Ectopic Pregnancy, Dysmenorrhea & Multiple Pregnancy

Ectopic Pregnancy
Definition :
This is said to occur when fertilized ovum is implanted on any sure other than the endometrial cavity. In 90% of the time, this happens in the Fallopian tube. Other sites where ectopic can occur include the cervix, ovaries, abdomen, etc.

Causes Of Ectopic Pregnancy
Most times, tubal ectopic pregnancy occur due to the delay in the passage of the fertilized ovum which is abnormal implantation.
Some etiological factors in ectopic pregnancy include the following :

• Pelvic inflammatory disease with salpingitis
• Previous pelvic surgeries 
• Other pelvic diseases eg. Endometriosis
• Congenital malformations of the Fallopian tubes 
• Progesterone IUCD (progestasert and mirena) 
• Idiopathic 
• History of precious ectopic pregnancy 
• History of infertility 
• IVF treatment 
• Age 35 years and above. 

Signs And Symptoms Of Ectopic Pregnancy

• Amenorrhea
• Abdominal pain 
• Vaginal bleeding. 

Types Of Clinical Presentation In Ectopic Pregnancy
A. Acute : this usually involved tubal rupture associated with hemperitoneum (bleeding in the abdominal cavity), severe abdominal pain and tenderness, hypotension, fast rapid pulse rate,  fainting spells, adnexal tenderness and cervical motion tenderness on vaginal examination.

B. Subacute or Chronic Ectopic : this is difficult to diagnose because there are no classical symptoms. However, it is characterized by amenorrhea, slight unilateral lower abdominal pain, with or without vaginal bleeding, painful sexual intercourse (dyspareunia). This is diagnosed definitely with ultrasound scan.

C. Silent Ectopic : this is where no symptoms exist and ectopic pregnancy is an accidental finding. It is discovered during an ultrasound scan for other indications or purposes.

Diagnostic Tools
These include the following :

• Beta human chorionic gonadotrophin (HCG) : this is crucial especially the initial value and the rate of rise. 
• Ultrasound is invaluable especially transvaginal ultrasound 
• Laparoscopic diagnosis/treatment
• Culdocentesis
• Paracentesis. 

Differential Diagnosis (other diseases to think of when suspecting an ectopic pregnancy)

• Miscarriage
• Tortion of ovarian cyst 
• Pelvic inflammatory disease 
• Appendicitis 

Treatment Of Ectopic Pregnancy

• Surgical for all ruptured ectopic
• Medical treatment can be attempted based on certain criteria which includes the gestational sac diameter, beta HCG level, of embryo is viable etc.

Dysmenorrhea
This is defined as pain that occurs during menstruation. It is simply known as painful menstruation. It is the most common gynecological complaint and has its attendant consequences for both the economy through loss at work or education or personal lives.

Classes Of Dysmenorrhea

• Primary dysmenorrhea
• Secondary dysmenorrhea 
• Membranous dysmenorrhea

Primary dysmenorrhea : here there is no demonstrable or known cause. It is the commonest type of dysmenorrhea. It occurs in about 58-85% of all cases of dysmenorrhea. It is very common among teen ages to 30 years. Most cases usually resolve following child birth and advancing age.

Secondary dysmenorrhea : here there is a specific or known cause of the painful menstruation. It's peak incidence is between 30-45 years.

Membranous dysmenorrhea : here a cast of the endometrial cavity is she'd as a entity. It is rare however, it causes intense pain with cramping which is due to passage of a cast of the endometrium through an undilated cervix.

Associated Events/Risks Factors (Possible Causes) Of Primary Dysmenorrhea

• Early menarchy/menstrual period 
• Heavy and long menstrual flow 
• Low consumption of fish eggs and fruits 
• Exposure to tobacco smoke 
• Increased production of prostaglandings. 

Causes Of Secondary Dysmenorrhea

• Endometeriosis (most common) 
• Adhesion following PID, previous pelvic surgeries, etc
• Pelvic inflammatory disease 
• Uterine displacement 
• Uterine fibroid 
• IUCD
• Cervical stenosis. 

Symptoms And Signs Of Dysmenorrhea
1. Pain : The pain of dysmenorrhea classically begins just before or at the onset of menstrual bleeding and persists the first 8 to 72 hours. This is assoc with cramping. The pain may radiate to the Lower back and thigh and assoc with nausea, weakness. There may be some psychosomatic symptoms.

2. Secondary dysmenorrhea occurs in both ovulatory and anvulatory cycles. The pain builds up during the luteal (1-2 weeks before the onset of menses) and reaches crescendo around the onset of menses and resolves few days after cessation of bleeding. It may be assoc with dysparuenia (painful intercourse).

Treatment Of Dysmenorrhea
Treatment can be medical or surgical. Primary dysmenorrhea usually responds to medical treatment while the response to secondary dysmenorrhea is variable.
1. Drug (medical) treatment
2. Non drug treatment

Medical Treatment
1. Non-Steroid Anti-inflammatory Drugs (NSAIDS)
Examples includes Ibuprofen, naproxane, mefenamic acid.
These should be instituted with the start of the period or pain, which ever comes first. It is less effective if treatment is delayed until after the onset of the symptoms.

2. Combined Oral Contraceptive Pills (COCP)
These inhibit ovulation. It also causes reduction in uterine contractility. More than 90% of cases obtain relief. They can be used together with NSAIDs.

3. Luteal Phase Progesterone : This promotes muscle relaxation and inhibits prostaglandings which cause contraction.

4. Medicated IUCD (IUCD laced with synthetic progesterone)

5. Dietary Therapy : This includes intake of certain foods such as vitamins B1, B6, and E, magnesium, omega-3 fatty acids

6. Topical heat massage therapy.

Surgical Treatment
This is often indicated in secondary dysmenorrhea and aimed at correcting the underlying pathology. This may involve hysterectomy and removal of Fallopian tubes and ovaries.


Multiple Pregnancy
Multiple pregnancy may be either twin pregnancy or higher order multiples (ie. More than 2 babies egm triplets, quadruplets, etc). This is said to occur when conception gives rise to 2 or more babies in the same pregnancy.
Twin Pregnancy
There are 2 types of twin pregnancy

• Identical twins 
• Fraternal (non -identical) twins. 

Identical twins : this occur when a single embryo created by a union of a sperm and egg, divides into 2 embryos. Each embryo in termed monozygotic, ie. genetically identical. When twinning process occurs early in the pregnancy especially in the first two weeks after conception, each fetus has its own separate placenta and gestational sac. However, if the twinning process occurs later after the placenta has been formed, the 2 embryos may share the same gestational sac.

Non-identical twins: this occurs when two separate eggs are each fertilized by two separate sperm cells. The two resultant embryos are termed dizygotic and are not genetically identical. Hence the twins are not genetically identical.

Some Risks Factors /Causes Of Multiple Pregnancy
1. Race : the incidence of multiple pregnancies vary according to the race or ethnicity. That's western Nigeria (yourba people) has the highest incidence of twin pregnancy in the world.

2. Heredity : it may run in the family

3. Higher age of the woman : the more a woman advances in age, the more likelihood she would have a multiple pregnancy

4. Previous history of multiple pregnancy : a woman who has has a multiple pregnancy in the past is more likely to have another multiple pregnancy in the subsequent pregnancies.

5. Maternal height and weight : the taller and larger a woman is, the higher the chances that she would have a multiple pregnancy.

6. Fertility drugs : multiple pregnancy is much higher in women who use fertility drugs such as ovulation induction drugs. This causes the ovaries to release more than one ovum/egg hence may increase the chances of multiple pregnancy.

7. Assisted reproductive technology : this includes in vitro fertilization , (also known as test tube baby). During this procedure multiple embryos are introduced into the woman's genital tracts in order to increase the chances for success. This in turn leads to multiple pregnancy.

8. Dietary factors : certain food in different parts of the world have been fingered as possible causes of multiple pregnancy. Typical in our own environment is the various species of yam in the western Nigeria (Yoruba land).

Average Duration Of Multiple Pregnancy
The duration of a normal singleton pregnancy ranges from 37 to 42 weeks from the time of last menstrual period. Twin pregnancy may occasionally be allowed to progress to 40 weeks but it is almost always delivery early. As the number of fetus increases, the expected  duration of pregnancy reduces. The average gestational age at the time of delivery is as follows :

• Singleton -- 40 weeks
• Twin ----------35 weeks 
• Triplet --------33 weeks
• Quadruplets --29 weeks

Complications Of Multiple Pregnancy

• Premature birth 
• Hypertension in pregnancy 
• Diabetes in pregnancy 
• Low birth weight
• Premature labour
• Anemia
• Nausea and vomiting (severe) 
• Heart burn
• Lack of sleep 
• Financial stress 

Delivery In Multiple Pregnancy
Delivery in a multiple pregnancy depends on many factors including :

• Number of fetuses
• Gestational age at delivery 
• Presentation of the leading twin (whether cephalic or breech, or other abnormal presentations).