Pregnancy

Placenta previa is when your placenta lies unusually low in a woman's uterus, next to or covering her cervix. This can cause severe bleeding during pregnancy and during or after delivery.

Once the fertilised embryo implants itself in the uterus, the placenta grows wherever the implantation occurs. Thus, if the embryo implants itself in the lower portion of the uterus, the placenta might grow over the cervix.

Women develop a higher risk for placenta previa if any of the following applies:

• They have had previous surgery to their uterus, for example, a C-section, or removal of growths in the uterus (fibroids) or any other operation involving the uterus
• They have delivered before
• They have had placenta previa before
• Women who smoke
• Women who are older than 35

The main sign of placenta previa is bright red vaginal bleeding, usually without pain in the second half of the pregnancy. The bleeding can be light or heavy. It is common for the bleeding to stop on its own, but it usually returns. It should be noted that there are other causes of bleeding during pregnancy, but if bleeding happens without pain, the chances it could be placenta previa are high. Placenta previa can be diagnosed with an ultrasound test. This test will show the placenta and where it is located within the womb. Also, if a woman bleeds during her pregnancy, especially in the second half, placenta previa can be suspected, and she will need an ultrasound to assess the baby and placenta.

Complications may include major haemorrhage (bleeding from the mother), shock from blood loss, foetal distress from lack of oxygen, premature labour or delivery, health risks to the baby if born prematurely, emergency C-section, hysterectomy if the placenta fails to come away from the uterine lining, blood loss for the baby and possible death.

The chances of having placenta previa are higher if one has had it before, compared to women who have never had it. However, most women who develop placenta previa experience it during their first pregnancy.

The method of treatment will depend on how severe the placenta previa is, i.e., to what extent does the placenta cover the opening of the cervix. Other treatment factors include how much bleeding has occurred, how far along the pregnancy is, and the general health of the mother and the baby. It is advisable to avoid sex or insert anything into the vagina and avoid strenuous activity. Treatment options include:

1. Bed rest: If there is little or no bleeding, the doctor may recommend bed rest at home. In some cases, mothers may need to lie in bed most of the time, whether at home or in hospital. Sitting and standing is done only when necessary.
2. Hospital admission: If bleeding is heavy, hospital admission is required. Other measures may be taken, such as monitoring the mother and baby's heart rates, monitoring the mother's blood pressure, and monitoring how much blood is lost. Fluids may be given intravenously. Some women might need to stay in the hospital until they give birth, but others can go home when the bleeding stops. Most of the time, pregnant women will also receive iron tablets if blood loss is significant and steroid medicines to help the baby's lungs develop faster in case of the need for an early delivery.
3. C-section: If the bleeding does not stop, even after admission and bed rest, or if the baby starts to suffer distress, then urgent delivery is needed by a C-section, even if the baby is premature.

The risk can be reduced by not smoking, but most other causes of placenta previa cannot be changed. It is a rare, unpreventable condition.

The procedure has changed over the years, with complications now a rare occurrence. Instead of seven days, women used now stay for just three. In most cases, a spinal block is used (anaesthetic injected below the spinal column into the spinal fluid) rather than a general anaesthetic. Each doctor has their own preferred way of performing a C-section, and they will assess their patients on a case-by-case basis to determine the best way to proceed.

There are a few standard elements that a woman should expect:

• You will meet your anaesthetist either before you go to theatre or as you are wheeled in
• Your anaesthetist will give you a breakdown of what will happen and ask a few general questions, including pertaining to your personal and family medical history.
• A drip will be inserted into your arm, and you will then be given a local anaesthetic in the area where the spinal block will be inserted.
• After three or four minutes, you will be given the spinal block
• You will then be asked to lie down, and after about five minutes, you will begin to feel a tingling sensation in your toes, and you will feel numb from the waist down
• A catheter will be inserted after this, saving you the discomfort
• Once you are prepped, your gynaecologist will start the procedure. You are now ready to welcome your bundle of joy into the world. It may take 10 – 20 minutes until you have your baby in your arms
• Once the baby has been delivered, the paediatrician will check your baby while the doctors complete the operation.
• Maintaining a healthy weight and being fit before and during the pregnancy could have an effect on the procedure itself and how well you recover. It is easier for the anaesthetist to perform the spinal block if a woman is not overweight. Further, women who pick up a lot of weight during pregnancy increase their risk of infection post-op since the wound can start gaping to allow excess fluid out. Finally, it is also important to have support at home as recovery is likely to be quicker if the mother is mobilised but not overdoing it.

Before being taken to the operating theatre for the C-section, a mom will be told what to expect. There are a number of doctors, assistants, and nurses in the theatre and, since space is limited, the mom is usually only allowed to have her husband or birth partner with her – although exceptions are made in special cases. Midwives and doulas are also allowed. The gynaecologist performs the C-section, which is a fairly quick and painless procedure, although the mom may feel some pulling. Most doctors and hospitals will now support the mom in doing immediate skin-on-skin contact with their babies if that is what they want, and they will be able to breastfeed soon after.

The size of the bump depends on several factors, including the amount of weight gained during pregnancy and a mother's weight gain during pregnancy. Further, women whose stomach muscles are not very strong because of a previous pregnancy or lack of exercise tend to carry bigger bumps compared to moms who are fit and have strong stomach muscles to hold their bump in. Finally, after a C-section, it is important to note that if a woman still has a bump after her baby is born, it is not because her stomach muscles have been cut but rather that she has to give her uterus time to shrink back to its normal size before she can expect to see any results.

Some pregnant women start snowing owing to:

• Weight gain
• Water retention
• Softer and swollen nasal cavities from hormonal changes
• Your baby pushing against your diaphragm
• When hormones and weight return to normal after birth, it is likely that the snoring will stop.

During pregnancy, a woman's metabolism increases, and she generates more heat and will therefore naturally sweat more. The intense physical exertion during birth and combined with a woman's high metabolism, cause a lot of sweating. For around six weeks after birth, while a woman's body works hard to release retained water, she may sweat even more.

At the end of a normal pregnancy, the cervix starts effacing and dilating owing to uterus contractions. An incompetent cervix usually effaces and dilates in the second trimester because of growing pregnancy pressure. It opens prematurely, and a late miscarriage occurs. An incompetent cervix can account for an estimated 10 – 15% of miscarriages that occur after 12 weeks.

The condition exists in 2 – 5% of women, and because it has been diagnosed more frequently in recent years, it can be treated more often. Other than painless, nonspecific contractions, there are no signs which suggest the cervix is likely to open, so diagnosis relies on catching the dilation early. Cervical incompetence is diagnosed based on the patient's history. At every check-up, we measure the cervix. If it is less than 2cm long (it should be 2 – 2.5cm long), there is a possibility that the cervix is incompetent. If a scan is done and shows amniotic fluid coming into the cervix, that also confirms it. Once cervical incompetence is diagnosed, a cervical cerclage (stitch) will be carried out to prevent the cervix from opening further – or to pull it closed. The cervical stitch is usually done between 12 and 16 weeks, as that is when cervical incompetence starts manifesting. The procedure is carried out under general anaesthetic, which is not harmful to the baby. It is typically done as a day-patient procedure followed by two days of bed rest. There is not much pain beyond mild cramping or an awareness of the stitch.

To avoid local trauma after the stitch is done, sex is not advised for a while. Progesterone tablets are usually prescribed for the mom to prevent contractions, and the woman is advised to take it easy for the rest of her pregnancy. Some moms are placed on permanent bed rest to relieve pressure on the cervix.

Cervical cerclage is usually effective, with only a 10% failure rate. In around 30% of cases, labour will be delayed until pregnancy has advanced a little – preferably to the point that the baby will have a fighting chance. In around 60% of cases, the stitch holds the cervix closed until the end of the pregnancy.

No medication is completely safe during pregnancy. Some can affect a baby's nervous system or cause premature labour. If a patient is on antidepressants, it is important for the gynaecologist to consult with the prescribing doctor or psychiatrist to get guidance on whether they are able to stop or not. Some patients can have a severe relapse, which can put them and their pregnancy at risk. Depending on how severe the depression is, doctors will generally try to keep the mother on some form of medication because symptoms can worsen in the first trimester.

Before they fall pregnant, women should see their gynaecologists and psychiatrists. If they fall pregnant without consultation, they should make an appointment to see them as soon as possible. Whichever approach the mother chooses in consultation with her doctors, her pregnancy will be treated as high-risk. If she is on medication, she will be advised to have regular visits with her gynaecologist and regular consultations with a psychiatrist. At around 20 weeks, she will typically visit a foetal medicine specialist to scan the baby for problems with the nervous system or brain fluid. Again, it is strongly advised that women on antidepressants see their gynaecologist and psychiatrist when they consider falling pregnant or once they know they are pregnant.