Women's Health Articles - Pregnancy
Take a look at articles about the most common questions and concerns women have about pregnancy and get the answers you need to understand your pregnancy.
By Date of Release Topic January 9, 1999 Vaginal Conditions After Delivery August 22, 1999 Prevention of Newborn HIV by Scheduled C/Section May 2, 1999 Perinatal Infections - What to Check For? December 13, 1998 Toxoplasmosis - A Serious Fetal Risk November 22, 1998 Ultrasound Can Miss Fetal Anomalies November 8, 1998 Health Consequences of Pregnancy September 27, 1998 What Genetic Screening is Needed in Pregnancy? August 9, 1998 Prevention of Preterm Birth June 28, 1998 Diabetic Tendency in Polycystic Ovary Syndrome April 12, 1998 Can Ultrasound Detect Down Syndrome? March 22, 1998 Exposure Risk to Fifth Disease - Parovirus B19 March 15, 1998 Is Nasal Stuffiness in Pregnancy Normal? January 18, 1998 Fetal Heart Rate Patterns January 11, 1998 Preterm Delivery Prediction With Fibronectin December 28, 1997 Itching During Pregnancy
Vaginal Conditions After Delivery
Frederick R. Jelovsek MD
"Does taking a bath increase your chances of getting an infection, yeast or UTI?
I am 29 years old, always have menstrual periods on time, although I am 9 weeks post partum. I seem to get a lot of yeast infections". A.N.
If someone told you there would not be any short or long term vaginal changes after delivery of a baby through the vagina, I am sure you would not believe them. Anytime a 4 inch (10 cm) diameter round object goes through an opening that cannot normally stretch beyond a 2 inch (5 cm) diameter opening, there is a strong likelihood of stretching, tearing and pain afterwards. When that is added to hormonal changes after delivery with or without breast feeding, a postpartum woman can have significant vaginal pain, dryness, burning, fear of intercourse, vaginal opening looseness, and even difficulty with losing control over urination, bowel movements or holding bowel gas.
Let us look at some of the changes that can take place in the lower genital tract after normal, uncomplicated vaginal deliveries.
Are vaginal infections or vaginal burning common after delivery?
The hormones of pregnancy, high estrogen and progesterone, decline rapidly after delivery. The result is an almost menopausal state with respect to vaginal lubrication. The condition is called vaginal atrophy with a rise in the pH of the vagina and a shift away from superficial vaginal cells that lubricate the vagina and provide protection from irritation (1).
This change also takes place on the outside of the vulva and is subject to any irritation from soaps, rubbing, or contact with chemicals in pads, condoms, lotions or other topically applied agents.
To answer your questions about whether baths can cause vaginitis or urinary tract infections (UTIs) in the postpartum time period, the answer is that they can produce SYMPTOMS of UTIs or vaginitis, i.e., pain with urination, frequency, vulvar burning, but they are NOT thought to produce actual infections.
They produce symptoms if soaps or bath oils are used that irritate the already very thin, sensitive skin in those areas around the vagina and urethra. This is more of an irritant vulvitis and urethritis rather than a vaginal yeast infection or a UTI. This does not mean that you cannot get a yeast infection or a UTI after delivery -- you certainly can -- but often it is a case of mistaken etiology.
If one looks at vaginal smears to after delivery to see how predominant this problem is, we find that about one third of non lactating women have atrophic changes for about six weeks before they start improving, but in 5% the atrophic pattern persists for a long time (2).
How long will the perineal pain from delivery last so I can know how long before I can resume intercourse?
One study that looked at how long, on the average, it took women to recover various functions after normal vaginal delivery found that the median time (time for 50% of subjects) "for perineal comfort in general (including walking and sitting) was 1 month (range, 0-6 months); 20% of women took more than 2 months to achieve general perineal comfort. For comfort during sexual intercourse, the median time was 3 months (range, 1 to more than 12 months); 20% of women took longer than 6 months to achieve comfort during sexual intercourse. " (3).
You would think that the pain with intercourse is only present if you have an episiotomy but that is not the case. In another study that looked at postpartum painful intercourse (dyspareunia), they found that 72% of postpartum women had pain especially at entrance to the vagina (4).
While this pain was more likely if a woman had a vaginal delivery, it was also present in over 20% of women who had Cesarean sections. Women who were nursing also had a higher incidence of painful sexual intercourse.
Therefore, in general, you should expect that it takes about month before perineal discomfort with walking or sitting goes away but it may easily take 2 months. Also it will take about 3 months before the discomfort with vaginal intercourse goes away but it may be 6 months or more.
What differences are there in vaginal symptoms after delivery if I have an episiotomy versus having no episiotomy?
It is very difficult to say for sure what difference in vaginal symptoms occur on the basis of having or not having an episiotomy. Even in older studies in which episiotomies were routinely performed, about 25% of women did not get one either because they delivered too fast or there was no concern whatsoever that the baby would cause tearing.
The randomized trials that have been performed in which half the women had routine episiotomy (only 73% actually had them as intended) and the other half had episiotomies in restricted to situations in which the doctors thought they would significantly tear if it was not performed (27%), can show us what happens when there is a decrease of almost 50% in the episiotomy rate (5).
These studies tell us that there is no difference in painful intercourse or incontinence by whether episiotomy was performed routinely or not. If episiotomy was causative of painful intercourse (dyspareunia) then we would have expected there to be a higher incidence of such problems in the group that had 50% more episiotomies.
This is also consistent with the study that found that the postpartum pain with sex was only located at the exact site of the incision line in 6% of cases when over 45% of women complained of discomfort with intercourse upon vaginal entry (4).
I have heard of women having problems of uncontrolled passing of gas or even stool from the anus after delivery. Is this likely to be a problem for me?
After vaginal delivery, some women do have difficulty holding their stool or gas. It occurs much more commonly after injury to the anal sphincter muscle, even if that injury is surgically repaired at the time of delivery, than it does if there is no tearing of the muscle.
Ultrasound imaging in one study demonstrated separated anal sphincter muscles in 40% of the women with obstetric anal sphincter lacerations, despite repair at the time of delivery but it also demonstrated sphincter lacerations 20% of the time that were apparently unrecognized at the time of delivery (6).
At 4 months after delivery continued anorectal dysfunction was reported by 43% of subjects in the laceration group versus only 7% of the control subjects
Recent studies suggest that the incidence of anal dysfunction as measured by ultrasound and anal pressure measurements is 8.7% but only 1-2% admit to significant symptoms (7). While incontinence of stool is not frequent, passing gas from the rectum involuntarily may happen as often as 26% of the time in some groups of women after delivery (8).
What about vaginal opening looseness or pelvic prolapse after delivery?
This is a common concern that both women and their partners have about delivery. Unfortunately there is almost no data concerning to what degree the vaginal opening is significantly loosened on a permanent basis.
Similarly there is a lack of studies determining how many women develop pelvic organ prolapse after delivery. No one even knows if episiotomy and repair results in less long term vaginal gaping.
Most investigators agree that postpartum perineal muscle strengthening exercises such as Kegel exercises, will help restore perineal tone. They have even been shown to decrease the incidence of urinary incontinence (9) but they need to be carried on for at least several months.
If a woman gets infected with the human immunodeficiency virus (HIV) and becomes pregnant, then the primary medical goal is to prevent the baby from becoming infected. Recent studies have helped clarify whether a planned Cesarean section can prevent what is called vertical transmission. In other words, some exposure of the baby to HIV virus does not occur until mother undergoes labor and delivery. At that time the virus must cross over from mother's blood to baby's blood. The question has been asked for quite a while as to whether C-section could prevent any instances of transmission. Before treatment with the antiviral drug zidovudine (ZDV), it did not seem that C-section had much effect. However ZDV has been shown to reduce the transmission rate itself and most women are now on ZDV therapy during pregnancy.
A recent publication from the American College of Obstetricians and Gynecologists, Scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. ACOG Committee Opinion. 1999;219:1-3, has given us information about HIV and pregnancy.
Without any ZDV treatment or C-section, about 25% of babies become infected with the HIV virus. When ZDV therapy is given to a woman during pregnancy, the incidence of infection is reduced to about 5-8%. When C-section is performed and ZDV is given during labor, the infection rate is further reduced to about 2%. It is on this basis that current recommendations are to perform scheduled C-Section after 39 weeks in order to minimize the chance of newborn infection.
Women who have low CD4 cell counts seem to have the most postpartum complications. This makes sense because those women have the most active disease with probably the greatest viral loads. Women with very low viral load counts of less than 1000 viral copies per ml of plasma (presumably due to effective ZDV therapy) actually have very low rates of the baby being infected. In these cases, C-section does not actually improve the newborn infection rate.
Women always have autonomy in whether or not to have surgery regardless of the effect on the baby. Courts have long upheld that a woman can refuse surgery even though that refusal may result in the baby dying or being significantly harmed directly due to that refusal.Informed consent for this scheduled delivery is necessary and whatever a woman decides should be honored.
Women with HIV should receive during pregnancy whatever antiviral chemotherapy is recommended according to current adult guidelines. Then in addition, they should receive intravenous therapy with an antiviral like ZDV starting about 3 hours before and then during the Cesarean delivery. The baby will then receive oral ZDV syrup for the first 6 weeks of life. Right now this is the best therapy for minimizing HIV infection in the newborn.
For years, doctors have routinely screened pregnant women for infections which affect the outcome of the pregnancy or cause birth defects in the baby. Gonorrhea and chlamydia are checked for with cervical smears and syphilis is assessed using a blood test. Each of these STDs can cause a problem in the newborn with eye infections and even congenital structural defects for syphilis. Hepatitis and HIV are other viral diseases that mainly are transmitted to the baby during birth so it is useful to know if they are present so that newborn infections can be prevented. There are other infections in pregnancy, however, that are frequently associated with preterm labor - bacterial vaginosis, group B streptococcus, urinary tract infections, trichomonas and mycoplasma hominis. Doctors are checking for these infections much more frequently now because of the serious impact that prematurity can make in a baby's survival. Approximately 80% of women undergoing preterm labor have one or more of these infections going on.
Burning urination and urinary frequency are signs of lower urinary tract infections. Vaginal discharge may also be a sign of infection especially if the discharge is any color other than clear or white or if there is an odor present spontaneously or with sexual relations. Many women are unaware that vaginal bleeding during pregnancy is also associated with vaginal infections.
In a study by French JI et al: Gestational bleeding, bacterial vaginosis, and common reproductive tract infections: Risk for preterm birth and benefit of treatment. Obstet Gynecol 1999;93:715-24, the authors found an 11% incidence of 1st trimester bleeding, 6.4% in the second trimester and 4.1% in the third trimester. By analysis, each of the infections of trichomonas, Chlamydia, and bacterial vaginosis, were associated with bleeding problems; group B streptococcal was not. In women with vaginal bleeding during pregnancy, 44% had bacterial vaginosis and 82% had positive cultures for ureaplasma urealyticum. Antibiotic treatment of infections when they were found antenatally resulted in a 50% reduction in the rate of preterm labor.
Group B strep is often associated with premature rupture of the membranes (broken bag of waters). A newborn can acquire group B Strep during labor and delivery and rarely die from the blood born sepsis it causes. Group B strep is extremely difficult to eradicate, however, so that it is not recommended to treat in early pregnancy because most infections come back. Rather, it is recommended to screen women who have had a previous pregnancy with a Group B strep infection, a history of a stillborn or neonatal death, or premature rupture of the membranes in the current pregnancy. Some doctors will also screen women with vaginal and rectal cultures for group B strep at 35-36 weeks of pregnancy and treat those women who are positive during labor and delivery. Penicillin or cephalosporin antibiotics are the treatments of choice.
Urinary tract infections lead to preterm labor as well as increase the risk for infections that ascend into the kidney, pyleonephritis, and may cause permanent kidney damage. From 3-10% of women have urinary tract infections in pregnancy and most of these are preceded by bacteria in the urine without any symptoms (asymptomatic bactiuria). Most screening tests in pregnancy are designed pick up asymptomatic bactiuria and treat it before it even becomes a UTI, much less a serious pyleonephritis. If a woman does have a pyleonephritis infection during pregnancy, she needs a kidney Xray after delivery to look for congenital anomalies of the urological tract. If the infection does not clear with adequate treatment in pregnancy imaging studies may need to be done during pregnancy to rule out any renal abscesses that do not clear up.
Yeast vaginitis does not seem to cause a problem producing preterm labor or an infection in the newborn. Trichomonas is associated with bleeding and preterm labor as was previously mentioned. A little heard of, but very common infection is mycoplasma hominis, mycoplasma genitalium and ureaplasma urealyticum. They can be cultured so frequently from the vagina and cervix that there is sometimes a question as to whether they really cause a problem. It may have do do with the amount of bacterial load rather than the presence of them that is important. Erythromycin is the treatment of choice for mycoplasma genitalium and ureaplasma urealyticum which are probably the infections to be concerned about. Not enough is known about these and doctors do not routinely culture for them. So unless there is a past history of preterm labor or delivery, it is uncertain to what degree these are clinically important.
You cannot diagnose human papilloma virus infection by Pap smear. You can suspect it, but the diagnosis is by DNA sequence subtyping of cervicovaginal smears. The incidence of positivity is 20-30% in all women delivering infants but if one considers historical infections and earlier in pregnancy testing, the overall incidence in the population is about 75%. Studies have shown anywhere from a 3% to a 37% transmission rate to the infant. There is less colonization of newborns when delivery is by C-Section (27%) than by vaginal delivery (51%), but the incidence of a newborn getting an active infection or a bad disease like laryngeal cord papillomas is extremely small. Most doctors consider the infant culture data evidence of contamination when the baby is delivered rather than infection since the positivity of the infant decreases over several months.
Is it safe to keep my cat during pregnancy? I've heard toxoplasmosis can be spread in cat litter? This is a very common question doctors are asked during antenatal care. One of our recent newsletters from the Motherisk Program had an excellent review written by Phillips, E: Toxoplasmosis - A true danger to the fetus Motherisk Newsletter 1998; 9:5-7. It answered many questions about this parasite infection caused by toxoplasma gondii:
Does toxoplasmosis infection occur from handling cat litter?
Human infection occurs mainly from the ingestion of raw lamb, pork or beef. Sometimes it can occur through eating poorly washed, raw vegetables contaminated with oocysts (toxoplasmosis eggs) or unpasteurized goat's milk or cheese. Rarely, it can come from eating oocysts in cat feces or even water system contamination. Inside cats have almost no exposure to toxoplasmosis, but even in that case, a non pregnant person ideally should be responsible for changing the cat litter.
What symptoms are produced by a toxoplasmosis infection?
Sometimes there are no symptoms with an infection, but when they do occur, they are mild. Tiredness, lymph node swelling, a generalized not feeling well and muscle aches are the most common, albeit nonspecific. symptoms.
What problems does toxoplasmosis infection cause for the baby?
Some babies have a classic triad of chorioretinitis (inflammation of the eye leading to blindness), hydrocephalus and calcium deposits in the brain leading to mental retardation. Others are asymptomatic at birth but develop these same problems and hearing loss in early childhood.
How often will an infected mother pass this toxoplasmosis infection to the baby?
If a mother is infected, about 30-40% of the time the infection is passed to the baby. The lowest rate of infection (15%) occurs in the first trimester but at that time there is the greatest severity of the disease resulting in abortions, stillborns and severe neurological problems. In the third trimester the infection rate is 60%, but the baby is only mildly affected. If infection occurs in the 6 months prior to pregnancy, fetal infection occurs only rarely.
How is toxoplasmosis infection diagnosed?
It is almost impossible to screen for toxoplasmosis infection. If a generalized infection is suspected, a blood test called an IgM can be drawn. The problem is that that blood level of IgM can remain elevated for up to 2 years after an infection. So you really can't tell if the infection was recent or not. Of course if the blood test is negative, that is reassuring although it can miss a very early infection. If the blood test is positive, ultrasound can be used to look for fetal infection but that is only a gross screen. Amniocentesis or fetal cord blood sampling can be performed but that is not available everywhere. A new test on amniotic fluid, PCR, is promising but not widely available.
How can I prevent getting toxoplasmosis from food?
- eat well cooked meat
- wash utensils and counters well after meat preparation
- wash hands after handling raw meat, vegetables and fruit and before eating.
- avoid contact with eyes and mucous membranes while preparing uncooked meat, raw vegetables and fruit
How can I avoid toxoplasmosis if I do have cats?
- empty cat litter daily (it takes 2-3 days for the toxoplasmosis oocysts to become infectious)
- wear gloves while handling cat litter
- wash hands after changing cat litter
- use boiling water to disinfect cat litter box
- avoid feeding cats uncooked meats
- wear gloves while gardening and wash hands well after contact with soil or sand
If you worry about toxoplasmosis or having cats, talk to your doctor.
This title is misleading because ultrasound is actually a very powerful diagnostic tool that has significantly changed diagnosis in pregnancy. On the other hand, it is not perfect and women will be misled and hurt if they think their baby can't have any birth defects or problems if the "ultrasound was normal". Well just how good can ultrasound be?
In a New Haven, Connecticut study, Magriples U, Copel JA: Accurate detection of anomalies by routine ultrasonography in an indigent clinic population. Am J Obstet Gynecol 1998; 179:978-81, 901 pregnant women underwent routine ultrasound scanning between 15-26 weeks of pregnancy. All of the mother's delivery records and the baby's nursery record were checked afterwards to determine whether there was or was not any birth anomaly of the baby.
- 21% of women needed an advanced scan of which half (10.8%) of those were because an abnormal result was suspected or found
- 3.1% (a third of the suspected abnormal screening scans) showed a fetal anomaly
- the average number of ultrasound scans per pregnancy was 1.8
- 21 babies actually had anomalies and 9 babies with anomalies were missed (sensitivity about 70%)
- 35 babies were suspected to have birth defects on screening ultrasound but turned out to be normal on targeted scan
- heart septum (ventricular) defect - surgery at one month
- imperforate anus - surgery at 3 days
- abnormal ear, congenital facial nerve palsy - surgery at 3 months
- Lung anomaly - baby died
- malposition of heart vessels (transposition) - surgery times 3
- clubfoot - nonsurgical therapy
- an unknown defect syndrome with poor feeding - feeding tube, foster care
- small (1 cm) spinal cord defect (meningomyelocoele) - surgery at 3 months
Well, what can we conclude from this study? If a second ultrasound is recommended after a screening scan, there's still a good chance that nothing is wrong, it just needs to be checked out. Most of the major birth defects are found but not all of them. Ultrasound can miss defects even in the best of hands. While no one can absolutely assure a pregnant mom that the baby will be normal, there's extremely good odds (97%) that the baby will be perfect.