With the flow
|tubular (ampullar, isthmic, interstitial); ovarian; abdominal; cervical-cervical
||progressing; tubal abortion; uterine tube rupture; dead
Unlike ICD-10 in the domestic literature, tubal pregnancy is divided into:
Interstitial tubal pregnancy is slightly less than 1% of ectopic pregnancy. Patients with interstitial tubal pregnancy in most cases turn to a doctor later than with an ampullar or an isthmic. The frequency of pregnancy in the uterine corner increases to 27% in patients who have a history of salpingoectomy and IVF and PE. With interstitial tubal pregnancy, most of the deaths due to ectopic pregnancy are associated, as it is often complicated by uterine rupture.
Ovarian pregnancy is divided into:
- developing on the surface of the ovary;
- developing intrafollikulyarno.
Abdominal pregnancy is divided into:
- primary (implantation in the abdominal cavity occurs initially);
Depending on the location of the implantation of the fetal egg, the ectopic pregnancy is divided into the tubal, ovarian, located in the rudimentary horn of the uterus, and the abdominal. Among all cases of tubal pregnancy, depending on the place of the fetus, ampullar, isthmic and interstitial are distinguished. Ovarian pregnancy can be observed in two versions: developing on the surface of the ovary and inside the follicle. Abdominal ectopic pregnancy is divided into primary (implantation initially occurs on the parietal peritoneum, epiploon or any organs of the abdominal cavity) and secondary (attachment of the fetal egg in the abdominal cavity after expulsion from the uterine tube). Ectopic pregnancy in the rudimentary horn of the uterus, strictly speaking, should be attributed to the ectopic version of uterine pregnancy, but the features of its clinical course make it necessary to consider this localization in the group of proximal ectopic pregnancies.
Among all types of ectopic pregnancy, it is common to distinguish often and rarely occurring forms. The first include an ampullar and isthmic localization of tubal pregnancy, which account for 93-98.5% of cases. The ampullar localization of tubal pregnancy occurs somewhat more frequently than ismystic.
Rare forms of ectopic pregnancy include interstitial (0.4-2.1%), ovarian (0.4-1.3%), abdominal (0.1-0.9%). Even more rarely occurs an ectopic pregnancy developing in the rudimentary horn of the uterus (0.1-0.9%), in the additional fallopian tube. To casuistry are extremely rare cases of multiple pregnancy with a variety of localization: the combination of uterine and tubal, bilateral tubal and other combinations of ectopic localization of the fetal egg.
The localization of the ectopic fetus is closely related to the features of the clinical course of the disease, among which the progressive and disturbed forms are distinguished. The violation of pregnancy can occur as an external rupture of the fetus: rupture of the ovary, rudimentary horn of the uterus, interstitial department of the uterine tube, often - the isthmic department, rarely - the ampullary. The second option of termination of pregnancy is internal rupture of the fetus, or tubal abortion. By this type most often there is a violation of pregnancy, located in the ampullar section of the tube. In recent years, in connection with the improvement of diagnostic capabilities, a tendency has emerged to isolate the regressing form of ectopic pregnancy.
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Abdominal (abdominal) pregnancy
They are referred to rare forms of ectopic pregnancy (0.3-0.4%). The localization of abdominal pregnancy is different: an omentum, a liver, sacro-uterine ligaments, a rectum-uterine depression. It can be primary (implantation occurs in the organs of the abdominal cavity) and secondary (initially implantation occurs in the tube, and then due to tubal abortion, the fertilized egg is expelled from the tube and re-implanted in the abdominal cavity). The difference is purely theoretical, and the initial implantation can only be established by histological examination, since by the time of surgery the tube is already macroscopically unchanged.
Abdominal pregnancy, both primary and secondary, is extremely rare. Progressing primary pregnancy is almost not diagnosed; interruption of it gives a picture of impaired tubal pregnancy.
Secondary abdominal pregnancy occurs after tubal abortion or rupture of the tube, extremely rarely after a uterine rupture. Abdominal pregnancy can be worn out to long periods, which poses a serious threat to the life of a woman, the fetus is rarely viable. More than half of the fruits show developmental defects.
Secondary abdominal pregnancy can be suspected in women who had early episodes of pain in the lower abdomen, accompanied by small bloody discharge from the vagina. Typical complaints of a woman on painful movements of the fetus. When an external examination of the patient can identify the wrong position of the fetus. Clearly feel its small parts. There are no contractions in the fetus, which are usually determined by palpation. In case of an internal examination, attention should be paid to the shift of the cervix up and to the side. In some cases, it is possible to palpate the uterus separately from the fetal plate. Ultrasound scanning reveals the absence of the uterine wall around the fetal bladder.
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One of the rare forms of ectopic pregnancy, its frequency is 0.1-0.7%. There are two forms of this pregnancy: intraphollicular and epiophoric. In the case of an intraphollicular form, fertilization and implantation occurs in the follicle, with epiophoreal - on the surface of the ovary.
The frequency ranges from 1 to 2,400 to 1 per 50,000 pregnancies. It is believed that the risk of its occurrence increases previous abortion or cesarean section, Asherman's syndrome, the use of the mother during pregnancy diethylstilbestrol, uterine fibroids, in vitro fertilization and embryo transfer. Ultrasonic signs of cervical pregnancy:
- absence of a fetal egg in the uterus or a false fetal egg;
- hyperechoic endometrium (decidual tissue);
- heterogeneity of myometrium;
- uterus in the form of an hourglass;
- dilatation of the cervical canal;
- fetal egg in the cervical canal;
- placental tissue in the cervical canal;
- closed inner throat.
After confirming the diagnosis, a blood group and Rh factor are determined, a venous catheter is installed, a written consent is obtained from the patient for performing the uterine extirpation if necessary. All this is caused by a high risk of massive bleeding. There are reports of efficacy in cervical pregnancy of intra-amniotic and systemic use of methotrexate. Diagnosis of cervical pregnancy is often exhibited only during diagnostic scraping for alleged abortion in the course or incomplete abortion, with the beginning of heavy bleeding. To stop bleeding, depending on its intensity, use a tight tamponade of the vagina, suture the lateral arches of the vagina, overlap the cervical seam on the cervix, introduce the cannula into the cervical canal of the Foley catheter and inflate the cuff. Embolization of bleeding vessels, ligation of uterine or internal iliac arteries is also used. With ineffectiveness of all these measures, the uterus is extirpated.
Pregnancy in the rudimentary horn of the uterus
Meet in 0.1-0.9% of cases. Anatomically, this pregnancy can be attributed to the uterine, but due to the fact that in most cases the rudimentary horn has no communication with the vagina, clinically such pregnancy proceeds as ectopic.
Pregnancy in the embryonic horn, which has an insufficiently developed muscular layer and an inferior mucosa, arises under the following conditions: the cavity of the horn communicates with the fallopian tube, the desquamation phase does not occur in the mucous membrane and, therefore, hematomas prevent the implantation of the fetal egg. The mechanism of penetration of the blastocyst into the cavity of the rudimentary horn is apparently associated with transpertonal migration of spermatozoa or an ovum.
Progressing pregnancy is diagnosed extremely rarely. It can be suspected on the basis of unusual data of internal gynecologic examination: the enlarged uterus (with a period of more than 8 weeks inconsistent with the period of delay in menstruation) is diverted to the side; from the opposite side, a tumor-like, painless formation of a softish consistency is associated with the uterus with a thick pedicle. Invaluable help is provided by ultrasound or laparoscopy.
The violation of pregnancy occurs as an external rupture of the fetus, is accompanied by heavy bleeding and requires urgent surgical intervention. The volume of the operation in typical cases is the removal of the rudimentary horn together with the adjacent fallopian tube.
It is 1 for 300 cases of ectopic pregnancy. It usually occurs again, when the fallopian tube ruptures at the mesenteric margin and penetrates the fetal egg between the leaves of the broad ligament. Intraligamentary pregnancy is also possible with a fistula that connects the uterine cavity and parameters. The placenta may be located on the uterus, bladder or pelvic wall. If you can not remove the placenta, leave it. There are reports of successful delivery of full-term intraligamentary pregnancies.
Rare variants of ectopic pregnancy
Combination of uterine and ectopic pregnancy
The frequency, according to different authors, is from 1 to 100 to 1 per 30,000 pregnancies. It is higher after induction of ovulation. Having determined a fetal egg in the uterus, ultrasound often does not pay attention to the second fetal egg. The results of a multiple study of the level of beta-subunit of CGT do not differ from those in normal pregnancy. In most cases, an operation is performed for an ectopic pregnancy and the uterine pregnancy is not interrupted. It is also possible to introduce into the fetal egg located in the fallopian tube, potassium chloride (with laparoscopy or through the lateral vaginal vault). Methotrexate is not used.
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Multiple ectopic pregnancy
It occurs even less often than a combination of uterine and ectopic pregnancy. There are many variants of the number and location of fetal eggs. About 250 cases of ectopic pregnancy of twins are described. In most cases, these are ampullar or istmic tubal pregnancies, but ovarian, interstitial tubal and abdominal pregnancy are also described. Ectopic pregnancies of twins and triplets are possible after resection of the fallopian tube and EP. Treatment is the same as in single pregnancy.
Pregnancy after hysterectomy
The most rare type of ectopic pregnancy is pregnancy after vaginal or abdominal uterine extirpation. Implantation of the embryo in the fallopian tube occurs shortly before or on the 1st day after the operation. Ectopic pregnancy is possible at any time after surgery if there is a communication of the abdominal cavity with the stump of the cervix or vagina.
Chronic ectopic pregnancy
This is a condition where a fetal egg after death is not fully organized, and viable chorionic villi remain in the fallopian tube. Chronic ectopic pregnancy occurs in cases when treatment for some reason was not carried out. The chorionic nares cause repeated hemorrhages in the wall of the fallopian tube, it gradually stretches, but is usually not torn. In chronic ectopic pregnancy, 86% of patients note pain in the lower abdomen, 68% - bleeding from the genital tract. At once both symptoms are observed in 58% of women. In 90% of patients, menstruation is absent for 5-16 weeks (an average of 9.6 weeks), almost all determine volume formation in the small pelvis. Occasionally, chronic ectopic pregnancy, there is compression of the ureters or intestinal obstruction. The most informative method for diagnosing chronic ectopic pregnancy is ultrasound. The concentration of β-subunit of CGT in serum is low or normal. Salpingectomy is indicated. Concomitant aseptic inflammation leads to adhesive process, in connection with this, together with the fallopian tube, it is often necessary to remove the ovary.
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In some cases, an ectopic pregnancy stops developing, and a fetal egg gradually disappears, or a complete tubal abortion occurs. Surgical treatment is not required. The frequency of such an outcome of an ectopic pregnancy and the conditions predisposing to it are unknown. It is also impossible to estimate its forecast. The content of the β-subunit of CGT can not serve as a guide.
Persistent ectopic pregnancy
Observe after organ-preserving operations on the fallopian tubes (salpingophotomy and artificial tubal abortion). Histologically, the embryo is usually absent, and the chorionic villus is found in the muscular shell. Implantation occurs medially from the scar on the fallopian tube. Implantation of chorionic villi in the abdominal cavity is possible. Recently, the frequency of persistent ectopic pregnancy has increased. This is explained by the wide spread of organ-preserving operations on the fallopian tubes. Characteristically, there is no reduction in the beta-subunit of HGT after surgery. It is recommended to determine the beta-subunit of CGT or progesterone on the 6th day after the operation and then every 3 days. The risk of persistent ectopic pregnancy depends on the type of operation, the initial concentration of the beta-subunit of HGT, the gestational age and the size of the fetal egg. The delay in menstruation of less than 3 weeks and the diameter of the fetal egg is less than 2 cm increase the risk of persistent ectopic pregnancy. When persistent ectopic pregnancy is carried out as a surgical (repeated salpingus or, more often, salpingectomy), and conservative treatment (the use of methotrexate). Many authors prefer conservative treatment, since chorionic villi can be found not only in the fallopian tube and, therefore, they are not always determined during the reoperation. If hemodynamic disturbances are indicated, surgery is indicated.