Ectopic pregnancy – implantation and development of a fetal egg outside the uterus (in the abdominal cavity, ovary, fallopian tube). Ectopic pregnancy is a serious and dangerous pathology, fraught with complications and relapses (re–occurrence), entailing loss of childbearing function and even a threat to a woman’s life. Being localized in addition to the uterine cavity, which is the only physiologically adapted for the full development of the fetus, a fertilized egg can lead to rupture of the organ in which it develops.
The development of a normal pregnancy occurs in the uterine cavity. After the fusion of an egg with a sperm in the fallopian tube, the fertilized egg that has begun division moves into the uterus, where the necessary conditions for further development of the fetus are physiologically provided. The gestation period is determined by the location and size of the uterus. Normally, in the absence of pregnancy, the uterus is fixed in the pelvis, between the bladder and rectum, and is about 5 cm wide and 8 cm long. Pregnancy for a period of 6 weeks can already be determined by some enlargement of the uterus. At the 8th week of pregnancy, the uterus increases to the size of a female fist. By the 16th week of pregnancy, the uterus is determined between the womb and the navel. During pregnancy for a period of 24 weeks, the uterus is determined at the navel level, and by week 28, the bottom of the uterus is already above the navel.
At the 36th week of pregnancy, the uterine floor reaches the costal arches and the xiphoid process. By the 40th week of pregnancy, the uterus is fixed between the xiphoid process and the navel. Pregnancy for a period of 32 weeks of gestation is established both by the date of the last monthly and the date of the first movement of the fetus, and by the size of the uterus and the height of its standing. If a fertilized egg for some reason does not get from the fallopian tube into the uterine cavity, tubal ectopic pregnancy develops (in 95% of cases). In rare cases, the development of ectopic pregnancy in the ovary or in the abdominal cavity has been noted.
In recent years, there has been a 5-fold increase in the number of cases of ectopic pregnancy (data from the US Centers for Disease Control). In 7-22% of women, repeated occurrence of ectopic pregnancy was noted, which in more than half of cases leads to secondary infertility. Compared with healthy women, patients who have had an ectopic pregnancy have a greater (7-13 times) risk of its recurrence. Most often, women from 23 to 40 years of age have a right-sided ectopic pregnancy. In 99% of cases, the development of ectopic pregnancy is noted in certain parts of the fallopian tube.
Ectopic pregnancy is a serious and dangerous pathology, fraught with complications and relapses (re–occurrence), entailing loss of childbearing function and even a threat to a woman’s life. Being localized in addition to the uterine cavity, which is the only physiologically adapted for the full development of the fetus, a fertilized egg can lead to rupture of the organ in which it develops. In practice, ectopic pregnancy of various localizations occurs.
Tubal pregnancy is characterized by the location of the fetal egg in the fallopian tube. It is noted in 97.7% of cases of ectopic pregnancy. In 50% of cases, the fetal egg is located in the ampullary section, in 40% – in the middle part of the tube, in 2-3% of cases – in the uterine part and in 5-10% of cases – in the fimbria of the tube. The rarely observed forms of ectopic pregnancy development include ovarian, cervical, abdominal, intraligmental forms, as well as ectopic pregnancy localized in the rudimentary horn of the uterus.
Ovarian pregnancy (observed in 0.2-1.3% of cases) is divided into intrafollicular (the egg is fertilized inside the ovulated follicle) and ovarian (the fetal egg is fixed on the surface of the ovary). Abdominal pregnancy (occurs in 0.1 – 1.4% of cases) develops when the fetal egg exits into the abdominal cavity, where it attaches to the peritoneum, omentum, intestines, and other organs. The development of abdominal pregnancy is possible as a result of IVF with infertility of the patient. Cervical pregnancy (0.1-0.4% of cases) occurs when the fetal egg is implanted in the area of the cylindrical epithelium of the cervical canal. It ends with profuse bleeding as a result of the destruction of tissues and blood vessels caused by deep penetration of the fetal egg villi into the muscular membrane of the cervix.
Ectopic pregnancy in the accessory horn of the uterus (0.2-0.9% of cases) develops with abnormalities of the structure of the uterus. Despite the attachment of the fetal egg intrauterine, the symptoms of pregnancy are similar to the clinical manifestations of uterine rupture. Intraligmental ectopic pregnancy (0.1% of cases) is characterized by the development of a fetal egg between the leaves of the broad ligaments of the uterus, where it is implanted when the fallopian tube ruptures. Heterotopic (multiple) pregnancy is extremely rare (1 case per 100-620 pregnancies) and is possible as a result of using IVF (assisted reproduction method). It is characterized by the presence of one fetal egg in the uterus, and another outside it.
The causes of ectopic pregnancy are factors that cause a violation of the natural process of the fertilized egg moving into the uterine cavity:
- previously postponed abortions
- hormonal types of contraception
- the presence of an intrauterine device
- ovulation stimulation
- assisted reproduction methods
- previously undergone surgery on appendages
- ectopic pregnancy in the past
- tumor processes in the uterus and appendages
- transferred inflammation of the appendages (chlamydia infection is especially dangerous)
- malformations of the genitals
- delayed sexual development
The following manifestations can serve as signs of the occurrence and development of ectopic pregnancy:
- Menstrual cycle disorder (menstrual delay);
- Bloody, “smearing” discharge from the genitals;
- Pain in the lower abdomen (pulling pains in the area of attachment of the fetal egg);
- Breast swelling, nausea, vomiting, lack of appetite.
An interrupted tubal pregnancy is accompanied by symptoms of intra-abdominal bleeding caused by the outpouring of blood into the abdominal cavity. There is a sharp pain in the lower abdomen, giving into the anus, legs and lower back; after the pain occurs, bleeding or brown spotting from the genitals is noted. There is a decrease in blood pressure, weakness, a frequent pulse of weak filling, loss of consciousness. In the early stages, it is extremely difficult to diagnose ectopic pregnancy; because the clinical picture is not typical, seeking medical help follows only with the development of certain complications.
The clinical picture of an interrupted tubal pregnancy coincides with the symptoms of ovarian apoplexy. Patients with symptoms of “acute abdomen” are urgently taken to a medical institution. It is necessary to immediately determine the presence of an ectopic pregnancy, perform surgery and eliminate bleeding. Modern diagnostic methods allow using ultrasound equipment and tests to determine the level of progesterone (“pregnancy hormone”) to establish the presence of ectopic pregnancy. All medical efforts are directed to the preservation of the fallopian tube. In order to avoid serious consequences of ectopic pregnancy, it is necessary to be monitored by a doctor at the first suspicion of pregnancy.
In the early stages, ectopic pregnancy is difficult to diagnose, since the clinical manifestations of pathology are atypical. As well as in uterine pregnancy, there is a delay in menstruation, changes in the digestive system (taste perversion, nausea, vomiting, etc.), softening of the uterus and the formation of the corpus luteum in the ovary of pregnancy. Interrupted tubal pregnancy is difficult to distinguish from appendicitis, ovarian apoplexy or other acute surgical pathology of the abdominal cavity and pelvis.
In the event of an interrupted tubal pregnancy, which is a threat to life, a quick diagnosis and immediate surgical intervention are required. It is possible to completely exclude or confirm the diagnosis of “ectopic pregnancy” with the help of ultrasound (the presence of a fetal egg in the uterus, the presence of fluid in the abdominal cavity and formations in the appendages are determined).
An informative way to determine ectopic pregnancy is the beta-HCG test. The test determines the level of chorionic gonadotropin (β-HCG) produced by the body during pregnancy. The norms of its content in uterine and ectopic pregnancy differ significantly, which makes this method of diagnosis highly reliable. Due to the fact that today surgical gynecology widely uses laparoscopy as a method of diagnosis and treatment, it has become possible to diagnose ectopic pregnancy with 100% accuracy and eliminate pathology.
Treatment of ectopic pregnancy
To treat the tubal form of ectopic pregnancy, the following types of laparoscopic operations are used: tubectomy (removal of the fallopian tube) and tubotomy (preservation of the fallopian tube when removing the fetal egg). The choice of method depends on the situation and the degree of complication of ectopic pregnancy. When preserving the fallopian tube, the risk of recurrent ectopic pregnancy in the same tube is taken into account.
When choosing a method of treatment for ectopic pregnancy, the following factors are taken into account:
- The patient’s intention to plan pregnancy in the future.
- The expediency of preserving the fallopian tube (depending on how pronounced the structural changes in the tube wall are).
- Repeated ectopic pregnancy in a preserved tube dictates the need for its removal.
- The development of ectopic pregnancy in the interstitial part of the tube.
- The development of the adhesive process in the pelvic region and, in this regard, the increasing risk of repeated ectopic pregnancy.
With a large blood loss, the only option to save the patient’s life is a cavity operation (laparotomy) and removal of the fallopian tube. With the unchanged state of the remaining fallopian tube, the reproductive function is not impaired, and a woman may have a pregnancy in the future. To establish an objective picture of the condition of the remaining fallopian tube after laparotomy, laparoscopy is recommended. This method also allows you to separate the adhesions in the pelvis, which serves to reduce the risk of repeated ectopic pregnancy in the remaining fallopian tube.
To prevent the occurrence of ectopic pregnancy, it is necessary:
- to prevent the development of inflammation of the genitourinary system, and if inflammation occurs – treat it in time
- before the planned pregnancy, be examined for the presence of pathogenic microbes (chlamydia, ureaplasma, mycoplasma, etc.). In case of their detection, it is necessary to undergo appropriate treatment together with her husband (permanent sexual partner)
- protect yourself during sexual life from unwanted pregnancy by using reliable contraceptives, avoid abortions (the main factor provoking ectopic pregnancy)
- if it is necessary to terminate an unwanted pregnancy, choose low-traumatic methods (mini-abortion) at the optimal time (the first 8 weeks of pregnancy), carry out the termination without fail in a medical institution by a qualified specialist, with anesthesia and further medical supervision. Vacuum abortion (mini-abortion) reduces the time of the operation, has few contraindications and significantly fewer undesirable consequences
- as an alternative to the surgical method of termination of pregnancy, you can choose a medical termination of pregnancy (taking the drug Mifegin or Mifepristone)
- after an ectopic pregnancy, undergo a rehabilitation course to preserve the possibility of having another pregnancy. To preserve childbearing function, it is important to be observed by a gynecologist and gynecologist-endocrinologist and follow their recommendations. A year after the operation, you can plan a new pregnancy, in the event of which it is necessary to register for pregnancy management at an early date. The prognosis is favorable.