Tubal pregnancy is a pathology of gestation characterized by implantation of the fetal egg in the fallopian tube. Manifestations depend on the term and option of termination of pregnancy. The disease may be asymptomatic or accompanied by pain syndrome, bloody discharge from the vagina, internal bleeding of varying severity. The diagnosis is established on the basis of anamnestic data, the results of gynecological examination, ultrasound examination, assessment of the level of chorionic gonadotropin in the blood. Treatment is more often surgical, with rupture of the fallopian tube, intensive therapy is carried out at the same time.
ICD 10
O00.1 Tubal pregnancy
General information
Tubal pregnancy is the most common form of ectopic pregnancy. The ectopic location of the fetal egg is one of the main problems of practical gynecology, the incidence of pathology is 1.5-6 cases per 100 gestations, the share of tubal nidation accounts for 95-98.5%. The peak incidence is registered in women aged 28-30 years. The progression of pregnancy continues until the fourth-twelfth (less often – twentieth) week, the outcome in two-thirds of patients is a tubal abortion, in the rest there is a rupture of the fallopian tube. Tubal implantation of the embryo is a life-threatening condition, its share in the structure of maternal mortality is about 7-8%.
Causes
Tubal pregnancy has a multifactorial nature. The main causes of its occurrence include violations of the transport of a fertilized egg and embryo implantation caused by anatomical or functional pathologies of the female reproductive system, changes in the enzyme activity of the trophoblast. Among the most significant risk factors are:
- Pathology of the genitals. 40-80% of cases of ectopic pregnancy are the result of acute or chronic salpingitis, entailing a violation of the patency of the fallopian tubes. Embryo implantation to the tube wall is often caused by myomatous lesions of the uterus, tubal endometriosis, ovarian formations, infantilism of the reproductive apparatus, congenital malformations of the uterus.
- Surgical operations. An important reason for the violation of egg transit is operations directly on the tubes (their ligation, fimbrioplasty). After surgical interventions on the pelvic organs, abdominal cavity (for example, appendectomy), the adhesive process may develop and, as a result, compression of the tubes, weakening of their peristalsis.
- Neuroendocrine disorders. The result of hormonal status disorders is a change in the functional activity of the fallopian tubes, the quality and quantity of enzymes synthesized by the trophoblast. Tubal ectopia of the blastocyst is often observed against the background of an imbalance of female sex hormones and hyperandrogenism caused by diseases of the ovaries, adrenal glands and hypothalamic-pituitary system.
- Features of contraception. Gestagenic oral contraceptives contribute to the violation of the gravidar transformation of the endometrium, weaken the contractile activity of the fallopian tubes. Prolonged use of an intrauterine contraceptive leads to changes in the mucous lining of the tubes, which also increases the risk of ectopic pregnancy.
Other causes of tubar pregnancy include age-related involution of the fallopian tubes (in women over 40 years old), artificial abortions, psychoemotional stress, sometimes provoking violations of tubal peristalsis. In addition, tubal nidationis one of the main complications of IVF and other infertility treatments involving the use of hormonal ovulation inducers.
Pathogenesis
Normally, a mature egg after leaving the ovarian follicle is captured by fimbrial villi located in the distal part of the fallopian tube, where fertilization occurs. Then, under the influence of peristalsis of the walls and flickering of the cilia of the epithelium of the tube, after three or four days, the blastocyst moves to the uterine cavity, after which the egg is attached to the endometrium ready to receive it. Under the influence of unfavorable factors, the movement of the zygote can stop at any stage, and implantation occurs on the appropriate segment of the tube.
With tubal nidation, the fecundum is formed from the inside by the endosalpinx, from the outside by the muscular and serous membranes of the tube. Unlike the uterus, this organ is not adapted to bearing a fetus due to weak extensibility, small thickness of muscle tissue, lack of adequate differentiation of the epithelium, sufficient blood supply. Thus, due to the increased pressure caused by the growth of the embryo and the destructive effects of the trophoblast, the gestational process inevitably ends with miscarriage.
The timing of the interruption depends on the size of the lumen of the tube, the thickness of the muscle layer of the attachment area of the fertilized egg. So, pregnancy in the fallopian tubes progresses longer due to the presence of a sufficiently thick muscular membrane, a good vascular supply of connective tissue. There is a description of isolated cases of full-term pregnancy that developed in this department.
The interruption may occur with a violation of the inner or outer capsule. If the internal capsule is damaged (such an outcome is characteristic of the attachment of the blastocyst in the parts remote from the uterus), the fetal egg is expelled into the abdominal cavity with the outpouring of a small amount of blood under the influence of contractions of the myosalpinx. If the embryo remains viable, a secondary abdominal pregnancy may develop. Damage to the external capsule of the fetus (usually during pregnancy in the proximal parts) is accompanied by perforation of the tube with massive bleeding.
Classification
According to the clinical course, a progressive, undeveloped and interrupted variant of tubal pregnancy is distinguished. Interruption of the gestation process can occur by the type of rupture of the tube (with violation of the integrity of all its layers) and tubal abortion (with destruction of the internal capsule of the fetus) with the expulsion of the rejected fetal egg, its movement into the abdominal cavity, rarely into the uterus. According to the place of implantation of the embryo in the tube , the following forms are distinguished:
- Ampoule. The fetus is located in the ampullary part of the fallopian tube, such localization accounts for up to 80% of cases of tubal pregnancy. Violation of this form most often occurs by the type of tubal abortion at the sixth to twelfth week with the expulsion of the embryo into the abdominal space.
- Isthmic. The second most common (up to 15-25%) form, characterized by nidation in the isthmus of the tube connecting the ampullary and uterine parts of the organ. The outcome is usually a rupture of the fallopian tube four to six weeks after fertilization.
- Fimbrialnaya. This type of localization accounts for 5% of cases of tubal implantation of a blastocyst. The embryo attaches to the fimbrial villi of its distal part (funnel). The expulsion of the egg at 6-12 weeks into the abdominal cavity occurs without rupture of the outer shell of the fecundum.
- Interstitial (intramural). The most rare (1-2%) and dangerous form. Lasts up to 10-16 weeks (sometimes up to five months or more), ends with a rupture of the tube or, much less often, the expulsion of the embryo (fetus) into the uterine cavity. Violation of the inter-day pregnancy is accompanied by the most pronounced bleeding.
There are also transitional forms of pathology – tubal-ovarian, tubal-abdominal, utero-tubal pregnancy. The casuistic cases include bilateral tubal, as well as heterotopic pregnancy with multiple pregnancies, when one embryonic chamber is attached inside the fallopian tube, and the other has a typical uterine localization. This complication is more often a consequence of the use of assisted reproductive technologies.
Tubal pregnancy symptoms
The subjective signs of the progression of ectopic pregnancy include symptoms of normal gestation (menstruation delay, breast enlargement, changes in appetite). An alarming manifestation is bleeding after a delay in menstruation, which is registered in 75-80% of patients with an abnormal embryo location. With the onset of tubal abortion, cramping pains may be observed, lasting several days or weeks, but in most patients this pathological condition is asymptomatic.
The bright symptoms inherent in the picture of an acute abdomen and internal hemorrhage are accompanied by a rupture of the tube. There is a sharp, sometimes unbearable abdominal pain, bloating, loss of loose stools, cold sweat, general weakness, fainting and anxiety, followed by drowsiness and confusion. A pronounced pain attack may be preceded by cramping pains with increasing intensity in the lower abdomen.
Complications
The most dangerous complication of tubal pregnancy is massive blood loss, entailing hemorrhagic shock, multiple organ failure. A more common (in 90% of patients) negative consequence is the adhesive process in the pelvis caused by traumatic injury and intra–abdominal bleeding, which often leads to infertility. Another result of the loss of large volumes of blood is the development of pituitary necrosis and associated pituitary-hypothalamic insufficiency (Sheehan syndrome).
Diagnostics
Diagnosis of tubal pregnancy is carried out by a gynecologist. Pathology can be suspected during a clinical examination based on anamnestic data, objective signs (painful tumor-like formation in the appendages, cyanosis of the vaginal and cervical mucous membranes, mismatch of the size of the uterus to the gestation period). Other mandatory diagnostic methods include:
- Ultrasound examination. Ultrasonography is the main method of detecting ectopic pregnancy (including progressive). Of particular value is transvaginal ultrasound, which allows you to visualize the fetal egg already in the first weeks of gestation. Among the diagnostic criteria of the disease are signs of gravidar endometrial hyperplasia in the absence of an embryo in the uterus, volumetric formation in the tube area, fluid accumulation behind the uterus.
- Hormonal research. The only specific biochemical marker of ectopic pregnancy is the beta subunit of human chorionic hormone (b–hCG) in blood serum. If patients with uterine pregnancy have an average increase in b-hCG by 63-66% in two days, then with the development of gestation outside the uterus in 83% of women, this indicator is less than 50-53%.
To clarify the diagnosis, an additional pelvic MRI, laparoscopy, and endometrial biopsy may be prescribed. Differential diagnosis is carried out with extra-tubal ectopic pregnancy, threatening, incipient and incomplete miscarriage during uterine pregnancy, adnexitis, cystic drift, tumor formations of the uterus and appendages, acute surgical pathology (appendicitis, peritonitis, cholecystitis, renal colic).
In patients with signs of intra-abdominal bleeding, diagnostic measures include assessment of the severity of blood loss and coagulopathy (measurement of blood pressure, pulse, respiratory rate, clinical blood test, coagulogram, diuresis). In case of hemorrhagic shock, diagnosis is carried out in the operating room with the involvement of a resuscitator, in parallel with intensive therapy.
Treatment of tubal pregnancy
Treatment (both surgical and conservative) is carried out in a medical institution with the mandatory presence of an intensive care unit and intensive care unit. Indications for surgical intervention are impaired (interrupted, interrupted) or progressive gestation with a high (from 5000 units) level of b-hCG. With reduced (up to 1000 IU/l) indicators of b-hCG, a wait-and-see tactic is used due to the high probability of spontaneous regression of pregnancy.
- Surgical operation. During the operation, hemostasis is performed, the fetal egg is removed. Indications for tubectomy – significant damage to the tube, severe bleeding, preservation of the second tube, disinterest in maintaining fertility. In other cases, you can limit yourself to conservative intervention (salpingotomy, segmental resection followed by plastic surgery, fimbrial evacuation). With intramural localization, hysteroresectoscopy, excision of the uterine angle or hysterectomy is performed.
- Conservative treatment. It is aimed at suppressing the growth of the embryo (as the main method) or the trophoblast tissues remaining after organ-preserving surgery, it is carried out with methotrexate. As an independent method, it is indicated for progressive ectopic pregnancy in patients with a b-hCG level of less than 1500-5000 IU/ l and a fetal egg size of up to 35 mm in order to preserve reproductive function.
- Intensive care. It begins at the prehospital stage, then it is carried out simultaneously with surgical intervention with massive blood loss, shock. It is aimed at correcting hemodynamic and hemostatic disorders, includes parenteral administration of solutions (plasma substitutes, crystalloids), transfusion of donor blood and its components, intraoperative reinfusion, the use of vasopressors and antifibrinolytics.
Women who wish to further realize their reproductive function, after performing conservative operations, are prescribed rehabilitation treatment, providing for the creation of an artificial hydroperitoneum, courses of antibiotics and hydrotubations, physiotherapy. The duration of rehabilitation measures reaches six months, during which time reliable contraception is necessary.
Prognosis and prevention
Mortality in tubal pregnancy is about 3.5 cases per 10,000 ectopic nidations. The prognosis of reproductive health after a tubal pregnancy is closer to unfavorable – the frequency of repeated cases reaches 7-17%, up to 50-70% of women after surgical treatment suffer from secondary infertility. The best results can be achieved with early diagnosis and treatment at the stage of developing pregnancy.
Primary prevention consists in rational contraception, thorough examination and treatment before pregnancy of women with inflammatory gynecological diseases, endocrine disorders. Secondary prevention measures – observation by a gynecologist of pregnant women from risk groups from the first weeks of gestation and patients who have recently undergone ectopic pregnancy, postoperative rehabilitation of generative function.
