Ectopic pregnancy (Graviditas ectopica s. extrauterina)

The development of the ovum outside the uterine cavity is a serious threat to the health and lives of women. Untimely delivery of surgical care may cause the death of a woman from acute anemia that develops as a result of internal bleeding on the ground break prodovolstvia.
Depending on the place of attachment of the fertilized eggs are distinguished ovarian pregnancy, in rudimentary uterine horn, pipe, abdominal (Fig. 45).


Fig. 45. Different forms of ectopic pregnancy.
and - ovarian (vnutrimolekulyarnoi) pregnancy; b - abdominal pregnancy (implantation of the embryo on serosa small intestine); - abdominal pregnancy (implantation in dopasowa space with the release of the fetus in the abdominal cavity); g - tube (anularea) pregnancy; d - pipe (isthmic) pregnancy; C - pipe (interstitial) pregnancy; W - intrauterine and ectopic (tubal) pregnancy.

Most common tubal pregnancy (graviditas tubaria), its frequency varies from 1.2 to 4.5% in relation to the total number of gynecologic patients (gg Gender, A. I. Kantorovich, B. N. Shaternik, A. D. Alovski, R. P. Makarov and others).
The incidence of some forms of ectopic pregnancy are given in table. 7.

Table 7. The incidence of some forms of ectopic pregnancy (A. D. Elovskomu)
Pregnancy The number of cases Percentage
Pipe .........
Ovarian .......
Abdominal.........
In a rudimentary Rog
1117
2
5
10
98,5
0,2
0,4
0,9
Total 1134 100,0

Development of a fertilized egg in the pipe is usually associated with various changes in the fallopian tubes, which prevent the free movement of a fertilized egg in the uterine cavity. Egg "stuck" at some stage the fallopian tubes, which can be caused as a clear morphological changes pipes, and purely functional disorders.
Anatomical changes in the pipes can be connected above all with the inherent characteristics of the female body, as with the infantilism of internal genital organs, with anomalies their embryonic development (extension tubes or blind moves along the pipe). Changes in the fallopian tubes,promoting occurrence of ectopic pregnancy, develop most often on grounds of previously deferred lung inflammation (catarrhal) any etiology, or, much less commonly, the result of traumatic changes of the epithelial surfaces of pipes. The first place among causal factors occupy the post-partum and post-abortion inflammation and inflammation after childhood infectious diseases. Inflammatory processes gonorrheal etiology are the cause of ectopic pregnancy is much less frequently, as this often occurs full closure of the abdominal end of the fallopian tube. Gonorrheal infection usually leads to infertility. In some cases, the defeat of the fallopian tubes, contributing to the development of ectopic pregnancy, occurs in the result of conducted intrauterine injection of iodine tincture, on the grounds that in the future there endosulfans and persistent cicatricoadhesive processes.
As already mentioned, the cause of ectopic pregnancy can be a purely functional disorders of pipes, namely the inability them to the correct contractile activity, which leads to "jam" eggs in a tube. In normal conditions the fallopian tubes carry the ramp, peristaltic (from the ovary to the uterus), antiperistaltic (from the uterus to the ovaries) and rotational-translational (turbinellidae) movement. In pathological conditions specified function pipes upset, resulting in delay in moving them fertilized eggs. Finally, an ectopic pregnancy can develop on the soil of coitus interruptus, sometimes used as a method to prevent pregnancy. The cause of tubal pregnancy in these cases is to slow the advancement of eggs and even in "jam" the past as a result of spasm in the field of pipe sphincters.
In the literature there are indications of the possibility of ectopic pregnancy in the result of conducted shortly before fertilization ventilation pipes.
In such cases, the patency of tubes, partially restored in the application of high pressure (180-200 mm RT. century), creates further opportunities only for penetration of sperm, but at the same time does not always ensure the passage through this pipe fertilized egg,
whereby the latter can be delayed.
Delay eggs in the fallopian tube may depend on excessively rapid development of the fertilized egg in the way of promoting it in the uterine cavity. This refers mainly to the cases when the egg gets into the pipe on the side, opposite to the ovary, from which it was thrown out. The reason migratio ovi externa is usually obstruction of pipes from ovulated ovary. However, a yellow body with passable fallopian tube is not always the same side. According to A. D. Elovskogo, the presence of yellow body with tubal pregnancy on the side of non-pregnant tube observed in 37%.
In clinical practice have to deal mainly with ectopic pregnancy that develops in the fallopian tube, and much less with other varieties. Therefore our exposition will concern only the clinic early tubal pregnancy.
Depending on a place of introduction of eggs in the fallopian tube distinguish interstitial pregnancy, or interstitial (graviditas interstitialis), isthmic (graviditas isthmica), ampullary (graviditas ampullaris) and pipe-ovarian (graviditas tuboovarialis) (Fig. 46).


Fig. 46. Schematic representation of different forms of ectopic pregnancy.
1 - graviditas interstitialis; 2 - graviditas tubaria (istmica); 3 - graviditas tubaria (ampullaris); 4 - graviditas fimbriaca; 5 - graviditas ovarica; 6 - graviditas tuboovarialis; 7 - graviditas abdominalis.


Under interstitial understand pregnancy, developing in the part of the pipe, which runs in the thickness of the uterine wall. When isthmic pregnancy egg attaches to the section of pipe between interstitial and anularea parts of the pipe.
Anularea pregnancy develops in the socket of the fallopian tubes, and less space between the fimbriae tube and ovary, especially when the accretion of the fimbriae. Pipe-ovarian pregnancy develops in the space between the fimbriae tubes and ovaries. Tubal pregnancy more often violated on the 4-b-th week of pregnancy, i.e. to the period coinciding with the beginning of the expected menstruation or with a lag of several days or even weeks.
Termination of ectopic pregnancy favors the anatomical structure of the fallopian tubes; mucous membrane tube is very thin and has no submucosal layer, allowing the chorionic villi directly penetrate into the muscle layer of the pipe and eventually grow it, spoiling and blood vessels. Besides decidual changes are formed in the mucosa is not always all over the pipe, but only on its separate parts (C. S. Gruzdev). The destruction of the chorionic villi blood vessels may occur one or another power bleeding. The degree of bleeding depends on the calibre of vessels, destroyed by the villi, and from the values of arterial blood pressure in them. At break of a pipe, certainly important and mechanical stretching her walls growing fetal egg, as the processes of hypertrophy and hyperplasia of muscular elements pipes do not run parallel with the growth of the ovum, and far behind it.
The fate of the ovum, privileges to the pipe can be different. Most often, there is "eating" the fibers of the pipe wall in the direction of the abdominal cavity; first breaks down muscle, and then the peritoneal layer. Detached completely from their original attachment of the fertilized egg is expelled into the abdominal cavity (less you experience a partial detachment eggs). This so-called outer break prodovolstvia or rupture of the pipe (ruptura tubae gravidae). The place of pipes, sprouted fibers can be dot or be a relatively large wound. As mentioned above, the degree of blood loss depends on where the implantation of the egg and the caliber of vessels, which have been eating villi the pipe wall.
In other cases there is an internal break prodovolstvia when chorionic villi leave that part of it, facing into the lumen of the tube. The fertilized egg is soaked with blood, and further peeled from the walls of a pipe and can be antiperistaltic reductions pipe expelled through ampullary part of the pipe in the free abdominal cavity. This phenomenon is called a tubal abortion (abortus tubarius). In these cases, intra-abdominal hemorrhage after the expulsion of the eggs from the pipe often stops, although the possibility of its recurrence is not excluded due to the fact that the chorionic villi, remaining in the pipe, it can corrode, causing the so-called gap pipes. The fertilized egg or the fruit, once in the abdominal cavity, is gradually absorbed. Only in individual cases, by the way is very rare, the fertilized egg continues to develop in the abdomen (sometimes even before the usual term of pregnancy). As a result, there is secondary, abdominal pregnancy. However, the placenta can be attached and outside the pipe - in different areas of the abdomen and even on different organs, including the liver. Usually, the fetus dies, and in the early period of pregnancy it can completely disappear; in the later stages of pregnancy, the fetus is exposed to different changes: maceration or mummification, and sometimes even a callous. When implementing the same infection of the fetus is exposed purulent destruction. Only in exceptional cases of abdominal pregnancy born at the date of childbirth and easy to remove the fetus from the abdominal cavity alive. Developing in the abdominal cavity fruit is often malosolone for extrauterine existence, because often they have different defects of development. The status of women with ectopic pregnancy, donativos until the time is always in great danger. Therefore, as soon as the diagnosis of abdominal pregnancy, the patient should immediately to operate, regardless of the status of the fetus and pregnancy.
Tubal abortion and rupture of the pipe is always accompanied by internal bleeding. This is the main risk of ectopic pregnancy. In some cases the blood, shed abroad in the cavity, with no way out into the abdominal cavity due to partial Sardinia free tube end or close his clots, accumulates in the pipe. As a result of hemorrhage pipe thickens to the size of sausages and more. Occurs blood tumor pipe (haematosalpinx). In other cases, the blood, partially poured out from inside the pipeline, becomes concentrated around it, forming blood cast - haematoma peritubaria. With significant bleeding from the lumen of the tube, the blood running down in the back dopasowa space and poses samotechny blood tumor (haematoma retrouterina).
Simultaneously with development of the fertilized eggs in a tube occur concurrent changes in the uterus: it increases in size, is more juicy, soft and slimy her hypertrophies and turns into decidual shell, reaching often thickness 1 see interruption tubal pregnancy decidual shell often comes from the uterus to the outside entirely in the form of a cast of the uterine cavity. Histological examination of the cast are detected only decidual cells, elements of chorion missing. This circumstance is of great diagnostic value: it says about ectopic pregnancy, and excludes the presence of intrauterine pregnancy.
Diagnosis of ectopic pregnancy is difficult because the clinical course it can be extremely diverse. Clinical features of ectopic pregnancy depend on the term of the latter, from the implantation of the egg and violated or whether it is still developing.
Clinically taken to distinguish between the undisturbed (progressive), perivous and was interrupted for a tubal pregnancy.