The Nutshell: Obstetrics

Pre-Term Labor

Preterm labor is the onset of regular contractions that results in the birth of a baby between 20 and 37 weeks, where a normal pregnancy should last about 40 weeks. It occurs in about 12 percent of all pregnancies in the United States and often the cause is unknown. Women at greatest risk are those who have had a previous preterm pregnancy. Babies born too early can develop breathing difficulties, infections, brain hemorrhages, bowel problems eye issues and developmental disabilities.

The earlier the delivery, the greater risk of problems. It is important to be seen early if you suspect preterm labor. This is usually a dull back ache, pelvic pressure or tightening of the womb that comes and goes that may or may not be painful. Sometimes it just feels like menstrual cramps. Nuisance contractions can come from dehydration so make sure you drink plenty of water, 4-8 8oz. glasses are advised. However, because medications given to stop the premature labor or help mature the baby’s lungs are more effective early in the process, it is important to notify your health provider immediately of any concerns.

If you are evaluated at the hospital, you may be placed on a monitor to see and/or measure any contractions. The monitor can also check the fetal heart rate and well-being. A vaginal swab may be done to look for fetal fibronectin, a substance found between the fetal sac and the lining of the womb. If the results are negative, our chance of going into labor within a week is very slim. Also urine is checked because a bladder infection can often give you symptoms of preterm labor. This is an important time to talk with your doctor about any concerns.

Those patients at risk for preterm labor can also be given medication in future pregnancies to reduce their risk of another early delivery.

Pre-Eclampsia

This is a medical condition where a pregnant woman develops high blood pressure and protein in the urine after her 20th week, usually in a patient with a previously normal blood pressure. Women can also complain of rapid weight gain (>2lbs. in a week) or significant swelling of their hands, face and feet). It can be more common in younger patients (<20), older patients (>40), and first pregnancy, those with diabetes, previous history of pre-eclampsia, new partner, obesity, twins, kidney disease and arthritis. Those who already have chronic high blood pressure can develop superimposed pre-eclampsia and are at risk of developing more severe symptoms and complications.

The exact cause of this disease is unknown but some believe it is related to an injury of the lining of the blood vessels. Patients complain of significant nausea/vomiting, headaches, blurred vision or visual disturbances and right upper quadrant pain. This can progress to seizures, strokes and placental abruption (pulling away of the placenta from the wall of the uterus). A condition called HELLP is a type of preeclampsia that has a significant involvement of the liver with an elevation of liver enzymes and low platelets (factors found in the blood that help clot).

The earlier in pregnancy this disease occurs and the more severe symptoms, the more concern. The only cure is to deliver the baby. Those who develop preeclampsia are at risk of developing it again in a future pregnancy.

Premature Rupture Membranes

Premature rupture of membranes (PROM) is when a patient breaks her bag of water before labor. Most of the water surrounding the baby is then lost. This can occur at term (greater than 37 weeks) or preterm (less than 37 weeks). The reason is unknown but some believe it may be due to poor nutrition, infections, cigarette smoking or overstretching the membrane sac as seen with twins. It is important if you think you are experiencing leaking of fluid from below, you contact your health provider.

If you are asked to go to the hospital, first a sterile speculum exam will be performed. The examiner will look for fluid in the vagina and take a swab. This is placed on a slide to look for “ferning” a crystallization pattern seen when the water bag is broke. They will also test a swap or “nitrazine” paper to any fluids in the vagina. A color change usually to purple or dark blue may signify also the bag may be broken.

Those who are ruptured more than 24 hours are at risk of developing an infection inside the womb. Most patients at term will go into labor. If it has been longer than 4-6 hours that the water has been leaking, some providers will give pitocin, a medication that will help initiate and strengthen labor contractions.

If this happens very preterm (32-34 weeks), some may try to prolong the pregnancy by giving antibiotics and medications to help mature the baby’s lungs. Pelvic exams should be limited as this may cause an increase in the risk of infection.

Post-Partum Depression

This is a serious condition and should concern all, family, friends and the health provider. It can happen soon after delivery, after a miscarriage, ectopic pregnancy or up to a year later. Many women experience the postpartum or “baby blues and experience anxiety, insomnia, irritability, mood swings, change in appetite, feelings of guilt and tearfulness one or two after pregnancy. These symptoms almost always go away and don’t require treatment.

Others are not so lucky and their symptoms persist and become more severe. Support and understanding are the best initial treatments. It is important to notify the health care provider because often women are in denial. Often time’s medications are necessary. A smaller number of women experience post partum psychosis and this is serious. These patients can become suicidal and harm their baby. Many hospitals are evaluating women after delivery for postpartum depression using a test called Edinburgh Postnatal Depression Scale. If you have concerns, ask to be tested.

Gestational Diabetes

Gestational diabetes is a problem with high blood sugars that is first discovered during pregnancy. That does not mean it hasn’t existed before, just never checked. Most women have no symptoms but can complain of increased thirst, frequent urination, and tiredness. A test called a one-hour glucola is done between 24-28 weeks of pregnancy. The test can be done earlier if you have risk factors like a strong family history of diabetes, obesity, previous stillbirth or gestational diabetes in an earlier pregnancy. A sugary drink (50 g sugar) is given and a blood test is performed in one hour to see how high the blood sugar is. Fasting is not necessary but you should not have had a large meal less than 3 hours before the test.

Normally, the body secretes insulin from the pancreas in response to a high blood sugar, causing the sugar to be absorbed by the muscle, red blood cells and fat cells or stored in the liver. In gestational diabetes, the body is unable to do that properly and the sugar remains high in the blood. If the blood test value is over 140mg/dl (some use 130 mg/dl), the health provider will order a more extended test called a 3 hour oral GTT. A fasting blood sugar (tested first thing in the morning and before eating) is performed. Another sugary drink (100 gr sugar) is given and the blood sugar is checked each hour for 3 hours. That gives you a total of 4 blood test values. If two of those are elevated, that patient is diagnosed with gestational diabetes. The initial treatment is to follow a diabetic diet, very important. This consists of about 1800-2300 kcal per day broken down into three small- to moderate-sized meals and one or more snacks. Fruits, vegetables, and complex carbohydrates like bread, cereal, pasta, and rice are recommended while limiting foods high in sugars.

Moderate exercise, approved by your health provider will also help lower your blood sugars. Patients are asked to monitor their blood sugar levels at home multiple times each day and record the results. The most common way is to prick your finger with a small lancet and put a drop of your blood into a machine that will give you a blood sugar reading.

For many, this is all that is needed and they are called a GDMA1. If the diet fails to control the diabetes, it is now called GDMA2. An oral medication called an oral hypoglycemic may be started or the patient may require multiple insulin injections. Controlling gestational diabetes is very important for the safe growth and development of the baby, who can be at risk for birth defects or macrosomia (baby too large, usually >8 lbs.) increasing the risk of trauma and neurologic injury at birth or Cesareans section. The health provider may order an HgA1C, which is a blood test that shows how well your blood sugar has been controlled over several months, and the values should be less than 7.