Management and Therapy of Early Pregnancy Complications: First and Second Trimesters

1. A Brief History of Obstetric Complications

Stefan Iliev Savchev1Juan Carlos Bello-Muñoz1Gian Carlo Di Renzo  and Luis Cabero Roura 


Maternal-Fetal Medicine Unit – Obstetrics Department, Quiron University Hospital Barcelona, Barcelona, Spain


Department of Obstetrics and Gynecology, Centre for Perinatal and Reproductive Medicine, Santa Maria della Misericordia University Hospiatal, Perugia, Italy


Department of Ob/Gyn and Center for Perinatal and Reproductive Medicine, Vall d’Hebron University Hospital, Universidad Autonoma de Barcelona, Barcelona, Spain

Gian Carlo Di Renzo


Luis Cabero Roura (Corresponding author)


People have been writing about the diseases of women for as long as there has been medical writing. Nearly a fifth of the oldest collections of western medical texts since that attributed to Hippocrates are dedicated to the female body [63]. Soranus of Ephesus, a renowned medical author who died prior to the birth of Galen (Fig. 1.1a, b), wrote his most important texts precisely on gynecology [46].


Fig. 1.1

Galen (a) and his book (b): “Galeni….omnia quae exant opera in Latinum sermonem conversa”. Juntarum quarta editionem. Venetiis 1565. Folio 360 × 240, front. Inc.Voll. 11

There exists a significant body of specialized gynecological texts, with more than a hundred chapters produced between the fourth and fifteenth centuries [53]. It has to be acknowledged that most of those texts were focused on the childbirth and its complications; but no doubt, early and late obstetric complications have also played an important role in history. There are a few well-preserved documents that emphasize how important some of those cases and their treatment were: For example, in 408 A.D. empress Eudoxia, wife of Byzantine emperor Arcadius, suffered a well-described septic abortion which, eventually, led to her death (Fig. 1.2). According to the chronicle kept by Cedrenus and Zonaras [50], the empress’ unborn child died, and a severe infectious process compromised the patient. “Blood mixed” with worms poured out from her genitals. So great was the malodour of the environment that all the herbs of India and the known perfumes could achieve nothing; her body smelled as if she had died many days previously. At the same time a high fever gripped her whole body, making it “a real pyre.” Her condition worsened and her entourage “summoned Abbot Arsakiosto give her the Holy Communion.” After that, “the child was aborted, dead.” Her entourage, satisfied, ordered a litany; unfortunately, during the ritual, the empress “vomited out her soul.” This, of course, had an important impact on the succession line to the throne and, therefore, in history.


Fig. 1.2

Septic abortion

Another matter of truly particular interest to the ancient people was whether or not a woman was capable of becoming or was, indeed, pregnant. In the ancient Egypt [3354], physicians had recognized the procreative relationship between sexual intercourse and pregnancy. They regarded the male’s contribution as a “seed” that is planted onto the fertile ground of the female uterus. The semen was believed to originate in the spinal cord (Fig. 1.3a, b). This misconception was set forward by Egyptian priests who were engaged with sacrifices of bulls to the gods. (They perceived the phallus of the bull as an extension of the spine, since bovine retractor penis muscles are attached to the sacral vertebrae.) Therefore, infertility was more a male nervous condition rather than a female tare. The maternal part in reproduction was unclear since they did not realize that sperm traveled to the uterus and to the tubes, nor did they recognize the ovaries. The female body served as an incubator for the fetus; the uterus was a vessel, but curiously the vital role of the placenta in fetal nourishment was already appreciated.


Fig. 1.3

Ancient Egyptian (a) and their concept of male fertility: the semen was believed to originate in the spinal cord (b)

Just a few from the known methods for pregnancy diagnosis in ancient Egypt have survived to our days – a thorough account of the number of matinal vomits and the “onion test” which consisted in putting an onion deeply into the vagina and checking the woman’s breath the morning after, thus considering an onion smell as a positive result (Fig. 1.4). No relationship between lack of menses and gestation is described in ancient texts. Consequently, early miscarriage was not taken into account, and pathologies as extrauterine pregnancy were not even considered possible.


Fig. 1.4

Onion test on dilute vaginal discharge morning after, thus considering an onion smell as a positive result

The first description of pregnancy tests comes from the Berlin Papyrus, which also gives instructions for predicting the sex of the fetus: urine from a pregnant woman was poured on grains of barley and emmer wheat. If they sprouted, a pregnancy was confirmed. If barley sprouted first, the fetus was a male. If the emmer wheat sprouted first, it meant a female, and if none grew the pregnancy would fail [85].

The correct diagnosis of the early pregnancy complications and their management are fairly recent, bound to the development of modern imaging techniques. We think it would be of readers’ interest to have a historic perspective of the perceptions and the understanding of ancient physicians about spontaneous abortion, recurrent pregnancy loss (miscarriage), and later ectopic pregnancy and gestational trophoblastic disease.

1.1 Miscarriage

Ancient cultures have applied a variety of fascinating therapies to prevent the occurrence and reoccurrence of miscarriage. Ceremonies of ritual purification, special prayers, and a variety of medicinal therapies were employed throughout the ages to prevent this feared event. Rituals to memorialize and help mourn the lost pregnancy were developed in many cultures [334379]. These rituals reinforce how deeply men and women were affected by early pregnancy loss [49].

The middle ages saw a big change to the attitude regarding early pregnancy loss, mainly because the interest of physicians, priests, and lawmen throughout was to determine whether there were criminal intentions or not behind the miscarriage. The actual causes of even recurrent miscarriages and the way to prevent or treat them remained largely neglected.

The figure of miscarriage was suspiciously scarcely considered in the nineteenth century. Jackson [44] looks at eighteenth-century British court records to document how women described pregnancy losses in defending themselves against infanticide charges. Dr. Shannon Withycombe [84] examined nineteenth-century medical and personal perspectives finding a veil upon the information regarding causes of miscarriage within the medical records of those times. Kastor argues from a close reading of sources from the Lewis and Clark expedition that Sacagawea was treated for a miscarriage on route (Fig. 1.5). Sacagawea was the hostage/wife of a Canadian mercenary hired by the explorers to guide them through the wild western territory of what today is the state of Nebraska. The chronicles from the expedition relate how the entire crowd was committed to stop because of a massive bleeding that had nearly cost the young woman her life and how she treated herself with “a tea made from roots and berries collected from the woods” [47].


Fig. 1.5

Detail of “Lewis and Clark at Three Forks” by Edgar Samuel Paxson, mural in lobby of Montana House of Representatives

Over the past five decades, scholars have begun to document the changing representations and experiences of miscarriage. Sources are thin for women’s experiences before the 1960s, so historical conclusions are, by all means, fairly speculative, though well argued [6669]. Clearly, the subject remained in the underworld of medical science until as long as the beginning of the twentieth century. As Hedley [35] mentioned “Neglecting a threatened abortion is to increase the danger of the ovum being expelled from the uterus and in the case of actual abortions, there is the considerable risk of infection if no care is taken.” It was, probably, the first mention of miscarriage as a pathological condition with its inherent risks.

As mentioned above, it was not until the first half of twentieth century when recurrent miscarriage and threatened abortion became medical subjects. The advent of hormones and hormonal therapy for conditions such as diabetes [55] or hypothyroidism [61] changed the prospects for successful pregnancy of affected patients. Few decades later, the interest switched to the immunology of recurrent miscarriage [2], which accepts the important role that autoimmune conditions played in the pathophysiology of this condition [18].

Throughout the last few decades, with the mass implementation of ultrasonography in the practice of gynecology, the diagnosis of nonviable pregnancy became straightforward, and the term missed abortion was added to the medical terminology [28]. The awareness that 20–30 % of all pregnancies end up with loss in the first half of pregnancy led to many studies on its etiology and important changes on the current perception of miscarriage and its genetical, hemorheological, immunological, and hormonal background. It could be said that, currently, physicians are able to establish the cause for the vast majority of those events [67].

1.2 Abortion

The practice of abortion as the medical removal of a fetus has been known since ancient times. Many of the methods employed in early and primitive cultures were nonsurgical. Physical activities like strenuous labor, climbing, paddling, weight lifting, or diving were common techniques. Others included the use of irritant leaves, fasting, bloodletting, pouring hot water onto the abdomen, and other dangerous methods [19]. Documents from more recent time provide us with the wide choice of abortifacient used in different cultures throughout the world. In the nineteenth century, the advance in surgery and anesthesia gave another tool for ending undesirable pregnancy. The criminalization of abortion only served to make it clandestine, proving it to be a dangerous procedure and often having serious consequences or resulting in death. The twentieth century witnessed legalization of abortion in most of the developed world, refining of the surgical technique, antibiotic prophylaxis, and introduction of modern medical abortion methods. Unfortunately in the developing world, where access to medical facilities is difficult, abortion continues to be a dangerous act, still claiming lives. Abortion-related mortality will occur mainly or exclusively as a result of unsafe abortion, as spontaneous abortion is rarely a cause of death. Unsafe abortion-related mortality is rather likely to be underreported because of stigma attached to the procedure. The number of maternal deaths due to unsafe abortions was usually estimated from community reports or hospital data of abortion deaths as a percentage of all maternal deaths. Besides, there is a consistent relationship between sub-register of cases and higher mortality rates among poor communities from developing countries [682].

1.3 Ectopic Pregnancy

From its indirect reference by Abulcasis (Fig. 1.6a, b) (936–1013) and until the nineteenth century, the ectopic pregnancy was known as a un iversally fatal accident. The first description of the mechanism of ectopic gestation comes from French physician Pierre Dionis (Fig. 1.7a, b), who in 1718 wrote, both accurately and poetically:


Fig. 1.6

Albucasis, based on “I grandi vecchi della medicina” by Luciano Sterpellone, 1988. (a) and abdominal pregnancy (b): Albucasis (936–1013), the Arab Muslim physician, is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates


Fig. 1.7

Pierre Dionis (a) in 1718 described a rupture of a tubal pregnancy (b)

If the egg is too big, or if the diameter of the tuba Fallopiana is too small, the egg stops and can get no farther, but shoots forth and takes root there; and, having the same communication with the blood vessels of the tuba that it would have had with those of the womb, had it fallen into it, it is nourished, and grows big to such a degree that the membrane of the tuba being capable of no such dilatation as that of the uterus, breaks at last, and the foetus falls into the cavity of the abdomen; which occasions the death of the mother by breaking open its prison [7].

By reporting successful treatment of tubal pregnancy with salpingectomy in 1884, Robert Lawson Tait (1845–1899) (Fig. 1.8a, b) started an era of almost 70 years of exclusively extirpative treatment of ectopic pregnancy. In 1888, Tait was able to report his results for 42 cases of laparotomy for ruptured ectopic pregnancy, with only two deaths, including that of his first case. In several of these cases, the pregnancy had clearly been discharged from the tube into the peritoneal cavity after some weeks of gestation, but had continued to grow until symptoms and signs demanded intervention. In another paper in 1888, Tait established clearly from a postoperative specimen that this course of events, hitherto only suspected, could indeed occur. Laparotomy remained the mainstay of treatment – and indeed of diagnosis – of ruptured ectopic pregnancy until the last two decades of the twentieth century. Diagnostic ultrasound (Fig. 1.9a, b), quantitative measurement of ß-hCG levels, and laparoscopic surgery now mean that in most cases of ectopic pregnancy, laparotomy can be avoided. Side by side our understanding of the natural history of ectopic pregnancy improved. Preservation of future fertility became possible with the introduction of conservative surgical procedures and with the use of methotrexate. In the 1980s, methotrexate was first used to treat ectopic pregnancies. A study by Stovall [77] described outpatient treatment of ectopic pregnancy with methotrexate. A single-dose protocol was developed subsequently. The advances in the surgical and medical treatment of ectopic pregnancy over the past 110 years achieved dramatic decrease in mortality rate from 72 to 90 % in 1880 to 0.14 % in 1990 [58].


Fig. 1.8

Robert Lawson Tait (a) reported a successful treatment of tubal pregnancy with salpingectomy in 1884 (b)


Fig. 1.9

Diagnostic ultrasound of a tubaric pregnancy: (a) draw representing the transvaginal examination of a tubal pregnancy; (b) an ultrasonographic tubaric pregnancy image

1.4 Gestational Trophoblastic Disease

The term trophoblastic disease describes a continuum of tumors that arise in the fetal chorion of the placenta. They have been known since antiquity but have been poorly understood. In 400 BC, Hippocrates first described hydatidiform mole (Fig. 1.10a, b) as “dropsy of the uterus”; while in 600 AD, Aetius of Amida described a uterus “filled with bladder-like objects,” which probably also represented this process.


Fig. 1.10

Hippocrates, based on a sculpture, (a) first described hydatidiform mole (b)

In 1700, Smellie first related the terms hydatid and mole, but it was not until 1827 that Velpeau and Boivin first recognized hydatids as cystic dilations of chorionic villi. Sanger in 1889, coined the term sarcoma uteri deciduocellulare as a malignant tumor derived from the decidua of pregnancy. In 1895, Marchand demonstrated these tumors to be the sequelae of pregnancy, abortion, or hydatidiform mole and described the proliferation of the syncytium and cytotrophoblast. In 1903, Teacher confirmed Marchand’s work and negated Sanger’s theory of sarcomatous degeneration of the decidua. Finally, Fels, Ernhart, Reossler, and Zondek (Fig. 1.11) demonstrated excessive levels of gonadotropic hormone in the urine of patients with these processes [34].


Fig. 1.11

Bernhard Zondek, based on a photograph

Historically, trophoblastic disease has been classified as either hydatidiform mole or gestational choriocarcinoma. They share three unusual characteristics as follows: (1) curability with chemotherapy, (2) production of human chorionic gonadotropin (hCG), and (3) origin in tissue genetically different from the host.

Metastatic gestational trophoblastic disease was first reported as showing a complete response to chemotherapy after treatment with methotrexate in 1956 [3748]. This initial report was followed in 1961 by documentation that approximately 50 % of the patients with this condition remained free of disease, and for the first time, there were 5-year survivors [36]. These tumors produce hCG, and measurement of this hormone was the basis for establishing the diagnosis, determining the response to chemotherapy, defining complete remission, and detecting the rare recurrences. hCG became the perfect “tumor marker” for this disease. Finally, because of its origin in fetal tissue, these tumors contain histocompatibility antigens derived from the father, which could elicit stronger immune responses than normally would be made to tumor-associated antigens.

Early in the history of successful chemotherapy for these tumors, it was assumed that the unparalleled success of chemotherapy was the result of synergistic effects between cytotoxic chemotherapy and immunologic rejection. Despite their rarity, these cases became interesting to many types of medical specialists. Because they can arise in any type of pregnancy (term delivery, abortion, and ectopic or molar pregnancy), obstetrician-gynecologists are responsible for the management of the pregnancy event and the detection of trophoblastic disease sequelae. Medical and gynecologic oncologists have continued to develop more effective chemotherapeutic programs for these tumors with the stated goal of curing all patients, an achievement which currently is possible except for the few patients at highest risk of not responding to treatment. Endocrinologists are involved in studying the biology and chemistry of hCG and its subunits and in developing sensitive and specific assays for these measurements. Pathologists are essential for diagnosing the various forms of trophoblastic neoplasm and differentiating these tumors from others that also may produce hCG. Cytogeneticists have contributed enormously to our understanding of the fertilization events that lead to the varieties of molar pregnancies. Finally, immunobiologists actively study the effects of the presence of paternal antigens in the tumor as a cause, part of the natural history, and in relation to the response to therapy of these tumors [5264].

1.4.1 Puerperal Infections

Considering the little available evidence and as the existing historical documents permit one to judge, childbed fever is a modern disease. The cases reported by Hippocrates generally identified as such were not indeed puerperal fever. Hippocrates himself never identified it as a separate and distinguishable disease [18].

Scholars have suspected first the existence of yet unclear disease of childbed fever in the second half of the seventeenth century at the Hôtel-Dieu in Paris. Phillipe Peu relates that mortality among childbearing women was very high, the year 1664 being particularly devastating [32]. The mortality because of puerperal fever continued to rise with the development of big teaching hospitals across Europe. So one could say that puerperal fever was, likely, the first nosocomial disease. Nonetheless, it took decades and hundreds of thousands of lives to realize that. It is impossible to write about the history of puerperal fever without mentioning one of the most unfairly treated heroes in the history of medicine: Dr. Ignaz Philipp Semmelweis (Fig. 1.12).


Fig. 1.12

Ignaz Philipp Semmelweis, based on a photograph, 1861

Dr. Semmelweis worked at the Vienna General Hospital’s maternity clinic on a 3-year contract from 1846–1849. There, as elsewhere in European and North American hospitals, puerperal fever was rampant, sometimes killing as many as 40 % of admitted patients. He was disturbed by these mortality rates and eventually developed a theory of infection, in which he theorized that decaying matter on the hands of doctors, who had recently conducted autopsies, was brought into contact with the genitals of birthgiving women during the medical examinations at the maternity clinic. Then he proposed a radical hand-washing theory using chlorinated lime [345].

From his theory, he was able to explain other features in the dataset, for instance, why mortality rates were remarkably higher during winter than summer, because of increased student activity and scheduled autopsies immediately before the rounds at the maternity clinic. He also registered how the second obstetrical clinic at Vienna General Hospital, which instructed midwife students, evidently had a lower mortality rate than the first one, where physicians were instructed.

He managed to oblige the assistants of the first clinic to avoid the morgue in the months of December 1846 and January, February, and March 1847. Restricting examinations to the minimum also reduced the opportunity for the patients to be touched by contaminated hands. With these simple interventions, mortality in the first clinic was dramatically reduced during those months [70].

He was also able to explain why women with extended dilation invariably died: “Infection occurs most often during dilation. […] is frequently necessary to penetrate the uterus in manual examination (Fig. 1.13) to determine the location and position of the fetus. Thus, before chlorine washings, almost every patient whose period dilation was extended died of childbed fever.”


Fig. 1.13

Uterine manual examination in puerperium, by hands of doctors, who had recently conducted autopsies

At that time, however, the germ theory of infection had not been developed, and Semmelweis’ ideas ran contrary to key medical beliefs and practices. His ideas were rejected and ridiculed. Quite unusually, his contract was not renewed, effectively expelling him from the medical community in Vienna. He died as an outcast in a mental institution a few years later [5].

In 1878 Robert Koch discovered that most infection-causing microbes were not airborne, but instead they were transferred from one surface to the other through direct contact. Consequently, there was a large transformation of the surgical field from antisepsis to asepsis, a process that attempted to create a germ-free environment in the operating room and the obstetrical ward.

Sir Joseph Lister (Fig. 1.14), between 1883 and 1897, was a British surgeon and a pioneer of antiseptic surgery (Fig. 1.15). By applying Louis Pasteur’ s advances in microbiology, he promoted the idea of sterile portable ports while working at the Glasgow Royal Infirmary. Lister successfully introduced carbolic acid (now known as phenol) to sterilize surgical instruments and to clean wounds, which led to a reduction in postoperative infections and made surgery safer for patients.


Fig. 1.14

Sir Joseph Lister. Based on “Trattato di Medicina Minore” by E. Cova, 1947


Fig. 1.15

Lister was the pioneer of antisepsis, using, primarily, the sterilization by fire. Based on “Manuale di Ostetricia” by Spirito. Edizioni Idelson, 1948

Finally, obstetricians in the United Kingdom succeeded in probing what Semmelweis seeked to demonstrate: that the advent of pathological anatomy, and consequently the increase in autopsies, was correlated to the incidence of childbed fever. Consequently hereto, maternity hospitals in the United Kingdom were independent institutions, removed from general hospitals. The students were forced to concern themselves exclusively with obstetrics, thus not carrying out germs from pathological autopsies.

The advent of asepsis and the later arrival of antisepsis changed definitively the face of puerperal fever. And numbers remained mainly unchanged until the middle of the twentieth century when antibiotics made their entrance in history.

Sir Alexander Fleming (6 August 1881–11 March 1955) was a Scottish biologist, pharmacologist, and botanist. His best-known discoveries are the enzyme lysozyme in 1923 and the antibiotic substance benzylpenicillin (penicillin G) from the mold Penicillium notatum in 1928, for which he shared the Nobel Prize in Physiology or Medicine in 1945 with Howard Florey and Ernst Boris Chain (Fig. 1.16).


Fig. 1.16

Sir Alexander Fleming discovered antibiotic substance benzylpenicillin (penicillin G) from the mold Penicillium notatum in 1928. Based on “I grandi vecchi della medicina”, by Luciano Sterpellone, 1988

Puerperal fever remains among the first five causes of maternal death around the world, but percentages have fallen far below the 0.01 % of deliveries in the developed world.

1.4.2 Obstetrics as a Medical Specialty

Midwifery remained an artisanal female role during the entire middle age. The figure of a “Man-Midwife” was equally feared and ridiculed for centuries. The role for the physician summoned to the bedside of a childbirthing woman was, mainly, the desperate surgical attempt to extract a dead fetus (usually in pieces) in order to save the mother’s life (Fig. 1.17).


Fig. 1.17

Midwife attending a cesarean section. Based on a 15th century German woodcut

During the sixteenth century, the French military surgeon Ambroise Paré (1510–1590) founded a school for midwives in Paris. Paré (Fig. 1.18) wrote about podalic version and breech extraction and about cesarean section (Fig. 1.19), which he is said to have either performed or supervised not only after the death of the mother but also, at least twice, on living women. One of Pare’s pupil midwives went on to attend the French court, and one of the babies she delivered – a girl named Henrietta Maria – eventually became queen of England at the age of 16 when she married King Charles I in 1625 [23].


Fig. 1.18

Ambroise Paré. Based on “Deux livres de chirurgie, de la génération de l’homme, et manière d’extraire les enfans hors du ventre de la mère”, 1573


Fig. 1.19

Extraction of a fetus in breech presentation, during a cesarean section. Based on “Foetus description” by J.P. Maygrier, 1822

The best known of the French accoucheurs was Francois Mauriceau (Fig. 1.20) (1637–1709), whose name is familiar to today’s obstetricians by reason of the so-called Mauriceau-Smellie-Veit maneuver for dealing with the aftercoming head in a breech delivery. In 1668 Mauriceau published his celebrated text, traite des maladies des femmes grosses, which was translated into several languages and went through many editions. Mauriceau was a visionary and a pioneer; nonetheless, he rejected the idea of performing cesarean section and, the only opportunity he had in his life to work with obstetric forceps, disappointed him forever.


Fig. 1.20

The female anatomy. Based on “De conceptu et generatione hominis” by Jacob Roof, Zurich, 1554

1.4.3 Operative Vaginal Delivery

Operative vaginal delivery has been described as far back as the sixth century BC in Hindu medicine. Further reference to instrumental delivery can be found in writings of Hippocrates during the Greek and Roman era between 500 BC and 500 AD. Intervention in these circumstances involving the use of surgical instruments or even kitchen utensils would serve purely to remove the dead fetus in an attempt to avoid maternal mortality [57]. The establishment of forceps-assisted delivery as a means of avoiding both maternal and neonatal morbidity has developed over several centuries and for many years was kept a closely guarded secret by its inventors.


In the sixteenth century, the French Huguenot William Chamberlen fled to England from Catherine de Medici after her ban on Protestant physicians, and it is with his two sons Peter Chamberlen, “the elder” (Fig. 1.21), and Peter Chamberlen, “the younger,” that the story of forceps as an instrument to deliver live infants begins. Both were members of the Barber Surgeons Company, and both fell out of favor with the College of Physicians for nonattendance at lectures. Despite this, Peter the elder and Peter the younger were both to have significant roles in the practice of “man-midwifery” or as it later became known, obstetric [2438].


Fig. 1.21

Peter Chamberlen. Based on “Trattato di Ostetricia e Ginecologia”, 1968

While it is not entirely clear which of the brothers invented forceps, it is often accredited to Peter the elder. The Chamberlain quest to protect their invention led to extensive means of concealment. The instruments themselves were always carried in a gilded chest and revealed once the woman had been blindfolded. The birth subsequently took place under blankets with only the Chamberlens in attendance of the patient. It was through these elaborate measures that the Chamberlens were able to keep the secret of forceps for nearly a century (Fig. 1.22).


Fig. 1.22

Chamberlen Forceps, from “Obstetric Forceps”, Kedarnath DAS, 1929

On 19 August 1670, Moriceau had a historic meeting with Hugh Chamberlen, who boasted of making a woman give birth in 8 min and offered to sell his secret invention, the forceps, for a large amount of money. So he was invited by Moriceau to apply the forceps on a stunted woman that he had failed to give birth to. Hugh Chamberlen was locked in a room together with the woman in labor, and, after 3 h of attempts, he failed to carry out the delivery. The patient died the following day, due to a uterine rupture. Hugh Chamberlen returned to London, and her family hid the invention of forceps for another two centuries, until forceps were found in the ceiling of a London house.

He did however gain a copy of “Observations sur la grossesse et l’accouchement”; Mauriceau’s 1668 (Fig. 1.23) text which he translated into English under the title “The Accomplish’t Midwife.” In the preface he publicly alludes to his secret instrument and says, “My lather, brothers, and myself (though none else in Europe, as I know) have, by God’s blessing and our industry, attained to, and long practised a way to deliver women in this case without any prejudice to them or their infants : though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy one or both with hooks.” He thus apologizes for not having divulged this secret: “there being my father and two brothers living that practise this art, I cannot esteem it my own to dispose of nor publish it without injury to them.”


Fig. 1.23

Francois Mauriceau and its instruments. Based on “Des maladies des femmes grosses et accouchées” by Mauriceau, 1668

In 1673 following the success of the translated text, Hugh became the physician in ordinary to King Charles II and in 1685 was elected a fellow of the Royal Society. Later while supporting James II, Hugh was accused by the College of Physicians of practicing without a license after the King’s forced abdication. This led him to flee to Holland where he is said to have sold some instruments to a Dutch obstetrician named Van Roonhuysen, to Cornelius Bokelman, and to Frederik Ruysch (a celebrated anatomist). In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it universally known. Very likely, all the known forceps from then and until our days are, somehow, heirs of that original model.

Several illustrious names were added to the list of improvers of the device, such as Dr. Simpson from Edinburgh, Dr. Franz Naegele from Heidelberg, or Dr. Kjelland from Oslo. With the improvement of surgical technique for cesarean section, operative delivery fell in decay. Nowadays, nearly a 10 % of deliveries around the world are assisted with forceps or, more recently, by vacuum cups [1523].

Turning (obstetric version) on its original conception was a procedure related to changing the position of a living child so that the feet were brought down foremost into the vagina. There is little evidence of its use at the antiquity. In the writings of Aspasia and Philumenus, we find directions for turning the child. Thus Philumenus states, “Si caput foetus locum obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur.” At a still later period, Celsus (Fig. 1.24a, b) gave similar directions, but to all appearance they also merely apply to a dead child “Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est,” and again he says, “Sed in pedes quoque conversus infans, non difficulter ex- trahitur. Quibus apprehensis per ipsas manus commode educitur” (Celsus, de Medicina, lib. vii. cap. 29.). From that time the whole subject seemed to sink into oblivion, until Pierre Franco in his work on surgery proposed the extraction of the child with the turning. Nowadays, obstetric version on its original inception is no longer considered a safe procedure. More recently the external cephalic version was developed as a mean for reducing the requirements of cesarean section because of breech presentation [81].


Fig. 1.24

Aurelius Cornelius Celsus (a), letterpress. Wellcome Library, London. Uterine dilatators (b), based on “Histoire des accouscements chez tout le peuples” by Witkkowski G.J., 1887

Cesarean Section

Although the early records of the cesarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed (Fig. 1.25). The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, 508 BC Scipio Africanus (Fig. 1.26), who lived about 200 years later and is said to have been born in a similar manner. There is no reason to suppose that Julius Caesar (Fig. 1.27) was born by this operation, or still less that it derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very unlikely if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor Naegele: that one of the noble patricians of Julian families at Rome had been delivered ex caso matris utcro and had been named Caesarea (“born through a cut”) from this circumstance, so that the name was derived from the operation, not the operation from the name. The earliest account of it in any medical work is that in the Chirurgia Guidonis de Cauliaco, published about the middle of the fourteenth century. Here, however, the practice is only spoken of as proper after the death of the mother. The first authentic operation upon a living woman in later times was the one by Jacob Nufer upon hisown wife in 1500. Dismayed by the agony and pain of his wife’s labour, he sought the help of no less than thirteen midwives to deliver their child and relieve his wife. For days they tried, and failed. When he could stand no longer to see his wife suffer, Nufer asked his wife if she would have the confidence in him to perform the operation. She agreed. Nufer seeked permission from the local authorities, who initially refused but eventually relented to Nufer’s persistent pleas. Nufer’s wife lived following the operation and eventually gave birth to five more children, all vaginally, including one set of twins. Owing to its fatal character ande the strong feeling against it, cesarean section was performed but rarely; still however sufficient evidence existed to mark its occasional success and urge its repetition in similar cases. The best documented surgical experience on cesarean section with some reports of survival is attributable to Francois Russet (1525–1598) in France [80]. In the second part of the nineteenth century, maternal mortality following classical cesarean section was still nearly 100 %.


Fig. 1.25

Representation of cesarean section on dead mother. From Gynaecological texts, Caesarean section. Wellcome Library, London


Fig. 1.26

Scipio Africanus. Based on the sculpture in Musei Archeologici, Naples


Fig. 1.27

Julius Caesar. Based on a coin, 47 b.C.

In 1876, the Italian obstetrician, Eduardo Porro (Fig. 1.28) developed a cesarean section technique consisting of uterine corpus amputation and suturing of the cervical stump into the abdominal wall incision in an attempt to prevent life-threatening hemorrhage and infection (Fig. 1.29).


Fig. 1.28

Eduardo Porro improved the so-called cesarean operation by excision of the uterus and adnexa, described in Della amputazione utero-ovarica come complemento di taglio cesareo (1876), the best known of his writings. In 1891, he was named senator of the kingdom by King Humbert I. Based on a portrait, Clendering Library Portrait Collection


Fig. 1.29

The cesarean section Porro’s technique. Based on “Dell’ amputazione utero-ovarica come completamento del taglio cesareo” by Edoardo Porro

The first operation was on patient named Giulia Cavallini (Fig. 1.30). She was born in Adria in Veneto and arrived at San Matteo in Pavia in April of 1876, newly married and pregnant for months. Giulia Cavallini has his chance: “High 1.48, had the pelvis deformed because of rickets that had struck her as a child” and Porro “soon becomes clear that the situation was dramatic: the birth canal is too narrow,” so Porro called this pelvis “the lost space.” Porro operated Giulia by cesarean section (Fig. 1.31) with the birth of Maria Alessandrina Cesarina: a healthy baby, that was fine, as well as her mother Giulia.


Fig. 1.30

Giulia Cavallini, the first patient operated by Porro. Based on a photograph in “Dell’amputazione utero-ovarica come completamento del taglio cesareo” by Edoardo Porro


Fig. 1.31

Porro cesarean method

The successful outcome in Porro’s test case was due to his adherence to surgical principles that are well recognized today, but were not firmly established in 1876. Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58 %. His innovative, carefully planned approach for cesarean hysterectomy was a major innovation in obstetric surgery.

Until the latter part of the nineteenth century, cesarean delivery was regarded as one of the most hazardous obstetric operations, to be undertaken only as a last resort. The operation was carried out 80 times in the United States before 1878, with a maternal mortality of 53 %. Abdominal hysterectomy, likewise, achieved medical respectability only in the closing decades of the nineteenth century. Before 1863, abdominal hysterectomy had proved fatal in almost 90 % of the patients in whom it was attempted; in only three cases had it been performed successfully in the United States. Cesarean hysterectomy becomes something of a paradox, therefore, when viewed in historical perspective, for it evolved from efforts to circumvent the mortal danger of abdominal delivery by the addition to it of a similarly formidable and dangerous procedure: uterine extirpation [71].

It was Max Sanger (Fig. 1.32) in 1882 who insisted that correctly suturing of the uterus was essential. Then, the advent of cesarean section without hysterectomy came along in the twentieth century. With the introduction of improved surgical techniques, asepsis, modern transfusion techniques, and Harris’ principle of early operation prior to possible infection, the mortality rates improved to be as low as 0.1 %, between the years 1943 and 1952.


Fig. 1.32

Max Sanger. Based on “Trattato di Ostetricia e Ginecologia”, 1968

Edwin Craigin, in 1916, stated the most quoted dictum in obstetrics: “Once a cesarean,always a cesarean” [59]. The dictum was valid as long as the typical cesarean section included a classical (upper segment) incision in the uterus. With the introduction of the transverse lower uterine segment incision by John Munro Kerr (Fig. 1.33) and recognition that this type of incision was not associated with an excessively high rate of uterine rupture during labor, a trial of vaginal birth after one previous cesarean section became and still is the most accepted policy.


Fig. 1.33

The transverse lower uterine segment incision. Based on “Cesarean Section: Lower Segment Operation” by Marshall J.M., 1939

1.4.4 Development of Modern Care for the Premature Infant and of the Fetal Monitoring

The nineteenth century saw shifting of the care for the future mother and her newborn from reducing mortality to focusing on morbidity. The best illustration for this is probably the fascinating birth and development of the care for the premature infant (Fig. 1.34). At the turn of the twentieth century, a baby born prematurely had dismal prospects for survival. Except for a few scattered pockets of medical interest, the knowledge, expertise, and technology necessary to help these infants was not available. “Preemies” who survived more than a day or two were often labeled “weaklings” or “congenitally debilitated” implying an inherent frailty. Survival of these tiny infants depended on many factors, mainly the degree of prematurity and the infant’s weight at birth. Many physicians pointed to the example of congenital syphilis to suggest premature birth to be nature’s way of expelling a defective fetus [62].


Fig. 1.34

Fragment of a crater of the late fifth century BC, preserved in the archaeological museum of the University of Bonn (Germany), representing the second birth of Dionysus who “disengaged” from the right thigh of Zeus

The premature infant occupied an ambiguous position between physician and mother as well as between fetus and newborn. These infants, like other newborns, were almost always born at home, unless the mother was so destitute to turn to the resources of a lying-in hospital. Although obstetricians were increasingly likely to be present at the birth of these infants over the course of the nineteenth century, their focus on the mother rarely allowed attention to the infant beyond initial resuscitation [51].

The first significant challenge to this equilibrium between doctor and mother was the invention in Paris of a medical technology directed at premature infants, the incubator. Its invention was associated with the French obstetrician Stephane Tarnier (Fig. 1.35), who in the 1870s sought to find a means to warm the numerous premature infants who routinely succumbed to hypothermia on the wards of Paris’ Maternité hospital. A visit to the chicken incubator display in the Paris zoo inspired him to have the zoo’s instrument maker install a similar device for the care of infants in 1880 (Fig. 1.36). The design of this incubator was hardly a novelty but Tarnier did two important contributions: He statistically compared premature infant mortality before and after the introduction of the device, showing reduced mortality by nearly a half, and placed the spotlight on premature infant. The second innovation was the use of Louis Antoine Champetier de Ribes’ balloon (Fig. 1.37) to promote the stimulation of childbirth, by mechanical expansion.


Fig. 1.35

Stephane Tarnier. Based on a photograph by Pierre Petit, with permission, Library of London


Fig. 1.36

Section of Tarnier’s incubator. Budin, The Nursling, 1907. Wellcome Library, London.


Fig. 1.37

Louis Antoine Champetier de Ribes’ balloon. Based on “Trattato di Ostetricia” by I. Clivio, 1945

In Nice, France, Alexandre Lion, a physician and son of an inventor, developed in the 1890s a much more sophisticated incubator than that of Tarnier (Fig. 1.38). A large metal apparatus equipped with a thermostat and an independent forced ventilation system, the Lion incubator was designed to compensate for less-than-optimal nursing or environment. The high point of Lion’s career was his opening of the Kinder-brutenstalt (“child hatchery”), an elaborate incubator baby show that became the surprise sensation of the Berlin Exposition of 1896. Medical professionals might have scoffed, but so great was the show’s popularity that similar (or still larger) shows became a regular feature of World Fairs at the turn of the century. International interest in the incubator, as measured by journal articles, surged far more dramatically than it had at the time of Tarnier’s invention [973].


Fig. 1.38

A much more sophisticated incubator of the last century. Based on “Cuveuse” by Rommel, 1913

Since the beginning of the nineteenth century, the design of the incubator changed remarkably by incorporating the ever evolving new technology. However, it cannot be viewed as the sole reason for dropping mortality rates for the premature born infants. A variety of supportive technologies came into being, both within the nursery (intravenous lines, monitors, and micromethod blood sampling) and outside (transport systems and referral networks) [76].

Another technological invention proved to change the practice of obstetrics for the decades to follow. The auscultation of the fetal heart rate and later the electronic fetal monitoring (EFM), introduced the concept of fetal well-being, fetal intrapartum distress, and means to prevent it.

Fetal heart sounds were reportedly first detected by Marsac in the 1600s. The idea that fetal heart rate could be used to determine fetal well-being was first proposed by Killian in the 1600s, but this went unnoticed until 1818 when Mayor and Kergaradec described the method of auscultating fetal heart sounds by placing the ear next to the maternal abdomen (Fig. 1.39). By 1833, Evory Kennedy, an English physician, published guidelines for fetal distress and recommended auscultation of the fetal heart rate as a tool of intrapartum monitoring. Few years earlier, Nauche and Maygrier conducted studies on fetal auscultation through the vagina, but were unsuccessful for aesthetic and functional reasons.


Fig. 1.39

J.A. de Kergaradec (1787–1877), the forgotten inventor and pioneer of the obstetrical stethoscope (upper figure) and the obstetrical stethoscopes of Pinard (image down). Based on “Trattato di Ostetricia Minore” by E. Cova, 1947

It is mandatory to mention the invention of Adolphe Pinard, an important Paris obstetrician, known for describing a significant number of obstetric maneuvers and signs and also for his devotion to public medicine and his life as a defender of medical care for pregnant women with little or no financial resources. In 1895 he invented the stethoscope, a simple, bell-shaped, conic device used to amplify the fetal heartbeat. It is likely the most widely used obstetric device in history has been a useful tool for fetal monitoring until the late 1970s in the developed world and still is in developing countries.

In 1893, von Winkel, working with the Pinard’s stethoscope, established criteria for fetal distress that remained unchanged until the advent of electronic fetal monitoring (tachycardia, FHR >160; bradycardia, FHR <100; irregular heart rate; passage of meconium; and gross alteration of fetal movement). By the turn of the twentieth century, various authors had described fever as a cause of fetal tachycardia, head compression and cord compression as a cause of bradycardia, and hyperstimulated uterine activity associated with a characteristic fetal heart rate response and asphyxia.

The fetal stethoscope – or fetoscope – was first described by David Hillis in 1917 at the Chicago Lying-In Hospital. Amid much controversy, in 1922, Joseph DeLee, Hillis’ superior at the same institution, described the device again, taking priority for its creation [16]. The device eventually became known as the DeLee-Hillis fetoscope and was at the forefront of intrapartum fetal monitoring for the next half century. Intermittent auscultation (IA) of the fetal heart rate during labor became widely recommended. Electric, amplified fetoscopes of Matthews, Marvel, and Kirschbaum made the task of fetal monitoring easier by the 1940s when IA became the emerging standard of care. It remained so until well into the 1970s and is used in some form even today [465].

However, in 1968, Benson et al. published results of a review of 24,863 labors in which IA was used throughout the 1950s. Their results concluded that IA was not a “reliable … indicator of fetal distress” except in the extreme situation of terminal bradycardia. This damning report emerged at a time when true electronic fetal monitoring (EFM) was being developed, and experts were quick to dismiss IA in favor of the hoped-for promise of EFM [1742].

In 1906 Cremer described the use of the fetal electrocardiogram using abdominal and intravaginal electrical leads that led other investigators to attempt to determine fetal status using electrocardiographic patterns only to conclude that fetal distress did not yield any consistent electrocardiographic patterns. In 1958, Hon, the pioneer of modern EFM, first described a system for capturing continuously the fetal ECG. In 1964, Callagan described a commercially viable system for capturing the FHR with Doppler technology. In the 1960s, EFM systems were made commercially available by Hon in the United States (1968), by Hammacher in Germany, and by Caldeyro-Barcia in Uruguay, father of, among other things, the Montevideo units and long-and short-term variability.

The spiral electrode or fetal scalp electrode (Fig. 1.40) as used today was introduced by Hon in 1972. More complex electronic methods of differentiating between genuine fetal signal and artifact were introduced over time to work in tandem with Doppler technology, giving rise to modern electronic autocorrelation. By 1975, just over twenty percent of labors were monitored with EFM, a number that now stands at well over eighty percent.


Fig. 1.40

The spiral electrode or fetal scalp electrode

Until recently, as new technologies have emerged, they have been adopted into clinical practice before large studies were carried out regarding their efficacies. IA was widely used for four decades before the first randomized clinical trials (RCTs), and EFM was used over a decade before the first RCT was available.

Many of the RCTs designed for EFM compare it to IA, though it should be remembered that Benson et al. were highly critical of IA in 1968. Cochrane has published a meta-analysis comparing EFM to IA which showed no difference between the two in low Apgar scores, NICU admissions, perinatal deaths, or the development of cerebral palsy (CP). There were a 50 % reduction in neonatal seizures, but a significant increase in operative vaginal delivery and cesarean delivery rates. Vintzeileos et al. did show a reduction in perinatal death in the EFM group as compared to IA, on the order of one perinatal death prevention for every 1000 births, but with an associated increase in the cesarean delivery rate of two- to threefold. Notwithstanding these controversies, EFM continues to be widely used today as a routine monitor of fetal well-being [26].

Despite the widespread use of electronic fetal monitors (Fig. 1.41a, b), uniformity of terminology and standards were not firmly established until 1997 when the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) along with other professional organizations adopted the terminology of the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop for use in describing fetal heart rate patterns [60].


Fig. 1.41

Major and oldest electronic fetal monitors: Sonicaid (a) and HP 8040A (b) compact EFM with printer

Ultrasonography was revolution in obstetrics (Fig. 1.42), since it monitored physiological and pathological pregnancy.


Fig. 1.42

An old ultrasound machine with linear probe. Modified from “Ecografia Ostetrica” by D’Addario, Kuriak. Piccin Nuova Libraria, 1989

Another important revolution was the obstetric locoregional and general anesthesia, born at 1800 by William Thomas Green Morton (1819–1868) (Fig. 1.43). At the beginning of the technique, it was used by chloroform with the mask (Fig. 1.44), made by Dr. David Lang who advised colleagues to continue anesthesia while he was dying.


Fig. 1.43

William Thomas Green Morton. Based on a photograph


Fig. 1.44

The technique was used by chloroform with the mask of Dr. David Lang

1.5 Some “Forgotten” Conditions

Many complications of pregnancy have been considered as overcome given that they are no longer prevalent in the developed world. However, some endemic diseases still carry an important burden on pregnancy risk when the pregnant women live in remote rural areas at the developing countries. Conditions such as Plasmodium falciparum malaria, schistosomiasis, Chagas’ disease, or leishmaniasis are still playing a part among the causes of maternal morbidity and even mortality worldwide [162223].

Last century witnessed the almost complete disappearance of some pregnancy complications like the false pregnancy (pseudocyesis) and puerperal fever (Fig. 1.46). Documented since antiquity, this pathology was still occurring once in 250 pregnancies in 1940s in the United States (Daley 1946) (Fig. 1.45). Nowadays pseudocyesis is all but disappeared, probably as a direct result of widespread access to ultrasound equipment.


Fig. 1.45

Lang advised colleagues to c ontinue anesthesia while he was dying


Fig. 1.46

Louis Pasteur was the first scientist to study infections in developing countries. Based on a photograph

The understanding of pregnancy complications has advanced enormously throughout the last century. Nowadays establishing early pregnancy units is widespread in the referral hospitals, and management of those complications is firmly evidence based. Unfortunately, in the developing world a number of those complications can still cost the lives of women, and there is much work to be done in order to improve the access to medical care in a timely manner (Fig. 1.47).


Fig. 1.47

In the past centuries, the evaluation of the arterial pulse was one of the few methods to clinically evaluate the maternal conditions

In the following chapters the readers will find up-to-date articles about the specific early pregnancy complications, their diagnosis, and management, presented by leading specialists in the field.

Overall, the goal of this textbook is to continue providing, in a readable, understandable, and well-illustrated format, the clinical and basic information on early pregnancy complications that can serve as a reference for the clinicians involved in the care of pregnant patients.



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