Abdominal (abdominal) pregnancy is spoken of when there is an ectopic pregnancy with the attachment of the ovum in the abdominal cavity. The condition is rare, the frequency is less than 0.5% of all ectopic pregnancies.

There are two types of abdominal pregnancy, depending on the mechanism by which the embryo enters the abdominal cavity.

• In the primary, ectopic attachment of the embryo takes place immediately after fertilization.
• In a secondary, a living embryo ends up in the abdominal cavity after a tubal abortion.

In the abdominal type of ectopic pregnancy, the embryo attaches to the peritoneum, omentum, muscles, ligaments, intestines, spleen, etc. The localization of pregnancy determines its course and prognosis.

Risk factors for ectopic abdominal pregnancy are abnormalities in the development of the genital organs, tumor processes in the fallopian tubes, a woman's age over 35, bad habits (smoking), surgery on the uterus, appendages and other pelvic organs.

In the vast majority of cases, the identification of abdominal pregnancy requires immediate surgery.

Causes

In most cases, in the etiopathogenesis of ectopic abdominal pregnancy, regardless of its type, there is a violation of the patency of the fallopian tube (or tubes).

Under normal conditions, after fertilization, the egg moves through the tube and enters the uterus, where implantation takes place.

In the presence of obstructions (tumors, adhesions, etc.) or in connection with a decrease in the peristalsis of the fallopian tube, the embryo that has entered the blastocyst stage cannot leave the tube in a natural way. Trophoblast filaments grow into the wall of an abdominal organ and implantation occurs. If the embryo is attached in a place with sufficient blood supply, the development of pregnancy continues. In other conditions, the embryo soon dies.

In a secondary abdominal pregnancy, the embryo is initially attached to the fallopian tube. After a tubal abortion with blood flow, the embryo is carried into the abdominal cavity, where re-implantation takes place. In the future, the development of pregnancy occurs in the same way as in the primary form.

The formation of membranes during the developing abdominal pregnancy occurs in the usual way.

Symptoms

The onset of an abdominal pregnancy is characterized by signs similar to those of a normal uterine pregnancy. The woman notes a delay in menstruation, swelling of the mammary glands, morning sickness. Pregnancy test is positive. Perversions of taste and emotional lability appear. Further, when examined by a gynecologist, a discrepancy between the size of the uterus and the gestational age is noted.

Quite often, this type of ectopic pregnancy is detected when intra-abdominal bleeding occurs due to the germination of chorionic villi in

vessels. In this case, the woman complains of severe pain in the lower abdomen, severe weakness. There is a decrease in blood pressure up to collapse, tachycardia. The limbs are cold, the skin is pale, covered with sweat. With massive bleeding, the phenomena of hemorrhagic shock, hemoperitoneum develop.

Important! Internal bleeding during abdominal pregnancy is a life-threatening condition. In this regard, the newly diagnosed abdominal pregnancy is an indication for hospitalization for emergency surgery.

In late pregnancy, the fetus is found outside the uterine cavity by palpation of the abdomen, the woman notes strong movements "just under the skin", small parts of the fetus are easily palpated through the abdominal wall.

Diagnostics

In the early stages, the diagnosis of abdominal pregnancy presents well-known difficulties. When making a diagnosis, the presence of risk factors in a woman, age, features of the obstetric history, menstrual cycle are taken into account.

To confirm the diagnosis, data from an objective examination, additional laboratory and instrumental research methods are used.

During a vaginal examination, there may be a discrepancy between the uterus and the expected gestational age, however, this criterion cannot be one hundred percent confirmation of the diagnosis of ectopic pregnancy.

A general blood test, a general urine test, blood and urine tests for chorionic gonadotropin, the level of which during an ectopic pregnancy is lower than during a normal pregnancy of the same period, are prescribed. According to the indications, the level of the hormone can be determined over time.

Prescribed ultrasound of the abdominal organs, if intra-abdominal bleeding is suspected, puncture of the posterior vaginal fornix, laparoscopy, radiography, computed tomography. In severe cases, a laparotomy is performed.

On ultrasound, as a rule, an empty uterus is found, the fertilized egg is localized outside of it or is absent.

Important! Laparoscopy is both diagnostic and therapeutic manipulation. Detection in the abdominal cavity of the ovum is an indication for its removal.

Differential diagnosis is carried out with uterine pregnancy with tumors of the uterus, with tumors of the uterus, ovary, abdominal organs, ectopic pregnancy of a different localization, corpus luteum cyst.

Complications

Abdominal pregnancy is a severe form of ectopic pregnancy and can cause many complications.

When a blastocyst is attached to a large vessel, chorionic villi germination through the vessel and bleeding may occur. As pregnancy progresses, the risk of intra-abdominal bleeding increases.

When the placenta grows into the organs, they are damaged. The clinic of this complication varies and depends on the location and severity of the damage.

With the progression of pregnancy, the fetal membrane unprotected by the wall of the uterus can rupture with an accidental impact, jolt. In this case, there is an outpouring of amniotic fluid into the abdominal cavity and the occurrence of diffuse peritonitis, later - sepsis. Fetal survival depends on the gestational age and the timeliness of the measures taken. For a woman, this complication is fatal.

A fetus with an abdominal pregnancy has a high risk of developing congenital malformations, intrauterine hypoxia. In the vast majority of cases, pregnancy is terminated on its own.

Forecast

With the timely detection of ectopic pregnancy, the prognosis for the life and health of a woman is favorable.

Expectant tactics are rarely used. Pregnancy is subject to surgical treatment. Natural delivery is not possible with this type of pregnancy.

In general, the risk of maternal mortality in abdominal pregnancies is almost 100 times higher than in uterine pregnancies. It is due, first of all, to the high risk of severe bleeding and late diagnosis of the condition. In some cases, along with the placenta, it is necessary to remove the part of the organ to which it is attached.

Successful abdominal pregnancies are extremely rare. Delivery is done by caesarean section. There is also a high risk of massive bleeding during surgery.

There is no specific prophylaxis for the condition. Women with a history of genital diseases, over 35 years old, smokers need to carefully monitor the course of pregnancy.

(fig. 156) is primary and secondary. Primary abdominal pregnancy is extremely rare, that is, a condition when the ovum from the very beginning is grafted into one of the abdominal organs (Fig. 157). In recent years, several reliable cases have been described. It is possible to prove the primary implantation of an egg on the peritoneum only in the early stages of pregnancy; in favor of this is the presence of functioning villi on the peritoneum, the absence of microscopic signs of pregnancy in the tubes and the ovary (MS Malinovsky).

Rice. 156. Primary abdominal pregnancy (according to Richter): 1 - uterus; 2 - rectum; 3 - fertilized egg.

Secondary abdominal pregnancy develops more often; in this case, the egg is initially grafted into the tube, and then, having entered the abdominal cavity during tubal miscarriage, is implanted again and continues to develop. A fetus with an ectopic pregnancy of late terms often has certain deformities arising as a result of unfavorable conditions for its development.

MS Malinovsky (1910), Sittner (1901) believe that the frequency of fetal deformities is exaggerated and is no more than 5-10%.

With an abdominal pregnancy in the first months, a tumor is determined, located somewhat asymmetric and resembling the uterus. Unlike the uterus, the fetus during an ectopic pregnancy does not shrink at hand. If it is possible to determine the uterus separately from the tumor (fetus) during vaginal examination, the diagnosis is facilitated. But with an intimate fusion of the fetus with the uterus, the doctor easily falls into a mistake and diagnoses uterine pregnancy. It should be borne in mind that the tumor is most often spherical or irregular in shape, limited in mobility and has an elastic consistency. The walls of the tumor are thin, do not contract on palpation, and parts of the fetus are sometimes surprisingly easy to determine when examined with a finger through the vaginal fornices.

If uterine pregnancy is ruled out or the fetus has died, probing of the uterine cavity can be used to clarify its size and position.

Rice. 157. Abdominal pregnancy: 1-piece loops welded to the fetus; 2 - adhesions; 3 - fruit container; 4-placenta; 5 - uterus.

In the beginning, an abdominal pregnancy may not cause any particular complaints from a pregnant woman. But as the fetus develops, in most cases, complaints of persistent, excruciating abdominal pains appear, which are the result of adhesions in the abdominal cavity around the ovum, causing reactive irritation of the peritoneum (chronic peritonitis). The pains intensify with the movement of the fetus and cause excruciating suffering to the woman. Lack of appetite, insomnia, frequent vomiting, constipation lead to exhaustion of the patient. All these phenomena are especially pronounced if the fetus, after rupture of the membranes, is in the abdominal cavity, surrounded by intestinal loops welded around it. However, there are times when the pain is mild.

By the end of pregnancy, the fetus occupies most of the abdominal cavity. Parts of the fetus in most cases are defined under the abdominal wall. On palpation, the walls of the fruit receptacle do not contract under the arm and do not become denser. Sometimes it is possible to identify a separately lying, slightly enlarged uterus. With a living fetus, its heartbeat and movements are determined. When radiography with filling the uterus with a contrasting mass, the size of the uterine cavity and its relationship with the location of the fetus are revealed. When an ectopic, in particular abdominal, pregnancy is worn out, labor pains appear, but the pharynx does not open. The fruit dies. If a rupture occurs, a picture of acute anemia and peritoneal shock develops. The risk of rupture of the fetus is greater in the first months of pregnancy, and decreases further. Therefore, a number of obstetricians, striving to get a viable fetus, consider it possible, in cases where the pregnancy exceeds VI-VII months and the ball is in a satisfactory condition, to wait with the operation and do it close to the expected date of birth (V.F. Snegirev, 1905 ; A.P. Gubarev, 1925, etc.).

MS Malinovsky (1910), on the basis of his data, believes that the operation at the end of a progressive ectopic pregnancy is not technically more difficult and is accompanied by no less favorable results than in the early months. However, most reputable obstetricians-gynecologists, both domestic and foreign, believe that for any diagnosed ectopic pregnancy, an operation should be performed immediately.

The rupture of the fetus during late pregnancy poses a huge danger to a woman's life. Ware points out that maternal mortality in late ectopic pregnancies was 15%. Timely diagnosis before surgery can reduce deaths in women. A number of cases are described in the literature when the development of an ectopic pregnancy stopped, a falling membrane was released from the uterus, regressive phenomena began and regular menstruation began. The fruit, undergoing encapsulation in such cases, is mummified or, impregnated with calcium salts, petrifies. Such a fossilized fetus (lithopedion) can be in the abdominal cavity for many years. A case of lithopedion staying in the abdominal cavity for 46 years has even been described. Sometimes the dead ovum undergoes suppuration, and the abscess is opened through the abdominal wall into the vagina, bladder or intestines. Together with pus, parts of the disintegrating skeleton of the fetus exit through the formed fistulous opening.

With the modern formulation of medical care, such outcomes of an ectopic pregnancy are the rarest exception. On the contrary, cases of the timely diagnosis of an ectopic pregnancy of late terms began to be published more often.

Surgery for progressive abdominal pregnancy, performed by gastrointestinal surgery, presents significant and sometimes great difficulties. After opening the abdominal cavity, the wall of the fetus is dissected and the fetus is removed, and then the fetal sac is removed. If the placenta is attached to the posterior wall of the uterus and the leaf of the broad ligament, then its separation does not present great technical difficulties. Bleeding places are covered with ligatures or stitches. If the bleeding does not stop, the main trunk of the uterine artery or the hypogastric artery must be ligated on the corresponding side.

In case of severe bleeding, the assistant should press the abdominal aorta to the spine with his hand before ligating the indicated vessels. The greatest difficulty is the separation of the placenta attached to the intestine and its mesentery or liver. Operation for an ectopic pregnancy of late terms is available only to an experienced surgeon and should consist in gluttony, removal of the fetus, placenta and stopping bleeding. The operator must be ready to perform a bowel resection if the placenta is attached to its walls or mesentery and during the operation this becomes necessary.

In the old days, because of the danger of bleeding during the separation of the placenta attached to the intestine or liver, the so-called method of marsupialization was used. In this case, the edges of the fetal sac or part of it were sewn into the abdominal wound and Mikulich's tampon was inserted into the cavity of the sac, covering the placenta remaining in the abdominal cavity. The cavity gradually decreased, there was a slow (within 1-2 months) release of the necrotizing placenta.

The method of marsupialization, designed for spontaneous rejection of the placenta, is antisurgical; under modern conditions, it can be used by an experienced operator only as a last resort, and also provided that the operation is performed as an emergency by an insufficiently experienced surgeon. With an infected fetus, marsupialization is indicated.

Mynors (1956) writes that with an ectopic pregnancy of late terms, the placenta is often left in situ, closing the abdominal wound. In this case, the placenta is detected by palpation for several months, while Fridman's reaction to pregnancy becomes negative after 5-7 weeks.

During the operation with late progressive ectopic pregnancy, despite the good condition of the patient, it is necessary to prepare in advance for blood transfusion and anti-shock measures.

During the operation, sudden severe bleeding may occur, and the delay in providing urgent care increases the danger to the woman's life.

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983

Abdominal pregnancy is a pregnancy in which an egg is implanted (implanted) into abdominal organs and the blood supply to the embryo comes from the vascular bed of the gastrointestinal tract. This usually happens in the following places:

• large oil seal;
• surface of the peritoneum;
• intestinal mesentery;
• liver;
• spleen.

Classification

There are the following abdominal pregnancy options:

• primary(the introduction of the egg into the abdominal cavity occurs initially, without entering the fallopian tube);
• secondary when a viable embryo enters the abdominal cavity from the tube after a tubal abortion has occurred.

information The existing classification does not represent any clinical interest due to the fact that by the time of the operation, the tube is most often already visually unchanged and it is possible to establish where the embryo was initially introduced only after microscopic examination of the removed material.

Causes

To the development of abdominal pregnancy leads to various pathologies of the fallopian tubes when their anatomy or function is impaired:

• chronic inflammatory diseases of the tubes (salpingitis, salpingo-oophoritis, hydrosalpinx and others), not treated in a timely manner or treated inadequately;
• previous operations on the fallopian tubes or on the abdominal organs (in the latter case, they may interfere with the normal movement of the egg);
• congenital malformations of the fallopian tubes.

Symptoms

The main groups of symptoms of abdominal pregnancy include:

1. Symptoms associated with dysfunction of the gastrointestinal tract:
   • nausea;
   • vomit;
2. Clinic "Sharp abdomen": suddenly, against the background of complete health, extremely severe pain appears, which can be very strong and even cause fainting; nausea, vomiting, bloating, symptoms of peritoneal irritation.
3. With the development of bleeding appears anemia.

Diagnostics

dangerous Diagnosis of abdominal pregnancy is usually late, and this pathology is detected already when bleeding has begun or significant damage to the organ into which the implantation has occurred.

World "gold" standard diagnosis of ectopic pregnancy, in general, are:

1. Blood test for(chorionic gonadotropin), which reveals a discrepancy between its level and the expected gestational age.
2. When the ovum is absent in the uterine cavity, however, it may be found in it.

The combined use of the above two methods makes it possible to diagnose "" in 98% of patients from the 5th week of pregnancy (1 week delay with a 28-day cycle).

With regard to abdominal pregnancy, then in the diagnosis of a large role will have clinical picture(it was described above), which is more like an acute surgical pathology.

It is also possible to carry out culdocentesis(puncture of the posterior fornix of the vagina) and when receiving non-clotting blood, we can talk about the onset of internal bleeding.

It should be noted the extreme information content of the diagnostic laparoscopy, in which it is possible to detect the ovum attached to one or another organ, and in some cases it turns out to be removed, which will lead to the cure of the woman. However, due to the fact that this method is invasive (in fact, it is an operation), it is in last place, being an extreme measure.

Treatment

Treatment is always only prompt(it is possible to carry out both laparotomy), and the operations are absolutely atypical and often extremely difficult in technical terms. Interventions will largely depend on where the implantation of the egg has occurred and the degree of organ damage. If possible, the operation is carried out by an obstetrician-gynecologist in conjunction with a surgeon.

In most cases, the following surgical options are used:

• A brace is applied to the umbilical cord to extract the fetus and stop blood flow in, the latter, if possible, is also removed. However, if there is a high risk of large blood loss, it is left in place.
• In the absence of the possibility of removing the placenta, marsupilization is performed: the amniotic cavity is opened and its edges are sutured to the edges of the wound on the anterior abdominal wall, a napkin is inserted into the cavity and the placenta rejection is awaited for a long time.

important The gynecological part of the operation is described above, however, the scope of the intervention can be significantly expanded, since other organs of the abdominal cavity are also involved in the process, damage to which is very likely.

Effects

The consequences depend on how much damaged the place of introduction of a fertilized egg. If in some cases surgical intervention is limited only to suturing the wound, in others it may become necessary to remove the entire organ or its part.

information A woman's reproductive function remains normal, unless, of course, any technical difficulties arose during the operation.

As for the consequences for the fetus, in 10-15% of cases they are viable, but in more than half, some congenital malformations are determined.

Ectopic pregnancy is a pregnancy pathology in which a fertilized egg is implanted ( is attached) outside the uterine cavity. This ailment is extremely dangerous, as it threatens to damage the internal genital organs of a woman with the development of bleeding, therefore, requires immediate medical attention.

The place of development of an ectopic pregnancy depends on many factors and in the vast majority of cases ( 98 – 99% ) falls on the fallopian tubes ( since a fertilized egg passes through them on the way from the ovaries to the uterine cavity). In the remaining cases, it develops on the ovaries, in the abdominal cavity ( implantation on bowel loops, on liver, omentum), on the cervix.


In the evolution of an ectopic pregnancy, it is customary to distinguish the following stages:

It is necessary to understand that the stage of ectopic pregnancy, at which the diagnosis occurred, determines the further prognosis and therapeutic tactics. The earlier this ailment is detected, the more favorable the prognosis. However, early diagnosis is fraught with a number of difficulties, since in 50% of women this ailment is not accompanied by any specific signs that would suggest it without additional examination. The onset of symptoms is most often associated with the development of complications and bleeding ( 20% of women have massive internal bleeding at the time of diagnosis).

The incidence of ectopic pregnancy is 0.25 - 1.4% among all pregnancies ( including among registered abortions, spontaneous abortions, stillbirths, etc.). Over the past several decades, the frequency of this ailment has increased slightly, and in some regions it has increased by 4 - 5 times compared with the indicator of twenty - thirty years ago.

Maternal mortality due to complications of ectopic pregnancy averages 4.9% in developing countries, and less than one percent in countries with advanced medicine. The main cause of death is delayed initiation of treatment and misdiagnosis. About half of cases of ectopic pregnancy remain undiagnosed until complications develop. Reducing the mortality rate is achieved thanks to modern diagnostic methods and minimally invasive treatment methods.

Interesting Facts:

• there have been cases of simultaneous occurrence of an ectopic and normal pregnancy;
• cases of ectopic pregnancy have been reported simultaneously in two fallopian tubes;
• the literature describes cases of multiple ectopic pregnancy;
• described isolated cases of full-term ectopic pregnancy in which the placenta was attached to the liver or omentum ( organs with sufficient area and blood supply);
• ectopic pregnancy in extremely rare cases can develop in the cervical uterus, as well as in the rudimentary horn that does not communicate with the uterine cavity;
• the risk of developing an ectopic pregnancy increases with age and reaches a maximum after 35 years;
• in vitro fertilization is associated with a tenfold risk of developing an ectopic pregnancy ( associated with hormonal disorders);
• the risk of developing an ectopic pregnancy is higher among women who have ectopic pregnancies, recurrent miscarriages, inflammatory diseases of the internal genital organs, and operations on the fallopian tubes in their medical history.

Anatomy and physiology of the uterus at conception

For a better understanding of how an ectopic pregnancy occurs, as well as to understand the mechanisms that can provoke it, it is necessary to understand how the normal conception and implantation of the ovum occurs.

Fertilization is the process of fusion of male and female germ cells - sperm and egg. This happens, usually after intercourse, when sperm pass from the vaginal cavity through the uterine cavity and fallopian tubes to the egg that leaves the ovaries.


Eggs are synthesized in the ovaries - the female genital organs, which also have hormonal function. In the ovaries, during the first half of the menstrual cycle, a gradual maturation of the egg occurs ( usually one egg at a time), with the change and preparation of it for fertilization. In parallel with this, the inner mucous layer of the uterus ( endometrium), which thickens and prepares to receive the ovum for implantation.

Fertilization becomes possible only after ovulation has occurred, that is, after the mature egg has left the follicle ( structural component of the ovary in which the ovum matures). This happens around the middle of the menstrual cycle. The ovum released from the follicle, together with the cells attached to it, forming a radiant crown ( protective outer sheath), falls on the fringed end of the fallopian tube from the corresponding side ( although there have been cases when women with one functioning ovary had an egg in the tube from the opposite side) and is carried by the cilia of the cells lining the inner surface of the fallopian tubes, deep into the organ. Fertilization ( meeting with sperm) occurs in the widest ampullar part of the tube. After that, the already fertilized egg with the help of the cilia of the epithelium, as well as due to the flow of fluid directed to the uterine cavity, and arising from the secretion of epithelial cells, moves through the entire fallopian tube to the uterine cavity, where it is implanted.

It should be noted that in the female body there are several mechanisms that cause a delay in the advancement of a fertilized egg into the uterine cavity. This is necessary so that the egg has time to go through several stages of division and prepare for implantation before entering the uterine cavity. Otherwise, the ovum may be incapable of penetration into the endometrium and can be carried out into the external environment.

The delay in the advancement of a fertilized egg is provided by the following mechanisms:

• Folds of the mucous membrane of the fallopian tubes. The folds of the mucous membrane significantly slow down the progress of the fertilized egg, since, firstly, they increase the path that it must pass, and secondly, they retard the flow of fluid that carries the egg.
• Spastic contraction of the isthmus of the fallopian tube ( part of the tube located 15 - 20 mm before the entrance to the uterus). The isthmus of the fallopian tube is in a state of spastic ( permanent) contractions within a few days after ovulation. This makes it much more difficult for the egg to move.

With the normal functioning of the female body, these mechanisms are eliminated within a few days, due to an increase in the secretion of progesterone, a female hormone that serves to maintain pregnancy and is produced by the corpus luteum ( the part of the ovary from which the egg came out).

Upon reaching a certain stage of development of the ovum ( the blastocyst stage, in which the embryo consists of hundreds of cells) the implantation process begins. This process, which takes place 5 to 7 days after ovulation and fertilization, and which normally should occur in the uterine cavity, is the result of the activity of special cells located on the surface of the ovum. These cells secrete special substances that melt the cells and the structure of the endometrium, which allows it to penetrate into the mucous layer of the uterus. After the introduction of the ovum has occurred, its cells begin to multiply and form the placenta and other embryonic organs necessary for the development of the embryo.

Thus, in the process of fertilization and implantation, there are several mechanisms, the malfunction of which can cause incorrect implantation, or implantation in a place other than the uterine cavity.

Violation of the activity of these structures can lead to the development of an ectopic pregnancy:

• Violation of the contraction of the fallopian tubes for the advancement of sperm. The movement of spermatozoa from the uterine cavity to the ampullar part of the fallopian tube occurs against the flow of fluid and, accordingly, is difficult. The contraction of the fallopian tubes promotes faster sperm movement. Violation of this process can cause an earlier or later meeting of the egg with sperm and, accordingly, the processes related to the advancement and implantation of the ovum may go a little differently.
• Violation of the movements of the cilia of the epithelium. The movements of the cilia of the epithelium are activated by estrogens - female sex hormones produced by the ovaries. The movements of the cilia are directed from the outer part of the tube to its entrance, in other words, from the ovaries to the uterus. In the absence of movements, or with their reverse direction, the ovum can remain in place for a long time or move in the opposite direction.
• Stability of spastic spasm of the isthmus of the fallopian tube. The spastic contraction of the fallopian tube is eliminated by progesterones. If their production is violated, or for any other reason, this spasm may persist and cause a delay in the ovum in the lumen of the fallopian tubes.
• Violation of the secretion of epithelial cells of the fallopian ( uterine) pipes. The secretory activity of the cells of the epithelium of the fallopian tubes forms a flow of fluid that promotes the advancement of the egg. In its absence, this process slows down significantly.
• Violation of the contractile activity of the fallopian tubes for the advancement of the ovum. The contraction of the fallopian tubes not only promotes the movement of sperm from the uterine cavity to the egg, but also the movement of the fertilized egg to the uterine cavity. However, even under normal conditions, the contractile activity of the fallopian tubes is rather weak, but, nevertheless, it facilitates the progression of the egg ( which is especially important in the presence of other violations).

Despite the fact that an ectopic pregnancy develops outside the uterine cavity, that is, on those tissues that are not intended for implantation, the early stages of formation and formation of the fetus and embryonic organs ( placenta, amniotic sac, etc.) occur normally. However, in the future, the course of pregnancy is inevitably disrupted. This can happen due to the fact that the placenta, which forms in the lumen of the fallopian tubes ( often) or on other organs, destroys blood vessels and provokes the development of hematosalpinx ( accumulation of blood in the lumen of the fallopian tube), intra-abdominal bleeding, or both. Usually this process is accompanied by fetal abortion. In addition, the growing fetus is highly likely to cause tube rupture or serious damage to other internal organs.

Causes of an ectopic pregnancy

Ectopic pregnancy is a pathology for which there is no single, well-defined cause or risk factor. This ailment can develop under the influence of many different factors, some of which still remain undetected.

In the vast majority of cases, an ectopic pregnancy occurs due to a violation of the process of transporting an egg or ovum, or due to excessive activity of the blastocyst ( one of the stages of development of the ovum). All this leads to the fact that the implantation process begins at the moment when the ovum has not yet reached the uterine cavity ( a separate case is an ectopic pregnancy with localization in the cervix, which may be associated with a delay in implantation or too rapid advancement of the ovum, but which occurs extremely rarely).

An ectopic pregnancy can develop for the following reasons:

• Premature blastocyst activity. In some cases, premature blastocyst activity with the release of enzymes that help melt tissues for implantation can cause an ectopic pregnancy. This may be due to some kind of genetic abnormality, exposure to any toxic substances, as well as hormonal disruptions. All this leads to the fact that the ovum begins to implant in the segment of the fallopian tube in which it is currently located.
• Violation of the movement of the ovum through the fallopian tubes. Violation of the movement of the ovum through the fallopian tube leads to the fact that the fertilized egg is retained in some segment of the tube ( or outside of it, if it was not captured by the fimbria of the fallopian tube), and at the onset of a certain stage of development of the embryo, it begins to implant in the corresponding region.

Impaired advancement of a fertilized egg to the uterine cavity is considered the most common cause of ectopic pregnancy and can occur due to many different structural and functional changes.

Violation of the movement of the ovum through the fallopian tubes can be caused by the following reasons:

• inflammatory process in the uterine appendages;
• operations on the fallopian tubes and abdominal organs;
• hormonal disruptions;
• endometriosis of the fallopian tubes;
• congenital anomalies;
• tumors in the small pelvis;
• exposure to toxic substances.

Inflammatory process in the uterine appendages

Inflammatory process in the uterine appendages ( fallopian tubes, ovaries) is the most common cause of ectopic pregnancy. The risk of developing this pathology is high, as in acute salpingitis ( inflammation of the fallopian tubes) and chronic. Moreover, infectious agents, which are the most common cause of inflammation, cause structural and functional changes in the tissues of the fallopian tubes, against which the probability of impairing the advancement of a fertilized egg is extremely high.

Inflammation in the uterine appendages can be caused by many damaging factors ( toxins, radiation, autoimmune processes, etc.), however, most often it occurs in response to the penetration of an infectious agent. Studies in which women with salpingitis took part, revealed that in the overwhelming majority of cases, this ailment is provoked by facultative pathogens ( cause disease only in the presence of predisposing factors), among which the strains that make up the normal human microflora ( colibacillus). The causative agents of sexually transmitted diseases, although they are somewhat less common, are of great danger, since they have pronounced pathogenic properties. Quite often, the defeat of the uterine appendages is associated with chlamydia - a genital infection, for which a latent course is extremely characteristic.

Infectious agents can enter the fallopian tubes in the following ways:

• Ascending path. Most infectious agents are carried in the ascending route. This happens with the gradual spread of the infectious and inflammatory process from the lower genital tract ( vagina and cervix) up - to the uterine cavity and fallopian tubes. This path is typical for causative agents of genital infections, fungi, opportunistic bacteria, pyogenic bacteria.
• Lymphogenous or hematogenous pathway. In some cases, infectious agents can be introduced into the uterine appendages along with the flow of lymph or blood from infectious and inflammatory foci in other organs ( tuberculosis, staphylococcal infection, etc.).
• Direct introduction of infectious agents. Direct introduction of infectious agents into the fallopian tubes is possible during medical manipulations on the pelvic organs, without observing the proper rules of asepsis and antiseptics ( abortion or ectopic manipulation outside of health care facilities), as well as after open or penetrating wounds.
• By contact. Infectious agents can penetrate the fallopian tubes by their direct contact with infectious and inflammatory foci on the abdominal organs.

Dysfunction of the fallopian tubes is associated with the direct effect of pathogenic bacteria on their structure, as well as with the inflammatory reaction itself, which, although aimed at limiting and eliminating the infectious focus, can cause significant local damage.

The impact of the infectious and inflammatory process on the fallopian tubes has the following consequences:

• The activity of the cilia of the mucous layer of the fallopian tubes is impaired. The change in the activity of the cilia of the epithelium of the fallopian tubes is associated with a change in the environment in the lumen of the tubes, with a decrease in their sensitivity to the action of hormones, as well as with partial or complete destruction of cilia.
• The composition and viscosity of the secretion of epithelial cells of the fallopian tubes changes. The impact of pro-inflammatory substances and waste products of bacteria on the cells of the mucous membrane of the fallopian tubes causes a violation of their secretory activity, which leads to a decrease in the amount of fluid produced, to a change in its composition and to an increase in viscosity. All this significantly slows down the advancement of the egg.
• Edema occurs, narrowing the lumen of the fallopian tube. The inflammatory process is always accompanied by swelling caused by tissue edema. This edema in such a limited space as the lumen of the fallopian tube can cause its complete blockage, which will lead either to the impossibility of conception or to an ectopic pregnancy.

Operations on the fallopian tubes and abdominal organs

Surgical interventions, even minimally invasive ones, are associated with some, even minimal traumatism, which can provoke some change in the structure and function of organs. This is due to the fact that connective tissue is formed at the site of injury or defect, which is not capable of performing a synthetic or contractile function, which occupies a slightly larger volume, and which changes the structure of the organ.

An ectopic pregnancy can be triggered by the following surgical procedures:

• Operations on the abdominal or pelvic organs that do not involve the genitals. Operations on the organs of the abdominal cavity can indirectly affect the function of the fallopian tubes, since they can provoke an adhesions, and can also cause disruption of their blood supply or innervation ( accidental or intentional intersection or injury of blood vessels and nerves during surgery).
• Genital surgery. The need for surgery on the fallopian tubes arises in the presence of any pathologies ( tumor, abscess, infectious and inflammatory focus, ectopic pregnancy). After the formation of connective tissue at the site of the incision and seam, the ability of the pipe to contract changes, and its mobility is impaired. In addition, its inner diameter may decrease.

Separately, mention should be made of such a method of female sterilization as tubal ligation. This method involves the imposition of ligatures on the fallopian tubes ( sometimes - their intersection or cauterization) during surgery. However, in some cases, this method of sterilization is not effective enough, and pregnancy still occurs. However, since due to the ligation of the fallopian tube, its lumen is significantly narrowed, normal migration of the ovum into the uterine cavity becomes impossible, which leads to the fact that it is implanted in the fallopian tube and an ectopic pregnancy develops.

Hormonal disruptions

The normal functioning of the hormonal system is extremely important for maintaining pregnancy, since hormones control the process of ovulation, fertilization and the movement of the ovum through the fallopian tubes. In the presence of any disruption of endocrine function, these processes may be disrupted, and an ectopic pregnancy may develop.

Of particular importance in the regulation of the work of the organs of the reproductive system are steroid hormones produced by the ovaries - progesterone and estrogen. These hormones have slightly different effects, since normally the peak concentration of each of them falls on different phases of the menstrual cycle and pregnancy.

Progesterone has the following effects:

• inhibits the movement of the cilia of the tubal epithelium;
• reduces the contractile activity of the smooth muscles of the fallopian tubes.

Estrogen has the following effects:

• increases the frequency of flickering of the cilia of the tubal epithelium ( too high a concentration of the hormone can cause them to immobilize);
• stimulates the contractile activity of the smooth muscles of the fallopian tubes;
• affects the development of the fallopian tubes during the formation of the genitals.

The normal cyclic change in the concentration of these hormones allows you to create optimal conditions for fertilization and migration of the ovum. Any changes in their level can cause the retention of the egg and its implantation outside the uterine cavity.

The following factors contribute to a change in the level of sex hormones:

• disruption of the ovaries;
• disruptions of the menstrual cycle;
• use of progestin-only oral contraceptives ( synthetic analogue of progesterone);
• emergency contraception ( levonorgestrel, mifepristone);
• induction of ovulation with clomiphene or gonadotropin injections;
• neurological and autonomic disorders.

Other hormones also, to one degree or another, are involved in the regulation of reproductive function. A change in their concentration up or down can have extremely adverse consequences for pregnancy.

Disruption of the following organs of internal secretion can provoke an ectopic pregnancy:

• Thyroid. Thyroid hormones are responsible for many metabolic processes, including the transformation of some substances involved in the regulation of reproductive function.
• Adrenal glands. The adrenal glands synthesize a number of steroid hormones that are essential for the normal functioning of the genitals.
• Hypothalamus, pituitary gland. The hypothalamus and pituitary gland are brain structures that produce a number of hormones with regulatory activity. Disruption of their work can cause a significant failure in the work of the whole organism, including the reproductive system.

Endometriosis

Endometriosis is a pathology in which functioning islets of the endometrium ( mucous layer of the uterus) are outside the uterine cavity ( most often - in the fallopian tubes, on the peritoneum). This ailment occurs when menstrual blood containing endometrial cells is thrown from the uterus into the abdominal cavity through the fallopian tubes. Outside the uterus, these cells take root, multiply and form foci that function and change cyclically during the menstrual cycle.

Endometriosis is a pathology in the presence of which the risk of developing an ectopic pregnancy increases. This is due to some structural and functional changes that occur in the reproductive organs.

With endometriosis, the following changes occur:

• the frequency of flickering of the cilia of the tubal epithelium decreases;
• connective tissue is formed in the lumen of the fallopian tube;
• the risk of infection of the fallopian tubes increases.

Genital anomalies

Anomalies of the genital organs can cause the movement of the ovum through the fallopian tubes to be difficult, slow, too long, or even impossible.

The following anomalies are of particular importance:

• Genital infantilism. Genital infantilism is a delay in the development of the body, in which the genitals have some anatomical and functional features. For the development of an ectopic pregnancy, it is of particular importance that the fallopian tubes with this ailment are longer than usual. This increases the time of migration of the ovum and, accordingly, facilitates implantation outside the uterine cavity.
• Stenosis of the fallopian tubes. Stenosis, or narrowing of the fallopian tubes, is a pathology that can occur not only under the influence of various external factors, but which can be congenital. Significant stenosis can lead to infertility, but less pronounced narrowing can only hinder the process of migration of the egg to the uterine cavity.
• Diverticula of the fallopian tubes and uterus. Diverticula are saccular protrusions of the organ wall. They significantly impede the transport of the egg, and in addition, they can act as a chronic infectious and inflammatory focus.

Tumors in the small pelvis

Tumors in the small pelvis can significantly affect the process of transporting the egg through the fallopian tubes, since, firstly, they can cause a change in the position of the genitals or their compression, and secondly, they can directly change the diameter of the lumen of the fallopian tubes and the function of epithelial cells. In addition, the development of some tumors is associated with hormonal and metabolic disorders, which, in one way or another, affect the reproductive function of the body.

Exposure to toxic substances

Under the influence of toxic substances, the work of most organs and systems of the human body is disrupted. The longer a woman is exposed to harmful substances, and the more they enter the body, the more serious violations they can provoke.

Ectopic pregnancies can occur when exposed to many toxic substances. Toxins contained in tobacco smoke, alcohol and drugs deserve special attention, as they are widespread and increase the risk of developing the disease more than three times. In addition, industrial dust, heavy metal salts, various poisonous vapors and other factors that often accompany the processes produced also have a strong effect on the mother's body and her reproductive function.

Toxic substances cause the following changes in the functioning of the reproductive system:

• delayed ovulation;
• change in the contraction of the fallopian tubes;
• decrease in the frequency of movement of the cilia of the tubal epithelium;
• impaired immunity with an increased risk of infection of the internal genital organs;
• changes in local and general blood circulation;
• changes in the concentration of hormones;
• neurovegetative disorders.

In Vitro Fertilization

In vitro fertilization deserves special attention, which is one of the ways to combat infertility in couples. With artificial insemination, the process of conception ( fusion of an egg with a sperm) occurs outside the woman's body, and viable embryos are artificially placed in the uterus. This method of conception is associated with a higher risk of developing an ectopic pregnancy. This is due to the fact that women who resort to this type of fertilization already have pathologies of the fallopian tubes or other parts of the reproductive system.

Risk factors

As mentioned above, an ectopic pregnancy is an ailment that can be triggered by many different factors. Based on the possible causes and mechanisms underlying their development, as well as on the basis of many years of clinical research, a number of risk factors have been identified, that is, factors that significantly increase the likelihood of developing an ectopic pregnancy.

Risk factors for the development of an ectopic pregnancy are:

• transferred ectopic pregnancies;
• infertility and its treatment in the past;
• in vitro fertilization;
• stimulation of ovulation;
• progestin-only contraceptives;
• the mother is over 35 years old;
• promiscuous sex;
• ineffective sterilization by bandaging or cauterizing the fallopian tubes;
• upper genital infections;
• congenital and acquired genital anomalies;
• operations on the abdominal organs;
• infectious and inflammatory diseases of the abdominal cavity and small pelvis;
• neurological disorders;
• stress;
• passive lifestyle.

Ectopic pregnancy symptoms

Symptoms of an ectopic pregnancy depend on the phase of pregnancy. During the period of progressive ectopic pregnancy, any specific symptoms are usually absent, and with termination of pregnancy, which can proceed as a tubal abortion or rupture of a tube, a vivid clinical picture of an acute abdomen arises, requiring immediate hospitalization.

Signs of a progressive ectopic pregnancy

Progressive ectopic pregnancy, in the overwhelming majority of cases, is no different in clinical course from a normal uterine pregnancy. During the entire period, while the development of the fetus takes place, hypothetical ( subjective feelings experienced by a pregnant woman) and probable ( identified during an objective examination) signs of pregnancy.

Presumptive(dubious)signs of pregnancy are:

• change in appetite and taste preferences;
• drowsiness;
• frequent mood swings;
• irritability;
• hypersensitivity to odors;
• increased sensitivity of the mammary glands.

Likely signs of pregnancy are:

• cessation of menstruation in a woman who is sexually active and is of childbearing age;
• bluish color ( cyanosis) the mucous membrane of the genital organs - the vagina and cervix;
• engorgement of the mammary glands;
• discharge of colostrum from the mammary glands with pressure ( matters only during the first pregnancy);
• softening of the uterus;
• contraction and hardening of the uterus during the study, followed by softening;
• asymmetry of the uterus in early pregnancy;
• mobility of the cervix.

The presence of these signs in many cases indicates a developing pregnancy, and at the same time, these symptoms are the same for both a physiological pregnancy and an ectopic one. It should be noted that doubtful and probable signs can be caused not only by the development of the fetus, but also by some pathologies ( tumors, infections, stress, etc.).

Reliable signs of pregnancy ( fetal heartbeat, fetal movement, palpation of its large parts) with an ectopic pregnancy occur extremely rarely, since they are characteristic of the later stages of intrauterine development, before the onset of which various complications usually develop - tubal abortion or rupture of the tube.

In some cases, a progressive ectopic pregnancy may be accompanied by pain and bloody discharge from the genital tract. Moreover, this pathology of pregnancy is characterized by a small amount of discharge ( unlike spontaneous abortion in uterine pregnancy, when pain is mild and discharge is abundant).

Signs of a tubal abortion

Tubal abortion occurs most often 2 to 3 weeks after the onset of a delay in menstruation as a result of rejection of the fetus and its membranes. This process is accompanied by a number of symptoms characteristic of spontaneous abortion combined with doubtful and probable ( nausea, vomiting, change in taste, delayed menstruation) signs of pregnancy.

A tubal abortion is accompanied by the following symptoms:

• Recurrent pain. Periodic, cramping pains in the lower abdomen are associated with contraction of the fallopian tube, as well as with its possible filling with blood. At the same time, the pains radiate ( give away) in the area of ​​the rectum, perineum. The appearance of constant acute pain may indicate a hemorrhage into the abdominal cavity with irritation of the peritoneum.
• Bloody discharge from the genital tract. The occurrence of bloody discharge is associated with the rejection of the decidually altered endometrium ( part of the placental-uterine system in which metabolic processes take place), as well as with partial or complete damage to the blood vessels. The volume of bloody discharge from the genital tract may not correspond to the degree of blood loss, since most of the blood through the lumen of the fallopian tubes can enter the abdominal cavity.
• Signs of latent bleeding. Bleeding during a tubal abortion may be insignificant, and then the general condition of the woman may not be disturbed. However, with a volume of blood loss of more than 500 ml, severe pains in the lower abdomen appear with irradiation to the right hypochondrium, interscapular region, right clavicle ( associated with irritation of the peritoneum with blood flow). Weakness, dizziness, fainting, nausea, vomiting occur. There is a rapid heartbeat, a decrease in blood pressure. A significant amount of blood in the abdomen can cause an enlarged or bloated abdomen.

Signs of a ruptured fallopian tube

The rupture of the fallopian tube, which occurs under the influence of a developing and growing embryo, is accompanied by a vivid clinical picture, which usually appears suddenly against the background of a state of complete well-being. The main problem with this type of termination of an ectopic pregnancy is profuse internal bleeding, which forms the symptomatology of the pathology.

A ruptured fallopian tube may be accompanied by the following symptoms:

• Lower abdominal pain. Lower abdominal pain occurs due to rupture of the fallopian tube, as well as due to irritation of the peritoneum with blood flow. The pain usually begins on the side of the "pregnant" tube with further spread to the perineum, anus, right hypochondrium, right clavicle. The pain is constant and acute.
• Weakness, loss of consciousness. Weakness and loss of consciousness occur due to hypoxia ( oxygen deficiency) of the brain, which develops due to a decrease in blood pressure ( against the background of a decrease in the volume of circulating blood), and also due to a decrease in the number of red blood cells that carry oxygen.
• Desires to defecate, loose stools. Irritation of the peritoneum in the rectal area can provoke frequent urge to defecate, as well as loose stools.
• Nausea and vomiting. Nausea and vomiting occur reflexively due to irritation of the peritoneum, as well as due to the negative effects of hypoxia on the nervous system.
• Signs of hemorrhagic shock. Hemorrhagic shock occurs when a large amount of blood loss, which directly threatens a woman's life. Signs of this condition are pallor of the skin, apathy, inhibition of nervous activity, cold sweat, shortness of breath. There is an increase in heart rate, a decrease in blood pressure ( the degree of reduction of which corresponds to the severity of blood loss).

Along with these symptoms, there are probable and presumptive signs of pregnancy, delayed menstruation.

Diagnostics of the ectopic pregnancy

Diagnosis of an ectopic pregnancy is based on a clinical examination and a number of instrumental studies. The greatest difficulties are presented by the diagnosis of a progressive ectopic pregnancy, since in most cases this pathology is not accompanied by any specific signs and in the early stages it is quite easy to overlook it. Timely diagnosis of a progressive ectopic pregnancy can prevent such formidable and dangerous complications as tubal abortion and rupture of the fallopian tube.

Clinical examination

Diagnosis of an ectopic pregnancy begins with a clinical examination, during which the doctor identifies some specific signs that indicate an ectopic pregnancy.

During a clinical examination, the general condition of the woman is assessed, palpation, percussion ( percussion) and auscultation, a gynecological examination is carried out. All this allows you to create a holistic picture of pathology, which is necessary for the formation of a preliminary diagnosis.

The data collected during the clinical examination may differ at different stages in the development of an ectopic pregnancy. With progressive ectopic pregnancy, there is some lag in the size of the uterus, a seal can be detected in the area of ​​the appendages from the side corresponding to the "pregnant" tube ( which is not always possible to identify, especially in the early stages). Gynecological examination reveals cyanosis of the vagina and cervix. Signs of uterine pregnancy - softening of the uterus and isthmus, asymmetry of the uterus, bending of the uterus may be absent.

With a rupture of the fallopian tube, as well as with a tubal abortion, there is a pallor of the skin, a rapid heartbeat, a decrease in blood pressure. When tapping ( percussion) dullness is noted in the lower abdomen, which indicates the accumulation of fluid ( blood). Palpation of the abdomen is often difficult, since irritation of the peritoneum causes contraction of the muscles of the anterior abdominal wall. A gynecological examination reveals excessive mobility and softening of the uterus, severe pain when examining the cervix. Pressure on the posterior vaginal fornix, which can be smoothed, causes acute pain ( "Scream of Douglas").

Ultrasound procedure

Ultrasound procedure ( Ultrasound) is one of the most important examination methods that allows you to diagnose an ectopic pregnancy at a fairly early stage, and which is used to confirm this diagnosis.

The following signs can help diagnose an ectopic pregnancy:

• enlargement of the body of the uterus;
• thickening of the lining of the uterus without detection of the ovum;
• detection of a heterogeneous formation in the area of ​​the uterine appendages;
• a fetal egg with an embryo outside the uterine cavity.

Of particular diagnostic value is transvaginal ultrasound, which allows you to detect pregnancy as early as 3 weeks after ovulation, or within 5 weeks after the last menstruation. This examination method is widely practiced in emergency departments and is extremely sensitive and specific.

Ultrasound diagnostics allows detecting uterine pregnancy, the presence of which in the overwhelming majority of cases makes it possible to exclude an ectopic pregnancy ( cases of the simultaneous development of normal uterine and ectopic pregnancy are extremely rare). An absolute sign of uterine pregnancy is the detection of a gestational sac ( term used exclusively in ultrasound diagnostics), yolk sac and embryo in the uterine cavity.

In addition to diagnosing an ectopic pregnancy, ultrasound can detect rupture of the fallopian tube, the accumulation of free fluid in the abdominal cavity ( blood), the accumulation of blood in the lumen of the fallopian tube. Also, this method allows for differential diagnosis with other conditions that can cause an acute abdomen clinic.

Women at risk, as well as women with in vitro fertilization, are subject to periodic ultrasound examination, since they have a ten times higher chance of developing an ectopic pregnancy.

Chorionic gonadotropin level

Chorionic gonadotropin is a hormone that is synthesized by the tissues of the placenta, and the level of which gradually increases during pregnancy. Normally, its concentration doubles every 48 - 72 hours. With an ectopic pregnancy, the level of chorionic gonadotropin will increase much more slowly than with a normal pregnancy.

Determination of the level of chorionic gonadotropin is possible using rapid pregnancy tests ( which are characterized by a fairly high percentage of false negative results), as well as by a more detailed laboratory analysis, which makes it possible to assess its concentration in dynamics. Pregnancy tests allow for a short period of time to confirm the presence of pregnancy and build a diagnostic strategy if an ectopic pregnancy is suspected. However, in some cases, chorionic gonadotropin may not be detected by these tests. The termination of pregnancy, which occurs with a tubal abortion and rupture of the tube, disrupts the production of this hormone, and therefore, during a period of complications, a pregnancy test can be false-negative.

Determination of the concentration of chorionic gonadotropin is especially valuable in conjunction with ultrasound, as it allows you to more correctly assess the signs detected by ultrasound. This is due to the fact that the level of this hormone directly depends on the period of gestational development. Comparison of the data obtained during ultrasound examination and after analysis for chorionic gonadotropin allows us to judge the course of pregnancy.

Progesterone level

Determining the level of progesterone in the blood plasma is another way of laboratory diagnosis of an abnormally developing pregnancy. Its low concentration ( below 25 ng / ml) indicates the presence of pregnancy pathology. A decrease in progesterone levels below 5 ng / ml is a sign of an unviable fetus and, regardless of the location of pregnancy, always indicates the presence of any pathology.

Progesterone levels have the following characteristics:

• does not depend on the period of gestational development;
• remains relatively constant during the first trimester of pregnancy;
• at an initially abnormal level, it does not return to normal;
• does not depend on the level of chorionic gonadotropin.

However, this method is not sufficiently specific and sensitive, so it cannot be used separately from other diagnostic procedures. In addition, during in vitro fertilization, it loses its significance, since during this procedure its level can be increased ( against the background of increased secretion by the ovaries due to previous stimulation of ovulation, or against the background of artificial administration of pharmacological preparations containing progesterone).

Puncture of the abdominal cavity through the posterior vaginal fornix ( culdocentesis)

Puncture of the abdominal cavity through the posterior fornix of the vagina is used in the clinical picture of an acute abdomen with suspected ectopic pregnancy and is a method that makes it possible to differentiate this pathology from a number of others.

With an ectopic pregnancy, dark non-clotting blood is obtained from the abdominal cavity, which does not drown when placed in a vessel with water. Microscopic examination reveals chorionic villi, particles of fallopian tubes and endometrium.

Due to the development of more informative and modern diagnostic methods, including laparoscopy, puncture of the abdominal cavity through the posterior vaginal fornix has lost its diagnostic value.

Diagnostic curettage of the uterine cavity

Diagnostic curettage of the uterine cavity with subsequent histological examination of the material obtained is used only in the case of a proven pregnancy anomaly ( low levels of progesterone or chorionic gonadotropin), for differential diagnosis with incomplete spontaneous abortion, as well as unwillingness or impossibility of continuing pregnancy.

With an ectopic pregnancy, the following histological changes are revealed in the material obtained:

• decidual transformation of the endometrium;
• lack of chorionic villi;
• atypical endometrial cell nuclei ( Arias-Stella phenomenon).

Despite the fact that diagnostic curettage of the uterine cavity is a fairly effective and simple diagnostic method, it can be misleading in the case of the simultaneous development of uterine and ectopic pregnancy.

Laparoscopy

Laparoscopy is a modern surgical method that allows minimally invasive interventions on the abdominal and pelvic organs, as well as diagnostic operations. The essence of this method lies in the introduction through a small incision into the abdominal cavity of a special instrument, a laparoscope, equipped with a system of lenses and lighting, which allows you to visually assess the state of the organs under study. With an ectopic pregnancy, laparoscopy makes it possible to examine the fallopian tubes, uterus, and pelvic cavity.

With an ectopic pregnancy, the following changes in the internal genital organs are detected:

• thickening of the fallopian tubes;
• purple-bluish coloration of the fallopian tubes;
• rupture of the fallopian tube;
• a fertilized egg on the ovaries, omentum or other organ;
• bleeding from the lumen of the fallopian tube;
• accumulation of blood in the abdominal cavity.

The advantage of laparoscopy is a rather high sensitivity and specificity, a low degree of trauma, as well as the possibility of operative termination of an ectopic pregnancy and elimination of bleeding and other complications immediately after diagnosis.

Laparoscopy is indicated in all cases of ectopic pregnancy, as well as if it is impossible to make an accurate diagnosis ( as the most informative diagnostic method).

Ectopic pregnancy treatment

Is it possible to have a baby with an ectopic pregnancy?

The only organ in a woman's body that can ensure adequate fetal development is the uterus. The attachment of the ovum to any other organ is fraught with malnutrition, structural changes, and rupture or damage to this organ. It is for this reason that an ectopic pregnancy is a pathology in which carrying and giving birth to a child is impossible.

Today in medicine there are no methods that would allow carrying an ectopic pregnancy. The literature describes several cases when, with this pathology, it was possible to bring children to a period compatible with life in the external environment. However, firstly, such cases are possible only under an extremely rare coincidence of circumstances ( one case in several hundred thousand ectopic pregnancies), secondly, they are associated with an extremely high risk for the mother, and thirdly, there is a likelihood of the formation of fetal pathologies.

Thus, carrying and giving birth to a child with an ectopic pregnancy is impossible. Since this pathology threatens the life of the mother and is incompatible with the life of the fetus, the most rational solution is to terminate the pregnancy immediately after diagnosis.

Is it possible to treat an ectopic pregnancy without surgery?

Historically, treatment for ectopic pregnancies has been limited to surgical removal of the fetus. However, with the development of medicine, some methods of non-surgical treatment of this pathology have been proposed. This therapy is based on the appointment of methotrexate, a drug that is an antimetabolite that can change synthetic processes in the cell and cause a delay in cell division. This drug is widely used in oncology to treat various tumors, as well as to suppress immunity during organ transplantation.

The use of methotrexate for the treatment of ectopic pregnancy is based on its effect on the tissues of the fetus and its embryonic organs with the arrest of their development and subsequent spontaneous rejection.

Drug treatment with methotrexate has a number of advantages over surgical treatment, as it reduces the risk of bleeding, negates tissue and organ injuries, and reduces the rehabilitation period. However, this method is not without its drawbacks.

When using methotrexate, the following side effects are possible:

• nausea;
• vomit;
• stomach pathology;
• dizziness;
• liver damage;
• suppression of bone marrow function ( fraught with anemia, decreased immunity, bleeding);
• baldness;
• rupture of the fallopian tube with progressive pregnancy.

Treatment of an ectopic pregnancy with methotrexate is possible under the following conditions:

• confirmed ectopic pregnancy;
• hemodynamically stable patient ( no bleeding);
• the size of the ovum does not exceed 4 cm;
• lack of fetal cardiac activity during ultrasound examination;
• no signs of rupture of the fallopian tube;
• the level of chorionic gonadotropin is below 5000 IU / ml.

Treatment with methotrexate is contraindicated in the following situations:

• the level of chorionic gonadotropin is higher than 5000 IU / ml;
• the presence of fetal cardiac activity during ultrasound examination;
• hypersensitivity to methotrexate;
• state of immunodeficiency;
• liver damage;
• leukopenia ( low white blood cell count);
• thrombocytopenia ( low platelet count);
• anemia ( low red blood cell count);
• active lung infection;
• kidney pathology.

Treatment is carried out by parenteral ( intramuscular or intravenous) the introduction of the drug, which can be single, and can last for several days. The entire period of treatment, the woman is under observation, since there is still a risk of rupture of the fallopian tube or other complications.

The effectiveness of treatment is assessed by measuring the level of chorionic gonadotropin over time. A decrease in it by more than 15% from the initial value on the 4-5th day after the administration of the drug indicates the success of the treatment ( during the first 3 days, the level of the hormone may be increased). In parallel with the measurement of this indicator, the function of the kidneys, liver, and bone marrow is monitored.

In the absence of the effect of drug therapy with methotrexate, surgical intervention is prescribed.

Treatment with methotrexate is associated with many risks, since the drug can negatively affect some of the vital organs of a woman, does not reduce the risk of rupture of the fallopian tube until the pregnancy ends completely, and, moreover, is not always effective enough. Therefore, the main method of treatment for ectopic pregnancy is still surgery.

It is necessary to understand that conservative treatment does not always produce the expected therapeutic effect, and in addition, due to the delay in surgical intervention, some complications may occur, such as rupture of the tube, tubal abortion and massive bleeding ( not to mention the side effects of methotrexate itself).

Surgery

Despite the possibility of non-surgical therapy, surgical treatment is still the main method of managing women with ectopic pregnancy. Surgical intervention is indicated for all women who have an ectopic pregnancy ( both developing and interrupted).

Surgical treatment is indicated in the following situations:

• developing ectopic pregnancy;
• an interrupted ectopic pregnancy;
• tubal abortion;
• rupture of the fallopian tube;
• internal bleeding.

The choice of surgical tactics is based on the following factors:

• the age of the patient;
• desire to have a pregnancy in the future;
• the condition of the fallopian tube from the side of pregnancy;
• the condition of the fallopian tube from the opposite side;
• localization of pregnancy;
• the size of the ovum;
• the general condition of the patient;
• the amount of blood loss;
• the condition of the pelvic organs ( adhesive process).

Based on these factors, the choice of a surgical operation is made. With a significant degree of blood loss, a serious general condition of the patient, as well as with the development of some complications, laparotomy is performed - an operation with a wide incision, which allows the surgeon to quickly stop bleeding and stabilize the patient. In all other cases, laparoscopy is used - a surgical intervention in which manipulators and an optical system are inserted through small incisions in the anterior abdominal wall into the abdominal cavity, allowing a number of procedures to be performed.

Laparoscopic access allows performing the following types of operations:

• Salpingotomy ( incision of the fallopian tube with extraction of the fetus, without removing the tube itself). Salpingotomy allows you to preserve the fallopian tube and its reproductive function, which is especially important in the absence of children or if the tube is damaged on the other side. However, this operation is possible only with the small size of the ovum, as well as with the integrity of the tube itself at the time of the operation. In addition, salpingotomy is associated with an increased risk of recurrent ectopic pregnancy in the future.
• Salpingectomy ( removal of the fallopian tube along with the implanted fetus). Salpingectomy is a radical method in which the "pregnant" fallopian tube is removed. This type of intervention is indicated in the presence of an ectopic pregnancy in the woman's medical history, as well as when the size of the ovum is more than 5 cm.In some cases, it is not possible to completely remove the tube, but only to excision the damaged part of it, which makes it possible to preserve its function to some extent.

It is necessary to understand that in most cases, intervention for an ectopic pregnancy is carried out urgently to eliminate bleeding and to eliminate the consequences of a tubal abortion or rupture of the tube, so the patients end up on the operating table with minimal preliminary preparation. If we are talking about a planned operation, then women are preliminarily prepared ( preparation is carried out in the gynecological or surgical department, since all women with an ectopic pregnancy are subject to immediate hospitalization).

Preparation for surgery consists in the following procedures:

• blood donation for general and biochemical analysis;
• determination of blood group and Rh factor;
• performing an electrocardiogram;
• ultrasound examination;
• consultation of a therapist.

Postoperative period

The postoperative period is extremely important for the normalization of a woman's condition, for the elimination of certain risk factors, as well as for the rehabilitation of reproductive function.

During the postoperative period, constant monitoring of hemodynamic parameters is carried out, as well as the administration of painkillers, antibiotics, anti-inflammatory drugs. After laparoscopic ( minimally invasive) a woman's operations can be discharged within one to two days, however, after a laparotomy, hospitalization is required for a much longer period of time.

After surgery and removal of the ovum, it is necessary to monitor chorionic gonadotropin weekly. This is due to the fact that in some cases, fragments of the ovum ( chorion fragments) may not be completely removed ( after operations that preserve the fallopian tube), or can be entered on other organs. This condition is potentially dangerous, since a tumor, chorionepithelioma, can begin to develop from the chorionic cells. To prevent this, the level of chorionic gonadotropin is measured, which normally should decrease by 50% during the first few days after surgery. If this does not happen, methotrexate is prescribed, which is able to suppress the growth and development of this embryonic organ. If after this the level of the hormone does not decrease, it becomes necessary for a radical operation with the removal of the fallopian tube.

In the postoperative period, physiotherapy is prescribed ( electrophoresis, magnetotherapy), which contribute to a faster recovery of reproductive function, and also reduce the likelihood of developing an adhesions.

The appointment of combined oral contraceptives in the postoperative period has two goals - to stabilize menstrual function and prevent pregnancy in the first 6 months after surgery, when the risk of developing various pathologies of pregnancy is extremely high.

Prevention of ectopic pregnancy

What should be done to avoid an ectopic pregnancy?

To reduce the likelihood of developing an ectopic pregnancy, the following recommendations should be followed:

• timely treat infectious diseases of the genital organs;
• periodically undergo an ultrasound scan or donate blood to the level of chorionic gonadotropin during in vitro fertilization;
• take tests for genital infections when changing a partner;
• use combined oral contraceptives to prevent unwanted pregnancies;
• timely treat diseases of internal organs;
• eat properly;
• correct hormonal disorders.

What should i avoid to prevent ectopic pregnancy?

To prevent ectopic pregnancy, it is recommended to avoid:

• infectious and inflammatory pathologies of the genital organs;
• genital infections;
• promiscuous sex life;
• use of progestin-only contraceptives;
• stress;
• a sedentary lifestyle;
• smoking and other toxic effects;
• a large number of operations on the abdominal organs;
• multiple abortions;
• in vitro fertilization.

Ectopic pregnancy is a very common complication. According to statistics, ectopic pregnancy is about 2% of all pregnancies, 98% of all ectopic pregnancies are - tubal pregnancy.

In fact, an ectopic pregnancy cannot be called a complication, since it in itself is not a normal pregnancy, and poses a threat to the life of the mother. What is an ectopic pregnancy, how to recognize it and take action in time?

Ectopic pregnancy classification

As we know, the onset of pregnancy is characterized by the fertilization of the egg by the sperm, and the subsequent release of the ovum into the uterine cavity, and then - and its attachment to the inner surface of the uterus. Fertilization of the egg takes place in the fallopian tube, and then the cell leaves the tube into the uterus. This is how a normal pregnancy develops.

An ectopic pregnancy also begins as normal. The sperm cell fertilizes the egg, but only later, for some reason, the zygote cannot enter the uterine cavity. She has no choice but to gain a foothold in the tube, in the same place where fertilization took place.

Ectopic pregnancies are divided into the following types:

- tubal pregnancy

- ovarian pregnancy

- cervical pregnancy

- abdominal pregnancy.

Ovarian pregnancy

Ovarian pregnancy is a pregnancy in which the ovum does not develop in the uterine cavity, but in the ovary. Ovarian pregnancy can occur for two reasons:

1. The sperm got into the follicle that just burst during ovulation, from which the egg did not have time to leave. Fertilization occurs immediately, as well as the attachment of a fertilized egg, after which pregnancy develops in the ovary.

2. There is also another option for the development of pregnancy in the ovary. The egg is fertilized immediately after being ejected from the follicle, remains in the ovary and attaches there.

Pregnancy in the ovary can develop safely. There are cases when women carried babies to the late stages of pregnancy. All this happens because the ovarian tissue is elastic. It is according to this principle that cysts grow in the ovary. Sometimes the size of the cyst can be impressive, and the reason for this is a feature of the ovarian tissue, which tends not only to stretch, but also to grow.

It is not always possible to diagnose an ovarian pregnancy. It is often mistaken for an ovarian cyst that needs to be operated on. It is most often possible to recognize pregnancy only during the operation, and sometimes only with a histological examination of the removed tissue after the surgical intervention. In addition, ovarian pregnancy is extremely rare.

Cervical pregnancy

In cervical pregnancy, the fetus does not develop in the uterus, but "slides" from the uterine cavity downward and is fixed in the cervix. Why is this happening? It is believed that structural and pathological changes in the inner surface of the uterus can interfere with normal uterine implantation. For example, extensive endometriosis. In this case, the embryo has no choice but to continue searching for a suitable place for implantation, and sometimes it turns out to be the cervix.

Cervical pregnancy is extremely dangerous for a woman. This type of pregnancy, along with a tubal ectopic pregnancy, has a high percentage of deaths, up to about 50% of all cases.

During pregnancy in the cervix, the survival rate of the embryo is practically zero, the fetus cannot be full-term until late. The maximum period until which the fetus can develop during cervical pregnancy is 5 months, after which the tissues of the cervix can no longer stretch. Then a spontaneous abortion occurs, accompanied by profuse bleeding.

The only possible solution for cervical pregnancy is surgery, in which it is necessary to remove the uterus with subsequent blood transfusion of the patient.

Cervical pregnancy can be diagnosed by several signs: there are signs of pregnancy, there is a pronounced deformation of the cervix, and the uterus itself does not correspond to the gestational age due to its small size.

Abdominal pregnancy

An abdominal pregnancy is a very unusual type of ectopic pregnancy that may seem like something of a fantasy. With an abdominal pregnancy, the fetus does not develop in the uterus, but outside the internal genital organs, that is, in the abdominal cavity. An abdominal pregnancy occurs when a fertilized egg is released into the abdominal cavity. The most common reason for this is the so-called tubal abortion, when an egg fertilized inside the tube is thrown out into the abdominal cavity. When this happens, then everything now depends on where exactly the fertilized egg is attached. If it sticks to a place where the blood supply is insufficient, then the fetus will quickly die. If the attachment occurs in a good place, then the fetus has every chance of successful development.

Abdominal pregnancy has its risks. Since the baby is not in the uterus, but directly inside the woman's abdomen, it is not so reliably protected. In addition, as the child grows, the internal organs of the woman may be damaged. Naturally, a woman cannot give birth to a child during abdominal pregnancy on her own. Therefore, she is shown gluttony. In abdominal pregnancy, fetal abnormalities, chronic intrauterine hypoxia due to insufficient blood supply and oxygen supply, and fetal death have high risks.

An abdominal pregnancy is often difficult to detect, as all the signs of pregnancy are present as in a normal pregnancy. If the doctor conducts an ultrasound study, then an experienced uzist may notice that the fetus is not surrounded by the uterus, and the uterus itself is slightly enlarged and does not correspond to the gestational age. On palpation at a sufficient gestational age, the doctor can determine that the fetus is palpable in the abdominal cavity.

If the diagnosis is incorrect, the doctor mistakes the non-enlarged uterus for a fibroid, a uterine tumor, or even a second fetus. However, there is a chance of having a healthy baby with an abdominal pregnancy. However, this type of pregnancy is very dangerous for the mother.

Tubal pregnancy

The most common of all ectopic pregnancies is a tubal pregnancy. Such a pregnancy occurs when the fertilized egg remains in the fallopian tube and does not enter the uterine cavity. It also happens that the ovum has already entered the uterus, but is somehow thrown back into the tube. If the egg remains in the tube and becomes fixed there, then a tubal ectopic pregnancy will occur. If a tubal abortion occurs, then the egg can gain a foothold outside the woman's genitals, and then an abdominal pregnancy occurs, which we talked about above.

A tubal pregnancy is very dangerous for a woman for several reasons:

1. Complexity of diagnosis. An ectopic pregnancy is very difficult to diagnose, and tubal rupture occurs early in pregnancy, up to about 9 weeks.

2. Massive bleeding and hemorrhagic shock. When the pipe ruptures, if the pregnancy was not diagnosed, massive blood loss occurs. If medical assistance was not provided on time, then the woman runs the risk of dying from hemorrhagic shock.

It is difficult to diagnose an ectopic pregnancy, because in the early stages the embryo is still very small, and it is not always possible to examine it on ultrasound. If the timing of pregnancy allows us to consider the fetus, then signs of an ectopic pregnancy can be: the absence of a fetal egg in the uterine cavity, as well as a thickening in the area of ​​the fallopian tube.

How to determine an ectopic pregnancy itself?

It is impossible to determine an ectopic pregnancy on your own, moreover, if you suspect it is necessary to consult a doctor, and not self-medicate. However, you can look for warning signs.

For example, you may be bothered by pain in the lower abdomen in any particular place, on the right or on the left. There may be scanty spotting, pinkish, or in the form of a "daub", despite the fact that pregnancy is established. Also, a weak second strip on the test can serve as an indirect sign of an ectopic pregnancy. This is because when the ovum is fixed outside the uterine cavity, it does not allow it to develop correctly, and the level of chorionic gonadotropin (hCG) does not increase correctly. In normal pregnancy, hCG doubles every day.

If the rupture of the tube has occurred, then the clinical picture is violent: there is a sharp, sharp pain in the fallopian tube, nausea, the patient may lose consciousness. There are physical signs of internal bleeding: pallor of the skin, blueness of the lips, sweating, a symptom of irritation of the peritoneum - soreness, tension in the abdomen.

With massive blood loss, a woman loses consciousness and dies without coming into it, from hemorrhagic shock, if medical assistance was not provided on time.

What if the pipe bursts?

First of all, you must immediately call the hospital. Lie on a sofa or bed, you can put ice on your stomach, and in no case - a heating pad or other heating devices. Don't use anything unless you are sure of what you are doing. Don't drink anything, don't take medicine. When an ambulance arrives, ask to be taken to an ambulance on a stretcher, do not try to go by yourself.

How is ectopic pregnancy treated?

When a pipe ruptures, an operation is necessary to remove it, since when the tissue breaks, the pipes turn out to be loosened, and their restoration turns out to be impossible. If an ectopic pregnancy is detected in advance, then the tube can be saved.

An operation in which you can get rid of the ovum, and at the same time save the tube, is called laparoscopy. With the help of laparoscopy, you can "suck" the ovum by analogy with a vacuum abortion, without damaging the tube. This is a very important point because tube preservation is essential for subsequent pregnancies. If the tube is removed, that later the chance of getting pregnant is only 50%, because the egg will now ripen in only one tube.

With the help of laparoscopy, operations are also performed to remove the fallopian tube. This operation is much more gentle than open surgery. The laparoscope is equipped with a miniature video camera, so the doctor sees everything that is operating. Operation with a laparoscope significantly reduces the risk of bleeding, as well as the formation of adhesions after surgery.

Causes of an ectopic pregnancy: where is the risk?

No one can say for sure why an ectopic pregnancy occurs, but here we list the main risk factors that could theoretically affect its development:

- Oral contraceptives. It is believed that synthetic hormones can affect the condition of the female genital organs.

- Surgery and abdominal surgery.

- Adhesion processes in the fallopian tubes.

- Scars on the inner surface of the uterus from scrapings and previous abortions.

- Inflammatory diseases of the genital organs, inflammation of the appendages.

- Anomalies in the development and structure of the uterus.

- Pathology of the function of the fallopian tubes, in which the advancement of the egg inside the tube may be impaired.

- Hormonal disorders and disruptions.

If you have found an ectopic pregnancy, then the operation must be done in any case. Get ready for it, listen to all the doctor's advice, and do not be afraid - in the future you have a good chance of getting pregnant again.