EXTRAUTERINE PREGNANCY (graviditas extrauterina seu ectopica) — pathological pregnancy, at a cut an oospore develops out of a cavity of the uterus. Depending on the place of implantation of egg (fig. 1) distinguish pipe, ovarian and belly pregnancy. To V. refer also pregnancy in a rudimentary horn of a uterus (fig. 4).
Most often pipe pregnancy (98,5 — 99,5%) meets. Much more rare — ovarian (0,2%), belly (0,11%) and pregnancy in a rudimentary horn of a uterus (0,19%).
In relation to number of gynecologic diseases the frequency of ectopic pregnancy fluctuates from 1 to 6%.
First message on V. it was made in 1611 Mr. of Riolani, before similar cases carried to hysterorrheses. In 1741 Mr. Levre (A. Levret, 1703 — 1780) gave the scientific description of this pathology. The intravital diagnosis for the first time in 1812 was made to Heim.
In domestic literature at first H. M. Ambodik-Maksimovich in 1784 would give V.'s description., then works on a pathogeny, diagnosis and treatment of this pathology appeared.
By the end of the 70th of 20 century a large number of works of domestic and foreign authors in which comprehensive illumination of this frequent pathology of pregnancy is given collected.
Etiology and pathogeny
Origins of V. are various. It can sometimes arise in connection with the accelerated development of a trophoblast and premature implantation of egg in a pipe on the way to a cavity of the uterus, especially at outside movement of egg (migratio ovi externa). In most cases disturbances of the mechanism of transportation of an oospore in a cavity of the uterus are the main reason.
Most often disturbances of rate of reduction of uterine tubes and their form are caused by the postponed or chronically current inflammatory process in appendages of a uterus which causes changes in mucous, muscular covers, in a serous cover, in the nervous and vascular device of a pipe inherent to it.
Inflammatory process changes structure and function of a ciliary epithelium of an endosalpinks, leads to pasting of folds of a mucous membrane, formation of diverticulums, narrowing of a gleam. Unions of a serous cover with surrounding fabrics not only break motility of pipes, but also reduce their gleam. All this promotes a delay of the developing egg in a cavity of a pipe with the subsequent its nidation (immersion) in it. Sokratitelny function of a pipe can change in connection with dysfunction of ovaries and at infantility.
A certain role in V.'s emergence. plays endometriosis of pipes.
In each case of emergence of V. the combination of several promoting reasons takes place, however the most frequent are inflammatory diseases of appendages of a uterus.
from the moment of V.'s emergence. and before its termination in an organism of the woman there are same changes, as at normal pregnancy. The exception makes a fruit bed where would develop characteristic only of V. processes.
Pipe pregnancy extremely seldom reaches big terms and is broken on 4 — 6 — the 8th week. This disturbance can go two ways — internal or outside (a rupture of a pipe).
At development of pregnancy in an ampullar part of a pipe of a vorsina of chorion destroy the part of a fruit bed turned into a gleam of a pipe that leads to an internal rupture of a fruit bed (fig. 2). Fetal egg gradually exfoliates from the bed (there is bleeding in a gleam of a pipe), perishes, becomes impregnated with blood — the so-called pipe blood drift is formed. If the abdominal end of a pipe is not closed, then due to reductions of a pipe fetal egg is pushed out in an abdominal cavity (pipe abortion — abortus tubarius) if it is corked — the hematosalpinx is formed. At insignificant bleeding the blood following from a gleam of a pipe is curtailed and accumulates around an ampullar part, forming haematocele peritubaria surrounded with the fibrinous capsule which is quite often soldered to nearby bodies.
At more considerable and repeated bleedings blood flows down in a uterine pryamokishechnoye space where it is curtailed, surrounded with the thick fibrinous capsule, forming a blood tumor (haematocele retrouterina).
If pregnancy develops in an isthmic part of a pipe, growth of egg happens towards a pipe wall, vorsina of chorion quickly destroy a muscular wall and a serous cover — there comes the outside rupture of a fruit bed (a rupture of a pipe) with this or that size of defect of a pipe (fig. 3) and most often with considerable intra belly bleeding.
At interstitial or intersticial pipe pregnancy the nidation of fetal egg occurs in an interstitial (uterine) part of a pipe, with a further growth a part of an isthmus of a pipe can be involved in a fruit bed.
As the fruit bed is surrounded by a muscular wall of a uterus, interstitial, or intersticial, pipe pregnancy is more often broken on 3 — 5th month as an outside rupture of a fruit bed.
Belly pregnancy happens primary (fetal egg is implanted on any abdominal organ at once) and secondary (fetal egg at first develops in a pipe, but at pipe abortion gets into an abdominal cavity and it is again implanted on other body).
The ovariocyesis is interrupted as an outside rupture of a fruit bed.
Pregnancy in a rudimentary horn of a uterus (fig. 4) proceeds as ectopic. The rudimentary horn is connected with a uterus (normally developed horn) a wide leg, edges in 85% of cases is not canalized. Pregnancy in it arises at migratio ovi externa.
Current and V.'s symptoms. stages of development and the nature of disturbance are diverse and depend on a form, however it is possible to allocate three main options.
Undisturbed V. normal (uterine) pregnancy of the corresponding term is followed by the same subjective and objective changes in an organism of the woman, as well as: delay of periods, nausea, morning vomiting, changes of appetite, nagrubaniye of mammary glands, cyanotic coloring of mucous membranes of a vagina and neck of uterus, increase and softening of a uterus. At ectopic pregnancy there can be decidual transformations of a mucous membrane of a uterus, a hypertrophy and a hyperplasia of muscle fibers. Therefore in the first 8 weeks of pregnancy the uterus increases in sizes; further the size of a uterus ceases to correspond to duration of gestation.
The pipe pregnancy which is interrupted as an outside rupture of a fruit bed (a rupture of a pipe) has a characteristic clinical picture. After a delay of periods, among full health there come strong colicy pains in the bottom of a stomach or in one of inguinal areas. Due to massive intra belly bleeding there is a frenikus-symptom (irradiation of pains to the area of a shoulder and shovel). The attack of pains often is followed by a short-term loss of consciousness. Then quickly the picture of abdominal shock with the phenomena of an acute anemia in the absence of outside bleeding accrues: pallor of integuments and visible mucous membranes, cold sweat, the sunk-down features, mydriatic pupils, in eyes expression of fear, a pale face, with a bluish shade in nasolabial folds. Pulse is frequent, weak filling, arterial pressure is lowered. Temperature is more often normal, subfebrile is more rare. Quickly symptoms of irritation of a peritoneum accrue: abdominal distention, morbidity at its palpation, a positive symptom of Shchetkin — Blyumberg in the absence of tension of an abdominal wall. In an abdominal cavity it is possible to find availability of free liquid (blood). Sometimes from a vagina there are insignificant bloody allocations, but them can not be since the deciduous cover in acute cases does not manage to exfoliate yet.
At an internal rupture of a fruit bed (a pipe abortion) the clinical picture is less indicative. The patient complains of the skhvatkoobrazny, gradually amplifying pains in the bottom of a stomach. At insignificant blood loss there is dizziness, the general weakness, is more rare — a short-term unconscious state. The phenomena of anemia are a little expressed, pulse, arterial pressure remain within norm.
Temperature sometimes happens subfebrile. On 2 — the 3rd day after developing of pains there are smearing bloody allocations from a genital tract. These phenomena can abate and again appear. At considerable bleeding blood accumulates in a free abdominal cavity, the frenikus-symptom, symptoms of anemia and shock appears; the pozadimatochny hematoma is formed. Fetal egg usually perishes.
Interruption interstitial, or intersticial, pregnancies happens as an outside rupture of a fruit bed. This gap, as a rule, is followed by the peritoneal shock and the most severe intra belly bleeding caused by the big size of a gap, loss of sokratitelny function of a uterine wall owing to growing into it vorsin chorion and existence of plentiful blood supply of this department (the ascending branch of a uterine artery).
Belly pregnancy in the first months can not cause complaints from the patient, but constant painful abdominal pains (reactive irritation of a peritoneum, commissural process), painful stir of a fruit, frequent nausea and vomiting, locks appear further. At the defined fetal egg the diagnosis of a uterine pregnancy with the beginning late abortion or premature births often is made. Vaginal examonation shows lack of disclosure of a neck of uterus.
A clinical picture of the interrupted ovariocyesis same, as well as at a rupture of a pipe.
At pregnancy in a rudimentary horn near a uterus tumorous education, related a leg is found.
Abortion in a rudimentary horn happens as an outside rupture of a fruit bed to the clinical picture reminding a hysterorrhesis.
Recognition of undisturbed pipe pregnancy works well in rare instances. In the presence of the general signs of pregnancy during the repeated bimanual research it is possible to pay attention to increase in the sizes of a pipe; the size of a uterus lags behind duration of gestation, a form its pear-shaped, it is not reduced at a palpation, Gorvits's sign — Hegara is absent (see. Pregnancy ). Positive biol, and immunol, reactions to pregnancy (see. Ashgeyma-Tsondeka reaction , Galli-Maynini reaction , Friedman reaction ) can only point to existence of pregnancy without its localization.
Practically the diagnosis of ectopic pregnancy is established when there comes its interruption. If it occurs as a rupture of a pipe, then diagnosis is usually not difficult. The bimanual research is usually painful therefore the patient strains a stomach, and it is not always possible to probe a uterus and its appendages, but it is possible to find smoothing of a side or back vault of the vagina, resistance of the arch and sharp morbidity at a palpation or shift of a neck of uterus of a kpereda («shout of Douglas»). The puncture of an abdominal cavity through a back vault of the vagina allows to establish availability of free blood in an abdominal cavity.
V.'s diagnosis., interrupted as a pipe abortion, is more difficult because of an indistinct clinical picture. If there is a bilateral increase in appendages, then often the thought of the doctor inclines towards inflammatory process. In similar cases positive takes biol, and immunol, reactions to pregnancy, existence of bloody allocations of dark-brown color from a genital tract, periodic colicy pains in the bottom of a stomach help to make the diagnosis correctly.
At a bimanual research in the field of appendages it is possible to probe a kolbasovidny form the tumor limited in mobility with not clear contours, painful, a softish consistence, with a pulsation of vessels. Existence of a peritubarny or zamatochny hematoma is shown by smoothing of a side or back vault of the vagina. During the squeezing by fingers of both hands of area of a hematoma there is a feeling of the parting heavy body, edges at assignment of fingers of an internal hand is returned to the initial place (Kogan's reception). Also morbidity at the shift of a neck of uterus to a bosom is characteristic (reception Banks). Quite often, however, at a gynecologic research only small increase in appendages which is not differing from that at hron, an adnexitis is defined.
For diagnosis the puncture of an abdominal cavity through the back arch is widely used. Receiving in punctate of dark blood with the smallest clots would certify V.'s presence. However this valuable and safe diagnostic reception is not absolutely reliable: in the presence of V. to 11% of cases of blood in punctate can not be, and in 0,5% it would be available in the absence of V.
At gistol, a research of scraping of a cavity of the uterus finding of decidual reaction of an endometria at absence vorsin would not tell chorion about V. yet. Such picture of an endometria can be at a persistent yellow body, a lyuteinovy cyst. Detection in an endometria of a phenomenon Arias-Stella is unconditional confirmation of existence of pregnancy, but without topical diagnosis (see. Arias-Stella phenomenon ). However it is necessary to consider that at x / z women with V. this phenomenon is absent.
The laparoscopy has high diagnostic value and allows to make the diagnosis at early stages of interruption of pipe pregnancy: detection of blood in an abdominal cavity, the gematotsel, a hematosalpinx, hemorrhage in an ovary.
Gisterosalpingografiya, especially during the use of water contrast agents, would be safe diagnostic reception at V. Indisputable signs are identification of fetal egg in a gleam of a pipe and a picture of a hematosalpinx, indirect — increase in a cavity of the uterus without defect of filling, expansion of a gleam of a pipe.
Use arterio-and flebografiya in V.'s diagnosis. is in a stage of studying.
Diagnostic characters of interstitial or intersticial pipe pregnancy are: asymmetry of a uterus, a slanting arrangement of its bottom owing to increase in one corner at the expense of fetal egg, the shift of an uterine fundus in other party for the same reason, an atypical (asymmetrical) otkhozhdeniye of round sheaves and pipes from corners of a uterus (on the party of a pregnant pipe they are located above — Ruge's sign — Simona); on border between a uterus and a fruit bed there is a furrow (interception). The uterus is completely mobile, the palpation of vaults of the vagina is painless and in them any tumorous education is not defined.
However these signs help to establish interstitial form of pipe pregnancy only during a chrevosecheniye more often, and operation would be made concerning intra belly bleeding at V.
Diagnosis of belly pregnancy presents great difficulties. Primary belly pregnancy can be proved only in early stages, having found the functioning fibers of fetal egg on a peritoneum at absence in an ovary and a pipe of microscopic signs of pregnancy (M. S. Alexandrov, L. F. Shinkareva).
Pathognomonic signs are lack of reduction of a fruit bed at its palpation and too accurate palpation of parts of a fruit. It is possible to palpate a uterus separately seldom, it is usually increased up to 3 — 4 months of pregnancy.
Important data for diagnosis can be obtained at a X-ray analysis of an abdominal cavity: the wrong provision and presentation, mixing of shadows of a fruit with shadows of intestines of mother, lack of a shadow of walls of a uterus around a fruit, more accurate, than usually, contrasting of shadows of a fruit.
In case of pregnancy in a rudimentary horn of a uterus at repeated researches noticeable increase in a tumor is defined, walls a cut are reduced at hand (unlike a cystoma of an ovary or a subserous fibromyoma). Detection of malformations of a vagina and neck of uterus helps to assume existence of pregnancy in a rudimentary horn. Before operation the correct diagnosis is established approximately in 15% of cases.
To Otdifferentsirovat an ovariocyesis from V. it is difficult for other localization before operation.
The differential diagnosis should be carried out more often with appendicitis (see), adnexitis (see) and the beginning uterine abortion (see. Abortion ). Also it is necessary to remember that the sudden beginning of a disease which is followed by severe pains in a stomach and an unconscious state with a loss of consciousness can be observed at peritonitis, intestinal impassability, twisting of a leg of tumors of an ovary, a rupture of ovarian cysts, etc.
At suspicion on V. the patient is subject to immediate hospitalization.
If V.'s diagnosis. it is established, the patient shall be immediately operated irrespective of weight of a state. Fight against shock, acute blood loss shall not delay operation, and be made at the same time (see. Hemotransfusion , Shock ).
It is better to use an inhalation intratracheal anesthesia which will also be a component of resuscitation actions. The choice of abdominal section does not matter, but the median lower laparotomy is simpler. After audit of bodies of a small pelvis find the struck pipe and make salpingectomy (see). Though cases of emergence of repeated pregnancy in the remained stump of a pipe are described, at pregnancy in an isthmic and ampullar part of a pipe it is klinovidno not necessary to excise a uterine part of a pipe as there can be hysterorrheses at the subsequent pregnancy and childbirth.
After a salpingectomy carefully exempt an abdominal cavity from liquid blood and clots which leaving can cause development of an infection, commissural process and emergence of Ilheus.
Reinfusion of the blood which is in an abdominal cavity is quite admissible provided that abortion (usually as a rupture of a pipe) was recent.
In the presence of a peritubarny or zamatochny hematoma, besides big prescription, surgical intervention presents certain difficulties. In these cases big commissural process of a uterus, appendages, capsules of a hematoma with loops of intestines, an epiploon, a bladder, a peritoneum of sidewalls of a basin takes place. It is not necessary to try to remove completely after removal of old clots the capsule of a hematoma, especially from the surface of intestines not to injure it. It is necessary to keep an ovary on the struck party, despite considerable treatment by its blood.
At the suppurated zamatochny blood tumor it is necessary to make back colpotomy (see) with emptying of an abscess and the subsequent drainage by a thick rubber tube. In these cases the laparotomy is dangerous because of inevitable development of peritonitis.
In the presence of interstitial pipe pregnancy wedge-shaped excision of a fruit bed from a corner of a uterus with simultaneous removal of a pipe is made. The integrity of a wall of a uterus is recovered by 2 rows of knotty catgut seams and peritonized by a round sheaf. If a condition of the patient satisfactory, then it is possible not to delete a pipe, and to make its implantation in a uterus. At big ruptures of a fruit bed it is necessary to make a defundation and even supravaginal amputation of a uterus. Treatment at pregnancy in a rudimentary horn of a uterus consists in excision only of a pregnant horn together with its pipe. The round sheaf which is dissected away from the deleted horn of a uterus is hemmed to a bottom of the remained second horn of a uterus.
At ovarian and belly pregnancy treatment consists fetal egg or a fruit with a placenta and a stop of bleeding at a distance.
Among transferred pipe pregnancy there is a considerable number of childless women, quite often (to 6%) there is repeated pregnancy in the remained pipe. In 60 — the 70th there were numerous works propagandizing the operations allowing to keep genital function at the women who transferred pipe pregnancy again.
Various plastic surgeries depending on a form of pipe pregnancy are made: a salpingotomy over fetal egg with enucleating of the last, a resection of a part of a pipe with the subsequent neostomy the end in the end or reimplantation of the rest of a pipe in a uterus, etc. Into a gleam of a pipe then tubular prostheses from alloplastichesky materials with their conclusion through a cavity of the uterus are inserted into a vagina or on a front abdominal wall. Materials for prostheses are used resorptional biol (a heterogeneous peritoneum, etc.). If the second pipe is impassable, then plastic surgery is made also on this pipe. If plastic surgery is planned, then the gisterosalpingografiya is made previously.
In the postoperative period this patient appoints antiinflammatory therapy up to hydrotubation with antibiotics, lidazy, a hydrocortisone (see. Hydrotubation ).
Modern achievements in the surgical equipment, anesthesiology, availability of powerful antibacterial agents allow to consider that in case of need preservations of genital function these operations shall replace a salpingectomy. If to sum up data of various authors who published results of similar operations at pipe pregnancy, then at the cases operated in 21% in terms from 1 to 4 years after operation the normal pregnancy which ended with childbirth took place.
Forecast. At modern diagnosis and treatment the forecast is usually favorable concerning life and working ability of the woman, is less favorable — concerning genital function.
Deaths at V. in our country are a rarity.
In prevention of B. major importance has the prevention of inflammatory diseases of generative organs, and in cases of their emergence — timely and their full treatment. As inflammatory diseases most often arise after abortions, broad fight against abortions, promotion of contraceptives would be included also into V.'s prevention. Full conservative treatment after the undergone operation for V. is of great importance. for prevention of its repeated emergence.
Bibliography: Alexandrov M. S. and Shinkarev L. F. Extrauterine pregnancy, M., 1961, bibliogr.; Becker of C. M. Patologiya of pregnancy, page 112, L., 1975, bibliogr.; Lebedev I. V. To a question of interstitial pregnancy, Vopr. okhr. mat. also it is put., No. 6, page 74, 1966; The Multivolume guide to obstetrics I gynecology, under the editorship of L. S. Persianinov, t. 3, book 1, page 120, M., 1964, bibliogr.; Christmas (About with I to and - N and) A. I. O transport of egg from an ovary in a uterus, L., 1947; Yakovlev I. I. Acute management at obstetric pathology, page 113, L., 1971; With 1 a r k J. F. a. Guy R. S. Abdominal pregnancy, Amer. J. Obstet. Gynec., v. 96, p. 511, 1966; Persaud V. Etiology of tubal ectopic pregnancy, Obstet, and Gynec., v. 36, p. 257, 1970.
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