Tag Archives: pregnancy

Multiple Births

twins

About one pregnancy in 30 results in multiple births, two or more children born at once. Almost all of these are twins. The frequency falls off dramatically as the numbers of births goes up with triplets rarer than twins, quadruplets rarer than triplets, and five or more births almost unheard of and nearly always as a result of medical intervention of some kind. Higher order live births are rare, more often some or all of the fetuses miscarry or are stillborn. In 2013, only 66 sets of quintuplets or higher were born in the United States, and there were more than 32 times as many twin births as all higher order births combined. In all, there are about 130,000 sets of twins born every year.

Common reasons for multiple births are older mothers—twinning is more common in mothers over 30—and fertility treatments, which often involve multiple ovulation or the creation of multiple embryos as a hedge against a greater risk of losing them. Fertility drugs, which encourage ovulation, often lead to multiple mature ova in one cycle. Twinning runs in families. A woman who is a twin is likely to have twins herself. Twins can be either monozygotic, developing from a single zygote that splits, or dizygotic, in which two ova are fertilized and two entirely separate zygotes develop. Triplets are sometimes monozygotic; triplets usually, and higher order births almost always, are either strictly polyzygotic or a combination of the two.

Multiple births are prone to complication. Because multiples are so hard on the gestational environment, it is quite common—moreso as the order increases—for one or more of the fetuses not to survive. The most births ever recorded is a woman who delivered octuplets after undergoing fertility treatments, but it is very rare for all eight fetuses to survive in such a pregnancy. Although more than 90 percent of single pregnancies are carried to term, more than half of twins and 91 percent of triplets are preterm, another factor affecting survival. Because of this, multiples tend to have low birth weight and are more prone than singletons to cerebral palsy.

Cerebral Palsy And Heredity

cerebral palsy

Damage to areas within the largest part of the brain—the cerebrum—typically before or during birth is called "cerebral palsy." This term refers not to one specific condition but is a name for a broad category of motor deficiencies that result in physical disability. The damage may result from inflammation, infection, or low birth weight or birth defects. Over half of all children with cerebral palsy have been found to have birth defects or low birth weight. Babies born with cerebral palsy may be floppy or stiff. Children with these conditions often exhibit language problems, not necessarily due to cognitive deficits—though such deficits are not uncommon—but as a result of respiratory problems or difficulties with facial muscle control.

The causes of cerebral palsy are not clear. Contrary to what was once believed, babies born with the umbilical cord wrapped around the neck, which actually happens in as many as a third of all pregnancies, are not at significantly higher risk for cerebral palsy. Rather, women who have infectious diseases such as rubella, chickenpox, or toxoplasmosis during pregnancy are more likely to have children with birth defects such as cerebral palsy. Multiple birth are associated with low birth weight, and particularly if there has been a miscarriage, one or more of the infants are at heightened risk for a form of cerebral palsy.

Researchers have also found a family connection in cerebral palsy. Siblings, children, and first cousins of children who are born with cerebral palsy are themselves at higher than normal risk of thee conditions. One study found that, while children who are twins are already three times as likely as single births to have some form of cerebral palsy, when one twin develops one, the other is 15 times more likely to do so as well. The same study showed younger siblings of children with cerebral palsy showed a sixfold increase in risk, roughly the same as children of parents with cerebral palsy.

The good news is that by adolescence, with proper treatment, children with cerebral palsy have quality of life roughly comparable to that of children who are not affected. In a survey, teenagers with cerebral palsy self-assessed as doing as well as—or better than in some areas—their peers.

Folic Acid And Health

folic foods

Only 400 μg per day of vitamin B9, or folic acid, taken prenatally can help the fetus to develop normally, avoiding miscarriage and reducing the risk of birth defects by nearly three fourths. In particular, it helps prevent spina bifida, a condition in which some of the vertebrae that ordinarily cover the spinal cord don’t fully close, leading to physical problems and neurological and cognitive deficits.

However, there are other birth defects that folic acid, which is a part of the cell division process that underlies almost all tissue formation and growth, can help prevent. It helps prevent all neural tube defects, the type of birth defect of which spina bifida is among the most common, and also congenital heart defects, cleft lip, and other conditions.

To be most useful in fetal development, folic acid should be taken early in the pregnancy—the most effective time to up B9 intake is the first four weeks after conception. Most people don’t know they’re pregnant for much of that time, which is why women who might become pregnant are generally advised to get their extra 400 μg daily, in order to be sure they’re ready. However, getting a head start—being sure to get that amount even before conception—has been shown to have benefits for the future fetus.

Moreover, folic acid is beneficial in adults as well, even men. Folic acid can help prevent colorectal cancer as well as cervical cancer. It’s good for the heart, lowering the risk of heart attack and stroke. It’s also good for a large number of other things. People worried about the effects of growing older should know B9 helps slow or prevent Alzheimer’s disease and a kind of progressive vision loss called age-related macular degeneration, as well as other signs of aging. It’s good for depression and sleep problems, nerve and muscle pain, and even AIDS.

Fortunately, folic acid is easy to get. There are supplements, but most people don’t need them. Vitamin B9 is found in leafy green vegetables, asparagus, okra, bananas, beans, oranges, lemons, organ meats, mushrooms and even yeast. By law it’s added to flour as well in the United States. Inadvertently omitting folic acid from the diet would be next to impossible.

Teenage Pregnancy

teen preg

Every day, more than 1,100 children are born to women under age 20. Those children face a higher lifetime risk of poverty, are likely to bee less educated, and tend to experience worse life outcomes than their peers born to adult women. Happily, thanks to educational and societal efforts, teenagers are becoming better informed about the risks of pregnancy and parenting and how to avoid that fate. However, although teenage pregnancy is on the decrease in recent years, it is still common enough to be an important issue.

A number of the issues with teenage motherhood are demographic—teenage mothers, for example, are less likely to have a become pregnant in a stable long-term relationship, and that itself could lead to medical and psychological issues. Teenage motherhood is also correlated with poverty and low educational attainment, with many pregnant teenagers having dropped out of school before becoming pregnant. However, there are also medical risks that are higher in younger mothers or first-time pregnancies. That’s why, globally, pregnancy and childbirth is the second leading cause of death for girls aged 15 to 19. Teenagers are less likely than adult women to have access to prenatal care, have poorer nutrition than their adult counterparts, and are more prone to certain pregnancy complications such as preeclampsia.

Unfortunately, there are a lot of beliefs about sex an pregnancy that surveys have found are common among teenagers but that have no basis in reality. Many people, for instance, believe that the fist time a woman has sex, she can’t get pregnant. Other beliefs relate to position—woman on top, standing up—or location, such as in water, as ways to prevent pregnancy. None of these are effective.

The rumor mill also circulates contraception methods, such as jumping up and down, bathing, or going to the bathroom right after sex, or even douching after, that are ineffective. These beliefs, in combination with health curricula in some schools that may give the impression that hormonal and barrier methods do not work, can result in pregnancies that could have been avoided.

Early Intervention For Spina Bifida

bifida

Spina bifida means split spine. Fetuses with spina bifida, one of the most common birth defects, develop with the two sides of the neural tube, a sheath of tissue that will form the spine, incompletely joined. This leads to gaps in the protective covering the spine normally provides for the spinal cord. When this happens, the baby’s nervous system is highly prone to infections that the neural tube ordinarily protects against. These infections can result in lifelong nervous system damage. In addition, the damaged neural tube causes cerebrospinal fluid to build up in the skull, putting pressure on the brain.

Infants with spina bifida may have paralysis of the legs, bowel and urinary incontinence, cognitive difficulties, or learning disabilities. The cerebreospinal fluid can cause or exacerbate these difficulties. In some cases, different parts of the neural tube, which will become parts of the brain itself, fail to join, leading to brain damage when the baby is born.

It is unclear exactly what causes spina bifida. There is a genetic component, but environmental factors are also known to be partly responsible. In particular, folic acid levels seem to be related to proper fusion of the neural tube, to the point that, though only about a third of pregnant women take folic acid, women who do so are 70 percent less likely to have babies with spina bifida. However, neural tube fusion is supposed to happen less than a month into pregnancy, before the expectant mother even necessarily realizes she’s pregnant. For this reason, some experts recommend that all women who intend or expect to become pregnant should take folic acid.

Another possibility is surgery on the fetus in the uterus. If ultrasound or other imaging shows incomplete neural tube fusion, surgical techniques are being investigate that will allow a surgeon to go in and fix the damage before the birth. In one study, this was shown to be cost-effective, sparing parents the financial costs of repeated surgeries and other treatments after birth. Prenatal in utero surgery also means the damage that the condition starts doing immediately after birth can be reduced, if not entirely eliminated. Research has shown that prenatal surgery prevents the buildup of cerebrospinal fluid, and babies born after surgery are more likely to eventually be able to walk unaided.

Risk Factors For Postpartum Depression

postpartum-depression-300x200

The hormonal rush of pregnancy and giving birth can wreak havoc on a woman’s emotional state. The mood swings that often accompany pregnancy don’t always go away once the baby is born. As many as one in four women experience clinical depression starting around four weeks after giving birth. Postpartum depression is more than simply low mood, or the lack of energy that comes from taking care of a new baby. Like other forms of depression, it is a potentially serious mental illness.

While new motherhood brings with it a certain amount of worry, postpartum depression goes beyond that. Lasting feelings of being overwhelmed, of regret over having a child, of not feeling any connection to the newborn or to anything at all, of emotional numbness, of guilt over feeling like a bad mother, or of wanting to run away and leave the baby behind are not simply the emotional roller-coaster of new motherhood; they may be signs of a serious illness—though often a treatable one.

There are some risk factors to be aware of. A woman with a prior history of clinical depression is prone to return to that state after having a baby. Women who are pregnant in stressful situations—such as young motherhood, unplanned pregnancy, facing motherhood alone, relationship difficulties, or financial problems—are more likely to develop postpartum depression, and lack of support is the biggest single risk factor. Sometimes, depression develops as a response to a temperamental or colicky baby; it can be triggered, in part, by fear of being an inadequate mother, and a baby who is responding poorly to parenting can seriously exacerbate that fear. Smoking makes the postpartum depression risk worse, even among women who quit for the duration of the pregnancy if they resumed after.

Another risk factor is the perceived—and often real—pressure to be The Perfect Mother. Although no mother is perfect, women are often made to feel as though the tiniest misstep during the child’s infancy can ruin them for life. This results in every decision becoming fraught with worry, and new mothers may freeze up as a result. One decision that is highly anxiety-provoking in this way is weather or not to breastfeed. Interestingly, while the dire consequences commonly predicted for formula-fed infants are often exaggerated if not invented, breastfeeding does lower the mother’s risk of postpartum depression. One reason for this may be that new mothers who attempt to breastfeed but are unsuccessful are more likely to develop depression, but breastfeeding also promotes mother-child bonding.

Men And Infertility

baby

When a couple spends more than a year trying to conceive without success, they can be diagnosed as infertile. Women over 35 can be diagnosed after six months, because fertility declines with age generally, and women at that age may not have the luxury of a year to try. However, only in about two-thirds of infertile couples does the problem lie with the woman, and only half of those is it with the woman exclusively. This is at odds with the common perception of infertility, which typically lays the issue at the feet of the female half of the couple. In spite of the vulnerability of sperm and sperm production to a host of medical issues and environmental factors—including celiac disease, diabetes, and even chemicals in some types of toothpaste—the clear and direct involvement of women in the reproductive process leads people to think of reproduction generally and problems interfering with it, primarily in terms of the role women play and the effects on women.

Unfortunately, this puts a great deal of stress on women, which can itself make conception more difficult. In a study, women who had increased levels of stress hormones had a harder time conceiving. Even subjects with no previous fertility problems were 29 percent less likely to be pregnant if they were found to have high levels of stress hormone levels rather than low levels. High-stress women were twice as likely to go a year without conceiving, the study found.

The focus on women means less attention paid to male infertility, which could harm the men suffering the problem and delay treatment of the underlying issue. Male infertility is linked to higher mortality, but it is also often responsive to relatively simple fixes that aren’t available to women. Research has found that men with two or more abnormalities in semen—including deficits in motility, odd shape, low semen volume, or low sperm count—have double the risk of death in the eight years following the initial evaluation for fertility issues. That suggests that men who aren’t being evaluated, who assume it is their female partners who have the problem, are unprepared for this higher risk. Moreover, they are unable to get treatment, which could be as simple as a synthetic version of the protein in sperm that primes the ovum for fertilization. This synthetic protein has not been used clinically but shows promise in research settings to help increase male fertility.

Birth By Cesarian Section

csection

Delivery by cesarean section is a surgical operation performed to make delivering a baby faster and more precise. The operation involves cutting into the mother’s abdomen to reach the uterus, and delivering the baby through this incision rather than the vagina. It is a controversial procedure, because there exists a belief that many cesarean sections are being performed needlessly, for the convenience of the doctor rather than for the benefit of the patient&mash;a cesarean allows greater control over the timing and duration of the birth, permitting more exact scheduling. As with any surgical procedures, there are inherent risks, an some, such as postpartum depression, unique to pregnancy. This is why many patient advocates want to see cesarean sections limited to cases in which vaginal delivery is itself expected to be unusually dangerous.

In some cases, however, even if there is a heightened risk with vaginal delivery, doctors or patients are reluctant to turn to cesarean section as an option. For example, in a breech birth, the fetus fails to turn around prior to the beginning of labor, creating a situation in which the head of the fetus can be trapped, which can be deadly for the fetus and harmful to the mother. Although this is one of the complications for which cesarean section is medically advised by most doctors, as many as 40 percent of mothers of breech fetuses prefer vaginal delivery.

Nonetheless, while the number of cesarean sections leveled off at the beginning of the decade, there has been a sharp increase in recent years. Many obstetricians are moving towards looking for specific criteria before suggesting a cesarean section, or performing one as an emergency procedure. These criteria include difficult labor, abnormal fetal heart rate, breech birth or other issues with the position of the fetus, or an unusually large fetus. Multiple births, particularly triplets or more, also often call for cesarean delivery.

In some cases, such as preeclampsia or overdue pregnancy, doctors may use medications or hormones to induce labor. Though this also carries risks, it does not increase the chances of cesarean delivery. In fact, recent studies have found that it reduces it; women who have labor induced are 12 percent less likely to have to undergo cesarean delivery than those who allowed nature to take its course.

Living With Cerebral Palsy

ganglia

Cerebral palsy is a term referring to any of a number of types of brain damage affecting the cerebellum, the largest part of the brain. Often, the damage is due to inflammation, caused by infection or related to low birth weight or birth defects. Over half of all children with cerebral palsy were found to have birth defects or low birth weight. Doctors once believed that cerebral palsy often resulted from obstructions preventing oxygen from reaching the baby’s brain during or immediately after birth, for example, the umbilical cord being wrapped around the baby’s neck. While this does occur, it is usually harmless, and rarely leads to cerebral palsy.

While causes of many cases of cerebral palsy have been found, it is not always clear why these things happen. Women who have rubella, chickenpox, toxoplasmosis, or certain other infectious diseases during pregnancy are more likely to have children with birth defects. Children born as multiples are likely to have low birth weight, and, especially in cases in which one of the children miscarried, are prone to cerebral palsy. Recent studies have also found a family link. The children, siblings, and even first cousins of people with cerebral palsy are particularly at risk for having the condition themselves.

There is no cure for cerebral palsy, but there are interventions that can help minimize the deficit and improve the child’s capabilities. These interventions are most effective the sooner they are given, when the brain tissue is less specialized; they generally involve training a healthy portion of the brain to take over or augment a function of the damaged part. That is why doctors try to make a diagnosis sooner rather than later, by tracking children known to be at risk of developing the disease, by looking for delays in reaching developmental milestones in the first year, an by looking for symptoms of cerebral palsy such as poor muscle tone and abnormal movements.

Researchers have now found a better way to treat the movement problems that cerebral palsy can cause. They have devised a rubric for classifying patients based on the nature of the deficit, determining that different types of movement issue benefit from different types of treatment. This will make it easier for treatments to be used that are tailored for the person’s needs.

Preecclampsia

preeclampsia

When pregnancy is accompanied by high blood pressure after 20 weeks and excessive protein in the urine, that is called preeclampsia, and it can be fatal. One in 15 pregnant women experience preeclampsia, usually in the third trimester but sometimes toward the end of the second. There are a number of factors that lead to preeclampsia, although the exact causes are not well understood. Abnormal placental development is thought to be a contributing factor, as well as insufficient blood blow to the uterus.

Because the condition is so sudden and so dangerous, clinicians pay close attention to risk factors for preeclampsia. It is more likely in the woman’s first pregnancy, her first pregnancy by a particular partner, or her first pregnancy after a long gap—all of which also suggests an immune component to the condition. Women who are under 20, who are over 40, who are obese during pregnancy, or who have a family history of preeclampsia are at heightened risk. Other risk factors are having had preeclampsia in a previous pregnancy, a multiple pregnancy, or a woman having diabetes or high blood pressure when she became pregnant.

In a new report, doctors recommend that women at risk for preeclampsia take a low-dose aspirin regimen, similar to that used to reduce stroke risk, after the first trimester. Once preeclampsia has developed, the only treatment is delivery, regardless of the stage of pregnancy, so early detection and prevention are very important. The aspirin regimen was shown to reduce preeclampsia incidence by 24 percent. Premature birth rates were reduced 14 percent, and fetal growth rates also improved in the study. Aspirin was not found to increase the risk of bleeding after delivery, or of harm to the fetus or newborn.

Beyond that, early detection is absolutely necessary to management and prevention. Norwegian researchers recently discovered a group of biological indicators of preeclampsia that can be found in blood or urine tests. This is an important finding for two reasons. First, in the long term, it can help provide insight into what is going on in the bodies of women with preeclampsia, helping us to understand and possibly prevent it. In the short term, it provides a test that can predict the condition well before symptoms—pain under the ribs on the right side, unusual nausea, headaches and dizziness, and blurred vision—develop, so that it can be better managed or even avoided.