Start your care with us early
We strive to provide you support early in your pregnancy. First trimester is a time of early emotional and physical changes, fetal development and introduction to some important information. Our first prenatal appointment ideally occurs in the weeks following conception. Usually, this is around 6 to 8 weeks of pregnancy. The first few visits are an opportunity to meet each other, answer your questions about pregnancy and midwifery care, cover your medical history, offer you a physical exam including a pap test and prenatal blood work, and support you in any decisions you are encountering…and get to know each other.
How to reach your midwife
At all times, a midwife is on call for you. The central line is: (604) 901-7806
The central number leads to a message that will tell you who is on call and how that midwife can be reached.
FOR NON-URGENT Calls
Leave us a message. We strive to return calls in 24-48 hours. Texting and emailing is not always reliable. Please let us know what the best way to reach you is.
Leave a message for the midwife on call between 9am & 9pm.
- Please respect that after-hours calls are welcome if they are for urgent concerns only.
Anytime: if you have an urgent call, call the midwife on call.
- If you don’t get a response within fifteen minutes, call again.
- If you still don’t get a response within another fifteen minutes, please try the off-call midwife.
- If you have no response from any of us, call Sechelt Hospital Maternity, inform them of your situation and ask for their help: (604) 989-6248.
Daytime (between 9am & 9pm):
- If you suspect you may be in labour, phone the midwife on call. A heads-up call can help us to arrange our day so that we will be available when you need us later.
Nighttime (between 9pm & 9am):
- If you know you are in active labour and/or need a midwife now, please page us urgently!
- If you do not need a midwife immediately, please wait until morning. We appreciate our chances to sleep through the night, and having a perky midwife when labour gets hard may be just what you need.
Lehe Spiegelman: (604) 603-0477
Jules Atkins: (778) 808-2959
Urgent concerns to call your midwife about:
- Spotting in pregnancy can be normal (especially after sex, vaginal exams of difficult bowel movements). Call us if you have any bleeding in pregnancy and note the time, amount and colour.
A gush of fluid from your vagina, especially if you are not more than 37 weeks pregnant
- note the time, amount, colour and odour (if any); also keep track of the baby’s movement (has it increased or decreased?)
Severe nausea and vomiting
- especially if you can’t eat or drink anything and feel dehydrated
Signs of urinary tract infection
- having to pee all the time, a burning sensation when you pee, feeling like you can’t empty your bladder, pain above or behind your pubic bone, lower backache, fever or chills, and/or generally feeling unwell
Signs of infection
- fever of 101° F. or over, sweats/chills, diarrhea, etc.
Unusual vaginal discharge
- especially if it smells bad or is green or yellow
- intense, persistent, or unusual pain
No fetal movement for more than 6 hours or a noticeable decrease in baby’s activity
- if you notice a decrease, sit quietly for two hours and count the movements – there should be at least SIX movements in two hours. Call us immediately if you do not count 6 movements in 2 hours.
Signs of pre-eclampsia or “toxemia”, which may include:
- a severe or persistent headache
- changes in your vision – blurring, double vision, spots, stars, etc.
- serious epigastric pain – pain just below your rib-cage, on either side or central
- muscular irritability, seizures
Signs of depression or anxiety
- especially if you are experiencing sudden and extreme mood changes, you are feeling very overwhelmed or unable to cope or you are having thoughts of harming yourself or your baby. We are here to help you get the support you need, anytime of day or night.
Or any other symptoms or conditions that are making you worried – it’s always better to get it checked out; don’t wait until the middle of the night!
Bleeding & cramping
What are the possible causes of bleeding or spotting?
- Cervical friability (i.e. cervix that bleeds easily for benign reasons)
- Growth spurt (common around 12 weeks, again around 20 weeks – often with cramping)
- Irritation or trauma, especially if infection, cervical cyst or polyp present
- Unknown causes
- Implantation spotting (i.e. as the fertilized egg attaches itself to the uterus it may cause some irritation and bleeding)
- Ectopic pregnancy (i.e. the embryo is growing outside the uterus)
SECOND & THIRD TRIMESTERS
- Cervical dilation
- Early labor “show” (a sign of cervical dilation starting to happen)
When should I worry about miscarriage?
Obviously miscarriage is what everyone worries about whenever they see spotting.
THE GOOD NEWS
One in three women experience spotting or bleeding in pregnancy. Only 50% of these go on to have miscarriages, the majority in the first trimester. While 40% of pregnancies end up in miscarriage, most of these are before 4 weeks of pregnancy (i.e. 2 weeks post conception, when you would miss your period). After 4 weeks, the miscarriage rate goes down to 15%. In addition, once your baby’s heartbeat has been heard, the chance of miscarriage goes down to 5%. Part of the reason that so many pregnant women experience spotting is that there is a tremendous increase in blood volume, which means that capillaries in the cervix are easily disturbed causing bleeding. This is the equivalent of having your gums bleed after brushing or starting a nosebleed by blowing your nose – both things that many pregnant women also experience for the same reason. An average non-pregnant woman has about 4 litres of blood. The same woman when pregnant will increase her blood volume to over 6 litres! With this large increase, some of it may “leak” out sometimes.
THE BAD NEWS
Miscarriage cannot be predicted, only diagnosed. If you are having signs of a threatened miscarriage, your midwife may be able to send you for some testing:
- Ultrasoundwill be able to determine if the embryo is implanted inside the uterus, and once you are past 6-7 weeks, if there is a heartbeat.
- Early in the first trimester, bloodwork that is repeated every 48 hours will be able to demonstrate whether your pregnancy hormones are increasing at an expected rate.
- If you are beyond 10-12 weeks gestation, your midwife may be able to find your baby’s heartbeat in the clinic with a Doppler.
In any case, by the time the bloodwork results are returned or an ultrasound appointment can be made, the situation will often have made itself obvious (i.e. either the bleeding stops, or becomes heavier and clearly a miscarriage).
What can I expect if I do have a miscarriage?
What to expect depends on how far along you are, and how the miscarriage is diagnosed. Generally, the later your gestation, the more physically intense the experience. Typically, the first sign may be spotting that progresses from brown to red over a few hours or days, then has a few hours of very intense cramping and heavy bleeding, subsiding into regular bleeding like a normal period. You may pass some clots or tissue. Or the (impending) miscarriage may be diagnosed during an ultrasound. If this is the case, you have two options:
- EXPECTANT MANAGEMENT i.e. waiting for your body to complete the miscarriage on its own. Sometimes this happens immediately. Sometimes it takes days to weeks. Acupuncture and/or certain herbs are safe to use to hasten this process – if you are interested, the herbalists at Gaia Gardens Herbal Pharmacy can help.
- MEDICAL MANAGEMENT i.e. inducing the miscarriage. A medically-induced miscarriage may include using medication to cause the uterus to contract and expel its contents; or it may include dilating your cervix and evacuating the uterus with instruments, under either local or general anesthetic. This latter procedure is occasionally necessary when miscarriages don’t complete on their own.
What if I am past the first trimester?
Once you are past the first trimester, it is unlikely you are losing the pregnancy. As in the first trimester, most causes of second and third trimester bleeding are benign, but at the same time should still be monitored.
Genetic Screening in BC
Genetic screening options are vast and range from being covered by your BC Medical Card to private pay options. Please talk with us so we can support you to make the best choice.
For a detailed guide on options available through our covered health care system, please read this pamphlet by Perinatal Services BC.
What is ultrasound?
During an ultrasound scan, very high frequency sound waves are produced by a transducer (the part of the machine which is placed on the body). The sound waves are passed into the body where they encounter structures (such as the fetus). When this happens, the waves reflect back, and the sound (or echo) is detected electronically and transmitted onto a screen as a dot. This results in a picture being formed, with strong echoes creating white dots (representative of bone), weaker echoes creating grey dots (tissue) and no reflection creating black dots (fluid).
Can ultrasound confirm that my baby is “normal”?
Ultrasound has been used for many years to gain information about developing babies. Ultrasound in many situations is considered a screening test rather than a diagnostic test. This means that there may be a small chance of false positives or false negatives when ultrasound is used as a diagnostic tool in pregnancy. However, ultrasound remains the method of choice for confirming the diagnosis of some conditions (i.e. spina bifida), and is considered a valuable tool to gain information about the developing fetus. The accuracy of an ultrasound is directly related to the skill of the technician performing the scan, and the quality of the equipment used.
At what point in pregnancy will I be offered an ultrasound?
- An ultrasound may be offered in the first trimester if there is any difficulty predicting a due date for the pregnancy (see below).
- For women interested in nuchal translucency screening, ultrasound is performed around 11 weeks. (Nuchal translucency is a genetic screening test which may give information about an increased probability of Down syndrome; this test is not covered by MSP for all women—refer to the Genetic Screening handout).
- All women in pregnancy are offered a “screening” or “detailed” scan at 18-21 weeks. At this point, ultrasound aims to verify that the baby is developing and growing normally.
- An ultrasound may be offered at other points in pregnancy for any of the following reasons: concern that the baby is not growing as expected, to investigate the source of vaginal bleeding, to diagnose cervical changes in cases of suspected preterm labour, to verify the position of a suspected breech baby, to follow up previously discovered concerns, to monitor a pregnancy that extends far past the due date, or as a visual aid during invasive procedures such as amniocentesis.
What are the benefits of having an ultrasound in pregnancy?
Dating: When performed in early pregnancy, ultrasound is considered a reliable method of predicting the estimated due date, especially for women who have irregular menstrual cycles, or are uncertain of when their last period was. Dating ultrasounds have been shown to reduce the number of pregnancies considered to be “post-term” and to decrease the rate of inductions for pregnancies extending far past the due date.
Number of Fetuses: Ultrasound can detect multiple (i.e. twin) pregnancies early on, which allows women access to specialized care sooner (multiple pregnancies can be associated with a higher rate of complications). Early detection also allows more time to prepare physically and psychologically for the birth of multiples.
Malformations of the Fetus: Approximately 35–50% of serious defects are diagnosed during a detailed ultrasound at 18-21 weeks. Ultrasound may also detect “soft markers”— characteristics of the fetal anatomy which are in themselves normal but can be associated with an increased chance of genetic anomalies. Detection of soft markers or true abnormalities allows women the chance to consider options to further diagnosis or rule out a condition (i.e. triple marker screen, amniocentesis), as well as the opportunity to consider termination of the pregnancy or the ability to engage resources/prepare for the birth of a special needs baby.
Uterine formation: Although rare, some women have a uniquely shaped uterus that increases the likelihood of complications such postpartum hemorrhage. More commonly, many women (30% over the age of 30) have uterine fibroids; in rare cases, they are large enough and low enough in the pelvis to make vaginal birth difficult or impossible. Detection by ultrasound may aid women and their caregivers in making birth plans, e.g. hospital instead of home.
Placental Location: Ultrasound can rule out placenta previa (a condition affecting 0.5% of the population where the placenta grows over top of the cervix; cesarean birth is indicated). For the small number of women affected by placenta previa, early detection may result in healthier moms and babies.
Parents’ Experience of Ultrasound: Many parents say that they are happy to see their baby move and swim around on screen. While the mother has often being feeling the baby move for a few weeks, a number of partners report that this is the first time the baby seems “real” and that this allows them to feel “more connected” to the pregnancy.
What are the limitations of ultrasound in pregnancy?
Dating: While some research shows ultrasound to be more effective in determining a due date than simply calculating based on a woman’s last menstrual cycle, the difference detected in most cases would be unimportant and not impact the outcome for mother or baby. (The exception to this would be in cases of preterm/post-term pregnancies)
Placental Location: There is no evidence that routine screening ultrasounds at 18-21 weeks improve outcomes for mother or baby in the case of placenta previa.
Malformations of the Fetus: At least 50% of fetal malformations will not be detected via ultrasound. Additionally, some malformations will be “diagnosed,” but in reality not be present, causing undue stress to expectant parents. Approximately 4 -17% of women who are told that their fetus has “soft markers” associated with an increased chance of Down syndrome will actually be carrying a genetically normal baby. Many women given this type of information consider proceeding to diagnostic testing (I.e. amniocentesis), which carries a degree of risk (1 in 200 chance of miscarriage following the procedure).
Estimated fetal size: Ultrasound only gives a rough estimate of fetal size. It is especially difficult to accurately estimate the size of very large or very small babies at term, when the margin of error is +/- 1lb. Therefore, ultrasound is only one tool of many that are used to estimate fetal size (and whether it will fit through a mother’s pelvis).
Parents’ Experience of Ultrasound: While an ultrasound has the potential to be a happy experience, real or mistaken diagnosis of abnormalities of the fetus can be very upsetting for parents. If soft markers are noted, some parents have a hard accepting even after further testing shows these markers are variations of normal, that their pregnancy or their baby is not abnormal. Some women also say it leaves them feeling “less connected” to their pregnancy to use external technology to view what they feel happening inside their bodies. As well, while most ultrasound technicians are warm and welcoming, the occasional one who is not may cause the parents to wrongly fear that something is wrong. (Any problems will be immediately addressed by the radiologist who supervises the technicians.)
Like choosing any test, families choosing ultrasound screening should consider the positive, negative or equivocal findings that could be revealed so as to be prepared for unexpected results, and the potential for further testing options to be offered.
Is ultrasound safe?
The effects of ultrasound are difficult if impossible to study, due to the many variables including age of the exposed fetus, different levels of exposure by different machines and different technicians, frequency of exposure, inherent genetic differences between fetuses, and a large variety of measurable outcomes. We can say, however, that so far there has been no well designed study to date linking ultrasound to adverse outcomes for mom or baby. As well, ultrasound has been used on millions of pregnant women for more than 30 years without any clear adverse effects. Recent literature may show a potential link between ultrasound exposure in pregnancy and subsequent left-handedness, especially in boys, but the significance of this, if any, is unknown.
At the same time, because there have never been any long term, scientific studies on ultrasound, most experts agree that ultrasound exposure should be minimized and only be used during pregnancy for medical indications.
Private ultrasound clinics offering 3-D images or videos have become very popular among expecting families. In 2004, the FDA (Food and Drug Administration in the USA) put out a caution discouraging women from obtaining “keepsake” ultrasounds during pregnancy. Their rationale for this cites studies that acknowledge ultrasound as a form of energy that can raise the temperature of tissue. While there is no evidence that this could harm a fetus, the FDA says that there is a potential that ultrasounds in pregnancy aren’t entirely innocuous.
Is there an alternative to having an ultrasound in pregnancy?
While it is considered the standard of care for women to be offered a detailed scan from 18-21 weeks in pregnancy, some debate exists about whether or not routine ultrasound is necessary in normal pregnancies. There are some alternatives for detection of some fetal anomalies (i.e. maternal serum screening —- see the Genetic Screening handout). The main alternative to having a routine ultrasound is simply to not have one. Women choosing to decline a scan in pregnancy ideally are aware of the benefits and limitations of ultrasound, as well as potential information that could be gained solely via this method of prenatal screening.
Can I find out the sex of my baby?
In BC, if discovered by ultrasound, the sex of the baby will not be disclosed until after 20 weeks. If you would like to know the sex of your baby but are still less than 20 weeks pregnant, you can request that the information is recorded on the ultrasound report given to your careprovider, who will then tell you after 22 weeks. Of course, when you go for your ultrasound there is no guarantee that the baby will be willing to show you! If the genitals are not easily seen, do not expect the technician to spend extra time looking, due to the high volume of patients needing to be seen for clinical reasons. And there is also the chance of making the wrong diagnosis, therefore the only way of being 100% sure is through chromosome analysis by amniocentesis or chorionic villus sampling.
What about Doppler use in the clinic?
The Doppler that careproviders in clinic settings use to verify the fetal heart rate, is a form of ultrasound. If you wish to minimize ultrasound exposure, your midwife can (occasionally or always) use a specially designed stethoscope called a fetoscope to listen to the heartbeat.
The limitations of using the fetoscope include:
- having to wait until the fetus is large enough to hear (usually after 20-24 weeks)
- sometimes it’s hard for parents to hear without a trained ear
- it is impractical to use during labour as mom needs to be lying flat
The advantages of using the fetoscope, besides minimizing ultrasound exposure, include:
- there is something magical about hearing the actual heartbeat of your baby, not an electronic representation produced by the Doppler technology
- helping to verify the position of the baby
Nausea in pregnancy
Only about 15% of women don’t suffer from nausea at some time during their pregnancy. More than half will have vomiting. Since each woman is different and each pregnancy is different, the severity will vary.
What causes nausea?
No one knows exactly what the cause is. It is believed that it’s a combination of the many physical changes taking place in the body, especially the higher levels of hormones during early pregnancy.
How long will it last?
Nausea usually starts between 5 and 6 weeks of pregnancy. Although common in the morning, “morning sickness” can actually last all day, or even be worse in the evening. For 80% of sufferers, nausea gradually lessens, with more and more nausea-free days, until it ceases completely around the 12th week – although physical or emotional stresses can causes temporary relapses. The other 20% of sufferers will have nausea for a longer period of time, some even until the end of pregnancy.
Is it dangerous to me or my baby?
Nausea, especially if severe, can be emotionally draining. Many women find that it interferes with usual daily activities, making it necessary to find ways to cope. But the large majority of the time nausea isn’t physically harmful to mom or baby. If you were healthy before you started pregnancy, your body and your baby will draw on your nutritional reserves. There is even a theory that the minimal nutrition of the first trimester during the stage when the placenta is growing, essentially tricks the body to grow a larger, more efficient placenta.
What if I can’t keep anything down?
About 1% of women suffer from excessive vomiting in pregnancy, a condition called “hyperemesis gravidarum”. In such cases, the lack of food, fluids and nutrients may be harmful to their health and the well-being of their baby, if left untreated. Treatment usually includes IV fluids, as dehydration makes the condition worse, which in turn increases the amount of nausea, vomiting and fluid loss.
Nausea Survival Strategies
Low blood sugar
- Having low blood sugar can cause or worsen nausea, so eat small, frequent meals.
- Carry snacks such as raw almonds (which also minimize heartburn).
- When you first wake up, eat a snack, and then rest for 15 minutes before getting out of bed.
- Keep a few crackers or bowl of nuts in the bathroom, so you can keep your blood sugar up by snacking during those middle of the night trips.
- Until your nausea decreases, eat according to your cravings – better to eat something, than nothing at all
Carbs & Proteins
- Eat protein for sustained energy. Try some just before bed to avoid morning nausea.
- Go for complex carbs, as refined carbs can quickly cause a blood sugar low.
- Some women find carbs (crackers, dry toast, popcorn, granola bars) more relieving, other prefer proteins (nuts, cheese,
Flavors, Smells, Textures
- Women may crave certain flavors: salty, sweet, sour. Find what works for you.
- Smelling citrus fruit – oranges and lemons – can help. Eating citrus also helps your body to efficiently absorb iron.
- Keeping the saliva flowing by sucking on something sour can help, but don’t do this on an empty stomach
- Avoid spicy, fatty and fried foods
- Try eating food cold, as it may not smell as strong as when hot. Try popsicles.
- Minimize cooking smells.
- The smells of coffee and red meat are often triggers.
- Don’t let dehydration make your nausea worse: drink at least 2 litres a day.
- Drinks that lessen nausea count towards your 2 litres: ginger tea, ginger ale, anything bubbly like sparkling water or seltzer
- Caffeine counts against your 2 litres, as it causes more dehydration – drink an extra cup of water for every cup of caffeine or ounce of chocolate
- Avoid letting your stomach to be fully empty
- Don’t take supplements on an empty stomach.
- Try digestive teas if indigestion, constipation or diarrhea is associated with your nausea: fennel, mint, chamomile, etc.
- Take digestive enzymes at mealtime, such as papain and bromelain.
- Try activated charcoal for a “sour” stomach, 2 capsules when nauseous, up to twice a day.
- Being tired makes nausea worse. In the first trimester it’s normal to need more sleep, so go to bed early.
- Take naps whenever you can.
- Emotional and physical stress can make nausea worse. You may need to take some time from work, or adjust your work hours.
- Avoid warm places as feeling hot can add to nausea.
- Many complementary therapies can help with nausea by decreasing physical stress: see your chiropractor, have a massage.
- Try finding relief through counseling and talking with others, to eliminate any psychological component
- CO2 buildup in the blood contributes to nausea, but can be reduced with cardiovascular activity like walking and swimming.
- Exercise in fresh air seems to be especially helpful.
- Try 25mg of Vitamin B6, up to 6 per day.
- The iron in daily vitamins can make nausea worse. Take vitamins with food or just before bed. If this doesn’t help, then decrease or stop taking daily vitamins until your nausea is gone. Vitamins are supposed to fill the nutrient gaps in your diet – if you eat worse because of increased nausea, then they are not helping. Continue to take folic acid alone on a daily basis.
- Take 250 mg capsules up to four times a day, or 5-6 cups of fluid per day. Try ginger ale, ginger beer, ginger tea, candied ginger or ginger-lemonade.
- Many essential oils are off-limits in pregnancy. However, smelling lavender and/or citrus essential oils may help. Try putting some in a bath.
- Research has been shown acupuncture to be effective. Look for a practitioner with experience in treating pregnant women.
- Try SeaBands, available at drugstores, designed to offset motion sickness by stimulating acupressure points in the wrist.
- Diclectin is a medication considered safe for treating nausea in pregnancy. It is a combination of Vitamin B6 and an antihistamine. It can have uncomfortable side effects such as dry mouth or sleepiness, so it’s usually only for serious nausea. Ask your midwife for more info and/or a prescription.
- There are other medications that may be suitable. Speak to your midwife about these options.
New guideline from the Journal of Obstetrics and Gynecologists of Canada: Management of Nausea and Vomiting of Pregnancy
The blood type of 85% of the world population is Rh positive. If you are part of the remaining 15% who are Rh negative, please read this handout.
How might my Rh factor affect my pregnancy?
Rh refers to your blood type. You are either Rh-positive or Rh-negative. For example, your blood type might be A-negative.
The Rh factor can cause problems if an Rh-negative mother and an Rh-positive father conceive a baby that is Rh-positive. It is not possible to know if the baby is Rh-positive until birth.
There are two steps involved in “sensitization” (also known as isoimmunization) when the mother’s blood sees her baby’s blood as foreign:
- Transplacental hemorrhage: During pregnancy, although mother and baby have separate blood systems, blood from the baby can sometimes cross the placenta into the mother’s system.
- Antibody formation: Once the baby’s blood has mixed into the mother’s system, the mother can become sensitized. This means she produces antibodies to fight the baby’s blood as if it were a harmful foreign substance. (Antibodies, for example, help us fight infections and viruses and are our body’s way of getting rid of whatever seems harmful to us)If these antibodies then cross the placenta to the baby, they will attack the fetal blood cells.
Once formed, antibodies are permanent. During the pregnancy when sensitization occurs, the baby is usually born before the mother develops enough antibodies to harm the baby. The concentration of antibodies becomes higher in later pregnancies, therefore the danger is greater for babies born after you have become sensitized.
What factors can cause Rh sensitization?
Sensitization can also occur after any physical violence, accident (such as a car accident) or procedure that might involve or cause bleeding from the placenta. These include, amniocentesis, chorionic villus sampling, abdominal injury, abruption of the placenta, miscarriage, placenta previa or external version of a breech baby.
Sensitization can occur even if a pregnancy ended in miscarriage, abortion, cesarean, or was an ectopic pregnancy.
How do I know if I have become Rh sensitized?
Your blood can be tested anytime to determine if you have any antibodies. This is usually done in the initial bloodwork, again at approximately 28 weeks, and then again shortly after the birth.
What happens if I become Rh sensitized?
Rh sensitization can result in hemolytic disease of the newborn. The seriousness of this condition can vary. Some babies have no symptoms. In more severe cases, problems such as hydrops can cause the baby to die before, or shortly after birth. Severe hemolytic disease of the newborn may be treated before birth by intrauterine blood transfusion.
In some babies it becomes apparent during pregnancy, other times, the first sign is jaundice in the first 24 hours, which usually requires a transfusion and intensive care.
An Rh sensitized mother can be checked during her pregnancy to see if the baby is developing blood disease, through the use of amniocentesis and ultrasound.
There are no immediate consequences to the mother if Rh sensitization occurs.
How can I try to prevent sensitization?
The most commonly accepted treatment is injection with Rh(D) immunoglobulin. In Canada, Rh(D)IG is packaged and sold as WinRho.
Although 90% of sensitizations occur during birth, 1-2% occur before the baby is born. Because of this, Rh(D)IG is offered at 28 weeks of pregnancy. It is protective till the birth, when there is the greatest risk of sensitization.
After the birth, the baby’s blood is tested for blood type. If baby is Rh+, you will be offered another dose of Rh(D)IG within 72 hours.
Rh(D)IG should also be administered within 72 hours of any other incident or indication (such as amniocentesis, abdominal trauma or bleeding from your uterus).
How effective is the treatment?
Rh(D)IG reduces, but does not eliminate the possibility of Rh sensitization. The risk of sensitization after birth of an Rh+ baby is:
7-17% without treatment
1-2% with postpartum treatment only
0.1 – 0.2% with antenatal (at 28weeks) and postpartum treatment
What are the risks of treatment?
Rh(D)IG is developed by injecting human volunteer donors (Rh-negative) with the positive Rh factor, then drawing their blood once antibodies have been formed. This blood is treated and screened for viruses (such as HIV and Hepatitis) and concentrated into a serum for injection. Rh(D)IG is a human-blood product and therefore is at risk of containing unknown viruses.
Injection of Rh(D)IG carries the risk of anaphylaxis, an extreme and very rare allergic reaction.
Some brands of Rh(D)IG, such as RhoGam which is used in the United States, contain the preservative thimerosol, which is a mercury derivative. Mercury crosses the placental barrier. The Canadian version, with the brand-name WinRho, does not contain a mercury preservative
Are there any alternative treatments?
There are no known alternative treatments to Rh(D)Ig injections.
Thalassemia & Pregnancy
What is thalassemia?
Thalassemia is the name of a group of inherited blood disorders. There are two main types of thalassemia: alpha and beta, in reference to the alpha and beta proteins that form hemoglobin in the blood. Hemoglobin is the oxygen-carrying component of red blood cells, so if the body doesn’t produce enough of either of these two proteins, the result is anemia that begins in early childhood and lasts throughout life.
What are the effects of thalassemia?
Thalassemia ranges widely in severity. Babies born with thalassemia may have mild to severe anemia, may develop jaundice, organ damage or even die.
How is thalassemia transmitted?
Thalassemia is an inherited disease, i.e. it is passed on by parents who have the thalassemia gene.
Because the gene is recessive, both parents must each pass on the thalassemia gene in order for the baby to have the full disease.
If the baby only inherits one gene, s/he will become a carrier but not express the full disease. Sometimes this carrier state is referred to as “thalassemia trait”. Most carriers lead normal, healthy lives. They may not even realize that they carry this gene.
When both parents are carriers:
- 1 in 4 chance that their child will inherit 2 thalassemia genes and have severe outcomes of the disease = Thalassemia major
- 2 in 4 chance that the child will inherit the thalassemia trait, i.e. become a carrier = Thalassemia minor
- 1 in 4 chance that the child will inherit 2 normal genes
How is thalassemia diagnosed?
When you do your routine blood test at the beginning of your pregnancy, one result we review is the Mean Corpuscular Volume, or MCV. The MCV reading determines the size of your red blood cells. For adults, if the MCV reading is less than 75 you may be a trait carrier. If your MCV reading indicates that you may have the thalassemia trait, additional blood tests can be performed to make sure.
Genetic counseling can also aid in identifying if you should have this blood test. Because thalassemia occurs most commonly among Mediterranean, Middle-Eastern, Asian, and African people, if you and your baby’s father are from any of these groups, you may want to consider genetic counseling and/or further testing.
During pregnancy, chorionic villus sampling (CVS) or amniocentesis can detect or rule out thalassemia in the fetus. Early diagnosis is important so that treatment can prevent complications.
What is the treatment for thalassemia?
The use of frequent blood transfusions and antibiotics has greatly improved the outlook for children born with thalassemia. Still, there is a chance that these babies will be born with major organ damage and may not live a full life span.
What is herpes?
The Herpes Simplex Virus (HSV) is one of the most common human viruses. There are two types of HSV, Type 1 (HSV-1) and Type 2 (HSV-2).
HSV is a recurrent viral infection, which means that once acquired, a person will always carry the virus. Usually the virus will remain dormant, but occasionally the virus will reactivate and cause an outbreak. During this time, a person is contagious.
How is herpes transmitted?
HSV prefers mucous membranes, but it can affect any area of the body. Infections of the mouth, lip or face (e.g. cold sores) are usually, although not always, caused by Type 1. Genital infections are usually, although not always, caused by Type 2.
HSV can only be spread by direct contact with an infectious person. S/he may have visible sores, sores in difficult to see places (e.g. on her cervix), or not have sores but be “shedding” cells that contain the virus.
It is estimated that up to 30% of North Americans have genital herpes, and about 80% will suffer from a cold sore sometime in their life. As many as 80% of infected adults do not know they carry HSV, either because they never had overt symptoms or because they didn’t recognize their symptoms.
How can herpes affect me?
True primary episode
The initial infection with HSV of any type is referred to as a true primary episode.
A primary outbreak is usually worse than a recurrent episode; people often report serious symptoms, such as pain, tingling, tenderness, and flu-like symptoms (such as fever, chills, headache, fatigue, muscle and joint aches). Depending on whether they now have oral or genital herpes, they will usually have swollen lymph glands around the neck or groin respectively.
Lesions usually appear on the infected area 2-14 days after being exposed to the virus. The lesions from a primary outbreak are generally larger, more numerous and last longer than those from a recurrent infection. The lesions may last for three weeks if no therapy is initiated.
There is an increased risk of transmission of the virus due to viral shedding for up to three months after the lesions from a primary infection have healed. Symptoms may or may not be present during this period.
Recommendations for Primary HSV Outbreaks in Pregnancy
Treatment at the end of the pregnancy with the anti-viral drug Acyclovir
If the outbreak is in the third trimester, it is recommended to birth by cesarean section due to high chance of viral shedding and therefore transmission to baby during vaginal birth
Non-primary, first episode
If someone with HSV-1 is then infected with HSV-2 (or vice versa), this referred to as a non-primary, first episode. This is not a true primary episode, because the HSV-1 antibodies moderate the effects of the HSV-2 infection (or vice versa). These episodes are usually worse than recurrent infections, but less than true primary infections.
A recurrent episode is a repeat outbreak triggered by an event that causes the virus to reactivate. Most people will have at least a few. Usually recurrences get milder and less frequent with time.
Sometimes the onset of an outbreak is preceded by symptoms such as tingling, pain, itching, burning, fatigue, fever and/or tenderness. Usually people with a history of herpes become aware of what their initial or prodromal symptoms are, as well as what can trigger outbreaks.
Sometimes the virus is present without any noticeable symptoms or lesions. This is called viral shedding.
How can herpes affect my baby?
Neonatal herpes infection occurs in 1 of every 2000-10,000 births. The most common time of transmission is as the baby passes through the birth canal, but it can also happen in the uterus or after the birth.
Almost all neonatal herpes infections occur as a result of true primary episode genital infection during late pregnancy when birth occurs before the development of protective maternal antibodies. Having a primary outbreak poses a higher risk to the newborn than a recurrent outbreak (up to 50% vs. 5%).
Neonatal herpes infection can be a variety of symptoms, ranging from an isolated sore to brain infection and, in rare cases, death. Neonatal herpes can be diagnosed only if it is looked for. The problem with treatment is less the difficulty of finding a useful drug and more the delay that often occurs before the diagnosis is made. If the mother has herpes, the pediatrician needs to know in order to consider the possibility of neonatal herpes when seeing a sick baby.
Recommendations for Maternal Herpes Outbreak in Labour
If you are in labour and you have herpes lesions around your cervix, vagina, labia, vulva, or anywhere where the baby might come in contact during the birth, it is recommended that you have a cesarean to avoid transmitting the virus to your baby.
If the lesions are not in an area where the newborn can come in immediate contact, we can cover these lesions with sterile tape and plan for a vaginal birth.
What are my options for testing?
You may already know you have HSV because your infection symptoms were obvious.
It is possible have a blood test to see if you carry antibodies to HSV-1 and/or HSV-2, which would indicate a past or present infection. This test will not tell us where on your body you were infected.
If you have an outbreak, a swab can be taken directly from the sores and used to verify that it is HSV, as well as determine which type.
Recommendation for HSV testing in pregnancy
If you have any lesions that could be HSV, it is recommended to do both a swab and a blood test.
If you have no history of HSV infection but your partner does, you may be at risk of having a primary outbreak. In this case, it is recommended that you have a blood test to see if you have HSV antibodies, and then practice safe sex for the rest of the pregnancy.
What are my options for treatment?
Prevention of infection
The number one preventative against genital herpes is safe-sex, such as using condoms and other barrier methods.
If your partner has a history of genital herpes but you have never had an outbreak (confirmed by a blood test), it may be recommended that your partner take Acyclovir for the duration of the pregnancy to prevent transmission
If either you or your partner is experiencing any prodromal symptoms, it is best to refrain from any intimate contact, wash hands frequently and not share eating utensils, lip balms, etc.
It is also important not to participate in kissing or oral sex if you or your partner has a cold sore.