Rare forms of ectopic pregnancy. Treatment of ectopic pregnancy outside the fallopian tubes

Ectopic pregnancy is one of the most common female diseases. Its most common form is tubal localization. It occurs in about one in a hundred pregnant women. This form accounts for up to 98% of all cases of ectopic attachment of the embryo. Such an arrangement gestational sac occurs more and more frequently. This is caused by the following factors:

• an increase in sexual activity, frequent change of partners, the spread of abortions and, as a result, an increase in infectious and inflammatory diseases of the uterus and appendages;
• more frequent use of methods for the treatment of infertility;
• wider application.

Causes and risk factors

The reasons why an ectopic, including tubal, pregnancy occurs are little understood. Of course, the basis of the disease is a violation of the movement of the fetal egg. However, the immediate causes of this are very difficult to establish, so doctors talk about risk factors for tubal pregnancy.

The main anatomical prerequisites for the formation of this condition:

• inflammatory process in the appendages ();
• pipe operations;
• intrauterine contraception.

The main reason for the development of pregnancy in the tube is acute or chronic salpingitis, or inflammation of the fallopian tube. In a patient who has undergone acute inflammation of the appendages, the risk of getting tubal localization increases by 6 times compared with a healthy woman. With salpingitis, contractility is impaired and. At the same time, the synthesis of substances that ensure the normal passage of the fetal egg into the uterus is disrupted. The hormonal function of the ovaries, often involved in the process of inflammation, also changes, which increases the disruption of the fallopian tubes.

The use of intrauterine contraceptives leads to the cessation of the movement of the cilia lining the tubes and promoting the fetal egg into the uterus. When using this method of contraception, the frequency of ectopic pregnancy is 20 times higher than in women using other methods of contraception.

For many diseases, operations are performed on the appendages, which significantly increase the risk of developing this condition. pathological condition. The probability of such an outcome depends on the volume of intervention, technique, access (laparotomy or laparoscopy) and other factors. If a woman has previously been operated on for a similar pregnancy, then the risk of recurrence of such a situation increases to 16%.

If a woman has had two or more induced abortions, her risk of developing an ectopic location of the embryo increases significantly.

Additional risk factors are infantilism, developmental anomalies or tumors of the uterus and appendages,.

Hormonal risk factors:

• the use of ovulation induction drugs for the treatment of infertility;
• in vitro fertilization;
• delayed ovulation;
• egg transmigration.

Ovulation inducers used to treat infertility, including in vitro fertilization, change the secretion of hormones and other substances responsible for contraction fallopian tubes. An ectopic pregnancy is likely in one in ten women taking these drugs.

Increase the likelihood of this condition and hormonal contraceptives containing only progestogens, which change the contractility of the fallopian tubes.

Transmigration (movement) of the egg occurs, for example, from the ovary through the abdominal cavity into the opposite fallopian tube. There, the already formed fetal egg is quickly attached. Another option: the egg formed during late ovulation is fertilized and enters the uterus, but does not have time to implant there. During the next menstruation, an immature fetal egg is “thrown” back into the fallopian tube.

After the implantation of the fetal egg in the tube, it begins to destroy its wall, unsuitable for the formation of the embryo. Termination of tubal pregnancy is inevitable. It proceeds in one of two ways:

• tubal abortion;
• pipe break.

Implantation of the ovum in ectopic and normal pregnancy

The course and signs of tubal pregnancy

The fetal egg in the wall of the tube is covered on the outside by its mucous membrane. As it grows, this shell thins and collapses. At the same time, dystrophic changes occur in the muscular wall of the tube, the fetal egg is poorly supplied with blood and dies. The fallopian tube begins to make anti-peristaltic contractions, as a result of which the fetal egg enters the abdominal cavity. If, nevertheless, it remains viable, there is a possibility of its attachment to the wall of the abdominal cavity, and the formation of a repeated ectopic pregnancy.

Simultaneously with the expulsion of the fetal egg, bleeding occurs in the wall of the tube. Blood with antiperistaltic contractions enters the abdominal cavity. A tubal abortion occurs.

A rupture of the tube occurs when the growing fetal egg destroys all the walls of the organ and is accompanied by intra-abdominal bleeding.

At what time is an ectopic pregnancy interrupted, as well as the options for such an interruption are determined by its location. If the fertilized egg is located near the mouth of the tube that opens into the uterus, a disturbed tubal pregnancy will occur about a month after fertilization in the form of a ruptured tube. With the localization of the embryo in the middle part, its development can last up to 16 weeks due to the thick muscle layer and good blood supply. However, with a rupture in this section, severe bleeding occurs, which can lead to the death of a woman. If the pregnancy develops in the ampulla, then it is terminated after 4-8 weeks by the type of tubal abortion.

In rare cases, a frozen tubal pregnancy is formed when the dead fetal egg gradually resolves or calcifies. In this case, there is no interruption.

The symptoms of tubal pregnancy in many cases are blurred, atypical, and varied. A progressive pregnancy in the fallopian tube is accompanied by the same signs as a normal one: there is no menstruation, taste and smell changes, nausea and vomiting appear, and the mammary glands engorge.

Then, when the tube ruptures, the woman suddenly has severe pain in the abdomen, spreading to the rectum and shoulder blade. They are accompanied by signs of internal bleeding - pallor, cold sweat, rapid pulse, decreased pressure, dizziness, loss of consciousness. There is severe pain when the cervix is ​​​​displaced in the opposite direction from the lesion. On examination, the posterior fornix of the vagina bulges. When it is punctured, dark non-clotting blood is obtained. There are minor bloody discharge from the genital tract.

An interrupted tubal pregnancy of the type of tubal abortion is often accompanied by mild symptoms - aching pain in the abdomen, menstrual irregularities. The most important role in the diagnosis is played by additional research methods.

Diagnostics

The main method for suspecting this pathology is. It is aimed primarily at identifying signs of uterine pregnancy, which allows you to almost completely eliminate the localization of the fetal egg in the tube. When using special vaginal sensors, a fetal egg in the uterus can be detected as early as 1.5 weeks after fertilization.

To confirm the tubal localization of the embryo, attention is paid to formations in the fallopian tubes, the presence of fluid in the abdominal cavity. Of course, the most informative is the detection of a developing fetal egg outside the uterus. However, the percentage of diagnosis of progressive tubal pregnancy does not exceed 5-8 cases out of 100.

An additional diagnostic method is to determine the level of chorionic gonadotropin by qualitative or quantitative methods. There are no absolute values ​​that are a criterion for this indicator. However, its level in most cases of tubal localization is lower than normal. Dynamic research is important. During uterine pregnancy, the concentration of chorionic gonadotropin doubles every two days, while there is no such doubling in tubal pregnancy.

The most informative method is laparoscopy. It allows you to determine the developing tubal pregnancy or the condition after its interruption, to assess the volume of blood loss, the condition of the uterus and appendages. However, laparoscopy should only be used after non-invasive methods have failed to establish a diagnosis.

Treatment

With an interrupted tubal pregnancy, surgical intervention. The advantage is laparoscopy. Laparotomy is performed with hemorrhagic shock or severe.

During the operation, the bleeding is stopped and the tube is removed. At the same time, they restore blood circulation, fight blood loss. In some cases, reconstructive plastic surgery is possible to save the organ. After organ-preserving surgery, observation is necessary to exclude transplantation of non-removed parts of the chorion.

In the recovery period, vitamins, iron preparations, and physiotherapy are prescribed to prevent adhesions. It is necessary to take oral contraceptives for at least six months to prevent pregnancy.

Two months after laparoscopy, it is advisable to re-intervention, remove the formed adhesions, assess the patency of the fallopian tube, clarify the indications for in vitro fertilization.

Interstitial (or interstitial) pregnancy. This form of pregnancy is extremely rare. Only a few cases have been published in the literature. Meanwhile, this type of ectopic pregnancy deserves great attention.

At the site of this type of ectopic pregnancy (the interstitial part of the fallopian tube), the wall of the fetus is formed by the muscles of the uterus. Violation of interstitial pregnancy according to the clinical picture is similar to other types of ectopic pregnancy and occurs within a period of 4 to 12 weeks as a result of rupture of the uterine wall, followed by expulsion of the contents into the free abdominal cavity. Cases of rupture of the fetus into the uterine cavity are extremely rare. Bleeding is profuse, which is explained by the deep penetration of the villi into the wall of the uterus and the eating of large-caliber vessels by them.

The diagnosis in most cases is established during the operation. Diagnostic features are: 1) unilateral deformation of the uterus in the direction of the bottom and posterior wall of the latter due to growth in this direction of the fetal egg; 2) atypical discharge of the round ligaments and tubes on the side of the development of an interstitial pregnancy (on the healthy side, the tube and ligament are located lower than on the opposite side, where an interstitial pregnancy develops); 3) full mobility of the uterus; 4) painlessness of the vaults and the absence of any tumor in them.

In the anamnesis, there are usually no indications of past diseases of the genital area.

A perforation in the interstitial part of the tube can sometimes be mistaken for a perforated hole in the fundus of the uterus in a previous induced abortion. In these cases, the anamnesis usually helps, and during the revision of the abdominal cavity, unchanged chorionic villi are found in the perforation.

Pregnancy in a rudimentary (rudimentary) horn. Recognition of this form of ectopic pregnancy is difficult. Establishing the diagnosis is facilitated by probing a wide and flat leg extending from the rudimentary horn to the lateral surface of a normal developed horn at the level of the internal os of the uterus. Sometimes probing the legs is difficult. The difference between a rudimentary horn and an ovarian cyst (stalked form) is that the latter has a longer and thinner stalk that extends from the side wall of the uterus much higher than the internal os. When the fetus-place of the rudimentary horn is ruptured, bleeding is noted. A fetus that has fallen into the abdominal cavity sometimes continues to develop in the latter if the placenta retains its connection with the wall of the rudimentary horn.

In other cases, the fetus dies, undergoing certain changes (maceration, suppuration), and sometimes it is removed in parts through the intestines.

Ovarian pregnancy(graviditas ovarica) develops either inside it (in the graafian vesicle, corpus luteum and theca folliculi), or on the free surface of the ovary.

The diagnosis of ovarian pregnancy is established during surgery, and finally specified during the subsequent histopathological examination of the removed preparation.

When recognizing an ovarian pregnancy, attention is paid to: 1) the apparent absence of an ovary on the side where there is a pregnancy; 2) the presence of ovarian tissue in the walls of the fetal sac, 3) the existence of a connection between the fetal sac and the uterus through its own ligament of the ovary; 4) the fact that the tube does not participate in the formation of the fetus and its topographic relationship to the fetus is the same as with an ovarian cyst; 5) for the presence of a connection between the fetal sac and the broad ligament (L. A. Krivsky).

Abdominal pregnancy(graviditas abdominalis s. peritonealis) is mostly secondary, usually it represents the outcome of a tubal (rupture of the pipe, tubal miscarriage, ruptured pregnant tube) or ovarian pregnancy and is extremely rare. In some cases, the fetus is located in the free abdominal cavity, in other cases, when the tube breaks and the egg penetrates between the sheets of the broad ligament, the fetus is located interligamentally. Cases of primary abdominal pregnancy are even less common, since in the abdominal cavity the conditions for the introduction and development of the egg are unfavorable (K. K. Skrobansky, K. P. Ulezko-Stroganova). The introduction of the chorionic villi and the development of the egg are possible only with special changes in the peritoneum (endometrioid heterotopia). The introduction and development of the egg on the peritoneum is facilitated by the decidual reaction of endometrial heterotopic areas.

Combination of intrauterine and ectopic pregnancy. Diagnosis in such cases is extremely difficult. In the domestic literature, cases have been published when, after surgical elimination of an ectopic pregnancy, the intrauterine pregnancy continued to develop and ended in term delivery with a live fetus.

Repeated ectopic pregnancy (in another tube) is observed in an average of 4%, cases of development are much less common. repeated pregnancy in the stump of the left tube, since usually the fallopian tube is removed completely. The literature describes cases of multiple tubal pregnancy with twins and triplets. There may be cases of simultaneous bilateral tubal pregnancy, as well as cases of cystic drift.

Although in most cases it is localized in the ampullar, isthmic, or fimbrial part of the fallopian tube, sometimes implantation occurs in unusual areas. Of all cases of ectopic pregnancy, about 2.4% is interstitial, 3.2% - ovarian, 1.3% - peritoneal, less than 0.15% - cervical ectopic pregnancy. With early and accurate diagnosis of such rare localizations of pregnancy in women with stable hemodynamics, conservative treatment is possible.

Further lit therapy for ectopic pregnancy for each of the above locations. It is important to remember that, due to the rarity of these conditions, all of the main data come from single reports or treatment reports of small groups of patients, and not from randomized trials.

Interstitial pregnancy. The interstitial part of the fallopian tube is its proximal part, surrounded by the muscular wall of the uterus. Its dimensions are approximately 0.7 mm wide and 1-2 cm long. Due to the surrounding myometrium, such a pregnancy may grow and not lead to rupture of the fallopian tube until the 7-16th week is reached. Clinically, pregnancy with such localization looks like a swelling on the side of the round ligament of the uterus.

Criteria for staging of this diagnosis by ultrasound: empty uterine cavity, visualization of the fetal egg at a distance of more than 1 cm from the most distant lateral edge of the uterine cavity, visualization of a thin layer of myometrium surrounding the fetal egg.

Traditional therapy for interstitial ectopic pregnancy is resection of the tubal angle of the uterus with laparotomy access, and it remains the method of choice in severe patients. Laparoscopic access has been proposed in the treatment of patients who do not wish to drug treatment. Most tubal angle resection techniques described in the literature involve injecting vasopressin into the myometrium to minimize blood loss, making a linear incision at the site of implantation of the ectopic pregnancy, then hydrodissecting to flush out the pregnancy products in a single conglomerate.

Some authors advocate application sutures to close the incision, others use electrocoagulation and secondary healing of the incision. The successful use of hysteroscopic access for the treatment of interstitial ectopic pregnancy has also been described.

In studies of the use of methotrexate for treatment of interstitial ectopic pregnancy found conflicting results. In a group of 14 patients with ectopic interstitial pregnancy, treatment with a single-dose regimen of methotrexate was 100% successful, with only one patient requiring a second injection of methotrexate due to insufficient reduction in the concentration of bhCG between the 4th and 7th days after injection.

In another treatment review of 20 patients with interstitial ectopic pregnancy the success rate of treatment with methotrexate was only 35%. Another review of the treatment of 41 patients with interstitial ectopic pregnancies with intramuscular, direct, and combined injections of methotrexate found an overall treatment success rate of 83%, with ectopic pregnancies resolved faster when drugs were administered by direct injection.

Based on these and other published reports of treatment in interstitial ectopic pregnancy, we can conclude that in patients with stable hemodynamics, the use of a multidose regimen of methotrexate administration will be a reasonable alternative to laparotomy.

Ovarian pregnancy. An ovarian ectopic pregnancy is difficult to distinguish from a tubal pregnancy before surgery because it is difficult to distinguish ovarian from tubal masses with ultrasound. Due to the good vascularization of the ovaries, an ectopic pregnancy of this localization appears earlier and often after the rupture. An ovarian pregnancy may be mistaken for a bleeding cyst formed from the corpus luteum until pathological analysis confirms the presence of chorionic villi.

Traditionally in therapy ovarian ectopic pregnancy using laparotomy access with the implementation of oophorectomy. There are reports of use in last years wedge resection and laparoscopic access. There is also information on the successful use of treatment with methotrexate.

INTERSTITIAL PREGNANCY - DIFFICULTY OF DIAGNOSIS

INTERSTITIAL PREGNANCY - DIFFICULTY OF DIAGNOSIS

Fetishcheva L.E., Zakharov I.S., U Shakova G.A., M ozes V.G., D emyanova T.N., V asyutinskaya Yu.V., P etrich L.N.

GAUZ "Regional clinical emergency hospital medical care them. M.A. Podgorbunsky,
Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University Ministry of Health of Russia,
Kemerovo

Fetishcheva Larisa Egorovna
doctor of the gynecology departmentGAUZ OKBSMP them. M.A. Podgorbunsky,Kemerovo, Russia
Email: [email protected]

Zakharov Igor Sergeevich
Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University of the Ministry of Health of Russia
E- mail: isza@ mail. en

Ushakova Galina Alexandrovna
Professor, Doctor of Medical Sciences, Head of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University of the Ministry of Health of Russia
Email: [email protected]

Moses Vadim Gelevich
Doctor of Medical Sciences, Professor of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University of the Ministry of Health of Russia

Demyanova Tamara Nikolaevna
head department of gynecologyKemerovo, Russia

Vasyutinskaya Julia Valerievna
deputy chief physician for obstetric and gynecological careGAUZ OKBSMP them. M.A. PodgorbunskyKemerovo, Russia

Petrich Lyubov Nikitichna
doctor of the gynecology departmentGAUZ OKBSMP them. M.A. PodgorbunskyKemerovo, Russia
Email: [email protected]

The ectopic location of the ovum is considered one of the most serious complications of the gravid process. The frequency of ectopic pregnancy is within 1%, and maternal mortality reaches 7%. By localization, ectopic pregnancy of the ampullar part of the fallopian tube prevails, which occurs in 95% of cases of atypical location of the fetal egg. A rarer form is interstitial fallopian tube pregnancy. According to the literature, in early gestational periods, the embryo is quite often localized in the indicated section, then it migrates into the uterine cavity and only in rare cases does this migration not occur, resulting in an ectopic pregnancy [3 ]. Sometimes this variant of ectopic pregnancy can progress up to the second trimester.
Among the risk factors for ectopic pregnancy, the leading place is occupied by inflammatory diseases, previous surgical interventions, adhesive disease of the pelvic organs, intrauterine contraception, etc. Noteworthy is the fact that recurrence of ectopic pregnancy occurs in 7.5–22% of cases, and secondary infertility occurs in 36–80% of patients. In addition, an increase in the risk of fetal ectopia is associated with the use of assisted reproductive technologies. According to the literature, the incidence of pregnancy localized in the uterine angle in women with a history of salpingectomy and induction of pregnancy is about 27%.
As a rule, progressive interstitial pregnancy does not manifest itself clinically until the moment of its interruption. This pathology poses the greatest danger, since the fetal egg is surrounded not by the wall of the fallopian tube, but by the myometrium. As a result, the rupture of the fetus occurs due to the germination of chorionic villi into the myometrium, which leads to rupture of the uterine angle and profuse bleeding.
Given that there are few publications on the above topic, below is a clinical case of an induced pregnancy that has reached a gestational age of 20 weeks, localized in the interstitial part of the fallopian tube.

CLINICAL CASE

pregnant Z., 35 years was observed for induced pregnancy in the antenatal clinic in Kemerovo. From the anamnesis it was found out that this pregnancy is the third one that arose using the method of in vitro fertilization. The first two ended in 2007 and 2014 with tubal lesions, which led to salpingectomy.
According to the history of life, the woman suffers from chronic pyelonephritis, obesity 2 tbsp., Periodic acute respiratory viral diseases. In 2007, she suffered from syphilis.
From the obstetric and gynecological history: menstruation was established from the age of 12, regular, for 5 days, after 28 days, moderate, painless. Sexual life from the age of 16. The sexual partner is 38 years old. As already noted, the woman has secondary infertility, which arose in connection with two ectopic pregnancies of tubal localization.
At the beginning of the gestational period, there were two embryos in the uterus, but one died at 7 weeks. Of the features of the course, it should be noted that during the ultrasound examination in the period of 8 weeks there was a suspicion of the localization of a viable embryoin the interstitial part of the fallopian tube. However, during the first ultrasound screening, the suspicion of an ectopic pregnancy was rejected.When performing the second screening at 20 weeks, no abnormalities in the development of the fetus were detected, however, it was noted that visualization was difficult due to the pronounced subcutaneous fat of the woman.
On October 30, 2016, the pregnant woman was admitted to the Regional Clinical Emergency Hospital named after. M.A. Podgorbunsky Kemerovo with complaints of pain, feeling of pressure in the abdomen, single vomiting, bloody discharge from the genital tract. According to the ultrasound examination of the abdominal organs, cholecystolithiasis was detected.
Taking into account the presence of pain in the abdomen, a differential diagnosis of a miscarriage with surgical diseases (acute pancreatitis, calculous cholecystitis) was carried out.
To clarify the diagnosis, a diagnostic videolaparoscopy was performed, which revealed: in all departments a large number of blood with clots; in the small pelvis - a pronounced adhesive process. Due to massive intra-abdominal bleeding and the impossibility of conducting a revision, to clarify the source of blood loss, the operation was extended to laparotomy.
When performing laparotomic intervention in the abdominal cavity, the following was found (Figure 1):in the region of the right uterine angle, capturing part of the right rib, bottom and anterior wall, an intimately presenting rounded soft formation measuring 20 * 15 * 20 cm, cyanotic-purple in color, with a pronounced vascular pattern and so thinned walls that small parts of the fetus; There was a rupture on the volumetric formation on the left, in the wound of which the placental tissue was located, from the place of the rupture there was scanty bleeding. The right appendages and the left fallopian tube were absent (removed earlier). In the region of the posterior leaf of the broad uterine ligament, on the left, an ovary, soldered with the help of coarse adhesions, was found to be of normal size. In addition, at the site of the rupture, a fetal bladder was determined. Only after the opening of the fetal bladder and the extraction of the fetus, the body of the uterus, deviated to the left by the fetus, became well visualized. At the same time, the size of the body of the uterus corresponded to 7–8 weeks of the conditional gestation period, the walls of the uterus were not changed. To the bottom, to the right corner, with the capture of the right rib, the fetus chamber was intimately presented, to the walls of the fruit chamber - the placenta. The removal of the segment of the uterus, where the fetus was located ( figure 2). Curettage of the uterine cavity was performed - the decidual tissue was removed. The walls of the uterus are sutured.

Picture 1.The receptacle of an ectopic pregnancy, located in the interstitial section of the right fallopian tube, extracted from the surgical wound

Figure 2. Macropreparation of the fetus-place

The total blood loss was 2500 ml. In the postoperative period, blood transfusion therapy was carried out in an adequate amount.
During the pathomorphological examination of the histological material, elements of the fallopian tube were found, which confirmed the assumption that the ovum was localized in the area of ​​the interstitial part of the fallopian tube.

CONCLUSION

The presented clinical case of ectopic location of the fetal egg in the interstitial part of the fallopian tube, in which pregnancy progressed up to 20 weeks of pregnancy, is a rather rare situation. Probably of no small importance for implantation in this department was the factor of assisted reproductive technologies in connection with the removal of the fallopian tubes. Difficulties in timely diagnosis were due to the lack of clear visualization in ultrasound examination in connection with a pronounced layer of subcutaneous fat in a woman. Attention is drawn to the mimicry of the clinical picture of abortion, which created certain difficulties in the differential diagnosis. Thus, the presented clinical case is a confirmation of the thesis about the presence of a high risk of ectopic location of the fetal egg in women who underwent in vitro fertilization.

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