The pregnancy which is characterized by implantation and development of fetal egg out of a uterus – in an abdominal cavity, an ovary, a uterine tube is called extra-uterine. Extra-uterine pregnancy – the serious and dangerous pathology fraught with complications and a recurrence (repeated emergence) involving loss of genital function and even threat of life of the woman. besides a uterine cavity which is only physiologically adapted for full development of a fruit the impregnated ovum can lead to a rupture of body in which it develops.
Development of normal pregnancy happens in a uterus cavity. After merge in a uterine tube of an ovum to a spermatozoon, the impregnated ovum which began division moves ahead in a uterus where necessary conditions for further development of a fruit are physiologically provided. The term of pregnancy is determined by location and size of a uterus. Normal in the absence of pregnancy the uterus is fixed in a small basin, between a bladder and a rectum, and has about 5 cm in width and 8 cm in length. Pregnancy of 6 weeks can already be determined by some increase in a uterus. On the 8th week of pregnancy the uterus increases to the sizes of a female fist. By 16th week of pregnancy the uterus is defined between a bosom and a navel. At pregnancy of 24 weeks the uterus is defined at the level of a navel, and by 28th week the uterus bottom already is above a navel.
On the 36th week of development of pregnancy the bottom of a uterus reaches costal arches and a xiphoidal shoot. By 40th week of pregnancy the uterus is fixed between a xiphoidal shoot and a navel. Pregnancy of 32 weeks of incubation is established as by date of the last monthly and date of the first movement of a fruit, and in size of a uterus and height of its standing. If the impregnated ovum for any reasons does not get from a uterine tube into a uterus cavity, pipe extra-uterine pregnancy develops (in 95% of cases). Development of extra-uterine pregnancy in an ovary or in an abdominal cavity is in rare instances noted.
In recent years increase by 5 times of number of cases of extra-uterine pregnancy (data of the Center for control of incidence of the USA) is noted. At 7-22% of women repeated emergence of extra-uterine pregnancy which in more than a half of cases leads to secondary infertility is noted. In comparison with healthy women of the patient, transferred extra-uterine pregnancy, have bigger (at 7-13 times) risk of its repeated development. Most often at women from 23 to 40 years right-hand extra-uterine pregnancy is noted. In 99% of cases development of extra-uterine pregnancy is noted in these or those departments of a uterine tube.
Extra-uterine pregnancy – the serious and dangerous pathology fraught with complications and a recurrence (repeated emergence) involving loss of genital function and even threat of life of the woman. besides a uterine cavity which is only physiologically adapted for full development of a fruit the impregnated ovum can lead to a rupture of body in which it develops. In practice extra-uterine pregnancy of various localizations meets.
Pipe pregnancy is characterized by an arrangement of fetal egg in a uterine tube. It is noted in 97,7% of cases of extra-uterine pregnancy. In 50% of cases fetal egg is in ampulyarny department, in 40% - in a middle part of a pipe, in 2-3% of cases – in a uterine part and in 5-10% of cases – in the field of pipe fimbriya. It is possible to carry yaichnikovy, cervical, belly, intraligamentarny forms, and also the extra-uterine pregnancy which is localized in a rudimentary horn of a uterus to seldom observed forms of development of extra-uterine pregnancy.
Yaichnikovy pregnancy (it is noted in 0,2-1,3% of cases) is subdivided on intrafollikulyarny (the ovum is impregnated in the ovulated follicle) and ovarialny (fetal egg is fixed on the surface of an ovary). Belly pregnancy (meets in 0,1 – 1,4% of cases) develops at an exit of fetal egg in an abdominal cavity where it is attached to a peritoneum, an epiploon, intestines, other bodies. Development of belly pregnancy is possible as a result of carrying out EKO at infertility of the patient. Cervical pregnancy (0,1-0,4% of cases) arises at implantation of fetal egg to the area of a cylindrical epithelium of the channel of a neck of a uterus. Comes to an end with plentiful bleeding as a result of the destruction of fabrics and vessels caused by deep penetration into a muscular cover of a neck of a uterus fetal egg.
Extra-uterine pregnancy in an additional horn of a uterus (0,2-0,9% of cases) develops at anomalies of a structure of a uterus. Despite an attachment of fetal egg vnutrimatochno, the symptomatology of a course of pregnancy is similar to clinical manifestations of a rupture of a uterus. Intraligamentarny extra-uterine pregnancy (0,1% of cases) is characterized by development of fetal egg between leaves of wide ligaments of uterus where it is implanted at a rupture of a uterine tube. Geterotopichesky (polycarpous) pregnancy is noted extremely seldom (1 case on 100-620 pregnancies) and is possible as a result of use of EKO (a method of an auxiliary reproduction). It is characterized by existence of one fetal egg in a uterus, and another – beyond its limits.
Signs of extra-uterine pregnancy
The following manifestations can serve as signs of emergence and development of extra-uterine pregnancy:
- Violation of a menstrual cycle (delay of monthly);
- Bloody, the "smearing" nature of allocation from genitals;
- Pain in the bottom of a stomach (nagging pains in the field of an attachment of fetal egg);
- Nagrubaniye of mammary glands, nausea, vomiting, lack of appetite.
The interrupted pipe pregnancy is followed by the symptoms of intra belly bleeding caused izlitiy blood in an abdominal cavity. The sharp pain in the bottom of a stomach giving to back pass, legs and a waist is characteristic; after developing of pain bleeding or brown bloody allocations from genitals is noted. Lowering of arterial pressure, weakness, frequent pulse of weak filling, consciousness loss is noted. At early stages to diagnose extra-uterine pregnancy extremely difficult; since the clinical picture is not typical, the request for medical assistance follows only at development of these or those complications.
The clinical picture of the interrupted pipe pregnancy coincides with ovary apopleksiya symptoms. Patients with symptoms of "a sharp stomach" are urgently brought to medical institution. It is necessary to define immediately existence of extra-uterine pregnancy, to make surgery and to eliminate bleeding. Modern methods of diagnostics allow to establish existence of extra-uterine pregnancy by means of the ultrasonic equipment and tests for determination of level of progesterone ("pregnancy hormone"). All medical efforts go for preservation of a uterine tube. In order to avoid serious consequences of extra-uterine pregnancy observation at the doctor at emergence of the first suspicions on pregnancy is necessary.
Reasons of extra-uterine pregnancy
As the causes of extra-uterine pregnancy serve the factors causing violation of natural process of advance of the impregnated ovum in a uterus cavity:
- earlier postponed termination of pregnancy
- hormonal types of contraception
- existence of an intrauterine spiral
- stimulation of an ovulation
- auxiliary methods of a reproduction
- earlier undergone operations on appendages
- extra-uterine pregnancy in the past
- tumoral processes in a uterus and appendages
- the postponed inflammations of appendages (the chlamydial infection is especially dangerous)
- malformations of genitals
- delay of sexual development
Diagnostics of extra-uterine pregnancy
At early stages it is difficult to diagnose extra-uterine pregnancy as clinical displays of pathology are atypical. Also as well as at uterine pregnancy the delay of periods, change from a gastrointestinal tract (a taste perversion, nausea attacks, vomiting etc.) are observed, a softening of a uterus and education in an ovary of a yellow body of pregnancy. It is difficult to distinguish the interrupted pipe pregnancy from appendicitis, an apopleksiya of an ovary or other sharp surgical pathology of an abdominal cavity and a small pelvis.
At emergence of the interrupted pipe pregnancy which is threat for life bystry establishment of the diagnosis and immediate surgical intervention is required. Completely it is possible to exclude or confirm the diagnosis "extra-uterine pregnancy" by means of ultrasonography (existence of fetal egg in a uterus, presence of liquid at a cavity of a stomach and education in the field of appendages is defined).
Informative way of definition of extra-uterine pregnancy is β-HG the test. By test the level of the horionichesky gonadotrophin (β-HG) developed by an organism at pregnancy is defined. Its standards of the contents at uterine and extra-uterine pregnancy significantly differ, as does this way of diagnostics highly reliable. Thanks to the fact that today the surgical gynecology widely applies a laparoscopy as a method of diagnostics and treatment, became possible with an accuracy of 100% to establish the diagnosis of extra-uterine pregnancy and to eliminate pathology.
Treatment of extra-uterine pregnancy
The following types of laparoscopic operations are applied to treatment of a pipe form of extra-uterine pregnancy: a tubektomiya (removal of a uterine tube) and a tubotomiya (preservation of a uterine tube during removal of fetal egg). The choice of a method depends on a situation and degree of a complication of extra-uterine pregnancy. At preservation of a uterine tube the risk of repeated emergence in the same pipe of extra-uterine pregnancy is taken into account.
At the choice of a method of treatment of extra-uterine pregnancy the following factors are considered:
- Intention of the patient further to plan pregnancy.
- Expediency of preservation of a uterine tube (depending on that, structural changes in a pipe wall are how expressed).
- Repeated extra-uterine pregnancy in the kept pipe dictates need of its removal.
- Development of extra-uterine pregnancy in interstitsialny department of a pipe.
- Development of adhesive process in a small pelvis and in this regard the increasing risk of repeated extra-uterine pregnancy.
At big blood loss band operation (laparotomy) and removal of a uterine tube remains the only option for rescue of life of the patient. At not changed condition of the remained uterine tube genital function is not broken, and the woman can have pregnancy in the future. For establishment of an objective picture of a state the remained ambassador of a laparotomy of a uterine tube carrying out a laparoscopy is recommended. This method also allows to divide solderings in a small basin that serves decrease in risk of repeated extra-uterine pregnancy in the remained uterine tube.
Prevention of extra-uterine pregnancy
To prevent emergence of extra-uterine pregnancy, it is necessary:
- not to allow development of inflammations of bodies of urinogenital system and if the inflammation arose – in time to treat him
- before the planned pregnancy to undergo inspection on presence of pathogenic microbes (hlamidiya, ureaplasmas, mycoplasmas, etc.). In case of their detection it is necessary to undergo the corresponding treatment together with the husband (the constant sexual partner)
- to be protected during sex life from undesirable pregnancy, using reliable contraceptives, to avoid abortions (the major factor provoking extra-uterine pregnancy)
- in case of need interruptions of undesirable pregnancy to choose low-traumatic methods (miniabortion) in optimum terms (the first 8 weeks of pregnancy), to carry out interruption by all means in medical institution by the qualified specialist, with anesthesia and further medical observation. Vacuum abortion (miniabortion) reduces time of carrying out operation, has few contraindications and the smaller quantity of undesirable consequences is considerable
- as an alternative a surgical way of termination of pregnancy it is possible to choose medicamentous termination of pregnancy (medicine reception Mifegin or Mifepriston)
- after the postponed extra-uterine pregnancy to take a rehabilitation course for preservation of an opportunity to have the following pregnancy. For preservation of genital function it is important to be observed at the gynecologist and the gynecologist-endocrinologist and to observe their recommendations. In a year after operation it is possible to plan new pregnancy at which emergence it is necessary to get registered in early terms on conducting pregnancy. The forecast at the same time – favorable.