Thursday, 2 June 2011

The early pregnancy. Visits to your obstetrician / miscarriages

Q  I am now pregnant. When should I see an obstetrician and what should I expect at this visit?

You should arrange for your first visit between 6 and 8 weeks. this is the best time unless you have a problem before this. He will want to do an ultrasound scan to confirm the pregnancy and to get an expected date of delivery (EDD). At 6 weeks it is possible to determine the presence of a heartbeat and exclude a pregnancy that is not in the womb but the tubes (ectopic pregnancy). He will take a full obstetric and gynaecological history, ask you about the regularity of your periods and past contraceptive use. Your height and weight are measured, your pulse and blood pressure taken, and urine examined for sugar, protein and signs of infection. In the early stage a transvaginal rather than an abdominal ultrasound scan would give a clearer picture. A PAP smear may be done depending on the obstetrician. (some do this after the delivery as it may cause bleeding).

Q  I have a positive pregnancy test, but do not feel any symptoms. Should I be worried?

In the first 4 weeks, most will not feel any symptoms. At 5 weeks, you may feel some tiredness and frequency of urine. Distension and loss of apetite, giddiness and abdominal pulling sensations are common. At 8-10 weeks, the hormone levels are at its peak and you may feel the most symptoms such as nausea and vomiting. In 20% pregnancies there are relatively no symptoms. Having symptoms is a good sign that the pregnancy is likely to be alright. However if there are no symptoms, you should not be unduly worried. An ultrasound scan by your obstetrician will determine if the foetus is alright.

Q  I am 6 weeks pregnant and have found out through an ultrasound scan that my baby's water bag is smaller than expected. Should I be unduly worried?

Assuming that your periods are regular, the size of the water bag should correspond to your period of amenorrhoea. the possible causes could be be wrong dates given, delayed ovulation or a blighted ovum (foetus that has not been growing). If your periods are irregular, then you may have conceived later and the foetus is actually smaller than 6 weeks. You should not be unduly worried as a single ultrasound scan will not distinguish between a blighted ovum and wrong dates. You should have a repeat ultrasound 2 weeks later to see if the foetus has grown. An ultrasound scan at 7 weeks will also pick up the foetal heartbeat and if present will rule out a blighted ovum.

Q  I have been for my first visit to my obstetrician. he has told me that he is not able to see the baby's water bag. Should I be worried?

In the early stages of pregnancy, it may not be possible to see the pregnancy sac. factors such as position of the womb, obesity, sophistication of the scanner will determine if a 4 week pregnancy can be seen. At 5 weeks, he should be able to see the pregnancy sac, if not it raises the possibility of an ectopic pregnancy. He may want to do serial hormone levels and ultrasound scans to rule out this possibility.

Q  I have been told that my baby has not been growing. Why is this and what is the cause?

If serial ultrasounds show a slow growth or abscence of a heartbeat then your pregnancy has undergone a miscarriage. This is termed a blighted ovum or missed abortion. It is due to an improperly formed foetus. As the hormone levels will rise slower or decrease, there may not be much in the way of pregnancy symptoms. Bleding may or may not be present. Very often the diahnosis is made even before bleeding occurs on ultrasound scan. The typical features would be an irregular shaped pregnancy sac, abscence of heartbeat and low or falling hormone levels. Your obstetrician will then perform an evacuation of the uterus. This should be done as soon as possible as any delay can result in infection or bleeding disorders.

Q  I am 7 weeks pregnant. I have noticed some bleeding. What is this due to and what should I do?

You are probably having a threatened miscarriage. Bleeding due to a threatened miscarriage is as common as 1:5 pregnancies. You should stop all physical activity and seek your obstetrician. He will want to do a vaginal examination as the bleeding may also be from a growth in the cervix. An ultrasound scan will determine the viability of the foetus. If the heartbeat is present then there is a good chance that with bed rest and hormonal support, the pregnancy will be an ongoing one. Bed rest for up to 4 days after the bleeding stops is important. If the bleeding is heavy and especially if there are cramps, your obstetrician may decide to admit you to hospital for rest.

Q  I am 7 weeks pregnant and have been having heavy bleeding with cramps. What will my obstetrician do?

Your obstetrician will want to determine whether a miscarriage has occured. Ultrasound scan will show an absent pregnancy sac or some products of conception if this is so. An evacuation to clean up the womb may be deemed necessary.

Q  I have had 3 first trimestor miscarriages. I am planning for a 4th pregnancy. What are the likely causes of recurrent miscarriages and what can be done?

There are various causes, including genetic abnormalities, hormonal problems, infections, excessive smoking or drinking, medical problems and anti-phospholipid antibody syndrome (APA). A blood test to screen for diabetes, systemic lupus erythematosis (SLE), APA, infections such as rubella, toxoplasmosis, cytomegalovirus and genetic karyotyping for both you and your husband will be done, including a hormone profile.
The treatment will depend on the cause. If a due to a lack of the pregnancy hormone, progesterone, treatment with utrogestan (micronised progesterone) together with human chorionic gonadotrophin injections has been shown to improve outcome greatly. If APA positive, treatment is with a combination of low dose aspirin and heparin.This is to reduce the clot formation in the placenta that impairs the blood supply to the foetus. The combination gives a success rate of 75%.

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