Ectopic pregnancy

Ectopic (ectopic – “displaced”) pregnancy is a pregnancy in which the fertilized egg is implanted “in the wrong place” – outside the uterine cavity. Pregnancy in ectopic pregnancy is impossible. Depending on the place of attachment of the fertilized egg, there are ovarian, tubal, abdominal, and cervical pregnancies. The most common (98% of ectopic pregnancies) is tubal pregnancy.

Tubal pregnancy

In tubal pregnancy, the ovum is implanted in the mucous membrane of the fallopian tube as deep as in the endometrium. Tubal pregnancy is divided into species depending on which department the ovum is located: isthmic, interstitial, ampullary and fimbrial. Ampullary and isthmic pregnancies are more common than all others.

There are the following clinical forms of tubal pregnancy:

1. Progressive (intact) pipe pregnancy. At such pregnancy at early terms of the woman there are no complaints, the condition is satisfactory. Body temperature is usually normal.
2. Broken pipe pregnancy. Options for abortion can be:
   • by type of tubal abortion. Violation of tubal pregnancy by the type of tubal abortion is most common when the ovum develops in the ampullary or fimbrial part of the tube.
   • by type of uterine rupture (with delayed menstruation for an average of 3-4 weeks.). If the development of a fertilized egg occurs in the isthmic part of the tube, the violation of pregnancy occurs by the type of rupture of the tube, which is accompanied, as a rule, by severe internal bleeding.

Causes of ectopic pregnancy

There are many reasons (risk factors) for ectopic pregnancy:

• Infectious inflammation appendages of the uterus, ovaries and bladder, as well as infectious complications after childbirth or abortion, scraping the uterus.
• Chronic salpingitis (inflammation of the fallopian tubes) increases the risk of ectopic pregnancy by 7 times. Chlamydial salpingitis is more often complicated by ectopic pregnancy than gonococcal.
• Congenital defects of the fallopian tube can lead to abnormalities in embryo implantation in the uterus and cause ectopic pregnancy.
• Adhesion process in the pelvis due to endometriosis causes narrowing of the fallopian tubes. This complicates the transport of the egg into the uterine cavity and can also lead to the implantation of the embryo in the fallopian tube – ie to the development of ectopic pregnancy.
• Operations.For example, when removing appendicitis or after a cesarean section, or after surgery on the fallopian tubes for inflammatory diseases.
• Infertility.In infertility, regardless of the cause, there is an increased risk of ectopic pregnancy, as well as long-term use of drugs containing hormones for the treatment of infertility.
• Hormonal disorders in the body of a pregnant woman and the age of a woman over 35 years.
• Intrauterine spiral. (Navy). Ectopic pregnancy can occur when using the IUD (intrauterine contraceptives).
• ECO. In vitro fertilization with embryo or zygote transfer, artificial insemination is complicated by ectopic pregnancy in approximately 5% of cases.

The above conditions can lead to obstruction of the fallopian tubes or violation of their contraction, which in turn leads to ectopic pregnancy.

Signs of ectopic pregnancy in the early stages

Signs in the early stages of ectopic pregnancy do not differ from the condition under normal conditions (uterine) pregnancy in the early stages: delayed menstruation, breast enlargement, nausea, unusual taste sensations, etc. That is, initially the body perceives this pathology as a normal pregnancy. At the broken ectopic pregnancy pallor of integuments and mucous membranes, frequent weak pulse can be noted, BP can be lowered. In the clinical analysis of pregnant blood – anemia is detected.

Probable clinical signs of ectopic pregnancy are the lag in the size of the uterus during the expected pregnancy and the pregnant woman’s complaint of pathological bleeding and pain in the lower abdomen.

Reliable diagnostic signs of ectopic pregnancy are the definition of the ovum in the fallopian tube by ultrasound or diagnostic laparoscopy.

Symptoms of ectopic pregnancy

During ectopic pregnancy, women have complaints:

• delayed menstruation;
• on dark bloody discharge from the genital tract;
• nausea, dizziness, single vomiting;
• lower abdominal pain of various nature and intensity;
• irradiation (spread) of pain in the lumbar region, buttocks, rectum, inner thigh.

Symptoms gradually increase as the ovum grows. The main symptom of ectopic pregnancy – pain. At the very beginning, the painful sensations in the lower abdomen are tolerable; paroxysmal (cramping) unilateral pain on the left or right can give in the rectum or lower back. If you have symptoms such as pain and bloody discharge (from slight dark brown to red), and there is a chance that you are pregnant, you need to see a doctor as soon as possible.

If you do not consult a doctor, then soon the pain of ectopic pregnancy becomes sharp. However, an attack of pain caused by a tubal abortion may last for several minutes, then the pain subsides, after which the attack may recur at various intervals. The abdomen is swollen, soft on palpation, painful over the pubic joint. Rupture of the fallopian tube is characterized by an attack of sharp pain with irradiation to the rectum, buttocks, thighs, clavicle. Dizziness, paleness, lethargy, cyanosis, possibly even fainting, cold sweats, pulse filamentous, tachycardia, low blood pressure.

Exacerbation of all symptoms indicates rupture of the fallopian tube and the onset of bleeding. This most often happens at 8 weeks of pregnancy, when the embryo begins to grow. Painkillers should not be taken at this time, as these drugs temporarily relieve symptoms and improve the picture, but the woman’s condition will only get worse.

HCG in ectopic pregnancy

HCG (human chorionic gonadotropin) is a hormone that is not present in the body of a non-pregnant woman, but which appears after fertilization due to its production by the chorion (embryonic membrane). Therefore, the pregnancy test will show a positive result even in ectopic pregnancy, but the second strip will be weaker than the control.

Determination of hCG helps to establish only the fact of pregnancy without specifying its location. Analysis of serum for beta-HCG in ectopic pregnancy shows a mismatch of hormone concentrations to the expected gestational age. When a woman becomes pregnant, the level of hCG rises very quickly – doubling every 2 days.

If the growth is slow (insignificant), it may indicate improper attachment of the fertilized egg and the presence of ectopic pregnancy. Thus, if the date of conception is known, the presence of ectopic pregnancy can be suspected on the basis of a single determination of hCG levels. If the date of conception is unknown and the diagnosis is doubtful, the level of the hCG beta subunit is determined again at intervals of 48 hours. In 85% of cases of ectopic pregnancy, the concentration of the beta subunit of hCG increases less than 2 times.

Determination of the level of hCG in the blood is positive in all cases of ectopic pregnancy, while the level of hCG in the urine is positive in only 50% of cases.

Ectopic pregnancy on ultrasound

Ultrasound examination of the pelvic organs can detect ectopic pregnancy at an early stage (absence of the ovum in the uterine cavity and its detection in the fallopian tube or ovary). With abdominal ultrasound, the ovum in the uterus can be detected at 6-7 weeks of pregnancy, and with vaginal (transvaginal ultrasound) – at 4.5-5 weeks.

Ultrasound is a widely used non-invasive method, in combination with the determination of hCG can provide high diagnostic accuracy and differentiate between uterine and ectopic pregnancy.

Normally, in diagnostic ultrasound, the diagnostic level of the beta subunit of hCG in the blood (the level at which the ovum begins to be visualized in the uterus) is 6500 IU / l, and in vaginal – 2500 IU / l.

Other informative methods of ectopic pregnancy are laparoscopy (examination of the abdominal cavity and its organs through perforation of the abdominal wall with an optical device – laparoscope) and puncture of the abdominal cavity through the posterior vault (if dark blood is detected, it is possible to conclude internal bleeding).

Treatment of ectopic pregnancy

The main method of treatment of ectopic pregnancy is surgery. Options for surgical access – laparoscopy or laparotomy. The question of the scope of surgery (tubotomy or tubectomy) in each case is decided individually.

At a tubotomy a uterine tube is cut and a fertilized egg is removed. At a tubectomy a uterine tube is removed. Extrusion of the ovum (artificial tubal abortion) is performed when it is localized in the fimbrial tube, excision of the uterine angle – when the localization of the ovum in the interstitial tube.

After the operation, a comprehensive therapy aimed at eliminating the causes of ectopic pregnancy and preparing the body for a normal pregnancy. With favorable treatment, doctors allow you to plan a pregnancy in 6-8 months.

Infectious diseases, including sexually transmitted diseases, should be treated promptly to avoid the development of ectopic pregnancy. Before you start planning a pregnancy, you must be examined and pass the necessary tests for the presence of mycoplasma, ureaplasma, chlamydia and other infections. The partner must also pass the tests. Self-medication should be avoided, and the use of IUDs and hormonal contraception should be used with caution without a doctor’s prescription.

Robert Holmes

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