Download Family planning

Family planning
is the planning of when to have children, and the use of birth control and other techniques to implement such
plans. Other techniques commonly used include sexuality education, prevention and management of sexually
transmitted infections, pre-conception counseling and management, and infertility management.
Family planning is sometimes used in the wrong way also as a synonym for the use of birth control, though it
often includes more. It is most usually applied to a female-male couple who wish to limit the number of
children they have and/or to control the timing of pregnancy (also known as spacing children). Family planning
may encompass sterilization, as well as abortion.
Family planning services are defined as "educational, comprehensive medical or social activities which enable
individuals, including minors, to determine freely the number and spacing of their children and to select the
means by which this may be achieved."
Purposes
Raising a child requires significant amounts of resources: time, social, financial, and environmental. Planning
can help assure that resources are available.
Waiting until the mother is at least 18 years old before trying to have children improves maternal and child
health. Also, if additional children are desired after a child is born, it is healthier for the mother and the child to
wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a
miscarriage or abortion, it is healthier to wait at least 6 months.
Modern methods
Some families use modern medical advances in family planning. For example in surrogacy treatments a woman
agrees to become pregnant and deliver a child for another couple or person.
In sperm donations, pregnancies are usually achieved using donated sperm by artificial insemination (either by
ICI or IUI) and less commonly by in vitro fertilization (IVF), usually known in this context as ART but
insemination may also be achieved by a donor having sexual intercourse with a woman for the sole purpose of
initiating conception. This method is known as natural insemination, or NI.
There is generally a demand for sperm donors who have no genetic problems in their family, 20/20 eyesight,
with excellent visual acuity, a college degree, and sometimes a value on a certain height and age.
Finances
Childbirth and prenatal health care cost averaged $7,090 for normal delivery in the US in 1996.[11] US
Department of Agriculture estimates that for a child born in 2007, a US family will spend an average of
$11,000 to $23,000 per year for the first 17 years of child's life. (Total inflation adjusted estimated expenditure:
$196,000 to $393,000, depending on household income.)
Planning ahead has always been imperative in affecting the outcome of life-changing situations for everyone,
which most certainly applies when it comes to pregnancy. Nearly fifty percent of the pregnancies nationwide
each year is unplanned and the occurrence is far more prevalent among women under the age of 25 or with low
income status. Lack of financial and emotional preparation often derives from unplanned parenthood that
subsequently leads to a serious burden to the surrounding family members. Optional government aid became
the only hope for many who are financially broken. Therefore, for women who are sexually active and have no
intentions for parenthood, birth control pills offer a simple and effective deterrent to unplanned pregnancy that
can adversely affect both family and society.
Birth control
With assertions of overpopulation, there have been asertions that birth control is the answer. Birth control is
techniques used to prevent unwanted pregnancy.
There are a range of contraceptive methods, each with unique advantages and disadvantages. Any of the widely
recognized methods of birth control is much more effective than no method. Behavioral methods that include
intercourse, such as withdrawal and calendar based methods have little up front cost and are readily available,
but are less effective in typical use than most other methods. Long-acting reversible contraceptive methods,
such as IUD and implant are highly effective and convenient, requiring little user action. When cost of failure is
included, IUDs and vasectomy are much less costly than other methods.
Policy
The world's largest international source of funding for population and reproductive health programs is the
United Nations Population Fund (UNFPA). The main goals of the International Conference on Population and
Development Program of Action are:
Universal access to reproductive health services by 2015
Universal primary education and closing the gender gap in education by 2015
Reducing maternal mortality by 75% by 2015
Reducing infant mortality
Increasing life expectancy
Reducing HIV infection rates in persons aged 15–24 years by 25% in the most-affected countries by 2005, and
by 25% globally by 2010
The World health organization (WHO) and World Bank estimate that $3.00 per person per year would provide
basic family planning, maternal and neonatal health care to women in developing countries. This would include
contraception, prenatal, delivery and post-natal care in addition to postpartum family planning and the
promotion of condoms to prevent sexually transmitted infections.
United States
Title X of the Public Health Service Act, is a US government program dedicated to providing family planning
services for those in need. But funding for Title X as a percentage of total public funding to family planning
client services has steadily declined from 44% of total expenditures in 1980 to 12% in 2006. Medicaid has
increased from 20% to 71% in the same time. In 2006, Medicaid contributed $1.3 billion to public family
planning.
Pregnancy can be a beautiful thing. But it can also be an inconvenient thing, a financially burdensome thing, a
physically dangerous thing, an emotionally and politically charged thing, and a scandalous thing. This is why
most women prefer to control their fertility: when pregnancy happens to them, they want it to be at its most
beautiful.
There are many ways to deal with an unwanted pregnancy, but they fall into just three basic categories: prevent
it, terminate it, or follow through with it. If you choose to carry an unplanned pregnancy to term, you have the
additional option of giving the child to another family through the process of adoption. We will go over all
these options here, starting with prevention, since it is the easiest and least traumatic way to control fertility.
Whatever your situation or your preference for handling it, bear in mind that I am not an expert or medical
professional, just a good researcher. The purpose of this page is to provide a brief overview of all your options.
If an option interests you, I encourage you to do further research and talk to a counselor or doctor before
making a final decision.
Unintended pregnancies are those in which conception was not intended by the female sexual partner.
Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999).
Unintended pregnancies are the primary cause of induced abortion, resulting in about 42 million induced
abortions per year. Unintended pregnancy is also linked to higher rates of maternal and infant deaths.
The use of modern contraceptive methods has greatly reduced the incidence of unintended pregnancy,
particularly in more developed countries. However the United States has an unusually high rate of unintended
pregnancy, especially among the poor.
Unintended pregnancies may arise within a committed relationship, such as marriage, as well as resulting from
casual sexual activity, or as a result of rape.
Causes
 Not using contraception.
 Using contraception inconsistently or incorrectly.
 Contraceptive failure (the method was used correctly, but did not work.) Accounts for relatively small
fraction of unintended pregnancies when modern highly effective contraceptives are used.
Reasons contraceptives might not have been used or been used incorrectly include:
 Coercion. Rape or involuntary sex which sometimes happens in the context of domestic violence.
Unintended pregnancies are more likely to be associated with abuse than intended pregnancies. This
may also include birth control sabotage - manipulation of someone's use of birth control to undermine
efforts to prevent pregnancy.
 Lack of knowledge about sex and reproduction. Including erroneous beliefs.
 Lack of knowledge or experience with the contraceptive, or lack of motivation to use it correctly.
 Lack of planning or ambivalence about whether to have a child.
Results
Unintended pregnancies result in poorer outcomes for the mother and for the child, if birth occurs. Unintended
pregnancy precludes pre-conception counseling, and pre-conception care, and delays initiation of prenatal care.
The great majority of abortions result from unintended pregnancies.
Results of unintended pregnancy include:
Prenatal care initiate later, and less adequate. Adversely affects health of woman and of child and less
preparation for parenthood. Delay from unintended pregnancy is in addition to that from other risk factors for
delay. Unwanted pregnancies have more delay than mistimed.
Unintended pregnancies preclude chance to resolve sexually transmitted diseases (STD) before pregnancy.
Untreated STD in pregnant woman can result in premature delivery, infection in newborn or infant death.
Preclude use of genetic testing to help make decisions about whether to become pregnant.
Women with an unintended pregnancy are more likely to suffer depression during or after pregnancy.
Poorer maternal mental health
Increased risk of physical violence during pregnancy
Reduced likelihood of breastfeeding, resulting in less healthy children
Lower mother-child relationship quality (see also Maternal bond)
More likely that mother smokes tobacco (about 30% more likely in the US) or drinks during pregnancy. Which
results in poorer health outcomes and additional costs for welfare system. (see also Fetal alcohol syndrome,
Fetal alcohol spectrum disorder)
Children whose births were unintended are:
Greater likelihood of low birth weight, particularly for unwanted pregnancies. In US eliminating all unwanted
pregnancies would reduce rate of low birth weight by 7% for blacks, and 4% for whites, helping to decrease the
large disparity in rates for whites vs. blacks. May be through increased risk preterm delivery.
Greater infant mortality. If all sexually active couples in the US had routineley used effective contrectiption in
1980, there would have been 1 million fewer abortions, 340,000 fewer live births that were unintended at
conception, 5,000 fewer infant deaths, and the infant mortality rate would have been 10% lower.
 likely to be less mentally and physically healthy during childhood,
 at higher risk of child abuse and neglect,
 less likely to succeed in school,
 more likely to live in poverty,
 more likely to need public assistance,
 more likely to have delinquent and criminal behavior.
Unintended pregnancies lead to higher rates of maternal morbidity, and threaten the economic viability of
families.
Women with unintended pregnancies have less education and participate less in the workforce than women
whose pregnancies are intended.
Induced abortions
A woman who finds herself pregnant may terminate the pregnancy by an abortion. A large proportion of
induced abortions worldwide are due to unwanted or mistimed pregnancy. Unintended pregnancies result in
about 42 million induced abortions per year worldwide. In the United States, over 92% of abortions are the
result of unintended pregnancy.
Abortion carries few health risks when performed in accordance with modern medical technique. It is far safer
than child birth. However where safe abortions are not available, abortion can contribute significantly to
maternal mortality and morbidity.
While decisions about abortion may cause some individuals psychological distress, some find a reduction in
distress after abortion. There is no evidence of widespread psychological harm from abortion. Unwanted
pregnancy and unwanted birth are also psychologically distressing, so considerations of psychological impact
of abortion should be in comparison to potential harm from these stressors.
Some find abortion morally objectionable.
Over the six years between 1995 and 2000 there were an estimated 338 million pregnancies that were
unintended and unwanted worldwide (28% of the total 1.2 billion pregnancies during that period). These
unwanted pregnancies resulted in nearly 700,000 maternal deaths (approximately one-fifth of maternal deaths
during that period). More than one-third of the deaths were from problems associated with pregnancy or
childbirth, but the majority (64%) were from complications from unsafe or unsanitary abortion. Most of the
deaths occurred in less developed parts of the world, where family planning and reproductive health services
were less available.
Pre and postnatal depression contributes to increased risk of suicide among pregnant women and mothers.
Suicide contributes to the rate of maternal mortality; where the rate of maternal deaths from physical causes is
reduced by medically safe abortions and child delivery, the proportion from psychological problems can
become more significant.
In cultures that practice honor killing, unintended pregnancy may increase the woman's chance of being killed.
Unwanted births
Infants whose births were not wanted are more likely to die of infanticide. Unwanted children may also be
abandoned, especially where social structures to handle adoption are not available. Unwanted children are
sometimes put up for adoption.
Prevention
Prevention includes comprehensive sexual education, availability of family planning services, including access
to a range of effective birth control methods. Most unintended pregnancies result from not using contraception,
many more result from using contraceptives inconsistently or incorrectly. Increasing use of long-acting
reversible contraceptives (such as IUD and contraceptive implants) decreases the chance of unintended
pregnancy by decreasing the chance of incorrect use. Method failure is relatively rare with modern, highly
effective contraceptives, and is much more of an issue when such methods are unavailable, unaffordable, or not
used.
In the United States, women who have an unintended pregnancy are more likely to have subsequent unplanned
pregnancies. Providing family planning and contraceptive services as part of prenatal, postpartum and post
abortion care can help reduce recurrence of unintended pregnancy.
Providing contraceptives and family planning services at low or no cost to the user helps prevent unintended
pregnancies. Many of those at risk of unintended pregnancy have little income, so even though contraceptives
are highly cost-effective, up front cost can be a barrier. Subsidized family planning services improve the health
of the population and saves money for governments and health insurers by reducing medical, education and
other costs to society.
Providing modern contraceptives to the 201 million women at risk of unintended pregnancy in developing
countries who do not have access to contraception would cost an estimated US$3.9 billion per year. This
expenditure would prevent an estimated 52 million unintended pregnancies annually, preventing 1.5 million
maternal and child deaths annually, and reduce induced abortions by 64% (25 million per year). Reduced
illness related to pregnancy would preserve 27 million healthy life years, at a cost of $144 per year of healthy
life.
It is theorized that preventing unintended pregnancies could help break the cycle of poverty.
Affordable contraceptive services should form the basis for child abuse prevention. "The starting point for
effective child abuse programming is pregnancy planning" US Surgeon General C. Everett Koop
Epidemiology
Note: Numbers and rates are for detected pregnancies. A large proportion of pregnancies miscarry before the
woman is aware of the pregnancy.
Incidence
The global rate of unintended pregnancy was 55 per 1,000 women aged 15–44 in 2008, of which 26 per 1,000
ended in abortion. The rate of intended pregnancy was 79 per 1,000. The estimated 208 million pregnancies in
2008 resulted in 102 million intended births, 41 million induced abortions, 33 million unintended births, and 31
million miscarriages.
Globally, the proportion of married women practicing contraception increased from 54% in 1990 to 63% in
2003. The global rate of unintended pregnancy declined from 69 per 1,000 women in 1995. The decline was
greatest in the more developed world.
Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999).
In developed world an estimated 49% of pregnancies were unintended, 36% in the developing world.
Unintended pregnancy is more likely among the poor, who have less access to contraceptives, less education
about sexuality and family planning, and may have fewer career opportunities. In the United States, teen
pregnancies are more likely than others to be unintended. Often as a result of lack of knowledge about sexuality
and contraceptives, inexperience using contraceptives, difficulty getting contraceptives, or lack of planning.
Women nearing menopause also have an increased risk of unintended pregnancy; as periods become less
regular, a woman may assume that she can no longer have children, and stop using contraceptives, or use them
less consistently.
By country/region
Europe
In France, 33% of pregnancies are unintended. Of women at risk for unintended pregnancy, only 3% do not use
contraception, and 20% use Intrauterine devices (IUDs).
United States of America
The United States rate of unintended pregnancies is higher than the world average, and much higher than that in
other industrialized nations. Almost half (49%) of U.S. pregnancies are unintended, more than 3 million
unintended pregnancies per year. Over 92% of abortions are the result of unintended pregnancy, unintended
pregnancies result in about 1.3 million abortions/year. The rate of abortions is high in the United States than in
other developed countries because of the higher rate of unintended pregnancies in the US. In 2001, 44% of
unintended pregnancies resulted in births, and 42% resulted in induced abortion and the rest in miscarriage. It
is estimated that more than half of US women have had an unintended pregnancy by age 45.
History
US birth rates declined in the 1970s. Factors that are likely to have led to this decline include: The introduction
of the birth control pill in 1960, and its subsequent rapid increase in popularity; the completion of legalization
of contraceptives in the 1960s and early 1970s; the introduction of federal funding for family planning in the
1960s and Title X in 1970; and the legalization of abortion, which was completed in 1973. The decline in birth
rate was associated with reductions in the number of children put up for adoption and reduction in the rate of
neonaticide.
It is unclear to what extent legalization of abortion may have increased the availability of the procedure. It is
estimated that before legalization about 1 million abortions were performed annually. Before legalization,
aboriton was probably one of the most common criminal activities. Before legalization, an estimated 1,000 to
10,000 women died each year from complications of poorly preformed abortions. Legalization was followed
by a decrease in pregnancy related deaths in young women, as well as decrease in hospital admissions for
incomplete or septic abortions, conditions more common than induced abortion.
The infanticide rate during the first hour of life dropped from 1.41 per 100,000 during 1963 to 1972 to 0.44 per
100,000 for 1974 to 1983; the rate during the first month of life also declined, whereas the rate for older infants
rose during this time.
The rate of unintended pregnancy declined significantly from 1987 until 1994, due to increased contraceptive
use. Since then until 2001 the rate has remained relatively unchanged.
Among poor women, the rate of unintended pregnancy and unintended birth rose from 1994 to 2001, while it
declined for the more affluent women (those >200% of federal poverty level). (Unintended pregnancy rose
almost 30% and unintended births rose 50% for those below federal poverty level.) Contraceptive use had been
increasing for years, but stopped in the 1990s, and began to decline among poorer women. Cuts in federal and
state family planning programs may account for the decreased use of contraceptives and increase in unintended
pregnancies.
Costs and potential savings
The public cost of unintended pregnancy is estimated to be about 11 billion dollars per year in short term
medical costs. This includes costs of births, one year of infant medical care and costs of fetal loss. Preventing
unintended pregnancy would save the public over 5 billion dollars per year in short term medical costs.
Savings in long term costs and in other areas would be much larger. By another estimate, the direct medical
costs of unintended pregnancies, not including infant medical care, was $5 billion in 2002.
Teens
Of the 800,000 teen pregnancies per year, over 80% were unintended in 2001. One-third of teen pregnancies
result in abortion. In 2002, about 9% of women at risk for unintended pregnancy were teenagers, but about
20% of the unintended pregnancies in the United States are to teenagers. A somewhat larger proportion of
unintended births are reported as mistimed, rather than unwanted, for teens compared to women in general
(79% mistimed for teens vs. 69% among all women in 1998).
Prevention
In the US it is estimated that 52% of unintended pregnancies result from couples not using contraception in the
month the woman got pregnant, and 43% result from inconsistent or incorrect contraceptive use; only 5% result
from contraceptive failure, according to a report from the Guttmacher Institute. Contraceptive use saved an
estimated $19 billion in direct medical costs from unintended pregnancies in 2002.
In 2006, publicly funded family planning services (Title X, medicaid, and state funds) helped women avoid
1.94 million unintended pregnancies, thus preventing about 860,000 unintended births and 810,000 abortions.
Without publicly funded family planning services, the number of unintended pregnancies and abortions in the
United States would be nearly two-thirds higher among women overall and among teens; the number of
unintended pregnancies among poor women would nearly double The services provided at publicly funded
clinics saved the federal and state governments an estimated $5.1 billion in 2008 in short term medical costs.
Nationally, every $1.00 invested in helping women avoid unintended pregnancy saved $3.74 in Medicaid
expenditures that otherwise would have been needed.
Reducing unintended pregnancy in the United States would be particularly desirable since abortion is such a
politically divisive issue.
Rape
A longitudinal study in 1996 of over 4000 women in the United States followed for 3 years found that the raperelated pregnancy rate was 5.0% among victims aged 12–45 years. Applying that rate to rapes committed in the
United States would indicate that there are over 32,000 pregnancies in the United States as a result of rape each
year.
History
Early ways of preventing unwanted pregnancy included withdrawal and various alternatives to intercourse; they
are difficult to use correctly and, while much better than no method, have high failure rates compared to
modern methods. Various devices and medications thought to have spermicidal, contraceptive, abortifacient or
similar properties were also used.
Abortions have been induced to prevent unwanted births since antiquity, abortion methods are described in
some of the earliest medical texts. The degree of safety of early methods relative to the risks of child birth is
unclear.
Infanticide (‘customary neonaticide’) or abandonment (sometimes in the form of exposure) are other traditional
way of dealing with babies that were not wanted or that a family could not support. Opinions on the morality or
desirability of the practices have changed through history.
Where modern contraceptives are not available, abortion has sometimes been used as a major way of
preventing unwanted birth. For instance in much of Eastern Europe and the former Soviet republics in the
1980s, desired family size was small, but modern contraceptive methods were not readily available, so many
couples relied on abortion, which was legal, safe, and readily accessible, to regulate births. In many cases, as
contraceptives became more available the rate of unintended pregnancy and abortion dropped rapidly during the
1990s.
In the 19th and 20th century, the desired number of pregnancies has declined as reductions in infant and
childhood mortality have increased the probability that children will reach adulthood. Other factors, such as
level of education and economic opportunities for women, have also lead to reductions in the desired number of
children. As the number of desired number of children decreases, couples spend more of their reproductive
lives trying to avoid unintended pregnancies.
In society and culture
Unintended pregnancy can be an indicator of premarital sex, which may carry social stigma, result in
persecution or honor killing. Sometimes, in order to prevent illegitimate children, forced marriages result. Such
marriages typically have poorer outcomes than voluntary marriage.
In many industrialized nations there is increasing acceptance of premarital sex, single parenting, and children
born outside wedlock.
Unintended pregnancy is common as a cause of stress or social stigma in fictional works. It plays a role in
many portrayals of illegitimacy and teen pregnancy.
Types of Birth Control
Reversible Methods of Birth Control
Intrauterine Devices (IUDs)
Copper T IUD-An IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the
uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. This IUD is more than 99% effective
at preventing pregnancy.
Levonorgestrel intrauterine system (IUS)-The IUS is a small T-shaped device like the IUD. It is placed inside
the uterus by a doctor. It releases a small amount of progestin each day to keep you from getting pregnant. The
IUS stays in your uterus for up to 5 years. The IUS is more than 99% effective at preventing pregnancy.
Hormonal methods
Oral contraceptives - Also called “the pill,” it contains the hormones estrogen and progestin. It is prescribed by
a doctor. A pill is taken at the same time each day. If you are older than 35 years and smoke, have a history of
blood clots or breast cancer, your doctor may advise you not to take the pill. The pill is 92–99% effective at
preventing pregnancy.
Mini pill - Unlike the pill, the mini-pill only has one hormone, progestin, instead of both estrogen and
progestin. It is prescribed by a doctor. It is taken at the same time each day. It is a good option for women who
can’t take estrogen. They are 92–99% effective at preventing pregnancy.
Patch-This skin patch is worn on the lower abdomen, buttocks, or upper body (but not on the breasts). This
method is prescribed by a doctor. It releases hormones progestin and estrogen into the bloodstream. You put on
a new patch once a week for three weeks. During the fourth week, you do not wear a patch, so you can have a
menstrual period. The patch is 92–99% effective at preventing pregnancy, but it appears to be less effective in
women who weigh more than 198 pounds.
Hormonal vaginal contraceptive ring - The ring releases the hormones progestin and estrogen. You place the
ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and
then put in a new ring. It is 92–99% effective at preventing pregnancy.
Injection or "shot". Women get shots of the hormone progestin in the buttocks or arm every three months from
their doctor. It is 97–99% effective at preventing pregnancy.
Implant. The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod
contains a progestin that is released into the body over 3 years. It is 99 percent effective at preventing
pregnancy.
Emergency contraception - Emergency contraception is NOT a regular method of birth control. Emergency
contraception can be used after no birth control was used during sex, or if the birth control method failed, such
as if a condom broke.
Women can take emergency contraceptive pills up to 5 days after unprotected sex, but the sooner the pills are
taken, the better they will work. There are three different types of emergency contraceptive pills available in the
United States. Some emergency contraceptive pills are available over the counter for women 17 years of age or
older. If younger than 17 years, emergency contraceptive pills are available by prescription.
Another type of emergency contraception is having your doctor insert the Copper T IUD into your uterus within
seven days of unprotected sex. This method is 99% effective at preventing pregnancy.
Barrier methods
Male condom. Worn by the man, a male condom keeps sperm from getting into a woman’s body. Latex
condoms, the most common type, help prevent pregnancy and HIV and other STDs as do the newer synthetic
condoms. “Natural” or “lambskin” condoms also help prevent pregnancy, but may not provide protection
against STDs, including HIV. Male condoms are 85–98% effective at preventing pregnancy. Condoms can only
be used once, and are most effective when used consistently and correctly. You can buy condoms, KY jelly, or
water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or
petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break.
Female condom. Worn by the woman, the female condom helps keeps sperm from getting into her body. It is
packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual
intercourse. Female condoms are 79–95% effective at preventing pregnancy when used consistently and
correctly, and may also help prevent STDs.
Diaphragm or cervical cap. Each of these barrier methods are placed inside the vagina to cover the cervix to
block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before
sexual intercourse, you insert them with spermicide to block or kill sperm. The diaphragm is 84–94% effective
at preventing pregnancy. Visit your doctor for a proper fitting because diaphragms and cervical caps come in
different sizes.
Spermicides - These products work by killing sperm and come in several forms-foam, gel, cream, film,
suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them
in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom,
diaphragm, or cervical cap. Spermicides alone are about 71–82% effective at preventing pregnancy. They can
be purchased in drug stores.
Fertility awareness and abstinence
Continuous abstinence - This method means not having vaginal intercourse at any time. It is the only 100%
effective way to prevent pregnancy.
Natural family planning or fertility awareness - Understanding your monthly fertility pattern can help you plan
to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you
are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If
you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to
get pregnant, you do not have sex on the days you are fertile, or you use a form of birth control on those days.
These methods are 75–99% effective at preventing pregnancy.
Permanent Methods of Birth Control
These methods are meant for people who want a permanent method of birth control. In other words, they never
want to have a child, or they do not want more children. The methods listed here are more than 99% effective at
preventing pregnancy.
Female Sterilization – Tubal ligation or “tying tubes.” - A woman can have her fallopian tubes tied (or closed)
so that sperm and eggs cannot meet for fertilization. The procedure can be done in a hospital or in an outpatient
surgical center. You can go home the same day of the surgery and resume your normal activities within a few
days. This method is effective immediately.
Transcervical Sterilization. A thin tube is used to thread a tiny device into each fallopian tube. It irritates the
fallopian tubes and causes scar tissue to grow and permanently plug the tubes. It can take about three months
for the scar tissue to grow, so use another form of birth control during this time. Return to your doctor for a test
to see if scar tissue has fully blocked your fallopian tubes.
Male Sterilization . Vasectomy-This operation is done to keep a man’s sperm from going to his penis, so his
ejaculate never has any sperm in it that can fertilize an egg. This operation is simpler than tying a woman’s
tubes. The procedure is done at an outpatient surgical center. The man can go home the same day. Recovery
time is less than one week. After the operation, a man visits his doctor for tests to count his sperm and to make
sure the sperm count has dropped to zero; this takes about 12 weeks. Another form of birth control should be
used until the man’s sperm count has dropped to zero
Gestosis
Gestosis of pregnant women include a number of pathological conditions that occur during pregnancy,
complicating its course. There are early gestosis, usually occurring in the first trimester of pregnancy, and late
gestosis, developing in the second half of pregnancy.
Early gestosis includes: vomiting in pregnancy (mild form), excessive vomiting and ptializm (salivation).
Etiological factor of gestosis, according to many authors, is the failure of mechanisms to adapt to emerged
pregnancy. Congenital and acquired deficiency of neuroendocrine regulation of adaptive responses (hypoxia,
infection, intoxication, malnutrition in the antenatal period, hereditary factors) contribute to gestosis
development, as well as presence of extragenital pathology in a woman (on the part of cardiovascular system hypertension, hypotension, cardiac defects, endocrine disease - diabetes mellitus, hyper-and hypothyroidism,
urinary tract disease - pyelonephritis, glomerulonephritis).
Early gestosis (vomiting during pregnancy) include vomiting, which is repeated several times during the day,
accompanied by nausea, a decrease in appetite, change in taste and olfactory sensations. In accordance with the
severity of the disease they distinguish:
• light form;
• moderate (moderate);
• excessive vomiting (severe).
Mild form corresponds to a phase of functional changes in nervous system (phase neuroses), the form of
medium gravity - intoxication phase (phase toxicity), a severe form corresponds to a phase of dystrophy.
Late gestational toxicosis often occurs in the third trimester of pregnancy and is characterized by multiple organ
failure. Late gestosis is manifested by three main symptoms - edema, proteinuria, arterial hypertension, at least
- more severe symptoms (convulsions, coma, etc.). In modern obstetrics late gestosis is denoted as OPGgestosis (under the name of three major symptoms). There are many classifications of late gestosis, but in
practical obstetrics they distinguish 4 main clinical forms:
• hydrocephalus of pregnant;
• nephropathy (mild, moderate, severe);
• pre-eclampsia;
• eclampsia.
We should also note pre-clinical stage of gestosis - pregestoz. All clinical forms of late gestosis are specific
stages of a single pathological process.
Excess weight gain during pregnancy is one of early signs of pregnancy complications called gestosis, an
evidence of initially hidden, and then, perhaps, obvious edema.
Hidden edema are detected with regular measurement of body weight (weighing a patient) and definition of
diuresis. If weight gain exceeds 300-400 g per week and negative diuresis will be identified, these symptoms
indicate underlying edema.
Explicit, visible swelling differ in the degree of distribution:
• I degree - swelling of feet and legs;
• II degree - edema of the lower extremities and the anterior abdominal wall;
• III degree - generalized edema up to anasarca.
Nephropathy of pregnancy is divided into three levels:
• mild (hypertension is not higher than 150/100 mm Hg. Art., swelling of feet not higher than shins, proteinuria
less than 1 g / l, the fundus has uneven caliber of retinal vessels);
• moderate (blood pressure not higher than 175/115 mm Hg. Art., swelling extended to the lower extremities
and abdominal wall, proteinuria of 1 g / l to 3 g / l, there is swelling of the retina);
• severe degree (blood pressure above 175/115 mm Hg. Art., Anasarca, proteinuria more than 3 g / l, the fundus
has hemorrhage, marked degenerative changes).
Pre-eclampsia - a critical, but a reversible condition, which developed against the background of severe
gestosis. In addition to the triad of symptoms of gestosis (OPG), a patient has a headache, nasal congestion,
visual disturbances. These signs are regarded as cerebral circulation disorder.
Eclampsia - the most severe form of pregnancy problem called gestosis, which is characterized by seizures with
loss of consciousness. The duration and number of seizures of eclampsia may be different. During a seizure
there develop abnormalities of cerebral blood flow, bleeding in the brain and its membranes. Hemorrhages in
internal organs are frequent. Hypoxia and metabolic disease are sharply increasing, there occurs acidosis. Renal
function is rapidly deteriorating, oligouriya increases. Internal organs often have degenerative changes.
Eclampsia is life-threatening for both mother and fetus.
The threat of termination and miscarriage
The most frequent complication of pregnancy is a threat of interruption and premature birth - one of the main
perinatal cause of morbidity and mortality. The main reasons for threat of abortion and miscarriage are:
• infectious diseases of mother;
• complications related to pregnancy;
• traumatic injuries;
• iso serological incompatibility of blood between mother and fetus;
• developmental anomalies of female genitalia;
• neuroendocrine pathology;
• various non-communicable diseases of mother;
• chromosomal abnormalities.
There are genetic reasons for miscarriage. In presence of chromosomal aberrations of an embryo there develops
the threat of interruption on early stages of pregnancy. Spontaneous miscarriage in this case can be regarded as
a device, worked out in the process of evolution, resulting in the birth of children with deformities is quite rare.
Endocrine causes of miscarriage include hypovaria, hyperandrogenism of different genesis (adrenal, ovarian),
thyroid dysfunction. The first place is occupied by mother’s infectious diseases. These are primarily latent
infectious diseases such as chronic tonsillitis, urinary organs infections, listeriosis, toxoplasmosis, mycoplasma
infection, chronic inflammatory diseases of genital organs and viral infections.
Under certain circumstances, there occurs an immunologic conflict in the mother-placenta-fetus, leading to the
risk of abortion and spontaneous abortion.
Among malformations of the uterus as a cause of miscarriages most common are: bicornuate, saddle, unicorns
uterus, intrauterine septum, doubling of the uterus, rudimentary uterus.
The reasons contributing to emergence of miscarriages also include genital infantilism, isthmic-cervical
insufficiency, uterine myoma and extragenital diseases of mother.
Ptyalism in pregnancy, or excessive salivation, is especially annoying for a small number of patients,
sometimes approaching 1 liter production per day. Medical treatment with tincture of belladonna or atropine
alter ptyalism only slightly so that reassurance of the time-limited nature of the problem is a mainstay of
management.
At least 66 % of women experience nausea and 50 % emesis in the first trimester, with the frequency of these
symptoms lessening as the second and third trimesters ensue. Classically, symptoms are predominantly present
in the morning (“morning sickness”), but they may occur throughout the day and evening.
The genesis of pregnancy-induced nausea and vomiting is not clear. It may be that the hormonal changes of
pregnancy are responsible. Chorionic gonadotropin, for instance, has been implicated on the basis that its levels
are rather high at the same time that nausea and vomiting are most common.
Light, moderate and severe degrees of vomiting are distinguished.
Light degree of vomiting accompanying with 2-4 times per day episodes of vomiting after taking meals.
general state of the woman is satisfactory, light tachycardia may be present.
Moderate degree of vomiting accompanying with 10 times and more per day episodes of vomiting which don’t
from taking meals. Weight loss, ketosis, increased temperature are present.
Frequent small feedings and avoidance of foods that are unpleasant to the patient usually relieve symptoms to a
manageable level. A variety of antiemetics can be prescribed if the above measures fail to provide adequate
relief, but unfortunately, none is completely effective and all carry risks (Metoclopramide, Meclizine,
Promethazine). Of historical interest is the compound medication Bendectin, a combination of the antihistamine
doxylamine and vitamin B6 (pyrodoxine), which was reasonable effective as an antiemetic in pregnancy.
Severe degree of vomiting is also called as Hyperemesis gravidarum (intractable emesis during pregnancy) is a
more severe form of nausea and vomiting, occurring in approximately 4 out of 1000 pregnancies (ccompanying
with 10 times and more per day episodes of vomiting) .
Fortunately, hyperemesis gravidarum has become uncommon. This syndrome is defined as vomiting
sufficiently pernicious to produce weight loss, dehydration, acidosis from starvation, alkalosis from loss of
hydrochloric acid in vomitus, and hypokalemia. It appears to be related to high or rapidly rising serum levels of
chorionic gonadotropin or estrogens. Goodwin and associates (1994) described significantly higher total as well
as free b-subunits of chorionic gonadotropin concentrations in women with hyperemesis compared with
asymptomatic controls. Hyperemesis may lead to transient hepatic dysfunction.
Dehydration is corrected as well as fluid and electrolyte deficits and acidosis or alkalosis. This requires
appropriate amounts of sodium, potassium, chloride, lactate or bicarbonate, glucose, and water, all of which
should be administered parenterally until vomiting has been controlled. Vomiting may be frequent and severe.
Schwartz and Rossoff (1994) described a woman whose retching led to bilateral pneumothoraces and
pneumomediastinum. A number of anti-emetics may be given to alleviate nausea and vomiting such as
promethazine, prochlorperazine, and chlorpromazine. Nageotte and colleagues (1996) reported success with
intravenous droperidol-diphenhydramine. For severe disease, metoclopramide may be given parenterally. This
stimulates motility of the upper intestinal tract without stimulating gastric, biliary, or pancreatic secretions. Its
anti-emetic properties apparently result from central antagonism of dopamine receptors. With persistent
vomiting, appropriate steps should be taken to diagnose other diseases, such as gastroenteritis, cholecystitis,
pancreatitis, hepatitis, peptic ulcer, pyelonephritis, and fatty liver of pregnancy.
In many instances, social and psychological factors contribute to the illness (Deuchar, 1995). With correction of
these circumstances, the woman usually improves remarkably while hospitalized, only to relapse after
discharge. Positive assistance with psychological and social problems is beneficial.
Godsey and Newman (1991) studied 140 women admitted for hyperemesis to the Medical University of South
Carolina Hospital. In 27 percent of these women, multiple admissions were necessary. In some women with
persistent and severe disease, parenteral nutrition is used (Levine and Esser, 1988). Enteral nutrition also has
been successfully used after acute nausea and vomiting subside (Boyce, 1992).
firmed at surgery.
Rare forms of gestosis in pregnancy:
1. dermatosis gravidarum, clinic, diagnosis, treatment;
2. tetania gravidarum, clinic, diagnosis, treatment;
3. osteomalacia gravidarum, clinic, diagnosis, treatment;
4. acute fatty liver of pregnancy, clinic, diagnosis, differential diagnosis (viral hepatitis, cholestasis), treatment;
5. bronchial asthma of pregnancy, clinic, diagnosis, differential diagnosis, treatment.
Classification on pregnancy induced hypertension.
1. Hypertensive disorders during pregnancy.
2. Edema during pregnancy.
3. Proteinuria during pregnancy.
4. Mild preeclampsia.
5. Moderate preeclampsia.
6. Severe preeclampsia.
7. Eclampsia.
“Superimposed” hypertensive disorders develop on the underlying preexisting diseases, such as Diabetes
Mellitus, Hypertensive disease, kidneys inflammatory diseases, thyroid and pulmonary dysfunction. They have
such peculiarities as:
1. early beginning;
2. severe duration;
3. isolated symptoms only presenting (isolated proteinuria, edema, or hypertension);
4. presence of atypical clinical findings such as paresthesia, insomnia, hypersalivation.
Chronic hypertension
Is defined as hypertension present before the twentieth week of gestation or beyond 6 weeks' postpartum.
Diagnosis of Coincidental (Chronic) Hypertension
All chronic hypertensive disorders, regardless of their cause, predispose to development of superimposed
preeclampsia or eclampsia. These disorders can create difficult problems with diagnosis and management in
women who are not seen until after midpregnancy. The diagnosis of coincidental or chronic underlying
hypertension is suggested by (1) hypertension (140/90 mm Hg or greater) antecedent to pregnancy, (2)
hypertension (140/90 mm Hg or greater) detected before 20 weeks (unless there is gestational trophoblastic
disease), or (3) persistent hypertension long after delivery. Additional historical factors that help support the
diagnosis are multiparity and hypertension complicating a previous pregnancy other than the first. There is also
usually a strong family history.
The diagnosis of chronic hypertension may be difficult to make if the woman is not seen until the latter half of
pregnancy. This is because blood pressure decreases during the second and early third trimesters in both
normotensive and chronically hypertensive women. Thus, a woman with chronic vascular disease, who is seen
for the first time at 20 weeks, will frequently have a normal blood pressure. During the third trimester, however,
blood pressure returns to its former hypertensive level, presenting a diagnostic problem as to whether the
hypertension is chronic or pregnancy induced.
Essential hypertension is the cause of underlying vascular disease in more than 90 percent of pregnant women.
McCartney (1964) studied renal biopsies from women with “clinical preeclampsia,” and found chronic
glomerulonephritis in 20 percent of nulliparas and in nearly 70 percent of multiparas. Fisher and co-workers
(1969), however, did not confirm this high prevalence of chronic glomerulonephritis.
Chronic hypertension causes morbidity whether or not a woman is pregnant. Specifically, chronic hypertension
may lead to premature cardiovascular deterioration, resulting in cardiac decompensation and/or cerebrovascular
accidents. Intrinsic renal damage may also result from chronic hypertensive disease. More commonly in young
women, hypertension develops as a consequence of underlying renal parenchymal disease. Dangers specific to
pregnancy complicated by chronic hypertension include the risk of pregnancy-aggravated hypertension, which
may develop in as many as 20 percent of these women. Additionally, the risk of abruptio placentae is increased
substantively. Moreover, the fetus of the woman with chronic hypertension is at increased risk for growth
restriction and death.
Diagnosis of Pregnancy-aggravated Hypertension
Preexisting chronic hypertension worsens in some women, typically after 24 weeks. Such pregnancyaggravated hypertension may be accompanied by proteinuria or pathological edema; the condition is then
termed superimposed preeclampsia. Often, the onset of superimposed preeclampsia develops earlier in
pregnancy than pure preeclampsia, and it tends to be quite severe and accompanied in many cases by fetal
growth restriction.
The most common hazard faced by pregnant women with chronic hypertensive vascular disease is the
superimposition of preeclampsia. The frequency of pregnancy-aggravated hypertension is difficult to specify
precisely because the incidence varies with the diagnostic criteria employed. If the diagnosis is made only on
the basis of (1) significant aggravation of the hypertension, (2) sustained proteinuria, and (3) generalized
edema, the incidence will be relatively low because delivery is often accomplished before intense superimposed
preeclampsia or eclampsia has developed. If, however, the diagnosis is made on the basis of a modest rise in
blood pressure and minimal to modest proteinuria, the incidence will be much higher.
Pregnancy-aggravated hypertension typically becomes manifest by a sudden rise in blood pressure that almost
always is complicated eventually by substantive proteinuria. Extreme hypertension—systolic pressure greater
than 200 mm Hg and diastolic pressure of 130 mm Hg or more, oliguria, and impaired renal clearance may
rapidly ensue; the retina may have extensive hemorrhages and cotton-wool exudates; and convulsions and coma
are likely. Therefore, in its most severe form, the resultant syndrome is similar to hypertensive encephalopathy.
With the development of superimposed preeclampsia or eclampsia, the outlook for both infant and mother is
grave unless the pregnancy is terminated. The frequency of fetal growth restriction and preterm delivery is
increased appreciably because of its relatively early onset in pregnancy, as well as the marked severity of the
process itself. If the infant is born alive and survives the perinatal period, however, long-term prognosis is
good.
The diagnosis requires documentation of chronic underlying hypertension. Pregnancy-aggravated hypertension
is characterized by worsening hypertension, keeping in mind that both systolic and diastolic pressures normally
rise as gestation increases.
Gestational hypertension - occurs after 20 weeks of pregnancy and doesn’t accompanies with proteinuria.
Hypertension - In pregnancy is generally defined as a diastolic blood pressure of 90 mm Hg or greater, as a
systolic blood pressure at or above 140 mm Hg at two estimations with the interval 4 hours or 160/110 mm Hg
at once.
Preeclampsia - Is defined as the development of hypertension with proteinuria or edema (or both).
Differential diagnosis of chronic hypertension and preeclampsia
Signs
Onset of hypertension
Duration of hypertension
Hereditary anamnesis
Age
Retina
Proteinuria
Hypertensive disease
Before pregnancy and in the
first 20 weeks of gestation
Constant, lasts during 3
months after delivery
Presence of hypertensive
disease in the parents, family
35-40 years old
Spasm of vessels,
hemorrhages
Absent
Preeclampsia
After 20 weeks of gestation
It disappears after 6 weeks or
3 months after delivery
Absent
20-25 years old
Vasospasm, edema of retina
Present
Clinical findings
1. Symptoms and signs
The pregnant woman is usually unaware of the two most important signs of preeclampsia—hypertension and
proteinuria. By the time symptoms develop such as headache, visual disturbances, or epigastric pain, the
disorder is almost always severe. Hence, the importance of prenatal care in the early detection and management
of preeclampsia is obvious.
1. Hypertension in pregnancy is generally defined as a diastolic blood pressure of 90 mm Hg or greater, as a
systolic blood pres-sure at or above 140 mm Hg, or as an increase in the diastolic blood pressure of at least 15
mm Hg or in the systolic blood pressure of 30 mm Hg or more when com-pared to previous blood pressures.
2. Weight gain – a sudden increase in weight may precede the development of preeclampsia. Weight increase of
about much more than 400 g per week is abnormal.
A sudden increase in weight may precede the development of preeclampsia, and indeed, excessive weight gain
in some women is the first sign. A weight increase of about 1 pound per week is normal, but when weight gain
exceeds more than 2 pounds in any given week, or 6 pounds in a month, developing preeclampsia should be
suspected. The suddenness of excessive weight gain is characteristic of preeclampsia rather than an increase
distributed throughout gestation. Such weight gain is due almost entirely to abnormal fluid retention and is
usually demonstrable before visible signs of nondependent edema such as swollen eyelids and puffy fingers. In
cases of fulminating preeclampsia or eclampsia, fluid retention may be extreme; and in these women, a weight
gain of 10 or more pounds per week is not unusual
3. Edema - peripheral edema is common in pregnancy, especially in the lower extremities; however, persistent
edema unresponsive to resting in the supine position is not normal, especially, when it also involves the upper
extremities and face
4. Headache - is unusual in milder cases but frequent in more severe disease. It is often frontal but may be
occipital, and it is resistant to relief from ordinary analgesics.
5. Abdominal pain – epigactric or right upper quadrant pain often is a symptom of severe preeclampsia and may
be indicated of imminent convulsions. It may be the result of stretching of the hepatic capsule, possibly by
edema and hemorrhage. Tenderness over the liver should be presented.
6. Visual disturbances – a spectrum of visual disturbances, ranging from slight blurring of vision to scotomas to
partial or complete blindness, may accompany preeclampsia. These develop as a result of vasospasm, ischemia,
andpetechial hemorrhages within the occipital cortex.
7. Hyperreflexia should be presented. The patellar and achilles deep tendom reflexes should be carefully
elicited and noted this symptom. The demonstration of clonus at the ankle is especially worrisome.
8. Any history of loss of consciousness or seizures, even in the patient with a known seizure disorder, may be
significant.
Assessment for proteinuria, edema, weight, hyperreflexia, headache, visual disturbances, epigastric pain is
obligatory daily.
Laboratory findings.
Test or Procedure
Maternal studies:
Proteinuria
Rationale
Proteinuria is defined as 300 mg or more urinary protein
during a 24-hour period or 30-100 mg per dL or more in
at least two random urine specimens collected 6 hours or
more apart
Hematocrit in complete
blood count/every 2 days
It increasing may signify worsening vasocanstriction and
decreased intravascular volume.
Platelet count/every 2 days
Thrombocytopenia and coagulopathy are associated with
worsening PIH.
Coagulation profile (PT,
PTT)
Fibrin split products
Liver function studies/
weekly
Serum creatinine/twice
weekly
24-hour urine for creatinine
clearance/twice weekly
Hepatocellular dysfunction is associated with worsening
PIH
Decreased renal function is associated with worsening
PIH.
24- hour for total
protein/twice weekly
Serum uric acid/twice
weekly
Fetal studies
Ultrasound for fetal growth
/every 2 weeks
To assess for pregnancy-associated hypertension effects
on the fetus, intrauterine growth restriction.
Amniotic fluid volume
Oligohydramnios
Fetal movement
record/daily
Biophysical profile/twice
weekly
Chronic fetal distress.
Nonstress test/twice weekly
Placental status
Assessment of different stages of PIH severity
Symptom of
evaluation
Mild
preeclampsia
Moderate
preeclampsia
Severe
Preeclampsia
Diastolic blood
pressure
Proteinuria in 24hour collection
90-99 mm Hg
100-109 mm Hg
> 110 mm Hg
< 0.3 g
< 0.3 - 5 g
>5g
Diuresis per hour
> 50 ml
> 40 ml
< 40 ml
Presence of edema
In lower extremities In lower
extremities, and
abdominal wall
> 150.000
80 - 150. 000
Generalized edema
Hematocrit
36 – 38
39 – 42
> 42
Serum creatinine
< 75 mkmol/L
75 – 120 mkmol/L
> 120 mkmol/L
Urea
< 4,5 mmol/L
4,5 – 8 mmol/L
> 8 mkmol/L
Number of
thrombocytes
< 80.000
Preeclampsia is classified as severe if there is a blood pressure greater than or equal to 170 mm Hg systolic or
110 mm Hg diastolic, marked proteinuria (generally > 5 g/24-hr urine collection, or 5 g/L or more on dipstick
of a random urine), oliguria, weight gain exceeds more than 900 g in a week, cerebral or visual disturbances
such as headache and scotomata, pulmonary edema or cyanosis, epigastric or right upper quadrant pain,
evidence of hepatic dysfunction, or thrombocytopenia. These myriad changes illustrate the multisystem
alterations associated with preeclampsia.
Complications of preeclapsia:
Maternal – placenta abruption, cerebral hemorrhage, renal and liver insufficiency, disseminated intravascular
coagulopathy, adrenal insufficiency, eclampsia.
Fetal – intrauterine growth retardation, fetal distress, intranatal fetal death, infant morbodity and mortality.
ECLAMPSIA is characterized typically by those same abnormalities as severe preeclampsia with the addition
of convulsions that are precipitated by pregnancy-induced hypertension. The seizures are grand mal and may
appear during pregnancy, during labor, or postpartum.
Treatment and prevention
The only known treatments for eclampsia or advancing pre-eclampsia are abortion or delivery, either by labor
induction or Caesarean section. However, post-partum pre-eclampsia may occur up to six weeks following
delivery even if symptoms were not present during the pregnancy. Post-partum pre-eclampsia is dangerous to
the health of the mother since she may ignore or dismiss symptoms as simple post-delivery headaches and
edema. Hypertension can sometimes be controlled with anti-hypertensive medication, but any effect this might
have on the progress of the underlying disease is unknown.
Women with underlying inflammatory disorders such as chronic hypertension or autoimmune diseases would
likely benefit from aggressive treatment of those conditions prior to conception, tamping down the overactive
immune system.
Thrombophilias may be weakly linked to pre-eclampsia. There are no high quality studies to suggest that blood
thinners will prevent pre-eclampsia in thrombophilic women.
In low-risk pregnancies the association between cigarette smoking and a reduced risk of pre-eclampsia has been
consistent and reproducible across epidemiologic studies. High-risk pregnancies (those with pregestational
diabetes, chronic hypertension, history of pre-eclampsia in a previous pregnancy, or multifetal gestation)
showed no significant protective effect. The reason for this discrepancy is not definitively known; research
supports speculation that the underlying pathology increases the risk of pre-eclampsia to such a degree that any
measurable reduction of risk due to smoking is swamped. A study into the effects of smoking on the incidence
of pre-eclampsia in African-American women found a significantly lower incidence of pre-eclampsia with
higher measured levels of nicotine. When adjusted for age, parity, and medical comorbidities the association
was still observable, but no longer significant. Medical authorities and anti-smoking advocates discourage
smoking in general during pregnancy.
Antihypertensive therapy
Antihypertensives may reduce maternal and fetal mortality among pregnancy patients with hypertension as
compared to placebo according to a randomized controlled trial. Overall, after three weeks of treatment, MAP
was lower in the isradipine group, but when compared with the placebo group, the difference in MAP did not
have statistical significance. After treatment with isradipine, those patients with no proteinuria experienced a
decrease of between 8.5 and 11.3 mmHg, whereas those with proteinuria experienced about only 1 mmHg
difference in systolic blood pressure. Those treated with placebo in both groups did not experience much
change in systolic blood pressure, regardless of proteinuria being present or not. Therefore, the authors
concluded proteinuric patients may respond differently from nonproteinuric patients to this treatment, where the
nonproteinuric patients responded the most to treatment with isradipine.
Labetolol or Nifedipine are often the antihypertensives of choice for eclampsia or pre-eclampsia according to
the CHEST 2007 study, especially Labetolol as it has little placental transfer.
Magnesium sulfate
In some cases, women with pre-eclampsia or eclampsia can be stabilized temporarily with magnesium sulfate
intravenously to forestall seizures while steroid injections are administered to promote fetal lung maturation.
Magnesium sulfate as a possible treatment was considered at least as far back as 1955, but only in recent years
did its use in the UK replace the use of diazepam or phenytoin. Evidence for the use of magnesium sulfate came
from the international MAGPIE study. When induced delivery needs to take place before 37 weeks gestation, it
is accepted that there are additional risks to the baby from premature birth that will require additional
monitoring and care.
Dietary and nutritional factors
The Farm (Tennessee) is a vegan community in Tennessee, famous for their successful natural birth outcomes.
Pre-eclampsia is virtually unknown in this community, with one study of 775 vegan mothers showing one only
case meeting the clinical criteria for pre-eclampsia. The study's authors concluded that "it is possible that a
vegan diet could alleviate most, if not all, of the signs and symptoms of preeclampsia."]
Studies of protein/calorie supplementation have found no effect on pre-eclampsia rates, and dietary protein
restriction does not appear to increase pre-eclampsia rates. No mechanism by which protein or calorie intake
would affect either placentation or inflammation has been proposed.
Studies conducted on the effect of supplementation with antioxidants such as vitamin C and E found no change
in pre-eclampsia rates. However, Drs. Padayatty and Levine with the NIH criticized the studies for overlooking
several key factors that would have been important to the success of the supplementation.
The La Universida Nacional Autonoma de Mexico study also used a combination other antioxidant vitamins,
such as vitamin C and E, in addition to L-arginine in the hopes of prevention of pre eclampsia in high-risk
women. In this double blind placebo controlled trial of approximately 700 women, the results indicated that
those who supported their diet with a combination of arginine and antioxidant vitamins experienced the
preventative effects and reduced incidence of pre eclampsia during their pregnancy.
Low levels of vitamin D may be a risk factor for pre-eclampsia, and calcium supplementation in women with
low-calcium diets found no change in pre-eclampsia rates but did find a decrease in the rate of severe
preeclamptic complications. Low selenium status is associated with higher incidence of pre-eclampsia. Some
other vitamin may also play a role.
Aspirin supplementation
Aspirin supplementation is still being evaluated as to dosage, timing, and population and may provide a slight
preventative benefit in some women; however, significant research has been done on aspirin and the results
thus far are unimpressive.
Exercise
There is insufficient evidence to recommend either exercise or bedrest as preventative measures.
Induction of paternal tolerance
Many studies have also suggested the importance of a woman's immunological tolerance to her baby's father,
whose genes are present in the young fetus and its placenta and which may pose a challenge to her immune
system. As the theory is further investigated, researchers are increasingly studying the importance of a woman's
continued exposure to her partner's semen as early as several years before conception. One study published in
the American Journal of Obstetrics and Gynecology involved several hundreds of women and found that
"women with a short period of cohabitation (less than 4 months) who used barrier methods for contraception
had a substantially elevated risk for the development of pre-eclampsia compared with women with more than
12 months of cohabitation before conception". However, the results from a study conducted in 2004 show that
the theory is still not conclusive. In that study, the researchers found that after adjustment and stratification, the
effect of barrier contraceptive use on the development of pre-eclampsia had disappeared, with both arms having
identical rates of pre-eclampsia. Although the study has since been criticized for its subjective adjustment of
data, it remains important because it demonstrates that there is still some contention over the degree to which
failure of tolerance induction can be attributed to prior exposure to the partner's sperm.
Continued exposure to a partner's semen has a strong protective effect against pre-eclampsia, largely due to the
absorption of several immune modulating factors present in seminal fluid.
Long periods of sexual cohabitation with the same partner fathering a woman's child significantly decreased her
chances of suffering pre-eclampsia. As one early study described, "although pre-eclampsia is a disease of first
pregnancies, the protective effect of multiparity is lost with change of partner". The study also concluded that
although women with changing partners are strongly advised to use condoms to prevent sexually transmitted
diseases, "a certain period of sperm exposure within a stable relation, when pregnancy is aimed for, is
associated with protection against pre-eclampsia".
Several other studies have since investigated the strongly decreased incidence of pre-eclampsia in women who
had received blood transfusions from their partner, those with long, preceding histories of sex without barrier
contraceptives, and in women who had been regularly performing oral sex, with one study concluding
"induction of allogeneic tolerance to the paternal human leukocyte antigen (HLA) molecules of the fetus may
be crucial. Data collected strongly suggest that exposure, and especially oral exposure to soluble HLA from
semen can lead to transplantation tolerance."
Other studies have investigated the roles of semen in the female reproductive tracts of mice, showing that
"insemination elicits inflammatory changes in female reproductive tissues" concluding that the changes "likely
lead to immunological priming to paternal antigens or influence pregnancy outcomes". A similar series of
studies confirmed the importance of immune modulation in female mice through the absorption of specific
immune factors in semen, including TGF-Beta, lack of which is also being investigated as a cause of
miscarriage in women and infertility in men.
According to the theory, the fetus and placenta both contain "foreign" proteins from paternal genes, but regular,
preceding and coincident exposure to the father's semen may promote immune acceptance and subsequent
implantation, a process which is significantly supported by as many as 93 currently identified immune
regulating factors in seminal fluid.
Having already noted the importance of a woman's immunological tolerance to her baby's paternal genes,
several Dutch reproductive biologists decided to take their research a step further. Consistent with the fact that
human immune systems tolerate things better when they enter the body via the mouth, the Dutch researchers
conducted a series of studies that confirmed a surprisingly strong correlation between a diminished incidence of
pre-eclampsia and a woman's practice of oral sex, and noted that the protective effects were strongest if she
swallowed her partner's semen. The researchers concluded that while any exposure to a partner's semen during
sexual activity appears to decrease a woman's chances for the various immunological disorders that can occur
during pregnancy, immunological tolerance could be most quickly established through oral introduction and
gastrointestinal absorption of semen. Recognizing that some of the studies potentially included the presence of
confounding factors, such as the possibility that women who regularly perform oral sex and swallow semen
also engage in more frequent intercourse, the researchers also noted that, either way, "the data still
overwhelmingly supports the main theory" behind all their studies-that repeated exposure to semen establishes
the maternal immunological tolerance necessary for a safe and successful pregnancy.
A team from the University of Adelaide has also investigated to see if men who have fathered pregnancies
which have ended in miscarriage or pre-eclampsia had low seminal levels of critical immune modulating
factors such as TGF-Beta. The team has found that certain men, dubbed "dangerous males", are several times
more likely to father pregnancies that would end in either pre-eclampsia or miscarriage. Among other things,
most of the "dangerous males" seemed to lack sufficient levels of the seminal immune factors necessary to
induce immunological tolerance in their partners.
Prevention and treatment of pregnancy induced hypertension
Prophylaxis and Early Treatment
Because women are usually asymptomatic and seldom notice the signs of incipient preeclampsia, its early
detection demands careful observation at appropriate intervals, especially in women known to be predisposed to
preeclampsia. Major predisposing factors are (1) nulliparity, (2) familial history of preeclampsia–eclampsia, (3)
multiple fetuses, (4) diabetes, (5) chronic vascular disease, (6) renal disease, (7) hydatidiform mole, and (8)
fetal hydrops.
Rapid weight gain any time during the latter half of pregnancy, or an upward trend in diastolic blood pressure,
even while still in the normal range, is worrisome. Every woman should be examined at least weekly during the
last month of pregnancy and every 2 weeks during the previous 2 months. At these visits, weight and blood
pressure measurements are made. All women should be advised to report immediately any symptoms or signs
of preeclampsia, such as headache, visual disturbances, epigastric distress, and puffiness of hands or face. The
reporting of any such symptoms calls for an immediate examination to confirm or exclude preeclampsia.
Natriuretic drugs, such as chlorothiazide and its congeners, have been overused severely in the past. Although
diuretics have been alleged to prevent preeclampsia, Collins and colleagues (1985) reviewed results of nine
studies of more than 7000 women and concluded that perinatal mortality was not improved when diuretics were
given. Furthermore, thiazides can induce serious sodium and potassium depletion, hemorrhagic pancreatitis,
and severe neonatal thrombocytopenia. The failure of natriuretic drugs to prevent preeclampsia raises serious
doubt about the efficacy of rigid dietary sodium restriction.
Wallenburg and co-workers (1986) reported their experiences with either 60 mg of aspirin or placebo to
angiotensin-sensitive primigravid women at 28 weeks. The reduced incidence of preeclampsia in the treated
group was attributed to selective suppression of thromboxane synthesis by platelets and sparing of endothelial
prostacyclin production. In a group of high-risk women with prior bad pregnancy outcomes due to hypertension
and placental insufficiency, Beaufils and colleagues (1985) reported that early prophylactic treatment with
dipyridamole and aspirin reduced recurrences. Benigni and colleagues (1989) and Schiff and associates (1989)
also reported salutary effects in high-risk women.
Spitz and colleagues (1988) reported that most angiotensin-sensitive women at high risk for developing
preeclampsia could be rendered refractory to angiotensin by a 1-week course of daily 81-mg aspirin.
They confirmed that low-dose aspirin significantly decreased thromboxane synthesis. Prostacyclin and
prostaglandin E2 synthesis were also decreased 20 to 30 percent by therapy. These same investigators reported
that approximately 20 percent of angiotensin-sensitive pregnant women given low-dose aspirin did not become
refractory to angiotensin, and all such women developed preeclampsia (Brown and associates, 1990). The
nonresponders to low-dose aspirin had a significant fall in thromboxane levels, but they also had significant
declines in prostacyclin and prostaglandin E2 levels.
Low-dose aspirin was not effective for women who already had mild pregnancy-induced hypertension (Schiff
and associates, 1990); however, women with moderate hypertension improved. Magness and colleagues (1991)
observed that less than 20 percent of women with early-onset pregnancy-induced hypertension failed to become
normotensive with hospitalization. In the 20 percent who remained hypertensive after hospitalization, low-dose
aspirin allowed prolongation of pregnancy compared with controls.
Low-dose aspirin may be effective in some women in preventing the development of pregnancy-induced
hypertension and fetal growth restriction (Imperiale and Petrulis, 1991). Hauth and co-workers (1993)
randomized 604 nulliparas to 60 mg aspirin or placebo beginning at 24 weeks. Only 1.7 percent of aspirintreated women developed preeclampsia versus 5.6 percent of controls (P < 0.01). Studies from the National
Institutes of Health sponsored Maternal–Fetal Medicine Network showed that aspirin prophylaxis significantly
decreased preeclampsia to 4.6 percent compared with 6.3 percent in nontreated controls (Sibai and colleagues,
1993). Overall, perinatal outcome was not improved, and women who took aspirin had significantly more
placental abruptions, although Hauth and colleagues (1995) concluded that these abruptions were of no clinical
importance.
In a study by the Royal College of Obstetricians and Gynecologists (CLASP, 1994), it was concluded that lowdose aspirin was ineffective to prevent preeclampsia. Similarly, the ECPPA Collaborative Group (1996), in a
study from 12 Brazilian teaching hospitals, concluded that low-dose aspirin did not decrease the incidence of
proteinuric preeclampsia in 1009 women randomized to aspirin or placebo. Both of these groups of
investigators used Korotkoff IV sound for diastolic pressure, and this may overestimate diastolic pressure by 7
to 15 mm Hg (Brown and colleagues, 1994; Lindheimer and Katz, 1992; Shennan and co-workers, 1996). In
their meta-analysis, the CLASP group concluded that low-dose aspirin reduced the incidence of preeclampsia
by about 25 percent.
Currently, the salutary effects of low-dose aspirin therapy remain to be proven for most groups of women. The
prevailing opinion is that normal women should not be treated, but selective treatment for certain high-risk
groups is acceptable (Cunningham and Gant, 1989; Hauth and Cunningham, 1995; Royal College of
Obstetricians and Gynecologists, 1996; Zuspan and Samuels, 1993).
Low-dose aspirin therapy appears to be safe for the fetus. Although most clinical trials have resulted in no
apparent maternal risks, Brown and colleagues (1990) noted a rapid clinical deterioration if therapy was
stopped suddenly.
The basic management objectives for any pregnancy complicated by pregnancy-induced hypertension are:
1. Termination of the pregnancy with the least possible trauma to the mother and the fetus.
2. Birth of the infant who subsequently thrives
3. Complete restoration of the health of the mother.
Hospitalization is considered for women with pregnancy-induced hypertension if there is a persistent or
worsened elevation in blood pressure or development of proteinuria. With hospitalization, a systematic study
should be instituted that includes the following:
1. A detailed medical examination followed by daily searches for development clinical findings such as
headache, visual disturbances, epigastric pain, and rapid weight gain.
2. Admittance weight and every day thereafter.
3. Admittance analysis for proteinuria and at least every 2 days thereafter.
4. Blood pressure readings with an appropriate-size cuff every 4 hours, except between midnight and morning,
unless the midnight pressure has increased.
5. Measurements of plasma creatinine, hematocrit, platelets, and serum liver enzymes, the frequency to be
determined by the severity of hypertension.
6. Frequent evaluation of fetal size and amnionic fluid volume by the same experienced examiner and by serial
sonography if remote from term.
If these observations lead to a diagnosis of severe preeclampsia, further management is the same as described
for eclampsia.
Reduced physical activity throughout much of the day is beneficial. Ample, but not excessive, protein and
calories should be included in the diet. Sodium and fluid intakes should not be limited or forced. Sedatives or
tranquilizers have been used routinely by some; we do not recommend them. Further management depends
upon (1) severity of preeclampsia, (2) duration of gestation; and (3) condition of the cervix. Fortunately, many
cases prove to be sufficiently mild and near enough to term that they can be managed conservatively until labor
commences spontaneously or until the cervix becomes favorable for labor induction. Complete abatement of all
signs and symptoms, however, is uncommon until after delivery. Almost certainly, the underlying disease
persists until after delivery!
1. Bed rest. Preferably with as much of the time as possible spent in a lateral decubitus position. In this position,
cardiac function and uterine blood flow are maximized and maternal blood pressures in most cases are
normalized. This improves uteroplacental function, allowing normal fetal growth and metabolism. ambulatory
treatment has no place in the management of PIH; bed-rest throughout the greater part of the day is essential.
2. Sedative drugs for normalization of status of central nervous system:
1.Droperidol – 2 ml IM, Seduxen – 2 ml IM. These drugs should be combined with Droperidol – 0,25 % - 2ml
IM or IV
3. Antihypertensive therapy eliminates vasospasm of macro- and microcirculation.
Antihypertensive drugs used in pregnancy:
1. spasmolytic agents – No-spani 2 % - 2-4 ml intramuscularly, Papaverine hydrochloride – 2 % - 2-4 ml IM,
Plathyphillinum – 0,2 % - 2, 0 – twice a day, Dibasol – 1 % 2-4 ml IM or IV, Euphyllinum – 2,4 % 10, 0 IV;
2. Nifedipine – calcium-channel blocker – in the dose 10 mg po q 4-8 hours;
3. Labetalol – a- and b- adrenergic blockers – in the dose 20-50 mg IV q 3-6 hours;
4. Methyldopa – false neurotransmission, central nervous system effect;
5. Thiazide – decreased plasma volume and cardiac output.
If diastolic pressure is repeatedly above 110 mm Hg – Hydralazine is preferred agent because of its
effectiveness and safety. An initial dose of 5 mg given as an intravenous bolus is increased by 5 to 10 mg every
20 minutes until suitable blood pressure is achieved. The goal of such therapy is to reduce the diastolic blood
pressure to the 90-11 mm Hg range. Labetolol is a useful second-line drug for women whose hypertension is
refractory to hydralazine.
Hydralazine is given intravenously whenever the diastolic blood pressure is 110 mm Hg or higher. It is
administered in 5- to 10-mg doses at 15- to 20-minute intervals until a satisfactory response is achieved. A
satisfactory response antepartum or intrapartum is defined as a decrease in diastolic blood pressure to 90 to 100
mm Hg, but not lower so that placental perfusion will not be compromised. Some recommend treatment of
diastolic pressures over 100 mm Hg and some use 105 mm Hg as a cutoff (Cunningham and Lindheimer, 1992;
Sibai, 1996).
Hydralazine so administered has proven remarkably effective, and importantly, cerebral hemorrhage has been
avoided. At Parkland Hospital, approximately 8 percent of all women with pregnancy-induced hypertension are
given hydralazine as described; this drug has been administered to more than 3500 women to control acute
peripartum hypertension. Seldom was another antihypertensive agent needed because of poor response to
hydralazine. In most European centers, hydralazine is also favored (Hutton and colleagues, 1992; Redman and
Roberts, 1993).
The tendency to give a larger initial dose of hydralazine when the blood pressure is higher must be avoided.
Figure 31–19 shows the mean arterial blood pressure responses to 5-mg hydralazine bolus doses. The response
to even 5- to 10-mg doses cannot be predicted by the level of hypertension; thus we always give 5 mg as the
initial dose. Hydralazine was injected more frequently than recommended in the protocol, and blood pressure
decreased in less than 1 hour from 240–270/130–150 mm Hg to 110/80 mm Hg. Ominous fetal heart rate
decelerations were evident when the pressure fell to 110/80 mm Hg, and the decelerations persisted until
maternal blood pressure increased.
4. Magnesium Sulfate is used to arrest and prevent the convulsions of eclampsia without producing generalized
central nervous system depression in either mother or the fetus. Magnesium sulfate may be given
intramuscularly in the dose 25 % -5, 0 2-3 times a day or by continuos intravenous infusion in the dose 8 % 200, 0 ml. It has spasmolytic, sedative, hypotensive and anticonvulsant effects.
Frequent evaluations of the patient's patellar reflex and respiration (> 14 respiratory act in a minute) are
necessary to monitor for manifestations of toxic serum magnesium concentrations. In addition, because
magnesium sulfate is excreted solely from the kidney, maintenance of urine output at > 30 ml/hr will avoid
accumulation of the drug. Reversal of the effects of excessive magnesium concentrations is accomplished by
the slow intravenous administration of 10% calcium gluconate along with oxygen supplementation and
cardiorespiratory support if needed.
The maximal dose of magnesium during a day in the case of severe preeclampsia is 50-80 ml (12,5 – 80 gram).
Sheme of magnesium administration in the case of severe preeclampsia and eclampsia:
1) Intravenous administration of Magnesium Sulfate - 12 ml 25 % during 5 minutes. At the same time –
intramuscularly administration of 4,5 – 6 g of Magnesium Sulfate in average dose 0,1 g per kg of patient’s
weight. Than this dose is repeated each 6 hours intramuscularly. The general dose in 24 hour should be not
exceed 24 gram. The course of treatment should be repeated after 12 hours.
2) Initial administration of 3 g IV and 4 g IM, followed by a 4,5-6 g every 4 hours maintenance dose.
3) administer 4-6 g of magnesium sulfate IV over 10-15 min, followed by a 2g/hour maintenance dose
(American).
5. Normalization of blood reology because of hemoconcentration – Trental, Curantil, Komplamin.
6. Limited intravenous fluid therapy under control of blood volume, hematocrit, 24-hours diuresis. Primarily
lactated Ringer’s containing 5 % dextrose – should be given at a rate of 60-125 ml per hour (not faster) unless
there is unusual fluid loss from vomiting, diarrhea, or, more likely, excessive blood loss at delivery. Oliguria is
common in severe preeclampsia and eclampsia, making it tempting to administer intravenous fluids more
vigorously. However, the infusion of large volumes of fluid enhances the maldistribution of extracellular fluid
and in that way increases the risk of pulmonary and cerebral edema.
Lactated Ringer solution is administered routinely at the rate of 60 mL/hr to no more than 125 mL/hr unless
there was unusual fluid loss from vomiting, diarrhea, or diaphoresis, or more likely, excessive blood loss at
delivery. Oliguria, common in cases of severe preeclampsia and eclampsia, coupled with the knowledge that
maternal blood volume is very likely constricted compared with normal pregnancy, make it tempting to
administer intravenous fluids more vigorously. The rationale for controlled, conservative fluid administration is
that the typical eclamptic woman already has excessive extracellular fluid that is inappropriately distributed
between the intravascular and extravascular spaces of the extracellular fluid compartment. Infusion of large
fluid volumes could and does enhance the maldistribution of extracellular fluid and thereby appreciably
increases the risk of pulmonary and cerebral edema (Benedetti and Quilligan, 1980b; Gedekoh and associates,
1981; Sibai and co-workers, 1987b).
For the patient with worsening preeclampsia or the patient who has severe preeclampsia or eclampsia,
stabilization with magnesium sulfate, antihypertensive therapy as indicated, monitoring for maternal and fetal
well-being, and delivery by induction or cesarean section are required. A 24-hour delay in delivery allow
steroid administration to enhance fetal pulmonary maturity may be indicated in some cases.
7. Avoidance of Diuretics and Hyperosmotic Agents. Potent diuretics further compromise placental perfusion,
because their immediate effects include further intravascular volume depletion, which most often is already
reduced compared with normal pregnancy. Therefore, diuretics are not used to lower blood pressure, so as not
to enhance the intensity of the maternal hemoconcentration and its adverse effects on the mother and fetus
(Zondervan and associates, 1988).
Once delivery is accomplished, in almost all cases of severe preeclampsia and eclampsia there is a spontaneous
diuresis that usually begins within 24 hours and results in the disappearance of excessive extravascular
extracellular fluid over the next 3 to 4 days..
With infusion of hyperosmotic agents, the potential exists for an appreciable intravascular influx of fluid and, in
turn, subsequent escape of intravascular fluid in the form of edema into vital organs, especially the lungs and
brain. Moreover, an oncotically active agent that leaks through capillaries into lungs and brain promotes
accumulation of edema at these sites. Most importantly, a sustained beneficial effect from their use has not been
demonstrated. For all of these reasons, hyperosmotic agents have not been administered, and use of furosemide
or similar drugs has been limited to the rare instances in which pulmonary edema was identified or strongly
suspected.