Ectopic pregnancy

At usual pregnancy the fertilized egg moves on a fallopian tube in a direction to a uterus where it is attached to a wall and starts to grow. But in the case of a condition such as an ectopic pregnancy, a fertilized egg does not enter the uterus, but begins to grow elsewhere, often in the fallopian tube. Therefore, such a pregnancy is often called a tubal ectopic.

In rare cases, the egg is attached to the ovary, the muscles of the abdominal cavity, or in the cervical canal. To save a fetus with such a pregnancy is impossible. If the egg begins to grow in the fallopian tube, the tube may be damaged or ruptured, which is fraught with severe bleeding, which can lead to death. If you have been diagnosed with an ectopic pregnancy, you should immediately interrupt it before complications develop.

[1], [2], [3], [4], [5]

Epidemiology

The prevalence of ectopic pregnancy in the United States has increased more than 4-fold and currently stands at 20 cases per 1000 pregnancies.

Ectopic pregnancy in the US - the cause of 10% of deaths of women associated with pregnancy. Most deaths are associated with bleeding and are potentially preventable.

Over the past decade there has been a clear trend towards an increase in the frequency of ectopic pregnancy. This fact can be given a twofold explanation. On the one hand, the prevalence of inflammatory processes of internal genital organs is constantly increasing; the number of surgical interventions on the fallopian tubes, which are carried out for the purpose of regulating childbearing, is increasing; the number of women using intrauterine and hormonal contraceptive methods is increasing; Inductors of ovulation are increasingly being introduced into the practice of infertility treatment. On the other hand, in recent years diagnostic capabilities have improved, allowing to detect undisturbed and even regressing ectopic pregnancy.

Currently, ectopic pregnancy occurs from 0.8 to 2.4 cases per 100 women who are given birth. In 4-10% of cases it is repeated.

[6], [7], [8], [9], [10], [11], [12]

Causes of the ectopic pregnancy

Ectopic pregnancy often occurs as a result of damage to the fallopian tubes. The fertilized egg can not reach the uterus and therefore is forced to attach to the wall of the tube.

Provocators of ectopic pregnancy:

• Smoking (the more you smoke, the higher the risk of ectopic pregnancy).
• Inflammation of the pelvic organs (the result of chlamydia or gonorrhea), which lead to the formation of scar tissue in the fallopian tubes.
• Endometriosis, which leads to the formation of scar tissue in the fallopian tubes.
• Exposure before birth to synthetic estrogen (dietilstilbestrolu).
• Previous ectopic pregnancy in the fallopian tubes.

Some medical interventions may increase the risk of ectopic pregnancy:

• Operations on the fallopian tubes in the pelvic organs (pipetting) or for the removal of scar tissue.
• Infertility treatment.

Ectopic pregnancy is associated with taking medications to ovulate more eggs. Scientists do not yet know what causes ectopic pregnancy - taking hormones or damaging the fallopian tubes.

If you are pregnant and are afraid of an ectopic pregnancy, you need to be examined carefully. Doctors do not always agree about the risk factors for ectopic pregnancy, but one thing is certain - the risk increases after the history of ectopic pregnancy, operation on the fallopian tubes, or pregnancy with an intrauterine device.

[13], [14], [15]

Pathogenesis

Implantation of the fetal egg outside the uterus cavity can occur due to disruption of the transport function of the fallopian tubes, as well as due to changes in the properties of the fetal egg itself. Combinations of both causative factors in the development of ectopic pregnancy are possible.

Fertilization of the ovum with the spermatozoon under normal conditions occurs in the fimbrial part of the ampulla of the uterine tube. Due to peristaltic, pendulum and turbulent movements of the tube, as well as due to the flickering of the ciliated epithelium of the endosalpinx, the crushed fetal egg reaches the uterine cavity 3-4 days later, where the blastocyst can be in the free state for 2-4 days. Then, having lost a brilliant shell, the blastocyst is immersed in the endometrium. Thus, implantation is performed on the 20th-21st day of the 4-week menstrual cycle. Disruption of the transport function of the fallopian tubes or accelerated development of the blastocyst can lead to the implantation of the fetal egg proximal to the uterine cavity.

Practice shows that the violation of the function of the pipe is most often associated with the inflammatory processes of any etiology. The predominant role is played by a nonspecific infection, the spread of which is promoted by abortion, intrauterine contraception, vitro-matic diagnostic interventions, complicated during the birth act and postpartum period, appendicitis transferred. In recent years, a high incidence of chlamydial infection of women operated on for ectopic pregnancy has been identified. Along with the inflammatory nature of the structure and function of the fallopian tubes, the role of endometriosis is extremely important.

The importance of surgical interventions on the fallopian tubes in the structure of causative factors leading to the occurrence of an ectopic pregnancy is constantly increasing. Even the introduction of microsurgery does not exclude such a danger.

The contractile activity of the tube is closely related to the nature of the hormonal status of the organism. Unfavorable hormonal background in women can be caused by a violation of the regulation of the menstrual cycle of any nature, age, and the use of exogenous hormonal drugs that contribute to the violation or induction of ovulation.

The inadequacy of blastocyst development to the place of physiological implantation is associated with excessive biological activity of the egg itself, leading to accelerated formation of trophoblast and possible nidation, not reaching the uterine cavity. It is almost impossible to find out the reason for such rapid development of the blastocyst.

Disturbance of the transport of the fetal egg can in some cases be explained by the peculiarities of its path, for example by external migration of the oocyte after surgical intervention on the appendages: the ovule from the single ovary passes through the abdominal cavity into the only tube of the opposite side. The cases of transperitoneal migration of spermatozoa are described for some malformations of internal genital organs.

In recent years, there have been reports of the possibility of tubal pregnancy after extracorporeal fertilization and transplantation of the blastocyst into the uterus.

In the tube, ovary, abdominal cavity and even in the embryonic horn of the uterus, there is no powerful specifically developed mucosa and submucosa, which is characteristic of physiological pregnancy. Progressing ectopic pregnancy stretches the fetus, and the villus of the chorion destroys the underlying tissue, including blood vessels. Depending on the localization of pregnancy, this process can occur faster or slower, accompanied by greater or lesser bleeding.

If the fetal egg develops in the isthmic section of the tube, where the height of the folds of the mucosa is small, the so-called basotropic (main) poch of the chorionic villi takes place, which quickly destroy the mucous, muscle and serous layers of the tube, and after 4-6 weeks this leads to perforation walls with the destruction of blood vessels, powerfully developed in connection with pregnancy. There is an abortion of pregnancy as an external rupture of the fetus, that is, a burst of the pregnant tube, which is accompanied by massive bleeding into the abdominal cavity. The same mechanism of abortion, localized in the interstitial department of the tube, is the same. However, in view of the considerable muscle layer surrounding this segment of the tube, the duration of pregnancy can be longer (up to 10-12 weeks or more). The blood loss due to the extremely developed blood supply of this area during rupture of the fetus, as a rule, is massive.

The integrity of the mesenteric margin of the tube is extremely rare. In this case, the fetal egg and the bleeding blood are between the leaves of the broad ligament. Casuetic cases are described when a fetal egg did not die, but continued to develop interconnected up to significant periods.

In the ampullar localization of tubal pregnancy, implantation of the fetal egg into the fold of the endosalpingus (columinal, or acrothropic, attachment) is possible. In this case, the growth of the villus of the chorion can be directed towards the lumen of the tube, which after 4 to 8 weeks after nidation is accompanied by a violation of the inner capsule of the embryo, and this, in turn, leads to a slight or moderate bleeding. The anti-peristaltic movements of the pipes can gradually expel the exfoliated fetal egg into the abdominal cavity: pipe abortion takes place. When the fimbrial part of the tube is closed, the blood draining into the lumen of the tube leads to the formation of hematosalping. When the ampoule is open, the blood, emerging from the tube and folding in the area of its funnel, can form a peritubar hematoma. Repeated more abundant bleeding leads to the accumulation of blood in the rectum-uterine cavity and the formation of a so-called commissural hematoma, delimited from the abdominal cavity by a fibrous capsule, which is welded to the intestinal loops and the omentum.

In extremely rare cases, the fetal egg expelled from the tube does not die, but is attached to the parietal or visceral peritoneum of the abdominal cavity organs (most often to the peritoneum of the rectum and uterine cavity). Secondary abdominal pregnancy develops, which can exist at different times, up to a full term. Even rarer the fetal egg can be implanted in the abdominal cavity primarily.

Ovarian pregnancy rarely exists for a long time. Usually there is an external rupture of the embryo, accompanied by significant bleeding. If pregnancy develops on the surface of the ovary, a similar outcome occurs early. In the case of intra-follicular localization, the interruption occurs later.

Neck pregnancy is a rare but potentially severe form of ectopic pregnancy due to high risk of bleeding. A nasal pregnancy is usually treated with methotrexate.

[16], [17], [18],

Symptoms of the ectopic pregnancy

During the first few weeks, ectopic pregnancy causes the same symptoms as usual: absence of menstrual cycle, fatigue, nausea and tenderness of mammary glands.

The main signs of ectopic pregnancy:

• Pain in the area of the pelvic organs or abdominal cavity, which can be acute one-sided, but eventually spread to the entire abdominal cavity. Pain is aggravated by movement or tension.
• Vaginal bleeding.

If you think you are pregnant and are observing the above symptoms, seek medical help immediately.

The first weeks of ectopic pregnancy do not differ from usual pregnancy. During this period, the following are observed:

• Lack of menstrual cycle.
• Soreness of the chest.
• Fatigue.
• Nausea.
• Frequent urination.

But if the ectopic pregnancy continues to develop, other symptoms occur, among which:

• Pain in the pelvic or abdominal region (usually 6-8 weeks after the termination of the menstrual cycle). The pain increases with movement or tension, it is acute, one-sided, eventually spreads to the entire abdominal cavity.
• Moderate or severe vaginal bleeding.
• Painful sensations during sexual intercourse or physical examination by a doctor.
• Pain in the shoulder area as a result of bleeding into the abdominal area under the stimulation of the diaphragm.

Symptoms of early ectopic pregnancy and miscarriage are often the same.

Usually at the beginning of pregnancy a fertilized egg moves along the fallopian tube towards the uterus where it is attached to the wall and begins to develop. But in 2% of diagnosed cases of pregnancy a fertilized egg stops outside the uterus and an ectopic pregnancy occurs.

With ectopic pregnancy, the fetus can not develop for a long time, but reaches a size that leads to rupture of the tube and bleeding, which is fraught with a fatal outcome for the mother. A woman who has symptoms of an ectopic pregnancy requires immediate medical attention. In most cases of ectopic pregnancy, a fertilized egg is attached to the fallopian tube. In rare cases:

• The egg cell is attached and begins to grow in the ovary, in the cervical canal or in the abdominal cavity (excluding organs of the reproductive system).
• One or more eggs develop in the uterus while parallel to the other egg (or several) grow in the fallopian tube, cervical canal or abdominal cavity.
• In very rare cases, the egg begins to develop in the abdominal cavity after removal of the uterus (hysterectomy).

When to seek help from a doctor?

If you are waiting for a child, carefully observe the symptoms that may indicate an ectopic pregnancy, especially if you are predisposed to it.

With vaginal bleeding and acute pain in the abdominal cavity (before or after diagnosing pregnancy or during treatment of an ectopic pregnancy):

• call for an ambulance;
• go to bed and rest;
• Do not make sudden movements until the doctor assesses the state of health.

In case of permanent minor pain in the abdominal cavity, contact your doctor.

[19]

Observation

To observe means to wait a bit and see if the state improves. But with an ectopic pregnancy because of the risk of a lethal outcome, stay at home and wait for a miracle. Immediately call an ambulance at the first sign of ectopic pregnancy.

Specialists to be contacted

• gynecologist
• family doctor
• ambulance

In the case of diagnosing an ectopic pregnancy, the treatment is performed by a gynecologist.

Forms

By localization	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:

• ampullar;
• istmic;
• interstitial.

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);
• secondary.

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.

[20], [21], [22], [23]

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.

[24], [25], [26], [27], [28], [29],

Ovarian Pregnancy

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.

Neck pregnancy

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.

Intraligamentary pregnancy

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.

[30], [31], [32], [33],

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.

[34], [35], [36], [37], [38], [39]

Spontaneous recovery

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.

Complications and consequences

Ectopic pregnancy can break the fallopian tube, which reduces the chances of the next pregnancy.

It is necessary to diagnose ectopic pregnancy at an early stage for the safety of a woman and to prevent severe bleeding. Perforated ectopic pregnancy requires immediate surgical intervention to stop severe bleeding in the abdominal cavity. The severed fallopian tube is removed completely or partially.

[40],

Diagnostics of the ectopic pregnancy

If you suspect that you are pregnant, buy a pregnancy test or give a urine test. To determine an ectopic pregnancy, a physician:

• will make an examination of the pelvic organs to reveal the size of the uterus and the presence of formations in the abdominal cavity;
• will appoint a blood test to detect a pregnancy hormone (the analysis is repeated after 2 days). At the early stage of pregnancy, the level of this hormone doubles every two days. Its low level indicates an abnormality - an ectopic pregnancy.
• The ultrasound shows an image of internal organs. The doctor diagnoses pregnancy for 6 weeks from the last menstrual cycle.

In most cases, ectopic pregnancy can be determined in the process of vaginal examination, ultrasound and a blood test. When symptoms of an ectopic pregnancy need:

• pass a vaginal examination, during which the doctor will determine the soreness in the area of the uterus or fallopian tubes, increasing the size of the uterus more than usual;
• make ultrasound (transvaginally or abnormally), which provides a clear image of the organs and their structure in the lower abdominal cavity. Transvaginal examination (ultrasound) is a more reliable method of diagnosing pregnancy, which can be determined as early as 6 weeks after the last menstrual cycle. In the case of an ectopic pregnancy, the doctor will not see signs of an embryo or fetus in the uterus, but a blood test will indicate an increased level of hormones.
• take a blood test two or more times to determine the level of hormones (human chorionic gonadotropin) with an interval of 48 hours. In the first weeks of normal pregnancy, the level of this hormone doubles every two days. Low or slightly increasing its level indicates an ectopic pregnancy or miscarriage. If the level of this hormone is too low, you need to do additional tests to identify the cause.

Sometimes a laparoscopy is performed to determine an ectopic pregnancy, which can be seen and interrupted at week 5. But it is not used often, because ultrasound and a blood test give accurate results.

The main complaints of patients with ectopic pregnancy:

• delay in menstruation (73%);
• bloody discharge from the genital tract (71%);
• pain of a different nature and intensity (68%);
• nausea;
• irradiation of pain in the lumbar region, rectum, inner thigh;
• combination of three of the above symptoms.

Laboratory and instrumental studies with ectopic pregnancy

Most informative in the diagnosis of ectopic pregnancy: the determination of the concentration of the β-subunit of chorionic gonadotropin (CGT) in the blood, ultrasound and laparoscopy.

For early diagnosis, carry out:

• transvaginal ultrasound;
• determination of the content of β-subunit of CGT in serum.

The combination of transvaginal ultrasound and determination of the concentration of the β-subunit of CGT makes it possible to diagnose pregnancy in 98% of patients from the 3rd week of pregnancy. Ultrasound diagnosis of ectopic pregnancy includes measurement of thickness of the endometrium, sonogasterography, color Doppler. Pregnancy in the uterine corner can be suspected with asymmetry of the uterus, asymmetrical position of the fetal egg, detected with ultrasound.

The main criteria for ultrasound diagnosis of ectopic pregnancy:

• heterogeneous adnexal structures and free fluid in the abdominal cavity (26.9%);
• heterogeneous adder structures without free fluid (16%);
• ectopically located fetal egg with a live embryo (palpitation is) (12.9%);
• ectopic location of the embryo (no heartbeat) (6.9%).

According to the results of ultrasound, there are 3 types of echographic picture of the uterine cavity in an ectopic pregnancy:

• I - thickened from 11 to 25 mm of endometrium without signs of destruction;
• II - the uterine cavity is enlarged, anteroposterior size is from 10 to 26 mm, the contents are mostly liquid, heterogeneous due to hematomas and gravitar endometrium, which has been rejected to varying degrees;
• III - the uterine cavity is closed, M-echo in the form of a hyperechoic strip from 1.6 to 3.2 mm (Kulakov VI, Demidov VN, 1996).

To clarify the diagnosis of tubal pregnancy, broken by the type of internal rupture of the embryo, there are numerous additional methods of investigation. The most informative and modern are the following:

• Determination in the serum or urine of the chorionic gonadotropin or its beta subunit (beta-chorionic gonadotropin).
• Ultrasound scanning.
• Laparoscopy.

At present, there are many ways to determine the chorionic gonadotropin. Some of them (for example, biological ones) lost their leading role. Due to their high specificity and sensitivity, preference is given to the radioimmunoassay method for quantifying B-chorionic gonadotropin in the blood serum. The immunoenzymatic methods for the detection of chorionic gonadotropin in the urine, as well as other variants of immunological tests (capillary, platelet) have been praised. Such well-known serological methods for determining chorionic gonadotropin in urine as a reaction to inhibition of erythrocyte agglutination or sedimentation of latex particles have the right to exist. All laboratory methods for diagnosing pregnancy are highly specific: the right answers are observed from 92 to 100 % already from the 9th to the 12th day after the fertilization of the egg. However, they establish only the fact of the existence of pregnancy without specifying its localization, so they can be used for. Conducting a differential diagnosis with the inflammatory process in the appendages, apoplexy of the ovary, endometriosis of the appendages and similar diseases.

Ultrasound (ultrasound) is a widely used non-invasive method, which in combination with the definition of beta-chorionic gonadotropin can provide high diagnostic accuracy. The main signs of tubal abortion detected by ultrasound include the absence of a fetal egg in the uterine cavity, an increase in appendages, and the presence of fluid in the rectal-uterine cavity. The pulsation of the embryonic heart during an ectopic pregnancy is rarely recorded.

Transvaginal ultrasound can detect a fetal egg in the uterine cavity at a concentration of beta-chorionic gonadotropin in the blood serum of 1000-1200 IU / L (approximately 5 days after the start of the last menstruation). Using transabdominal ultrasound, a fetal egg in the uterine cavity can be detected at a concentration of beta-chorionic gonadotropin in the serum of more than 6000 IU / L.

The most informative method, which allows to make a differential diagnosis with almost 100% accuracy, is laparoscopy. The high evaluation of the diagnostic capabilities of laparoscopy is somewhat reduced by the fact that this method is aggressive, it can not be used in all patients, as complications are possible during its implementation.

Contraindications to laparoscopy are cardiac and pulmonary insufficiency; all kinds of shock, peritonitis; intestinal obstruction; all diseases and conditions, accompanied by a violation of blood clotting; adhesive process in the abdominal cavity; flatulence; obesity; presence of infectious diseases. Serious complications rarely accompany laparoscopy. The most common lesions are small and large intestine, omentum, vessels, as well as emphysema of the abdominal wall, omentum and mediastinum. Therefore, until today, the opinion remains that the endoscopy should be carried out as the final stage of the examination.

The method known to gynecologists, such as the puncture of the uterine and rectal cavity deepening, conducted through the posterior vaginal fornix, did not lose its significance. Getting liquid dark blood with small clots confirms the presence of tubal pregnancy. However, it should be remembered that the absence of blood in the punctuation does not allow you to make a categorical conclusion.

In many cases, histological examination of the endometrial scraping helps in differential diagnosis. The absence of chorionic villi in the presence of decidual transformations of the mucous membrane or other more subtle changes in the endometrium (the structure of the reverse development of the mucosa after a pregnancy, a spiral vial, the transformation of the uterine epithelium in the form of the Arias-Stella phenomenon and the Overbeck's "light glands") is most often in favor of ectopic pregnancy.

In difficult cases for diagnosis, hysterosalpingography can be used with the introduction of water-soluble contrast agents or a variety of it-selective salpingography after pre-catheterization of the fallopian tubes during hysteroscopy. Penetration of the contrasting substance between the fetal egg and the wall of the tube (the symptom of flow) and the uneven imbibition of the fetal egg are characteristic of tubal pregnancy.

Progressing tubal pregnancy, unfortunately, is rarely diagnosed. The reason for this is the lack of convincing clinical symptoms. However, the use of modern research methods makes it possible to recognize the ectopic pregnancy before it is interrupted. Early diagnosis, in turn, contributes to timely adequate treatment, preserving not only the health, but also the reproductive function of women.

Progressive tubal pregnancy exists for a short time: 4-6 weeks, rarely longer. There are almost no obvious symptoms, characteristic only for a progressing ectopic pregnancy. At a delay or at unusual for the patient monthly signs there can be signs peculiar to physiological or complicated uterine pregnancy: a perversion of taste, a nausea, a salivation, a vomiting, nagreganie mammary glands, sometimes insignificant pains in a bottom of a stomach, not having certain character. The general condition of the patient is quite satisfactory. Gynecological examination in the early stages of progressive tubal pregnancy usually does not reveal data confirming the diagnosis. Cyanosis and loosening of the mucous membrane of the vagina and cervix are expressed slightly. Due to hyperplasia and hypertrophy of the muscular layer and the transformation of the mucous membrane into decidual size of the uterus in the first 6-7 weeks corresponds to the delay in menstruation. The enlargement of the uterus, however, is not accompanied by a change in its shape, which remains pear-shaped, somewhat flattened in anteroposterior direction. The softening of the isthmus is weakly expressed. In some cases, it is possible to palpate an enlarged tube and to detect pulsation of vessels through the lateral arches. It is much easier to suspect a progressing tubal pregnancy, if the duration of its existence exceeds 8 weeks. It is from this time that the size of the uterus lags behind the expected duration of pregnancy. The possibility of detecting a thickened uterine tube increases.

All the above microsymptoms make us suspect a progressing tubal pregnancy if they are found in women who have had an ectopic pregnancy in the past, abortions, complicated appendicitis, inflammatory processes of appendages that suffered from infertility, or used intrauterine or hormonal contraceptives.

Clarification of the diagnosis in such cases should be carried out only in a hospital. The plan of examination of the patient depends on the availability of the hospital, its laboratory and hardware capabilities. The optimal variant of the examination: mandatory determination of chorionic gonadotropin in the serum or urine and ultrasound scanning, if necessary - laparoscopy.

If it is impossible to use ultrasound and laparoscopy, the examination takes a longer time. Carrying out of diagnostic actions can be two-fold, depending on the attitude of the patient to a possible uterine pregnancy. Confirming the desired pregnancy by any available method of determining the chorionic gonadotropin. The doctor performs a dynamic observation of the patient during such a time, which will allow to determine the location of the fetal egg by an ordinary vaginal examination. If a woman is not interested in pregnancy, then scraping of the uterine cavity and a histological examination of the removed tissue or gnsterosalpingography can be performed. Once again, it should be emphasized that the examination of a patient with suspected progression of ectopic pregnancy should be carried out in a hospital where an operating room can be deployed at any time to provide emergency surgical care.

[41], [42], [43], [44], [45]

Follow-up diagnosis after treatment

A week after the treatment of the ectopic pregnancy, you again need to check several times the level of the hormone of pregnancy (human chorionic gonadotropin). If his level falls, ectopic pregnancy is interrupted (sometimes in the first days after treatment, the hormone level may rise, but then, as a rule, falls). In some cases, the tests are repeated for a longer time (from weeks to months) until the doctor is satisfied that the hormone level has fallen to a minimum.

What should I think about?

If you are pregnant and are at risk, you should be carefully screened. Doctors do not always agree about the risk factors for ectopic pregnancy, but one thing is certain - the risk increases after the history of ectopic pregnancy, surgery on the fallopian tubes or pregnancy with a simultaneous intrauterine device.

The pregnancy test, which is sold in pharmacies and involves a urinalysis, will always accurately indicate the state of pregnancy, but can not reveal a pathology, namely, an ectopic pregnancy. Therefore, after you have received a positive result at home and suspect an ectopic pregnancy, you need to see a doctor who will prescribe a blood test and ultrasound if necessary.

[46], [47], [48], [49], [50]

Differential diagnosis

For differential diagnosis of undeveloped or discontinuous uterine pregnancy and ectopic pregnancy, scraping of the uterine cavity is performed. With ectopic pregnancy, a decidual tissue without chorionic villi is revealed in the scrapie, the Arias-Stella phenomenon (hyperchromic endometrial cells). With intermittent uterine pregnancy in scraping, there are remnants or parts of the fetal egg, the elements of the chorion.

Progressive tubal pregnancy is differentiated with:

• uterine pregnancy of early terms;
• dysfunctional uterine bleeding;
• chronic inflammation of the uterine appendages.

Termination of pregnancy by the type of rupture of the tube is differentiated with:

• ovarian apoplexy;
• perforation of stomach and duodenum ulcers;
• ruptured liver and spleen;
• torsion of the cyst or ovarian tumor;
• acute appendicitis;
• acute pelvioperitonitis.

Pregnancy, interrupted by the type of rupture of internal fertility (tubal abortion) must be differentiated with:

• abortion;
• exacerbation of chronic salpingo-oophoritis;
• dysfunctional uterine bleeding;
• torsion of the ovarian tumor;
• ovarian apoplexy;
• acute appendicitis.

Treatment of the ectopic pregnancy

Treatment includes taking medications and surgical intervention. In most cases, measures must be taken immediately for the safety of women. Medical products are prescribed in case of early diagnosis of this anomaly before the fallopian tube is damaged. The most common one for interruption of pregnancy is one or two medications of the drug Methotrexate. In this case there is no need for surgical intervention. But for certainty, you need to do repeated blood tests.

If an ectopic pregnancy takes longer, a safer option is surgery. If possible, laparoscopy (a small incision of the abdominal cavity), but in an emergency case, the incision will be much larger.

In most cases, ectopic pregnancy is interrupted immediately to avoid rupture of the fallopian tube and severe loss of blood. Treatment depends on the period of diagnosis of pregnancy and the general state of health of a woman. If there is no bleeding during an ectopic pregnancy, a woman can choose a means of interrupting it - medications or surgical intervention. Medical preparations. Such a drug as methotrexate is used to interrupt ectopic pregnancy. In this case, general anesthesia and incision are excluded. But it causes side effects and requires a blood test for several weeks to ensure that the treatment is effective.

Methotrexate has a positive effect if:

• the level of the pregnancy hormone in the blood is below 5.000;
• gestational age - up to 6 weeks;
• the embryo does not have cardiac activity.

Surgical intervention

If an ectopic pregnancy causes serious symptoms, such as bleeding and high levels of a hormone, surgery should be performed because the likelihood of the effectiveness of medications is reduced to a minimum, and the rupture of the fallopian tube becomes obvious. If possible, make laparoscopy (a small incision of the cavity). In the case of rupture of the fallopian tube, urgent surgical intervention is required.

Sometimes it is obvious that an ectopic pregnancy will result in an arbitrary miscarriage. Then treatment is not required. But the doctor still insists on blood tests to make sure that the level of the hormone falls.

Sometimes an ectopic pregnancy can not be cured:

• If the hormone level does not fall and the bleeding does not stop after taking methotrixate, you need to do the operation.
• After the operation, you can take methotrixate.

Operative treatment of ectopic pregnancy

With ectopic pregnancy, the first thing is prescribed Methotrexate, but several times blood tests are done.

There are several types of surgery for tubal ectopic pregnancy: salpingostomy (creating an opening in the fallopian tube connecting her cavity with the abdominal cavity) or salpingectomy (removal of the fallopian tube).

Salpingostomy has an effect similar to that of methotrexate, since both agents have the same efficacy and preserve the possibility of a future pregnancy.

The operation is a quick way to solve the problem, but after it there are scars that can provoke problems during a future pregnancy. Operations on the fallopian tube cause harm to it depending on the location and size of the embryo, as well as on the type of surgical intervention.

Surgical intervention is the only way to interrupt ectopic pregnancy, if the period exceeds more than 6 weeks or there is internal bleeding.

At any time, the surgical interruption of ectopic pregnancy is the most effective way. If the gestation period is more than 6 weeks, while bleeding is observed, the operation is the only way to solve the problem. If possible, laparoscopy (a small incision of the cavity), after which the process of recovery does not take long.

Choice of surgical intervention

Interruption of ectopic pregnancy is carried out in two ways, namely, by salpingostomy and salpingectomy.

• Salpingostomy. The embryo is removed by extracting it through a small hole in the fallopian tube, which heals by itself or the seams are superimposed. Such a surgical intervention is performed if the embryo is less than 2 cm and is located at the far end of the fallopian tube.
• Salpingectomy. A part of the fallopian tube is removed, and parts of it are connected. This operation is carried out in the case of a pipe stretching and the risk of its rupture.

These both surgical interventions are performed by laparoscopy (a small incision) or a routine operation in the abdominal cavity. Laparoscopy does less harm, and the recovery process lasts faster than lapotomy (autopsy). But in the case of abdominal ectopic pregnancy or an ectopic abortion of an ectopic pregnancy, lapotension is usually performed.

What should I think about?

When the embryo is in the undamaged fallopian tube, the doctor will make every effort to terminate the pregnancy without damaging the tube. In the case of a rupture of the fallopian tube, an emergency abortion surgery is performed.

[51], [52], [53]

Treatment of ectopic pregnancy at home

If you are a high-risk group, buy a pregnancy test. With a positive result, go to the gynecologist, who must confirm the pregnancy. Tell your doctor about your fears.

If you are taking methotrixate to interrupt an ectopic pregnancy, be prepared for side effects.

If you interrupted ectopic pregnancy, it does not matter what week it may take to mourn the loss. Often, women experience depression as a result of a sharp hormonal change after the termination of pregnancy. If symptoms of depression are observed for a longer time, you need to go to a consultation with a psychologist.

Talk to other women who have experienced the same loss, or with friends.

Medication for ectopic pregnancy

Medical drugs are used only in the early stages of diagnosing ectopic pregnancy (when the embryo did not rupture the fallopian tube). Medical products cause less damage to the fallopian tubes than surgery.

They are appointed at early stages of diagnosing ectopic pregnancy in the absence of bleeding, and also when:

• the hormonal level is less than 5.000;
• passed no more than 6 weeks after the last menstrual cycle;
• the embryo does not have a heart rhythm yet.

In the case of a gestation period of more than 6 weeks, a surgical procedure is performed, which is considered a safer and more correct way of aborting the pregnancy.

What should I think about?

Methotrixate is prescribed for early ectopic pregnancy, but if the period exceeds 6 weeks, the operation is considered safer and the correct way to interrupt it.

At the same time you need to do several blood tests to make sure that the level of the hormone falls.

Methotrexate can cause unpleasant side effects, for example, nausea, upset stomach or diarrhea. According to statistics, one in four women experience abdominal pain while increasing the dosage of this drug in order to achieve greater efficacy. Pain may be the result of fetal progression in the fallopian tube or a negative effect of the drug on the body.

Methotrexate or surgery?

If an ectopic pregnancy is diagnosed at an early stage and it does not cause a rupture of the fallopian tube, the use of methotrexate is permitted. At the same time, there is no need to perform an operation, harm is minimal, and a woman can become pregnant again. If you do not plan to have another child in the future, surgical intervention is the best option, as the result will be achieved more quickly, and the risk of bleeding will be reduced to a minimum.

Other types of treatment

Ectopic pregnancy is a threat to the life of a woman, so immediate measures are taken to interrupt her. For this purpose, surgical intervention is performed, certain medications are administered and blood tests are done. There is no other way to treat this condition, since there is a risk of severe bleeding and death.

Prevention

If you smoke, you need to give up this harmful habit, since smokers are more prone to abnormalities of pregnancy, and the more you smoke, the greater the risk of ectopic pregnancy.

Safe sex (for example, the use of a condom) - the prevention of sexually transmitted diseases, and, consequently, the inflammation of the pelvic organs, which lead to the formation of scar tissue in the fallopian tubes, which is the cause of ectopic pregnancy.

To prevent ectopic pregnancy is impossible, but timely diagnosis (at the beginning) will help avoid complications that can lead to death. Women who are at risk should be screened early in pregnancy.

[54], [55], [56]

Forecast

A woman always experiences a difficult pregnancy. For a while you can even burn and gain the support of family and friends in this difficult period. Sometimes there is depression. If it is observed for more than two weeks, consult a doctor. Often women are concerned about the question of how she will be able to get pregnant again. Ectopic pregnancy does not mean that a woman becomes barren. But one thing is clear:

• it may be difficult to conceive;
• the risk of repeated ectopic pregnancy is high enough.

When you are pregnant again, tell your doctor about the previous ectopic pregnancy. Regular blood tests in the first weeks of pregnancy will help to identify possible deviations at an early stage.

Future fertility

Future fertility and the possibility of repeating an ectopic pregnancy depend on whether you are entering a high-risk group. Risk factors: smoking, use of assisted reproductive technologies and damage to the fallopian tube. If you have an undamaged single fallopian tube, salpingostomy and salpingectomy affect equally your ability to become pregnant again. If the second tube is damaged, the doctor usually recommends salpingostomy, which increases the chances of becoming a mother again.

[57], [58], [59]