Can pregnancy develop in the abdominal cavity? Ectopic pregnancy

Ectopic pregnancy is a pregnancy pathology in which a fertilized egg implants ( attached) outside the uterine cavity. This disease is extremely dangerous, as it threatens to damage the woman’s internal genital organs with the development of bleeding, and therefore requires immediate medical care.

Development location outside intrauterine pregnancy depends on many factors and in the vast majority of cases ( 98 – 99% ) falls on the fallopian tubes ( since a fertilized egg passes through them on its way from the ovaries to the uterine cavity). In the remaining cases, it develops on the ovaries, in abdominal cavity (implantation on intestinal loops, liver, omentum), on the cervix.

In the evolution of ectopic pregnancy, it is customary to distinguish the following stages:

It is necessary to understand that the stage of ectopic pregnancy at which the diagnosis occurred determines further prognosis and therapeutic tactics. The earlier this disease is detected, the more favorable the prognosis. However, early diagnosis is associated with a number of difficulties, since in 50% of women this disease is not accompanied by any specific signs that would suggest it without additional examination. The occurrence of symptoms is most often associated with the development of complications and bleeding ( 20% of women have massive internal bleeding at the time of diagnosis).

The incidence of ectopic pregnancy is 0.25 – 1.4% among all pregnancies ( including among registered abortions, spontaneous abortions, stillbirths, etc.). Over the past few decades, the frequency of this disease has increased slightly, and in some regions it has increased 4 to 5 times compared to the figure twenty to thirty years ago.

Maternal mortality due to complications of ectopic pregnancy averages 4.9% in developing countries, and less than one percent in countries with advanced medical care. The main cause of mortality is delay in treatment and misdiagnosis. About half of ectopic pregnancies remain undiagnosed until complications develop. Reducing the mortality rate can be achieved thanks to modern diagnostic methods and minimally invasive treatment methods.

Interesting Facts:

cases of simultaneous occurrence of ectopic and normal pregnancy;
cases of ectopic pregnancy simultaneously in two fallopian tubes have been reported;
the literature describes cases of multiple ectopic pregnancies;
Isolated cases of full-term ectopic pregnancy have been described in which the placenta was attached to the liver or omentum ( organs with sufficient area and blood supply);
In extremely rare cases, ectopic pregnancy can develop in the cervical uterus, as well as in a rudimentary horn that does not communicate with the uterine cavity;
the risk of developing an ectopic pregnancy increases with age and reaches a maximum after 35 years;
In vitro fertilization carries a tenfold risk of developing an ectopic pregnancy ( associated with hormonal imbalances);
The risk of developing an ectopic pregnancy is higher among women who have a medical history of ectopic pregnancies, recurrent miscarriages, inflammatory diseases of the internal genital organs, and operations on the fallopian tubes.

Anatomy and physiology of the uterus at conception

To better understand how an ectopic pregnancy occurs, as well as to understand the mechanisms that can provoke it, it is necessary to understand how normal conception and implantation occur ovum.

Fertilization is the process of fusion of male and female reproductive cells - sperm and egg. This usually happens after sexual intercourse, when sperm pass from the vaginal cavity through the uterine cavity and fallopian tubes to the egg released from the ovaries.

Eggs are synthesized in the ovaries - the female genital organs, which also have a hormonal function. In the ovaries, during the first half of the menstrual cycle, gradual maturation of the egg occurs ( usually one egg per menstrual cycle), with changes and preparation for fertilization. In parallel with this, the inner mucous layer of the uterus undergoes a number 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 the maturation of the egg occurs). This happens approximately in the middle menstrual cycle. The egg released from the follicle, together with the cells attached to it, forming the corona radiata ( outer shell that performs a protective function), falls on the fringed end of the fallopian tube from the corresponding side ( although there have been cases where in women with one functioning ovary the egg ended up in the tube on the opposite side) and is transported by the cilia of the cells lining the inner surface of the fallopian tubes deep into the organ. Fertilization ( meeting with sperm) occurs in the widest ampullary part of the tube. After this, the already fertilized egg with the help of the cilia of the epithelium, as well as due to the flow of fluid directed towards the uterine cavity and resulting from secretion epithelial cells, moves through the entire fallopian tube to the uterine cavity, where its implantation occurs.

It should be noted that the female body has several mechanisms that cause a delay in the advancement of the fertilized egg into the uterine cavity. This is necessary so that the egg has time to go through several stages of division and prepare for implantation before entering the uterine cavity. Otherwise, the fertilized egg may be unable to penetrate the endometrium and may be carried into the external environment.

The delay in the advancement of the fertilized egg is ensured by the following mechanisms:

Folds of the mucous membrane of the fallopian tubes. The folds of the mucous membrane significantly slow down the advancement of the fertilized egg, since, firstly, they increase the path that it must travel, and secondly, they delay the flow of fluid carrying the egg.
Spastic contraction of the isthmus of the fallopian tube ( part of the tube located 15 - 20 mm before the entrance to the uterus). The isthmus of the fallopian tube is in a spastic state ( permanent) contractions for several days after ovulation. This makes it much more difficult for the egg to move forward.

During normal operation female body these mechanisms are eliminated within a few days due to an increase in the secretion of progesterone, a female hormone that serves to maintain pregnancy and is produced by the corpus luteum ( part of the ovary from which the egg is released).

Upon reaching a certain stage of development of the fertilized egg ( blastocyst stage, in which the embryo consists of hundreds of cells) the implantation process begins. This process, which takes place 5 to 7 days after ovulation and fertilization, and which should normally occur in the uterine cavity, is the result of the activity of special cells located on the surface of the fertilized egg. These cells secrete special substances that melt the cells and structure of the endometrium, which allows them to penetrate the mucous layer of the uterus. After the implantation of the fertilized egg has occurred, its cells begin to multiply and form the placenta and other embryonic organs necessary for the development of the embryo.

Thus, during the process of fertilization and implantation, there are several mechanisms, the disruption of which can cause incorrect implantation, or implantation in a place other than the uterine cavity.

Disturbance in the activity 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 uterine cavity to the ampullary part of the fallopian tube occurs against the flow of fluid and, accordingly, is difficult. Contraction of the fallopian tubes promotes faster movement of sperm. A disruption of this process may cause an earlier or later meeting of the egg with the sperm and, accordingly, the processes relating to the advancement and implantation of the fertilized egg may proceed somewhat differently.
Impaired movement of epithelial cilia. The movement of epithelial cilia is activated by estrogens, female sex hormones produced by the ovaries. The movements of the cilia are directed from the outer part of the tube to its entrance, in other words, from the ovaries to the uterus. In the absence of movements, or if they are in the opposite direction, the fertilized egg can 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. If their production is disrupted, or for any other reason, this spasm may persist and cause retention of the fertilized egg in the lumen of the fallopian tubes.
Impaired secretion of fallopian epithelial cells ( uterine) pipes The secretory activity of fallopian tube epithelial cells forms a fluid flow that promotes the advancement of the egg. In its absence, this process slows down significantly.
Violation of the contractile activity of the fallopian tubes to promote the fertilized egg. Contraction of the fallopian tubes not only promotes the movement of sperm from the uterine cavity to the egg, but also the movement of the fertilized egg to the uterine cavity. However, even under normal conditions, the contractile activity of the fallopian tubes is quite weak, but, nevertheless, it facilitates the advancement of the egg ( which is especially important in the presence of other disorders).

Despite the fact that an ectopic pregnancy develops outside the uterine cavity, that is, on those tissues that are not intended for implantation, the early stages of the formation and formation of the fetus and embryonic organs ( placenta, amniotic sac, etc.) happen normally. However, in the future the course of pregnancy is inevitably disrupted. This may occur due to the fact that the placenta, which forms in the lumen of the fallopian tubes ( more often) or on other organs, destroys blood vessels and provokes the development of hematosalpinx ( accumulation of blood in the lumen of the fallopian tube), intra-abdominal bleeding, or both at the same time. Usually this process is accompanied by abortion of the fetus. In addition, there is an extremely high chance that the growing fetus will cause a ruptured tube or serious damage to other internal organs.

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 unidentified.

In the vast majority of cases, ectopic pregnancy occurs due to a disruption in the transport of the egg or fertilized egg, or due to excessive activity of the blastocyst ( one of the stages of development of the fertilized egg). All this leads to the fact that the implantation process begins at a time when the fertilized egg has not yet reached the uterine cavity ( a separate case is an ectopic pregnancy localized in the cervix, which may be associated with delayed implantation or too rapid advancement of the fertilized egg, but which occurs extremely rarely).

An ectopic pregnancy can develop for the following reasons:

Premature blastocyst activity. In some cases, premature activity of the blastocyst with the release of enzymes that help melt tissue for implantation can cause an ectopic pregnancy. This may be due to some genetic abnormalities, exposure to any toxic substances, as well as hormonal imbalances. All this leads to the fact that the fertilized egg begins to implant in the segment of the fallopian tube in which it is located this moment.
Impaired movement of the fertilized egg through the fallopian tubes. Violation of the movement of the fertilized egg through the fallopian tube leads to the fact that the fertilized egg is retained in some segment of the tube ( or outside it, if it was not captured by the fimbriae of the fallopian tube), and upon the onset of a certain stage of embryo development, it begins to implant in the corresponding region.

Impaired movement of a fertilized egg into the uterine cavity is considered the most common cause of ectopic pregnancy and can occur due to many different structural and functional changes.

Impaired movement of the fertilized egg through the fallopian tubes can be caused by the following reasons:

inflammatory process in the uterine appendages;
operations on the fallopian tubes and abdominal organs;
hormonal imbalances;
fallopian tube endometriosis;
congenital anomalies;
tumors in the pelvis;
exposure to toxic substances.

Inflammatory process in the uterine appendages

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 ( inflammation of the fallopian tubes), as well as chronic. Moreover, infectious agents, which are the most common cause of inflammation, cause structural and functional changes in the tissue of the fallopian tubes, against the background of which there is an extremely high probability of disruption of the advancement of the fertilized egg.

Inflammation in the uterine appendages can be caused by many damaging factors ( toxins, radiation, autoimmune processes, etc.), however most often it occurs in response to the penetration of an infectious agent. Studies in which women with salpingitis took part found that in the vast majority of cases this disease is provoked by facultative pathogens ( cause disease only in the presence of predisposing factors), among which the most important are the strains that make up the normal human microflora ( coli). The causative agents of sexually transmitted diseases, although somewhat less common, pose a great danger, as they have pronounced pathogenic properties. Quite often, damage to the uterine appendages is associated with chlamydia - a sexually transmitted infection, which is extremely characterized by a latent course.

Infectious agents can enter the fallopian tubes in the following ways:

Ascending path. Most infectious agents are introduced through the ascending route. This occurs with the gradual spread of an infectious-inflammatory process from the lower genital tract ( vagina and cervix) upward – to the uterine cavity and fallopian tubes. This path is typical for pathogens of sexually transmitted infections, fungi, opportunistic bacteria, and pyogenic bacteria.
Lymphogenic or hematogenous route. In some cases, infectious agents can be introduced into the uterine appendages along with the flow of lymph or blood from infectious and inflammatory foci in other organs ( tuberculosis, staphylococcal infection, etc.).
Direct introduction of infectious agents. Direct introduction of infectious agents into the fallopian tubes is possible during medical manipulations on the pelvic organs, without observing the proper rules of asepsis and antiseptics ( abortions or ectopic procedures outside of medical facilities), as well as after open or penetrating wounds.
By contact. Infectious agents can penetrate the fallopian tubes through direct contact with infectious and inflammatory foci on the abdominal organs.

Dysfunction of the fallopian tubes is associated with the direct impact 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 disrupted. Changes in the activity of the cilia of the epithelium of the fallopian tubes are associated with a change in the environment in the lumen of the tubes, with a decrease in their sensitivity to the action of hormones, as well as with partial or complete destruction of the cilia.
The composition and viscosity of the secretion of epithelial cells of the fallopian tubes changes. The impact of pro-inflammatory substances and bacterial waste products on the cells of the mucous membrane of the fallopian tubes causes a disruption of their secretory activity, which leads to a decrease in the amount of fluid produced, a change in its composition and an increase in viscosity. All this significantly slows down the progress of the egg.
Swelling occurs, narrowing the lumen of the fallopian tube. The inflammatory process is always accompanied by swelling caused by tissue edema. This swelling is so limited space how the lumen of the fallopian tube can cause its complete blockage, which will lead to either the inability to conceive or to an ectopic pregnancy.

Surgeries on the fallopian tubes and abdominal organs

Surgical interventions, even minimally invasive ones, are associated with some, even minimal, trauma, which can provoke some changes in the structure and function of organs. This is due to the fact that at the site of injury or defect, connective tissue is formed, which is not capable of performing a synthetic or contractile function, which occupies a slightly larger volume, and which changes the structure of the organ.

An ectopic pregnancy can be caused by the following surgical interventions:

Surgeries on the abdominal or pelvic organs that do not affect the genitals. Surgeries on the abdominal organs can indirectly affect the function of the fallopian tubes, as they can provoke adhesions, and can also cause disruption of their blood supply or innervation ( accidental or intentional intersection or injury of blood vessels and nerves during surgery).
Operations on the genital organs. The need for surgery on the fallopian tubes arises in the presence of any pathologies ( tumor, abscess, infectious-inflammatory focus, ectopic pregnancy). After the formation of connective tissue at the site of the incision and suture, the ability of the pipe to contract changes and its mobility is impaired. In addition, its internal diameter may decrease.

Separately, mention should be made of such a method of female sterilization as tubal ligation. This method involves applying ligatures to the fallopian tubes ( sometimes – their intersection or cauterization) during surgery. However, in some cases this method of sterilization is not effective enough, and pregnancy still occurs. However, since due to ligation of the fallopian tube its lumen is significantly narrowed, normal migration of the fertilized egg into the uterine cavity becomes impossible, which leads to the fact that it implants in the fallopian tube and an ectopic pregnancy develops.

Hormonal imbalances

The normal functioning of the hormonal system is extremely important for maintaining pregnancy, since hormones control the process of ovulation, fertilization and the movement of the fertilized egg through the fallopian tubes. If there are any disruptions in endocrine function, these processes may be disrupted, and an ectopic pregnancy may develop.

Of particular importance in regulating the functioning of the organs of the reproductive system are steroid hormones produced by the ovaries - progesterone and estrogen. These hormones have slightly different effects, since normally the peak concentrations of each of them occur at different phases of the menstrual cycle and pregnancy.

Progesterone has the following effects:

inhibits the movement of cilia of the tubal epithelium;
reduces the contractile activity of the smooth muscles of the fallopian tubes.

Estrogen has the following effects:

increases the frequency of flickering of the cilia of the tubal epithelium ( too high a concentration of the hormone can cause their immobilization);
stimulates the contractile activity of the smooth muscles of the fallopian tubes;
influences the development of the fallopian tubes during the formation of the genital organs.

Normal cyclic changes in the concentration of these hormones make it possible to create optimal conditions for fertilization and migration of the fertilized egg. Any changes in their level can cause the egg to be retained and implanted outside the uterine cavity.

The following factors contribute to changes in the level of sex hormones:

disruption of ovarian function;
disruptions 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.

Other hormones also, to varying degrees, take part in the regulation of reproductive function. A change in their concentration up or down can have extremely adverse consequences for pregnancy.

Disruption of the following internal secretion organs can provoke an ectopic pregnancy:

Thyroid. Thyroid hormones are responsible for many metabolic processes, including the transformation of certain substances involved in the regulation of reproductive function.
Adrenal glands. The adrenal glands synthesize a number of steroid hormones that are necessary for the normal functioning of the genital organs.
Hypothalamus, pituitary gland. The hypothalamus and pituitary gland are brain structures that produce a number of hormones with regulatory activity. Disruption of their work can cause a significant disruption in the functioning of the entire body, including the reproductive system.

Endometriosis

Endometriosis is a pathology in which the functioning endometrial islets ( lining of the uterus) find themselves outside the uterine cavity ( most often - in the fallopian tubes, on the peritoneum). This disease occurs when menstrual blood containing endometrial cells flows from the uterine cavity into the abdominal cavity through the fallopian tubes. Outside the uterus, these cells take root, multiply and form foci that function and change cyclically during the menstrual cycle.

Endometriosis is a pathology, the presence of which increases the risk of developing an ectopic pregnancy. This is due to some structural and functional changes that occur in the reproductive organs.

The following changes occur with endometriosis:

the frequency of flickering of the cilia of the tubal epithelium decreases;
connective tissue is formed in the lumen of the fallopian tube;
the risk of fallopian tube infection increases.

Abnormalities of the genital organs

Abnormalities of the genital organs can cause the movement of the fertilized egg through the fallopian tubes to be difficult, slow, too long, or even impossible.

The following anomalies are of particular significance:

Genital infantilism. Genital infantilism is a delay in the development of the body, in which the genital organs have certain anatomical and functional features. For the development of ectopic pregnancy, it is of particular importance that the fallopian tubes with this disease are longer than usual. This increases the migration time of the fertilized egg and, accordingly, promotes implantation outside the uterine cavity.
Fallopian tube stenosis. Stenosis, or narrowing of the fallopian tubes, is a pathology that can occur not only under the influence of various external factors, but which may be congenital. Significant stenosis can cause infertility, but a less pronounced narrowing can only interfere with the process of migration of the egg to the uterine cavity.
Diverticula of the fallopian tubes and uterus. Diverticula are sac-like protrusions of the organ wall. They significantly complicate the transport of the egg, and in addition, they can act as a chronic infectious and inflammatory focus.

Tumors in the pelvis

Tumors in the pelvis can significantly affect the process of transporting the egg through the fallopian tubes, since, firstly, they can cause a change in the position of the genital organs or their compression, and secondly, they can directly change the diameter of the lumen of the fallopian tubes and the function of epithelial cells. In addition, the development of some tumors is associated with hormonal and metabolic disorders, which, one way or another, affect the reproductive function of the body.

Exposure to toxic substances

Under the influence of toxic substances, the functioning of most organs and systems of the human body is disrupted. The longer a woman is exposed harmful substances, and the more they enter the body, the more serious disorders they can provoke.

Ectopic pregnancy can occur due to exposure to a variety of toxic substances. Toxins contained in tobacco smoke, alcohol and drugs deserve special attention, as they are widespread and increase the risk of developing the disease by more than three times. In addition, industrial dust, heavy metal salts, various toxic fumes and other factors that often accompany these processes also have a strong impact on the mother’s body and her reproductive function.

Toxic substances cause the following changes in the reproductive system:

delayed ovulation;
change in contraction of the fallopian tubes;
decreased frequency of movement of cilia of the tubal epithelium;
impaired immunity with an increased risk of infection of the internal genital organs;
changes in local and general blood circulation;
changes in hormone concentrations;
neurovegetative disorders.

In Vitro Fertilization

In vitro fertilization deserves special attention, as it is one of the ways to combat infertility in a couple. With artificial insemination, the process of conception ( fusion of egg with sperm) occurs outside the woman's body, and viable embryos are placed artificially in the uterus. This method of conception is associated with a higher risk of developing an ectopic pregnancy. This is explained by the fact that women who resort to this type of fertilization already have pathologies of the fallopian tubes or other parts of the reproductive system.

Risk factors

As mentioned above, ectopic pregnancy is a disease that can be caused by many different factors. Based on the possible causes and mechanisms underlying their development, as well as on the basis of many years of clinical research, a number of risk factors have been identified, that is, factors that significantly increase the likelihood of developing an ectopic pregnancy.

Risk factors for the development of ectopic pregnancy are:

previous ectopic pregnancies;
infertility and its treatment in the past;
in vitro fertilization;
stimulation of ovulation;
progestin contraceptives;
mother's age is more than 35 years;
promiscuity;
ineffective sterilization by ligating or cauterizing the fallopian tubes;
infections of the upper genitalia;
congenital and acquired anomalies of the genital organs;
operations on the abdominal organs;
infectious and inflammatory diseases of the abdominal cavity and pelvic organs;
neurological disorders;
stress;
passive lifestyle.

Symptoms of ectopic pregnancy

Symptoms of an ectopic pregnancy depend on the phase of its development. During the period of progressive ectopic pregnancy, any specific symptoms are usually absent, and in case of termination of pregnancy, which can occur as a tubal abortion or tube rupture, a clear clinical picture arises acute abdomen requiring immediate hospitalization.

Signs of a progressive ectopic pregnancy

Progressive ectopic pregnancy, in the vast majority of cases, is no different in clinical course from normal intrauterine pregnancy. Throughout the entire period while fetal development occurs, presumptive ( subjective sensations experienced by a pregnant woman) and probable ( detected during an objective examination) signs of pregnancy.

Presumptive(dubious)signs of pregnancy are:

changes in appetite and taste preferences;
drowsiness;
frequent mood changes;
irritability;
increased sensitivity to odors;
increased sensitivity of the mammary glands.

Possible signs of pregnancy are:

cessation of menstruation in a woman who is sexually active and of childbearing age;
bluish color ( cyanosis) mucous membrane of the genital organs - vagina and cervix;
engorgement of the mammary glands;
release of colostrum from the mammary glands when pressed ( only relevant during first pregnancy);
softening of the uterus;
contraction and hardening of the uterus during the examination followed by softening;
asymmetry of the uterus on early stages pregnancy;
cervical mobility.

The presence of these signs in many cases indicates a developing pregnancy, and at the same time, these symptoms are the same for both physiological pregnancy and ectopic pregnancy. It should be noted that doubtful and probable signs can be caused not only by fetal development, but also by certain pathologies ( tumors, infections, stress, etc.).

Reliable signs of pregnancy ( fetal heartbeat, fetal movements, palpation of large parts of the fetus) during ectopic pregnancy occur extremely rarely, as they are typical for later stages intrauterine development, before the onset of which various complications usually develop - tubal abortion or tubal rupture.

In some cases, a progressive ectopic pregnancy may be accompanied by pain and bleeding from the genital tract. Moreover, this pathology of pregnancy is characterized by a small amount of discharge ( in contrast to spontaneous abortion during intrauterine pregnancy, when the pain is mild and the discharge is profuse).

Signs of tubal abortion

Tubal abortion occurs most often 2–3 weeks after the onset of delayed 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.

Tubal abortion is accompanied by the following symptoms:

Periodic pain. Periodic, cramping pain in the lower abdomen is associated with contraction of the fallopian tube, as well as its possible filling with blood. The pain radiates ( give away) in the area of the rectum, perineum. The appearance of constant acute pain may indicate hemorrhage into the abdominal cavity with irritation of the peritoneum.
Bloody discharge from the genital tract. The occurrence of bloody discharge is associated with rejection of decidually changed endometrium ( part of the placental-uterine system in which metabolic processes occur), as well as with partial or complete damage to blood vessels. The volume of bloody discharge from the genital tract may not correspond to the degree of blood loss, since most of the blood through the lumen of the fallopian tubes can enter the abdominal cavity.
Signs of hidden bleeding. Bleeding during a tubal abortion may be insignificant, and then the woman’s general condition may not be affected. However, when the volume of blood loss is more than 500 ml, severe pain lower abdomen with irradiation to the right hypochondrium, interscapular region, right clavicle ( associated with irritation of the peritoneum by bleeding). Weakness, dizziness, fainting, nausea, and vomiting occur. There is an increased heart rate and decreased blood pressure. A significant amount of blood in the abdominal cavity can cause an enlarged or bloated abdomen.

Signs of a ruptured fallopian tube

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 heavy internal bleeding, which forms the symptoms of the pathology.

A ruptured fallopian tube may be accompanied by the following symptoms:

Lower abdominal pain. Pain in the lower abdomen occurs due to a rupture of the fallopian tube, as well as due to irritation of the peritoneum by the gushing blood. The pain usually begins on the side of the “pregnant” tube with further spread to the perineum, anus, right hypochondrium, and right collarbone. The pain is constant and acute.
Weakness, loss of consciousness. Weakness and loss of consciousness occur due to hypoxia ( oxygen deficiency) of the brain, which develops due to a decrease in blood pressure (against the background of a decrease in circulating blood volume), and also due to a decrease in the number of red blood cells that carry oxygen.
The urge to defecate, loose stool. Irritation of the peritoneum in the rectal area can provoke a frequent urge to defecate, as well as loose stools.
Nausea and vomiting. Nausea and vomiting occur reflexively due to irritation of the peritoneum, as well as due to negative impact hypoxia on nervous system.
Signs of hemorrhagic shock. Hemorrhagic shock occurs when there is a large amount of blood loss, which directly threatens the woman’s life. Signs of this condition are pallor skin, apathy, inhibition of nervous activity, cold sweat, shortness of breath. There is an increase in heart rate, a decrease in blood pressure ( the degree of reduction of which corresponds to the severity of blood loss).

Along with these symptoms, probable and presumptive signs of pregnancy and delayed menstruation are noted.

Diagnosis of ectopic pregnancy

Diagnosis of ectopic pregnancy is based on a clinical examination and a number of instrumental studies. The greatest difficulty is in diagnosing a 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 overlook it. Timely diagnosis of progressive ectopic pregnancy makes it possible to prevent such dangerous and dangerous complications such as tubal abortion and fallopian tube rupture.

Clinical examination

Diagnosis of ectopic pregnancy begins with a clinical examination, during which the doctor identifies some specific signs that indicate an ectopic pregnancy.

During a clinical examination, the general condition of the woman is assessed, palpation and percussion are performed ( percussion) and auscultation, a gynecological examination is performed. All this allows you to create a holistic picture of the pathology, which is necessary to form a preliminary diagnosis.

The data collected during the clinical examination may vary at different stages of the development of an ectopic pregnancy. With a progressive ectopic pregnancy, there is some lag in the size of the uterus; a compaction may 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. Signs of intrauterine pregnancy - softening of the uterus and isthmus, asymmetry of the uterus, and inflection of the uterus may be absent.

With a rupture of the fallopian tube, as well as with a tubal abortion, pale skin, rapid heartbeat, and decreased blood pressure are noted. When tapping ( percussion) there is dullness in the lower abdomen, which indicates fluid accumulation ( 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 when examining the cervix. Pressing on the posterior vaginal fornix, which may be flattened, causes acute pain ( "Douglas' cry").

Ultrasonography

Ultrasonography ( Ultrasound) is one of the most important examination methods, which makes it possible to diagnose an ectopic pregnancy at a fairly early stage, and which is used to confirm this diagnosis.

The following signs help diagnose an ectopic pregnancy:

enlargement of the uterine body;
thickening of the uterine mucosa without detection of the fertilized egg;
detection of a heterogeneous formation in the area of the uterine appendages;
fertilized egg with an embryo outside the uterine cavity.

Transvaginal ultrasound is of particular diagnostic importance, as it can detect pregnancy as early as 3 weeks after ovulation, or within 5 weeks after the last menstruation. This examination method is widely practiced in emergency departments and is extremely sensitive and specific.

Ultrasound diagnostics makes it possible to detect intrauterine pregnancy, the presence of which in the vast majority of cases allows us to exclude ectopic pregnancy ( cases of simultaneous development of normal intrauterine and ectopic pregnancy are extremely rare). An absolute sign intrauterine pregnancy is considered to be the discovery of a gestational sac ( term used exclusively in ultrasound diagnostics), yolk sac and the embryo in the uterine cavity.

In addition to diagnosing an ectopic pregnancy, ultrasound can detect a rupture of the fallopian tube, the accumulation of free fluid in the abdominal cavity ( blood), accumulation of blood in the lumen of the fallopian tube. This method also allows for differential diagnosis with other conditions that can cause an acute abdomen.

Women at risk, as well as women with in vitro fertilization, are subject to periodic ultrasound examinations, as they have a ten times higher chance of developing an ectopic pregnancy.

Human chorionic gonadotropin level

Human chorionic gonadotropin is a hormone that is synthesized by the tissues of the placenta, and the level of which gradually increases during pregnancy. Normally, its concentration doubles every 48 to 72 hours. During an ectopic pregnancy, human chorionic gonadotropin levels will increase much more slowly than during a normal pregnancy.

Determining the level of human chorionic gonadotropin is possible using rapid pregnancy tests ( which are characterized by a fairly high percentage of false negative results), as well as through more detailed laboratory analysis, which allows us to evaluate its concentration over time. Pregnancy tests allow you to confirm the presence of pregnancy within a short period of time and build a diagnostic strategy if you suspect an ectopic pregnancy. However, in some cases, human chorionic gonadotropin may not be detected by these tests. Termination of pregnancy, which occurs during tubal abortion and rupture of the tube, disrupts the production of this hormone, and therefore, during complications, a pregnancy test may be falsely negative.

Determining the concentration of human chorionic gonadotropin is especially valuable in combination with ultrasound examination, as it allows a more correct assessment of the signs detected on 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 from ultrasound examination and analysis of human chorionic gonadotropin allows one to judge the course of pregnancy.

Progesterone level

Determining the level of progesterone in blood plasma is another method of laboratory diagnosis that is incorrect developing pregnancy. Its low concentration ( below 25 ng/ml) indicates the presence of pregnancy pathology. A decrease in progesterone levels below 5 ng/ml is a sign of a non-viable fetus and, regardless of the location of pregnancy, always indicates the presence of some pathology.

Progesterone levels have the following features:

does not depend on the period of gestational development;
remains relatively constant during the first trimester of pregnancy;
if the level is initially abnormal, it does not return to normal;
does not depend on the level of human chorionic gonadotropin.

However, this method is not sufficiently specific and sensitive, so it cannot be used separately from other diagnostic procedures. In addition, during in vitro fertilization it loses its significance, since during this procedure its level can be increased ( against the background of increased secretion by the ovaries due to previous stimulation of ovulation, or against the background artificial administration pharmacological preparations containing progesterone).

Abdominal puncture through the posterior vaginal fornix ( culdocentesis)

Puncture of the abdominal cavity through the posterior vaginal fornix is used in the clinical picture of an acute abdomen with suspected ectopic pregnancy and is a method that allows one to differentiate this pathology from a number of others.

During an ectopic pregnancy, dark, non-coagulable blood is obtained from the abdominal cavity, which does not sink when placed in a vessel with water. Microscopic examination reveals chorionic villi, particles of the fallopian tubes and endometrium.

Due to the development of more informative and modern methods diagnostics, including laparoscopy, puncture of the abdominal cavity through the posterior vaginal fornix has lost its diagnostic value.

Diagnostic curettage of the uterine cavity

Diagnostic curettage of the uterine cavity followed by histological examination of the obtained material is used only in the case of a proven pregnancy anomaly ( low levels of progesterone or human chorionic gonadotropin), for differential diagnosis with incomplete spontaneous abortion, as well as in case of reluctance or impossibility to continue pregnancy.

In case of ectopic pregnancy, the following histological changes are revealed in the obtained material:

decidual transformation of the endometrium;
absence of chorionic villi;
atypical nuclei of endometrial cells ( Arias-Stella phenomenon).

Despite the fact that diagnostic curettage of the uterine cavity is quite effective and simple method diagnosis, it can be misleading in the case of simultaneous development of intrauterine and ectopic pregnancy.

Laparoscopy

Laparoscopy is a modern surgical method that allows for minimally invasive interventions on the abdominal and pelvic organs, as well as diagnostic operations. The essence of this method is to introduce a special laparoscope instrument through a small incision into the abdominal cavity, equipped with a system of lenses and lighting, which allows you to visually assess the condition of the organs being examined. In case of ectopic pregnancy, laparoscopy makes it possible to examine the fallopian tubes, uterus, and pelvic cavity.

With an ectopic pregnancy, the following changes in the internal genital organs are detected:

thickening of the fallopian tubes;
purplish-bluish coloration of the fallopian tubes;
rupture of the fallopian tube;
fertilized egg on the ovaries, omentum or other organ;
bleeding from the lumen of the fallopian tube;
accumulation of blood in the abdominal cavity.

The advantage of laparoscopy is a fairly high sensitivity and specificity, a low degree of trauma, as well as the possibility of surgically terminating an ectopic pregnancy and eliminating bleeding and other complications immediately after diagnosis.

Laparoscopy is indicated in all cases of ectopic pregnancy, as well as if it is impossible to make an accurate diagnosis ( as the most informative diagnostic method).

Treatment of ectopic pregnancy

Is it possible to have a baby with an ectopic pregnancy?

The only organ in a woman’s body that can ensure adequate development of the fetus is the uterus. Attachment of the fertilized egg to any other organ is fraught with malnutrition, changes in structure, as well as rupture or damage to this organ. It is for this reason that ectopic pregnancy is a pathology in which bearing and giving birth to a child is impossible.

To date, there are no methods in medicine that would allow an ectopic pregnancy to occur. The literature describes several cases where, with this pathology, it was possible to carry children to a term compatible with life in the external environment. However, firstly, such cases are possible only under extremely rare circumstances ( one case in several hundred thousand ectopic pregnancies), secondly, they are associated with an extremely high risk for the mother, and thirdly, there is a possibility of the formation of pathologies in the development of the fetus.

Thus, bearing and giving birth to a child with an 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, treatment for ectopic pregnancy was limited to surgical removal of the fetus. 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 prescription of methotrexate, a drug that is an antimetabolite that can change synthetic processes in the cell and cause a delay in cell division. This drug is widely used in oncology to treat various tumors, as well as to suppress immunity during organ transplantation.

The use of methotrexate for the treatment of ectopic pregnancy is based on its effect on fetal tissue and its embryonic organs, arresting their development and subsequent spontaneous rejection.

Drug treatment using methotrexate has a number of advantages over surgical treatment, as it reduces the risk of bleeding, negates trauma to tissues and organs, and reduces the rehabilitation period. However, this method is not without its drawbacks.

The following side effects are possible when using methotrexate:

nausea;
vomit;
stomach pathologies;
dizziness;
liver damage;
suppression of bone marrow function ( is fraught with anemia, decreased immunity, bleeding);
baldness;
rupture of the fallopian tube during progressive pregnancy.

Treatment of ectopic pregnancy with methotrexate is possible under the following conditions:

confirmed ectopic pregnancy;
hemodynamically stable patient ( no bleeding);
the size of the fertilized egg does not exceed 4 cm;
absence of fetal cardiac activity during ultrasound examination;
no signs of fallopian tube rupture;
human chorionic gonadotropin level is below 5000 IU/ml.

Treatment with methotrexate is contraindicated in the following situations:

human chorionic gonadotropin level above 5000 IU/ml;
presence of fetal cardiac activity during ultrasound examination;
hypersensitivity to methotrexate;
state of immunodeficiency;
liver damage;
leukopenia ( low white blood cell count);
thrombocytopenia ( low platelet count);
anemia ( low number of red blood cells);
active lung infection;
kidney pathology.

Treatment is carried out by parenteral ( intramuscular or intravenous) administration of the drug, which can be one-time or can last for several days. The woman is under observation throughout the entire treatment period, as there is still a risk of fallopian tube rupture or other complications.

The effectiveness of treatment is assessed by measuring the level of human chorionic gonadotropin over time. A decrease in it by more than 15% from the initial value on days 4–5 after administration of the drug indicates the success of treatment ( During the first 3 days, hormone levels may be elevated). In parallel with the measurement of this indicator, the function of the kidneys, liver, and bone marrow is monitored.

If there is no effect from drug therapy with methotrexate, surgical intervention is prescribed.

Treatment with methotrexate is associated with many risks, since the drug can negatively affect some of a woman’s vital organs, does not reduce the risk of fallopian tube rupture until the pregnancy is completely terminated, and, moreover, is not always quite effective. Therefore, the main treatment method for ectopic pregnancy is still surgery.

It is necessary to understand that conservative treatment does not always produce the expected therapeutic effect, and in addition, due to a delay in surgical intervention, some complications may occur, such as tubal rupture, tubal abortion and massive bleeding ( not to mention the side effects from methotrexate itself).

Surgery

Despite the possibilities of non-surgical therapy, surgical treatment still remains the main method of managing 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 choice of surgical tactics is based on the following factors:

patient's age;
desire to have a pregnancy in the future;
condition of the fallopian tube during pregnancy;
condition of the fallopian tube on the opposite side;
localization of pregnancy;
fertilized egg size;
general condition of the patient;
volume of blood loss;
condition of the pelvic organs ( adhesive process).

Based on these factors, the choice of surgical operation is made. If there is a significant degree of blood loss, the patient’s general condition is severe, as well as the development of certain complications, a laparotomy is performed - an operation with a wide incision, which allows the surgeon to quickly stop the bleeding and stabilize the patient. In all other cases, laparoscopy is used - a surgical intervention in which manipulators and an optical system are inserted into the abdominal cavity through small incisions in the anterior abdominal wall, allowing a number of procedures to be carried out.

Laparoscopic access allows the following types of operations:

Salpingotomy ( incision of the fallopian tube with extraction of the fetus, without removing the tube itself). Salpingotomy allows you to preserve the fallopian tube and its reproductive function, which is especially important if there are no children or if the tube on the other side is damaged. However, this operation is possible only if the fetal egg is small in size, as well as if the tube itself is intact at the time of the operation. In addition, salpingotomy is associated with an increased risk of recurrent ectopic pregnancy in the future.
Salpingectomy ( removal of the fallopian tube along with the implanted fetus). Salpingectomy is radical method, in which the “pregnant” fallopian tube is removed. This type Intervention is indicated if there is an ectopic pregnancy in the woman’s medical history, as well as if 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 excise its damaged part, which allows to some extent to preserve its function.

It is necessary to understand that in most cases, intervention for ectopic pregnancy is carried out urgently to eliminate bleeding and to eliminate the consequences of tubal abortion or tube rupture, so patients end up on the operating table with minimal preliminary preparation. If we are talking about a planned operation, then women are pre-prepared ( preparation is carried out in the gynecological or surgical department, since all women with an ectopic pregnancy are subject to immediate hospitalization).

Preparation for surgery consists of the following procedures:

donating blood for general and biochemical analysis;
determination of blood group and Rh factor;
performing an electrocardiogram;
conducting ultrasound examination;
consultation with a therapist.

Postoperative period

The postoperative period is extremely important for the normalization of a woman’s condition, for eliminating certain risk factors, as well as for the rehabilitation of reproductive function.

During the postoperative period, constant monitoring of hemodynamic parameters is carried out, and painkillers, antibiotics, and anti-inflammatory drugs are administered. After laparoscopic ( minimally invasive) after surgery, women can be discharged within one to two days, but after laparotomy, hospitalization is required for a much longer period of time.

After surgery and removal of the fertilized egg, it is necessary to monitor human chorionic gonadotropin weekly. 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 can be transferred to other organs. This condition is potentially dangerous, since a tumor, chorionepithelioma, can begin to develop from chorion cells. 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 prescribed, which can suppress the growth and development of this embryonic organ. If after this the hormone level does not decrease, there is a need for radical surgery to remove the fallopian tube.

In the postoperative period, physiotherapy is prescribed ( electrophoresis, magnetic therapy), which contribute to faster restoration of reproductive function, and also reduce the likelihood of developing adhesions.

The prescription of combined oral contraceptives in the postoperative period has two goals - stabilization of menstrual function and prevention of pregnancy in the first 6 months after surgery, when the risk of developing various pregnancy pathologies is extremely high.

Prevention of ectopic pregnancy

What should you do to avoid an ectopic pregnancy?

To reduce the likelihood of developing an ectopic pregnancy, the following recommendations should be followed:

treat in a timely manner infectious diseases genitals;
periodically undergo an ultrasound examination or donate blood to check the level of human chorionic gonadotropin during in vitro fertilization;
get tested for sexually transmitted infections when changing partners;
use combined oral contraceptives to prevent unwanted pregnancy;
promptly treat diseases of internal organs;
Healthy food;
correct hormonal disorders.

What should you avoid to prevent ectopic pregnancy?

To prevent ectopic pregnancy, it is recommended to avoid:

infectious and inflammatory pathologies of the genital organs;
sexually transmitted infections;
promiscuity;
use of progestin contraceptives;
stress;
sedentary lifestyle;
smoking and other toxic exposures;
a large number of operations on the abdominal organs;
multiple abortions;
in vitro fertilization.

Abdominal pregnancy is a pregnancy in which the egg is implanted (introduced) into the abdominal organs and the blood supply to the embryo comes from the vascular bed gastrointestinal tract. This usually happens in the following places:

large oil seal;
peritoneal surface;
intestinal mesentery;
liver;
spleen.

Classification

The following are distinguished: abdominal pregnancy options:

primary(the introduction of the egg into the abdominal cavity occurs initially, without entering the fallopian tube);
secondary, when a viable embryo enters the abdominal cavity from the tube after a tubal abortion has occurred.

information The existing classification is not of any clinical interest due to the fact that by the time of the operation the tube is most often already visually unchanged and it is possible to establish where the embryo initially implanted only after a microscopic examination of the removed material.

Causes

To the development of abdominal pregnancy results from various pathologies of the fallopian tubes when their anatomy or function is disrupted:

chronic inflammatory diseases of the tubes (salpingitis, salpingoophoritis, hydrosalpinx and others), not treated in a timely manner or treated inadequately;
previous operations on the fallopian tubes or on the abdominal organs (in the latter case, they may interfere with the normal advancement of the egg);
congenital anomalies of the fallopian tubes.

Symptoms

The main groups of symptoms of abdominal pregnancy include:

Symptoms associated with dysfunction of the gastrointestinal tract:
- nausea;
- vomit;
Clinic "acute abdomen": suddenly, against the background of complete health, extremely pronounced pain appears, which can be very severe and even cause fainting; nausea, vomiting, bloating, symptoms of peritoneal irritation.
When bleeding develops, it appears anemia.

Diagnostics

dangerous Diagnosis of abdominal pregnancy is usually late, and this pathology is detected already when bleeding has begun or significant damage to the organ in which implantation has occurred.

The world's "gold" standard Diagnosis of ectopic pregnancy, in general, are:

Blood test for(chorionic gonadotropin), which reveals a discrepancy between its level and the expected duration of pregnancy.
When the fertilized egg is absent in the uterine cavity, it is possible to detect it in it.

The combined use of the two above methods makes it possible to diagnose "" in 98% of patients from the 5th week of pregnancy (1 week of delay with a 28-day cycle).

As for abdominal pregnancy, the diagnosis will have a big role clinical picture(it was described above), which is more reminiscent of acute surgical pathology.

It is also possible to carry out culdocentesis(puncture of the posterior vaginal vault) and when blood does not clot, we can talk about internal bleeding that has begun.

It should be noted that the conduct is extremely informative diagnostic laparoscopy, in which it is possible to detect a fertilized egg attached to one or another organ, and in some cases it is possible to remove it, which will lead to the woman’s cure. However, due to the fact that this method is invasive (essentially it is an operation), it comes in last place, being a last resort.

Treatment

Treatment is always surgical(both laparotomy and laparotomy are possible), and the operations are completely atypical and often extremely complex technically. Interventions will largely depend on where the egg was implanted and the degree of damage to the organ. If possible, the operation is performed by an obstetrician-gynecologist together with a surgeon.

In most cases, the following surgical options are used:

A staple is placed on the umbilical cord to extract the fetus and stop blood flow into the umbilical cord; the latter, if possible, is also removed. However, if there is a high risk of large blood loss, it is left in place.
If it is not possible to remove the placenta, marsupilinization is performed: the amniotic cavity is opened and its edges are sutured to the edges of the wound on the anterior abdominal wall, a napkin is inserted into the cavity and a long time is waited for the placenta to be rejected.

important The gynecological part of the operation is described above, but the scope of the intervention can be significantly expanded, since other organs of the abdominal cavity are also involved in the process, damage to which is very likely.

Consequences

The consequences depend on how damaged the site of implantation of the fertilized egg is. If in some cases surgical intervention is limited only to suturing the wound, then in others it may be necessary to remove the entire organ or part of it.

information The woman’s reproductive function remains normal, unless, of course, any technical difficulties arose during the operation.

As for the consequences for the fetus, in 10-15% of cases they are viable, but in more than half, certain congenital malformations are determined.

During the normal course of pregnancy, the fertilized egg attaches to the wall of the uterus, where further development of the embryo occurs.

Implantation of the fertilized egg into the mucous membrane of the ovary, fallopian tube, or abdominal cavity is called an ectopic pregnancy.

Types of ectopic pregnancy

According to the place of attachment of the fertilized egg, ectopic pregnancy can be tubal, ovarian, cervical and abdominal.

Types of ectopic pregnancy

Tubal ectopic pregnancy

Tubal pregnancy occurs in 98% of ectopic pregnancies.

This type of ectopic pregnancy occurs due to the fact that the fertilized egg does not move along the fallopian tube to exit into the uterine cavity and gain a foothold there, but is implanted into the wall of the tube itself.

Tubal pregnancy can develop in different parts of the fallopian tube, and according to this it is divided into ampullary (accounts for 80% of all cases of tubal pregnancies), isthmic (accounts for 13% of the total number of tubal pregnancies), interstitial (accounts for 2%) and fimbrial (accounts for 5%).

In ampullary tubal pregnancy, rupture of the fallopian tube usually occurs somewhat later than in other cases, somewhere around 8-12 weeks, since this part of the tube is the widest and the fetus can reach large sizes until he becomes cramped and bursts the fallopian tube. Less common, but still possible, is another outcome - tubal abortion.

Isthmic tubal pregnancy most often ends in tubal rupture at an early stage, at about 4-6 weeks of pregnancy, since the isthmus of the fallopian tube is its narrowest part. After the tube ruptures, the egg is released into the abdominal cavity.

With interstitial tubal pregnancy, pregnancy can develop up to 4 months (14-16 weeks), since the myometrium of this section of the fallopian tube can stretch to large sizes. It is this section of the fallopian tube that connects directly to the uterus; it has a developed blood supply network, so rupture of the tube is accompanied by large blood loss, which can be fatal. If the uterus is significantly damaged, extirpation (removal) is prescribed.

In fimbrial tubal pregnancy, the fetus develops at the exit of the fallopian tube (in the fimbriae - villi).

Any type of tubal ectopic pregnancy ends in termination and is expressed by rupture of the fallopian tube or detachment of the fertilized egg from the wall of the fallopian tube and its expulsion into the abdominal cavity with subsequent death of the fetus (this process is called tubal abortion).

Ovarian ectopic pregnancy

Ovarian pregnancy occurs in approximately 1% of women among the total number of women with an ectopic pregnancy.

An ovarian ectopic pregnancy occurs when a sperm fertilizes an egg that has not yet been released from the dominant follicle or the fertilized egg attaches to the ovary instead of moving through the tubes towards the uterine cavity.

Thus, ovarian pregnancy is divided into two forms: intrafollicular - when implantation occurs inside the follicle, and epiophoral - when implantation occurs on the surface of the ovary.

Cervical pregnancy

Pregnancy in the cervical canal of the uterus is quite rare, namely 0.1% of all cases of ectopic pregnancy. During cervical pregnancy, the fertilized egg penetrates the mucous membrane of the cervix.

There is also a cervical-isthmus type of pregnancy, when the fertilized egg attaches to the isthmus of the uterus.

Cervical pregnancy can develop up to the 2nd trimester of pregnancy.

Abdominal pregnancy

This is a rare case of ectopic pregnancy. Abdominal pregnancy can be primary or secondary.

During primary abdominal pregnancy, fertilization of the egg and the implantation of the fertilized egg itself occurs in the abdominal cavity.

During a secondary abdominal pregnancy, fertilization occurs in the fallopian tube, and then the fertilized egg is released into the abdominal cavity, where it attaches to the internal organ of the peritoneum (liver, spleen, etc.). Secondary abdominal pregnancy is a consequence of tubal abortion, thus, an interrupted tubal pregnancy develops into another type of ectopic pregnancy.

An abdominal pregnancy is extremely rarely carried to term, but if the fetus manages to attach to tissues with good blood circulation, the child is born as a result of such pregnancy, but with defects and soon dies.

As a result of abdominal pregnancy, the mother’s organs adjacent to the developing fetus are also greatly affected, which is extremely dangerous for the woman’s life.

Ectopic pregnancy in the rudimentary uterine horn

Pregnancy in a rudimentary uterine horn is a fairly rare phenomenon, which is also usually classified as an ectopic type, since the fetus attaches to the wall of the defective uterus and leads to miscarriage with rupture of the uterine horn.

This only happens in women with a congenital anomaly of the anatomical structure of the uterus, when even during the formation and development of her own reproductive system, while in the womb of her mother, there was a failure in the formation of the internal genital organs (this happened somewhere at 13-14 weeks of embryonic development ).

Each of the types of pregnancy described above cannot result in the birth of a healthy child, since the fetus cannot develop normally and reach its full maturity; it will not have enough nutrients or space for development.

An ectopic pregnancy ends either in abortion (spontaneous or mechanical), or, in case of untimely diagnosis, in surgical intervention and/or rupture of the tissues of the reproductive organs.

Symptoms of ectopic pregnancy

Usually, with an ectopic pregnancy, all the signs of a normal pregnancy remain: delayed menstruation, morning sickness, breasts are full and painful, there is an unusual taste in the mouth, weakness is felt in the body, and the pregnancy test shows two lines. Moreover, the hCG level can increase at a normal pace, but if the dynamics of the hCG level show a slow increase in the hCG level (i.e., the hCG level increases more slowly than 50% every 2 days), then this is the first sign of an ectopic pregnancy.

In general, the first signs of an ectopic pregnancy in the early stages are prolonged spotting, spotting pain in the place where the ectopic pregnancy develops, nagging pain in the lower abdomen or pain that radiates to the lower back or anus.

In later stages, the main signs of ectopic pregnancy include increasing pain that cannot be tolerated, increased body temperature, and loss of consciousness from painful shock. This condition is typical for organ rupture and heavy blood loss.

It is possible to accurately determine whether a pregnancy is ectopic only with the help of an ultrasound.

A diagnostic doctor, using special equipment to scan the pelvic organs, will examine the uterine cavity to determine whether a fertilized egg has settled in it. If the fertilized egg was not detected in the uterus, visualization of fluid in the abdominal cavity and/or in the retrouterine space, and blood clots is noted, then such a pregnancy will be designated as ectopic.

Causes of ectopic pregnancy

An ectopic pregnancy can develop for various reasons. Below are the causes of ectopic pregnancy according to the specific type of ectopic pregnancy.

Causes of tubal pregnancy

This usually occurs due to a violation of the peristalsis of the fallopian tube, that is, due to a violation of its ability to contract, or due to other processes that impede the patency of the fallopian tubes (with adhesions, tumors, disruption of the structure of the fimbriae, bending of the tube, underdevelopment of the tubes (genital infantilism ) etc.)

So untimely treatment inflammatory diseases tubes (salpingitis, hydrosalpinx, for example) or previous operations on the fallopian tubes are usually the reasons for the development of tubal pregnancy.

Causes of ovarian pregnancy

After the dominant follicle ruptures, the egg meets the sperm while still in the ovary. Further, the fertilized egg, for one reason or another, does not continue its movement to the uterine cavity, but is attached to the ovary.

The cause of such a failure during pregnancy may be a previous infectious disease of the uterine appendages or inflammation of the endometrium, obstruction of the fallopian tubes, endocrine and genetic disorders, etc.

Causes of cervical pregnancy

Cervical pregnancy occurs due to the fact that the fertilized egg cannot attach to the wall of the uterus. Implantation of the fertilized egg into the wall of the cervical canal occurs due to a previous mechanical abortion or caesarean section, the formation of adhesions in the uterine cavity, fibroids and due to various anomalies in the development of the uterus.

Causes of abdominal pregnancy

Abdominal pregnancy develops with obstruction of the fallopian tubes and other acquired or congenital pathologies.

Typically, abdominal pregnancy is a consequence of the release of a fertilized egg into the abdominal cavity after a rupture of the fallopian tube (after a tubal abortion).

Consequences of ectopic pregnancy

An ectopic pregnancy that is not diagnosed in time can lead to rupture of the fallopian tube and further surgical removal (for tubal pregnancy), ovary (for ovarian pregnancy), large blood loss and removal of the uterus (for cervical pregnancy) and even death.

Treatment of ectopic pregnancy

There are two ways to treat ectopic pregnancy: medication and surgery.

Drug treatment means taking a drug (usually an injection of Methotrexate) that causes the death of the fetus with its further resorption. This way, you can save the fallopian tube or ovary, which will make it possible to get pregnant normally and give birth to a child in the future.

Surgical treatment means curettage of the fetus and/or removal of its attachment site (fallopian tube, ovary or uterine horn).

There are two ways to access the pelvic organs - laparoscopic and laparotomy.

Laparotomy- this is an incision in the anterior abdominal wall, as in a conventional operation, and laparoscopy is small punctures of the abdomen, through which all manipulations take place.

Laparoscopy is a modern type of surgical intervention, after which no scars remain, and the postoperative recovery period is minimized

For tubal ectopic pregnancy, two types of surgical intervention using laparoscopic access are possible: salpingotomy or tubotomy (a conservative type of operation in which the fertilized egg is removed while preserving the fallopian tube) and salpingectomy or tubectomy (a radical type of operation in which the fallopian tube is removed along with the fetus ).

But preservation of the fallopian tube is possible only at the progressive stage of ectopic pregnancy, that is, when the attachment of the fertilized egg has occurred, but the rupture or strong stretching of the tube wall has not yet occurred.

Also, to decide whether to leave the fallopian tube, the surgeon must consider the following factors:

does the patient want more children in the future (usually women who already have children do not want to take risks in the future, but the likelihood of a repeat ectopic pregnancy is very high, they tell the doctor that this pregnancy was not wanted anyway and they do not intend to have more children) ;
the presence and degree of structural changes in the wall of the fallopian tube (for example, strong stretching of the wall of the tube by the growing fetus), the condition of the epithelium and fimbriae of the tube, the severity of the adhesive process (most often the condition of the tube is so poor that it will not be able to fully perform its functions in the future, such a tube cannot participate in the normal course of pregnancy, and the likelihood of an ectopic pregnancy is so great that there is no point in leaving it);
whether the ectopic pregnancy is repeated for a given tube (as a rule, if an ectopic pregnancy is repeated in the same fallopian tube, it is removed, since the subsequent development of an abnormal pregnancy in the same tube is inevitable);
whether a reconstructive plastic surgery was previously performed to restore the patency of this fallopian tube (if “yes, such an operation was once performed on this tube,” then its preservation is not carried out, it is no longer suitable);
the area where the fertilized egg is attached (when a fertilized egg is implanted into the wall of the interstitial section of the fallopian tube - the narrowest part - usually no operation is performed to preserve the tube);
the condition of the second fallopian tube (if there is no second tube or if its condition is worse than that of the woman being operated on, a decision is made to leave the tube so that the woman has a chance to become pregnant in the future).

With heavy internal bleeding the only way To save a woman's life is laparotomy (removal of the fallopian tube).

After removal, restoration of the fallopian tube is not carried out, since the tube tends to contract, which helps the fertilized egg move from the ovary towards the uterine cavity, which is not possible with the implantation of an artificial section of the tube.

In case of ovarian ectopic pregnancy, treatment includes removal of the fertilized egg and wedge resection of the ovary (in this case, the ovary is preserved and after a time restores its functions) or, in a critical case, oophorectomy (removal of the ovary).

Cervical pregnancy poses the greatest danger to a woman. Previously, the only way to treat cervical pregnancy was considered to be extirpation or hysterectomy (removal of the uterus), since the tissues in this area contain many blood vessels and nodes, and any operation is fraught with large blood loss, and the risk of death is very high. But modern medicine is aimed at preserving the uterus, so gentle treatment methods are used - medical abortion (using methotrexate injection) if an ectopic pregnancy is detected at an early stage, and if an ectopic pregnancy is diagnosed late and severe bleeding begins, hemostatic measures are carried out (cervical tamponade with a Foley catheter, applying a circular suture to the cervix or ligating the internal iliac arteries, etc.), and then removing the fertilized egg.

Treatment of abdominal pregnancy is a complex operation to remove the fetus from the peritoneum. Depending on the complexity of the case, surgical intervention can be either laparoscopic or laparotomy.

Take a urine test for hCG to confirm pregnancy, and after 2-3 days take this test again to track changes in hCG;
Contact your gynecologist with a complaint about bloody discharge from the genital tract or abdominal pain (if any), providing the results of a urine test for hCG as proof of your pregnancy;
Get an ultrasound to determine the type of pregnancy (uterine or ectopic);
In the event of an ectopic pregnancy, re-visit your gynecologist to receive medication treatment (in the early stages) or a referral for surgery (in an emergency when the ectopic pregnancy was detected late).

A case from obstetric practice

In my obstetric practice, there was a case when menstruation seemed to come on time or with a slight delay, and before menstruation the test showed negative result, but immediately after it, the pregnancy test shows, albeit pale, a second line, and the hCG level also confirms pregnancy. And after a while, the woman’s pregnancy is determined by ultrasound to be ectopic.

It is assumed that the first test could not yet detect pregnancy, and the bleeding was not a normal monthly menstruation, it was a reaction of the endometrium to an unusual pregnancy.

The pregnancy developed in the fallopian tube and, unfortunately, the surgeon was forced to remove it; it was of little use for further use. Two years after this incident, this young woman came to see me again; she was carrying a child under her heart, who is now quickly running up the stairs on the playground.

And in my practice there are dozens or even hundreds of such cases of pregnancy occurring in the presence of only one tube (even if it is narrow-passing), and this is great!

A. Berezhnaya, obstetrician-gynecologist

Self-diagnosis and self-medication during ectopic pregnancy are unacceptable.

This leads to its untimely detection, and as a consequence, to extensive internal bleeding and even death.

A woman can only assume that the pregnancy is ectopic, but she cannot treat it independently without the help of specialists.

At the first signs or suspicions, for the sake of your own health, contact a gynecologist. This will save you the opportunity to become a happy mother in the future.

Be healthy and sensible!

Most women are happy when they find out they are pregnant. It’s good when it develops normally and the growing tummy pleases the eye every day. But everything is not always so good. Two lines on the test will be a real curse if the embryo implanted outside the uterus. This pathological condition leads to serious consequences. Why does it occur and what to do if a woman finds out about an ectopic pregnancy?

Physiology

An ectopic (ectopic) pregnancy occurs when the fertilized egg is implanted outside the uterine cavity. This is very dangerous for the life and health of a woman.

Ectopic pregnancy is not that rare. About 2% of pregnancies are ectopic.

Fertilization of the egg takes place in the fallopian tube, then the zygote (the same fertilized egg) descends into the uterus and finds a “convenient place”, settles there and develops. The process lasts about a week.

During an ectopic pregnancy, the zygote remains in the tube, cervix or enters the ovary or abdominal cavity, localizes there and grows, causing tissue stretching with the threat of rupture and internal bleeding. Implantation during ectopic pregnancy is somewhat shorter than during normal pregnancy, and lasts 4–5 days from the moment of fertilization.

general information

Ectopic pregnancy is a dangerous pathology characterized by ectopic attachment of the fertilized egg. General information on this issue will make it possible to understand why and how this happens.

Risk factors

No woman is immune from ectopic pregnancy. Back in the 17th century, doctors of that time described cases of this pathology, and in the 18th century the first attempts to treat it were made.

Even after IVF, ectopic pregnancy is possible. During the procedure, the embryo is implanted in the uterine area, but it can migrate to the tube, ovary or cervix.

There are factors that increase the risk of getting this pathology. The main ones:

previous operations on the fallopian tubes and abortions;
sterilization;
ectopic pregnancies that have occurred in the past;
intrauterine devices;
inflammatory processes in the pelvic organs, both cured and progressive;
hormonal disorders;
infertility for more than two years;
mother's age is more than 35 years;
smoking;
severe stress;
slowness of sperm in a partner.

The mechanism of pathology development

Any pregnancy occurs due to the fusion of a sperm with an egg in the fallopian tubes. The zygote needs to reach the uterus and gain a foothold there for further development in the conditions provided for this by nature. The small unit of life does not move towards the uterus on its own. In this she is helped by special cilia of the epithelium: they line the inside of the fallopian tubes.

The process is disrupted if the cilia are damaged or do not perform their function correctly. Then the zygote does not have time to get into the uterus and remains in the tube, enters the ovary or abdominal cavity and continues to grow. This is how an ectopic pregnancy occurs, the consequences of which without timely treatment are very dire.

Classification

Ectopic pregnancy is divided into:

tubal pregnancy (most common);
ovarian pregnancy;
cervical pregnancy;
pregnancy in the abdominal cavity;
heterotopic pregnancy (one fertilized egg is located in the uterus, and the other outside it);
pregnancy in the scar after cesarean section (isolated cases).

Pathogenesis

How to distinguish an ectopic pregnancy from a normal one? In the early stages, ectopic pregnancy practically does not appear. Symptoms characteristic of normal pregnancy are possible: delayed menstruation, engorgement of the mammary glands, mild toxicosis. In the first 2 months after fertilization of the egg, the uterus enlarges due to hormonal changes, but then stops growing. However, over such a long period of time, an ectopic pregnancy will definitely make itself known.

The fertilized egg grows outside the uterine cavity. An increase in its size provokes pressure on surrounding tissues and their trauma.

The main signs and symptoms of any uncomplicated ectopic pregnancy, that is, at 2–4 weeks:

bloody issues from the vagina;
pain in the lower abdomen;
feeling of fullness in the stomach;
constipation

4–6 weeks is the period of pronounced clinical manifestations of ectopic pregnancy. The fertilized egg is already so large that it is no longer possible not to notice the signs of pathology. Abdominal pregnancy usually manifests itself later, but the main sign of a critical condition with this pathology is regular and debilitating abdominal pain. Such sensations indicate internal bleeding of a mild nature.

If the fertilized egg was fixed in the tube, then, most likely, a critical increase in the size of the egg will cause its rupture and, accordingly, very heavy internal bleeding. At this moment, the woman will feel acute pain until she loses consciousness. Pallor of the skin, slow pulse, vomiting, and weakness are noted. Sometimes the fertilized egg breaks open inside the tube (tubal miscarriage). This situation has a more favorable prognosis, because internal organs remain intact. Other types of ectopic pregnancy will also not go unnoticed. Pain and internal bruises will definitely manifest themselves.

The symptoms of ectopic pregnancy superficially resemble an incipient miscarriage during intrauterine pregnancy. Doctors often do not immediately determine what happened, and any delay is dangerous.

Consequences

Any type of ectopic pregnancy is extremely dangerous. How formerly pathology If it is identified and measures taken to eliminate it, the less serious the consequences will be. Untreated ectopic pregnancy can cause:

internal bleeding and associated anemia;
rupture of the fallopian tube, ovary;
pain shock;
adhesions in the pelvic area;
infertility;
death.

If you consult a doctor in time, you can reduce the risk of serious consequences. Therefore, for any unpleasant sensations in the abdominal area and in case of cycle disorders, you need to visit a gynecologist and be examined in accordance with his recommendations.

Diagnostics

Many doctors make a real diagnosis too late, when the woman is already in critical condition. This happens because the symptoms of the pathology are blurred or absent at all. If menstruation is late, positive test It is recommended to do an ultrasound for pregnancy. If the study does not reveal a fertilized egg, then you should sound the alarm, since there is a possibility that the embryo is outside the uterine cavity, but is still too small to be visualized using ultrasound. How can you accurately detect an ectopic pregnancy in the early stages? Medical examination To make an accurate diagnosis, it takes place in several stages.

Gynecological examination. The doctor should listen to the woman, paying attention Special attention in response to her complaints, calculate the approximate gestational age, finding out the date of the last menstruation, and then examine the patient. The gynecologist will be alerted to spotting and severe pain when palpating the abdomen.
Lab tests. If a woman is pregnant, her hCG level increases. To make a diagnosis, it is necessary to observe the dynamics of hCG. Normally, it doubles every 48 hours. With an ectopic and frozen pregnancy, hCG will not grow as quickly, but in the first case the fertilized egg is not visualized in the uterine cavity on ultrasound, and in the second it is easy to detect.
Ultrasound. To confirm the diagnosis, it is necessary to determine where the fertilized egg is located. To do this, a transvaginal ultrasound is performed 4–5 weeks after ovulation. This method is more accurate than conventional ultrasound. Detection of a fertilized egg in the ovary, tube or abdominal cavity confirms an ectopic pregnancy. Indirect signs of pathology detected by ultrasound are an increase in the size of the ovaries, accumulation of fluid in the peritoneum and behind the uterus. The absence of a fertilized egg in the uterus is an imprecise sign of ectopic pregnancy; in this case, further studies are prescribed as indicated.
Puncture of the posterior vaginal vault (culdocentesis). If internal bleeding is suspected due to a ruptured tube, women undergo a puncture from the pouch of Douglas, a special area of the peritoneum located between the rectum and uterus. Using a long needle, the doctor takes contents from this area, piercing the posterior vaginal fornix. Presence of blood with a large number of blood clots or blood clots – reliable sign ectopic pregnancy.
Laparoscopy. If other methods fail to determine the nature of pregnancy, doctors prescribe laparoscopy to diagnose the pathology. To do this, under anesthesia, a small incision is made in the abdomen, an optical device is inserted into it, the peritoneal area is inflated with carbon dioxide and the cavity is examined, looking for the fertilized egg. If it is found, it is deleted.

Treatment

All women with suspected ectopic pregnancy are taken by ambulance to the gynecological department, and with acute pain and bleeding - to the nearest surgical department.

A high level of hCG (more than 1500 IU/l), together with other symptoms, indicates a progressive ectopic pregnancy. In this case, as well as in life-threatening situations (with internal bleeding, painful shock), surgical treatment is directly indicated for the woman. It can be radical (the fertilized egg with its receptacle is removed) and organ-preserving.

An alternative to surgical intervention is the use of the drug Methotrexate. In Russia, it is prescribed for the treatment of various tumors and autoimmune diseases, and the instructions do not describe dosages and methods of use for ectopic pregnancy. However, in other countries the drug is actively used to remove the fertilized egg from the tubes, ovaries and cervix, as well as the peritoneal cavity. Methotrexate has an embryotoxic effect, that is, it prevents the division of embryonic cells and destroys it for excretion naturally. The medicine is injected intravenously (the dosage is selected by the doctor), after which the hCG level in dynamics. If Methotrexate has worked, then the level of the hormone should steadily decrease.

Non-surgical treatment is a good alternative that helps preserve a woman’s reproductive health. It can be used only in the very early stages of pathology, and it is quite difficult to detect it so early. Therefore, surgery is often the only option to save the patient’s life.

Forecast

Even if a woman has an ectopic pregnancy, she does not need to give up on herself. During surgery, as a rule, only one tube and ovary are removed. These organs are paired, which means that ovulation and conception are possible with the help of the remaining intact ovary and tube. Removal of both tubes will entail physiological infertility, but even in this case, if there is a uterus, IVF will come to the rescue.

A woman who has experienced an ectopic pregnancy should take care of herself for at least another six months (and preferably longer) and use protection. The choice of contraception method should be left to the attending physician. There are many reasons for an ectopic pregnancy, and which of them provoked improper attachment of the fertilized egg is an open question. After treating this pathology, you need to undergo additional examinations and find out for sure why it arose. Many women will undergo testing for tubal patency to rule out recurrence.

Prevention

Every woman who does not want to experience an ectopic pregnancy should know about methods of preventing it. Prevention of pathology comes down to the following set of measures:

timely treatment of inflammatory diseases of the pelvic organs;
planning pregnancy and conducting the necessary diagnostic examinations (including for the presence of pathogenic microorganisms);
exclusion of abortions (reliable contraception during periods undesirable for pregnancy);
high-quality rehabilitation after cases of ectopic pregnancy;
conducting healthy image life and avoiding stress.

All these measures will help reduce the risk of ectopic pregnancy and increase the chances of conceiving and giving birth to a long-awaited baby without complications.

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Can pregnancy develop in the abdominal cavity? Ectopic pregnancy

Anatomy and physiology of the uterus at conception

Causes of ectopic pregnancy

Inflammatory process in the uterine appendages

Surgeries on the fallopian tubes and abdominal organs

Hormonal imbalances

Endometriosis

Abnormalities of the genital organs

Tumors in the pelvis

Exposure to toxic substances

In Vitro Fertilization

Risk factors

Symptoms of ectopic pregnancy

Signs of a progressive ectopic pregnancy

Signs of tubal abortion

Signs of a ruptured fallopian tube

Diagnosis of ectopic pregnancy

Clinical examination

Ultrasonography

Human chorionic gonadotropin level

Progesterone level

Abdominal puncture through the posterior vaginal fornix ( culdocentesis)

Diagnostic curettage of the uterine cavity

Laparoscopy

Treatment of ectopic pregnancy

Is it possible to have a baby with an ectopic pregnancy?

Is it possible to treat an ectopic pregnancy without surgery?

Surgery

Postoperative period

Prevention of ectopic pregnancy

What should you do to avoid an ectopic pregnancy?

What should you avoid to prevent ectopic pregnancy?

Classification

Causes

Symptoms

Diagnostics

Treatment

Consequences

Types of ectopic pregnancy

Symptoms of ectopic pregnancy

Causes of ectopic pregnancy

Consequences of ectopic pregnancy

Treatment of ectopic pregnancy

Physiology

general information

Risk factors

The mechanism of pathology development

Classification

Pathogenesis

Consequences

Diagnostics

Treatment

Forecast

Prevention

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