Diseases Unique To and Of Pregnancy

December 14, 2007

Pregnancy Disease Overview

Pregnancy is a unique state of interaction between two dynamic systems, the mother-to-be and the baby-to-be. Since each baby has a complement of the the father's essence, the woman has over time developed a special talent of immunological, physiological, and anatomical tolerance to the new arrangement. The father's input into the whole project (DNA) can be likened to an invader, demonstrated by problems such as Rh and other blood incompatibilities. There are many disease states that are a result of the father's invasion (participation) into this state (See below). There are also third party offenders that can compromise a pregnancy (infections, trauma, etc.) Pregnancy is indeed special and miraculous. Below are some items worthy of note for prospective parents.

Abnormal Pap Smears in Pregnancy

Pregnant patients have no special protection from abnormal pap smears. This condition is typically though of as a gynecological condition, but when it occurs in the pregnanc state, diagnosis and treatment are modified somewhat so as not to affect the well-being of the pregnancy.

News of an abnormal pap smear is the most frequent reason for a call back to an obstetrician-gynecologist's office. This report is always difficult to hear over a telephone, and many doctors prefer to give the details face to face, only increasing the anxiety between the time of the phone call and the scheduled conference. As it is, though, a pregnant patient is already seeing her doctor frequently, so this appointment usually comes fairly soon.

Although it's true the dreaded "abnormal pap" can run the gamut from mere harmless inflammation of the cervix (mouth of the womb) all the way to cancer, often it's of the harmless variety. And pregnancy has certain affects on the pH of the vagina and the total vaginal environment that can cause inflammatory changes of the cervix that mimic disease.

We are victims of our own technology in that the screens we use to search for disease aren't very specific and result in a lot of false bad news (a false positive). Ironically, that's the good news. Further evaluation clears the patient and she leaves the office with more expense but with a clear sense of well-being. But there's also the false good news (a false negative), a report that is re-assuringly normal, resulting in the patient going her way for the rest of her pregnancy with possibly advancing disease. Luckily, this advance is very slow. Which brings us to the real beauty of the pap smear:

    Even though it is sometimes wrong, if a woman actually has a pre-cancerous condition, sooner or later the pap will definitely pick it up. And if an abnormal pap is missed during pregnancy, then it will most likely be identified after delivery in plenty enough time to address the abnormality.

The real test to judge the merits of a pap smear result is an office procedure called colposcopy. A colposcope, although nothing more than a microscope on a stick, evaluates the entire pap smear area stereoscopically, easily guiding the specialist to the areas that caused an abnormal pap--areas that are biopsied with tiny clippings--perhaps with some mild cramping. These clippings, however, are not the scattered loose cells strewn over a slide as in a pap. Instead they are actual "chunks" (microscopic, of course) of the tissue the way it sits in the cervix. This yields a result of certainty that will be either no cause for concern or a need for treatment. Most of the treatments involve simply eliminating the abnormal tissue. The slow development of abnormal tissue can safely see a patient through her pregnancy until it can be treated one to three months post-partum.

Colposcopy is safe in pregnancy, even when there are biopsies, because these are done on the superficial cervix and don't involve the deeper layers responsible for holding a pregnancy in. Because of its safety, an obstetrician is obligated to use colposcopy to make the diagnosis during pregnancy the same as during non-pregancy.

When there is inflammation, the doctor can seek a cause, like a yeast infection, for instance. This can be treated and resolved. When there is an actual pre-cancerous lesion, called dysplasia, it can be followed with intermittent colposcopies during the pregnancy until it can be eliminated after delivery. Rarely there is a dysplasia so serious (severe dysplasia) or even cancer that warrants immediate intervention. A GYN oncologist (gynecological cancer specialist) can make recommendations that may include a cone biopsy.

A cone biopsy involves cutting out a cone-shaped piece of the tip of the cervix so that the severity of the lesion can be identified better and also to actually eliminate the lesion (therapy). This gets a little scarier, but only because it's so rare now to do a cone biopsy during pregnancy. It must be remembered that before colposcopy, cone biopsies were frequent. Today in my practice, I do maybe one a year during pregnancy. It's not that dangerous, actually, but you are involving deeper tissue in that structural part of the uterus that holds in the pregnancy. Premature delivery due to an incompetent cervix is a risk, but so far, I haven't seen it in my practice, attesting to the safety of this procedure when done correctly and when absolutely necessary.

The causes of an abnormal pap are numerous. As mentioned above, a simple vaginal infection, such as yeast, can push a patient into a needless colposcopy--but no one can say it's needless until after it's done. An area of healing from recent infection can mimic disease. Also, a bacterial infection, such as from rectal bacteria, can cause the non-specific finding that prompts colposcopy. And pregnancy itself makes everything look worse under a microscope. Many researchers are now coming to the conclusion that mild to moderate dysplasia may even go away after the hormonal effects of the pregnancy are out of the system. (Hmmm....let's be careful.)

The overwhelming main cause of truly abnormal pap smears is infection with the condyloma virus, or sexually acquired Human Papilloma Virus (HPV). Also, as if you needed another reason to quit smoking in pregnancy, nicotine is concentrated thirty times more in the blood in the cervix than anywhere else in the body, linking it as a co-carcinogen. Specific strains of the condyloma vius cause both warts and cervical dysplasia (a truly pre-cancerous lesion). Not all dysplasias cause cervical cancers, but all cervical cancers usually start with dysplasias. So if there are warts, dysplasia must be suspected and ruled out with colposcopy.

As with all worries of pregnancy, pre-natal care is the golden standard of a safe pregnancy. Anything else is out-of-sight/out-of-mind, a time-bomb the count-down for which is not heard.

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Pre-eclampsia (Pregnancy-Induced Hypertension)

There is a unique disease seen only in pregnancy. Most feel it is an autoimmune condition--generally, the mother rejecting a foreign body, the baby. Traditionally, it's been said that there is still one great pillar in obstetrics left blank for the discoverer of the cause. Now we know that that pillar will be immortalized with thousands of pioneering names, since the biochemistry involved in this terrible disease is so complex, it's complexity growing the more we learn.

Clinically, the obstetrician sees a complex of signs and symptoms that include high blood pressure (hypertension), swelling, proteinurea (spilling protein in the urine), and hyperreflexia (brisk reflexes). These are the flashy things noticed during prenatal care that will tip off an obstetrician. There may be much going on behind the scenes before these things are clinically evident, however. Clotting mechanisms may be subtly altered, vascular volume will be affected, and growth of the baby slowed due to deterioration of the placenta.

The liver can be affected in a most dramatic presentation called HELLP syndrome. This may represent a life-threatening event and prompts immediate intervention. An end-stage of this complication may be something called DIC (Disseminated Intravascular Coagulopathy) in which all of the clotting factors are consumed microscopically throughout the body leading to massive hemorrhage.

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      Of course, as is evident throughout this website, pre-natal care is so important in heading off such complications of pregnancy.

Seizures can occur with pre-eclampsia, but then it's called eclampsia. This is when swelling is so severe that there is actual brain swelling. Spots in front of the eyes (called scotomata) should be addressed immediately, along with right upper abdominal pain and severe headaches. Stabilizing patients after eclampsia is a major challenge in obstetrics, calling into play help from internists, neurologists, and hematologists.

Pre-eclampsia is most commonly a phenomenon of first pregnancies, older pregnancies (35-45), and conditions wherein a patient is "more" pregnant than normal--twins, triplets, etc. In a well managed pre-natal program, the typical patient who may develop this condition usually presents near the end of the pregnancy so that intervention doesn't involved anguished decisions of delivering premature babies. Mild pre-eclampsia is even followed conservatively when it occurs near the end of a pregnancy, because the cure is imminent. The cure is delivery.

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RH Sensitization in Pregnancy

Having Rh Negative blood (rH-) is not really a disease, but it can create a pathological condition applicable to pregnancy. This pathological condition is a disease unique to pregnancy (and careless transfusions). If a woman is Rh Negative and she conceives a child with a Rh Positive man, there's a chance that their son or daughter may be Rh positive. This is statistically no big deal.

But at the time of delivery, when the placenta is removed, there is some mixing of maternal and fetal blood. If enough of the fetal blood enters the maternal circulation, the mother's blood sees this blood as foreign and will make antibodies to attack the strange red blood cells. Thankfully, the baby is in the nursery by that time, and everyone's happy.

Except the next baby.

If the following baby is also Rh Positive, the mother's anti-Rh+ antibodies can pass through the placenta and begin attacking the baby's own blood. The baby's blood is destroyed in a process called hemolysis, and the severe resulting anemia can cause a condition described historically as Erythroblastalis Fetalis. Erythroblastalis fetalis causes swelling and death of the baby. Treatment involves either delivery if out of the severely premature range, or transfusion of the unborn baby (done with ultrasound-guided amniocentesis into the baby's abdomen).

Today, erythroblastalis fetalis is rare, because we give an injection, called RhoGam, to Rh Negative mothers of Rh Positive babies. RhoGam is also an anti-Rh Positive antibody. When the mother's body sees it, it's fooled into thinking there's already been an adequate response and makes no antibodies on its own. The antibodies of RhoGam don't attack subsequent babies because they're much bulkier molecules and don't pass through the placenta to the baby.

If there's any question, there's a test called the Kleinhauer-Betke test (a blood test done on the mother) which can quantitate the amount of blood mixing between mother and baby. This is useful with miscarriages and ectopic pregnancies, as well as suspected mixing, like bleeding during a pregnancy.

With the rarity of this condition, most perinatologists are using the same science to fight other blood type incompatibilities. The results can be the same, both good with intervention or bad without.

Once again, prenatal care rules.

    Question:

    I am 41 and expecting my 5th child. Last September I had a miscarriage. My 1st son was born at 26 weeks weighing 1 pound 11 ounces, he is now a healthy 21 year old. But my concern is regarding Rh- blood type. My last two pregnancies (son - 16yrs and daughter 14yrs) my blood test results were that I have Rh- blood and received the antibody injections during pregnancy and after delivery. I am going to a different doctor for this baby, which I am now feeling like is a BIG mistake. But the blood test came back stating that I am 0+ and that I am not Rh-.
         How can my blood type change?
    What dangers are involved if I receive the antibody while pregnant if I am not Rh-? I was already given an injection in the first trimester because of bleeding.
    Is it possible for an Rh- blood type switch by itself to Rh+?

    Answer:

    "Rh," another marker for types of blood, can be either Rh Negative or Rh Positive. If a patient with Rh Negative blood were to receive blood from a Rh Positive donor, she would make antibodies to the Rh Positive blood given to her. The same thing happens if she has a baby, through inheritance from the father, who would have Rh Positive blood, like the father. At the time of delivery when the placenta separates, there is some mixing of maternal and fetal blood. Some blood does get into the maternal bloodstream, and this is just like receiving a blood transfusion from a Rh Positive donor. The mother would then make antibodies to this Rh Positive blood. But since the mother is RH Negative, it's no big deal, because these antibodies will only attack Rh Positive blood, of which the mother has none.

Until the next pregnancy.

     
    If the next baby she's carrying is once again Rh Positive, then her old anti-Rh Positive antibodies, small enough to pass from her circulation through the filtering of the placenta into the baby's bloodstream, will attack the baby's red blood cells.
    Up to 15% of women have Rh Negative blood, but now we can give Rh Immune-globulin, big bulky anti-Rh Positive antibodies which fool the body into thinking the defense has already been launched. Therefore, no antibodies are made by the mother. And since these are bulky molecules, they won't pass on to the fetus. These "blocking" antibodies therefore protect the fetus.
    Now that we have that out of the way, I can address your question. No, it isn't possible to change blood types. But Rh Positive women are identified by their Rh Positive red blood cells. There is a very weak variant called the "Du" variant. It is actually an Rh Positive antigen, which would make a woman "Rh Positive," but since it is very weakly expressed in tests, it's possible to be mistakenly read as Rh Negative. Today, any Rh Negative woman should be tested further for the Du variant. If it's positive, then the blood type is corrected to Rh Positive, and no Rh Immune-globulin need be given. If this is the case for you, then you received these shots for nothing with your previous pregnancies. Fear not, getting Rh immune-globulin when you're Rh Positive does no harm, except for your pocketbook. But before you go clobbering anyone on the head, do know that this is a recent test. So it may be that your new doctor has it right and that your previous doctors didn't have the technology back then to check for the Du variant.
    Of course, it doesn't hurt to ask your doctor, just in case your blood tubes got mixed up with someone else's!

    Although you didn't ask, I'll also tell you that if you were truly Rh Negative, you need the Rh immune-globulin even after a miscarriage, since there can be mixing of maternal and fetal blood there too. We also give this shot to Rh Negative mothers who have undiagnosed bleeding during their pregnancy, car accidents, and version (converting a breech to a head-first baby).

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Sexually Transmitted Diseases (STDs), the gift from the goddess of love

We used to call them "venereal" diseases. The origin of this word comes from the goddess of love, Venus. Interestingly, so does the word, venerate. Today, gynecologists call them sexually transmitted diseases, or STDs. Just because a patient is pregnant she has no special protection from STDs. In fact, in pregnancy diagnosis is even more crucial, for infections can affect pregnancies in severe ways.

The standard part of any initial pregnancy work-up involves a screen for STDs. The routine exam checks for inflamed lymph nodes and liver sensitivity. Lymph nodes can enlarge with any infection from an area of the body that drains their way. The liver can indicate hepatitis, one of the deadliest risks from sexually transmitted disease. It's ironic that most people fear AIDS, because age-old hepatitis can be quite lethal. The pelvic exam is done to see if there's any undue tenderness or abnormal discharge, indicating possible infection from gonorrhea or chlamydia. In the course of the pelvic exam, specific cultures for gonorrhea and chlamydia are taken as well, and a pap smear is done which could show infection with Human Papilloma Virus, or HPV. HPV, a sexually acquired virus, can lead to cancer of the cervix, especially in smokers.

An abnormal discharge can prompt what's called a "wet prep." This is the same test that can see yeast, but it's also used to diagnose sexually acquired trichomonas, an organism that can lead to severe burning and vaginal discharge as well as be passed on to other sexual partners.

Blood work in pregnancy, besides looking to identify blood type and immunity to Rubella, is also used to screen for STDs. Syphilis is making a big comeback. The initial lesion is painless and therefore often missed. A patient leading what she thinks is a normal life may one day develop severe neurological dysfunction as an end stage of this easy-to-cure disease if undiagnosed during its first stages. As mentioned above, the risk of hepatitis lurks as well, and blood tests can tell whether there is an acute infection as well as indicate whether there is something chronic going on. HIV infection, the virus that causes AIDS, is also a blood test.

Unless there's an obvious lesion, herpes can't be diagnosed without a positive culture. But herpes cultures are frequently unreliable. Blood work may show the body's reaction to herpes (antibodies), but this STD is a loose end that only time can diagnose or exclude. In pregnancy it poses a particular risk.

In contrast to herpes and syphilis, there are other nasty skin lesions which probably don't affect the pregnancy to any great extent. Molluscum contagiosum is a little organism that can cause raised bumps that need to be scraped off of the labia, thighs, or perianal areas. HPV, besides precancerous lesions of the cervix, can cause venereal warts which can be very difficult to eradicate, the chemical used prohibited in pregnancy.

In summary, there are many things out there which pose additional risk to the pregnancy as well as the woman who is pregnant. Some have been implicated in premature delivery, and others have cause abnormalities that are tragic. The obstetrician is keenly aware of the possibilities.

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STD Hotline

The American Social Health Association, under contract with the Centers for Disease Control and Prevention, operates the National STD Hotline where patients can call in anonymously to receive information and counseling.
1-800-227-8922


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