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Pregnancy Bliss | Reproductive Health Hub

Two mid-trimester (pre-term) births

Question:  I am 24 years. This was my 2nd baby. I lost the 1st baby at 24 weeks as a result of depression. The 2nd one at 27½ weeks weighed 780 grams. The doctors claimed that she developed difficulties in breathing after birth. He then advised that when I conceive next I get McDonald stitches at 3 months & bed rest at 6 months. Is that in order? Could my blood group (O-ve) have something in this? Also, at 3 months of the second pregnancy I had an operation due to an ovarian cyst.The cut was done vertically which left a big scar to date. Could this also have contributed to the premature labour? K. (Kenya)

Answer: There are a few issues we need to look at here.

You have had two consecutive premature deliveries, both of them being relatively extreme as they occurred before the third trimester. Could there be a connection between the two? It is distinctly possible. Let me state that the theory that your first premature birth (at 24 weeks) was caused by ‘depression’ is extremely doubtful. Depression does not cause preterm delivery. The suggestion of your doctor that a McDonald suture should be inserted in your subsequent pregnancy is clearly based on the assumption that you have cervical weakness. That sounds to be a quite reasonable plan to me, bearing in mind your obstetric history. Both your very early labours and delivery could have been because of that. This is a condition that can be hard to confirm but that strategy is worth a serious consideration. Putting a cervical suture (such as McDonald’s) could mean the difference between another preterm delivery and a term pregnancy with a healthy baby. The subject of cervical weakness and cervical cerclage is discussed in more detail here:  It is indeed recommended that a cervical suture be inserted just after the first trimester (3 months).

Your blood group is extremely unlikely to have contributed in this. In any case, if you are Rhesus negative but have no antibodies, there should be no risk to your baby. If you are unsure about your status regarding Rhesus antibodies, it will be worthwhile to check with your doctor. In the same vein, I would expect that you had anti-D injection administered after each of your two deliveries to prevent development of these antibodies that could affect your future pregnancies. The subject of Rhesus disease is discussed here:

Abdominal surgery during pregnancy can lead to miscarriage or preterm labour. However, if this was to happen, it will do so soon after the operation, at most within 24-72 hours. Your surgery was several weeks before the labour and delivery took place and is therefore almost certainly unconnected.

Your doctor was almost certainly correct on the information that your daughter had breathing difficulties and that may be the main reason she did not survive.  At such an early gestation, respiratory difficulties are inevitable and they can be extremely difficult to manage. In the absence of advanced neonatal facilities and expertise, such a baby probably  has little chance of survival. It may be worthwhile therefore, considering that you have had two preterm deliveries, that you have steroid injections administered at around 26-27 weeks in your next pregnancy. This is, just in case the same thing happens again. The steroids accelerate maturation of the baby’s lungs in the womb and if early arrival was to happen, that will give the baby a much better chance of survival. You need only two injections (betamethasone or dexamethasone) at 12 mg given intra-muscular 12 to 24 hours apart.

Heart murmur, sub-aortic membrane and pregnancy

Question:  A heart murmur was identified in a 34 year old pregnant woman with 8 weeks gestation due to a thin subaortic membrane present causing turbulent blood flow in the LVOT. OTHER THAN THAT THE HEART IS NORMAL AND THERE IS NO HYPERTENSION. The patient has a two and a half year old son that was delivered naturally. This murmur was never noticed before. Is it necessary to have a C-section for the present delivery? The murmur could have been a result of training to intensity using resistance training, circuit and interval training for several years especially after the first baby's birth. What type of exercise can the mother perform now and after the present baby's birth as exercise was a great part of her lifestyle? How high can one raise the heart rate? S. (Malta)

Answer: The main issue here is really the recently identified subaortic membrane. I am assuming this lady had an echocardiogram to establish this diagnosis. If that is the case, the first stop should be a review by a specialist cardiologist. A sub-aortic membrane is a very significant heart condition in the sense that it can be progressive, sometimes with quite serious health consequences It is therefore important to have a review by an expert to see what is happening now and whether there is any effect on cardiac function at present. I am sure you will be aware that this membrane, which is really fibrous tissue, is found just beneath the aortic valve (hence the name). Because of its location, it can cause partial obstruction of blood flow from the left side of the heart into this major vessel, the aorta. That can have consequences which can be progressive in severity. As you mentioned in your question, the left ventricular outflow tract (LVOT) blood flow has been found to be turbulent in this case.

It is not at all surprising that the murmur was not identified during the first pregnancy three years ago. It may have developed since. I am not prepared to speculate as to how the membrane, and therefore the murmur, came about. I very much doubt, however, that the previous active lifestyle has anything to do with this development. If the sub-aortic membrane has affected cardiac function, that may influence mode of delivery in this pregnancy but a caesarean section is not inevitable. As for future exercise types, the issue is the same, namely; the cardiac function. It all means,that review by a cardiologist is an absolute-must first stop for this lady. It may be worthwhile to mention here that in many such cases, surgery to excise the membrane is recommended as the definitive treatment.

Causes of placenta praevia

Question:  What are the causes of placenta praevia? K. (Kenya)

Answer: In strict terms, there is no such thing as a ‘cause’ of placenta praevia. We talk about associated factors. It is indeed the case that some conditions do predispose to the development of placenta praevia. These include multiple pregnancy (twins etc.), previous caesarean section, smoking during pregnancy, advanced maternal age, high parity and several others.

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