PROGRAVID

FERTILITY

2009-06-30T07:08:00.002+07:00

Fertility is the natural capability of giving life. As a measure, "fertility rate" is the number of children born per couple, person or population. This is different from fecundity, which is defined as the potential for reproduction (influenced by gamete production, fertilisation and carrying a pregnancy to term). Infertility is a deficient fertility.

Human fertility depends on factors of:

Human fertility

Both women and men have hormonal cycles which determine both when a woman can achieve pregnancy and when a man is most virile. The female cycle is approximately twenty-eight days long, but the male cycle is variable. Men can ejaculate and produce sperm at any time of the month, but their sperm quality dips occasionally, which scientists guess is in relation to their internal cycle.

Furthermore, age also plays a role, especially for women.

Menstrual cycle

Although women can become pregnant at any time during their menstrual cycle, peak fertility occurs during just a few days of the cycle: usually two days before and two days after the ovulation date^[3]. This fertile window, varies from woman to woman, just as the ovulation date often varies from cycle to cycle for the same woman^[4]. The ovule is usually capable of being fertilized for up to 48 hours after it is released from the ovary. Sperm survive inside the uterus between 48 to 72 hours on average, with the maximum being 120 hours (5 days).

These periods and intervals are important factors for couples using the rhythm method of contraception.

Female fertility

The average age of menarche in the United States is about 12.5 years.^[5] In postmenarchal girls, about 80% of the cycles were anovulatory in the first year after menarche, 50% in the third and 10% in the sixth year.^[6][7] Women's fertility peaks around the age of 19-24, and often declines after 30.^{[citation needed]} With a rise in women postponing pregnancy,^[8] this can create an infertility problem. Of women trying to get pregnant, without using fertility drugs or in vitro fertilization:

At age 30, 75% will get pregnant within one year, and 91% within four years.
At age 35, 66% will get pregnant within one year, and 84% within four years.
At age 40, 44% will get pregnant within one year, and 64% within four years.^[9]

The above figures are for pregnancies ending in a live birth and take into account the increasing rates of miscarriage in the aging population. According to the March of Dimes, "about 9 percent of recognised pregnancies for women aged 20 to 24 ended in miscarriage. The risk rose to about 20 percent at age 35 to 39, and more than 50 percent by age 42".^[10]

Birth defects, especially those involving chromosome number and arrangement, also increase with the age of the mother. According to the March of Dimes, "At age 25, a woman has about a 1-in-1,250 chance of having a baby with Down syndrome; at age 30, a 1-in-1,000 chance; at age 35, a 1-in-400 chance; at age 40, a 1-in-100 chance; and at 45, a 1-in-30 chance."^[11]

The use of fertility drugs and/or invitro fertilization can increase the chances of becoming pregnant at a later age. Successful pregnancies facilitated by fertility treatment have been documented in women as old as 67.^[12]

Doctors recommend that women over 30 who have been unsuccessful in trying to conceive for more than 6 months undergo some kind of fertility testing.^[13]

Male fertility and age

Erectile dysfunction increases with age,^[14] but fertility does not decline in men as sharply as it does in women. There have been examples of males being fertile at 94 years old.^[14] However, evidence suggests that increased male age is associated with a decline in semen volume, sperm motility, and sperm morphology.^[15] In studies that controlled for female age, comparisons between men under 30 and men over 50 found relative decreases in pregnancy rates between 23% and 38%.^[15]

Cause of decline

Sperm count declines with age, with men aged 50-80 years producing sperm at an average rate of 75% compared with men aged 20-50 years. However, an even larger difference is seen in how many of the seminiferous tubules in the testes contain mature sperm;

In males 20-39 years old, 90% of the seminiferous tubules contain mature sperm.
In males 40-69 years old, 50% of the seminiferous tubules contain mature sperm.
In males 80 years old and older, 10% of the seminiferous tubules contain mature sperm.^[14]

Recent research has suggested increased risks for health problems for children of older fathers. A large scale Israeli study found that the children of men 40 or older were 5.75 times more likely than children of men under 30 to have an autism spectrum disorder, controlling for year of birth, socioeconomic status, and maternal age.^[16] Increased paternal age has also been correlated to schizophrenia in numerous studies.^[17][18][19]

The American Fertility Society recommends an age limit for sperm donors of 50 years or less,^[20] and many fertility clinics in the United Kingdom will not accept donations from men over 40 or 45 years of age. ^[21] In part because of this fact, more women are now using a take-home baby rate calculator to estimate their chances of success following invitro fertilization. ^[22]

References

http://www.gfmer.ch/Books/Reproductive_health/The_demography_of_fertility_and_infertility.html
http://www.enotes.com/public-health-encyclopedia/fecundity-fertility
http://www.duofertility.com/en/my-body/my-cycle/my-fertile-period.html
Creinin MD, Keverline S, Meyn LA (October 2004). "How regular is regular? An analysis of menstrual cycle regularity". Contraception 70 (4): 289–92. doi:10.1016/j.contraception.2004.04.012. PMID 15451332.
Anderson SE, Dallal GE, Must A (April 2003). "Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart". Pediatrics 111 (4 Pt 1): 844–50. doi:10.1542/peds.111.4.844. PMID 12671122. http://pediatrics.aappublications.org/cgi/content/full/111/4/844?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT.
Apter D (February 1980). "Serum steroids and pituitary hormones in female puberty: a partly longitudinal study". Clin. Endocrinol. (Oxf) 12 (2): 107–20. doi:10.1111/j.1365-2265.1980.tb02125.x. PMID 6249519.
Apter D (February 1980). "Serum steroids and pituitary hormones in female puberty: a partly longitudinal study". Clin. Endocrinol. (Oxf) 12 (2): 107–20. doi:10.1111/j.1365-2265.1980.tb02125.x. PMID 6249519. http://www3.interscience.wiley.com/journal/119590594/abstract.
http://findarticles.com/p/articles/mi_m1077/is_1_62/ai_n16807720 "Late-in-life Pregnancy"
"Fertility Treatment Less Successful After 35". WebMD. http://www.webmd.com/content/article/89/100183.htm. Retrieved on July 4 2006.
"Pregnancy After 35". March of Dimes. http://www.marchofdimes.com/professionals/14332_1155.asp. Retrieved on May 21 2008.
"The sterility tax can be reestablished in Russia". http://russia-ic.com/business_law/in_depth/253/. Retrieved on September 22 2006.
"Spanish woman ' is oldest mother'". BBC News. http://news.bbc.co.uk/2/hi/health/6220523.stm. Retrieved on 2006-12-30.
Female Fertility Testing
^a ^b ^c Effect of Age on Male Fertility Seminars in Reproductive Endocrinology. Volume, Number 3, August 1991. Sherman J. Silber, M.D.
^a ^b Kidd SA, Eskenazi B, Wyrobek AJ (February 2001). "Effects of male age on semen quality and fertility: a review of the literature". Fertil. Steril. 75 (2): 237–48. doi:10.1016/S0015-0282(00)01679-4. PMID 11172821. http://linkinghub.elsevier.com/retrieve/pii/S0015-0282(00)01679-4.
Reichenberg A, Gross R, Weiser M, et al. (September 2006). "Advancing paternal age and autism". Arch. Gen. Psychiatry 63 (9): 1026–32. doi:10.1001/archpsyc.63.9.1026. PMID 16953005. http://archpsyc.ama-assn.org/cgi/content/abstract/63/9/1026.
Malaspina D, Harlap S, Fennig S, et al. (April 2001). "Advancing paternal age and the risk of schizophrenia". Arch. Gen. Psychiatry 58 (4): 361–7. doi:10.1001/archpsyc.58.4.361. PMID 11296097. http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=11296097.
Sipos A, Rasmussen F, Harrison G, et al. (November 2004). "Paternal age and schizophrenia: a population based cohort study". BMJ 329 (7474): 1070. doi:10.1136/bmj.38243.672396.55. PMID 15501901.
Malaspina D, Corcoran C, Fahim C, et al. (April 2002). "Paternal age and sporadic schizophrenia: evidence for de novo mutations". Am. J. Med. Genet. 114 (3): 299–303. doi:10.1002/ajmg.1701. PMID 11920852.
Plas E, Berger P, Hermann M, Pflüger H (August 2000). "Effects of aging on male fertility?". Exp. Gerontol. 35 (5): 543–51. doi:10.1016/S0531-5565(00)00120-0. PMID 10978677. http://linkinghub.elsevier.com/retrieve/pii/S0531-5565(00)00120-0.
Age Limit of Sperm Donors in the United Kingdom Pdf file
http://www.formyodds.com

Reviewed by Bambang Widjanarko Obstetrician & Gynecologist

Can You Determine the Sex of Your Baby?

2009-06-30T06:53:00.001+07:00

You’re trying to get pregnant and you’re wondering if there’s any way you can get that little girl or boy that you so desire. Admit it, someone told you if you eat a certain food or have sex in a certain position, you can control the sex of your baby and part of you thought, "why not?" In the case of most of these old wives tales, it can’t hurt to try, but are some of them dangerous? And remember, for all of the women who claim that one or more of these tricks worked for them, there are just as many who will tell you that they didn’t work at all!

Cultural Beliefs
The ancient Mayans believed that you could determine the sex of a baby by looking at the mother’s age at conception and the year of conception. If both numbers are even or both are odd, then the baby will be a girl. If one number is even and the other is odd, the baby is a boy. Some people will tell you that this absolutely works, but we figure the odds are about 50/50.

The Chinese also have a method for predicting the sex of a baby. The belief is that if you compare the mother’s age at conception and the month of conception you can accuratly predict the sex of the baby using a chart. A quick office poll reveals that the Chinese method has about the same rate of success as the Mayans – 50%.

Don’t feel like putting all of your faith in the Chinese or Mayan methods? Here are a few other methods that some people claim will work:

If You Want a Girl:

Eat lots of chocolate and other sweets If you’re not diabetic or pre-diabetic, go for it – but in moderation! We all know that too many sweets are bad for blood sugar, waist-lines and teeth.
Both of you should eat lots of fish and veggies It may not get you a girl, but eating healthy is never a bad idea.
If the woman orgasms first, you’ll have a girl/
The missionary position will produce girls
If the woman is on top you’ll have a girl

If you Want a Boy:

Eat lots of salty foods We’re not so sure that this is a good idea. Too much salt can cause hypertension and in some cases, stomach cancer. If you already have high-blood pressure, definitely don’t try this.
Eat lots of red meat
There are a lot of vegetarians who will tell you that you can have a boy without eating any meat. While moderate intake of red meat is fine, too much does carry some health risks; consumption of too much red meat has been linked to colon cancer and heart disease. If you want to try this, consider choosing organic meat. Meat from cattle that have been fed grass contains more omega three and six fatty acids (the good fats), and less saturated fat.
Let the man initiate love making
Make love standing up
Lie down for a while after sex
Have sex while on all-fours

Other Pearls of Wisdom A common claim is that more boys are conceived on odd numbered days and more girls on even numbered days. If you want a girl, try to conceive when the moon is a quarter full and for a boy try when the moon is full. Some people claim that the time of day can affect the baby’s gender too – girls are conceived in the afternoon and boys at night.

What Doctors Say Sorry to say, the scientific community doesn’t put any stock in any pregnancy folklore. Probably because all of these methods produce no more than a 50/50 chance of conceiving a child of the sex you prefer. Of course, there are some scientific theories about how to choose the sex of your baby. The most popular one involves keeping track of your ovulation cycles and mucous production.

Another scientific method of gender selection is called Percoll density gradient centrifugation procedure, also known as "sperm spinning". The sperm is placed in a centrifuge and spun. The Y (male-producing) sperm rises to the top of the centrifuge and the X (girl-producing) sperm goes to the bottom. This method has about a 77% success rate, however it is expensive and time consuming and requires undergoing in-vitro fertilization. In other words – it’s not a try at home method.

Sexual Positon and Baby Making

2009-06-30T06:45:00.001+07:00

Best Sexual Positions for Baby Making

Obviously, if the time is right a woman may conceive regardless of sexual position. All of us likely could cite a case where actual intercourse did not take place but pregnancy occurred! Still, if you want to optimize your odds consider these suggestions. All are speculative by scientific standards, but considered successful by parents worldwide.

Upping the Odds with Effective Positions

Missionary Position (a.k.a. Man on top): Overwhelmingly, experts and parents alike agree that having the man positioned on top offers the greatest possibility of conception. The degree of penetration combined with the prone position of the woman allows the sperm to be deposited near the cervical opening. Additional "pluses" for this position allow both partners to communicate through sensual looks, intimate kisses, touch and oral stimulation of breasts and nipples (for both partners!), and movement.

From Behind (a.k.a. "doggy style"): The woman kneels before the man, facing away. Penetration is then from behind, enabling the man to enter with deeper thrusts and deposit the sperm close to the cervix. Due to the control this offers the man, his orgasms may be more intense as well.

Want to have even more fun with this position? The man can reach around and fondle his partner's breast or clitoris during intercourse and perhaps even following his own orgasm for additional stimulation. The woman may find she can pleasure her partner by reaching between, "tickling" his testicles gently as he moves and/or stroking the base of his penis. The resulting orgasms may surprise you both!

Spooning: The woman lays with her back to her partner and he cuddles her from behind. Penetration will not be as deep, but both partners are often quite relaxed which can also lead to achieving conception. The woman is able to move against her partner, inviting stimulation and allowing him to enter her from behind. The man is able to manually stimulate the woman's breasts and clitoris. Gentle kisses and communication between the two of you may ignite more pleasure. Something to try? The woman may want to help guide her partner's touch. She may also be able to reach and stroke him as he enters.

"Living on the Edge": Take this one literally! The woman lays on the edge of the bed or couch. The man can then enter from the front from either a standing or kneeling position. Like the missionary position, this allows the man to enjoy a good penetration. The unusual position may excite you both. Again, manual stimulation of both partners can add even more pleasure and intensity. Gravity, ladies, remains on your side helping the sperm meet their goal!

"Scissors": No, this is not your average "rock, paper, scissors" game! This position is one of the more unique used -- but may be just outside of the ordinary enough for you both to increase your enjoyment and result in achieving pregnancy. There are a few variations of this but the basics involve the woman lying on her side; bottom leg is between your partner's legs; top leg may be lifted up or straddled over his side. Men, lay perpendicular to your partner; bottom leg under hers; top leg between hers so the two of you are like "scissors" with the your view being your partner's back. Be certain to adjust either the angle or proximity if needed for comfort. Penetration from this position can and should be sensual for both partners.

Trying for a Certain Gender?

Whether you want a precious baby girl or a bouncing baby boy, positioning actually may play a role (along with timing and other factors.) Male sperm (Y-chromosome) are known for being faster swimmers than their female (X-chromosome) counterparts. They also tend to die off quicker while the female sperm live longer.

Those wishing for a boy may find it best to settle on "doggy style" position. This allows the penetration to be deeper, shortening the distance the sperm carrying the Y-chromosome must travel. According to what is known as the Shettles™ method, the optimal time to conceive a male child is close to ovulation -- generally by having sexual intercourse within the window 24 hours prior to ovulation to 12 hours after. Male sperm also supposedly prefer a more alkaline environment for swimming so ladies, avoid dairy and up the sodium intake. Men, drinking caffeine before sex (NOT alcohol!) can boost the speed of your Y’s!

Dreaming of a girl? Opt for a position with shallow penetration, such as spooning. A greater window of opportunity allows the slower, but much more resilient "female sperm" to take their time in reaching their destination. These sperm typically survive three to five days, and in some (rare) cases up to seven! Female (X-chromosome) sperm tend to prefer a more acidic environment. Increasing dairy products and sweets (don't forget those more natural, healthy sources such as fruits) may provide an additional aid.

How Important is Orgasm?

What about the O-factor? Obviously, for the male's role, achieving orgasm certainly aids in distributing sperm to its intended destination. Don't forget though that female orgasm can be as equally important, particularly after the man has climaxed! The reasoning? Achieving female orgasm can improve the environment for the sperm to swim and survive. The resulting contractions help draw the sperm up and into the cervix -- ready to meet that egg and "make" a baby!

The most important dynamic is to relax and enjoy being intimate with your partner. While certainly increasing your personal knowledge and understanding of your fertility is important, you will likely find that leaving that outside the bedroom will allow you both to focus on your love and desire to pleasure one another versus feeling as if being intimate is now yet another chore on your to-do list.

For those that have been trying for a year or more may wish to seek out medical advice regarding their and/or their partner's fertility.

SEXUAL INTERCOURSE, OVULATION AND CONCEPTION

2009-06-30T06:30:00.001+07:00

Many women who are trying to conceive want to learn when ovulation and implantation occur and what are usual miscarriage or pregnancy loss rates. Quite often the numbers women are given are based on averages, theoretical numbers and sometimes just plain guesses because it is such a difficult topic to scientifically investigate. New data comes available periodically but it is not always promptly and widely disseminated even on the Net.

When does implantation take place?

One such relatively recent study tells us that implantation does not always take place on day 7 after ovulation. In fact it very rarely does. This study by AJ Wilcox accurately determined the day of implantation by very sensitive pregnancy test (HCG) measurement compared to ovulation.

HCG hormone starts being produced when the pregnancy implants into the uterine lining. The findings in normal women trying to conceive included:

first appearance of HCG (implantation) occurred 6-12 days after ovulation
84% of the pregnancies implanted on days 8-10 after ovulation
early pregnancy loss increased with later implantation -
implantation early pregnancy loss rate
- 13% by day 9
- 26% on day 10
- 52% on day 11
- 86% on day 12 or more

Overall the total pregnancy loss up to 6 weeks was 25%. Now that seems very high to most people but keep in mind many of these pregnancy losses occurred so early that women often were not aware they were even pregnant. The normal early pregnancy loss rate that most women know about is 15-18% of clinically recognized pregnancies so almost 40% of all pregnancy loss is unrecognized.

When is the best time to have intercourse in order to get pregnant?

Wilcox had also performed previous work in 1995 (2) which demonstrated that pregnancy only occurs if intercourse occurs within the 6 days prior to and including ovulation. Intercourse after the day of ovulation does not result in pregnancy. The probability of conception ranged from 10% when intercourse occurred five days before ovulation to 33% when it occurred on the day of ovulation itself.

This is the data that suggests the best timing of intercourse in order to conceive is day 10, 12, 14 and 16 (in case of late ovulation) of a 28 day cycle or days -4, -2, 0, +2 in relation to expected ovulation in the case of cycles different than 28 days.

When should I begin testing with home urine tests?

Most home pregnancy tests that check urine beta-HCG are sensitive to 20-25 mIU/ml of HCG. The general rule-of thumb is to test at the time when you are a day late for your menses or about 15 days after ovulation. The test can be positive anywhere from about 2-3 days prior to a missed menses to 4-5 days after.

Testing really does depend upon how regular your menses are or in other words how regular ovulation occurs. If you tend to be late (longer than 28 days) with your periods or the timing of menses varies by several days each cycle, then it is better not to waste pregnancy tests by testing at day 28-29 after the last period starts.

Are ovulation prediction tests worth doing?

Pelvic ultrasound looking at the ovaries is considered the gold standard in ovulation prediction in a research setting but obviously in a practical application of a woman trying to conceive, ultrasound is not used. Urinary LH testing has been shown to have a 100% correlation with ultrasound as far as predicting the timing of ovulation. In that same study, they looked at cervical mucous changes, basal body temperatur (BBT) charts and salivary ferning. Cervical mucous changes only had a correlation of 48%, salivary ferning correlated 37% and BBT has a 30% correlation.

For the home tests that measure LH surge that immediately precedes ovulation, detection of LH occurs at above 30 mIU/ml. This means that women with polycyctic ovarian syndrome who have slightly higher resting LH values are still not falsely detected as ovulating. The urinary LH spike occurs about 24-36 hours prior to ovulation so it is very useful for women trying to conceive because it gives them a window of warning. The test will show positive for one or two days and rarely 3 days if you catch a spike right at the beginning and it is a large release of LH.

What Should You Do After Intercourse To Increase Your Chances Of Getting Pregnant?

What should you do after intercourse to increase your chances of getting pregnant? Well, ask your grandma! There are a lot of tips and tricks that suggest that you can increase your odds of getting pregnant, even after intercourse, by following certain routines. These may work with some women and might not work with the rest. Though not completely scientific, they have shown marked results in some women who swear by them. Douching for example was once a popular method to increase your chances of getting pregnant, but today it has been shrugged off as a myth.

Will having intercourse in the morning help?

Some studies claim that a man’s sperm count may be higher in the morning as compared to other times of the day. But other studies also show that the differences in sperm count are so minimal that it does not matter much in terms of getting pregnant. For example, assume that your sperm count goes from 87 million in the evening to 88 million in the morning. This may sound significant in numbers. But understand that it doesn’t change much if you are talking about a tough conception history. That’s so because, after all, it only takes one sperm to do the job.

One of the surest ways is to have intercourse as often as you can! So stop worrying about the clock and have sex whenever the mood strikes you — day or night.

Will timing intercourse during the monthly cycles help?

Yes, definitely. If you really want to swing the odds of getting pregnant in your favor, you should try and start timing sex sessions as close to ovulation as you can. For most women that’s about halfway between periods and the most fertile period in the month. Our article on ovulation will help you better understand the process and give you an idea of when you’ll ovulate.

It also helps to keep in mind that while it’s important to understand your cycle and the changing patterns of cervical mucus and basal temperature, it’s equally important to try to relax, enjoy sex and the warm feeling of being parents soon. Believe it or not, the more relaxed you are, the better your chances of conceiving.

What can we do after intercourse to increase our odds?

For most healthy couples, getting pregnant isn’t difficult, and no special arrangements need to be made beyond depositing the man’s semen into the woman’s vagina. Generally, the sperm reach the cervix within seconds of ejaculation. But if you have been trying hard and long enough, here’s a secret. Lie flat after intercourse and raise your legs to 30 degrees. This helps the cervical and vaginal muscles to relax and facilitates the movement of cervical mucus. If your man has enough sperm count and you have the right consistency of cervical mucus, this method will greatly help to increase your chances of getting pregnant.

Even doctors recommend that a woman should lie down with her legs slightly raised after intercourse to increase her chances of conception. This greatly helps in women who are trying to get pregnant because the sperm doesn’t have to fight gravity as they make their way to the egg. There is no scientific evidence of this improving the chances of getting pregnant, but many people have tried it to aid conception. It is a harmless technique and worth a shot.

Even after trying various techniques and therapies, if you still encounter trouble in conceiving, you must consult a doctor for advice on how to proceed.

NUTRITION and PREGNANCY

2009-06-30T05:58:00.001+07:00

A balanced diet is a basic part of good health at all times in your life. During pregnancy, your diet is even more important. The foods you eat are the main source of nutrients for your baby. As your baby grows, you will need more of most nutrients. This pamphlet will help you learn more about:

Good food choices for you and your baby
Nutrients you will need
Healthy weight gain

Eating right during your pregnancy is one of the best things you can do for yourself and your baby.

Before You Become Pregnant

The best time to begin eating a healthy diet is before you become pregnant. This will help you and your baby start out with the nutrients you both need.

If you are planning to become pregnant, visit your doctor. Getting good health care before you are pregnant will help you throughout your pregnancy. As part of your visit, you will be asked about your family life, work, and lifestyle, including your diet. You and your doctor will discuss how to eat right before and during your pregnancy and which nutrients are especially important, such as folic acid.

A Healthy Diet

The first step toward healthy eating is to look at the foods in your daily diet. Early in pregnancy, morning sickness can affect your eating habits. You may crave certain foods or not feel like eating. If this happens, you still should try to eat a variety of foods each day to help ensure you are getting the right amount of nutrients.

Having healthy snacks that you can eat during the day is a good way to get the nutrients and extra calories you need. You may find it easier to eat snacks and small meals throughout the day rather than three big meals a day. This also may help you avoid nausea and heartburn.

Healthy eating also means avoiding things that may be harmful. This includes alcohol (beer, wine, or mixed drinks) and illegal drugs, which may cause birth defects and other problems for the baby. Smoking cigarettes is especially harmful to a pregnant woman and her baby.

You also may want to avoid or limit your caffeine intake during pregnancy. Although some studies suggest drinking three or more cups of coffee per day may increase the risk of miscarriage, there is no proof that caffeine causes miscarriage.

Meal Planning

Planning meals in advance can help ensure you and your family eat a balanced diet. The food pyramid developed by the U.S. Department of Agriculture can help you choose what to eat (www.mypyramid.gov) (see Table 1). It takes into account your age, sex, and your amount of daily physical activity and shows the number of servings you should have each day from each of the six food groups:

Grains
Vegetables
Fruit
Oils
Milk
Meat and beans

Basic Nutrients

Every diet should include proteins, carbohydrates, fats, vitamins, and minerals. To be sure your diet provides you with the right amount of nutrients, you should know which foods are good sources of each.

The RDA—recommended daily allowance—on food labels shows the levels of nutrients you need every day. During pregnancy, the RDAs are higher for most nutrients. Table 2 shows the key nutrients you and your baby will need during your pregnancy.

Extra Nutrients

Pregnant women need extra iron and folic acid, and these are usually prescribed in pill form as supplements. Sometimes a prenatal supplement that contains these two nutrients plus vitamins and minerals is recommended. Ask your doctor or nurse how your needs can be best met.

Women should take 400 micrograms of folic acid daily, in addition to a well balanced diet, for at least 1 month before pregnancy and during the first 3 months of pregnancy. This can help prevent neural tube defects, which affect the spine and skull of the fetus.

Women who have had a child with a neural tube defect are more likely to have another child with this problem. These women need much higher doses of folic acid—4 milligrams daily. It should be taken for at least 1 month before pregnancy and during the first 3 months of pregnancy. Women who need 4 milligrams should take folic acid as a separate supplement, not as part of a multivitamin.

Check with your doctor before taking any vitamins, herbs, or other supplements that are not prescribed for you. They might be harmful during pregnancy. Just because a product is natural does not mean it is safe to use during pregnancy.

Weight Gain

When you are pregnant, you need to eat more to help the growth and development of your baby, as well as for the changes in your own body that promote a healthy pregnancy. During at least the last 6 months of pregnancy, you need to eat or drink about 100 more calories per day than you did before you were pregnant.

How much weight you gain during pregnancy depends on your weight before pregnancy (see box). A healthy gain for most women is between 25 and 35 pounds. If you are overweight, you should gain less, but some weight gain is normal. If you are underweight, you should gain more. Talk with your doctor about the amount of weight you can expect to gain. This may vary if you are pregnant with more than one baby.

Special Concerns

Vegetarian Diets

If you are a vegetarian, you can continue your diet during your pregnancy. However, you will need to plan your meals with care to ensure you get the nutrients you and your baby need. Be sure you are getting enough protein and that it is the correct type. You will probably need to take supplements, especially iron, vitamin B12, and vitamin D.

Lactose Intolerance

Milk and other dairy products are the best sources of calcium in your diet. Some women have symptoms such as bloating, diarrhea, gas, and indigestion after drinking milk or eating dairy products. This is known as lactose intolerance.

During pregnancy, these symptoms often improve. But if you still have problems after eating or drinking dairy products, talk with your doctor or dietitian. He or she may prescribe calcium supplements if you cannot get enough calcium from other foods. Calcium also can be found in cheese, yogurt, sardines, certain types of salmon, spinach, and fortified orange juice.

Mercury

Fish and shellfish are good sources of protein, omega-3 fatty acids, and other nutrients. However, pregnant women should not eat certain kinds of fish because they contain high levels of a form of mercury that can be harmful to the developing fetus.

You should avoid eating shark, swordfish, king mackerel, or tilefish during pregnancy. These large fish contain high levels of mercury. Albacore tuna also is high in mercury so you may want to choose canned chunk light tuna instead. Other types of fish are fine in limited amounts. You can eat up to 12 ounces (about two meals) of other varied fish and shellfish per week.

Check local advisories about fish caught in local rivers and streams. If there is no advice about them, it may be safe to eat up to 6 ounces (one meal) per week of fish from local waters. During that week, do not eat any other fish.

Listeriosis

Listeriosis is an illness caused by bacteria that can occur in unpasteurized milk and soft cheese and prepared and uncooked meats, poultry, and shellfish. It can be particularly harmful to pregnant women and their babies.

Symptoms occur several weeks after you eat the food. They can include fevers, chills, muscle aches, and back pain. In some cases, there may be no symptoms at all. When a pregnant woman is infected, the disease can cause miscarriage or stillbirth.

Because the symptoms of listeriosis are like the flu, it can be difficult to diagnose. If you have a fever or flu-like illness, check with your doctor who may take samples from your vagina, cervix, and blood to be checked. If the bacteria are found, you and your baby can be treated with antibiotics. If there is a chance that a newborn is infected, he or she also can be tested and treated.

To prevent listeriosis, wash all fresh fruits and vegetables before using them. While you are pregnant, do not eat:

Unpasteurized milk or soft cheeses
Raw or undercooked meat, poultry, shellfish
Prepared meats, such as hot dogs or deli meats, unless they are reheated until steaming hot

Always be sure to wash your hands and any utensils, countertops, or cutting boards that have been in contact with uncooked meats.

Pica

During pregnancy, some women feel strong urges to eat non-food items such as clay, ice, laundry starch, or cornstarch. This is called pica. Pica can be harmful to your pregnancy. It can affect your intake of nutrients and can lead to constipation and anemia. Talk with your doctor if you have any of these urges. He or she may be able to suggest other things you can do when you feel the urge to eat non-food items.

Finally...

Eating right during your pregnancy is one of the best things you can do for yourself and your baby. Take a look at the foods in your daily diet. Make sure they provide the nutrients you and your baby need. It is never too late to start eating a healthy diet.

PREGNANCY AFTER 35

2009-06-30T05:49:00.001+07:00

What you need to know:
Healthy women from age 35 into their 40s usually have healthy pregnancies. If problems do arise, they can usually be successfully treated.

Women over age 35 have an increased risk of:

Fertility problems
High blood pressure
Diabetes
Multiple pregnancy (twins or more)
Miscarriage
Placenta previa, a condition in which the placenta is in the wrong place and covers the cervix
Cesarean section
A baby with a genetic disorder

Because of these increased risks for women over 35, prenatal care is especially important.

What you can do:
No matter what your age, see your health care provider before trying to get pregnant. This is especially important if you:

Have a chronic medical condition, such as diabetes, a seizure disorder or high blood pressure
Are on long-term medication

If not under control, some medical conditions can cause risks for you and your baby.

If you are older than 35 and don’t get pregnant after trying for six months, see your health care provider.

A Mommy After 35

Most healthy women from age 35 into their 40s have healthy pregnancies. Most women over 35 are in good health. Good prenatal care and healthy habits can help you reduce certain risks. If problems do arise for women over 35, they can usually be successfully treated.

No matter what your age, see your health care provider before trying to get pregnant if you:

Have a chronic medical condition, such as diabetes, a seizure disorder or high blood pressure
Are on long-term medication

If not under control, some medical conditions can cause risks for you and your baby.
If you are older than 35 and don’t get pregnant after trying for six months, see your health care provider. Older women may find it harder to get pregnant than younger women because fertility declines with age. In many cases, infertility can be treated.
Prenatal Care Is Important
Prenatal care is especially important for women over 35 because:

They’re more likely to get high blood pressure and diabetes for the first time during pregnancy.
They may choose to have testing for Down syndrome, a combination of mental retardation and physical defects.

Healthy Habits
To help reduce risks during pregnancy:

Eat healthy foods.
Gain a healthy amount of weight.
Exercise, with your health care provider’s guidance.
Don’t drink alcohol, smoke or take illegal drugs.
Don’t take any medications or herbal supplements without first checking with your health care provider.

Prenatal Screening Tests
Ask your provider about prenatal screening tests for the baby. For instance, amniocentesis is often recommended for pregnant women 35 or older.
In amniocentesis, the health care provider inserts a thin needle through the woman’s abdomen. A small amount of amniotic fluid (the fluid that surrounds and protects the baby) is removed and tested for chromosomal abnormalities such as Down syndrome or a specific genetic disorder for which the fetus is at risk. Test results are usually available within a week or two. Most women who have prenatal screening tests learn that the baby is healthy and feel reassured by the results.

HUMAN FERTILIZATION

2009-06-30T05:35:00.001+07:00

Human fertilization is the union of a human egg and sperm, usually occurring in the ampulla of the fallopian tube. It is also the initiation of prenatal development. Scientists discovered the dynamics of human fertilization in the nineteenth century.

Fertilization (also known as conception, fecundation and syngamy), is the fusion of gametes to produce a new organism. The process involves a sperm fusing with an ovum, which eventually leads to the development of an embryo.

It is when first of all the acrosome at the head tip produces enzymes, which cuts through the outer jelly coat of the egg. After that has happened, the sperm plasma fuses with the egg’s plasma membrane. Finally, the Head disconnects with the body, and the egg can now travel down the Fallopian tube to reach the womb, where the baby grows.

Fertilization may or may not involve sexual intercourse. In vitro fertilisation (IVF) is a process by which egg cells are fertilized by sperm outside the womb, in vitro. Sperm is propelled through the female reproductive tract by flagellation and may get through the jelly coat through a process called sperm activation. The oocyte and sperm fuse once the sperm is through the corona radiata and the zona pellucida; two layers covering and protecting the oocyte from fertilization by more than one sperm.

Corona radiata

Human ovum examined fresh in the liquor folliculi. The zona pellucida is seen as a thick clear girdle surrounded by the cells of the corona radiata.
The egg itself shows a central granular deutoplasmic area and a peripheral clear layer, and encloses the germinal vesicle, in which is seen the germinal spot.

The egg binds the sperm through the corona radiata, a layer of follicle cells on the outside of the secondary oocyte. Fertilization is when the nuclei of a sperm and an egg fuse. The successful fusion of gametes form a new organism

Acrosome reaction

The acrosome reaction must occur to mobilise enzymes within the head of the spermatozoon to degrade the zona pellucida.

Zona pellucida

The sperm then reaches the zona pellucida, which is an extra-cellular matrix of glycoproteins. A special complementary molecule on the surface of the sperm head then binds to a ZP3 glycoprotein in the zona pellucida. This binding triggers the acrosome to burst, releasing enzymes that help the sperm get through the zona pellucida.

Some sperm cells consume their acrosome prematurely on the surface of the egg cell, facilitating for other surrounding sperm cells, having on average 50% genome similarity, to penetrate the egg cell. It may be regarded as a mechanism of kin selection.

Cortical reaction

Once the sperm cells find their way past the zona pellucida, the cortical reaction occurs: cortical granules inside the secondary oocyte fuse with the plasma membrane of the cell, causing enzymes inside these granules to be expelled by exocytosis to the zona pellucida. This in turn causes the glyco-proteins in the zona pellucida to cross-link with each other, making the whole matrix hard and impermeable to sperm. This prevents fertilization of an egg by more than one sperm.

Fusion

The sperm fuses with the oocyte, enabling fusion of their genetic material, in turn.

Cell membranes

The cell membranes of the secondary oocyte and sperm fuse together.

Transformations

Both the oocyte and the sperm go through transformations, as a reaction to the fusion of cell membranes, preparing for the fusion of their genetic material.

The oocyte now completes its second meiotic division. This results in a mature ovum. The nucleus of the oocyte is called a pronucleus in this process, to distinguish it from the nuclei that are the result of fertilization.

Diagram showing the reduction in number of the chromosomes in the process of maturation of the ovum.

Second meiotic division :

Events involving meiosis, showing chromosomal crossover

The sperm's tail and mitochondria degenerate with the formation of the male pronucleus. This is why all mitochondria in humans are of maternal origin.

Replication

The pronuclei migrate toward the center of the oocyte, rapidly replicating their DNA as they do so to prepare the new human for its first mitotic division.

Mitosis

The male and female pronuclei don't fuse, although their genetic material do so. Instead, their membranes dissolve, leaving no barriers between the male and female chromosomes. During this dissolution, a mitotic spindle forms around them to catch the chromosomes before they get lost in the egg cytoplasm. By subsequently performing a mitosis (which includes pulling of chromatids towards centrioles in anaphase) the cell gathers genetic material from the male and female together. Thus, the first mitosis of the union of sperm and oocyte is the actual fusion of their chromosomes.

Each of the two daughter cells resulting from that mitosis have one replica of each chromatid that was replicated in the previous stage. Thus, they are genetically identical.

In other words, the sperm and oocyte don't fuse into one cell, but into two identical cells.

EPILEPSY and PREGNANCY

2009-06-29T22:42:00.004+07:00

Epilepsy and Pregnancy Increased Risks

	General Population	Women with Epilepsy
Major Malformations	2 to 3 Percent	4 to 8 Percent
Minor Malformations	5 to 10 Percent	10 to 15 Percent
Fetal Death	2 to 7 Percent	2 to 14 Percent

More than 90 percent of women with epilepsy will have normal, healthy infants. However, they are at greater risk for complications of pregnancy, labor and adverse pregnancy outcomes than women without epilepsy. Preconceptional counseling and coordination of care among all members of the health care team is key to treating women with epilepsy of reproductive age.

Conception

Fertility

Women with epilepsy have fewer children than women in general, with a fertility rate 25 to 33 percent lower than average. While personal choice and/or societal pressure may play some role in this disparity, research has indicated that women with epilepsy have a higher incidence of menstrual irregularities, polycystic ovarian disease and reproductive endocrine disorders. Any of these may reduce fertility.

Unplanned Pregnancies

Women with epilepsy taking certain anti-epileptic drugs (AEDs) may experience failure of hormonal birth control methods. Some of the medications [carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital, and primidone) and topiramate] may lower concentrations of estrogen, thus reducing effectiveness of the hormonal contraceptive.

Congenital Malformations

Major Malformations

Major malformations are defined as defects of medical, surgical or cosmetic importance. This type of anomaly, which will seriously affect a child’s life, occurs in 2 to 3 percent of all liveborn children. For women with epilepsy on one seizure medication, the incidence is estimated to be 4 to 8 percent and possibly greater for women with epilepsy taking more than one drug. Types of major malformations occurring most often in children of women with epilepsy are orofacial clefts, cardiac abnormalities and neural tube defects.

Folic acid supplementation (at a minimum dose of 0.4 mg daily) is especially important prior to conception and during pregnancy in women with epilepsy to lower the risk of neural tube defects in the offspring.

In general, AED polypharmacy and higher blood levels of AEDs are associated with the increased incidence of birth defects in infants born to women with epilepsy. A single AED at the lowest possible dose for efficacy is recommended whenever possible.

Minor Anomalies

The incidence of minor physical defects in infants born to women with epilepsy is approximately 15 percent. Features such as hypertelorism, epicanthal folds, shallow philtrum, distal digital hypoplasia, and simian creases are often present as a familial trait. Although the incidence is reported as 2 to 3 times greater in women with epilepsy, these may be present in infants whose mothers use other types of medication or have excessive alcohol intake during pregnancy. Many of these minor physical defects appear to be idiopathic in nature. These anomalies do not cause any serious problems and are primarily of cosmetic concern.

Other CNS Effects

A greater incidence of mental retardation and/or microcephaly has been reported in children of women with epilepsy, but these studies have been inconsistent and have not always been controlled for other possible contributing factors (such as inherent genetics, and the effects of maternal seizures or AEDs in utero).

However, developmental delays may be significant in terms of risk to infants of women with epilepsy. Factors other than the maternal epilepsy that are thought to be important are IQ scores in the mother and AED polypharmacy (particularly exposure to phenobarbital in utero).

Spontaneous Abortion

There is no increased risk of early fetal death (the not uncommon, spontaneous abortion within the first 20 weeks post-conception) in women with epilepsy. Late fetal loss (a stillbirth or spontaneous abortion after 20 weeks of pregnancy) shows an increased incidence in women with epilepsy, as much as twofold over the general population (2 to 7 percent of all pregnancies and 2 to 14 percent in women with epilepsy, depending on the study).

Anti-epileptic Medications

Concerns

As stated earlier, the risk for adverse effects on the fetus increases when maternal AED polypharmacy is present. All commonly used AEDs have been associated with congenital malformations. Some of the newer AEDs have not been used in large enough numbers to have meaningful data.

Valproic acid (with a risk of 1 to 2 percent), and to a lesser degree, carbamazepine (with a risk of 0.5 percent) have been associated with neural tube defects, specifically spina bifida. Folate supplementation used prior to conception and throughout the childbearing years may minimize this risk.

Many experts believe that trimethadione is contraindicated in women with epilepsy who might become pregnant because it has been associated with a high incidence of fetal loss and congenital malformations.

You may wish to encourage all pregnant women taking AEDs to register with the North American AED Pregnancy Registry housed at Massachusetts General Hospital, Harvard Medical School. The toll free number is (888) 233-2334.

Management

Uncontrolled seizures, particularly generalized tonic-clonic episodes, are hazardous during pregnancy and discontinuing AEDs may pose a greater risk for both mother and fetus than the possible adverse effects of the medication. Miscarriage, trauma related to falls, fetal hypoxia and acidosis are all possible sequelae of maternal seizures.

Status epilepticus carries a high mortality rate for mother and fetus, and generalized seizures occurring during labor can result in fetal bradycardia.

During pregnancy, one quarter to one third of women with epilepsy have an increase in seizure frequency despite continued use of AEDs. Decreased protein binding of AEDs, increased drug clearance, and increased maternal plasma volume during pregnancy may lower serum concentrations of AEDs, requiring more frequent laboratory assessments, and dosage adjustments.

Plasma levels of unbound AEDs should be monitored closely throughout pregnancy and for at least 8 weeks following delivery, as it is common for levels to rise in the postpartum period.

Pregnancy Complications

Other potential obstetrical problems seen more frequently in women with epilepys are hyperemesis, gravidarum, vaginal bleeding, and anemia. Difficulties during labor and delivery include premature labor, failure to progress, and an increased rate of cesarean sections.

Hemorrhagic Disorder of the Newborn

This is a unique hemorrhagic disease of the neonate that occurs in the first 24 hours of life. Maternal AEDs competitively inhibit vitamin K transport across the placenta and the infant has prolonged prothrombin and partial thromboplastin times. The risk can be reduced by maternal supplementation with oral vitamin K (at a dose of 10 mg/ day) during the last month of pregnancy. This specific neonatal disorder seems to be associated with exposure to AEDs in utero (phenobarbital, primidone, phenytoin, and perhaps others).

Risk of Seizures in the Child

There is a higher risk for women with epilepsy to have children with the condition than for men with epilepsy. Seizure type and age of onset also affect incidence of epilepsy in the child. It is encouraging to recognize that even for patients in the highest risk groups, the risk that an offspring will develop epilepsy is less than 10 percent. Also see Genetics.

REFERENCES

Holmes LB, Harvey EA, Coull BA, et al. The teratogenicity of anticonvulsant drugs. NEJM. 2001;344(15):1132-1138.
Yerby M. Treatment of epilepsy during pregnancy. In: Wyllie E, ed. The Treatment of Epilepsy, Second Edition. Baltimore: Williams & Wilkins; 1996:785-798.
Practice parameter: management issues for women with epilepsy (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1998;51:944-8.
Seizure disorders in pregnancy. In: ACOG Educational Bulletin. Washington, DC: American College of Obstetricians and Gynecologists; 1996:231.

GENITAL HERPES and PREGNANCY

2009-06-29T22:31:00.001+07:00

Most women with genital herpes give birth to healthy babies. However, if you suffer from genital herpes there is a very small risk that your baby will catch the infection and if she does the results can be serious, even fatal. That's why it is important to tell your midwife if you or your partner have ever had an outbreak of genital herpes or if you think you have any of the symptoms. Extra care can then be taken of you and your baby.

What is genital herpes?

Genital herpes is caused by the herpes simplex virus which also causes cold sores around and in the mouth. Genital herpes is usually caused by herpes simplex virus type 2 (HSV-2), while cold sores are usually caused by herpes simplex virus type 1 (HSV-1). However, genital herpes can also be caused by HSV-1. Once you have been infected with a herpes virus it stays in your body for life, only becoming active every now and again.

How might genital herpes affect my pregnancy?

If you had genital herpes before you became pregnant then the risk of your baby becoming infected is very low, even if you have an outbreak during your pregnancy or during labour. This is because your body has had time to develop antibodies to the herpes simplex virus and this immunity is passed on to your baby during pregnancy. Your baby will continue to be immune for up to three months after the birth.
If you catch genital herpes for the first time in the first or second trimester of your pregnancy, there is a slight risk that it will affect your developing baby. The infection has been linked to miscarriage, intrauterine growth retardation (IUGR), premature labour, microcephaly (where the baby's brain is underdeveloped) and hydrocephaly (where fluid builds up around the baby's brain) but this happens very rarely. Your doctor will probably refer you to a genitourinary medicine (GUM) clinic where you will be given a 5-day course of an oral antiviral medicine, usually acyclovir. The acyclovir will help to reduce your discomfort and speed up the healing or your sores. It is safe to use in pregnancy.
Your baby is at greater risk if you catch genital herpes for the first time in late pregnancy before you have had time to develop antibodies to the virus and to pass this immunity on to your baby. Your baby can catch the virus through direct contact with an active sore, which is weeping or inflamed, during birth. If a baby catches the infection at birth it is called neonatal herpes. About four in ten babies develop neonatal herpes when born vaginally to women with a first infection when they come to give birth.
In the UK, only one or two babies in 100,000 catch neonatal herpes, but it can be very serious and even fatal. Neonatal herpes can cause infection in a baby's skin, eyes or mouth and may damage the brain or other organs. If your baby does catch neonatal herpes, effective treatment with antiviral medicine for you and your baby can help prevent and minimise long term damage to your baby's health.

Will I need to have a caesarean?

If you suspect you have an active genital herpes infection in the last trimester of pregnancy it is vital that you tell your midwife or doctor. If you have never had herpes before then you will probably be advised to have a planned caesarean section, particularly if you have your first outbreak in the last six weeks of pregnancy. This is to minimise the risk of transmitting the virus to your baby.
If you want to go ahead with a vaginal delivery, then your obstetrician will try to avoid any invasive procedures such as ventouse or forceps and will give you intravenous acyclovir during labour and delivery as this may reduce the risk of your baby catching herpes. Your newborn baby will also be given acyclovir.
If it is not your first infection, you will probably be given acyclovir daily for the last four weeks of pregnancy. You will not be advised to have a caesarean as your baby will probably have immunity to the virus.

Can I breastfeed if I have herpes?

The herpes virus is not transmitted through breastmilk so having herpes shouldn't stop you from breastfeeding, providing you don't have any sores on your breasts. Make sure that sores elsewhere on your body are covered and wash your hands frequently and carefully. If you are taking acyclovir, it will be excreted in your breastmilk but is not thought to be harmful.

What are the symptoms of a genital herpes infection?

Symptoms vary a lot from person to person. What most people do find is that symptoms are usually worse, and last longer, the first time they have a herpes outbreak. Symptoms of a primary or first infection may include:
• painful sores over your genitals and buttocks
• itching
• stinging when passing urine
• vaginal discharge
• swollen glands in the groin area
• flu-like symptoms including fever, headache and muscle aches
A primary episode can last two to three weeks.
With a second or later infection you may get no symptoms at all or just a small area of irritation. If it is not your first outbreak, it will probably be over within three to five days.
Whether or not you have symptoms, it is important to remember that you are still contagious during a herpes recurrence. In fact, most infections occur when the person passing it on has no noticeable symptoms. This is why it is important to tell your midwife if you or your partner suspect you may have had a herpes outbreak in the past.

How can I avoid catching the virus while I am pregnant?

If your partner has genital herpes you need to be particularly careful when you are pregnant. As the virus can be transmitted without your partner knowing that he is having an outbreak there are no foolproof methods to avoid catching herpes. In fact, the virus is most infectious when, or just before, symptoms appear. You can catch herpes from penetrative and non-penetrative sex (vaginal or anal), from oral sex, and by sharing sex toys. Condoms may help to reduce the risk of catching herpes from your partner, or you may want to avoid sex altogether. You should also be aware that you can catch genital herpes from your partner if he has oral herpes and performs oral sex.

Who can help?

Talk to your GP or midwife or contact the Herpes Viruses Association for more information.

CHICKENPOX and PREGNANCY

2009-06-29T22:30:00.001+07:00

Effects of Chicken Pox on the Pregnant Woman and her Unborn Child

Chicken pox is usually a benign, self-limited, viral infection caused by the varicella virus. However, chicken pox acquired during pregnancy causes an increase risk of complications to the mother and the infant. The time of infection, during early pregnancy or near delivery, determines the risk to mother and child.

Pregnant Women Exposed to Chicken Pox
Pregnant women who have a history of a previous chicken pox infection or who have been immunized have antibodies to the virus. These antibodies are transferred to the infant through the placenta throughout the pregnancy. Therefore, pregnant women who are immune and are exposed to someone with chicken pox do not need to worry about complications for themselves or their infant.

Testing for Immunity in Pregnancy
All women should be questioned about previous chicken pox infection or immunization at their first prenatal visit. Of those women who do not remember a past infection or immunization, 80% to 90% have antibodies and are considered immune. For this reason, testing for antibodies is controversial, but many practitioners obtain this test at the first prenatal visit.

Maternal Complications of Chicken Pox in Pregnancy
A primary chicken pox infection occurs in only 0.05% to 0.07% of pregnancies because most women of childbearing age have immunity to the varicella virus because of a previous infection or immunization. Women who do acquire chicken pox while pregnant, especially in the third trimester, are at a greater risk of developing varicella pneumonia. Varicella pneumonia is a potentially life-threatening infection of the lungs by the varicella virus.

Infant Complications of Chicken Pox in Early Pregnancy
Primary chicken pox infection in the first trimester of pregnancy, especially weeks 8 to 12, carries a 2.2% risk of congenital varicella syndrome, a syndrome of birth defects in the infant. The most common manifestation of congenital varicella syndrome is scarring of the skin. Other abnormalities that can occur include a smaller than normal head, eye problems, low birth weight, small limbs, and mental retardation.

Infant Complications of Chicken Pox in Late Pregnancy
If a woman acquires a primary chicken pox infection within 5 days before and 2 days after delivery, her newborn is at risk for disseminated varicella infection. Disseminated varicella infection occurs when the virus infects a newborn before the transfer of protective maternal antibodies. This overwhelming viral infection leads to death in 25% of cases.

Treatment of Pregnant Women with Chicken Pox
Women who acquire primary chicken pox during pregnancy should be treated with the antiviral drug acyclovir (Zovirax) which seems to be safe in pregnancy. Pregnant women with varicella pneumonia should be treated with IV acyclovir and be observed in the hospital. In addition women who are not immune to varicella, but are exposed may be treated with varicella-zoster immunoglobulin (VZIG), a substance that triggers an immune response against the varicella virus.

Treatment of Infants with Chicken Pox
Infants whose mothers develop varicella 5 days before delivery or 2 days following delivery should receive VZIG after birth. Infants who develop varicella during the first 2 weeks of life should be treated with IV acyclovir.

SMOKING and PREGNANCY

2009-06-29T22:29:00.001+07:00

Smoking is a major public health problem. All smokers face an increased risk of lung cancer, other lung diseases, and cardiovascular and other disorders. Smoking during pregnancy can harm the health of both a woman and her unborn baby. Currently, at least 10 percent of women in the United States smoke during pregnancy. ⁽¹⁾
In the United States and in other industrialized countries, 18 percent of women smoke.⁽²⁾ This proportion is somewhat smaller in developing countries where only 8 percent of women smoke.⁽³⁾ Statistics from the United States are compelling. According to the U.S. Public Health Service ⁽⁴⁾ , if all pregnant women in this country stopped smoking, there would be an estimated:

11 percent reduction in stillbirths
5 percent reduction in newborn deaths

Cigarette smoke contains more than 2,500 chemicals. It is not known for certain which of these chemicals are harmful to the developing baby, but both nicotine and carbon monoxide play a role in causing adverse pregnancy outcomes.

How can smoking harm the newborn?
Smoking nearly doubles a woman's risk of having a low-birthweight baby. In 2004, 11.9 percent of babies born to smokers in the United States were of low birthweight (less than 5½ pounds), compared to 7.2 percent of babies of nonsmokers ⁽¹⁾. Low birthweight can result from poor growth before birth, preterm delivery or a combination of both. Smoking has long been known to slow fetal growth. Smoking also increases the risk of preterm delivery (before 37 weeks of gestation) ⁽⁵⁾. Premature and low-birthweight babies face an increased risk of serious health problems during the newborn period, chronic lifelong disabilities (such as cerebral palsy, mental retardation and learning problems), and even death.

The more a pregnant woman smokes, the greater her risk of having a low-birthweight baby. However, if a woman stops smoking even by the end of her second trimester of pregnancy, she is no more likely to have a low-birthweight baby than a woman who never smoked ⁽⁶⁾.
A recent study suggests that women who smoke anytime during the month before pregnancy to the end of the first trimester are more likely to have a baby with birth defects, particularly congenital heart defects ⁽⁷⁾. The risk of heart defects appears to increase with the number of cigarettes a woman smokes.

Can smoking cause pregnancy complications?
Smoking is associated with a number of pregnancy complications. Smoking cigarettes doubles a woman's risk of developing placental problems ⁽⁴⁾ . These include:

Placenta previa (a low-lying placenta that covers part or all of the opening of the uterus)
Placental abruption (in which the placenta peels away, partially or almost completely, from the uterine wall before delivery)

Both can result in heavy bleeding during delivery that can endanger mother and baby, although cesarean delivery can prevent most deaths.

Smoking in pregnancy increases a woman's risk of premature rupture of the membranes (PROM), when the sac that holds the baby inside the uterus breaks before completion of 37 weeks of pregnancy ⁽⁴⁾.(Usually, when it breaks, normal labor ensues within a few hours.) If the rupture occurs before 37 weeks of pregnancy, it often results in the birth of a premature baby.

Does smoking affect fertility?
Cigarette smoking can cause reproductive problems before a woman even becomes pregnant. Studies show that women who smoke may have more trouble conceiving than nonsmokers ⁽⁴⁾ . Studies suggest that fertility returns to normal after a woman stops smoking.

Does smoking during pregnancy cause other problems in babies or young children?
A 2003 study suggests that babies of mothers who smoke during pregnancy undergo withdrawal-like symptoms similar to those seen in babies of mothers who use some illicit drugs ⁽⁸⁾ . For example, babies of smokers appear to be more jittery and difficult to soothe than babies of nonsmokers.

Babies whose mothers smoked during pregnancy are up to three times as likely to die from sudden infant death syndrome (SIDS) as babies of nonsmokers ⁽⁵⁾ .

Studies suggest that babies of women who are regularly exposed to secondhand smoke during pregnancy may have reduced growth and may be more likely to be born with low birthweight ^(5). Pregnant women should avoid exposure to other people's smoke.

How can a woman stop smoking?
The March of Dimes recommends that women stop smoking before they become pregnant and do not smoke throughout pregnancy and after the baby is born. A woman's health care provider can refer her to a smoking-cessation program or suggest other ways to help her quit. The March of Dimes supports a 5- to 15-minute, 5-step counseling approach called “The 5 A's,” which is performed by the health care provider during routine prenatal visits. This approach has been shown to improve smoking cessation rates among pregnant women by at least 30 percent .

Studies suggest that certain factors make it more likely that a woman will be successful in her efforts to quit smoking during pregnancy. These include:

Attempting to quit in the past
Having a partner who doesn't smoke
Getting support from family or other important people in her life
Understanding the harmful effects of smoking

How does exposure to smoke after birth affect a baby?
It is important to stay smoke-free after the baby is born. Parents should refrain from smoking in the home and should ask visitors to do the same. Babies who are exposed to smoke suffer from more lower-respiratory illnesses (such as bronchitis and pneumonia) and ear infections than do other babies. Babies who are exposed to their parents' smoke after birth also may face an increased risk of asthma and SIDS.

Smoking harms a mother's health, too. Smokers have an increased risk of lung and other cancers, heart disease, stroke and emphysema (a potentially disabling and, sometimes, deadly lung condition). Quitting smoking makes parents healthier and better role models for their children.

Does the March of Dimes fund research on the risks of smoking during pregnancy?
The March of Dimes has long supported research on the risks of smoking during pregnancy. In the 1970s, March of Dimes-supported research suggested that nicotine and carbon monoxide reduce the supply of oxygen to the baby, perhaps explaining how these chemicals in cigarette smoke reduce fetal growth.

In 2002, a March of Dimes grantee published a study that may shed light on why some women who smoke cigarettes during pregnancy have low-birthweight babies and others do not ⁽¹⁰⁾ . The researcher reported that pregnant women who smoke are more likely to have a premature or low-birthweight baby if they have either of two common genetic traits (which influence the body's ability to dispose of certain chemicals). These findings could lead to better ways to identify and treat women at high risk of having a low-birthweight baby.

A current March of Dimes grantee is investigating whether smoking at a critical stage of embryonic palate development increases the risk of cleft lip/palate.

What resources are available for health care providers?

The American College of Obstetricians and Gynecologists provides information for health care providers to assist them as they help patients stop smoking.
Smoking Cessation for Pregnancy and Beyond is a free CME course for health care providers available from Dartmouth Medical School.

References

Martin, J.A., et al. Births: Final Data for 2004. National Vital Statistics Reports, volume 55, number 1, September 29, 2006.
Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Fact Sheet: Women and Smoking. February 28, 2007.
World Health Organization (WHO). Women and the Tobacco Epidemic: Challenges for the 21st Century. 2001.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2004. Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta Georgia, May 2004.
Centers for Disease Control and Prevention (CDC). What Do We Know About Tobacco Use and Pregnancy. June 11, 2007.
American College of Obstetricians and Gynecologists (ACOG). Smoking Cessation during Pregnancy. ACOG Committee Opinion, number 316, October 2005.
Malik, S., et al. Maternal Smoking and Congenital Heart Defects. Pediatrics, volume 121, number 4, April 2008, pages e810-e816.
Law, K.L., et al. Smoking During Pregnancy and Newborn Neurobehavior. Pediatrics, volume 111, number 6, June 2003, pages 1318-1323.
Centers for Disease Control and Prevention (CDC). Preventing Smoking During Pregnancy. November 2005.
Wang, X., et al. Maternal Cigarette Smoking, Metabolic Gene Polymorphism, and Infant Birth Weight. Journal of the American Medical Association, volume 287, number 2, January 9, 2002, pages 195-202.

ALCOHOL and PREGNANCY

2009-06-29T22:27:00.001+07:00

Drinking alcohol during pregnancy can cause a wide range of physical and mental birth defects. The term “fetal alcohol spectrum disorders” (FASDs) is used to describe the many problems associated with exposure to alcohol before birth. Each year in the United States, up to 40,000 babies are born with FASDs ⁽¹⁾ .

Although many women are aware that heavy drinking during pregnancy can cause birth defects, many do not realize that moderate or even light drinking also may harm the fetus. In fact, no level of alcohol use during pregnancy has been proven safe. Therefore, the March of Dimes recommends that pregnant women do not drink any alcohol, including beer, wine, wine coolers and liquor, throughout their pregnancy and while nursing. In addition, because women often do not know they are pregnant for a few months, women who may be pregnant or those who are attempting to become pregnant should not drink alcohol.

Recent government surveys indicate that about 1 in 12 pregnant women drink during pregnancy ⁽²⁾ . About 1 in 30 pregnant women report binge drinking (five or more drinks on any one occasion) ⁽²⁾ . Women who binge drink or drink heavily greatly increase the risk of alcohol-related damage to their babies.

When a pregnant woman drinks, alcohol passes through the placenta to her fetus. In the fetus’s immature body, alcohol is broken down much more slowly than in an adult's body. As a result, the alcohol level of the baby's blood can be higher and remain elevated longer than the level in the mother's blood. This sometimes causes the baby to suffer lifelong damage.

What are the hazards of drinking alcohol during pregnancy?
Drinking alcohol during pregnancy can cause FASDs, with effects that range from mild to severe. These effects include mental retardation; learning, emotional and behavioral problems; and defects involving the heart, face and other organs. The most severe of these effects is fetal alcohol syndrome (FAS), a combination of physical and mental birth defects.

Drinking alcohol during pregnancy increases the risk for miscarriage and premature birth (before 37 completed weeks of pregnancy) ^{(3, 4)}. Studies also suggest that drinking during pregnancy may contribute to stillbirth. A 2008 Danish study found that women who binge drink three or more times during the first 16 weeks of pregnancy had a 56 percent greater risk for stillbirth than women who did not binge drink ⁽³⁾ . Another 2008 study found that women who had five or more drinks a week were 70 percent more likely to have a stillborn baby than non-drinking women ⁽⁵⁾ .

What is fetal alcohol syndrome (FAS)?
FAS is one of the most common known causes of mental retardation. It is the only cause that is entirely preventable. Studies by the Centers for Disease Control and Prevention (CDC) suggest that between 1,000 and 6,000 babies in the United States are born yearly with FAS ⁽⁶⁾ .

Babies with FAS are abnormally small at birth and usually do not catch up on growth as they get older. They have characteristic facial features, including small eyes, a thin upper lip and smooth skin in place of the normal groove between the nose and upper lip. Their organs, especially the heart, may not form properly. Many babies with FAS also have a brain that is small and abnormally formed. Most have some degree of mental disability. Many have poor coordination, a short attention span and emotional and behavioral problems.

The effects of FAS and other FASDs last a lifetime. Even if not mentally retarded, adolescents and adults with FAS and other FASDs are at risk for psychological and behavioral problems and criminal behavior ⁽²⁾ . They often find it difficult to keep a job and live independently ^{(2, 6)}.

What are other FASDs?
The CDC estimates that about three times the number of babies born with FAS are born with some, but not all, of the features of FAS ⁽²⁾ . These FASDs are referred to as alcohol-related birth defects (ARBDs) and alcohol-related neurodevelopmental disorders (ARNDs).

The term ARBDs describes physical birth defects that can occur in many organ systems, including the heart, liver, kidneys, eyes, ears and bones.
The term ARNDs describes learning and behavioral problems associated with prenatal exposure to alcohol. These problems can include learning disabilities; difficulties with attention, memory and problem solving; speech and language delays; hyperactivity; psychological disorders and poor school performance.

Children with ARBDs and ARNDs do not have the characteristic facial features associated with FAS ⁽¹⁾ .

In general, ARBDs are more likely to result from drinking alcohol during the first trimester, when organs are forming rapidly. Drinking at any stage of pregnancy can affect the brain, resulting in ARNDs, and can also affect growth.

An older term called fetal alcohol effects (FAEs) is sometimes used to describe alcohol-related damage that is less severe than FAS. The more specific diagnostic categories of ARBDs and ARNDs are now more frequently used.

How much alcohol is too much during pregnancy?
No level of drinking alcohol has been proven safe during pregnancy. According to the U.S. Surgeon General, the patterns of drinking that place a baby at greatest risk for FASDs are binge drinking and drinking seven or more drinks per week ⁽⁷⁾ . However, FASDs can occur in babies of women who drink less.

Researchers are taking a closer look at the more subtle effects of moderate and light drinking during pregnancy.

A 2002 study found that 14-year-old children whose mothers drank as little as one drink a week were significantly shorter and leaner and had a smaller head circumference (a possible indicator of brain size) than children of women who did not drink at all ⁽⁸⁾ .
A 2001 study found that 6- and 7-year-old children of mothers who had as little as one drink a week during pregnancy were more likely than children of non-drinkers to have behavior problems, such as aggressive and delinquent behaviors. These researchers found that children whose mothers drank any alcohol during pregnancy were more than three times as likely as unexposed children to demonstrate delinquent behaviors ⁽⁹⁾ .
A 2007 study suggested that female children of women who drank less than one drink a week were more likely to have behavioral and emotional problems at 4 and 8 years of age. The study also suggested similar effects in boys, but at higher levels of drinking ⁽¹⁰⁾ .
Other studies report behavioral and learning problems in children exposed to moderate drinking during pregnancy, including attention and memory problems, hyperactivity, impulsivity, poor social and communication skills, psychiatric problems (including mood disorders) and alcohol and drug use ⁽²⁾ .

Is there a cure for FASDs?
There is no cure for FASDs. However, a 2004 study found that early diagnosis (before 6 years of age) and being raised in a stable, nurturing environment can improve the long-term outlook for individuals with FASDs ⁽¹¹⁾ . Children who experienced these protective factors during their school years were two to four times more likely to avoid serious behavioral problems resulting in trouble with the law or confinement in a psychiatric institution.

If a pregnant woman has one or two drinks before she realizes she is pregnant, can it harm the baby?
It is unlikely that the occasional drink a woman takes before she realizes she is pregnant will harm her baby. The baby’s brain and other organs begin developing around the third week of pregnancy, however, and are vulnerable to damage in these early weeks. Because no amount of alcohol has been proven safe during pregnancy, a woman should stop drinking immediately if she even suspects she could be pregnant, and she should not drink alcohol if she is trying to become pregnant.

Is it safe to drink alcohol while breastfeeding?
Small amounts of alcohol do get into breastmilk and are passed on to the baby. One study found that breastfed babies of women who had one or more drinks a day were a little slower in acquiring motor skills (such as crawling and walking) than babies who had not been exposed to alcohol ⁽¹²⁾ . Large amounts of alcohol may interfere with ejection of milk from the breast.

For these reasons, the March of Dimes recommends that women not drink alcohol while they are breastfeeding. Similarly, the American Academy of Pediatrics (AAP) recommends that breastfeeding mothers not drink alcohol ⁽¹³⁾. However, according to the AAP, an occasional alcoholic drink probably doesn’t hurt the baby, but a mother who has a drink should wait at least 2 hours before breastfeeding her baby ⁽¹³⁾ .

Can heavy drinking by the father contribute to FASDs?
There is no proof that heavy drinking by the father can cause FASDs. But men can help their partner avoid alcohol by not drinking during their partner’s pregnancy.

Where can a woman get help to stop drinking alcohol?
Some women find it difficult to stop drinking. These organizations can help:

National Council on Alcoholism and Drug Dependence (NCADD), (800) NCA-CALL (622-2255)
Substance Abuse Treatment Facility Locator, (800) 622-HELP (4357)

Resources

The Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence, (866) 786-7327
FASD Support Site
Fetal Alcohol Spectrum Disorders, U.S. Centers for Disease Control and Prevention

References

Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Fetal Alcohol Spectrum Disorders. 2007.
Centers for Disease Control and Prevention (CDC). Fetal Alcohol Spectrum Disorders. Updated 5/2/06.
Strandberg-Larsen, K., et al. Binge Drinking in Pregnancy and Risk of Fetal Death. Obstetrics and Gynecology, volume 111, number 3, March 2008, pages 602-609.
Sokol, R.J., et al. Extreme Prematurity: An Alcohol-Related Birth Defect. Alcoholism Clinical and Experimental Research, volume 31, number 6, June 2007, pages 1031-1037.
Aliyu, M.H., et al. Alcohol Consumption During Pregnancy and the Risk of Early Stillbirth among Singletons. Alcohol, volume 42, August 2008, pages 369-374.
Bertrand, J., et al., National Task Force on FAS/FAE. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. Atlanta, GA: Centers for Disease Control and Prevention, July 2004.
Surgeon General. Surgeon General’s Advisory on Alcohol Use in Pregnancy. February 21, 2005.
Day, N.L., et al. Prenatal Alcohol Exposure Predicts Continued Deficits in Offspring Size at 14 Years of Age. Alcoholism Clinical and Experimental Research, volume 26, number 10, 2002, pages 1584-1591.
Sood, B., et al. Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7. Pediatrics, volume 108, number 2, August 2001, page e34.
Sayal, K., et al. Prenatal Alcohol Exposure and Gender Differences in Childhood Mental Health Problems: A Longitudinal Population-Based Study. Pediatrics, volume 119, number 2, February 2007, pages e426-434.
Streissguth, A.P., et al. Risk Factors for Adverse Life Outcomes in Fetal Alcohol Syndrome and Fetal Alcohol Effects. J Dev Behav Pediatr, volume 25, number 4, August 2004, pages 228-238.
Little, R.E., et al. Maternal Alcohol Use During Breast-Feeding and Infant Mental and Motor Development at One Year. New England Journal of Medicine, volume 321, number 7, August 17, 1989, pages 425-430.
American Academy of Pediatrics (AAP). AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, volume 115, number 2, February 2005, pages 496-506.

RUBELLA and PREGNANCY

2009-06-29T22:26:00.001+07:00

(German measles)

This factsheet describes how a child can be affected when a woman has rubella (often called German Measles) while she is pregnant. It also talks about some of the ways that children affected by rubella can be helped, and tells you where to go for advice and support.

What is rubella?

Prior to immunisation, rubella was a common disease of childhood. It is caused by a virus which is spread in the air as droplets - by coughing and sneezing.

When someone has been in contact with the virus it takes two to three weeks to develop. When it does, they will generally feel unwell and off-colour for the first five days, with swollen glands, and a light temperature or a sore throat. If a rash develops, it will start on the face, and spread downwards over the body and limbs, and this may cause pain and discomfort in the limbs - especially in women. Some people have rubella, but show no symptoms at all.

What happens if a woman has rubella when she is pregnant?

Sometimes the mother will not pass the rubella onto the baby. However, if she has rubella in the early stages of her pregnancy then there is a greater chance of the virus passing through the cord to the developing baby.

A child affected by rubella during pregnancy will be said to have congenital rubella. Children born with congenital rubella will have the virus circulating in their bloodstream for up to 20 months after they are born. They will normally pose no risk to others, but anyone in direct contact with children with congenital rubella is advised to be screened and immunised as necessary.

About vaccination

Most women today choose to protect themselves from rubella by being immunised before they become pregnant, and this has greatly reduced the numbers of children affected. Even if a woman has already been immunised however, it is important that she has a blood test before becoming pregnant to ensure that she is still immune. The rubella vaccine is now given to children when they are between 12 and 15 months old. This is given in combination with the vaccinations for measles and mumps - called the MMR vaccination. Children receive a booster injection before they start school.

How can rubella affect the baby?

We do not fully understand how the baby is affected by the virus. The virus seems to affect the cells of parts of the baby's body that are being developed at the time of infection. Sometimes there is insufficient blood supply which can harm organs which have developed already. However, every child is different. Some children will appear to be unaffected, but they should be followed up during childhood, particularly for hearing loss. Anyone with congenital rubella should have regular health check-ups, including vision and hearing assessments throughout their life.

Where might the damage occur?

The stage of pregnancy when the rubella infection occurs is the most important factor determining what kind of harm, if any, occurs. Rubella in the first two months of pregnancy is likely to affect the baby and may cause a number of impairments. After 18 weeks gestation, although rubella infection may be passed on to the baby, the chances of the baby being affected may be minimal. The most commonly affected organs include the ears, the eyes, and the heart.

1. The eyes

The eyes develop during the early stages of pregnancy. Several things may happen:

Cataracts

Between three and seven weeks the eye lenses may be affected and become cloudy. A cloudy lens is called a cataract - sometimes people will use the term congenital cataracts. This means that the baby will have cloudy lens from birth. Again, the degree of cataract can vary enormously - from a small clouded area to the complete lens being affected. Sometimes one eye only will be affected- sometimes both.

Small eye

Sometimes the size of one or both eyes will be affected, although this is quite rare.

Colouring of the retina

Babies who are born with rubella have speckled colouring or pigment on the back of their eye, although this does not affect their sight.

Eye movement

The eyes may jump from side to side in a flickering movement. This eye condition is known as nystagmus.

Less common eye problems

There are several rare conditions which may affect the baby - optic atrophy, corneal haze, and glaucoma. If your child has these problems please ask your ophthalmologist (see below) for more information.

2. The heart

The heart is a complicated organ, and many different problems can be caused by the virus. These problems are best explained to you on an individual basis by your paediatrician in the hospital who will explain the difficulties your child is facing.

3. The ears

A common problem for babies affected by the rubella virus is hearing loss. This can vary considerably from mild to severe, and may affect one or both ears. The part of the ear which is damaged is the Corti. This is the inner ear or Cochlea which links the ear to the brain. The hearing loss is known as sensori neural.

The amount of hearing loss can vary a great deal, and hearing may deteriorate over a period of time.

4. Neurological problems

The rubella virus may or may not affect the child's brain, and difficulties can vary from mild to severe. If a child has any of these problems, then it is best to discuss these with a paediatrician who can offer individual advice.

Conditions that may occur:

Lethargy, irritability, learning difficulties, small head (microcephaly), large soft spot on the head, movement problems, poor balance and posture, lack of coordination seizures. Some children may have associated behaviour problems. Other rarer conditions have been associated with babies affected by rubella. If you notice anything out of the ordinary, it is best to discuss the situation with your health visitor or GP who can refer you to a paediatrician for specialist advice.

What support do children affected by rubella need?

Children who have been affected by Rubella may have to cope with an impairment of both sight and hearing, as well as other disabilities - although this will vary a great deal. Many children will have some sight and/or hearing however, and it is important to make as much use of these possible. The other senses - touch and smell in particular - must also be developed to the full.

The biggest challenges facing children affected by Rubella, will be to learn to communicate, to move around safely, and to find out about the world around them. It is vital that these children get specialist help which is geared towards their particular combination of abilities and impairments as soon as possible. Intensive one-to-one teaching developed for work with deafblind children for example, can help them to understand the human interaction that is the basis of communication. Children can learn various ways to communicate such as using symbols, objects of reference, sign language, and braille.

All children and adults affected by Rubella have the capacity to learn and achieve. But without the right kind of help, their mental and physical development may be slower because of lack of stimulation. Early intervention, with continuing intensive educational support is the key to a child's future development, although extra support may be needed throughout a person's lifetime.

FOLIC ACID and PREGNANCY

2009-06-29T22:24:00.001+07:00

Having a healthy baby means making sure you're healthy, too. One of the most important things you can do to help prevent serious birth defects in your baby is to get enough folic acid every day — especially before conception and during early pregnancy.

What Is Folic Acid?

Folic acid, sometimes called folate, is a B vitamin (B9) found mostly in leafy green vegetables like kale and spinach, orange juice, and enriched grains. Repeated studies have shown that women who get 400 micrograms (0.4 milligrams) daily prior to conception and during early pregnancy reduce the risk that their baby will be born with a serious neural tube defect (a birth defect involving incomplete development of the brain and spinal cord) by up to 70%.

The most common neural tube defects are spina bifida (an incomplete closure of the spinal cord and spinal column), anencephaly (severe underdevelopment of the brain), and encephalocele (when brain tissue protrudes out to the skin from an abnormal opening in the skull). All of these defects occur during the first 28 days of pregnancy — usually before a woman even knows she's pregnant.

That's why it's so important for all women of childbearing age to get enough folic acid — not just those who are planning to become pregnant. Only 50% of pregnancies are planned, so any woman who could become pregnant should make sure she's getting enough folic acid.

Doctors and scientists still aren't completely sure why folic acid has such a profound effect on the prevention of neural tube defects, but they do know that this vitamin is crucial in the development of DNA. As a result, folic acid plays a large role in cell growth and development, as well as tissue formation.

Getting Enough Folic Acid

The Centers for Disease Control and Prevention (CDC) recommends that all women of childbearing age — and especially those who are planning a pregnancy — consume about 400 micrograms (0.4 milligrams) of folic acid every day. Adequate folic acid intake is very important before conception and at least 3 months afterward to potentially reduce the risk of having a fetus with a neural tube defect.

So, how can you make sure you're getting enough folic acid? In 1998, the U.S. Food and Drug Administration mandated that folic acid be added to enriched grain products — so you can boost your intake by looking for breakfast cereals, breads, pastas, and rice containing 100% of the recommended daily folic acid allowance. But for most women, eating fortified foods isn't enough. To reach the recommended daily level, you'll probably need a vitamin supplement.

During pregnancy, you require more of all of the essential nutrients than you did before you became pregnant. Although prenatal vitamins shouldn't replace a well-balanced diet, taking them can give your body — and, therefore, your baby — an added boost of vitamins and minerals. Some health care providers even recommend taking a folic acid supplement in addition to your regular prenatal vitamin. Talk to your doctor about your daily folic acid intake and ask whether he or she recommends a prescription supplement, an over-the-counter brand, or both.

Also talk to your doctor if you've already had a pregnancy that was affected by a neural tube defect. He or she may recommend that you increase your daily intake of folic acid (even before getting pregnant) to lower your risk of having another occurrence.

DIABETES and PREGNANCY

2009-06-29T22:08:00.001+07:00

General Information About Diabetes

Diabetes and Pregnancy

Type 1 and Type 2 Diabetes and Pregnancy

Gestational Diabetes

Prevention of Problems

Diabetes is often detected in women during their childbearing years and can affect the health of both the mother and her unborn child. Poor control of diabetes in a woman who is pregnant increases the chances for birth defects and other problems for the baby. It might cause serious complications for the woman, also. Proper health care before and during pregnancy will help prevent birth defects and other poor outcomes, such as miscarriage or stillbirth.

What is diabetes?
Diabetes is a condition in which the body cannot use the sugars and starches (carbohydrates) it takes in as food to make energy. The body either makes too little insulin in the pancreas or cannot use the insulin it makes to change those sugars and starches into energy. As a result, the body collects extra sugar in the blood and gets rid of some sugar in the urine. The extra sugar in the blood can damage organs of the body, such as the heart, eyes, and kidneys, if it is allowed to collect in the body too long. The 3 most common types of diabetes are Type 1, Type 2, and gestational.

Type 1 diabetes is a condition in which the pancreas makes so little insulin that the body can’t use blood sugar for energy. Type 1 diabetes must be controlled with daily insulin shots.
Type 2 diabetes is a condition in which the body either makes too little insulin or can’t use the insulin it makes to use blood sugar for energy. Often Type 2 diabetes can be controlled through eating a proper diet and exercising regularly. Some people with Type 2 diabetes have to take diabetes pills or insulin or both.
Gestational diabetes is a type of diabetes that occurs in a pregnant woman who did not have diabetes before she was pregnant. Often gestational diabetes can be controlled through eating a proper diet and exercising regularly, but sometimes a woman with gestational diabetes must also take insulin shots. Usually gestational diabetes goes away after pregnancy, but sometimes it doesn’t. Also, many women who have had gestational diabetes develop Type 2 diabetes later in life.

What are some common problems caused by diabetes?
People with diabetes can get high blood pressure, kidney disease, nerve damage, heart disease, and blindness. Young women with diabetes might not have these problems yet. The damage caused by these problems often happen in people whose blood sugar has been out of control for years. Keeping blood sugar under control can help prevent the damage from happening.
People with diabetes can go into “diabetic coma” if their blood sugar is too high. They can also develop blood sugar that is too low (hypoglycemia) if they don’t get enough food, or they exercise too much without adjusting insulin or food. Both diabetic coma and hypoglycemia can be very serious, and even fatal, if not treated quickly. Closely watching blood sugar, being aware of the early signs and symptoms of blood sugar that is too high or too low, and treating those conditions early can prevent these problems from becoming too serious.

How does a person get diabetes?
We don’t know exactly how people get diabetes. However, it appears that both genetics and personal lifestyle play a role in who gets diabetes. Some people have diabetes that “runs” in the family. Lack of exercise, poor eating habits, and obesity seem to increase the risk of developing Type 2 diabetes in other people. In some, but not all cases, Type 2 diabetes can be controlled if people lose weight, eat right, and exercise regularly.

Can a person prevent problems from diabetes?
A person with diabetes who keeps her blood sugar as close to normal as possible has fewer problems than a person who does not keep his blood sugar in “tight control.” A woman with diabetes who can get pregnant should watch her blood sugar closely to prevent problems if she should get pregnant. To keep blood sugar in tight control, a person can manage her diabetes with a strict plan:

Eat healthy foods from personal diabetes meal plan
Exercise regularly
Monitor blood sugar often
Take medications on time, including insulin if ordered by the doctor.
Know how to adjust food intake, exercise, and insulin depending on the results of blood sugar tests
Control or treat low blood sugar and high blood sugar
Follow up with health care provider regularly

How does gestational diabetes differ from Type 1 or Type 2 diabetes?
Gestational diabetes happens in a woman who develops diabetes during pregnancy. Some women have more than one pregnancy affected by diabetes that disappears after the pregnancy ends. About half of women with gestational diabetes will develop Type 2 diabetes later.
If not controlled, gestational diabetes can cause the baby to grow extra large and lead to problems with delivery for the mother and the baby. Gestational diabetes might be controlled with diet and exercise, or it might take insulin as well as diet and exercise to get control.
Type 1 and Type 2 diabetes often are present before a woman gets pregnant. If not controlled before and during pregnancy, Type 1 and Type 2 diabetes can cause the baby to have birth defects and cause the mother to have problems (or her problems to worsen if they are already present), such as high blood pressure, kidney disease, nerve damage, heart disease, or blindness. Type 1 diabetes must be controlled with a balance of diet, exercise, and insulin. Type 2 diabetes might be controlled with diet and exercise, or it might take diabetes pills or insulin or both as well as diet and exercise to get control.

Will my baby have diabetes?
Babies born to mothers with diabetes do not come into the world with diabetes. However, if the mother’s diabetes was not controlled during pregnancy, the baby can very quickly develop low blood sugar after birth and must be watched very closely until his or her body adjusts the amount of insulin it makes.
Extra large babies are more likely to become obese and to develop Type 2 diabetes later in life. They especially need to develop healthy eating and regular exercise habits as they grow up to lessen the chance of obesity and Type 2 diabetes.

If the father of the developing baby has diabetes, does his diabetes affect the pregnancy?
Diabetes in the father does not affect the developing baby during pregnancy. However, depending on the type of diabetes the father has, the baby might have a greater chance of developing diabetes later in life.

What can happen to a woman with Type 1 or Type 2 diabetes who becomes pregnant?
Pregnancy is a time when a woman’s body goes through lots of changes as it nurtures a developing baby. All women need more nutrients, rest, and energy to grow the baby when they are pregnant. They also need to be physically active. When a woman with diabetes is pregnant, changes happen in her blood sugar, often quickly. If a woman with diabetes does not keep good control of her blood sugar, she might get some of the common problems of diabetes, or those problems might get worse if she already has them. Out of control blood sugar could lead to a woman having a miscarriage. Out of control blood sugar might also cause high blood pressure in a woman during pregnancy, and she will need extra visits to the doctor. High blood pressure during pregnancy might lead to a baby being born early and also could cause seizures or a stroke (a blood clot in the brain that can lead to brain damage) in the woman during labor and delivery. Sometimes, out of control blood sugar causes a woman to make extra large amounts of amniotic fluid around the baby which might lead to preterm (early) labor. Another problem common to a pregnant woman with uncontrolled diabetes is that her baby grows too large. Besides causing discomfort to the woman during the last few months of pregnancy, an extra large baby can lead to problems during delivery for both the mother and the baby.

What can happen to the baby of a woman with Type 1 or Type 2 diabetes during pregnancy?
Diabetes in a pregnant woman can cause the baby to have birth defects, miscarry, be born early and have a low birth weight, be stillborn, or grow extra large and have a hard delivery.
A woman who has Type 1 or Type 2 diabetes that is not tightly controlled has a higher chance of having a baby with a birth defect than does a woman without diabetes. The organs of the baby form during the first two months of pregnancy, often before a woman knows that she is pregnant. Out of control blood sugar can affect those organs while they are being formed and cause serious birth defects, such as those of the brain, spine, and heart, or can lead to miscarriage of the developing baby.
If the woman’s blood sugar remains out of control throughout the pregnancy, the baby likely will grow extra large. Out of control diabetes causes the baby’s blood sugar to be high. The baby makes more insulin and uses the extra calories or stores them as fat. The baby is “overfed” and grows extra large. Extra large babies can occur in women with any out of control diabetes, including Type 1, Type 2, and gestational. The extra large baby can cause problems during and after delivery. Nerve damage to the baby can happen from pressure on the baby’s shoulder during delivery. A newborn might have quickly changing blood sugars after delivery. A large baby born to a woman with diabetes might have a greater chance of being obese and/or developing Type 2 diabetes later in life.
If the woman with diabetes has problems that lead to a preterm birth, the baby might have breathing problems, heart problems, bleeding into the brain, intestinal problems, and vision problems. A woman with diabetes might have a baby born on time with low birth weight. A baby with low birth weight might have problems with eating, gaining weight, fighting off infections, and staying warm.

What can happen to a pregnant woman with gestational diabetes?
A pregnant woman who does not have diabetes can develop “gestational diabetes” later in pregnancy. A woman with gestational diabetes will need to watch her blood sugar closely and balance food intake, exercise, and, if needed, insulin shots to keep her blood sugar in control. If a woman with gestational diabetes does not keep her blood sugar in good control, she could have several problems. She might have an extra large baby, have high blood pressure, deliver too early, or need to have a cesarean section (an operation to get the baby out of the mother through her abdomen). The extra large baby might cause the woman to feel uncomfortable during the last months of pregnancy. Also, it could lead to problems for both the woman and the baby during delivery. When the baby is delivered surgically by a cesarean section (C-section), it takes longer for the woman to recover from childbirth. High blood pressure when a woman is pregnant might lead to an early delivery and could cause seizures or a stroke in the woman.
Sometimes gestational diabetes in women does not go away after delivery. These women have converted to Type 2 diabetes. A woman whose diabetes does not go away after delivery will need to manage her diabetes for the rest of her life.

What can happen to the baby of a woman with gestational diabetes?
A woman who has gestational diabetes has less chance of having a baby with a birth defect than does a woman with Type 1 or Type 2 diabetes. Since gestational diabetes develops later in pregnancy, the baby’s organs are already formed. If her blood sugar is not controlled, a woman with gestational diabetes still has a greater chance of having a stillborn baby than a woman who doesn’t have diabetes.
If the woman’s blood sugar remains out of control throughout the pregnancy, the baby likely will grow extra large. Out of control diabetes causes the baby’s blood sugar to be high. The baby makes more insulin and uses the extra calories or stores them as fat. The baby is “overfed” and grows extra large. Extra large babies can occur in women with any out of control diabetes, including Type 1, Type 2, and gestational.
The extra large baby can cause problems during and after delivery. Nerve damage to the baby can happen from pressure on the baby’s shoulder during delivery. A newborn might have quickly changing blood sugars after delivery. A large baby born to a woman with diabetes might have a greater chance of being obese and/or developing Type 2 diabetes later in life.
If the woman with diabetes has problems that lead to a preterm birth, the baby might have breathing problems, heart problems, bleeding into the brain, intestinal problems, and vision problems. A woman with diabetes might have a baby born on time with low birth weight. A baby with low birth weight might have problems with eating, gaining weight, fighting off infections, and staying warm.

Can a woman with diabetes prevent the problems to herself and to her baby during pregnancy?
If a woman with diabetes keeps her blood sugar in tight control before and during pregnancy, she can lessen her risk of having a baby with a birth defect to that of a woman who doesn’t have diabetes. Controlling her blood sugar also reduces the risk that a woman will develop common problems of diabetes, or that the problems will get worse during pregnancy. The baby is less likely to grow extra large during her pregnancy if a woman keeps her blood sugar in tight control.

How can a woman with diabetes who wants to get pregnant prevent problems to herself and her baby?

Plan the pregnancy. Unplanned pregnancies are more common among women with diabetes than among women who do not have diabetes. About 70% of women with diabetes don’t plan their pregnancies as compared to about 50% of women who don’t have diabetes. It is very important for a woman with diabetes to get her body ready before she becomes pregnant.
See her doctor. Her doctor needs to look at the effects that diabetes has had on her body already, talk with her about getting and keeping control of her blood sugar, change medications if needed, and plan for frequent follow-up. Her doctor will remind her about the usual steps to get ready for pregnancy, such as to take prenatal vitamins (with folic acid), stop smoking, avoid alcohol, eat right, exercise, and avoid stress.
Eat healthy foods from a meal plan made for her as a person with diabetes. If a woman is overweight, she might try to lose weight before getting pregnant as part of her plan to get her blood sugar in control. Talking with a dietitian can help her plan a good diet for a person with diabetes, especially if she plans to lose weight before she gets pregnant. A dietitian can also help her learn how to control her blood sugar while she is pregnant.
Exercise regularly. Exercise is another way to keep blood sugar under control. Exercise helps to balance food intake. A woman should begin a regular exercise plan before she gets pregnant and stick with the exercise plan both while she is pregnant and after the baby comes.
Monitor blood sugar often. Because pregnancy causes the body’s need for energy to change, blood sugar levels can change very quickly. A pregnant woman with diabetes needs to check her blood sugar more often, sometimes 6 to 8 times a day, which might be higher than when she is not pregnant. Checking blood sugar levels often can help a woman keep her blood sugar in control.
Take medications on time. If insulin is ordered by a doctor, a pregnant woman with diabetes should take it when it’s needed. She should know how to adjust food intake, exercise, and insulin, depending on the results of her blood sugar tests, to keep the blood sugar in the range of tight control. For more information, see the American Diabetes Association website at http://www.diabetes.org/type-1-diabetes/tight-control.jsp .
Control and treat low blood sugar quickly. Keeping tight blood sugar control can lead to a chance of low blood sugar at times. A pregnant woman with diabetes should have a ready source of carbohydrates, such as glucose tablets or gel, on hand at all times. It’s helpful to teach family members and close co-workers or friends how to help in case of a severe low blood sugar reaction.
Follow-up with the doctor regularly. A pregnant woman with diabetes needs to see her doctor more often than does a pregnant woman without diabetes. Together, the woman can work with her doctor to prevent or catch problems early. Although there are no guarantees, a woman with diabetes who gets and keeps her blood sugar in control is more likely to have a healthy pregnancy and a healthy baby.

CHRONIC HYPERTENSION and PREGNANCY

2009-06-29T22:06:00.001+07:00

Chronic Hypertension and Pregnancy

Highlights

What is chronic hypertension?

If you had high blood pressure before you got pregnant, or if you're diagnosed with it before you reach 20 weeks, you have chronic hypertension. Up to 5 percent of women start their pregnancies with this condition. High blood pressure is defined as a reading of 140/90 or higher, even if just one of the numbers is higher. Severe chronic hypertension is 180/110 or higher.
Chronic hypertension isn't the only reason you might have high blood pressure during pregnancy. If you develop high blood pressure after 20 weeks of pregnancy, you'll be diagnosed with gestational hypertension. (If your blood pressure doesn't return to normal within 12 weeks after giving birth, your diagnosis changes to chronic hypertension.) If you develop hypertension after 20 weeks of pregnancy and have protein in your urine, you may have a condition called preeclampsia.

How does having chronic hypertension affect my pregnancy?

Having chronic hypertension significantly increases your risk of developing preeclampsia. Preeclampsia that develops in addition to your already existing chronic hypertension is called "superimposed preeclampsia." Up to 1 in 4 women with chronic hypertension and as many as half of women with severe chronic hypertension will develop superimposed preeclampsia during pregnancy.
Chronic hypertension also puts you at increased risk for a number of other pregnancy complications, including intrauterine growth restriction, preterm birth, placental abruption, and stillbirth. If your chronic hypertension is mild, your risk for these complications during pregnancy is not too much higher than it would be if you had normal blood pressure — that is, as long as you have no other existing medical problems, your hypertension doesn't get worse during pregnancy, and you don't develop superimposed preeclampsia. The more severe your hypertension, however, the higher your risk for these problems, and developing superimposed preeclampsia increases your risk even more. Your risk is also higher if you've had hypertension for a long time and it's done some damage to your cardiovascular system, kidneys, or other organs, or if your hypertension is a result of an underlying medical condition such as diabetes, kidney disease, or lupus.

How is chronic hypertension managed during pregnancy?

Ideally, before getting pregnant, you discussed your plans to conceive with the healthcare provider who manages your hypertension and let your pregnancy provider know about your hypertension at a preconception visit. Among other things, they might have changed your high blood pressure medication, because some antihypertensive drugs, such as ACE inhibitors, may raise the risk of birth defects when taken during pregnancy.
If that didn't happen before you got pregnant, call your provider right away and be sure to discuss any medications you're on. (If you don't have a pregnancy provider yet, call the provider who's been managing your hypertension.) Depending on your condition, you may be referred to a perinatologist (a high-risk specialist).
At your first visit with your pregnancy caregiver, be prepared to tell her everything you know about your hypertension — for instance, when it started, what tests or work-up procedures have been performed, and what medications you've taken in the past and are currently taking (if any). It's a good idea to arrange for a copy of your medical records to be sent ahead of time (or bring them with you) so your caregiver can review your blood pressure readings over time, as well as the results of lab tests and other evaluations.
If blood and urine tests relating to your hypertension haven't been done recently, she'll probably order a complete set now. And depending on your condition and what's been done in the past, she may order an EKG, an ultrasound of your kidneys, an eye exam, and possibly other tests If this is the first time you've been diagnosed with hypertension, then you'll have a complete work-up, including tests to rule out other conditions that may be causing your high blood pressure.
If you have severe hypertension, you'll need to continue taking blood pressure medication during your pregnancy. Your doctor may need to switch your usual medication to one that's safer for your baby, though, especially if you were on an ACE inhibitor-type medication. She may decide to hospitalize you for a few days so you can be monitored closely until your medication is adjusted and your blood pressure is under control. It's critically important to keep taking your medication, because severe uncontrolled hypertension can be life-threatening.
If you have mild chronic hypertension (without other complications, such as advanced diabetes or kidney disease), your caregiver may advise you to stop taking your blood pressure medication or to reduce your dose. Being off medication temporarily is unlikely to cause problems for you. If you're not currently taking blood pressure medication, your caregiver probably won't recommend starting it now. That's because pregnancy itself tends to lower your blood pressure at the end of the first trimester and keep it down throughout much of the second trimester. And if your pressure gets too low, it may actually reduce blood flow to the placenta in some cases. Plus, studies suggest that blood pressure medication won't lower your risk of developing pregnancy complications. That said, if your pressure starts to get too high, you'll be started on medication (or have your dose increased) to protect you from the serious consequences of severe hypertension.
Whether your hypertension is severe or mild, it's important to keep all of your prenatal appointments so your caregiver can monitor you and your baby and spot any developing problems, such as rising blood pressure, signs of preeclampsia, or poor fetal growth. You'll have more frequent prenatal visits and lab tests to monitor how you're doing. In addition to the usual second-trimester ultrasound, you'll have periodic ultrasounds in your third trimester to monitor your baby's growth and your amniotic fluid level, as well as regular fetal testing (nonstress tests or biophysical profiles) and possibly Doppler ultrasounds (to check blood flow to your baby).
If at any time during pregnancy your blood pressure gets too high, you'll be hospitalized until it's under control, and if you develop superimposed preeclampsia, you'll be hospitalized until you give birth. Depending on your condition and your baby's health, you may have to deliver early, even if your baby is premature.
You'll need to pay particular attention to your salt intake: Avoid the saltshaker, try to use fresh foods instead of prepared or processed ones, and check labels for sodium content. If you've never had nutritional counseling or are unclear about how to keep your salt intake within the limit recommended by your caregiver, ask her for a referral to a registered dietitian who can help devise a diet plan that works for you. She may also recommend cutting back on activity and avoiding aerobic exercise. If you smoke or drink alcohol, it's now even more important to stop, since they can both make your hypertension worse.

What warning signs should prompt a call to my caregiver?

Once your baby starts moving regularly, your caregiver may ask you to do "fetal kick counts," that is, to keep track of your baby's movements. (This is a good way to for you to monitor your baby's well-being between prenatal appointments.) Let your practitioner know immediately if you notice that your baby is less active than usual. Also call your caregiver right away if you have:

Any headache, but especially a severe, persistent, or pounding one
A pounding sensation in your chest or heart palpitations
Dizziness
Swelling in your face or puffiness around your eyes, more than slight swelling of your hands, or excessive or sudden swelling of your feet or ankles
Weight gain of more than 4 pounds in a week.
Vision changes, including double vision, blurriness, seeing spots or flashing lights, light sensitivity, or temporary loss of vision
Intense pain or tenderness in your upper abdomen
Nausea or vomiting (other than morning sickness in early pregnancy)

What will happen after I give birth?

With chronic hypertension, particularly if it's severe, you're at risk for complications as your cardiovascular system adjusts to all the changes in your body after you give birth — so after delivery, you'll be monitored very closely for at least 48 hours.

Also, since preeclampsia can develop after delivery, let your practitioner know immediately if you develop any symptoms of the disorder, even after you're discharged home. You'll start taking blood pressure medication again or have your dosage adjusted as necessary. Let your practitioner know if you plan to breastfeed, because that will affect her choice of blood pressure medication for you.

In addition to taking whatever medication is prescribed and seeing your primary care provider regularly, you'll need to take good care of yourself to reduce your risk of long-term complications from hypertension, such as heart or kidney disease and stroke.

Try to maintain a healthy lifestyle, paying particular attention to your diet and weight, avoiding tobacco, and limiting how much alcohol you drink. When your postpartum recovery is complete and your practitioner gives you the go-ahead to begin exercising, ask your doctor what kind of exercise regime is best for your individual situation, and stick to it.

HEPATITIS and PREGNANCY

2009-06-29T22:04:00.001+07:00

The word 'hepatitis' means an infection or inflammation of the liver. If the liver becomes inflamed due to an infection with a virus it is called 'viral hepatitis'. However, the liver can also become inflamed through excessive alcohol intake or by taking certain medications or being exposed to certain chemicals.

Some viral hepatitis infections only cause a temporary dysfunction of the liver, while others can cause permanent liver damage (called 'cirrhosis'). In some cases, a small number of people with cirrhosis may eventually experience liver failure or liver cancer later in life. However, this will depend on the type of hepatitis involved.

There are 3 main types of viral hepatitis. These are:

Hepatitis A virus (HAV). Hepatitis A or 'hep A' is the most common type of hepatitis. It is transmitted by coming in contact with contaminated faeces (bowel motions) through water supplies, foods washed in contaminated water or eating utensils handled by the unwashed hands of an infected person. Some people become infected with the virus through occupational exposure by working with sewerage, handling the faeces of patients in hostels or hospitals or changing babies in childcare settings. Hepatitis A does not cause long term liver problems and there are vaccinations available if you feel you are at risk of coming in contact with the virus. Many people are vaccinated as a precaution before travelling overseas (especially to developing countries).

Hepatitis B virus (HBV). Hepatitis B or 'hep B' is transmitted by coming in contact with infected blood of another person. This can be through the sharing of injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries.

It can also be transmitted through their saliva or having unprotected sex with an infected person. The hepatitis B virus can cause long term liver problems for some people. Vaccinations are now available to protect against hepatitis B and the vaccination of babies during the first 6 months after birth is now offered routinely in Australia. You can read more about this in Hepatitis B vaccination.

Hepatitis C virus (HCV). Hepatitis C or 'hep C' (previously known as 'non A - non B hepatitis') is transmitted by coming into contact with the blood of an infected person. Hepatitis C is not transmitted through saliva and very rarely through sexual contact. Infection with the hepatitis C virus can happen by sharing injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries. At present there is no vaccine available to protect against hepatitis C.

In recent years there have been additional types of viral hepatitis identified. These are relatively rare so far but can include hepatitis E or 'HEV' (which is similar to hepatitis A), Hepatitis D (HDV) and hepatitis G (HGV). At present these types of hepatitis are not routinely tested for during pregnancy.

NOTE:

Be aware that even though all types of viral hepatitis infect and inflame the liver, not all hepatitis infections produce obvious physical signs. There are many people who are 'carriers' of a hepatitis virus, meaning they are infected with the virus and are capable of infecting others but are not aware they have the infection themselves. Also each type of hepatitis can be transmitted from one person to another in different ways.

Effects on the pregnancy

If a woman knows she has hepatitis or discovers she has it during her pregnancy, the most common concerns are how this will affect her pregnancy and her unborn baby.

In most cases the pregnancy itself will not affect the severity of the hepatitis infection for the woman, or the long term course of the hepatitis disease. (Unless it is found to be the rarer type of hepatitis E or 'HEV', which can become worse during pregnancy. This type of hepatitis is similar to hepatitis A.)

The unborn baby does not tend to have any health concerns if their mother has hepatitis. However, it is sometimes possible for the baby to become infected with the virus around the time of birth or during their early childhood years. Transmission of the virus during pregnancy does not usually happen, but the risk for this can be increased if the mother first becomes infected just before she conceives or during her pregnancy (this mainly relates to hepatitis C).
Most women with hepatitis will have a normal pregnancy, but the physical process of pregnancy can put added strain on a woman's liver. For a few women this may lead to complications or health concerns during pregnancy and can include:

Gallstones or 'cholelithiasis'. About 6% of women with hepatitis can develop gallstones (or 'cholelithiasis') during their pregnancy. This may present as abdominal pain and sometimes jaundice. Cholelithiasis may need to be treated with an operation to remove the gallstones if they do not pass naturally into the woman's bowel. The timing of this will depend on the severity of the condition, weighing up the risks of miscarriage or premature birth.

Cholestasis. A few women may be at increased risk of developing cholestasis of pregnancy. This condition is characterised by itching of the skin, especially the hands and feet. You can read more in cholestasis.

Acute fatty liver of pregnancy. Although rare, hepatitis can predispose a few women to a condition called 'acute fatty liver of pregnancy'. This is a life-threatening condition for the woman that may require delivering her babyprematurely and possible treatment for the woman in an intensive care facility. However, most women normally recover quickly after the baby is born. If a pregnant woman becomes very unwell before the birth of her baby, the baby may also be unwell and can in some cases be stillborn.

Pregnant women who have (or carry) the hepatitis virus require regular blood tests during their pregnancy to check the functioning of their liver. These are called 'Liver Function Tests' or 'LFT's'. Depending on the results of the tests, these may be done every few months, monthly or perhaps weekly if the levels appear to be rising. Be aware that it is normal for pregnant women to have increased alkaline phosphatase levels (3 to 4 times higher than normal) because the placenta creates alkaline phosphatase. However, ALT levels (or 'alanine aminotransferase serum') increase if the woman is ill from hepatitis or if liver damage is occurring. (The normal ALT range for women is 10 - 32 U/L.)

NOTE:Women with hepatitis should not be treated any differently by their healthcare professionals during the pregnancy, labour, birth or postnatal recovery. All caregivers handling blood products and performing medical procedures involving blood exposures treat every person in the same way. This is known as 'universal precautions' and means the caregiver will wear gloves when taking blood and gloves gowns and goggles or glasses when caring for women giving birth or having a Caesarean operation, regardless of whether they are positive for hepatitis or not. However, women who are infectious with hepatitis A do need to be isolated from other women and babies when being cared for in a hospital setting.

Support

Finding out you have hepatitis can come as quite a shock and bring up a range of emotionsYour caregiver should discuss at length the implications of having the virus and any effects on your pregnancy, family, relationships and overall health as well as any health concerns for your baby. Usually your close personal contacts (such as your partner) will need to be tested for the virus. But you are not obliged to tell other members of the family, friends or work colleagues and the results of your test should be kept confidential.
Obtaining up to date information and counselling with people who understand your situation can provide immediate and ongoing support. These are usually provided by volunteer and health department organisations that specialise in hepatitis. At present in Australia there is no central organisation that provides national services. Most are state based and funded and usually have local numbers in capital cities and toll free numbers for rural residents. Ask your caregiver about what is available in your area or use the phone book or a search of the Internet to locate these organisations.

Reviewed by Bambang Widjanarko Obstetrician & Gynecologist

Juni 2009

TOXOPLASMOSIS and PREGNANCY

2009-06-29T15:26:00.001+07:00

Toxoplasmosis and Pregnancy

Reviewed by the Bambang Widjanarko

Last updated: Juni 2009

Highlights

What is toxoplasmosis?

Toxoplasmosis is an infection you can get from a microscopic parasite called Toxoplasma gondii. Although the infection is generally a mild, symptomless illness for people with healthy immune systems, it's risky to get during pregnancy because the parasite can sometimes infect the placenta and your baby.
The number of babies born in the United States with toxoplasmosis (known as "congenital toxoplasmosis") is relatively small, but the infection can be devastating, causing stillbirth or long-term damage. Fortunately, there's a lot you can do to avoid becoming infected in the first place.

What are my chances of getting toxoplasmosis and infecting my baby?

The Centers for Disease Control (CDC) estimates that only about 15 percent of women of childbearing age are immune to toxoplasmosis. So unless you know for sure that you're immune, you should take steps to avoid becoming infected. Fortunately, the number of women who contract the disease during pregnancy is still relatively small and not all of them transmit the infection to their babies.
If you get infected with toxoplasmosis in the first trimester, the risk that your baby will also be infected is about 15 percent. The risk rises to about 30 percent if you get infected in the second trimester and to 60 percent in the third trimester. Somewhere between 1 and 10 in 10,000 babies in the United States contract the infection in utero each year.
There's also a very small risk of infecting your baby if you contract the infection within three months before you conceive. To be on the safe side, some experts recommend that infected women wait six months before trying to conceive.

How is toxoplasmosis spread?

Some experts believe that about half of toxoplasmosis infections are caused by eating raw or undercooked infected meat, but you can also get the parasite in other ways, such as eating unwashed contaminated produce, drinking contaminated water, or handling contaminated soil, cat litter, or meat and then touching your mouth, nose, or eyes. Toxoplasmosis can't be transmitted from person to person, with the exception of transmission from mother to baby during pregnancy or from an infected blood transfusion or organ transplant.

Do I have to get rid of my cat?

No. You've probably heard that cat feces and litter are a major source of toxoplasmosis, but that doesn't mean you need to get rid of your beloved pet. It just means you'll need to take some extra precautions. Here's the scoop on how cats can transmit the infection.
Felines are a natural host for the parasite and it reproduces in their intestines. A cat may become infected with toxoplasmosis from eating infected prey or undercooked meat, or anything contaminated by the feces of another infected cat. The parasites then form "oocysts" in the cat's gut, and the cat excretes up to 10 million oocysts daily for about a week to ten days. (Oocysts can't be seen with the naked eye, and in most cases you'll have no idea that your cat is sick.)
The oocysts first become infectious 24 hours or so after they're excreted. Under the right conditions, they can live in the soil, sand, or litter and remain infectious for up to 18 months. During this time, they spread, contaminating water, fruits, and vegetables, and infecting warm-blooded species, including humans, that ingest them.
So while it's possible to get infected with toxoplasma oocytes from direct contact with cat feces (such as handling the litter of a newly infected cat), you can also be exposed to oocytes elsewhere (for example, while gardening, eating unwashed vegetables, or drinking contaminated water).
Although only cats pass the parasite in their feces, other infected species harbor the parasite in their tissue forever, in so-called "tissue cysts." Heat will kill the parasites, but if you eat raw or undercooked meat (or touch it and then touch your mouth, nose, or eyes), you can be infected by these tissue cysts. Pork, lamb, and game meat (like venison) are major culprits, but any type of meat may be infected, so all meat should be handled and cooked appropriately.

So how do I avoid getting infected?

Here are some guidelines, whether you have a cat or not:

Cook meat well. Use a food thermometer to test the internal temperature of meat. Most meat should be cooked to a temperature of 160 degrees Fahrenheit, or 180 degrees F in the thigh for whole poultry. If you're not actually measuring the temperature of the meat, cook it until it's no longer pink in the middle. Be sure not to sample meat you're cooking before it's done.
Avoid salt-cured or smoked meats such as Genoa salami, Parma ham, and prosciutto unless you first heat them until they're steaming. For example, they're fine if cooked on a pizza. But if not cooked, they're risky because they might have been processed without thorough heating or with no heat at all. Also, don't eat dried meats like jerky, which may have not gotten sufficiently hot during the drying process.
Don't drink unpasteurized milk or products made from unpasteurized milk, and avoid raw eggs.
Wash or peel fruits and vegetables before eating.
Wash counters, cutting boards, dishes, utensils, and your hands with hot, soapy water after preparing unwashed produce or uncooked meat, poultry, or seafood.
Don't touch your mouth, nose, or eyes while preparing food, and always wash your hands before eating. Also make sure open sores aren't in contact with potential sources of exposure to the parasite. Wear disposable gloves if you have cuts on your hands.
Keep flies and cockroaches away from your food.
Avoid contaminated water. Use bottled water when camping or traveling to developing countries.
Wear gloves while gardening, and don't touch your hands to your mouth, nose, or eyes until they've been washed thoroughly afterward.
Avoid public sandboxes and cover your child's sandbox when it's not in use. If that's not always possible, then stay out of it as well. (Toxoplasmosis isn't likely to be harmful for your child and you can't catch it from him if he does get it, but you do need to stay away from sand that might contain infected cat feces.)
Don't get a new kitten or cat while you're pregnant, and don't play with stray cats or kittens.
If you have a cat, have other people empty the litter box, and have them do it daily. This reduces the risk of infection because the oocysts aren't infectious for the first 24 hours after they're excreted. If you must do the job, wear disposable gloves and wash your hands well afterward. Some even suggest wearing a mask in case any particles become airborne when the litter is stirred up, and disinfecting the box by pouring near-boiling water into it five minutes before you handle it.
To keep your cat from becoming infected while you're pregnant, feed him only commercial cat food or well-cooked table scraps, never raw or undercooked meat. Keep him indoors so he won't hunt down potentially infected prey like mice or birds. (Remember, though, that even an indoor cat might catch a mouse.)
Keep Kitty off of the kitchen counter and dining table.
Though it's unlikely your cat has any parasites in his fur, it's a good idea to wash your hands after playing with him, especially before eating or otherwise putting your hands to your mouth.

How will I know if I get toxoplasmosis?

Without testing, you probably won't know you've been infected because the vast majority of people with healthy immune systems don't have any symptoms at all. If you do, you may have painless swollen lymph glands and other generally mild symptoms like muscle aches, fatigue, headache, fever, and possibly a sore throat or a rash. Only rarely do more serious symptoms arise in otherwise healthy people. Sometimes toxoplasmosis is suspected when certain fetal abnormalities are picked up during a prenatal ultrasound, though most infected babies look normal.
Blood tests that can detect toxoplasmosis antibodies that indicate immunity or recent infection, but experts disagree over whether pregnant women need to be screened routinely. In the United States, where the disease isn't very common, some worry that screening all pregnant women would result in too many false positive results, leading to undue anxiety and costly follow-up testing. Others argue that even though congenital toxoplasmosis is relatively rare, the consequences can be devastating, so they advocate prenatal testing for all women or universal newborn testing or both.
The American College of Obstetricians and Gynecologists (ACOG) doesn't recommend screening pregnant women, with the exception of those who are HIV-positive or when infection is suspected. In contrast, in France, where the disease is more common, , all women are tested, and those who aren't immune are tested monthly during pregnancy.
Talk about the pros and cons of testing with your doctor or midwife and together you can make a decision that's right for you. And be sure to call your caregiver if you have swollen glands or other reasons to suspect you've been infected.
If it seems as though you might be infected, your blood will tested to measure your levels of two antibodies (IgG and IgM). Depending on the results, you may need to be tested again in two to three weeks and have your blood sent to a toxoplasmosis "reference lab." This is done both to confirm the initial results and to help pinpoint when you might have become infected.

What will happen if I do get toxoplasmosis?

If test results suggest that you got toxoplasmosis while pregnant, your practitioner will begin treating you with an antibiotic that may lower your risk of transmitting the disease to your baby. And since not all maternal infections are transmitted to the baby, you'll have an amniocentesis to determine whether your baby also has the infection. (The lab will do a special DNA test on your amniotic fluid to check for the presence of the toxoplasmosis parasite.) You'll also have a series of ultrasounds throughout your pregnancy to look for abnormalities in your developing baby.
If your amniotic fluid shows that your baby has been infected or an ultrasound shows a problem, you'll probably be referred to a specialist for care, and you may also want to talk to a genetic counselor about the risks to your baby. Depending on your baby's gestational age, you'll be given the option to end the pregnancy. If you continue the pregnancy, you'll be given other antibiotics to take beginning some time in the second trimester to reduce the risk of problems for your baby.

What could happen if my baby gets toxoplasmosis and how will he be treated?

The consequences for your baby can range from mild to severe.

It's unclear whether toxoplasmosis can cause miscarriage, though in some cases it can result in stillbirth or death shortly after birth.

Congenital toxoplasmosis can affect your baby's brain, causing structural and neurological problems, such as mental or motor developmental delays, cerebral palsy, and epilepsy.
It can affect other organs too, most commonly the eyes, leading to visual impairment and sometimes blindness. Other signs of toxoplasmosis may include an enlarged liver and jaundice, an enlarged spleen, a low platelet count, a rash, a heart or lung infection, and enlarged lymph nodes.
The vast majority of babies with congenital toxoplasmosis, particularly those infected later in pregnancy, look normal at birth but may develop serious problems such as vision impairment (and possibly blindness) and developmental delays months or even many years later. For this reason and because treating babies effectively reduces the progression of the disease, some experts say that all babies in the United States should be tested for toxoplasmosis. Currently only Massachusetts and New Hampshire routinely do so.
If your baby tests positive for toxoplasmosis at birth, he'll be treated with antibiotics for about a year, even if he has no symptoms. Special hearing and eye exams will be done, as well as a sonogram or CAT scan of his head and other tests as needed. Studies show that although treatment after birth may not reverse all the damage that occurred before birth, it will greatly reduce a baby's risk of developing new problems during infancy and beyond.

MENSTRUATION

2009-06-29T15:14:00.001+07:00

Menstruation is the shedding of the uterine lining - endometrium. It occurs on a regular basis in reproductive-age females of certain mammal species. Overt menstruation (where there is bleeding from the vagina) is found primarily in humans and similar relatives such as chimpanzees. The females of other placental mammal species have estrous cycles, in which the endometrium is reabsorbed by the animal (covert menstruation) at the end of its reproductive cycle. Many zoologists regard this as different from a "true" menstrual cycle.

Overview

Eumenorrhea denotes normal, regular menstruation that lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal). The average blood loss during menstruation is 35 millilitres with 10-80 mL considered normal; many women also notice shedding of the endometrium lining that appears as tissue mixed with the blood. (Sometimes this is erroneously thought to indicate an early-term miscarriage of an embryo.)

An enzyme called plasmin — contained in the endometrium — tends to inhibit the blood from clotting. Because of this blood loss, premenopausal women have higher dietary requirements for iron to prevent iron deficiency.

Many women experience uterine cramps, also referred to as dysmenorrhea, during this time, caused largely by the contractions of the uterine muscle as it expels the endometrial blood from the woman's body. A vast industry has grown to provide drugs to aid in these cramps, as well as sanitary products to help manage menses.

Menstruation is the most visible phase of the menstrual cycle. Menstrual cycles are counted from the first day of menstrual bleeding, because the onset of menstruation corresponds closely with the hormonal cycle.

During pregnancy and for some time after childbirth, menstruation is normally suspended; this state is known as amenorrhoea, i.e. absence of the menstrual cycle.

If menstruation has not resumed, fertility is low during lactation.

The average length of postpartum amenorrhoea is longer when certain breastfeeding practices are followed; this may be done intentionally as birth control (lactational amenorrhea method).

Menstrual cycle

The menstrual cycle is a cycle of physiological changes that occurs in pubescent females. Overt menstruation (where there is blood flow from the vagina) occurs primarily in humans and other mammals such as chimpanzees.

Females of other species of placental mammal undergo estrous cycles, in which the endometrium is completely reabsorbed by the animal (covert menstruation) at the end of its reproductive cycle. This article focuses on the human menstrual cycle.

The menstrual cycle, under the control of the endocrine system, is necessary for reproduction. It may be divided into three distinct phases:

Ovulation defines the transition from the follicular phase to the luteal phase.

The length of each phase varies from woman to woman and cycle to cycle, though the average menstrual cycle is 28 days.

Hormonal contraception interferes with the normal hormonal changes with the aim of preventing reproduction.

Stimulated by gradually increasing amounts of estrogen in the follicular phase, menses slow then stop, and the lining of the uterus thickens.

Follicles in the ovary begin developing under the influence of a complex interplay of hormones, and after several days one or occasionally two become dominant (non-dominant follicles atrophy and die).

Approximately mid-cycle, 24-36 hours after the Luteinizing Hormone (LH) surges, the dominant follicle releases an ovum, or egg in an event called ovulation.

After ovulation, the egg only lives for 24 hours or less without fertilization while the remains of the dominant follicle in the ovary become a corpus luteum ; this body has a primary function of producing large amounts of progesterone.

Under the influence of progesterone, the endometrium (uterine lining) changes to prepare for potential implantation of an embryo to establish a pregnancy.

If implantation does not occur within approximately two weeks, the corpus luteum will involute, causing sharp drops in levels of both progesterone and estrogen. These hormone drops cause the uterus to shed its lining in a process termed menstruation.

In the menstrual cycle, changes occur in the female reproductive system as well as other systems (which lead to breast tenderness or mood changes, for example). A woman's first menstruation is termed menarche, and occurs typically around age 12. The end of a woman's reproductive phase is called the menopause, which commonly occurs somewhere between the ages of 45 and 55.

Phases

The menstrual cycle is divided into several phases. The average length of each phase is shown below:

Name of phase	Average start day assuming a 28-day cycle	Average end day
Menstrual phase	1	4
Follicular phase (also known as proliferative phase)	5	13
Ovulation (not a phase, but an event dividing phases)	12	16
Luteal phase (also known as secretory phase)	15	26
Ischemic phase (some sources group this with luteal phase)	27	28

Menstruation

Menstruation is also called menstrual bleeding, menses, catamenia or a period. The flow of menses normally serves as a sign that a woman has not become pregnant. (However, this cannot be taken as certainty, as a number of factors can cause bleeding during pregnancy ; some factors are specific to early pregnancy, and some can cause heavy flow.) During the reproductive years, failure to menstruate may provide the first indication to a woman that she may have become pregnant.

Eumenorrhea denotes normal, regular menstruation that lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal). The average blood loss during menstruation is 35 milliliters with 10–80 ml considered normal. (Because of this blood loss, women are more susceptible to iron deficiency than are men.) An enzyme called plasmin inhibits clotting in the menstrual fluid. Cramping in the abdomen, back, or upper thighs is common during the first few days of menstruation. When menstruation begins, symptoms of premenstrual syndrome (PMS) such as breast tenderness and irritability generally decrease. Many sanitary products are marketed to women for use during their menstruation.

Follicular phase

This phase is also called the proliferative phase because a hormone causes the lining of the uterus to grow, or proliferate, during this time.

Through the influence of a rise in follicle stimulating hormone (FSH) during the first days of the cycle, a few ovarian follicles are stimulated. These follicles, which were present at birth and have been developing for the better part of a year in a process known as folliculogenesis, compete with each other for dominance. Under the influence of several hormones, all but one of these follicles will stop growing, while one dominant follicle in the ovary will continue to maturity. The follicle that reaches maturity is called a tertiary, or Graafian, follicle, and it forms the ovum.

As they mature, the follicles secrete increasing amounts of estradiol, an estrogen. The estrogens initiate the formation of a new layer ofendometrium in the uterus, histologically identified as the proliferative endometrium. The estrogen also stimulates crypts in the cervix to produce fertile cervical mucus, which may be noticed by women practicing fertility awareness.

Ovulation

When the egg has nearly matured, the level of estradiol in the body has increased enough to trigger a sudden release of luteinizing hormone (LH) from the anterior pituitary gland. In the average cycle this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary, causing the fully developed follicle to release its secondary oocyte. The secondary oocyte promptly matures into an ootid and then becomes a mature ovum. The mature ovum has a diameter of about 0.2 mm.

Which of the two ovaries—left or right—ovulates appears essentially random; no known left/right co-ordination exists. Occasionally, both ovaries will release an egg; if both eggs are fertilized, the result is fraternal twins.

After being released from the ovary, the egg is swept into the fallopian tube by the fimbria, which is a fringe of tissue at the end of each fallopian tube. After about a day, an unfertilized egg will disintegrate or dissolve in the fallopian tube.

Fertilization by a spermatozoon, when it occurs, usually takes place in the ampulla, the widest section of the fallopian tubes. A fertilized egg immediately begins the process of embryogenesis, or development. The developing embryo takes about three days to reach the uterus and another three days to implant into the endometrium. It has usually reached the blastocyst stage at the time of implantation.

In some women, ovulation features a characteristic pain called mittelschmerz (German term meaning middle pain). The sudden change in hormones at the time of ovulation sometimes also causes light mid-cycle blood flow.

Luteal phase

Corpus Luteum

The luteal phase is also called the secretory phase. An important role is played by the corpus luteum, the solid body formed in an ovary after the egg has been released from the ovary into the fallopian tube. This body continues to grow for some time after ovulation and produces significant amounts of hormones, particularly progesterone.^[2] Progesterone plays a vital role in making the endometrium receptive to implantation of the blastocyst and supportive of the early pregnancy; it also has the side effect of raising the woman's basal body temperature.

After ovulation, the pituitary hormones FSH and LH cause the remaining parts of the dominant follicle to transform into the corpus luteum, which produces progesterone and estrogens. The hormones produced by the corpus luteum also suppress production of the FSH and LH that the corpus luteum needs to maintain itself. Consequently, the level of FSH and LH fall quickly over time, and the corpus luteum subsequently atrophies. Falling levels of progesterone trigger menstruation and the beginning of the next cycle. From the time of ovulation until progesterone withdrawal has caused menstruation to begin, the process typically takes about two weeks, with ten to sixteen days considered normal. For an individual woman, the follicular phase often varies in length from cycle to cycle; by contrast, the length of her luteal phase will be fairly consistent from cycle to cycle.

The loss of the corpus luteum can be prevented by fertilization of the egg; the resulting embryo produces human chorionic gonadotropin(hCG), which is very similar to LH and which can preserve the corpus luteum. Because the hormone is unique to the embryo, mostpregnancy tests look for the presence of hCG.

OVULATION

2009-06-29T15:00:00.001+07:00

Ovulation is the process in the females menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum (also known as an oocyte, female gamete, or casually, an egg) that participates in reproduction. Ovulation also occurs in the estrouc cycle of other female mammals, which differs in many fundamental ways from the menstrual cycle.

The process of ovulation is controlled by the hypothalamus of the brain and through the release of hormones secreted in the anterior lobe of the pituitary gland, (Luteinizing hormon (LH) and Follicle Stimulating Hormon (FSH)).

In the follicular (pre-ovulatory) phase of the menstrual cycle, the ovarian follicle will undergo a series of transformations called cumulus expansion, this is stimulated by the secretion of FSH. After this is done, a hole called the stigma will form in the follicle, and the ovum will leave the follicle through this hole.

Ovulation is triggered by a spike in the amount of FSH and LH released from the pituitary gland.

During the luteal (post-ovulatory) phase, the ovum will travel through the fallpoian tubes toward the uterus. If fertilized by a sperm, it may perform implantation there 6–12 days later.

Order of changes in ovary.
1 - Menstruation
2 - Developing follicle
3 - Mature follicle
4 - Ovulation
5 - Corpus luteum
6 - Deterioration of corpus luteum

In humans, the few days near ovulation constitute the fertile phase.

The average time of ovulation is the fourteenth day of an average length (twenty-eight day) menstrual cycle. It is normal for the day of ovulation to vary from the average, with ovulation anywhere between the tenth and nineteenth day being common.

Cycle length alone is not reliable indicator of the day of ovulation. While in general an earlier ovulation will result in a shorter menstrual cycle, and vice versa, the luteal (post-ovulatory) phase of the menstrual cycle may vary by up to a week between women.

Periovulatory phase

For ovulation to be successful, the ovum must be supported by both the corona radiata and cumulus oophorous granulosa cells. The latter undergo a period of proliferation and mucification known as cumulus expansion. Mucification is the secretion of a hyaluronic acid -rich cocktail that disperses and gathers the cumulus cell network in a sticky matrix around the ovum. This network stays with the ovum after ovulation and have been shown to be necessary for fertilization.

An increase in cumulus cell number causes a concomitant increase in antrum fluid volume that can swell the follicle to over 20 mm in diameter. It forms a pronounced bulge at the surface of the ovary called the blister.

Ovulatory phase

Through a signal transduction cascade initiated by LH, proteolytic enzymes are secreted by the follicle that degrade the follicular tissue at the site of the blister, forming a hole called the stigma. The cumulus – oocyte complex (COC) leaves the ruptured follicle and moves out into the peritoneao cavity through the stigma, where it is caught by the fimbriae at the end of the fallopian tube (also called the oviduct). After entering the oviduct, the ovum-cumulus complex is pushed along by cilia, beginning its journey toward the uterus.

By this time, the oocyte has completed meiosis I, yielding two cells: the larger secondary oocyte that contains all of the cytoplasmic material and a smaller, inactive first polar body. Meiosis II follows at once but will be arrested in the metaphase and will so remain until fertilization. The spindle apparatus of the second meiotic division appears at the time of ovulation. If no fertilization occurs, the oocyte will degenerate approximately twenty-four hours after ovulation.

The mucous membrane of the uterus, termed the stratum functionalis, has reached its maximum size, and so have the endometrial glands, although they are still non-secretory.

Postovulatory phase

The follicle proper has met the end of its lifespan. Without the ovum, the follicle folds inward on itself, transforming into the corpus luteum (pl. corpus lutea), a steroidogenic cluster of cells that produces estrogen and progesterone. These hormones induce the endometrial glands to begin production of the proliferative endometrium and later into secretory endometrium, the site of embryonic growth if fertilization occurs. The action of progesterone increases basal body temperature by one-quarter to one-half degree Celsius (one-half to one degree Fahrenheit). The corpus luteum continues this paracrine action for the remainder of the menstrual cycle, maintaining the endometrium, before disintegrating into scar tissue during menses.

Fertility signals

Knowing your own body and being able to tell when you are fertile / ovulating is an important skill and one that every woman should have.
The fact is, there are only certain times in a woman's cycle when she is fertile or ovulating and can get pregnant. So it pays off to know when those times are.

Your body will give you clear clues and signals as to when fertility is approaching and occurring.

A brief note, this system of observing fertility changes has nothing to do with the rhythm method. The rhythm method does not use bodily signals and is often very unreliable due to factors like the ignorance of the natal lunar phase, sickness, stress etc. If you are simply counting days and guessing when you should be fertile, this could be slowing down your bid to conceive.

A woman is fertile when she is ovulating and ovulation usually occurs mid cycle. In fact, ovulation almost always occurs 14 days before the next bleed. Sometimes women do experience a longer or shorter post ovulatory phase (than 14 days) but this usually indicates that there is a hormonal imbalance.

Ovulation occurs 14 days before next bleed this is the rule. And the fertile window can start a few days before that.

See diagram below :

Spontaneous ovulation can also occur during your natal lunar phase.
The table below provides a rough description of the very real physical and emotional symptoms that you can observe throughout your menstrual cycle. It is a brief guide that I have put together from my own observation.

These are some of the signals that you can observe and note down on your Personal Charting System. The time frame is very approximate, so don't worry if your cycle is not the same - everyone is individual.

Week 1 From first day of bleeding	Bleeding and the various symptoms felt during this part of the cycle varies with the individual, ranging from, cramping, back ache, hollow feeling inside vagina or the sensation that your innards will fall out to no ill effects at all. At the post bleeding phase there is generally an increase in physical energy and vitality. The individual is more outgoing and sociable. Sleep patterns and appetite return to normal. Vaginal mucus is dry or absent .
Week 2	As ovulation approaches cervical mucus become wetter, slippery, white (whatever is your individual pattern.)
Ovulation Day 14 approximately	Mucus is very wet and slippery, easily allowing penetration of sperm. Other symptoms may include tender breasts, mood swings, increase in libido, cramps, break through bleeding, desire to be with your partner.
Week 3 After Ovulation moving into pre-menstrual phase	Mucus production slows, becomes drier and thicker . Moods balance out again.
Week 4 Pre-menstrual phase	Pre-menstrual symptoms kick in, which depending upon you, range from bloating, cramps, headaches, mood swings, food cravings, and insomnia. Energy levels decrease, libido may increase. Desire for solitude increases as does intuitive ability.

The table above is not the definitive guide, and each cycle may not be the same, it all depends on how you are and what's going on in your life.

When you observe your body you will start to see a very clear pattern of what happens in your body during your menstrual cycle.

The main fertility indicators to look for are:

Cervical mucus
Bodily symptoms - that is moods, aches, libido, appetite, sleep patterns
Basal Temperature

cervical mucus

EMOTIONAL PREPARATION TO BECOME A MOTHER

2009-06-29T14:31:00.001+07:00

There are thousands of articles about the physical preparation that a healthy pregnancy requires and very few about the psychological aspects of it. I titled this article “How to emotionally prepare for motherhood” because the psychological changes that start before your become pregnant do not end at birth. Glade B. Curtis, M.D.,OB/GYN & Judith Schuler, M.S. in their book Pregnancy Week by Week, suggests that “pregnancy is not a 9 months deal but should last at least 12 because it takes at least that time for our bodies to adjust and, even longer for our minds to be ready.” It is important to remember that pregnancy is a period of transition. It is a period when we will be laying the foundation for :

a healthy child’s development,
a healthy mother’s adjustment, and
a strong relationship between mother and child.

As important as it is that we take care of our bodies during and even before pregnancy, it is crucial that we take certain steps in order to be at our best psychologically during pregnancy and after child birth. Here some main considerations:

Redefine yourself to include the role of motherhood in your life. Every person’s identity is formed by the various roles that they perform in the world. Becoming a mother is one more such role and it has psychological implications. What does it mean for you to be a mother? What is the value for you, your family, to society? Is this role more or less important than other roles you currently play in your life? Does it create a conflict within you and/or with others in your life?

Research shows more and more the importance of the mother-child relationship on the healthy development of a person. It is not a matter of simply providing room and board. Susan Johnson’s, Ph.D., founder of Emotionally Focus Therapy (EFT) for couples, in her latest book (2008) “Hold Me Tight,” explains in detail how the need to connect to another human being (in this case to the caretaker) is innate to all of us; as much as the need to eat and be dressed. Becoming a parent is about being emotionally present and connected to your child. Consider a prenatal class to learn about bonding techniques to enhance the relationship with your baby.

Assess your partnership. The thought of a baby solving the problems in an old marriage myth that thousands of couples prove false each year. If you and your partner are currently experiencing problems, put your communications skills to work. Develop or maintain a healthy relationship and look to prevent problems in the future. Do not expect the baby to make a miracle. In addition, there will be stressful moments for sure and you both will need to have a solid foundation of trust and communication with each other to make it through successfully.

Try to maintain a healthy mental state. Remember that you are not sick but your whole self is experiencing a transition so do not wait for things to be exactly as they were before pregnancy. Accept change, and avoid becoming frustrated. Be prepared for things to be different and you will deal with change easier. Remember, a positive attitude will be your best ally.

Expect mood swings. Nearly all pregnant women are prone to emotional ups and downs due to the rapid production of hormones. Accept that you will feel down from time to time and do not fight it. It is perfectly normal. However, keep you eyes open on inadequate hormone production, especially estrogen (low levels produce more depression, fatigue and lethargy) and progesterone (more irritation, anxiety, and edgy).

Use all resources around you; do not try to do it alone. Rely on family, friends, your husband and practice stress management techniques. A survey conducted by the baby charity Tommy's in the UK discovered that 9 in every 10 expectant “mums” are stressed, so find ways to reduce it. This is not the time to be a superwoman and if you don’t ask for help you will end up exhausted and overwhelmed. Some people want to help, but are timid to intervene. Let’s be clear about when and how they can help us.

Prevent mental health complications. Pregnancy is a time when our past comes back to hunt us. Relationships issues, fears, and the way we deal with life and crisis will surface. The relationship with your own mother, confidence in yourself, trust in others to be there for you etc are some of the main issues that pregnant women deal with, regardless of them being aware or not. If you find yourself overly stressed, often depressed, or if you’ve had a history of depression or mental problems, be aware of it and do not hesitate to ask for help. If you suffer(ed) from low self-esteem, eating disorders, or have body image problems, pregnancy can be a very vulnerable time. A new survey in London has revealed that one in every 50 pregnant women develops an eating disorder. Your image of yourself while you are pregnant is very important. Women with a good self-esteem tend to feel good when pregnant and women with low self-esteem may experience complications. Keep in mind that it is ok to consult with a specialist if you need it.

Learn how to baby-proof your marriage. In other words, how to become a mom without giving up being a wife. Remember that while you are incorporating one more role in your life it is important that you do not drop the others completely. The Journal of Personality and Social Psychology shows that having a baby impacts a marriage in ways new parents never anticipated. Research done by the Bringing Baby Home Program shows that relationship satisfaction decreased up to 67 percent for new parents. Many couples and men complain that after the birth of a baby, the mother has no more time or energy for them or the relationship. Even the most capable man still needs you and your relationship too. Remember that both roles are important and that one the biggest gift you can give to your child is a strong and healthy marriage.

Plan and balance your new life. Trying to develop a new and balanced lifestyle that takes into consideration all areas of your life. Again remember that even though being a mother is the main priority, especially at the beginning, you will do better if you dedicate some time to take care of your self, your relationship, and come back to the child. Too much of a good thing is not good. So add variety to you, your family and your baby’s life.

Congratulations on your pregnancy! Good luck with the new born!

Reviewed by : Bambang Widjanarko, obstetrician & gynecologist

Juni 2009

MALE REPRODUCTIVE SYSTEM

2009-06-29T14:17:00.001+07:00

The human male reproductive system consists of a number of sex organs that are a part of the human reproductive process. In the case of men, these sex organs are located outside a man’s's body, around the pelvic region.

The main male sex organs are the PENIS and the tESTIS which produce semen and sperm, which as part of sexual intercourse fertilize an ovum in a woman's body and the fertilized ovum (zygote) gradually develops into a fetus, which is later born as a child.

PENIS

The penis (plural penises, penes) is an external sexual organ of certain biologically male organisms, in both vertebrates and invertebrates.

The penis is a reproductive organ, technically an intromittent organ, and for placental mammals, additionally serves as the external organ of urination. The penis is generally found on mammals and reptiles.

The penis has a long shaft and enlarged tip called the glans penis. The penis is the male copulatory organ. When the male becomes sexually aroused, the penis becomes erect and ready for sexual intercourse. Erection is achieved because blood sinuses within the erectile tissue of the penis become filled with blood. The arteries of the penis are dilated while the veins are passively compressed so that blood flows into the erectile cartilage under pressure. The male penis is made of two different tissues,and soft spongey tissue. Cartlidge is not in the penis.

Corpus Cavernosum

The corpus cavernosum penis is one of a pair of sponge-like regions of erectile tissuewhich contain most of the blood in the male penis during erection. This is homologousto the corpus cavernosum clitoridis in the female. The term literally means "cave-like body" (plural: corpora cavernosa).

The two corpus cavernosa and corpus spongiosum (also known as the corpus cavernosum urethrae in older texts and in the diagram to the right) are three expandable erectile tissues along the length of the penis which fill with blood during erection. The two corpora cavernosa lie along the penis shaft, from the pubic bones to the head of the penis, where they join. These formations are made of a sponge-like tissue containing irregular blood-filled spaces lined by endothelium and separated by connective tissue septa. The corpus spongiosum is one smaller region along the bottom of the penis, which contains the urethra and forms the glans penis.

In some circumstances, release of nitric oxide precedes relaxation of muscles in the corpora cavernosa and corpus spongiosum. The spongy tissue fills with blood, from arteries down the length of the penis. A little blood enters the corpus spongiosum; the remainder engorges the corpora cavernosa, which expand to hold 90% of the blood involved in an erection, increasing both in length and in diameter. The function of the corpus spongiosum is to prevent compression of the urethra during erection.

Blood can leave the erectile tissue only through a drainage system of veins around the outside wall of the corpus cavernosum. The expanding spongy tissue presses against a surrounding dense tissue (tunica albuginea) constricting these veins, preventing blood from leaving. The penis becomes rigid as a result. The glans penis, the expanded cap of the corpus spongiosum, remains more malleable during erection because its tunica albuginea is much thinner than elsewhere in the penis.

TESTICLES

The testicle (from Latin testiculus, diminutive of testis, meaning "witness" [of virility], plural testes) is the male generative gland in human. The testes hang outside the abdominal cavity of the male within the scrotum. They begin their development in the abdominal cavity but descend into the scrotal sacs during the last 2 months of fetal development. This is required for the production of sperm because internal body temperatures are too high to produce viable sperm.

Function

Like the ovaries (to which they are homologous), testes are components of both the reproductive system (being gonads) and theendocrine system (being endocrine glands). The respective functions of the testes are:

producing sperm (spermatozoa)
producing male sex hormones of which testosterone is the best-known
Both functions of the testicle, sperm-forming and endocrine, are under control of gonadotropic hormones produced by the anteriorpituitary:
luteinizing hormone (LH)
follicle-stimulating hormone (FSH)

EPIDIDYMAE

The epididymis (pronounced /ɛpɨˈdɪdɨmɪs/, plural: epididymides /ɛpɨˌdɪdɨˈmiːdiːz/) is part of the male reproductive system and is present in all male mammals. It is a narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens.

The epididymus is a whitish mass of tightly coiled tubes cupped against the testicles. It acts as a storage place for sperm before they enter the vasa deferentia, tubes that carry sperm form the testes to the urethra.

Role in storage of sperm and exhaggeration

Spermatozoa formed in the testis enter the caput epididymis, progress to the corpus, and finally reach the cauda region, where they are stored. Sperm entering the caput epididymis are incomplete - they lack the ability to swim forward (motility) and to fertilize an egg. During their transit in the epididymis, sperm undergo maturation processes necessary for them to acquire these functions.^[1] Final maturation is completed in the female reproductive tract (capacitation).

During ejaculation, sperm flow from the lower portion of the epididymis (which functions as a storage reservoir). They have not been activated by products from the prostate gland, and they are unable to swim, but are transported via the peristaltic action of muscle layers within the vas deferens, and are mixed with the diluting fluids of the seminal vesicles and other accessory glands prior to ejaculation (forming semen).

The epididymis possesses numerous, long atypical microvilli. These processes are often called stereocillia; this is incorrect, as they neither contain the microtubular structures of cilia nor function like cilia.

1: Epididymis
2: Head of epididymis
3: Lobules of epididymis
4: Body of epididymis
5: Tail of epididymis
6: Duct of epididymis
7: Deferent duct (ductus deferens or vas deferens)

reviewed by Bambang Widjanarko

Last Juni 2009

IS PARENTHOOD FOR YOU?

2009-06-29T05:44:00.001+07:00

Posing the question

For some people this is the world's easiest question — they've always been able to see themselves as parents, they have their life set up the way they want it, and they're ready to go. Others go back and forth on this one for years, or feel the need to do a little serious wobbling before taking the plunge. Some just never get the call.

Wherever you are on the spectrum, even if you know you want to do it, you can make a conscious decision about whether to become a parent. And whether you're having trouble deciding whether you want to have a child, or are just wondering whether you're ready to take on this lifelong project, we hope this article will help you get closer to a decision.

One thing's for sure: No one has to have children. The world's not short on people to populate it, and whether to become a parent is completely up to you and whatever hopes and dreams you have for your life.

The hardship factor

Being a parent is really fun, and satisfying in a way you can't fully imagine when you don't have children. And it's really hard work — more work than you can imagine until you've done it.

It's hard because of the sheer volume of demands on your time and energy, with few breaks to refresh and recharge; it's hard because parents almost never have enough time, money, emotional support, training, or preparation to do the job they want to do; it's hard because it puts your own emotional issues squarely in your face as your children inevitably push every button you have; and it's hard because the mistakes you make — and you'll make some, for sure — affect the ones you love the most: your children.

Having a child is a major life change, and because women everywhere bear the major responsibility for raising children, it's a change that in general affects women's lives more than men's. It means adding the way society treats parents (not well) on top of the way society treats women (ditto).

"Parenting — the vitally important job of raising the next generation — is treated economically almost like a hobby," says Patty Wipfler. "Women already don't get enough pay, support, or recognition for their contributions to society, and becoming a parent kind of squares that."

Men as a whole are more involved as parents today than ever before, but the day-to-day housework, meal-making, emotional counseling, childcare, purchasing, and household details and logistics still tend to fall — unpaid — to the woman of the house

That's not to say it's an easy decision for men. Both men and women face unhappy tradeoffs between work and parenthood in modern society, with women usually having to choose parenting to the detriment of work, and men usually having to choose work to the detriment of parenting.

Men's patterns of workaholism, reinforced by most workplaces today, are fueled by a new sense of responsibility for the family. Long hours of work increase the sense of emotional isolation that most men deal with anyway, and many feel frustrated at not being able to be the kind of father they wish they could be.

A reality check

With all the romanticized images of children and parenthood floating around, hardly anyone gets a realistic idea of what it's like to be a parent before they actually become one.

If you never had to carry a 5-pound sack of flour around for a week in junior high, psychologist Harriet Lerner's book The Mother Dance: How Children Change You can serve as an on-paper preview, or you can always get a real-life glimpse by caring for a friend's or relative's baby overnight. Or try assuming you've made the decision to have a child and then spend a week thinking about how that makes you feel and all the ways your life would change; then assume you've decided not to have one and live with that for a week.

Parenthood isn't for everyone. Maybe you've never wanted children; maybe you have other ambitions for yourself that caring for children would make impossible.

"We are this wonderfully creative species," says Mindy Toomay, a fiction and cooking writer and teacher who is entirely comfortable with her decision not to have children. "But so many people never explore their creative or spiritual potential because family demands get in the way. For me it felt like it would be an impediment — it has been for a lot of people I know, particularly women." And certainly there are instances of people becoming parents and then regretting their decision.

Then again, some people are surprised by how much they like being a parent. "I did catering during high school so I wouldn't have to babysit," says Sally Webb, now the mother of two small boys. "But I found I really love being a mom."

Most people, especially women, are brought up to expect that they'll be parents. From baby dolls to baby showers, girls and women are surrounded by images and expectations from parents, peers, religion, advertising, and the media. But the decision to be a parent is not up to your mother, your father, your friends, your church, or even any expectations you might have grown up with. It's your life, and it's up to you.

Are you ready to have a baby?

The following series of questions, developed by our staff with help from San Francisco psychotherapists Ann Davidman and Denise Carlini, is designed for you to discuss with your partner or a friend, mull over on your own, write about in your journal, take to your therapist — whatever helps you take a good look at them.

If you would be having a child with a partner, show these questions to your partner and see whether you would be comfortable with his or her answers. The questions are meant to be answered by both men and women.

"A lot of our work is helping people to understand their ambivalence so they can move on to the next step of making a decision," says Davidman. "We've found that ambivalence can be a result of emotional issues the person isn't completely aware of, such as unresolved grief."

They suggest you start by asking, "What do you want for you?" – regardless of your current situation, regardless of what you might have to go through to get what you want, such as finding a partner if you want one.

If you think you might want a child, don't even ask yourself at this point how that will come about, whether biologically, through adoption, or whatever. Just concentrate on your personal wishes and desires.

Do you spend time with children? Do you enjoy it?
What did you enjoy about being a child? What didn't you enjoy?
What did you appreciate about the parenting you received? What didn't go well?
What messages did you get about what a parent is supposed to be?
How do you feel as you answer these questions?

PRECONCEPTION HEALTH CARE

2009-06-29T05:35:00.001+07:00

Why is a preconception check up important ?
What does agenetic councelor do ?
Why should women of childbearung age take a folic acid ?
What vaccines might a woman need before pregnancy ?
What maternal illness should be treated before pregnancy ?
How long should a woman wait between pregnancies ?
How can preconception care help prevent problem that occurred in past pregnancies ?
What can a woman do to help stay healthy before pregnacy ?
Why should a woman try to achieve a healthy weight before pregnancy ?
References

Preconception health care is care a woman of childbearing age receives before pregnancy or between pregnancies. This type of care looks at biomedical, behavioral and social risk factors that may affect a woman’s health. The goal is to provide information and treatment before pregnancy that can improve a woman’s health and help reduce risks to her future baby.

All women of childbearing age can take steps before they get pregnant to improve their chances of having a healthy, full-term baby. By getting preconception health care, a woman can learn what steps she can take before pregnancy to protect her health and give her baby the best chance to be healthy.

Why is a preconception checkup important?
A preconception checkup can help assure that a woman is as healthy as possible before she conceives. Her provider can identify and often treat health conditions that can pose a risk in pregnancy, such as high blood pressure, diabetes or certain infections. The provider can give her information on things like nutrition, weight, smoking , drinking alcohol and occupational exposures that can pose pregnancy risks. The provider also can make sure a woman’s vaccinations are up to date and that any medications she takes are safe during pregnancy.

The provider can ask a woman about her health history, as well as that of her partner and her family. If the woman or her partner has a history of birth defects or prematurity, or if either has a high risk for a genetic disorder based on family hystory, ethnic background or age, the provider may suggest seeing a genetic concelor.

What does a genetic counselor do?
A genetic counselor discusses the risks for a genetic disease in a couple’s future children. The counselor can arrange blood tests (called carrier tests) that can identify carriers of many genetic diseases. If both parents are carriers of a disease, each child has a 25 percent chance of inheriting the disease. Carrier tests are given for a variety of conditions, including:

Cystic fibrosis CF), a disease of the lungs and digestive system that is most common in Caucasians, but can affect children from many backgrounds
Tay – Sachs disease, which causes fatal brain damage and is more common in people of Eastern European Jewish ancestry and in some non-Jewish individuals of French-Canadian and Cajun ancestry
Sickle cell disease, a blood disorder that mainly affects African-Americans
Thalassemia, a blood disorder that mainly affects those of Mediterranean, African and South Asian descent

Genetic screening and counseling before pregnancy may reassure a couple that their children are not at increased risk for a specific inherited disease. Genetic counseling also allows carriers the opportunity to understand their risk and discuss options. Women who can benefit from genetic counseling include:

Women over age 35
Women who have certain genetic disorders, such as phenylketonuria (PKU)
Women who have had a child with a neural tube defect (NTDs), a birth defect of the brain and spinal cord

Why should women of childbearing age take folic acid?
Folic acid is a B vitamin that can help prevent birth defects, particularly NTDs. Studies show that if all women consumed the recommended amount of folic acid before and during early pregnancy, up to 70 percent of all NTDs could be prevented ^{(1, 2)}. Studies also suggest that folic acid may help prevent some other birth defects, including cleft lip and palate and some birth defects involving the heart ⁽¹⁾. A recent study also suggests that women who take folic acid for a least 1 year before becoming pregnant may reduce their risk of having a premature baby ⁽⁴⁾.

To prevent NTDs, most clinicians recommends that all women who could become pregnant take a multivitamin containing 400 micrograms of folic acid every day starting before pregnancy, along with eating healthy foods. This advice, based on recommendations from the Institute of Medicine (IOM) ⁽³⁾, assures that a woman gets all the folic acid and other vitamins she needs.

A woman also can get folic acid by eating a serving of folic acid-enriched cereal every day that contains 100 percent of the daily value (DV) of folic acid (400 micrograms). Healthy food choices include foods that are fortified with folic acid and foods that contain folate, the natural form of folic acid found in foods. Many grain products, including flour, rice, pasta, bread and cereals, are fortified with folic acid. Folate-rich foods include green leafy vegetables, dried beans, legumes, oranges and orange juice.

A woman who has had a pregnancy affected by an NTD should take a higher dose of folic acid. Taking a higher dose of folic acid daily (4,000 micrograms or 4 milligrams), beginning at least 1 month before pregnancy and in the first trimester of pregnancy, reduces by about 70 percent the risk of having another affected pregnancy ⁽⁵⁾. Women with diabetes or epilepsy and women who are obese are at increased risk of having a baby with an NTD ⁽¹⁾. Women with these conditions should consult their providers before pregnancy about taking a larger dose of folic acid.

What vaccines might a woman need before pregnancy?
At a preconception visit, the health care provider may do a blood test to see if a woman is immune to rubella (German measles) and chickenpox. Both of these diseases can cause birth defects and other complications if a woman gets them during pregnancy.

If a woman is not immune, she should be vaccinated before pregnancy. She should then wait 1 month after vaccination before attempting to get pregnant.

Women who are at high risk for hepatitis B (such as health care workers) and have not been vaccinated for it should consider getting the hepatitis B vaccine before or during pregnancy. This disease can be passed on to the baby during delivery. A provider also may recommend other vaccines, such as the flu shot.

What maternal illnesses should be treated before pregnancy?

Diabetes: Women with poorly controlled diabetes that started before pregnancy are about 3 times more likely than women without diabetes to have a baby with a serious birth defect (6). They also are at increased risk for miscarriage and stillbirth and for having a baby that is very large. Controlling blood sugar before pregnancy and during the first few months of pregnancy can help prevent birth defects.
High blood pressure: Chronic high blood pressure can increase the risk of pregnancy complications, including placental problems (solusio placenta), poor fetal growth and preeclampsia (a pregnancy-related disorder characterized by high blood pressure and protein in the urine).
Systemic lupus erythematosus (SLE): This autoimmune disorder can cause arthritis-like symptoms, kidney disease, skin rashes and other problems. Affected pregnant women are at increased risk for miscarriage, poor fetal growth, preterm labor and stillbirth ⁽⁷⁾ . However, if symptoms are well controlled before pregnancy, the risk of these complications is reduced.
Seizures: Some seizure control medications increase the risk of birth defects. During a preconception visit, a provider may adjust a woman’s dose or switch her to a drug that is safer for the fetus. A woman should not stop taking seizure medication without asking her provider, as seizures themselves might harm a fetus.
PKU: Women with this inherited condition cannot process certain proteins. They must eat a special diet and be carefully monitored before and during pregnancy to prevent mental retardation and birth defects in their offspring ⁽⁶⁾.
Kidney disease: Some women with severe kidney disease may suffer additional kidney damage during pregnancy, and their babies may be at increased risk for death, premature delivery or poor growth ⁽⁷⁾.

How long should a woman wait between pregnancies?
For most women, it’s best to wait at least 18 months before getting pregnant again. This gives a woman’s body enough time to get ready physically for another pregnancy. It also gives her time to adjust to life as a mom. Shorter time intervals between pregnancies may increase the risk of premature birth ⁽⁸⁾ . However, not all women can wait 18 months because of their age or other reasons. A woman should talk to her health care provider to determine the right amount of time for her.

How can preconception care help prevent problems that occurred in past pregnancies?
Even if a woman has not had problems in a previous pregnancy, preconception care can help prevent birth defects or pregnancy complications in a future pregnancy. For example, taking folic acid can help prevent NTDs, and treatment of certain health conditions, such as high blood pressure, can help prevent premature delivery. A 2006 report from the Centers for Disease Control and Prevention (CDC) recommends that all women who have had a previous pregnancy that ended in an adverse outcome receive evaluation and treatment between pregnancies to reduce the risk in future pregnancies ⁽⁶⁾.

Preconception care is important for women who have had a miscarriage, stillbirth or premature delivery. The health care provider can review a woman’s medical record and may recommend tests to help determine the cause of an adverse outcome. The tests may include blood tests and imaging tests, such as ultrasound. If tests show that a health problem in the woman may have contributed to the outcome, treatment between pregnancies often can reduce the risk of the problem recurring in another pregnancy. If a woman had a previous premature delivery, the provider may recommend lifestyle changes, such as quitting smoking, and discuss the possibility of treatment with the hormon progesterone during her next pregnancy to help reduce the risk of another premature delivery.

What can a woman do to help stay healthy before pregnancy?
A woman should:

Avoid alcohol. Drinking alcohol during pregnancy can cause physical and mental birth defects called fetal alcohol syndrome (FAS). Because no amount of alcohol has been proven safe in pregnancy, pregnant women and women considering becoming pregnant should avoid it entirely.
Quit smoking. Smoking during pregnancy nearly doubles the risk for having a low-birthweight baby. It also increases the risk for premature delivery, other pregnancy complications and sudden infant death syndrome (SIDS) (9). Smoking also may make it more difficult to conceive ⁽⁹⁾ .
Stay away from cocaine and other illicit drugs and prescription drugs not prescribed for her. These drugs pose many risks, including premature delivery, low birthweight , birth defects, learning or behavioral problems, and withdrawal symptoms.
Fully cook all meat and don’t change a cat’s litter box. Undercooked meat and cat feces can contain a parasite that causes an infection called toxoplasmosis, which can cause birth defects. Another way to avoid cat feces is to wear gloves when working in the yard or garden.
Avoid contact with all rodents, including pet hamsters, mice and guinea pigs. These animals can carry a virus that can harm your baby ⁽¹⁰⁾ .
Avoid sitting in hot tubs and saunas. These may elevate body temperature and, possibly, increase the risk for NTDs ⁽¹⁾ .
Avoid hazardous chemicals, such as solvents (substances that dissolve other substances, like paint thinner). Working with solvents may increase a woman’s risk for miscarriage or having a baby with birth defects ⁽¹¹⁾.
Avoid eating fish that can be high in mercury. Mercury is a metal that can harm an unborn baby; it often is found in fish. Pregnant women and women considering pregnancy should not eat fish that are high in mercury, like shark, swordfish, king mackerel and tilefish ⁽¹²⁾ . These women can eat up to 12 ounces per week of fish that are low in mercury, including shrimp, salmon, pollock, catfish and canned light tuna. They should eat no more than 6 ounces of albacore (white) tuna per week. Women should always check with their local health department before eating any fish they catch themselves ⁽¹²⁾ .

Why should a woman try to achieve a healthy weight before pregnancy?
Women who begin pregnancy overweight or obese may be at increased risk of having high blood pressure and diabetes, having a baby with certain birth defects, having labor and delivery complications, and having a stillborn baby ^{(6, 7)} . They also may have more difficulties becoming pregnant ⁽¹³⁾. Women who are underweight may be at increased risk of having a premature or low-birthweight baby ⁽⁷⁾ . A woman can help reduce her risk for these complications by attaining a healthy weight before pregnancy.

References

Centers for Disease Control and Prevention (CDC). Folic Acid: Frequently Asked Questions. Updated 1/30/08.
Berry, R.J., et al. Prevention of Neural Tube Defects with Folic Acid in China. New England Journal of Medicine, volume 341, number 20, November 11, 1999, pages 1485-1490.
Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes: Folate, Other B Vitamins, and Choline. Washington, D.C., National Academy Press, April 7, 1998.
Bukowski, R., et al. Preconception Folate Prevents Preterm Delivery (abstract). American Journal of Obstetrics and Gynecology, Special Supplement, Society for Maternal and Fetal Medicine 28th Annual Meeting, volume 197, number 6, December 2007.
Centers for Disease Control and Prevention (CDC). Folic Acid: PHS Recommendations. Updated 7/26/05.
Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR). Preconception Care Work Group and the Select Panel on Preconception Care. Recommendations to Improve Preconception Health and Health Care – United States. Morbidity and Mortality Weekly Reports, volume 55, no. RR-6, April 21, 2006.
American College of Obstetricians and Gynecologists (ACOG). Your Pregnancy and Birth, 4th edition. ACOG, Washington, DC, 2005.
Conde-Agudelo, A., et al. Birth Spacing and Risk of Adverse Perinatal Outcomes. Journal of the American Medical Association, volume 295, number 15, April 19, 2006, pages 1809-1823.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General – 2004. Office on Smoking and Health, Atlanta, GA..
Centers for Disease Control and Prevention (CDC). Lymphocytic Choriomeningitis Virus (LCMV) and Pregnancy: Facts and Prevention. Updated 9/20/06. .
Khattak, S., et al. Pregnancy Outcome Following Gestational Exposure to Organic Solvents. Journal of the American Medical Association, March 24/31 1999, volume 281, number 12, pages 1106-1109.
U.S. Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA). What You Need to Know About Mercury in Fish and Shellfish. Accessed 5/4/06.
American Society for Reproductive Medicine. Patient’s Fact Sheet: Weight and Fertility. Revised 8/01, accessed 5/8/06.

Reviewed by Bambang Widjanarko, 0bstetrician&gynecologist

Juni 2009

FEMALE REPRODUCTIVE SYSTEM

2009-06-29T05:16:00.001+07:00

The female reproductive system contains two main parts:

The uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the male's sperm through to the fallopian tubes; and
The ovaries, which produce the female's egg cells.

The vagina meets the external organs at the vulva, which includes the labia, clitoris and urethrae. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes.

At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviduct, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the uterus, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina.

The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation.

THE FEMALE EXTERNAL GENITAL ORGAN

THE FEMALE INTERNAL GENITAL ORGAN

1: fallopian tube, 2: bladder, 3: pubic bone, 4: g-spot, 5: clitoris, 6: urethra, 7: vagina, 8: ovary, 9:sigmoid colon, 10: uterus, 11: fornix, 12: cervix, 13:rectum, 14: anus

VAGINA :

The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female .
The vagina is the place where semen semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the vagina from infection and is a sign of puberty.

CERVIX :

The cervix (or neck of the uterus) is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri". Cervix means neck in Latin.

Anatomi cervix :

Ectocervix

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is 3 cm long and 2.5 cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips.

External os

The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.

Endocervical canal

The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures 7 to 8 mm at its widest in reproductive-aged women.

Internal os

The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.

Cervical crypts

There are pockets in the lining of the cervix known as cervical crypts. They function to produce cervical fluid.

UTERUS :

The uterus (Latin word for womb) is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during gestation. The term uterus is used consistently within the medical and related professions; the Germanic term,womb is more common in everyday usage. The plural of uterus is uteruses or uteri.

One end, the cervix, opens into the vagina; the other is connected on both sides to the Fallopian tubes.

FALLOPIAN TUBE :

The Fallopian tubes, named after Gabriel Fallopius (Gabriele Fallopio), also known as oviducts, uterine tubes, and salpinges (singular salpinx) are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into theuterus.

There are two Fallopian tubes attached to either side of the cornual end of the uterus at the axilla of Welch. Each terminates at or near one ovary forming a structure called the fimbria.

The Fallopian tubes are not directly attached to the ovaries, but open into the peritoneal cavity (essentially the inside of the abdomen); they thus form a direct communication between the peritoneal cavity and the outside via the vagina. In human, the Fallopian tubes are about 7–14 cm long.

If a Fallopian Tube is missing from the pair, then the other fallopian tube that is functional could still be a way of carrying an egg down to the uterus.

Regions

There are four regions of the fallopian tube from the ovary to the uterus:^[1]

Infundibulum - contains fimbria
Ampulla - usual site of fertilization
Isthmus
Intramural oviduct - inside wall of uterus

OVARIES

The ovary is an ovum-producing reproductive organ, often found in pairs as part of the female reproductive system. Ovaries in females are homologous to testes in males, in that they are both gonads and endocrine glands.

Ovaries are oval shaped and, in the human, measure approximately 3 cm x 1.5 cm x 1.5 cm (about the size of a Greek olive). The ovary (for a given side) is located in the lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of the ureter and the internal iliac artery.

Each ovary is then attached to the fimbria of the fallopian Tube. Usually each ovary takes turns releasing eggs every month; however, if there was a case where one ovary was absent or dysfunctional then the other ovary would continue providing eggs to be released.

Hormones

Ovaries secrete both Estrogen and Progesterone. Estrogen is responsible for the appearance of secondary sex characteristics of females at puberty and for the maturation and maintenance of the reproductive organs in their mature functional state. Progesteronefunctions with Estrogen by promoting cyclic changes in the endometrium (it prepares the endometrium for pregnancy), as well as by helping maintain the endometrium in a healthy state during pregnancy.

Reviewed by Bambang Widjanarko, Obstetrician & Gynecologist

Last Juni 2009