Pregnancy is a critical period for both the mother and child and the mother needs to take special care to ensure optimum health, not only for herself but also the child. Some of the common complaints as well as a few precautions like usage of drugs were discussed earlier.
An important complication is ectopic pregnancy. The word ectopic is derived from the Greek ektopos which means "out of place." Normally, the fertilised ovum (the egg) implants in the cavity of the uterus. If it should implant elsewhere it is called an ectopic pregnancy. While the commonest site for an ectopic pregnancy is one of the fallopian tubes, it can also implant at other sites such as the outlet of the uterus (the cervix) or the ovary or even inside the abdominal cavity.
The uterus is designed by nature to nourish the growing child and also to expand adequately with growth of the child. When the pregnancy implants at an ectopic site, it establishes communication with blood vessels at that site for nourishment. However, other sites are not designed to support growth of the foetus when it becomes larger.
The usual natural course in such cases is rupture of the organ supporting the ectopic pregnancy. Bleeding is often massive enough to be life threatening.
Ectopic pregnancy is an important and common problem. The statistics are frightening. Fairly reliable statistics are available for the USA. There it is reported that about 2 per cent of all pregnancies are ectopic in nature. This is a huge number. Further, about 9 per cent of all pregnancy-related deaths can be attributed to an ectopic pregnancy, making it the single largest cause of such deaths.
The ovum is normally released from the ovaries and passes through the fallopian tubes into the cavity of the uterus where it implants after fertilisation. Should this migration be interfered with, the ovum can implant ectopically in the tubes or elsewhere.
Infection affecting the organs in the lower abdomen goes under the name of Pelvic Inflammatory Disease and is a not so uncommon illness. The commonest cause of such infection is a germ called Chlamydia and in many cases the infection is without significant symptoms. More the number of episodes of pelvic inflammatory disease, the higher the chances of the woman developing ectopic pregnancy in the future.
Pelvic inflammatory disease is believed to cause not only mechanical obstruction by narrowing the fallopian tube but also interferes with its motility which normally promotes the passage of the ovum to the uterus. Narrowing or injury to the tubes from other conditions such as surgery on the tubes also predisposes to ectopic pregnancy. A history of prior ectopic pregnancy also increases the chances of a future pregnancy being ectopically located very substantially.
Other predisposing factors are use of fertility drugs and use of intra-uterine contraceptive device. Smoking is also a risk factor and advanced age of the mother is another risk factor for ectopic pregnancy.
Symptoms which should make a woman suspicious about the possibility of an ectopic pregnancy include pain on one side of the abdomen in a woman who has missed a period. Associated vaginal bleeding is also common. However, many women with an ectopic pregnancy have atypical symptoms which are difficult to differentiate from those of an otherwise normal pregnancy, such as excessive fatigue or nausea.
With wide availability and utilisation of ultrasound by gynaecologists, undetected ectopic pregnancy is becoming the exception rather than the rule, at least in women attending regular antenatal clinics. Serial blood test for hCG (human chorionic gonadotrophin) are also helpful. In early pregnancy they usually double in two to three days and if this does not happen, it suggests possibility of ectopic pregnancy.
A woman with established rupture of the tube or with substantial bleeding due to an ectopic pregnancy constitutes a medical emergency and treatment is necessarily surgical. For patients who have minimal symptoms or are detected incidentally on ultrasonography, medical treatment in the form of methotrexate injections is fairly effective. This drug is also used in the treatment of cancer and to suppress the immune response in conditions like severe rheumatoid arthritis. Advantage of this treatment over conventional surgical treatment is lesser disruption or damage to the tissues and so hopefully lesser chances of ectopic implantation of the ovum in future pregnancies. It is also, worth noting that about a fourth of all ectopic pregnancies detected on ultrasonography in women without symptoms resolve spontaneously.
Miscarriage and causes
Miscarriage and spontaneous abortion are synonymous terms denoting loss of the pregnancy. These terms are applied to loss of the pregnancy before the 20th week after which the condition is described as premature delivery. The symptoms of an abortion include passage of blood, clots and tissues. Passage of watery fluid signifies rupture of the membranes and is also part and parcel of a miscarriage. Abdominal cramps can also denote the occurrence of a miscarriage. However, cramps in the first trimester also occur in normal pregnancy and unless associated with bleeding or passage of tissues or unless very severe are unlikely to be due to a miscarriage. Cramping pain can also occur from an ectopic pregnancy.
In addition to these local symptoms, women with a miscarriage may report disappearance of general symptoms associated with the pregnancy such as nausea. The blood levels of hCG, the hormone measured in blood and urine pregnancy tests, also shows a steep fall with termination of the pregnancy.
Bleeding does not always signify loss of the pregnancy. Implantation of the fertilised ovum is associated with a little bleeding in a goodly percentage of women, maybe about 25 per cent. It is estimated that of the women reporting bleeding during the first trimester (the first three months of the pregnancy) only about a half will go on to complete abortion. However, when bleeding is associated with passage of tissues or watery fluid, it means that the pregnancy is lost.
A number of more or less self-explanatory terms are used to describe the stages of a spontaneous abortion. Threatened abortion is the first stage usually associated with symptoms like a little bleeding but without passage of tissues or watery fluids. Abdominal cramps may be present but are usually not too prominent. A threatened abortion is a very common occurrence in pregnancy with some authorities estimating its frequency at about 30 per cent of all pregnancies. About half of such cases go on to loss of the pregnancy. Incidentally, about 1 per cent of couples face the problem of recurrent miscarriages with repeated loss of pregnancy.
It may be difficult for the doctor to differentiate bleeding due to a threatened abortion from other causes such as an ectopic pregnancy. This is especially so if ultrasonography does not show the pregnancy clearly. Ultrasonography is a very operator sensitive and patient sensitive investigation and early pregnancy may easily be overlooked, especially in an obese woman. If the pregnancy test (hCG levels in blood) suggest the probability of a pregnancy and ultrasonography does not reveal the pregnancy inside the uterus, it would suggest the possibility of an ectopic pregnancy.
Inevitable abortion is the next stage in the natural course of a spontaneous abortion. At this stage, bleeding is heavier and abdominal cramps are fairly prominent. However, there is still no passage of tissues. As the name clearly states, the pregnancy is beyond salvage.
Incomplete and complete abortion describes the partial and total loss of the tissues of the pregnancy respectively. The woman complains of passage of tissues and of blood and clots. In incomplete abortion, some of the tissues are still retained in the uterus while in complete abortion the uterine cavity is free of such retained tissues. Physical examination by the gynaecologist as well as examination by ultrasonography is helpful in differentiating between the two. In a completed abortion, the pain will have subsided but in an incomplete abortion the abdominal cramps often continue till all the uterine contents are emptied.
Another term is "missed" abortion and this is exactly what it is. The spontaneous termination of the pregnancy occurs with hardly any symptoms. The dead foetus is retained within the uterine cavity but without causing bleeding or pain. Ultrasonography is of help in confirming the diagnosis.
The commonest cause of a miscarriage is a chromosomal abnormality in the foetus inconsistent with continuation of life. About 80 per cent of all miscarriages occur in the first trimester and of these about 90 per cent are attributed to such chromosomal abnormalities. In the second trimester, other conditions are more often contributory to the occurrence of miscarriages. Even then, chromosomal abnormalities are estimated to account for more than 30 per cent of miscarriages in the second trimester.
Courtesy : Gulf Today