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Treatment methods for ectopic pregnancy. Ectopic pregnancy: causes, early signs, diagnosis, treatment

Treatment methods for ectopic pregnancy. Ectopic pregnancy: causes, early signs, diagnosis, treatment

The physiological development of pregnancy occurs only in the uterine cavity. However, the possibility of an atypical, ectopic localization of the embryonic egg cannot be excluded - outside the uterus, in the cervix, in the ampullary section of the fallopian tube, located in the muscles of the uterus, simultaneously in the uterus and the ampullary section of the fallopian tube. An ectopic pregnancy is one that occurs as a result of implantation of a fertilized egg outside the uterine cavity.

Causes and mechanism of development

Types of pathology and health hazards

Depending on the location of the fertilized egg, ectopic pregnancy is divided into:

  1. Tubal, which occurs on average in 1.5% of women and 95% of all variants of ectopic localization. A tubal pregnancy can develop in any part of the fallopian tube.
  2. Ovarian, capable of developing on the surface of the ovary or inside the follicle.
  3. Abdominal, which occurs in the abdominal cavity initially or as a result of the expulsion of a fertilized egg from the fallopian tube.

Why is an ectopic pregnancy dangerous?? It occurs in 1.5-1.9% of women and often leads to infertility. But its main danger lies in the threat to the woman’s life due to the growth of the embryo and tissue rupture at the site of the fertilized egg or spontaneous abortion. Rupture of the fallopian tube or other fetal site (in the ovary) on average in 13-14% ends in death as a result of heavy blood loss and is the main cause of death in women in the first trimester.

Risk factors

To date, the causes of ectopic pregnancy represent one of the most controversial aspects of the field of obstetrics and gynecology. Despite the fact that many of them are beyond doubt, some questions still remain unanswered.

Sometimes, for unexplained reasons, an ectopic pregnancy can develop in the absence of visible pathological abnormalities. However, the basis of its mechanism are pathological conditions that disrupt the physiological properties of the fertilized egg and/or its movement along the fallopian tube. Therefore, in practical gynecology, not so much the causes as the risk factors for the development of ectopic pregnancy are considered.

The most probable of them are combined into 3 groups according to their underlying characteristics:

  1. Anatomical.
  2. Hormonal.
  3. Doubtful or controversial.

Anatomical changes are the cause of dysfunction of the tubes associated with the transport of the fertilized egg. They may arise as a result of:

  • Inflammatory processes in the fallopian tubes or in the pelvic cavity, which occupy a leading place in the structure of ectopic pregnancy. On average, half of women who have had an ectopic pregnancy have suffered primarily from salpingitis or adnexitis in the past. These diseases lead to damage to their muscle layer and receptor apparatus, disruption of the secretion of nucleic acids, glycogen and protein complexes necessary for the normal functioning of the egg, as well as damage to the synthesis of steroid hormones by the ovaries.
  • Use of intrauterine contraceptives (3-4%). Moreover, the longer their use, the longer their use, the higher the risk of ectopic implantation of an embryonic egg - two-year use increases the risk by 2, and longer use increases the risk by 2.5-4.2 times. This is explained by the almost complete destruction of the ciliated epithelial cells of the mucous membrane in the fallopian tubes after 3 years of use of intrauterine contraception.
  • Surgical interventions for pelvic diseases, inflammatory processes, tubal plastic surgery for infertility, etc., leading to.
  • Tumors and surgical method sterilization.

Hormonal risk factors include:

  • Endocrine diseases and hormonal disorders in the body, leading to.
  • Application hormonal drugs regarding somatic and autoimmune diseases.
  • Use of hormonal contraceptives.
  • The use of ovulation stimulants in order to prepare for in vitro fertilization - human chorionic gonadotropin, clomiphene, GnRH agonists.
  • Impaired synthesis of prostaglandins, which affect the processes of contraction and relaxation of the muscle fibers of the fallopian tubes.
  • Excessive biological activity of the embryo membranes.
  • Migration of an egg from one ovary to the contralateral (opposite) ovary through the abdominal cavity.

Controversial risk factors:

  • Congenital anomalies of the uterus and genetic disorders.
  • Deviations in the concentration of sperm prostaglandins.
  • Sperm quality, including increased sperm activity.
  • Presence of endometriosis and diverticula in the fallopian tubes.

A combination of various factors is also possible, which further increases the risk of pathology.

Idea of ​​the development mechanism

It allows you to understand the signs of an ectopic pregnancy, the development of which in the fallopian tube occurs as a result of the introduction of a fertilized egg into the mucous membrane and the formation of a habitat for the embryo. From the side of the tube lumen, the mucous membrane envelops the fertilized egg, forming the inner capsule, and the serous and muscular layers - the outer capsule.

Termination of pregnancy is caused by the inability of the walls of the fallopian tube to nidate the egg and develop the embryo:

  • insignificant thickness of the muscle layer, unable to withstand a significant increase in internal volume;
  • the absence of tubular glands in the mucous membrane and its division into the main and functional layers, which is characteristic of the walls of the uterus;
  • lack of resistance to the destructive proliferation of cells in the outer layer of the embryo membrane.

Further development of the embryo is accompanied by the destruction of the vessels of the mucous membrane of the fallopian tube by the villi of the fetal membrane, the formation of hemorrhages and disruption of its blood supply, the gradual destruction of the membrane of the embryo from the side of the tubal lumen and gradual detachment from the walls.

As a result of this, the embryo dies and is expelled by contractions of the fallopian tube into the abdominal cavity, which is accompanied by bleeding. This option is called a tubal abortion. The second possible outcome is an increase in the size of the fertilized egg and destruction of the walls of the tube, followed by their rupture, which is accompanied by significant bleeding and pain.

The duration of tubal pregnancy is 5-8 weeks, ectopic (in the isthmic department) - 10-12 weeks.

Symptoms of ectopic pregnancy

Clinical signs of a progressive ectopic pregnancy are drowsiness, weakness and lethargy, nausea and vomiting, changes in taste and olfactory sensations, lack of menstruation on time (in 73%), engorgement of the mammary glands. That is, these are the same doubtful and probable signs that accompany a normal intrauterine pregnancy. However, in the 2nd – 3rd week the following may occur:

  1. Pain in the lower abdomen of varying nature and intensity (in 68%). Usually they are in the nature of paroxysmal contractions. Often the pain in the lower abdomen radiates to the rectum.
  2. Slight intermittent dark spotting (49%).
  3. The combination of these two symptoms with delayed menstruation (65%). In some cases, there is not a complete delay in menstruation, but the appearance of very slight bleeding.

Resolution of tubal pregnancy can occur according to the following type:

  1. Tubal abortion, which occurs 10-12 days after the start of the due period of menstruation. It occurs as a result of rupture of the membranes of the fetal sac, usually proceeds in a protracted form and is erased in nature - the general condition does not worsen, the pain is aching, constant and unexpressed, blood is gradually released from the genital tract. If more than half a liter of blood accumulates in the abdominal cavity, the general condition worsens somewhat.
  2. A rupture of the fallopian tube, in which a significant amount of blood is poured into the abdominal cavity. The rupture is accompanied by acute sudden pain in the abdomen above the womb from the pathological process and its further spread to the entire lower half of the abdomen. Nausea and vomiting, the urge to defecate, and a sharp deterioration in general condition occur, expressed in pallor and wetness of the skin, an increase in heart rate and a decrease in blood pressure, loss of consciousness. In the absence of emergency surgical care, rapid development of hemorrhagic shock with an unfavorable outcome is possible.

Diagnostics

Diagnosis of the developing process of pathological localization at the initial stages is difficult due to the absence of obvious specific symptoms. Suspicion of an ectopic pregnancy may occur if:

  • presence of risk factors;
  • delay in menstruation and the presence of doubtful and reliable signs of pregnancy itself;
  • even slight pain over the womb or, moreover, the appearance of bloody discharge.

Will the test show an ectopic pregnancy? Exist various express- tests intended for home use. They are based on the determination of hCG in urine ( human chorionic gonadotropin person). But the “home” express method is only qualitative and not quantitative testing, that is, it only determines the presence increased amount HCG, not its numerical value. Therefore, this method cannot serve as a source to suggest the presence of ectopic implantation of the fertilized egg.

Carrying out a quantitative blood test for hCG during an ectopic pregnancy can serve as an important objective confirmation of its development. Human chorionic gonadotropin is a hormone produced by the fetal membrane of the embryo and ensures the relationship between a woman and her unborn child. Normally, its concentration in the blood is less than 5 IU/l. It begins to increase in the very early stages of pregnancy. From the 6-8th day after fertilization to the end of the third week, hCG increases from 5.8 to 750 IU/l, reaching 155,000 IU/l by the 8th week.

The amount of the hormone between the second and fifth weeks of normal pregnancy doubles every 36 hours. Determining it in the blood is the most reliable in terms of diagnosing its early stages.

If the initial content of the hormone in the blood is below the norm corresponding to the duration of pregnancy, or the increase in its concentration in 3 studies occurs more slowly than normal, then this most likely suggests the presence of ectopic implantation and development of the embryo, the threat of miscarriage, placental insufficiency, undeveloped pregnancy. The information content of the method is 96.7%.

To clarify the diagnosis, it is carried out, with the help of which it is still impossible to determine the exact location of the fertilized egg. But scanning provides an opportunity to assume, based on indirect signs, the presence of pathology. If necessary, diagnostic laparoscopy is performed to more accurately determine the site of implantation of the fertilized egg.

Treatment of ectopic pregnancy

If an ectopic pregnancy is disrupted, emergency surgery is always indicated. During endoscopic diagnosis or in case of tubal abortion, but the woman’s condition is satisfactory, it is possible to remove an ectopic pregnancy laparoscopically, which can to some extent reduce the likelihood of subsequent disorders or infertility. If the tube ruptures or the general condition is severe, laparotomy is performed, its removal and bleeding are stopped. Sometimes, in order to preserve it, it is possible to “squeeze” the fertilized egg out of the tube or remove the latter through an incision in it, followed by suturing the wall.

In recent years, work has been carried out to study the possibility conservative treatment developing ectopic pregnancy. However, so far there is no general consensus regarding medications, their dosages and effectiveness.

By ectopic pregnancy, medical specialists mean a serious pathology of pregnancy, as a result of which the fertilized egg attaches not to the uterine cavity, but outside it. In the vast majority of cases, it is dangerous for the woman, and the fetus itself is not viable. What are the causes and symptoms of this problem? How to treat it and is it possible to save the fetus? You will learn about this and much more below.

What is an ectopic pregnancy?

An ectopic pregnancy is the attachment and development of a fertilized egg outside the uterus. In the vast majority of cases, it is localized in the fallopian tubes, only occasionally becoming established in the ovaries or abdominal cavity. This condition is a clear pathology, which, once identified, requires qualified medical care.

Early ectopic pregnancy

The most important task of gynecologists specializing in servicing representatives of the fair sex in an interesting position is the timely detection of ectopic pregnancy early stages fetal development. It is then that the chances of a successful outcome for a woman are highest. The later the pathology is detected, the more likely serious complications, including death, are likely to occur.

As modern medical statistics show, the above problem occurs on average in 2 percent of future mothers. In 99 percent of cases out of 100, the prescription of a medical consultation implies an abortion with maximum precautions carried out by a team of experienced specialists.

Danger of ectopic pregnancy

The main dangers include:

  1. The formation of persistent infertility, as well as a significant increase in the risk of miscarriages in the future. In half of the cases, when a representative of the fair sex conceives again, an ectopic pregnancy forms again;
  2. Mechanical impact on organs located in areas of localization of ectopic pregnancy with disruption of their functioning;
  3. Rupture of the tube, ovaries, rudimentary horn during the development of the fetus in an atypical place for it. As a consequence, severe shock symptoms, a sharp drop in all vital signs, and in the absence of surgical and resuscitation measures, the logical outcome is death.

Risk factors and groups

As modern medical statistics show, in half of the cases of ectopic pregnancy in the fair sex, the following groups of factors are present:

  1. Inflammatory processes in the female genital organs. These can be both chronic pathologies and acute conditions of a bacterial, fungal, or viral nature;
  2. Surgical operations in the abdominal area. Almost all types of surgical intervention in the abdominal cavity in women lead to a significant increase in the risk of ectopic pregnancy in the future;
  3. Regular use of emergency contraception. The use of gestagens and antigestagens immediately after unprotected sexual intercourse to 100% neutralize the possibility of unwanted pregnancy carries numerous risks. One of them is a possible ectopic pregnancy;
  4. Various tumors of the uterus and appendages;
  5. Congenital and acquired anomalies in the development of the female genital organs;
  6. Significant change hormonal levels caused by pathological mechanisms;
  7. Physiological or pathological disturbance of transport function in the fallopian tube.

Causes of ectopic pregnancy

Don't miss ours! Find out what happens at each stage of your pregnancy.

The main reason for this type of pregnancy is blockage of the fallopian tube or disruption of its rhythmic contractions. This undoubtedly dangerous condition occurs only when the fertilized egg cannot enter the uterus, most often remaining in the tube (up to 98 percent of cases), less often in the rudimentary horn, ovaries or abdominal cavity. In the latter cases, the future fetus is ejected from the fallopian tube, but in the opposite direction. It should be understood that there are no necessary conditions for the preservation and development of the embryo, and the ectopic pregnancy itself leads to serious complications.

Why does such a blockage or reverse ejection of the unborn fetus occur? Modern medicine has not yet established the exact reasons, but it has been able to find patterns with risk factors that most often accompany pathology.

Main risk factors:

  1. Age over 35 years;
  2. The woman had previously had an abortion;
  3. Active inflammatory process in the reproductive tubes or ovaries;
  4. Malignant or benign tumors;
  5. Underdevelopment of the genital organs and associated hormonal disorders;
  6. The use of an intrauterine device exceeds its nominal service life.

At the very early stage of development, an ectopic pregnancy is no different from a classic one. In the first weeks after conceiving a child, a woman may experience nausea, soreness of the mammary glands, their enlargement, hardening and swelling. In addition, representatives of the fair sex are often diagnosed with subjectively frequent mood swings, increased appetite, drowsiness during the day, a significant change in taste and olfactory sensations, general weakness, as well as a delay in the regular menstrual cycle.

The main manifestations of the pathological clinic of ectopic pregnancy begin after conception. A fertilized egg actively penetrates the fallopian tube or the structure of the internal epithelium of the abdominal organs, after which it begins to destroy it - the above described soft fabrics are not intended for this kind of influence. Further, the process of development of an ectopic pregnancy can proceed in two ways - spontaneous abortion with the release of the embryo into the abdominal cavity, or rupture of the organ where the fetus is localized.

Possible manifestations of adverse symptoms

  1. Pain syndrome. At the first stage - aching, of medium strength with associated pain during defecation or urination. At the second stage - severe dagger pain on the left or right in the lower abdomen;
  2. Bleeding. Scanty uterine discharge, reminiscent of menstruation, but lasting for a long period of time. There is a significant drop in progesterone levels. Heavy bleeding mainly in internal organs;
  3. Protrusion and pain in the posterior vaginal vault, unstable localization of the uterus;
  4. Shock. It occurs in the later stages as a consequence of spontaneous miscarriage into the abdominal cavity or due to a ruptured tube. Characterized by pale skin, weak but frequent pulse, significant drop in blood pressure, multiple loss of consciousness;
  5. Lethal outcome in the absence of qualified medical care.

Diagnostics. How to determine an ectopic pregnancy?

Given the danger of ectopic pregnancy, as much as possible early diagnosis Such a pathological condition is the most important preliminary stage that helps preserve the health and even life of a woman.

Since in the first weeks of the development of ectopic pathology no serious external symptoms appear, except for the classic manifestations of pregnancy, the main recommendation during this period is to contact a gynecologist as quickly as possible.

In all known cases of a combination of delayed regular menstruation, non-menstrual bleeding from the vagina and pain, the problem described above can and should be suspected.

Despite popular opinion, detecting a fertilized egg using ultrasound outside the uterus is quite problematic, especially after conception. An ultrasound examination may show the absence of an embryo in the uterus, which, along with the characteristic symptoms of pregnancy, may indicate its ectopic nature.

The main criteria for combined diagnostics in this situation:

  1. Preliminary positive pregnancy test;
  2. Absence of fertilized egg on classical and intravaginal ultrasound;
  3. Free fluid behind the uterus or in the abdominal cavity (at stage 2 of the development of ectopic pregnancy in the presence of internal bleeding);
  4. (chorionic gonadotropin) above 1500 mIU/ml, no significant increase in its concentration when repeated analysis after 48 hours (less than 1.5 times) or a decrease in values ​​over the same period.

What to do?

First of all, don't panic. At the slightest suspicion of an ectopic pregnancy, you should immediately contact a gynecologist who will prescribe a comprehensive diagnosis. If a problem is detected and the diagnosis is confirmed, the woman will be scheduled for surgery to remove the embryo and prescribed treatment for related problems.

An ectopic pregnancy is a direct threat to the life of a representative of the fair sex and a clear indication for abortion, regardless of timing! In the world, there are only isolated cases of gestation and delivery by cesarean section during an ectopic pregnancy - all of them are unique in their own way, since the embryo was attached in the abdominal cavity, ovaries, liver, omentum or rudimentary horn. In 99 percent of cases, doctors diagnose tubal pathology. It is impossible to carry a child in the fallopian tube - the organ is too small for it and quickly collapses, causing internal bleeding, miscarriage of the fetus into the abdominal cavity, or its tissues simply rupture (maximum before after conception, usually by 10-13 weeks). In all of the above cases, immediate surgical intervention, intensive care and a series of resuscitation measures are required.

Therapy for ectopic pregnancy is developed individually depending on the duration, location of the embryo, and the presence of associated complications.

The main technique is surgical

  1. Emergency surgery to stop intra-abdominal bleeding with restoration of basic hemodynamic parameters;
  2. Laparotomy is performed for any location of the fetus or involuntary miscarriage in cases of ectopic pregnancy. Immediately prescribed in case of hemorrhagic shock;
  3. Tubectomy. Removal of the fallopian tube with the fetus. Prescribed for repeated cases of ectopic pregnancy, organ rupture, large diameter embryo, cicatricial changes in the structure of soft tissues and other complications;
  4. Milking. Conservative plastic surgery to squeeze out the fertilized egg if it is localized in the fimbrial region. The procedure preserves the organ and its reproductive properties, but is possible only in the absence of complications and not in all cases;
  5. Tubotomy. Tube resection with removal of the fertilized egg. Used in the absence of complications, ruptures and small size of the embryo in the early stages of its development;
  6. Surgical intervention for non-tubal ectopic pregnancies. Rare cases require special surgical intervention. Pregnancy in a rudimentary horn is an indication for its removal. In case of ovarian ectopia, resection of an area of ​​healthy tissue is performed while preserving the organ. In the case of ectopic abdominal pregnancy, excision of the fetal receptacle with parallel complex hemostasis.

Alternative technique

In the last decade, medicine in modern developed Western countries has increasingly used conservative methods of treating ectopic pregnancy. We are talking about the use of chemotherapy - local injections of methotrexate, performed with complex transvaginal ultrasound monitoring or laparoscopy. This cytostatic effectively stops the development and resolves the fertilized egg in the early stages of ectopic pregnancy, when the size of the embryo does not exceed 3 centimeters.

The technique requires great precision and professionalism; it is indicated for uncomplicated forms of pathology and planned surgery. In some cases, it can lead to bleeding from the mesosalpinx - then chemotherapy is stopped and immediately proceeded to laparotomy. At the moment, the above scheme is not applied in Russia and post-Soviet countries due to little knowledge, lack of necessary equipment and the experience of medical specialists, although it is considered promising due to its low invasiveness, as well as the high chances of complete preservation of reproductive function in the fair sex after recovery.

Complementary therapy

Includes rehabilitation measures (mainly exercise therapy), physiotherapeutic procedures (from massage and acupuncture to magnetic therapy and UHF/UV), concomitant use of medications according to indications (hepatoprotectors, analgesics, corticosteroids, antibiotics for secondary infections, etc.), vitamin supplements -mineral complexes.

In some cases, a woman may need psychological or psychotherapeutic help, comprehensive post-operative care. You cannot become pregnant again within six months after surgery - it is rational to use oral contraception and condoms.

Consequences

An ectopic pregnancy can have a very serious impact on a woman's health.

Typical consequences:

  1. Significant reduction or complete disappearance of reproductive function due to removal of the fallopian tube, ovaries or any other important organ for medical reasons;
  2. Neuroendocrine and vegetative-vascular disorders of a wide spectrum;
  3. A significant increase in the risk of a repeat ectopic pregnancy in the event of conception;
  4. Adhesive processes in the pelvis;
  5. Numerous regular bacterial infections of the genital organs, due to a decrease in the level of local immunity;
  6. Fatal outcome in the absence of qualified medical care in the event of spontaneous miscarriage or rupture of the fallopian tube.

Pregnancy after ectopic

If a representative of the fair sex has a first ectopic pregnancy without complications, then the chances of a subsequent successful normal conception in the uterus are assessed modern statistics in 50 percent - while every fifth woman is diagnosed with a repeat ectopic pregnancy, and a third become completely infertile.

In the case of complications, poorly tolerated operations, the presence of scars and adhesions, direct removal of one fallopian tube and other negative aspects, the chances of subsequent childbearing rapidly decrease.

Prevention of ectopic pregnancy

The first step for every woman who wants to reduce the chances of developing an ectopic pregnancy is timely treatment of any inflammatory processes in the pelvic organs. Along the way, preventive therapy should be carried out not only for the fair sex, but also for their partners, this especially applies to the presence of an increased concentration of chlamydia, ureaplasma, and mycoplasma in a couple.

The second important point is correct contraception. After all, abortion, as a radical remedy for an unplanned child, still remains the main culprit in subsequent ectopic forms of pregnancy. The use of methods that are reliable and safe for a woman’s health will allow us to adequately plan for future additions to the family.

The use of “emergency” contraceptives after unprotected sexual intercourse is strictly not recommended - they are huge side effects. It is better to immediately contact a specialized medical institution and, under the supervision of specialists, carry out an abortion, which is not only relatively safe and low-traumatic, but also includes the necessary post-abortion rehabilitation.

From general recommendations We can note the classic activities that increase the average quality of human life and reduce the risks of various chronic diseases, which together can affect a woman’s health and increase the risks of ectopic pregnancy:

  1. Normalization of circadian rhythms of sleep and rest;
  2. Correction of the power plan;
  3. Regular physical exercise;
  4. Taking multivitamin complexes;
  5. Refusal bad habits;
  6. Preliminary advance planning of a new addition to the family;
  7. Regular medical examinations.

Useful video

Ectopic pregnancy. Signs and symptoms. What to do?

Ectopic pregnancy is rightfully considered by doctors to be the most insidious and unpredictable gynecological disease. Ectopic pregnancy is not so rare, occurring in approximately 0.8 - 2.4% of all pregnancies. In 99 - 98% it is a tubal pregnancy. After an illness, especially a tubal pregnancy, a woman’s chances of remaining childless increase. What are the symptoms of an ectopic pregnancy, the reasons for its occurrence, treatment, complications - this is what our article is about.

Ectopic pregnancy: how is it classified?

An ectopic (ectopic) pregnancy is a pathology characterized by the fact that the embryo is localized and grows outside the uterine cavity. Depending on where the implanted egg was “located,” tubal, ovarian, abdominal, and pregnancy in the rudimentary uterine horn are distinguished.

Pregnancy in the ovary can be of 2 types:

  • one progresses on the ovarian capsule, that is, outside,
  • the second directly in the follicle.

Abdominal pregnancy occurs:

  • primary (conception and implantation of the egg to the internal organs of the abdominal cavity occurred initially)
  • secondary (after the fertilized egg is “thrown out” of the fallopian tube, it attaches to the abdominal cavity).

Case study: A young nulliparous woman was brought to the gynecology department by ambulance. All the symptoms of bleeding into the abdominal cavity are present. During a puncture of the abdominal cavity, dark blood enters the syringe through the pouch of Douglas of the vagina. Diagnosis before surgery: ovarian apoplexy (no missed period and test negative). During the operation, an ovary with a rupture and blood in the abdomen are visualized. Ovarian apoplexy remained as a clinical diagnosis until the histological results became known. It turned out that there was an ovarian pregnancy.

At what stage can an ectopic pregnancy be detected?

The disease is most easily diagnosed after the pregnancy is terminated (either a tubal rupture or a completed tubal abortion). This can happen at different times, but usually within 4 to 6 weeks. In case of further growth of pregnancy, it is possible to suspect its ectopic localization if probable date at 21–28 days, the presence of hCG in the body and the absence of ultrasound signs of intrauterine pregnancy. A pregnancy that has “chosen” a place in the embryonic horn of the uterus can be interrupted later, at 10–16 weeks.

Early symptoms of ectopic pregnancy

When do early symptoms of ectopic pregnancy appear? If a woman has regular menstrual cycle, this pathology can be suspected when a delay in menstruation occurs. However, an ectopic pregnancy that continues to grow and develop is practically no different from a pregnancy that is in the uterus in the early stages. The patient usually notes the following first symptoms of ectopic pregnancy:

Firstly, this is an unusual regular menstruation - its delay or. Secondly, mild or moderate nagging pain due to stretching of the wall of the fallopian tube due to the growth of the fertilized egg. The test for an ectopic pregnancy is most often positive.

  • women report a delay in menstruation in 75-92% of cases
  • pain in the lower abdomen - 72-85%, both mild and intense
  • bloody discharge - 60-70%
  • signs of early toxicosis (nausea) - 48-54%
  • enlarged and painful mammary glands - 41%
  • pain radiating to the rectum, lower back - 35%
  • positive (not for everyone) pregnancy test

The erroneous opinion of many is that if there is no delay in menstruation, then the diagnosis of ectopic pregnancy can be excluded. Very often, spotting vaginal discharge during ectopic pregnancy is perceived by some women as normal menstruation. According to some authors, VD can be detected in 20% of cases before a missed period. Therefore, a thorough history taking and a complete examination are very important for the timely establishment of this diagnosis.

During an examination by a gynecologist, he reveals cyanosis and softening of the cervix, an enlarged, soft uterus (the first signs of pregnancy). When palpating the appendage area, it is possible to identify an enlarged and painful tube and/or ovary on one side (tumor-like formations in the appendage area - in 58% of cases, pain when trying to deviate the uterus - 30%). Their contours are not clearly palpable. When palpating a tumor-like formation in the appendages, the doctor compares the size of the uterus and the period of delayed menstruation (an obvious discrepancy) and prescribes additional research:

  • Ultrasound of the internal organs of the genital area
  • Analysis for hCG content and
  • The progesterone content during an ectopic pregnancy is lower than during a normal pregnancy and there is no increase in hCG after 48 hours if the pregnancy is ectopic

An ectopic pregnancy interrupted by a tubal abortion is characterized by a typical triad of symptoms and signs:

  • pain in the lower abdomen
  • bloody discharge from the genital tract
  • as well as delayed menstruation

Pain in the lower abdomen is explained by an attempt or pushing of the fertilized egg from the fallopian tube. Hemorrhage inside the tube causes its overstretching and antiperistalsis. In addition, blood entering the abdominal cavity acts on the peritoneum as an irritant, which aggravates the pain syndrome.

A sudden, dagger-like pain in the iliac regions against the background of complete health helps to suspect a tubal abortion. Pain, as a rule, occurs after 4 weeks of delay of menstruation, radiates to the anus, hypochondrium, collarbone and leg. Such attacks can be repeated repeatedly, and their duration ranges from several minutes to several hours.

If the internal hemorrhage is minor or moderate, an ectopic pregnancy may remain unrecognized for a long time and have no special symptoms. Some patients, in addition to the listed symptoms, note the appearance of pain during bowel movements. A painful attack is accompanied by weakness, dizziness, and nausea. A slight increase in temperature is explained by the absorption of spilled blood in the abdomen.

If intra-abdominal bleeding continues, the woman’s condition worsens and the pain intensifies. Bloody discharge from the genital tract is nothing more than a rejection of the mucous membrane in the uterus, transformed for future implantation of the egg (decidua), and they appear a couple of hours after the attack, and are associated with a sharp drop in progesterone levels. A characteristic feature of such discharge is its persistent repetition; neither hemostatic drugs nor curettage of the uterine cavity help.

When a fallopian tube rupture occurs, its signs

The timing of damage to the fallopian tube is directly related to the part of the tube in which the embryo is implanted. If it is in the isthmic section, rupture of the fetal sac occurs at 4–6 weeks; when the fertilized egg “occupies” the interstitial section, the period is extended to 10–12 weeks. If the embryo has chosen a place for further development - the ampullary part of the tube, which is located next to the ovary, rupture occurs after 4 - 8 weeks.

Fallopian tube rupture is a dangerous way to terminate an ectopic pregnancy. It occurs suddenly and is accompanied by the following symptoms:

  • with severe pain
  • drop in blood pressure
  • increased heart rate
  • general deterioration of condition
  • the appearance of cold sweat and
  • pain radiates to the anus, leg, lower back

All of the listed signs of ectopic pregnancy are caused by both severe pain and massive bleeding into the abdominal cavity.

During an objective examination, pale and cold extremities, increased heart rate, rapid and weak breathing are determined. The abdomen is soft, painless, and may be slightly swollen.

Massive hemorrhage contributes to the appearance of signs of peritoneal irritation, as well as muffled percussion tone (blood in the abdomen).

A gynecological examination reveals cyanosis of the cervix, an enlarged, soft uterus that is shorter than the expected gestational age, pastiness or a formation similar to a tumor in the groin area on the right or left. An impressive accumulation of blood in the abdomen and pelvis leads to the fact that the posterior fornix becomes flattened or protrudes, and its palpation is painful. There is no bloody discharge from the uterus; it appears after the operation.

Puncture of the abdominal cavity through the posterior vaginal fornix allows obtaining dark, non-coagulating blood. This procedure is painful and is rarely used for pipe rupture (pronounced clinical picture: sharp pain, painful and hemorrhagic shock).

Case study: A primigravida young woman was sent from the antenatal clinic to the gynecology department to maintain her pregnancy. But as soon as she was admitted, the pregnancy was disrupted by a tube rupture. At the appointment, no alarming formation was palpable in the area of ​​the appendages, and the diagnosis sounded like a 5-6 week pregnancy, threatened with miscarriage. Luckily, the woman went to see a doctor. There was no time to conduct a gynecological examination, blood pressure was 60/40, pulse 120, severe pallor, significant dagger pain, and as a result, loss of consciousness. They quickly opened the operating room and took the patient. There was about 1.5 liters of blood in the abdomen, and the burst tube was about 8 weeks pregnant.

Why does ectopic pregnancy occur?

Attachment of the fertilized egg outside the uterine cavity is caused by impaired peristalsis of the fallopian tubes or a change in the properties of the fertilized egg. Risk factors:

  • inflammatory processes in the pelvis

Inflammatory processes of the appendages and uterus lead to neuroendocrine disorders, obstruction of the fallopian tubes, and dysfunction of the ovaries. Among the main risk factors is chlamydial infection (salpingitis), which in 60% of cases leads to ectopic pregnancy (see).

  • intrauterine device

Intrauterine contraceptives lead to ectopic pregnancy in 4% of cases; with long-term use (5 years), the risk increases 5 times. Most experts believe that this is due to inflammatory changes that accompany the presence of a foreign body in a woman’s uterus.

  • abortions

), especially numerous, contribute to the growth of inflammatory processes of the internal genital organs, adhesions, impaired peristalsis and narrowing of the tubes; 45% of women after artificial termination of pregnancy subsequently have a high risk of developing an ectopic pregnancy.

U smoking woman the risk of developing an ectopic pregnancy is 2-3 times higher compared to a non-smoker, since nicotine affects tubal peristalsis, contractile activity of the uterus, and leads to various immune disorders.

  • malignant neoplasms of the uterus and appendages
  • hormonal disorders (including stimulation of ovulation, after IVF, taking a mini-pill, impaired production of prostaglandins)
  • fallopian tube surgery, tubal ligation
  • abnormal development of a fertilized egg
  • sexual infantilism (long, crimped tubes)
  • endometriosis (causes inflammation and adhesion formation)
  • stress, overwork
  • age (over 35 years old)
  • congenital malformations of the uterus and tubes
  • genital tuberculosis

What is the danger of ectopic pregnancy?

Ectopic pregnancy is scary due to its complications:

  • severe bleeding - hemorrhagic shock - death of a woman
  • inflammatory process and intestinal obstruction after surgery
  • recurrence of ectopic pregnancy, especially after tubotomy (in 4–13% of cases)

Case study: A woman was admitted to the emergency room with classic symptoms of an ectopic pregnancy. During the operation, the tube was removed from one side, and upon discharge the patient was given recommendations: to be examined for infections, treated if necessary, and to abstain from pregnancy for at least 6 months (the pregnancy was desired). Less than six months have passed, the same patient is admitted with a tubal pregnancy on the other side. The result of non-compliance with the recommendations is absolute infertility (both tubes were removed). The only good news is that the patient has one child.

Methods for preserving appendages and should they be preserved?

An ectopic pregnancy is an emergency and requires immediate surgery. The most common procedure is a salpingectomy (removal of the tube) because in most cases the fallopian tube is severely damaged (regardless of the stage of pregnancy) and a future pregnancy has a serious risk of being ectopic again.

In some cases, the doctor decides on a salpingotomy (incision of the tube, removal of the fertilized egg, suturing the incision in the tube). Tubal-preserving surgery is performed when the size of the ovum is no more than 5 cm, the patient’s condition is satisfactory, and the woman’s desire to preserve reproductive function (ectopic relapse). It is possible to carry out fimbrial evacuation (if the fertilized egg is in the ampullary section). The embryo is simply squeezed out or sucked out of the tube.

Segmental pipe resection is also used (removal of the damaged section of the pipe followed by suturing of the pipe ends). In the early stages of tubal pregnancy, drug treatment is allowed. Methotrexate is injected into the cavity of the tube through the lateral vaginal fornix under ultrasound control, which causes the dissolution of the embryo.

Will tube patency remain after surgery? This depends on many factors:

  • Firstly, early activation of the patient (prevention of adhesions) and physical treatment
  • Secondly, adequate rehabilitation therapy
  • Thirdly, the presence/absence of postoperative infectious processes

Questions and answers:

  • How to protect yourself after an ectopic pregnancy?

Taking purely progestational (mini-pill) drugs and inserting an IUD are not recommended. It is advisable to take oral combined contraceptives.

  • Can a pregnancy test show where it is located?

No, the test shows that there is a pregnancy.

  • The delay is 5 days, the test is positive, but the fertilized egg is not visualized in the uterus. What to do?

It is not necessary that an ectopic pregnancy has occurred. It is necessary to repeat the ultrasound after 1 - 2 weeks and conduct a blood test for hCG (in the early stages, pregnancy in the uterus may not be visible).

  • I had acute adnexitis, does that mean I have a high risk of developing an ectopic pregnancy?

The risk, of course, is higher than in healthy women, but it is necessary to be examined for sexually transmitted infections, hormones and treated.

  • When can you plan a pregnancy after an ectopic?

Definition of disease. Causes of the disease

Ectopic pregnancy(or ectopic pregnancy) is a pathology that develops as a result of implantation and development of the fertilized egg not in the uterus, but outside it.

Most often, the attachment of a fertilized egg occurs in the fallopian tubes. In rare cases, it attaches to the ovaries, rudimentary uterine horn, and cervical canal. Even less commonly, this occurs intraligamentously (between the ligaments) and in the abdominal cavity. The growth of an embryo located in any of these organs can lead to its rupture, which is a threatening condition for reproductive health and even for the life of a woman. At the moment, ectopic pregnancy occupies one of the first places among diseases leading to intra-abdominal bleeding, the mortality rate for this pathology reaches 7.4%.

The cause of most cases of ectopic pregnancy is a violation of the peristaltic function of the cylindrical ciliated epithelium lining the fallopian tubes. The following factors may contribute to this:

If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of ectopic pregnancy

A progressive ectopic pregnancy before complications arise is similar to a pregnancy of uterine localization, accompanied by very sparse clinical symptoms. Often, only ultrasound examination becomes the starting point for making a diagnosis.

The first signs of ectopic pregnancy include delayed menstruation, intermittent pain of varying intensity in the lower abdomen spreading to the rectum, “spotting” bloody or brownish discharge from the vagina, enlarged and engorged breasts (“stone breasts”), and symptoms of toxicosis. A characteristic sign of this pathology is abdominal pain at the site of attachment of the fertilized egg. In many ways, the symptoms are determined by the location and stage of development of the embryo.

The most acute clinical signs of this pathology appear when the ectopic pregnancy is complicated. Complications are accompanied by hemorrhage into the abdominal cavity and acute abdominal pain. Typically, termination of an ectopic pregnancy occurs at 4-6 weeks.

Pathogenesis of ectopic pregnancy

In the absence of pathological factors, the nuclei of the egg and sperm merge in the ampullary section of the fallopian tubes, then the already fertilized egg migrates and is implanted into the uterine cavity. The transport function is performed by the cilia of the epithelium covering the fallopian (uterine) tubes. Due to impaired or decreased peristalsis of the epithelium, there is a risk of developing ectopic pregnancy. The receptacle for the fetus, if the type of pregnancy is tubal, is formed directly from the membranes of the fallopian tubes.

Classification and stages of development of ectopic pregnancy

The fundamental signs of the clinical classification of ectopic pregnancy are considered to be the localization and clinical picture of the disease.

By localization

1.pipe(98%) - characterized by the attachment of the fertilized egg in the fallopian tube (ampullary, isthmic, interstitial and fimbrial sections);

2. ovarian(0.1-0.7%) - intrafollicular (the egg fuses with the sperm in the ovulated follicle) or epiofollicular (attachment and development of the fertilized egg on the surface of the ovary);

3. pregnancy in a vestigial horn uterus (0.1-0.9%) - possible in the presence of developmental anomalies of this organ; in such a horn the muscle wall is not well developed, which can lead to rupture and bleeding; however, the literature has documented situations where the outcome of such a pregnancy was favorable;

4.abdominal(0.3-0.4%) - the fertilized egg attaches to the abdominal cavity, implants into the intestines, omentum, peritoneum and its organs;

5.cervical(0.1-0.4%) - attachment of the fertilized egg to the columnar epithelium of the cervix;

6. intraligamentary(0.1%) - the fertilized egg is attached between the layers of the wide uterine ligaments due to rupture of the fallopian tube;

7. pregnancy in fallopian tube stump (0,08-0,1%);

8.heterotopic- one fertilized egg is attached to the uterus, and the other outside its cavity; a rare pathology, but its frequency is increasing significantly due to the development of assisted reproduction methods.

The literature also describes situations that do not fall under any of the classification points: attachment of a fertilized egg to the uterine cavity in the area of ​​the cesarean section scar and intramural (wall) localization.

According to the clinical course ectopic pregnancy occurs:

A) progressive;

b) interrupted:

  • tubal abortion;
  • rupture of the fallopian tube.

Complications of ectopic pregnancy

Ectopic pregnancy, regardless of location, is fraught with serious complications! Any suspicion of an ectopic pregnancy requires consultation with a gynecologist and emergency hospitalization.

The most common outcome of ectopic pregnancy is massive bleeding inside the abdominal cavity. In such cases, patients need emergency surgical therapy, intraoperative and external hemostasis (stopping bleeding with FFP drugs, tranex), and also need to restore the volume of circulating blood.

Often, an ectopic pregnancy is complicated by a rupture of the fallopian tube into which the fertilized egg was implanted. In this case, the woman will begin to experience symptoms of an “acute abdomen”:

  • sudden sharp pain in the lower abdomen, spreading to the rectum, lumbar region, lower limbs;
  • spotting or bloody discharge from the vagina, often quite copious;
  • There may be dry mouth, general weakness, dizziness due to low blood pressure, even loss of consciousness.

The clinical course of an interrupted tubal pregnancy is similar to ovarian apoplexy (hemorrhage into the ovary), so it is necessary to carry out a clear differential diagnosis and provide full assistance in a timely manner.

During the development of pregnancy in the abdominal cavity, a woman may not complain until a certain period. However, later the patients actively complain of general weakness, fainting, dizziness, and pain in the lower abdomen. Later, symptoms of anemia develop - the skin and mucous membranes of the mouth turn pale. This is due to compression and/or damage to small or medium-sized abdominal vessels. Internal bleeding occurs as a result of the germination of large vessels by chorionic villi. When the egg attaches in a place with poor blood supply, the fertilized egg dies. If the fetus is implanted in a well-supplied area, the pregnancy may continue to develop, but it is rarely carried to normal gestational age. Symptoms during abdominal pregnancy are very variable, the difference in manifestations depends on the site of attachment of the fertilized egg and the degree of damage to the internal organs.

The clinical picture of cervical pregnancy depends on the gestational age (the total number of weeks of pregnancy) and the level of attachment of the fertilized egg. It is noteworthy that women rarely report pain during such a pregnancy, more characteristic feature are bleeding from the vagina, sometimes quite profuse, often profuse (very strong). The cervical type of pregnancy is especially dangerous for the life and health of the patient: the cervix has a good blood supply, so the risks of developing massive bleeding, thrombohemorrhagic syndrome (DIC), and hemorrhagic shock are much higher! As a rule, the development of cervical pregnancy occurs before 8-12 weeks.

Ovarian pregnancy is often terminated in the early stages, in extremely rare cases it reaches the second trimester. The clinical picture in this case is similar to that of a tubal rupture due to an interrupted tubal pregnancy. A pregnancy complication occurs in the ovary when organ tissue ruptures and subsequent bleeding.

Pregnancy in the rudimentary uterine horn rarely reaches significant gestation periods, however, there are cases when such a pregnancy reached more serious periods and even ended in delivery. A rudimentary pregnancy is also clinically similar to a tubal pregnancy; it is terminated by the rupture of the receptacle of a fertilized egg, with the characteristic appearance of heavy bleeding and a clinical picture of hemorrhagic shock.

Diagnosis of ectopic pregnancy

Unfortunately, diagnosing an ectopic pregnancy in the short term is quite difficult due to the fact that the clinical symptoms are similar to the normal course of pregnancy, when the development of the fertilized egg occurs in the uterus. Life history and data on gynecological pathologies are important components for making a diagnosis. During a bimanual examination, the gynecologist discovers a slightly enlarged, soft and mobile uterus; in the projection of the uterine appendages, he palpates a pasty formation, which may turn out to be mobile with unclear contours or rounded with a pasty consistency. During displacement of the uterus, an acute pain sensation radiating to the anus is detected. Examination of the mucous membranes of the vagina and cervix in the speculum may reveal cyanosis (cyanosis). Identification of characteristic early signs of pregnancy - Hegar's symptom (softening of the uterus in the isthmus area) and Piskacek's sign (protrusion of the uterus with a dome-shaped asymmetrical shape) - indicates a weakly positive or completely negative result.

As a rule, if menstruation is delayed, women perform a pregnancy test on their own before seeing a doctor. A more informative method at this stage would be to determine hCG level(β-hCG, human chorionic gonadotropin) in the blood, produced during pregnancy. The reference values ​​of this hormone during intrauterine pregnancy differ significantly from the same values ​​during ectopic pregnancy - such a difference will help narrow the diagnostic search. An insufficient increase in hCG may indicate not only an ectopic pregnancy, but also a violation of intrauterine pregnancy. Progesterone levels will also vary significantly.

Enough effective method determining the location of the fertilized egg is an ultrasound transvaginal sensor. During an ultrasound examination, it is possible to identify not only echographic signs of pregnancy and determine the amount of fluid in the abdominal cavity and pouch of Douglas, which is a predetermining factor in deciding the issue of pregnancy. surgical intervention. The most reliable echographic signs are identified paraovarian formations with uneven and unclear contours, and Doppler sonography will distinguish a false fertilized egg.

Diagnostic laparoscopy is perhaps the most informative technique necessary for making a diagnosis. At the time of the procedure, the surgeon is able to visualize the location of the embryo and carry out sanitation (rehabilitation) of the abdominal cavity, dissect adhesions, and conduct surgical therapy.

Differential diagnosis of ectopic pregnancy at the prehospital stage is carried out with the threat of miscarriage, dysfunctional metrorrhagia; in acute pain syndrome - with ovarian apoplexy, pelvioperitonitis, torsion of the leg, appendicitis, perforation of a hollow organ.

Treatment of ectopic pregnancy

Mostly, treatment of ectopic pregnancy is carried out only by surgery. The choice of access - laparoscopic or laparotomy - initially depends on the location of the ectopic pregnancy, complications that have developed (massive bleeding in the abdominal cavity), the qualifications of the surgeon and the equipment of the surgical hospital where the patient was taken.

The most favorable prognosis is found in women with tubal ectopic pregnancy. The operation of choice for this localization of pregnancy is most often a tubectomy (removal of the tube to which the fertilized egg is attached). If the fertilized egg is in the fimbrial region, it is possible to evacuate it, that is, “squeeze” the embryo through the ampulla of the fallopian tube.

tubectomy

In some cases, it makes sense to perform organ-preserving reconstructive surgery - salpingotomy and removal of the fertilized egg. The justification for such a surgical intervention will be the presence of a single fallopian tube in a woman, as well as the patient’s decision to preserve reproductive function. However, there are a number of factors when performing such an operation is impossible:

  1. if reconstructive surgery of this pipe has already been performed;
  2. significant structural changes due to pipe rupture.

The purpose of this operation is to restore the integrity and patency of the fallopian tube. Preference is given to a minimally invasive laparoscopic approach to avoid the formation of adhesions. For the most effective prevention of adhesions, the use of anti-adhesion barriers - special gels introduced endoscopically into the cavity of the fallopian tubes - has become widespread. According to research, the gel introduced intraoperatively remains in the tube for 3-5 days, which allows you to gain time for the restoration of the mesothelium.

Complications of salpingotomy performed include:

  • in the early postoperative period: development of bleeding from the operated fallopian tube during the first postoperative day;
  • persistence and further development of chorionic tissue (its cells can remain in the wall of the fallopian tube and continue to divide after removal of the ectopic pregnancy itself).

Complications of a tubectomy include:

Pregnancy in the rudimentary uterine horn, unfortunately, is not always resolved in favor of the patient. Sometimes the surgeon even has to resort to radical surgery - amputation of the uterus, however, timely diagnosis of pathology and identification of anatomical and physiological features of the uterus can significantly affect the outcome.

Cervical and cervical-isthmus localizations of pregnancy not so long ago doomed patients to unconditional removal of the uterus: due to the fact that the implanted embryo has a good blood supply, other attempts to resolve pathological pregnancy ended in massive bleeding and had serious consequences for the woman’s health. Currently, techniques have emerged that help preserve the uterus and the ability to realize reproductive function. Embolization of the uterine arteries is carried out, as a result of which the blood flow decreases and the nutrition of the chorion decreases. Vacuum aspiration or curettage of the fertilized egg is performed under ultrasound control. In some cases, at one stage, arterial administration of the drug Methotrexate, an embryotoxic drug, is indicated.

In addition, in parallel, the patient is prescribed antibacterial drugs, hemostatic therapy and measures aimed at removing pain. Based on the severity of the condition, correction of blood volume and antianemic drugs are carried out.

Forecast. Prevention

Based on the risk factors leading to ectopic pregnancy, you can make a list of rules that should be followed to prevent it:

  1. First of all, when preparing to conceive a child, it is necessary to perform a full examination, which necessarily includes a transvaginal ultrasound, in order to identify pathologies of the genitourinary system, as well as clarify the anatomical and physiological features (bicornuate uterus);
  2. avoid questionable sexual relations in order to prevent the development of infection, use barrier contraception;
  3. it is necessary to promptly and correctly treat inflammatory diseases of the genital organs, see a gynecologist and not self-medicate;
  4. if it is necessary to carry out an abortion, choose the least traumatic methods, follow all doctor’s prescriptions in the postoperative period;
  5. reduce the number of stress factors, if possible, refuse to work at night, observe the work and rest schedule;
  6. quit smoking.

If these simple rules are followed, the prognosis for the disease is favorable.

Bibliography

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Ectopic pregnancy is considered a very serious problem, since in 5-10% of cases it is the cause female infertility. That is why it is very important to identify it as early as possible, which is easy to do if you know its main signs.

Ectopic pregnancy is known among doctors as one of the most unpredictable and insidious gynecological diseases. Ectopic pregnancy occurs quite often - 0.8-2.4% of all pregnancy cases. Moreover, in 98-99% of cases such pregnancy is tubal. After suffering from illness and especially tubal pregnancy, a woman runs the risk of becoming childless. Therefore, you need to understand in detail the symptoms of ectopic pregnancy.

Classification of ectopic pregnancy

Ectopic (ectopic) pregnancy is a gynecological pathology, which is characterized by the fact that the embryo attaches and grows outside the uterine cavity. Depending on the location of the implanted egg, it is customary to distinguish the following types of ectopic pregnancy:

  • abdominal;
  • ovarian;
  • pipe;
  • pregnancy in the rudimentary uterine horn.

In turn, pregnancy in the ovary is divided into pregnancy directly in the follicle and pregnancy outside (develops on the ovarian capsule). Abdominal pregnancy can be primary (conception and attachment of the egg to the internal organs in the abdominal cavity occurred initially), as well as secondary (the fertilized egg joined the abdominal organs after being released from the fallopian tube).

Example from practice.

A young woman who had not yet given birth was brought to the gynecological department by ambulance. During the initial examination, all signs of hemorrhage into the abdominal cavity were present. When performing a puncture of the abdominal cavity by inserting a syringe into the pouch of Douglas, dark-colored blood enters the syringe. Preoperative diagnosis: ovarian apoplexy (based on the absence of missed periods and a negative pregnancy test). During the operation, visualization of the ovary revealed its rupture and the presence of blood in the abdomen. Ovarian apoplexy remained a clinical diagnosis until the results of histological examination were obtained. In fact, there was an ovarian ectopic pregnancy.

How early can an ectopic pregnancy be detected?
The easiest way to determine the pathology is after its interruption (either a completed tubal abortion, or a variant of a tubal rupture). This outcome could occur on different terms however, in most cases it is 4-6 weeks. If the pregnancy continues to grow, then its ectopic localization can be suspected and determined at a period of 21-28 weeks, in the absence of signs of intrauterine pregnancy on ultrasound and the presence of hCG in the body. Pregnancy, which is located in the rudimentary horn of the uterus, can be terminated a little later at 10-16 weeks.

Early symptoms of ectopic pregnancy

If a woman has a regular menstrual cycle, then such a pathology can be suspected if it is disrupted and a delay occurs. However, if an ectopic pregnancy continues to grow and develop, then in the early stages it does not differ from intrauterine pregnancy. Typically, patients experience the following first symptoms of ectopic pregnancy:

First of all, there is unusual menstruation in the form of scanty periods or their delay. Secondly, moderate or mild nagging pain appears due to stretching of the walls of the fallopian tube, due to the growth of the fertilized egg. In most cases, a pregnancy test for an ectopic pregnancy is positive.

  • pain radiating to the lower back, rectum – 35%;
  • painful and enlarged mammary glands – 41%;
  • signs early development toxicosis (nausea) – 48-54%;
  • presence of bloody discharge – 60-70%;
  • pain in the lower abdomen, both intense and weak – 72-85%;
  • Delayed menstruation is observed in 72-92% of cases of ectopic pregnancy.

There is a misconception that if there is no delay in menstruation, then the diagnosis of “ectopic pregnancy” can be completely excluded. Quite often, spotting vaginal discharge during the development of an ectopic pregnancy is perceived by many women as a normal menstrual cycle. According to some authors, it is possible to determine the presence of ectopic pregnancy before the onset of a missed period in 20% of cases. That is why a thorough history taking and a complete examination is very important for a timely diagnosis.

During an examination by a gynecologist, he notes a soft, enlarged uterus, softening and cyanosis of the cervix (the first signs of pregnancy). During palpation of the area of ​​the uterine appendages, a painful and enlarged tube and ovary are determined on one side (in 58% of cases - tumor-like formations in the area of ​​the appendages, in 30% - pain when trying to deviate the uterus). The contours of the formations are clearly palpable. In the process of palpation of the formation in the appendage, the doctor can compare the period of delay of menstruation and the size of the uterus (the discrepancy is obvious), and also prescribe additional studies:

  • analysis for progesterone and hCG levels;
  • with an ectopic pregnancy, the progesterone content is lower than in the case of a normal pregnancy, and there is no increase in hCG, after 48 hours with an ectopic pregnancy;
  • Ultrasound examination of the reproductive system and internal organs.

If an ectopic pregnancy is interrupted by a tubal abortion, then a characteristic triad of signs is present:

  • delayed menstruation;
  • bloody discharge from the genital tract;
  • pain in the lower abdomen.

Pain in the lower abdomen can be explained by pushing or trying to push the fertilized egg out of the fallopian tube. Intratubal hemorrhage causes its overstretching and lack of peristalsis. In addition, the blood that enters the abdominal cavity has an irritating effect on the peritoneum, which only aggravates the pain.

The sudden appearance of a sharp, dagger-like pain in the iliac region against the background of seemingly complete health helps to suspect the fact of a tubal abortion. Pain most often occurs 4 weeks after a missed period and radiates to the hypochondrium, legs, collarbone, anus. Such attacks can be repeated several times, and their duration varies from several minutes to hours.

If there is internal hemorrhage of a moderate or minor nature, then the detection of an ectopic pregnancy may be significantly delayed in time, since significant signs will be absent.

Some patients, in addition to the above symptoms, have pain during bowel movements. A painful attack is accompanied by nausea, dizziness, and weakness. A slight increase in body temperature can be explained by the process of blood absorption in the abdominal cavity.

If intra-abdominal bleeding does not stop, then this manifests itself in the form of a deterioration in the woman’s well-being and increased pain. The presence of bloody discharge from the genital tract is nothing more than a rejection of the lining of the uterus, which has been transformed to attach an egg to it. Such discharge appears several hours after the attack and is associated with a sharp decrease in progesterone levels. One of the characteristic distinctive features Such discharge is persistently repeated: the discharge does not stop even after taking hemostatic drugs and curettage of the uterine cavity.

Timing and signs of fallopian tube rupture

The timing of fallopian tube rupture directly depends on which part of the fallopian tube the embryo was attached to. If the fertilized egg is in the isthmic section, then the tube ruptures at 4-6 weeks, but if the embryo attaches in the interstitial section, then the period before its rupture is extended to 10-12 weeks. If the fertilized egg is laid in the ampullary part of the fallopian tube, adjacent to the ovary, then rupture occurs at approximately 4-8 weeks of pregnancy.

Fallopian tube rupture is very in a dangerous way getting rid of an ectopic pregnancy. Its occurrence occurs suddenly and is accompanied by a number of signs:

  • severe pain;
  • general deterioration of condition;
  • increased heart rate;
  • drop in blood pressure;
  • the appearance of cold sweat and loss of consciousness;
  • pain radiates to the lumbar region, leg, anus.

The above signs of ectopic pregnancy are caused by severe pain and heavy bleeding into the abdominal cavity.

During the objective examination, cold and pale extremities, increased heart rate and mild rapid breathing are recorded. The abdomen is painless, soft, and slight bloating may be present.

Massive hemorrhage provokes the appearance of intense signs of irritation of the peritoneum and muted percussion tone (presence of blood in the abdomen).

During a gynecological examination, cyanosis of the cervix, a soft, enlarged and smaller than expected uterus, pastiness or formation in the groin area on the left or right are established. The significant accumulation of blood in the pelvis and abdomen causes the posterior fornix to protrude or flatten, and palpation becomes painful. There is no bloody discharge from the uterus itself and appears after the operation. During puncture of the abdominal cavity, dark, non-coagulating blood enters the syringe through the posterior vaginal fornix. This procedure is very painful and is rarely used for rupture of the fallopian tube (severe symptoms: hemorrhagic and painful shock, sharp pain).

Case study:

A young woman with her first pregnancy was admitted from the antenatal clinic to the gynecology department to maintain the pregnancy. However, after admission, the pregnancy was disrupted due to a rupture of the fallopian tube. At the appointment, during palpation of the appendage area, suspicious formations were not palpable, and the diagnosis sounded like a 5-6 week pregnancy with a threat of termination. A gynecological examination was not performed due to lack of time, since there was marked pallor, pulse 120, blood pressure 60/40, intense stabbing pain and loss of consciousness as a result of the above-described condition. The patient was urgently taken to the operating room. There was about 1.5 liters of blood in the abdominal cavity, and in the ruptured fallopian tube there was a fertilized egg at the 8th week of development.

Causes of ectopic pregnancy

Attachment of the embryo outside the uterine cavity is due to a change in the properties of the fertilized egg or a violation of the peristalsis of the fallopian tubes. Risk factors:

  • inflammatory processes in the pelvic area.

The inflammatory process of the uterus and appendages leads to the development of neuroendocrine disorders, dysfunction of the ovaries, and obstruction of the fallopian tubes. Among the main risk factors, salpingitis (chlamydial infection) should also be highlighted, which in 60% of cases causes the development of ectopic pregnancy.

  • Intrauterine device.

Intrauterine methods of contraception cause ectopic pregnancy in 4% of cases, and if the duration of their use exceeds 5 years, the risk automatically increases 5 times. Most researchers of this trend believe that such statistics depend on inflammatory changes that develop in response to the presence of a foreign body in the body.

  • Abortion.

Artificial termination of pregnancy (abortion), especially numerous, contributes to the development of inflammatory processes in the internal genital organs of a woman, disruption of peristalsis of the fallopian tubes, and the development of adhesions. About 45% of women after an abortion have a high probability of developing an ectopic pregnancy in the future.

Women who smoke are more likely to develop ectopic pregnancy (2-3 times) than non-smokers. This is due to the fact that nicotine has a detrimental effect on the contractile activity of the uterus, peristalsis of the tubes and causes various immune disorders.

  • genital tuberculosis;
  • congenital malformations of the tubes and uterus;
  • age over 35 years;
  • overwork, stress;
  • endometriosis (provokes inflammation and the formation of adhesions);
  • sexual infantilism (twisted, long pipes);
  • improper development of the fertilized egg;
  • tubal ligation, fallopian tube surgery;
  • hormonal disorders (stimulation of ovulation after IVF, impaired production of prostaglandins, taking mini-pills);
  • malignant formations of the appendages and the uterus itself.

The risk of developing an ectopic pregnancy

Ectopic pregnancy is especially dangerous due to its complications:

  • recurrence of ectopic pregnancy, especially after tubotomy (4-13% of cases);
  • intestinal obstruction and inflammation after surgery;
  • secondary infertility;
  • adhesions in the pelvic area;
  • severe bleeding – hemorrhagic shock – death.

Example from practice.

A woman was admitted from the emergency department with signs of an ectopic pregnancy. During the operation, the surgeon removed the tube from one side, and upon discharge it was recommended to undergo examination for infections, treatment (if obstruction occurs) and protection from pregnancy for 6 months, since the pregnancy was planned. Before the end of 6 months, the patient was admitted to the department with an ectopic pregnancy in another tube. As a result, resection of both tubes and complete infertility. The patient's only consolation was the presence of one child, who had previously been born without incident.

Methods for preserving the uterine appendages and is there a need to preserve them?

An ectopic pregnancy in gynecology is considered an emergency and requires immediate surgery. In most cases, a salpingectomy is performed, since most often the fallopian tube is so damaged that a future pregnancy may be ectopic.

In some cases, doctors decide on a possible salpingotomy (incision of the fallopian tube with removal of the fertilized egg and then applying sutures to the incision of the tube).

An operation to preserve the tube is carried out provided that the egg does not exceed 5 cm in diameter, the woman is in satisfactory condition and wishes to preserve reproductive function. It is possible to perform fimbrial evacuation (when the fertilized egg is located in the ampullary section). The embryo is aspirated or squeezed out of the tube.

As one of the operation options, segmental resection of the pipe is performed (removal of the damaged part of the pipe with suturing of the pipe ends). If a tubal pregnancy is recognized early, drug treatment may be used. To do this, Methotrexate is injected into the cavity of the tube, which dissolves the embryo. The procedure is performed through the lateral vaginal fornix under ultrasound guidance.

Maintaining tube patency after surgery is a controversial issue and depends on many factors:

  • firstly, early activation of the patient (measures to prevent adhesions) and appropriate physical treatment;
  • secondly, adequate therapy during rehabilitation;
  • thirdly, the absence/presence of infectious processes after surgery.

The most popular questions regarding ectopic pregnancy

  • What methods of contraception should I use after an ectopic pregnancy?

The introduction of intrauterine devices and the use of purely progestational drugs (mini-pills) are not recommended. Most the best option is taking oral contraceptives of combined action.

  • Can a pregnancy test show the location of an ectopic pregnancy?

No. A pregnancy test cannot show the location of the fertilized egg.

  • The delay is five days and the test answer is positive, but the fertilized egg cannot be visualized in the uterus. What to do?

This does not mean that we can speak with confidence about an ectopic pregnancy. To exclude such a pathology, you should undergo an ultrasound scan after 1-2 weeks, and also perform a blood test for the presence of hCG. In very early stages, pregnancy in the uterus may not be visualized.

  • I suffered from acute andexitis, does this mean that I have a very high risk of having an ectopic pregnancy?

Of course, in this case, the risk is higher compared to a healthy woman, but it is advisable to be examined for hormones and sexually transmitted infections and treat them (if detected).

  • How long after an ectopic pregnancy can I plan a new pregnancy?

To exclude possible complications The desired pregnancy can be planned no earlier than after 6 months.

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