Rare Ectopic Pregnancy, again

In the last blog entry I detailed the story of Zahra Aboutalib, a Moroccan woman with a rare complication of an ectopic pregnancy, a lithopedion.  The second incredibly rare complication of an ectopic pregnancy that I will cover happened to an English woman named Jane Ingram.  Jane was a 32 year old woman living in Suffolk, England, when she discovered in early 1999 that she was pregnant for the third time.  She and her husband Mark had a total of four children from previous marriages; this was their first child together.

Shortly into the pregnancy, a routine scan showed that she was carrying twins.  Continued abdominal pain led to further scans that showed eighteen weeks into pregnancy that Jane was indeed carrying triplets, the third baby had not implanted in the uterus as the other two had and had ruptured Jane’s fallopian tube.  This baby, the only boy of the pregnancy, had miraculously survived the rupture and continued to grow attaching his placenta to the outside of Jane’s uterus.  Jane had not been taking fertility drugs, a frequent cause of sets of multiple babies.

Immediately, the rarity of Jane’s case caught the attention of top doctors in the United Kingdom and leading obstetrician Davor Jurkovic at King’s College Hospital in London became the lead attending physician.  Jurkovic placed the odds of all three children and the mother surviving this situation were one in 60 million–if they did all survive it would be the first time in medical history.

Jane was closely monitored and at twenty-nine weeks, eleven weeks prematurely, it was decided that the cesarean section should go ahead.  A team of twenty-six medical professional assembled at King’s College Hospital on September 3, 1999 to assist in the two-hour long procedure.  The twin girls, Olivia (2lbs 10oz) and Mary (2lbs 4oz) were delivered first and the procedure went routinely.  The next challenge was to safely access the boy, who was in an awkward position.  Doctors decided to shift Jane’s intestines in order to reach him and successfully delivered Ronan (2lbs 4oz).

Amazingly, the triplets were born with no more complications than would be expected of any other triplets born at twenty-nine weeks.  Each was kept in the intensive care unit and placed on ventilators.  They only remained on the ventilators for about a week, Ronan being the first to grow strong enough to not need its assistance.  The worry remained that the pieces of Ronan’s placenta that could not be removed would cause complications for Jane.  No such complications arose and Jane was discharged from the hospital after about a week.

Today, the triplets are in fine health and not long ago celebrated their ninth birthdays.  The parents say that each has his or her own very distinct personality.  Doctors and newspapers have called Ronan a miracle baby.  Mark Ingram described himself shortly after the birth of the triplets as “the luckiest man on earth.”  With such amazing odds against them, many point to Jane’s optimistic though realistic attitude as the key to their survival.  So what do you think about Jane and her triplets?  Such a rare complication is not likely to be see again during our lifetimes.  Comments, questions, or otherwise?  You know what to do!

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Rare Ectopic Pregnancy

Last night The Learning Channel replayed a program that I originally saw about a year ago entitled “Extraordinary Pregnancies.” It told the story of two women and their ‘extraordinary pregnancies’: Zahra in Morocco and Jane in England. The program is the repackaging of two other British programs that aired several years ago. Both women experienced rare complications from ectopic pregnancies. Each case is fascinating, to me at least, so let’s explore their cases a little more in depth–Zahra here, Jane in the next entry.

Zahra Aboutalib, a woman from just outside Casablanca, became pregnant at twenty-six years old and early in her pregnancy experienced excruciating abdominal pain. The pain eventually went away and in 1955 she went into labor. After laboring for more than two days, her family decided to take her to the closest hospital. In the hospital she saw other women undergo cesarean section and die because of the poor conditions in the hospital. Doctors told her she must have a c-section, too, and she decided she did not want to die too. She left the hospital still in pain and went home. Eventually the pain ceased and she remained pregnant. In Moroccan culture, there is a belief that babies can “sleep” inside of their mothers for indefinite periods of time. Assuming she had a sleeping baby, Zahra continued her life and adopted three children remaining pregnant for 46 years until terrible pain returned in her early 70s. Her children finally insisted she see a doctor. Doctors examined her and believed she had an ovarian tumor. After several rounds of testing and imaging, the doctors realized she was still carrying the child she conceived nearly five decades before.

When Zahra had become pregnant years before she had had an ectopic pregnancy in the fallopian tube. An ectopic pregnancy is any implantation of a fertilized egg outside of the uterus. As the fetus grew the fallopian tube expanded and finally burst, cause the pain early in her pregnancy. This occurrence can be quite dangerous for the mother and very often results in the death of the fetus. Amazingly, Zahra’s fetus continued to grow and attached itself through its placenta to Zahra’s internal organs. Because her fetus was outside of the uterus she could not vaginally deliver the child when she went into labor. C-section would have been the only way to extricate the child, though because of the dangerous circumstances she and her child may have perished. When the pain of labor subsided it was because her child has died inside of her. Her body could not absorb the child and, recognizing it as a foreign object, began to calcify the child resulting in what is called a lithopedion (stone child).

When the doctors decided to operate they faced a difficult challenge. The calcification of the baby Zahra bore had attached itself to many of her internal organs and her peritoneum (the lining of the abdominal cavity). The surgery was dangerous, but after hours of delicate maneuvering the surgeons were able to remove the whole, calcified child from Zahra’s stomach. The medical team dissected the lithopedion to study just how the calcification process works in cases like this. Zahra’s is one of the oldest lithopedions ever recorded. Zahra recovered fully from the procedure and returned to normal life.

Lithopedions are rare and are an extremely interesting occurrence. As the world moves towards a more Western model of medicine it is less likely that lithopedions will develop as most ectopic pregnancies can be surgically treated with less of a risk of to the mother and child. However, when other complications arise, that may change as we will see with the case of Jane in the next entry. Stay tuned! Comments, question? I’d love to hear from you.

The First Oophorectomy

Having had an oophorectomy, I am incredibly interested in the surgical removal of ovaries.  Removal of one ovary is called a unilateral oophorectomy; removal of both is bilateral.  Usually, when an ovary is removed, the fallopian tube associated with it is also removed.  This is called a salpingo-oophorectomy.  My interest usually lies in new surgical techniques and the philosophical implications of an oophorectomy.  But, of course, my training in history leads me inevitably to investigating the historical genesis of the oophorectomy.

So, where and when was the first successful oophorectomy performed, you ask?  Actually, it happened just down the road from here in Danville, Kentucky on Christmas Day, 1809.  Who’d have guessed it, right?  Actually, this is not the most talked about first in medical history so it could have easily passed me by had I not spent a summer in Danville five years ago.  There is a statue to the surgeon who performed the first oophorectomy (referred to then as an ovariotomy) alongside his interred remains in a park very near Centre College in Danville.

Ephraim McDowell, the surgeon in question, was a sparsely trained country surgeon in Kentucky between 1795 and 1830.  He studied medicine at various places in Virginia and Scotland, though never attained a degree.  (He was later granted an honorary M. D. in 1825 from the University of Maryland.)  He married Sarah Shelby, the daughter of the first Governor of Kentucky Isaac Shelby.  McDowell’s practice was nothing out of the ordinary until December 13, 1809 when he was summoned to attend to a woman in Green County, Kentucky about 60 miles away.

This woman, Jane Todd Crawford, 46, was believed to be pregnant past term.  Upon examination, McDowell diagnosed a very large ovarian tumor.  He explained to Crawford the dangers of both leaving the tumor untreated and of operating on the tumor.  No such operation had been performed successfully before, so she would almost certainly die as a result, though she was likely to die quickly otherwise.  She decided to move forward with the surgery.  She arrived at McDowell’s house on Christmas as prescribed to undergo the operation.

McDowell began the surgery without the aid of anesthetics or antiseptics.  The procedure took 25 minutes.  He removed a cystic mass, partially solid and partially liquid, weighing 22.5 pounds.  Crawford not only recovered, but lived for thirty-two more years.  McDowell did not write up the notes on this case until seven years afterward in which time he performed several more abdominal surgeries successfully.  When he did write up his notes, he mentioned that when visiting Crawford in her room five days following the surgery he found her making her bed.  (Having undergone the same procedure with modern benefits and a tumor only half that size, I can tell you that is nothing short of miraculous.)

The reasons McDowell and subsequent scholars have pointed to as the reasons why his surgical techniques are several in number.  First of all, McDowell carefully cleansed every surface he touched including bathing Crawford’s intestines before replacing them in the abdomen.  Also, McDowell removed the blood that collected in Crawford’s open abdomen before suturing the incision.  Blood left in the body following surgery accounted for a great number of illnesses and deaths during that time.  Another step taken by McDowell to ensure success was placing a ligature at the base of the affected fallopian tube where it met the uterus.  This ensured that blood would not continue to flow to the ovary and tumor during the operation.  Furthermore, McDowell closed the abdomen with large interrupted sutures including adhesive to promote the apposition of skin.

McDowell’s innovations and sheer daring culminated in an achievement that is often referred to as the founding of abdominal surgery.  There is some debate over whether he was the first to perform an “ovariotomy,” though it seems clear to me he was.  It is a stretch to say he was the first to successfully perform an abdominal surgery, especially considering the first recorded, mutually-successful cesarean section was performed in 1500 in Switzerland.  In any event, McDowell’s techniques were pioneering and generally successful.  Modern procedures still closely resemble what McDowell did in 1809.  Questions?  Comments?  Go for it.

Vaginal Rejuvenation

While there are a myriad of possible gynecological surgeries, which ones do women elect to have performed?  In the past tubal ligation and varying degrees of hysterectomy have been the most popular elective gynecological surgeries.  In the 1990s, though, elective c-sections began to boom.  Recently, however, a growing movement has developed in backlash to the increased number of unnecessary c-sections in the United States–both voluntary and involuntary.  Now, there is a new trend towards cosmetic gynecological surgeries such as “vaginal rejuvenation” procedures.

What are currently the most popular “vaginal rejuvenation” surgeries?  Labiaplasties are rising in popularity.  A labiaplasty is a plastic surgery that involves tightening of loose labial folds or removal of extra tissue of the vulva.  After childbirth, with age, because of disease, or because of genetics women may have labia that they feel is large or perhaps too loose.  Surgeons can perform reductions of this tissue to make it smaller and/or tighter feeling.  These surgeries can now be done with the assistance of laser, which are meant to help the healing process.  The American College of Obstetricians and Gynecologists (ACOG) issued a statement in 2007 stating that there is no documentation of the efficacy and safety of such a procedure.  The risks include those inherent with any surgical procedure (clots, bad reaction to anesthesia, etc), botched outcome leading to further complications or surgeries, and the ring of scar tissue created causing issues with childbirth.  A woman with such scar tissue would be less likely to be able to deliver vaginally, and would face enormous complications if she did.  Young women have labiaplasties more often than older women, thus the concern for childbirth.

Other “vaginal rejuvenation” surgeries include hymenorrhaphy and vaginoplasty.  Hymenorrhaphy is rarer than labiaplasty and bears fewer risks.  It is a simpler surgery in which an already ruptured hymen is recreated in order for the woman to prove (or feign) virginity.  Vaginoplasties are much more invasive and dangerous.  A vaginoplasty is performed in order to tighten or reconstruct vaginal muscles.  Reasons for vaginoplasty can include disease, childbirth, or other trauma to the vagina.  However, many women now seek vaginoplasties because they feel it will increase their pleasure and sensitivity during sex.  As the ACOG points out, though, there is no evidence to support this assumption.  Vaginoplasties are also very common among males seeking gender reassignment surgeries, as a vagina can be created out of penile or scrotal tissue.  Most associations and societies of plastic and cosmetic surgeons do not yet count or keep track of the abovementioned plastic surgeries, or have only recently begun tracking them.  So it is difficult to say how many such surgeries are performed every year.  However, it is clear even from the basic figures that the numbers of these elective surgeries are increasing exponentially every year.  (One figure shows that about 600 were performed in 2005, 1,000 in 2006, and over 4,000 in 2007.)  It is a whole other topic to discuss the socio-psychological reasons why women choose such surgeries, but what do you think?  Would you ever be willing to go under the knife for such a procedure?  Other comments or questions?  Shoot!