Ectopic pregnancy - Causes, symptoms and treatment. MF.

Fertilization - the fusion of the sperm and the egg, takes place in the fallopian tube. The fertilized egg descends into the uterine cavity, is attached to its wall - so the normal pregnancy begins. But a fertilized egg may not enter the uterine cavity, lingering in one of the fallopian tubes, sometimes - quite rarely - pregnancy develops in the free abdominal cavity or ovary, an ectopic pregnancy occurs.

Ectopic pregnancy( a synonym for ectopic pregnancy) is a pathological form of pregnancy, in which implantation( attachment) and development of the fetal egg occurs outside the uterus.

The incidence of ectopic pregnancy is approximately 2-3% of the total number of pregnancies. In recent years, there has been a tendency for this pathology to grow.

Causes of an ectopic pregnancy:

To the possible reasons provoking occurrence of an ectopic pregnancy carry:

- infectious-inflammatory diseases of a uterus, appendages and a bladder;
- congenital anomalies in the structure of the fallopian tubes, because of which a fertilized egg can not reach the uterine cavity;

- surgical interventions on the fallopian tubes;
- hormonal disorders;
- frequent curettage of the uterine cavity, including abortions;
- wearing an intrauterine device;
- long reception of hormonal preparations from infertility;
- external genital endometriosis( proliferation of endometrioid tissue outside the uterus);
- adhesive process in the small pelvis;
- tumors of the fallopian tubes and ovaries;
- tuberculosis of the fallopian tubes.

All these conditions can lead to impaired contraction of the fallopian tubes or to blockage, leading to the development of an ectopic pregnancy. Uncovered, not eliminated cause, which entailed ectopic pregnancy - a pledge of its recurrence.

Depending on the location of the fetal egg, the following types of ectopic pregnancy are distinguished:

- tubal pregnancy is the most common type of ectopic pregnancy( about 98%).In this case, the fetal egg is attached to the mucous membrane of the uterine tube. Depending on the part of the fallopian tube into which the fetal egg-tube pregnancy is implanted, it can be: ampullar, isthmic, interstitial and fimbrial;
- ovarian pregnancy - implantation of the fetal egg in the cavity of the ovarian follicle;
- abdominal pregnancy - the fetal egg is fixed in the abdominal cavity;
- cervical pregnancy - the fetal egg is attached and develops in the cervical canal.

Ovary, abdominal and cervical pregnancies are extremely rare.

Symptoms of an ectopic pregnancy

Symptoms of an ectopic pregnancy progress gradually as the fetal egg grows in the wrong place.

The pain symptom is one of the main symptoms of an ectopic pregnancy. At the beginning of the pregnancy, the pain is of a tolerable nature - it is disturbed by the pulling pains in the lower abdomen, which can give back and the rectum. If you do not immediately go to the doctor, the condition deteriorates quickly - the pain becomes sharp stitching. There is dizziness, weakness, nausea, vomiting.

Arterial blood pressure decreases, pulse increases, fainting is possible. The exacerbation of symptoms occurs due to rupture of the uterine tube and the beginning of internal bleeding. Most often, this occurs at 6-8 weeks of gestation( if counted from the first day of the last menstruation), when the embryo begins to grow. It is not recommended to take painkillers( such as No-shpa), as they can temporarily relieve pain and smooth the clinical picture, but the woman's condition will deteriorate rapidly.

It is characteristic of the appearance of dark red spotting blood discharge, which can be temporary and correspond to the day of supposed menstruation. But more often allocation of allocation appears after a delay of a menses. Possible "contact" bleeding, i.e.the appearance of secretions immediately after intercourse. If the pain syndrome is not expressed, the ectopic pregnancy can easily be confused with a normal uterine pregnancy and bloody discharge is often perceived as a threat of miscarriage, especially if the pregnancy test is positive. With any severity of such symptoms, an immediate appeal to the gynecologist and urgent hospitalization are necessary.

Diagnosis of an ectopic pregnancy

Ectopic pregnancy causes in the body of a woman the same changes as uterine pregnancy: delay of menstruation, engorgement of the mammary glands, the appearance of colostrum, nausea, perversion of taste, etc. The uterus softens, and the yellow body of pregnancy is also formed in the ovary. That is, the organism at the first stages perceives this pathological condition as the norm and tries to preserve it. That is why the diagnosis of progressive tubal pregnancy is extremely complicated. Diagnostic errors in the presence of interrupted tubal pregnancy are explained, first of all, by the fact that the clinic of this disease does not have a characteristic picture and develops as another acute pathology in the abdominal cavity and small pelvis.

First of all, the aborted tubal pregnancy must be differentiated with apoplexy of the ovary and acute appendicitis.

As a rule, in case of presence of the clinic of "acute abdomen", consultation of related specialists( surgeons, urologists) is also necessary.

Since the aborted tubal pregnancy is an acute surgical pathology, the diagnosis must be made very quickly, since an increase in the time to the beginning of the operation leads to an increase in the magnitude of blood loss and can be life threatening condition.

Diagnosis of an ectopic pregnancy includes:

- examination of a gynecologist. When examined, the abdomen is swollen and tense, and a doctor's examination causes painful sensations. On the right or left, depending on the location of the fetal egg, palpation of the abdomen is palpated with a tumor-like formation. Unlike normal pregnancy, the size of the uterus with ectopic pregnancy does not correspond to the true duration of pregnancy, there is a lag in dimensions. The cervix in the mirrors is cyanotic in color, as in normal pregnancy. In cervical pregnancy, the cervix is ​​significantly enlarged;
- a clinical blood test. Characteristic decrease in hemoglobin, erythrocytes, hematocrit;increased level of leukocytes and ESR;
- ultrasound of pelvic organs with a vaginal sensor - reveals an abnormal arrangement of the fetal egg, blood in the abdominal cavity with a rupture of the fallopian tube;
- determination of the hormone level of hCG( human chorionic gonadotropin) in the blood. If the pregnancy is normal, then the level of hCG in the blood should increase by half every day. With ectopic pregnancy, the level of hCG is significantly lower than in normal pregnancy;
- diagnostic laparoscopy( microsurgical method of examination of pelvic organs under anesthesia) - highly informative method, which allows accurate diagnosis;
- puncture through the posterior vaginal vault - the needle is inserted into the rectum-uterine cavity. Isolation of dark blood with clots from the needle indicates internal bleeding;
- in controversial situations, the surgeon's consultation is shown to exclude acute surgical pathology.

Even if the diagnosis of an ectopic pregnancy is doubtful, the clinical manifestations of the disease are poorly expressed, and additional methods of investigation( ultrasound and puncture) are not informative - a strict dynamic observation of the patient in a hospital with a control of hCG level in the blood is shown. If the patient's condition worsens, the level of hCG is higher than normal, but does not correspond to the level of normal pregnancy-emergency laparoscopy is shown to confirm the diagnosis and treatment. The sooner an ectopic pregnancy is diagnosed and the operation is performed, the greater the chances of maintaining the reproductive function of a woman and avoiding unpleasant complications, so early diagnosis is extremely important.

In emergency situations with severe pain syndrome, a complex of diagnostic measures is reduced to gynecological examination, ultrasound and express diagnostics of blood, after which the patient is operated urgently.

What to do if you suspect an ectopic pregnancy

First of all, if there is pain and bleeding - immediately call an ambulance. Before the doctor's arrival, do nothing. No painkillers, no warmers or ice on the stomach and no enemas.

In case of rupture of the fallopian tube and internal bleeding, an emergency operation is vital.

Treatment of an ectopic pregnancy

The method of treatment of an ectopic pregnancy is strictly surgical. There are two types of surgical treatment of ectopic pregnancy - laparoscopy( microsurgical operation) and laparotomy( operation with dissection of the abdominal wall).

Laparoscopy:

During laparoscopy under general anesthesia( anesthesia with complete loss of sensitivity), 3 small punctures on the abdomen with a diameter of 1 cm are made. Carbon dioxide is injected into the abdominal cavity. Trocars are introduced( working tools) - special laparoscopic tubes and a laparoscope, due to which it is possible to visualize the condition of the pelvic organs on the monitor. Depending on the condition of the uterine tube, the size and location of the fetal egg, the surgeon can produce tubotomy( incision of the uterine tube) or tubectomy( removal of the uterine tube).

With tubotomy, the uterine tube is dissected and the fetal egg is removed. Then the uterine tube is sutured or coagulated. Tubotomy helps to preserve the "pregnant" fallopian tube and this is the main advantage of this method. The operation is performed by women who want to have a baby in the future, but on condition that the affected uterus is kept in a safe state, i.e.there are no significant structural changes, otherwise retention of the uterine tube is not advisable.

Tubectomy is performed in those cases when changes in the fallopian tube are irreversible( with a broken tubal pregnancy), as well as in case of recurrence of tubal pregnancy in the same fallopian tube after tubotomy. With a pronounced adhesion process in the small pelvis, it is also more appropriate to perform a tubectomy. During the tubectomy, the portion of the broad uterine ligament adjacent to the uterine tube( "mesosalpinx") and the isthmic department of the fallopian tube are consistently coagulated and dried out. The fetal egg, together with the removed fallopian tube, is removed from the abdominal cavity. Carry out a thorough sanation of the abdominal cavity.

A decision in favor of tubotomy or tubectomy during laparoscopy is assisted by salpingoscopy-a detailed examination of another unchanged fallopian tube, which allows one to evaluate its functionality( the patency of the tube, the presence or absence of adhesions, etc.).

Laparoscopy has a number of advantages over laparotomy: absence of scarring after surgery, minor blood loss during surgery, therefore in the vast majority of cases laparoscopy is used to treat an ectopic pregnancy.

Laparotomy:

Laparotomy is used in exceptional cases in difficult situations. The main indication for a laparotomy with an ectopic pregnancy is a lot of blood loss, which can threaten the life of the patient. During laparotomy, an anterior incision is made in the anterior abdominal wall under general anesthesia. The surgeon hands out the uterus with the pregnant tube and ovary into the surgical wound. The clamp is placed on the mother end of the tube. In parallel, another clamp is applied to the ovarian ligament. Then, in the places of the clamps, the pipe is crossed and bandaged. The mesosalpinx, captured by a clamp, is stitched. Defects of the peritoneum are closed by imposing gray-serous sutures on the mesosalpinx and the round ligament of the uterus. Pregnant uterine tube is removed.

If a patient underwent a previous laparotomy and removal of a single fallopian tube, she should be recommended laparoscopy to assess the condition of the remaining tube, the separation of adhesions in the small pelvis, which would reduce the risk of developing a repeated ectopic pregnancy in a single fallopian tube.

Regarding the rare forms of ectopic pregnancy - the approach is individual. Operative accesses are the same as in tubal pregnancy. An exception is cervical pregnancy.

In ovarian pregnancy, remove the part of the ovary into which the fetal egg was implanted. In abdominal pregnancy, the fetal egg is removed and haemostasis is carried out( stopping bleeding).

In case of cervical pregnancy, the situation is more complicated. The operation is performed strictly laparotomically, followed by removal of the uterus. Postponement of surgical intervention can lead to profuse bleeding with a fatal outcome. Fortunately, this kind of ectopic pregnancy is an extreme rarity.

Recently, methods of treating tubal pregnancy with medicines( for example, hormonal preparations) have been developed, but the expediency of these methods has not yet been confirmed.

To treat an ectopic pregnancy with folk remedies is by no means possible! This is not just not useful, but also dangerous for life. Only a timely appeal to a gynecologist will help to avoid complications.

Rehabilitation after an ectopic pregnancy:

In the postoperative period, dynamic monitoring of the patient's condition in a hospital environment is necessary. Be sure to conduct infusion therapy in the form of droppers to restore the water-electrolyte balance after heavy blood loss( crystalloid solutions, rheopolyglucin, fresh frozen plasma).For the prevention of infectious complications, antibiotics are used( Cefuroxime, Metronidazole).Rehabilitation after the ectopic pregnancy should be aimed at restoring reproductive function after surgery. These include: prevention of adhesions;contraception;normalization of hormonal changes in the body.

To prevent adhesions, enzyme preparations( Lidase) are used intramuscularly.

Rehabilitation period, as a rule, runs smoothly. After surgery, the patient must adhere to a special diet - recommended fractional meals( cereals, cutlets, broths).For a speedy recovery a week after the operation, a course of physiotherapy( magnetotherapy, electrophoresis, laser therapy) is shown.

Physiotherapeutic methods in rehabilitation period:

• alternating pulsed magnetic field of low frequency,
• low-frequency ultrasound,
• tonic currents( ultratonoterapiya),
• low-intensity laser therapy,
• electrostimulation of fallopian tubes;
• UHF therapy,
• zinc electrophoresis, lidase,
• ultrasound in pulsed mode.

For the duration of the course of anti-inflammatory therapy and for 1 month after the end, contraception is recommended, and the question of its duration is decided individually, depending on the patient's age and features of her reproductive function. Undoubtedly, the desire of a woman to maintain her reproductive function should be taken into account. The duration of hormonal contraception is also strictly individual, but usually it should not be less than 6 months after the operation.

After laparoscopy, it is prescribed approximately 4-5 days after the operation, and after laparotomy 7-10 days later. Postoperative sutures are removed for 7-8 days after the operation.

All patients who underwent ectopic pregnancy are recommended to be protected from pregnancy within the next six months after surgery in order to avoid repeated relapses of ectopic pregnancy and to prepare the body for a normal pregnancy.

After the completion of rehabilitation activities, before recommending the patient to plan the next pregnancy, it is advisable to perform diagnostic laparoscopy, which allows to assess the status of the fallopian tube and other organs of the small pelvis. If control laparoscopy revealed no pathological changes, then the patient is allowed to plan pregnancy in the next menstrual cycle.

Complications of ectopic pregnancy:

- intraabdominal bleeding due to rupture of the fallopian tube - with large blood loss leads to hemorrhagic shock and death is possible;
- adhesive process in the small pelvis;
- infertility;
- in the postoperative period there may be infectious complications and intestinal obstruction;
- recurrence of the disease( more often after tubotomy in the operated fallopian tube).

Preventing and preventing ectopic pregnancy:

- timely treatment of infectious and inflammatory diseases of the pelvic organs, including sexual infections. Before the planned pregnancy, it is necessary to make a comprehensive examination for the presence of chlamydia, mycoplasmas, ureaplasmas and other pathogenic microbes in order to get rid of them as soon as possible. This examination with you must go through a husband( or a regular sexual partner);
- abortion. In the event of an unwanted pregnancy, the operation should be performed at the optimal time( during the first 8 weeks of pregnancy), necessarily in a medical institution by a highly qualified doctor and with the obligatory subsequent appointment of postabortion rehabilitation;
- refusal to use intrauterine spirals;
- reception of hormonal contraceptives for protection from unwanted pregnancy.

Questions and answers of an obstetrician-gynecologist on the topic of ectopic pregnancy:

1. Is it possible to treat ectopic pregnancy with tablets?
No, you can not. It's life-threatening.

2. How fast can I get pregnant after an ectopic?
Immediately, but it is desirable to be protected for 6 months to normalize the hormonal background.

3. How painful is laparoscopy for ectopic pregnancy?
The operation is performed exclusively under general anesthesia and the patient does not feel anything at all.

4. When can I have sex after laparoscopy?
A month after the operation.

5. Can I put a spiral after an ectopic pregnancy?
It is undesirable, hormonal contraception is preferable.

6. Is it possible to determine an ectopic pregnancy in a pregnancy test?
No, it's impossible. The test determines only the lack or presence of pregnancy.

7. How to distinguish uterine pregnancy from ectopic in terms of hCG?
Only the level of hCG can not be diagnosed. It is necessary to make an additional ultrasound.

8. I have a monthly delay of 2 days, the test is positive, and a fetal egg in the uterus is not visible on the ultrasound. Does this mean I have an ectopic?
At such a short time, the fetal egg is not always visible in normal pregnancy. You need to check the level of hCG.

Obstetrician-gynecologist, cms. Christina Frambos