Complication in 2nd Trimester

For most women, the 2^nd trimester is relatively problem free period. The hormonal changes are setting and you still may fit into your pre pregnancy clothes. This period usually involves antenatal visits, routine tests,        and maintaining healthy lifestyles. But, some complications do occur. It is important to recognize them early and treat them effectively so that it will benefit you and your baby. Some of these problems are 

• Bleeding.
• Incompetent Os - Miscarriage  incompetence.
• Pre term labour.

Bleeding:

Although miscarriage is less common in the 2^nd trimester than in the 1^st, a risk still exists. Any kind of bleeding should be reported to the obstetrician immediately.If bleeding is spotty, there is no cause for concern as it may be due to local vaginal or cervical infections. Moderate to severe bleeding is a cause of concern probably as it can be a sign of impending abortion.   .

Incompetent Os:

Also known, as ‘painless abortion’ is a well-recognised cause of pregnancy loss in late 2^nd trimester. The mouth of the uterus (cervix) begins to open (dilate) and thin out (effacement) before a pregnancy has reached full and nine months (full term). This occurs in the absence of pain and uterine contractions and without much pain or uterine contractions.

How often does this occur?

It is relatively uncommon, occurring in 1 - 2 % of all pregnancies. However as it leads to repeated miscarriages, it is important to identify and treat it.

Causes:
The premature opening of the mouth of uterus with its thinning is primarily due to weakness in the cervical musculature. The sphincter, which is closed normally, is not able to withstand the pressure of growing pregnancy. 

The incompetent cervix could be a result of cervical trauma,  

• Due to overzealous mechanical dilatation of the cervix. 
• Deep cervical laceration during delivery.  
• Extensive conisation of cervix for the treatment of cervical dysplasia (early cervical carcinoma). 
• Other women who are at the risk are women with polyhydramnios (excessive amount of amniotic fluid, more than 2 – 5 liters), multiple pregnancy (causing excessive stretching of uterine musculature). 
• Structural defects of the genital tract.

What do you feel?

The process is relatively painful and onset may be marked by: 

• Excessive mucus discharge through the vagina followed by spotting and bleeding. 
• A sensation of pressure or heaviness in the lower abdomen, surprisingly no pain.

How to arrive at a diagnosis?

The typical history of repeated midtrimester miscarriage is often enough to diagnose the condition. In pregnancy, some tests may be useful for confirmation, such as:

• Ultrasonography: It will show opening of the mouth of uterus (internal os) with funneling and bulging of the foetal membranes (sac) into the cervix.
• Vaginal swab for culture of bacteria to rule out infection and treat it if present.
• Urine and blood examination for general condition.

Treatment

• Treatment of vaginal or cervical infection.
• Cervical cerclage operation: This is a small procedure by which a stitch is taken at the mouth of uterus for mechanical closure. This stitch must be removed at 37 completed weeks of pregnancy or at the time of initiation of labour, whichever is earlier. The ideal time to do the operation is around 18 – 20 weeks of pregnancy. However, the placement of circlage stitch doesn’t completely protect women from ‘incompetent os’ or preterm labour.
• Additional treatment such as bed rest and tocolytic agent (medication which prevents uterine contraction) may also be needed.

• Previous preterm birth.
  
• Pregnancy with twins, triplets or more.    .
• Repeated 2^nd trimester abortion.
• Polyhydramnios (excessive amniotic fluid around baby more than 2.5 liters).
• Placenta praevia. 
• Infection of the amniotic fluid or the foetal membranes.
• Abnormalities of the mother’s uterus.
• Serious illness or disease in the mother.
• Smoking, heavy working conditions, poor socioeconomic class, etc.

• Cramping lower abdominal pain like period pains either constant or comes and goes, This is usually lower down below the umbilicus in the centre.
• Low, dull, backache (constant or comes and goes).
• Pressure (feels like the baby is pushing down, feels heavy).
• Abdominal cramping (with or without diarrhoea).
• Increase or change in vaginal discharge (may be mucous, watery, light or bloody.
• Fluid leaking from the vagina.
• Uterine contractions that are 10 minutes apart or closer (may be painless). Women are 75% accurate in their ability to recognise warning symptoms of preterm labour.

• Urine examination and culture: presence of urinary infection needs to be treated.
• Vaginal discharge: microscopy and culture and treatment accordingly.

• Screening for infections – like urinary  or vaginal – and its treatment.
• Understanding the warning signals.
• Avoiding intercourse.
• Changing the working conditions from heavy to moderate work.
• Ultrasonography at regular intervals to know the status of the mouth of the uterus (cervix).
• Regular antenatal visits and check up.

• Bed rest.
• Hospitalisation – may or may not be required– depends on your obstetrician.
• Antibiotics – to treat infection.
• Medicines, which prevents or reduce the onset of uterine contractions.
• Steroid therapy – this depends upon the stage of pregnancy and labour for facilitating long growth of the foetus.
• If the delivery is inevitable, it is advisable see that you deliver at a centre with to have a good neonatal unit as a back up, so that your baby receives best care immediately.