It does not work to take antibiotics for GBS before labor. The bacteria can grow back so fast that taking the medicine before you begin labor does not prevent the bacteria from spreading to your baby during childbirth.

Other people in the house, including kids, are not at risk of getting sick from GBS.

If you think you might have a cesarean section or go into labor early (premature), talk with your doctor or nurse about your personal GBS plan.

What You Can Do before Labor * Ask your doctor for a GBS test when you are 35 to 37 weeks pregnant (9th month).

* If you are allergic to penicillin or other antibiotics, make sure to tell your doctor or nurse about any reactions you have had.

* If your test shows that you carry the bacteria, talk with your doctor about a plan for labor.

* Continue your regular check-ups, and always call your doctor or nurse if you have any problems.

When Your Water Breaks or When You Go into Labor If you have not had your GBS test when labor starts, remind the staff that you do not know your GBS status.

If you are a GBS carrier: * Go to the hospital. The antibiotics work best if you get them at least 4 hours before you deliver.

* Tell the labor and delivery staff at the hospital that you are a group B strep carrier.

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Group B Streptococcus (GBS) * Speak up if you are allergic to penicillin.

* Expect to get IV antibiotics (medicine through the vein) during labor.

* It is fine to breastfeed after your baby is born.

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Chapter 55.

Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Chapter Contents.Section 55.1-Ectopic Pregnancy ............................................... 430 Section 55.2-Blighted Ovum ..................................................... 431 Section 55.3-What Is a Miscarriage? ....................................... 433 Section 55.4-Incompetent Cervix Can Lead to Miscarriage .......................................................... 435 Section 55.5-Drug Offers Alternative to Surgical Treatment after Miscarriage .............................. 437 Section 55.6-What Is a Stillbirth? ............................................ 439 Section 55.7-Research on Miscarriage and Stillbirth ............ 441 Section 55.8-Coping with Pregnancy Loss .............................. 443 429.

Pregnancy and Birth Sourcebook, Third Edition Section 55.1 Ectopic Pregnancy "Ectopic Pregnancy," 2009 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission.

Most pregnancies happen in the uterus (womb). An ectopic pregnancy is one that happens outside of the uterus. Often, an ectopic pregnancy happens in one of the fallopian tubes, which run from the ovaries to the uterus.

If you have a positive pregnancy test, and the pregnancy cannot be seen on ultrasound, you may have an ectopic pregnancy. You also may have a normal pregnancy, but it's too early to see the fetus by ultrasound.

You will have a blood test. The test will be repeated in 2 days. The results can help tell if you have an ectopic pregnancy.

An ectopic pregnancy is rare, but it is a serious condition. It can be life-threatening if you do not get medical care. An ectopic pregnancy can grow until it breaks through the fallopian tube. This is very painful. It can cause serious bleeding inside your lower belly (abdomen).

If this happens, you need to be treated in a hospital right away.

An ectopic pregnancy is removed either by taking medicines or by having surgery.

Signs that you may have an ectopic pregnancy include: * severe lower belly pain; * lower belly pain that gets worse; * shoulder pain; * fainting or dizzy spells; * nausea or vomiting; * heavy v.a.g.i.n.al bleeding.

If you have any of these problems, call your doctor or go to an emergency room right away.

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Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Tests after Treatment Tests after Treatment After you are treated for an ectopic pregnancy, your doctor may have you come back for an ultrasound or blood tests. These tests are very important.

Losing a Pregnancy There is no right way to react to losing a pregnancy. Many women are overcome with grief. You and your partner may want to seek a counselor or pregnancy loss support group.

Follow-Up If you have any concerns about your diagnosis, treatment, or effects of the treatment, or if you have questions about future pregnancies, talk to your doctor.

Section 55.2 Blighted Ovum "Blighted Ovum," 2006 American Pregnancy a.s.sociation (www.americanpregnancy.org). Reprinted with permission.

Chances are you didn't even know you were pregnant or had just found out you were expecting when you received the shattering news that there is no visible developing embryo on the ultrasound. You are probably feeling sad and confused. As you take time to understand what this means, also take time to grieve as you would for any loss.

And remember you are not alone.

What is a blighted ovum?

A blighted ovum (also known as "anembryonic pregnancy") happens when a fertilized egg attaches itself to the uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo itself. A blighted ovum usually occurs within the first trimester 431 Pregnancy and Birth Sourcebook, Third Edition before a woman knows she is pregnant. A high level of chromosome abnormalities usually causes a woman's body to naturally miscarry.

How do I know if I am having or have had a blighted ovum?

A blighted ovum can occur very early in pregnancy, before most women even know that they are pregnant. You may experience signs of pregnancy such as a missed or late menstrual period and even a positive pregnancy test. It is possible that you may have minor abdominal cramps, minor v.a.g.i.n.al spotting, or bleeding. As with a normal period, your body may flush the uterine lining, but your period may be a little heavier than usual.

Many women a.s.sume their pregnancies are on track because their hCG [human chorionic gonadotropin] levels are increasing. The placenta can continue to grow and support itself without a baby for a short time, and pregnancy hormones can continue to rise, which would lead a woman to believe she is still pregnant. A diagnosis is usually not made until an ultrasound test shows either an empty womb or an empty birth sac.

What causes a blighted ovum?

A blighted ovum is the cause of about 50% of first trimester miscarriages and is usually the result of chromosomal problems. A woman's body recognizes abnormal chromosomes in a fetus and naturally does not try to continue the pregnancy because the fetus will not develop into a normal, healthy baby. This can be caused by abnormal cell division, or poor quality sperm or egg.

Should I have a D&C or wait for a natural miscarriage?

This is a decision only you can make for yourself. Most doctors do not recommend a D&C [dilation and curettage] for an early pregnancy loss. It is believed that a woman's body is capable of pa.s.sing tissue on its own and there is no need for an invasive surgical procedure with a risk of complications. A D&C would, however, be beneficial if you were planning on having a pathologist examine the tissues to determine a reason for the miscarriage. Some women feel a D&C procedure helps with closure, mentally and physically.

How can a blighted ovum be prevented?

Unfortunately, in most cases a blighted ovum cannot be prevented.

Some couples will seek out genetic testing if multiple early pregnancy 432 Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth loss occurs. A blighted ovum is often a one time occurrence, and rarely will a woman experience more than one. Most doctors recommend couples wait at least 13 regular menstrual cycles before trying to conceive again after any type of miscarriage. loss occurs. A blighted ovum is often a one time occurrence, and rarely will a woman experience more than one. Most doctors recommend couples wait at least 13 regular menstrual cycles before trying to conceive again after any type of miscarriage.

Section 55.3 What Is a Miscarriage?

From "Miscarriage," by the National Inst.i.tute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the National Inst.i.tutes of Health, May 24, 2007.

What is a miscarriage?

A miscarriage, sometimes called pregnancy loss, is the loss of pregnancy from natural causes before the 20th week of pregnancy. Most miscarriages occur very early in the pregnancy, often before a woman even knows she is pregnant.

What causes a miscarriage?

There are many different causes for a miscarriage, some known and others unknown. In most cases, there is nothing a woman can do to prevent a miscarriage.

There are some factors that may contribute to miscarriage.

* The most common cause of miscarriage in the first trimester is a chromosomal abnormality in the fetus. This is usually results from a problem with the sperm or egg that prevents the fetus from developing properly.

* During the second trimester, problems with the uterus or cervix can contribute to miscarriage.

* Women with a disorder called polycystic ovary syndrome are three times more likely to miscarry during the early months of pregnancy than women who don't have the syndrome.

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Pregnancy and Birth Sourcebook, Third Edition Women who have miscarriages can and often do become pregnant again, with normal pregnancy outcomes.

What are the symptoms of and treatments for miscarriage?

Signs of a miscarriage can include: * v.a.g.i.n.al spotting or bleeding; * cramping or abdominal pain; and * fluid or tissue pa.s.sing from the v.a.g.i.n.a.

Although v.a.g.i.n.al bleeding is a common symptom when a woman has a miscarriage, many pregnant women have spotting early in their pregnancy but do not miscarry. But, pregnant women who have symptoms such as bleeding should contact their health care provider immediately.

Women who miscarry early in their pregnancy usually do not need any treatment. In some cases, a woman may need a procedure called a dilatation and curettage (D&C) to remove tissue remaining in the uterus. A D&C can be done in a health care provider's office, an outpatient clinic, or a hospital.

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Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Section 55.4 Section 55.4 Incompetent Cervix Can Lead to Miscarriage "Incompetent Cervix: Weakened Cervix," 2007 American Pregnancy a.s.sociation (www.americanpregnancy.org). Reprinted with permission.

During pregnancy, as the baby grows and gets heavier, it presses on the cervix. This pressure may cause the cervix to start to open before the baby is ready to be born. This condition is called incompetent cervix or weakened cervix, and it may lead to a miscarriage or premature delivery. However, an incompetent cervix happens in only about 1 out of 100 pregnancies.

What causes an incompetent or weakened cervix?

A weakened cervix can be caused by one or more of the following conditions: * previous surgery on the cervix; * damage during a difficult birth; * malformed cervix or uterus from a birth defect; * previous trauma to the cervix, such as a D&C (dilation and curettage) from a termination or a miscarriage; * DES (diethylstilbestrol) exposure.

How will I know if I have an incompetent cervix?

Incompetent cervix is not routinely checked for during pregnancy and therefore is not usually diagnosed until after a second or third trimester miscarriage has occurred.

Women can be evaluated before pregnancy, or in early pregnancy by ultrasound, if they have any of the factors that are potential causes of incompetent cervix.

Diagnosis can be made by your physician though a pelvic exam or by an ultrasound. The ultrasound would be used to measure the cervical opening or the length of the cervix.

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Pregnancy and Birth Sourcebook, Third Edition How often does an incompetent cervix happen?

An incompetent or weakened cervix happens in about 12% of pregnancies. Almost 25% of babies miscarried in the second trimester are due to incompetent cervix.

What is the treatment for a weakened cervix?

The treatment for an incompetent or weakened cervix is a procedure that sews the cervix closed to reinforce the weak cervix. This procedure is called a cerclage and is usually performed between week 1416 of pregnancy. These sutures will be removed between 3638 weeks to prevent any problems when you go into labor.

Removal of the cerclage does not result in spontaneous delivery of the baby. A woman would not be eligible for a cerclage if: * there is increased irritation of the cervix; * the cervix has dilated 4 cm; * membranes have ruptured.

Possible complications of cervical cerclage include uterine rupture, maternal hemorrhage, bladder rupture, cervical laceration, preterm labor, and premature rupture of the membranes. The likelihood of these risks is very minimal, and most health care providers feel that a cerclage is a life saving procedure that is worth the possible risks involved.

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Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Section 55.5 Section 55.5 Drug Offers Alternative to Surgical Treatment after Miscarriage From "Drug Offers Alternative to Surgical Treatment After Miscarriage,"

by the National Inst.i.tutes of Health (NIH, www.nih.gov), August 24, 2005.

A drug first used to reduce the risk of stomach ulcers in people taking certain types of painkillers offers an alternative to surgery after miscarriage, according to a study by researchers at the National Inst.i.tute of Child Health and Human Development of the National Inst.i.tutes of Health and other research inst.i.tutions.

The study appeared in the August 18, 2005, New England Journal of Medicine New England Journal of Medicine.

The drug, misoprostol, has been used to reduce the risk of stomach ulcers that occur in people who take certain pain relievers for arthritis. Misoprostol is now more commonly used to induce labor, as it stimulates contractions of the uterus.

In recent years, physicians have begun prescribing misoprostol in place of surgery to women who have experienced a miscarriage. Until the current study, however, no large-scale studies have been undertaken to evaluate the safety and effectiveness of the drug in treating miscarriage.

"This is the first comprehensive study to show that misoprostol is an effective alternative to surgery in the treatment of miscarriage,"

said Duane Alexander, MD, Director of the National Inst.i.tute of Child Health and Human Development (NICHD). "Unlike conventional surgery, which is usually conducted in an operating room, treatment with misoprostol can be done on an outpatient basis."

The study authors wrote that pregnancy failure, or miscarriage, occurs in 15 percent of pregnancies. With miscarriage, in some cases, a fetus dies in the womb, explained the study's first author, Jun Zhang, MD, PhD, an investigator in the Epidemiology Branch of NICHD's Division of Epidemiology, Statistics, and Prevention Research. In other cases, a fetus may no longer be present, and women may carry a placenta and sac of amniotic fluid.

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Pregnancy and Birth Sourcebook, Third Edition In all of these cases, the standard treatment is a surgical procedure known as vacuum aspiration. In this procedure, the cervix is dilated, and a suction device is used to remove the uterine contents.

As an alternative, women and their doctors may choose to wait for the uterus to expel the tissue without additional medical treatment.

Such expulsion is by no means certain, and may take more than a month. Many women, grieving from the failed pregnancy, may prefer not to wait. Occasionally, the uterus may fail to expel the remaining fetal tissue, and in some of these cases, the uterus may become infected.

Within the last few years, physicians have used misoprostol to treat pregnancy failure, and some researchers have conducted a few small studies of the drug's effectiveness in treating that condition. However, no definitive evidence existed to determine whether the drug was safe and effective enough for routine medical practice.

For the current study, Dr. Zhang and colleagues at several inst.i.tutions enrolled 652 women who experienced pregnancy failure. Of these, 491 were a.s.signed at random to receive misoprostol. The rest of the women underwent vacuum aspiration. The women in the misoprostol group were treated with 4 v.a.g.i.n.al doses of misoprostol, each containing 200 mcg of the drug. If the uterus had not expelled its contents by the end of three days, the women received a second misoprostol treatment. If, after 5 more days had pa.s.sed, the uterine contents still had not been expelled, the women were offered vacuum aspiration.

By the end of the third day, 71 percent of the women receiving misoprostol experienced complete uterine expulsion. After 5 more days had pa.s.sed, a total of 84 percent of the misoprostol group had complete uterine expulsion. The misoprostol treatment failed for 16 percent of the group, however. In contrast, 3 percent of the vacuum aspiration group experienced treatment failure, and needed to undergo the procedure a second time. Complications from either misoprostol or vacuum aspiration-uterine hemorrhage and infection of the uterine lining-were rare, occurring in less than 1 percent of each group.

Of the women in the misoprostol group, 78 percent said they would choose the drug again if they needed to, and 83 percent said they would recommend it to other women.

Dr. Zhang noted that, because misoprostol causes uterine contractions, treatment with the drug could bring about abdominal pain and cramping. The researchers treated minor pain caused by the treatment with ibuprofen and treated more intense pain with codeine.

He added that the misoprostol treatment provided an effective alternative for women who preferred to avoid the surgical procedure.

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