Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 27. Issues during pregnancy

If you face an unexpected problem during your pregnancy, you may be concerned, confused and even frightened. This section describes some of the problems pregnant women may face and how these conditions are often treated. Take heart because many problems that develop during pregnancy can be successfully managed. Listen to your care provider’s advice and ask questions until you feel that you fully understand the complication and how best to treat it.

If you’re enjoying a problem-free pregnancy, there’s no need to read this chapter. Reading about things that could go wrong will just worry you unnecessarily.

BLOOD CONCERNS

Here are some blood complications moms-to-be may experience.

Rhesus factor incompatibility Rhesus (Rh) factor incompatibility occurs when a pregnant mother and her fetus have different Rh blood types. Rh factor is a type of protein found on the surface of red blood cells. Those with Rh factor are called Rh positive. Those without it are called Rh negative.

When you’re not pregnant, your Rh status has no effect on your health. If you’re Rh positive, you have no cause for concern during pregnancy either. But if you’re Rh negative and your baby is Rh positive — which is likely if your partner is Rh positive — a problem called Rh factor incompatibility can result. Your body sees the Rh positive factor in your baby’s blood as a foreign substance. If exposed to the Rh positive protein, your body starts making antibodies to destroy it. The result can be a destruction of red blood cells in your baby. If left untreated, this can cause mild to severe fetal complications. In very rare cases, it can lead to death.

It usually takes one Rh incompatible pregnancy for your body to build up enough antibodies to the point that they could harm your baby. If you’re Rh negative, your partner is Rh positive and this is your first pregnancy, Rh incompatibility is unlikely to be a problem for you. Your risk is higher during future pregnancies. Fortunately, the problem is almost always preventable

Treatment The key to preventing Rh factor incompatibility is a medication that consists of antibodies against Rh positive cells, called Rh immune globulin (RhIg). An RhIg injection will mask any Rh positive cells that may be floating around in your bloodstream. With no Rh factor to fight, antibodies will not form. Think of it as a pre-emptive strike against the formation of Rh antibodies. Because of the development of RhIg and its safety, fetal Rh disease is now rare.

If you test Rh negative early in your pregnancy, you may have a blood test to check for Rh antibodies about 28 to 29 weeks into your pregnancy. If results show you’re not yet producing Rh antibodies, your care provider can give you an injection of RhIg.

If you’re one of the few women who do have Rh antibodies, you can be tested on a regular basis throughout the second trimester to determine the level of antibodies in your blood. Further testing may be recommended to monitor the health of the fetus. If the level of antibodies becomes too high, steps can be taken to prevent harm to the baby. They may include blood transfusions to the fetus while still in the uterus or, in some cases, early delivery. After birth, the baby may have anemia and may develop jaundice that requires treatment.

Iron deficiency anemia Iron deficiency anemia is a condition marked by a decline in the number of red blood cells in your body. It results when your body isn’t getting the iron it needs to fuel red blood cell production.

Iron deficiency anemia develops most often in the second half of pregnancy, after the 20th week. That’s because for the first 20 weeks of pregnancy, as your body makes more and more blood, you make the fluid portion of blood (plasma) more quickly than you make red blood cells. This results in lower red blood cell concentrations overall. However, in about 20 percent of women, the amount of iron available is inadequate to produce the red blood cells necessary to catch up with blood volume, resulting in iron deficiency anemia.

When you’re pregnant, it can be a challenge to keep your iron stores at an adequate level through diet alone. That’s why many care providers prescribe iron supplements during pregnancy. If you’re taking a daily prenatal vitamin, you’ll generally be able to steer clear of iron deficiency anemia.

Signs and symptoms If you have a mild case of iron deficiency anemia, you may not even notice any problems. If, how-ever, you have a moderate or severe case, you may be pale, excessively tired and weak, short of breath, and dizzy or lightheaded. Heart palpitations and fainting spells also may indicate iron deficiency anemia. An unusual symptom of iron deficiency anemia is the desire to consume nonfood items. Common targets of this craving include ice chips, cornstarch and even clay.

If you experience this condition, called pica, contact your care provider. Your baby may be struggling to get enough oxygen because red blood cells are the carriers of oxygen to your baby.

Treatment Treatment consists of consuming enough iron, which is prescribed in capsule or tablet form. Very rarely, iron supplementation may be given by muscle injection or intravenously. In some cases, a blood transfusion also may be necessary. This is done only if a pregnant woman is severely anemic and has an ongoing source of blood loss.

DEPRESSION

Almost everyone experiences a depressed mood once in a while. But if your depressed mood is long term and it interferes with your ability to eat, sleep, work, concentrate, interact with others and enjoy life, you may possibly be experiencing depression.

Depression can be a problem for women during pregnancy, and it’s especially common after pregnancy (postpartum). It’s estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

During pregnancy, factors that can contribute to depression include:

 Health difficulties

 An unexpected pregnancy

 Pressure on family finances

 Unrealistic expectations of childbirth and parenting

 Insufficient social or emotional support

 Unresolved issues from your childhood

Certain personality traits and lifestyle choices can make you more vulnerable. For instance, having low self-esteem and being overly self-critical, pessimistic and easily overwhelmed by stress can put you at increased risk of depression. A diet that’s deficient in folate and vitamin B-12 may cause symptoms of depression, as well.

Signs and symptoms Two of the main symptoms of depression are loss of interest in normal daily activities and feeling sad, helpless or hopeless. Other signs and symptoms of depression can often be mistaken for common problems of pregnancy. That can make depression during pregnancy easy to overlook. For a care provider to diagnose depression, most of the following signs and symptoms must be present most of the day, nearly every day for at least two weeks:

 Sleep disturbances

 Impaired thinking or concentration

 Significant and unexplained weight gain or loss

 Agitation or slowed body movements

 Fatigue

 Low self-esteem

 Loss of interest in sex

 Thoughts of death

Depression can cause a wide variety of physical complaints as well. These can include itching, blurred vision, excessive sweating, dry mouth, headache, backache and gastrointestinal problems. Many people with depression also have symptoms of anxiety, such as persistent worry or a sense of impending danger.

If you think you may be depressed, talk with your care provider about it.

Treatment Depression is a serious illness that requires treatment. Ignoring this diagnosis can put you and your baby at risk. Most often, depression that occurs during pregnancy is treated with counseling and psychotherapy. Antidepressant medications may be used as well. Many of these medications appear to pose little risk to developing babies. If medication is required, your care provider can determine which one is the safest for you to take during pregnancy.

Having depression before or during pregnancy can increase your risk of postpartum depression, which is discussed in Chapter 29. Untreated depression can become a chronic condition that can return before or during subsequent pregnancies.

EARLY LABOR

A full-term pregnancy is defined as one in which birth occurs between 37 and 42 weeks after the start of your last menstrual period. Preterm labor refers to contractions that begin opening the cervix before the completion of the 37th week.

Babies who are born this early often have low birth weight, defined as less than 5½ pounds. Their low weight, along with various other problems associated with preterm birth, puts them at risk of certain health problems.

No one knows exactly what causes preterm labor. In many cases, it occurs among women who have no known risk factors. Care providers and researchers have identified factors that seem to increase risk. These include:

 Previous preterm labor or birth

 A pregnancy with twins, triplets or other multiples

 Previous miscarriages or abortions

 Excess amniotic fluid (hydramnios)

 An infection of the amniotic fluid or fetal membranes

 Abnormalities in your uterus

 Problems with your placenta

 Pre-existing medical conditions

 Bleeding during your pregnancy

 A dilated cervix

 Infection

 Preeclampsia, a condition characterized by high blood pressure

Signs and symptoms For some women, the clues that labor is starting are unmistakable. For others, the signs and symptoms are more subtle. You may have contractions that feel like a tightening in your abdomen. If the contractions aren’t painful, only by feeling your abdomen with your hand may you realize that you’re having them. Some women go into preterm labor without feeling any uterine contractions.

Women sometimes attribute contractions to gas pain, constipation or movement of the fetus. Other signs and symptoms may include:

 Pain in the abdomen, pelvis or back

 Pelvic pressure

 Increased urination

 Diarrhea

 Menstrual-type or abdominal cramps

 Light vaginal spotting or bleeding

 Watery discharge from your vagina

If you have a watery discharge, it may be amniotic fluid, a sign that the membranes surrounding the fetus have ruptured (your water has broken). If you pass the mucous plug — the mucus that builds in the cervix during pregnancy — you may notice this as a thick discharge tinged with blood.

If you have any concerns about what you’re feeling — especially if you have vaginal bleeding along with abdominal cramps or pain — contact your care provider or your hospital.

Treatment Unfortunately, treatment for premature labor hasn’t been very effective. Medications to stop labor, called tocolytics, are effective at slowing or stopping uterine contractions, but only for a short time. More effective treatment for preterm labor is one of the most sought-after developments in obstetrics.

Women experiencing preterm contractions whose membranes are intact are first evaluated for a change in cervical dilation. If the cervix isn’t changing but contractions continue, a fetal fibronectin test may be done. Fetal fibronectin is a kind of glue between the baby’s membranes and wall of the uterus. If fetal fibronectin isn’t detected in a cervical sample, it’s highly unlikely the contractions will cause delivery of the baby within the next week.

Most women in preterm labor receive fluids through an intravenous (IV) catheter and are asked to rest in bed. Sometimes, these measures alone seem to stop preterm labor. If contractions decrease and your cervix isn’t dilating, you may be sent home and may be advised to limit activities. If contractions continue and your cervix dilates, your care provider may recommend a medication called betamethasone. This corticosteroid medication passes across the placenta and helps promote maturity of the baby’s lungs, so baby can breathe better after birth.

Sometimes, preterm labor results from other complications, such as uterine infection or placental abruption. If these complications are a greater threat to the baby than is prematurity, delivery is actually encouraged. Premature rupture of the amniotic membranes is another cause of premature birth. In some instances, a care provider may recommend a baby be delivered early if the mother develops a serious health problem, such as severe high blood pressure.

If you’ve had one premature birth, you have an increased risk of going into premature labor again. Recent studies suggest weekly injections of the hormone 17 hydroxyprogesterone might be helpful in preventing preterm labor in women who previously experienced preterm birth before their 35th week of pregnancy.

MAKING THE BEST OF BED REST

Your care provider has prescribed bed rest due to complications of your pregnancy. For the first few hours, it seems wonderful. You have permission to rest, and your family is waiting on you hand and foot.

Then reality sets in. You can’t go to work, weed your garden or play tag with your children. You can’t shop for groceries, take a walk around the block or meet your friends at the movies. How can you make the best of the situation?

Start by focusing on the fact that you’re doing what’s best for you and your baby. Your care provider wouldn’t suggest bed rest otherwise. Total bed rest is important because it can:

 Decrease the pressure of the baby on the cervix and reduce cervical stretching, which may cause premature contractions and miscarriage.

 Increase blood flow to the placenta, helping your baby receive maximal nutrition and oxygen. This is particularly important if the baby isn’t growing as rapidly as he or she should.

 Help your organs, especially your heart and kidneys, to function more efficiently, improving problems with high blood pressure.

Work closely with your care provider to understand exactly what your restrictions are. Ask questions, such as:

 What position should I use while lying down?

 Can I sit up at times? If so, for how long at any one time?

 Can I get up to use the bathroom?

 Can I take a bath or shower?

 Is sexual activity off-limits?

 Is any type of physical activity allowed?

 Are there any exercises I should do while in bed?

Tips for bed rest To make bed rest tolerable, try these tips:

 Set up your bedroom so that everything you need is within reach from the bed.

 Organize your day. Schedule specific times to phone the office, connect with your spouse, watch television, read, and so on.

 Take up a new hobby, such as making a scrapbook, painting or knitting.

 Learn relaxation and visualization techniques. They’ll help not only during bed rest but also during labor and delivery.

 Work on crossword puzzles.

 Write emails to friends or call them on the phone.

 Help your family stay organized. Record schedules on a calendar, make weekly menus, or pay bills and balance the checkbook.

 Read. Try books, magazines or newspapers you don’t usually buy.

 Plan for your baby’s arrival by buying any necessities, either online or from catalogs.

EXCESSIVE VOMITING

Nausea and vomiting in early pregnancy are common. But at times, vomiting during pregnancy can become frequent, persistent and severe. This is known as hyperemesis gravidarum. The cause of this condition appears to be linked to higher than usual levels of the pregnancy hormones human chorionic gonadotropin (HCG) and estrogen. Hyperemesis gravidarum is more common in first pregnancies, among young women and among women carrying more than one baby.

Signs and symptoms Persistent, excessive vomiting is the main sign. In some cases, vomiting can be so severe that a pregnant woman may experience weight loss, become lightheaded or faint, and show signs of dehydration.

If you have nausea and vomiting so severe that you can’t keep food or liquids down, contact your care provider. If it’s not treated, hyperemesis gravidarum can keep you from getting the nutrition and fluids you need. If it lasts long enough, it can affect the development of your baby.

Before treating you for this condition, your care provider may want to rule out other possible causes of the vomiting. They include gastrointestinal disorders, diabetes or a condition called molar pregnancy, which is discussed in Chapter 30.

Treatment Mild cases of hyperemesis gravidarum are treated with reassurance, avoidance of foods that trigger vomiting, over-the-counter medications and small, frequent meals. Severe cases often require intravenous (IV) fluids, prescription medications and, possibly, hospitalization.

GESTATIONAL DIABETES

Diabetes is a condition in which the levels of blood sugar (glucose) in the blood aren’t properly regulated. When diabetes develops in a woman who didn’t have the condition before pregnancy, it’s called gestational diabetes. This condition is thought to result from metabolic changes brought on by the effects of pregnancy hormones, combined with the mother’s propensity toward developing the disease.

The risk of developing gestational diabetes is higher in some women, particularly those who:

 Are older than age 30

 Have a family history of diabetes

 Are obese

 Gave birth to a large baby in a previous pregnancy

Black, Hispanic and Native American women are at increased risk of developing gestational diabetes, just as they are at increased risk of type 2 diabetes.

Although gestational diabetes isn’t usually a threat to the mother’s health, care providers test for it because it poses some risks for the baby. One major risk for babies of women with gestational diabetes is excessive weight at birth (macrosomia). In addition, babies exposed to high blood sugar in the uterus may develop very low blood sugar when the umbilical cord is cut and the sugar supply halted. This can cause newborn seizures, if not recognized.

If gestational diabetes goes undetected, the baby has an increased risk of stillbirth or death. When the problem is properly diagnosed and managed, the risks to your baby can be decreased.

Signs and symptoms Generally, gestational diabetes doesn’t cause any symptoms. For that reason, a glucose challenge test generally is performed at 24 to 28 weeks of pregnancy. It may be done earlier if your care provider thinks you’re at high risk of developing gestational diabetes. About half the women who develop diabetes during pregnancy have no risk factors for the condition. For that reason, most care providers choose to check all women for gestational diabetes, regardless of their age or risk factors.

For the glucose challenge test, you’ll be asked to drink a glucose solution. After an hour, a sample of your blood is drawn and the glucose level is checked. If the results are abnormal, a second test, called a three-hour glucose tolerance test, is done. For this follow-up test, you fast overnight and then are given another glucose solution to drink. Blood tests are taken before the test and then hourly over a three-hour period.

Gestational diabetes is diagnosed in only a small percentage of women who undergo follow-up testing.

Treatment Controlling your blood sugar level is the key to managing gestational diabetes. In most cases, this can be done by way of diet, exercise and regular testing of your blood glucose level.

Most care providers will ask you to monitor your glucose at home on a regular basis. This is usually done first thing in the morning before you’ve eaten and again two hours after meals to see how high glucose levels climb after eating.

If, despite diet and exercise, your blood glucose level remains too high, an oral medication may be used to control your blood sugar. This approach is safe for the baby and effective for many women. If an oral medication doesn’t work, you may need insulin injections.

Your care provider may also advise regular monitoring of the baby during the last weeks of pregnancy with ultrasound. However, as your baby grows, it becomes more difficult to accurately estimate his or her weight via ultrasound. Most care providers try to deliver the baby by the due date. If labor hasn’t begun on its own by 40 weeks, it may be started (induced).

Shortly after delivery, gestational diabetes often disappears. To make sure that your glucose level returns to normal, your care provider may check it periodically after delivery. If you experience gestational diabetes in one pregnancy, your risk of developing it in another pregnancy is increased. Your risk of developing diabetes later in life also is increased.

INFECTION

Pregnancy doesn’t make you immune from everyday infections and illnesses — you can still get sick. Pregnancy may, however, change the way an infection is managed by your care provider. This section explores the relationship between pregnancy and various infections.

Chickenpox Chickenpox (varicella) is caused by the varicella-zoster virus. A vaccine to prevent chickenpox became available in 1995. Now, children are routinely vaccinated against the illness. People who had chickenpox or have been vaccinated against it are typically immune to the virus. If you’re not sure whether you’re immune, your care provider can perform a blood test to find out.

In childhood, chickenpox is generally a mild disease. However, in adults — and especially in pregnant women — it can be serious.

Managing chickenpox Chickenpox early in pregnancy very rarely results in birth defects. The greatest threat to the baby is when a mother develops chickenpox the week before birth. It can cause a serious, life-threatening infection in a newborn. Usually, an injection of a drug called varicella-zoster immune globulin (VZIG) can lessen the severity of the infection if a baby is treated quickly after birth. The mother also needs protection with VZIG to diminish the severity of the disease.

Cytomegalovirus Cytomegalovirus (CMV) is a common viral infection. In healthy adults, almost all CMV infections go unrecognized. Between 50 and 80 percent of adults in the United States are infected with CMV by age 40. A pregnant woman with CMV can infect her baby with the virus before birth, during delivery or while breast-feeding. Women who contract CMV for the first time during pregnancy may pass a severe congenital infection on to their babies.

Managing cytomegalovirus It’s important to be educated about CMV and how it’s transmitted. Good hygienic practices, such as hand-washing, can minimize the risk of infection. An amniocentesis can test for infection in the fetus if CMV is diagnosed in a pregnant woman. Your care provider may recommend a series of ultrasounds to see if the fetus develops structural problems related to the infection. If the baby is affected, treating a mother with CMV antibody during pregnancy might be helpful.

A small percentage of infants show signs and symptoms of CMV at birth. These include severe liver problems, seizures, blindness, deafness and pneumonia. Some of these babies die. The majority of those who live have serious neurological defects.

Fifth disease Fifth disease (erythema infectiosum) is a contagious infection common among school-age children. The condition is caused by the human parvovirus B19. It’s also called slapped cheek disease because the most noticeable part of the infection in children is the bright red rash on the cheeks.

Infection often occurs without signs or symptoms. For this reason, many adults may not know if they had the infection in childhood. Once you’ve had it, you’re generally immune from getting it again.

Between one-fourth and one-half of pregnant women remain susceptible to the B19 virus during pregnancy, so it’s not uncommon for expectant women to contract the infection.

The great majority of these women will have healthy babies. In rare cases, however, fifth disease in the mother can cause severe, even fatal, anemia in the fetus. The anemia can cause congestive heart failure, manifested by a severe form of swelling (edema) called fetal hydrops. If a fetus develops this complication, it may be possible to give the fetus a blood transfusion through the umbilical cord.

Managing fifth disease Currently, no vaccine exists to prevent fifth disease. Antiviral therapy hasn’t been shown to benefit women with the infection. If a pregnant woman has been exposed to fifth disease or is suspected of having it, blood tests can help determine immunity or confirm infection. If the tests show evidence of infection, additional ultrasounds might be done for up to 12 weeks to watch for possible signs of anemia and congestive heart failure in the fetus.

German measles German measles (rubella) is a viral infection that’s sometimes confused with measles (rubeola), but each of these illnesses is caused by a different virus.

German measles is extremely rare in the United States. Most children are vaccinated against it at a young age. However, small outbreaks of rubella continue to occur in the United States. Therefore, it’s possible for you to become infected during pregnancy if you aren’t immune.

Managing German measles German measles is a mild infection. However, if you contract it while you’re pregnant, it can be dangerous. The infection can cause miscarriage, stillbirth or birth defects. The highest risk to the fetus is during the first trimester, but exposure to rubella during the second trimester also is dangerous.

Early in their pregnancies, women are routinely tested for rubella immunity. If you’re pregnant and found not to be immune, avoid contact with anyone who may have been exposed to German measles. Vaccination isn’t recommended during pregnancy. However, you can be vaccinated after childbirth so that you will be immune in future pregnancies.

Group B streptococcus About 1 in 4 adults in the United States carry a bacterium known as group B streptococcus (GBS). For women with GBS, the organism may reside in the colon, rectum or vagina. Typically, GBS lives harmlessly in the body. However, pregnant women who harbor GBS may pass it to their babies during labor and delivery. Babies, especially preterm babies, don’t handle the bacteria in the same manner as do adults. If they acquire this infection, they can become seriously ill.

Managing group B streptococcus Using antibiotics during labor to treat women who carry the bacterium prevents most fetal infections. If tests indicate you carry GBS, remind your care provider at the beginning of labor so that you’re given antibiotics.

If GBS does infect a newborn, the resulting illness can take one of two forms: early-onset infection or late-onset infection. In early-onset infection, a baby typically becomes sick within hours after birth. Problems can include infection of the fluid in and around the brain (meningitis), inflammation and infection of the lungs (pneumonia) and a life-threatening condition called sepsis, which can cause fever, difficulty breathing and shock. Late-onset infection occurs within a week to a few months after birth and usually results in meningitis.

Herpes Herpes is caused by the herpes simplex virus. It comes in two forms: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Type 1 causes cold sores around the mouth and nose, but it may also involve the genital area. Type 2 causes painful genital blisters that rupture and become sores. After an initial outbreak, the virus remains dormant in infected areas, periodically reactivating.

Managing herpes Antiviral drugs can help reduce the number of reactivations or shorten their length. Sometimes, the drugs are used to help avoid recurrences late in pregnancy.

If you develop genital herpes, your baby can potentially become infected with the virus when passing through the birth canal. The most serious risk for a newborn is when the mother has her first (primary) herpes infection just before labor. A recurring episode of herpes at childbirth poses much less of a risk. For more information, see herpes in Chapter 29.

After a baby is born, he or she can become infected with herpes by direct contact with someone who has a cold sore. Anyone with a cold sore should avoid kissing a baby and should wash his or her hands before touching a baby.

HIV and AIDS Acquired immunodeficiency syndrome (AIDS) is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). When HIV infects a person, the virus can lie dormant for years. It’s not until the virus becomes active and weakens the body’s immune system that the condition becomes known as AIDS.

Left untreated, women with HIV can pass the infection on to their babies during pregnancy and delivery or through their breast milk.

Managing HIV and AIDS HIV testing is now a routine part of prenatal care. In some instances, repeat testing may be done in late pregnancy. If you think you may be at risk of HIV or AIDS, let your care provider know. Treatments are available that can greatly reduce a mother’s chance of passing on HIV to her baby. Drug treatments begun before or during pregnancy also can improve the health and prolong the life of most infected women.

If baby does acquire the infection, early treatment can slow the progression of the disease and improve survival rates.

For more information, see HIV and AIDS in Chapter 29.

Influenza A woman who didn’t receive an influenza (flu) vaccination may acquire influenza during pregnancy. Even if you were vaccinated, you could become infected by an influenza strain not covered by the vaccine. If you think you may have the flu, contact your care provider right away.

Managing influenza The Centers for Disease Control and Prevention (CDC) recommends a woman in any trimester of her pregnancy who has the flu receive treatment with antiviral medications. The CDC believes the benefits of antiviral therapy outweigh potential risks of the drugs. Antiviral treatment is most beneficial if it begins within two days of the start of symptoms.

Listeriosis Listeriosis is an illness caused by a type of bacteria called Listeria monocytogenes. Most infections result from eating contaminated foods, including processed foods such as deli meats and hot dogs, unpasteurized milk and soft cheeses.

Most healthy people exposed to listeria don’t become ill, but the infection can cause flu-like symptoms such as fever, fatigue, nausea, vomiting and diarrhea. These problems are somewhat more likely during pregnancy.

Managing listeriosis If you contract listeriosis during pregnancy, the infection can be passed from you to your fetus through the placenta and lead to premature delivery, miscarriage, stillbirth or the death of the baby shortly after birth.

It’s important to make every effort to prevent exposure to listeria during pregnancy. Avoid consuming unpasteurized dairy products or deli meats that haven’t been well refrigerated and reheated before consumption.

Toxoplasmosis Toxoplasmosis is a parasitic infection that’s passed from cats to humans. Outdoor soil or sandboxes, especially those in warm climates, may contain the parasite from outdoor cats. The risk of infection from cleaning an indoor cat’s litter box is low.

A pregnant woman who contracts toxoplasmosis can pass the infection on to her baby, and the baby can develop serious complications. To help avoid infection:

 Wear gloves when gardening or handling soil and wash your hands thoroughly when done.

 Thoroughly wash the soil off all fruits and vegetables grown outdoors.

 If you have a cat, have someone else clean its litter box.

Managing toxoplasmosis Toxoplasmosis during pregnancy may result in miscarriage, fetal growth problems or preterm labor. The majority of fetuses who acquire toxoplasmosis develop normally. However, the disease can cause problems, including blindness or impaired eyesight, an enlarged liver or spleen, jaundice, seizures, and mental retardation.

If toxoplasmosis infection is suspected, your care provider can check for it with a blood test. Treating toxoplasmosis during pregnancy can be difficult, and it isn’t clear whether the medications used to treat it are effective for baby.

PLACENTAL PROBLEMS

The placenta provides your baby with nutrients and oxygen. In a normal pregnancy, it remains attached to the uterine wall until shortly after your baby is born. Occasionally, problems can develop with the placenta that can cause serious complications if not identified early.

Placental abruption Placental abruption occurs when the placenta separates from the inner wall of the uterus before delivery. What causes this to happen is unknown, but it can be life-threatening for you and your baby. The most common condition associated with placental abruption is high blood pressure (hypertension). This is true whether the high blood pressure developed during your pregnancy, or you had it before conception.

Placental abruption also appears to be more common in black women, women who are older — especially those older than age 40 — women who’ve had many children, women who smoke, and women who abuse alcohol or drugs during pregnancy. Very rarely, trauma or injury to the mother may cause placental abruption.

Signs and symptoms In the early stages of placental abruption, you may not experience signs or symptoms. When they do occur, the most common is bleeding from the vagina. The bleeding may be light, heavy or somewhere in between. The amount of bleeding doesn’t necessarily correspond to how much of the placenta has separated from the inside of the uterus. Other signs or symptoms may include:

 Back or abdominal pain

 Uterine tenderness

 Rapid contractions

 A uterus that feels rigid or hard

Treatment The condition of the mother and baby and the stage of the pregnancy are taken into account. Electronic monitoring may be used to look at the baby’s heart rate patterns. If the monitoring shows no signs the baby is in immediate trouble and baby is still too premature, the mother may be hospitalized and her condition monitored closely.

If the baby has reached maturity and placental abruption is minimal, a vaginal delivery is possible. If an abruption progresses and signs indicate that the mother or baby is in jeopardy, immediate delivery is generally necessary. A mother who experiences severe bleeding may need blood transfusions.

There’s a chance that placental abruption will recur in a subsequent pregnancy. Stopping smoking and treatment for substance abuse can greatly reduce the chance of recurrent abruption.

Placenta previa In some pregnancies, the placenta is located low in the uterus and partly or completely covers the opening of the cervix. This is called placenta previa, and it poses a potential danger to the mother and baby because of the risk of excessive bleeding before or during delivery. Placenta previa occurs in about 1 in 200 pregnancies and may take one of two forms:

 Marginal placenta previa. The edge of the placenta lies within 2 centimeters of the cervical opening but doesn’t cover it. Vaginal delivery may be possible.

 Placenta previa. The placenta covers the cervical opening, making vaginal delivery impossible because of the risk of massive bleeding.

The cause of placenta previa isn’t known, but like placental abruption, it’s more common in women who’ve had children before, older women and women who smoke. Previous uterine surgery may increase the risk. Prior cesarean birth seems to significantly increase the risk.

Signs and symptoms Painless vaginal bleeding is the main sign of placenta previa. The blood is usually bright red, and the amount may range from light to heavy. The bleeding may stop, but it nearly always recurs days or weeks later.

Almost all cases of placenta previa can be detected by ultrasound before any bleeding has occurred. Because even the gentlest cervical examination can cause hemorrhage, it’s done only when delivery is planned and only when an immediate cesarean birth can be performed. As the uterus enlarges, the placenta may move from the cervical opening, so several ultrasounds may be done.

Treatment Treatment depends on several factors, including whether the fetus is mature enough to be born and whether you’re experiencing vaginal bleeding. If the placenta is close to but not covering the cervix and there’s no bleeding, you may be allowed to rest at home. Because of the chance of premature birth, medication may be given to enhance the maturity of the baby’s lungs.

If bleeding episodes are recurrent, you may be kept in the hospital and a cesarean birth may be planned for when your baby can safely be delivered. If bleeding starts and can’t be controlled, an emergency cesarean birth generally is necessary.

Women who’ve experienced placenta previa in a previous pregnancy have a small chance of having it again in a future pregnancy. In most cases, placenta previa can be detected early and accurately. If the placenta lies over the area in the uterus of a prior cesarean birth scar, you may be at risk of placenta accreta, a condition where the placenta grows into the muscle of the uterus. This makes the next cesarean more complicated.

PREECLAMPSIA

Preeclampsia occurs during pregnancy and is marked by:

 High blood pressure

 Protein in the urine after the 20th week of pregnancy

The condition used to be called toxemia because it was once thought to be caused by a toxin in a pregnant woman’s bloodstream. It’s now known that preeclampsia doesn’t result from a toxin, but its true cause isn’t known.

Preeclampsia affects 2 to 8 percent of all pregnancies and occurs most often during a woman’s first pregnancy. Other risk factors include carrying two or more fetuses (multiple pregnancy), diabetes, high blood pressure (hypertension), kidney disease, rheumatologic disease such as lupus, and family history. Preeclampsia is more common in very young women and women older than age 35.

Signs and symptoms Women may have preeclampsia for several weeks before signs and symptoms develop, including high blood pressure and protein in the urine. In some women, the first sign of preeclampsia is a sudden weight gain — more than 2 pounds in a week or 6 pounds in a month. The weight gain is due to the retention of fluids. Headaches, vision problems and pain in the upper abdomen also may occur.

The diagnosis of preeclampsia typically begins when blood pressure is consistently elevated over a period of time. A single high blood pressure reading doesn’t mean you have preeclampsia. In pregnant women, a blood pressure reading of 140/90 millimeters of mercury (mm Hg) or higher is considered above the normal range.

Preeclampsia has various degrees of severity. If the only sign you have is elevated blood pressure, your care provider may call your condition gestational hypertension.

There’s also a severe form of pre-eclampsia known as HELLP syndrome. It’s distinguished from milder forms of the condition by breakup of red blood cells, elevated liver enzyme values and a low blood platelet count.

Treatment The only cure for pre-eclampsia is delivery; however, medications to treat high blood pressure in pregnancy may be used to protect the mother.

A mild case of preeclampsia is often managed at home with bed rest and regular monitoring of your blood pressure. Your care provider may want to see you a few times a week to check your blood pressure, urine protein levels and the status of your baby. A more severe case often requires a stay in a hospital where testing of the baby’s well-being can be done regularly. Left untreated, pre-eclampsia can result in eclampsia, a severe complication marked by seizures, which has significant risks for both mother and baby.

If preeclampsia becomes severe, even well before the due date, labor may be induced or a cesarean birth performed to protect the mother and the baby.

After delivery, blood pressure usually returns to normal within several days or weeks. Blood pressure medication may be prescribed when you’re dismissed from the hospital. If blood pressure medicine is necessary, it often can be gradually decreased and then stopped a month or two after delivery. Your care provider may want to see you frequently after you go home from the hospital in order to monitor your blood pressure.

The risk that preeclampsia will happen in a subsequent pregnancy depends on how severe it was during the first pregnancy. With mild preeclampsia, the risk of recurrence is low. But if pre-eclampsia was severe in a first pregnancy, the risk in future pregnancies is higher.

SLOWED FETAL GROWTH

Intrauterine growth restriction (IUGR) describes a condition in which babies don’t grow as fast as they should while inside the uterus. These babies are smaller than normal during pregnancy, and at birth they weigh less than the 10th percentile for their gestational age.

Each year in the United States, as many as 100,000 full-term babies are born weighing less than 5½ pounds. IUGR may stem from problems with the placenta that prevent it from delivering enough oxygen and nutrients to the fetus. The condition may also be caused by:

 High blood pressure in the mother

 Cigarette smoking

 Severe malnutrition or poor weight gain in the mother

 Drug or alcohol abuse

 Chronic disease in the mother, such as type 1 diabetes or heart, liver or kidney disease

 Preeclampsia or eclampsia

 Placental and cord abnormalities

 Multiple fetuses

 Antiphospholipid antibody syndrome, a rare immune system disorder

IUGR may also occur because of an infection, birth defect or chromosome abnormality. It can also develop without a known cause.

Medical advances and early diagnosis have greatly reduced serious complications of growth restriction. However, these babies can still develop problems.

Signs and symptoms If you’re carrying a growth-restricted baby, you may have few, if any, signs and symptoms. This is why your care provider regularly checks to see if your baby is growing, including measuring your uterus at each of your prenatal visits.

If IUGR is suspected, an ultrasound exam likely will be done to measure the baby’s size. Blood flow measurements in the umbilical cord and fetal vessels may be measured with an ultrasound technique called Doppler analysis.

Treatment To treat growth restriction, the first step is to identify and reverse any contributing factors, such as smoking or poor nutrition. You and your care provider will monitor the baby’s condition, and you may be asked to keep a daily record of the baby’s movements. Ultrasound exams generally are done every three weeks to track the baby’s growth and the volume of amniotic fluid. If you’re pregnant with twins, IUGR can affect both babies to the same degree. Or it may affect one twin more than the other.

If tests and ultrasounds show that the baby is growing and isn’t in danger, the pregnancy may continue until labor begins on its own. But if test results indicate that the fetus may be in danger or isn’t growing properly, your care provider may recommend an early delivery.

Careful monitoring and early intervention often can lessen the dangers faced by growth-restricted babies. A focus on good prenatal care, including getting excellent nutrition and eliminating smoking and alcohol use, will increase your chances of having a healthy baby.

Even if you do have a growth-restricted baby, size at birth may not be an indication of how well he or she will grow and develop. Many growth-restricted babies catch up to their normal-sized counterparts by 18 to 24 months. Unless these babies have serious birth defects, the chances are good for most of them to have normal intellectual and physical development in the long term.