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Wednesday, May 22, 2013
- It is in the breech position at 37 weeks pregnant?
- I'm starting my tenth week, and my doctor could not pick up the baby's heartbeat?
- My amniotic fluid is "borderline low"? What is the acceptable range for amniotic fluid measurement (I believe mine was 11.69)? Aside from increasing my hydration, is there anything else I can do, or should be concerned about?
- There is blood in my urine sample?
- My blood pressure reading goes up?
- I have a small amount of black discharge after sex?
- I have a jello-like discharge as large as a fingernail?
- I'm having twins and one "baby is lagging"?
- I measure too large?
- I'm having contractions at 5 months?
- My appetite is decreasing as the baby grows?
- I notice a lack of fetal movement after 20 weeks?
About three percent of babies at term and in labor are in the breech position. The vast majority of these babies are normal, healthy babies who just decided not to turn to the head-down (cephalic) position. There are uncommon causes of breech presentation including Down's Syndrome, anencephaly, neuromuscular disorders or the shape of your uterus.
There is still a good chance your baby will be cephalic at the time of labor. In one study of women who attempted and failed external version (pushing on the baby to flip the baby's head down), 20% had cephalic babies when they went into labor.
The earliest a fetal heartbeat can be heard is ten weeks, but that doesn't mean that every fetus will be heard at ten weeks. Depending on the position of the uterus, placement of the placenta and size of the patient, one may not hear a heartbeat until weeks later.
The amniotic fluid is usually measured as the sum of the largest vertical pocket in the four quadrants of the uterus (with the bellybutton as the center). Normal is generally 7-8cm at the low end and 24-28cm at the upper end. If yours was 11.69cm at 35 weeks, you are ok. Hydration and bedrest on the left side can increase fluid.
The treatment for oligohydramios (decreased amniotic fluid) depends on the cause, severity and gestational age. The most common cause is rupture of the membranes. If the pregnancy has progressed past 34-36 weeks, one might consider delivery. At an earlier gestational age, watchful waiting (assuming no other problems) could be advised until a more advanced gestational age is appropriate. Fetal stress can lead to decreased blood flow to the fetal kidneys resulting in a decreased urine production and therefore decreased fluid. If this is felt to be the case, then measures like bedrest to help promote blood flow while waiting for fetal maturity are appropriate. When it is felt that delivery is safer than the stressful environment, induction of labor is considered. A detailed ultrasound may be performed to look for any problems with the development of the fetal kidneys that would decrease urine production. In many cases the cause of low fluid isn't known. Often times, a repeat scan after increasing fluid intake may show that this was a transient event that can be watched with repeat scans. If a cause is not found and the pregnancy is near term, induction of labor is again considered.
Protein and leukocytes in urine is very common in pregnancy. As a clean catch becomes technically more difficult to obtain in pregnancy, you are more likely to get leukocytes and protein contamination from the vagina. If they persist, and are more than just trace amounts, your doctor may send a sample for culture to see if a bladder infection exists. Blood in the urine is less common, but can occur if there is any vaginal bleeding. If the bleeding persists, a workup should be done to look for the cause. Although a bladder infection can cause blood in the urine, antibiotics shouldn't be blindly given without a culture or symptoms. Other causes could be kidney stones, kidney disease, or inflammation/irritation of the bladder. If persistent without a known cause, a consult with a urologist or nephrologist may be necessary.
Pre-eclampsia is defined as hypertension with the loss of protein in the urine and/or swelling in the hands or face (not the legs) in a pregnancy of greater than 20 weeks. The diagnosis isn't always that cut and dry. Often, many other factors go into the diagnosis of pre-eclampsia. Even the definition of hypertension has been changing. Current literature suggests that a blood pressure reading greater than 140/90 mmHg is considered hypertension, although women have had pre-eclampsia complications without this level of elevation. Some medications such as labetalol or hydralazine are commonly used to control severe hypertension that could be harmful to the mom and baby. Others such as the angiotensin converting enzyme inhibitors can be harmful.
Early in pregnancy the cervix (opening to the womb) is often delicate and can bleed after intercourse or a vaginal exam. Over time the discharge will become darker as it is old blood. Worrisome bleeding is heavy and associated with cramping. You should avoid intercourse until your obstetrician can determine that there is no serious cause for your bleeding.
During pregnancy there is an increase in the mucous secretions for the vaginal or cervical areas. These secretions are often thick, white and acidic. These secretions will accumulate in the cervical canal and form a mucous plug. This plug stays in place until the cervix begins to efface and dilate. If you are pregnant and ready to deliver, you may be passing part of your mucous plug. However, there could be another cause of this discharge including an infection. Some of the most common types of infections are: Trichomoniasis which is often asymptomatic in women. If there is a discharge it is usually yellow-green, frothy and odorous. Chlamydia has a thin or purulent drainage. Gonorrhea is usually asymptomatic, but may have a purulent, greenish-yellow discharge. Candidiasis (yeast) often has a thick white curdy discharge with severe itching.
"Lagging growth" or discordant growth for twins is defined as a difference in fetal weight of more than 15-20%, depending on institution. Although I cannot calculate a difference in weight from the data you gave me, I do not think there is a significant difference if there is an actual difference at all. Ultrasound has an approximately 15% error is measurement. The reason that comparative twin growth is important is that a large difference in their weights may be a sign of impending stillbirth of one of the twins. While this has traditionally been a concern in twins with one sac, it is also seen in twins with two sacs.
Measuring "large for dates" can indicate several things. For convenience sake, I will list them.
The most common thing is that everything is fine and you are just measuring larger than expected. Fundal height (the measurement done at each visit) is inexact.
This may be several things including normal uterine activity or fetal movement. The biggest concern is if this is preterm (or early) labor. The general rule of thumb is if you are having more than 4 contractions an hour that are not relieved with sitting/lying down, you should seek medical attention immediately.
It is very common to have a decreased appetite in the latter part of pregnancy. As the fetus grows, it compresses the stomach giving you a sensation of feeling full earlier than usual. The hormonal changes in pregnancy also slow down the mechanical functions of your stomach and intestines. Many pregnant women benefit from eating several smaller meals/snacks rather than the traditional three large meals. Your doctor follows your weight gain with each visit and this is an important number to follow to assure that you are getting adequate calories and nutrition for the fetus.
Fetal movement will usually be felt regularly after the 20th week of pregnancy. Any change in fetal movement (other than a 1-2 hour sleep cycle that some fetuses have) should be discussed with your physician. Decreased or absent fetal movement may be a sign of fetal distress.
Kick tests (fetal movement counts) are used to monitor fetal wellbeing. You should monitor fetal movements (not just kicks) over a period of time (30-60 minutes). There is no right or wrong number of movements. You are trying to establish a baseline of fetal movements for your baby. A significant decline in fetal movements is an indicator that more specific tests of fetal wellbeing need to be performed. Most women who need more specific tests have normal testing. Fetal movement tests are best if performed after about 28 weeks.
Last Reviewed: May 28, 2002
Arthur T Ollendorff, MD
Associate Professor of Obstetrics and Gynecology
College of Medicine
University of Cincinnati