Chapter 41.

Amniotic Fluid Abnormalities Chapter Contents.Section 41.1-Polyhydramnios (Excessive Amniotic Fluid) .... 350 Section 41.2-Potter Syndrome and Oligohydramnios (Inadequate Amniotic Fluid) .............................. 351 349.

Pregnancy and Birth Sourcebook, Third Edition Section 41.1 Polyhydramnios (Excessive Amniotic Fluid) "Polyhydramnios," 2009 A.D.A.M., Inc. Reprinted with permission.

Definition Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn infant.

Considerations Amniotic fluid surrounds and cushions the infant throughout development. There may be too little or too much amniotic fluid due to problems in the fetus.

Polyhydramnios can occur if the fetus does not swallow and absorb amniotic fluid in normal amounts. This can happen due to gastrointestinal disorders, brain and nervous system (neurological) problems, or a variety of other causes. Polyhydramnios may also be related to increased fluid production, as is the case with certain fetal lung disorders.

Sometimes, no specific cause for polyhydramnios is found.

Causes * Achondroplasia * Anencephaly * Beckwith-Wiedemann syndrome * Diaphragmatic hernia * Duodenal atresia * Esophageal atresia * Gastroschisis * Gestational diabetes * Hydrops fetalis * Multiple gestation (for example, twins or triplets) 350.

Amniotic Fluid Abnormalities What to Expect at Your Office Visit This condition is discovered during pregnancy, and evaluated before delivery. If the health care provider finds a fetal abnormality, the baby will be delivered in a hospital with specialists who can provide immediate evaluation and treatment.

Doc.u.menting polyhydramnios may include: * history of this pregnancy; * history of previous pregnancies and health of the children delivered; * other family history; * ultrasound scans of the fetus.

Section 41.2 Potter Syndrome and Oligohydramnios (Inadequate Amniotic Fluid) "Potter Syndrome," 2009 A.D.A.M., Inc. Reprinted with permission.

Alternative Names Potter phenotype Definition Potter syndrome and Potter phenotype refers to a group of findings a.s.sociated with a lack of amniotic fluid and kidney failure in an unborn infant.

Causes In Potter syndrome, the primary problem is kidney failure. The kidneys fail to develop properly as the baby is growing in the womb.

The kidneys normally produce the amniotic fluid (as urine).

Potter phenotype refers to a typical facial appearance that occurs in a newborn when there is no amniotic fluid. The lack of amniotic fluid is called oligohydramnios. Without amniotic fluid, the infant is not 351 Pregnancy and Birth Sourcebook, Third Edition cushioned from the walls of the uterus. The pressure of the uterine wall leads to an unusual facial appearance, including widely separated eyes.

Potter phenotype may also lead to abnormal limbs, or limbs that are held in abnormal positions or contractures.

Oligohydramnios also stops development of the lungs, so the lungs do not work properly at birth.

Symptoms * Widely separated eyes with epicanthal folds, broad nasal bridge, low set ears, and receding chin * Absence of urine output * Difficulty breathing Exams and Tests A pregnancy ultrasound may show lack of amniotic fluid, absence of fetal kidneys, or severely abnormal kidneys in the unborn baby.

The following tests may be used to help diagnose the condition in a newborn: * X-ray of the abdomen * X-ray of the lungs Treatment Resuscitation at delivery may be attempted pending the diagnosis. Treatment will be provided for any urinary outlet obstruction.

Outlook (Prognosis) This is a very serious condition, usually deadly. The short term outcome depends on the severity of lung involvement. Long-term outcome depends on the severity of kidney involvement.

Prevention There is no known prevention.

References Behrman RE. Nelson Textbook of Pediatrics. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa: WB Saunders; 2004. 17th ed. Philadelphia, Pa: WB Saunders; 2004.

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Chapter 42.

Birth Defects Chapter Contents.Section 42.1-Birth Defects That May Be Diagnosed during Pregnancy ................................................ 354 Section 42.2-Birth Defects and Developmental Disabilities ........................................................... 358 353.

Pregnancy and Birth Sourcebook, Third Edition Section 42.1 Birth Defects That May Be Diagnosed during Pregnancy "Overview of Birth Defects," 2008 Children's Hospital of Pittsburgh (www.chp.edu). Reprinted with permission.

What is a birth defect?

A birth defect is a health problem or physical change, which is present in a baby at the time he/she is born. Birth defects may be very mild, where the baby looks and acts like any other baby, or birth defects may be very severe, where you can immediately tell there is a health problem present. Some of the severe birth defects can be life threatening, where a baby may only live a few months, or may die at a young age (in their teens, for example).

Birth defects are also called congenital anomalies or congenital abnormalities. The word congenital means present at birth. The words anomalies and abnormalities mean that there is a problem present in a baby.

What causes birth defects to occur?

There are many reasons why birth defects happen. Most occur due to environmental and genetic factors, but often the cause is unknown.

Who is affected by birth defects?

Birth defects have been present in babies from all over the world, in families of all nationalities and backgrounds. Anytime a couple becomes pregnant, there is a chance that their baby will have a birth defect. Most babies are born healthy. In fact, 97 out of 100 babies are born healthy. Anytime a couple becomes pregnant, there is a 3 to 4 percent chance that their baby will have a birth defect. The 3 to 4 percent number is sometimes called the background rate for birth defects, or the population risk for birth defects. In a family where birth defects are already present in family members or the parents themselves, the 354 Birth Defects chance for a couple to have a child with a birth defect may be higher than the background rate of 3 to 4 percent.

What are the genetic and environmental causes of birth defects?

When a baby is born with a birth defect, the first question usually asked by the parents is "how did this happen?" Sometimes, this question cannot be answered. This can be very upsetting for parents because it is normal to seek an answer as to why your baby has a health problem. For some birth defects, however, there is a known cause, which may have to do with either genetic or environmental factors, or a combination of the two. Here is some general information and terms related to the different causes of birth defects: * Inheritance: Inheritance: Inheritance is a word used to describe a trait given to you or pa.s.sed on to you from one of your parents. Examples of inherited traits would be your eye color or blood type. Inheritance is a word used to describe a trait given to you or pa.s.sed on to you from one of your parents. Examples of inherited traits would be your eye color or blood type.

* Chromosome abnormalities: Chromosome abnormalities: Chromosomes are stick-like structures in the center of each cell (called the nucleus) that contain your genes. Chromosomes are stick-like structures in the center of each cell (called the nucleus) that contain your genes.

* Single gene defects: Single gene defects: Genes are what determine your traits. Genes are what determine your traits.

Sometimes, a child can inherit not only those genes responsible for their normal traits such as the color of their eyes, but also disease causing genes that result in a birth defect.

* Multifactorial inheritance: Multifactorial inheritance: Multifactorial inheritance means that "many factors" (multifactorial) are involved in causing a birth defect. The factors are usually both genetic and environmental. Multifactorial inheritance means that "many factors" (multifactorial) are involved in causing a birth defect. The factors are usually both genetic and environmental.

* Teratogens: Teratogens: A teratogen is an agent, which can cause a birth defect. It is usually something in the environment that the mother may be exposed to during her pregnancy. It could be a prescribed medication, a street drug, alcohol use, or a disease that the mother has, which could increase the chance for the baby to be born with a birth defect. A teratogen is an agent, which can cause a birth defect. It is usually something in the environment that the mother may be exposed to during her pregnancy. It could be a prescribed medication, a street drug, alcohol use, or a disease that the mother has, which could increase the chance for the baby to be born with a birth defect.

Why are birth defects a concern?

Although some birth defects have a single abnormality, others have abnormalities in multiple body systems or organs. Birth defects may cause life-long disability and illness, and with some, survival is not possible.

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Pregnancy and Birth Sourcebook, Third Edition Some birth defects, such as mental r.e.t.a.r.dation, are non-treatable disabilities. However, many physical defects can be treated with surgery. Repair is possible with many defects including cleft lip or palate and certain heart defects.

How are birth defects diagnosed?

Many birth defects can be diagnosed before birth with special tests (prenatal diagnosis). Chromosomal abnormalities such as Down syndrome can be diagnosed before birth by a.n.a.lyzing cells in the amniotic fluid or from the placenta.

Fetal ultrasound during pregnancy can also give information about the possibility of certain birth defects, but ultrasound is not 100 percent accurate, since some babies with birth defects may look the same on ultrasound as those without problems. A chromosome a.n.a.lysis, whether performed on a blood sample or cells from the amniotic fluid or placenta, is over 99.9 percent accurate.

Tests that help screen for birth defects include the following: * Alpha-fetoprotein: Alpha-fetoprotein: This blood test measures the levels of alpha-fetoprotein (AFP), a protein released by the fetal liver and found in the mother's blood. AFP is sometimes called MSAFP (maternal serum AFP). AFP screening may be included as one part of a two, three, or four-part screening, often called a multiple marker screen. The other parts may include the following. This blood test measures the levels of alpha-fetoprotein (AFP), a protein released by the fetal liver and found in the mother's blood. AFP is sometimes called MSAFP (maternal serum AFP). AFP screening may be included as one part of a two, three, or four-part screening, often called a multiple marker screen. The other parts may include the following.

* hCG: hCG: Human chorionic gonadotropin (hCG) is a hormone secreted by the early placental cells. High hCG levels may indicate a fetus with Down syndrome (a chromosomal abnormality that includes mental r.e.t.a.r.dation and distinct physical features). Human chorionic gonadotropin (hCG) is a hormone secreted by the early placental cells. High hCG levels may indicate a fetus with Down syndrome (a chromosomal abnormality that includes mental r.e.t.a.r.dation and distinct physical features).

* Estriol: Estriol: A hormone produced by the placenta and by the fetal liver and adrenal glands. Low levels may indicate a fetus with Down syndrome. A hormone produced by the placenta and by the fetal liver and adrenal glands. Low levels may indicate a fetus with Down syndrome.

* Inhibin: Inhibin: A hormone produced by the placenta. A hormone produced by the placenta.

* Chorionic villus sampling (CVS): Chorionic villus sampling (CVS): a prenatal test that involves taking a sample of some of the placental tissue. This tissue contains the same genetic material as the fetus and can be tested for chromosomal abnormalities and some other genetic problems. Testing is available for other genetic defects and disorders depending on the family history and availability of laboratory testing at the time of the procedure. In comparison to 356 a prenatal test that involves taking a sample of some of the placental tissue. This tissue contains the same genetic material as the fetus and can be tested for chromosomal abnormalities and some other genetic problems. Testing is available for other genetic defects and disorders depending on the family history and availability of laboratory testing at the time of the procedure. In comparison to 356 Birth Defects amniocentesis (another type of prenatal test), CVS does not provide information on neural tube defects such as spina bifida. For this reason, women who undergo CVS also need a follow-up blood test between 16 to 18 weeks of their pregnancy, to screen for neural tube defects.

* Amniocentesis: Amniocentesis: a procedure used to obtain a small sample of the amniotic fluid that surrounds the fetus to diagnose chromosomal disorders and open neural tube defects (ONTDs) such as spina bifida. Testing is available for other genetic defects and disorders depending on the family history and availability of laboratory testing at the time of the procedure. The American College of Obstetricians and Gynecologists (ACOG) recommends amniocentesis around 15 weeks to 20 weeks of pregnancy for those women who are at increased risk for chromosome abnormalities, such as women who are over age 35 years of age at delivery, or those who have had an abnormal maternal serum screening test, indicating an increased risk for a chromosomal abnormality or neural tube defect. However, in some situations, amniocentesis may be performed as early as 14 weeks. a procedure used to obtain a small sample of the amniotic fluid that surrounds the fetus to diagnose chromosomal disorders and open neural tube defects (ONTDs) such as spina bifida. Testing is available for other genetic defects and disorders depending on the family history and availability of laboratory testing at the time of the procedure. The American College of Obstetricians and Gynecologists (ACOG) recommends amniocentesis around 15 weeks to 20 weeks of pregnancy for those women who are at increased risk for chromosome abnormalities, such as women who are over age 35 years of age at delivery, or those who have had an abnormal maternal serum screening test, indicating an increased risk for a chromosomal abnormality or neural tube defect. However, in some situations, amniocentesis may be performed as early as 14 weeks.

* Ultrasound: Ultrasound: a diagnostic technique that uses high-frequency sound waves to create an image of the internal organs. Many birth defects can be detected with ultrasound. Sometimes, birth defects are not diagnosed until physical examination of the baby after birth. To confirm the physical findings, a small blood sample can be taken and the chromosomes can be a.n.a.lyzed. This information is important in determining the risk for that birth defect in future pregnancies. a diagnostic technique that uses high-frequency sound waves to create an image of the internal organs. Many birth defects can be detected with ultrasound. Sometimes, birth defects are not diagnosed until physical examination of the baby after birth. To confirm the physical findings, a small blood sample can be taken and the chromosomes can be a.n.a.lyzed. This information is important in determining the risk for that birth defect in future pregnancies.

Prevention of Birth Defects Research is ongoing to find and treat the causes of many birth defects. Immunizations of the mother against certain infections, such as rubella, can prevent infection. Much has been learned about the dangerous effects of alcohol on the developing baby and women are now advised to not drink during pregnancy.

In recent years, a strong link has been discovered between the lack of the B-vitamin folic acid and the development of neural tube defects such as spina bifida. Taking a vitamin containing sufficient folic acid before conception and in early pregnancy can often help prevent many serious defects.

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Pregnancy and Birth Sourcebook, Third Edition Section 42.2 Birth Defects and Developmental Disabilities Excerpted from "Birth Defects and Developmental Disabilities," by the National Inst.i.tute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the U.S. Department of Health and Human Services, September 18, 2006.

The March of Dimes Birth Defects Foundation defines "birth defects" as: an abnormality of structure, function, or metabolism (body chemistry) present at birth that results in physical or mental disability, or is fatal. To date, researchers have identified thousands of different birth defects. Currently, birth defects rank as the leading cause of death for infants during the first year of life. Birth defects can be caused by different factors, such as the following: * Genetic problems that result from the failure of one or more genes to work properly * Problems with the number or structure of chromosomes, such as extra or missing groups of genes * Things that happen to a woman during pregnancy, such as getting rubella or German measles while pregnant, having untreated or uncontrolled diabetes while pregnant, being around or in contact with dangerous chemicals in the environment while pregnant, or using drugs or alcohol during pregnancy These factors can change normal infant growth or development resulting in different types of birth defects, such as the following: * Physical problems with body parts or structures: Some physical problems include cleft (has a gap or split) lip or cleft palate, heart defects, and abnormal limbs, such as a club foot * Functional problems with how a body part or body system works: These problems are often called developmental disabilities and can include things like these: 358.

Birth Defects * Nervous system or brain problems, such as learning dis- abilities, behavioral disorders, speech or language difficulties, muscle spasms or convulsions, and movement trouble * Sensory problems, such as cataracts of the eyes, blindness, hearing loss, or deafness * Metabolic disorders involve a body process or chemical pathway or reaction, such as conditions that limit the body's ability to get rid of waste materials or harmful chemicals.

* Degenerative disorders are conditions that might not be obvious at birth, but steadily make worse one or more aspects of health.

In some cases, birth defects can result from a combination of these factors, or they can affect many parts or processes in the body, which may lead to both physical and functional problems, to different degrees.

Some of these types of birth defects and developmental disabilities are described below.

Physical Birth Defects Researchers and health care providers use the term neural tube defects to describe one important category of birth defects. These problems are related to the growth and development of the brain and spinal cord. Neural tube defects can include conditions like anencephaly, a fatal condition in which much of the brain does not develop; and spina bifida, in which the membranes around the spinal cord don't close properly, or the cord itself is not completely normal. People with spina bifida may have difficulty walking or be unable to walk without help, or they may have abnormal limbs. The condition is also a.s.sociated with other structural problems with the body. In half of all babies born with spina bifida, the resulting problems are severe enough to result in death.

Research in this area has shown that getting the right amount of folic acid before and during pregnancy can prevent most neural tube defects. The U.S. Public Health Service recommends that women of childbearing age get at least 400 micrograms of folic acid each day, through food sources and/or supplements. Health care providers recommend that women supplement their diets with folic acid for 3 months before conception, and then for at least the 3 three months of pregnancy. Findings from research supported by the National Inst.i.tute of Child Health and Human Development (NICHD) and other 359 Pregnancy and Birth Sourcebook, Third Edition agencies indicate that the right amount of folic acid can help prevent certain birth defects and other problems during pregnancy.

In some cases, spina bifida can be detected in the womb. This early detection may allow surgeons to correct the spinal cord problems before birth, but researchers have yet to confirm this idea. If this research proves effective, it could alleviate many of the lasting effects of these problems. To learn more about this type of surgery, the NICHD is supporting the MOMS (Management of Meningomyelocele Study) trial, a clinical trial that will compare the safety and effectiveness of surgery before birth, with surgery performed right after birth in correcting spinal cord problems. The research is part of the Maternal-Fetal Medicine Unit (MFMU) Network, an NICHD-supported program that uses 14 sites around the country to conduct clinical trials related to the mechanisms of pregnancy and birth.

Functional Birth Defects/Developmental Disabilities This complex group of birth defects involves a problem with the operation of a part of the body, a system in the body, or a process or pathway in the body. Although this information groups these developmental disabilities into general categories, many functional birth defects affect multiple body parts or systems. For example, a metabolic disorder may lead to nervous system or brain problems. This website groups the information to make it easier to remember.

Nervous System/Brain Problems As mentioned above, some birth defects affect the functioning of the brain, which can impact intelligence and learning. This section describes some of the more commonly known functional birth defects.

Mental r.e.t.a.r.dation: The term "mental r.e.t.a.r.dation" describes a certain range of scores on an IQ (intelligence quotient) test. Mental r.e.t.a.r.dation can result from a number of different birth defects, including: The term "mental r.e.t.a.r.dation" describes a certain range of scores on an IQ (intelligence quotient) test. Mental r.e.t.a.r.dation can result from a number of different birth defects, including: * In the past, a specific type of bacterial infection, called Hib, was a leading cause of mental r.e.t.a.r.dation in the United States. But, as a result of NICHD-supported research on this infection, researchers funded by the NICHD were able to develop a vaccine to prevent the infection from occurring. Since the discovery of the vaccine, Hib has been nearly eliminated in the United States, and in other areas where the vaccine is available. As a result, 360 Birth Defects Hib is also no longer a cause of mental r.e.t.a.r.dation in the United States and other areas.

* Down syndrome describes a set of mental and physical characteristics related to having an extra copy of a specific chromosome, Chromosome 21. This set of symptoms includes mental r.e.t.a.r.dation. Interventions and treatments for the symptoms of Down syndrome can allow many individuals with this condition to live healthy, productive lives. NICHD-supported work in Down syndrome includes efforts to understand some of the other problems a.s.sociated with the condition, such as heart defects and early mental decline.

* Fragile X syndrome is the most common inherited form of mental r.e.t.a.r.dation. Parents with few or no symptoms can pa.s.s the condition on to their children through genes. A defect in a specific part of a specific gene, called the Fragile X Mental r.e.t.a.r.dation 1 gene, or FMR1, causes the body to produce low amounts or none of a certain protein. This protein is vital to normal brain development; without enough of it, the brain doesn't grow properly, leading to the symptoms of Fragile X. In 1991, NICHD-supported researchers were the first to identify that a change in the FMR1 gene caused Fragile X. This and other NICHD-supported research has continued in hopes of finding out what the protein that is lacking or missing does in the brain. In response to the Children's Health Act of 2000, the NICHD created three centers for Fragile X research, to ensure that this work can continue. In addition, the NICHD is working with other agencies and organizations dedicated to understanding Fragile X to further knowledge about this condition. The Inst.i.tute's Families and Fragile X Syndrome publication describes what is currently known about and what research is being done to learn more about Fragile X.

Autism spectrum disorders: Other developmental disabilities include problems like autism spectrum disorders, a range of problems that can affect a person's ability to communicate, social skills, and intelligence. Because autism is diagnosed on a spectrum, people with this condition can be severely affected, or have only mild symptoms; but they all have a type of autism. Other developmental disabilities include problems like autism spectrum disorders, a range of problems that can affect a person's ability to communicate, social skills, and intelligence. Because autism is diagnosed on a spectrum, people with this condition can be severely affected, or have only mild symptoms; but they all have a type of autism.

Sensory-Related Developmental Disabilities Sensory-related problems are often an important part of complex birth defect patterns. For instance, children with congenital rubella, 361 Pregnancy and Birth Sourcebook, Third Edition a collection of problems that a child whose mother had rubella or German measles while pregnant may have, are likely to be deaf, and to develop cataracts of the eyes. Children with Williams syndrome have trouble seeing spatial relationships between objects around them. Those with Fragile X syndrome are often very sensitive to loud noises; they may overreact or have outbursts in reaction to such sounds.

Metabolic Disorders This group of functional birth defects affects a person's metabolism, which is the way the body builds up, breaks down, and otherwise processes the materials it needs to function. For example, digestion, how your body breaks down food into its smaller parts, is a metabolic process. Two commonly known metabolic disorders include: * Phenylketonuria, also called PKU, is a condition in which a problem with a specific enzyme, a protein that speeds up certain chemical reactions, causes mental r.e.t.a.r.dation. NICHD-supported researchers developed a dietary therapy that helps to balance the amount of this enzyme in the body, which has almost eliminated mental r.e.t.a.r.dation in people with PKU. Conclusions from the NIH Consensus Development Conference on PKU: Screening and Management recommend that this dietary therapy continue throughout life. Women known to have PKU should follow the diet while they are pregnant to prevent mental r.e.t.a.r.dation in their children. The NICHD hopes to use its successes with PKU research as a model for efforts on other diseases.

* Hypothyroidism is a hormonal condition that, if left untreated in a pregnant woman, can cause mental r.e.t.a.r.dation in her baby.

The thyroid is a gland in the body that makes a chemical signal called a hormone. Hormones help to regulate certain functions in the body, including p.u.b.erty and pregnancy. Without enough thyroid hormone in the mother's body, the fetus' brain won't develop correctly, resulting in mental r.e.t.a.r.dation. NICHD-supported researchers found that, by identifying women who have this condition early in or before pregnancy, treatments to get the level of thyroid hormone back to normal can prevent mental r.e.t.a.r.dation in some cases. In addition, NICHD research found that children who are born with hypothyroidism could also be treated with thyroid hormone to prevent many of the long-term effects of this condition.

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Birth Defects Degenerative Disorders Some infants born with degenerative disorders appear normal at birth, but then lose abilities or functions due to the condition. In these cases, the defect is usually not detected until an older age, when the child or person starts to show signs of a problem. Degenerative disorder can cause physical, mental, and sensory problems, depending on the specific defect.

In one type of degenerative disorder, early onset X-linked adrenoleukodystrophy, also called X-ALD, boys develop normally until between ages 4 and 8. After this point, they begin to lose brain and nervous system function. Eventually, boys with X-ALD lose so much of their brain and neural abilities that they appear to be in a "frozen" state, unable to move and communicate. X-ALD was the focus of the movie Lorenzo's Oil, which described one family's efforts to spur scientific progress.

Another type of degenerative birth defect is Rett syndrome. This disorder, which usually affects girls, is caused by a specific genetic abnormality. The NICHD's efforts to understand these types of birth defects focus on screening techniques that allow early detection of these problems, and strategies to treat or relieve some of the symptoms of these conditions. Other work is underway to find the cellular mechanisms or genetic markers for these conditions.

Additional Research and Other Resources on Birth Defects Research on birth defects often begins by focusing on the specific effects of the problem on an infant. Sometimes, the effects of birth defects can be severe, such as not being able to walk, having organ systems that aren't complete, or even death. Once scientists know the outcomes of a certain problem, they can backtrack, following the problem back to early stages of development to isolate when it might have happened. Knowing when the problem first occurred can offer insight into how it occurred.

Through this general scheme, NICHD-supported researchers and their colleagues have made great progress in understanding the characteristics of certain birth defects, the patterns that these problems take, and possible points in growth and development where the problems might occur. And, armed with this understanding, researchers have developed interventions to prevent some birth defects, methods of identifying birth defects early in development, and possible treatments for birth defects.

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Pregnancy and Birth Sourcebook, Third Edition The NICHD's research on birth defects has not only improved the chances of survival for those affected, but has also improved the quality of life for many people impacted by birth defects and their families.

The NICHD and other Inst.i.tute are currently conducting a number of clinical trials related to birth defects.

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Chapter 43.

Bleeding and Blood Clots in Pregnancy Chapter Contents.Section 43.1-Bleeding during Early Pregnancy ...................... 366 Section 43.2-Blood Clots ........................................................... 367 365.

Pregnancy and Birth Sourcebook, Third Edition Section 43.1 Bleeding during Early Pregnancy "Bleeding in Early Pregnancy," 2003 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission. Reviewed by David A. Cooke, MD, FACP, March 31, 2009. Dr. Cooke is not affiliated with the University of Pittsburgh Medical Center.

Many women have some bleeding from the v.a.g.i.n.a in pregnancy.

Sometimes the pregnancy continues with no ill effects. But bleeding could be an early sign of miscarriage. If you are pregnant and have bleeding, call your doctor or midwife.

Symptoms to Watch For * If you have any bleeding, apply a pad and call your doctor or midwife. Write down the time and the amount of bleeding. Call the doctor or midwife again if you have to change your pad more often than once an hour. Rest with your feet up until the bleeding slows down.

* If you have cramping with the bleeding, you can take acetami-nophen (such as Tylenol).

* If you pa.s.s anything that looks like tissue onto the pad or into the toilet, call your doctor. He or she probably will have you come to the emergency department. You will be asked to bring a sample of the tissue with you.