Causes of ectopic pregnancy in women, signs and development in the early stages
Among developmental anomalies, additional fallopian tubes, aplasia, etc. are observed. These and other defects of the development of the reproductive organs are formed in a female child during intrauterine development. This is due to bad habits of the mother, taking prohibited medications, infections of the genital area, radiation exposure.
Chronic infectious inflammation of the fallopian tubes - salpingitis - leads to adhesions. The neuromuscular apparatus suffers, which invariably affects the contractile function, due to which the peristalsis of the tube is disturbed. This is the main cause of obstruction of a fertilized egg through the fallopian tubes, where it remains.
Endometriosis refers to the pathological proliferation of the endometrium, glandular tissue of the uterus, outside the uterus itself, in our case in one or both fallopian tubes, which leads to an imbalance in the processes of contraction / relaxation of the muscles of the tubes. Peristalsis is disturbed, and the zygote does not have time to get to the uterus, attaching itself to the wall of the tube.
In vitro fertilization
IVF is the only way to conceive a child after surgical removal of the fallopian tubes and in other cases of infertility. Although the egg cell after artificial insemination is placed directly in the uterus, but, paradoxically, it is often implanted elsewhere. Every 20th IVF ends with an ectopic pregnancy.
The reasons for the development of the embryo outside the uterus can be:
- Use of an intrauterine device. It mechanically protects against attachment of the ovum to the wall of the uterus, but does not exclude the possibility of fixation in the tubes or other atypical place.
- Hormonal contraceptives such as mini-pili. Contraceptive pills without estrogen are prescribed according to the indications of only a certain category of women: heavy smokers, nursing mothers before the onset of half a year to a baby, etc. Such OK are unable to completely suppress the ovulation process, therefore in the cases listed above their use is justified. For other women, such contraception may lead to the attachment of a zygote to the wall of another organ.
Factors that increase the risk of ectopic pregnancy
These adverse factors include:
- previous pregnancy with the development of the fetus outside the uterus (7–13 times more likely to cause a recurrent ectopic pregnancy),
- sexually transmitted infections, especially chlamydia,
- repeated abortions or forced therapeutic and diagnostic curettage,
- ovarian hyperstimulation in order to conceive naturally,
- endocrine disorders.
In 35-50% of cases, it is difficult to establish the cause of ectopic pregnancy.
In the event of a pulling, and even more acute, pain in the lower abdomen, often accompanied by bloody discharge, severe weakness, palpitations, and loss of consciousness, an ambulance must be urgently called. These symptoms may indicate internal bleeding due to a ruptured tube or other organ during ectopic pregnancy.
Only timely diagnostics, confirming the presence of an ectopic pregnancy and determining the exact place of attachment of the ovum, as well as an emergency operation will help to avoid the development of serious complications that threaten life.
Author: Nadezhda Martynova, doctor
specifically for Mama66.ru
How is ectopic pregnancy
Approximately 1.5% of all fetal development occurs outside the uterus. The blockage of the fallopian tube or its violation are the main reason why a fertilized egg does not get into the uterus after conception. Because of this, it is mounted on the place where it stopped - it may be the wall of the fallopian tube, ovaries, cervical or abdominal cavity. These organs do not have the function of fetal development, their walls are not stretched, so there is not enough space for the embryo.
If the development of the embryo outside the uterus is overlooked, then at the 5th week of term the outer shell of the embryo will develop and grow into the walls of the organs with their rupture. There is profuse bleeding, sharp pains, resembling contractions, it becomes bad, dizzy, a woman loses consciousness. If a large vessel is damaged, then due to blood loss, the woman is at risk of death.
In the case when it is not the organ wall that breaks, but the membrane of the ovum, it goes into the abdominal cavity. This condition was called tubal abortion, accompanied by severe pain in the lower abdomen, general weakness, and a headache. These symptoms are less pronounced than in case of tubular rupture, and proceed more slowly. Gradually, the pain disappears, which gives the impression of a normal state of the body, but the bleeding continues. It can lead to serious consequences, so it is better to go to the doctor for any period of development of weakness.
Development of the fetus outside the uterus is dangerous because it cannot be detected in the early stages. It proceeds with similar symptoms from the uterus - delayed menstruation, nausea, softening of the uterus, the formation of the corpus luteum in the ovary. Even with bleeding and rupture of the walls of organs, pathology is easily confused with appendicitis, ovarian apoplexy, or other pathologies of an acute nature requiring surgical intervention.
Anatomy and physiology of the uterus at conception
For a better understanding of how an ectopic pregnancy occurs, as well as for understanding the mechanisms capable of provoking it, it is necessary to understand how the normal conception and implantation of the ovum occurs.
Fertilization is the process of merging the male and female germ cells - sperm and egg. This usually happens after sexual intercourse, when sperm pass from the vaginal cavity through the uterus and fallopian tubes to the ovum released from the ovaries.
Ovules are synthesized in the ovaries - the female genital organs, which also have hormonal function. In the ovaries during the first half of the menstrual cycle, there is a gradual maturation of the egg (usually one egg per menstrual cycle), with the change and preparing it for fertilization. In parallel with this, the internal mucous layer of the uterus undergoes a series of structural changes (endometrium), which thickens and prepares to accept the fertilized egg for implantation.
Fertilization becomes possible only after ovulation has occurred, that is, after the mature egg has left the follicle (structural component of the ovary in which egg maturation occurs). This happens around the middle of the menstrual cycle. The ovum released from the follicle together with the cells attached to it forming a radiant crown (outer shell performing a protective function), falls on the fringed end of the fallopian tube from the corresponding side (although cases have been reported in females with one ovarian function, the egg cell is in the tube from the opposite side) and transferred by the cilia of the cells lining the inner surface of the fallopian tubes, deep into the body. Fertilization (meeting with sperm) occurs in the widest ampular part of the pipe. After that, the fertilized egg with the help of cilia of the epithelium, and also due to the flow of fluid directed to the uterus, and resulting from the secretion of epithelial cells, moves through the entire fallopian tube to the uterus, where it is implanted.
It should be noted that in the female body there are several mechanisms that cause a delay in the advancement of a fertilized egg into the uterine cavity. It is necessary for the egg to go through several stages of division and prepare for implantation before it enters the uterine cavity. Otherwise, the ovum may be incapable of penetration into the endometrium and may be carried out into the external environment.
The delay in the progress of a fertilized egg is provided by the following mechanisms:
- The folds of the mucous membrane of the fallopian tubes. The folds of the mucous membrane significantly slow down the progress of the fertilized egg, because, firstly, they increase the path that it must go, and secondly, they delay the flow of fluid that carries the egg.
- Spastic contraction of the cervical isthmus (part of the tube located at 15 - 20 mm to the entrance into the uterus). The isthmus of the fallopian tube is in a state of spastic (permanenta) reduction within a few days after ovulation. This greatly complicates the promotion of the egg.
Upon reaching a certain stage of development of the ovum (the blastocyst stage where the germ consists of hundreds of cells) the implantation process begins. This process, which takes place 5–7 days after ovulation and fertilization, and which normally should occur in the uterus, is the result of the activity of special cells located on the surface of the ovum. These cells secrete special substances that melt the cells and the structure of the endometrium, which allows them to penetrate the mucous layer of the uterus. After the introduction of the egg, its cells begin to multiply and form the placenta and other embryonic organs necessary for the development of the embryo.
Thus, in the process of fertilization and implantation, there are several mechanisms, the disruption of which may cause incorrect implantation or implantation in a place other than the uterus.
Violation of these structures can lead to the development of ectopic pregnancy:
- Impaired contraction of the fallopian tubes to promote sperm. The movement of sperm from the uterus to the ampullary part of the fallopian tube occurs against the flow of fluid and, therefore, is difficult. Contraction of the fallopian tubes facilitates faster sperm flow. Violation of this process may cause an earlier or later meeting of the egg with sperm and, accordingly, the processes relating to the promotion and implantation of the ovum may go somewhat differently.
- Violation of cilia epithelium. The movement of cilia of the epithelium is activated by estrogen - the female sex hormones produced by the ovaries. The movements of the cilia are directed from the outside of the tube to its entrance, in other words, from the ovaries to the uterus. In the absence of movements, or when they are the opposite direction, the ovum may remain in place for a long time or move in the opposite direction.
- Stability of spastic spasm of the isthmus of the fallopian tube. Spastic contraction of the fallopian tube is eliminated by progesterones. In case of violation of their products, or for any other reason, this spasm may persist and cause a delay in the ovum in the lumen of the fallopian tubes.
- Disturbance of secretion of fallopian epithelial cells (uterinea) pipes. The secretory activity of the epithelial cells of the fallopian tubes generates a current of fluid that promotes the advancement of the egg. In its absence, this process is significantly slowed down.
- Violation of the contractile activity of the fallopian tubes to promote the ovum. The contraction of the fallopian tubes not only promotes the movement of the sperm from the uterus to the egg, but also the movement of the fertilized egg to the uterus. However, even under normal conditions, the contractile activity of the fallopian tubes is rather weak, but, nevertheless, it facilitates the progress of the egg (which is especially important in the presence of other violations).
Causes of ectopic pregnancy
Ectopic pregnancy is a pathology for which there is no one, strictly defined cause or risk factor. This disease can develop under the influence of many different factors, some of which still remain undetected.
In the overwhelming majority of cases, an ectopic pregnancy arises because of a disruption in the process of transporting an egg or a ovum, or because of excessive activity of the blastocyst (one of the stages of development of the ovum). All this leads to the fact that the implantation process begins at the moment when the ovum has not yet reached the uterus (A separate case is an ectopic pregnancy with localization in the cervix, which may be associated with delayed implantation or too rapid advance of the ovum, but which occurs very rarely).
Ectopic pregnancy can develop for the following reasons:
- Premature blastocyst activity. In some cases, premature blastocyst activity with the release of enzymes that promote the melting of tissues for implantation can cause ectopic pregnancy. This may be due to some genetic abnormalities, exposure to any toxic substances, as well as hormonal disruptions. All this leads to the fact that the ovum begins to implant in the segment of the fallopian tube in which it is located at the moment.
- Violation of the promotion of the ovum through the fallopian tubes. Violation of the progress of the ovum through the fallopian tube leads to the fact that the fertilized egg is delayed in some segment of the tube (either outside of it if she was not caught by the fringe of the fallopian tube), and at the onset of a certain stage of development of the embryo begins to implant in the corresponding region.
Impaired fertilized egg to the uterus is considered the most common cause of ectopic pregnancy and can occur due to many different structural and functional changes.
Violation of the promotion of the ovum through the fallopian tubes can be caused by the following reasons:
- inflammatory process in the uterine appendages,
- surgery of the fallopian tubes and abdominal organs,
- hormonal disruptions
- endometriosis of the fallopian tubes,
- congenital anomalies
- tumors in the pelvis,
- exposure to toxic substances.
Inflammatory process in the uterus
The inflammatory process in the uterine appendages (fallopian tubes, ovaries) is the most common cause of ectopic pregnancy. The risk of developing this pathology is high as in acute salpingitis (tubal inflammation), and in chronic. Moreover, infectious agents, which are the most common cause of inflammation, cause structural and functional changes in the tissues of the fallopian tubes, against the background of which the likelihood of impaired fertilized egg cells is extremely high.
Inflammation in the uterine appendages can be caused by a number of damaging factors (toxins, radiation, autoimmune processes, etc.), but most often it occurs in response to penetration of the infectious agent. Studies in which women with salpingitis took part revealed that in the overwhelming majority of cases this ailment was provoked by facultative pathogens (cause disease only in the presence of predisposing factors), among which the strains constituting the normal microflora of the person (E. coli). The causative agents of sexually transmitted diseases, although less common, are more dangerous because they have pronounced pathogenic properties. Quite often, the defeat of the uterus appendages is associated with chlamydia - a genital infection, for which the latent course is extremely characteristic.
Infectious agents can enter the fallopian tubes in the following ways:
- Ascending path. Most infectious agents are ascending. This happens with the gradual spread of the infectious-inflammatory process from the lower parts of the genital tract (vagina and cervix) up to the cavity of the uterus and fallopian tubes.This pathway is characteristic of pathogens of genital infections, fungi, opportunistic bacteria, pyogenic bacteria.
- Lymphogenous or hematogenous pathway. In some cases, infectious agents can be carried to the uterine appendages along with a current of lymph or blood from infectious and inflammatory foci in other organs (tuberculosis, staph infection, etc.).
- Direct entry of infectious agents. Direct introduction of infectious agents into the fallopian tubes is possible with medical manipulations on the pelvic organs, without following the proper rules of asepsis and antisepsis (abortions or ectopic manipulations outside medical facilities), as well as after open or penetrating wounds.
- By contact. Infectious agents can penetrate the fallopian tubes through their direct contact with infectious and inflammatory lesions on the abdominal organs.
Impaired function of the fallopian tubes is associated with the direct effect of pathogenic bacteria on their structure, as well as with the inflammatory reaction itself, which, although aimed at limiting and eliminating the infectious focus, can cause significant local damage.
The impact of the infectious-inflammatory process on the fallopian tubes has the following consequences:
- The activity of the cilia of the mucous layer of the fallopian tubes is disturbed. Changes in the activity of cilia of the epithelium of the fallopian tubes are associated with changes in the environment in the lumen of the tubes, with a decrease in their sensitivity to the action of hormones, as well as with the partial or complete destruction of the cilia.
- The composition and viscosity of secretion of fallopian tubes epithelial cells changes. The impact of pro-inflammatory substances and waste products of bacteria on the cells of the mucous membrane of the fallopian tubes causes a violation of their secretory activity, which leads to a decrease in the amount of produced fluid, to a change in its composition and to an increase in viscosity. All this significantly slows the progress of the egg.
- There is swelling, narrowing the lumen of the fallopian tube. The inflammatory process is always accompanied by swelling caused by tissue swelling. This edema in such a limited space as the lumen of the fallopian tube can cause its complete blockage, which will lead either to the impossibility of conception or to an ectopic pregnancy.
Operations on the fallopian tubes and abdominal organs
Surgical interventions, even minimally invasive, are associated with some, even if minimal, injuries that can provoke some changes in the structure and function of organs. This is due to the fact that in the place of injury or defect connective tissue is formed, which is not able to perform a synthetic or contractile function, which takes up a slightly larger volume, and which changes the structure of the organ.
An ectopic pregnancy can be triggered by the following surgical procedures:
- Operations on the abdominal organs or the small pelvis, not affecting the genitals. Operations on the abdominal organs can indirectly affect the function of the fallopian tubes, as they can trigger adhesions, and can also cause a violation of their blood supply or innervation (accidental or deliberate intersection or injury of vessels and nerves during surgery).
- Operations on the genitals. The need for surgery on the fallopian tubes occurs in the presence of any pathologies (tumor, abscess, infectious and inflammatory focus, ectopic pregnancy). After the formation of connective tissue at the site of the incision and the seam, the ability of the pipe to reduce is changed, its mobility is disturbed. In addition, its internal diameter may decrease.
The normal functioning of the hormonal system is extremely important for maintaining pregnancy, since hormones control the process of ovulation, fertilization and the promotion of the ovum through the fallopian tubes. If there are any disruptions of the endocrine function, these processes may be impaired, and an ectopic pregnancy may develop.
Of particular importance in the regulation of the organs of the reproductive system are steroid hormones produced by the ovaries - progesterone and estrogen. These hormones have a slightly different effect, since normally the peak concentration of each of them occurs in different phases of the menstrual cycle and pregnancy.
Progesterone has the following effects:
- inhibits the movement of cilia tube epithelium,
- reduces the contractile activity of the smooth muscles of the fallopian tubes.
- increases the frequency of blinking of the cilia of the tubular epithelium (too high concentration of hormone can cause their immobilization),
- stimulates the contractile activity of the smooth muscles of the fallopian tubes,
- affects the development of the fallopian tubes in the formation of genital organs.
Changes in the level of sex hormones contribute to the following factors:
- disruption of the ovaries,
- failures of the menstrual cycle
- use of progestin-only oral contraceptives (synthetic progesterone analogue),
- emergency contraception (levonorgestrel, mifepristone),
- induction of ovulation using clomiphene or gonadotropin injections,
- neurological and autonomic disorders.
The disruption of the following organs of internal secretion may trigger an ectopic pregnancy:
- Thyroid. Thyroid hormones are responsible for a variety of metabolic processes, including the transformation of certain substances involved in the regulation of reproductive function.
- The adrenal glands.The adrenal glands synthesize a number of steroid hormones that are necessary for normal functioning of the genital organs.
- Hypothalamus, pituitary gland. The hypothalamus and pituitary glands are brain structures that produce a number of hormones with regulatory activity. Violation of their work can cause a significant disruption in the work of the whole organism, including the reproductive system.
Abnormalities of the genitals
Abnormalities of the genitals can be the reason for which the movement of the ovum through the fallopian tubes will be difficult, slow, too long, or impossible.
The following anomalies are of particular importance:
- Genital infantilism. Genital infantilism is a delay in the development of an organism, in which the genitals have some anatomical and functional features. For the development of ectopic pregnancy is of particular importance that the fallopian tubes with this disease is longer than normal. This increases the migration time of the ovum and, accordingly, facilitates implantation outside the uterus.
- Stenosis of the fallopian tubes.Stenosis, or narrowing of the fallopian tubes, is a pathology that can occur not only under the influence of various external factors, but which can be congenital. Significant stenosis can cause infertility, but a less pronounced narrowing can only hinder the migration of the egg to the uterus.
- Diverticula of uterine tubes and uterus. Diverticula are bag-shaped protrusions of the organ wall. They significantly complicate the transport of the egg, and in addition, can act as a chronic infectious and inflammatory focus.
Exposure to toxic substances
Under the influence of toxic substances, the work of most organs and systems of the human body is disturbed. The longer a woman is exposed to harmful substances, and the greater the number of them enters the body, the more serious violations they can provoke.
Ectopic pregnancy can occur under the influence of a variety of toxic substances. Toxins in tobacco smoke, alcohol and narcotic substances deserve special attention, as they are widespread and increase the risk of developing the disease more than three times. In addition, industrial dust, salts of heavy metals, various toxic fumes and other factors that often accompany the processes produced, also have a strong effect on the mother's body and its reproductive function.
Toxic substances cause the following changes in the reproductive system:
- delayed ovulation
- change in contraction of the fallopian tubes,
- reducing the frequency of movement of the cilia of the tubular epithelium,
- impaired immunity with an increased risk of infection of internal genital organs,
- change of local and general blood circulation,
- changes in the concentration of hormones
- neurovegetative disorders.
Ectopic pregnancy - causes and effects
Ectopic pregnancy today is a fairly common pathology. As we all know, a normal pregnancy occurs as follows - the egg is fertilized in the fallopian tube, then it moves and enters the uterine cavity, where there is a lot of room for the egg to develop. The ovum is successfully attached to the wall of the uterus and the development of the fetus begins. In the case of ectopic pregnancy this does not occur - the fertilized egg does not fall into the uterus. A fertilized egg can enter and begin to develop in the tube itself, in the ovary, in the abdominal cavity, in the horn of the uterus, etc.
Ectopic pregnancy poses a huge health hazard. If during its not to find out and not to take measures, then there can be a deadly outcome because of loss of blood. When an egg develops in a tube or some organ, it can rupture the organ. But if the rupture has not yet occurred, the pregnant woman can still slowly lose blood due to the small ruptures of the organ capillaries.
Ectopic pregnancy is of two types:
Progressive Ectopic Pregnancy very dangerous, since in the early stages it is almost impossible to diagnose it. There are practically no symptoms, the size of the uterus corresponds to the required size at this time of normal pregnancy, there is no bleeding.
Abnormal or interrupted ectopic pregnancy has a brighter picture - paroxysmal pain in the lower abdomen, bleeding, blood pressure drops, the size of the uterus is increased, often palpation feels a painful soft education on the right or left of the uterus.
Diagnosis of ectopic pregnancy
It is not always easy to diagnose ectopic pregnancy, especially when it comes to early pregnancy. The first symptoms and signs of ectopic pregnancy may appear from 4 to 10 weeks of pregnancy. However, not all women pay attention to this and consult a doctor.
An interrupted ectopic pregnancy must be diagnosed at the time. If you diagnose pregnancy and perform the operation before the onset of a shock, you can save a woman’s life. If pathology is diagnosed before a pipe or organ breaks, then the reproductive functions of the woman can be maintained. If the operation is not performed at the time of death.
Usually, doctors diagnose an ectopic pregnancy in the following ways:
- palpation: when probing, you can detect a soft formation, like a tumor,
- blood and urine tests, which determine the level of human chorionic gonadotropin, which must constantly increase during the normal course of pregnancy (during ectopic pregnancy, the level does not change or is below normal),
- determine the level of the hormone progesterone, which also increases during normal uterine pregnancy,
- make an ultrasound that can accurately show whether there is a fetus in the uterus or not. If an ultrasound shows that there is no fetus in the uterus, but all other signs indicate the presence of pregnancy, an ectopic pregnancy is diagnosed.
It is best to resort to vaginal ultrasound, as it can show an accurate picture for another 4-5 weeks, and the usual ultrasound after only 6 weeks. In this case, every day is of great importance.
Causes of ectopic pregnancy
Ectopic pregnancy today is becoming more and more common and this is due to the fact that the number of women suffering from various gynecological diseases has increased since the early years of life. The most dangerous are the surgeries on the fallopian tubes and sterilization. It is worth noting that they increase the risk of developing ectopic pregnancy and postponed abortions.
In fact, any gynecological diseases, both advanced and progressive, can cause the development of this pathology.
We list the most common causes of ectopic pregnancy in the early stages:
- inflammatory processes of appendages,
- reducing the contractility of the fallopian tubes,
- functional disorders in the reproductive system,
- previously transferred ectopic pregnancy, etc.
Treatment of ectopic pregnancy
Unfortunately, it is not possible to save the fetus in the diagnosis of ectopic pregnancy, so the only correct treatment in this case will be a surgical operation. In most cases today is done laparoscopy - this operation is not complicated, as only a few micron-cuts are done. After such an operation, there are practically no complications and the rehabilitation period is short.
After undergoing ectopic pregnancy and surgery, a woman should be monitored regularly by a gynecologist.
In some cases, when the fallopian tube remains intact, doctors resort to drug method - With the help of certain drugs, a fertilized egg is destroyed and is independently removed from the uterus. This is the most humane and painless way. However, it only works when an ectopic pregnancy is detected at a certain stage.
There are also more serious interventions - tubotomy and tubectomy.
Tubotomy - an operation to open the abdominal cavity, cut the fallopian tube and extract the fetus. Then the blood vessels are sealed to stop the bleeding. In most cases, the rehabilitation process is normal, and the pipe recovers its function. A woman can become pregnant again.
Tubectomy - This is the most serious operation, with the help of it the affected pipe is completely removed. This operation is resorted to in the most extreme cases, as a rule, when the pipe has already burst and the woman’s life is threatened. If the operation is successful and the second pipe remains intact, then there is a chance that the woman can still have children.
What kind of treatment will be in each case, no one can know in advance. It all depends on the specific situation, at what stage the ectopic pregnancy is and how urgent measures are to be taken.
Effects of ectopic pregnancy
If women have suffered an ectopic pregnancy and again wants to try to get pregnant, she must do it deliberately and be sure to be seen by a doctor both during the planning period of the pregnancy and from the first days of her.
According to statistics, after suffering an ectopic pregnancy, the chance to get a normal uterine pregnancy is 50%, the second ectopic pregnancy is 20%, and infertility is 30%. As you can see, the numbers are not very consoling, so here you need to prepare and plan everything thoroughly. If the treatment of ectopic pregnancy was medical and all the tubes remained intact, then the chance of a normal pregnancy increases, and the second ectopic falls.
Ectopic pregnancy, signs, symptoms, effects
Tags: symptoms of ectopic pregnancy, treatment of ectopic pregnancy, how to determine ectopic pregnancy, the level of hcc in ectopic pregnancy, how to become pregnant after ectopic pregnancy, causes of ectopic pregnancy
Ectopic pregnancy (BMP) is a rather dangerous disorder, especially terrible for a woman, also because it is often difficult to determine her symptoms even for a professional gynecologist. It is for this reason that the question of how to determine an ectopic pregnancy is so difficult to answer the question of many women, and it’s not worth doing it at home on your own. В первую очередь еще и потому, что для диагностики этого нарушения используются специальные процедуры и анализы - например, замер уровня ХГЧ, который при ВМБ отличается от нормального.The same applies to the causes of the "disease", of which there can be a lot. And it is their proper clarification that determines the subsequent treatment. At the same time, it is important to be aware that ectopic pregnancy itself is not a sentence yet, and compliance with all the necessary conditions allows you to save the health of the future mother, and sometimes the life of the future child.
As the name implies - pregnancy develops outside the uterus. This is one of the most formidable gynecological diagnoses, until recently, sounded like a sentence. In the dolaparoscopic era, the only treatment option was to remove the fallopian tube (tubal pregnancy is the most common type of ectopic). A repeated ectopic with the removal of the remaining tube completely eliminates the spontaneous occurrence of pregnancy. If the tubes are removed, the only way to get pregnant is an IVF procedure (in vitro fertilization).
Of particular concern is the sharp increase in the frequency of ectopic pregnancy (3-5 times over the past 20 years, according to various observations). In the 70s. the prevalence of such a violation in the United States increased about 3 times, in the 80s the same dynamics was noted. Today, in the US, 1.4% of all pregnancies are extrauterine. In Russia - 1.13 cases per 100 pregnancies, or 3.6 cases per 100 live births. Ectopic pregnancy is the main cause of death for women in the first trimester of pregnancy. The risk of this complication increases with age and is highest in women aged 35-44. The relative risk of death in ectopic pregnancy is about 10 times higher than during childbirth, and 50 times higher than with induced abortion.
Types of ectopic pregnancy (depending on the place of attachment of the ovum release):
- tubal pregnancy (in 98% of cases)
- other rare localizations
It happens that when several eggs are fertilized, they are all attached outside the uterus (multiple ectopic pregnancy), for example, in both tubes, or some of them are still fixed in the uterus (combined ectopic pregnancy). When combined (heterotopic) form, you can do the operation - remove the pregnant tube. Uterine pregnancy may persist. The frequency of this pathology is increasing due to the use of modern assisted reproduction technologies (IVF), reaching in these cases the frequency of 1 per 100-620 pregnancies.
Only a uterine pregnancy can a woman successfully deliver and give birth to a healthy child.
Causes of ectopic pregnancy
It is believed that the main cause of the Navy is a violation of the transport of a fertilized egg.
The problem is that small, nimble spermatozoa are able to overcome the constricted portion of the fallopian tube, and a large, cumbersome egg can not do this. Sperm cells find an egg in the fallopian tube, merge with it, but the road to the uterus is blocked.
It should be noted that such a complication of pregnancy as tubal pregnancy (the most frequent variant of ectopic pregnancy) occurs ONLY in humans.
The mechanism itself is not completely clear, but the factors leading to the development of this complication are known for certain:
- Inflammatory diseases of the genital organs
As banal salpingoophoritis (Chronic salpingitis is found in about half of women with an ectopic pregnancy. It has been shown that this disease increases the risk of ectopic pregnancy 7 times), so are specific (chlamydia, tubal tuberculosis, etc.). Inflammatory changes in the pipes lead to a violation of their transport function, narrowing of the lumen, etc.
Use of intrauterine contraceptives (IUD, IUD, or "spiral")
By preventing the fixation of a fertilized egg in the uterus and, thus, preventing the further development of pregnancy, these contraceptives do not reduce, and some of their types even increase the risk of ectopic pregnancy.
Since abortions cause damage to the inner layer of the uterus, which is necessary for the normal attachment of a fertilized egg, damage to the muscular system of the cervix, which can manifest itself by "falling through" the ovum and then fixing it in the cervix. In addition, artificial termination of pregnancy is often complicated by inflammatory diseases of the genital organs.
Tumors and tumor formation of appendages
leading to compression of the lumen of the fallopian tube and / or disruption of the formation of sex hormones that affect the activity of the fallopian tubes.
By causing local inflammatory changes, disrupting the local balance of regulatory substances, endometriotic tissue prevents pregnancy from occurring at several levels at once, including at the stage of its normal attachment, which can also be reflected in its incorrect fixation.
Surgical intervention on the pelvic organs
Interventions leading to adhesions in the abdominal cavity (including appendectomy) and, as a result, impaired patency of the fallopian tubes.
Plastic surgery on fallopian tubes
Ectopic pregnancy occurs in 25% of cases after surgery on the fallopian tubes
Anomalies of the position of genital organs and sexual infantilism
Excessive crimpiness and length of the fallopian tubes, changes in their functional activity + impaired secretion of sex hormones.
In vitro fertilization with embryo transfer or zygote, artificial insemination is complicated by ectopic pregnancy in approximately 5% of cases.
shortly before or shortly after conception, it prevents implantation of the embryo into the uterus and can lead to the development of an ectopic pregnancy or miscarriage, warns the Journal of Clinical Investigation.
The mechanism of ectopic pregnancy
With a progressive (developing) ectopic pregnancy, most often tubal, the fertilized egg is embedded in the muscular wall of the uterine tube. The growing fetal egg stretches the thinned walls of the fallopian tube, which takes a spindle shape.
Ectopic pregnancy is manifested by delayed menstruation, positive pregnancy tests (!), Because The level of hCG (human chorionic gonadotropin) is increased by pain in the lower abdomen with irradiation to the rectum, bloody discharge from the genital tract.
In the fallopian tube there are not enough conditions for the normal development of pregnancy, and after a few weeks the fertilized egg partially exfoliates from the wall of the tube and its contractions begins to be expelled into the abdominal cavity, which is accompanied by intraperitoneal bleeding and manifestation of bouts of pain, dizziness.
If the supply of elasticity of the pipe wall is exhausted before detachment of the ovum occurs, then a very dangerous complication will develop - pipe rupture. This causes severe internal bleeding, acute anemia, and even shock. In every third patient, a violation of ectopic pregnancy proceeds according to the type of tube rupture, which is accompanied by abundant bleeding.
When to go to the doctor
The sooner you consult a doctor for female consultation about a probable pregnancy (delayed menstruation, change in appetite, nausea, engorgement of the mammary glands), the better.
If you carried out a pregnancy test at home, then take it with you to see a doctor. Indistinct staining of one of the strips may indirectly indicate a possible ectopic pregnancy (the level of hCG in ectopic pregnancy is somewhat lower than in uterine pregnancy).
The main symptoms of an aborted tubal pregnancy are:
- Abdominal pain occurs in 95% of cases of ectopic pregnancy. Initially, there is a slight passing pain in one of the iliac regions. As the duration of pregnancy increases, the pain increases, becomes continuous and spreads to the entire lower abdomen.
- The delay of menstruation from several days to several weeks is observed in 90% of cases.
- Bleeding from the genital tract occurs in 50-80% of cases. The bleeding caused by the rejection of the endometrium due to low levels of sex hormones. The severity of the discharge varies from scant to menstrual. Sometimes bleeding contain fragments of the discarded decidual membrane. This complicates the differential diagnosis of ectopic pregnancy with incomplete abortion.
- Abdominal tenderness to palpation is noted in 80-90% of cases and is expressed in varying degrees: from minor to very intense.
- Soreness of the uterus during a bimanual examination is a persistent symptom that is often combined with cervical soreness when it is displaced.
- In 50% of patients in the area of the uterus or in the rectovascular uterus, a mass is palpated. In about half of the cases, it is a cyst of the corpus luteum and is located on the opposite side of the ovum.
- An increase in the uterus is observed in 25% of cases of ectopic pregnancy. The size of the uterus is usually less than the estimated duration of pregnancy.
- Lowering blood pressure, dizziness, weakness, loss of consciousness. In this case, immediately call the ambulance.
Detection of an ectopic pregnancy. Diagnostics
The examination begins with an ultrasound and a blood test for CG (chorionic gonadotropin is a hormone that is formed by the membranes of the fetus from the very early stages of pregnancy). Diagnosis of ectopic pregnancy is based on an increase in chronic hepatitis, the absence, according to ultrasound, of the ovum in the uterus, and, especially, its detection in the expanded fallopian tube.
Since uterine pregnancy is very rarely combined with an ectopic (1 case per 10,000–30,000 pregnancies), the detection of the ovum in the uterus excludes an ectopic pregnancy. With abdominal ultrasound, the fertilized egg in the uterus can be detected at 6-7 weeks of gestation, and with vaginal ultrasound - at 4.5-5 weeks of gestation. In 10% of cases of ectopic pregnancy, erroneous results are related to the fact that a cumulative fluid or blood clots are considered to have an ovum in the uterus.
However, laparoscopy is the most reliable and reliable diagnostic method.
Laparoscopic examination allows you to visually assess the condition of the uterus, fallopian tubes, the presence and amount of blood in the abdominal cavity. In addition to a quick and accurate diagnosis, laparoscopy allows you to apply the optimal, most gentle health of a woman's surgical tactics. Before the start of laparoscopy, the only method for treating ectopic pregnancy was to remove a tube with a fetal egg. Removing the second fallopian tube forever prevented a woman from becoming pregnant by herself.
Treatment of ectopic pregnancy
The sequence of events is dictated by the features of localization of the ovum, the nature of the interruption of tubal pregnancy, the duration of the disease, the severity of the patient's condition, her age, the presence of her children, the desire to have children in the future, as well as concomitant somatic and gynecological diseases.
With a small blood loss, laparoscopic surgery is often performed. The surgeon inserts the instrument through a small incision in the skin, he sees the surgical field and manipulations on the monitor (the laparoscope is equipped with an optical system).
The possibilities of laparoscopy (optical zoom, the work of miniature instruments) allow in many cases to save the fallopian tube.
The operation consists in opening the fallopian tube, removing elements of the ovum from it and evacuating them from the abdominal cavity. Tubotomy allows you to save the pipe, as an organ capable of fully performing its function
With far-reaching development of tubal pregnancy, the fallopian tube may change irreversibly, leaving no hope of maintaining its “health” in the future. Theoretically, in this case it is possible to produce a tubotomy without removing the tube. Unfortunately, such a disfigured fallopian tube will not function normally and will most likely lead to a repetition of ectopic pregnancy. Laparoscopy allows you to reliably assess the condition of the "pregnant" tube and resort to tubectomy only in exceptional cases when it is much more dangerous to save the tube than to remove it.
For any laparoscopic intervention, the abdominal cavity is thoroughly washed from the blood that has entered it, which eliminates the formation of adhesions. In addition to the surgery for ectopic pregnancy during laparoscopy, it is possible to assess the state of the second appendages, and, if necessary, perform simultaneous reconstructive intervention (dissection of adhesions, restoration of the pipe patency)
With significant blood loss (which often occurs when the fallopian tube ruptures), immediate surgery is required, fighting blood loss and shock. Laparoscopic access in these conditions does not apply, because requires longer preparation.
A medical method for the treatment of tubal pregnancy is also described, when a drug that stops further cell division is administered to the fertilized egg under ultrasound control. However, he did not find widespread use due to the presence of complications.
Recovery after ectopic pregnancy, planning a new pregnancy
Rehabilitation after ectopic pregnancy should be aimed at restoring reproductive function after surgery. These include: prevention of adhesions, contraception, the normalization of hormonal changes in the body. Physiotherapy methods are widely used to prevent adhesions: a low-frequency alternating pulsed magnetic field, low-frequency ultrasound, overtonal frequency currents (ultrasound therapy), low-intensity laser therapy, tubal electrostimulation, UHF-therapy, zinc electrophoresis, lydase, and pulsed ultrasound. For 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 the characteristics of her reproductive function. Of course, you should take into account the desire of women to preserve reproductive function. The duration of hormonal contraception is also purely individual, but usually it should not be less than 6 months after surgery.
After the end of rehabilitation measures, before recommending to the patient to plan the next pregnancy, it is advisable to perform diagnostic laparoscopy, which allows to assess the condition of the fallopian tube and other pelvic organs. If the control laparoscopy revealed no pathological changes, the patient is allowed to plan the pregnancy in the next menstrual cycle.
Rare forms of ectopic pregnancy
Ovarian pregnancy develops during fertilization of the egg in the cavity of the follicle. Although it is known that an egg cell is ready for fertilization even before ovulation, many authors believe that during an ovarian pregnancy, an already fertilized egg is implanted into the ovary.
Cervical pregnancy develops upon implantation of a fertilized egg in the cervical canal. Fetal egg penetrates into the mucous membrane of the cervical canal, and sometimes - in the underlying connective tissue. The prevalence of cervical pregnancy is about 0.1%. The first manifestation of cervical pregnancy is often bleeding. It usually occurs before the 20th week of pregnancy, can be abundant and often requires termination of pregnancy.
Cervical pregnancy is usually diagnosed in the II trimester. Such a pregnancy rarely ends with the birth of a viable fetus. Previously, maternal mortality reached 45%, and the only treatment was extirpation of the uterus.
Abdominal pregnancy is 0.003% of all cases of ectopic pregnancy. There are primary and secondary abdominal pregnancy. Under primary understand the implantation of a fertilized egg in the abdominal cavity. A secondary abdominal pregnancy is formed when the fertilized egg is in the abdominal cavity after a tube abortion. Cases of secondary abdominal pregnancy are described in the outcome of uterine pregnancy, when, after a rupture of the uterus, the fertilized egg falls into the space between the leaves of the broad ligament of the uterus. Occasionally abdominal pregnancy develops to long terms. At the same time, severe complications are possible - massive bleeding due to placental abruption or damage to internal organs.
Rare forms include Ectopic pregnancy in the uterus horn, accounting for 0.2-0.9% of cases. Despite the fact that implantation of the ovum in the horn of the uterus, in terms of topographic anatomy, is characteristic of uterine pregnancy, but the clinical manifestations are identical to those of uterine rupture.
Very rare (0.1%) occurs Intraligamental ectopic pregnancywhen the gestational egg develops between the leaves of the wide ligament of the uterus, where it falls (again) after rupture of the tube wall in the direction of the mesentery of the fallopian tube.
There is a spontaneous recovery from ectopic pregnancy
Крайне редко внематочная беременность прекращает развиваться, а плодное яйцо постепенно рассасывается, или происходит трубный аборт - то есть плодное яйцо «выбрасывается» в полость матки. В таких случаях хирургическое лечение, как правило, не требуется. But sincein the case of an ectopic pregnancy, it is impossible to predict a variant of its course, due to the high risk of intra-abdominal bleeding, as well as a high threat to life, surgical treatment is always needed on an emergency basis.
Pregnancy test can help establish the diagnosis of ectopic pregnancy by the brightness of the color indicator
The fact is that a pregnancy test registers the presence of human chorionic gonadotropin in a woman’s body, that is, a hormone that is produced only during pregnancy.
It appears both in uterine and ectopic pregnancy, however, in ectopic pregnancy its concentration and increase are significantly lower.
A negative pregnancy test also does not exclude the presence of an ectopic pregnancy, since the content of human chorionic gonadotropin can be very low and not be recorded by primitive home tests !!
The presence of menstruation 100% indicates the absence of ectopic pregnancy
Quite often in patients with ectopic pregnancy in the days of menstruation bloody discharge from the genital tract. This is not menstruation, as such, but the reaction of the endometrium to the presence of pregnancy in the fallopian tube. This fact, as a rule, misinforms patients and leads to the fact that the visit to the gynecologist can be delayed.
As mentioned above, an ectopic pregnancy is a disease that can be triggered by many different factors. Based on the possible causes and mechanisms underlying their development, as well as on the basis of long-term clinical studies, a number of risk factors have been identified, that is, factors that significantly increase the likelihood of developing ectopic pregnancy.
Risk factors for developing an ectopic pregnancy are:
- postponed ectopic pregnancies,
- infertility and its treatment in the past
- in vitro fertilization
- stimulation of ovulation
- progestin contraceptives,
- maternal age over 35 years
- ineffective sterilization by tying or cauterization of the fallopian tubes,
- infections of the upper genital organs,
- congenital and acquired genital anomalies,
- abdominal surgery,
- infectious and inflammatory diseases of the abdominal cavity and small pelvis,
- neurological disorders
- passive lifestyle.
Symptoms of ectopic pregnancy
Symptoms of ectopic pregnancy depend on the phase of its development. During the period of progressive ectopic pregnancy, any specific symptoms are usually absent, and abortion, which can occur as a tube abortion or tube rupture, there is a vivid clinical picture of acute abdomen, requiring immediate hospitalization.
Signs of progressive ectopic pregnancy
Progressive ectopic pregnancy, in the vast majority of cases, is no different in clinical course from normal uterine pregnancy. During the entire period while the development of the fetus occurs, suspected (subjective feelings experienced by a pregnant) and probable (detected during a physical examination) signs of pregnancy.
Presumptive (doubtful) signs of pregnancy are:
- nausea, vomiting,
- change in appetite and taste preferences,
- frequent mood swings
- hypersensitivity to odors
- increase the sensitivity of the mammary glands.
The likely signs of pregnancy are:
- the cessation of menstruation in a woman who lives sexually and is of child-bearing age,
- bluish color (cyanosis) the mucous membrane of the genital organs - vagina and cervix,
- breast engorgement,
- excretion of colostrum from the mammary glands under pressure (matters only during the first pregnancy),
- softening of the uterus,
- contraction and hardening of the uterus during the examination with subsequent softening,
- asymmetry of the uterus in early pregnancy,
- cervical mobility.
The presence of these signs in many cases indicates developing pregnancy, and at the same time, these symptoms are the same for both physiological and ectopic pregnancies. It should be noted that doubtful and probable signs can be caused not only by the development of the fetus, but also by some pathologies (tumors, infections, stress, etc.).
Reliable signs of pregnancy (fetal heartbeat, fetal movement, palpation of large partswhen ectopic pregnancy occurs extremely rarely, since they are characteristic of the later stages of intrauterine development, before the onset of which various complications usually develop - tubal abortion or rupture of the tube.
In some cases, a progressive ectopic pregnancy can be accompanied by pain and bloody discharge from the genital tract. At the same time for this pathology of pregnancy is characterized by a small amount of discharge (in contrast to spontaneous abortion in uterine pregnancy, when the pain is mild and the discharge is abundant).
Signs of tubal abortion
Pipe abortion occurs most often at 2 - 3 weeks after the onset of menstruation as a result of rejection of the fetus and its membranes. This process is accompanied by a number of symptoms characteristic of spontaneous abortion in combination with doubtful and probable (nausea, vomiting, change in taste, delayed menstruation) signs of pregnancy.
Pipe abortion is accompanied by the following symptoms:
- Periodic pain. Periodic, cramping pain in the lower abdomen associated with the contraction of the fallopian tube, as well as its possible filling with blood. Pain while radiating (give away) in the region of the rectum, perineum. The appearance of persistent acute pain may indicate a hemorrhage into the abdominal cavity with peritoneal irritation.
- Spotting from the genital tract. The occurrence of bleeding is associated with rejection of decidually modified endometrium (part of the placental-uterine system, in which metabolic processes occur), as well as with partial or complete damage to the blood vessels. The amount of bleeding from the genital tract may not match the degree of blood loss, since most of the blood through the lumen of the fallopian tubes can enter the abdominal cavity.
- Signs of latent bleeding. Bleeding with tubal abortion may be insignificant, and then the general condition of the woman may not be disturbed. However, with a blood loss of more than 500 ml, severe abdominal pain appears with irradiation to the right hypochondrium, interscapular region, right collarbone (due to irritation of the peritoneum with blood flowed). There is a weakness, dizziness, fainting, nausea, vomiting. There is rapid heartbeat, lowering blood pressure. A significant amount of blood in the abdominal cavity can cause an increase or bloating of the abdomen.
Signs of rupture of the fallopian tube
The rupture of the fallopian tube, which occurs under the influence of a developing and growing embryo, is accompanied by a vivid clinical picture, which usually occurs suddenly against the background of a state of complete well-being. The main problem with this type of termination of ectopic pregnancy is profuse internal bleeding, which forms the symptoms of pathology.
Rupture of the fallopian tube may be accompanied by the following symptoms:
- Lower abdominal pain. Abdominal pain occurs due to rupture of the fallopian tube, as well as due to irritation of the peritoneum with the drained blood. The pain usually begins on the side of the "pregnant" tube with a further spread to the crotch region, anus, right hypochondrium, right clavicle. The pain is permanent, acute.
- Weakness, loss of consciousness. Weakness and loss of consciousness occur due to hypoxia (oxygen deficiencya) a brain that develops due to a decrease in blood pressure (against the background of a decrease in circulating blood volume), as well as due to a decrease in the number of red blood cells that carry oxygen.
- Urging to stool, loose stools. Irritation of the peritoneum in the rectum can cause frequent urge to defecate, as well as loose stools.
- Nausea and vomiting. Nausea and vomiting occur reflexively due to peritoneal irritation, and also due to the negative effects of hypoxia on the nervous system.
- Signs of hemorrhagic shock. Hemorrhagic shock occurs when a large amount of blood loss, which directly threatens the life of a woman. Signs of this condition are paleness of the skin, apathy, inhibition of nervous activity, cold sweat, shortness of breath. There is an increase in heartbeat, lower blood pressure (the degree of reduction which corresponds to the severity of blood loss).
Diagnosis of ectopic pregnancy
Diagnosis of ectopic pregnancy is based on clinical examination and a number of instrumental studies. The most difficult is the diagnosis of progressive ectopic pregnancy, since in most cases this pathology is not accompanied by any specific signs and in the early stages it is quite easy to lose sight of. Timely diagnosis of progressive ectopic pregnancy can prevent such terrible and dangerous complications as tubal abortion and uterine rupture.
Diagnosis of ectopic pregnancy begins with a clinical examination, during which the doctor identifies some specific signs indicating ectopic pregnancy.
During the clinical examination, the general condition of the woman is assessed, palpation, percussion (percussion) and auscultation, carried out gynecological examination. All this allows you to create a holistic picture of the pathology, which is necessary for the formation of a preliminary diagnosis.
The data collected during the clinical examination may vary at different stages of ectopic pregnancy. With progressive ectopic pregnancy, there is a certain lag in the uterus in size, a seal can be detected in the area of the appendages on the side corresponding to the "pregnant" tube (which is not always possible to identify, especially in the early stages). A gynecological examination reveals cyanosis of the vagina and cervix. Symptoms of uterine pregnancy - softening of the uterus and isthmus, asymmetry of the uterus, bend of the uterus may be absent.
At rupture of the uterine tube, as well as with tubal abortion, pallor of the skin, rapid heartbeat, decrease in blood pressure are noted. When tapping (percussion) there is a blunting in the lower abdomen, which indicates the accumulation of fluid (of blood). Palpation of the abdomen is often difficult, since irritation of the peritoneum causes contraction of the muscles of the anterior abdominal wall. Gynecological examination reveals excessive mobility and softening of the uterus, severe pain in the study of the cervix. Pressing on the posterior vaginal fornix, which can be smoothed, causes sharp pains ("Douglas scream").
Ultrasound procedure (Ultrasound) is one of the most important methods of examination, which allows to diagnose ectopic pregnancy at a fairly early stage, and which is used to confirm this diagnosis.
The following symptoms allow you to diagnose ectopic pregnancy:
- enlarged uterus,
- thickening of the uterine mucosa without the detection of the ovum,
- detection of a heterogeneous formation in the uterine appendages,
- gestational egg with an embryo outside the uterus.
Ultrasound diagnosis allows to detect uterine pregnancy, the presence of which, in the overwhelming majority of cases, makes it possible to exclude an ectopic pregnancy (cases of simultaneous development of normal uterine and ectopic pregnancy are extremely rare). The absolute sign of uterine pregnancy is the detection of a gestational sac (term used exclusively in ultrasound diagnosis), the yolk sac and embryo in the uterus.
In addition to the diagnosis of ectopic pregnancy, ultrasound can detect rupture of the fallopian tube, the accumulation of free fluid in the abdominal cavity (of blood), accumulation of blood in the lumen of the fallopian tube. Also, this method allows differential diagnosis with other conditions that can cause the clinic of acute abdomen.
Periodic ultrasound scans include women at risk, as well as women with in vitro fertilization, since they have a ten times higher chance of developing an ectopic pregnancy.
Chorionic gonadotropin level
Chorionic gonadotropin is a hormone that is synthesized by placental tissues, and the level of which gradually increases during pregnancy. Normally, its concentration is doubled every 48 - 72 hours. With ectopic pregnancy, the level of chorionic gonadotropin will increase much more slowly than during normal pregnancy.
The determination of the level of human chorionic gonadotropin is possible with the help of rapid pregnancy tests (which are characterized by a fairly high percentage of false-negative results), as well as by more detailed laboratory analysis, allowing to evaluate its concentration over time. Pregnancy tests allow for a short period of time to confirm the presence of pregnancy and build a diagnostic strategy for suspected ectopic pregnancy. However, in some cases, chorionic gonadotropin may not be detected by these tests. The termination of pregnancy, which occurs during tubal abortion and rupture of the tube, violates the production of this hormone, and therefore in the period of complications a pregnancy test may be false-negative.
Determining the concentration of human chorionic gonadotropin is particularly valuable in conjunction with ultrasound, as it allows to correctly assess the signs detected by ultrasound. This is due to the fact that the level of this hormone directly depends on the period of gestational development. Comparison of data obtained by ultrasound and after analysis of chorionic gonadotropin, allows to judge the course of pregnancy.
Diagnostic curettage of the uterus
Diagnostic curettage of the uterus and subsequent histological examination of the material obtained is used only in the case of a proven pregnancy anomaly (low levels of progesterone or chorionic gonadotropin), for differential diagnosis with incomplete spontaneous abortion, as well as the unwillingness or impossibility of continuing pregnancy.
When ectopic pregnancy in the resulting material revealed the following histological changes:
- decidual transformation of the endometrium,
- lack of chorionic villi,
- atypical endometrial cell nuclei (Arias-Stella phenomenon).
Despite the fact that diagnostic curettage of the uterus is quite an effective and simple method of diagnosis, it can be misleading in the case of simultaneous development of uterine and ectopic pregnancy.
Laparoscopy is a modern surgical method that allows for minimally invasive interventions on the abdominal organs and small pelvis, as well as diagnostic operations. The essence of this method is the introduction through a small incision into the abdominal cavity of a special instrument of the laparoscope, equipped with a system of lenses and illumination, which allows you to visually assess the state of the studied organs. In ectopic pregnancy, laparoscopy makes it possible to examine the fallopian tubes, uterus, and pelvic cavity.
When ectopic pregnancy revealed the following changes in the internal genital organs:
- thickening of the fallopian tubes,
- purple-cyanotic color of the fallopian tubes,
- rupture of the fallopian tube,
- gestational egg on the ovaries, gland or other organ,
- bleeding from the lumen of the fallopian tube,
- accumulation of blood in the abdominal cavity.
Shown laparoscopy in all cases of ectopic pregnancy, as well as the inability to make an accurate diagnosis (as the most informative diagnostic method).
Is it possible to have a baby in an ectopic pregnancy?
The only organ in a woman’s body that can ensure adequate development of the fetus is the uterus.Attaching a gestational sac to any other organ is fraught with eating disorders, changes in structure, and also rupture or damage to this organ. It is for this reason, ectopic pregnancy is a pathology in which the bearing and birth of a child is impossible.
Today in medicine there are no ways that would allow to carry ectopic pregnancy. The literature describes several cases where, with this pathology, it was possible to bring children to a time that is compatible with life in the external environment. However, firstly, such cases are possible only under extremely rare circumstances (one case per several hundred thousand ectopic pregnancies), secondly, they are associated with an extremely high risk for the mother, and thirdly, there is the likelihood of fetal developmental pathologies.
Thus, the carrying and birth of a child during ectopic pregnancy is impossible. Since this pathology threatens the life of the mother and is incompatible with the life of the fetus, the most rational solution is to terminate the pregnancy immediately after diagnosis.
Is it possible to treat an ectopic pregnancy without surgery?
Historically, the treatment of ectopic pregnancy has been limited only to surgery with fetal extraction. However, with the development of medicine, some methods of non-surgical treatment of this pathology have been proposed. The basis of such therapy is the appointment of methotrexate - a drug that is an antimetabolite that can change the synthetic processes in the cell and cause a delay in cell division. This drug is widely used in oncology for the treatment of various tumors, as well as to suppress immunity during organ transplants.
The use of methotrexate for the treatment of ectopic pregnancy is based on its effect on the tissues of the fetus and its embryonic organs with arrest of their development and subsequent spontaneous rejection.
Drug treatment using methotrexate has several advantages over surgical treatment, as it reduces the risk of bleeding, nullifies the injuries of tissues and organs, reduces the rehabilitation period. However, this method is not without flaws.
When using methotrexate, the following side effects are possible:
- stomach pathology,
- liver damage,
- bone marrow suppression (fraught with anemia, decreased immunity, bleeding),
- rupture of uterine tube progressive pregnancy.
- confirmed ectopic pregnancy
- hemodynamically stable patient (no bleeding),
- the size of the gestational egg does not exceed 4 cm
- lack of cardiac activity of the fetus by ultrasound,
- no signs of rupture of the fallopian tube,
- human chorionic gonadotropin levels below 5000 IU / ml.
- level of human chorionic gonadotropin above 5000 IU / ml,
- the presence of cardiac activity of the fetus by ultrasound,
- hypersensitivity to methotrexate,
- immunodeficiency state
- liver damage,
- leukopenia (few white blood cells),
- thrombocytopenia (low platelet count),
- anemia (low red blood cell count),
- active infection of the lungs
- stomach ulcer,
- kidney pathology.
The effectiveness of treatment is assessed by measuring the level of human chorionic gonadotropin over time. Reducing it by more than 15% of the initial value on the 4th-5th day after the injection indicates the success of the treatment (hormone levels may be elevated during the first 3 days). In parallel with the measurement of this indicator, the function of the kidneys, liver, bone marrow is monitored.
In the absence of the effect of drug therapy with the help of methotrexate, surgical intervention is prescribed.
Treatment with methotrexate is fraught with many risks, since the drug can adversely affect some of the vital organs of a woman, does not reduce the risk of rupture of the fallopian tube until complete termination of pregnancy, and, moreover, is not always sufficiently effective. Therefore, surgery is still the main treatment for ectopic pregnancy.
It is necessary to understand that conservative treatment does not always produce the expected therapeutic effect, and besides, due to the delay of the surgical intervention, some complications can occur, such as rupture of the pipe, tubal abortion and massive bleeding (not to mention the side effects of methotrexate itself).
Despite the possibility of non-surgical treatment, surgical treatment is still the main method of management for women with ectopic pregnancy. Surgical intervention is indicated for all women who have an ectopic pregnancy (both developing and interrupted).
Surgical treatment is indicated in the following situations:
- developing ectopic pregnancy
- interrupted ectopic pregnancy
- tubal abortion
- rupture of the fallopian tube,
- internal bleeding.
- the age of the patient
- desire to have a future pregnancy
- condition of the fallopian tube from the side of pregnancy,
- the condition of the fallopian tube on the opposite side,
- localization of pregnancy
- the size of the ovum,
- general condition of the patient,
- blood loss
- condition of the pelvic organs (adhesion process).
Laparoscopic access allows the following types of operations:
- Salpingotomy (incision of the fallopian tube with fetal extraction, without removing the tube itself). Salpingotomy allows you to save the fallopian tube and its reproductive function, which is especially important in the absence of children or in case of damage to the pipe from the other side. However, this operation is possible only with small sizes of the ovum, as well as with the integrity of the pipe itself at the time of the operation. In addition, salpingotomy is associated with an increased risk of recurrent ectopic pregnancy.
- Salpingectomy (removal of the fallopian tube together with the implanted fetus). Salpingectomy is a radical method in which the removal of the "pregnant" fallopian tube. This type of intervention is indicated in the presence of an ectopic pregnancy in a woman’s medical history, as well as when the size of the ovum is more than 5 cm. In some cases, it is not possible to completely remove the tube, but only to exclude the damaged part of it, which makes it possible to preserve its function.
Preparation for surgery consists in the following procedures:
- blood donation for general and biochemical analysis,
- determination of blood group and Rh factor
- consultation of the therapist.
The postoperative period is extremely important for the normalization of the woman’s condition, for the elimination of certain risk factors, and also for the rehabilitation of the reproductive function.
During the postoperative period, hemodynamic parameters are continuously monitored, and the introduction of painkillers, antibiotics, and anti-inflammatory drugs is carried out. After laparoscopic (minimally invasivea) a woman’s surgery can be discharged within one to two days, but after a laparotomy, hospitalization is required for a much longer period of time.
After surgery and removal of the ovum, it is necessary to monitor chorionic gonadotropin on a weekly basis. This is due to the fact that in some cases fragments of the ovum (chorion fragments) may not be completely removed (after operations preserving the fallopian tube), or may be listed on other bodies. This condition is potentially dangerous, since a tumor, the chorionepithelioma, may begin to develop from the cells of the chorion. To prevent this, the level of human chorionic gonadotropin is measured, which normally should decrease by 50% during the first few days after surgery. If this does not happen, methotrexate is administered, which is able to suppress the growth and development of the embryonic organ. If the level of the hormone does not decrease after that, there is a need for a radical operation with removal of the fallopian tube.
In the postoperative period, physiotherapy is prescribed (electrophoresis, magnetic therapy), which contribute to a more rapid restoration of reproductive function, as well as reduce the likelihood of adhesions.
The purpose of combined oral contraceptives in the postoperative period has two goals - stabilization of the menstrual function and prevention of pregnancy in the first 6 months after the operation, when the risk of developing various pathologies of pregnancy is extremely high.
Physical changes in the mother's body
They can be detected both in the tubes and directly in the uterus. In the first case, adhesions can be observed, scar formation, which makes it difficult for the fertilized egg to pass to the normal place for development. The mucous membrane of the tubes loses its elasticity and, as a result, is not capable of a qualitative reduction. In addition, the lumen is significantly narrowed. In total, these factors and cause ectopic pregnancy.
The following causes can lead to changes, twisting or the formation of adhesions and scars in the tubes and cavity of the uterus:
- operations (laparoscopy is not an exception),
- cancer process in the female genital organs,
- genital infections
- inflammatory process,
- history of abortion
- genital infections.
It is worth noting that both scars and adhesions are successfully treated or removed by doctors without significant cost to women.
We recommend to read an article on curettage and surgical interventions. From it you will learn about the causes of surgical interventions, possible consequences and treatment, frozen fetus, as well as what may be after medical abortion.
It also happens that before planning a pregnancy, a woman does not even know about the features of the internal organs. And after the terrible diagnosis “ectopic pregnancy”, trying to understand the causes of pathology, she finds out that her tubes are either too short, or, conversely, too long, tortuous. Often this is a congenital anomaly, embedded in the intrauterine development. The reasons here may be hiding in the wrong lifestyle of a mother of a woman: drinking alcohol after conception, working in hazardous production, as well as being exposed to radiation.
Paradoxically, even the use of contraceptives can trigger an ectopic pregnancy. Often at risk are women who prefer intrauterine devices and mini-pill tablets. The former are quite a strong method of contraception, but one should not forget that they protect the uterus from the attachment of the ovum, but do not protect the fallopian tubes or other organs. However, pregnancy is the result, rather, of the negligence of a woman. After all, it can develop for those who do not follow the advice of doctors and use the spiral for more than 5 years. It is worth remembering that in any method of contraception has its own side effects, and the spiral - is no exception.
The mini-pill tablets (as well as medroxyprogesterone injections) do not contain the hormone estrogen, which leads to an incomplete suppression of ovulation. That is, with their admission is possible both natural and ectopic pregnancy. Women can conceive with them, neglecting doctors' advice on the rules of admission. This type of contraception is recommended only:
- women over 35,
- smoking more than half a pack of cigarettes a day,
- when breastfeeding up to six months baby
- by the way.
Doctors still strongly recommend young girls to use combination contraceptives.
Artificial insemination (IVF, ICSI)
It would seem that when conceiving in this way, all risks should be minimized. However, as the practice of obstetrics and gynecology proves, every 20th couple who have undergone the procedure receive an ectopic pregnancy as a result. Of course, the embryo itself sits down directly in the uterus, but by chance it can start moving further.
The IVF procedure becomes for many couples the only chance to become parents. But even despite all the high prices, the experience of doctors and other factors, no one is insured against the improper development of pregnancy. That is why doctors advise getting a child out of the tube only in severe cases. All the rest should initially try to conceive on their own, having undergone a preliminary comprehensive examination and having treated all existing diseases.
In vitro fertilization
The hormonal background of a woman plays a huge role in matters of her health, monthly cycle, the ability to conceive and the course of pregnancy. If one of the hormones, progesterone, is in the body in insufficient quantities, it reduces the probability of conception, and if successful, seriously complicates the development of the fetus. He also provokes an ectopic pregnancy, because due to low rates the fallopian tubes are poorly reduced, delaying the fertilized egg.
Smoking can also be the cause of abnormal attachment, since nicotine works in a woman’s body on the same principle as progesterone deficiency.
Paradoxically, even douching performed at the wrong time can disrupt plans for a happy pregnancy.
Age is another adverse factor. The American lifestyle, actively imposed on us from TV screens, stimulates women to initially build a career, build a family nest, and only after giving birth. As a result, conception occurs already after 30 years, which automatically puts the future mother by our doctors in the category of "old-aged" and forces to keep careful control over the development of pregnancy and the state of the woman's body. From the same age, the risk of improper attachment of a fertilized egg in the body increases significantly.
How to avoid ectopic pregnancy
Prevention of ectopic pregnancy is the only real chance not to experience frustration and not to undergo the procedure of cleaning. For this woman needs:
- Try to lead a correct lifestyle, having sex with a regular partner. Ideally, in advance, before conception, to be tested together for the presence of various sexually transmitted infections. If there is no trust in the person yet, then use a condom. It only protects 100% of the infection and unwanted at the moment of pregnancy.
- Even if there is no infection or the condom is not at hand, a woman should still take care of herself and her health. There are many methods of contraception to avoid unwanted conception and, as a result, abortion. After all, each intervention can lead to inflammation of the pelvic organs, the formation of adhesions, scarring, and in general can become a “final point” on the path to infertility.
- Approach the process of conception wisely. It is now quite simple in any city to undergo a full examination before conception, in order to eliminate the risk of infectious diseases, deviations and other troubles on the way to a healthy pregnancy. Even if the pipes already have adhesions, doctors will help solve this problem in a very short time. Planning for pregnancy, especially for expectant mothers from the age group of 30+, is a reasonable approach to minimize the risks in the matter of carrying a child and his development.
- Try to avoid hypothermia, abandon synthetic underwear. The fact is that these causes provoke inflammation, which naturally leads to further problems. In addition, the process may turn into chronic and, as a result, the girl will face the verdict of "infertility."
Ectopic pregnancy is a phenomenon that has been studied in detail. However, no doctor will decide the 100% reason for her appearance. In any case, only proper planning of pregnancy, regular visits to the gynecologist, timely decision on conception and careful attention to your body reduce the chances of anomalous attachment of a fertilized egg to a minimum.