Symptoms of pregnancy in the abdominal cavity. Abdominal abdominal pregnancy. Causes and risk factors

In today's article we will talk about pregnancy, which for some objective reason develops outside the uterus, a container for a fertilized egg, specially intended for this purpose.

Types of ectopic pregnancy

There are several main, most common types ectopic pregnancy:

Tubal pregnancy is a type of pregnancy when ovum attached to the walls of the fallopian and fallopian tubes;
Ovarian pregnancy - when fertilization and development of the fertilized egg occurs directly in the ovary or on its surface;
Cervical - with this type of pregnancy, the zygote (fertilized egg) is attached to the cervix;
Abdominal pregnancy - in this case, the fertilized egg is implanted directly in the abdominal cavity.

Let's take a closer look at the development of abdominal pregnancy.

Features of abdominal pregnancy

This is a fairly rare type of pregnancy; it occurs in only one woman in a thousand. Abdominal pregnancy can be divided into two subtypes:

Primary abdominal pregnancy. In this case, it means implantation of the zygote directly in the abdominal cavity.
Secondary pregnancy. This means that the fertilized cell is introduced into the abdominal cavity due to the termination of any other type of ectopic pregnancy. For example, when the fetus develops in the fallopian tube up to certain period. If the fetus has reached such a size that the tube has ruptured, then it is very likely that the fetus will enter the abdominal cavity and will continue to develop there.

I would immediately like to draw attention to the fact that any ectopic pregnancy is a direct threat to the health and life of a woman. A tubal or abdominal pregnancy can be determined with great difficulty by ultrasound, even if the examination is carried out by experienced diagnosticians using the most modern equipment.

Diagnosis of abdominal pregnancy

Abdominal pregnancy, as mentioned above, can only be determined by a qualified specialist, however, there are some symptoms and signs by which one can understand that a pathological pregnancy is developing. Among these symptoms are the following:

On early stages During pregnancy, a woman feels severe pain in the lower abdomen and notices bloody discharge from the vagina.
When palpated in the abdominal cavity, characteristic compactions and parts of the fetus are felt, while the uterus is palpated separately and of very small size;
Often, abdominal pregnancy is accompanied by an increase in temperature of unknown etymology.
When abdominal pregnancy occurs, all the signs of a normal pregnancy are present (nausea, weakness, dizziness, odor intolerance, morning vomiting), although the test does not show such.

As a rule, if the doctor suspects an abdominal pregnancy, he carefully examines the woman during an ultrasound. However, this modern method is not always able to identify the place where the fertilized egg is attached in the abdominal cavity. If an ultrasound examination does not show any useful information, then the doctor has the right to prescribe a diagnosis using fluoroscopy, computed tomography, or magnetic resonance imaging.

In conclusion, I would like to say that in cases of ectopic pregnancy, there is only one way out - surgery to terminate the pregnancy. Because, firstly, babies developing outside the uterus are not viable, and secondly, such a pregnancy poses a real threat to the life of the mother.

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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.

The place of development of an ectopic 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 the 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 better 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 of the fertilized egg occurs.

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 ends 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 fluid flow directed to the uterine cavity and resulting from the secretion of 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 the normal functioning of the female body, these mechanisms are eliminated within a few days, thanks 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, early stages education 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 pipe rupture 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 in such a limited space as the lumen of the fallopian tube can cause its complete blockage, which will lead either to the impossibility of conception or to an ectopic pregnancy.

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 a connective tissue, 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 placing ligatures on 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;
affects 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 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 some 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 what large quantity they enter the body, the more serious disorders they can provoke.

Ectopic pregnancy can occur due to exposure to a variety of toxic substances. Special attention The toxins contained in tobacco smoke, alcohol and drugs deserve 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 the processes carried out 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 species fertilization, there are already 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 during pregnancy termination, which can occur as a tubal abortion or tube rupture, a clear clinical picture of an acute abdomen arises, 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 in early 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, since they are characteristic of later stages of 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. Emergence bloody discharge 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 appears in the lower abdomen with irradiation to the right hypochondrium, interscapular region, and 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.
Urge to defecate, loose stools. 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 the negative effects of hypoxia on the 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 pale 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 a progressive ectopic pregnancy makes it possible to prevent such formidable and dangerous complications as tubal abortion and rupture of the fallopian tube.

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 of intrauterine pregnancy is the detection of a gestational sac ( term used exclusively in ultrasound diagnostics), yolk sac and 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 of an incorrectly 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 of artificial administration of pharmacological drugs 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 level 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 a fairly effective and simple diagnostic method, it can be misleading in the case of simultaneous development of uterine 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 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 a radical method in which the “pregnant” fallopian tube is removed. This type of 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 the damaged part of it, which makes it possible to preserve its function to some extent.

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;
carrying out 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:

promptly treat infectious diseases of the genital organs;
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.

(Fig. 156) is primary and secondary. Primary abdominal pregnancy is extremely rare, that is, a condition when the fertilized egg is grafted onto one of the abdominal organs from the very beginning (Fig. 157). In recent years, several reliable cases have been described. Primary implantation of the egg on the peritoneum can only be proven in the early stages of pregnancy; c, this is supported by the presence of functioning villi on the peritoneum, the absence of microscopic signs of pregnancy in the tubes and ovary (M. S. Malinovsky).

Rice. 156. Primary abdominal pregnancy (according to Richter): 1 - uterus; 2 - rectum; 3 - fertilized egg.

Secondary abdominal pregnancy develops more often; in this case, the egg is initially implanted in the tube, and then, having entered the abdominal cavity during a tubal miscarriage, it is implanted again and continues to develop. The fetus during a late ectopic pregnancy often has certain deformities that arise as a result of unfavorable conditions for its development.

M. S. Malinovsky (1910), Sittner (1901) believe that the frequency of fetal deformities is exaggerated and amounts to no more than 5-10%.

During abdominal pregnancy, in the first months, a tumor is detected that is located somewhat asymmetrically and resembles the uterus. Unlike the uterus, the fetal receptacle does not contract under the arm during an ectopic pregnancy. If it is possible to identify the uterus separately from the tumor (fetal sac) during vaginal examination, the diagnosis is simplified. But with intimate fusion of the fetal sac with the uterus, the doctor easily makes a mistake and diagnoses intrauterine pregnancy. It should be borne in mind that the tumor is most often spherical or irregular in shape, limited in mobility and has an elastic consistency. The walls of the tumor are thin, do not shrink upon palpation, and parts of the fetus are sometimes surprisingly easy to identify when examined with a finger through the vaginal fornix.

If intrauterine pregnancy is excluded or the fetus has died, probing of the uterine cavity can be used to clarify its size and position.

Rice. 157. Abdominal pregnancy: 1-fiche loops fused to the fetal receptacle; 2 - fusions; 3 - fruit container; 4-placenta; 5 - uterus.

At first, abdominal pregnancy may not cause any particular complaints from the pregnant woman. But as the Fetus develops, in most cases complaints of constant, excruciating abdominal pain appear, resulting from an adhesive process in the abdominal cavity around the fetal egg, causing reactive irritation of the peritoneum (chronic peritonitis). The pain intensifies with fetal movement and causes excruciating suffering for the woman. Lack of appetite, insomnia, frequent vomiting, constipation lead to exhaustion of the patient. All of these phenomena are especially pronounced if the fetus, after rupture of the membranes, is in the abdominal cavity, surrounded by intestinal loops fused around it. However, there are cases when the pain is moderate.

By the end of pregnancy, the fetal receptacle occupies most of the abdominal cavity. Parts of the fetus are in most cases identified under the abdominal wall. Upon palpation, the walls of the fetal sac do not contract under the hand and do not become denser. Sometimes it is possible to identify a separate, slightly enlarged uterus. When the fetus is alive, its heartbeat and movements are determined. X-rays with filling of the uterus with a contrast mass reveal the size of the uterine cavity and its relationship with the location of the fetus. When an ectopic, particularly abdominal, pregnancy is carried to term, labor pains appear, but the throat does not open. The fetus dies. If the fetal sac ruptures, a picture of acute anemia and peritoneal shock develops. The risk of rupture of the fetal sac is greater in the first months of pregnancy, and subsequently decreases. Therefore, a number of obstetricians, trying to obtain a viable fetus, find it possible in cases where the pregnancy exceeds VI-VII months and the pregnancy is in satisfactory condition, to wait with the operation and do it close to the expected due date (V.F. Snegirev, 1905 ; A.P. Gubarev, 1925, etc.).

M. S. Malinovsky (1910), based on his data, believes that surgery at the end of a progressive ectopic pregnancy is technically no more difficult and is accompanied by no less favorable results than in early months. However, most authoritative obstetricians and gynecologists, both domestic and foreign, believe that any diagnosed ectopic pregnancy should undergo surgery immediately.

Rupture of the fruit receptacle during later pregnancy poses a huge danger to a woman’s life. Ware indicates that the maternal mortality rate for late ectopic pregnancies was 15%. Timely diagnosis before surgery can reduce mortality in women. A number of cases have been described in the literature when the development of an ectopic pregnancy stopped, the uterine membrane was released from the uterus, regressive phenomena began and regular menstruation began. The fruit, subjected to encystation in such cases, becomes mummified or, saturated with calcium salts, petrifies. Such a fossilized fetus (lithopedion) can remain in the abdominal cavity for many years. There is even a case of lithopedion remaining in the abdominal cavity for 46 years. Sometimes a dead fertilized egg suppurates, and the abscess opens through the abdominal wall into the vagina, bladder or intestines. Along with the pus, parts of the decaying fetal skeleton emerge through the resulting fistula opening.

With modern medical care, such outcomes of ectopic pregnancy are the rarest exception. On the contrary, cases of timely diagnosis of late ectopic pregnancy have become increasingly published.

Surgery for progressive abdominal pregnancy, performed by transection, presents significant and sometimes great difficulties. After opening the abdominal cavity, the wall of the fetal sac is dissected and the fetus is removed, and then the amniotic sac is removed. If the placenta is attached to the posterior wall of the uterus and the broad ligament, then its separation does not present any great technical difficulties. Ligatures or puncturing sutures are applied to bleeding areas. If the bleeding does not stop, it is necessary to ligate the main trunk of the uterine artery or the hypogastric artery on the corresponding side.

In case of severe bleeding, before ligating these vessels, the assistant should press the abdominal aorta to the spine with his hand. The greatest difficulty is the separation of the placenta attached to the intestine and its mesentery or liver. Surgery for late ectopic pregnancy is only available to an experienced surgeon and should consist of transection, removal of the fetus, placenta, and stopping bleeding. The operator must be prepared to perform a bowel resection if the placenta is attached to its walls or mesentery and this becomes necessary during the operation.

In earlier times, due to the risk of bleeding during the separation of the placenta attached to the intestines or liver, the so-called marsupialization method was used. At the same time, the edges sac or parts of it were sewn into the abdominal wound and a Mikulicz tampon was inserted into the cavity of the sac, covering the placenta remaining in the abdominal cavity. The cavity gradually decreased, and a slow (over 1-2 months) release of the necrotizing placenta occurred.

The marsupialization method, designed for spontaneous rejection of the placenta, is antisurgical, with modern conditions it can be used by an experienced operator only as a last resort, and also under the condition that the operation is performed as an emergency by an insufficiently experienced surgeon. If the fetal sac is infected, marsupialization is indicated.

Mynors (1956) writes that in late ectopic pregnancies the placenta is often left in situ, covering the abdominal wound. In this case, the placenta is detected by palpation for several months, but Friedman’s reaction to pregnancy becomes negative after 5-7 weeks.

During surgery for late progressive ectopic pregnancy, despite the good condition of the patient, it is necessary to prepare in advance for blood transfusion and anti-shock measures.

During the operation, severe bleeding may suddenly occur, and a delay in providing emergency care increases the danger to the woman’s life.

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983

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 of the 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.

– a pregnancy in which the fertilized egg is implanted not in the uterus, but in the abdominal cavity. Risk factors are inflammatory diseases of the appendages, surgeries on the reproductive organs, long-term use of IUDs, genital infantilism, pelvic tumors, endocrine disorders and stress. In its manifestations, before complications arise, abdominal pregnancy resembles normal gestation. There is a high probability of internal bleeding and damage to abdominal organs. The diagnosis is made on the basis of complaints, anamnesis, data from a general and gynecological examination and the results of instrumental studies. Treatment is surgical.

Abdominal pregnancy is a pregnancy in which the embryo is implanted not in the uterine cavity, but in the omentum, peritoneum, or on the surface of the abdominal organs. Accounts for 0.3-0.4% of the total number of ectopic pregnancies. Risk factors for the development of abdominal pregnancy are pathological changes in the reproductive system, age, stress and endocrine disorders. The outcome depends on the location of implantation of the fertilized egg, the level of blood supply and the presence of large vessels in the area of embryo implantation. Fetal death, damage to large vessels and internal organs are possible. Abdominal pregnancy is an indication for urgent surgery. Treatment of this pathology is carried out by obstetricians-gynecologists.

Causes of abdominal pregnancy

The sperm penetrates the egg in the ampulla of the fallopian tube. As a result of implantation, a zygote is formed, covered with a shiny membrane of the egg. Then the zygote begins to divide and simultaneously moves along the fallopian tube under the influence of peristaltic contractions and vibrations of the cilia of the tubal epithelium. In this case, the undifferentiated cells of the embryo are held together by a common zona pellucida. The cells are then divided into two layers: the inner (embryoblast) and outer (trophoblast). The embryo enters the blastocyst stage, enters the uterine cavity and “sheds” the zona pellucida. The trophoblast villi penetrate deeply into the endometrium—implantation occurs.

Abdominal pregnancy occurs in two cases. The first is if the fertilized egg is in the abdominal cavity at the time of implantation (primary abdominal pregnancy). The second is if the embryo is first implanted in the fallopian tube, then rejected as a tubal abortion, enters the abdominal cavity and is re-implanted on the surface of the peritoneum, omentum, liver, ovary, uterus, intestines or spleen (secondary abdominal pregnancy). It is often not possible to distinguish between the primary and secondary forms, since a scar forms at the site of primary implantation after rejection of the embryo, which is not detected during standard studies.

Risk factors for the development of abdominal pregnancy are inflammatory diseases of the ovaries and fallopian tubes, adhesions and disturbances in the contractility of the tubes as a result of surgical interventions, elongation of the tubes and slowdown of tubal peristalsis during genital infantilism, mechanical compression of the tubes by tumors, endometriosis of the fallopian tubes, IVF and long-term use of the intrauterine device. In addition, the likelihood of abdominal pregnancy increases with diseases of the adrenal glands and thyroid gland and with an increase in the level of progesterone, which slows down tubal peristalsis. Some authors point to a possible connection between abdominal pregnancy and premature activation of trophoblast.

In smoking women, the risk of abdominal pregnancy is 1.5-3.5 times higher than in non-smokers. This is due to decreased immunity, disturbances in the peristaltic movements of the fallopian tubes and delayed ovulation. Some researchers point to a connection between abdominal pregnancy and stress. Stressful situations negatively affect the contractile activity of the fallopian tubes, causing antiperistaltic contractions, as a result of which the embryo is retained in the tube, attached to its wall, and then, after a tubal abortion, is re-implanted in the abdominal cavity.

In recent decades, the problem of ectopic pregnancy (including abdominal pregnancy) in women of late reproductive age has become increasingly urgent. The need to build a career and improve their social and financial situation encourages women to postpone having a child. Meanwhile, with age, hormonal levels change, tubal peristalsis becomes less active, and various neurovegetative disorders occur. In women over 35 years of age, the risk of developing abdominal pregnancy is 3-4 times higher than in women under the age of 24-25 years.

The course of abdominal pregnancy depends on the characteristics of the site of attachment of the embryo. If implanted in an area with poor blood supply, the fetus dies. When attached in a place with an extensive network of small vessels, the embryo can continue to develop, as during normal gestation. Moreover, the likelihood of congenital malformations during abdominal pregnancy is much higher than during normal gestation, since the fetus is not protected by the uterine wall. Abdominal pregnancies are extremely rarely carried to term. When large vessels grow into chorionic villi, massive internal bleeding occurs. Invasion of the placenta into the tissue of parenchymal and hollow organs causes damage to these organs.

Symptoms of abdominal pregnancy

Before complications arise, abdominal pregnancy exhibits the same symptoms as during normal gestation. In the early stages, nausea, weakness, drowsiness, changes in taste and olfactory sensations, absence of menstruation and engorgement of the mammary glands are observed. During a gynecological examination, it is sometimes possible to discover that the fetus is not in the uterus, and the uterus itself is slightly enlarged and does not correspond to the gestational age. In some cases, the clinical picture of abdominal pregnancy is not recognized, but is interpreted as a multiple pregnancy, pregnancy with a myomatous node or congenital anomalies of the uterus.

Subsequently, a patient with abdominal pregnancy may complain of pain in the lower abdomen. When small vessels are damaged, increasing anemia is observed. Clinical manifestations of damage to internal organs are highly variable. Sometimes such complications during abdominal pregnancy are mistaken for a threat of uterine rupture, premature placental abruption or a threat of interruption of gestation. Severe weakness, dizziness, fainting, loss of consciousness, darkening of the eyes, increased sweating, pain in the lower abdomen, pallor of the skin and mucous membranes indicate the development of internal bleeding - an emergency pathology that poses an immediate danger to the life of the pregnant woman.

Diagnosis and treatment of abdominal pregnancy

Early diagnosis of abdominal pregnancy is extremely important, as it allows you to avoid the development of dangerous complications and eliminate the threat to the life and health of the patient. The diagnosis is established based on gynecological examination and ultrasound results. To avoid diagnostic errors, the study begins with the identification of the cervix, then visualizes the “empty” uterus and the fertilized egg located to the side of the uterus. When performing an ultrasound in the late stages of abdominal pregnancy, an unusual localization of the placenta is detected. The fetus and placenta are not surrounded by the walls of the uterus.

In doubtful cases, laparoscopy is performed - a minimally invasive therapeutic and diagnostic intervention that allows one to reliably confirm an abdominal pregnancy and, in some cases (in the early stages of gestation), remove the fertilized egg without performing a major operation. In later stages, when placental villi grow into the abdominal organs, laparotomy is required. The extent of surgical intervention during abdominal pregnancy is determined by the location of the placenta. Suturing or resection of the organ, intestinal anastomosis, etc. may be required.

The prognosis for the mother with early detection and timely surgical treatment of abdominal pregnancy is usually favorable. With late diagnosis and the development of complications, there is a very high risk unfavorable outcome (death due to bleeding, severe damage to internal organs). The likelihood of a successful abdominal pregnancy being carried to term is extremely low. The literature describes isolated cases of successful surgical delivery in late gestation, but such an outcome is considered as casuistic. It is noted that babies born as a result of abdominal pregnancy often have developmental abnormalities.