Sometimes the acidic stomach contents flows backwards into the esophagus where it cause severe irritation of the delicate inner lining of the esophagus. This acid reflux is felt as a burning chest pain known as heartburn. It is usually acute and can be easily treated and may then never occur again. However, sometimes there is ongoing reflux irrespective of the usual trigger factors. Acid reflux is more correctly known as gastroesophageal reflux disease (GERD), although the latter term is usually used to refer to the more chronic state.

 Causes of Acid Reflux

Acid reflux is the main cause of heartburn but the burning chest pain can sometimes be related to other causes that may not involve the gastrointestinal tract. Heartburn and cardiac pain are often mistaken for one another and it is not uncommon for a person with severe heartburn to present at the emergency room believing that they are having a heart attack. While this is not common in youngerwomen, the risks is nevertheless present and more so in older women and those with a history of heart disease.

Most cases of acid reflux in pregnancy are acute – it arises in pregnancy and resolves soon after childbirth. However, women with a history of reflux, even prior to pregnancy, are likely to experience an exacerbation during pregnancy with the condition persisting after childbirth unless suitable treatment is initiated. Acid reflux is largely due to a dysfunctional lower esophageal sphincter but may also occur with delayed gastric emptying and increased intra-abdominal pressure. In pregnant, the expanding uterus increases the intra-abdominal pressure, pushes against the stomach and the higher than normal levels of female hormones affects normal upper gastrointestinal motility and the functioning of the lower esophageal sphincter.

The condition is more likely to be worse after eating a heavy meal, when lying down or with the intake of alcohol or cigarette smoking, both of which should be stopped during pregnancy. It may also be exacerbated by strenuous physical activity, bending over and with emotional upset.

Symptoms of Acid Reflux

Heartburn is a symptom of acid reflux and not a disease on its own. Other signs and symptoms may be present including :

• Nausea
• Regurgitation
• Upper middle abdominal pain
• Sour taste in the mouth
• Sore throat particularly in the morning that eases during the course of the day.

Sometimes reflux is asymptomatic and is then referred to as silent reflux disease.

Medication for Reflux in Pregnancy

Reflux, like any disease or symptom in pregnancy, should be managed conservatively as far as possible. Dietary change and avoiding trigger factors are the first step that a pregnant women should undertake. Sleeping slightly elevated and avoiding eating for at least 2 to 3 hours before bedtime should also be considered. Never use any antireflux medication without first consulting with a medical practitioner. Some of these medication may have adverse effects in pregnancy. Antacids, sucralfates and H2-antagonists can be used during pregnancy. While proton pump inhibitors may be used, it should utilized cautiously or avoided altogether as with H2-antagonists in the first trimester of pregnancy.

]]> http://www.phaa.com/acid-reflux-gerd-and-heartburn-in-pregnancy.htm/feed 0 http://www.phaa.com/reasons-for-a-spontaneous-abortion-in-first-12-to-24-weeks-of-pregnancy.htm http://www.phaa.com/reasons-for-a-spontaneous-abortion-in-first-12-to-24-weeks-of-pregnancy.htm#comments Wed, 02 Nov 2011 20:17:44 +0000 Dr. Chris http://www.phaa.com/?p=720 Miscarriage is the lay term for what is medically referred to as a spontaneous abortion. It refers to the loss of a pregnancy in the early stages, usually prior to 20 weeks or before the the fetus reaches 500 grams, where it is not viable for the fetus to exist outside of the uterus. It is also known as early pregnancy loss before 12 weeks although this term may also include an induced abortion where a woman purposefully undergoes any medical or surgical treatment to end the pregnancy. Late miscarriages occur after the first 12 weeks and before the first 24 weeks of pregnancy. Up to 20% of pregnancies (2 out of 10) end in miscarriage and in the majority of cases this occurs in the first trimester (12 weeks).  However, miscarriage is mainly a once  off occurrence and a woman may go on to have a health full term pregnancy afterwards. Less than 1 out of 100 women will experience 2 to 3 consecutive miscarriages.

There is no guarantee that every pregnancy will go on to full term despite the best efforts of the mother, caregivers and medical professionals. While some factors such as advancing maternal age, generally over 35 years, is known to be associated with a greater risk of miscarriage, there is no sure way of knowing at the outset whether a pregnancy will end with the delivery of a healthy baby or in a miscarriage. Nevertheless, if a miscarriage happens more than once consecutively, it needs to be investigated further.

Reasons for Spontaneous Abortion

The exact reason for a miscarriage cannot always be determined. Intensive investigation is warranted in the event of recurrent spontaneous abortions.  Some of the possible causes of a miscarriage includes :

• Genetic abnormalities, also known as chromosomal abnormalities, are the most common causes of miscarriage with most occurring within the first trimester and less frequently before 24 weeks.
• Various factors, sometimes unknown, may be teratogenic (causes embryo malformation) or mutagenic (causes gene mutation). This can at times be associated with lifestyle factors such as cigarette smoking, alcohol consumption and illicit drug use.
• Structural problems of the uterus, cervix and endocervical canal. This includes uterine fibroids.
• Previous uterine surgery can cause adhesions (scar tissue) which may also complicate the pregnancy and lead to miscarriage. This is known as Asherman’s syndrome. Certain medication may also be a causative factor particularly in an unplanned pregnancy. Surgical and medical factors are known as iatrogenic causes. Read more on drugs that affect pregnancy.
• Infections such as rubella (German measles), toxoplasmosis and Listeria infection.
• Chronic diseases particularly endocrine and gynecological disorders such as polycystic ovary syndrome, thyroid disorders, uncontrolled diabetes mellitus, Cushing syndrome and corpus lutem deficiency which is more often acute. Other conditions such as kidney disease, systemic lupus erythematosus (SLE), severe hypertension, sickle cell anemia and antiphospholipid-antibody syndrome may also be associated with a miscarriage.
• Lifestyle factors including tobacco use, alcohol consumption, illicit substances like cocaine and crack and excessive caffeine intake.
• Psychological and physical stress may also be responsible for a miscarriage.
• Injury to the pregnant uterus may be associated with assault, car accidents, falls or even a high voltage electric shock can also cause a miscarriage depending on the severity of the trauma.

Symptoms of a Miscarriage

The most common and pronounced symptom of miscarriage is vaginal bleeding during pregnancy. Sometimes a miscarriage may occur without a woman even knowing that she is pregnant and is marked by unusually heavy periods. This is often ignored and normal periods resumes afterwards. It is important to note that bleeding in the first trimester does not in every case mean that there is a miscarriage. Most women who do experience this type of pregnancy bleed go on to carry full term and give birth to a healthy baby.

Other symptoms of a miscarriage may include abdominal pains and cramps which may also extend to the back. Apart from blood, there may be a copious discharge of fluid from the vagina along with pieces of tissue. Fever, chills, generalized body pains and a foul smelling vaginal discharge may also be present. Some of these symptoms can occur with other pregnancy-related and gynecological disorders that requires further investigation.

Stages of Abortion

There are several terms that are used to describe different types of abortion. The four types known as threatened, inevitable, incomplete and complete abortion are four stages seen in spontaneous abortion.

• Threatened abortion is where the pregnancy is at risk and it typically presents as vaginal bleeding in early pregnancy. About half of all cases can be treated and managed effectively to ensure a normal and healthy full term pregnancy. Threatened abortion is often seen as the first stage of spontaneous abortion.
• Inevitable abortion is where the pregnancy cannot be saved and the cervix dilates in preparation to expel the products of conception. It is marked by vaginal bleeding in addition to abdominal cramping and pain with lower back pain. Inevitable abortion is considered as the second stage of spontaneous abortion.
• Incomplete abortion is where some of the products of conception pass out of the uterus through the dilated cervix and is expelled through the vagina. Along with the symptoms mentioned above under threatened and inevitable abortion, there is also gushing of fluid from the vagina along with pieces of tissue.  Not all the products of conception are expelled though and intervention may be necessary. This is considered to be the third stage of abortion.
• Complete abortion is where all the products of conception have been expelled from the uterus. The vaginal bleeding and abdominal pain peaks and gradually subsides as all the contents are expelled. The cervical dilatation resolves and the os closes. This is considered to be the fourth and final stage of a miscarriage.

Sometimes the products of conception are fully retained and this is known as a missed abortion.

Causes of Melasma

Melasma does not only occur in pregnancy but is more common in altered hormonal states such as pregnancy, or with the use or oral contraceptives and hormone replacement therapy (HRT) in menopause. It can affect men but 90% of the cases occur in women. The exact mechanism for the development of melasma is still not fully understood. It appears that photo-aging as a result of sunlight exposure is a major factor and this may also be associated with estrogen sensitivity of these cells. The concentration of the natural skin pigmentation, melanin, is increased along with the number of melanin-producing cells (melanocytes) containing more melanosomes than normal. Other risk factors for melasma include :

• Darker-skinned individuals.
• Living in areas of intense sun exposure.
• Family history particularly a first-degree relative like a parent, sibling or child.
• Certain cosmetics particularly fragranced skin applications.
• Skin disorders and growths like moles.

Melasma may also be associated with unknown causes and risks (idiopathic).

Signs and Symptoms

Melasma may occur in three different patterns – centrofacial (in the centre of the face), malar (on the cheeks) or mandibular (along the jaw). The patches of hyperpigmentation are irregularly shaped but occur on both sides of the face. Melasma is classified into three types whether the pigmentation occurs in the superficial or deep layers of the skin or in both. Typically darker brown patches lie more superficially in the epidermis while lighter brown patches occur deeper in the dermis. Mixed types of pigmentation are a combination of dark and light brown patches affecting both the epidermis and dermis. Melasma does not present with any itching although patients may report some tingling or burning when exposed to intense sunlight.

Treatment of Melasma

Melasma is diagnosed based on the physical presentation. A Wood’s lamp will help to differentiate between epidermal, dermal and mixed  types of melasma. Hydroquinone, tretinoin and azelaic acid are the main topical applications used in the treatment of melasma. These applications are used on its own or sometimes combined along with other agents like fluocinolone acetonide. Corticosteroids are less frequently used these days. Laser therapy and chemical peels may be effective to varying degrees. However, the greatest difficulty lies with sun exposure which aggravates the condition. Although sun exposure cannot be totally avoided, patients on treatment should try to minimize sun exposure. While sunscreens with a high protective factor may be helpful, it does not preclude the need to avoid the sun. Results may vary – epidermal pigmentation responds better to treatment than mixed or dermal types.

Health Before Pregnancy

There are many aspects of one’s health that needs to be taken into consideration before falling pregnant. Any chronic conditions should be properly treated and appropriately managed. If using chronic medication then it is important to discuss with your doctor whether this medication is suitable during pregnancy or any other alternative measures that may need to be taken. NEVER stop taking prescribed medication without seeking advice from your doctor.

Conditions such as diabetes mellitus and high blood pressure are common ailments and have a significant impact on pregnancy. Both conditions are largely silent for months or even years and therefore remain undiagnosed for long periods of time. Screening for diabetes and hypertension as well as other conditions prior to conception, despite the lack of symptoms, is an important part of preconception checkups. Identifying these conditions at the outset will allow your doctor to differentiate between the chronic forms and gestational diabetes and gestational hypertension.

Health extends beyond the absence of any identifiable disease, whether acute or chronic. The prevalence of obesity in this day and age is also a health consideration for women planning to conceive. It has a host of implications for conceiving and may lead to several complications during pregnancy. Weight management, either loss or gain, to attain as close as normal a BMI (body mass index) is essential and is not an overnight endeavor. Therefore planning a pregnancy and taking the necessary health measures should be commenced at least 6 months prior to conception.

Falling Pregnant

It may take up to 6 months of regular intercourse to fall pregnant and therefore couples who are trying to conceive should not be concerned if pregnancy does not occur immediately. However, should conception not occur after 6 months of trying, it is advisable to consult with a gynecologist for further evaluation.

It is important to focus sexual activity around the time of ovulation – when the ovary releases an egg cell into the fallopian tube. Ovulation occurs between 12 to 16 days prior to menstruation and women with irregular cycles can ovulate more than once in a month but this is difficult to predict. Signs and symptoms like a thicker vaginal discharge and ovulation discomfort/pain (Mittelschmerz) may be an indicator of ovulation.

It is important to bear in mind that the egg cell (ovum) may only survive for as short a time period as 12 to 24 hours. If fertilized, implantation will occur within 6 to 12 days after ovulation. Pregnancy may therefore not be detectable immediately after fertilization. Stress, illness and other health and lifestyle factors may all affect ovulation, fertilization or implantation and should therefore be kept to a minimum.

]]> http://www.phaa.com/planning-for-pregnancy-preconception-pre-pregnancy-advice.htm/feed 0 http://www.phaa.com/low-pregnant-belly-carrying-baby-low-in-pregnancy.htm http://www.phaa.com/low-pregnant-belly-carrying-baby-low-in-pregnancy.htm#comments Thu, 13 Oct 2011 21:50:54 +0000 Dr. Chris http://www.phaa.com/?p=660 Pregnant women, especially first time mothers, have many concerns relating to pregnancy and rightfully so. Pregnancy is a delicate period in a women’s life and utmost care should be taken. Education about the facts of pregnancy from diet to lifestyle and signs of impending danger are important in maintaining a healthy pregnancy and giving birth to a healthy baby. One of the many concerns is whether carrying the baby low is a indicative of any problem in pregnancy or not. Another common query is whether a low pregnant belly is an indication of the baby’s gender.

Causes of Carrying Baby Low

Carrying a baby low is neither the sign of a problem in pregnancy nor is it an indication of the baby’s gender. There are numerous factors that play a role in whether the baby is carried higher or lower than what one would expect. Most importantly though it is about expectation and preconceived ideas – pregnant women should not define the norm based on what others say or on the similarities or differences from other pregnant women around them.

Some of the reasons why a woman carries a baby low is due to her body shape and musculature. Better developed abdominal muscles make for a firmer tummy and this can determine how low the pregnant belly will sit. The muscles and supporting ligaments in and around the uterus also play a role and after the first pregnancy some women may find that the belly sits lower in subsequent pregnancies. Stretched muscles may not only be seen after subsequent pregnancies but also with a reduced level of fitness.

A heavier baby will also contribute to a lower lying pregnant belly as would multiple births (twins, triplets and so on). This is an important factor to bear in mind when listening to mothers who went through pregnancies decades prior. In the 70s and 80s the average birth weight was about 20% less than today. The rise in birth weight means that the baby will be carried lower than women did in yesteryear. At the same time, memory is often unreliable after so many years.

Lastly, a low sitting belly may be a sign of impending labor. The pressure in the abdomen lessens (known as the lightening) and the pressure in the pelvis rises. Other signs and symptoms indicative of impending labor may also be present like more frequent Braxton Hick’s contractions. This does not, however, indicate impending labor in the short term, but occurs as a preparation for labor in a few weeks. If the “drop” occurs too early in pregnancy along with other symptoms of labor then it may be a preterm delivery and extra care for both mother and baby is necessary.

Complications of a Low Pregnant Belly

A low pregnant belly does not indicate any danger or problems in pregnancy. However, carrying the baby low can exacerbate lower back pain which is common in pregnancy. The change in the center of gravity differs to the shift seen in carrying the baby higher. Arching the back is one way that pregnant women compensate for this shift but this may need to be more pronounced in order to “pull” against the lower lying belly. Furthermore, where the low lying pregnant belly is associated with a larger and therefore heavier baby, the strain on the back is compounded even further.

Types of Hypertension

Essential hypertension is the most common type of high blood pressure. It occurs for no known reason and may arise irrespective of pregnancy. It is a chronic type of hypertension that tends to get worse over time although lifestyle modification and medication can control it to some extent. In some instances it can arise during pregnancy although it is most likely not due to the pregnant state. It tends to continue after delivery and is defined by its persistence 6 weeks after delivery.

Gestational hypertension is high blood pressure that arises in pregnancy due to the pregnant state. The blood pressure tends to return to normal after childbirth but there is an increased risk of developing essential hypertension later in life. Gestational hypertension needs to be approached with caution as it may be a sign of pre-eclampsia – a potentially fatal condition in pregnancy. Therefore every case of gestational hypertension even in the absence of other signs is considered as pre-eclampsia until proven otherwise.

Pre-eclampsia, previously known as toxemia of pregnancy, is a dangerous condition that arises in pregnant women for no known reason. There are number of risk factors associated with pre-eclampsia including obesity, first pregnancy, family history of pre-eclampsia, multiple pregnancy and diabetes. However, even women without these risk factors may develop pre-eclampsia. Other typical signs and symptoms include swelling of the face and hands and protein in the urine. There may also be changes in vision, severe headaches, abdominal pain, nausea and vomiting and dizziness.

Treatment of Hypertension in Pregnancy

The treatment options depend on the type of hypertension and severity of the condition. While starting medication for hypertension during pregnancy is avoided as far as possible, if necessary it may be prescribed. Women who have pre-existing hypertension and are on anti-hypertensive medication should not stop drug therapy once they fall pregnant without consulting with a doctor. Bed rest, dietary modification like a low sodium diet and even weight control may all help with minimizing hypertension.

In pre-eclampsia, an early delivery is necessary even if this means giving birth to a pre-term baby. This is the only cure for pre-eclampsia which if left untreated can be life-threatening to both mother and the unborn child. However, if pre-eclampsia occurs very early in pregnancy where delivery is not a viable option as yet then close monitoring is essential. Drug therapy may also be commenced. In severe cases, however, labor may be induced or a Cesarean section conducted despite the baby’s gestational age.

Constipation During Pregnancy

Constipation is defined simply as three or less bowel movements in a week with the passage of hard stools, straining during defecation and a feeling of incomplete bowel emptying after a movement. Not all women who are constipated will have every feature mentioned above and often constipation to the individual is seen as any reduction in frequency of bowel movement from the normal state.

Although constipation is the more common type of bowel irregularity in pregnancy, some woman may even experience diarrhea or periods of constipation interspersed with diarrhea. It is also not uncommon for women with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) to experience an exacerbation of their condition. As a general guideline, a women who experiences a change in bowel movement during pregnancy, even a minor change, should seek medical advice if this is causing discomfort.

Causes of Constipation in Pregnancy

Constipation is a symptom, not a disease, that is associated with slower bowel activity, reduced water and fiber intake or abnormal contraction of the anal sphincters. The causes of constipation in woman who are not pregnant is not significantly different from that in a pregnant woman. However, the changes in the hormone levels in pregnancy and the growing uterus may contribute to constipation to a greater extent than in non-pregnant women.  Certain nutritional supplements used in higher doses during pregnancy may also contribute to constipation. Lack of physical activity is another factor that is more prominent in the later stages of pregnancy.

Treatment and Remedies

Simple dietary changes are often effective in most cases, if not for totally resolving the constipation, then at least for providing significant relief. Increasing water intake and eating high fiber foods including fruits and vegetables  is usually sufficient. Although the amount of physical activity may be reduced with pregnancy, walking and swimming are two activities that do not put significant strain on the back and joints and is still effective.

Medication should be avoided as far as possible. Laxatives can be used but should only be considered after consulting with a doctor. Certain laxatives, including herbal laxatives, can cause contractions and should be avoided as far as possible. Reduce the intake of aluminimum-containing antacids for heartburn as these often cause or aggravate constipation. Any other medication that has been prescribed by a doctor should not be discontinued without first seeking medical advice.

Fortunately, most women get over this condition by the fourth month, and can then go on to enjoy a non-eventful pregnancy and childbirth, with delivery of a normal healthy baby. For the unlucky few, morning sickness can continue unabated for a longer period or even throughout pregnancy. Most women cope sufficiently well with frequent small meals, reassurance from the doctor, and emotional support from the partner.

In rare cases, the vomiting may be so severe as to cause dehydration and weight loss. This is a serious condition, known as hyperemesis gravidarum, which needs more active management so as not to jeopardize pregnancy.

What Causes Morning Sickness?

The term “morning sickness” is a misnomer since nausea and vomiting of pregnancy can occur not only in the mornings but at any time of the day or night. However, most women have it in the mornings and it is usually aggravated by the smell of food, cooking, or any pungent smell.

The cause of morning sickness is not very clear but a hormonal factor seems to be involved. Increased levels of hormones such as human chorionic gonadotropin (hCG), estrogen, and progesterone have been implicated. Morning sickness is more likely to occur in women carrying multiple pregnancies, such as twins or triplets, where there is excess of circulating hormones. Excess thyroid hormones or low blood sugar may be other causative factors. It has also been seen that women who have a vomiting tendency are more likely to suffer from morning sickness. Stress or a history of vomiting in previous pregnancies may also predispose.

Does Morning Sickness harm the Baby?

Whether morning sickness can harm the baby is a major concern for most mothers. Unless the vomiting is so severe as to cause dehydration and weight loss in the mother (hyperemesis gravidarum), it is unlikely to cause any harm to the baby. However, in case of hyperemesis gravidarum there remains the risk of preterm labor or a low birth weight baby. This can usually be avoided with timely hospitalization and appropriate treatment. It has been noted that even with excessive vomiting, if a weight gain of more than 7 kg can be managed during the pregnancy, complications for the baby can be avoided.

Another point that has been noticed is that uncomplicated nausea and vomiting of pregnancy can actually decrease the chance of miscarriage. However, it does not follow that absence of morning sickness is an indication of impending miscarriage.

Treatment of Morning Sickness

Home remedies are usually sufficient to reduce morning sickness. These may include dietary measures such as taking small frequent meals, avoiding rich and spicy foods, and taking more foods such as dry toast, crackers, broth, and gelatin. Fluid replacement and thiamine injection may be given for severe vomiting. Hospitalization and intravenous fluid and nutrient replacement may be required for hyperemesis gravidarum. Antiemetics (drugs to prevent vomiting) should only be taken if prescribed by the attending doctor.

Guidelines for Pregnancy Weight Gain

Although there is no hard and fast rule, it is generally accepted that a weight gain between 10 and 12.5 kilograms (22 to 28 pounds) during pregnancy is adequate. This will of course vary in different women and will be guided by factors such as your BMI and weight before pregnancy, whether you suffer from diabetes, or if you are pregnant with twins, triplets, or more. Each pregnancy is different and your healthcare provider is the right person to guide you in this respect.

It should also be remembered that many women lose weight in the first trimester of pregnancy, often due to morning sickness. As long as this weight loss is not excessive, it should not be a cause for worry. Steady weight gain from the second trimester onwards should reassure you that your baby is getting adequate nutrition on a regular basis.

Being obese before pregnancy

BMI is a measure of your weight in relation to your height. A woman with BMI of 30 or more is considered obese. Even if you fall in this category, it will still be necessary for you to eat a healthy diet that will provide sufficient nutrients to your baby. Although you will be advised to gain weight, it should strictly be between 5 to 9 kg (11 to 20 lbs), with a weekly gain of 0.2 to 0.3 kg from the second trimester onwards.

Being overweight before pregnancy

A woman with BMI between 25 and 29.9 is considered to be overweight. The recommended weight gain during pregnancy for overweight women is usually between 7 to11 kg (15 to 25 pounds) and should not exceed this limit. The average weight gain per week should be 0.2 to 0.3 kg (0.5 to 0.7 lbs) from the second trimester onwards. The focus should be on a healthy diet.

Normal weight before pregnancy

Your weight is considered normal if your BMI is between 18.5 and 24.9. Your pregnancy weight gain should be between 11 to 16 kg (25 to 35 lbs). The average weight gain per week should ideally be between 0.4 to 0.5 kg (0.8 to 1 lb).

Being underweight before pregnancy

If your BMI is less than 18.5, you will be considered underweight. To ensure that your baby’s growth is adequate, you will need to gain some extra weight during pregnancy. A weight gain of 13 to 18 kg is usually recommended, with a steady gain of 0.5 to 0.6 kg (1 to 1.3 lbs) per week.

If you are carrying twins, triplets or more

Your pregnancy weight gain should definitely be more than normal, but it should not be double or triple the amount. Excessive weight gain is not at all desirable.

Dangers of Excessive Weight Gain during Pregnancy

• Gestational diabetes.
• Large baby.
• Difficult childbirth.
• Increased chances of cesarean section.
• Hypertension (high blood pressure).
• Preeclampsia and eclampsia.
• Preterm delivery.
• Leg pain.
• Varicose veins.
• Studies suggest that babies born to obese mothers are at increased risk of developing congenital heart defects.

Dieting is not an option during pregnancy, so in case of excessive weight gain during thistime, simple exercises such as walking and swimming may be recommended by your healthcare provider. Dietary changes may help.

Dangers of Less Weight Gain during Pregnancy

• Premature baby.
• Small baby.
• Low birth weight.

A healthy diet, adequate exercise, and enough rest can ensure proper weight gain during pregnancy.