ARTICLES OF ABNORMAL OBSTETRICS CASES

ECTOPIC PREGNANCY
Ectopic pregnancy describes the implantation of the fertilized ovum on any tissue other
than the lining of the uterus.7 Potential sites of ectopic pregnancy include the fallopian
tube, ovary, cervix, and abdomen. Ninety-five percent of ectopic gestations occur in
the fallopian tubes . Tubal pregnancies occur with equal frequency on the right and
left sides and may develop in any section of the tube, although they are more common
in the distal two-thirds. Most fallopian implantations are located in the ampullary and
isthmic segments; however, interstitial and infundibula pregnancies occur. Ovarian
pregnancies account for about one percent of all ectopic, while abdominal pregnancies
constitute the remaining three to four percent. Cervical pregnancies are rare.
One out of every 100 to 300 pregnancies is ectopic, and the prevalence is increasing.
The classic triad of symptoms, amenorrhea, abdominal pain, and abnormal bleeding,
varies greatly among individuals, and ectopic pregnancies frequently are confused
with other conditions, such as ovarian cyst, pelvic inflammatory disease, and
spontaneous abortion. Ruptured ectopic pregnancies cause haemorrhage and shock
and are the leading cause of maternal mortality in the first trimester. Although
conservation surgery and tuboplasty have improved the fertility outlook of the ectopic
patient, only one-third of such women will be delivered of a live baby. In this overview
of ectopic pregnancy, the etiology, symptoms, physical findings, and
management/treatment are presented.

Most tubal pregnancies are caused by tubal obstruction or delayed passage of the
fertilized ovum. Pelvic inflammatory disease is the most commonly cited cause of
impaired tubal transport and partial tubal obstruction. Gonococcal pelvic inflammatory
disease is considered responsible for a large percentage of cases; however, recent
studies indicate that mixed aerobic and anaerobic bacterial flora cause many tubal
infections. Chlamydia, tuberculosis, and other specific bacteria are also implicated.
Chronic salpingitis generally does not cause complete obstruction of the tube.
However, mucosal damage occurs, resulting in luminal narrowing, formation of
diverticula, and impairment of ciliary activity and peristalsis. These factors create an
environment that fosters tubal implantation. Green speculates that more prompt and
effective treatment of salpingitis predisposes to tubal pregnancies since infection is
arrested before complete tubal closure occurs. Cite the increasing incidence of pelvic
inflammatory disease as a reason for the rise in ectopic pregnancies. Congenital tubal
anomalies, uterine fibroids, endometriosis, and previous abdominal or tubal surgery
with resultant scarring and adhesions also can interfere with the normal passage of
the fertilized ovum.
Women who have had tubal ligation as a means of birth control seem to be at greater
risk for tubal pregnancy since the sterilization procedure is aimed at preventing
intrauterine pregnancy. Therefore, the overall rate of tubal to intrauterine pregnancy in
these women is inflated. Although most intrauterine devices (IUDs) have been
withdrawn from use, past or current use of an IUD appears to in- crease a woman’s
risk of ectopic pregnancy.2 Some researchers have documented an increased
incidence of pelvic inflammatory disease among IUD users. Other factors that
contribute to the occurrence of pelvic inflammatory disease are the frequency of sexual
activity, multiple sexual partners, and previous pelvic infections

Ectopic pregnancies are more common in nonwhites and women older than 35 years
of age. A previous history of infertility is not uncommon. The occurrence of one ectopic
gestation greatly increases the likelihood of a second such pregnancy; 5 to 11% of
these women will have another ectopic gestation.16 Only about one-third of women
experiencing one ectopic pregnancy will be delivered of a live baby

Many patients with an ectopic pregnancy initially will be diagnosed as having pelvic
inflammatory disease. Abdominal pain is characteristic of both conditions, and a
thorough history and physical examination are required to rule out a potentially fatal
ectopic pregnancy. In pelvic inflammatory disease, laboratory tests may provide
important clues if the infection is active, since elevated sedimentation rates, increased
leukocytes, and fever may be present. Bleeding is uncommon, and abdominal pain
and tenderness are generally bilateral. Pregnancy tests are negative. Ovarian cysts
and corpus luteum and folliele cysts can cause sudden, severe unilateral pain, similar
to that of an ecotpic pregnancy. A palpable, unilateral mass may make differentiation
from a tubal pregnancy difficult. Ultrasound and pregnancy tests can be useful in
differentiating ovarian and corpus luteum cysts from ectopic pregnancy.

The female patient of childbearing age who presents to an emergency room or

physician’s office with complaints of abdominal pain and possibly amenorrhea, and
then bleeding, requires a thorough examination. A careful history by the nurse with
specific questions about menstrual cycles, pelvic inflammatory disease, recent
symptoms, and prior pregnancies may yield vital information. The nurse is also
responsible for observing and monitoring the patient while a variety of diagnostic tests
are being performed. Prompt recognition of changes in the patient’s condition may
lead to interventions that can reduce morbidity and mortality. The nurse should briefly
explain various diagnostic tests (e.g., ultrasound, culdocentesis, and pelvic
examination) and support and reassure the patient and family.
Physical findings, like symptoms, vary markedly and frequently depend on the
acuteness of the patient’s condition. A bi-manual vaginal examination is used to detect
masses and localize discomfort. Adnexal tenderness is the most frequently noted
finding on pelvic examination in patients with an ectopic pregnancy,13 and an adnexal
mass may be palpable. Although cervical tenderness is not a prevalent complaint, it
may be present in some individuals. Abdominal pain is common. Rebound and
guarding may be present, and some patients experience abdominal distention and
diminished bowel sounds. Vital signs in patients with tubal pregnancies do not vary
markedly from normal values unless tubal rupture and internal bleeding have occurred.
At that time, symptoms reflect haemorrhage and shock, with a rapid pulse and lowered
blood pressure. Elevated body temperatures are uncommon. Dizziness, syncope, and
decreased urine output may occur as a result of blood loss.

Once an ectopic pregnancy is suspected, additional diagnostic tests may help confirm
the diagnosis. Biochemical tests rely on the determination of the amount of HCG
produced by the trophoblastic cells of the developing embryo. HCG has two subunits,
alpha and beta, which are measured by different laboratory studies. The as-says that
measure the alpha sub-uint HCG are available within several minutes to two hours;
however, their sensitivity varies from 30 to 94%. Of these, the serum radio receptor
assay is the most sensitive.18 Serum and urine tests are also available for the
measurement of the beta subunit HCG. The serum radioimmunoassay can detect
HCG seven days after conception, requires 3 to 24 hours, and has an 89 to 100%
sensitivity. The urine immunoenzymatic assay for beta subunit HCG detects HCG
levels 14 days after conception, requires only 1 hour, and has a reported sensitivity of
90 to 100%. When available, concentrated urine is preferred for this test.

The acute rupture of a fallopian tube constitutes a surgical emergency. The nurse must
closely monitor vital signs and look for signs of shock and hemorrhage while preparing
the patient for surgery. Procedures often include type and cross-match of blood, shave
and preparation of the surgical site, insertion of a Foley catheter, and intravenous
fluids. Medication may be required for the severe pain that generally accompanies
tubal rupture.

The type of surgical intervention depends largely on the patient’s condition, the extent
of tubal damage, and the preference and experience of the surgeon. Historically, a
tubal pregnancy often boded sterility since one or both tubes and ovaries were
removed to prevent future ectopics. In recent years, however, conservation surgery
has improved the fertility potential of the ectopic patient. Nurses are important
members of the health team in the identification and management of ectopic
pregnancies; however, they also have a role in prevention and education. Knowledge
of risk factors helps the nurse counsel individuals who may be at increased risk for
ectopic pregnancy. Prompt treatment of pelvic inflammatory disease is important
because tubal patency usually is preserved if pelvic inflammatory disease is treated
within two days of symptom on-set. Encouragement of early prenatal care also can
help decrease mortality. The rising incidence of ectopic pregnancy is a problem that
nurses will see in many clinical areas; however, its morbidity and mortality can be
reduced through effective nursing care

When an unruptured ectopic gestation is in the ampullary portion of the tube as in

approximately two-thirds of cases, the trophoblastic tissue can be “milked” through the
tube. In this procedure, the tube is manipulated externally to dislodge the embryo from
its attachment to the tube wall and move it out of the fallopian tube. Speculation exists,
however, that this procedure may leave residual tissue in the tube, rendering the tube
wall rough and susceptible to future ectopic implantations. Therefore, the preferred
technique is a short, linear incision over the ectopic gestation, followed by careful
removal of the trophoblastic tissue. Segmental resection and tubal anastomosis are
advocated for the treatment of ectopics in the isthmic section of the tube, because the
segments are small and of uniform size. Although an abdominal incision frequently is
used, laparoscopic techniques are possible for the simple resection of a small,
unruptured ectopic gestation. The laparoscope is inserted through an incision near the
umbilicus. A second small incision is made above the pubic arch to facilitate surgery.

If the tube has ruptured, the patient’s life is of foremost concern. Death due to
hemorrhage is the primary consideration, and an emergency laparotomy is performed.
After bleeding is controlled, the ectopic gestation is surgically removed, leaving as
much of the tube as possible for reconstructive surgery if desired by the patient. The
distal and proximal ends of the tube generally are sutured to prevent the occurrence
of other ectopic gestations. If damage to the tube and adjacent tissues is severe,
salpingectomy (surgical removal of the fallopian tube) may be indicated. Removal of
the ovary on the affected side may be performed; however, it is generally left in place
to minimize ovarian dysfunction. All blood and clots are lavaged from the peritoneum
to minimize the development of adhesions, which are thought to contribute to ectopic
pregnancies. Reconstructive surgery usually is postponed until the patient’s condition
is more stable.
Postoperative care of the ectopic patient is similar to the nursing care provided to any
patient with abdominal surgery. Ectopic patients are often given broad-spectrum
antibiotics prophylactically. Steroids generally are administered for several days to
diminish the postoperative inflammation that can contribute to the Development of
adhesions. Hospital stay generally is five to seven days.

SHOULDER DYSTOCIA
Is when, after delivery of the head, the baby's anterior shoulder gets caught above the
mother's pubic bone. Signs include retraction of the baby's head back into the vagina,
known as "turtle sign". Complications for the baby may include brachial plexus
injury or clavicle fracture. Complications for the mother may
include vaginal or perineal tears, postpartum bleeding, or uterine rupture.
Risk factors include gestational diabetes, previous history of the condition, operative
vaginal delivery, obesity in the mother, an overly large baby, and epidural
anesthesia It is diagnosed when the body fails to deliver within one minute of delivery
of the baby's head.[2] It is a type of obstructed labour.
Shoulder dystocia is an obstetric emergency. Initial efforts to release a shoulder
typically include: with a woman on her back pushing the legs outward and upward,
pushing on the abdomen above the pubic bone, and making a cut in the vagina.[3] If
these are not effective efforts to manually rotate the babies shoulders or placing the
women on all fours may be tried. Shoulder dystocia occurs in approximately 0.4% to
1.4% of vaginal births. Death as a result of shoulder dystocia is very uncommon
One complication of shoulder dystocia is damage to the upper brachial plexus nerves.
These supply the sensory and motor components of the shoulder, arm and hands. The
ventral roots (motor pathway) are most prone to injury. The cause of injury to the baby
is debated, but a probable mechanism is manual stretching of the nerves, which in
itself can cause injury. Excess tension may physically tear the nerve roots out from the
neonatal spinal column, resulting in total dysfunction.

 Klumpke paralysis
 Erb's Palsy
 Fetal hypoxia
 Fetal death
 Cerebral palsy
 Maternal postpartum bleeding (11%)
 Perineal lacerations and 3rd/4th degree tears, extended episiotomies
 Uterine rupture
About 16% of deliveries where shoulder dystocia occurs have conventional risk
factors. These include diabetes, fetal macrosomia, and maternal obesity.
Risk factors:

 Age >35
 Short in stature
  Small or abnormal pelvis
 More than 42 weeks gestation
 Estimated fetal weight > 4500g
 Maternal diabetes (2-4 fold increase in risk)
Factors which increase the risk/are warning signs:

 Need for oxytocics

 Prolonged first or second stage of labour
 Turtle sign (head bobbing in the second stage)
 Failure to restitute
 No shoulder rotation or descent
 Instrumental delivery
Recurrence rates are relatively high (if you had shoulder dystocia in a previous delivery
the risk is now 10% higher than in the general population).[9]
A number of labor positions and maneuvers are sequentially performed in attempt to
facilitate delivery. These include:

 McRoberts maneuver involves hyperflexing the mother's legs tightly to her

abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar
spine). If this maneuver does not succeed, an assistant applies pressure on the
lower abdomen (suprapubic pressure), and the delivered head is also gently
pulled. The technique is effective in about 42% of cases
 Suprapubic pressure (or Rubin I)
 Rubin II or posterior pressure on the anterior shoulder, which would bring the baby
into an oblique position with head somewhat towards the vagina .

 Active delivery of the anterior arm



Step 1: Index and middle fingers insertion with the hand opposite the baby's face

Step 2: Baby's head slightly tilted downward with the free hand


Step 3: Two fingers are placed on the humerus like a splint

Step 4: Baby's hand appears under the maternal pubic symphysis, allowing the
anterior arm to be delivered

 Woods' screw maneuver which leads to turning the anterior shoulder to the
posterior and vice versa (somewhat the opposite of Rubin II maneuver)
 Jacquemier's maneuver (also called Barnum's maneuver), or delivery of
the posterior shoulder first, in which the forearm and hand are identified in the birth
canal, and gently pulled.
 Gaskin maneuver involves moving the mother to an all fours position with the back
arched, widening the pelvic outlet
More drastic maneuvers include

 Zavanelli's maneuver, which involves pushing the baby's head back in with
performing a cesarean section.[19] or internal cephalic replacement followed
by Cesarean section
 Intentional causing clavicular fractures, which reduces the diameter of the
shoulders that requires to pass through the birth canal.
 Maternal symphysiotomy, which makes the opening of the birth canal laxer by
breaking the connective tissue between the two pubes bones.
 Abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates
vaginal delivery of the impacted shoulder.

PRETERM LABOR
Preterm labor occurs when regular contractions result in the opening of your cervix
after week 20 and before week 37 of pregnancy.

Preterm labor can result in premature birth. The earlier premature birth happens, the
greater the health risks for your baby. Many premature babies (preemies) need special
care in the neonatal intensive care unit. Preemies can also have long-term mental and
physical disabilities.

The specific cause of preterm labor often isn't clear. Certain risk factors might increase
the risk, but preterm labor can also occur in pregnant women with no known risk
factors. Understand the signs and symptoms of preterm labor and next steps.

Signs and symptoms of preterm labor include:

 Regular or frequent sensations of abdominal tightening (contractions)

 Constant low, dull backache

 A sensation of pelvic or lower abdominal pressure

 Mild abdominal cramps

 Vaginal spotting or light bleeding

 Preterm rupture of membranes — in a gush or a continuous trickle of fluid after

the membrane around the baby breaks or tears

 A change in type of vaginal discharge — watery, mucus-like or bloody

If you experience these signs or symptoms or you're concerned about what you're
feeling, contact your health care provider right away. Don't worry about mistaking false
labor for the real thing. Everyone will be pleased if it's a false alarm.

Preterm labor can affect any pregnancy. Many factors have been associated with an
increased risk of preterm labor, however, including:

 Previous preterm labor or premature birth, particularly in the most recent

pregnancy or in more than one previous pregnancy

 Pregnancy with twins, triplets or other multiples

 Problems with the uterus, cervix or placenta

 Smoking cigarettes or using illicit drugs

 Certain infections, particularly of the amniotic fluid and lower genital tract

 Some chronic conditions, such as high blood pressure and diabetes

 Stressful life events, such as the death of a loved one

  Too much amniotic fluid (polyhydramnios)

 Vaginal bleeding during pregnancy

 Presence of a fetal birth defect

 An interval of less than six months between pregnancies

 Infection of tissues that surround and support your teeth (periodontal disease)

Complications of preterm labor include delivering a preterm baby. This can pose a
number of health concerns for your baby, such as low birth weight, breathing
difficulties, underdeveloped organs and vision problems. Children who are born
prematurely also have a higher risk of learning disabilities and behavioral problems.

You might not be able to prevent preterm labor — but there's much you can do to
promote a healthy, full-term pregnancy. For example:

 Seek regular prenatal care. Prenatal visits can help your health care provider
monitor your health and your baby's health. Mention any signs or symptoms that
concern you. If you have a history of preterm labor or develop signs or symptoms
of preterm labor, you might need to see your health care provider more often
during pregnancy.

 Eat a healthy diet. Some research suggests that a diet high in polyunsaturated
fats (PUFAs) is associated with a lower risk of premature birth. PUFAs are found
in nuts, seeds, fish and seed oils.

 Avoid risky substances. If you smoke, quit. Ask your health care provider about
a smoking cessation program. Illicit drugs are off-limits, too.

 Consider pregnancy spacing. Some research suggests a link between

pregnancies spaced less than six months apart and an increased risk of
premature birth. Consider talking to your health care provider about pregnancy
spacing.

 Be cautious when using assisted reproductive technology (ART). If you're

planning to use ART to get pregnant, consider how many embryos will be
implanted. Multiple pregnancies carry a higher risk of preterm labor.

If your health care provider determines that you're at increased risk of preterm labor,
he or she might recommend taking additional steps to reduce your risk, such as:

 Taking preventive medications. If you have a history of premature birth, your

health care provider might suggest weekly shots of a form of the hormone
 progesterone called hydroxyprogesterone caproate starting during your second
trimester and continuing until week 37 of pregnancy. In addition, your health care
provider might offer progesterone, which is inserted in the vagina, as a preventive
measure against preterm birth. If you are diagnosed with a short cervix before
week 24 of pregnancy, your health care provider might also recommend use of
progesterone until week 37 of pregnancy.

 Managing chronic conditions. Certain conditions, such as diabetes and high

blood pressure, increase the risk of preterm labor. Work with your health care
provider to keep any chronic conditions under control.
If you have a history of preterm labor or premature birth, you're at risk of a subsequent
preterm labor. Work with your health care provider to manage any risk factors and
respond to early warning signs and symptoms.

There is a significantly increased risk of shoulder dystocia as birth weight linearly

increases. From a prospective point of view, however, prepregnancy and antepartum
risk factors have exceedingly poor predictive value for the prediction of shoulder
dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing
accuracy with increasing birth weight, and an overall tendency to overestimate the
birth weight. Induction of labor for suspected fetal macrosomia has not been shown to
alter the incidence of shoulder dystocia among nondiabetic patients. The concept of
prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore
avoid brachial plexus injury has not been supported by either clinical or theoretic data.
Although many maneuvers have been described for the successful alleviation of
shoulder dystocia, there have been no randomized controlled trials or laboratory
experiments that have directly compared these techniques. Despite the introduction
of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized
trend towards the avoidance of fundal pressure, it has been shown that the rate of
shoulder-dystocia associated brachial plexus palsy has not decreased. The simple
occurrence of a shoulder dystocia event before any iatrogenic intervention may be
associated with brachial plexus injury.

For many years, long-standing opinions based solely on empiric reasoning have
dictated our understanding of the detailed aspects of shoulder dystocia prevention and
management. Despite its infrequent occurrence, all healthcare providers attending
pregnancies must be prepared to handle vaginal deliveries complicated by shoulder
dystocia.