Cardiovascular and cervical

Neck and pterygium-cervical pregnancy is a relatively rare complication of pregnancy, which is a distal option for ectopic pregnancy.

With true cervical pregnancy, the fetal egg develops only in the cervical canal. In cervical-cervical pregnancy, the fetus is the cervix and the isthmus region. Neck and neck-and-neck cervical localization is observed in 0.3-0.4% of cases from all variants of ectopic (ectopic) pregnancy. In relation to all pregnancies, cervical and cervical-cervical pregnancy occurs from 1:12 500 to 1:95 000.

Neck-neck and cervical pregnancies pose a serious threat not only to health, but also to the life of the patient. The cause of death most often is bleeding (in 75-85% of cases), less often - an infection.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of cervical and neck and neck caries

The emergence of a distal ectopic pregnancy is associated with the following causative factors: the impossibility or hindered nidation of the fetal egg in the uterine body due to the inferiority of the endometrium or the insufficient maturity of the trophoblast, in the presence of circumstances conducive to the blastocyst slipping into the cervical canal. Such conditions arise in women who have had a complicated course of previous childbirth and the postpartum period, multiple abortions, surgical interventions on the uterus, uterine myoma, and ischemic-cervical insufficiency.

The trophoblast, and then the villi of the chorion implanted in the cervix and in the region of the isthmus of the uterus of the fetal egg, penetrate the mucosa and penetrate the muscle layer. The melting of muscle cells and blood vessels leads to bleeding and impaired pregnancy. In some cases, the wall of the cervix can be completely destroyed and the chorionic villus can penetrate into the parameter or into the vagina.

In view of the lack of protective mechanisms inherent in the decidual shell of the uterus, the cervical wall is quickly destroyed by the developing fetal egg. In true cervical pregnancy, this process takes place within 8, less than 12 weeks. In case of neck and neck carcinoma, pregnancy may last for a longer time: 16-20-24 weeks. It is extremely rare pathological distal ectopic pregnancy can be worn before the term of childbirth.

[10], [11], [12], [13], [14]

Symptoms of cervical and neck and neck caries

Symptoms of cervical pregnancy are largely determined by the period of pregnancy and the level of implantation of the fetal egg. The main manifestation of the disease is bleeding from the genital tract on the background of the previous delay of the next monthly with no pain symptom. Bleeding can be mild, profuse or profuse. In many patients before the onset of bleeding, there are periodically appearing scant smearing character of the discharge of blood. In some pregnant women, such secretions appear only in the early periods, and then more or less prolonged time the pregnancy proceeds without pathological manifestations.

In a number of patients, cervical pregnancy first manifests itself in the manufacture of artificial abortion.

Many authors believe that the diagnosis of cervical pregnancy presents certain difficulties. A belated diagnosis of cervical pregnancy is largely due to the rarity of the disease, so doctors forget about it. With this position, you can agree, but the degree of difficulty with which a practical doctor meets in the diagnosis of cervical pregnancy is different.

Diagnosis of cervical and neck-and-neck pregnancy

It is quite easy to diagnose a true cervical pregnancy of 8-12 weeks, if the nidation of the fetal egg occurred in the lower or middle part of the cervix. In typical cases, we are talking about pregnant women who had a history of childbirth and abortions, who are admitted to the hospital for bleeding of varying degrees of severity. The general condition of the patient corresponds to the volume of blood loss. When examined with the help of mirrors, an eccentric location of the external pharynx is found, and in a number of patients a network of dilated venous vessels is visible on the vaginal part of the cervix. In a bimanual study, the cervix appears to be a spherically enlarged, soft consistency, and on it in the form of a "cap" is a small denser body of the uterus, immediately behind the external yaw palpates a fetal egg closely connected with the walls of the cervix; The attempt to separate it with a finger or instrument is accompanied by increased bleeding.

It is more difficult to diagnose cervical pregnancy, in which the bed of the fetus is located in the upper part of the cervical canal. In such cases, patients can also note meager discharge of blood from early pregnancy. And then there is a strong bleeding without a pain symptom. Examination with the help of mirrors does not reveal pathological changes in the cervix, which turns out to be cyanotic, as in ordinary pregnancy, with the central location of the external pharynx. In bimanual examination, an experienced physician can pay attention to the short vaginal part of the cervix, above which, in the enlarged upper part of the cervix with the adjoining denser body of the uterus, there is a fetus. The data of the gynecological examination are thus not indicative, therefore in such situations the correct diagnosis is most often established with curettage, (sometimes repeated) of the uterus. Carrying out this operation, the doctor should pay attention to the following points:

1. the expansion of the external throat is very easy, but accompanied by heavy bleeding;
2. there is no feeling of passing through the instrument of an internal pharynx;
3. removal of the fetal egg is difficult and does not lead to the stop of bleeding;
4. after emptying the fruit by the curette, one can feel a depression ("niche") in the place of the former attachment of the fetal egg; confirm the presence of a "niche" and thinning of the neck wall can be, by entering a finger into the cervical canal.

Sometimes it is necessary to clarify the diagnosis after scraping the uterus, produced by another doctor. In such cases, it is possible to detect an enlarged bag in the form of a flabby upper part of the cervix. If you can enter a finger into the cervical canal, then revealing the niche and thinning the cervical wall confirms the diagnosis.

Significant difficulties are the diagnosis of cervico-cervical pregnancy, since typical symptoms associated with changes in the cervix (eccentric location of the external pharynx, balloon-like expansion of the cervix with a slight increase in the uterine body), in such cases, as a rule, absent. It is possible to suspect this complication of pregnancy on the basis of periodically recurring bleeding, which with increasing duration of pregnancy becomes more abundant. In the first trimester of pregnancy, it is often noteworthy that repeated bleeding is not accompanied by pain (the body of the uterus is intact) and the fetal egg is not expelled. However, doctors do not attach due importance to these features of the course of pregnancy, as heavy bleeding prompts to quickly determine the duration of pregnancy and start emptying the uterus. Meanwhile, careful gynecological examination can reveal a shortening of the vaginal part of the cervix, a softened enlarged upper part of the cervix that merges with the denser body of the uterus, which does not correspond to the gestation period. When starting to remove the fetal egg and scraping the walls of the embryo, it should always be remembered that this manipulation can be of invaluable help in diagnosing both cervical and cervical-cervical pregnancy. Difficulty in evacuating the fetal egg, continuing and even increasing bleeding, revealing a crater-like depression in the wall of the fetus - these are the landmarks that help to recognize this pathology.

Pterygium-cervical pregnancy in the second trimester has no pathognomonic symptoms. The longer the gestation period, the more often the clinic of peremechanical cervical pregnancy resembles the clinical manifestations of placenta previa. The correct diagnosis is often established after the birth of the fetus. The delay of the afterbirth or parts requires an instrumental or (more rarely) finger entry into the uterus, in which the attentive physician discovers the overgrowth and thinning of the lower segment of the cervix and the intact body of the uterus.

In recent years, a great help for the timely diagnosis of cervical and perechechno-cervical pregnancy has an ultrasound. Transverse and longitudinal scanning makes it possible to determine the collobion expansion of the cervix, which is larger than the body of the uterus.

Some women in the enlarged cervical canal not only visualize the fetal egg, but also register the cardiac activity of the embryo.

[15], [16]

Treatment of cervical and neck and neck caries

Treatment of patients with cervical and pterygular-cervical pregnancy at present can only be surgical. The operation should be started immediately, as soon as the diagnosis is established. The slightest delay in the actions of the doctor conceals the threat of death of the patient from profuse bleeding.

The operation of choice is the extirpation of the uterus, which should be performed in 3 stages:

1. vasoconstriction, ligation of blood vessels;
2. resuscitation measures;
3. uterus removal.

Such interventions as suturing on bleeding vessels of the cervix or conservative plastic surgery on the neck with excision of the fetal bed can not be recommended for general practice.