Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Moreover, because it could be performed on an outpatient basis, the misoprostol treatment was less expensive and could provide women more privacy and convenience than vacuum aspiration. Roughly one in four women experience miscarriage, so the availability of a non-surgical treatment may provide an effective alternative for many women, he added. Moreover, because it could be performed on an outpatient basis, the misoprostol treatment was less expensive and could provide women more privacy and convenience than vacuum aspiration. Roughly one in four women experience miscarriage, so the availability of a non-surgical treatment may provide an effective alternative for many women, he added.

"Misoprostol is inexpensive and does not need to be refrigerated,"

Dr. Zhang said. "It could provide treatment for miscarriage in developing countries where safe surgical treatment may not be readily accessible."

Section 55.6 What Is a Stillbirth?

From "Stillbirth," 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, September 10, 2006.

What is a stillbirth?

A stillbirth is the loss of pregnancy due to natural causes after the 20th week of pregnancy. It can occur before delivery or during delivery.

What are the signs of a stillbirth?

In some cases of stillbirth, the mother may notice a decrease in the movement or kicking of the fetus. In these cases, the health care provider uses an ultrasound, a machine that uses sound waves to create a picture of the fetus, to learn more about its health.

If the fetus has died, an autopsy and placental examination is performed to get information on why the baby died. But it is not always possible to tell why the baby died.

If you are pregnant and have concerns about stillbirth, ask your health care provider if there are ways he or she wants you to track movement.

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Pregnancy and Birth Sourcebook, Third Edition What are the causes of a stillbirth?

Causes of a stillbirth may include: * problems with the placenta, such an abruption in which the placenta peels away from the uterine wall; * chromosomal abnormalities resulting from defects in the sperm or egg that make the fetus unable to develop properly; * other physical problems in the fetus; * fetuses that are small for their gestational age or not growing at an appropriate rate; or * bacterial infections that can cause complications and death to the fetus.

In at least half of all cases, researchers can find no cause for the pregnancy loss.

What medical procedures are used when there is a still- birth?

In some cases it is medically necessary for a woman to deliver the fetus immediately after the diagnosis of a stillbirth.

In other cases, the couple can decide when they want to deliver the fetus.

A health care provider can induce labor or perform a caesarean section to deliver the fetus. A woman will usually go into labor on her own within two weeks after the fetal death.

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Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Section 55.7 Section 55.7 Research on Miscarriage and Stillbirth Excerpted from "Research on Miscarriage and Stillbirth," 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, September 15, 2006.

Miscarriage The NICHD supports and conducts research on the causes of miscarriage in hopes of finding ways to prevent women from having them.

For instance, NICHD-supported researchers recently found that women with a disorder called polycystic ovary syndrome (PCOS) are three times more likely to miscarry during the early months of pregnancy than women who don't have PCOS. Women with PCOS often have great difficulty getting pregnant naturally.

Research has found that women with PCOS also tend to have a condition called insulin resistance, which means their bodies have trouble using the insulin they make to get energy from their cells.

Insulin resistance often occurs before someone develops diabetes. To treat this insulin resistance, researchers had been prescribing a drug called metformin. What they found was that metformin not only reduced insulin resistance, but it also brought about changes to the uterine lining that could help women with PCOS get pregnant and reduce the risk of miscarriage during their first trimester (the first three months) of pregnancy.

Studies are now underway to confirm the positive effects of the using metformin in women with PCOS, and to evaluate the safety of taking the drug throughout pregnancy. The NICHD's Reproductive Sciences Branch, through its Reproductive Medicine Network (RMN) is currently conducting a clinical trial for the treatment of infertility related to PCOS, using metformin. The RMN website provides more information on this trial and on the RNM itself.

Other NICHD-supported research is trying to learn more about repeated miscarriage. Researchers estimate that between 1 percent and 2 percent of women in the United States has more than one miscarriage without a known cause. Women who experience repeated 441 Pregnancy and Birth Sourcebook, Third Edition miscarriages may undergo expensive and lengthy tests to try to identify a cause, but often get no answers. NICHD researchers, examining the v.u.l.v.a of these women have found that many of them share a genetic mutation, or change. This mutation, on one of the X chromosomes, was found in nearly 15 percent of women who had a history of repeated, unexplained miscarriage. If this genetic mutation is confirmed as a cause of repeated miscarriages, researchers may be able to develop a simple blood test that could predict a woman's chances of having a miscarriage in future pregnancies.

Stillbirth In spite of how often stillbirth occurs, and how emotionally painful it can be, little research has been done on this type of pregnancy loss. To encourage more research on stillbirth, the NICHD is supporting a new research initiative, Research on the Scope and Causes of Stillbirth in the United States. Through this effort, the NICHD will create a network of research sites whose sole focus will be on understanding stillbirth, its features, its causes, and its effects on a woman's uterus. Patients in this network will include women from a variety of ethnic and economic backgrounds to provide a clearer picture of this problem. Through this initiative, the NICHD hopes to support work that may some day be able to predict and prevent stillbirths.

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Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth Section 55.8 Section 55.8 Coping with Pregnancy Loss "Pregnancy Loss: How to Cope,"

2008 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission.

Pregnancy loss can happen anytime during a pregnancy. It may be a miscarriage, a tubal (ectopic) pregnancy, a stillbirth, or it may be the death of a baby shortly after birth (neonatal death).

When you have a pregnancy loss, you may feel both physical and emotional pain. Every woman reacts differently to the loss. There are no right or wrong feelings. You may have strong feelings of loss no matter how early or how late you were in the pregnancy.

At first you may feel a sense of shock and disbelief. Your emotions may range from guilt and sadness, to anger and feeling out of control. You may wonder if you or someone else could have prevented your loss. You may want to be with family and friends or you may want to spend time alone. All of this is normal. The length of time needed to grieve is different for everyone. More important than the length of time is just allowing yourself to grieve.

How the Father May Cope The father may react differently to the loss. He may focus on your health and feel the need to protect you. He may feel helpless and not know what to do to "make it better." You and the father may not share the same feelings at the same time. The father may find other ways of grieving and coping. This does not mean he doesn't care or feel sad.

Grieving will be different for each of you, and that's okay. It's important to talk and support each other.

Helping Children Cope You may have other children who need help understanding and coping with the loss. Resources are available that can help you explain the pregnancy loss to your children.

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Pregnancy and Birth Sourcebook, Third Edition For more information, call a women's and children's hospital to speak with a social worker.

How Others May Respond Others may not respond in the ways you hope or expect. This can range from statements such as, "you can have another baby," to say-ing nothing at all. Allow your family and friends to provide the love and support you need at this difficult time.

Support A pregnancy loss may leave you feeling alone. You may wonder, "Are there other women who feel the way I do?" or "Am I normal?" The answer is yes.

Helpful Tips * Be patient and take care of yourself, emotionally and physically.

* Remember that everyone grieves in his or her own way. You and your loved ones may be at different points in the grief process.

* Let others know what you need. Family and friends may not know how to help.

* Remember that you are not alone. Consider attending a support group or ask your nurse, doctor, or midwife to help you find a social worker.

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Chapter 56.

Preterm and Postterm Labor and Birth Chapter Contents.Section 56.1-What Is Preterm Labor? ..................................... 446 Section 56.2-Preventing Preterm Labor and Birth ................ 448 Section 56.3-Common Treatment to Delay Labor Decreases Preterm Infants' Risk for Cerebral Palsy ..................................................... 453 Section 56.4-Overdue Pregnancy ............................................. 456 445.

Pregnancy and Birth Sourcebook, Third Edition Section 56.1 What Is Preterm Labor?

From "Preterm Labor and Birth," 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, April 6, 2009.

What are preterm labor and birth?

Preterm labor (also called premature labor) is labor that begins before 37 weeks of pregnancy. Because the fetus is not fully grown at this time, it may not be able to survive outside the womb. Health care providers will often take steps to try to stop labor if it occurs before this time.

A baby born before 37 weeks of pregnancy is considered a preterm birth (or premature birth). Preterm births occur in about 12 percent of all pregnancies in the United States. It is one of the top causes of infant death in this country.

Who is at risk for preterm labor and birth?

Health care providers currently have no way of knowing which women will experience preterm labor or deliver their babies preterm.

But there are factors that place a woman at higher risk for preterm labor or birth: * certain infections, such as bacterial vaginosis and trich.o.m.oniasis; * shortened cervix; * previously given birth preterm.

What are the challenges to a baby born preterm?

Premature infants may face a number of health challenges, including: * low birth weight; * breathing problems because of underdeveloped lungs; 446.

Preterm and Postterm Labor and Birth * underdeveloped organs or organ systems; * greater risk for life-threatening infections; * greater risk for a serious lung condition, known as respiratory distress syndrome; * greater risk for cerebral palsy (CP); * greater risk for learning and developmental disabilities.

They may need to stay in the hospital for several weeks or more, often in a neonatal intensive care unit (NICU).

What methods are used to prevent preterm delivery?

Research supported by the National Inst.i.tute of Child Health and Human Development (NICHD) found that treating high-risk pregnant women (those who have previously had a spontaneous preterm baby) with a certain type of progesterone reduces the risk of another preterm delivery. The treatment worked among all ethnic groups in the study and improved outcomes for the babies. Efforts to find out whether the treatment works for other at-risk women, such as those having twins and triplets, are ongoing.

Bed rest and medications that relax the muscles in the uterus are also commonly used to try to stop preterm labor.

Researchers have found that other methods of stopping preterm labor are not as effective as once thought. For instance, NICHD-supported researchers have found that home uterine monitors are not effective for predicting or preventing preterm labor.

In addition, NICHD-funded research found that screening women who don't show any symptoms of infection, but who have bacterial vaginosis, and treating them with antibiotics did not prevent preterm birth.

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Pregnancy and Birth Sourcebook, Third Edition Section 56.2 Preventing Preterm Labor and Birth This section contains text from "Preventing Preterm Labor and Premature Birth," 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, August 13, 2007, and "Research on Preterm Labor and Premature Birth," by the NICHD, October 20, 2006.

Preventing Preterm Labor and Premature Birth Preterm birth, defined as birth before the fetus is at 37 weeks' gestation, is a major public health priority for the United States and a major research priority for the NICHD. In 2003, one out of every eight infants born was preterm-accounting for more than $18.1 billion in hospital expenditures. Preterm infants are at high risk for a variety of disorders, including mental r.e.t.a.r.dation, cerebral palsy, and vision impairment. These infants are also at high risk for long-term health issues, including cardiovascular disease (heart attack, stroke, and high blood pressure) and diabetes.

The NICHD supports and conducts a large portfolio on preterm birth. Among the main goals of this research is finding a way to prevent births from occurring before an infant is strong enough to survive outside the womb. Because women who have one preterm birth are considered to be at high risk for another preterm birth, investigators have focused their attention on trying to prevent preterm birth among these high-risk women.

Researchers have had success using a treatment of a specific type of progesterone-called 17P. Progesterone is a hormone that the body makes to support pregnancy. In fact, the word "progesterone"

means "for pregnancy." An NICHD Maternal-Fetal Medicine Units (MFMU) Network study, which began in 2003, set out to determine whether injections of 17P could reduce the number of preterm births among women who had already had one preterm birth. The results were remarkable: for women carrying one baby and with a history of preterm delivery, injections of 17P reduced preterm birth by one third.

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Preterm and Postterm Labor and Birth Women carrying two or more babies are also at risk for preterm delivery, so researchers in the MFMU Network studied whether or not injections of 17P could prevent preterm delivery among these women. Recently reported results from this study indicate that 17P is not effective at reducing preterm delivery among women carrying twins. However, the treatment is still a proven way to reduce preterm birth among women carrying a single baby who have had a preterm delivery before.

Studies are also underway to try and prevent preterm delivery among women with other risk factors for preterm delivery, including those who have a shortened cervix (the lower part of the uterus) and those who have certain infections.

The NICHD research portfolio on preterm birth includes not only preventing preterm labor and delivery, but also ways to care for infants who are born preterm. Research on the preterm infant ranges from ways to help the lungs mature to what types of facilities provide the best care for preterm infants. Some of the research extends beyond the infant period into childhood and adulthood, tracking developmental progress and cognitive features.

In this way, NICHD's preterm birth and infant portfolio embodies the Inst.i.tute's mission of promoting healthy development through the lifespan.

Research on Preterm Labor and Premature Birth Health care providers consider labor to be preterm if it starts before 37 weeks of pregnancy. Because a fetus is not fully grown at 37 weeks, and it may not be able to survive outside the womb, health care providers will often take steps to stop labor if it starts before this time.

Common methods for trying to stop labor include bed rest and medications that relax the muscles in the uterus involved with labor and delivery.

However, the American College of Obstetricians and Gynecologists (ACOG) recently reported that many of the methods used to stop preterm labor are ineffective. The ACOG announcement confirms NICHD-supported research, which found that home uterine monitors were not effective for predicting or preventing preterm labor.

If efforts to stop labor fail, then the baby could be born prematurely.

Premature infants face a number of health challenges, including low birth weight, breathing problems, and underdeveloped organs and organ systems. Many infants that are born prematurely need to stay 449 Pregnancy and Birth Sourcebook, Third Edition in the hospital until their health is stable, sometimes several weeks or more.

Despite attempts to stop labor, many cases of preterm labor end in premature birth. Premature birth occurs in between 8 percent to 10 percent of all pregnancies in the United States; it remains one of the top causes of infant death in this country. Infants who survive being born prematurely are at increased risk for certain life-long health effects, such as cerebral palsy, blindness, lung diseases, learning disabilities, and developmental disabilities.

Current NICHD-supported research is trying to identify markers and predictors of preterm labor and premature birth. In one study, researchers are investigating premature rupture of membranes (PROM), a situation in which the membranes that support the fetus in the womb break (sometimes referred to as "when a woman's water breaks") before the fetus is fully developed. PROM can lead to preterm labor and premature birth. Researchers found that, in some cases, the womb and the fetus produce enzymes, proteins that speed up certain chemical reactions, which can cause the membranes to break apart.

Further research is now underway to figure out whether other features may make some women more likely to experience PROM. The findings of this research may lead to new methods of preventing PROM and some premature births.

Past research revealed that certain infections can make a woman more likely to experience preterm labor and give birth early. For instance, women who have bacterial vaginosis, the most common v.a.g.i.n.al infection for women of reproductive age, are more likely than other women to experience preterm labor and give birth prematurely.

Similarly, women who have trich.o.m.oniasis, a s.e.xually transmitted infection, are also more likely to give birth prematurely than women who don't have the infection. It would stand to reason, then, that treating these infections would prevent premature births in these cases. But, NICHD-supported studies have shown that treating these infections is not an effective way to prevent premature birth. Further research is now underway to find other options for treating these infections that may reduce the risk of premature birth.

One effective way to understand preterm labor and premature delivery is to study the characteristics of women who have given birth prematurely. One group of NICHD-supported researchers found that, among women who had given birth prematurely in the past, a shortened cervix could be a warning sign in preterm labor for a current pregnancy. With this knowledge, scientists can work to develop ways 450 Preterm and Postterm Labor and Birth of preventing this shortening of the cervix, which may help to prevent preterm labor and premature delivery.

In addition, research on preterm labor and premature birth is ongoing through the NICHD's Maternal-Fetal Medicine Units (MFMU) Network, a research program that uses 14 sites around the country to conduct studies related to the mechanisms of pregnancy and birth.

Researchers in the MFMU Network recently completed a clinical trial, which showed that the hormone progesterone may prevent repeated premature birth in a specific group of women, those who were carrying a single fetus, and who previously gave birth prematurely, between 20 and 26 weeks of pregnancy. In this trial, the progesterone treatment started between the 16th and 20th week of pregnancy, and continued through the 36th week of pregnancy. This finding may help to reduce future premature births among women who have a history of preterm labor and premature delivery.

NICHD-supported researchers were also working to see whether having more uterine contractions during pregnancy could be a warning sign of premature birth. Many pregnant women have uterine contractions throughout their pregnancies. These contractions are often mild and usually occur after the mid-way point of pregnancy. But, this research showed that, even though how often a woman had contractions was significantly related to premature birth, it wasn't an effective way to predict which mothers would give birth prematurely.

Infant Problems Related to Premature Birth Babies that are born prematurely face a number of problems, including low birth weight, respiratory and breathing difficulties, and underdeveloped organs and organ systems. Some research also suggests that babies born prematurely are at higher risk for certain health problems as they get older. To find ways to minimize the impact of premature birth on the health of infants, the NICHD supports and conducts observational and interventional studies on these topics.

Low Birth Weight (LBW) and Very Low Birth Weight (VLBW) LBW refers to any baby that weighs less than 2,500 grams (about 5 pounds, 8 ounces). VLBW describes an infant that weighs less than 1,500 grams (about 3 pounds, 5 ounces). LBW and VLBW infants are at higher risk than other infants for a variety of problems, including cerebral palsy, sepsis (a type of blood infection), chronic lung disease, 451 LBW refers to any baby that weighs less than 2,500 grams (about 5 pounds, 8 ounces). VLBW describes an infant that weighs less than 1,500 grams (about 3 pounds, 5 ounces). LBW and VLBW infants are at higher risk than other infants for a variety of problems, including cerebral palsy, sepsis (a type of blood infection), chronic lung disease, 451 Pregnancy and Birth Sourcebook, Third Edition and death. These infants are also at higher risk for hypothermia, low body temperature, which can be dangerous.

Research is now underway to learn how to increase the level of nutrition for these infants, to improve their survival rates, and find out what, if any, long-term these conditions have on overall health.

Respiratory Distress Syndrome (RDS) In RDS, the baby has trouble breathing. RDS can result from various situations, such as: * The baby's lungs aren't fully developed. Health care professionals can give these infants certain types of steroids, called corticosteroids, to help the lungs mature more quickly. These steroids may also lower the risk of brain injury. Sometimes, giving the lungs a little extra push in their development can help the baby breathe easier, which allows the infant to get stronger. Health care providers may also give corticosteroids to a woman who is at risk of delivering her baby before 34 weeks of pregnancy, to try to prevent the infant from developing RDS.

* The lungs are missing an important material. For the lungs to work properly, their lining has to be completely covered with a slick, soapy coating called surfactant. A growing fetus doesn't make enough surfactant to breathe outside of the womb until a certain point in development. Babies born prematurely have about 5 percent of the total surfactant that they need, which puts them at high risk for RDS. Through research conducted and supported by the NICHD, premature babies can now receive replacement surfactant to coat their lungs and allow for easier breathing. In some cases, getting replacement surfactant can prevent RDS from occurring at all; in other cases, the replacement surfactant saves the baby's lungs from long-term damage.

In addition to the treatments for these situations, premature infants may also benefit from being placed on a respirator, a machine that helps them breathe by inflating and deflating their lungs. Oxygen treatments or treatments using nitric oxide may also improve the breathing.

Through this and other NICHD-supported research into the problems faced by premature infants, survival rates for premature infants with RDS are nearly 95 percent. The NICHD and other Inst.i.tutes are also conducting clinical trials related to RDS.

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