* If you have a fever of 101 degrees Fahrenheit or higher, call your doctor.

If you call your doctor or midwife with any of these symptoms, he or she probably will want to examine you. You also may need to have blood tests.

If you have any questions or concerns about these symptoms, talk to your doctor or midwife.

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Bleeding and Blood Clots in Pregnancy Section 43.2 Blood Clots Excerpted from "Deep Vein Thrombosis," by the National Heart, Lung and Blood Inst.i.tute (NHLBI, www.nhlbi.nih.gov), part of the National Inst.i.tutes of Health, November 2007.

What Is Deep Vein Thrombosis?

Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together.

Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body.

A blood clot in a deep vein can break off and travel through the bloodstream. The loose clot is called an embolus. When the clot travels to the lungs and blocks blood flow, the condition is called pulmonary embolism, or PE.

PE is a very serious condition. It can damage the lungs and other organs in the body and cause death.

Blood clots in the thigh are more likely to break off and cause PE than blood clots in the lower leg or other parts of the body.

Blood clots also can form in the veins closer to the skin's surface.

However, these clots won't break off and cause PE.

Other Names for Deep Vein Thrombosis * Blood clot in the legs * Venous thrombosis * Venous thromboembolism (VTE). This term is used for both deep vein thrombosis and pulmonary embolism.

What Causes Deep Vein Thrombosis?

Blood clots can form in your body's deep veins when: * damage occurs to a vein's inner lining. This damage may result from injuries caused by physical, chemical, and biological factors.

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Pregnancy and Birth Sourcebook, Third Edition Such factors include surgery, serious injury, inflammation, or an immune response.

* blood flow is sluggish or slow. Lack of motion can cause sluggish or slowed blood flow. This may occur after surgery, if you're ill and in bed for a long time, or if you're traveling for a long time.

* your blood is thicker or more likely to clot than usual.

Certain inherited conditions (such as factor V Leiden) increase blood's tendency to clot. This also is true of treatment with hormone replacement therapy or birth control pills.

Who Is at Risk for Deep Vein Thrombosis?

Many factors increase your risk for deep vein thrombosis (DVT).

They include: * a history of DVT.

* disorders or factors that make your blood thicker or more likely to clot than normal. Certain inherited blood disorders (such as factor V Leiden) will do this. This also is true of treatment with hormone replacement therapy or using birth control pills.

* injury to a deep vein from surgery, a broken bone, or other trauma.

* slow blood flow in a deep vein from lack of movement. This may occur after surgery, if you're ill and in bed for a long time, or if you're traveling for a long time.

* pregnancy and the first 6 weeks after giving birth.

* recent or ongoing treatment for cancer.

* a central venous catheter. This is a tube placed in vein to allow easy access to the bloodstream for medical treatment.

* being older than 60 (although DVT can occur in any age group).

* being overweight or obese.

* your risk for DVT increases if you have more than one of the risk factors listed above.

What Are the Signs and Symptoms of Deep Vein Thrombosis?

The signs and symptoms of deep vein thrombosis (DVT) may be related to DVT itself or to pulmonary embolism (PE). See your doctor 368 Bleeding and Blood Clots in Pregnancy right away if you have symptoms of either. Both DVT and PE can cause serious, possibly life-threatening complications if not treated.

Deep Vein Thrombosis Only about half of the people with DVT have symptoms. These symptoms occur in the leg affected by the deep vein clot. They include: * swelling of the leg or along a vein in the leg; * pain or tenderness in the leg, which you may feel only when standing or walking; * increased warmth in the area of the leg that's swollen or in pain; and * red or discolored skin on the leg.

Pulmonary Embolism Some people don't know they have DVT until they have signs or symptoms of PE. Symptoms of PE include: * unexplained shortness of breath; * pain with deep breathing; and * coughing up blood.

Rapid breathing and a fast heart rate also may be signs of PE.

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Chapter 44.

Cholestasis of Pregnancy Some women experience a very severe itching in late pregnancy.

The most common cause of this is cholestasis, a common liver disease that only happens in pregnancy. Cholestasis of pregnancy is a condition in which the normal flow of bile in the gallbladder is affected by the high amounts of pregnancy hormones. Cholestasis is more common in the last trimester of pregnancy when hormones are at their peak, but it usually goes away within a few days after delivery. According to Cincinnati Children's Hospital Medical Center, cholestasis occurs in about 1 out of 1,000 pregnancies but is more common in Swedish and Chilean ethnic groups. Cholestasis is sometimes referred to as extrahepatic cholestasis which occurs outside the liver, intrahepatic cholestasis which occurs inside the liver, or obstetric cholestasis.

What causes cholestasis of pregnancy?

Pregnancy hormones affect gallbladder function, resulting in slowing or stopping the flow of bile. The gallbladder holds bile that is produced in the liver, which is necessary in the breakdown of fats in digestion. When the bile flow is stopped or slowed down, this causes a build up of bile acids in the liver which can spill into the bloodstream.

"Cholestasis of Pregnancy," 2008 American Pregnancy a.s.sociation (www .americanpregnancy.org). Reprinted with permission.

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Pregnancy and Birth Sourcebook, Third Edition What are the symptoms of cholestasis of pregnancy?

* Itching, particularly on the hands and feet (often is the only symptom noticed) * Dark urine color * Light coloring of bowel movements * Fatigue or exhaustion * Loss of appet.i.te * Depression Less common symptoms include: * Jaundice (yellow coloring of skin, eyes, and mucous membranes); * Upper-right quadrant pain; * Nausea.

Who is at risk for cholestasis of pregnancy?

One to 2 pregnancies in 1000 are affected by cholestasis. The following women have a higher risk of getting cholestasis during pregnancy: * Women carrying multiples * Women who have previous liver damage * Women whose mother or sisters had cholestasis How is cholestasis of pregnancy diagnosed?

A diagnosis of cholestasis can be made by doing a complete medical history, physical examination, and blood tests that evaluate liver function, bile acids, and bilirubin.

How will the baby be affected if the mother is diagnosed with cholestasis?

Cholestasis may increase the risks for fetal distress, preterm birth, or stillbirth. A developing baby relies on the mother's liver to remove bile acids from the blood; therefore, the elevated levels of maternal bile cause stress on the baby's liver. Women with cholestasis should be monitored closely and serious consideration should be given to inducing labor once the baby's lungs have reached maturity.

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Cholestasis of Pregnancy What is the treatment for cholestasis of pregnancy?

The treatment goals for cholestasis of pregnancy are to relieve itching. Some treatment options include: * Topical anti-itch medications or medication with corticosteroids; * Medication to decrease the concentration of bile acids such as ursodeoxycholic acid; * Cold baths and ice water slow down the flow of blood in the body by decreasing its temperature; * Dexamethasone is a steroid that increases the maturity of the baby's lungs; * Vitamin K supplements administered to the mother before delivery and again once the baby is born to prevent intracranial hemorrhaging; * Dandelion root and milk thistle are natural substances that are beneficial to the liver; * Bi-weekly non-stress tests which involve fetal heart monitoring and contraction recordings; * Regular blood tests monitoring both bile serum levels and liver function.

Treatment for cholestasis of pregnancy needs to be determined by your physician who will take the following criteria into consideration: * Your pregnancy, overall health, and medical history * The extent of the disease * Your tolerance of specific medications, procedures, or therapies * Expectations for the course of the disease * Your opinion or preference Treatments that should not be used for cholestasis include: * Antihistamines * Aveeno and oatmeal bath There are conflicting views on using the medication cholestyramine for treatment of cholestasis. In the past, this medication was readily used 373 Pregnancy and Birth Sourcebook, Third Edition to treat this condition, but some studies have shown that cholestyramine may not be as effective as other treatments and potentially has some adverse side effects such as blocking essential vitamins like Vitamin K (a vitamin that is already deficient in women with cholestasis).

What are the chances of the mother getting cholestasis in another pregnancy?

Whether or not a woman will get cholestasis in future pregnancies is debatable. However, some sources claim that women who have had cholestasis of pregnancy have up to a 90% chance of having this repeat in future pregnancies.

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Chapter 45.

Gestational Diabetes What is gestational diabetes?

Gestational diabetes is diabetes that is found for the first time when a woman is pregnant. Out of every 100 pregnant women in the United States, three to eight get gestational diabetes. Diabetes means that your blood glucose (also called blood sugar) is too high. Your body uses glucose for energy. But too much glucose in your blood can be harmful.

When you are pregnant, too much glucose is not good for your baby.

What causes gestational diabetes?

Changing hormones and weight gain are part of a healthy pregnancy. But both changes make it hard for your body to keep up with its need for a hormone called insulin. When that happens, your body doesn't get the energy it needs from the food you eat.

What is my risk of gestational diabetes?

To learn your risk for gestational diabetes, check each item that applies to you. Talk with your doctor about your risk at your first prenatal visit.

* I have a parent, brother, or sister with diabetes.

"What I Need to Know about Gestational Diabetes," by the National Inst.i.tute of Diabetes and Digestive and Kidney Diseases (NIDDK, www.niddk.nih .gov), part of the National Inst.i.tutes of Health, April 2006.

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Pregnancy and Birth Sourcebook, Third Edition * I am African American, American Indian, Asian American, Hispanic/Latino, or Pacific Islander.

* I am 25 years old or older.

* I am overweight.

* I have had gestational diabetes before, or I have given birth to at least one baby weighing more than 9 pounds.

* I have been told that I have "pre-diabetes," a condition in which blood glucose levels are higher than normal, but not yet high enough for a diagnosis of diabetes. Other names for it are "impaired glucose tolerance" and "impaired fasting glucose."

If you checked any of these risk factors, ask your health care team about testing for gestational diabetes.

* You are at high risk if you are very overweight, have had gestational diabetes before, have a strong family history of diabetes, or have glucose in your urine.

* You are at average risk if you checked one or more of the risk factors.

* You are at low risk if you did not check any of the risk factors.

When will I be checked for gestational diabetes?

Your doctor will decide when you need to be checked for diabetes depending on your risk factors.

* If you are at high risk, your blood glucose level may be checked at your first prenatal visit. If your test results are normal, you will be checked again sometime between weeks 24 and 28 of your pregnancy.

* If you have an average risk for gestational diabetes, you will be tested sometime between weeks 24 and 28 of pregnancy.

* If you are at low risk, your doctor may decide that you do not need to be checked.

How is gestational diabetes diagnosed?

Your health care team will check your blood glucose level. Depending on your risk and your test results, you may have one or more of the following tests.

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Gestational Diabetes Fasting blood glucose or random blood glucose test: Your doctor may check your blood glucose level using a test called a fasting blood glucose test. Before this test, your doctor will ask you to fast, which means having nothing to eat or drink except water for at least 8 hours. Or your doctor may check your blood glucose at any time during the day. This is called a random blood glucose test. Your doctor may check your blood glucose level using a test called a fasting blood glucose test. Before this test, your doctor will ask you to fast, which means having nothing to eat or drink except water for at least 8 hours. Or your doctor may check your blood glucose at any time during the day. This is called a random blood glucose test.

These tests can find gestational diabetes in some women, but other tests are needed to be sure diabetes is not missed. Your health care provider will check your blood glucose level to see if you have gestational diabetes.

Screening glucose challenge test: For this test, you will drink a sugary beverage and have your blood glucose level checked an hour later. This test can be done at any time of the day. If the results are above normal, you may need further tests. For this test, you will drink a sugary beverage and have your blood glucose level checked an hour later. This test can be done at any time of the day. If the results are above normal, you may need further tests.

Oral glucose tolerance test: If you have this test, your health care provider will give you special instructions to follow. For at least 3 days before the test, you should eat normally. Then you will fast for at least 8 hours before the test. If you have this test, your health care provider will give you special instructions to follow. For at least 3 days before the test, you should eat normally. Then you will fast for at least 8 hours before the test.

The health care team will check your blood glucose level before the test. Then you will drink a sugary beverage. The staff will check your blood glucose levels 1 hour, 2 hours, and 3 hours later. If your levels are above normal at least twice during the test, you have gestational diabetes.

How will gestational diabetes affect my baby?

Untreated or uncontrolled gestational diabetes can mean problems for your baby, such as: * being born very large and with extra fat-this can make delivery difficult and more dangerous for your baby; * low blood glucose right after birth; and Table 45.1. Above-Normal Results for the Oral Glucose Tolerance Test Fasting Above-Normal Results for the Oral Glucose Tolerance Test Fasting 95 or higher At 1 hour 180 or higher At 2 hours 155 or higher At 3 hours 140 or higher Note: Some labs use other numbers for this test. These numbers are for a test using a drink with 100 grams of glucose.

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