Treatment for ectopic pregnancy

The goal of treatment is to eliminate the ectopic pregnancy. The main method of treating ectopic pregnancy is considered to be surgical.

The introduction of laparoscopic surgery into practice has led to a decrease in the number of laparotomy operations for ectopic pregnancy from the total number of surgical interventions. The scope of surgical intervention (tubotomy or tubectomy) is decided individually in each case. When deciding on the possibility of performing organ-preserving surgery, it is necessary to take into account the nature of the surgical 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 along the entire length of the fetal receptacle);
• repeated pregnancy in a tube that has previously undergone organ-preserving surgery;
• ectopic pregnancy after reconstructive plastic surgery on the fallopian tubes due to tubal-peritoneal infertility factor;
• localization of the fertilized egg in the interstitial part of the fallopian tube;
• pronounced adhesion process of the pelvic organs.

Indications for hospitalization

• Delayed menstruation, presence of bloody discharge from the genital tract and pain in the lower abdomen of varying nature and intensity with possible irradiation (to the thigh, groin area, anus).
• Delayed menstruation, absence of bloody discharge from the genital tract and positive results of hCG in the blood, regardless of the presence or absence of ultrasound signs of an ectopic pregnancy.
• Delayed menstruation, determination of pastosity in the vaults (left or right) during bimanual examination.
• Detection of ultrasound signs of ectopic pregnancy.

Surgical treatment of ectopic pregnancy

Currently, gynecologists around the world have a unified point of view on the treatment of tubal ectopic pregnancy: as soon as the diagnosis is established, the patient must undergo surgical treatment. At the same time, there is an active discussion, clarification and improvement of traditional and development of new methods of surgical interventions. The nature of the operation is regulated by many factors: the localization of the ovum, the severity of pathological changes in the affected and opposite tube, the degree of blood loss, general condition, age and the desire of the patient to have a pregnancy in the future.

If the termination of pregnancy occurs as a result of a ruptured tube or those cases of tubal abortion that are accompanied by heavy bleeding, the time factor comes first when providing emergency care. Success can be expected if the interaction of the gynecological surgeon and the anesthesiologist-resuscitator is carried out clearly and quickly. The anesthesiologist carries out resuscitation measures in a short time aimed at bringing the patient out of shock, achieving relative stabilization of her condition, and begins anesthesia. By this time, the gynecologist must be ready for surgical intervention. The operation of choice in such a situation is the removal of the fetal receptacle, i.e. the fallopian tube. The life-threatening condition of the patient dictates the need for surgical intervention in 3 stages:

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

The abdominal cavity can be opened by any approach that the surgeon is most comfortable with: lower midline laparotomy, transverse suprapubic incision according to Pfannenstnl or Czerny. The affected tube is quickly brought into the wound and hemostatic clamps are applied to its uterine end and mesosalpinx. At this point, the operation is temporarily stopped until the anesthesiologist signals that it can be continued. At this point, the operating physician can assist the anesthesiologist in resuscitation measures by supplying him with blood taken from the abdominal cavity. Reinfusion of autologous blood is not technically difficult. The operating nurse should always have a sterile kit ready, consisting of a glass jar (preferably graduated), a funnel and a small ladle-cup. 100-200 ml of isotonic sodium chloride solution are poured into a jar and the blood scooped out of the abdominal cavity is filtered through a funnel covered with 8 layers of gauze soaked in the same solution. For reinfusion, it is allowed to use apparently unchanged blood (no hemolysis, abundant fatty inclusions) in case of acute bleeding (no more than 12 hours since the onset of the attack) and in the absence of signs of infection (normal body temperature, appropriate condition of the abdominal organs). Infusion of autologous blood helps to quickly bring the patient out of shock, does not require preliminary determination of the blood group and Rh factor, or compatibility tests.

It is most rational to begin blood reinfusion after applying hemostatic clamps. However, it is quite acceptable and even advisable to begin transfusion immediately in case of massive bleeding to prevent blood loss. In such cases, after opening the peritoneum, its edges are lifted with four instruments, and the blood ready to flow out of the abdominal cavity is quickly scooped out. Then, having widened the peritoneal incision, the fallopian tube is removed, hemostatic clamps are applied, and the remaining blood is collected.

The operation can be continued only with the permission of the anesthesiologist. The tube is cut off. The clamps on its uterine end and mesosalpinx are replaced with catgut ligatures. Peritonization is usually performed using the round uterine ligament. Then, under continued full anesthesia, the remnants of liquid blood and clots are carefully removed. The abdominal wall is tightly sutured layer by layer.

Salpingectomy surgery is performed in some women even in the absence of massive bleeding. In such cases, the indications for it are significant pathological changes in the fallopian tube caused by a disrupted pregnancy or previous inflammation. The tube is subject to removal in women who are not interested in preserving reproductive function and are over 35 years old.

Surgeries for old tubal pregnancy with organized peritubal or retrouterine hematoma can be quite complicated due to adhesions with intestinal loops, omentum, uterus and its ligaments. Loose adhesions are carefully separated by blunt means, dense ones - by sharp means. The hematoma capsule must be removed, but this should be done with great care. It is better to leave part of the capsule on the intestinal wall than to injure it. After releasing the appendages, they must be carefully examined, old blood clots and remnants of the capsule must be carefully removed from the surface of the ovary using a swab. In the vast majority of cases, this can be done, and the scope of the operation is limited to salpingectomy. If the ovary is damaged, then either it is resected, or the appendages are removed entirely.

Organ-preserving operations for tubal pregnancy can be performed if the following conditions are met:

• satisfactory condition of the patient with compensated blood loss at the time of surgery;
• the patient's health condition does not prevent her from carrying the pregnancy to term and giving birth in the future;
• minimal changes in the fallopian tube (the ideal condition is a progressive pregnancy);
• a woman's desire to preserve reproductive function;
• highly qualified surgeon.

The widest range of conservative operations is available in specialized institutions that use microsurgical methods for treating tubal ectopic pregnancy. The most common of these are: salpingotomy performed in the ampullary or isthmic sections of the tube; segmental resection of the isthmic section with end-to-end anastomosis. Successful microsurgical interventions require an operating microscope, special instruments, and biologically inactive suture material (nylon or Dexon threads 6-0 or 8-0). In salpingogomy, an incision is made along the antimesenteric edge of the tube with a needle electrode with minimal cutting current. The fertilized egg is carefully removed with tweezers or an electric suction device. All bleeding vessels are carefully coagulated. The incisions are sutured with two rows of sutures.

If the fertilized egg is located in the ampullar section close to the fimbriae, there is no particular need to open the tube. The fertilized egg can be carefully squeezed out, the fetal receptacle can be carefully examined, and the vessels can be coagulated. Such an operation is possible in a regular non-specialized hospital, which has access to elements of microsurgery.

Segmental resection with end-to-end anastomosis is performed in isthmic pregnancy. Mini-clamps are applied to both sides of the section of the tube containing the fertilized egg. A 6-0 nylon ligature is passed through the mesosalpinx, sticking the needle under one clamp and pricking it out under the other. The altered section of the tube is excised. The ligature is tightened. Bleeding vessels are coagulated. The ends of the tubes are connected with two rows of sutures: the first row - through the muscular layer and serous membrane, the second - sero-serous.

If there are no conditions for performing a microsurgical operation, and the patient is extremely interested in preserving the reproductive function, then it is possible to limit 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 fallopian tube by anastomosing the preserved sections is performed after 6 months if the patient has only one tube, or after 12 months if the patient does not become pregnant with a preserved but defective second tube.

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

1. thorough removal of liquid blood and clots from the abdominal cavity;
2. constant moistening of the surgical field with isotonic sodium chloride solution;
3. management of the postoperative period against the background of hydroperitoneum created by the introduction of a dextran (polyglucin) solution.

In early stages of a progressive pregnancy, when the diameter of the fallopian tube does not exceed 4 cm, or in cases of abnormal pregnancy with minor damage to the tube and moderate blood loss, gentle operations can be performed under laparoscopy. The most common type of intervention in these conditions is salpingotomy. The instrument is inserted through an additional incision in the suprapubic area. Using an electrocoagulator or carbon dioxide laser, the wall of the tube is dissected; the fertilized egg is carefully removed with an electric suction device or tweezers; bleeding areas are coagulated. Authors with experience in such operations note a number of advantages of the method: minimal trauma to the abdominal wall, short hospitalization, rapid recovery of working capacity, and a high percentage of fertility preservation.

In recent years, there have been reports in the literature on the possibility of non-surgical treatment of progressive ectopic pregnancy of early stages. Short courses of methotrexate or steroid drugs with antiprogesterone action lead to resorption of the ovum without damaging the mucous membrane of the tube. This therapeutic direction is certainly promising and requires comprehensive research.

Treatment of abdominal ectopic pregnancy of any stage is only surgical. The nature of surgical intervention is extremely broad and unpredictable. It depends on the stage of pregnancy and the site of implantation of the fertilized egg. In the early stages of interrupted abdominal pregnancy, a small excision of the tissues of the bleeding area and the application of several stitches is sufficient. In such situations, the main difficulty is not in the technical implementation of the operation, but in detecting the location of the pregnancy. The implantation site is most often located on the peritoneum of the uterorectal cavity.

At later stages of pregnancy, the villi of the placenta penetrate deeply into the underlying tissue, so it is necessary to remove the placental site along with the placenta: perform amputation or extirpation of the uterus, remove appendages, perform resection of the intestine, amputate part of the greater omentum, etc. Often, the joint participation of a surgeon and a gynecologist is necessary for the successful performance of the operation.

Treatment of ovarian pregnancy is, of course, surgical. There are different types of operations: from ovarian resection to removal of appendages. The choice of the scope of intervention depends on the degree of damage to the ovary.

Salpingotomy

It is considered the main operation on the tubes in case of ectopic pregnancy. Conditions:

• fertility preservation;
• stable hemodynamics;
• size of the fertilized egg <5 cm;
• the fertilized egg is located in the ampullary, infundibular or isthmic region.

Squeezing of the fertilized egg is performed when it is localized in the fimbrial section of the tube. Dissection of the uterine angle is performed when the fertilized egg is localized in the interstitial section of the tube.

Indications:

• hCG content >15 thousand IU/ml;
• history of ectopic pregnancy;
• the size of the fertilized egg is more than 5 cm.

In case of other pathological changes of the other tube (hydrosalpinx, sactosalpinx), bilateral salpingectomy is recommended. The possibility of this must be discussed with the patient in advance and written consent for the specified scope of surgical intervention must be obtained.

Conservative methods of treatment of ectopic pregnancy

Conditions for conservative treatment of ectopic pregnancy:

• progression of tubal pregnancy;
• the size of the fertilized egg is no more than 2–4 cm.

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

In most cases, methotrexate is used for conservative management of patients with ectopic pregnancy; less commonly, potassium chloride, hypertonic dextrose solution, prostaglandin preparations, and mifepristone are used. Medications are used parenterally and locally (administered into the fallopian tube through the lateral vaginal fornix under ultrasound control, during laparoscopy, or transcervical catheterization of the fallopian tube).

Methotrexate is an antitumor agent of the antimetabolite group that inhibits dihydrofolic acid reductase, which is involved in its reduction to tetrahydrofolic acid (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 activity of liver enzymes, hepatitis, and pneumonia. In case of ectopic pregnancy, the drug is administered in low doses that do not cause severe side effects. If several administrations of methotrexate are planned, calcium folinate is prescribed. This is an antidote to methotrexate, reducing the risk of its side effects (the dose should be equal to the dose of methotrexate, administered within 1 hour).

[ 1 ], [ 2 ]

Scheme No. 1

Methotrexate at a dose of 1 mg/kg/day intramuscularly every other day, calcium folinate at a dose of 0.1 mg/kg/day intramuscularly every other day, starting from the 2nd day of treatment. Methotrexate is discontinued when the content of the β-subunit of hCG in the blood serum decreases by 15% per day. Calcium folinate is administered for the last time on the day following the discontinuation of methotrexate. Upon completion of treatment according to the specified scheme, the concentration of the β-subunit of hCG is determined weekly until normalization. If the β-subunit of hCG ceased to decrease and an increase was noted, methotrexate was prescribed again. The effectiveness of treatment according to the specified scheme is 96%.

Scheme No. 2

Methotrexate is administered once at a dose of 50 mg/ ^m2, calcium folinate is not prescribed. The effectiveness of treatment according to this scheme is 96.7%.

The effectiveness and probability of normal pregnancy after using both regimens are approximately the same. Indications for the appointment of methotrexate.

• Elevated serum hCG β-subunit levels after organ-preserving surgery on the fallopian tube performed for ectopic pregnancy (persistent ectopic pregnancy).
• Stabilization or increase in the concentration of the β-subunit of hCG in the blood serum within 12–24 hours after separate diagnostic curettage or vacuum aspiration, if the size of the ovum in the area of the uterine appendages does not exceed 3.5 cm.
• Determination by vaginal ultrasound of a fertilized egg with a diameter of no more than 3.5 cm in the area of the uterine appendages with a serum hCG β-subunit content of more than 2000 IU/l in the absence of a fertilized egg or fluid accumulation in the uterine cavity.

The patient is observed on an outpatient basis. In case of severe prolonged pain in the lower abdomen, hematocrit is determined and a vaginal ultrasound is performed, which allows to clarify whether a tube has ruptured. Ultrasound is not performed to assess the condition of the ovum during methotrexate treatment. It is necessary to evaluate the ultrasound results in case of ectopic pregnancy with caution, since fluid accumulation in the recto-uterine pouch is observed both in developing and interrupted ectopic pregnancy. In case of a rapid decrease in hematocrit or hemodynamic disorders, surgical treatment is indicated. After treatment with methotrexate, contraception is recommended for 2 months.

However, given the side effects of methotrexate when multiple administrations in fairly large doses are required to treat EB, a number of researchers have attempted to improve the technique. In 1987, W. Feichtinger and Kemeter solved the problem by providing the maximum effect with a minimum dose of methotrexate using local injections of the drug under transvaginal monitoring. The drug is administered into the lumen of the ovum after preliminary aspiration of the amniotic fluid. A single dose ranges from 5 to 50 mg and is determined by the gestational age. A. Fujishita et al. used a suspension of methotrexate containing Lipiodol Ultra-Fluid with phosphatidylcholine to enhance the therapeutic effect of methotrexate. According to the authors, the use of the suspension reduces the frequency of persistent pregnancy by 44% compared to the use of pure methotrexate.

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

Advantages of laparoscopic tuboscopy

• Objective assessment of the condition of the “pregnant” fallopian tube.
• Determining the safest point for pipe puncture.
• Ensuring hemostasis by injecting hemostatic agents into the mesosalpinx and/or point coagulation of the area of the proposed puncture. Organizational and therapeutic technologies that allow organ-preserving operations for tubal pregnancy.
• Early referral of the patient to a women's consultation center or clinic.
• Carrying out diagnostic measures (β-hCG, ultrasound) and observation for no more than 2 days in a women's consultation center and a polyclinic.
• Timely hospitalization and laparoscopy no later than 24 hours after hospitalization.
• 24-hour endoscopic service in the hospital.

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

Observation

Women who have had an ectopic pregnancy need to undergo dispensary observation at their place of residence. Patients with unrealized reproductive function are shown control laparoscopy to clarify the condition of the fallopian tubes after 3 months, after organ-preserving operations.

Remote results of treatment of ectopic (extrauterine) pregnancy cannot be considered favorable. 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 characteristics of the clinical course of ectopic pregnancy (the nature of damage to the fetal receptacle and the degree of blood loss), on the volume and technique of surgical treatment, on the completeness and duration of rehabilitation measures in the postoperative period. The most favorable result is given by organ-preserving operations performed using microsurgical techniques before the tubal pregnancy is disrupted.

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

1. general impact on the body by prescribing agents that increase non-specific defenses, stimulate hematopoiesis, and enhance anabolic processes;
2. conducting a course of physiotherapy;
3. conducting a course of hydrotubations.

Medicines are prescribed from the first day of the postoperative period, physiotherapy and hydrotubation - from the 4th-5th day (immediately after the cessation of bloody discharge from the genital tract). Repeated courses of rehabilitation therapy are preferably carried out 3, 6, 12 months after the operation. During this time, the woman should protect herself from pregnancy.

Rehabilitation measures are also indicated for those patients who have had both tubes removed and there is no question of restoring fertility. It is known that such a contingent of women often have neuroendocrine shifts, ovarian dysfunction and vegetative-vascular changes. Such patients are indicated for the use of sedatives, vitamins, regulatory physiotherapy and hormonal drugs.