Treatment of ectopic pregnancy

The goal of the treatment is elimination of ectopic pregnancy. The main method of treating ectopic pregnancy is considered surgical.

The introduction of laparoscopic surgery into practice led to a reduction in the number of laparotomy operations for ectopic pregnancy from the total number of surgical interventions. The scope of surgical intervention (tubotomy or tubectomy) in each case is decided individually. When deciding whether to perform an organ-preserving operation, it is necessary to take into account the nature of operative access (laparoscopy or laparotomy) and the following factors:

• the patient's desire to have a pregnancy in the future;
• morphological changes in the wall of the tube ("old" ectopic pregnancy, thinning of the wall of the tube all over the fetal well);
• repeated pregnancy in a tube previously subjected to an organ-preserving operation;
• ectopic pregnancy after reconstructive-plastic operations on the fallopian tubes for tubal peritoneal factor of infertility;
• localization of the fetal egg in the interstitial department of the fallopian tube;
• pronounced adhesion process of the pelvic organs.

Indications for hospitalization

• The delay of menstruation, the presence of bloody discharge from the genital tract and pain in the lower abdomen of a different nature and intensity with possible irradiation (into the thigh, into the groin, the anus).
• The delay of menstruation, the absence of bloody discharge from the genital tract and the positive results of HGT in the blood, regardless of the presence or absence of ultrasound signs of ectopic pregnancy.
• Delay in menstruation, determination in two-handed examination of pastosity in the vaults (left or right).
• Identification of ultrasound signs of ectopic pregnancy.

Surgical treatment of ectopic pregnancy

Currently, gynecologists around the world have a common view on the treatment of tubal ectopic pregnancy: once the diagnosis is established, the patient should be subjected to surgical treatment. At the same time, there is an active discussion, clarification and improvement of traditional methods and development of new methods of surgical interventions. The nature of the operation is regulated by many factors: the localization of the fetal egg, the severity of pathological changes in the affected and opposite tube, the degree of hemorrhage, the general condition, the age and the desire of the patient to have a pregnancy in the future.

If the interruption of pregnancy occurs in the ballroom by the type of rupture of the tube or those cases of tubal abortion accompanied by heavy bleeding, the time factor is the first priority in the provision of emergency care. You can count on success if the interaction of the surgeon-gynecologist and anesthesiologist-resuscitator is carried out clearly and quickly. The anesthetist carries out resuscitation measures in a short time "aimed at removing the patient from shock, achieving relative stabilization of her condition, and begins anesthesia. To this time the gynecologist should be ready for surgical intervention. The operation of choice in this situation is the removal of the fetus, that is, the uterine tube. A life threatening state of the patient dictates the need for an operative intervention in 3 stages:

1. abdominal hemorrhage, stopping bleeding;
2. resuscitation measures;
3. continuation of the operation.

Opening of the abdominal cavity can be performed with any access that the surgeon has better: lower mid laparotomy, a transverse suprapubic incision along Pfannensthln or Cherni. In the wound, the affected tube is quickly removed and hemostatic clamps are placed on its uterine end and mesosalpinx. This operation is temporarily stopped until the anesthesiologist signals the possibility of its continuation. At this point, the operating doctor can help the anesthetist in carrying out resuscitation measures, providing him with blood taken from the abdominal cavity. Autoblood reinfusion does not present technical complexity. The operating sister should always have a sterile set, consisting of a glass jar (better graded), a funnel and a scoop-cup. In the jar pour 100-200 ml of isotonic sodium chloride solution and through the funnel, covered with 8 layers of gauze, moistened with the same solution, filter the blood, scooped out of the abdominal cavity. For reinfusion, it is allowed to consume externally unchanged blood (absence of hemolysis, abundant fatty inclusions) with acute bleeding "(prescription from the beginning of an attack no more than 12 hours) and in the absence of signs of infection (normal body temperature, corresponding state of the abdominal cavity organs). Infusion of autoblood helps to bring the patient out of shock more quickly, does not require a preliminary determination of the blood group and rhesus-affiliation, conducting tests for compatibility.

The most rational is to begin reinfusion of blood after applying the hemostatic clamps. However, it is quite acceptable and even appropriate for massive bleeding to prevent the loss of blood to begin transfusion immediately. In such cases, after opening the peritoneum, the edges are raised by four instruments, quickly scooped out the blood, ready to pour out of the abdominal cavity. Then, expanding the incision of the peritoneum, remove the fallopian tube, apply hemostatic clamps and collect the remaining blood.

Continue the operation only with the permission of an anesthesiologist. Cut off the pipe. Clamps on the uterine end of her and mesosalpinex are replaced with catgut ligatures. Peritonization is usually performed using a round uterine ligament. Then, under the continued full-fledged anesthesia, the remains of liquid blood and clots are carefully removed. The abdominal wall is layered suturedly tightly.

Surgery of salpingectomy is performed in some women and in the absence of massive bleeding. In such cases, the indications for it are significant pathological changes in the uterine tube, due to impaired pregnancy or previous inflammation. Removal is subject to a trumpet in women who are not interested in maintaining reproductive function and over 35 years of age.

Operations with an old tubal pregnancy with an organized perituburn or zamatochnoy hematoma are quite difficult due to fusion with loops of the intestines, omentum, uterus and its ligaments. Friable spikes are carefully separated by a blunt path, dense - sharp. The hematoma capsule should be removed, but it should be done with great care. It is better to leave a part of the capsule on the wall of the gut, than to cause her injury. After releasing the appendages, they must be carefully inspected, using a tuffer, carefully remove from the surface of the ovary old blood clots and the remains of the capsule. In the vast majority of cases, this can be accomplished, and the scope of the operation is limited to salpingectomy. If the ovary is damaged, then either resect it, or remove the appendages entirely.

Organoservicing operations for tubal pregnancy can be carried out under the following conditions:

• satisfactory condition of the patient with compensated blood loss at the time of surgery;
• the patient's state of health, which does not prevent future pregnancy and childbirth;
• minimal changes in the uterine tube (ideal condition - progressive pregnancy);
• the woman's desire to maintain reproductive function;
• high qualification of the surgeon.

The most wide range of conservative operations in specialized institutions, where microsurgical techniques are used to treat tubal ectopic pregnancy. The most common of these are: salpingotomy, carried out in the ampullar or ismic section of the tube; segmental resection of the isthmic department with an end-to-end anastomosis application. For successful implementation of microsurgical interventions, an operating microscope, a special instrumentation, a biologically inactive suture material (nylon or dexon threads 6-0 or 8-0) is required. With salpingo-geology, the incision is made on the anti-scraping edge of the tube with a needle electrode with a minimal cutting current. The fetal egg is carefully removed with tweezers or an electric pump. Carefully coagulate all the bleeding vessels. The incisions are sewn with two rows of seams.

If the fetal egg is located in the ampullar compartment close to the pili, then it is not necessary to open the tube. The fetal egg can be gently squeezed out, carefully examine the fetal well, coagulate the vessels. Such an operation is possible in a conventional nonspecialized hospital, which is quite accessible elements of microsurgery.

Segmental resection with end-to-end anastomosis is performed with an istmic pregnancy. On both sides of the pipe section containing the fetal egg, mini-clamps are applied. Through the mesosalpinx, a nylon ligature of 6-0 is carried out, inserting the needle under one clamp and puncturing under the other. The changed section of the pipe is excised. Ligature is tightened. Bleeding vessels coagulate. The ends of the pipes are joined by two rows of seams: the first row - through the muscle layer and serosa, the second - gray-serous.

If there are no conditions for carrying out a microsurgical operation, and the patient is extremely interested in maintaining reproductive function, it is possible to confine oneself to resection of the altered section of the tube with ligation of the stumps with non-absorbable ligatures. Microsurgical restoration of the integrity of the uterine tube by anastomosing the stored sites is performed after 6 months if the patient has this tube only, or 12 months later, if the patient does not become pregnant with a preserved but defective second tube.

The success of organ-saving operations is largely provided by measures aimed at preventing the adhesion process. These include:

1. careful removal of the abdominal cavity of liquid blood and clots;
2. constant moistening of the operating field with isotonic sodium chloride solution;
3. the maintenance of the postoperative period against the backdrop of a hydroperitoneum created by the administration of a solution of dextro (polyglucin).

At small terms of a progressing pregnancy, when the diameter of the fallopian tube does not exceed 4 cm, or with an abnormal pregnancy with a small tube damage and moderate blood loss, gentle operations can be performed under laparoscopy conditions. The most common variant of intervention in these conditions is salpingolotomy. The instrument is inserted through an additional incision in the suprapubic region. With the help of an electric coagulator or a carbon dioxide laser, the wall of the pipe is dissected; the egg is carefully removed with an electric pump or tweezers; bleeding sites coagulate. Authors who have experience of such operations note a number of advantages of the method: minimal injury of the abdominal wall, short hospitalization, rapid restoration of work capacity, high percentage of fertility preservation.

In recent years, there have been reports in the literature about the possibility of non-operative treatment of a progressive ectopic pregnancy of small terms. Short courses of methotrexate or steroid preparations of antiprogestronic action lead to resorption of the fetal egg without damaging the mucous membrane of the tube. This therapeutic area is certainly promising and requires a comprehensive study.

Treatment of abdominal ectopic pregnancy of any term is only surgical. The nature of surgical intervention is extremely wide and unpredictable. It depends on the period of pregnancy and the place of implantation of the fetal egg. In the early stages of an aborted abdominal pregnancy, a small excision of the tissues of the bleeding site and the imposition of several stitches are sufficient. In such situations, the main difficulty is not in the technical implementation of the operation, but in the detection of the localization of pregnancy. The site of implantation is most often found on the peritoneum of the uterine-rectum groove.

For large periods of pregnancy, the villi placenta penetrate deeply into the underlying tissue, so you have to remove the placental site together with the placenta: to amputate or extirpate the uterus, remove the appendages, resect the bowel, amputate a part of the large omentum, etc. Often a successful operation requires a joint participation of a surgeon and gynecologist.

Treatment of ovarian pregnancy, of course, is surgical. Different variants of operations are possible: from ovarian resection to removal of appendages. The choice of the amount of intervention depends on the degree of damage to the ovary.

Salpingotreatment

Consider the main operation on the tubes for ectopic pregnancy. Conditions:

• preservation of fertility;
• stable hemodynamics;
• the size of the fetal egg is <5 cm;
• the fetal egg is located in the ampullar, infundibular or isthmic department.

Extrusion of the fetal egg is produced when it is localized in the fimbrial section of the tube. Dissection of the uterine angle is carried out when the fetal egg is localized in the interstitial section of the tube.

Indications:

• content of CGT> 15 thousand IU / ml;
• ectopic pregnancy in anamnesis;
• the size of the fetal egg is more than 5 cm.

With other pathological changes in the other tube (hydrosalpinx, saktosalpinks), two-sided salpingectomy is recommended. The possibility of it must be discussed with the patient in advance and written consent is obtained for the specified amount of surgical intervention.

Conservative methods of treatment of ectopic pregnancy

Conditions for conservative treatment of ectopic pregnancy:

• progression of tubal pregnancy;
• the size of the fetal egg is not more than 2-4 cm.

It is believed that the drug therapy of ectopic pregnancy is promising. But the method was not widely used, in particular, due to the low frequency of diagnosis of progressive tubal pregnancy. In modern practical gynecology, the surgical method of treatment is considered to be a priority.

In most cases, methotrexate is used for conservative management of a patient with an ectopic pregnancy, less commonly used: potassium chloride, hypertonic dextrose solution, prostaglandin preparations, mifepristone. The drugs are used parenterally and topically (injected into the uterine tube through the lateral vaginal fornix under the supervision of ultrasound, with laparoscopy or transcervical catheterization of the fallopian tube).

Methotrexate is an antitumor agent of the antimetabolite group that inhibits the reductase of dihydrofolic acid involved in its reduction into tetrahydrofolic (a carrier of carbon fragments necessary for the synthesis of purine nucleotides and their derivatives). Side effects include leukopenia, thrombocytopenia, aplastic anemia, ulcerative stomatitis, diarrhea, hemorrhagic enteritis, alopecia, dermatitis, increased hepatic enzyme activity, hepatitis, pneumonia. With ectopic pregnancy, the drug is administered in low doses, not causing serious side effects. If several administrations of methotrexate are scheduled, calcium folinate is prescribed. This antidote to methotrexate, reducing the risk of its side effects (the dose should be equal to the dose of methotrexate, enter within 1 hour).

[1], [2]

Scheme No. 1

Methotrexate in a dose of 1 mg / kg / day / m / day, calcium folinate at a dose of 0.1 mg / kg / day IM in a day, starting on the 2nd day of treatment. Methotrexate is canceled when the content of the β-subunit of CGT in serum is reduced by 15% per day. Calcium folinate is injected the last time the day after the cancellation of methotrexate. At the end of the treatment, the concentration of the β-subunit of CGT is determined weekly until normalization. If the β-subunit of CGT ceased to decrease and there was an increase, methotrexate was administered repeatedly. The effectiveness of treatment according to this scheme is 96%.

Scheme No. 2

Methotrexate is administered once in a dose of 50 mg / m ², calcium folinate is not prescribed. The effectiveness of treatment under this scheme is 96.7%.

The effectiveness and likelihood of a normal pregnancy after applying the two schemes are approximately the same. Indications for the appointment of methotrexate.

• Increased content of β-subunit of HGT in the blood serum after organ-preserving operation on the fallopian tube performed for ectopic pregnancy (persistent ectopic pregnancy).
• Stabilization or increase in the concentration of the β-subunit of CGT in blood serum for 12-24 hours after separate diagnostic curettage or vacuum aspiration if the size of the fetal egg in the area of the uterine appendages does not exceed 3.5 cm.
• Definition of a fetal egg with a diameter of no more than 3.5 cm in the region of the uterine appendages when the content of the β-subunit of HGT in the blood serum exceeds 2000 IU / L in the absence of a fetal egg or fluid accumulation in the uterine cavity.

The patient is observed outpatiently. With a strong prolonged pain in the abdomen, a hematocrit is determined and a vaginal ultrasound is performed, which makes it possible to determine if the tube has broken. To assess the condition of the fetal egg on the background of treatment with methotrexate, ultrasound is not performed. Evaluate the results of ultrasound with ectopic pregnancy should be cautious, since the accumulation of fluid in the rectum-uterine cavity is observed in both developing and interrupted ectopic pregnancy. With rapid reduction of hematocrit or hemodynamic disorders, surgical treatment is indicated. After treatment with methotrexate, contraception is recommended for 2 months.

But taking into account the side effect of methotrexate, if necessary, repeated administration in sufficiently large doses for the treatment of EB, a number of researchers have made attempts to improve the technique. In 1987, W. Feichtinger and Kemeter solved the problem, providing the maximum effect with a minimal dose of methotrexate by using local injections of the drug under the control of transvaginal monitoring. The drug is injected into the lumen of the fetal egg after preliminary aspiration of the amniotic fluid. A single dose is from 5 to 50 mg and is determined by the gestational age. A. Fujishita et al. To enhance the therapeutic effect of methotrexate, its suspension, including ultra-fluid lipidol with phosphatidylcholine, was used. According to the authors, the use of the suspension reduces the incidence of persistent pregnancy by 44% compared to the use of pure methotrexate.

However, practical experience and literature data convince us that ultrasound salpingo-centeses is associated with a high risk of damage to the mesosalpinx vascular network and the fallopian tube. Therefore, currently it is advisable to perform laparoscopic salpingosentesis.

Benefits of Laparoscopic Tuboscopy

• Objective assessment of the state of the "pregnant" uterine tube.
• Determination of the most safe puncture point of the pipe.
• Providing hemostasis by injecting hemostatics into the mesosalpinks and / or point coagulation of the area of the proposed puncture. Organizational and therapeutic technologies, allowing to make organ-saving operations of tubal pregnancy.
• Early treatment of the patient in a women's consultation or a clinic.
• Carrying out of diagnostic measures (β-CGT, ultrasound) and observation no more than 2 days in the women's consultation and polyclinic.
• Timely hospitalization and laparoscopy no later than 24 hours after hospitalization.
• Round-the-clock endoscopic service in a hospital.

[3], [4], [5], [6]

Observation

Women who have undergone an ectopic pregnancy need regular follow-up at their place of residence. Patients with unrealized reproductive function are shown with control laparoscopy to clarify the state of the fallopian tubes after 3 months, after organ-saving operations.

Long-term results of treatment of ectopic (ectopic) pregnancy can not be considered safe. In 25-50 % of cases, women remain infertile, in 5-30 % - have a repeated tubal pregnancy. Such a spread of statistical data depends on the clinical course of ectopic pregnancy (the nature of damage to the fetus and the degree of blood loss), the volume and technique of surgical treatment, the completeness and duration of rehabilitation activities in the postoperative period. The most favorable result is provided by organ-preserving surgeries, performed with the use of microsurgical techniques before the violation of tubal pregnancy.

In the postoperative period, an individual treatment plan is planned for each patient, including a set of measures that operate in three directions:

1. general effect on the body by the appointment of funds that increase nonspecific protective forces, stimulating hemopoiesis, enhancing anabolic processes;
2. conducting a course of physiotherapy;
3. conducting a course of hydrotubations.

Medicinal preparations are prescribed from the first day of the postoperative period, physiotherapy and hydroturbation - from the 4th-5th day (immediately after the cessation of bloody discharge from the genital tract). Repeated courses of rehabilitation therapy should preferably be performed at 3, 6, 12 months after the operation. All this time the woman should be protected from pregnancy.

Rehabilitation measures are shown to those who are sick. In which both pipes are removed and there is no question of restoring fertility. It is known that such a contingent of women often have non-neuroendocrine changes, ovarian dysfunction and vegetovascular changes. Such a patient shows the use of sedatives, vitamins, regulating physiotherapy and hormonal drugs.