings that may be suggestive of placenta accreta include:
1. Loss of normal hypoechoic retroplacental zone
2. Multiple vascular lacunae (irregular vascular spaces) within placenta, giving "Swiss cheese" appearance
3. Blood vessels or placental tissue bridging uterine-placental margin, myometrial-bladder interface, or crossing the uterine serosa
4. Retroplacental myometrial thickness of <1 mm
5. Numerous coherent vessels visualized with 3-dimensional power Doppler in basal view
Although there are isolated case reports of placenta accreta being diagnosed in the first trimester or at the time of abortion <20 weeks' gestational age, the predictive value of first-trimester ultrasound for this diagnosis remains unknown. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should undergo follow-up imaging in the third trimester with attention to the potential presence of placenta accreta.
Many factors can contribute to the loss of uterine muscle tone, including:
- overdistention of the uterus
- multiple gestations
- polyhydramnios
- fetal macrosomia
- prolonged labor
- oxytocin augmentation of labor
- grand multiparity (having given birth 5 or more times)
- precipitous labor (labor lasting less than 3 hours)
- magnesium sulfate treatment of preeclampsia
- chorioamnionitis
- halogenated anesthetics
- uterine leiomyomata
- full bladder
- retained colyledon, placental fragments
- placenta previa
- placental abruption
- constriction ring
- incomplete separation of the placenta
Eclampsia is a disorder of pregnancy characterized by seizures in the setting of pre-eclampsia. Typically the pregnant woman develops hypertension and proteinuria before the onset of a convulsion (seizure).
- Long-lasting (persistent) headaches
- Blurry vision
- Photophobia (i.e. bright light causes discomfort)
- Abdominal pain
- Either in the epigastric region (the center of the abdomen above the navel, or belly-button)
- And/or in the right upper quadrant of the abdomen (below the right side of the rib cage)
- Altered mental status (confusion)
Any of these symptoms may present before or after a seizure occurs. It is also possible that none of these symptoms will develop.
Other cerebral signs may immediately precede the convulsion, such as nausea, vomiting, headaches, and cortical blindness. If the complication of multi-organ failure ensues, signs and symptoms of those failing organs will appear, such as abdominal pain, jaundice, shortness of breath, and diminished urine output.
The most common symptoms of RLP are:
- Sudden pain in the lower abdomen, usually in the right side of the pelvic area that can extend to the groin.
- Shooting abdominal pain when performing sudden movements or physical exercise. Pain is sudden, intermittent and lasts only for a few seconds.
There are 2 major categories of IUGR: symmetrical and asymmetrical. Some conditions are associated with both symmetrical and asymmetrical growth restriction.
HELLP usually begins during the third trimester; rare cases have been reported as early as 21 weeks gestation. Often, a woman who develops HELLP syndrome has already been followed up for pregnancy-induced hypertension (gestational hypertension), or is suspected to develop pre-eclampsia (high blood pressure and proteinuria). Up to 8% of all cases occur after delivery.
Women with HELLP syndrome often appear non-toxic. Early symptoms can include:
- In 90% of cases, either epigastric pain described as "heartburn" or right upper quadrant pain develops.
- In 90% of cases, malaise occurs.
- In 50% of cases, nausea or vomiting happen.
Gradual but marked onset of headaches (30%), blurred vision, and paresthesia (tingling in the extremities) can occur. Edema may occur, but its absence does not exclude HELLP syndrome. Arterial hypertension is a diagnostic requirement, but may be mild. Rupture of the liver capsule and a resultant hematoma may occur. If a woman has a seizure or coma, the condition has progressed into full-blown eclampsia.
Disseminated intravascular coagulation is also seen in about 20% of all women with HELLP syndrome, and in 84% when HELLP is complicated by acute renal failure. Pulmonary edema is found in 6% of all women with HELLP syndrome, and when HELLP is complicated by acute renal failure, pulmonary edema is found in 44% of women with the syndrome.
A woman with symptoms of HELLP can be misdiagnosed in the early stages, increasing the risk of liver failure and morbidity. Rarely, after a caesarean section surgery, a woman may have signs and symptoms of a shock condition mimicking either pulmonary embolism or reactionary haemorrhage.
Pregnancy-induced hypercoagulability is probably a physiologically adaptive mechanism to prevent "post partum" hemorrhage. Pregnancy changes the plasma levels of many clotting factors, such as fibrinogen, which can rise up to three times its normal value. Thrombin levels increase. Protein S, an anticoagulant, decreases. However, the other major anticoagulants, protein C and antithrombin III, remain constant. Fibrinolysis is impaired by an increase in plasminogen activator inhibitor-1 (PAI-1 or PAI) and plasminogen activator inhibitor-2 (PAI-2), the latter synthesized from the placenta. Venous stasis may occur at the end of the first trimester, due to enhanced compliance of the vessel walls by a hormonal effect.
Also, pregnancy can cause hypercoagulability by other factors, e.g. the prolonged bed rest that often occurs "post partum" that occurs in case of delivery by forceps, vacuum extractor or Caesarean section.
A study of more than 200,000 women came to the result that admission to inpatient care during pregnancy was associated with an 18-fold increase in the risk of venous thromboembolism (VTE) during the stay, and a 6-fold increase in risk in the four weeks after discharge, compared with pregnant women who did not require hospitalization. The study included women admitted to hospital for one or more days for reasons other than delivery or venous thromboembolism.
Pregnancy after the age of 35 augments the risk of VTE, as does multigravidity of more than four pregnancies.
Pregnancy in itself causes approximately a five-fold increased risk of deep venous thrombosis. Several pregnancy complications, such as pre-eclampsia, cause substantial hypercoagulability.
Hypercoagulability states as a pre-existing condition in pregnancy include both acquired ones, such as antiphospholipid antibodies, and congenital ones, including factor V Leiden, prothrombin mutation, proteins C and S deficiencies, and antithrombin III deficiency.
Abdominal pains during pregnancy may be due to various pathologies. RLP is one of the most common and benign of these pains. However, diagnosis of RLP is problematic. Some of the conditions that may present symptoms similar to those of RLP are appendicitis, ectopic pregnancy, kidney stones, urinary tract infection, uterine contractions, inguinal hernia, ovarian cysts, and endometriosis. If abdominal pain is continuous and accompanied by vaginal bleeding, excessive vaginal discharge, fever, chills, or vomiting, then it is most unlikely to be RLP and immediate consultation with a health care provider is warranted.
Physical examination, ultrasonography, and blood and urine tests may be able to pinpoint the actual cause of abdominal pain. In some cases, however, RLP was only diagnosed during exploratory surgery.
Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus.
At least 60% of the 4 million neonatal deaths that occur worldwide every year are associated with low birth weight (LBW), caused by intrauterine growth restriction (IUGR), preterm delivery, and genetic/chromosomal abnormalities, demonstrating that under-nutrition is already a leading health problem at birth.
Intrauterine growth restriction can result in a baby being Small for Gestational Age (SGA), which is most commonly defined as a weight below the 10th percentile for the gestational age. At the end of pregnancy, it can result in a low birth weight.