It is very important to pay attention to the color of pill as many of the above brands have several colors within a given package.
Important:
The dosage schedule requires that a woman begin this treatment as soon as possible after unprotected intercourse, preferably prior to 72 hours, or 3 days, after unprotected intercourse. It may still be effective up to 5 days after intercourse. A woman must take one dose immediately and a second dose 12 hours later for 2 doses in 12 hours.
Side-effects include nausea and vomiting, which is worse with the combination pill, and which may require anti-nausea medication, irregular bleeding, breast tenderness, abdominal pain, dizziness, headache and fatigue.
No follow-up medical care is required. However, after treatment a woman will have her menses up to 7 days early or 7 days late. If her menses is greater than 7 days late, the woman should take a pregnancy test. If bleeding continues after the 7 days, a miscarriage must be ruled out. If irregular bleeding is accompanied by abdominal pain, an ectopic pregnancy must be considered.
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Endometriosis
Under Development.
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Fibroids
Fibroids are smooth muscle tumors of the uterus. These tumors are normally benign with only 1 in 2000 presenting as a malignant growth called a sarcoma. Because they are typically benign, they do not require any treatment unless they cause troublesome symptoms. Still, fibroids are the leading reason a hysterectomy is performed. Fibroids, also referred to as leiomyomas, grow from a single uterine smooth muscle cell. Though they all develop within the uterine wall (intramural fibroids), they may enlarge and grow either inward towards the uterine lining (submucous fibroids) or outward towards the surface of the uterus (subserosal fibroids). Depending upon their size and location, fibroids may cause abnormal bleeding, which is more common in submucous fibroids, or pelvic pain or pressure, which is more common in very large fibroids.
Fibroids may be present in up to 80% of women, and they cause troublesome symptoms in 25% to 50% of women who have them. The actual cause of fibroids remains unknown. They vary in size from very tiny to extremely large. The largest ones may place pressure on surrounding organs such as the bowel, causing rectal pressure and constipation, and the bladder, where they may cause urinary retention or urinary incontinence. The largest ones may grow so large that they begin to degenerate centrally causing significant pain symptoms. More commonly, they may be of a relatively small size but still cause symptoms, the most common of which is menorrahgia, or prolonged and/ or heavy menstrual flow. Fibroids also cause painful menstrual periods, called dysmenorrhea.
Fibroids may also interfere with a woman’s ability to conceive or maintain a pregnancy. They may also be responsible for pain in pregnancy, the onset of premature labor, a breech or other abnormal presentation or an increased rate of cesarean section, depending upon their location and size. However, most women with fibroids are able to conceive and have an uncomplicated pregnancy.
The most common treatment for fibroids is surgical removal of either the fibroid itself (myomectomy) or of the entire uterus (hysterectomy). There is no effective long-term medical treatment for fibroids. However, a recently developed alternative to surgery is the use of a radiographic (x-ray guided) procedure called uterine artery embolization, or UAE. In this procedure, a catheter is placed in the femoral artery in a woman ’s right groin and directed to the uterine artery on the left side of her body. The radiologist then injects a substance that embolizes, or blocks, the uterine artery. This causes the blood flow to the uterus and fibroid to decrease. This procedure may decrease the size of the fibroid, thereby decreasing the symptoms caused by the previously enlarged fibroid. This procedure, like all medical procedures, has risks. Please take the time to ask Dr. Giarratana or Colleen Wheeler about this procedure and about other treatment options.
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Hormone Replacement Therapy and Alternatives
Under Development
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Hysterectomy: Indications and Alternatives
Under Development
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Infertility: Workup and Management Options
Under Development
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Libido: Low Sex Drive
Under Development
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The Mammogram and Breast Cancer Screening
Under Development
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Osteoporosis
Under Development
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The Pap Test: Cervical Cancer Screening
The Pap test is performed by taking a sample of cells from the surface of the cervix using either a wooden spatula or a specialized brush. These cells are then smeared on a glass microscope slide or placed in a liquid for later processing. The test is used to detect abnormal, potentially precancerous, cells that could lead to cancer of the cervix if left untreated. By detecting these precancerous changes early, they can be treated and cervical cancer can be prevented.
The Pap test is a screening test, so an abnormal result only suggests that a true cervical abnormality is present, it does not prove it. The Pap test is done in order to identify those women who require a cervical biopsy, used to determine whether an actual abnormality exists.
The cervix is covered with a layer of skin which is undergoing constant turnover, with new cells growing from the bottom of this layer and moving up towards the surface of the skin. When these cells reach the surface of the cervix they are shed and may be picked up in the Pap test. A pathologist can look at these cells and determine if they are abnormal. If you receive an abnormal Pap smear, then you will be called back to the office for a procedure called a colposcopy, during which your cervix will be inspected closely and biopsies of the cervix taken, if necessary.
Cervical cancer is caused by exposure to and infection with the human papilloma virus, or HPV, which is spread through sexual intercourse. You can avoid exposure to this virus by delaying first intercourse, avoiding partners who have had numerous other partners and limiting your own number of sexual partners. Using condoms may help prevent the spread of some, but not all, cases of HPV infection. Finally, a new vaccine against HPV has recently been approved, which may eventually limit the number of new cases of HPV and cervical cancer.
The American cancer Society has recently established new guidelines for cervical cancer screening. The following is taken directly from the web site of the American Cancer Society, "cancer.org":
"The American Cancer Society recommends the following guidelines for early detection:"
- All women should begin cervical cancer testing (screening) about 3 years after they begin having vaginal intercourse, but no later than when they are 21 years old. Testing should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test.
- Beginning at age 30, women who have had 3 normal Pap test results in a row may get tested every 2 to 3 years with either the conventional (regular) or liquid-based Pap test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be tested yearly.
- Another reasonable option for women over 30 is to get tested every 3 years (but not more frequently) with either the regular Pap test or liquid-based Pap test, plus the HPV DNA test (see below for more information on this test).
- Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer testing. Women with a history of cervical cancer, DES exposure before birth, HIV infection, or a weakened immune system should continue to have testing as long as they are in good health.
- Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer testing, unless the surgery was done as a treatment for cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix (simple hysterectomy) should continue to follow the guidelines above.
- Some women believe that they do not need exams by a health care professional once they have stopped having children. This is not correct. They should continue to follow American Cancer Society guidelines.
Although the Pap test has been more successful than any other screening test in preventing a cancer, it is not perfect. One of its limitations is that Pap tests are examined by humans, so an accurate analysis of the hundreds of thousands of cells in each sample is not always possible. Engineers, scientists, and doctors are working together to improve this test. Because some abnormalities may be missed (even when samples are examined in the best laboratories), it is not a good idea to have this test less often than American Cancer Society guidelines recommend.
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Increasing the Accuracy of Your Pap Tests
There are several things you can do to make your Pap test as accurate as possible:
- Try not to schedule an appointment for a time during your menstrual period.
- Do not douche for 48 hours before the test.
- Do not have sexual intercourse for 48 hours before the test.
- Do not use tampons, birth control foams, jellies, or other vaginal creams or vaginal medications for 48 hours before the test.
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Pelvic Exam Versus Pap Test
Many people confuse pelvic exams with Pap tests. The pelvic exam is part of a woman's routine health care. During a pelvic exam, the doctor looks at and feels the reproductive organs, including the uterus and the ovaries and may screen for sexually transmitted illnesses. But the pelvic exam will not find cervical cancer at an early stage and cannot find abnormal cells of the cervix. The Pap test is usually done just before the pelvic exam, when the doctor removes cells from the cervix by gently scraping or brushing with a special instrument. Pelvic exams may help find other types of cancers and reproductive problems, but only Pap tests give information on early cervical cancer or precancers.
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How the Pap Test Is Done
Cytology is the branch of science that deals with the structure and function of cells. It also refers to tests to diagnose cancer by looking at cells under the microscope. The Pap test (or Pap smear) is a procedure used to collect cells from the cervix for cervical cytology testing.
The health care professional first places a speculum, a metal or plastic instrument that keeps the vagina open so that the cervix can be seen clearly, inside the vagina. Next, a sample of cells and mucus is lightly scraped from the ectocervix (part next to the vagina) using a small spatula. A small brush or a cotton-tipped swab is used to take a sample from the endocervix (part closest to the body of the uterus). There are 2 main options for preparing the cell samples for testing in the laboratory, where specially trained technologists (cytotechnologists) and doctors (pathologists) look at the samples under a microscope.
The sample can be smeared directly onto a glass microscope slide, which is then sent to the laboratory. For about 50 years, all cervical cytology samples were handled this way. This method works quite well and is relatively inexpensive. However, cells smeared onto the slide are sometimes piled up on each other, so cells at the bottom of the pile cannot be clearly seen. Also, infections of the cervix or vagina may cause inflammatory (pus) cells, increased mucus, yeast cells, or bacteria that hide the cervical cells.
Another problem with direct smears is that the cells may become distorted by drying out. Cells can be difficult to examine accurately if they are not treated with alcohol to preserve them immediately after they are spread on the slide.
A newer method called liquid-based cytology, or liquid-based Pap test, can remove some of the mucus, bacteria, yeast, and pus cells in a sample and can spread the cervical cells more evenly on the slide. Instead of being directly placed on a slide, the sample is placed into a special preservative solution. This new method, also known by brand names ThinPrep or AutoCyte, also prevents cells from drying out and becoming distorted. Recent studies show that liquid-based testing can slightly improve detection of cancers, greatly improve detection of precancers (SILs -- described below), and reduce the number of tests that need to be repeated. This method is more expensive than a usual Pap smear.
Another approach to improving the Pap test is the use of computerized instruments that can spot abnormal cells in Pap tests. The AutoPap instrument has been approved by the US Food and Drug Administration (FDA) for retesting Pap test samples that were interpreted as normal by technologists. It is also approved by the FDA for initial testing of Pap tests, instead of testing by a technologist. However, a technologist would still examine all smears identified as abnormal by the AutoPap.
These computerized instruments can find abnormal cells that are sometimes missed by technologists. Most of the abnormal cells found in this way are in rather early stages, such as atypical squamous cells (ASCs), but high-grade abnormalities missed by human testing are sometimes found by the computerized instrument. Scientists do not yet know whether the instrument can find enough high-grade abnormalities missed by human testing to have a significant impact on preventing invasive cervical cancers. Automated testing also increases the cost of the cervical cytology testing.
For now, the most important way to improve early detection of cervical cancer is to make certain that all women are tested according to American Cancer Society guidelines. Unfortunately, many of the women most at risk for cervical cancer are not being tested often enough or at all.
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How Pap Test Results Are Reported
The most widely used system for describing Pap test results is The Bethesda System (TBS). This system has been revised twice since it was developed in 1988 – first in 1991 and, most recently, in 2001. The information that follows is based on the 2001 version.
The general categories are:
- negative for intraepithelial lesion or malignancy
- epithelial cell abnormalities
- other malignant neoplasms
Negative for intraepithelial lesion or malignancy: This first category means that no signs of cancer or precancerous changes or other significant abnormalities were found. Some specimens in this category appear entirely normal. Other findings may be unrelated to cervical cancer, such as evidence of reproductive system infections (yeast, herpes, or Trichomonas, for example). Some cases may also show reactive cellular changes, which is a response of cervical cells to infection or other irritation.
Epithelial cell abnormalities: The second TBS category, epithelial cell abnormalities, means that the cells of the lining layer of the cervix show changes that might be cancer or a precancerous condition. This category is divided into several groups for squamous cells and glandular cells.
The epithelial cell abnormalities for squamous cells are called:
- Atypical squamous cells (ASCs); these are further divided into ASC-US & ASC-H
- Low-grade squamous intraepithelial lesions (SILs)
- High-grade SILs
- Squamous cell carcinoma
Atypical squamous cells: This term is used when it is not possible to tell (from how the cells look under a microscope) whether the abnormal cells are caused by an infection, another cause of irritation, or by a precancer. The Pap test is usually repeated after several months, or other tests, such as colposcopy (explained below) and biopsy may be recommended, depending on the patient's history and the results of previous Pap tests and whether a high grade SIL is suspected (ASC-H). Most doctors recommend having an HPV test in this situation. If this shows no HPV, then only usual follow-up is needed. If it does show HPV, colposcopy is recommended.
Squamous intraepithelial lesions (SILs): These abnormalities are subdivided into low-grade SIL and high-grade SIL. All patients should have colposcopy. High-grade SILs are less likely than low-grade SILs to go away without treatment and are more likely to eventually develop into cancer if they are not treated. However, treatment can cure all SILs and prevent true cancer from developing. A Pap test cannot determine for certain whether a woman has a high- or low-grade SIL. It merely flags the result as fitting into one of these abnormal categories. The need for treatment is based on further testing and examination (see below). The HPV test is less helpful because most of these women will test positive for HPV.
Squamous cell carcinoma: This cytology result shows that the woman is likely to have an invasive squamous cell cancer. Further testing will be done to be sure of the diagnosis before doctors recommend treatments such as radiation therapy, chemotherapy, or radical surgery.
The Bethesda System also describes epithelial cell abnormalities for glandular cells. Cancers of the glandular cells are reported as adenocarcinomas. In some cases, the pathologist examining the cells can suggest whether the adenocarcinoma started in the endocervix, in the endometrium (the upper part of the uterus), or elsewhere in the body. When the glandular cells have features that do not permit a clear decision as to whether they are cancerous, the term used is atypical glandular cells. The patient usually undergoes further testing if her cervical cytology result shows atypical glandular cells.
Other types of cancer: These can be uncommon forms of cancer such as malignant melanoma, sarcomas, and lymphoma. Compared with squamous cell carcinoma and adenocarcinoma, these cancers affect the cervix very rarely.
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The HPV DNA Test
As mentioned earlier, the most important risk factor for developing cervical cancer is having had the human papillomavirus (HPV). Doctors can now test for the types of HPV that are most likely to cause cervical cancer ("high-risk" types) by looking for pieces of their DNA in cervical cells. The test is done in a similar way to the Pap test in terms of how the sample is collected, and in some cases can even be done on the same sample.
The HPV DNA test can be used in 2 situations:
The FDA recently approved it for use as a screening test in combination with the Pap test in women over 30 years old (see American Cancer Society screening guidelines above). It is not recommended as a screening test in women under 30 because the test is not as useful in this population. Women in their 20s who are sexually active are much more likely to have an HPV infection (most of which will go away on their own), so the results of the test are not as significant and may be more confusing. For more information, see the American Cancer Society document, "What Every Woman Should Know About Cervical Cancer and the Human Papilloma Virus."
The HPV DNA test is also used in women with slightly abnormal Pap test results to find out if more testing or treatment might be needed (see next section).
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Other Tests for Women With Abnormal Cervical Cytology Results
Because the Pap test is a screening test rather than a diagnostic test, if you have an abnormal result, you will need to have other tests (colposcopy and biopsy, and sometimes an endocervical scraping) to find out whether a precancerous change or cancer is present. Nearly all doctors recommend one or more of these tests for women with a Pap result of SIL or atypical glandular cells.
Doctors are less certain about what to do when the result is atypical squamous cells. Some recommend colposcopy and biopsy if ASC-H and less commonly for ASC-US, and others recommend a repeat Pap test after several months for ASC-US. In making decisions about follow-up, some doctors take into account your previous Pap test results, whether you have any cervical cancer risk factors, whether you have remembered to have Pap tests done in the past, and whether the test result is ASC-H or ASC-US.
Recently, some doctors have started using an intermediate step, testing for HPV. If a high-risk type of HPV is found in women with atypical squamous cells, doctors are more inclined to do a colposcopy for all ages. Generally, if you have SIL or ASC-H, a colposcopy will be done. If the biopsy shows SIL, or cervical intra-epithelial neoplasia, steps will be taken to prevent an actual cancer from developing.
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Colposcopy: If certain symptoms suggest cancer or if the Pap test shows abnormal cells, you will need to have an additional test called a colposcopy. In this procedure you will lie on the exam table as you do with a pelvic exam. A speculum is placed in the vagina to expose the cervix. The doctor will use the colposcope to examine the cervix. The colposcope is an instrument with magnifying lenses very much like binoculars. With the colposcope, doctors can see the surface of the cervix closely and clearly.
The exam is not painful, has no side effects, and can be done safely even if you are pregnant. If abnormal areas are seen on the cervix, a biopsy (removal of a small tissue sample usually after numbing the cervix) is done. The sample is sent to a pathologist to look at under a microscope. A biopsy is the only way to tell for certain whether an abnormal area is a precancer, a true cancer, or neither.
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Cervical biopsies: Several types of biopsies are used to diagnose cervical precancers and cancers. For precancers and early cancers, some types of biopsies can completely remove the abnormal tissue and may be the only treatment needed. In some situations, additional treatment of precancers or cancers is needed.
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Colposcopic biopsy: For this type of biopsy, a doctor or other health care professional first examines the cervix with a colposcope to find the abnormal areas. Using a biopsy forceps, he or she will remove a small (about 1/8-inch) section of the abnormal area on the surface of the cervix. The biopsy procedure may cause mild cramping or brief pain, and you may have light bleeding afterward. A local anesthetic may be used to numb the cervix.
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Endocervical curettage (endocervical scraping): This procedure is usually done at the same time as the colposcopic biopsy. A narrow instrument (the curette) is inserted into the endocervical canal (the passage between the outer part of the cervix and the inner part of the uterus). Some of the tissue lining the endocervical canal is removed by scraping with the curette. This tissue sample is sent to the laboratory for examination.
Because the colposcope allows a view only of the outer part of the cervix and not into the endocervix, health care professionals use an endocervical speculum or endocervical scraping to find out if this area is affected by precancer or cancer. A local anesthetic may be used to numb the cervix. Patients may have a temporary sensation, similar to a severe menstrual cramp, and they may have light bleeding after the procedure.
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Cone biopsy: In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the ectocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal.
The transformation zone (the border between the ectocervix and endocervix) is contained within the cone. This is the area of the cervix where precancers and cancers are most likely to develop. The cone biopsy is also a treatment and can be used to completely remove many precancers and very early cancers.
There are 2 methods commonly used for cone biopsies: the loop electrosurgical excision procedure (LEEP; also called large loop excision of the transformation zone [LLETZ]) and the cold knife cone biopsy.
- LEEP (LLETZ): The tissue is removed with a thin wire loop that is heated by electrical current and acts as a scalpel. For this procedure, a local anesthetic is used, and it can be done in your doctor's office. It takes only about 10 minutes. You may have mild cramping during and after the procedure, and mild to moderate bleeding may persist for several weeks.
- Cold knife cone biopsy: A surgical scalpel or a laser as a scalpel is used rather than a heated wire to remove tissue. It requires general anesthesia (you are asleep during the operation) and is done in a hospital, but no overnight stay is needed. After the procedure, cramping and some bleeding may persist for a few weeks.
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How biopsy results are reported: The terms for reporting biopsy results are slightly different from The Bethesda System for reporting Pap test results. Instead of The Bethesda System term "squamous intraepithelial lesion (SIL)," biopsy reports use 2 other terms, "cervical intraepithelial neoplasia (CIN)" and, rarely, "dysplasia," to refer to precancerous changes. The terms for reporting cancers ("squamous cell carcinoma" and "adenocarcinoma") are the same.
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How Patients With Abnormal Pap Test Results Are Treated to Prevent Cervical Cancers From Developing
If an area of SIL is seen during the colposcopy and usually confirmed by biopsy, your doctor will be able to remove the abnormal area by using such biopsy techniques as the LEEP (LLETZ procedure) or a cold knife cone biopsy or by destroying the abnormal cells with cryosurgery or laser surgery.
During cryosurgery, the doctor uses a metal probe cooled with liquid nitrogen to kill the abnormal cells by freezing them.
In laser surgery, the doctor uses a focused beam of high-energy light to vaporize (burn off) the abnormal tissue. This is done through the vagina, with local anesthesia.
Both of these outpatient treatments can be done in a doctor's office or clinic. After treatment, you may have a watery brown discharge for a few weeks.
These treatments are almost always effective in destroying precancers and preventing them from developing into true cancers. You will need follow-up exams to make sure that the abnormality does not come back. If it does, treatments can be repeated.
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Vaccines
Under Development
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Pelvic Pain and Painful Intercourse
Under Development
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Polycystic Ovary Syndrome (PCOS)
Under Development
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Premenstrual Syndrome (PMS)
Under Development
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Urinary Incontinence
Under Development
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Weight Loss: Obesity Management
Under Development
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Obstetrics
Air Travel in Pregnancy
 Air travel during pregnancy is safe for most women and most domestic airlines allow pregnant women to fly up until 36 weeks of gestation. Most international carriers use 35 weeks as the cutoff. Please check with your individual carrier for their rules on air travel. You may need medical documentation of gestational age in order to travel. General recommendations for those who do fly include drinking plenty of water, wearing a seat belt while sitting and improving circulation by standing and walking periodically.
Many common obstetric emergencies occur in the first and third trimesters. Any woman having a possible ectopic pregnancy, bleeding suggesting miscarriage, preterm labor, pregnancy induced hypertension, poorly controlled diabetes, placental abnormalities or sickle cell disease or trait should not fly. Women with poor lung function should consider carrying supplemental oxygen for air travel. However, in the absence of these known complications or other serious medical problems, air travel is safe in all trimesters.
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Antenatal Fetal Testing
Antenatal fetal testing is used in pregnancies identified as at-risk pregnancies. Certain medical and obstetrical diagnoses and situations may place a fetus at risk for poor outcome. Antenatal fetal testing is used in these pregnancies to evaluate the health of the fetus and increase the likelihood of a good outcome. When danger is identified in late pregnancy, immediate induction of labor and delivery is typically the best course of action. However, when caring for a fetus of young gestational age, delivery simply because a bad outcome is merely a possibility might actually be more harmful to the fetus and newborn. In these situations, there are several testing procedures which can help ensure fetal health, and identify those fetuses for which immediate delivery is necessary.
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Antenatal screening tests
Under Development
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The Apgar Score Explained
Any woman who has had a baby recently knows that all babies receive a lot attention from the nursing staff at birth. These nurses immediately evaluate each newborn in order to determine which babies require the most aggressive attention. The nurses assess, or score, an infant. Sometimes a specialized provider called a neonatal nurse practitioner, or NNP, will be called to the delivery room to evaluate a baby. An NNP is always in the room if the delivery is assisted with either forceps or a vacuum device and at the time of Cesarean section. Doctors, nurses and NNPs use a simple tool to evaluate the newborn. This tool is the Apgar score.
In 1952, when Virginia Apgar devised a scoring system designed to assess the clinical status of a newborn, the Apgar score was born. Dr. Apgar was trying to devise a system to determine which babies required resuscitation, or aggressive medical care. The Apgar score is determined by observation and evaluation of the infant’s heart rate, respiratory effort, muscle tone, reflex irritability and color. After observation of the infant with regard to each of these clinical findings, the infant is given either 0, 1 or 2 points for each of the five clinical determinants. Thus, the Apgar score may be as low as 0 and as high as 10. These observations are made at 1 minute and again at 5 minutes after birth. So, your baby will receive two scores.
In a simplified way, the first score indicates just how much your baby enjoyed his or her labor experience, while the second score indicates how well your baby is adapting to life outside your uterus. The first score is not quite as important as the second score. Even the second score is not really that important all by itself. Remember, this scoring system was devised as an aid to providers in the delivery room. It was not meant to be used to predict future outcomes, and it is not very good for anything other than just what Dr. Apgar envisioned so many years ago, as an aid to people taking care of newborns immediately after birth.
Unfortunately, too much importance is placed upon the Apgar score by some parents. Many feel that any score under a “10 and 10” indicates their baby is in trouble. The most common scores are 8 at 1 minute and 9 at 5 minutes. However, a 5-minute Apgar score of 7 to 10 is considered normal. Scores of 4, 5 and 6 at 5 minutes are considered to be intermediate and are not an indication that a given baby will suffer any long-term neurologic problems. Only a score of 0 to 3 at five minutes may be indicative a future neurologic problems in the baby, and then only if there are other associated physical problems with a newborn. Even a low score at 5 minutes loses its significance if the newborn continues to improve clinically.
Thus, if your baby is given a low score at 5 minutes, the neonatal nurse practitioner (NNP) attending your baby will repeat the Apgar score at 10, 15 and 20 minutes. The most important thing to remember if such a thing happens at the time of your delivery is that the ability of your baby to respond to its new environment outside the uterus is what is most important. As long as your baby continues to improve, as demonstrated by an improving Apgar score, the Apgar score at 1 and 5 minutes is not that important.
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Bleeding in Pregnancy
Bleeding in pregnancy is not uncommon. There are many causes, some of which may be very serious, yet bleeding is not necessarily a sign that something is wrong with your pregnancy. Something as simple as a vaginal yeast infection, a recent cervical exam, a pap smear, an ultrasound using the vaginal probe, a benign cervical polyp or even recent vaginal intercourse could cause bleeding in all three trimesters.
Bleeding in the first trimester requires that an ultrasound be performed to confirm that the pregnancy is inside the uterus and not an ectopic pregnancy, located in the fallopian tube or elsewhere outside the uterus. If an ectopic pregnancy is found early enough, it may be treated with medication rather than surgery. So, it is important to make this diagnosis early, if possible.
First-trimester bleeding may also indicate an impending spontaneous abortion, or miscarriage, though you will probably experience very heavy, bright-red bleeding and associated uterine cramping if a miscarriage is occurring. When your pregnancy is too early to be confirmed by ultrasound, blood tests may aid in confirming a healthy pregnancy. However, very early in pregnancy, it may be difficult to differentiate between an ectopic pregnancy, a miscarriage or a healthy pregnancy.
The final diagnosis may require time and sequential ultrasounds and hormonal blood level analysis. Unfortunately, miscarriage occurs in at least 20% of pregnancies. There is also a serious abnormality of pregnancy, called a molar pregnancy, that must be found early and treated. Finally, the placenta may implant very low in the uterus near to or covering the cervix. This is called a placenta previa.
Significant causes of bleeding in the second and third trimesters include a placenta previa, placental abruption and the onset of cervical dilation due to either preterm labor or actual labor at term. Both placenta previa and placental abruption, in which the placenta separates from the uterine wall either spontaneously or as the result of significant high blood pressure or because of trauma, occur in 1% or less of pregnancies.
If bleeding occurs in your pregnancy you should always remember that it is common and may not indicate a serious problem. Still, all episodes of vaginal bleeding in pregnancy need to be evaluated. Please call our office if you experience bleeding in your pregnancy.
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Cesarean Section
Cesarean section is an operation used to deliver an infant through an incision made in the abdominal wall and through the uterus. This operation may be performed for a variety of reasons, such as maternal illness requiring immediate delivery, multiple gestations (e.g.: twins), fetal intolerance to labor, arrest of normal labor and even simply because a woman requests a cesarean delivery. The cesarean section is a safe operation and should not be feared. The expectant mother should not approach a cesarean section with excessive concern about how her baby will handle the surgery, as one could argue that it is the safest form of delivery for an infant. For the woman herself, cesarean section is extremely safe.
Cesarean section may be necessary to deliver a woman who has severe high blood pressure, as in preeclampsia (toxemia), or in an unstable diabetic patient with kidney or heart disease. Some women who have had severe pelvic injury may require a surgical deliver. Women with placenta previa, a condition in which the placenta has implanted low enough in the uterus to cover the cervix, must be delivered by way of cesarean section, as must women in whom their fetus has come to lie in an odd position within the uterus.
The American College of Obstetricians and Gynecologists advises that all breech deliveries be performed by cesarean section, though vaginal delivery is still possible in selected patients who have a fetus in the breech position. Even though twins may be delivered vaginally in most cases, sometimes the babies are positioned in
such a way to require a cesarean section. All women with a twin gestation may also choose to be delivered by way of a cesarean section. Triplets and higher level, multiple pregnancies must be delivered by way of a cesarean section.
Though each woman's labor is different, most labors progress at a predictable pace. For example, first labors usually progress at 1 centimeter of cervical dilation per hour, while most second labors progress at 2 centimeters per hour. A woman whose labor falls off this expected progress in labor, called the labor curve, may ultimately require cesarean delivery. This indication for cesarean section is referred to as a failure to progress in labor, but should not be seen as a failure by a woman, since progress in labor is totally out of her control. (See section on labor.)
Some women who have had a very difficult first labor and delivery may request surgical delivery in order to avoid a second bad experience. Many doctors feel that a previous 4th degree vaginal and perineal laceration (See section on episiotomy.) is indication enough for scheduling a cesarean section to avoid the possibility of further perineal trauma. Finally, some women wish to avoid the labor experience completely, because of fears of significant vaginal trauma with vaginal delivery of a large infant, and may ask for a planned, or elective, cesarean section. While the desire for an elective cesarean section is an unusual request, usually made by the older woman who knows she will have only one child, each woman has the right to have a say in how she is delivered.
There will always be a debate as to whether women who have had one cesarean section may attempt a vaginal delivery with their successive pregnancies or whether they must always be delivered by way of a cesarean section. There are good reasons to support each side of this argument. However, most women who undergo a cesarean delivery choose to have an elective cesarean section with each subsequent delivery, rather than attempt a trial of labor and possible vaginal birth, the so called vaginal birth after cesarean section, or VBAC.
On average, about 60% of VBACs are successful, especially in women whose first cesarean section was for a non-obstetrical, non labor-related, indication, such as previous breech presentation. A general rule is that any woman having a first cesarean section for a known obstetrical indication, such as failure to progress in labor, is more likely to have a repeat cesarean section with her next pregnancy if she were to attempt a vaginal delivery. However, most women who have had a previous cesarean section can successfully deliver her next baby vaginally if she wishes to try.
The most important reason that a woman will choose to undergo a scheduled, repeat cesarean delivery rather than attempt a VBAC is the fear of uterine rupture during labor. The risk of uterine rupture is low, averaging about 1/2 to 1 percent of women in labors in which there is a previous uterine scar. This risk rises in the woman who has had more than one previous cesarean section. However, if uterine rupture does occur, the results could be catastrophic, leading to the death or severe illness of both mother and baby in 25% to 50% of women who experience a uterine rupture. For this reason, most women will choose a repeat cesarean section over a trial of labor.
A cesarean section takes about 30 to 45 minutes to complete. The baby can be delivered very quickly in a cesarean section, as fast as under a minute in emergencies, but usually within a few minutes of starting the non-emergent surgery. The repair of the uterus and abdomen is the longest part of the procedure, taking at least 25 minutes to complete. Elective and repeat cesarean sections are usually scheduled for the morning, at 7:30 A. M., so the new mother has the entire first day after her delivery to recover and get to know her infant.
As with all surgery, it is important to have an empty stomach prior to cesarean section, so it is advised that a woman not eat or drink anything on the day of her surgery. Most, but not all women, are able to return to a regular diet the day after surgery. While women undergoing a vaginal delivery may choose to remain in the hospital for 48 hours after delivery, the woman who has a cesarean section has the option of staying in the hospital for up to 96 hours, or 4 days, after her delivery, though some women choose to leave the hospital sooner.
Most scheduled cesarean sections are performed using spinal anesthesia. The woman who has been laboring with the aid of an epidural will have a cesarean section with this same epidural. Though a very small number of women who do not wish to remain aware at the time of their surgery opt for general anesthesia, regional anesthesia (epidural and spinal anesthesia) is safer and allows for a smoother recovery after surgery. Please refer to the section on obstetrical anesthesia for more details on the options for anesthesia in during labor and delivery, and in cesarean section.
Recovery after cesarean section is usually a reasonably comfortable experience. Even though cesarean section is a major abdominal surgery, women who have a cesarean section do much better postoperatively than women who undergo other abdominal surgeries. The main reason for this is that they must do better, they have a child who needs them. Early ambulation, or walking, is known to improve postoperative recovery. While all surgical patients are encouraged by their nurses to ambulate, the new mother is also asked, or commanded, by her baby to do so. Thus, a new baby is a strong motivating factor in ensuring a speedy recovery.
Pain management is usually not a problem after cesarean section when compared with recovery from a vaginal delivery. Generally, the least pain is experienced by the woman who has a rapid second labor without vaginal trauma. (No, you do not get to choose the length of your actual labor.) This is followed closely in severity by a vaginal delivery in a woman sustaining "only" a 1st or 2nd degree perineal laceration. (See section on episiotomy.) Higher level vaginal trauma, especially the 4th degree laceration occurring after a difficult or prolonged labor, which saps a great deal of energy, may actually be more difficult for a woman to recover from than a cesarean section, especially a scheduled cesarean section.
If the surgery is accomplished with either an epidural or spinal anesthetic, the anesthesiologist will usually place a long-acting narcotic in the anesthetic medicine. This medicine may give near-total pain relief for 18 to 24 hours. Thereafter, oral narcotic medicine is offered, though many women may find adequate relief of most pain with ibuprofen (Motrin®). All women who deliver a baby, whether vaginally or by cesarean section, go home with a prescription for narcotic medication.
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Circumcision
Circumcision is a surgical procedure in which the foreskin covering the end of the penis is removed. Parents may choose to have their babies circumcised for personal, religious or social reasons. Circumcision is usually performed by a doctor in the hospital in the first days of life, but if done for religious reasons, it may be performed many days after the baby leaves the hospital. Most babies in America are circumcised while most babies in England, for example, are not. There are some medical benefits of circumcision. However, circumcision is more of an elective procedure than a necessary one.
The benefits of circumcision are a decreased urinary tract infection rate in circumcised infants, a lower risk of penile cancer in circumcised men, easier cleansing of the penis and a slightly lower risk of skin infections of the penis and of sexually transmitted diseases. Since the number of males who might experience any of these benefits is statistically small, these benefits do not add up to a true medical indication for circumcision. The risks of circumcision include infection, bleeding and injury to the penis. Though the risks are real, the risk of a significant problem is rare.
Dr. Giarratana performs circumcision using the Gomco device. He first anesthetizes the penis using xylocaine injected into the skin of the penis using a very tiny needle. The circumcision is performed once the skin is anesthetized and cleansed with an antiseptic solution. The foreskin is loosely attached to the tip of the penis, or glans. This loose attachment is broken and the foreskin is pulled down onto the shaft of the penis. A bell is then placed over the glans to protect the penis and the foreskin is pulled back upwards and over the bell. Then, a clamp is placed over the bell. Once tightened, this clamp compresses the foreskin between the bell and the clamp. The foreskin is then trimmed and the Gomco device is gently removed to complete the circumcision.
Care of the penis after the circumcision is simple. Vaseline® ointment is placed on top of and around the penis each time the diaper is changed. The Vaseline® acts to prevent both the penis from sticking to the diaper and your baby’s bowel movement from sticking to his penis. This prevents trauma to the skin of the penis, allowing for uninterrupted healing. The Vaseline® is used for 3 to 4 days, by which time the skin should be healed. Pain may be managed with acetaminophen (Tylenol®).
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Episiotomy
Episiotomy is one of the most common surgical procedures in obstetrics. Episiotomy refers to an incision made into the skin and underlying tissue between the vagina and the anus. This incision is made in order to increase the diameter of the vaginal opening at the time of vaginal delivery. It is dome to prevent severe lacerations and to increase the likelihood of a successful vaginal delivery in difficult situations or when the infant is very large. Like anything in obstetrics, it should not be performed simply as a matter of routine. Rather, it should be used only in situations that truly require that it be performed.
The risk of vaginal trauma, or laceration, in a given woman is typically the result of 5 factors: a first labor, prolonged labor, prolonged second (pushing) stage, large infants and operative (forceps or vacuum assisted) vaginal deliveries. For example, episiotomy is rarely required in women having their second child, especially if she has a history of a rapid labor, average sized babies and has a short second stage. Conversely, since laceration is more likely in the woman who has more than one of the above risk factors present, an episiotomy would probably be offered in the woman who has all 5 of the factors in play. I say “offered” because you always have the right to refuse any type of procedure. If Dr. Giarratana believes an episiotomy to be in your best interest, he will discuss this with you prior to performing the episiotomy. If you say no, and there is no emergent need to deliver your baby, then he will honor your wishes without debate.
Should you sustain a laceration at the time of your delivery, it will be examined and determined to be of a certain “degree” ranging from first degree to fourth degree.
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The characteristics of each level of laceration are as follows:
- First Degree: Laceration of the superficial skin only.
- Second Degree: Laceration of skin and underlying tissue, called the perineum, or perineal body, but no laceration of the anal sphincter.
- Third Degree: Laceration down to and across the body of the anal sphincter.
- Fourth Degree: Laceration with all the above characteristics and further tearing of the skin of the rectum.
Obviously, it is in a woman’s best interest to avoid any and all obstetrical trauma. However, vaginal and perineal laceration is a common complication at delivery. The most important step at the time of delivery is to determine the true nature of the laceration. Only after this is done can the appropriate repair can be performed. With a good repair, any degree of laceration should heal completely and satisfactorily in time. Most women report that pain is present for 4 to 7 days after delivery with episiotomy or laceration.
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Exercise in Pregnancy and the Postpartum Period
Under Development
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Fifth Disease: Parvovirus Infection and Pregnancy
Under Development
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Induction of Labor
Under Development
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Nausea and Vomiting in Early Pregnancy
Under Development
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Obstetric Anesthesia: Pain Management in Labor
Labor can and does cause you to experience pain. Many women are able to get through their labor process using only their determination and Lamaze breathing. In the past, this was all women could rely on during labor. You must believe that you, too, could make it through labor without anesthesia, just as all women did in the past. However, you will need excellent support from your family, or a labor coach, in order to have a drug free delivery. The vast majority of women will choose to have some form of anesthesia for their labors, usually in the form of an epidural. This section describes the options for pain management which are available to help you complete labor with less pain.
The pain of labor may be managed medically with local anesthesia given only at the time of delivery, with intravenous narcotics given throughout labor or with regional anesthesia, such as an epidural. A woman may choose any one, or even all, of these methods to assist her in labor. While all are safe and effective, each method has limitations.
For the woman who has chosen to labor without medical assistance, using Lamaze breathing and good coaching, the pain experienced with the actual delivery of her infant may be lessened with the use of local anesthesia. Local anesthesia is given in an injection of a local anesthetic agent such as lidocaine, a fast-acting anesthetic agent, in order to numb the vaginal tissues. This anesthetic may be given as a regional nerve block, called a pudendal nerve block, which produces anesthesia, or numbness, over the entire lower vaginal and vulva. This nerve block must be injected around both the right and left pudendal nerves, which are found along the vaginal side walls. Once the injection is given, the anesthesia will take effect within minutes and last for up to an hour.
If a woman cannot tolerate this procedure, which is only slightly uncomfortable, or if she is making very rapid progress in labor, such that the pudendal nerve block may not have time to even take effect, a local anesthetic may be injected directly into the skin and underlying tissue of the lower vagina and perineum (the area between the vaginal and anus). This injection is not as effective over a large area as the pudendal nerve block, but it is quick and will relieve the pain associated with an episiotomy procedure or laceration occurring at the time of delivery. This option also gives anesthesia for about an hour.
Intravenous narcotics may be used to ease the pain associated with uterine contractions in labor. They would not be very useful for the pain of actual delivery, and could not be given close to delivery in any event as they may affect the newborn if given to the laboring woman too close to her delivery. These medicines may be given as often as every hour. They tend to "take the edge off" of labor pains, while causing sedation in the woman who receives them. This sedating effect is usually welcomed by the laboring woman, but it is also the reason some woman do not
like to use narcotics in labor. These woman do not like the way narcotics make them feel, reporting that they make them feel "out of it" and unable to be alert at the time of delivery.
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The epidural is a regional anesthetic, meaning it gives anesthesia to a wide region of the body.
Depending upon how it is administered, it may relieve only the pain of contractions during the first stage of labor, remove all pain and sensation during labor and delivery or it could even be used for a cesarean section. The epidural may be given at any stage of labor. Some doctors feel it interferes with the labor process, while most feel it may be given to a woman at any stage of her labor. The epidural is placed in the lower, or lumbar, region of the back. A needle is directed into the space just above the tissue, called the dura, which surrounds the spinal cord, allowing it to be protected by a fluid called cerebrospinal fluid, or CSF. The dura surrounds both the spinal cord and the brain creating, in effect, a sac around these structures. The CSF, therefore, bathes both the spinal cord and the brain. Once in the space above the dura, the epidural space, a thin catheter is threaded through the needle and into the epidural space. The catheter is left in place while the needle is removed. So, the laboring woman may move from side to side throughout her labor, whenever it is necessary to do so. Anesthetic is then placed into the epidural space by injecting it into the catheter.
The anesthetic agents used for epidural anesthesia have different onsets of action and last for variable amounts of time. These differences in each medication’s characteristics give the anesthesiologist a wide range of options when managing the epidural. The epidural may be used throughout labor, with more anesthetic administered as necessary to allow for pain relief while, at the same time, allowing the woman to continue to move her lower body. The longer it is used, and the higher the concentration of the anesthetic agent used, the more likely it is that a woman will be unable to move her legs throughout labor. While this may make the woman a bit uncomfortable, it may just seem odd to her, and it is not dangerous. Once the epidural is removed and the drug effect wears off, the woman should have no lingering side effects.
The most common risk of receiving the epidural is the development of a spinal headache. The target site for the anesthesiologist during placement of the epidural is the epidural space. This is in contrast to placement of a spinal, for which the target site is through the dura and into the CSF. If, during the procedure, the anesthesiologist places the epidural needle through the dura and into the CSF, there is a chance that you might develop a spinal headache as the CSF leaks out through the hole that was placed in the dura. Penetration of the dura during epidural placement occurs about 2% of the time, but only 50% of these patients will develop the spinal headache. This means that 1% of patients who receive an epidural will develop a spinal headache. This number rises to 3% for patients receiving a spinal anesthetic.
You might be wondering why more patients receiving a spinal do not develop a headache, since the dura is penetrated in 100% of patients who receive a spinal anesthetic. The reason for this is that the spinal needle is a very fine needle that places only a very small hole in the dura. While CSF may still leak out of this hole, it does so only slowly. The epidural needle is much larger than the spinal needle, since the epidural catheter must be threaded through the center of this needle. The hole created in the dura by this needle is relatively large, which allows the CSF to leak out more quickly. This may create some pressure changes around the brain and spinal cord, which may lead to the development of a spinal headache. Treatment for a spinal headache is interesting in its simplicity.
Since the problem creating the headache is the presence of a hole in the dura, the best way to treat this headache is to patch the hole. This patch, called a blood patch, is performed by taking a sample of the patient's own blood and placing it into the epidural space where it clots and patches the defect in the dura. This usually brings immediate relief of the headache symptoms. The blood patch may need to be repeated if the headache returns, but this is unusual. Prior to even considering the blood patch, the person who has a spinal headache should remain lying down, drink plenty of fluids and take a caffeine tablet. This may be all that is required to manage the headache symptoms. Often, however, the blood patch is the only thing that will treat the symptoms of a spinal headache.
It is important to know that the epidural is a regional anesthetics and can be manipulated by the anesthesiologist to completely numb only a small region of your body, or numb you completely from the waist down. The goal after initial placement is to numb the nerves that are responsible for the pain of your contractions. This will allow you to feel little or no symptoms of your contractions. As your baby travels farther into your pelvis and through the birth canal, you nay begin to have increased sensation and require additional anesthetic medicine in order to take this new sensation away. This is not unusual and is expected by the anesthesiologist. The epidural is not a device one can simply place and forget. It is a device that requires periodic attention by your anesthesiologist if it is to work properly.
The anesthetic drugs have variable onsets of action and durations of action. So, all of these drugs will eventually wear off and will have to be replenished. Often, your anesthesiologist will place you on a pump that gives continuous dosing of the drug, and allows you to dose yourself throughout your labor simply by pushing a button. Still, it is not unusual for the anesthesiologist to have to further manipulate the dosing of the epidural as your labor progresses and you get closer to delivery.
It is important to realize that the epidural is not a perfect device, and you will sometimes have some sensation with your delivery, even with an epidural. Epidural management is a balancing act, because the anesthesiologist wants to take away your pain but does not want to anesthetize the nerves going to the muscles in your legs if they can avoid this. While you can still push with poor muscle control in your legs, this sometimes makes it difficult for you to do so effectively. So, the goal is good anesthesia, but not too good.
Finally, if you require a cesarean section for delivery, you will be offered a spinal anesthetic. The spinal is another regional anesthetic. It works much like the epidural, but while the epidural is placed above the dura, into the epidural space, the spinal is placed through the dura and into the CSF. A very fine needle is used for this procedure, and a stronger concentration of anesthetic medicine. Depending upon which medicine is used, and its concentration, the spinal may last for 1 to 2, or more, hours. The anesthesiologist will vary the medications depending upon the planned surgery.
If you have labored with an epidural and require a cesarean section in order to deliver your baby, the anesthesiologist will try to use your epidural for the surgery. The anesthesiologist will dose your epidural very heavily to give you adequate anesthesia for delivery. If your surgery is emergent and your baby must be delivered quickly, there may not be enough time to dose your epidural and the anesthesiologist may be required to give you a general anesthetic. But, for scheduled cesarean sections, the advantages of the spinal over an epidural are that it is can be placed more quickly, it produces anesthesia faster and it creates a very strong anesthetic effect.
Any regional anesthetic will cause the blood vessels in your lower extremities to dilate, which can cause your blood pressure to drop. Usually, the blood vessels in your upper extremity will constrict a bit to help maintain your blood pressure. There are times, however, when your blood pressure will drop, which will be sensed by you as lightheadedness, nausea and vomiting. Your baby will also sense this drop in blood pressure and her heart rate will drop. This is a fairly frequent occurrence. To prevent this, the anesthesiologist will order several bags of intravenous (IV) fluid be given to you prior to both the epidural and the spinal. If you still have a drop in blood pressure, the anesthesiologist will give you a medicine to help raise your pressure.
This is very effective, but takes time to work, and all the while you will be nauseous. So, the best thing is to prevent this drop in blood pressure from happening. Delaying your epidural until the IV fluid has infused is the best way to prevent this problem. Keep this in mind while you are asked to wait patiently until the IV fluid has been given.
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Prenatal Care Schedule
Prenatal Visit Schedule:
- 00-28 weeks ---- every 4 weeks
- 28-36 weeks ---- every 2-3 weeks
- >36 weeks ---- weekly
During your visits you will alternate between seeing Dr. Giarratana and Colleen Wheeler.
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Important Dates to Remember:
Initial Visit: Review medical history, perform physical examination and pap smear, obtain blood tests. Laboratory evaluation includes a complete blood count (CBC), a test for syphilis (RPR), blood type with Rh status and antibody screen, Rubella immunity, Hepatitis B, HIV, thyroid screen (TSH), urine culture, and a cervical culture for chlamydia and gonorrhea. Optional First Trimester Tests ( not covered by all insurance plans): Cystic Fibrosis screening- blood test to determine if you are a carrier of cystic fibrosis (a heritable severe chronic respiratory/ multi system disease). First trimester testing for Down Syndrome and other chromosomal abnormalities-ultrasound and blood test done here at our office. Requires 16 week blood test to complete the screen.
16 week visit: Optional Quad Screen blood test ( screening for neural tube defects and chromosomal abnormalities, including trisomy 13, 18, and 21). If you will be 35 years old, or older at the time of delivery, then you will be offered an amniocentesis to evaluate the chromosomes of your baby. (All tests other than amniocentesis are screening tests and do not guarantee the absence of problems. The amniocentesis is essentially 100% accurate.) A higher level ultrasound is a noninvasive option for women 35 years or older, who desire further reassurance short of having an amniocentesis.
20 week visit: A Level-1 ultrasound is done to confirm the dates of your pregnancy. The sex of your baby can often be determined at this time.
28 week visit: Blood test for gestational diabetes and for anemia. If you are Rh negative, you will receive a RhoGAM® injection about three days after checking an antibody screen.
28-32 weeks:
- Pre-register for hospital
- Select Pediatrician.
- Take prenatal classes. ( You may wish to schedule these classes as soon as possible after you begin obstetric care)
36 week visit: Group B streptococcus vaginal culture. Begin cervical examinations
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Recurrent Spontaneous Abortion
Recurrent pregnancy loss, or recurrent spontaneous abortion(miscarriage), is diagnosed in a woman who has experienced two or more pregnancy losses. These loses may be consecutive or may occur in between successful pregnancies. The exact reason for even a single miscarriage is often not clear and attempting to find the reason for repeated losses is difficult. However, there are six main areas of investigation into recurrent spontaneous abortion the make up the work-up for this problem. These areas are as follows: genetic analysis for chromosome abnormalities, a search for an infectious cause, structural uterine abnormalities, hormonal imbalance, maternal illness and an autoimmune cause in which the woman makes antibodies which attack and disrupt the placenta. Some environmental causes of pregnancy loss are under the control of individual women who smoke, drink significant amounts of caffeine, or who abuse alcohol or drugs in pregnancy. It goes without saying that women who have decided to start a family should strive toward a healthy lifestyle.
We do know that most miscarriages are the result of a chromosome abnormality. This abnormality may occur when the sperm or egg are created, at the time of conception or as the initial cell divisions in the formation of a human occur. Because nearly 60% of miscarriages are due to chromosome abnormalities, the tissue lost at the time of a first miscarriage is not usually submitted for chromosome analysis. The assumption is that a chromosome abnormality is probably present, but it is most likely due to a chance occurrence and does not mean it will happen again. However, with repeated pregnancy loss, the pregnancy tissue and the blood of both parents are sent for chromosome analysis to rule out a fixed chromosome problem. Chromosome abnormalities occur with a frequency of 25% (autosomal recessive), 50% (autosomal dominant) or 100%, in the case of a balanced shift of chromosomal material. In this last case, either the mother will be unable to create a normal egg or the father will be unable to create a normal sperm. There is no treatment for this type of abnormality, so in order to conceive, such a couple would have to use either a donated egg or sperm, depending upon which partner is affected.
Infection as a cause of pregnancy loss is unusual. There are only a few bacteria which can cross the placenta, and if this occurs once it does not mean that it will occur with successive pregnancies. There are some significant infections which can cause serious fetal injury, such as toxoplasmosis, rubella (German measles), cytomegalovirus (CMV) and primary (first-time) herpes.
The uterus forms from two halves in fetal life. Once these halves come together there is a wall, or septum, between them. This septum should dissolve and disappear, but sometimes remains in place. This creates a septate uterus, one of several uterine abnormalities, or anomalies, which can interfere with a woman's chances for successful pregnancy. Trauma to the uterus, including surgical trauma, can also interfere with completion of a pregnancy. These and other uterine structural problems may be evaluated using a test called a hysterosalpingogram, or HSG. This test is done by a radiologist who instills a dye into the uterus and takes pictures of the dye's progress in the uterus and through the tubes. If any abnormalities are found, surgery is often, but not always, indicated to repair these problems in order for this woman to carry a baby to term. Other uterine abnormalities that can interfere with pregnancy are uterine fibroids and an incompetent cervix.
Hormonal problems often make conception and pregnancy difficult if not impossible. Hormonal abnormalities may also interfere with the ability to carry a pregnancy beyond the first trimester. Though some hormonal problems, like an overactive or under active thyroid, may interfere with the ability to conceive, the hormonal problem most often associated with recurrent pregnancy loss is a progesterone deficiency. Progesterone is produced by the ovary after the egg is released in a process called ovulation. Since the egg is contained inside a developing follicle, this early phase in which the egg develops is referred to as the follicular phase. Once the follicle releases the egg, it develops into a structure called a corpus luteum, or yellow body, because of the yellow color of this structure. The corpus luteum is what produces progesterone in the second half, or luteal phase, of the menstrual cycle. If inadequate progesterone is produced, the woman is said to have a luteal phase defect (LPD). Fortunately, a luteal phase defect is often the easiest problem to treat. This treatment may involve simply supplementing the progesterone with drug therapy, or may involve the use of a fertility drug, such as clomiphene citrate (Clomid or Serophene).
Maternal illnesses which may interfere with a woman’s ability to maintain a pregnancy include systemic lupus erythematosus and other autoimmune diseases (discussed below), congenital heart disease, kidney disease, especially if associated with high blood pressure (hypertension) and poorly controlled insulin dependent diabetes mellitus. Diabetic women with kidney, heart or retinal disease may see pregnancy worsen their illness. Diabetics in poor control prior to conceiving also run an increased risk of fetal anomalies, as well, so it is very important that diabetic women seek to obtain strict control of their disease prior to trying to conceive.
Finally, autoimmune disease may interfere with the developing pregnancy if the pregnant woman produces antibodies, referred to as anti-phospholipid antibodies, which attack and disable the placenta. One such antibody, called lupus anticoagulant, has been directly linked to pregnancy loss. Though the production of anti-phospholipid antibodies effects only 5% of women with recurrent pregnancy loss, any pregnancy loss after 12 weeks (second or third trimester) raises the suspicion of an autoimmune problem. The treatment for these women may be as simply as taking 81 milligrams of aspirin daily, or advice to use heparin injections twice daily once pregnancy is diagnosed to interfere with the action of these anti-phospholipid antibodies.
It must be said that, in the vast majority of cases, the work-up for recurrent spontaneous abortion is negative, meaning no reason is found to explain the recurrent miscarriages. However, even without the work-up and without any particular treatment the woman with recurrent pregnancy loss still has an over 60% chance of carrying a pregnancy to term. If a treatable medical problem is found, the chances may improve. Some women choose not to undergo the work-up, or to have only part of the tests performed. These women may request the broad treatment offered to women with a negative work-up as follows: an antibiotic to treat any infectious agent present, low-dose (81 milligram) aspirin treatment and some form of treatment for presumed luteal phase defect.
The problem of recurrent pregnancy loss is a devastating one for the couple trying to have a family. Though this frustrating problem has possible causes, the true cause may remain uncertain. In the absence of a diagnosed problem, often simply having the courage to "try just one more time" is all it takes to achieve a successful pregnancy.
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Even in the most ideal circumstance, as when a woman begins this treatment immediately after intercourse, the treatment is only 75% effective, for a 25% failure rate. However, this 25% failure rate is not based on all women who use this type of contraception, only those women who would be expected to conceive if they did not use it. It is important to know that pregnancy may occur in only about 10% of women after unprotected or poorly-protected intercourse. So, only 10 women out of 100 will become pregnant after intercourse even if they are trying to conceive. This is why it sometimes takes a full year of trying for many women to conceive. 