Ectopic pregnancy

The incidence is low 1:700 and unless there is a history of pelvic infection causing some damage to the lining of the fallopian tubes, an ectopic pregnancy is not common. Ectopic pregnancy is a pregnancy that is outside the womb. It can be on any portion of the fallopian tube or even grow on the ovary. This abnormal location of the pregnancy means that it is not possible for the pregnancy to grow to full term and needs to be removed. The risks with an ectopic pregnancy are that as it grows in the tube, it will erode through the tube and rupture a blood vessel resulting in bleeding into the abdomen.

Thus the importance of an early check-up with the obstetrician as he will be able to diagnose an ectopic pregnancy before any serious mishap. Unfortunately an ectopic may be difficult to view on ultrasound scan but will be suspected if there is no pregnancy sac in the womb, and blood pregnancy hormone levels show a slow rise. Sometimes the sac can be seen in the tube and it will give the typical vivid appearance of surrounding blood vessels called the 'ring of fire'.

Diagnosis is by laparoscopy ( inserting a telescope through the belly button) and viewing the fallopian tubes. Treatment is either removing the pregnancy alone by cutting open the afected tube, or removing th entire tube if it is too badly damaged. The alternative is to use a cancer drug to try and dissolve the pregnancy.

Syphillis and pregnancy

Syphillis is a sexually transmitted disorder. With the rising incidence of sexually transmitted disorders especially in China, routine screening during pregnancy is important. Syphillis may have no symptoms especially in the early stages but the infection can cause sudden death of the foetus after 28 weeks. If it is not screened for and therefore missed would be a travesty as if detected, a single dose of penicillin antibiotic would avoid a stilbirth due to this sexually transmitted disorder.

Why you should sleep on your left side

A recent article  showed that sleeping on the back and right side predisposes to a higher incidence of sudden death of the foetus. Although further studies need to be done, it would be prudent to follow this rule especially if you are in your third trimestor. The incidence of stilbirth is not high and is less than 1: 10000. Very often it is attributed to a cord accident but in a large proportion no obvious cause is found. It may be that sleeping on the back and right could well be a cause. Pregnant women have always been told to sleep on the side and the reason is that there is a major vessel running parallel to the spine on the right and behind the womb. As the womb expands there will be increased pressure on this vessel. This blood vessel also supplies the foetus with oxygen and nutrition. The womb is naturally tilted to the right, thus it would make sense that sleeping on the right and back would increase the pressure on this vessel possibly reducing the oxygen to the foetus.
So always remember to sleep on the LEFT side!

http://www.medscape.com/viewarticle/744648?sssdmh=dm1.695983

Down's Syndrome and other chromosome abnormality testing

With more women having children after the age of 35 years, testing for Down's Syndrome ( Mongolism ) and other chromosome abnormalities has become even more important. The test with the highest accuracy of course would be the amniocentesis, however this is an invasive procedure and it would not be practicle to perform this on every pregnant woman above 35 years. Testing has evolved from the triple test (measuring 3 markers in the blood at 15 weeks onwards ) to tests which are done in the first trimestor ie 11 -14 weeks.

In my practise, I will start with looking for the nasal bone between 11and 14 weeks. An absent nasal bone is strongly suggestive of a chromosome problem.  I will do two tests. The first is the measurement of the nuchal translucency ( this is the fluid at the back of the foetal neck which is present in all foetus's but is greatly increased in one with a chromosome disorder ). This should be <2.5mm. There are false positives and I increase the accuracy by combining this test with measurement of 2 markers in the blood, one a hormone beta-HCG and a protein PAPP-A. The combination of these tests is called the Oscar test. This gives a predictive accuracy of 95% for a chromosome abnormality.

If the tests are positive then an amniocentesis or CVS is offered. The alternative is to retest with a triple test and nasal bone measurement at 16 weeks, and if positive an amniocentesis should be done as the likelihood of a chromosome abnormality is high.

Normal delivery or caesarean section?

Obstetricians have always been taught that normal delivery was best, unless there was an indication for a caesarean section. It was assumed that every pregnant woman would want to have a normal delivery. But is normal delivery really better? The caesarean section rates have always been on the rise and now account for about 1 in 3-4 deliveries. I would say that after 25+ years of practising obstetrics, it would appear to me that a caesarean section delivery has a lot more going for it than a normal delivery. I will probably be shot down by many fellow obstetricians for this statement. However I have seen way more complications arising from a normal delivery than caesarean sections. Many pregnant women are unaware that a normal delivery has a higher risk to the baby ( this is only logical since a baby would be more prone to foetal distress having to traverse the female pelvis in its passage to this world, and a long labour may leave both mother and baby exhausted and more prone to potential hazards ). One would argue that recovery is faster with a normal delivery. This may not necessarily be true for a long labour or one with multiple vaginal tears.

Pregnant women now want to be more involved in decision making with regard to mode of delivery and this is a good thing so that a proper informed decision can be made. The obstetricians role is now more of a facilitator and educator in the antenatal care and delivery of the baby. Having weighed the pros and cons joint decisions are made, sometimes even with the input of of various family members.

Premature labour

One of the many concerns I often get asked is will my baby come early? The question should actually be will my baby be premature or preterm. Labour anytime before 37 weeks would be considered as premature. It is common for the baby to come between 37 and 40 weeks but this is not a problem. The incidence of preterm labour is about 12% of all pregnancies. The most common causes are infections eg strept B, trauma to cervix eg after an abortion or cone biopsy, multiple pregnancies, poor nutrition, inadequate rest, chronic medical illnesses eg asthma. In a large number, the cause is unknown. The preterm labour tends to recur with each pregnancy.

Your obstetrician may want to perform a vaginal scan in the early or late second trimestor to determine the length of your cervix if there is a history of preterm labour or other risk factors. A short cervix ( between 10-21mm ) indicates a high risk of preterm labour.

Rest and good nutrition are very important. It is my practise to start the pregnancy with utrogestan as very often early threatened miscarriage and later preterm labour are associated with a lack of the pregnancy hormone, progesterone. Utrogestan is micronised progesterone and is very safe for use in pregnancy. I will continue this until 36 weeks. I have many patients with recurring miscarriages and preterm labour, when put on utrogestan achieve a full term and healthy baby. Tocolytics such as ventolin can be added if there are signs of excessive uterine contractions or impending labour.It also appears that consuming moderate amounts of  fish prevents preterm labour and tends to prolong the pregnancy in a recent study.

Bleeding in early pregnancy

The most common problem in the first 12 weeks of pregnancy is bleeding. This can be very alarming and distressing but the good thing is that although common, the majority resolve without adverse effect on the foetus. The miscarriage rate is about 1:5 overall.

Bleeding is most often due to insufficient pregnancy hormone, progesterone. The pregnancy then threatens to dislodge from the uterine wall resulting in bleeding. If the bleeding is slight, it will appear as a brown stain but if more serious there will be passage of clots associated with abdominal cramps.

It is prudent to visit your gynaecologist early in the pregnancy ( best time is 5-6 weeks) especially if there has been a previous pregnancy with bleeding ( since bleeding in pregnancy tends to repeat itself with each pregnancy ). Treatment can then be instituted before too much damage has been done. It is especially not wise to come after repeated episodes of bleeding as each subsequent bleed may jeopardise the foetus. A scan can be done to determine if the foetal heartbeat is seen. This is usually detectable at 6 weeks pregnancy. Hormone therapy can then be instituted. If there is heavy bleeding, or a history of more than one miscarriage, it is my practice to administer a course of HCG injections + utrogestan. If only slight bleeding,  bed rest and utrogestan is administered. With hormonal treatment, the bleeding should stop within a few days and if it persists more than a week, should be reviewed to exclude other causes for the bleeding.