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ECTOPIC PREGNANCY

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ECTOPIC PREGNANCY 

MAIN SYMPTOMS: 

Ectopic pregnancy implies a pathology of the course of pregnancy, in which the fertilized egg attaches to areas outside the uterus, where it normally occurs. An ectopic pregnancy, the symptoms of which manifest as in the usual course of pregnancy, is a condition in which medical care must be provided to the patient as a matter of urgency due to the urgency of the risk of death from complications associated with this pathology. 

GENERAL DESCRIPTION 

Normal pregnancy is fertilized by the sperm of the egg, which occurs in the fallopian tube, after which the zygote (i.e. diploid cell, including the double chromosome set and formed, respectively, during the merger of the sperm and egg) is sent to the uterine cavity. In the uterus, its further development takes place, it is in its conditions that this becomes possible, in particular, due to the fact that there is enough space for this. But if an ectopic pregnancy, then the zygote does not fall into the uterine cavity, or its attachment to the tube, or pushing it out from there, because of which it moves in the opposite direction. As a result, either its attachment to the ovary or attachment to the peritoneal region occurs.

Given the fact that in any of these environments, with the exception of the uterus, there are no conditions for the subsequent development of the embryo, then pregnancy can be said to be doomed. In this case, the chorionic villi (villi that completely surround the ovum) germinate in the tissues of the organ that are not adapted to this, which causes damage to them, and subsequent bleeding (it occurs in the abdominal cavity). 

Ectopic pregnancy is a pthology diagnosed in 2% of the total number of pregnancies. According to where ectopic pregnancy specifically focuses, its varieties such as tubal pregnancy, abdominal or ovarian pregnancy, as well as pregnancy occurring in the area of ​​the rudimentary horn of the uterus are determined. Pregnancy in the rudimentary horn of the uterus is extremely rare, but tubal pregnancy is diagnosed in the vast majority of cases - it accounts for about 98% of ectopic pregnancies. Also allowed is such a variant of ectopic pregnancy as a heterotopic pregnancy, in which there are two fetal eggs, one of which is localized in the uterus, and the other - outside of it. 

If we dwell on the statistical data on the pathology we are considering, then it can be singled out that in the framework of the last decade, the frequency of its occurrence has increased two, or even three times. According to countries positioned as industrialized, for example, it is possible to determine the relevance of this phenomenon by 1000 pregnancies for 12-14 of them. If this pathology is not diagnosed in a timely manner, then it will not only lead to a state of "acute abdomen", but may also be fatal. 

Already noted tubal ectopic pregnancy, if we consider it in some more detail, about 60-95% of cases concentrate in the ampullary section of the fallopian tube, about 15% in the department of isthmic, and in 1-3% in the interstitial department (or in the intramural department). About 0.4% of cases of ectopic pregnancy account for ovarian pregnancy, and 0.01% of cases occur in pregnancy occurring in the cervical environment. 

female reproductive system
female reproductive system

CAUSES OF PATHOLOGY 

In about 30-50% of cases, the reasons that provoked ectopic pregnancy cannot be determined. Meanwhile, there are some risk factors that can lead to a similar outcome, in short they look like this: 

  • pre-pregnancy surgery in the abdominal cavity; 
  • contraceptive features (hormonal effects in particular); 
  • tumor pathology of the uterus and appendages;
  • hormonal deficiency, hormonal failure;
  •  disruption of transport function, relevant to the fallopian tubes; certain forms of abnormalities affecting the genitals;
  •  lifestyle features (bad habits, dependence, overload of various types).

The main cause of ectopic pregnancy is considered to be slow progress through the fallopian tube of the ovum or egg, as well as an increased degree of trophoblast activity (the outer layer of embryo cells within one of the developmental stages, more precisely, the blastocyst stage). 

Disturbance of the normal process of egg migration along the course of the fallopian tube can be caused by inflammatory processes that are relevant to the appendage area, as well as the already noted previous transfer operations carried out in the environment of the abdominal organs, especially if we are talking about tubal operations. In the latter case, the result of surgical intervention are characteristic structural structures (which are probably known to the reader as adhesions), as well as functional changes that disrupt the function of the fallopian tubes by changing their contractile ability. 

In addition, an ectopic pregnancy is quite often diagnosed in patients who have undergone an earlier IVF procedure (in vitro fertilization), due to which it can be assumed how important hormonal disorders are when considering the causes of the development of ectopic pregnancy. With the introduction of drugs, which are based on progesterone, it has a slowing effect on peristalsis of the fallopian tubes, which causes the subsequent predisposition of the ovum to implantation until it enters the uterine cavity. The following factors are considered as factors provoking peristalsis of the peristalsis: intrauterine contraceptives, actual diseases of the endocrine system (adrenal glands, thyroid gland), prolonged lactation, endometriosis . 

Genital infantilism is also one of the main reasons against which an ectopic pregnancy develops. Genital infantilism means, in particular, such a feature of the fallopian tubes as their elongation and tortuosity in combination with the aforementioned predisposing factor in the form of delayed peristalsis. 

An ectopic pregnancy, which, under its definition, summarizes both ectopic pregnancy and uterine pregnancy, but proceeds under the condition of atypical implantation of the ovum, especially often develops against the background of tumors and tumor-like formations concentrated in the pelvic area. In this case we are talking about such pathologies as ovarian cysts , uterine myoma, ovarian tumors, and so on. On their background there is a compression of the fallopian tubes, which causes the risk of ectopic pregnancy. In practice, such cases are noted in which the female gamete (reproductive cell) is sent from the ovary to the fallopian tube from the opposite side, due to which she has to travel a greater distance, the evidence of this process is the appearance of a yellow body in the ovary from the side that is opposite during tubal pregnancy. 

With the introduction of chorionic villi into the fallopian tube, which is accompanied by the production of proteolytic enzymes, its subsequent melting is caused, it gradually becomes thinner, and then destroyed, which is accompanied by the opening of blood vessels (i.e., their walls). Due to the development and gradual growth in the tube of the ovum, tubal pregnancy due to its progression is mainly spontaneously interrupted for a period of 6-8 weeks. Thus, tubal abortion occurs, within the framework of which the process of detachment from the tube wall of the ovum becomes relevant. Pipe rupture occurs less frequently. 

Tube rupture in ectopic pregnancy

Even more rare in the course of tubal ectopic pregnancy is the death of the embryo and its subsequent resorption (resorption), this is accompanied by the subsequent formation of hydrosalpinx or hematosalpinx. If we are talking about the full version of the tube abortion, accompanied, respectively, by the complete release of the ovum in the abdominal cavity, then in this case it is usually subject to subsequent death, after which it is calcified and then mummified in this environment. 

As for abdominal or ovarian pregnancy, then its variants develop after fertilization of the egg, after its release from the ovary. Meanwhile, mainly both of these variants of ectopic pregnancy are compared with the secondary process of implantation of a viable embryo, which hit the surface of the omentum, liver or pelvic peritoneum as a result of tubal abortion. 

A cervical pregnancy is accompanied by the primary implantation of the ovum into the medium of the cervical canal, or after it has been out of the womb, together with the chorionic villi. 

On the verge of casuistry, the cases described in practice are perceived, in the framework of which an ectopic pregnancy was being hatched (in this case, as a rule, it was abdominal), after which the fetus was extracted by the celiac section. Attaching the placenta in this case occurred either to the liver or to the omentum, and, as the reader can understand, pregnancy itself in such cases may be permissible, despite the conditions of its course. 

“Acute abdomen” develops due to spontaneous abortion of tubal pregnancy, which occurs similarly to tubal abortion, as well as, as previously indicated, due to rupture of the tube. 

Types of ectopic pregnancy

Tubal pregnancy can be progressive or interrupted. For a start, we will focus on the latter, that is, interrupted ectopic pregnancy, which, in turn, can proceed as a tube abortion or as a pipe rupture. 

ECTOPIC PREGNANCY AS A TUBE ABORTION 

The development of the clinical picture of tubal abortion occurs in a long-term manner, it is determined by probable and dubious signs, usually indicating pregnancy. Thus, such manifestations as nausea and vomiting, weakness and drowsiness, an altered state of taste and olfactory sensations are considered as doubtful signs. With regard to the likely signs of pregnancy, they are understood to include such manifestations as delayed menstruation and an altered state of the mammary glands (their engorgement in particular). These two groups of symptoms are combined in parallel with symptoms indicating abortion. 

Delay of menstruation (noted mainly in the period of 2-3 weeks) may be accompanied by the appearance in patients of complaints of lower abdominal pain, these pains are cramping in nature. In addition, it is noted and the spread of such pain to the rectum, from the genital tract there are dark spotting, scarce in volume. These discharges are caused by the uterine mucosa that has undergone changes, which occurred on the background of abortion. In some cases, the specified delay of menstruation is not noted by a woman, while the days of menstruation are accompanied by the appearance of scanty bleeding. With regard to emerging pain, they are due to the fact that there is an intensive contraction of the fallopian tube, against the background of which, in turn, there is either partial or complete detachment of the ovum from it. 

With a small intra-abdominal blood loss, the state of the patients remains almost unchanged, if there is pain, it has an insignificant and dull character of manifestation. Moreover, in some cases, the symptoms manifest themselves so poorly that it is rather difficult to diagnose the pathology only on the basis of them. 

The pattern of pathology changes if 500 or more milliliters of blood has entered the abdominal cavity. This is accompanied by the occurrence of pain expressed in the character of its own manifestation, which extends to the area of ​​the right hypochondrium, to the right side of the clavicle and to the interscapular region. As additional symptoms, dizziness, weakness, vomiting, and fainting are allowed. 

The most accurate diagnostic method for this case of pathological pregnancy is laparoscopy, which determines the possibility of carrying out a visual assessment of the general condition relevant to the pelvic organs, including the possibility of assessing the condition of the fallopian tubes. 

ECTOPIC PREGNANCY BY TUBE RUPTURE 

Basically, such a pregnancy develops during the period of 6-10 weeks of pregnancy. Manifestations of symptoms are quite intense in the nature of the intensity, the reason for this is the acute form of intra-abdominal bleeding, against the background of which there are no difficulties in diagnosing the condition of the patients. 

With a relatively prosperous general condition, pain appears in the lower abdomen, mainly from the side of the tube to which the pregnancy directly relates. Such soreness is prone to spreading to the right clavicle, to the rectum, in some cases, loose stools, false urges to defecate appear (also defined as tenesmus). 

In addition, there is a sudden weakness, followed by loss of consciousness, and if the blood loss was significant, then hemorrhagic shock develops in the patients. The condition of the patients is characterized by their general lethargy and apathy, the skin is pale, pallor is noted and behind the mucous membranes, shortness of breath and cold sweat appear. The pressure decreases, the pulse quickens, abdominal distention and marked tension on the part of its lower parts are noted, probing of the area determines a sharp pain, as well as symptomatology indicating general irritability of the peritoneum. When tapping low-lying areas of the abdomen, the sound is muffled, which has a certain significance in diagnostics, the limit of muffling is shifted according to the change in the occupied body position. 

An additional (bimanual) study reveals the excessive mobility of the softened enlarged uterus (which is defined as a floating uterus symptom), while cervical dislocations are accompanied by soreness, pain occurs in the pronounced variant of the manifestation from the posterior vaginal vault. On the basis of the clarity of the picture of the pathological state under consideration, additional measures of research for diagnosing the pathology of pregnancy in this case are not required. 

PROGRESSIVE ECTOPIC PREGNANCY 

Prevention of the development of tubal abortion or rupture of the tube is based to the greatest extent on the implementation of the principles of timely diagnosis, as well as therapy directed to the address of progressive pregnancy. This condition is not accompanied by a clinic relevant to the "acute abdomen." At its core, progressive pregnancy is an ectopic early pregnancy, proceeding in the same way as a normal pregnancy. In other words, the symptoms of ectopic pregnancy correspond to uterine pregnancy, the symptoms similar to each other, we will highlight below. 

First of all, we note that the probable and doubtful signs of pregnancy are also relevant here, we considered them above, this is engorgement of the mammary glands, an altered state of smell, delayed menstruation, etc. 

Two-handed vaginal-abdominal method of research, meanwhile, allows you to determine the inconsistency of gestational pregnancy with the size of the uterus, in some cases, the formation of a spindle-like type of elastic or soft consistency, which is concentrated within the region of appendages, is felt when palpation is felt. The uterus in the early period of pregnancy is increased slightly, which is why it is not possible to determine its condition. 

With regard to the specifics of diagnosis, with progressive tubal pregnancy in particular, an important role is given to ultrasound, laparoscopy and blood tests to identify the level of CG. 


Laparoscopy for ectopic pregnancy