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Causes and risk factors for ectopic pregnancy. The clinical signs and symptoms.

If an ectopic (ectopic) pregnancy, the fertilized egg develops outside the uterus: in the abdomen, on the ovaries, the fallopian tubes, cervix. In industrialized countries, the average frequency of ectopic pregnancy is 1.2-1.7% relative to the total number of pregnancies. In Russia, an ectopic pregnancy occurs in 1.13 cases per 100 pregnancies, or 3.6 cases per 100 live births. Due to the fact that the location of abnormal pregnancy, development of its blood supply from the ovum formed pathological implantation space. With further growth of the pregnancy creates a risk of rupture body in which developing ectopic pregnancy, due to the fact that only the uterus is adapted to accommodate the growing fetus.

In case of late diagnosis and without adequate treatment of ectopic pregnancy can be dangerous for a woman's life. In addition, ectopic pregnancy can lead to infertility. Every 4th female patient develops repeated ectopic pregnancy, every 5-6 arises adhesive process in the pelvis, and in 3/4 of women after surgical treatment of secondary infertility arises.

The most common among all sites of ectopic pregnancy occurs tubal pregnancy (97.7%). In this fertilized egg is located in the pipe section ampullar 50% of cases, in the middle of the tube to the 40% portion of the mother tube in 2-3% of patients and in the pipe fimbriae 5-10%.  Ovarian, cervical, abdominal, intraligamentarnaya and develop in a rudimentary uterine horn pregnancy is a rare form of ectopic pregnancy. Ovarian pregnancy occurs in 0.2-1.3% of patients. There are two forms of ovarian pregnancy: when the fertilized ovum takes place inside the cavity of the follicle to ovulate, and when the implantation of the ovum takes place on the surface of the ovary.  Abdominal pregnancy occurs in 0,1-1,4% of cases. In primary abdominal pregnancy, the ovum is implanted directly on the right peritoneum, omentum, intestines or other internal organs of the abdominal cavity. Secondary abdominal pregnancy is generated when the fertilized egg gets into the abdominal cavity of the pipe. There is information about the possibility of a primary abdominal pregnancy after IVF in the treatment of infertility patient. The frequency of cervical pregnancy is 0.1-0.4%. In this fertilized egg is implanted in the columnar epithelium of the cervical canal. Trophoblastic villi penetrate deeply into the cervical muscle membrane, which leads to the destruction of tissue and its blood vessels and ends in a massive hemorrhage.

It is a rare form of ectopic pregnancy in the uterine horn extension, accounting for 0.2-0.9% of cases. Despite the fact that the implantation of the ovum in the uterine horn in terms of topographical anatomy characteristic uterine pregnancy, but clinical signs are identical to those of uterine rupture. Very rarely (0.1%) occurs intraligamentarnaya ectopic pregnancy, where the fertilized egg develops between the sheets of the broad ligament of the uterus, which falls (second) after the rupture of the pipe wall to the side of the mesentery of the fallopian tube. Rarely seen and heterotopic (Multiple) pregnancy, when the uterus has one fertilized egg, and the other is located outside of the uterus. The frequency of this disease is increasing in connection with the use of modern technologies of assisted reproduction (IVF) in this case reaching a frequency of 1 to 100-620 pregnancies

Causes and risk factors for ectopic pregnancy

  • transferred inflammatory diseases of the uterus (the most dangerous in this sense is a chlamydial infection);
  • transferred prior ectopic pregnancy (risk probability of repeated ectopic pregnancy increases by 7-13 times);
  • intrauterine device;
  • stimulation of ovulation;
  • surgeries on pipes;
  • tumors and tumor-like formations of the uterus and appendages;
  • endometriosis;
  • genital infantilism;
  • hormonal contraception;
  • anomalies of the genital organs;
  • transferred before abortion;
  • the use of auxiliary methods of reproduction.

Against the background of these pathological conditions violated the physiological promotion of a fertilized egg toward the uterus.

Clinical signs and symptoms

In most cases, there is a tubal pregnancy, which is usually formed in the right fallopian tube. The clinical picture depends on the location of the ovum, the duration of pregnancy, whether the pregnancy progresses, or it is interrupted. In the latter case, the clinical manifestations depend on the nature of abortion - the type of tubal abortion or a rupture of the pipe.
The classic clinical signs interrupted ectopic pregnancy are: pain, delayed menstruation and vaginal bleeding. However, not all cases, there are these typical manifestations. Patients with ectopic pregnancy and there are some other symptoms that can occur in the early stages and intrauterine pregnancy: nausea, breast enlargement, fatigue, cramping abdominal pain, pain in the shoulder.
Symptoms unique to the progressive tubal pregnancy, does not exist. The patient observed exactly the same feeling as a normal progressive uterine pregnancy. However, gynecological examination in progressive tubal pregnancy symptoms are the following: insufficient softening of the uterus and its isthmus; bland cyanosis of the mucous membranes of the vagina and cervix; preservation of pear-shaped uterus; no early signs of intrauterine pregnancy; appendages determined in tumor formation, or kolbasovidnoy oval shape, or a soft elastic consistency; limited mobility and pain of this education.

Tubal pregnancy is usually suspended for 4-6 weeks (much less to develop an 8-week period). Most tubal pregnancy is terminated on the type of tubal abortion, accompanied by cramping pains, testifies to damage the integrity of the ovum. Characterized by sudden onset of pain, which may be accompanied by complaints of severe weakness, dizziness, nausea, sweating. It is also possible loss of consciousness. Pain can give to the anus, lower back, legs. Usually after a while (a few hours) after the pain attack in 50-80% of patients from the genital tract bleeding or scant notes dark, sometimes brown spotting. In the early stages of the embryo dies, the bleeding stops, resorption takes place ovum. At a later date the ovum entirely rejected and getting into the abdominal cavity, can be implanted in the various organs that can be realized in the form of an abdominal pregnancy. However, most often after the rejection of the ovum bleeding does not stop, and the clinical picture depends on the severity of blood loss. In most cases, tubal abortion is not characterized by the presence of a massive intra-abdominal bleeding and severe anemia. Symptoms erased, the disease is usually slow, from a few days to a few weeks.

Every third female patient violation of ectopic pregnancy proceeds as pipe rupture, accompanied by profuse bleeding. Patients usually marked a sharp severe pain in the abdomen, extending to the rectum, collarbone, upper quadrant. There is a sharp deterioration, weakness, cold sweats, loss of consciousness, dizziness, nausea, vomiting. At external survey indicated confusion, apathy; pale skin and mucous membranes; pallor or cyanosis of the lips; cold sweat; dyspnea. As a result of significant blood loss with intraperitoneal bleeding occurs tinnitus, flashing "flies" before their eyes, drop in systolic blood pressure below 80 mm Hg. Art. The abdomen was soft, moderately swollen, defined by a sharp pain in the lower divisions. When vaginal study determined cyanosis or pallor of the mucous membranes of the vagina and cervix; the absence of external bleeding; enlarged and soft texture of the uterus; sharp pain in the cervical motion to the pubis; often marked flattening of the arch of the side; tumor formation testovatoy consistency detected in the area of appendages.

Diagnosis of ectopic pregnancy

When progressive tubal pregnancy diagnosis is often difficult. It should focus on the data history (past illnesses, delayed menstruation, etc.), taking into account the risk factors.   The largest medical data can be obtained at a vaginal examination. Of great importance for the diagnosis of ectopic pregnancy and the differential diagnosis with other diseases have an ultrasound. The most reliable criterion for ultrasonic detection of ectopic pregnancy is located outside the uterine cavity of the ovum with a living embryo is visualized cardiac activity, and for more than 7 weeks of its motor activity. However, the frequency of such clinical situations is not more than 8%. Carrying sighting puncture recto-uterine pouch under ultrasound for suspected terminate a pregnancy increases the efficiency of research by 1.5-2 times, allowing to diagnose intra-abdominal bleeding is minimal.
Important diagnostic value is laparoscopy, which allows you to visually determine the condition of the uterus, ovaries, tubes, blood loss, the localization of ectopic gestational sac, to evaluate the nature of pregnancy (progressive or impaired), and in many cases - to carry out surgery. Determination of beta-subunit of human chorionic gonadotropin is currently an auxiliary test to identify ongoing pregnancy. The results of this test are significant in conjunction with other studies.

Ectopic pregnancy should be distinguished from: progressive uterine pregnancy small period of time; and began threatening abortion; corpus luteum cyst with hemorrhage; ovarian apoplexy; inflammation of the uterus; dysfunctional uterine bleeding; torsion legs pridatkovogo education; circulatory disorders of fibroids in the node; acute appendicitis, peritonitis.

Treatment of an ectopic pregnancy

The main treatment for an ectopic pregnancy is surgical. However, over the past two decades are increasingly using minimally invasive surgery techniques in order to maintain the tube and its function. Worldwide laparoscopy in the treatment of patients with ectopic pregnancy has become the method of choice in most cases. The operation with the opening of the abdominal cavity is usually used for the treatment of those patients who have hemodynamic disturbances, as well as the localization of fetal eggs in a rudimentary uterine horn. In addition, such access is advantageous for surgeons who do not speak laparoscopy, and in patients where the laparoscopic approach obviously difficult (e.g., when expressed obesity, abdominal presence of significant amounts of blood and in severe adhesions in the abdominal cavity). The choice of surgical approach and the nature of the operation for tubal pregnancy depends on the general condition of the patient, blood loss volume, severity of adhesions in a small pelvis, localization and size of the gestational sac, the quality of equipment and qualification of endoscopic endoscopist.

Rehabilitation measures after an ectopic pregnancy should be aimed at the restoration of reproductive function following surgery. These include: the prevention of adhesions; contraception; normalization hormonal changes. To prevent adhesions widely used physiotherapy techniques: AC pulsed magnetic field of low frequency, low-frequency ultrasound, supersonic frequency currents (ultratonotherapy), low-level laser therapy, electrical stimulation of the fallopian tubes; UHF therapy, electrophoresis zinc lidazy and ultrasound in a pulsed mode. In the course of anti-inflammatory therapy and for 1 month after the recommended contraception, the question of its duration is achieved individually, depending on the age of the patient and the features of its reproductive function. Of course, should take into account a woman's desire to preserve reproductive function. The duration of hormonal contraception and especially individual, but will usually not be less than 6 months after surgery.

After the end of rehabilitation, before recommending to plan another pregnancy, it is advisable to perform a diagnostic laparoscopy to assess the condition of the fallopian tubes and other pelvic organs. If the control laparoscopy revealed no abnormalities, the patient was allowed to get pregnant in the next menstrual cycle.


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