Ectopic pregnancy is rightly considered by doctors to be the most insidious and unpredictable gynecological disease. Ectopic pregnancy is not so rare, at about 0.8 – 2.4% of all pregnancies. 99 – 98% is a tubal pregnancy. After an illness, especially tubal pregnancy, a woman’s chances of remaining childless increase. What are the symptoms of ectopic pregnancy, the reasons for its occurrence, treatment, complications – this is our article.
Ectopic pregnancy: how is it classified?
Ectopic (ectopic) pregnancy is a pathology characterized by the fact that the embryo is localized and grows outside the uterus. It depends on where the implanted egg cell was “deployed” and secrete tubular, ovarian, abdominal and pregnancy in the rudimentary horn of the uterus.
Pregnancy in the ovary can be 2 types:
- one progresses on the ovarian capsule, that is, outside,
- the second is directly in the follicle.
Abdominal pregnancy is:
- primary (conception and implantation of the egg to the internal organs of the abdominal cavity initially occurred)
- secondary (after the fertilized egg was thrown out of the fallopian tube, it is attached in the abdominal cavity).
Example from practice: A young nursing woman was brought to the gynecology department by ambulance. All the symptoms of bleeding into the abdominal cavity are present. During puncture of the abdominal cavity, dark blood enters the syringe through the Douglas vaginal space. Diagnosis before surgery: ovarian apoplexy (no menstrual delay and test negative). During surgery, the ovary is visualized with a rupture and blood in the abdomen. Ovarian apoplexy remained as a clinical diagnosis until histology results were known. It turned out that there was an ovarian pregnancy.
How long can determine an ectopic pregnancy?
The disease is easiest to determine after the pregnancy is interrupted (either a pipe rupture variant or a complete pipe abortion). This can happen at different times, but usually in 4 – 6 weeks. In case of further growth of pregnancy, it is possible to suspect its ectopic localization with a probable period of 21 to 28 days, the presence of hCG in the body and the absence of ultrasound signs of uterine pregnancy. Pregnancy, which “chose” itself a place in the embryonic horn of the uterus, can be interrupted later, in 10 – 16 weeks.
Early symptoms of ectopic pregnancy
When do early symptoms of ectopic pregnancy develop? If a woman has a regular menstrual cycle, it is possible to suspect this pathology in the event of a delayed menstruation. However, continuing to grow and develop ectopic pregnancy, is practically no different from pregnancy, which is in the uterus in the early stages. The patient usually notes the following first symptoms of ectopic pregnancy:
First, it is an unusual regular menstruation – its delay or scanty menstruation. Secondly, mild or moderate pains of the pulling character due to the stretching of the wall of the fallopian tube due to the growth of the ovum. The test for ectopic pregnancy is most often positive.
- Delay in menstruation is noted by women in 75-92% of cases.
- pain in the lower abdomen, 72-85%, both weak and intense
- bleeding – 60-70%
- signs of early toxicosis (nausea) – 48-54%
- enlarged and painful mammary glands – 41%
- pains radiating to the rectum, lower back – 35%
- positive (not all) pregnancy test
The erroneous opinion of many is that if there is no delay in menstruation, the diagnosis of ectopic pregnancy can be excluded. Very often spotting vaginal discharge during ectopic pregnancy, some women perceive as normal menstruation. According to some authors, it is possible to identify WB in 20% of cases before the monthly delay. Therefore, it is very important to take a thorough history and complete examination for the timely establishment of this diagnosis.
During the examination by the gynecologist, he reveals cyanosis and softening of the cervix, an enlarged, soft uterus (the first signs of pregnancy). On palpation of the appendage area, it is possible to determine on one side an enlarged and painful tube and / or ovary (tumor-like formations in the region of the appendages – in 58% of cases, pain when trying to deflect the uterus – 30%). Their contours are not clearly detectable. On palpation of the tumor-like formation in the appendages, the doctor compares the size of the uterus and the period of the delay of menstruation (a clear discrepancy) and prescribes an additional study:
- Ultrasound of the organs of internal organs of the sexual sphere
- Analysis of the content of hCG and progesterone
- The progesterone content in ectopic is lower than during normal pregnancy and there is no increase in hCG after 48 hours if the ectopic pregnancy
A terminated ectopic pregnancy with tubal abortion is characterized by a typical triad of symptoms, signs:
- lower abdominal pain
- bloody discharge from the genital tract
- and also menstruation delay
Abdominal pain due to the attempt or pushing the ovum from the fallopian tube. Hemorrhage into the inside of the tube causes its overstretching and anti-peristaltic. In addition, the blood entering the abdominal cavity acts on the peritoneum as an irritant, which exacerbates the pain syndrome.
Suddenly arising dagger pain in the ileal areas against the background of complete health helps to suspect tubal abortion. Pain, as a rule, occurs after 4 weeks of delayed menstruation, gives to the anus, hypochondrium, collarbone and leg. Such attacks can be repeated several times, and their duration from several minutes to several hours.
If the internal hemorrhage is minor or moderate, the ectopic pregnancy can remain unrecognized for a long time, without any special signs. Some patients, in addition to these symptoms, noted the appearance of pain in the process of defecation. A painful attack is accompanied by weakness, dizziness, nausea. A slight increase in temperature is due to the absorption of blood in the stomach.
If intra-abdominal bleeding continues, the woman’s condition worsens and the pain intensifies. Spotting from the genital tract is nothing more than rejection of the mucous membrane in the uterus, transformed for future implantation of the egg (decidual layer), and they appear a couple of hours after the attack, and are associated with a sharp drop in progesterone levels. A characteristic distinguishing feature of such secretions is their persistent repetition; neither hemostatic preparations nor curettage of the uterus cavity help.
When rupture of the fallopian tube occurs, its signs
The timing of damage to the fallopian tube is directly related to where the embryo is fixed in the tube. If it is located in the isthmic department, the rupture of the fruit tree occurs on the 4-6 week, with the “occupation” of the interstitial fetal egg, the terms are extended, up to 10-12 weeks. If the embryo chooses a place for further development of the ampullary tube, which is located near the ovary, the gap occurs after 4 to 8 weeks.
Rupture of the fallopian tube is a dangerous way to terminate ectopic pregnancy. Arises suddenly and is accompanied by the following symptoms:
- with severe pain
- a fall in blood pressure
- increased heart rate
- general deterioration
- the appearance of cold sweat and loss of consciousness
- pain radiating to the anus, leg, lower back
All of the above signs of ectopic pregnancy are caused by a pronounced pain attack and massive bleeding into the abdominal cavity.
During an objective examination, pale and cold extremities, increased heart rate, rapid and weak breathing are determined. The abdomen is soft, painless, maybe slightly swollen.
Massive hemorrhage contributes to the appearance of signs of peritoneal irritation, as well as muffled percussion tone (blood in the abdomen).
A gynecological examination reveals cervical cyanosis that is enlarged, soft and less than the expected duration of the uterus, pastos or education, similar to a tumor in the inguinal region on the right or left. An impressive accumulation of blood in the abdomen and in the small pelvis leads to the fact that the posterior fornix smoothes or bulges, and its palpation is painful. There are no bleeding from the uterus, they appear after the operation.
Puncture the abdominal cavity through the posterior fornix of the vagina allows for dark, non-coagulable blood. This procedure is painful and is rarely used in case of a pipe rupture (severe clinical picture: sharp pain, painful and hemorrhagic shock).
Example from practice: A first pregnant young woman was sent from the antenatal clinic to the gynecology department to save the pregnancy. But as soon as she entered, the pregnancy was disrupted by the type of tube rupture. At the reception in the area of appendages of the alarming formation was not palpated, and the diagnosis sounded like a pregnancy of 5-6 weeks, the threat of interruption. Fortunately, the woman went to the doctor. Gynecological examination was once carried out, pressure 60/40, pulse 120, severe pallor, significant dagger pain, and as a result, loss of consciousness. Quickly deployed the operating room and took the patient. There was about 1.5 liters of blood in the stomach, and a pregnancy for about 8 weeks in a bursting tube.
Why does an ectopic pregnancy occur?
The attachment of the ovum outside the uterus is caused by impaired peristalsis of the fallopian tubes or a change in the properties of the ovum. Risk factors:
- inflammatory processes in the pelvis
Inflammatory processes of the appendages and the uterus lead to neuroendocrine disorders, obstruction of the fallopian tubes, and ovarian dysfunction. Chlamydial infection (salpingitis), which in 60% of cases leads to ectopic pregnancy, is one of the main risk factors (see Chlamydia in women: symptoms, treatment).
Intrauterine contraceptives in 4% of cases lead to ectopic pregnancy, with prolonged use (5 years) the risk increases 5 times. Most experts believe that this is due to inflammatory changes that accompany the presence of a foreign body in the uterus of a woman.
Abortions (consequences), especially numerous, contribute to the growth of inflammatory processes of internal genital organs, adhesions, impaired peristalsis and narrowing of pipes, 45% of women after an artificial termination of pregnancy later have a high risk of ectopic.
In a smoking woman, the risk of ectopic development is 2–3 times higher than that of a non-smoker, since nicotine affects the peristalsis of the tubes, the contractile activity of the uterus leads to various immunity disorders.
- malignant neoplasm of the uterus and appendages
- hormonal disorders (including ovulation stimulation, after IVF, mini-drinking, impaired prostaglandin production)
- fallopian tube surgery, tubal ligation
- improper development of a fertilized egg
- sexual infantilism (pipes are long, twisted)
- endometriosis (causes inflammation and adhesions)
- stress, overwork
- age (over 35)
- congenital malformations of the uterus and tubes
- genital tuberculosis
What is the danger of ectopic pregnancy?
Ectopic pregnancy is terrible for its complications:
- severe bleeding – hemorrhagic shock – death of a woman
- adhesions in the pelvis
- secondary infertility
- inflammatory process and intestinal obstruction after surgery
- relapse of ectopic pregnancy, especially after tubotomy (in 4–13% of cases)
Example from practice: An ambulance received a woman with classic ectopic pregnancy symptoms. During the operation, the tube was removed on the one hand, and when the patient was discharged, recommendations were given: to be examined for infection, to be treated if necessary and to abstain from pregnancy for at least 6 months (pregnancy was desired). Less than six months, the same patient comes with a pipe pregnancy on the other hand. The result of non-compliance with the recommendations is absolute sterility (the pipes are both removed). I am glad that the patient has 1 child.
Ways to preserve appendages and whether to save them?
Ectopic pregnancy is an emergency and requires immediate surgery. Salpingoectomy (removal of the tube) is most often performed, since in most cases the fallopian tube is seriously damaged (regardless of the gestational age) and future pregnancy has a serious risk of being ectopic again.
In some cases, the doctor decides the issue of salpingotomy (tube incision, removal of the ovum, stitching the incision in the tube). The preserving tube operation is done with a size of the ovum of no more than 5 cm, the patient is in a satisfactory condition, and the woman wants to preserve her reproductive function (ectopic recurrence). It is possible to carry out a fimbrial evacuation (if the fetal egg is in the ampullary section). The embryo is simply squeezed out or sucked out of the tube.
Segmental resection of the tube is also used (removal of the damaged part of the tube with subsequent stitching of the tube ends). In the early stages of tubal pregnancy, drug treatment is allowed. Methotrexate is introduced into the cavity of the tube through the lateral vaginal fornix under ultrasound control, which causes the embryo to dissolve.
Will the pipe passability after surgery? It depends on many factors:
- Firstly, early activation of the patient (prevention of adhesions) and physiotherapy
- Secondly, adequate rehabilitation therapy.
- Third, the presence / absence of postoperative infectious processes
- How to protect yourself after an ectopic pregnancy?
Acceptance of pure gestagenic (mini-pili) drugs and the introduction of the IUD is not recommended. It is advisable to take oral contraceptives combined.
- A pregnancy test can show where it is located?
No, the test shows that there is a pregnancy.
- The delay is 5 days, the test is positive, and in the uterus the ovum is not visualized. What to do?
Not necessarily what happened ectopic pregnancy. It is necessary to repeat the ultrasound in 1 – 2 weeks and carry out a blood test for hCG (in the early stages of pregnancy in the uterus may not be visible).
- I had acute adnexitis, so I have a high risk of developing an ectopic pregnancy?
The risk, of course, is higher than in healthy women, but it is necessary to be examined for genital infections, hormones and treatment.
- When can I plan a pregnancy after ectopic?
Desired pregnancy planning is recommended no earlier than six months.