Signs and Symptoms of Genital Herpes.

It is during a primary, or first, episode that genital herpes is most likely to be passed on to the fetus, so call your practitioner if you experience the following symptoms of infection: fever, headache, malaise, and achiness for two or more days, accompanied by genital pain, itching, pain when urinating, vaginal and urethral discharge, and tenderness in the groin, as well as lesions that blister and then crust over. Healing of the lesions generally takes place within two to three weeks, during which time the disease can still be transmitted.

Your Obstetrical History.

In Vitro Fertilization (IVF).

"I conceived my baby through in vitro fertilization. How different will my pregnancy be?"

Some well-deserved congratulations on your IVF success! With all you've been through to get to this point, you've earned some smooth sailing-and happily, you're likely to get it. The fact that you conceived in a laboratory rather than in bed shouldn't affect your pregnancy all that much, at least once the first trimester is over. Early on, however, there will be some differences in your pregnancy and your care. Because a positive test doesn't necessarily mean that a pregnancy will be sustained, because trying again can be so emotionally and financially draining, and because it's not known right off how many of the test-tube embryos are going to develop into fetuses, the first six weeks of an IVF pregnancy are usually more nerve-wracking than most. In addition, if you've miscarried in previous tries, intercourse and other physical activities may be restricted. As an added precaution, the hormone progesterone will likely be prescribed to help support your developing pregnancy during the first two months.

But once this period is past, you can expect that your pregnancy will be pretty much like everyone else's-unless it turns out that you're carrying more than one fetus, as over 30 percent of IVF mothers do. If you are, see Chapter 16 Chapter 16.

The Second Time Around.

"This is my second pregnancy. How will it be different from the first?"

Since no two pregnancies are exactly alike, there's no predicting how different (or how similar) these nine months will be from the last. There are some generalities, however, about second and subsequent pregnancies that hold true at least some of the time (like all generalities, none will hold true all of the time): [image] You'll probably "feel" pregnant sooner. Most second timers are more attuned to the early symptoms of pregnancy and more apt to recognize them. The symptoms themselves may vary from last time-you may have more or less morning sickness, indigestion, and other tummy troubles; you may be more tired (especially likely if you were able to nap in your first pregnancy but now barely have the chance to sit down) or less tired (perhaps because you're too busy to notice how tired you really are or because you're so used to being tired); you may have more urinary frequency or less (though it's likely to appear sooner). You'll probably "feel" pregnant sooner. Most second timers are more attuned to the early symptoms of pregnancy and more apt to recognize them. The symptoms themselves may vary from last time-you may have more or less morning sickness, indigestion, and other tummy troubles; you may be more tired (especially likely if you were able to nap in your first pregnancy but now barely have the chance to sit down) or less tired (perhaps because you're too busy to notice how tired you really are or because you're so used to being tired); you may have more urinary frequency or less (though it's likely to appear sooner).Some symptoms that are typically less pronounced in second and subsequent pregnancies include food cravings and aversions, breast enlargement and sensitivity, and worry (since you've already been there, done that, and lived to tell about it, pregnancy is less likely to induce panic).[image] You'll "look" pregnant sooner. Thanks to abdominal and uterine muscles that are more lax (there's no gentler way to put that), you're likely to "pop" much sooner than you did the first time. You may notice, too, that you'll carry differently than you did with baby number one. Baby number two (or three or four) is liable to be larger than your firstborn, so you may have more to carry around. Another potential result of those "loosened-up" abdominals: Backache and other pregnancy pains may be exacerbated. You'll "look" pregnant sooner. Thanks to abdominal and uterine muscles that are more lax (there's no gentler way to put that), you're likely to "pop" much sooner than you did the first time. You may notice, too, that you'll carry differently than you did with baby number one. Baby number two (or three or four) is liable to be larger than your firstborn, so you may have more to carry around. Another potential result of those "loosened-up" abdominals: Backache and other pregnancy pains may be exacerbated.[image] You'll probably feel movement sooner. Something else to thank those looser muscles for-chances are you'll be able to feel baby kicking much sooner this time around, possibly as early as 16 weeks (maybe sooner, maybe later). You're also more likely to know it when you feel it, having felt it before. Of course, if the last pregnancy left you with lots of extra abdominal padding that you haven't been able to shed, those first kicks might not be so easy to feel. You'll probably feel movement sooner. Something else to thank those looser muscles for-chances are you'll be able to feel baby kicking much sooner this time around, possibly as early as 16 weeks (maybe sooner, maybe later). You're also more likely to know it when you feel it, having felt it before. Of course, if the last pregnancy left you with lots of extra abdominal padding that you haven't been able to shed, those first kicks might not be so easy to feel.[image] You may not feel as excited. That's not to say you aren't thrilled to be expecting again. But you may notice that the excitement level (and that compulsion to tell everyone you pass in the street the good news) isn't quite as high. This is a completely normal reaction (again, you've been here before) and in no way reflects on your love for this baby. Keep in mind, too, that you're preoccupied (physically and emotionally) with the child who's already here. You may not feel as excited. That's not to say you aren't thrilled to be expecting again. But you may notice that the excitement level (and that compulsion to tell everyone you pass in the street the good news) isn't quite as high. This is a completely normal reaction (again, you've been here before) and in no way reflects on your love for this baby. Keep in mind, too, that you're preoccupied (physically and emotionally) with the child who's already here.[image] You will probably have an easier labor and a faster delivery. Here's the really good part about those laxer muscles. All that loosening up (particularly in the areas involved in childbirth), combined with the prior experience of your body, may help ensure a speedier exit for baby number two. Every phase of labor and delivery is likely to be shorter, with pushing time significantly reduced. You will probably have an easier labor and a faster delivery. Here's the really good part about those laxer muscles. All that loosening up (particularly in the areas involved in childbirth), combined with the prior experience of your body, may help ensure a speedier exit for baby number two. Every phase of labor and delivery is likely to be shorter, with pushing time significantly reduced.

You may wonder how to tell baby number one about the new baby who's on the way. Realistic, empathetic, and age-appropriate preparation for your firstborn to make the life-changing transition from only child to older child should begin during pregnancy. For tips, see What to Expect the First Year What to Expect the First Year and and What to Expect the Toddler Years. What to Expect the Toddler Years. Reading picture books such as Reading picture books such as What to Expect When Mommy's Having a Baby What to Expect When Mommy's Having a Baby and and What to Expect When the New Baby Comes Home What to Expect When the New Baby Comes Home to your child will also help with older sib preparations. to your child will also help with older sib preparations.

"I had a perfect first baby. Now that I'm pregnant again, I can't shake the fear that I won't be so lucky this time."

Your chances of hitting the baby jackpot once again are excellent-in fact, better still for already having a successful pregnancy under your reexpanding belt. Also, with each pregnancy you get the chance to up the odds even more, by accentuating all those pregnancy positives (good medical care, diet, exercise, and lifestyle choices).

Your Obstetrical History Repeating Itself.

"My first pregnancy was very uncomfortable-I must have had every symptom in the book. Will I be that unlucky again?"

In general, your first pregnancy is a pretty good predictor of future pregnancies, all things being equal. So you are a little less likely to breeze comfortably through pregnancy than someone who already has. Still, there's always the hope that your luck will change for the better. All pregnancies, like all babies, are different. If, for example, morning sickness or food cravings had you down in your first pregnancy, they may be barely noticeable in the second (or vice versa). Though luck, genetic predisposition, and the fact that you've experienced certain symptoms before have a lot to do with how comfortable or uncomfortable this pregnancy will be, other factors-including some that are within your control-can alter the prognosis to some extent. The factors include: General health. Being in good all-around physical condition gives you a better shot at having a comfortable pregnancy. Being in good all-around physical condition gives you a better shot at having a comfortable pregnancy.

Weight gain. Gaining weight at a steady rate and keeping the gain within the recommended guidelines (see Gaining weight at a steady rate and keeping the gain within the recommended guidelines (see page 166 page 166) can improve your chances of escaping or minimizing such pregnancy miseries as hemorrhoids, varicose veins, stretch marks, backache, fatigue, indigestion, and shortness of breath.

Diet. It can't offer any guarantees, but eating well (see It can't offer any guarantees, but eating well (see Chapter 5 Chapter 5 to find out how) improves every pregnant woman's chances of having a healthier and more comfortable pregnancy. Not only can it up your odds of avoiding or minimizing the miseries of morning sickness and indigestion, it can help you fight excessive fatigue, combat constipation and hemorrhoids, and prevent urinary tract infections and iron-deficiency anemia-even head off headaches. And if your pregnancy turns out to be uncomfortable anyway, by eating well you'll have bestowed on your baby the best chances of being born healthy. to find out how) improves every pregnant woman's chances of having a healthier and more comfortable pregnancy. Not only can it up your odds of avoiding or minimizing the miseries of morning sickness and indigestion, it can help you fight excessive fatigue, combat constipation and hemorrhoids, and prevent urinary tract infections and iron-deficiency anemia-even head off headaches. And if your pregnancy turns out to be uncomfortable anyway, by eating well you'll have bestowed on your baby the best chances of being born healthy.

Fitness. Getting enough and the right kind of exercise (see Getting enough and the right kind of exercise (see page 215 page 215 for guidelines) can help improve your general well-being. Exercise is especially important in second and subsequent pregnancies because abdominal muscles tend to be more lax, making you more susceptible to a variety of aches and pains, most notably backache. for guidelines) can help improve your general well-being. Exercise is especially important in second and subsequent pregnancies because abdominal muscles tend to be more lax, making you more susceptible to a variety of aches and pains, most notably backache.

Lifestyle pace. Leading a harried and frenetic life (and who doesn't these days?) can aggravate or sometimes even trigger one of the most uncomfortable of pregnancy symptoms-morning sickness-and exacerbate others, such as fatigue, headache, backache, and indigestion. Getting some help around the house, taking more breaks away from whatever fries your nerves, cutting back at work, letting low-priority tasks go undone for the time being, or practicing relaxation techniques or yoga can help you chill out-and feel better. Leading a harried and frenetic life (and who doesn't these days?) can aggravate or sometimes even trigger one of the most uncomfortable of pregnancy symptoms-morning sickness-and exacerbate others, such as fatigue, headache, backache, and indigestion. Getting some help around the house, taking more breaks away from whatever fries your nerves, cutting back at work, letting low-priority tasks go undone for the time being, or practicing relaxation techniques or yoga can help you chill out-and feel better.

Other children. Some pregnant women with other children at home find that keeping up with their offspring keeps them so busy that they barely have time to notice pregnancy discomforts, major or minor. For others, all the running around that comes with running after kids tends to aggravate pregnancy symptoms. For example, morning sickness can increase during times of stress (the getting-to-school or the getting-dinner-on-the-table rush, for instance); fatigue can be heightened because there doesn't seem to be any time to rest; backaches can be an extra pain if you're doing a lot of child toting; even constipation becomes more likely if you never have a chance to use the bathroom when the urge strikes. You are also more likely to come down with colds and other illnesses, courtesy of older germ-spreading kids. (See Some pregnant women with other children at home find that keeping up with their offspring keeps them so busy that they barely have time to notice pregnancy discomforts, major or minor. For others, all the running around that comes with running after kids tends to aggravate pregnancy symptoms. For example, morning sickness can increase during times of stress (the getting-to-school or the getting-dinner-on-the-table rush, for instance); fatigue can be heightened because there doesn't seem to be any time to rest; backaches can be an extra pain if you're doing a lot of child toting; even constipation becomes more likely if you never have a chance to use the bathroom when the urge strikes. You are also more likely to come down with colds and other illnesses, courtesy of older germ-spreading kids. (See Chapter 20 Chapter 20 for preventing and dealing with such illnesses.) for preventing and dealing with such illnesses.) It's not realistic to always put your pregnant body first when you've got other kids clamoring for care (the days of pampered pregnancy ended with your first delivery). But taking more time to take care of yourself-putting your feet up while you read that story, napping (instead of vacuuming) while your toddler naps, getting into the healthy snack habit even when there's no time for sit-down meals, and taking advantage of help whenever it's available-can help lighten the load your body's carrying, minimizing those pregnancy miseries.

"I had some complications with my first pregnancy. Will this one be just as rough?"

One complicated pregnancy definitely doesn't predict another one. While some pregnancy complications can repeat, many don't repeat routinely. Others may have been triggered by a onetime event, such as an infection or accident, which means they're extremely unlikely to strike twice. Your complications won't recur, either, if they were caused by lifestyle habits that you've now changed (like smoking, drinking, or using drugs), an exposure to an environmental hazard (such as lead) to which you are no longer exposed, or by not getting medical care early in pregnancy (assuming you've sought care early on this time). If the cause was a chronic health problem, such as diabetes or high blood pressure, correcting or controlling the condition prior to conception or very early in pregnancy can greatly reduce the risk of repeat complications. Also keep this in mind: Even if the complications you faced last time have a chance of reoccurrence, earlier detection and treatment (because you and your practitioner will be on the lookout for a repeat) can make a big difference.

Discuss with your practitioner the complications you had last time and what can be done to prevent them from being repeated. No matter what the problems or their causes (even if no cause was ever pinpointed), the tips in the response to the previous question can help make your pregnancy more comfortable, and safer for both you and your baby.

Back-to-Back Pregnancies.

"I became pregnant unexpectedly just 10 weeks after I delivered my first child. What effect will this have on my health and on the baby I'm now carrying?"

Expanding your family (and your belly) again a little sooner than expected? Starting another pregnancy before you've fully recovered from the last one can be hard enough without adding stress to the mix. So first of all, relax. Though two closely spaced pregnancies can take their physical toll on a mom-to-be who just became a mom, there are lots of things you can do to help your body better handle the challenge of back-to-back baby making, including: [image] Getting the best prenatal care, starting as soon as you think you're pregnant. Getting the best prenatal care, starting as soon as you think you're pregnant.[image] Eating as well as you can (see Eating as well as you can (see Chapter 5 Chapter 5). It's possible your body has not had a chance to rebuild its stores of vitamins and nutrients, and that can put you at a nutritional disadvantage, particularly if you're still nursing. You may need to overcompensate nutritionally to be sure both you and the baby you are carrying don't get short-changed. Pay particular attention to protein and iron (ask your practitioner whether you should take a supplement) and be sure to continue taking your prenatal vitamins. Try not to let lack of time or energy (you'll have little of both, that's for sure) keep you from eating enough. Healthy grazing may help you fit those nutrients into your busy schedule.[image] Gaining enough weight. Your new fetus doesn't care whether or not you've had time to shed the extra pounds his or her sibling put on you. The two of you need the same weight gain this pregnancy, too, unless your practitioner prescribes otherwise. So shelve any weight loss plans for now. A carefully monitored gradual weight gain will be relatively easy to take off afterward, particularly if it was gained on a high-quality diet, and especially once you have a young toddler and an infant to keep up with. Watch your weight gain carefully, and if the numbers don't start climbing as they should, monitor your calorie intake more closely and follow the tips for increasing weight gain on Gaining enough weight. Your new fetus doesn't care whether or not you've had time to shed the extra pounds his or her sibling put on you. The two of you need the same weight gain this pregnancy, too, unless your practitioner prescribes otherwise. So shelve any weight loss plans for now. A carefully monitored gradual weight gain will be relatively easy to take off afterward, particularly if it was gained on a high-quality diet, and especially once you have a young toddler and an infant to keep up with. Watch your weight gain carefully, and if the numbers don't start climbing as they should, monitor your calorie intake more closely and follow the tips for increasing weight gain on page 180 page 180.[image] Fair-share feeding. If you're breastfeeding your older baby, you can continue as long as you feel up to it. If you are completely exhausted, you may want to supplement with formula or consider weaning altogether. Discuss the options with your practitioner. If you decide to continue breastfeeding, be sure to get enough extra calories to feed both your baby and your fetus (ask your practitioner what to aim for). You will also need plenty of rest. Fair-share feeding. If you're breastfeeding your older baby, you can continue as long as you feel up to it. If you are completely exhausted, you may want to supplement with formula or consider weaning altogether. Discuss the options with your practitioner. If you decide to continue breastfeeding, be sure to get enough extra calories to feed both your baby and your fetus (ask your practitioner what to aim for). You will also need plenty of rest.[image] Resting up. You need more than may be humanly (and new-motherly) possible. Getting it will require not only your own determination but help from your spouse and others as well-who should take over as much of the cooking, housework, and baby care as possible. Set priorities: Let less important chores or work go undone, and force yourself to lie down when your baby is napping. If you're not breastfeeding, let daddy take over nighttime feedings; if you are, at least have him do the baby fetching at 2 Resting up. You need more than may be humanly (and new-motherly) possible. Getting it will require not only your own determination but help from your spouse and others as well-who should take over as much of the cooking, housework, and baby care as possible. Set priorities: Let less important chores or work go undone, and force yourself to lie down when your baby is napping. If you're not breastfeeding, let daddy take over nighttime feedings; if you are, at least have him do the baby fetching at 2 A.M A.M.[image] Exercising. But just enough to energize you, not enough to exhaust you. If you can't seem to find the time for a regular pregnancy exercise routine, build physical activity into your day with your baby. Take him or her for a brisk walk in the stroller. Or enroll in a pregnancy exercise class or swim at a club or community center that offers baby-sitting services. Exercising. But just enough to energize you, not enough to exhaust you. If you can't seem to find the time for a regular pregnancy exercise routine, build physical activity into your day with your baby. Take him or her for a brisk walk in the stroller. Or enroll in a pregnancy exercise class or swim at a club or community center that offers baby-sitting services.[image] Eliminating or minimizing all other pregnancy risk factors that apply to you, such as smoking and drinking. Your body and your baby-to-be don't need any extra stress. Eliminating or minimizing all other pregnancy risk factors that apply to you, such as smoking and drinking. Your body and your baby-to-be don't need any extra stress.

Having a Big Family.

"I'm pregnant for the sixth time. Does this pose any additional risk for my baby or for me?"

On your way to testing out that cheaper-by-the-dozen theory? Happily-for you and for your large brood-women receiving good prenatal care have an excellent chance of having healthy, normal babies in sixth (and later) pregnancies. In fact, beyond a small jump in the incidence of multiple births (twins, triplets, and so on-which could mean that your large brood could potentially grow even larger still), these more-the-merrier pregnancies are almost as likely to be uncomplicated as any first or second.

So enjoy your pregnancy and your large family. But while you're at it: [image] Get rest-all the rest you can get. Sure, you could probably do pregnancy in your sleep by now, but that doesn't mean you should try. Every pregnant woman needs her rest, but pregnant women who are also caring for a houseful of other children (plus the house they're filling) need even more. Get rest-all the rest you can get. Sure, you could probably do pregnancy in your sleep by now, but that doesn't mean you should try. Every pregnant woman needs her rest, but pregnant women who are also caring for a houseful of other children (plus the house they're filling) need even more.[image] Get help-all the help you can get. This will make getting that rest you need possible (or, at least, somewhat possible). Start with your spouse, who should be shouldering what he can in terms of child and house care, but don't stop there. If you haven't already, teach your older children to be more self-sufficient and assign them age-appropriate chores. Any nonessential chores you can't pass off to someone else, skip for now. Get help-all the help you can get. This will make getting that rest you need possible (or, at least, somewhat possible). Start with your spouse, who should be shouldering what he can in terms of child and house care, but don't stop there. If you haven't already, teach your older children to be more self-sufficient and assign them age-appropriate chores. Any nonessential chores you can't pass off to someone else, skip for now.[image] Feed yourself. Moms with many mouths to feed often neglect to feed their own. Not only does meal skipping or junk-food-grabbing shortchange you these days (leaving you with even less energy than you already have), but it shortchanges the baby you have on board. So take the time to eat well. Making healthy snacking a habit can help a lot (and finishing off PB&J scraps and half-eaten chicken fingers doesn't necessarily count). Feed yourself. Moms with many mouths to feed often neglect to feed their own. Not only does meal skipping or junk-food-grabbing shortchange you these days (leaving you with even less energy than you already have), but it shortchanges the baby you have on board. So take the time to eat well. Making healthy snacking a habit can help a lot (and finishing off PB&J scraps and half-eaten chicken fingers doesn't necessarily count).[image] Watch your weight. It's not uncommon for women who've had several pregnancies to put on a few extra pounds with each baby. If that's been the case with you, be particularly careful to eat efficiently and keep your gain on target (a target that should be determined by your practitioner). On the flip side, make sure you're not so busy you don't eat enough to gain adequate weight. Watch your weight. It's not uncommon for women who've had several pregnancies to put on a few extra pounds with each baby. If that's been the case with you, be particularly careful to eat efficiently and keep your gain on target (a target that should be determined by your practitioner). On the flip side, make sure you're not so busy you don't eat enough to gain adequate weight.

Previous Abortions.

"I've had two abortions. Will they affect this pregnancy?"

Multiple first-trimester abortions aren't likely to have an effect on future pregnancies. So if your abortions were performed before the 14th week, chances are there's no cause for concern. Multiple second-trimester abortions (performed between 1. and 27 weeks), however, may slightly increase the risk of premature delivery. In either case, be sure your practitioner knows about the abortions. The more familiar he or she is with your complete obstetrical and gynecological history, the better care you will receive.

Do Tell.

Whatever gynecological or obstetrical history is in your past, now's not the time to try to put it behind you. Telling your practitioner everything about your history is more important (and relevant) than you might think. Previous pregnancies, miscarriages, abortions, surgeries, or infections may or may not have an impact on what happens in this pregnancy, but any information you have about them-or any aspect of your obstetrical and gynecological history-should be passed on to your practitioner (all will be handled with confidentiality). The more he or she knows about you, the better care you'll get.

Preterm Birth.

"I had a preterm delivery in my first pregnancy. I've eliminated all my risk factors, but I'm still worried about having a repeat preterm labor."

Congratulations on doing everything you can to make sure your pregnancy is as healthy as possible this time around-and to give your baby the very best chances of staying on board until term. That's a great first step. Together with your practitioner, there are probably even more steps you can take to minimize the chances for a repeat preterm labor.

First, ask your practitioner about the latest research into preventing preterm labor. Researchers have found that the hormone progesterone-given as shots or a gel during weeks 16 through 36-reduces the risk for preterm birth in women with a prior history of one. If you've had a previous preterm birth, ask your practitioner if you're a good candidate for progesterone.

Second, ask your practitioner if one of the two screening tests available for predicting whether you're at risk for preterm birth would be right for you. Usually, these tests are only recommended for high-risk women since positive test results aren't an accurate predictor of early delivery, but negative results can help avoid unnecessary interventions-and needless anxiety. The fetal fibronectin (fFN) screening test detects a protein in the vagina only present if there has been a separation of the amniotic sac from the uterine wall (an early indicator of labor). If you have a negative fFN test, it's unlikely you'll go into preterm labor within the next few weeks after the test (so you can breathe easy). If it's positive, your risk of going into preterm labor is significantly higher, and your practitioner may take steps to prolong your pregnancy and prepare your baby's lungs for an early delivery.

The second screening test is for cervical length. The length of your cervix is measured via ultrasound, and if there are any signs that the cervix is shortening or opening, your practitioner may take some steps to reduce your risk of early delivery, such as putting you on bed rest or perhaps stitching your cervix closed (if you're before 22 weeks).

Knowledge is always power-but in this case, knowledge can also help prevent your second baby from being born too soon. And that's a very good thing.

Incompetent Cervix.

"I had a miscarriage in the fifth month of my first pregnancy. The doctor said it was caused by an incompetent cervix. I just had a positive home pregnancy test, and I'm worried that I'll have the same problem again."

The good news (and there is is good news here) is that it doesn't have to happen again. Now that your incompetent cervix has been diagnosed as the cause of your first pregnancy loss, your obstetrician should be able to take steps to prevent it from causing another loss. With proper treatment and careful watching, the odds of your having a healthy pregnancy and a safe delivery this time around are greatly in your favor. (If you have a different practitioner now, make sure you share your history of incompetent cervix so you can receive the best care possible.) good news here) is that it doesn't have to happen again. Now that your incompetent cervix has been diagnosed as the cause of your first pregnancy loss, your obstetrician should be able to take steps to prevent it from causing another loss. With proper treatment and careful watching, the odds of your having a healthy pregnancy and a safe delivery this time around are greatly in your favor. (If you have a different practitioner now, make sure you share your history of incompetent cervix so you can receive the best care possible.) An incompetent cervix, one that opens prematurely under the pressure of the growing uterus and fetus, is estimated to occur in 1 or 2 of every 100 pregnancies; it is believed responsible for 10 to 20 percent of all second- trimester miscarriages. It can be the result of genetic weakness of the cervix, extreme stretching of or severe lacerations to the cervix during one or more previous deliveries, an extensive "cone" biopsy done for precancerous cervical cells, or cervical surgery or laser therapy. Carrying more than one fetus can also lead to incompetent cervix, but if it does, the problem will not usually recur in subsequent single-fetus pregnancies.

Incompetent cervix is usually diagnosed when a woman miscarries in the second trimester after experiencing progressive painless effacement (shortening and thinning) and dilation of the cervix without apparent uterine contractions or vaginal bleeding.

To help protect this pregnancy, your ob may perform cerclage (a procedure during which the opening of the cervix is stitched closed) when you're in your second trimester (anywhere from 12 to 22 weeks). Although recent research has seriously questioned the effectiveness of cerclage (more study needs to be done), many practitioners still perform it routinely. More often, however, doctors will only do cerclage when an ultrasound or a vaginal exam shows that the cervix is shortening or opening. The simple procedure is performed through the vagina under local anesthesia. Twelve hours after surgery, you'll be able to resume normal activities, though sexual intercourse may be prohibited for the rest of your pregnancy, and you may need frequent medical exams. When the sutures will be removed depends partly on the doctor's preference and partly on the situation. Usually they're removed a few weeks before your estimated due date. In some cases, they may not be removed until labor begins, unless there is infection, bleeding, or premature rupture of the membranes.

Your Pregnancy Profile and Preterm Birth.

Here's the good news: It's far more likely your baby will be arriving late (as in overdue) than early. Just about 12 percent of labors and births are considered premature, or preterm-that is, occurring before the 37th week of pregnancy. And around half of these occur in women who are known to be at high risk for premature delivery, including the ever-multiplying percentage of moms-to-be of multiples.

Is there anything you can do to help prevent preterm birth if your pregnancy profile puts you at higher risk for it? In some cases, there isn't-even when a risk factor is identified (and it won't always be), it can't necessarily be controlled. But in other cases, the risk factor or factors that might lead to an early birth can be controlled or at least minimized. Eliminate any that apply to you, and you may up the chances that your baby will stay put contentedly until term. Here are some known risk factors for premature labor that can be controlled: Too little or too much weight gain. Gaining too little weight can increase the chances your baby will be born early, but so can packing on too many pounds. Gaining just the right number of pounds for your pregnancy profile can give your baby a healthier uterine environment and, ideally, a better chance of staying there until term. Gaining too little weight can increase the chances your baby will be born early, but so can packing on too many pounds. Gaining just the right number of pounds for your pregnancy profile can give your baby a healthier uterine environment and, ideally, a better chance of staying there until term.

Inadequate nutrition. Giving your baby the healthiest start in life isn't just about gaining the right number of pounds-it's about gaining them on the right types of foods. A diet that lacks necessary nutrients (especially folate) increases your risk for premature delivery. a diet that's nutrition packed decreases that risk. In fact, some evidence indicates that eating well regularly can lower the risk of early delivery. Giving your baby the healthiest start in life isn't just about gaining the right number of pounds-it's about gaining them on the right types of foods. A diet that lacks necessary nutrients (especially folate) increases your risk for premature delivery. a diet that's nutrition packed decreases that risk. In fact, some evidence indicates that eating well regularly can lower the risk of early delivery.

Lots of standing or heavy physical labor. Check with your practitioner to see if you should cut back on the time you spend on your feet, especially later on in pregnancy. Long periods of being on your feet-especially when it involves Check with your practitioner to see if you should cut back on the time you spend on your feet, especially later on in pregnancy. Long periods of being on your feet-especially when it involves heavy heavy physical labor and lifting-has been linked to preterm labor in some studies. physical labor and lifting-has been linked to preterm labor in some studies.

Extreme emotional stress. Some studies have shown a link between extreme emotional stress (not your everyday "I've got too much to do and not enough time to do it" stress) and premature labor. Sometimes the cause of such excessive stress can be eliminated or minimized (by quitting or cutting back at an unhealthily high-pressure job, for example); sometimes it's unavoidable (as when you lose your job or there's been illness or death in the family). Still, many kinds of stress can be reduced with relaxation techniques, good nutrition, a balance of exercise and rest, and by talking the problem out with your spouse or friends, your practitioner, or a therapist. Some studies have shown a link between extreme emotional stress (not your everyday "I've got too much to do and not enough time to do it" stress) and premature labor. Sometimes the cause of such excessive stress can be eliminated or minimized (by quitting or cutting back at an unhealthily high-pressure job, for example); sometimes it's unavoidable (as when you lose your job or there's been illness or death in the family). Still, many kinds of stress can be reduced with relaxation techniques, good nutrition, a balance of exercise and rest, and by talking the problem out with your spouse or friends, your practitioner, or a therapist.

Alcohol and drug use. Expectant moms who use alcohol and illegal drugs boost their risk of having a premature delivery. Expectant moms who use alcohol and illegal drugs boost their risk of having a premature delivery.

Smoking. Smoking during pregnancy may be linked to an increased risk of premature delivery. Quitting before conception or as early as possible in pregnancy is best, but quitting at any time in pregnancy is definitely better than not quitting at all. Smoking during pregnancy may be linked to an increased risk of premature delivery. Quitting before conception or as early as possible in pregnancy is best, but quitting at any time in pregnancy is definitely better than not quitting at all.

Gum infection. Some studies show that gum disease is associated with preterm delivery. Some researchers suspect that the bacteria that cause inflammation in the gums can actually get into the bloodstream, reach the fetus, and initiate early delivery. Other researchers propose another possibility: The bacteria that cause inflammation in the gums can also trigger the immune system to produce inflammation in the cervix and uterus, triggering early labor. Practicing good oral hygiene and getting regular dental care can prevent the bacterial infection and possibly lower your risk for an early labor. Treatment for existing infections prior to pregnancy-though not necessarily during pregnancy-may also help lower the risk for a variety of complications, including preterm labor. Some studies show that gum disease is associated with preterm delivery. Some researchers suspect that the bacteria that cause inflammation in the gums can actually get into the bloodstream, reach the fetus, and initiate early delivery. Other researchers propose another possibility: The bacteria that cause inflammation in the gums can also trigger the immune system to produce inflammation in the cervix and uterus, triggering early labor. Practicing good oral hygiene and getting regular dental care can prevent the bacterial infection and possibly lower your risk for an early labor. Treatment for existing infections prior to pregnancy-though not necessarily during pregnancy-may also help lower the risk for a variety of complications, including preterm labor.

Incompetent cervix. The risk of premature delivery as a result of an incompetent cervix-in which a weak cervix opens early (and, unfortunately, can be suspected only after a woman has experienced a late miscarriage or premature labor once before)-can possibly be reduced by suturing the cervix closed and/or by closely monitoring the length of the cervix via ultrasound (see The risk of premature delivery as a result of an incompetent cervix-in which a weak cervix opens early (and, unfortunately, can be suspected only after a woman has experienced a late miscarriage or premature labor once before)-can possibly be reduced by suturing the cervix closed and/or by closely monitoring the length of the cervix via ultrasound (see page 45 page 45 for more information). for more information).

History of premature deliveries. Your chances of premature delivery are higher if you've had one in the past. If you've had a prior preterm labor and delivery, your practitioner may prescribe progesterone during the second and third trimesters of this pregnancy to avoid a repeat preterm birth. Your chances of premature delivery are higher if you've had one in the past. If you've had a prior preterm labor and delivery, your practitioner may prescribe progesterone during the second and third trimesters of this pregnancy to avoid a repeat preterm birth.

The following risk factors aren't controllable, but in some cases they can be somewhat modified. In others, knowing they exist can help you and your practitioner best manage the risks, as well as greatly improve the outcome if an early birth becomes inevitable.

Multiples. Women carrying more than one fetus deliver an average of three weeks early (though it has been suggested that full term for twins is actually 37 weeks, which might mean that three weeks early isn't early at all). Good prenatal care, optimal nutrition, and the elimination of other risk factors, along with more time spent resting and restriction of activity as needed in the last trimester, may help prevent a too-early birth. See Women carrying more than one fetus deliver an average of three weeks early (though it has been suggested that full term for twins is actually 37 weeks, which might mean that three weeks early isn't early at all). Good prenatal care, optimal nutrition, and the elimination of other risk factors, along with more time spent resting and restriction of activity as needed in the last trimester, may help prevent a too-early birth. See Chapter 16 Chapter 16 for more information. for more information.

Premature cervical effacement and dilation. In some women, for reasons unknown and apparently unrelated to an incompetent cervix, the cervix begins to thin out and open up early. Recent research suggests that at least some of this early effacement and dilation may be related to a shorter-than-normal cervix. A routine ultrasound of the cervix midpregnancy uncovers which women are at high risk. In some women, for reasons unknown and apparently unrelated to an incompetent cervix, the cervix begins to thin out and open up early. Recent research suggests that at least some of this early effacement and dilation may be related to a shorter-than-normal cervix. A routine ultrasound of the cervix midpregnancy uncovers which women are at high risk.

Pregnancy complications. Such complications as gestational diabetes, preeclampsia, and excessive amniotic fluid, as well as problems with the placenta, such as placenta previa or placental abruption, can make an early delivery more likely. Managing these conditions as best as possible may prolong pregnancy until term. Such complications as gestational diabetes, preeclampsia, and excessive amniotic fluid, as well as problems with the placenta, such as placenta previa or placental abruption, can make an early delivery more likely. Managing these conditions as best as possible may prolong pregnancy until term.

Chronic maternal illness. Chronic conditions, such as high blood pressure; heart, liver, or kidney disease; or diabetes may raise the risk for preterm delivery, but good medical management and self-care may reduce it. Chronic conditions, such as high blood pressure; heart, liver, or kidney disease; or diabetes may raise the risk for preterm delivery, but good medical management and self-care may reduce it.

General infections. Certain infections (some sexually transmitted diseases; urinary, cervical, vaginal, kidney, and amniotic fluid infections. can put a mother-to-be at high risk for preterm labor. When the infection is one that could prove harmful to the fetus, early labor may be the body's way of attempting to rescue the baby from a dangerous environment. Preventing the infection or promptly treating it may effectively prevent a too-soon birth. Certain infections (some sexually transmitted diseases; urinary, cervical, vaginal, kidney, and amniotic fluid infections. can put a mother-to-be at high risk for preterm labor. When the infection is one that could prove harmful to the fetus, early labor may be the body's way of attempting to rescue the baby from a dangerous environment. Preventing the infection or promptly treating it may effectively prevent a too-soon birth.

Under age 17. Teen moms-to-be are often at a higher risk for preterm delivery. Good nutrition and prenatal care can reduce risk by helping to compensate for the fact that both mother and baby are still growing. Teen moms-to-be are often at a higher risk for preterm delivery. Good nutrition and prenatal care can reduce risk by helping to compensate for the fact that both mother and baby are still growing.

You'll have to be alert for signs of an impending problem in the second or early third trimester: pressure in the lower abdomen, bloody discharge, unusual urinary frequency, or the sensation of a lump in the vagina. If you experience any of these, call your doctor right away.

Rh Incompatibility.

"My doctor said my blood tests show I am Rh negative. What does that mean for my baby?"

Fortunately, it doesn't mean much, at least now that both you and your doctor know about it. With this knowledge, simple steps can be taken that will effectively-and completely-protect your baby from Rh incompatibility.

What exactly is Rh incompatibility, and why does your baby need protection from it? A little biology lesson can help clear that up quickly. Each cell in the body has numerous antigens, or antenna-like structures, on its surface. One such antigen is the Rh factor. Everyone inherits blood cells that either have the Rh factor (which makes the person Rh positive) or lack the factor (which makes them Rh negative). In a pregnancy, if the mother's blood cells do not have the Rh factor (she's Rh negative) while the fetus's blood cells-inherited from dad-do have it (making the fetus Rh positive), the mother's immune system may view the fetus (and its Rh-positive blood cells) as a "foreigner." In a normal immune response, her system will generate armies of antibodies to attack this foreigner. This is known as Rh incompatibility.

All pregnant women are tested for the Rh factor early in pregnancy, usually at the first prenatal visit. If a woman turns out to be Rh positive, as 85 percent are, the issue of compatibility is moot because whether the fetus is Rh positive or Rh negative, there are no foreign antigens on the fetus's blood cells to cause the mother's immune system to mobilize.

When the mother is Rh negative, as you are, the baby's father is tested to determine whether he is Rh positive or negative. If your spouse turns out to be Rh negative, your fetus will be Rh negative, too (since two "negative" parents can't make a "positive" baby), which means that your body will not consider it "foreign." But if your spouse is Rh positive, there's a significant possibility that your fetus will inherit the Rh factor from him, creating an incompatibility between you and the baby.

This incompatibility is usually not a problem in a first pregnancy. Trouble starts to brew if some of the baby's blood enters the mother's circulation during her first pregnancy or delivery (or abortion or miscarriage). The mother's body, in that natural protective immune response, produces antibodies against the Rh factor. The antibodies themselves are harmless-until she becomes pregnant again with another Rh-positive baby. During the subsequent pregnancy, these new antibodies could potentially cross the placenta into the baby's circulation and attack the fetal red blood cells, causing very mild (if maternal antibody levels are low) to very serious (if they are high) anemia in the fetus. Only very rarely do these antibodies form in first pregnancies, in reaction to fetal blood leaking back through the placenta into the mother's circulatory system.

Prevention of the development of antibodies is the key to protecting the fetus when there is Rh incompatibility. Most practitioners use a two-pronged attack. At 28 weeks, an Rh-negative expectant mom is given a vaccine-like injection of Rh-immune globulin, known as RhoGAM, to prevent the development of antibodies. Another dose is administered within 72 hours after delivery if blood tests show her baby is Rh positive. If the baby is Rh negative, no treatment is required. RhoGAM is also administered after a miscarriage, an ectopic pregnancy, an abortion, chorionic villus sampling (CVS), amniocentesis, vaginal bleeding, or trauma during pregnancy. Giving RhoGAM as needed at these times can head off problems in future pregnancies.

If an Rh-negative woman was not given RhoGAM during her previous pregnancy and tests reveal that she has developed Rh antibodies capable of attacking an Rh-positive fetus, amniocentesis can be used to check the blood type of the fetus. If it is Rh negative, mother and baby have compatible blood types and there's no cause for concern or treatment. If it is Rh positive, and thus incompatible with the mother's blood type, the maternal antibody levels are monitored regularly. If the levels become dangerously high, ultrasound tests are done to assess the condition of the fetus. If at any point the safety of the fetus is threatened because hemolytic or Rh disease has developed, a transfusion of Rh-negative blood to the fetus may be necessary.

The use of RhoGAM has greatly reduced the need for transfusions in Rh-incompatible pregnancies to less than 1 percent, and in the future may make this lifesaving procedure a medical miracle of the past.

A similar incompatibility can arise with other factors in the blood, such as the Kell antigen, though these are less common than Rh incompatibility. If the father has the antigen and the mother does not, there is again potential for problems. A standard screening, part of the first routine blood test, looks for the presence of circulating antibodies in the mother's blood. If these antibodies are found, the father of the baby is tested to see if he is positive, in which case the management is the same as with Rh incompatibility.

Your Medical History.

Rubella Antibody Levels.

"I was vaccinated against rubella as a child, but my prenatal blood test shows my rubella antibody levels are low. Should I be concerned?"

There's not much cause for concern when it comes to rubella these days, at least in the United States. Not because the illness isn't still harmful to the unborn (it still can be, particularly in the first trimester; see page 506 page 506), but because it's next to impossible to catch it. The CDC considers rubella to be eradicated in the United States, and since most children and adults have been-and will continue to be-vaccinated against rubella, the chances of being exposed to the illness are virtually nil.

Though you won't be immunized during pregnancy, you will be given a new rubella vaccine right after you deliver, before you even leave the hospital. It's safe then, even if you're breastfeeding.

Immunizations in Pregnancy.

Since infections of various sorts can cause pregnancy problems, it's a good idea to take care of all necessary immunizations before conceiving. Most immunizations using live viruses are not recommended during pregnancy, including the MMR (measles, mumps, and rubella) and varicella (chicken pox) vaccines. Other vaccines, according to the CDC, shouldn't be given routinely but can be given if they're needed. These include hepatitis A and pneumococcal vaccine. You also can be immunized safely against tetanus, diphtheria, pertussis, and hepatitis B with vaccines containing dead, or nonactive, viruses. In the must-have department: The CDC recommends that every woman who is pregnant during flu season (generally October through April) receive a flu shot.

For more information about which vaccines are safe during pregnancy and which, if any, you may need (particularly if you'll be traveling to exotic destinations), check with your practitioner.

Obesity.

"I'm about 60 pounds overweight. Does this put me and my baby at higher risk during pregnancy?"

Most overweight-and even obese (defined as someone whose weight is 20 percent or more over her ideal weight)-mothers have completely safe pregnancies and completely healthy babies. Still, obesity always poses extra health risks, and that's the case during pregnancy, too. Carrying a lot of extra weight while you're carrying a baby increases the possibility of certain pregnancy complications, including high blood pressure and gestational diabetes. Being overweight poses some practical pregnancy problems, too. It may be tougher to date your pregnancy accurately without an early ultrasound, both because ovulation is often erratic in obese women and because some of the yardsticks practitioners traditionally use to estimate a due date (the height of the fundus, or top of the uterus, the size of the uterus, hearing the heartbeat) may be difficult to read through layers of fat. The padding may also make it impossible for the practitioner to determine a fetus's size and position (as well as make it harder for you to feel those first kicks). Finally, delivery difficulties can result if the fetus is much larger than average, which is often the case with obese mothers (even among those who don't overeat during pregnancy, and particularly with those who are diabetic). And if a cesarean delivery is necessary, the over-ample abdomen can complicate both the surgery and recovery from it.

Then there's the issue of pregnancy comfort, or rather discomfort-and unfortunately, as the pounds multiply, so do those uncomfortable pregnancy symptoms. Extra pounds (whether they're pounds you already had or pounds you added during pregnancy) can spell extra backache, varicose veins, swelling, heartburn, and more.

Daunted? Don't be. There's plenty you and your practitioner can do to minimize the risks to you and your baby and the discomfort for you-it'll just take some extra effort. On the medical care side, you will probably undergo more testing than the typical low-risk pregnant woman: ultrasound early on to date your pregnancy more accurately, and later to determine the baby's size and position; at least one glucose tolerance test or screening to determine if you are showing any signs of developing gestational diabetes; and, toward the end of your pregnancy, nonstress and other diagnostic tests to monitor your baby's condition.

Pregnancy After Gastric Bypass.