Ectopic pregnancy

Ectopic pregnancy can not be tolerated before the term and, eventually, interrupted or regressed. In ectopic pregnancy, implantation occurs outside the uterine cavity - in the fallopian tube (in its intramural region), in the cervix, in the ovary, in the abdominal cavity, or in the small pelvis. Early symptoms and symptoms include pelvic pain, vaginal bleeding, and tenderness in the movement of the cervix. When the tube breaks, there may be fainting or hemorrhagic shock. Diagnosis is based on determining the level of beta-hCG and the results of ultrasonography. Treatment consists in laparoscopic or open surgical operation or intramuscular injection of methotrexate.

The frequency of development of ectopic pregnancy (in general, 2/100 diagnosed pregnancies) increases with increasing maternal age. Other risk factors include history of pelvic inflammatory disease (especially due to Chlamydia trachomatis), tube surgery, previous ectopic pregnancies (the risk of recurrence is 10%), cigarette smoking, exposure to diethylstilbestrol and previous induced abortions. The likelihood of pregnancy with intrauterine devices (IUD) is low, but about 5% of such pregnancies are ectopic. At the same time, ectopic and intrauterine pregnancy occurs in only 1 in 10 000-30 000 pregnancies, but is more common among women who have used ovulation induction or additional reproductive methods, such as in vitro fertilization and gamete transfer into the fallopian tubes (GIFT); in such cases, the probability of this ectopic pregnancy is 1% or less.

The most frequent site of ectopic implantation is the uterine tube in the interstitial compartment. There is rarely an implantation in the cervical region, on the cicatricial rumen, ovaries, in the abdominal cavity and small pelvis. The rupture of ectopic pregnancy leads to bleeding, which can be gradual or intense enough to cause hemorrhagic shock. The intraperitoneal blood causes peritonitis.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Symptoms Ectopic pregnancy

Symptoms of ectopic pregnancy

Symptoms of ectopic pregnancy vary. Most patients note pain in the small pelvis, sometimes cramping, bleeding from the vagina or both of these symptoms. Menstruation may be absent, but it may occur on time. The rupture is characterized by sudden, severe pain, accompanied by a syncope or symptoms and signs of hemorrhagic shock or peritonitis. Rapid bleeding is more likely with ectopic pregnancy in the rudimentary horn of the uterus.

There may be soreness in the movement of the cervix, one-sided or bilateral soreness of the appendages or swelling of the appendages. The uterus may be slightly enlarged, but the increase is less than expected based on the last menstrual period.

Diagnostics Ectopic pregnancy

Diagnosis of ectopic pregnancy

Ectopic pregnancy is suspected in any woman of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless of sexual, contraceptive and menstrual anamnesis. Clinical examination (including examination of pelvic organs) is not sufficiently informative. For diagnosis, the definition of hCG in urine is required, this method is sensitive in 99% of cases when determining pregnancy (ectopic and uterine). If the urine test for hCG is negative, and according to clinical data, the ectopic pregnancy is not confirmed, and the symptoms do not recur or worsen, further examination is not performed. If the urine test is positive or the results of a clinical study indicate an ectopic pregnancy, it is necessary to quantify the hCG in the blood serum and ultrasonography of the pelvic organs. If the quantitative index is less than 5 mIU / ml, then the ectopic pregnancy can be excluded. If an intrauterine gestational sac is found in ultrasonography, ectopic pregnancy is unlikely (except for women using assisted reproductive technologies), however, pregnancies in the rudimentary horn of the uterus and intra-abdominal can be similar to uterine pregnancy. The results of ultrasonography suggesting ectopic pregnancy (noted in 16-32%) include a complex (a mixture of solid and cystic) formations, especially in the appendages; free fluid in a blind bag and the absence of a gestational sac in the uterus during an over-vaginal examination, especially if the level of HCG is more than 1000-2000 mIU / ml. The absence of an intrauterine sac at a hCG greater than 2000 mIU / ml indicates the presence of an ectopic pregnancy. The use of vaginal and color Doppler ultrasonography can improve diagnosis.

If the ectopic pregnancy is unlikely and the condition of the patients is compensated, a series of measurements of the hCG level can be performed on an outpatient basis. Usually the indicator doubles every 1.4-2.1 days to the 41st day; when ectopic pregnancy (and abortion) values may be lower than expected in this period, and usually do not double so quickly. If the initial assessment or series of measurements of hCG indicate an ectopic pregnancy, diagnostic laparoscopy may be necessary to confirm it. With an unclear diagnosis, you can determine the level of progesterone; if it is 5 ng / ml, then a viable intrauterine pregnancy is unlikely.

[12], [13], [14], [15], [16], [17]

Treatment Ectopic pregnancy

Treatment of ectopic pregnancy

The treatment of hemorrhagic shock; hemodynamically unstable patients require immediate laparotomy. Compensated patients are usually laparoscopic; but sometimes a laparotomy is required. If possible, salpingolotomy is performed, usually using an electroscalpel or laser, to save the tube and evacuate the fetal egg. Salpingectomy is indicated in cases of recurrence of ectopic pregnancy and at a size of more than 5 cm, when the tubes are severely damaged, and if in the future the birth of a child is not planned. Removing only irrevocably damaged parts of the tube increases the chance that tubal repair will help restore fertility. The pipe can be restored directly during the operation or not restored. After pregnancy in the rudimentary horn of the uterus, the tube and the involved ovary are usually preserved, but sometimes restoration is impossible, and hysterectomy is necessary.

If there is an undisturbed trumpet pregnancy of 3.0 cm in diameter, cardiac fetal activity is not detected and the hCG level is ideally less than 5000 mIU / ml, but less than 15,000 mIU / ml is allowed, then a single intramuscular injection of a 50 mg / m2. The determination of hCG and ultrasonography is repeated approximately on the 4th and the 7th day. If the level of hCG does not decrease> 15%, then a second dose of methotrexate or surgical treatment is needed. Approximately 10-30% of women with methotrexate require a repeated dose of the drug. The success rate with methotrexate is approximately 87%; 7% of women have serious complications (for example, a gap). Surgical treatment of ectopic pregnancy is indicated in cases when methotrexate can not be used (eg, at a hCG> 15,000 mIU / ml) or when its use is ineffective.

Forecast

What prognosis does the ectopic pregnancy have?

Ectopic pregnancy is fatal to the fetus, but if the treatment is performed before the rupture, then maternal mortality is very rare. In the US, an ectopic pregnancy accounts for 9% of maternal deaths associated with pregnancy.