Antenatal Check

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Antenatal Check-Up

Fetal abnormalities can be detected through antenatal checks during antenatal visits. Depending onmother's family history, medical background, previous pregnancies and age, your doctor may recommenda range of tests deemed suitable.

Routine Tests :

At your initial visit, your caregiver will take a blood sample and feel your abdomen; at this and subsequentvisits your blood pressure (BP) and urine will be assessed. Most often, hospitals and clinics scheduleappointments every 4 weeks until week 28, then it becomes every 2 weeks until week 36 and then weekly.

Blood And Urine Tests

Blood test is taken to check blood group, hemoglobin levels (to check for anemia) and immunity to rubella (apostnatal vaccination will be given if you are not immune). This blood test also checks for Aids, syphilis, diabetes,hepatitis and rhesus status. The blood pressure reading taken at your first visit will be used as a barometer to

measure subsequent readings. It is normal for your BP to be higher in the later part of pregnancy. Urine is checkedfor ketones, protein and glucose.The presence of

ketones affects the transportation of oxygen in the blood protein indicates preeclampsia or some infection Ultrasound scanning The scan is pain-free and there

is no risk of miscarriage. It is routinely done at 16-18 weeks. High pitched sound waves are reflectedback off the baby and replicated electronically as an image on a screen. It confirms dates and multiplepregnancies, detects abnormalities and placental position.

Special Tests

Most of these tests are optional; you are not obliged to have them. Your decision should be based onsound judgment; you must understand what is being offered and why, and also the risks involved. Finallyyou should consider the possibility of the results being positive and whether or not to terminate thepregnancy. Support and counseling services are available in case of such an outcome.

Transvaginal Scan

Carried out from 5-6 weeks, a probe is inserted into the vagina giving a clear vi ew of the developing baby. Advantages - results are instantDisadvantages - baby is exposed to high frequency sound

CVS (Chrorionic Villus Sampling)

Detects chromosomal and genetic disorders such as Downs's syndrome and sickle cell anemia. A tube is insertedinto the uterus at 8-12 weeks and cells are taken from placental tissue surrounding the embryo.

Advantages - very accurate and preliminary results within 48 hoursDisadvantages - risk of miscarriage (roughly 1 in 100)

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Nuchal Test

Non-invasive ultrasound scan carried out at 12 weeks to detect chromosomal disorders. 'Nuchal' means neck: thescan checks for abnormal thickness in the fold at the back of the baby's neck. When combined with a blood test, thistest is 80-90% accurate in predicting Down's syndrome.

Advantages - non invasive and no risk of miscarriageDisadvantages - none

AFP (Alpha-Fetoprotein Test)

Blood test that checks blood protein levels and neurological problems such as spina bifida or hydrocephalus. It iscarried out at weeks 15-18. Accuracy is not good: high and low levels of alpha-fetoprotein can be found in womencarrying healthy fetuses and those who are very nauseous. Results take about 10 days.

Advantages - non invasive with no side effectsDisadvantages - 50% accuracy, false positive rate of 5-10%

Amniocentesis

Sample of amniotic fluid taken under local anesthesia through the abdominal wall at 16 -18 weeks to test for disorderssuch as Down's syndrome. Results in 2-3 weeks

Advantages - accuracy of 90%; reveals baby's gender which is important with some disordersDisadvantages - risk of miscarriage (less than 1 in 100); discomfort, side effects such as bleeding, infection; screensfew defects

Triple/Quadruple/Leeds/Bart's Tests

Combination of blood tests to assess risk of chromosomal defects or problems such as anencephaly (absence of abrain) or spina bifida.

Advantages - no risk of miscarriageDisadvantages - accuracy between 60 - 80%

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What is an ultrasound scan?

An ultrasound scan in pregnancy is a painless procedure that uses high frequency sound waves to

produce a two-dimensional black and white image. This image can help identify possible problems with

your pregnancy or baby.

Your ultrasound will be performed by a sonographer (a health professional qualified to perform ultrasound

scans). It can take from 10 to 40 minutes to complete.

A gel is applied to your abdomen to allow sound waves to pass from the ultrasound probe into the uterus.

The ultrasound probe is moved over your abdomen and an ultrasound image is produced by the reflection

of the sound waves off the baby. Your bladder should be comfortably full to get a clear image.

When deciding whether or not to have an ultrasound scan in pregnancy, it is important that you

understand the purpose and limitations of the procedure.

What are the benefits of having a routine ultrasound scan in pregnancy?

Knowing your dates

An ultrasound scan provides a reliable indication of how many weeks pregnant you are.

Reliable dating is important for a number of reasons:

* If you choose to have screening for Down syndrome or spina bifida, it is important to

perform these screenings at certain dates in the pregnancy.

* If you go into labour prematurely, knowing your dates will help assist the doctors with

the type of support your baby may require when he/she is born.

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* At the end of your pregnancy, having a clear indication of the duration will prevent

unnecessary induction of labour or increased risks with prolonged pregnancy when

dates are assumed to be less than expected.

Bonding

It is now well recognised that seeing your baby on an ultrasound scan can assist with parent and infant

bonding.

Having a routine ultrasound scan in pregnancy

Dealing with any problems

It is an advantage to identify a problem during the pregnancy for a number of reasons:

* You will have time to receive adequate counselling and preparation prior to the birth and may

experience less anxiety after the birth.

* You will have the opportunity to research the problem and look at your options.

* You may have the opportunity to decide whether you wish to continue with the pregnancy.

* Surgery or other treatment can be planned for immediately after birth if required.

* Your carers will be well informed and prepared so that a plan can be put in place.

* You can plan the most appropriate place and type of birth.

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At what stages of pregnancy should ultrasound scans be performed?

Dating ultrasound scan at 6 to 14 weeks

The purpose of a dating ultrasound scan in pregnancy is to:

* confirm how many weeks pregnant you are and obtain an accurate due date. If you have an irregular

cycle, or have recently taken hormonal contraception, your last menstrual period will not be an accurate

method for estimating your due date. It is therefore advisable to have an early ultrasound scan to

determine this. Late ultrasound scans have reduced accuracy when estimating due dates

* determine the number of babies you are carrying

* check your baby is growing in the correct place i.e. not an ectopic pregnancy, which develops outside

the uterus

* diagnose missed miscarriage

* check you babys development

* diagnose any uterine abnormalities which may pose a problem for pregnancy or birth, i.e. fibroids,

ovarian cysts or an unusual shape to your uterus.

Mid-pregnancy ultrasound scan at 18 to 22 weeks

The purpose of a mid-pregnancy ultrasound scan is to:

* confirm how many weeks pregnant you are if you have not had an early ultrasound scan (although it is

less reliable at this stage of pregnancy)

* identify any structural abnormalities with the baby

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* locate your placenta

* monitor the growth of your baby

* assess the volume of fluid around your baby.

Having a routine ultrasound scan in pregnancy

What are the limitations of having an ultrasound scan in pregnancy?

* The accuracy can depend on your weight, the stage of your pregnancy, position of your baby,

visibility/type of abnormality, equipment used and the skill of the sonographer.

* An ultrasound scan cannot detect every possible problem or abnormality.

* As with all screening tests, there is a potential for false positive or false negative results. This means

that some women can be told that there may be a problem when there is not, and some will be falsely

reassured that everything is well.

* Some findings of minor physical problems can be found in unaffected pregnancies/babies finding

these unusual variants may cause considerable anxiety for you until the end of your pregnancy.

Is ultrasound in pregnancy safe?

Ultrasound scanning has been used in pregnancy for nearly three decades. There has been no proven

association between ultrasound exposure in pregnancy and possible harmful effects to your baby.

Apparent ill-effects reported in small studies have not been confirmed or substantiated in larger

randomised controlled trials.

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uideline on the Use of Ultrasound in Pregnancy

The use of ultrasound in pregnancy

The use of ultrasound has become widespread in obstetric practice in Malaysia. It isavailable in nearly all government hospitals and is being used by all private gynaecologistsand several general practitioners. It is used to determine gestational age, detection ofmultiple pregnancies and foetal anomalies. Its lack of risk of exposure has encouraged allpractitioners to use ultrasound freely and routinely without indication.

This increase in use has raised concerns regarding the safety, usefulness and necessities ofultrasound in pregnancy. These concerns prompted the Perinatal Society of Malaysia tosponsor a consensus workshop by inviting the Malaysian Society of Ultrasound in Medicine

and the Obstetrical and Gynaecological Society of Malaysia to participate and arrive at someconsensus in 4 areas. The Workshop was held on 17 th June, 1995 in Kuala Lumpur and apanel of experts was initiated. Their names are listed in the acknowledgement.

The 4 areas where consensus were arrived at were:

1. The role of routine ultrasound in pregnancy. 2. The role of ultrasound for specific indications and a guideline on the indications. 3. The training aspects of the ultrasonographer. 4. The safety of ultrasound.

1. The role of routine ultrasound in pregnancy in Malaysia

The panel felt that it is useful that all pregnancies be scanned at about 20 weeks ofgestation although some of the literature (which can be criticised) state that there is nosignificant advantage in perinatal outcome . 1 The members of the panel felt that in theMalaysian context, there is still a high preponderance of pregnant women who are unsure ofdates, and having accurate dating by ultrasound is vital for obstetric management. There isalso some value in establishing foetal well-being, in detecting foetal anomalies, in detectingmultiple pregnancies, in diagnosing abnormal placental sites and in detecting pelvic masses.

If pregnant women were to receive ultrasound examinations by indications only then it isestimated that at least 70% of women would receive at least one scan 2 and therefore itseems inappropriate that the remaining 30% should be denied an ultrasound examination.

The committee also agreed that prior to an ultrasound examination, patients should beinformed of the clinical indication, the benefits and the limitations of the ultrasound findingsshould be made. The patients are entitled to a written report and the minimum informationon this should include:

The baseline ultrasound should examine

1. Foetal number. 2. Cardiac activity.

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3. Gestational age.

biparietal diameter femur length

4. Placental localisation. 5. Adequacy of amniotic fluid. 6. Gross pelvic masses

The information on this should include a disclaimer stating that it is acceptable that thereare limitations in the procedure. Ultrasound examination performed solely to satisfy theparents wishes to detect foetal sex, or to view the foetus should be actively discouraged.

2. The role of ultrasound for specific indications

There is no doubt that ultrasound is useful in certain clinical situations. The indications arelisted below.

Indications for ultrasonography during pregnancy:

1. Estimation of gestational age for patients with uncertain clinical dates or significantuterine size/clinical dates discrepancy.

2. Evaluation of foetal growth. 3. Vaginal bleeding of undetermined aetiology in pregnancy. 4. Determination of foetal presentation. 5. Suspected multiple pregnancy. 6. Adjunct to amniocentesis or special procedures. 7. Pelvic mass. 8. Suspected hydatidiform mole. 9. Suspected ectopic pregnancy. 10. Suspected foetal death. 11. Suspected uterine abnormality. 12. Intrauterine contraceptive device localisation. 13. Biophysical evaluation of foetal well-being. 14. Suspected polyhydramnios or oligohydramnios. 15. Suspected abruptio placentae. 16. Adjunct to external version from breech to vertex presentation. 17. Estimation of foetal weight and/or presentation, in premature rupture of membranes

and/or preterm labour. 18. Abnormal maternal serum alpha-foetoprotein value. 19. Follow-up observation of identified foetal anomaly. 20. Follow-up evaluation of placental location for identified "placenta-praevia". 21. History of previous congenital anomaly. 22. Serial evaluation of foetal growth in multiple gestation.

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For detailed ultrasound the panel felt that there are facilities in certain obstetric units inMalaysia for detailed anomaly scans. The indications for referral for such scans aredependent on the clinicians judgement. The possible indications are listed below.

All patients may be advised to have an anomaly ultrasound and appropriate diagnosticprocedure based on the following indication(s):

1. Risk based on history.

previous affected child family history

2. Risk based on maternal conditions.

diabetes congenital heart disease

3. Risk based on foetal conditions.

breech multiple pregnancy liquor volume abnormalities

i. oligohydramnios ii. polyhydramnios

discrepancy between dates and uterine size

i. small for gestational age

ii. large for gestational age

4. Risk based on investigations.

abnormal maternal serum AFP triple test suspected anomaly on ultrasound

5. Follow-up anomaly ultrasound. 6. Patients who request for anomaly scan at 20 weeks.

The panel emphasised that there are limitations to an anomaly ultrasound and a detailedultrasound only allows the detection of structural anomalies and not all anomalies will bedetected. Hence, a reported normal ultrasound does not necessarily guarantee a normalbaby (both structural and chromosomal). Patients should be made fully aware of this.

In case of suspected foetal compromise, ultrasound can be used for foetal assessment.Methods available include biophysical methods and doppler.

In transvaginal ultrasound, verbal consent prior to the procedure should be obtained.Transvaginal scan should be used where indicated and these include:

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i. First trimester problems which are difficult to assess. ii. Placenta praevia.

iii. Adnexal masses.

3. The training aspects of the ultrasonographer

The level of expertise required in ultrasound scanning can be divided into 3 levels, i .e. level1, level 2 and level 3. The objectives and requirements are as below:

Level 1 (Basic)

Objectives:

1. To understand the basic functions of the ultrasound scanner and its optimumutilisation.

2. Reliably confirm viable pregnancy using abdominal scanning. 3. Make accurate measurements to assess gestation age in first and early second

trimester including CRL, BPD, HC, FL, AC.

4. Diagnose multiple pregnancy. 5. Establish foetal presentation. 6. Assessment of liquor volume AFI/single pool. 7. Exclude placenta praevia.

Requirements:

Attendance at one basic course and the remainder in an accredited hospital by members ofa board run by Obstetrical & Gynaecological Society or Ultrasound in Medicine or PerinatalSociety of Malaysia or senior members of the Obstetrics department of the accreditedhospital.

Perform 100 ultrasound scans under supervision with a logbook consisting of 30 casescomprising of the following:

1. Ability to do mid and late pregnancy scans and to obtain appropriatemeasurements for gestational age.

2. Ability to come to a conclusion regarding viability and maturity in earlypregnancy problems.

3. Identify common adnexal masses. 4. Ability to scan for assessment of liquor volume.

Level 2 (Intermediate)

Objectives:

1. Detailed scanning of the mid-trimester foetus (routine). 2. Detection of foetal anomalies at any gestation including basic foetal echo. 3. Doppler studies and its application in obstetrics. 4. Application of transvaginal scanning (TVS) in pregnancy. 5. Amniocentesis.

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Requirements:

Attended accredited intermediate and/or advanced courses.1 year experience after basic level accreditation and incorporation into postgraduate trainingprogrammes.

Master in Obstetrics and Gynaecology. Post MRCOG in accredited hospitals.

Level 3 (Advanced)

Objectives:

1. Ability to do advanced procedures for foetal diagnosis and therapy. 2. Provide second or expert opinion in doubtful cases. 3. Provide training for Level 1 and Level 2 courses.

Requirements:

1. Attended accredited courses e.g. RCOG/RCR in Foetal Medicine for 1 year oraccredited local courses.

2. Scholarship in recognised Foetal Medicine training centres abroad.

e.g.

DDU (Australia) RCOG/RCR course accreditation MMed (Foetal Medicine) Birmingham

4. The safety of ultrasound

Any consideration in the use of diagnostic ultrasound in obstetrics must weigh the benefitsagainst the potential risks. The safety of ultrasound in pregnancy is dependent on theenergy delivered to a target such as the foetus which varies with the ultrasound frequency,intensity, duration of exposure and the distance of the transducer from the target. Mosttransducers used in diagnostic ultrasonography procedures emit energies less than 20mW/cm at the transducer face. This is far below the arbitrary hazard level of ultrasoundexposure to tissues, which is more than 100mW/cm.

However, specialised ultrasonographic investigations, like pulsed doppler, can have energyoutput levels which may reach up to 100mW/cm. Hence the use of pulsed dopplerespecially transvaginal colour doppler should be related to special circumstances only and tothe shortest duration possible. Transvaginal scans have been in use increasingly over thepast few years. There is no added risk in its use when compared to the abdominal scan,despite concerns regarding the proximity of the transducer to the foetus.

In general, ultrasound exposure at intensities usually produced by diagnostic ultrasoundinstruments has not been found to cause any harmful biological effects on the foetus orpregnant woman. However, the judicious use of ultrasound in pregnancy is theresponsibility of the operator. Also, the operator is responsible for completing theexamination in as short a duration as possible, using scan modes and power outputs which

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result in energy exposure which are as low as reasonably achievable. As such, the operatorshould be well-versed with the equipment as well as being adequately trained. In relation todoppler ultrasonography, its use should be limited to centres with operators of at leastintermediate or level 2 training.

tetanus toxoid - injection

GENERIC NAME: TETANUS TOXOID - INJECTION (TET-a-nus TOX-oyd)

USES: This medication is given to provide protection (immunity) agains ttetanus (lockjaw) in adultsand children 7 years or older. Vaccination is the best way to protect against this life-threateningdisease. Vaccines work by causing the body to produce its own protection (antibodies). Tetanusvaccine is usually first given to infants with 2 other vaccines for diphtheria and whoopingcough (pertussis) in a series of 3 injections. This medication is usually used as a "booster" vaccineafter this first series. Closely follow the vaccination schedule provided by the doctor.Boosterinjections may be needed at the time of injury in older children and adults if it has been 5-10 yearssince the last tetanus vaccine was received. Booster injections should also be given every 10 yearseven if no injury has occurred. This injection or an injection with tetanus/diphtheria ortetanus/diphtheria/pertussis may be used for the booster.

HOW TO USE: Read the Vaccine Information Statement available from your health care providerbefore receiving the vaccine. If you have any questions, consult your health care provider.This

medication is given by injection into a muscle by a health care professional, usually into the upperarm or upper thigh.This medication should not be given to people who currently have aninfection/illness. If possible, schedule the vaccination later after the illness is over.

SIDE EFFECTS: Mild fever , joint pain, muscle aches, nausea, tiredness, orpain /itching /swelling/redness at the injection site may occur. Acetaminophen may be used to reducethese effects. If any of these effects persist or worsen, tell the doctor or pharmacistpromptly.Remember that the doctor has prescribed this medication because he or she has judgedthat the benefit is greater than the risk of side effects. Most people using this medication do not haveserious side effects.Tell the doctor immediately if any of these rare but very serious side effects

occur: tingling of the hands/feet, hearing problems, trouble swallowing, muscle weakness,seizures.A very serious allergic reaction to this drug is rare. However, seek immediate medicalattention if you notice any symptoms of a serious allergic reaction, including: rash , itching/swelling(especially of the face/tongue/throat), severe dizziness , trouble breathing.This is not a complete listof possible side effects. If you notice other effects not listed above, contact your doctor orpharmacist.Contact your doctor for medical advice about side effects. The following numbers do notprovide medical advice, but in the US, you may report side effects to the Vaccine Adverse Event

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Reporting System (VAERS) at 1-800-822-7967. In Canada, you may report side effects to HealthCanada at 1-866-234-2345.PRECAUTIONS: Before you or your child receives this vaccination, tell the doctor or pharmacist ifyou or your child is allergic to it; or to any other vaccines; or if you or your child has any otherallergies. This product may contain inactive ingredients (such as latex), which can cause allergicreactions or other problems. Talk to your pharmacist for more details.This medication should not beused if you or your child has certain medical conditions. Before using this medicine, consult thedoctor or pharmacist if you or your child has: history of severe reaction to vaccine (e.g.,paralysis ,encephalopathy ).Before using this medication, tell the doctor or pharmacist your or yourchild's medical history, especially of: bleeding disorders (e.g. ,hemophilia , low platelets), historyof Guillain-Barre syndrome , high fever (higher than 103 degrees F/39 degrees C) after previousvaccination, other reaction (e.g., swelling, itching at injection site) after previous vaccination, immunesystem disorders (e.g., autoimmune disorders, radiation treatment), illness/infection, seizures, othernervous system disorders (e.g., paralysis, numbness/tingling, extreme drowsiness, confusion).Thismedication may contain mercury (in the preservative thimerosal) and should not be used in children

younger than 7 years.During pregnancy , this medication should be used only when clearly needed.Discuss the risks and benefits with your doctor.It is not known whether this drug passesinto breast milk. Consult your doctor before breast-feeding.DRUG INTERACTIONS : Your doctor or pharmacist may already be aware of any possible druginteractions and may be monitoring you or your child for them. Do not start, stop, or change thedosage of any medicine before checking with the doctor or pharmacist first.Before you or your childreceives this vaccine, tell the doctor or pharmacist of all prescription and nonprescription/herbalproducts you or your child may use, especially of: "blood thinners" (e.g., warfarin ), corticosteroids(e.g., hydrocortisone ,prednisone ), cancer chemotherapy, drugs that weaken the immune system(e.g., cyclosporine, efalizumab , tacrolimus ), other recent/planned vaccinations (e.g.,

diphtheria/tetanus toxoids).This document does not contain all possible interactions. Therefore,before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of allyour medications with you, and share the list with your doctor and pharmacist.OVERDOSE: If overdose is suspected, contact your local poison control center or emergency roomimmediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canadaresidents can call a provincial poison control center.NOTES: There are various combinations of vaccines available. Based on you or your child's age,medical condition, and any previous reactions to vaccines, the health care professional will decidewhich vaccine to use. Discuss the risks and benefits of vaccination with the health care provider.History of infection with tetanus does not protect against future infections with this bacteria. You or

your child should still receive this vaccine if the doctor orders it.MISSED DOSE: It is important to receive each vaccination as scheduled. Be sure to make a note ofwhen the vaccination was last given for your/your child's medical record.STORAGE: Not applicable. This vaccine is given in a doctor's office or clinic and will not be stored athome.

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Tetanus facts Tetanus is frequently a fatal infectious disease.

Tetanus is caused by a type of bacteria ( Clostridium tetani ). The tetanus bacteria often enter the body through a puncture wound , which can be caused by

nails, splinters, insect bites, burns, any skin break, and injection-drug sites.

All children and adults should be immunized against tetanus by receiving vaccinations. A tetanus booster is needed every 10 years after primary immunization or after a puncture or

other skin wound which could provide the tetanus bacteria an opportunity to enter the body.

What is tetanus?Tetanus is an acute, often-fatal disease of the nervous system that is caused by nerve toxinsproduced by the bacterium Clostridium tetani . This bacterium is found throughout the world in the soiland in animal and human intestines.

Where do tetanus bacteria grow in the body?Contaminated wounds are the sites where tetanus bacteria multiply. Deep wounds or those withdevitalized (dead) tissue are particularly prone to tetanus infection.

Puncture wounds, such as those caused by nails, splinters, or insect bites, are favorite locations ofentry for the bacteria. The bacteria can also be introduced through burns , any break in the skin, andinjection-drug sites. Tetanus can also be a hazard to both the mother and newborn child (by meansof the uterus after delivery and through the umbilical cord stump).

The potent toxin that is produced when the tetanus bacteria multiply is the major cause of harm in

this disease.

How does the tetanus toxin cause damage to the body?The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates.This region is called the neuromuscular junction. The tetanus toxin amplifies the chemical signalfrom the nerve to the muscle, which causes the muscles to tighten up in a continuous ("tetanic" or"tonic") contraction or spasm. This results in either localized or generalized muscle spasms . Tetanustoxin can affect neonates to cause muscle spasms, inability to nurse, and seizures. This typicallyoccurs within the first two weeks after birth and can be associated with poor sanitation methods incaring for the umbilical cord stump of the neonate. Of note, because of tetanus vaccinationprograms, there have only be a few cases of neonatal tetanus reported in the U.S. since 1990, andin each of these cases, the mothers were incompletely immunized. Worldwide, however, neonataltetanus is still, unfortunately, common.

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What is the incubation period for tetanus?The incubation period between exposure to the bacteria in a contaminated wound and developmentof the initial symptoms of tetanus ranges from two days to two months, but it's commonly within 14days of injury.

What is the course of the tetanus disease? What are the symptoms andsigns of tetanus?During a one- to seven-day period, progressive muscle spasms caused by the tetanus toxin in theimmediate wound area may progress to involve the entire body in a set of continuous musclecontractions. Restlessness, headache , and irritability are common.

The tetanus neurotoxin causes the muscles to tighten up into a continuous ("tetanic" or "tonic")contraction or spasm. The jaw is "locked" by muscle spasms, giving the name "lockjaw" (also called"trismus "). Muscles throughout the body are affected, including the vital muscles necessary for

normal breathing. When the breathing muscles lose their power, breathing becomes difficult orimpossible and death can occur without life-support measures. Even with breathing support,infections of the airways within the lungs can lead to death.

What is the treatment for tetanus?Comment on this Share Your Story

General measures to treat the sources of the bacterial infection with antibiotics and drainage arecarried out in the hospital while the patient is monitored for any signs of compromised breathingmuscles. Treatment is directed toward stopping toxin production, neutralizing its effects, and

controlling muscle spasms. Sedation is often given for muscle spasm, which can lead to life-threatening breathing difficulty.

In more severe cases, breathing assistance with an artificial respirator machine may be needed.

The toxin already circulating in the body is neutralized with antitoxin drugs. The tetanus toxin causesno permanent damage to the nervous system after the patient recovers.

After recovery, patients still require active immunization because having the tetanus disease doesnot provide natural immunization against a repeat episode.

How is tetanus prevented? Active immunization ("tetanus shots") plays an essential role in preventing tetanus. Preventativemeasures to protect the skin from being penetrated by the tetanus bacteria are also important. Forinstance, precautions should be taken to avoid stepping on nails by wearing shoes. If a penetratingwound should occur, it should be thoroughly cleansed with soap and water and medical attention

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should be sought. Finally, passive immunization can be administered in selected cases (withspecialized immunoglobulin ).

What is the schedule for active immunization (tetanus shots)? All

children should be immunized against tetanus by receiving a series of five DTaPvaccinations which generally are started at 2 months of age and completed at approximately 5 yearsof age. Booster vaccination is recommended at 11 years of age with Tdap.Follow-up booster vaccination is recommended every 10 years thereafter. While a 10-year period ofprotection exists after the basic childhood series is completed, should a potentially contaminatedwound occur, an "early" booster may be given in selected cases and the 10 years "clock" reset.

What are the side effects of tetanus immunization?Side effects of tetanus immunization occur in approximately 25% of vaccine recipients. The mostfrequent side effects are usually quite mild (and familiar) and include soreness, swelling, and/or

redness at the site of the injection. More significant reactions are extraordinarily rare. The incidenceof this particular reaction increases with decreasing interval between boosters.

What is passive immunization (by way of specialized immunoglobulin)?In individuals who exhibit the early symptoms of tetanus or in those whose immunization status isunknown or significantly out of date, the tetanus immunoglobulin (TIG) is given into the musclesurrounding the wound with the remainder of the dose given into the buttocks.

Syntocinon (oxytocin)

How does it work?Syntocinon injection contains a synthetic version of the naturally-occurring hormone oxytocin. It works in the sameway as the natural hormone.

Oxytocin is normally released by the pituitary gland in the brain towards the end of pregnancy to stimulate the smoothmuscle of the uterus (womb). The oxytocin causes the muscle of the uterus to contract during labour so that the babycan be pushed out.

Synthetic oxytocin is used to induce labour for medical reasons, or if labour has not started naturally. The dose of themedicine is adjusted until the contractions produced are in a similar pattern to that of normal labour.Synthetic oxytocin can also be used to stimulate labour that has started naturally, but is considered too weak to pushout the baby. In this case the medicine strengthens the contractions of the uterus.

After the baby has been born, Syntocinon may be given to stimulate contractions that help push out the placenta andprevent heavy bleeding.Syntocinon is given as a drip into a vein.

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What is it used for? Starting (inducing) labour. Stimulating labour when the contractions are considered too weak. Preventing or controlling heavy bleeding following delivery of the child (post-partum

haemorrhage). During caesarian section following delivery of the child.

Management of certain types of miscarriage .

Warning! Syntocinon should not be started if you have been given a vaginal prostaglandin in the previous six hours. The frequency, strength and length of contractions, as well as the baby's heartbeat, will all need to be monitored

while you receive this medicine. If high doses of this medicine are needed over a long period of time it may cause too much water to be retained in

your body and the concentration of sodium in your blood to drop. Your doctor or midwife will take various measures

to avoid this and may restrict the amount of fluid you can drink.

Use with caution in Women over 35 years of age. Women with a small pelvis for whom vaginal delivery may be difficult. Women who have previously had a caesarian section. Heart disease. High blood pressure caused by pregnancy (pre-eclampsia). Situations when the womb begins to contract less strongly.

Not to be used in Women having unusually strong uterine contractions. Cases where the baby is short of oxygen (foetal distress). Cases where there is an obstruction that would prevent vaginal delivery. Situations when inducing labour is inadvisable or vaginal delivery is not possible, for example, if the baby is in the

wrong position, or if the woman has a low lying placenta (placenta praevia), a very small pelvis, or a scar on thewomb from a previous caesarian section.

Syntocinon should not be used for prolonged periods if: your contractions do not increase with the treatment

you have severe pre-eclamptic toxaemia (high blood pressure, protein in the urine and swelling) you have severe problems with your heart or blood circulation.This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor orpharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacistimmediately.

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Pregnancy and breastfeedingCertain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safelyused in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby.

Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine. This medicine is widely used to start labour. This medicine may pass into breast milk in small amounts, but will not have any harmful effect when you breastfeed

your newborn baby, because it will be rapidly inactivated in the baby's gut.

Side effectsMedicines and their possible side effects can affect individual people in different ways. The following are some of theside effects that are known to be associated with this medicine. Just because a side effect is stated here does notmean that all people using this medicine will experience that or any side effect.

Common (affect between 1 in 10 and 1 in 100 people) Headache. Nausea and vomiting. Slow or fast heartbeat. Bleeding.

Uncommon (affect between 1 in 100 and 1 in 1000 people) Irregular heartbeats (arrhythmias).

Rare (affect between 1 in 1000 and 1 in 10,000 people) Skin rashes. Allergic reaction associated with shortness of breath, low blood pressure (causing dizziness, lightheadedness,

feeling faint) or shock (blood pressure too low to maintain blood supply to the tissues). Increased risk of blood clots in the blood vessels following the birth of the baby.

Some women may experience spasm of the muscles of the womb at what would normally be considered low doses. A dose that is too high may cause very strong contractions of the womb that could result in tearing of the womb ortissue damage. It could also result in distress, suffocation or death of the baby.If high doses of this medicine together with large amounts of fluid are given over long periods of time, waterintoxication and low levels of sodium in the blood may occur. (Symptoms include headache, loss of appetite, nausea,vomiting, abdominal pain, lethargy, drowsiness, unconsciousness and seizures.)The side effects listed above may not include all of the side effects reported by the medicine's manufacturer.

For more information about any other possible risks associated with this medicine, please read the informationprovided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?Your doctor or midwife will make sure that all medicines given during labour are compatible.Prostaglandins increase the effect of oxytocin and vice-versa. Syntocinon should not be started if you have beengiven a vaginal prostaglandin in the previous six hours. If you are given oxytocin after a prostaglandin yourcontractions should be carefully monitored.If oxytocin is given during or after an epidural it may enhance the blood pressure raising effect of medicines given to

constrict the blood vessels.Some inhaled anaesthetics used for general anaesthesia (cyclopropane or halothane) may reduce the effect ofoxytocin. There may also be an increased risk of a drop in blood pressure and abnormal heart beats if oxytocin isgiven with these general anaesthetics.

Other medicines containing the same active ingredientThere are currently no other medicines available in the UK that contain oxytocin alone.Syntometrine contains oxytocin in combination with ergometrine.

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Syntocinon syntocinon) Injection, Solution

[Sandoz Pharmaceuticals Corporation ]

Syntocinon (oxytocin) injection, USP

Caution: Federal law prohibits dispensing without prescription.

DESCRIPTION

Syntocinon (oxytocin) is a synthetic, (1-6) cyclic nonapeptide. Chemically, oxytocin is

designated as Glycinamide, L-cysteinyl-L-tyrosyl-L-isoleucyl-L-glutaminyl-L-asparaginyl-

L-cysteinyl-L-prolyl- L-leucy1-, cyclic (1-6)-disulfide.

The structural formula is:

Syntocinon (oxytocin) injection is provided as a sterile solution for intravenous or

intramuscular administration. Each 1 mL of solution contains 10 USP or International

Units of oxytocin and the following inactive ingredients:

acetic acid, NF, qs to ....................... pH 4 0.3

alcohol, USP............................ 0.61 % by vol.

chlorobutanol, NF ..........,................... 0.5%

sodium acetate, USP ...,........................ 1 mg

sodium chloride, USP ........................ 0.017 mg

water for injection, USP, qs to ..................... 1 mL

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CLINICAL PHARMACOLOGY

The pharmacologic and clinical properties of Syntocinon (oxytocin) are identical with

the naturally occurring oxytocic principle of the posterior lobe of the pituitary.

Syntocinon (oxytocin) injection does not contain the amino acids characteristic ofvasopressin, and therefore has fewer and less severe cardiovascular effects.

Syntocinon (oxytocin) exerts a selective action on the smooth musculature of the

uterus, particularly toward the end of pregnancy, during labor and immediately following

delivery. Oxytocin stimulates rhythmic contractions of the uterus, increases the

frequency of existing contractions, and raises the tone of the uterine musculature.

Syntocinon (oxytocin), when given in appropriate doses during pregnancy, is capable

of eliciting graded increases in uterine motility from a moderate increase in the rate andforce of spontaneous motor activity to sustained tetanic contraction.

Syntocinon (oxytocin) is promptly effective after parenteral administration. Following

intramuscular injection, the myotonic effect on the uterus appears in 3-7 minutes, and

persists for 30-60 minutes. With intravenous injection, the uterine effect appears within

1 minute and is of more brief duration.

INDICATIONS AND USAGE

Important Notice

Syntocinon (oxytocin) injection is indicated for the medical rather than the elective induction of labor. Available

data and information are inadequate to define the benefits to risk considerations in the use of the drug product for

elective induction. Elective induction of labor is defined as the initiation of labor for convenience in an individual

with a term pregnancy who is free of medical indications.

Antepartum

Syntocinon (oxytocin) is indicated for the initiation or improvement of uterine

contractions, where this is desirable and considered suitable, in order to achieve early

vaginal delivery for fetal or maternal reasons. It is indicated for (1) induction of labor in

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patients with a medical indication for the initiation of labor, such as Rh problems,

maternal diabetes, pre-eclampsia at or near term, when delivery is in the best interest of

mother and fetus or when membranes are prematurely ruptured and delivery is

indicated; (2) stimulation or reinforcement of labor, as in selected cases of uterine

inertia; (3) as adjunctive therapy in the management of incomplete or inevitable

abortion. In the first trimester, curettage is generally considered primary therapy. In the

second trimester abortion, oxytocin infusion will often be successful in emptying the

uterus. Other means of therapy, however, may be required in such cases.

Postpartum

Syntocinon (oxytocin) injection is indicated to produce uterine contractions during the

third stage of labor and to control postpartum bleeding or hemorrhage.

CONTRAINDICATIONS

Syntocinon (oxytocin) injection is contraindicated in any of the following conditions:

Significant cephalopelvic disproportion; unfavorable fetal positions or presentations

which are undeliverable without conversion prior to delivery (transverse lies); i.e., in

obstetrical emergencies where the benefit-to-risk ratio for either the fetus or the mother

favors surgical intervention; in cases of fetal distress where delivery is not imminent;

prolonged use in uterine inertia or severe toxemia; hypertonic uterine patterns; patients

with hypersensitivity to the drug; induction or augmentation of labor in those cases

where vaginal delivery is contraindicated, such as cord presentation or prolapse, total

placental previa, and vasa previa.

WARNINGS

Syntocinon (oxytocin), when given for induction or stimulation of labor, must be

administered only by the intravenous route and with adequate medical supervision in a

hospital.

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PRECAUTIONS

General

All patients receiving intravenous oxytocin must he under continuous observation bytrained personnel with a thorough knowledge of the drug and qualified to identify

complications. A physician qualified to manage any complications should be

immediately available.

When properly administered, oxytocin should stimulate uterine contractions similar to

those seen in normal labor. Overstimulation of the uterus by improper administration

can be hazardous to both mother and fetus. Even with proper administration and

adequate supervision, hypertonic contractions can occur in patients whose uteri arehypersensitive to oxytocin.

Except in unusual circumstances, oxytocin should not be administered in the following

conditions: prematurity, borderline cephalopelvic disproportion, previous major surgery

on the cervix or uterus including cesarean section, over-distention of the uterus, grand

multiparity, or invasive cervical carcinoma. Because of the variability of the

combinations of factors which may be present in the conditions listed above, the

definition of unusual circumstances must be left to the judgment of the physician. Thedecision can only be made by carefully weighing the potential benefits which oxytocin

can provide in a given case against rare but definite potential for the drug to produce

hypertonicity or tetanic spasm.

Maternal deaths due to hypertensive episodes, subarachnoid hemorrhage, rupture of

the uterus, and fetal deaths due to various causes have been reported associated with

the use of parenteral oxytocic drugs for induction of labor or for augmentation in the first

and second stages of labor.

Oxytocin has been shown to have an intrinsic antidiuretic effect, acting to increase

water reabsorption from the glomerular filtrate. Consideration should, therefore, be

given to the possibility of water intoxication, particularly when oxytocin is administered

continuously by infusion and the patient is receiving fluids by mouth.

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Drug Interactions

Severe hypertension has been reported when oxytocin was given 3-4 hours following

prophylactic administration of a vasoconstrictor in conjunction with caudal block

anesthesia. Cyclopropane anesthesia may modify oxytocin's cardiovascular effects, so

as to produce unexpected results such as hypotension. Maternal sinus bradycardia with

abnormal atrioventricular rhythms has also been noted when oxytocin was used

concomitantly with cyclopropane anesthesia.

Carcinogenesis, Mutagenesis, Impairment of Fertility

There are no animal or human studies on the carcinogenicity and mutagenicity of this

drug, nor is there any information on its effect on fertility.

Pregnancy

Teratogenic Effects

Animal reproduction studies have not been conducted with oxytocin. There are no

known indications for use in the first trimester of pregnancy other than in relation to

spontaneous or induced abortion. Based on the wide experience with this drug and its

chemical structure and pharmacological properties, it would not be expected to present

a risk of fetal abnormalities when used as indicated.

Nonteratogenic Effects

See ADVERSE REACTIONS in the fetus or infant.

Labor and Delivery

See INDICATIONS AND USAGE.

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Nursing Mothers

Syntocinon (oxytocin) may be found in small quantities in mother's milk. If a patient

requires the drug postpartum to control severe bleeding, she should not commence

nursing until the day after Syntocinon (oxytocin) has been discontinued.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

ADVERSE REACTIONS

The following adverse reactions have been reported in the mother: Anaphylactic

reaction, Postpartum hemorrhage, Cardiac arrhythmia, Fatal afibrinogenemia, Nausea,

Vomiting, Premature ventricular contractions, and Pelvic hematoma.

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity,

spasm, tetanic contraction, or rupture of the uterus.

The possibility of increased blood loss and afibrinogenemia should be kept in mind

when administering the drug.

Severe water intoxication with convulsions and coma has occurred, associated with a

slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced

water intoxication has been reported.

The following adverse reactions have been reported in the fetus or infant:

Due to induced uterine motility: Bradycardia, Premature ventricular contractions and

other arrhythmias, Permanent CNS or brain damage, and Fetal death.

Due to use of oxytocin in the mother: Low Apgar scores at 5 minutes. Neonatal jaundice, and Neonatal retinal hemorrhage.

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DRUG ABUSE AND DEPENDENCE

There is no evidence that Syntocinon (oxytocin) has been abused or has provoked

drug dependence.

OVERDOSAGE

Overdosage with oxytocin depends essentially on uterine hyperactivity, whether or not

due to hypersensitivity to this agent. Hyperstimulation with strong (hypertonic) or

prolonged (tetanic) contractions, or a resting tone of 15-20 mm H 2O or more between

contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal

lacerations, postpartum hemorrhage, uteroplacental hypoperfusion, and variable

deceleration of fetal heart, fetal hypoxia, hypercapnia, or death. Water intoxication with

convulsions, which is caused by the inherent antidiuretic effect of oxytocin, is a serious

complication that may occur if large doses (40-50 mL/minute) are infused for long

periods. Treatment of water intoxication consists of discontinuation of oxytocin,

restriction of fluid intake, diuresis, IV hypertonic saline solution, correction of electrolyte

imbalance, control of convulsions with judicious use of a barbiturate, and special

nursing care for the comatose patient.

DOSAGE AND ADMINISTRATION

Dosage of oxytocin is determined by uterine response. The following dosage

information is based upon the various regimens and indications in general use.

Parenteral drug products should be inspected visually for particulate matter and

discoloration prior to administration, wherever solution and container permit.

A. Induction of Stimulation of Labor

Intravenous infusion (drip method) is the only acceptable method of administration for

the induction or stimulation of labor.

Accurate control of the rate of infusion flow is essential. An infusion pump or other such

device and frequent monitoring of strength of contractions and fetal heart rate are

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necessary for the safe administration of oxytocin for the induction or stimulation of labor.

If uterine contractions become too powerful, the infusion can be abruptly stopped, and

oxytocin stimulation of the uterine musculature will soon wane.

1. An intravenous infusion of non-oxytocin containing solution should be started.

Physiologic electrolyte solution should be used except under unusual circumstances.

2. To prepare the usual solution for infusion, the contents of one 1-mL ampul are combined

aseptically with 1,000 mL of non-hydrating diluent. The combined solution, rotated in the

infusion bottle to insure thorough mixing, contains 10 mU/mL. Add the container with

dilute oxytocin solution to the system through use of a constant infusion pump or other

such device, to control accurately the rate of infusion.

3. The initial dose should be no more than 1-2 mU/minute. The dose may be gradually

increased in increments of no more than 1-2 mU/minute, until a contraction pattern hasbeen established which is similar to norma1 labor.

4. The fetal heart rate, resting uterine tone, and the frequency, duration, and force of

contractions should be monitored.

5. The oxytocin infusion should be discontinued immediately in the event of uterine

hyperactivity or fetal distress. Oxygen should be administered to the mother. The mother

and the fetus must be evaluated by the responsible physician.

B. Control of Postpartum Uterine Bleeding1. Intravenous Infusion (Drip Method): To control postpartum bleeding, 10-40 units of

oxytocin may be added to 1,000 mL of a non-hydrating diluent and run at a rate

necessary to control uterine atony.

2. Intramuscular Administration : 1 mL (10 units) of oxytocin can be given after delivery of

the placenta.

C. Treatment of Incomplete or Inevitable Abortion

Intravenous infusion with physiologic saline solution, 500 mL, or 5% dextrose in

physiologic saline solution to which 10 units of Syntocinon (oxytocin) have been added

should be infused at a rate of 20-40 drops/minute.

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PreeclampsiaDefinitionPreeclampsia is defined as high blood pressure and excess protein in the urine after 20 weeks of

pregnancy in a woman who previously had normal blood pressure. Even a slight increase in blood

pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious even fatal complications for both you and your baby.

If you have preeclampsia, the only cure is delivery of your baby. If you're diagnosed with preeclampsia

too early in your pregnancy for delivery to be an option, you and your doctor face a challenging task. Your

baby needs more time to mature, but you need to avoid putting yourself or your baby at risk of serious

complications.

SymptomsPreeclampsia can develop gradually but often starts abruptly, after 20 weeks of pregnancy. Preeclampsia

may range from mild to severe. If your blood pressure was normal before your pregnancy, signs and

symptoms of preeclampsia may include:

High blood pressure (hypertension) 140/90 millimeters of mercury (mm Hg) or greater documented

on two occasions, at least six hours but no more than seven days apart

Excess protein in your urine (proteinuria)

Severe headaches

Changes in vision, including temporary loss of vision, blurred vision or light sensitivity

Upper abdominal pain, usually under your ribs on the right side

Nausea or vomiting

Dizziness

Decreased urine output

Sudden weight gain, typically more than 2 pounds (0.9 kilogram) a week

Swelling (edema), particularly in your face and hands, often accompanies preeclampsia. Swelling isn't

considered a reliable sign of preeclampsia, however, because it also occurs in many normal pregnancies.

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When to see a doctor

Contact your doctor immediately or go to an emergency room if you have severe headaches, blurred

vision or severe pain in your abdomen.

Because headaches, nausea, and aches and pains are common pregnancy complaints, it's difficult toknow when new symptoms are simply part of being pregnant and when they may indicate a serious

problem especially if it's your first pregnancy. If you're concerned about your symptoms, contact your

doctor.

CausesPreeclampsia used to be called toxemia because it was thought to be caused by a toxin in a pregnant

woman's bloodstream. This theory has been discarded, but researchers have yet to determine whatcauses preeclampsia. Possible causes may include:

Insufficient blood flow to the uterus

Damage to the blood vessels

A problem with the immune system

Poor diet

Other high blood pressure disorders during pregnancy Preeclampsia is classified as one of four high blood pressure disorders that can occur during pregnancy.

The other three are:

Gestational hypertension. Women with gestational hypertension have high blood pressure, but no

excess protein in their urine. Some women with gestational hypertension eventually develop

preeclampsia.

Chronic hypertension. Chronic hypertension is high blood pressure that appears before 20 weeks of

pregnancy or lasts more than 12 weeks after delivery. Usually, chronic hypertension was present but

not detected before pregnancy.

Preeclampsia superimposed on chronic hypertension. This condition occurs in women who have

chronic high blood pressure before pregnancy who then develop worsening high blood pressure and

protein in the urine during pregnancy.

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Risk factorsPreeclampsia develops only during pregnancy. Risk factors include:

History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing

the condition.

First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy.

New paternity. Each pregnancy with a new partner increases the risk of preeclampsia over a second or

third pregnancy with the same partner.

Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than 40.

Obesity. The risk of preeclampsia is higher if you're obese.

Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or othermultiples.

Prolonged interval between pregnancies. This seems to increase the risk of preeclampsia.

Diabetes and gestational diabetes. Women who develop gestational diabetes have a higher risk of

developing preeclampsia as the pregnancy progresses.

History of certain conditions. Having certain conditions before you become pregnant such as

chronic high blood pressure, migraine headaches, diabetes, kidney disease, rheumatoid arthritis or lupus

increases the risk of preeclampsia.

Other possible factors

Researchers are studying whether these factors may be associated with a higher risk of preeclampsia:

Having other health conditions. There's some evidence that both urinary tract infections and

periodontal disease during pregnancy are associated with an increased risk of preeclampsia, which may

indicate that antibiotics could play a role in prevention of preeclampsia. More study is needed.

Vitamin D insufficiency. There's also some evidence that insufficient vitamin D intake increases the risk

of preeclampsia, and that vitamin D supplements in early pregnancy could play a role in prevention. Morestudy is needed.

High levels of certain proteins. Pregnant women who had high levels of certain proteins in their blood

or urine have been found to be more likely to develop preeclampsia than are other women. These

proteins interfere with the growth and function of blood vessels lending evidence to the theory that

preeclampsia is caused by abnormalities in the blood vessels feeding the placenta. Although more

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research is needed, the discovery suggests that a blood or urine test may one day serve as an effective

screening tool for preeclampsia.

ComplicationsMost women with preeclampsia deliver healthy babies. The more severe your preeclampsia and the

earlier it occurs in your pregnancy, however, the greater the risks for you and your baby. Preeclampsia

may require induced labor and delivery. Cesarean birth isn't always needed in these cases. But your

doctor might recommend cesarean delivery if inducing labor becomes difficult due to the gestational age

of your baby. The earlier the gestational age, the more difficult inducing labor might be.

Complications of preeclampsia may include:

Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying blood to the placenta. If

the placenta doesn't get enough blood, your baby may receive less oxygen and fewer nutrients. This can

lead to slow growth, low birth weight, preterm birth and breathing difficulties for your baby.

Placental abruption. Preeclampsia increases your risk of placental abruption, in which the placenta

separates from the inner wall of your uterus before delivery. Severe abruption can cause heavy bleeding

and damage to the placenta, which can be life-threatening for both you and your baby.

HELLP syndrome. HELLP which stands for hemolysis (the destruction of red blood cells), elevated

liver enzymes and low platelet count

syndrome can rapidly become life-threatening for both you andyour baby. Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right

abdominal pain. HELLP syndrome is particularly dangerous because it can occur before signs or

symptoms of preeclampsia appear.

Eclampsia. When preeclampsia isn't controlled, eclampsia which is essentially preeclampsia plus

seizures can develop. Symptoms of eclampsia include upper right abdominal pain, severe headache,

vision problems and change in mental status, such as decreased alertness. Eclampsia can permanently

damage your vital organs, including your brain, liver and kidneys. Left untreated, eclampsia can cause

coma, brain damage and death for both you and your baby.

Cardiovascular disease. Having preeclampsia may increase your risk of future cardiovascular disease.

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Hypertension in Pregnancy Hypertension (high blood pressure) is a common medical disorder, affecting 20 to 30 percent of American adults. It tends to be a hidden or silent problem that usually does not cause obvioussymptoms but can eventually lead to heart disease, heart attack, and other potentially fatal illnesses.Modern health care has decreased the number and severity of complications due to high bloodpressure; in fact, mild hypertension during pregnancy does not cause adverse effects for mostwomen or their babies. Nevertheless, hypertension does complicate as many as 7 to 10 percent ofpregnancies and is still one of the leading causes of death among expectant mothers. Severehypertension increases a mother's risk of heart attack, heart failure , stroke, an dkidney failure . When apregnant mother's blood pressure is severely elevated, oxygen and nutrients cannot pass as easilythrough the placenta and to the baby. As a result, fetal growth restriction, premature birth, andplacental abruption (separation of the placenta from the uterus) may occur.Prenatal care is important for all pregnant women. If you are pregnant and have hypertension, early

prenatal care is invaluable. You and your doctor will discuss many issues during your pregnancy,including the use of anti-hypertensive medications and the possible need to deliver your babyprematurely.The third trimester lasts from week 28 to the birth of the baby. This may be an excitingand stressful time for you and your partner. New issues may emerge. You may wonder: How will laborand delivery go? Will my baby be healthy? Will I be a good parent? Should I breast-feed? Am I readyfor this? These may be similar to the fears you had when you first discovered you were pregnant,only this time they are more real. These thoughts are normal; it is okay to be a little scared. Theimportant thing is that you learn as much as you can about what you can expect during these lastfew months of pregnancy, during delivery, and after the baby is born.

This area covers many of the concerns women and their partners have during the third trimester.You will learn about the office visits and screening tests you should have during these months, alongwith warning signs of complications you should watch for. This area also covers some of the physicalchanges common in the last months of pregnancy and ways you can relieve these symptoms andkeep yourself healthy through diet and exercise. If you are concerned about a possible symptom orcomplication of pregnancy, talk to your doctor or health care provider.

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High Blood Pressure and Women

Many people mistakenly believe that high blood pressure, also called hypertension, is more common among men.The truth is nearly half of all adults with high blood pressure are women. Beginning at age 65, after the onsetof menopause , women are actually more likely to have this disease than men.

While HBP isn't directly related to gender, certain woman's issues can increase your risk. Discover how high bloodpressure relates to your stage in life.

Blood pressure during childbearing years

Do birth control pills cause high blood pressure? Medical researchers have found that birth control pills increase blood pressure in some women. It's morelikely to occur if you're overweight, have had high blood pressure during pregnancy, have a family history ofHBP or have mild kidney disease. The combination of birth control pills and cigarette use may be especiallydangerous for some women.

Before you begin taking oral contraceptives:o

Talk to your doctor about the risks.o Make sure your doctor measures and records your blood pressure before prescribing the pill.o Have your blood pressure checked every six months or so.

Is it safe to get pregnant if my blood pressure is high? By following the recommendations of your doctor and carefully managing your blood pressure, you can helpensure a normal pregnancy and a healthy baby. However, high blood pressure can be dangerous for bothmother and baby. If you are taking HBP medication and want to become pregnant, first consult your doctor.

Also keep in mind that if you already have high blood pressure, pregnancy could make it more severe.

Is it safe to get pregnant if I am taking ACE inhibitors or ARBs for high blood pressure? If you're taking an ACE inhibitor or an ARB and think you might be pregnant, see your doctor immediately.These drugs have been shown to be dangerous to mother and baby alike during pregnancy. They cancause low blood pressure, severe kidney failure, dangerously high potassium levels and even death of thenewborn.

As a woman with high blood pressure, what precautions should I take if I want to become pregnant? Each pregnancy is different, and your doctor will give you recommendations for your situation. Most womenwith high blood pressure should follow these precautions before becoming pregnant.

o Get your blood pressure under control.o Watch your diet and limit salt and sodium.o Be active and exercise. Regular physical activity will help you control your blood pressure and

increase your physical condition.o If you're overweight, lose weight to help you have a safer pregnancy and a healthier baby.o Stop using tobacco and alcohol.o If you're on medication for high blood pressure (or any other condition), discuss all of your

medications, including over-the-counter drugs and supplements, with all of your doctors. Neverstop taking a prescription medication without first consulting the doctor who prescribed it.

Why is it so important to control my blood pressure during pregnancy? Failing to do so could result in:

o Harm to the mother's kidneys and other organso Low birth weight and early delivery of the infant

I'm pregnant, and I've never had high blood pressure before, but I do now. Will I always have it? Some women who have never had HBP develop it while they are pregnant. This condition is known asPregnancy Induced Hypertension (PIH). It usually disappears after delivery. According to the National Heart,Lung, and Blood Institute (NHLBI), high blood pressure affects 6-8 percent of all pregnancies in the UnitedStates. Almost 70 percent of these cases are in first-time pregnancies. If the mother is not treated, HBP is

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dangerous to both the mother and baby. That's why doctors usually keep a close watch on a woman's bloodpressure during pregnancy.

PIH is closely related to preeclampsia, or toxemia of pregnancy. This disorder can endanger the lives of bothmother and child. Specifically, it can:

o Harm the placentao Damage the mother's kidneys, liver and braino Cause fetal complications such as low birth weight, premature birth and stillbirth

My prenatal clinic says I have preeclampsia because my urine has protein in it and my bloodpressure is high. Are my baby and I in danger? Preeclampsia is a condition that typically begins after the 20th week of pregnancy and may continue sixweeks after delivery. It's characterized by high blood pressure and elevated protein in the urine, which iscaused by kidney problems. This kind of hypertension usually disappears after delivery. If it doesn't, it shouldbe controlled with careful, long-term treatment as with all other types of HBP.

You are at a higher risk for developing preeclampsia if you: o Have high blood pressure before becoming pregnanto Have developed high blood pressure or preeclampsia in a previous pregnancyo Are obese prior to pregnancyo Are under age 20 or over age 40o Are pregnant with more than one babyo Have diabetes, kidney disease, rheumatoid arthritis, lupus or scleroderma

The rate of preeclampsia has increased over the past decade by nearly one-third. This is due in part to arise in numbers of older mothers and multiple births, where preeclampsia is more likely to develop.

Not all women have noticeable symptoms of preeclampsia. When symptoms do occur, they can include:

o Swellingo Sudden weight gaino Headacheso Changes in vision

How can I be sure that I won't get pregnancy induced hypertension or preeclampsia? There is no proven way to prevent PIH or preeclampsia and no test that will predict or diagnose theseconditions. Only regular visits to your doctor will ensure that you're having a safe pregnancy. Your doctor willtrack your blood pressure and check the level of protein in your urine. For a healthy pregnancy, you should:

o Get early and regular care from your doctor. Don't miss appointments.o Follow all of your doctor's recommendations.o Do what you can to help manage your blood pressure, including limiting sodium intake and getting

regular physical activity.

Remember, even with HBP and preeclampsia, you can have a successful pregnancy if you follow this advice.

Am I at greater risk for high blood pressure after menopause?

As a woman grows older, her chance of having high blood pressure becomes greater than a man's. You may havehad normal blood pressure most of your life, but after menopause your chances of developing HBP increaseconsiderably.

See your doctor regularly to have your blood pressure monitored. If you are diagnosed with HBP, follow theprescribed course of treatment .

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Researchers discover insight intopregnancy-induced hypertensionResearchers have identified an enzyme linked to pregnancy-induced hypertension also known aspre-eclampsia a pregnancy complication characterized by high blood pressure and swelling due tofluid retention. The findings could be used to better screen for and treat this condition.

Pregnancy-induced hypertension, which occurs in approximately 10 percent of pregnancies, is amajor cause of maternal and fetal deaths, yet the cause is unknown.The study, led by researchers in Cleveland Clinic's Lerner Research Institute, examined mice forcorin an enzyme normally present in the heart and determined that the deficiency of this enzymein the uterus may be an underlying cause of the disease. The study was published today in Nature .Pregnancy poses a major challenge for controlling blood pressure. As blood volume increases,maintaining normal blood pressure becomes more difficult. During pregnancy, the narrow, curlyuterine arteries are enlarged to thin-walled vessels, an adaptive change important for maintainingnormal maternal blood pressure and boosting blood flow to the fetus. However, in pregnant womenwith hypertension, the changes in uterine arteries become defective.While this study was initially conducted on mice, the researchers extended their study to patientswith pre-eclampsia. The researchers found that many pre-eclamptic patients had low levels of corinin their uterus, and corin gene mutations in pre-eclamptic patients were identified."Additional studies on corin or its related molecules may help to develop new methods to diagnoseand treat pregnancy-induced hypertension," said Qingyu Wu, M.D., Ph.D., a researcher in theDepartment of Molecular Cardiology in Cleveland Clinic's Lerner Research Institute and the leadresearcher on the study.

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Preterm Prelabour Rupture of Membranes (Green-top44)This is the first edition of the guideline, published in January 2006 (with minor ammendments made in October 2010).

The aim of this guideline is to make recommendations relating to the diagnosis, investigation and management of

women with preterm prelabour rupture of the membranes (PPROM). The guideline evaluates various antenatal testsin helping to predict the fetus at risk from intrauteri