What is not uterine. Terms and signs of rupture of the fallopian tube. Cramping pain in the iliac region

Ectopic or ectopic pregnancy is a pathology in which the ovum is fixed outside the cavity of the genital organ. This condition is dangerous and requires mandatory monitoring. It is important to identify the first signs of an ectopic pregnancy in the early stages.

The fallopian tube is not intended for carrying a fetus and may rupture, so a woman cannot avoid surgical intervention.

Ectopic pregnancy is a fairly rare pathology that can occur in women for various reasons. After the ovum enters the uterine cavity, its attachment to the walls of the organ begins, and pregnancy develops. In the event that any malfunctions occur in the body, the fertilized egg attaches in other organs, without getting into the cavity of the genital organ.

A woman should know what an ectopic pregnancy is, the signs and symptoms of such a pathology, and the possible consequences.

Reasons for development

Experts name the reasons that can:

• Inflammatory processes in the appendages and fallopian tubes... Mucous exudate accumulates on their surface, partial destruction of the villi and loss of sensitivity are observed. As a result, the processes that advance the ovum to the uterus are inhibited, which disrupts its implantation.
• Tumors. Neoplasms of a malignant and benign nature lead to the fact that the lumen of the oviducts is blocked. As a result, the zygote cannot enter the cavity of the genital organ and, in some cases, attaches itself to the abdominal cavity.
• Anatomical abnormalities. Ectopic pregnancy can lead to a bicornuate uterus or double fallopian tubes. Such pathologies are easily diagnosed by ultrasound and serve as a reason for attributing the patient to a risk group.
• Violation of the level of hormones in the body. Pathologies such as polycystic ovaries, thyroid malfunctions and hormonal cycle disorders are capable of causing a stop in the peristaltic movements of the oviducts. The consequence of this is the fact that the ovum cannot move normally into the uterine cavity.

Often, an ectopic pregnancy is diagnosed in women who have previously undergone gynecological surgery. Any intervention in the pelvic area and inflammation of the reproductive system can cause the appearance of adhesions and disrupt the patency of the fallopian tubes.

Early signs of ectopic pregnancy

A rather dangerous type is an ectopic pregnancy, in which two fertilized eggs are implanted. One embryo is attached in the uterine cavity, and the other - anywhere outside it. It is quite problematic to diagnose such a pathology in the early stages, since the embryo is in the uterus and at first no abnormalities are noticeable. The second fertilized egg is actively growing, which leads to rupture and serious consequences.

Every woman should know the symptoms of an abnormal pregnancy, which will allow her to seek medical help in a timely manner.

Obstruction of the fallopian tubes is one of the causes of ectopic pregnancy

When do they appear?

As medical practice shows, there are no special signs of an ectopic pregnancy at an early stage of its development. It successfully disguises itself as a normal pregnancy and is accompanied by such as delayed menstruation and swelling of the mammary glands.

Usually, pain is localized on one side of the abdomen in the area of ​​damage to the fallopian tubes. In the event that a cervical pregnancy is observed or the fetus develops in the abdominal cavity, the patient may feel pain in the middle of the abdomen.

Women should know how to understand that the embryo is attached outside the uterine cavity. Pathology can be accompanied by the development of the following clinical picture:

• with positive;
• sharp and cramping pain, indicating rupture of the ovum;
• spotting in the middle of the cycle.

In a situation where the embryo detaches and dies, the woman develops internal bleeding. The characteristic signs of such a pathological condition are the weakness of the body and increased pallor of the mucous membrane of the mouth and lips.

When an ectopic pregnancy is interrupted, the embryo begins to disintegrate and causes an inflammatory process in the peritoneum. A characteristic manifestation of improper attachment of a fertilized egg can be a sharp rise in body temperature and a drop in blood pressure. In addition, the level of hemoglobin is greatly reduced, which leads to the development of anemia.

Is it possible to find out before the delay?

It is impossible to independently determine that the pregnancy is ectopic. Usually, its course is accompanied by the same symptoms as in a normal pregnancy. The woman notes minor changes in the condition of the mammary glands and. In addition, there is an aversion to certain foods and odors.

In order to determine an ectopic pregnancy, it is imperative to register with a doctor. He will prescribe all the necessary studies and diagnose pathology in a timely manner.

It is possible to determine pregnancy without a test when measuring, which is recorded in a special schedule. With a successful conception, it never drops below 37 degrees. A situation when menstruation is absent, the temperature remains elevated, may indicate the onset of pregnancy.

On the video about pathology

What will the test show?

In order to determine for sure an ectopic pregnancy, a test must be done. In the early stages, it is recommended to perform the test at frequent intervals, and preferably every day. With proper pregnancy, the levels of hCG in the blood will rapidly increase, and the strip will become brighter and brighter.

In the event that a woman does test after test, but the strips remain faded, then this may indicate fertilization outside the uterus. Will the test show an ectopic pregnancy?

When to see a doctor?

The first symptoms in which you need to call an ambulance:

• acute pain in the abdomen, which radiates to the lumbar region and leg;
• a sharp drop in blood pressure;
• increased weakness of the body;
• loss of consciousness;
• copious from the genital tract.

Ultrasound is considered one of the accurate studies with which it is possible to determine an ectopic pregnancy. The device allows you to scan each organ, determine the darkening and reveal the exact localization of the embryo, if any.

In no case does an ectopic pregnancy end in childbirth, since the tube always ruptures. This pathological condition leads to profuse bleeding and the development of hemorrhagic shock. In the absence of timely medical care, an ectopic pregnancy can be fatal.

Ectopic pregnancy is rightfully considered by doctors to be the most insidious and unpredictable gynecological disease. Ectopic pregnancies are not so rare, in about 0.8 - 2.4% of all pregnancies. In 99 - 98% this is a tubal pregnancy. After suffering an illness, especially a tubal pregnancy, a woman's chances of being childless increase. What are the symptoms of an ectopic pregnancy, the reasons for its appearance, 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 uterine cavity. It depends on where the implanted ovum is "stationed" in the tubal, ovarian, abdominal and pregnancy in the rudimentary uterine horn.

Pregnancy in the ovary can be of 2 types:

• one progresses on the ovarian capsule, that is, outside,
• the second directly in the follicle.

Abdominal pregnancy occurs:

• primary (conception and implantation of an egg to the internal organs of the abdominal cavity occurred initially)
• secondary (after the ovum is "thrown" from the fallopian tube, it is attached to the abdominal cavity).

Practical example: A young nulliparous woman was delivered to the gynecology department by ambulance. All the symptoms of bleeding into the abdominal cavity are present. During the puncture of the abdominal cavity, dark blood enters the syringe through the Douglas space of the vagina. Diagnosis before surgery: ovarian apoplexy (there is no delay in menstruation and the test is negative). During the operation, the ruptured ovary and blood in the abdomen are visualized. Ovarian apoplexy remained a clinical diagnosis until histology results were known. It turned out that there was an ovarian pregnancy.

How long can an ectopic pregnancy be determined?

The disease is easiest to determine after the pregnancy is terminated (either a tube rupture or a completed tubal abortion). This can happen at different times, but, as a rule, in 4 - 6 weeks. In the 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 has "chosen" a place for itself in the rudimentary horn of the uterus, can be interrupted later, at 10 - 16 weeks.

Early symptoms of ectopic pregnancy

When do the early symptoms of ectopic pregnancy appear? If a woman has a regular menstrual cycle, this pathology can be suspected when a delay in menstruation occurs. However, the ectopic pregnancy that continues to grow and develop is practically no different from pregnancy, which is in the uterus in the early stages. The patient usually notes the following first symptoms of an ectopic pregnancy:

Firstly, this is an unusual regular menstruation - its delay or. Secondly, mild or moderate pulling pains due to stretching of the fallopian tube wall due to the growth of the ovum. The test for an ectopic pregnancy is most often positive.

• a delay in menstruation is noted by women in 75-92% of cases
• pain in the lower abdomen - 72-85%, both weak and intense
• bloody discharge - 60-70%
• signs of early toxicosis (nausea) - 48-54%
• enlarged and painful breasts - 41%
• pain radiating to the rectum, lower back - 35%
• positive (not all) pregnancy test

The misconception of many is that if there is no delay in menstruation, then the diagnosis of an ectopic pregnancy can be ruled out. Very often, spotting vaginal discharge during ectopic pregnancy is perceived by some women as normal menstruation. According to some authors, it is possible to identify WB in 20% of cases before the delay in menstruation. Therefore, it is very important to take a thorough history and complete examination for the timely establishment of this diagnosis.

During examination by a gynecologist, he reveals cyanosis and softening of the cervix, an enlarged, soft uterus (the first signs of pregnancy). When palpating the area of ​​the appendages, it is possible to determine on one side an enlarged and painful tube and / or ovary (tumor-like formations in the area of ​​the appendages - in 58% of cases, pain when trying to deviate the uterus - 30%). Their contours are not clearly felt. When palpating a tumor-like formation in the appendages, the doctor compares the size of the uterus and the period of delay in menstruation (obvious discrepancy) and prescribes an additional study:

• Ultrasound of the organs of the internal organs of the genital area
• Analysis for the content of hCG and
• The content of progesterone with an ectopic is lower than with a normal pregnancy and there is no growth of hCG after 48 hours if the pregnancy is ectopic

An interrupted ectopic pregnancy by tubal abortion is characterized by a typical triad of symptoms, signs:

• lower abdominal pain
• bloody discharge from the genital tract
• as well as delayed menstruation

Lower abdominal pain is due to the attempt or expulsion of the ovum from the fallopian tube. Hemorrhage inside the tube causes its hyperextension and antiperistalsis. In addition, the blood entering the abdominal cavity acts on the peritoneum as an irritant, which aggravates the pain syndrome.

Sudden, stabbing pain in the iliac regions against the background of complete health helps to suspect a tubal abortion. Pain, as a rule, occurs after 4 weeks of delay in menstruation, radiates to the anus, hypochondrium, collarbone and leg. Such attacks can be repeated several times, and their duration is from several minutes to several hours.

If the internal hemorrhage is minor or moderate, an ectopic pregnancy may remain unrecognized for a long time, and may not have any special signs. Some patients, in addition to the listed symptoms, note the appearance of pain during bowel movements. A painful attack is accompanied by weakness, dizziness, nausea. The slight increase in temperature is due to the absorption of the poured blood in the abdomen.

If intra-abdominal bleeding continues, the woman's condition worsens, and the pain increases. Bloody discharge 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 feature of such secretions is their persistent repetition, neither hemostatic drugs nor curettage of the uterine cavity help.

When a fallopian tube rupture occurs, the symptoms are

The timing of damage to the fallopian tube is directly related to the part of the tube where the embryo is fixed. If he is in the isthmic department, the rupture of the fetus occurs at 4 - 6 weeks, with the "occupation" of the ovum of the interstitial department, the time is lengthened, up to 10 - 12 weeks. If the embryo has chosen a place for further development of the ampullary part of the tube, which is located next to the ovary, rupture occurs after 4 to 8 weeks.

Fallopian tube rupture is a dangerous way to end an ectopic pregnancy. It occurs suddenly and is accompanied by the following symptoms:

• with severe pain
• drop in blood pressure
• increased heart rate
• general deterioration
• cold sweat and
• pain radiates to the anus, leg, lower back

All of these signs of ectopic pregnancy are due to both a pronounced painful 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, and may be slightly distended.

Massive hemorrhage contributes to the appearance of signs of irritation of the peritoneum, as well as muffling of the percussion tone (blood in the abdomen).

A gynecological examination reveals cyanosis of the cervix, an enlarged, soft and shorter than the expected gestational age of the uterus, pastiness, or a tumor-like tumor in the groin 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 is ​​smoothed out or protrudes, and its palpation is painful. Bloody discharge from the uterus is absent, they appear after the operation.

Puncture of the abdominal cavity through the posterior vaginal fornix produces dark, non-clotting blood. This procedure is painful and is rarely used in case of rupture of the tube (pronounced clinical picture: sharp pain, painful and hemorrhagic shock).

Practical example: A pre-pregnant young woman was sent from the antenatal clinic to the gynecology department to preserve her pregnancy. But as soon as she entered, the pregnancy was disrupted as a pipe rupture. At the reception in the area of ​​the appendages, the alarming formation was not palpated, and the diagnosis sounded like a pregnancy of 5-6 weeks, the threat of termination. Successfully the woman went to the doctor. There was no time for a gynecological examination, pressure 60/40, pulse 120, severe pallor, significant dagger pain, and as a result, loss of consciousness. The operating room was quickly deployed and the patient was taken. There was about 1.5 liters of blood in the stomach, and in the burst tube, the pregnancy was about 8 weeks.

Why does an ectopic pregnancy occur?

The attachment of the ovum outside the uterine cavity is due to a violation of the peristalsis of the fallopian tubes or a change in the properties of the ovum. Risk factors:

• inflammatory processes in the small pelvis

Inflammatory processes of the appendages and uterus lead to neuroendocrine disorders, obstruction of the fallopian tubes, and dysfunction of the ovaries. Among the main risk factors, there is a chlamydial infection (salpingitis), which in 60% of cases leads to an ectopic pregnancy (see).

• intrauterine device

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 a woman's uterus.

• abortion

), especially numerous, contribute to the growth of inflammatory processes of the internal genital organs, adhesions, impaired peristalsis and narrowing of the tubes, 45% of women after artificial termination of pregnancy in the future have a high risk of developing an ectopic.

In a woman who smokes, the risk of developing an ectopic is 2-3 times higher than in a nonsmoker, since nicotine affects the peristalsis of the tubes, the contractile activity of the uterus, and leads to various disorders of the immune system.

• malignant neoplasms of the uterus and appendages
• hormonal disorders (including stimulation of ovulation, after IVF, taking mini-pills, impaired production of prostaglandins)
• fallopian tube surgery, tubal ligation
• abnormal development of a fertilized egg
• sexual infantilism (pipes are long, convoluted)
• endometriosis (causes inflammation and adhesions)
• stress, overwork
• age (over 35)
• congenital malformations of the uterus and tubes
• genital tuberculosis

What is the danger of an ectopic pregnancy?

Ectopic pregnancy is terrible for its complications:

• severe bleeding - hemorrhagic shock - death of a woman
• inflammation and intestinal obstruction after surgery
• recurrence of ectopic pregnancy, especially after tubotomy (in 4 - 13% of cases)

Practical example: An ambulance was sent to a woman with classic symptoms of an ectopic pregnancy. During the operation, the tube was removed from one side, and when the patient was discharged, recommendations were given: to be examined for infections, to be treated if necessary and to refrain from pregnancy for at least 6 months (the pregnancy was desired). Less than six months later, the same patient comes with a tubal pregnancy from the other side. The result of non-compliance with the recommendations is absolute infertility (both tubes are removed). The only good news is that the patient has 1 child.

Ways to preserve appendages and should they be preserved?

An ectopic pregnancy is an emergency and requires immediate surgery. Most often, salpingectomy (tube removal) is 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 on a salpingotomy (incision of the tube, removal of the ovum, suturing the incision in the tube). The tube-preserving operation is performed when the size of the ovum is not more than 5 cm, the patient is in a satisfactory condition, the woman wishes to preserve fertility (ectopic recurrence). It is possible to carry out fimbrial evacuation (if the ovum is in the ampulla). The embryo is simply squeezed out or sucked out of the tube.

Segmental pipe resection is also used (removal of the damaged section of the pipe with subsequent stitching of the pipe ends). In the early stages of tubal pregnancy, drug treatment is allowed. Methotrexate is injected into the tube cavity through the lateral fornix of the vagina under ultrasound control, which causes the embryo to dissolve.

Will the tubal patency remain after the operation? It depends on many factors:

• First, early activation of the patient (prevention of adhesions) and physiotherapy
• Secondly, adequate rehabilitation therapy
• Thirdly, the presence / absence of postoperative infectious processes

Questions and Answers:

• How to protect yourself after an ectopic pregnancy?

Reception of purely gestagenic (mini-pili) drugs and the introduction of an IUD is not recommended. It is advisable to take combined oral contraceptives.

• Can a pregnancy test show where it is located?

No, the test shows that there is a pregnancy.

• The delay is 5 days, the test is positive, and the ovum is not visualized in the uterus. What to do?

It is not necessary that an ectopic pregnancy has occurred. It is necessary to repeat the ultrasound scan after 1 - 2 weeks and conduct a blood test for hCG (in the early stages, pregnancy in the uterus may not be visible).

• I have 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 screened for sexually transmitted infections, hormones and be treated.

• When can you plan a pregnancy after an ectopic?

In a normal pregnancy, the fertilized egg moves up the fallopian tube towards the uterus, where it attaches to the wall and begins to grow. But in the case of a condition such as an ectopic pregnancy, the fertilized egg does not enter the uterus, but begins to grow elsewhere, often in the fallopian tube. Therefore, such pregnancies are often referred to as tubal ectopic pregnancies.

In rare cases, the egg is attached to the ovary, abdominal muscles, or cervical canal. It is impossible to save the fetus during such a pregnancy. If an egg begins to grow in the fallopian tube, the tube may be damaged or ruptured, causing severe bleeding that can be fatal. If you have been diagnosed with an ectopic pregnancy, it should be terminated immediately before complications develop.

ICD-10 code

O00 Ectopic [ectopic] pregnancy

Epidemiology

The prevalence of ectopic pregnancies in the United States has more than quadrupled and currently stands at 20 per 1000 pregnancies.

Ectopic pregnancies in the United States are responsible for 10% of pregnancy-related deaths in women. Most deaths are bleeding-related and potentially preventable.

Over the past decade, there has been a clear trend towards an increase in the incidence of ectopic pregnancies. This fact can be explained in two ways. On the one hand, the prevalence of inflammatory processes of the internal genital organs is constantly growing; an increase in the number of surgical interventions on the fallopian tubes, which are carried out in order to regulate childbirth; the number of women using intrauterine and hormonal methods of contraception is increasing; ovulation inducers are increasingly being introduced into the practice of treating infertility. On the other hand, in recent years, diagnostic capabilities have improved, allowing the detection of undisturbed and even regressing ectopic pregnancy.

Currently, ectopic pregnancies occur from 0.8 to 2.4 cases per 100 delivering women. In 4-10% of cases, it is repeated.

Causes of an ectopic pregnancy

Ectopic pregnancies often result from damage to the fallopian tubes. The fertilized egg cannot reach the uterus and is therefore forced to attach to the tube wall.

Ectopic pregnancy provocateurs:

• Smoking (the more you smoke, the higher your risk of ectopic pregnancy).
• Inflammation of the pelvic organs (the result of chlamydia or gonorrhea), which leads to the formation of scar tissue in the fallopian tubes.
• Endometriosis, which leads to the formation of scar tissue in the fallopian tubes.
• Exposure to synthetic estrogen (diethylstilbestrol) before birth.
• Previous ectopic pregnancy in the fallopian tubes.

Certain medical interventions can increase the risk of an ectopic pregnancy:

• Operations on the fallopian tubes in the pelvic area (tubal ligation) or to remove scar tissue.
• Infertility treatment.

An ectopic pregnancy has been linked to taking medications to ovulate more eggs. Scientists do not yet know what causes an ectopic pregnancy - hormone intake or damage to the fallopian tubes.

If you are pregnant and fear an ectopic pregnancy, you need to be carefully examined. Doctors do not always agree on the risk factors for ectopic pregnancy, but one thing is clear - the risk increases after a history of ectopic pregnancy, fallopian tube surgery, or pregnancy with an intrauterine device.

Pathogenesis

Implantation of the ovum outside the uterine cavity can occur due to a violation of the transport function of the fallopian tubes, as well as in connection with a change in the properties of the ovum itself. Combinations of both causal factors in the development of an ectopic pregnancy are possible.

Fertilization of an egg by a sperm cell under normal conditions occurs in the fimbrial section of the ampulla of the fallopian tube. Due to the peristaltic, pendulum-like and turbulent movements of the tube, as well as due to the flickering of the ciliated epithelium of the endosalpinx, the cleavage ovum reaches the uterine cavity after 3-4 days, where the blastocyst can be in a free state for 2-4 days. Then, having lost the zona pellucida, the blastocyst plunges into the endometrium. Thus, the implantation is carried out on the 20-21st day of the 4-week menstrual cycle. Violation of the transport function of the fallopian tubes or the accelerated development of the blastocyst can lead to implantation of the ovum proximal to the uterine cavity.

Practice shows that dysfunction of the tube is most often associated with inflammatory processes of any etiology. The predominant role is played by a nonspecific infection, the spread of which is facilitated by abortion, intrauterine contraception, intrauterine diagnostic interventions, a complicated course of labor and the postpartum period, and appendicitis. In recent years, a high incidence of chlamydial infection in women operated on for ectopic pregnancy has been revealed. Along with the inflammatory nature of the violation of the structure and function of the fallopian tubes, the role of endometriosis is extremely important.

The importance of surgical interventions on the fallopian tubes in the structure of causal factors leading to the occurrence of ectopic pregnancy is constantly increasing. Even the introduction of microsurgery does not exclude such a danger.

The contractile activity of the tube is closely related to the nature of the hormonal status of the body. Unfavorable hormonal levels in women can be caused by dysregulation of the menstrual cycle of any nature, age, as well as the use of exogenous hormonal drugs that contribute to the disturbance or induction of ovulation.

The inadequacy of the development of the blastocyst to the place of physiological implantation is associated with the excessive biological activity of the egg itself, leading to accelerated formation of trophoblast and possible nidation, before reaching the uterine cavity. It is almost impossible to find out the reason for such a rapid development of the blastocyst.

Disruption of the transport of the ovum in some cases can be explained by the peculiarities of its path, for example, external migration of the egg after surgery on the appendages: the egg from a single ovary through the abdominal cavity enters the only tube on the opposite side. Cases of transperitoneal migration of spermatozoa with some malformations of internal genital organs are described.

In recent years, there have been reports of the possibility of tubal pregnancy after in vitro fertilization and blastocyst transplantation into the uterus.

In the tube, ovary, abdominal cavity, and even in the rudimentary horn of the uterus, there is no powerful, specifically developed mucous membrane and submucosa inherent in physiological pregnancy. A progressive ectopic pregnancy stretches the fetus, and the chorionic villi destroy the underlying tissue, including the blood vessels. Depending on the location of pregnancy, this process can proceed faster or slower, accompanied by more or less bleeding.

If the ovum develops in the isthmic section of the tube, where the height of the folds of the mucous membrane is small, the so-called basotropic (main) growth of chorionic villi takes place, which quickly destroy the mucous, muscular and serous layers of the tube, and after 4-6 weeks this leads to perforation walls with vascular destruction, powerfully developed in connection with pregnancy. There is an interruption of pregnancy as an external rupture of the fetus, that is, rupture of the pregnant tube, which is accompanied by massive bleeding into the abdominal cavity. The same is the mechanism of termination of pregnancy localized in the interstitial section of the tube. However, due to the significant muscle layer surrounding this section of the tube, the duration of pregnancy can be longer (up to 10-12 weeks or more). Blood loss due to the extremely developed blood supply to this area during rupture of the fetus, as a rule, is massive.

The integrity of the mesenteric edge of the tube is extremely rare. In this case, the ovum and the outflowing blood end up between the leaves of the broad ligament. Casuistic cases are described when the ovum did not die, but continued to develop interconnectively until significant periods of time.

With ampullar localization of tubal pregnancy, implantation of the ovum into the fold of endosalping is possible (columnar, or acrotropic, attachment). In this case, the growth of chorionic villi can be directed towards the lumen of the tube, which, 4-8 weeks after nidation, is accompanied by a violation of the inner capsule of the fetus, and this, in turn, leads to slight or moderate bleeding. Antiperistaltic movements of the tubes can gradually expel the exfoliated ovum into the abdominal cavity: a tubal abortion occurs. When the fimbrial section of the tube is closed, the blood flowing into the lumen of the tube leads to the formation of hematosalping. With an open lumen of the ampoule, blood flowing out of the tube and curling up in the area of ​​its funnel can form a peritubar hematoma. Repetitive, more profuse bleeding leads to the accumulation of blood in the rectal-uterine cavity and the formation of the so-called extrauterine hematoma, delimited from the abdominal cavity by a fibrous capsule, soldered to the intestinal loops and the omentum.

In extremely rare cases, the ovum, expelled from the tube, does not die, but attaches to the parietal or visceral peritoneum of the abdominal organs (most often to the peritoneum of the rectal-uterine cavity). A secondary abdominal pregnancy develops, which can exist for different times, up to full term. Even less often, the ovum can be implanted in the abdominal cavity primarily.

Ovarian pregnancy rarely lasts long. Usually, an external rupture of the fruit receptacle occurs, accompanied by significant bleeding. If pregnancy develops on the surface of the ovary, this outcome occurs early. In the case of intrafollicular localization, the interruption occurs later.

Cervical pregnancy is a rare but potentially severe form of ectopic pregnancy due to the high risk of bleeding. Cervical pregnancies are usually treated with methotrexate.

Ectopic pregnancy symptoms

During the first few weeks, an ectopic pregnancy causes the same symptoms as a normal pregnancy: missing menstrual periods, fatigue, nausea, and breast tenderness.

The main signs of an ectopic pregnancy:

• Pain in the pelvic or abdominal region, which can be acute on one side, but eventually spread to the entire abdominal cavity. The pain increases with movement or exertion.
• Vaginal bleeding.

If you think you are pregnant and still observe the above symptoms, seek immediate medical attention.

The first weeks of an ectopic pregnancy are no different from a normal pregnancy. During this period, the following are observed:

• Lack of a menstrual cycle.
• Breast soreness.
• Fatigue.
• Nausea.
• Frequent urination.

But if the ectopic pregnancy continues to occur, other symptoms occur, including:

• Pain in the pelvic or abdominal area (usually by 6-8 weeks after the end of the menstrual cycle). The pain increases with movement or tension, it is acute, one-sided, over time spreads to the entire abdominal cavity.
• Moderate to severe vaginal bleeding.
• Painful sensations during intercourse or physical examination by a doctor.
• Pain in the shoulder area resulting from bleeding into the abdominal area under irritation of the diaphragm.

The symptoms of an early ectopic pregnancy and miscarriage are often the same.

Usually at the beginning of pregnancy, the fertilized egg moves up the fallopian tube towards the uterus, where it attaches to the wall and begins to develop. But in 2% of diagnosed cases of pregnancy, the fertilized egg stops outside the uterus and an ectopic pregnancy occurs.

With an ectopic pregnancy, the fetus cannot develop for a long time, but reaches such a size, which leads to rupture of the tube and bleeding, which is fraught with death for the mother. A woman who has symptoms of an ectopic pregnancy requires immediate medical attention. In most ectopic pregnancies, the fertilized egg is attached to the fallopian tube. In rare cases:

• The egg attaches and begins to grow in the ovary, in the cervical canal, or in the abdomen (excluding the organs of the reproductive system).
• One or more eggs develop in the uterus while in parallel another egg (or several) grow in the fallopian tube, cervical canal or abdominal cavity.
• In very rare cases, an egg begins to develop in the abdomen after the uterus is removed (hysterectomy).

When to seek help from a doctor?

If you are expecting a baby, watch carefully for symptoms that may indicate an ectopic pregnancy, especially if you are predisposed to it.

For vaginal bleeding and acute abdominal pain (before or after pregnancy is diagnosed or during treatment for an ectopic pregnancy):

• call an ambulance;
• go to bed and rest;
• do not make sudden movements until your doctor assesses your health.

Contact your doctor for persistent minor abdominal pain.

Observation

To observe means to wait a little and see if the condition improves. But with an ectopic pregnancy, due to the risk of death, it is impossible to stay at home and wait for a miracle. Call an ambulance right away at the first sign of an ectopic pregnancy.

Professionals to contact

• gynecologist
• family doctor
• ambulance doctor

In the case of diagnosing an ectopic pregnancy, the treatment is carried out by a gynecologist.

Forms

Unlike ICD-10 in the domestic literature, tubal pregnancy is divided into:

• ampullary;
• isthmic;
• interstitial.

Interstitial tubal pregnancies account for just under 1% of ectopic pregnancies. Patients with interstitial tubal pregnancy in most cases see a doctor later than with ampullary or isthmic. The incidence of pregnancy in the uterine corner increases to 27% in patients with a history of salpingectomy and IVF and PE. Interstitial tubal pregnancies are associated with most of the deaths associated with ectopic pregnancies in general, as they are often complicated by uterine rupture.

Ovarian pregnancy is divided into:

• developing on the surface of the ovary;
• developing intrafollicularly.

Abdominal pregnancy is divided into:

• primary (implantation in the abdominal cavity occurs initially);
• secondary.

Depending on the localization of implantation of the ovum, ectopic pregnancy is divided into tubal, ovarian, located in the rudimentary uterine horn, and abdominal. Among all cases of tubal pregnancy, depending on the place of the fetus, ampullaria, isthmic and interstitial are distinguished. Ovarian pregnancy can be observed in two ways: developing on the surface of the ovary and inside the follicle. Abdominal ectopic pregnancy is divided into primary (implantation initially occurs on the parietal peritoneum, omentum, or any organs of the abdominal cavity) and secondary (attachment of the ovum in the abdominal cavity after its expulsion from the fallopian tube). Ectopic pregnancy in the rudimentary horn of the uterus, strictly speaking, should be attributed to the ectopic type of uterine pregnancy, but the peculiarities of its clinical course force us to consider this localization in the group of proximal variants of ectopic pregnancy.

Among all types of ectopic pregnancy, it is customary to distinguish between frequent and rare forms. The first include ampullar and isthmic localization of tubal pregnancy, which account for 93-98.5% of cases. Ampular localization of tubal pregnancy occurs somewhat more often than isthmic.

Rare forms of ectopic pregnancy include interstitial (0.4-2.1%), ovarian (0.4-1.3%), abdominal (0.1-0.9%). Even less common is an ectopic pregnancy that develops in the rudimentary uterine horn (0.1-0.9%), in the accessory fallopian tube. Casuistry includes extremely rare cases of multiple pregnancies with various localization: a combination of uterine and tubal, bilateral tubal and other combinations of ectopic localization of the ovum.

The localization of the ectopic fruit-receptacle is closely related to the peculiarities of the clinical course of the disease, among which there are progressive and disturbed forms. Violation of pregnancy can occur as an external rupture of the fetus: rupture of the ovary, rudimentary horn of the uterus, interstitial part of the fallopian tube, often isthmic, rarely ampullary. The second option for termination of pregnancy is an internal rupture of the fetus, or tubal abortion. According to this type, most often there is a violation of pregnancy located in the ampullary section of the tube. In recent years, in connection with the improvement of diagnostic capabilities, there has been a tendency to isolate a regressive form of ectopic pregnancy.

Abdominal (abdominal) pregnancy

Belong to rare forms of ectopic pregnancy (0.3-0.4%). Localization of abdominal pregnancy is different: omentum, liver, sacro-uterine ligaments, rectal-uterine cavity. It can be primary (implantation occurs in the abdominal organs) and secondary (initially, implantation occurs in the tube, and then, due to tubal abortion, the fertilized egg is expelled from the tube and is re-implanted in the abdominal cavity). This difference is of purely theoretical interest, and the initial implantation can be established only by histological examination, since by the time of the operation the tube is already macroscopically unchanged.

Abdominal pregnancy, both primary and secondary, is extremely rare. Progressive primary pregnancy is hardly diagnosed; interrupting it gives a picture of a disturbed tubal pregnancy.

Secondary abdominal pregnancy occurs after a tubal abortion or rupture of the tube, very rarely - after a ruptured uterus. An abdominal pregnancy can be extended to a long time, which poses a serious threat to a woman's life, while the fetus is rarely viable. More than half of the fetuses have developmental defects.

Secondary abdominal pregnancy can be suspected in women who had episodes of pain in the lower abdomen in the early stages, accompanied by small bleeding from the vagina. Typical complaints of a woman about painful movements of the fetus. An external examination of the patient can reveal the wrong position of the fetus. clearly feel its small parts. There are no contractions of the fetuses, which are usually determined by palpation. With an internal examination, attention should be paid to the displacement of the cervix up and to the side. In some cases, it is possible to palpate the uterus separately from the fetus. An ultrasound scan reveals the absence of a uterine wall around the fetal bladder.

Ovarian pregnancy

One of the rare forms of ectopic pregnancy, its frequency is 0.1-0.7%. There are two forms of this pregnancy: intrafollicular and epiophoral. With the intrafollicular form, fertilization and implantation occurs in the follicle, with the epiophoral form - on the surface of the ovary.

Cervical pregnancy

The incidence ranges from 1 in 2,400 to 1 in 50,000 pregnancies. It is believed that the risk of its occurrence is increased by a previous abortion or caesarean section, Asherman's syndrome, the use of diethylstilbestrol by the mother during pregnancy, uterine fibroids, in vitro fertilization and embryo transfer. Ultrasound signs of cervical pregnancy:

• absence of a fetal egg in the uterus or a false fetal egg;
• hyperechogenicity of the endometrium (decidual tissue);
• heterogeneity of the myometrium;
• hourglass uterus;
• expansion of the cervical canal;
• the ovum in the cervical canal;
• placental tissue in the cervical canal;
• closed internal pharynx.

After confirming the diagnosis, the blood group and Rh factor are determined, a venous catheter is installed, and the patient's written consent is obtained to perform extirpation of the uterus if necessary. All of this is due to the high risk of massive bleeding. There are reports of the effectiveness of intra-amnial and systemic use of methotrexate in cervical pregnancy. The diagnosis of cervical pregnancy is often made only during diagnostic curettage for the alleged abortion in progress or incomplete abortion, when profuse bleeding has begun. To stop bleeding, depending on its intensity, a tight vaginal tamponade is used, the lateral fornix of the vagina is sutured, a circular suture is applied to the cervix, a Foley catheter is inserted into the cervical canal and the cuff is inflated. Embolization of bleeding vessels, ligation of the uterine or internal iliac arteries are also used. If all the above measures are ineffective, the uterus is extirpated.

Pregnancy in the rudimentary horn of the uterus

Occur in 0.1-0.9% of cases. Anatomically, this pregnancy can be attributed to uterine, however, due to the fact that in most cases the rudimentary horn does not have communication with the vagina, clinically, such a pregnancy proceeds as ectopic.

Pregnancy in the rudimentary horn, which has an underdeveloped muscle layer and a defective mucous membrane, occurs under the following conditions: the horn cavity communicates with the fallopian tube, the desquamation phase does not occur in the mucous membrane and, therefore, the formation of hematomas does not occur, which prevents the implantation of the ovum. The mechanism of penetration of the blastocyst into the cavity of the rudimentary horn, apparently, is associated with the transperntoneal migration of spermatozoa or ovum.

Progressive pregnancy is rarely diagnosed. It can be suspected on the basis of unusual data from an internal gynecological examination: an enlarged uterus (for periods of more than 8 weeks, inappropriate to the period of delay in menstruation) is rejected to the side; on the opposite side, a tumor-like, painless formation of a softish consistency associated with the uterus with a thick leg is determined. Ultrasound or laparoscopy is invaluable.

Violation of pregnancy occurs as an external rupture of the fetus, accompanied by profuse bleeding and requires urgent surgical intervention. The scope of the operation in typical cases is the removal of the rudimentary horn together with the adjacent fallopian tube.

Intraligamentary pregnancy

It accounts for 1 in 300 cases of ectopic pregnancy. It usually occurs a second time, when the fallopian tube ruptures along the mesenteric edge and the ovum penetrates between the leaves of the broad ligament. Intraligamentary pregnancy is also possible with a fistula connecting the uterine cavity and parametrium. The placenta can be located on the uterus, bladder, or pelvic wall. If it is impossible to remove the placenta, it is left. There are reports of successful delivery of full-term intraligamentary pregnancies.

Rare variants of ectopic pregnancy

Combination of uterine and ectopic pregnancy

The frequency, according to different authors, ranges from 1 in 100 to 1 in 30,000 pregnancies. It is located higher after the induction of ovulation. Having identified the fertilized egg in the uterus, during ultrasound, they often do not pay attention to the second fertilized egg. The results of multiple studies of the level of the beta-subunit of hCG do not differ from those in normal pregnancy. In most cases, an operation is performed for an ectopic pregnancy and the uterine pregnancy is not interrupted. It is also possible to introduce potassium chloride into the ovum located in the fallopian tube (with laparoscopy or through the lateral fornix of the vagina). Methotrexate is not used.

Multiple ectopic pregnancy

It is even less common than a combination of uterine and ectopic pregnancy. There are many options for the number and location of fetal eggs. About 250 cases of ectopic twin pregnancies have been described. In most cases, these are ampullary or isthmic tubal pregnancies, but ovarian, interstitial tubal and abdominal pregnancies are also described. Ectopic pregnancies of twins and triplets are possible after resection of the fallopian tube and EN. Treatment is the same as for singleton pregnancies.

Pregnancy after extirpation of the uterus

The rarest type of ectopic pregnancy is pregnancy after vaginal or abdominal extirpation of the uterus. Embryo implantation in the fallopian tube occurs shortly before or on the 1st day after the operation. An ectopic pregnancy is possible at any time after the operation if there is a message of the abdominal cavity with the stump of the cervix or vagina.

Chronic ectopic pregnancy

This is a condition when the ovum after death is not fully organized, and viable chorionic villi remain in the fallopian tube. Chronic ectopic pregnancy occurs when treatment has not been carried out for any reason. Chorionic villi cause repeated hemorrhages in the wall of the fallopian tube, it gradually stretches, but usually does not rupture. In chronic ectopic pregnancy, 86% of patients note pain in the lower abdomen, 68% - spotting from the genital tract. Both symptoms are observed at once in 58% of women. In 90% of patients, menstruation is absent for 5-16 weeks (an average of 9.6 weeks), almost all of them determine the volumetric formation in the small pelvis. Occasionally, with chronic ectopic pregnancy, there is compression of the ureters or intestinal obstruction. The most informative method for diagnosing chronic ectopic pregnancy is ultrasound. The concentration of β-subunit of hCG in blood serum is low or normal. Salpingectomy is indicated. Concomitant aseptic inflammation leads to an adhesive process, and therefore, together with the fallopian tube, it is often necessary to remove the ovary.

Spontaneous recovery

In some cases, an ectopic pregnancy stops developing, and the ovum gradually disappears, or a complete tube abortion occurs. No surgical treatment is required. The frequency of this outcome of an ectopic pregnancy and the conditions predisposing to it are unknown. It is also impossible to assess his forecast. The content of the β-subunit of CHT cannot serve as a guideline.

Persistent ectopic pregnancy

Observed after organ-preserving operations on the fallopian tubes (salpingotomy and artificial tubal abortion). During histological examination, the embryo, as a rule, is absent, and chorionic villi are found in the muscular membrane. Implantation occurs medially from the fallopian tube scar. Implantation of chorionic villi in the abdominal cavity is possible. Recently, the incidence of persistent ectopic pregnancy has increased. This is explained by the widespread use of organ-preserving operations on the fallopian tubes. The absence of a decrease in the beta-subunit of hCG after surgery is characteristic. It is recommended to determine the beta subunit of hCG or progesterone on the 6th day after the operation and then every 3 days. The risk of persistent ectopic pregnancy depends on the type of surgery, the baseline concentration of the beta-subunit of hCG, the gestational age, and the size of the ovum. A delay in menstruation of less than 3 weeks and a fetal egg diameter of less than 2 cm increases the risk of persistent ectopic pregnancy. In case of persistent ectopic pregnancy, both surgical (repeated salpingotomy or, more often, salpingectomy) and conservative treatment (use of methotrexate) are performed. Many authors prefer conservative treatment, since the chorionic villi can be found not only in the fallopian tube and, therefore, they are not always determined during reoperation. In case of hemodynamic disturbance, an operation is indicated.

Complications and consequences

An ectopic pregnancy can rupture the fallopian tube, decreasing the chances of another pregnancy.

An ectopic pregnancy should be diagnosed at an early stage for the woman's safety and to prevent heavy bleeding. A perforated ectopic pregnancy requires immediate surgery to stop severe bleeding in the abdomen. A ruptured fallopian tube is removed in whole or in part.

Diagnostics of the ectopic pregnancy

If you suspect that you are pregnant, buy a pregnancy test or have a urine test. To determine an ectopic pregnancy, your doctor:

• will examine the pelvic organs to identify the size of the uterus and the presence of formations in the abdominal cavity;
• will prescribe a blood test to detect the pregnancy hormone (the analysis is repeated after 2 days). In the early stages of pregnancy, the level of this hormone doubles every two days. Its low level indicates an anomaly - an ectopic pregnancy.
• An ultrasound scan shows an image of the internal organs. The doctor diagnoses pregnancy 6 weeks from the last menstrual cycle.

In most cases, an ectopic pregnancy can be identified through vaginal examination, ultrasound and blood tests. With symptoms of an ectopic pregnancy, you need:

• undergo a vaginal examination, during which the doctor will determine soreness in the uterus or fallopian tubes, an increase in the size of the uterus larger than usual;
• do an ultrasound (transvaginal or abnominal), which provides a clear image of the organs and their structure in the lower abdominal cavity. Transvaginal examination (ultrasound) is a more reliable way of diagnosing pregnancy, which can be determined as early as 6 weeks after the last menstrual cycle. In the case of an ectopic pregnancy, the doctor will not see signs of an embryo or fetus in the uterus, but a blood test will indicate elevated hormone levels.
• have a blood test two or more times to determine the level of hormones (human chorionic gonadotropin) at intervals of 48 hours. In the first weeks of a normal pregnancy, the level of this hormone doubles every two days. A low or slightly increasing level of it indicates an ectopic pregnancy or miscarriage. If the level of this hormone is too low, additional tests need to be done to determine the cause.

Laparoscopy is sometimes done to check for an ectopic pregnancy, which can be seen and terminated at 5 weeks. But it is not often used because ultrasound and blood tests give accurate results.

The main complaints of patients with ectopic pregnancy:

• delayed menstruation (73%);
• bloody discharge from the genital tract (71%);
• pains of various nature and intensity (68%);
• nausea;
• irradiation of pain to the lumbar region, rectum, inner thigh;
• a combination of three of the above symptoms.

Laboratory and instrumental studies for ectopic pregnancy

The most informative in the diagnosis of ectopic pregnancy: determination of the concentration of the β-subunit of chorionic gonadotropin (HCT) in the blood, ultrasound and laparoscopy.

For early diagnosis, carry out:

• transvaginal ultrasound;
• determination of the content of β-subunit of hCG in blood serum.

The combination of transvaginal ultrasound and determination of the concentration of the β-subunit of cGT makes it possible to diagnose pregnancy in 98% of patients from the 3rd week of pregnancy. Ultrasound diagnostics of ectopic pregnancy includes measurement of endometrial thickness, sonohysterography, color dopplerometry. Pregnancy in the uterine corner can be suspected with the asymmetry of the uterus, the asymmetric position of the ovum, detected by ultrasound.

The main criteria for ultrasound diagnosis of ectopic pregnancy:

• heterogeneous appendages and free fluid in the abdominal cavity (26.9%);
• heterogeneous appendage structures without free fluid (16%);
• an ectopically located ovum with a living embryo (there is a heartbeat) (12.9%);
• ectopic location of the embryo (no heartbeat) (6.9%).

According to the results of ultrasound, 3 types of echographic picture of the uterine cavity are distinguished in case of an ectopic pregnancy:

• I - endometrium thickened from 11 to 25 mm without signs of destruction;
• II - the uterine cavity is dilated, the anteroposterior size is from 10 to 26 mm, the contents are mainly liquid, heterogeneous due to hematometers and gravidar endometrium, which is torn away to varying degrees;
• III - the uterine cavity is closed, M-echo in the form of a hyperechoic strip from 1.6 to 3.2 mm (Kulakov V.I., Demidov V.N., 1996).

To clarify the diagnosis of tubal pregnancy, impaired by the type of internal rupture of the fetus, there are numerous additional research methods. The most informative and up-to-date are the following:

• Determination of chorionic gonadotropin or its beta subunit (beta-chorionic gonadotropin) in blood serum or urine.
• Ultrasound scanning.
• Laparoscopy.

Currently, there are many ways to determine the chorionic gonadotropin. Some of them (for example, biological) have lost their leading role. Due to its high specificity and sensitivity, preference is given to the radioimmunological method for the quantitative determination of B-chorionic gonadotropin in blood serum. The enzyme immunoassay methods for detecting chorionic gonadotropin in urine, as well as other variants of immunological tests (capillary, plate), deserved a positive assessment. Such well-known serological methods for the determination of chorionic gonadotropin in urine, such as the reaction of inhibition of agglutination of erythrocytes or sedimentation of latex particles, have a right to exist. All laboratory methods for diagnosing pregnancy are highly specific: the correct answers are observed from 92 to 100 % already from the 9-12th day after fertilization of the egg. However, they establish only the fact of the existence of pregnancy without specifying its localization, therefore they can be used for. carrying out a differential diagnosis with an inflammatory process in the appendages, ovarian apoplexy, endometriosis of the appendages and similar diseases.

Ultrasound examination (ultrasound) is a widespread non-invasive method that, when combined with the determination of beta-chorionic gonadotropin, can provide high diagnostic accuracy. The main signs of tubal abortion, identified by ultrasound, include the absence of the ovum in the uterine cavity, an increase in the appendages, and the presence of fluid in the rectal uterine cavity. Pulsation of the heart of the embryo during ectopic pregnancy is rarely recorded.

Transvaginal ultrasound allows you to determine the ovum in the uterine cavity at a concentration of beta-chorionic gonadotropin in the blood serum of 1000-1200 IU / L (approximately 5 days after the start of the last menstruation). With the help of transabdominal ultrasound, the ovum in the uterine cavity can be detected when the concentration of beta-chorionic gonadotropin in the blood serum is more than 6000 IU / L.

The most informative method, which allows for differential diagnosis with almost one hundred percent accuracy, is laparoscopy. The high assessment of the diagnostic capabilities of laparoscopy is somewhat reduced by the fact that this method is aggressive, it cannot be used in all patients, since complications are possible during its implementation.

Contraindications to laparoscopy are heart and pulmonary failure; all types of shock, peritonitis; intestinal obstruction; all diseases and conditions accompanied by blood clotting disorders; adhesive process in the abdominal cavity; flatulence; obesity; the presence of infectious diseases. Serious complications rarely accompany laparoscopy. Most often, there are injuries of the small and large intestine, omentum, blood vessels, as well as emphysema of the abdominal wall, omentum and mediastinum. Therefore, to this day, the opinion that endoscopy should be carried out as the final stage of the examination remains relevant.

The method well-known to gynecologists, which is the puncture of the utero-rectal cavity of the abdominal cavity, carried out through the posterior fornix of the vagina, has not lost its significance. The receipt of liquid dark blood with small clots confirms the presence of tubal pregnancy. However, it should be remembered that the absence of blood in the punctate does not allow a categorical conclusion.

In many cases, the differential diagnosis is helped by histological examination of the endometrial scraping. The absence of chorionic villi in the presence of decidual transformations of the mucous membrane or other more subtle changes in the endometrium (structures of the reverse development of the mucous membrane after a pregnancy violation, tangles of spiral vessels, transformation of the uterine epithelium in the form of the Arias-Stella phenomenon and Overbeck's "light glands") most often testifies in favor of ectopic pregnancy.

In difficult-to-diagnose cases, you can use hysterosalpingography with the introduction of water-soluble contrast agents or its type - selective salpingography after preliminary catheterization of the fallopian tubes during hysteroscopy. Penetration of a contrasting substance between the ovum and the tube wall (a symptom of flow) and uneven impregnation of the ovum with it are characteristic of tubal pregnancy.

Progressive tubal pregnancy, unfortunately, is rarely diagnosed. The reason for this is the lack of convincing clinical symptoms. However, the use of modern research methods makes it possible to recognize an ectopic pregnancy before its termination. Early diagnosis, in turn, contributes to timely adequate treatment that preserves not only health, but also the woman's reproductive function.

Progressive tubal pregnancy exists for a short period of time: 4-6 weeks, rarely longer. There are practically no obvious symptoms characteristic only for progressive ectopic pregnancy. With a delay or with unusual menstruation for the patient, signs characteristic of a physiological or complicated uterine pregnancy may appear: taste perversion, nausea, salivation, vomiting, engorgement of the mammary glands, sometimes minor pain in the lower abdomen that does not have a specific character. The general condition of the patient is quite satisfactory. Gynecological examination in the early stages of progressive tubal pregnancy usually does not reveal data confirming the diagnosis. Cyanosis and loosening of the mucous membrane of the vagina and cervix are not very pronounced. Due to hyperplasia and hypertrophy of the muscle layer and the transformation of the mucous membrane into the decidual size of the uterus in the first 6-7 weeks correspond to the period of delay in menstruation. The enlargement of the uterus, however, is not accompanied by a change in its shape, which remains pear-shaped, somewhat flattened in the anteroposterior direction. The softening of the isthmus is poorly expressed. In some cases, it is possible to palpate the enlarged tube and detect the pulsation of the vessels through the lateral arches. It is much easier to suspect a progressive tubal pregnancy if the duration of its existence exceeds 8 weeks. It is from this time that the lag in the size of the uterus from the expected period of pregnancy is found. The possibility of detecting a thickened fallopian tube increases.

All of the above microsymptoms make one suspect a progressive tubal pregnancy if they are found in women who have already had an ectopic pregnancy in the past, abortions, a complicated course of appendicitis, who have had inflammatory processes of the appendages, who have suffered from infertility or who have used intrauterine or hormonal contraceptives.

Clarification of the diagnosis in such cases should be carried out only in a hospital setting. The patient's examination plan depends on the equipment of the hospital, its laboratory and hardware capabilities. The best option for examination: mandatory determination of chorionic gonadotropin in serum or urine and ultrasound scanning, if necessary - laparoscopy.

If it is impossible to use ultrasound and laparoscopy, the examination takes a longer time. Diagnostic measures can be twofold, depending on the patient's attitude to a possible uterine pregnancy. Confirming the desired pregnancy with any available method for determining chorionic gonadotropin. the doctor carries out dynamic monitoring of the patient for such a time that will determine the localization of the ovum with a conventional vaginal examination. If a woman is not interested in pregnancy, then curettage of the uterine cavity and histological examination of the removed tissue or gnsterosalpingography can be performed. Once again, it should be emphasized that the examination of a patient with suspected progressive ectopic pregnancy should be carried out in a hospital, where an operating room can be deployed at any time to provide emergency surgical care.

Follow-up diagnosis after treatment

One week after the treatment of an ectopic pregnancy, the level of the pregnancy hormone (human chorionic gonadotropin) should be checked again several times. If its level falls, then the ectopic pregnancy is interrupted (sometimes in the first days after treatment, the level of the hormone may increase, but then, as a rule, it falls). In some cases, tests are repeated for a longer time (from weeks to months) until the doctor is convinced that the level of the hormone has dropped to a minimum.

What should you think about?

If you are pregnant and at risk, you should be carefully examined. Doctors do not always agree on the risk factors for ectopic pregnancy, but one thing is clear - the risk increases after a history of ectopic pregnancy, fallopian tube surgery, or pregnancy with a simultaneous intrauterine device.

A pregnancy test, which is sold in pharmacies and involves a urine test, will always accurately indicate the state of pregnancy, but cannot reveal a pathology, namely, an ectopic pregnancy. Therefore, after you have received a positive result at home, and you suspect an ectopic pregnancy, you need to consult a doctor who will prescribe a blood test and an ultrasound scan if necessary.

Termination of pregnancy by the type of rupture of the tube is differentiated from:

• ovarian apoplexy;
• perforation of gastric and duodenal ulcers;
• ruptured liver and spleen;
• torsion of the leg cyst or ovarian tumor;
• acute appendicitis;
• acute pelvioperitonitis.

Pregnancy interrupted by the type of rupture of the internal fetus (tubal abortion) must be differentiated from:

• abortion;
• exacerbation of chronic salpingo-oophoritis;
• dysfunctional uterine bleeding;
• torsion of the legs of the ovarian tumor;
• ovarian apoplexy;
• acute appendicitis.

Ectopic pregnancy treatment

Treatment includes medications and surgery. In most cases, measures must be taken immediately for the safety of the woman. Medicines are prescribed when this anomaly is diagnosed early, even before the fallopian tube is damaged. Most often, one or two doses of Methotrexate are sufficient to terminate a pregnancy. In this case, there is no need for surgical intervention. But to be sure, you need to do repeated blood tests.

If an ectopic pregnancy has been going on for a longer time, surgery is a safer option. If possible, laparoscopy is done (a small incision in the abdominal cavity), but in an emergency, the incision will be much larger.

In most cases, an ectopic pregnancy is terminated immediately to avoid rupture of the fallopian tube and severe blood loss. Treatment depends on how long the pregnancy is diagnosed and the woman's general health. If there is no bleeding during an ectopic pregnancy, a woman can choose a means of terminating it - medication or surgery. Medicines. A drug such as methotrexate is used to terminate an ectopic pregnancy. In this case, general anesthesia and cavity incision are excluded. But it has side effects and requires a blood test over several weeks to be sure that the treatment is effective.

Methotrexate has a positive effect if:

• the level of the pregnancy hormone in the blood is below 5,000;
• gestational age - up to 6 weeks;
• the embryo does not yet have cardiac activity.

Surgical intervention

If an ectopic pregnancy is causing serious symptoms, such as bleeding and high hormone levels, surgery should be done because the chances of the drugs being effective are minimized and the fallopian tube will rupture. If possible, laparoscopy is done (a small incision in the cavity). If the fallopian tube ruptures, urgent surgery is required.

It is sometimes obvious that an ectopic pregnancy will result in an arbitrary miscarriage. Then no treatment is required. But the doctor will still insist on blood tests to make sure that the level of the hormone is falling.

Sometimes an ectopic pregnancy does not respond to treatment:

• If the hormonal level does not drop and the bleeding does not stop after taking methotrixate, surgery is necessary.
• Methotrixate can be taken after surgery.

Surgical treatment of ectopic pregnancy

In case of an ectopic pregnancy, the first thing to do is Methotrexate, but blood tests are done several times.

Several types of surgical intervention are performed for tubal ectopic pregnancy: salpingostomy (creating an opening in the fallopian tube connecting its cavity with the abdominal cavity) or salpingectomy (removing the fallopian tube).

Salpingostomy has a similar effect to methotrexate, since both drugs are equally effective and preserve the possibility of future pregnancy.

Surgery is a quick way to solve the problem, but it leaves scars that can provoke problems during a future pregnancy. Fallopian tube operations harm it depending on the place of attachment and the size of the embryo, as well as the type of surgery.

Surgery is the only way to terminate an ectopic pregnancy if it is more than 6 weeks old or if there is internal bleeding.

At any time, surgical termination of an ectopic pregnancy is the most effective way. If the pregnancy is more than 6 weeks, and bleeding is observed, surgery is the only way to solve the problem. If possible, laparoscopy is performed (a slight incision of the cavity), after which the recovery process does not take long.

Choice of surgery

The termination of an ectopic pregnancy is carried out in two ways, namely, by salpingostomy and salpingectomy.

• Salpingostomy. The embryo is removed by removing it through a small opening in the fallopian tube, which heals on its own, or stitches are applied. Such a surgical intervention is performed if the embryo is less than 2 cm and is located at the far end of the fallopian tube.
• Salpingectomy. A portion of the fallopian tube is removed and the parts are connected. This operation is performed when the pipe is stretched and there is a risk of rupture.

Both of these surgeries are performed by laparoscopy (a small incision) or conventional abdominal surgery. Laparoscopy is less harmful and the recovery process is faster than lapotomy (opening the abdomen). But in the case of an abdominal ectopic pregnancy or an emergency termination of an ectopic pregnancy, laparotomy is usually performed.

What should you think about?

When the embryo is in an intact fallopian tube, the doctor will make every effort to terminate the pregnancy without damaging the tube. In the event of a ruptured fallopian tube, an emergency operation to terminate the pregnancy is performed.

Ectopic pregnancy treatment at home

If you are in a high-risk group, buy a pregnancy test. If the result is positive, go to the gynecologist, who must confirm the pregnancy. Tell your doctor about your concerns.

If you are taking methotrixate to terminate an ectopic pregnancy, be prepared for side effects.

If you have terminated an ectopic pregnancy, no matter what week, it may take time to mourn the loss. Often women experience depression as a result of sudden hormonal changes after pregnancy termination. If the symptoms of depression are observed for a longer time, you need to go to the consultation with a psychologist.

Talk to other women who have experienced the same loss or friends.

Medication for ectopic pregnancy

Medicines are used only in the early stages of diagnosing an ectopic pregnancy (when the embryo has not ruptured the fallopian tube). Medicines do less damage to the fallopian tubes than surgery.

They are prescribed in the early stages of diagnosing an ectopic pregnancy in the absence of bleeding, as well as when:

• hormonal level less than 5,000;
• no more than 6 weeks have passed since the last menstrual cycle;
• the embryo has no heart rate yet.

In the case of a pregnancy of more than 6 weeks, surgery is performed, which is considered a safer and surer way to terminate a pregnancy.

What should you think about?

At an early stage of an ectopic pregnancy, methotrixate is prescribed, but if the period exceeds more than 6 weeks, the operation is considered a safer and surer way to interrupt it.

In this case, you need to do a blood test several times to be sure that the level of the hormone is falling.

Methotrexate can cause unpleasant side effects, such as nausea, upset stomach, or diarrhea. According to statistics, one in four women experience abdominal pain when the dosage of this drug is increased in order to achieve greater effectiveness. Pain can be the result of fetal movement in the fallopian tube or the negative effects of the drug on the body.

Methotrexate or surgery?

If an ectopic pregnancy is diagnosed early and has not ruptured the fallopian tube, methotrexate is allowed. At the same time, there is no need to perform an operation, the harm is minimal, and the woman can become pregnant again. If you are not planning to have another baby in the future, surgery is the ideal option because the result will be achieved faster and the risk of bleeding will be minimized.

Other treatments

An ectopic pregnancy is a threat to a woman's life, so measures are immediately taken to terminate it. For this purpose, surgery is performed, certain medications are prescribed and blood tests are done. There is no other treatment for this condition as there is a risk of severe bleeding and death.

Prophylaxis

If you smoke, you need to give up this bad habit, since smokers are more prone to pregnancy abnormalities, and the more you smoke, the more the risk of ectopic pregnancy increases.

Safe sex (for example, using a condom) is the prevention of sexually transmitted diseases, and, consequently, inflammatory processes of the pelvic organs, which lead to the formation of scar tissue in the fallopian tubes, which is the cause of ectopic pregnancy.

It is impossible to prevent an ectopic pregnancy, but timely diagnosis (at the very beginning) will help to avoid complications that can lead to death. Women who are at risk should be carefully screened early in pregnancy.

Forecast

A woman is always going through a difficult abortion. For some time, you can even grieve and enlist the support of loved ones and friends during this difficult period. Sometimes depression appears. If it has been observed for more than two weeks, consult your doctor. Often women are worried about how she can get pregnant again. An ectopic pregnancy does not mean that a woman becomes infertile. But one thing is clear:

• it may be difficult to get pregnant;
• the risk of re-ectopic pregnancy is quite high.

If you get another pregnancy, be sure to tell your doctor about your previous ectopic pregnancy. Regular blood tests during the first weeks of pregnancy can help identify possible abnormalities early.

Future fertility

Future fertility and the possibility of a recurrence of an ectopic pregnancy depend on whether you are at increased risk. Risk factors: smoking, use of assisted reproductive technologies, and damage to the fallopian tube. If you have one intact fallopian tube, salpingostomy and salpingectomy affect your ability to get pregnant again. If the second tube is damaged, your doctor will usually recommend a salpingostomy, which increases your chances of becoming a mom again.

It's important to know!

Ectopic pregnancies cannot be carried to term and will eventually terminate or regress. In ectopic pregnancy, implantation occurs outside the uterine cavity - in the fallopian tube (in its intramural section), the cervix, ovary, abdominal cavity or in the small pelvis.

An ectopic pregnancy is a pathology, as a result of which the attachment of a fertilized female cell does not occur in the uterine cavity. The disease is dangerous to health and life, and therefore women of reproductive age who are sexually active should be aware of its signs and course.

Only an attentive attitude to one's well-being and timely access to medical care will avoid serious consequences.

What is it and what happens in a woman's body?

An ectopic pregnancy is pathological, due to the "irregularity" of the process, or rather the "non-penetration" of the fertilized egg (ovum) into the uterus. For some reason, the egg after fertilization is fixed outside the uterus, where it continues its short development.

Depending on the place where the ovum is attached, an ectopic pregnancy is:

• tubal (fixed in the fallopian tube);
• ovarian (fixed in the ovary);
• abdominal (attached to the abdominal cavity);
• ectopic pregnancy that develops in the rudimentary horn of the uterus (rare).

The order in this list of types corresponds to the frequency at which anomalies occur. In addition, in medicine, there is another rare (fortunately) type of ectopic pregnancy called heteroscopic pregnancy. In this case, we are talking about uterine - normal, and ectopic pregnancies at the same time. That is, a woman ovulated two eggs at once in one menstrual period, and both were fertilized. But one of the fetal eggs was fixed in the uterus, as it should be, and the second - in a place not intended for it, a tube, an ovary or another.

What are the reasons for the abnormal location of the fetus?

The exact reasons why conception occurs this way cannot be given by any doctor, but they single out risk groups who may have an ectopic pregnancy:

1. Violation of the properties of the most fertile egg;
2. Unreliable contraception against the background of diseases of the female stripe system;
3. Hormonal imbalance;
4. Anatomical features of the fallopian tubes - excessively tortuous, long, "obstruction";
5. Earlier surgical operations on the abdominal and pelvic organs;
6. Often, signs of ectopic pregnancy after the production of modern reproductive technologies - in vitro fertilization;
7. Tumor formations on the uterus and its appendages, abdominal organs, disrupting the patency of the fallopian tubes;
8. Chronic inflammatory processes of the female reproductive system. They contribute to the disruption of the functionality and anatomy of the fallopian tubes, for example, reducing their contractility, which means their ability to push the egg that has found the sperm is reduced. Consequently, the implantation will be in some part of the tube or in the abdominal cavity, and an ectopic pregnancy occurs.

In 30-50% of cases of ectopic pregnancy, the causes remain unknown. Risk factors include:

1. Surgical interventions in the abdominal cavity.
2. Contraception.
3. Hormonal failure or hormonal deficiency.
4. Inflammatory diseases and infections of the female genital organs.
5. Violation of the transport function in the fallopian tubes.
6. Tumors of the uterus and its appendages.
7. Anomalies in the development of the genital organs.

Symptoms for an ectopic pregnancy may be exactly the same as for a normal pregnancy.

Symptoms and early signs

A fertilized egg can stop anywhere along the path from the ovary to the uterus. This can be the abdomen, the ovarian area, or the fallopian tube. Such a pathology occurs due to an inflammatory or adhesive process in the reproductive organs and the abdominal cavity.

In this case, the very first symptoms of an ectopic pregnancy correspond to the early signs of uterine embryo attachment:

1. There will be a delay in menstruation;
2. The breasts will become tender, slightly painful, and enlarged;
3. More frequent urination;
4. The test will show a positive result in the form of two strips;
5. Signs of toxicosis may appear;
6. The mood will become changeable;
7. The basal temperature will be elevated, which happens during a physiological pregnancy; if the rectal temperature is below 37 degrees, then it is likely that the embryo has died;
8. The general body temperature can also rise to subfebrile values ​​- 37.2–37.5 degrees.

In addition to general signs in the early stages, ectopic pregnancy is characterized by specific symptoms:

1. General weakness, malaise, chills are characteristic.
2. The body temperature may rise. Basal temperature is higher than general values, mostly subfebrile.
3. The appearance of bloody discharge from the genital tract like menstruation. They can be dark brown or brownish. It is important not to confuse them with menstruation if there was a long delay. It should be remembered that there may not be visible bleeding if blood accumulates in the abdominal cavity.
4. Along with the discharge, severe pains appear in the abdominal region of a cutting nature. In this case, the localization of pain depends on in which part the embryo develops. The pain syndrome increases with movements, changes in body position.
5. If there is a lot of blood loss, dizziness and fainting appear. This lowers blood pressure.

With such symptoms, it is necessary to rush to the doctor, otherwise the exfoliated ovum will cause irreparable damage to the woman's health.

The sensitive hormone test is positive, there is constant pain on the right or left, spotting after a delay, the preliminary diagnosis is an ectopic pregnancy. Previously, women with such a diagnosis were immediately operated on for health reasons, since it was impossible to establish the cause of the symptoms before 8 weeks. Fortunately for our generation, it is possible to find out such a diagnosis sooner. Hormonal tests, ultrasound, diagnostic laparoscopy help in this.

Symptoms depending on the type

For each type of pathological fixation of the ovum, there are characteristic symptoms

1. Ovarian ectopic pregnancy does not show any pathological symptoms for a long time. This is because the follicle can stretch to fit the size of the embryo. But when the limit of elasticity is reached, a strong point pain in the lower abdomen appears, gradually it spreads to the lower back and the area of ​​the large intestine. The defecation becomes painful. The attack lasts from several minutes to hours and is accompanied by dizziness, lightheadedness.
2. Tubal ectopic pregnancy is manifested by pain on the left or right side, depending on where the fertilized egg was implanted. If it is fixed in the wide ampulla part, then the symptom appears at 8 weeks, if in the narrow (in the isthmus) - then at 5-6. The pain intensifies during walking, turning the torso, and sudden movements.
3. An ectopic pregnancy in the abdominal cavity in the early stages has symptoms that are no different from those of the usual. But as the embryo grows, there are dysfunctions of the gastrointestinal tract (constipation, diarrhea, nausea, vomiting), signs of an "acute abdomen" (sharp pain, bloating, fainting).
4. Cervical and cervical-isthmus ectopic pregnancy is pain-free. Spotting comes to the fore - from smearing to profuse, profuse, posing a threat to life. Due to the increase in the size of the cervix, urination disorders (for example, frequent urge) develop.

When does a pipe rupture occur?

It is difficult to pinpoint when the worst will happen. The term can be as long as 4 weeks, and you can last up to 16.

1. The earliest tube rupture in an ectopic pregnancy occurs at 4-6 weeks if the ovum stops in the middle of the fallopian tube. This is the narrowest part of the pipe and can only stretch up to 2 mm. At the 4th week, the embryo is approximately 1 mm in diameter. If it ruptures, there will be severe pain and internal bleeding in the abdomen.
2. The lower part of the tube is able to "hide" an ectopic pregnancy even up to 3 months. This part has a more elastic muscle layer. A woman may not feel any signs until the time when the embryo has increased to 5 mm.
3. The ampullar part, which is located near the ovary, is able to sustain an egg cell for up to 4-8 weeks. But in this situation, the pipe breaks in rare cases. Most often, the egg will grow up to 2 mm and fall out into the abdominal cavity. The pipe breaks only if this gap is deformed.

Up to 3-4 weeks, a tubal ectopic pregnancy may not reveal itself at all as a pathology.

Uterine (fallopian) tube rupture

Rupture of the fallopian tube during ectopic pregnancy is the most serious complication that can be fatal for a woman. This condition always occurs suddenly and has pronounced symptoms:

• severe, sharp, "dagger" pain in the lower abdomen;
• a sharp drop in blood pressure indicators;
• critical increase in heart rate;
• the appearance on the forehead and palms of cold clammy sweat;
• significant deterioration in general well-being, up to loss of consciousness.

Any examination of a woman in this state is not required - hemorrhagic shock, loss of consciousness and deafening pain in a previously diagnosed pregnancy are the basis for the provision of emergency surgical care.

Diagnostics

In all cases of delayed menstruation, pain and bloody discharge, an ectopic pregnancy should be suspected. With symptoms of shock, a positive pregnancy test, the absence of the ovum in the uterus and a large amount of fluid in the abdominal cavity by ultrasound, the diagnosis of an ectopic pregnancy is not difficult. In other cases, the concentration of hCG in the blood and transvaginal ultrasound are of decisive importance.

If the hCG level exceeds 1500 mIU / ml, and the ovum in the uterine cavity is not detected, this may indicate an ectopic pregnancy. If the hCG level is below 1500mIU / ml, then it is advisable to repeat the analysis after 48 hours. An increase of less than 1.6 times, the absence of growth or a drop in the level of hCG testify in favor of an ectopic pregnancy.

Detection of the ovum outside the uterus by ultrasound is quite rare, in most cases they are guided by such signs as the absence of the ovum in the uterus, the presence of free fluid behind the uterus and a heterogeneous volumetric formation in the region of the appendages on one side.

Surgery

Surgical treatment of pathology - tubal ectopic pregnancy is performed by several methods known in medicine. To interrupt and get rid of pathology, it is used:

1. Laparoscopy is an operative, relatively sparing method of disposal, since it allows not to make an incision in the abdominal cavity, preserves the fallopian tube, and makes a puncture into it. This is a reliable diagnostic method and the most reliable.
2. Tubectomy is an operation to remove a tube with a pathology; in the case of an ectopic pregnancy, it is performed if it cannot be preserved. Tubectomy is used more often in case of repeated pregnancy outside the uterine cavity. In emergency cases, when it is necessary to save a woman, the removal of the ovary is also possible.
3. Tubotomy (salpingotomy) is the second variant of the operation performed in case of impossibility of using milking. The surgeon is forced to cut the fallopian tube in the area of ​​attachment of the undeveloped ovum, remove its fragments, and sew up the fallopian tube after the procedure. Part of the tube may need to be removed if the embryo is too large. Tubotomy makes it possible to preserve the genital organ, which is then able to perform its functions fully. In the future, a woman may become pregnant, although the percentage of this possibility is decreasing.
4. Milking (extrusion) - this surgical procedure is advisable in case of an anomaly of the ovum - detachment, the egg itself from the fallopian tube is extracted by extrusion, and the genital organ is preserved. True, the use of such a gentle method is not always possible, but in the case of the location of the zygote near the exit from the pipe. And the decisive factors are the facts of stopping the development of the zygote in the embryo and its detachment, as well as the location of the ovum in the tube of the uterus.

Most often, laparoscopy is performed. Until the fallopian tube bursts, it is preserved, although there is a high probability of developing a second parallel ectopic pregnancy in it. The best solution is to remove the fallopian tube before it ruptures. Surgical removal of the tube is performed during the laparoscopy procedure.

All patients who have undergone an ectopic pregnancy are advised to protect themselves from pregnancy for the next 6 months after surgery in order to avoid repeated relapses of ectopic pregnancy and to prepare the body for a normal pregnancy.

Rehabilitation after surgery

In the postoperative period, dynamic monitoring of the patient's condition in a hospital setting is necessary. Be sure to carry out infusion therapy in the form of droppers to restore the water-electrolyte balance after profuse blood loss (crystalloid solutions, rheopolyglucin, fresh frozen plasma). For the prevention of infectious complications, antibiotics are used (Cefuroxime, Metronidazole). Rehabilitation measures after an ectopic pregnancy should be aimed at restoring reproductive function after surgery. These include: prevention of adhesions; contraception; normalization of hormonal changes in the body.

The rehabilitation period usually goes smoothly. After the operation, the patient must adhere to a special diet - fractional meals (cereals, cutlets, broths) are recommended. For a speedy recovery a week after the operation, a course of physiotherapy (magnetotherapy, electrophoresis, laser therapy) is indicated.

Physiotherapy methods in the rehabilitation period:

• currents of supratonic frequency (ultratonotherapy),
• low-intensity laser therapy,
• electrical stimulation of the fallopian tubes;
• variable pulsed magnetic field of low frequency,
• low-frequency ultrasound,
• UHF therapy,
• electrophoresis of zinc, lidase,
• pulsed ultrasound.

For the duration of the course of anti-inflammatory therapy and for another 1 month after the end, contraception is recommended, and the question of its duration is decided individually, depending on the age of the patient and the characteristics of her reproductive function. Of course, the woman's desire to preserve her reproductive function should be taken into account. The duration of hormonal contraception is also highly individual, but usually it should not be less than 6 months after the operation.

After laparoscopy, they are discharged approximately 4-5 days after surgery, and after laparotomy in 7-10 days. Postoperative sutures are removed 7-8 days after surgery.

After the end of rehabilitation measures, before recommending the patient to plan the next pregnancy, it is advisable to perform diagnostic laparoscopy, which allows to assess the condition of the fallopian tube and other organs of the small pelvis. If no pathological changes are detected during control laparoscopy, then the patient is allowed to plan pregnancy in the next menstrual cycle.

Question answer

1) I had an ectopic pregnancy for 4-5 weeks in the ampullary tube. Conducted laparoscopy with squeezing the ovum and preserving the tube. The next day after the operation, the surgeon prescribed an injection of methotrexate (I understood that for reliability). They put in droppers for 3 days, probably with some kind of medicine. No adhesions were found. What is the likelihood of a recurrent ectopic? And what additional examinations would you recommend? And treatment still needs to be carried out to exclude a recurrent ectopic? The surgeon advises an X-ray with a contrast agent and maybe again laparoscopy to restore the function of the tubes, but I really don't want to go through 3 laparoscopy again (1 - removal of fibroids and adhesions on the tubes, then the birth of a child, and 2 - removal of the gallbladder). I really want a second child.

• Unfortunately, is there a risk that the situation will repeat itself? and with each ectopic pregnancy, it increases greatly, especially in women after 35 years. At the planning stage of pregnancy, of the possible examinations, this is only the diagnosis of the patency of both fallopian tubes (what the doctor suggested to you). But it is not recommended to plan conception immediately after such a procedure (the effect of X-ray + contrast), but after an X-ray with contrast, the likelihood of normal pregnancy increases, since the contrast, passing through the tubes, improves their patency. But for a start, you can do an echohysterosalpingography (ultrasound). It is not as reliable as an X-ray, but it should show obvious problems with the patency of the tubes, if any.

2) I am 26 years old. This year in April I had an ectopic pregnancy. The operation was performed by extruding the pipe, and the pipe was saved. Then the doctors said that no adhesions or bends were found in the tube. And strictly half a year to be protected. As for the second month irregular cycle. Month were supposed to be on November 11, but they are still not there, already a month's delay, I'm afraid that wb. Are there any chances of pregnancy? What should be done to avoid repeated wb ???? What should be done for a normal pregnancy? I have a daughter, she is 1.5 years old, I want more children.

• Donate blood for hCG and then you will find out if there is a pregnancy or not. In addition, tracking hCG in dynamics, one can assume the presence of wb. Normally, hCG should double every 2 days. If the growth of hCG is poor, then one of the reasons for this is an ectopic pregnancy. Since there are no adhesions and bends, then something cannot be done to avoid repeating wb. Increases the risk of developing wb, taking hormonal contraceptives or the presence of a spiral before planning pregnancy, therefore it is recommended, after canceling OC or removing the spiral, to refrain from unprotected PA for 3 menstrual cycles. Also, taking progesterone (Utrozhestan, etc.) when planning a pregnancy can increase the risk of WB.

3) The delay is five days and the test response is positive, while the ovum cannot be visualized in the uterus. What to do?

• This does not mean that it is safe to talk about an ectopic pregnancy. To exclude such a pathology, an ultrasound scan should be performed in 1-2 weeks, as well as a blood test for the presence of hCG. In the very early stages, pregnancy in the uterus may not be visualized.

4) How long after an ectopic pregnancy can a new pregnancy be planned?

• To exclude possible complications, the desired pregnancy can be planned no earlier than 6 months later.

Prophylaxis

An ectopic pregnancy is impossible to predict - there are too many factors that can lead to such a development of events. But doctors have developed specific preventive measures:

• keep a calendar of the menstrual cycle and, in case of minor violations, consult a gynecologist;
• from the moment of the onset of sexual activity, regularly visit a gynecologist for preventive examinations and early diagnosis of inflammatory / infectious diseases;
• planning a pregnancy - for example, before conception, undergo a full examination by doctors of general and narrow specialties;
• timely and fully treat any pathology of the organs of the reproductive system, including inflammatory and infectious diseases.

Ectopic pregnancy is considered a rather complex and dangerous pathology. But if medical measures were carried out at an early stage of the pathology or when the fallopian tube ruptured, competent measures were taken, then the prognosis will be favorable. Modern advances in medicine make it possible not only to save a woman's life, but also provide her with the opportunity to have children in the future.