In the early stages of its course, the tubal localization of pregnancy does not differ from a normal uterine pregnancy, only after a certain time, when the ovum becomes too large in size and overstretches the fallopian tube, disturbing symptoms appear. At the same time, the speed of manifestation of symptoms and their nature largely depend on the place of attachment of the ovum in the fallopian tube itself: in the initial part of the fallopian tube, in the middle, at the place of transition of the fallopian tube into the uterus. Also, the manifestations of tubal localization of pregnancy depend on the duration of the pregnancy. The most minimal manifestations are observed at the beginning of pregnancy. With an increase in the duration of pregnancy, the symptoms increase gradually.
The manifestations of interrupted and interrupted pregnancy are also different, which is associated with possible outcomes of pathological pregnancy. So, a tubal pregnancy can end:

1. tubal miscarriage, when the ovum is expelled from the cavity of the tube into the uterus, and then into the vagina and out;
2. removing the ovum into the abdominal cavity;
3. rupture of the fallopian tube.

Immediately after implantation of the ovum in one or another section of the fallopian tube, the developing tubal pregnancy is characterized by minor pulling pains in the lower abdomen, in some cases the pain is localized more to the right or left, depending on which tube the ovum is located in. All the characteristic early signs of pregnancy also take place: absence of menstruation, nausea, vomiting, frequent urination, special sensitivity to odors, etc. It should be noted that, in addition to minor pain sensations in the lower abdomen, tubal pregnancy can be characterized by the appearance of spotting bloody (red , dark brown discharge) discharge, but this symptom may not be present. Over time, a noticeable tumor-like formation can be noted to the right or left of the uterus, depending on the localization of the ovum.
Rupture of the fallopian tube is a rather serious and dangerous condition. It is characterized by the development of life-threatening internal bleeding. In this regard, there is a sharp soreness (which may even be accompanied by clouding of consciousness or fainting), dizziness, weakness. The rupture of the fallopian tube can be spontaneous or be the result of physical activity (as a result of heavy lifting, playing sports, intercourse, etc.).
One of the first signs of a rupture of the fallopian tube are symptoms of increasing internal bleeding: bloating appears, acute pain is long enough, tension in the anterior abdominal wall can be noted. The emerging pain is caused not only directly by the rupture (mechanical trauma) of the fallopian tube, but also by irritation of the sensitive pain receptors of the peritoneum by pouring blood. Very often, before the rupture occurs, a woman may feel a strong attack of cramping pains, which is associated with movements of the wall of the fallopian tube, which is overstretched due to the growth of the ovum. Severe weakness and fainting are characteristic of ongoing bleeding, it can also be accompanied by subsequent loss of consciousness. As a rule, with the development of such symptoms, a woman is admitted to a hospital where:

1. clinical examination;
2. laboratory diagnostics of blood, which determines a general decrease in the number of erythrocytes and hemoglobin, an increase in ESR (erythrocyte sedimentation rate), which is the main indicator of the inflammatory process in the body, unexpressed leukocytosis;
3. puncture of the posterior fornix of the vagina (for blood determination).

Appropriate emergency infusion (intravenous) therapy and preparation for surgery are performed immediately. You also need to know about the possible death of the ovum directly in the cavity of the fallopian tube. This, in its symptoms and signs, may be similar to the inflammatory process of the fallopian tube and ovaries.
As a result of such death, the ovum can leave the cavity of the fallopian tube either into the uterine cavity, and then into the vagina, or into the abdominal cavity, which is called tubal abortion. However, in the case of tubal miscarriage, situations of secondary attachment of the ovum to the peritoneum were noted in the event of its viability.
In another case, the ovum can be located directly on the surface of the ovary. For this pregnancy, the presence of a thin, easily traumatized capsule of the fetus is specific. In some cases, the ovum during ovarian pregnancy is located in the cavity of the follicle, in this regard, such a pregnancy can develop for a rather long time. The manifestation of the characteristic symptoms of pregnancy in this case depends on the depth of the location of the ovum in the follicle cavity. Thus, the deeper location of the fetus provides extremely heavy bleeding in the event of spontaneous abortion.
A rather rare form of ectopic pregnancy is an interconnective pregnancy. Such localization of pregnancy deserves special attention due to the possibility of achieving large sizes and terms. This is due to the attachment of the ovum directly to the tube and its further development towards the broad ligament. Such a pregnancy for a very long time (up to the 24th week of pregnancy) is, by all indications, difficult to distinguish from the uterine form of pregnancy. Periodic spotting in the broad ligament, which causes blood to accumulate, and some displacement of the uterus to the side, may indicate an inter-ligamentous pregnancy. In this case, the ultrasound scanning method is of great importance in diagnostics.
The most rare form of ectopic pregnancy is abdominal. This form of the ectopic location of the ovum can be primary (in the case of implantation (introduction) of the ovum on the peritoneum initially) and secondary (the ovum in this case is attached to the peritoneum after moving it from the cavity of the fallopian tube). It is noted that implantation of the ovum in the case of abdominal localization of pregnancy occurs, as a rule, in places free from intestinal motility. Most often, the ovum is strengthened behind the uterus or in the area of ​​the liver and spleen. Diagnosis of this type of pregnancy location is often difficult.
The following pathological variants of pregnancy are uterine variants of the abnormal location of pregnancy. So, pregnancy can be located in the rudimentary (accessory) horn of the uterus with a sickle shape. This localization of the ovum is explained by the direct connection of the rudimentary horn of the uterus with the tube. However, there is no exit into the vagina from this process. The inferiority of the course of this kind of pregnancy is associated not only with the lack of communication with the vagina, but also with the fact that the muscle layer and mucous membrane in the rudimentary horn of the uterus are defective. Termination of pregnancy, as a rule, in this case occurs at a period of 8 to 16 weeks. In case of rupture of the wall of the rudimentary horn of the uterus with a developing ovum, intense bleeding occurs, completely repeating the symptomatology of the picture of rupture of the fallopian tube during tubal pregnancy.
Pregnancy at the junction of the fallopian tube into the uterine cavity proceeds with the same symptoms as in the rudimentary uterine horn. This kind of pregnancy develops until later dates (up to 20 weeks) and ends with a systematic external rupture of the fetus. As a result of such an acute situation, the main symptoms will be symptoms of massive blood loss or shock from blood loss.
Cervical pregnancy deserves special attention. Initially, a cervical pregnancy in the early stages is asymptomatic, with signs that characterize any uterine pregnancy. In the future, bloody discharge may appear, often after sexual contact or gynecological examination. On a chair, a gynecologist can easily determine an elongated (bulbous) increase in the cervix, while with a small body of the uterus, which often turns out to be even smaller than that of a supposedly pregnant woman. With this form of pregnancy, there is a great danger of profuse bleeding, which threatens the woman's life.
A progressive ectopic pregnancy of any location at a short time proceeds with similar symptoms as a normal uterine pregnancy, and is not accompanied by any special symptoms. So, signs of cervical pregnancy are a delay in menstruation and subjective signs (change in taste, nausea, vomiting, etc.), only pulling prolonged pain can be the first symptoms of an atypical cervical location of the ovum. The body of the uterus in this case is slightly enlarged, but less than for the corresponding period of uterine pregnancy. A gynecological examination on a chair helps to diagnose any atypical location of the ovum during an ectopic pregnancy.
As a common symptom for all ectopic pregnancies, an atypical symptom for a normal pregnancy, the appearance of periodic spotting without the effect of treatment can be considered. The same kind of symptoms can be attributed to varying degrees of intensity of pain in the lower abdomen. Additional research methods that are carried out in a medical institution help to diagnose an ectopic pregnancy: biological, serological and immunological tests, ultrasound and endoscopic research method, colposcopy - examination of the cervix, laparoscopy - direct examination of the abdominal cavity through small punctures in the abdominal wall, laparotomy - examination of the abdominal cavity directly during the operation.
Treatment of an ectopic pregnancy is carried out exclusively by surgical removal of the ovum, since due to the impossibility of full development of the ovum outside the uterine cavity, there is a great threat to the health and life of a woman. Surgical intervention in each case is individual, which is determined by the location of the ectopic pregnancy, its condition (progressive, interrupted or interrupted), the state of the woman herself. In cases of massive bleeding, the operation is performed on an emergency basis, in this case it is necessary to stop the bleeding with parallel measures to replenish the blood loss (transfusion of blood, erythrocyte mass, plasma and blood substitutes). If the ovum is located in the fallopian tube, then during the operation the tube is removed along with the ovum.
Surgical treatment for localization of pregnancy at the place of transition of the fallopian tube into the uterine cavity consists in excision of a small adjacent area of ​​the uterus.
With an ovarian pregnancy, the operation consists in removing part of the ovary, and in the absence of such an opportunity, the ovary is removed along with the ovum.
Pregnancy of the rudimentary horn of the uterus necessitates the removal of the rudimentary horn along with the tube.
The most difficult is the surgical treatment of abdominal and cervical pregnancy, as a result of which the uterus is removed without appendages.

Prevention of ectopic pregnancy

It is necessary to know and remember that the process of conceiving and bearing a child is an extremely difficult mechanism, therefore it requires a conscious approach and a rather serious attitude. The risk of an ectopic pregnancy in an absolutely healthy woman with uncomplicated heredity due to the occurrence of ectopic pregnancies, with the absence of bad habits and a normal working regime is minimal. The modern level of development of medicine and diagnostic equipment allows early detection of the presence of an ectopic pregnancy, which helps to avoid the severe consequences of the development of such pregnancies and allows most women to have children in the future. Preventive measures include carrying out a diagnostic examination in the proper volume of the whole body of a woman a year before the planned pregnancy and, if necessary, undergoing a course of treatment. Therefore, timely diagnosis and treatment of infectious diseases, including sexually transmitted diseases, are the main task in the prevention of a possible ectopic pregnancy. It should be noted that the risk of atypical localization of pregnancy in women with hormonal level disorders in the body and, as a consequence, menstrual cycle disorders is quite high. In this regard, the regulation of the activity of the endocrine glands (thyroid gland, pituitary gland, adrenal glands, ovaries, etc.) and the regulation of the menstrual cycle is one of the methods for preventing the occurrence of an ectopic ovum during pregnancy. Complex and controlled regulation, the normal content of hormones in the blood before conceiving a child will greatly reduce the risk of an ectopic pregnancy. Preparation for pregnancy should also include an ultrasound examination of the genitals in order to determine the absence or presence of congenital anomalies of their development, and from this examination, the preparatory stage can begin.
At the same time, 6-12 months before the expected pregnancy, it is very important not to use intrauterine contraceptives (intrauterine device), to limit the use of oral contraceptives. The best option would be to use a barrier method of contraception in combination with spermicides (condoms, caps - female condoms, vaginal pills, suppositories or creams).
During a comprehensive examination, it is important for a woman to consult a cardiologist, endocrinologist, gastroenterologist, urologist and other specialists. This is especially true for women with chronic diseases of the organs and systems of the heart, kidneys, liver, etc. restoration of the reproductive system. Of great importance is the fact that surgical interventions on the abdominal organs can also be one of the factors in the occurrence of an ectopic pregnancy (most often due to an adhesions), therefore, such women need a gynecologist's consultation on the advisability of an ultrasound or X-ray examination method.
Many women know that the process of conceiving and strengthening and introducing the ovum is extremely sensitive to the effects of harmful chemicals, potent medicinal substances, to a lack of nutrients, pronounced physical and psycho-emotional stress. All of these harmful factors can increase the risk of an ectopic pregnancy.

Ectopic pregnancy is a fairly common female disease. And the most common form is tubal pregnancy. The percentage of women suffering from it is about 1 in 100. In 98% of the ectopic attachment of the embryo has such an arrangement. There are certain factors that affect fetal attachment:

Despite the widespread occurrence of ectopic - and tubal - pregnancies, the underlying causes are not clear. There is no doubt that impaired fetal movement is the cornerstone of the disease. However, more obvious reasons are not easy to identify. Therefore, doctors have introduced the concept of "risk factors".

Risk factors

There are a number of basic anatomical preconditions that precede tubal pregnancy:

• inflammation of the appendages;
• surgical intervention applied to pipes;
• intrauterine contraception.

It is assumed that the most likely cause of tubal pregnancy is salpingitis (inflammation in the tubes). Patients suffering from acute inflammation of the appendages are at risk of coming to tubal localization more often than healthy women six times. Salpingitis reduces patency and the ability to contract the fallopian tube. Along with this, the synthesis of substances that help the ovum to enter the uterus is upset. The hormonal work of the ovaries is disrupted because they are also involved in the inflammatory process. As a result, the functionality of the fallopian tubes decreases.

Intrauterine contraceptives interfere with the movement of the cilia located in the tubes. After that, the advancement of the ovum also stops. As history shows, the risk of ectopic pregnancy is 20 times increased compared to other methods of contraception.

Certain diseases lead to operations of the appendages. A tubal pregnancy is a consequence of surgical intervention. Patients who have undergone artificial termination of pregnancy two or more times have a greater risk of getting an ectopic fetal position. In addition, risk factors include developmental pathologies, infantilism, adventitious and uterine tumors, and endometriosis.

There are certain hormonal risks. Ovulation inducer drugs are used in the treatment of infertility, rebuild hormonal secretion and change other substances that contribute to the contraction of the uterine tubes. Case histories indicate that the likelihood of ectopic pregnancy in patients using inducers occurs every 10th time. Hormonal contraceptives with progestogen alone increase the likelihood of ectopic pregnancy because they negatively affect the contractility of the tubes.

Risk factors include in vitro fertilization, transfer (transmigration) of the egg, and suspension of ovulation. Speaking of transmigration, we mean the transfer of an egg from, say, the ovary to the opposite tube of the uterus through the abdominal cavity. Then the egg is quickly attached. Or you can consider the option when the egg, formed during delayed ovulation, is fertilized, moves into the uterus, but does not have time to implant. And during menstruation, it goes back into the fallopian tube. Then implantation occurs and the subsequent destruction of the tube wall, since it is not adapted to the maturation of the embryo. No medical history describes the possibility of preserving the fetus in a tubal pregnancy. There are only two options: pipe rupture or abortion.

Symptoms of a tubal pregnancy

How does a tubal pregnancy proceed and what signs and symptoms precede it? The fertilized egg, while in the tube, is wrapped in its shell. In the process of egg growth, the shell comes off "no". At the same time, the muscle wall undergoes dystrophic transformation, the blood supply to the egg deteriorates, which leads to its death. The fallopian tube, by contracting, brings the egg into the abdominal cavity. It is possible that it is to some extent viable - then a repeated ectopic pregnancy is possible when the egg is attached to the walls of the abdominal cavity. Meanwhile, bleeding occurs in the wall in the tube, the blood goes into the abdominal cavity, causing a tubal abortion.

Location of the embryo in the tube

When determining the timing of termination of an ectopic pregnancy, considering possible methods, one should be guided by the location of the egg. If it is attached to the tubal orifice, a crisis can be expected 4.5 weeks after fertilization. If the fetus is located in the middle, development will last up to 16 weeks. The term is lengthened due to the muscle layer and high-quality blood supply. The position of the embryo is very dangerous - rupture leads to huge blood loss, increasing the risk of death. Pregnancy, when the fetus enters the ampullar region, ends like a tubal abortion after 4-8 weeks. An extremely rare story is when a tubal pregnancy becomes "frozen". In this case, the dead embryo may dissolve or calcify, but abortion does not occur.

Considering the history and symptoms of the disease, it is impossible to draw a clear picture. Often, the signs are atypical, have no definite boundaries and are very diverse. The initial symptoms of a developing tubal pregnancy repeat the signs of normal conception:

• the menstrual cycle is interrupted;
• there is a change in olfactory and gustatory sensations;
• the mammary glands swell.

Pipe rupture symptoms

After the rupture, the symptoms change dramatically, the state of health is rapidly deteriorating. Observed:

If an ectopic (tubal) pregnancy is interrupted, like a tubal abortion, symptoms may be vague, limited to an irregular menstrual cycle and aching pain.

Definition of an ectopic pregnancy

Often women ask the question - will the test show an ectopic pregnancy? Two strips during the test will be available, but the answer to the question of what kind of pregnancy can hardly be expected, but an ultrasound scan will 100% dispel all doubts. By the way, there are times when the symptoms are in place, but the pregnancy test does not indicate. But what is interesting is that during an ectopic pregnancy, the second strip is often poorly visible. This phenomenon is explained by the increased hCG hormone. The analysis of hCG can clarify the situation. In the case of the location of the embryo in the uterus, the concentration of the hormone will gradually increase, indicating a normal pregnancy. However, in cases of deviations in values, developmental pathology can be suspected. Normal pregnancy is accompanied by a doubling of hCG every 2 days. A deviation of the hCG index from the norm can be a symptom of other diseases. Low rates indicate a lack of progesterone in hormonal disorders.

With the help of ultrasound, you can find out about the presence of an ectopic pregnancy

With the manifestation of even mild symptoms suggesting a developmental pathology, diagnosis is necessary. The main way to confirm symptoms is transvaginal ultrasound examination. The main task is to identify signs of pregnancy in the uterus, excluding the possibility of the location of the fetus in the fallopian tube. The method is very accurate, thanks to special sensors, fetal detection is possible at 1.5 weeks of conception.

Another way to determine a pathological pregnancy is a puncture. It is used quite rarely, since the method is quite painful. Moreover, it does not provide a 100% guarantee. Puncture diagnosis is carried out by inserting a needle through the posterior fornix of the vagina to collect fluid samples in the uterine cavity. If there is blood in the samples, the anomaly is confirmed.

The most informative method of all possible is laparoscopy. The method is good in that it fully allows you to confirm or deny the symptoms of a developing ectopic pregnancy, assess the severity of the condition in case of interruption, and determine the amount of lost blood. It is also possible to assess the condition of the appendages and the uterus. But this method also carries with it certain dangers. The appointment of laparoscopy is made only when non-invasive methods of establishing a diagnosis have been exhausted, and a reliable answer has not been obtained.

Treatment for pathological pregnancy

Treatment of an interrupted pathological pregnancy involves surgery. Again, we are talking about laparoscopy. The use of laparotomy is also possible, but only in cases of hemorrhagic shock or with the current adhesive process. The operation involves stopping the blood and removing the damaged tube. Then blood circulation is restored, and the consequences of blood loss are removed. In some cases, the use of reconstructive plastic techniques is required in order to preserve the organ. If such an operation is carried out, then observation is required after it.

The recovery period involves:

• taking vitamins;
• taking medications containing iron;
• physiotherapy prescribed to prevent adhesions;
• taking oral contraceptives for six months to prevent pregnancy.

Laparoscopy involves a second procedure after two months. It is required to assess the patency of the uterine tube, to remove the formed adhesions. The possibility of in vitro fertilization is also being considered.

It should be understood that this kind of pathology is not without consequences. Moreover, they can affect after a certain time. The main complication is the inability to conceive a child if the tubes were removed. The shock state will also make itself felt, since the organs were subjected to oxygen starvation.

Tubal pregnancy can occur due to the following reasons.
adhesions, narrowing of the tubes due to inflammatory diseases, with endometriosis, after tube surgery, tube anomalies;
hormonal insufficiency, infantilism, young age (long, thin, twisted pipes);
antiperistalsis of the tubes due to neurohumoral disorders;
rapid development of the ovum and increased trophoblast activity.

There are cases when an ectopic pregnancy occurred against the background of intrauterine and hormonal contraception, as well as after the use of drugs to stimulate ovulation, with in vitro fertilization and embryo transfer. Due to the presence of several risk factors, the likelihood of an ectopic pregnancy increases.

Pathogenesis:

Due to the delay of the ovum in the tube or its rapid development, it is introduced into the mucous membrane of the tube (endosalpinx).
The fallopian tubes cannot be a full-fledged fruit receptacle (a thin mucosa, devoid of a decidual reaction, does not limit the introduction of trophoblast into the tube wall, the thin muscular membrane cannot withstand the effects of the ovum).

Despite the fact that there is no ovum in the uterus, the mucous membrane is converted into the decidua. Tubal pregnancy most often occurs in the ampullar section, somewhat less often in the isthmic section, and very rarely in the interstitial section.

Complications:

Due to the inferiority of the fetus, the abortion of the pregnancy occurs rather quickly by the type of tubal abortion or by the type of rupture of the tube. In the ampullar section, there is more often an interruption like a tubal abortion.

In this section, the ovum is less embedded in the wall of the tube and protrudes more into the lumen of a rather wide ampullary part, gradually stretching the mucous membrane.
The inner capsule usually ruptures, the ovum exfoliates and falls into the lumen of the tube, antiperistaltic contractions of the muscular layer of the tube expel the ovum from its lumen into the abdominal cavity.

The abortion process is accompanied by pain and bleeding into the lumen of the tube, from where the blood enters the abdominal cavity. For the isthmuses and interstitial sections, an interruption of the type of rupture of the pipe is more characteristic. The rupture of the fallopian tube occurs due to the germination of all layers of the tube by trophoblast, while the vessels are damaged, and bleeding occurs.

In the isthmic section, the rupture of the tube usually occurs after 4-6 weeks, and in the interstitial (with a more pronounced muscular membrane) a little later - after 10-12 weeks. The rupture is accompanied by pain, severe bleeding occurs, since in these parts, especially the intrauterine, there is very good blood supply.
Due to large blood loss, hemorrhagic shock develops.

Symptoms and Diagnosis:

Distinguish between progressive, interrupted and interrupted tubal pregnancy. Diagnosing a progressive tubal pregnancy is difficult. It is necessary to pay special attention when menstruation is delayed in a woman with a burdened gynecological history (inflammation of the appendages, abortion, infertility and its treatment, menstrual irregularities, the use of intrauterine and hormonal contraception, in case of ectopic pregnancy in the past, in young, infantile women).

Doubtful and probable symptoms inherent in normal pregnancy can also appear during tubal pregnancy, however, the changes in the uterus are less pronounced, the size of the uterus does not correspond to the gestational age, the tube is enlarged. This can be detected by bimanual examination, and there are often diagnostic errors. Ultrasound diagnostics (including transvaginal ultrasound) is of great importance. A chorionic gonadotropin test (urinalysis, blood count) must be positive.

In case of an interrupted tubal pregnancy, in addition to the above symptoms, there may be bleeding. Cramping and aching pains in the lower abdomen appear. External bleeding is associated with detachment of the decidual membrane of the uterus.

An interrupted tubal pregnancy can proceed as a tubal abortion or rupture of the fallopian tube. In both cases, pains are noted in the area of ​​the tube, and the pains can be strong and sudden. In connection with internal bleeding from ruptured vessels and ongoing blood loss, symptoms of internal bleeding appear: weakness, dizziness, pale skin, pulse quickened, blood pressure lowered.

With significant blood loss, there may be loss of consciousness. Blood enters the abdominal cavity, accumulates in the Douglas space. As a result, a woman feels pain in the rectal area, especially when sitting down.

There are diffuse pains in the abdomen, in case of irritation of the endings of the phrenic nerve, a "phrenicus symptom" appears, in which pain radiates to the region of the clavicle and scapula (especially in the supine position). The abdomen is swollen, painful on palpation. A vaginal examination reveals soreness and flattening in the region of the posterior fornix. External bleeding caused by the detachment of the decidua cannot be the cause of such a serious condition; internal bleeding should be suspected.

Differential diagnosis is carried out with the threat of termination during uterine pregnancy, with ovarian apoplexy, painful ovulation, inflammation of the appendages, torsion and rupture of the ovarian cyst, torsion of the subserous myomatous node, appendicitis.

Additional research methods: puncture of the posterior fornix, laparoscopy.

Urgent care:

Call a doctor if this is a hospital department. In the conditions of a antenatal clinic, an ambulance call. Provide transportation in an accessible way in FAP conditions. At the pre-medical level, lay the woman on a gurney or stretcher with the head end lowered, calm down, establish contact with the vein and conduct intravenous fluid transfusion (to replenish the BCC), introduce hemostatic agents (dicinone or sodium ethamsylate), ice on the lower abdomen.

Monitor hemodynamic parameters, well-being and condition of the patient. If necessary, use cardiac drugs, establish contact with a second vein, and provide urgent hospitalization.

Treatment:

Treatment of an ectopic pregnancy is operative: with the help of laparoscopy or laparotomy, the tube is removed along with the fetus. In recent years, due to the improvement of endoscopic methods, early diagnosis and organ-preserving operations have been possible.

The peculiarities of diagnostics, surgical interventions, as well as the peculiarities of preoperative preparation and postoperative care are studied in the course of gynecology.

Ectopic pregnancy is a pregnancy characterized by implantation and development of the ovum outside the uterus - in the abdominal cavity, ovary, fallopian tube. Ectopic pregnancy is a serious and dangerous pathology, fraught with complications and relapses (reoccurrence), entailing a loss of fertility and even a threat to a woman's life. Localized in addition to the uterine cavity, which is the only physiologically adapted for the full development of the fetus, a fertilized egg can lead to rupture of the organ in which it develops.

General information

The development of a normal pregnancy occurs in the uterine cavity. After the fusion of the egg with the sperm in the fallopian tube, the fertilized egg that began division moves into the uterus, where the necessary conditions for the further development of the fetus are physiologically provided. The gestational age is determined by the location and size of the uterus. Normally, in the absence of pregnancy, the uterus is fixed in the small pelvis, between the bladder and rectum, and is about 5 cm wide and 8 cm long. A 6-week pregnancy can already be identified by a slight increase in the uterus. At the 8th week of pregnancy, the uterus enlarges to the size of a woman's fist. By the 16th week of pregnancy, the uterus is defined between the bosom and the navel. In a 24-week pregnancy, the uterus is determined at the level of the navel, and by 28 weeks the bottom of the uterus is already above the navel.

At 36 weeks of pregnancy, the fundus of the uterus reaches the costal arches and the xiphoid process. By the 40th week of pregnancy, the uterus is fixed between the xiphoid process and the navel. Pregnancy for a period of 32 weeks of gestation is established both by the date of the last menstruation and the date of the first movement of the fetus, and by the size of the uterus and the height of its standing. If a fertilized egg for any reason does not enter the uterine cavity from the fallopian tube, a tubal ectopic pregnancy develops (in 95% of cases). In rare cases, the development of an ectopic pregnancy in the ovary or in the abdominal cavity has been noted.

In recent years, there has been a 5-fold increase in the number of cases of ectopic pregnancies (data from the US Centers for Disease Control). In 7-22% of women, the recurrence of ectopic pregnancy was noted, which in more than half of the cases leads to secondary infertility. Compared with healthy women, patients who have undergone an ectopic pregnancy have a greater (7-13 times) risk of its recurrence. Most often, women from 23 to 40 years old have a right-sided ectopic pregnancy. In 99% of cases, the development of an ectopic pregnancy is noted in certain parts of the fallopian tube.

General information

Ectopic pregnancy is a serious and dangerous pathology, fraught with complications and relapses (reoccurrence), entailing a loss of fertility and even a threat to a woman's life. Localizing in addition to the uterine cavity, which is the only physiologically adapted for the full development of the fetus, a fertilized egg can lead to rupture of the organ in which it develops. In practice, there is an ectopic pregnancy of various localizations.

A tubal pregnancy is characterized by the location of the ovum in the fallopian tube. It is noted in 97.7% of cases of ectopic pregnancy. In 50% of cases, the ovum is located in the ampullar section, in 40% - in the middle part of the tube, in 2-3% of cases - in the uterine part and in 5-10% of cases - in the area of ​​the fimbriae of the tube. Rarely observed forms of development of ectopic pregnancy include ovarian, cervical, abdominal, intraligamentary forms, as well as ectopic pregnancy, localized in the rudimentary uterine horn.

Ovarian pregnancy (observed in 0.2-1.3% of cases) is divided into intrafollicular (the egg is fertilized inside the ovulated follicle) and ovarian (the fertilized egg is fixed on the surface of the ovary). Abdominal pregnancy (occurs in 0.1 - 1.4% of cases) develops when the ovum leaves the abdominal cavity, where it attaches to the peritoneum, omentum, intestines, and other organs. The development of an abdominal pregnancy is possible as a result of IVF with infertility of the patient. Cervical pregnancy (0.1-0.4% of cases) occurs when the ovum is implanted into the area of ​​the cylindrical epithelium of the cervical canal. Ends with profuse bleeding as a result of the destruction of tissues and blood vessels caused by deep penetration of the villi of the ovum into the muscular membrane of the cervix.

Ectopic pregnancy in the accessory horn of the uterus (0.2-0.9% of cases) develops with abnormalities in the structure of the uterus. Despite the attachment of the ovum intrauterinely, the symptoms of the course of pregnancy are similar to the clinical manifestations of uterine rupture. Intraligamentary ectopic pregnancy (0.1% of cases) is characterized by the development of the ovum between the leaves of the wide ligaments of the uterus, where it is implanted when the fallopian tube ruptures. Heterotopic (multiple) pregnancy is extremely rare (1 case per 100-620 pregnancies) and is possible as a result of using IVF (assisted reproduction method). It is characterized by the presence of one ovum in the uterus, and the other outside it.

Signs of an ectopic pregnancy

Signs of the emergence and development of an ectopic pregnancy can be the following manifestations:

• Violation of the menstrual cycle (delayed menstruation);
• Bloody, "smearing" character of discharge from the genitals;
• Pain in the lower abdomen (pulling pain in the area of ​​attachment of the ovum);
• Breast engorgement, nausea, vomiting, lack of appetite.

An interrupted tubal pregnancy is accompanied by symptoms of intra-abdominal bleeding due to the outflow of blood into the abdominal cavity. Characterized by a sharp pain in the lower abdomen, radiating to the anus, legs and lower back; after the onset of pain, bleeding or brown spotting from the genitals is noted. There is a decrease in blood pressure, weakness, frequent pulse of weak filling, loss of consciousness. In the early stages, it is extremely difficult to diagnose an ectopic pregnancy; since the clinical picture is not typical, seeking medical help follows only with the development of certain complications.

The clinical picture of an interrupted tubal pregnancy coincides with the symptoms of ovarian apoplexy. Patients with symptoms of "acute abdomen" are urgently delivered to a hospital. It is necessary to immediately determine the presence of an ectopic pregnancy, perform surgery and eliminate bleeding. Modern diagnostic methods allow using ultrasound equipment and tests to determine the level of progesterone ("pregnancy hormone") to establish the presence of an ectopic pregnancy. All medical efforts are directed to the preservation of the fallopian tube. In order to avoid serious consequences of an ectopic pregnancy, it is necessary to observe a doctor at the first suspicion of pregnancy.

Causes of an ectopic pregnancy

Diagnostics of the ectopic pregnancy

In the early stages, an ectopic pregnancy is difficult to diagnose, since the clinical manifestations of the pathology are atypical. As well as in uterine pregnancy, there is a delay in menstruation, changes in the digestive system (taste perversion, bouts of nausea, vomiting, etc.), softening of the uterus and the formation of a corpus luteum of pregnancy in the ovary. An interrupted tubal pregnancy is difficult to distinguish from appendicitis, ovarian apoplexy, or other acute surgical pathology of the abdominal cavity and pelvis.

In the event of an interrupted tubal pregnancy, which is a threat to life, a quick diagnosis and immediate surgical intervention is required. It is possible to completely exclude or confirm the diagnosis of "ectopic pregnancy" with the help of an ultrasound scan (the presence of a fetal egg in the uterus, the presence of fluid in the abdominal cavity and formation in the area of ​​the appendages are determined).

An informative way to determine an ectopic pregnancy is the β-hCG test. The test determines the level of chorionic gonadotropin (β-hCG) produced by the body during pregnancy. The norms of its content during uterine and ectopic pregnancy differ significantly, which makes this diagnostic method highly reliable. Due to the fact that today surgical gynecology widely uses laparoscopy as a method of diagnosis and treatment, it has become possible with 100% accuracy to diagnose an ectopic pregnancy and eliminate the pathology.

Ectopic pregnancy treatment

For the treatment of the tubal form of ectopic pregnancy, the following types of laparoscopic operations are used: tubectomy (removal of the fallopian tube) and tubotomy (preservation of the fallopian tube while removing the ovum). The choice of method depends on the situation and the degree of complication of an ectopic pregnancy. When preserving the fallopian tube, the risk of recurrence of an ectopic pregnancy in the same tube is taken into account.

When choosing a method for treating an ectopic pregnancy, the following factors are taken into account:

• The patient's intention to plan a pregnancy in the future.
• The feasibility of preserving the fallopian tube (depending on how pronounced the structural changes in the wall of the tube).
• Repeated ectopic pregnancy in a preserved tube dictates the need to remove it.
• The development of an ectopic pregnancy in the interstitial tube.
• The development of an adhesive process in the pelvic area and, in connection with this, an increasing risk of repeated ectopic pregnancy.

With large blood loss, the only option to save the patient's life is an abdominal operation (laparotomy) and removal of the fallopian tube. With the unchanged state of the remaining fallopian tube, the reproductive function is not impaired, and the woman may have a pregnancy in the future. To establish an objective picture of the state of the fallopian tube remaining after laparotomy, laparoscopy is recommended. This method also allows the adhesions in the pelvis to be separated, which serves to reduce the risk of re-ectopic pregnancy in the remaining fallopian tube.

Ectopic pregnancy prevention

To prevent the occurrence of an ectopic pregnancy, you must:

• prevent the development of inflammation of the organs of the genitourinary system, and if inflammation has arisen, treat it in time
• before the planned pregnancy, undergo an examination for the presence of pathogenic microbes (chlamydia, ureaplasma, mycoplasma, etc.). If they are found, it is necessary to undergo appropriate treatment together with the husband (permanent sexual partner)
• protect during sexual activity from unwanted pregnancy, using reliable contraceptives, avoid abortion (the main factor provoking an ectopic pregnancy)
• if it is necessary to terminate an unwanted pregnancy, choose low-traumatic methods (mini-abortion) at the optimal time (the first 8 weeks of pregnancy), carry out the termination without fail in a medical institution by a qualified specialist, with anesthesia and further medical supervision. Vacuum abortion (mini-abortion) reduces the time of the operation, has few contraindications and significantly fewer undesirable consequences
• as an alternative to the surgical method of termination of pregnancy, you can choose medical termination of pregnancy (taking the drug Mifegin or Mifepristone)
• after an ectopic pregnancy, undergo a rehabilitation course to preserve the possibility of having the next pregnancy. To preserve fertility, it is important to be observed by a gynecologist and a gynecologist-endocrinologist and follow their recommendations. A year after the operation, you can plan a new pregnancy, in the event of which it is necessary to register for pregnancy management at an early date. At the same time, the forecast is favorable.

Symptoms

Symptoms of a tubal pregnancy

An ectopic pregnancy is understood as the implantation of a fertilized egg not in the uterine cavity, but in the fallopian tube. It should be noted that an ectopic pregnancy can occur in parallel and concurrently with a normal pregnancy. Frequent use of intrauterine contraception and coils, which disrupt the normal peristaltic movements of the tubes, can lead to such changes. At the initial stage, an ectopic pregnancy can proceed without characteristic complaints. Violations occur at 6-8 weeks of tubal pregnancy. Most often, a tubal abortion occurs, in which the fallopian tube ruptures. With the development of tubal abortion in patients, all signs of acute internal bleeding are noted, namely: acute cutting, accompanied by bloody discharge from the genitals.

Diagnostics

Diagnosis of tubal pregnancy

The diagnosis of ectopic pregnancy is based on the clinical picture, which develops as a result of rupture of the fallopian tube, which leads to intracavitary bleeding. The specified clinical picture develops 2-3 months after the cessation of menstruation. Since the clinical picture of ectopic (ectopic) pregnancy requires differential diagnosis, on the one hand, with normal (uterine) pregnancy and, on the other hand, with uterine bleeding of a different nature, such patients require urgent hospitalization for further examination in the hospital. If an ectopic is suspected, it is necessary to measure the level of chorionic gonadotropin in the blood. This analysis will establish the very fact of pregnancy. Then an ultrasound of the pelvic organs is performed. Signs of an ectopic pregnancy are the absence of the ovum in the uterine cavity and the presence of fluid in the abdominal cavity and the formation in the area of ​​one of the appendages during the established pregnancy. If, after the ultrasound, diagnostic questions remain, it is carried out, which is the most accurate method for diagnosing this disease.

Treatment

Treatment of tubal pregnancy

Treatment of an ectopic pregnancy can be medical and surgical. Conservative (drug) methods include the appointment of methotrexate. Taking this drug early in the pregnancy can lead to the termination of pregnancy and resorption of the ovum. However, conservative treatment should be carried out under the supervision of a gynecologist with mandatory research by all available methods. With the progression of tubal pregnancy, laparoscopic surgery is used, which often allows for organ-preserving surgery. Tubal rupture and acute blood loss are indications for emergency surgery. In this case, a midline laparotomy (incision of the anterior abdominal wall) is performed, and, most often, the removal of the tube (sometimes together with the ovary). The volume of the operation depends on the patient's condition and the degree of blood loss.

Prevention

Prevention of tubal pregnancy

The main direction of the primary prevention of ectopic pregnancy is the correct and timely treatment of chronic inflammatory diseases of the female genital area, ovarian dysfunction and the fight against abortion. It should be remembered that in women who have had an ectopic, the risk of repeated ectopic pregnancy is up to 20%. Therefore, patients who have undergone an ectopic pregnancy require the supervision of a gynecologist: if they develop pregnancy, an immediate ultrasound scan is required to determine the location of the ovum.