Volume 03 Issue 07-2023
44
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
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03
ISSUE
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Publisher:
Oscar Publishing Services
Servi
ABSTRACT
Ectopic pregnancy is the most common pathology in gynecologic practice, leading to the reduction and loss of
reproductive function. Diagnosis of ectopic pregnancy in cases of its occurrence interrupts and intra-abdominal
bleeding does not provide significant difficulties. Of interest is the search for ectopic gestational sac located in rare
forms of ectopic pregnancy. Although progress has been made in the diagnosis and treatment of ectopic pregnancy
is not possible to achieve reduction of complications associated with it.
KEYWORDS
Ectopic pregnancy, risk factors, diagnostics, treatment.
INTRODUCTION
Ectopic pregnancy occupies one of the leading places
in the structure of maternal mortality: it is in the first
place as the cause of intra-abdominal bleeding and in
second place in the structure of acute gynecological
diseases. An ectopic pregnancy was first described in
the 17th century, but the diagnosis was made only after
the death of the patient. The case of intravital
diagnosis of an ectopic pregnancy was recorded in
1812. Until 1870, only 500 cases of ectopic pregnancy
were described in the world literature, and the
treatment methods used did not give a positive result.
In 2018, the maternal mortality rate from an ectopic
pregnancy in Russia amounted to 0.26 per 100,000 live
births, and in Uzbekistan - 0.29 [3, 14]. The purpose of
this review article is to provide obstetrician-
gynecologists with the most complete information
Research Article
CLINICAL CHANGES IN ECTOPIC PREGNANCY OBSERVED IN WOMEN
Submission Date:
July 20, 2023,
Accepted Date:
July 25, 2023,
Published Date:
July 30, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue07-09
Kulmatov G
‘Anijon
Otakhonovich
Student, Urgench Branch Of Tashkent Medical Academy, Urgench, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 07-2023
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Publisher:
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Servi
about the problems associated with an ectopic
pregnancy and how to solve them. An ectopic
pregnancy is one of the common causes leading to
infertility. Ectopic pregnancy does not belong to the
considered reproductive losses, however, to date, it
continues to remain one of the main problems of
reproductive medicine related to the subsequent
fertility of a woman. After an ectopic pregnancy, many
develop adhesions in the pelvis, in 60-80% of patients -
infertility, in 20-30% of patients - repeated ectopic
pregnancy [8].
In recent years, there has been a tendency to increase
the frequency of ectopic pregnancy. One of the main
factors in the occurrence of an ectopic pregnancy is
inflammatory diseases of the female genital organs,
which in the etiology of an ectopic pregnancy make up
42-80% [2, 24]. Particularly noteworthy are sexually
transmitted infections, and this is especially true for
chlamydial salpingitis, which occurs in 50-60% of
patients with ectopic pregnancy. Inflammatory
diseases of the internal genital organs lead to impaired
patency, damage to the neuromuscular apparatus of
the fallopian tube and neuroendocrine disorders,
which contributes to the occurrence of an ectopic
pregnancy. An equally important risk factor for ectopic
pregnancy is abortion, almost every second woman
has a history of it [8, 21]. The frequency of ectopic
pregnancy with the use of intrauterine contraceptives
(IC) reaches 3-4%, which is almost 20 times more than
in the general population. While taking oral
contraceptives
containing
progestogens,
the
frequency of ectopic pregnancy rises to 2 per 100
women / years, which is apparently caused by the
inhibitory effect of progestogens on the uterine
mucosa and a slowdown in the contractile activity of
the fallopian tubes against the background of
preserved ovulation [6, 15].
Against the background of taking ovulation inducers,
the frequency of an ectopic pregnancy increases to
10%, and with the development of ovarian
hyperstimulation syndrome, the risk of ectopic
pregnancy increases three times in comparison with
the general population. Previous surgical interventions
on the tubes are also a risk factor for the development
of an ectopic pregnancy. Reconstructive plastic
surgery is often accompanied by a violation of the
anatomy. This explains the very high (up to 25%)
frequency of ectopic pregnancy after such operations.
Operations that are accompanied by a high risk of tubal
pregnancy are salpingostomy, neosalpingostomy,
fimbrioplasty,
ovariosalpingolysis,
and
tube
anastomosis [19, 4].
The presence of tumors or tumor-like formations of the
uterus and appendages, endometriosis of the uterus
and appendages, genital infantilism, the onset of
pregnancy in late reproductive age, smoking 1.5-3.5
times increases the risk of an ectopic pregnancy.
Sometimes an ectopic pregnancy occurs in women
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with perfectly normal fallopian tubes that do not have
known risk factors. Thus, the factors contributing to
the occurrence of an ectopic pregnancy are diverse,
but they are often found in combination. The most
common form of ectopic pregnancy is tubal (96.5-
98.5%). The location of the ovum in the fallopian tube,
according to the United States and Russia, is presented
as follows: interstitial department - 2-3% and 2-3%,
respectively; isthmic - 11-12% and 10-40%; ampullar - 80%
and 30-60%; fimbrial - 4-5% and 5-10% [1, 22].
About 5% of ectopic pregnancies have a rare
localization: simultaneously in both tubes, in the
interstitial part of the tube, ovary, closed rudimentary
horn, cervix, between the leaves of the broad
ligament, abdominal cavity, scar area after cesarean
section, transitional form, combination of uterine and
ectopic pregnancy. Information on the prevalence of
rare forms of ectopic pregnancy is limited and
presented as follows: ovarian - 1: 7000 births, in a
closed rudimentary horn - 1: 100000 births, cervical - 1:
8000 - 18000 births, abdominal - 1: 3000-10000 births [1,
18] . One of the rarest forms of ectopic pregnancy is
simultaneous bilateral tube pregnancy - 5 cases per 1
million studies of surgical material. Rare forms of
ectopic pregnancy are often not taken into account by
practitioners, are diagnosed late and cause high
maternal morbidity and mortality.
Interstitial pregnancy accounts for 2% of ectopic
pregnancies. Patients with interstitial tubal pregnancy
in most cases go to the doctor later than with ampullar
or isthmic. The pregnancy rate in the uterine angle
increases to 27% in patients with a history of
salpingoectomy, IVF, and embryo transfer. Interstitial
tubal pregnancy is associated with most of the deaths
caused by ectopic pregnancy in general, since it is often
complicated by a rupture of the uterus.
Ovarian pregnancy is one of the rarest ectopic
pregnancy options: of 200 ectopic pregnancies, one is
truly ovarian. In recent years, an increase in its
frequency has been noted, which is associated with
some types of intrauterine and oral hormonal
contraception.
Pregnancy in a closed rudimentary horn occurs due to
the transperitoneal migration of a fertilized egg or
sperm. Anatomically, this pregnancy can be attributed
to the uterine one, however, due to the fact that in
most cases the rudimentary horn has no message with
the vagina, clinically such a pregnancy proceeds as an
ectopic one. The development of pregnancy in a closed
rudimentary horn leads to its rupture early due to a
significant defect in the structure of the endometrium
and severe hypoplasia of the myometrium.
Cervical pregnancy is quite rare, but it is very
dangerous. The risk of cervical pregnancy is increased
by a previous abortion or cesarean section, Asherman's
syndrome, the mother taking diethylstilbestrol, uterine
fibroids and IVF during pregnancy. In this case, the
Volume 03 Issue 07-2023
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Publisher:
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ovum is implanted in the cylindrical epithelium of the
cervical canal. The trophoblast villi penetrate deep into
the muscle membrane of the neck, which leads to the
destruction of its tissues and blood vessels, and ends
with massive bleeding. With an intraligamentary
ectopic pregnancy, the fetal egg develops between the
leaves of the wide ligament of the uterus, where it
enters a second time after a rupture of the tube wall
towards the mesentery of the fallopian tube.
Abdominal pregnancy, both primary and secondary, is
extremely rare, in about 1.4% of cases of ectopic
pregnancy. Abdominal pregnancy is usually the result
of secondary implantation: tubal miscarriage, rupture
of the uterus, rupture of the elementary horn of the
uterus, rupture of the ovary. A fetal egg can attach to
various organs of the abdominal cavity. Very rarely,
abdominal pregnancy reaches a long time. As a rule, it
ends with rupture of the capsule of the fetus in the
early stages, heavy bleeding and peritoneal shock. The
clinical manifestations of abdominal pregnancy are
diverse, depending on the location and gestational
age. The prognosis for mother and fetus during
abdominal pregnancy is very serious. Maternal
mortality, usually from massive blood loss, reaches
20%, and perinatal - 40-95%. Congenital malformations
and deformities are observed in 21.4% of the fetuses.
Some cases of abdominal pregnancy are described,
with a manifesting picture of an acute abdomen and
hemorrhagic shock.
Diagnosis of abdominal pregnancy is very difficult. A
classic finding with ultrasound scan is the absence of
echoes of the myometrium between the maternal
bladder and the fetus, poor visualization of the
placenta. To confirm the diagnosis, CT and MRI can be
useful to distinguish between the anatomical
structures, the place of attachment of the placenta and
the vascular connections involved. Differential
diagnosis
of
abdominal
pregnancy
includes
miscarriage, intrauterine fetal death, placental
abruption, acute abdomen during pregnancy, uterine
fibroids with intrauterine pregnancy.
Late abdominal pregnancy with a live fetus requires
immediate surgical intervention. The attitude of
doctors to the separation of the placenta remains
controversial. Its separation during surgery may be
accompanied by damage to neighboring organs,
bleeding. Complications with an abandoned placenta:
bleeding, infections, bowel obstruction, preeclampsia,
failure to breastfeed due to placental hormones. It is
extremely rare (1: 30000) that a combination of uterine
and ectopic pregnancy (heterotopic pregnancy) is
observed when there is a normally developing uterine
in combination with tube pregnancy in the uterine
cavity. In recent years, due to the use of assisted
reproductive technologies in the treatment of
infertility (stimulation of ovulation), the frequency of
heterotopic pregnancy has increased to 1: 100
pregnancies.
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In recent years, with the increasing prevalence of
delivery by cesarean section, a new form of ectopic
pregnancy has appeared - in the area of the uterine
scar. Kanat-Pektas M. and co-authors. (??) presented a
systematic review of clinical trials of women with
ectopic pregnancy in the scar area after cesarean
section. A thorough search of electronic databases
showed that between January 1978 and April 2014, 274
articles were published. The methods of treatment and
restoration of fertility in this form of ectopic pregnancy
are considered. The most commonly used methods
were systemic administration of methotrexate,
embolization of the uterine artery, dilation and
curettage, hysterotomy and hysteroscopy. According
to the review, hysteroscopy and laparoscopic
hysterotomy are safe and effective surgical methods.
Uterine embolization should be reserved for cases of
massive bleeding or if arteriovenous malformation is
suspected. Systemic administration of methotrexate,
dilatation, and curettage are not recommended as
first-line treatment. These procedures are associated
with a high risk of complications and hysterectomy.
Some researchers propose to distinguish the so-called
transitional forms of tubal pregnancy, in which the
fetal egg is simultaneously located in neighboring
sections of the tube or in adjacent organs of the
abdominal cavity: tubal abdominal, tubal-ovarian,
fimbrial, etc.
In general, the diagnosis of an ectopic pregnancy is
quite difficult. This is due to a variety of clinical
manifestations - from minor pain in the lower abdomen
with scanty spotting from the genital tract to
hemorrhagic shock. Abdominal pain is observed in 95%
of cases of ectopic pregnancy. Delayed menstruation
from several days to several weeks occurs in 90% of
cases. Bloody discharge from the genital tract occurs in
50-80% of cases. Soreness of the uterine appendages
during bimanual examination is a constant symptom,
which is often combined with soreness of the cervix
when it is displaced. An increase in the uterus is
observed in 25% of cases of an ectopic pregnancy. The
size of the uterus is usually less than the expected
gestational age.
Of great importance for the diagnosis of ectopic
pregnancy
are
additional
research
methods:
ultrasound scan, determination of the level of the HCG
subunit in the blood, as well as laparoscopy.
Transvaginal ultrasound scanning has a high
resolution. A progressive uterine pregnancy can be
diagnosed already from 1.5-3 weeks, while the
diameter of the fetal egg is 4 mm. The cardiac activity
of the embryo is determined after a 3.5-week gestation
period. The transvaginal ultrasound technique allows
you to visualize the fetal egg about 1 week earlier than
with the transabdominal technique. Color Doppler
Mapping (CDM) allows you to visualize increased
vascularization in the area of ectopic trophoblast. This
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increases the diagnostic sensitivity during ectopic
pregnancy from 71 to 87% compared with transvaginal
ultrasound.
Son elastography is a new promising method in the
early diagnosis of ectopic pregnancy. It made it
possible in 100% of cases to accurately diagnose an
ectopic pregnancy with a moderate increase in the
level of HCG, when the visualization of the fetal egg
using standard imaging modes was still not available.
Of great importance in the diagnosis of ectopic
pregnancy is the identification of the level of human
chorionic gonadotropin, which is determined starting
from the 7-8th day after fertilization. HCG is different in
carbohydrate and amino acid composition, therefore,
quantitative determination of it increases specificity
and significantly increases the accuracy of diagnosis.
The rate of increase in HCG levels in the blood helps to
differentiate between normal and ectopic or non-
developing pregnancy. In normal pregnancy, the HCG
content in the blood doubles every 2 days.
Currently, the possibility of radioimmunological testing
of HCG in blood serum makes it possible to establish a
diagnosis of ectopic pregnancy in 98.8% of cases. If by
immunological tests the amount of HCG is detected at
about 1 IU / ml, then radioimmunological testing
reveals significantly lower amounts of HCG - 1 mIU / ml.
The advantages of the radioimmunological method for
determining HCG are its high sensitivity and specificity,
the absence of cross-reactions with other hormones
and proteins that are identical in structure, and the
ability to accurately determine the daily amount of
secreted hormone. A type of radioimmunological
control is the immunoradiometric method - the
determination of antigen using labeled antibodies,
which allows the detection of HCG in serum a week
before the expected menstruation. Laparoscopy is the
most accurate, reliable and informative method for
detecting an ectopic pregnancy, and in almost 100% of
cases it allows you to establish the correct diagnosis,
and in many cases to carry out surgical treatment.
Laparoscopy also has known disadvantages. Usually, if
a patient is suspected of having an ectopic pregnancy,
laparoscopy should be performed at the final stage,
when the use of other, less invasive research methods
does not allow the doctor to establish an accurate
diagnosis [21, 26].
Puncture of the abdominal cavity through the
posterior arch retains its relevance and significance,
allows you to diagnose an interrupted and interrupted
ectopic pregnancy in various conditions and in the
absence of the possibility of using ultrasound. The
advantages of culdocentesis are the speed and relative
safety of the procedure. The disadvantages include
soreness and frequent dubious results. Curettage of
the uterine cavity in order to diagnose an ectopic
pregnancy is undesirable.
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At the present stage, there are several different
approaches to the treatment of tubal pregnancy:
surgical, drug and expectant management of patients.
A common method for treating ectopic pregnancy is
the surgical method. Over the past two decades,
minimally invasive surgery techniques have been used
predominantly. Laparoscopic access in the treatment
of patients with ectopic pregnancy worldwide has in
most cases become the method of choice.
Laparoscopy has undeniable advantages over
laparotomy: a small incision, a shorter duration of the
operation, an insignificant frequency of complications,
the possibility of implementing organ-preserving
principles, shortening the patient's hospital stay, and
early physical and social rehabilitation. Dynamic
laparoscopy is especially indicated in cases of
suspected chorionic persistence: visual monitoring of
the fallopian tube, its reorganization, and, according to
indications, local administration of methotrexate,
however, there have recently been opponents of
methotraxate administration [24].
With laparoscopy, both radical (salpingoectomy) and
conservative plastic surgery are performed. Organ
preserving operations on the fallopian tube are
possible in the form of salpingotomy followed by
suturing of the wall of the fallopian tube after removal
of the ovum or salpingostomy, when the incision of the
wall of the fallopian tube is not sutured after removal
of the ovum and the wound heals by secondary
intention. After any of these techniques for treating an
ectopic pregnancy, the fallopian tube can maintain its
normal function.
The nature of plastic surgery depends on the location
of the fetal egg. When localized in the fimbrial region,
the fetal egg is extruded (rather traumatic
manipulation) or aspirated using an aquapurator.
When the fetal egg is localized in the tube ampule,
salpingotomy is also more often performed. With
isthmic localization of the ovum, salpingotomy or
resection of the tube segment with the ovum with
anastomosis is applied end-to-end. With interstitial
localization
of
the
ovum,
laparotomy
and
salpingoectomy with excision of the tubular angle of
the uterus are advisable. With this localization, it is
usually not possible to use laparoscopic access.
The necessary conditions for laparoscopic operations
are a satisfactory condition of the patient and stable
hemodynamics. An absolute contraindication for
laparoscopy in ectopic pregnancy is hemorrhagic shock
of the 3-4th degree, which most often occurs with
blood
loss
exceeding
1500
ml.
Relative
contraindications
are:
unstable
hemodynamics
(hemorrhagic shock of 1-2 degree) with blood loss not
exceeding 1500 ml; interstitial localization of the ovum;
the location of the ovum in the extra uterine horn;
rupture of the wall of the fallopian tube. General
contraindications for laparoscopy: obesity, severe
adhesions, cardiovascular and pulmonary failure.
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However, there are reports of the successful use of
laparoscopic surgery with significant blood loss,
rupture of the tube, interstitial and "old" tube
pregnancy.
Laparotomy is used to treat those patients who have
hemodynamic disturbances, as well as localization of
the fetal egg in the region of the rudimentary uterine
horn. Laparotomy access is preferred for surgeons
who do not own laparoscopy in patients where
laparoscopic access is obviously difficult: with severe
obesity, the presence of a significant amount of blood
in the abdominal cavity, with a pronounced adhesive
process in the abdominal cavity.
For drug treatment, the most commonly used
anticancer drug is methotrexate, which is a structural
analogue of folic acid. Methotrexate prevents the
transition of folic acid into its active form. This leads to
disruption of the synthesis of amino acids, which are
necessary for the formation of DNA in the embryo. In
1982, Tapaka first reported the successful treatment of
interstitial pregnancy with methotrexate in a 19-year-
old woman. The patient was diagnosed with
laparotomy, the abdominal wall is tightly sewn, and
methotrexate was given parenterally. According to the
results of hysterosalpingography performed after
treatment, both pipes were passable. Methods of
administration of methotrexate are different: systemic
administration
orally
and
parenterally;
local
administration with laparoscopy, under ultrasound
control or transcervical; combined introduction (a
combination of systemic and local methods). The
dosage of methotrexate is individual.
In recent years, a relatively new method has come into
clinical practice - endovascular uterine artery
embolization (UAE). According to some researchers,
UAE, devoid of a number of serious limitations of
surgical and conservative treatment, may become the
method of choice in patients with cervical pregnancy.
A method for the combined treatment of cervical
pregnancy was proposed, consisting of superselective
embolization of the uterine arteries in combination
with the intra-arterial administration of methotrexate
and the use of mifepristone (600 mg) orally. This
method allowed to preserve the reproductive function
of women.
The technique of operation during abdominal
pregnancy depends on the location of the fetal egg.
Usually, the operation is reduced to the removal of the
fetal egg and subsequent hemostasis. Implantation of
a fetal egg in the abdominal cavity (in the omentum,
intestine, parietal or visceral peritoneum) is rare, but if
this happens, pregnancy can be terminated. In such
cases, with laparotomy, the main technical difficulties
are in the separation of the placenta. In most cases, it
is better not to touch the placenta, especially in the
second or third trimester of pregnancy, hoping for its
spontaneous resolution. To accelerate and enhance
this process, methotrexate can be administered.
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Treatment for ovarian pregnancy involves removal of
the fetal egg or wedge-shaped resection of the ovary
and maintaining the maximum amount of healthy
ovarian tissue. Ovariectomy is rarely required.
Treatment of pregnancy in a rudimentary horn consists
in the removal of a rudimentary horn with an adjacent
fallopian tube. With intraligamentary localization of
pregnancy, the peritoneum of the broad ligament
above the hematoma is first dissected, which is
removed together with the fetal egg, then
salpingoectomy is performed.
Ectopic pregnancy increases the risk of re-ectopic
pregnancy and future fertility problems. According to
one study, the incidence of pregnancy after
conservative or surgical treatment of ectopic
pregnancy was 80%, and the average time until
conception was 9-12 months, and fertility after
expectant management and surgical treatment is the
same. Ectopic pregnancy increases the risk of
developing a similar condition in the future by 7-13
times. This means that in 50-80% the next pregnancy
will be uterine and in 10- 25% - ectopic. All patients with
ectopic pregnancy should be informed of the increased
risk of its occurrence in the future.
The high probability of repeated ectopic nidation of the
fetal egg after organ-preserving operations for tubal
pregnancy dictates the need to improve methods of
organ-saving
treatment
and
postoperative
rehabilitation, as well as a delayed study of the
condition of the fallopian tubes after organ-preserving
treatment to highlight a group of patients at high risk
for repeated ectopic pregnancy.
CONCLUSION
This article provides an overview of the types of
ectopic pregnancy, risk factors and current aspects of
treatment, namely:
•
information on an ectopic pregnancy, frequency of
occurrence, risk factors that contribute to the
development of this pathology, and classification
of this pathology;
•
describes modern methods of diagnosis and
treatment
of
this
pathology,
possible
complications
during
surgery
and
the
postoperative period.
This review article will be useful to obstetricians,
gynecologists working in gynecological clinics
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54
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VOLUME
03
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SJIF
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