(Fig. 156) is primary and secondary. Primary abdominal pregnancy is extremely rare, that is, a condition when the fertilized egg is grafted onto one of the abdominal organs from the very beginning (Fig. 157). In recent years, several reliable cases have been described. Primary implantation of the egg on the peritoneum can only be proven in the early stages of pregnancy; c, this is supported by the presence of functioning villi on the peritoneum, the absence of microscopic signs of pregnancy in the tubes and ovary (M. S. Malinovsky).
Rice. 156. Primary abdominal pregnancy (according to Richter): 1 - uterus; 2 - rectum; 3 - fertilized egg.
Secondary abdominal pregnancy develops more often; in this case, the egg is initially implanted in the tube, and then, having entered the abdominal cavity during a tubal miscarriage, it is implanted again and continues to develop. The fetus during a late ectopic pregnancy often has certain deformities that arise as a result of unfavorable conditions for its development.
M. S. Malinovsky (1910), Sittner (1901) believe that the frequency of fetal deformities is exaggerated and amounts to no more than 5-10%.
During abdominal pregnancy, in the first months, a tumor is detected that is located somewhat asymmetrically and resembles the uterus. Unlike the uterus, the fetal receptacle does not contract under the arm during an ectopic pregnancy. If it is possible to identify the uterus separately from the tumor (fetal sac) during a vaginal examination, the diagnosis is simplified. But with intimate fusion of the fetal sac with the uterus, the doctor easily makes a mistake and diagnoses intrauterine pregnancy. It should be borne in mind that the tumor is most often spherical or irregular in shape, limited in mobility and has an elastic consistency. The walls of the tumor are thin, do not shrink upon palpation, and parts of the fetus are sometimes surprisingly easy to identify when examined with a finger through the vaginal fornix.
If intrauterine pregnancy is excluded or the fetus has died, probing of the uterine cavity can be used to clarify its size and position.
Rice. 157. Abdominal pregnancy: 1-fiche loops fused to the fetal receptacle; 2 - adhesions; 3 - fruit container; 4-placenta; 5 - uterus.
At first, abdominal pregnancy may not cause any particular complaints from the pregnant woman. But as the Fetus develops, in most cases complaints of constant, excruciating abdominal pain appear, resulting from an adhesive process in the abdominal cavity around the fetal egg, causing reactive irritation of the peritoneum (chronic peritonitis). The pain intensifies with fetal movement and causes excruciating suffering for the woman. Lack of appetite, insomnia, frequent vomiting, constipation lead to exhaustion of the patient. All of these phenomena are especially pronounced if the fetus, after rupture of the membranes, is in the abdominal cavity, surrounded by intestinal loops fused around it. However, there are cases when the pain is moderate.
By the end of pregnancy, the fetal receptacle occupies most of the abdominal cavity. Parts of the fetus are in most cases identified under the abdominal wall. Upon palpation, the walls of the fetal sac do not contract under the hand and do not become denser. Sometimes it is possible to identify a separate, slightly enlarged uterus. When the fetus is alive, its heartbeat and movements are determined. X-rays with filling of the uterus with a contrast mass reveal the size of the uterine cavity and its relationship with the location of the fetus. When an ectopic, particularly abdominal, pregnancy is carried to term, labor pains appear, but the throat does not open. The fetus dies. If the fetal sac ruptures, a picture of acute anemia and peritoneal shock develops. The risk of rupture of the fetal sac is greater in the first months of pregnancy, and subsequently decreases. Therefore, a number of obstetricians, trying to obtain a viable fetus, find it possible in cases where the pregnancy exceeds VI-VII months and the pregnancy is in satisfactory condition, to wait with the operation and do it close to the expected due date (V.F. Snegirev, 1905 ; A.P. Gubarev, 1925, etc.).
M. S. Malinovsky (1910), based on his data, believes that surgery at the end of a progressive ectopic pregnancy is technically no more difficult and is accompanied by no less favorable results than in the early months. However, most authoritative obstetricians and gynecologists, both domestic and foreign, believe that any diagnosed ectopic pregnancy should undergo surgery immediately.
The rupture of the fetus during late pregnancy is a great danger to the life of a woman. Ware indicates that maternal mortality in late ectopic pregnancy was 15%. Timely diagnosis before surgery can reduce mortality in women. A number of cases are described in the literature when the development of an ectopic pregnancy stopped, a falling membrane was released from the uterus, regressive phenomena began and regular menstruation began. The fetus, undergoing encystation in such cases, is mummified or, saturated with calcium salts, petrifies. Such a fossilized fetus (lithopedion) can be in the abdominal cavity for many years. There is even a case of lithopedion remaining in the abdominal cavity for 46 years. Sometimes a dead ovum becomes suppurated, and the abscess opens through the abdominal wall into the vagina, bladder, or intestines. Together with pus, parts of the decaying fetal skeleton come out through the formed fistulous opening.
With the modern formulation of medical care, such outcomes of ectopic pregnancy are the rarest exception. On the contrary, cases of timely diagnosis of late ectopic pregnancy have become increasingly published.
The operation for a progressive abdominal pregnancy, performed by abdominal surgery, presents significant, and sometimes great difficulties. After opening the abdominal cavity, the wall of the fetal sac is dissected and the fetus is removed, and then the amniotic sac is removed. If the placenta is attached to the posterior wall of the uterus and the broad ligament, then its separation does not present any great technical difficulties. Ligatures or puncturing sutures are applied to bleeding areas. If the bleeding does not stop, it is necessary to ligate the main trunk of the uterine artery or the hypogastric artery on the corresponding side.
In case of severe bleeding, before ligating these vessels, the assistant should press the abdominal aorta to the spine with his hand. The greatest difficulty is the separation of the placenta attached to the intestine and its mesentery or liver. Surgery for late ectopic pregnancy is only available to an experienced surgeon and should consist of transection, removal of the fetus, placenta, and stopping bleeding. The operator must be prepared to perform a bowel resection if the placenta is attached to its walls or mesentery and this becomes necessary during the operation.
In earlier times, due to the risk of bleeding during the separation of the placenta attached to the intestines or liver, the so-called marsupialization method was used. In this case, the edges of the fetal sac or part of it were sewn into the abdominal wound and a Mikulicz tampon was inserted into the cavity of the sac, covering the placenta remaining in the abdominal cavity. The cavity gradually decreased, and a slow (over 1-2 months) release of the necrotizing placenta occurred.
The method of marsupialization, designed for spontaneous rejection of the placenta, is anti-surgical; under modern conditions, it can be used by an experienced operator only as a last resort, and also under the condition that the operation is performed as an emergency by an insufficiently experienced surgeon. If the fetal sac is infected, marsupialization is indicated.
Mynors (1956) writes that in late ectopic pregnancies the placenta is often left in situ, covering the abdominal wound. In this case, the placenta is detected by palpation for several months, but Friedman’s reaction to pregnancy becomes negative after 5-7 weeks.
During surgery for late progressive ectopic pregnancy, despite the good condition of the patient, it is necessary to prepare in advance for blood transfusion and anti-shock measures.
During the operation, severe bleeding may suddenly occur, and a delay in providing emergency care increases the danger to the woman’s life.
Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983
Abdominal pregnancy is one of the types of ectopic conception, during which the embryonic component is attached to the abdominal region. Moreover, such a location, due to the growth of the embryo and in the absence of proper diagnosis, can lead to organ rupture and subsequent bleeding.
Features of the abdominal formation of the embryo
A fertilized cell cannot grow and form outside the reproductive organs, i.e. full-term pregnancy is possible only in the uterus. Therefore, any deviation from this norm and the introduction of the egg into other organs leads to serious consequences.Thus, pregnancy in the abdominal cavity is characterized by pathological changes when the egg attaches to the peritoneum, liver, spleen or intestines, while the embryo is fed from the bloodstream of the gastrointestinal tract.
There are 2 types of abdominal pregnancy:
- primary - the initial implantation of the egg in the abdominal cavity;
- secondary pathology involves the entry of a viable embryo from the fallopian tube, after tubal fertilization, into the peritoneum.
Causes of abdominal pregnancy
Abdominal attachment of the fertilized egg, like any other pregnancy outside the uterus, indicates a pathological process in the mucous membrane of the fallopian tubes. Risk factors most often include the following deviations:- inflammatory reactions and diseases of the reproductive organs;
- the presence of adhesions or disturbances in the contractile function of the tubes, which lead to the inability to move the egg;
- congenital anomalies in the anatomy of the reproductive organs;
- diseases of the endocrine system.
According to statistics, the older a woman is (over 35 years), the worse the reproductive system functions, the chances of having a healthy child are reduced, and the risk of ectopic conception increases significantly. The situation is associated with hormonal changes and a decrease in the activity of tubal peristalsis.
Diagnosis of pregnancy in the peritoneum
It is quite difficult even for qualified specialists to determine abdominal pregnancy before complications arise. Basically, symptomatic manifestations are caused by normal signs that are characteristic of the initial period of gestation (toxicosis, change in taste preferences, soreness of the mammary glands, etc.). Using ultrasound at an early stage, it is also impossible to make an accurate diagnosis, since the clinical picture can be mistaken for multiple conception or the diagnosis is established as gestation with the presence of formation anomalies.Progressive abdominal pregnancy is characterized by more obvious symptoms, when, after 8 weeks, parts of the fetus can be recognized by palpation of the peritoneum, severe pain in the lower abdomen and bleeding occurs.
If the clinical picture is unclear, diagnosis includes MRI or computed tomography. The most informative method is laparoscopy, which allows not only to clarify the location of the embryo in the abdominal cavity, but also to immediately remove it.
Treatment of abdominal pregnancy
Treatment of abnormal attachment of the ovum involves only surgical intervention. At an early stage, laparoscopy with minimal intervention or laparotomy in a later period of gestation with dissection of the peritoneal tissue is mainly used.In case of timely diagnosis and detection of abnormal fetal development, the prognosis for a woman is more than favorable. When an already developed fetus is detected, the risks for the patient increase, even to death, due to the opening of heavy bleeding or due to injury to internal organs.
There are isolated stories in medical practice when a woman was able to carry a child in the peritoneum. At the same time, a planned operation to remove the baby was scheduled for an earlier date, and after that the baby was placed in boxes for premature babies in order to prevent possible complications associated with an unformed body.
Abdominal pregnancy is a pregnancy in which the egg is implanted (introduced) into the abdominal organs and the blood supply to the embryo comes from the vascular bed of the gastrointestinal tract. This usually happens in the following places:
- large oil seal;
- peritoneal surface;
- intestinal mesentery;
- liver;
- spleen.
Classification
The following are distinguished: abdominal pregnancy options:
- primary(the introduction of the egg into the abdominal cavity occurs initially, without entering the fallopian tube);
- secondary, when a viable embryo enters the abdominal cavity from the tube after a tubal abortion has occurred.
information The existing classification is not of any clinical interest due to the fact that by the time of the operation the tube is most often visually unchanged and it is possible to establish where the embryo initially implanted only after a microscopic examination of the removed material.
Causes
To the development of abdominal pregnancy results from various pathologies of the fallopian tubes when their anatomy or function is disrupted:
- chronic inflammatory diseases of the tubes (salpingitis, salpingoophoritis, hydrosalpinx and others), not treated in a timely manner or treated inadequately;
- previous operations on the fallopian tubes or on the abdominal organs (in the latter case, they may interfere with the normal advancement of the egg);
- congenital anomalies of the fallopian tubes.
Symptoms
The main groups of symptoms of abdominal pregnancy include:
- Symptoms associated with dysfunction of the gastrointestinal tract:
- nausea;
- vomit;
- Clinic "acute abdomen": suddenly, against the background of complete health, extremely pronounced pain appears, which can be very severe and even cause fainting; nausea, vomiting, bloating, symptoms of peritoneal irritation.
- When bleeding develops, it appears anemia.
Diagnostics
dangerous Diagnosis of abdominal pregnancy is usually late, and this pathology is detected already when bleeding has begun or significant damage to the organ in which implantation has occurred.
The world's "gold" standard Diagnosis of ectopic pregnancy, in general, are:
- Blood test for(chorionic gonadotropin), which reveals a discrepancy between its level and the expected duration of pregnancy.
- When the fertilized egg is absent in the uterine cavity, it is possible to detect it in it.
The combined use of the two above methods makes it possible to diagnose "" in 98% of patients from the 5th week of pregnancy (1 week of delay with a 28-day cycle).
As for abdominal pregnancy, the diagnosis will have a big role clinical picture(it was described above), which is more reminiscent of acute surgical pathology.
It is also possible to carry out culdocentesis(puncture of the posterior vaginal vault) and when blood does not clot, we can talk about internal bleeding that has begun.
It should be noted that the conduct is extremely informative diagnostic laparoscopy, in which it is possible to detect a fertilized egg attached to one or another organ, and in some cases it is possible to remove it, which will lead to the woman’s cure. However, due to the fact that this method is invasive (essentially it is an operation), it comes in last place, being a last resort.
Treatment
Treatment is always surgical(both laparotomy and laparotomy are possible), and the operations are completely atypical and often extremely complex technically. Interventions will largely depend on where the egg was implanted and the degree of damage to the organ. If possible, the operation is performed by an obstetrician-gynecologist together with a surgeon.
In most cases, the following surgical options are used:
- A staple is placed on the umbilical cord to extract the fetus and stop blood flow into the umbilical cord; the latter, if possible, is also removed. However, if there is a high risk of large blood loss, it is left in place.
- If it is not possible to remove the placenta, marsupilinization is performed: the amniotic cavity is opened and its edges are sutured to the edges of the wound on the anterior abdominal wall, a napkin is inserted into the cavity and a long time is waited for the placenta to be rejected.
important The gynecological part of the operation is described above, but the scope of the intervention can be significantly expanded, since other organs of the abdominal cavity are also involved in the process, damage to which is very likely.
Consequences
The consequences depend on how damaged the site of implantation of the fertilized egg is. If in some cases surgical intervention is limited only to suturing the wound, then in others it may be necessary to remove the entire organ or part of it.
information The woman’s reproductive function remains normal, unless, of course, any technical difficulties arose during the operation.
As for the consequences for the fetus, in 10-15% of cases they are viable, but in more than half, certain congenital malformations are determined.
Most women are happy when they find out they are pregnant. It’s good when it develops normally and the growing tummy pleases the eye every day. But everything is not always so good. Two lines on the test will be a real curse if the embryo implanted outside the uterus. This pathological condition leads to serious consequences. Why does it occur and what to do if a woman finds out about an ectopic pregnancy?
Physiology
An ectopic (ectopic) pregnancy occurs when the fertilized egg is implanted outside the uterine cavity. This is very dangerous for the life and health of a woman.
Ectopic pregnancy is not that rare. About 2% of pregnancies are ectopic.
Fertilization of the egg takes place in the fallopian tube, then the zygote (the same fertilized egg) descends into the uterus and finds a “convenient place”, settles there and develops. The process lasts about a week.
During an ectopic pregnancy, the zygote remains in the tube, cervix or enters the ovary or abdominal cavity, localizes there and grows, causing tissue stretching with the threat of rupture and internal bleeding. Implantation during ectopic pregnancy is somewhat shorter than during normal pregnancy, and lasts 4–5 days from the moment of fertilization.
general information
Ectopic pregnancy is a dangerous pathology characterized by ectopic attachment of the fertilized egg. General information on this issue will make it possible to understand why and how this happens.
Risk factors
No woman is immune from ectopic pregnancy. Back in the 17th century, doctors of that time described cases of this pathology, and in the 18th century the first attempts to treat it were made.
Even after IVF, ectopic pregnancy is possible. The embryo during the procedure is planted in the uterus, but it can migrate into the tube, ovary or cervix.
There are factors that increase the risk of getting this pathology. The main ones:
- previous operations on the fallopian tubes and abortions;
- sterilization;
- ectopic pregnancies that have occurred in the past;
- intrauterine devices;
- inflammatory processes in the pelvic organs, both cured and progressive;
- hormonal disorders;
- infertility for more than two years;
- mother's age is more than 35 years;
- smoking;
- severe stress;
- slowness of sperm in a partner.
The mechanism of pathology development
Any pregnancy occurs due to the fusion of the sperm with the egg in the fallopian tubes. The zygote needs to get to the uterus and gain a foothold there for further development in the conditions provided for by nature. The small unit of life does not move towards the uterus on its own. Special cilia of the epithelium help her in this: they are lined from the inside of the fallopian tubes.
The process is disrupted if the cilia are damaged or do not perform their function correctly. Then the zygote does not have time to get into the uterus and remains in the tube, enters the ovary or into the abdominal cavity and continues to grow. This is how an ectopic pregnancy is formed, the consequences of which without timely treatment are very deplorable.
Classification
Ectopic pregnancy is divided into:
- tubal pregnancy (most common);
- ovarian pregnancy;
- cervical pregnancy;
- pregnancy in the abdominal cavity;
- heterotopic pregnancy (one fetal egg is located in the uterus, and the other outside it);
- pregnancy in the scar after cesarean section (isolated cases).
Pathogenesis
How to distinguish an ectopic pregnancy from a normal one? In the early stages, ectopic pregnancy practically does not appear. There may be symptoms characteristic of a normal pregnancy: delayed menstruation, engorgement of the mammary glands, mild toxicosis. In the first 2 months after the fertilization of the egg, due to hormonal changes, the uterus increases, but then stops growth. However, over such a long period of time, an ectopic pregnancy will definitely make itself felt.
The fertilized egg grows outside the uterine cavity. An increase in its size provokes pressure on the surrounding tissues and their trauma.
The main signs and symptoms of any uncomplicated ectopic pregnancy, that is, for a period of 2-4 weeks:
- bleeding from the vagina;
- pain in the lower abdomen;
- feeling of fullness in the stomach;
- constipation
4-6 weeks - the period of pronounced clinical manifestations of ectopic pregnancy. The fetal egg is already so large that it is already impossible not to notice the signs of pathology. Abdominal pregnancy usually manifests itself later, but the main sign of a critical condition in this pathology is regular and debilitating pain in the abdomen. Such sensations indicate internal bleeding of a mild nature.
If the fetal egg was fixed in the tube, then, most likely, a critical increase in the size of the egg will cause it to rupture and, accordingly, very profuse internal bleeding. At this moment, the woman will feel acute pain until she loses consciousness. Pallor of the skin, slow pulse, vomiting, and weakness are noted. Sometimes the fertilized egg breaks open inside the tube (tubal miscarriage). This situation has a more favorable prognosis, because the internal organs remain intact. Other types of ectopic pregnancy will also not go unnoticed. Pain and internal bruises will definitely manifest themselves.
The symptoms of an ectopic pregnancy superficially resemble a miscarriage that has begun during a uterine pregnancy. Doctors often do not immediately determine what happened, and any delay is dangerous.
Consequences
Any type of ectopic pregnancy is extremely dangerous. The sooner the pathology is identified and measures taken to eliminate it, the less serious the consequences will be. Untreated ectopic pregnancy can cause:
- internal bleeding and associated anemia;
- rupture of the fallopian tube, ovary;
- pain shock;
- adhesions in the pelvic area;
- infertility;
- death.
If you consult a doctor in time, you can reduce the risk of serious consequences. Therefore, for any discomfort in the abdomen and for violations of the cycle, you need to come to an appointment with a gynecologist and be examined in accordance with his recommendations.
Diagnostics
Many doctors make a real diagnosis too late, when the woman is already in critical condition. This happens because the symptoms of the pathology are blurred or absent at all. If your period is late or your pregnancy test is positive, it is recommended to do an ultrasound. If the study does not reveal a fertilized egg, then you should sound the alarm, since there is a possibility that the embryo is outside the uterine cavity, but is still too small to be visualized using ultrasound. How can you accurately detect an ectopic pregnancy in the early stages? A medical examination to make an accurate diagnosis takes place in several stages.
- Gynecological examination. The doctor must listen to the woman, paying special attention to her complaints, calculate the approximate length of pregnancy, find out the date of the last menstruation, and then examine the patient. The gynecologist will be alerted to spotting and severe pain when palpating the abdomen.
- Lab tests. If a woman is pregnant, her hCG level increases. To make a diagnosis, it is necessary to observe the dynamics of hCG. Normally, it doubles every 48 hours. With an ectopic and frozen pregnancy, hCG will not grow as quickly, but in the first case the fertilized egg is not visualized in the uterine cavity on ultrasound, and in the second it is easy to detect.
- Ultrasound. To confirm the diagnosis, it is necessary to determine where the fertilized egg is located. To do this, a transvaginal ultrasound is performed 4–5 weeks after ovulation. This method is more accurate than conventional ultrasound. Detection of a fertilized egg in the ovary, tube or abdominal cavity confirms an ectopic pregnancy. Indirect signs of pathology detected by ultrasound are an increase in the size of the ovaries, accumulation of fluid in the peritoneum and behind the uterus. The absence of a fertilized egg in the uterus is an imprecise sign of ectopic pregnancy; in this case, further studies are prescribed as indicated.
- Puncture of the posterior vaginal vault (culdocentesis). If internal bleeding is suspected due to a ruptured tube, women undergo a puncture from the pouch of Douglas, a special area of the peritoneum located between the rectum and uterus. Using a long needle, the doctor takes contents from this area, piercing the posterior vaginal fornix. The presence of blood with a large number of blood clots or blood clots is a reliable sign of an ectopic pregnancy.
- Laparoscopy. If other methods fail to determine the nature of pregnancy, doctors prescribe laparoscopy to diagnose the pathology. To do this, under anesthesia, a small incision is made in the abdomen, an optical device is inserted into it, the peritoneal area is inflated with carbon dioxide and the cavity is examined, looking for the fertilized egg. If it is found, it is deleted.
Treatment
All women with suspected ectopic pregnancy are taken by ambulance to the gynecological department, and with acute pain and bleeding - to the nearest surgical department.
A high level of hCG (more than 1500 IU/l), together with other symptoms, indicates a progressive ectopic pregnancy. In this case, as well as in life-threatening situations (with internal bleeding, painful shock), surgical treatment is directly indicated for the woman. It can be radical (the fertilized egg with its receptacle is removed) and organ-preserving.
An alternative to surgical intervention is the use of the drug Methotrexate. In Russia, it is prescribed for the treatment of various tumors and autoimmune diseases, and the instructions do not describe dosages and methods of use for ectopic pregnancy. However, in other countries the drug is actively used to remove the fertilized egg from the tubes, ovaries and cervix, as well as the peritoneal cavity. Methotrexate has an embryotoxic effect, that is, it prevents the division of embryonic cells and destroys it for excretion naturally. The medicine is injected intravenously (the dosage is selected by the doctor), after which the hCG level is monitored over time. If Methotrexate has worked, then the level of the hormone should steadily decrease.
Non-surgical treatment is a good alternative that helps preserve a woman’s reproductive health. It can be used only in the very early stages of pathology, and it is quite difficult to detect it so early. Therefore, surgery is often the only option to save the patient’s life.
Forecast
Even if a woman has an ectopic pregnancy, she does not need to give up on herself. During surgery, as a rule, only one tube and ovary are removed. These organs are paired, which means that ovulation and conception are possible with the help of the remaining intact ovary and tube. Removal of both tubes will entail physiological infertility, but even in this case, if there is a uterus, IVF will come to the rescue.
A woman who has experienced an ectopic pregnancy should take care of herself for at least another six months (and preferably longer) and use protection. The choice of contraception method should be left to the attending physician. There are many reasons for an ectopic pregnancy, and which of them provoked improper attachment of the fertilized egg is an open question. After treating this pathology, you need to undergo additional examinations and find out for sure why it arose. Many women will undergo testing for tubal patency to rule out recurrence.
Prevention
Every woman who does not want to experience an ectopic pregnancy should know about methods of preventing it. Prevention of pathology comes down to the following set of measures:
- timely treatment of inflammatory diseases of the pelvic organs;
- planning pregnancy and conducting the necessary diagnostic examinations (including for the presence of pathogenic microorganisms);
- exclusion of abortions (reliable contraception during periods undesirable for pregnancy);
- high-quality rehabilitation after cases of ectopic pregnancy;
- maintaining a healthy lifestyle and avoiding stress.
All these measures will help reduce the risk of ectopic pregnancy and increase the chances of conceiving and giving birth to a long-awaited baby without complications.