Ectopic pregnancy is an abnormal pregnancy in which the fertilized egg is implanted outside, rather than within, the uterine cavity. The most common site is the fallopian tube – one of a pair of long, slender tubes extending from the uterus to the region of the ovary.

With prompt diagnosis, appropriate surgery, and control of bleeding, the prognosis is good. Rarely, in an abdominal ectopic pregnancy, the fetus may even survive to term. Usually, the woman can achieve a normal subsequent pregnancy.

What Causes it?

Ectopic pregnancy occurs when some conditions prevent or slow the passage of the fertilized egg through the fallopian tube and into the uterine cavity. Such conditions include:

• endosalpingitis, an inflammatory reaction that narrows the fallopian tube

• diverticulosis, the formation of blind pouches (diverticulae) that cause fallopian tube abnormalities

• tumors that press against the fallopian tube

• previous surgery, such as tubal ligation, or adhesions from previous abdominal or pelvic surgery.

Using an IUD for birth control may increase the risk of ectopic pregnancy by affecting the cells that line the uterus.

What are its Symptoms?

Ectopic pregnancy sometimes causes symptoms of normal pregnancy but may cause no symptoms other than mild abdominal pain (especially if the pregnancy is in the abdomen). With fallopian tube pregnancy, the woman typically has abnormal menstrual periods (or no periods), followed by slight vaginal bleeding and pelvic pain on the side of the pregnancy. If the tube ruptures, she may have life-threatening complications, such as heavy bleeding, shock, and peritonitis (inflammation of the abdominal wall lining) .

Ectopic pregnancy also may cause sharp pain the lower abdomen, possibly radiating to the shoulders and neck. This pain is commonly triggered by activities that increase abdominal pressure, such as a bowel movement. During a pelvic exam, the woman may feel extreme pain if her cervix is moved or if the examiner touches the structures adjoining the uterus. The uterus feels tender and abnormally son.

How is it Diagnosed?

The doctor may suspect ectopic pregnancy from the woman’s history, symptoms, and pelvic exam results, and will confirm the diagnosis with a variety of serum tests, ultrasound scans, vaginal fluid analysis (culdocentesis), laparoscopy, and possibly exploratory laparotomy.

The doctor must also rule out certain conditions, such as uterine abortion, appendicitis, fallopian tube inflammation, and twisting of the ovary.

How is it Treated?

If culdocentesis reveals blood in the abdominal wall lining, the doctor surgically removes the affected fallopian tube. If the woman wishes to have children, she can undergo microsurgery to repair the fallopian tube; the ovary is saved, if possible. However, if the ectopic pregnancy is in an ovary, the ovary must be removed. If the pregnancy is in an abnormal site within the uterus, a hysterectomy (removal of the uterus) may have to be performed. In an abdominal pregnancy, the fetus is surgically removed (except in rare cases, when the fetus survives to term or calcifies undetected in the abdominal cavity).

Supportive treatment includes transfusions of whole blood or packed red cells to replace excessive blood loss, intravenous antibiotics to treat infection, iron supplements, and a high-protein diet.

Premature labor is the onset of rhythmic uterine contractions that produce cervical changes (dilation and effacement) after fetal viability but before fetal maturity. It usually occurs between the 26th and 37th week of gestation. Approximately 5 % to 10% of pregnancies end in premature labor, which is responsible for about 75% of new­born deaths and many birth defects.

What Causes it?

Possible causes of premature labor may include “breaking water,” or premature rupture of the membranes (occurs in 30% to 50% of cases), preeclampsia, chronic hypertensive vascular disease, excessive amniotic fluid, multiple pregnancy, placenta previa, placental separation, incompetent cervix, abdominal surgery, trauma, structural anomalies of the uterus, infections (such as German measles or toxoplasmosis), congenital adrenal hyperplasia, and death of the fetus.

Other important predisposing factors include:

• Fetal stimulation: Genetically imprinted information tells the fetus that nutrition is inadequate and that a change in environment is required for its well-being; this provokes labor.

• Progesterone deficiency: Decreased placental production of progesterone – thought to be the hormone that maintains pregnancy­triggers labor.

• Oxytocin sensitivity: Labor begins because the myometrium becomes hypersensitive to oxytocin, the hormone that normally induces uterIne contractions.

• Myometrial oxygen deficiency: The fetus becomes increasingly proficient in obtaining oxygen, depriving the myometrium of the oxygen and energy it needs to function normally, thus making the myometrium irritable .

• Maternal genetics: A genetic defect in the mother shortens gestation and precipitates premature labor.

What are its Symptoms?

Like labor at term, premature labor produces rhythmic uterine contractions, cervical dilation and effacement, possible rupture of the membranes, expulsion of the cervical mucus plug, and a bloody discharge.

How is it Diagnosed?

Premature labor is confirmed by the combined results of a prenatal history, a physical exam, signs and symptoms, and ultrasound (if available) showing the position of the fetus in relation to the mother’s pelvis. A vaginal exam confirms progressive cervical effacement and dilation.

How is it Treated?

Treatment is designed to suppress premature labor when tests show immature fetal lung development, cervical dilation of less than 1.5 inches (4 centimeters), and the absence of any factors that would prevent continuation of the pregnancy. Measures consist of bed rest and, when necessary, drug therapy.

Beta-adrenergic stimulants, such as Bricanyl, Vasodilan, or, Yutopar, inhibit uterine contractions. Side effects include rapid hear: rate (mother and fetus) and high blood pressure (mother). Magnesium sulfate relaxes the uterine muscle and may produce side effects in the mother, such as drowsiness, slurred speech, flushing, decreased reflexes, gastrointestinal symptoms, and a slow respiratory rate. Side effects in the fetus or newborn may include central nervous system depression, decreased respiratory rate, and decreased sucking reflex.

Maternal factors that jeopardize the fetus and make premature delivery the preferred choice include intrauterine infection, placental separation, placental insufficiency, and severe preeclampsia. Among the fetal problems that become more dangerous as pregnancy nears term are severe isoimmunization and congenital anomalies.

Treatment and delivery require intensive team effort, focusing on:

• continuously assessing the infant’s health through fetal monitoring

• avoiding amniotomy (surgical rupture of fetal membranes), if possible, to prevent cord prolapse or damage to the infant’s tender skull

• maintaining adequate hydration through I.V. fluids

• avoiding sedatives and narcotics that might harm the infant. Morphine or Demerol may be required to minimize pain; these drugs have little effect on uterine contractions but depress central nervous system function and may cause fetal respiratory depression. They should be administered in the smallest dose possible and only when extremely necessary.

Preventing premature labor requires good prenatal care, adequate nutrition, and proper rest. A procedure that reinforces an incompetent cervix may be done at 14 to 18 weeks’ gestation to help prevent premature labor in women with a history of this disorder.

In this condition, the placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage. This separation, a common cause of bleeding during the second half of pregnancy, occurs most often in women over age 35 who’ve had multiple pregnancies.

The prognosis for the fetus depends on gestational age and amount of blood lost; the mother’s prognosis is good if hemorrhage can be controlled. A firm diagnosis in the presence of heavy maternal bleeding generally requires termination of pregnancy.

What Causes it?

The cause of placental separation is unknown. Predisposing factors include trauma (such as a direct blow to the uterus or bleeding due to needle puncture of the placenta during amniocentesis), chronic or pregnancy-induced high blood pressure, having more than five children, short umbilical cord, dietary deficiency, smoking, advanced maternal age, and pressure on the vena cava from an enlarged uterus.

In placental separation, blood vessels at the placental bed rupture spontaneously because of a lack of resiliency or abnormal changes in uterine vasculature. High blood pressure complicates the situation, as does an enlarged uterus, which can’t contract enough to seal off the torn vessels. Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely.

What are its Symptoms?

Placental separation produces a wide range of symptoms, depending on the extent of placental separation and the amount of blood that the mother loses.

Mild placental separation (marginal separation) develops gradually and produces mild to moderate bleeding, vague lower abdominal discomfort, mild to moderate abdominal tenderness, and uterine irritability. Fetal heart tones remain strong and regular.

Moderate placental separation (about 50% placental separation) may develop gradually or abruptly and produces continuous abdominal pain, moderate dark red vaginal bleeding, a tender uterus that remains firm between contractions, barely audible or irregular and slowed fetal heart tones and, possibly, signs of shock. Labor usually starts within 2 hours and often proceeds rapidly.

Severe placental separation (70% placental separation) develops abruptly and causes agonizing, unremitting uterine pain (described as tearing or knifelike); a boardlike, tender uterus; moderate vaginal bleeding; rapidly progressive shock; and absence of fetal heart tones.

In addition to hemorrhage and shock, other complications may include kidney failure and disseminated intravascular coagulation. Death of the mother and fetus may result.

How is it Diagnosed?

Diagnostic measures for placental separation include observation of signs and symptoms, a pelvic exam, and ultrasound. Decreased hemoglobin and platelet counts support the diagnosis.

How is it Treated?

Treatment of placental separation is designed to assess, control, and restore the amount of blood lost; to deliver a viable infant; and to prevent blood clotting disorders. Immediate measures include starting an intravenous infusion of appropriate fluids to offset fluid losses, monitoring fluid status, various blood studies, electronic fetal monitoring, and monitoring of maternal vital signs and vaginal bleeding.

After these measures, prompt delivery by cesarean section is necessary if the fetus is in distress. If the fetus is not in distress, monitoring continues; delivery is usually performed at the first sign of fetal distress.