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Pregnancy in the interstitial part of the fallopian tube symptoms. Interstitial pregnancy - diagnostic difficulties

We include rare forms of ectopic pregnancy: interstitial, interligamentous, ovarian, pregnancy in the rudimentary horn, abdominal and tubal-abdominal, including full-term, multiple combined and, finally, cervical.
Interstitial, or interstitial, pregnancy occurs in approximately 1% of ectopic pregnancies. Localized in the narrowest part of the tube with a diameter of only 1 mm, the fertilized fertilized egg is quickly implanted into the muscular wall of the angle of the uterus, mainly along its posterior wall.

Figure: Disturbed interstitial pregnancy (posterior view, diagram).

Figure: Interstitial ectopic pregnancy. Rupture of the uterine horn with the passage of the fetus.

A.I. Osyakina-Rozhdestvenskaya considers tubal adenomyosis or nodous salpingitis to be the cause of interstitial pregnancy. As the fertilized egg grows, the uterus acquires an uneven shape with protrusion of the gravid angle, similar to the protrusion with Piskacek's symptom, but to a greater extent. The outcome of such a pregnancy is very dangerous: usually in the 3rd month, an external rupture of the fetal sac occurs with profuse bleeding into the abdominal cavity and a state of shock, reminiscent of a terrible picture of a complete rupture of the uterus.
A.I. Osyakina-Rozhdestvenskaya recommends paying attention before a stroke and on the operating table to the following 4 signs characteristic of interstitial pregnancy: 1) oblique shape of the uterine fundus with a high position of the gravid horn; 2) constriction between the pregnant horn and the rest of the uterine fundus; 3) departure of the round ligament medially and below the gestational sac; 4) high standing of the appendages on the pregnant side.
Pregnancy interligamentous or between the leaves of the broad ligament, interligamentous hematoma, is observed when the fetal sac is ruptured towards the mesosalpinx between the leaves of the broad ligament.

Figure: Intraligamentary pregnancy (Hehne). 1 – uterus; 2 – pipe; 3 – ovary; 4 – fruit container.

In the future, an extensive hematoma anterior to the uterus may develop. With good nutrition and good shelter between the leaves of the broad ligament, the embryo sometimes dies late. The round ligament is located anteriorly or posteriorly in the direction of growth of the fetal sac. For diagnosis, puncture of the posterior (anterior with caution!) fornix is required. During the operation, the peritoneum of the broad ligament is incised.
Ovarian pregnancy is very rare and even with surgery it is not easy to prove. If the egg is implanted on the surface of the ovary, then the fetal receptacle ruptures easily and early. If the fruit receptacle is located in the hylus ovarii zone, growing into the broad ligament, then good development conditions are created for the fertilized egg. Rupture of the fetal sac is accompanied by severe bleeding into the abdominal cavity and a state of shock. External ovarian pregnancy is usually diagnosed as a ruptured tube; its symptoms are the integrity of the tube on the side of pregnancy, the transition of ovarian tissue and its own ligament to the fetal receptacle (needs to be confirmed histologically). Treatment is surgical removal of the appendages and fetal sac.
Pregnancy in the rudimentary uterine horn. This type of pregnancy, not being ectopic in the strict sense of the word, belongs to its variety due to the similarity of the clinical picture and outcomes with it.
The diagnosis is made by finding the vaginal septum. The stalk of the rudimentary horn differs in that it extends from the uterus at the level of the internal os, wider and flatter than the stalk of the ovarian cyst. The rudimentary horn ruptures at the 4-5th month, but often the pregnancy reaches even later stages and is even carried to term. The uterus and cervix are deviated in the direction opposite to the gravid horn. During palpation at the fundus of the uterus, the upper surface of the leg of the rudimentary horn is found in the form of a bridge connecting both horns. The appendages and round ligament arise at the base of the fruit receptacle, closer to the outer edge of the horn. It is not difficult to recognize the rupture of the embryonic horn, since its picture is similar to the rupture of the pregnant tube: it occurs unexpectedly, usually in the upper part of the horn, and is accompanied by severe bleeding and shock. Treatment is urgent laparotomy.
Abdominal pregnancy can be primary or secondary. The possibility of primary implantation of a fertilized egg on the free peritoneum, sometimes far from the uterus and appendages, has now been proven; the fruit receptacle was found in the area of the liver and spleen.
Secondary abdominal pregnancy is much more common than primary pregnancy. It is formed as a result of rupture of the fetal sac with the subsequent release of the fertilized egg with an undisturbed amnion into the abdominal cavity; here she can be brought to term. An ectopic pregnancy can be suspected if there is severe pain in the second half associated with fetal movement. When examining through the vagina, it is sometimes possible to feel the small uterus next to the fetal head. At the end of pregnancy, false contractions appear that are not accompanied by opening of the throat. If help is not provided, the full-term fetus dies and becomes mummified or calcified (lithopedion).

Figure: Post-term tubal-abdominal pregnancy (own case). 1 – preparation of the fetus with placenta and fruit receptacle; 2 – removed uterus.

Figure: Fossilized fetus that has been in the womb for 14 years (Steckel). 1 – lime shell; 2 – fundus of the uterus; 3 – fetal skull bones.

We present our own case of a full-term secondary abdominal pregnancy, which we operated on after a three-year stay of the fetus in the abdominal cavity.
Patient M.K., 44 years old, was admitted to the hospital with complaints of pain and swelling in the lower abdomen. Ill for 3 years. Before the onset of the disease, menstruation stopped and the patient considered herself pregnant, although before that time she had not been pregnant for 10 years. At the 7th week after a missed period, the patient fainted, which recurred 4 times over the course of a month. From the 5th month I began to feel the movement of the fetus. Fetal movement was felt until 9 months, after which contractions began, as before childbirth. The contractions soon stopped, labor did not occur, and the patient stopped feeling the movement of the fetus. The abdomen began to shrink and after 3 months a dense, painful “lump” formed in the abdomen, due to which the patient lay in bed for almost a year.
Objective examination: the entire lower abdomen is occupied by a dense tumor emanating from the pelvis, reaching a level 2 cm above the navel; the tumor is slightly mobile, slightly painful, its surface is slightly bumpy. The body of the uterus is not contoured and goes directly into the tumor. The diagnosis fluctuated between uterine fibroids and ectopic pregnancy. The operation was performed under spinal anesthesia. The abdominal cavity was opened through a midline incision. A tumor larger than an adult's head was discovered. Along the posterior surface, the tumor turned out to be fused to the sigmoid colon, and its anteroinferior segment was fused to the posterior leaf of the broad ligament. When the tumor was removed, it turned out that it was closely adjacent to the uterus, shifted to the right side.
When the tumor was separated from the uterus, part of the left tube remained with the uterus, while the fimbrial end of the tube remained with the tumor. The ovaries are cystically degenerated. A supravaginal amputation of the uterus and appendages was performed. The abdominal cavity is sewn up tightly. Smooth postoperative course. When cut, about a tablespoon of straw-colored liquid poured out of the dense fibrous sac of the tumor. In the cavity of the sac, which turned out to be a receptacle for the fetus, a female fetus was found, well preserved, in a state of mummification. The fetus seems to be compressed along its length: the head is in sharp flexion, the limbs are pressed to the chest and are deformed, the spine is in sharp kyphosis. The length of the fruit is about 50 cm, the circumference of the head is 30 cm, the weight of the fruit with capsule is 1976 g, the nails protrude beyond the flesh of the fingers. The placenta is the size of a saucer, flattened, and lies on the inner side of the fetal sac. The fruit receptacle is a skin, dense, connective tissue membrane closely adjacent to the fruit. The fimbrial end of the left tube is attached outside the fruit receptacle; its end is scarred. The right tube is normal; both ovaries are cystically degenerated.
Diagnosis: secondary abdominal full-term pregnancy. The fertilized egg, which developed near the ampulla of the left tube, soon (fainting from the 7th week) came out through the rupture site at the free edge of the tube, where there were scar changes. Since the amnion and chorion were undisturbed, the egg was able to develop further, mainly because the placenta received good nutrition from three sources: through art. tubaria from the tube, from the newly formed vessels of the append, epiploicae of the sigma and significant vessels of the omentum. The membranes became covered with an inflammatory film, from which a dense fibrous capsule of the fetus subsequently developed.
No special deformations of the fetus were found.
Under favorable conditions, an ectopic pregnancy can reach late stages (6-7 months) and even be carried to term. Most patients with late ectopic pregnancy experience abdominal pain that coincides with fetal movements. The pain is often accompanied by vomiting, nausea, and constipation. The thinner the fruit receptacle, the stronger the pain. When diagnosing a late ectopic pregnancy, it is important to be able to distinguish the uterus from the fetal receptacle: a groove is determined between them. Some authors inject 0.25-0.5 ml of pituitrin subcutaneously for diagnostic purposes; the uterus contracts, but the fetal sac, which is devoid of muscles, does not contract at all. V.K. Rymashevsky suggests palpating the uterus, which contracts well, to diagnose late ectopic pregnancy; The fetal sac does not contract during palpation, but parts of the fetus are easily identified in it.
Multiple and combined ectopic pregnancies are not often diagnosed. For diagnosis, it is important that with this combination there is no bleeding from the uterus, despite the presence of other signs of an interrupted ectopic pregnancy. To avoid complications, surgery for this disease (chromectomy) must be performed urgently; In this case, the intrauterine pregnancy can be preserved. Cases of bilateral tubal pregnancy, a case of lithopedion in the presence of an intrauterine progressive pregnancy, and bilateral ectopic pregnancy have also been described. Repeated ectopic pregnancy occurs in approximately 5%.
During cervical pregnancy, egg implantation, development of trophoblast and placenta occur in the cervical canal, while chorionic villi and placenta grow into the muscle tissue of the cervix. Pregnancy is usually disrupted in the early stages and is accompanied by heavy bleeding, which can cause the death of the mother from acute anemia.
Cervical pregnancy is very rare. Of the 38 described cases, only 22 were histologically proven.
The etiopathogenesis of the disease is similar to the etiopathogenesis of placenta previa - atrophic and dystrophic state of the endometrium, repeated abortions, postpartum febrile illnesses, etc.
Symptoms at the onset of the disease are not pronounced; later, dark bloody discharge appears, which can suddenly turn into life-threatening bleeding. When examined using mirrors, a flask-shaped neck is revealed, deformed with protrusion of one of the walls (the site of egg implantation); the external pharynx is displaced eccentrically, the finger inserted there feels the fertilized egg, but cannot bypass it due to the intimate ingrowth of chorionic villi into the wall of the cervix.

Figure: Cervical pregnancy. On the right, the villi are attached to the wall of the cervix.

This symptom makes it possible to differentiate cervical pregnancy from retention of the fertilized egg in the cervical canal due to incomplete abortion; eccentric location of the pharynx is the second differential diagnostic symptom.

Picture: Incomplete abortion.

Often, cervical pregnancy is combined with fibromatosis. Curettage, especially repeated ones, causes increased bleeding. The most radical method of treatment is urgent abdominal wall extirpation of the uterus. More conservative operations are also proposed. Thus, P.I. Rulle and A.M. Mikhelson recommended removal of the fertilized egg during cervical pregnancy by longitudinal dissection of the cervix.
There are only isolated reports of cervical and cervical-isthmus pregnancies carried out conservatively. In the clinic of the Crimean Medical Institute, K.K. Lapko carried out a case of cervical-isthmus pregnancy of six weeks (after three curettages) by applying three interrupted silk sutures to the posterior-left wall of the cervix through its entire thickness. The bleeding has stopped. The sutures were removed on the 3rd day. She was discharged after 17 days of treatment for anemia in satisfactory condition.

INTERSTITIAL PREGNANCY – DIFFICULTIES IN DIAGNOSIS

Fetishcheva L.E., Zakharov I.S., U shakova G.A., M ozes V.G., D emyanova T.N., V Asyutinskaya Yu.V., P etrich L.N.

GAUZ "Regional Clinical Hospital of Emergency Medical Care named after. M.A. Podgorbunsky",
FSBEI HE Kemerovo State Medical University Russian Ministry of Health,
Kemerovo

Fetishcheva Larisa Egorovna
gynecology department doctorGAUZ OKBSMP im. M.A. Podgorbunsky,Kemerovo, Russia
Email: [email protected]

Zakharov Igor Sergeevich
Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University, Ministry of Health of Russia
E- mail: isza@ mail. ru

Ushakova Galina Aleksandrovna
Professor, Doctor of Medical Sciences, Head of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University, Ministry of Health of Russia
Email: [email protected]

Moses Vadim Gelevich
Doctor of Medical Sciences, Professor of the Department of Obstetrics and Gynecology No. 1, Kemerovo State Medical University, Ministry of Health of Russia

Demyanova Tamara Nikolaevna
head gynecology departmentKemerovo, Russia

Vasyutinskaya Yulia Valerievna
deputy Chief Physician for Obstetrics and Gynecology CareGAUZ OKBSMP im. M.A. PodgorbunskyKemerovo, Russia

Petrich Lyubov Nikitichna
gynecology department doctorGAUZ OKBSMP im. M.A. PodgorbunskyKemerovo, Russia
Email: [email protected]

The ectopic location of the ovum is considered one of the most serious complications of the gravidar process. The incidence of ectopic pregnancy is within 1%, and maternal mortality reaches 7%. By localization, ectopic pregnancy of the ampullary part of the fallopian tube predominates, which occurs in 95% of cases of atypical location of the ovum. A more rare form is interstitial fallopian tube pregnancy. According to the literature, in the early gestational stages the embryo is quite often localized in the indicated section, then it migrates into the uterine cavity and only in rare cases does this migration not occur, resulting in an ectopic pregnancy [3 ]. Sometimes this variant of ectopic pregnancy can progress until the second trimester.
Among the risk factors for ectopic pregnancy, the leading place is occupied by inflammatory diseases, previous surgical interventions, adhesive disease of the pelvic organs, intrauterine contraception, etc. It is noteworthy that recurrence of ectopic pregnancy occurs in 7.5–22% of cases, and secondary infertility occurs in 36–80% of patients. In addition, an increased risk of ectopic ovum formation is associated with the use of assisted reproductive technologies. According to the literature, the frequency of pregnancy localized in the uterine angle in women with a history of salpingectomy and induction of pregnancy is about 27%.
As a rule, a progressive interstitial pregnancy does not manifest itself clinically until it is terminated. This pathology poses the greatest danger, since the fertilized egg is surrounded not by the wall of the fallopian tube, but by the myometrium. As a result, rupture of the fetal sac occurs due to the growth of chorionic villi into the myometrium, which leads to rupture of the uterine angle and profuse bleeding.
Considering that publications related to the above topic are few, below is a clinical case of the course of an induced pregnancy that has reached a gestational age of 20 weeks, localized in the interstitial part of the fallopian tube.

CLINICAL CASE

Pregnant Z., 35 years old, was observed for induced pregnancy in the antenatal clinic in Kemerovo. From the anamnesis it was found that this pregnancy is the third one that occurred using the in vitro fertilization method. The first two ended in 2007 and 2014, having tubal localizations, which was the reason for performing salpingectomies.
According to the life history, the woman suffers from chronic pyelonephritis, stage 2 obesity, and periodic acute respiratory viral diseases. In 2007, she suffered from syphilis.
From the obstetric and gynecological history: menstruation began at the age of 12, regular, every 5 days, every 28 days, moderate, painless. Sexual life from the age of 16. Sexual partner is 38 years old. As already noted, the woman has secondary infertility, which arose in connection with two ectopic pregnancies of tubal localization.
At the beginning of the gestational period, there were two embryos in the uterus, but one died at 7 weeks. Of the peculiarities of the course, it should be noted that during an ultrasound examination at 8 weeks, a suspicion arose about the localization of a viable embryoin the interstitial part of the fallopian tube. However, during the first ultrasound screening, the suspicion of ectopic pregnancy was rejected.When performing the second screening at 20 weeks, no abnormalities in fetal development were detected, but it was noted that due to the woman’s pronounced subcutaneous fat, visualization was difficult.
On October 30, 2016, the pregnant woman was admitted to the Regional Clinical Emergency Hospital named after. M.A. Podgorbunsky, Kemerovo, with complaints of pain, a feeling of pressure in the abdomen, single vomiting, bloody discharge from the genital tract. An ultrasound examination of the abdominal organs revealed cholecystolithiasis.
Taking into account the presence of pain in the abdomen, differential diagnosis of the onset of miscarriage with surgical diseases (acute pancreatitis, calculous cholecystitis) was carried out.
To clarify the diagnosis, diagnostic video laparoscopy was performed, which revealed: a large amount of blood with clots in all sections; in the small pelvis there is a pronounced adhesive process. Due to massive intra-abdominal bleeding and the impossibility of a revision, the operation was extended to laparotomy to clarify the source of blood loss.
When performing laparotomy in the abdominal cavity, the following was discovered (Figure 1):in the area of the right uterine angle, capturing part of the right rib, fundus and anterior wall, an intimately presenting round softish formation measuring 20 * 15 * 20 cm, bluish-purple in color, with a pronounced vascular pattern and such thinned walls that small ones were easily identified through them was determined parts of the fruit; There was a rupture in the space-occupying lesion on the left, in the wound of which there was placental tissue, and there was scanty bleeding from the rupture site. The right adnexa and left fallopian tube were absent (previously removed). In the area of the posterior leaf of the broad uterine ligament on the left, an ovary of normal size, sealed with the help of rough adhesions, was identified. In addition, at the site of the rupture, a fetal sac was detected. Only after opening the amniotic sac and removing the fetus, the body of the uterus, deviated to the left by the fetal receptacle, became clearly visualized. In this case, the size of the uterine body corresponded to 7–8 weeks of the conditional pregnancy, the walls of the uterus were not changed. To the bottom, right corner, with the capture of the right rib, the fetal receptacle was intimately presented, to the walls of the fetal receptacle - the placenta. The segment of the uterus where the fetal sac was located was removed ( Figure 2). Curettage of the uterine cavity was performed and decidual tissue was removed. The walls of the uterus are sutured.

Picture 1.The receptacle of an ectopic pregnancy, localized in the interstitial part of the right fallopian tube, removed from the surgical wound

Figure 2. Macropreparation of the fetal receptacle

Total blood loss was 2500 ml. In the postoperative period, blood transfusion therapy was carried out in an adequate volume.
During a pathomorphological examination of the histological material, elements of the fallopian tube were discovered, which confirmed the assumption that the fertilized egg was localized in the interstitial region of the fallopian tube.

CONCLUSION

The presented clinical case of ectopic location of the ovum in the interstitial part of the fallopian tube, in which pregnancy progressed up to 20 weeks of pregnancy, is a rather rare situation. Probably, the factor of assisted reproductive technologies in connection with the removal of the fallopian tubes was of no small importance for implantation in this department. Difficulties in timely diagnosis were due to the lack of clear visualization during ultrasound examination due to the pronounced layer of subcutaneous fat in the woman. Noteworthy is the mimicry of the clinical picture of abortion, which created certain difficulties in carrying out differential diagnosis. Thus, the presented clinical case confirms the thesis that there is a high risk of ectopic location of the ovum in women who underwent in vitro fertilization.

LITERATURE/ REFERENCES

1. Strizhakov AN, Davydov AI, Shahlamova MN, Belotserkovtseva LDEctopicpregnancy. M.: Medicine, 2001. 215 p. Russian. (Strizhakov A.N., Davydov A.I., Shakhlamova M.N., Belotserkovtseva L.D. Ectopic pregnancy. - M.: Medicine, 2001. 215 p.)
2. Guriev TD, Sidororva IS Ectopic pregnancy. M.: Practical Medicine, 2007. 96 p. Russian. (Guriev T.D., Sidorva I.S. Ectopic pregnancy. - M.: Practical Medicine, 2007. 96 p.)
3. Hachkuruzov SG Ultrasound diagnosis of ectopic pregnancy.M.: MEDpress-Inform, 2009. 448 p. Russian. (Khachkuruzov S.G. Ultrasound diagnosis of ectopic pregnancy.– M.: MEDpress-inform, 2009. 448 p.)
4. Utkin EV, Kulavskiy VA Inflammatory diseases of the pelvic organs in women. Moscow, 2015. Russian. (Utkin E.V., Kulavsky V.A. Inflammatory diseases of the pelvic organs in women. - Moscow, 2015.)
5. Bezhenar VF, Ai lamazian E K,Ba iliuk EN, Tsypurdeeva AA, Polenov NI The etiology, pathogenesis, and prevention of commissure formation during small pelvic surgery.Rossiyskiy vestnik akushera-ginekologa. 2011; (2): 90–100. Russian. (Bezhenar V.F., Ailamazyan E.K., Baylyuk E.N., Tsypurdeeva A.A. Etiology, pathogenesis and prevention of adhesions during operations on the pelvic organs // Russian Bulletin of Obstetrician-Gynecologist.2011. № 2. WITH . 90–100.)
6. Adamian LV, Kozachenko AV, Kondratovich LM Peritoneal adhesions: the history of researh, classification and pathogenesis (a review). Problemy reproduction. 2013; (6): 7–13. Russian. (Adamyan L.V., Kozachenko A.V., Kondratovich L.M. Adhesive process in the abdominal cavity: history of study, classification, pathogenesis (Literature review) // Problems of reproduction. 2013. No. 6. P. 7–13. )
7. Zakharov IS, Ushakova GA, Demyanova TN, Bolotova SN, Fetischeva LE, Petrich LN, Dodonova GH Adhesive disease of the pelvic organs: modern prevention opportunities. Consilium Medicum. 2016; 18(6): 71–73.Russian. (Zakharov I.S., Ushakova G.A., Demyanova T.N., Bolotova S.N., Fetishcheva L.E., Petrich L.N., Dodonova G.H. Adhesive disease of the pelvic organs: modern possibilities prevention // Consilium Medicum.2016. T . 18, № 6. WITH . 71–73.)
8. Golota VJa, Martynova LI The prevalence of ectopic pregnancy in the modern world.Pediatrics, obstetrics and gynecology. 2001; (6): 106–108. Ukrainian. ( Golota V . I ., Martinova L . І . Width of post-uterine vagusity in current minds // Pediatrics , obstetrics and gynecology . 2001. № 6. WITH. 106–108.)
9. Ivaniuta LI, Barnash AM The effectiveness of laparoscopy in the examination and treatment of women with endometriosis and tubal combination-form peritonealnoyi infertility.Women health.2004; 3 (19): 126-129. Ukrainian. ( Ivanyuta L . І ., Barnash A . M . The effectiveness of closed laparoscopy in women with endometriosis and tubal - peritoneal form of infertility // Women's health . 2004. T. 3, No. 19. P. 126–129.)
10. Anikin SS, Livshits, IV, Fishing AN Etiopathogenesis tubal pregnancy and its impact on women's reproductive health.Crimean journal of experimental and clinical medicine. 2012; 2 (3-4): 4–9. Russian. (Anikin S.S., Livshits I.V., Rybalka A.N. Etiopathogenesis of tubal pregnancy and its impact on women’s reproductive health // Crimean Journal of Experimental and Clinical Medicine. 2012. Vol. 2, No. (3-4). pp. 4–9.)

Ending. Starts at No. 45 from 11/24/10

The present.

One of the authors of this essay (L.A. Kozlov), being a graduate student at the Department of Obstetrics and Gynecology No. 1 of KSMI in the late 50s of the last century, witnessed the following clinical diagnostic and treatment activities of the department staff. Assistant Sofya Gabdullovna Khairullina (Safina), while performing an artificial termination of pregnancy for a period of 9-10 weeks, removed the fetus and was unable to remove chorionic tissue. According to the chain of command, she called the head of the gynecological department, assistant M.V. Monasypov. During a bimanual examination, she noted an asymmetrical shape of the uterus due to protrusion of the left corner, which was regarded as Piskacek’s symptom. To her surprise, after checking the uterine cavity with curettes, she also did not find chorion. Marshida Valeevna was at one time a capable graduate student of Prof. V.S. Gruzdeva remembered the interstitial variant of the localization of the fertilized egg. In addition, assistant worked side by side with her. N.I. Frolova, who only 10 years ago published data on cases of ectopic pregnancy observed in the clinic over 10 years, among which 2% had interstitial localization. Prof. was immediately invited for a consultation. P.V. Manenkov. After carefully listening to the report of two assistants, he examined the patient, confirmed the presumptive diagnosis and performed a laparotomy. The picture I saw is still in my mind: a pink uterus and a moderately bluish protruding left corner of it, a little more on the side of the back wall. Having palpated the softest area of the protrusion, Pavel Vasilyevich made an incision with one movement of a scalpel, from which pale pink chorionic tissue immediately emerged. Having carefully removed it, he sewed up the defect, and the operation was completed. Only now did it finally become clear to everyone present that this was a tubal-uterine variant of interstitial pregnancy

"Better to see once than hear a hundred times"(proverb)

Just at this time, R.R.’s monograph was published. Makarova “Ectopic pregnancy” (L., 1958). Pointing out that “... in the interstitial part, pregnancy develops infrequently, in only 1 percent of all cases,” he allows for the development of the fallopian tube variant. In diagnosis, he suggests relying on Ruge’s symptom (oblique uterine fundus), but warns of a possible error due to Piskacek’s symptom in a normal intrauterine pregnancy. On page 69 we find: “during implantation, the fetal bladder very quickly sinks into the muscular layer of the angle of the uterus, up to perforation. This section of the tube passes through the thickness of the angle of the uterus closer to the posterior wall, so protrusion during an impaired pregnancy and a perforation hole are more often found on the posterior wall of the angle of the uterus.”

Soon another monograph was published: M.S. Alexandrov, L.F. Shinkarev “Ectopic pregnancy” (M., 1961). Based on extensive material from the gynecological department of the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky (5064 cases of ectopic pregnancy), the authors note that “A special place is occupied by pregnancy in the interstitial part of the tube, which is relatively rare and, in its clinical manifestations, is one of the most dangerous forms of ectopic pregnancy.” Its frequency has increased. If A.D. Alovsky (1945) it was 2.9%, in G.E. Goffman (1956) - 3.8%, then according to their data - 9.45%. The authors distinguish between a “pure” form and a “mixed” one. Clinical features include development to “later stages” and rupture of the tube in 84.9% with severe bleeding due to “... the abundant blood supply to this area by the vessels of the uterine and ovarian arteries.” The remaining 15.1% were diagnosed with progressive pregnancy. In addition, they emphasize (p. 61) that the diagnosis of interstitial pregnancy “... is the most difficult... and the diagnosis is usually established only during surgery... A tumor palpated through the fornix is difficult to distinguish from the body of the uterus.” They refer to Ruge’s sign “...the location of the uterine fundus in a steeply oblique position and a higher standing of the appendages on the affected side.” Treatment is surgical, which “...requires special vigilance and speed of execution. The nature of the operation is excision of the corresponding angle of the uterus along with the tube.”

It can be assumed with a high degree of probability that this monograph summed up a certain result of the development of the doctrine of ectopic pregnancy in our country. This is confirmed by a highly professional analysis of vast clinical material. A well-known and very impressive share in it was the interstitial localization of the ovum. Just think that its frequency of 9.45% amounted to 479 cases in absolute numbers (!). This, undoubtedly, allowed the authors to speak in many ways no longer conjecturally, but affirmatively. But a monograph is just a publication of the experience of an individual medical institution and individual authors. And its circulation is usually limited. There was a need for guidelines for the broad mass of doctors and, especially, for doctors dealing with emergency care. Such generalizations soon appeared.

“A doctor looking for a solution to a difficult problem in books is usually not satisfied with the basic provisions contained in textbooks... the textbook does not always describe rare forms of pathology, sometimes they are only mentioned” (L.S. Persianinov)

Hero of socialist labor, academician of the USSR Academy of Sciences, Leonid Semenovich Persianinov, for many years, being the director of the All-Union Research Institute of Obstetrics and Gynecology, always believed that “the practical activity of an obstetrician-gynecologist is multifaceted, complex and responsible.” He had every reason to say so, for he had extensive practice as an ordinary doctor. This is what he wrote: “Working after graduating from medical school for a number of years in local and district hospitals, I especially clearly understood and appreciated the importance of manuals on obstetrics and other areas of clinical medicine.” Apparently, this understanding prompted him, literally a year after the above-described monograph, to publish together with prof. I.L. Braude's book “Emergency care for obstetric and gynecological pathologies” (M., 1962). In the preface, the authors wrote: “This manual is intended mainly for doctors working in district and district hospitals.”

At the same time, during these same years, he conceived and published the “Multi-volume (six volumes) manual on obstetrics and gynecology” (M., 1961-1964). In both (M., 1962, vol. 3, book 1, pp. 120-163) he published chapters on ectopic pregnancy, in which rare forms of it are a separate line. They highlight the installation positions at that time. Let us briefly outline what concerns interstitial pregnancy:

1. The exact location of this variety before surgery is usually not possible.

2. Pregnancy most often ends at 3-5 months with an external rupture with severe and sometimes fatal bleeding.

3. As an exception, there may be an internal rupture of the fetal sac with the release of the fertilized egg into the uterine cavity.

4. Diagnostic signs:

- oblique position of the uterine fundus (Ruge-Simon symptom);

- the fruit container has a wide base;

- there is a groove at its border with the uterus (M.S. Malinovsky’s symptom);

- full mobility of the uterus;

- free and painless vaginal vaults.

5. Treatment - surgical with excision of the uterine angle; sometimes supravaginal amputation or uterine defundation.

To be fair, it should be said that all this was a logical development of the reasoning that L.S. Persianinov outlined it in the first edition of the very popular “Obstetric Seminar” (Minsk, 1957, volume 1 and 1960, volume 2), and in its second edition (Tashkent, 1973, vol. 1, pp. 205-212) there are already six pages dedicated to interstitial pregnancy.

Dear reader! All of the above in the “Present” is the logical conclusion of the “Past” of interstitial pregnancy, the result of which was summed up by L.Ya. Tseitlin in the “Guide to Women’s Diseases” by L.A. Krivsky (L., 1927, chapter 31, pp. 876-877).

In subsequent years, two more monographs were published: M.M. Medvedkova, G.A. Dudkevich - “Ectopic Pregnancy” (Yaroslavl, 1965) and I.M. Gryaznova - “Ectopic Pregnancy” (M., 1980), but there was nothing new in them about interstitial pregnancy.

“Anyone who has not prepared himself theoretically enough for the clinic always has to repent at the bedside of a woman in labor, since there is neither the time nor the opportunity to dwell on all those theoretical considerations that are necessary in order to correctly and clearly understand the process taking place before us. » (N.I. Rachinsky)

After a major reconstruction, the obstetrics and gynecology clinic named after. prof. V.S. Gruzdeva entered service at the end of 1988. From 1989 to 2010, there were 399 cases of ectopic pregnancy, including 7 (1.8%) cases with the ovum localized in the interstitial part of the tube. Here is a brief description of them.

Observation 1. M., 38 years old, was admitted for termination of pregnancy according to medical advice. indications at 18 weeks. From the anamnesis: 2 births, 1 abortion, without complications. Objectively: VDM is 3 transverse fingers below the navel. Bimanual: the vagina is free, the neck is cylindrical, the pharynx is closed. The body of the uterus corresponds to 18 weeks of pregnancy, the appendages are not palpable, the fornix is free, the discharge is serous. At the stage of external and internal examination, the doctor did not note any peculiarities in the internal genital organs. An ultrasound revealed the location of the placenta along the posterior wall and left rib, spreading downwards, with the lower edge reaching the internal os. Taking into account the data obtained from the objective study, it was decided to attempt to terminate the pregnancy with a transcervical infusion of a hypertonic sodium chloride solution during a full-blown operating room. When inserting a needle with a mandrel into the cervical canal, an obstacle was encountered. The manipulation has stopped. There is no bleeding. Laparotomy. It turned out that the body of the uterus was enlarged up to 18 weeks of pregnancy, asymmetrical (!) due to significant (!) protrusion of the left half. The right half is much smaller, dense, pink in color. The left half is thinned, imbibed with blood and resembles Cuveler's uterus. There was an impression of a bicornuate uterus with pregnancy in the left horn. Attention was drawn to the extension of the convexity more to the anterior wall with its pronounced thinning, but without a defect. A longitudinal incision was made in this area. A female fetus weighing 400 grams was extracted. An attempt to separate the placenta was unsuccessful due to its deep intimate ingrowth into the thickness of the myometrium. Due to severe bleeding, supravaginal amputation of the uterine body without appendages was performed. Total blood loss 800 ml. The postoperative period was without complications. Discharged on day 9 with recovery.

Macro specimen: on the amputated section of the uterus there is a hole with a diameter of 3 mm, through which the probe passed to a depth of 5 cm, deviating to the right, into the area of the smaller, dense and externally unchanged half. A section of this area revealed a smooth uterine cavity with a hypertrophied endometrium with thickened walls and completely free of elements of the fertilized egg. Through the incision of the left half, a closed depression in the thickness of the uterus is visible with parts of the placental tissue located in it, growing intimately into the myometrium, which is abundantly saturated with blood. A careful examination of this area did not reveal a picture resembling the uterine cavity. Final diagnosis: left-sided interstitial (intramural) pregnancy with extension into the thickness of the anterior wall (according to V.S. Gruzdev, Fig. 1, position 5). A photograph of the macroscopic specimen is kept in the museum of the department. So, this observation confirms that late preoperative diagnosis is difficult for both the clinician and the ultrasound diagnostician.

Observation 2. M., 34 years old, was admitted with suspected ectopic pregnancy. 2 births, 3 abortions, no complications. In the past, she underwent diathermoconization of the cervix. From the anamnesis: against the background of a 2-week delay in menstruation, nagging pain appeared in the lower abdomen. Home hCG test is positive. Objectively: the abdomen is of regular shape, participates in the act of breathing, is soft, painless. Bimanual: the vagina is free, the neck is cylindrical, the pharynx is closed. The body of the uterus is in anteversio-flexio, evenly enlarged until 4-5 weeks of pregnancy, dense, painless. The Horwitz-Hegar sign is not expressed. The appendages on both sides are not palpable. The arches are free and painless. The discharge is serous. An ultrasound did not detect a fertilized egg in the uterine cavity, but in the right corner of the uterus outside its cavity, in the interstitial section of the tube, a fertilized egg with a living embryo was localized, the CTE of which was 6 mm. But for some reason, the doctor performing the ultrasound doubted me and made a second diagnosis - pregnancy in the right horn of the uterus. At a repeat ultrasound 3 days later, he confidently stated that the patient was 4 weeks pregnant in the right horn of the uterus. At this stage of management, a decision was made and curettage of the uterine cavity was performed. An abundant scraping was obtained (according to ultrasound, the endometrium was 13 mm), macroscopically resembling chorionic tissue (cold water test). Subsequent observation and dynamic ultrasound revealed a pattern resembling remnants of chorionic tissue in the right corner, and bimanual asymmetry of the uterus was determined due to protrusion of the right corner. Ultimately, the clinical diagnosis leaned in favor of interstitial ectopic pregnancy. A laparotomy was performed. It turned out that the body of the uterus is asymmetrical due to a rounded protrusion of the right corner, bluish-purple in color with softening along the posterior wall. A 2 cm incision was made in this area and obvious chorionic tissue immediately emerged. A right-sided tubectomy with resection of the right angle was performed. The uterine defect is sutured. At the woman's request, the left fallopian tube was ligated according to Kirchhoff. Discharged with recovery.

Macro specimen: fallopian tube with a resected angle of the uterus, in the thickness of which there was a large amount of chorionic tissue. Now the doubts of the ultrasound specialist and the difficulty of diagnosis have become clear. In this observation there was a tubal-uterine variant of interstitial pregnancy (according to V.S. Gruzdev, Fig. 1, paragraph 3)

Observation 3. G., was admitted with DUB and suspected ectopic pregnancy. Medical history: 8 months ago I removed the IUD, which I had worn for 4.5 years. Immediately pregnancy occurred. A mini-abortion, after which menstruation began to come irregularly and with delays. A month before admission, amid another delay, an ultrasound scan was performed: “there is no pregnancy, but menstruation will be coming soon.” And indeed, after 10 days the next menstruation came, but it lasted longer and more abundantly than always. 4 days after the end of menstruation, after coitus, bleeding came without pain. The gradual increase prompted them to see a doctor. They said: “Everything is fine.” However, severe bleeding occurred, which forced her to go to the hospital, where, for the purpose of hemostasis, the uterine cavity was curetted. The scraping obtained was scanty in the form of tissue scraps. The bleeding has decreased. Bimanual: the vagina is free, the neck is cylindrical, moderately hypertrophied, the pharynx is closed. The body of the uterus is in anteversio-flexio, slightly larger than normal size, dense, painless. Lateral displacement of the uterus causes slight pain without precise localization; the Horwitz-Hegar sign is negative. The left appendages are not palpable. On the right and slightly in front, a dense (!) formation 4 × 4.5 cm is palpated, slightly painful with an uneven surface and fairly clear contours. This formation is connected with a wide base to the right angle of the uterus. An emergency home hCG test was performed - positive. Ultrasound shows suspicion of ectopic pregnancy with possible interstitial localization. But there may also be a subserous fibromatous node with necrosis and the formation of a remallation cavity.

Dear Reader! Here we will divert your attention and remind you that necrosis and remalation are processes related to each other. As a result of remalification of the node, cavities (pseudocysts) with detritus are formed, reminiscent of a dead fertilized egg. V.N. Demidov et al. write “If a cavity is formed as a result of tumor necrosis, then on scanograms it is revealed as an anechoic formation with smooth or uneven contours, surrounded in some cases by a border of tissue of slightly increased echogenicity” (Ultrasound diagnostics in gynecology. M., 1990, p. 60 -71). This picture may be mistaken for pregnancy. At one time we had several such observations. One of them was published in Kazan Medical Journal, 1997, No. 6, pp. 460-461. A mini-abortion was performed on a patient who was 4 weeks pregnant. After this, over the course of a month, diagnoses were made: progressive pregnancy with repeated curettage, pregnancy in the atretic horn, and, finally, a fibromatous node with necrosis, which was confirmed by laparotomy and histological examination.

Let's return to our observation. The next day, laparotomy was performed as planned. It turned out that the body of the uterus is slightly larger than normal size. The right corner of the dark purple color protruded sharply with a 4 × 5 cm formation connected to the body by a wide base. The fallopian tube departs from it. The right round ligament is attached to the uterus medial to this formation. The left appendages are unchanged. An excision of the right corner of the uterus was performed within healthy tissue without penetration into the uterine cavity. The defect is sutured. Recovery.

Macroscopic specimen: on the section, the fertilized egg is located at the transition of the interstitial part to the isthmic part. Thus, this observation demonstrates the interstitial-isthmic localization of the fetal egg (according to V.S. Gruzdev, Fig. 1, paragraph 4).

Observation 4. L., 39 years old, was admitted for an induced abortion at will during pregnancy 10-11 weeks. History: 1 birth, 6 abortions - without complications. Bimanual: the vagina is free, the neck is cylindrical, the pharynx is closed. The body of the uterus in retroversion-flexio is enlarged up to 11 weeks, deviated to the right, asymmetrical due to an increase in the left angle, softish consistency. The appendages are not palpable. The vaults are free. The discharge is serous. It has been suggested that there is a pregnancy in the left horn of the uterus. The uterus was probed: the probe goes straight up, but does not enter the left horn. The cervical canal was expanded to No. 12. When curettage, a scraping was obtained consisting of decidual tissue; there were no elements of the fertilized egg. Ultrasound (cito) - the body of the uterus is 78 × 51 × 73 mm, on the left in the fundus there is a fertilized egg with a living embryo. KTE = 53 mm. Conclusion: 12 weeks pregnancy in rudimentary horn. A repeated bimanual examination suggested interstitial pregnancy, since the body of the uterus was one with a “small depression in the form of a jumper” between the right and left halves (M.S. Malinovsky’s symptom). Emergency laparotomy. It turned out that the body of the uterus itself corresponded to 8 weeks of pregnancy. The left corner is uniformly enlarged in diameter up to 8 cm, cyanotic, contains a fertilized egg, resected. The defect is sutured. At the woman’s request, the right tube was ligated according to V.S. Gruzdev. Recovery. Conclusion - this observation is most similar to a true interstitial pregnancy (according to V.S. Gruzdev, Fig. 1, paragraph 2). Interest of observation: diagnosis of interstitial pregnancy during examination before laparotomy.

Observation 5. N., 31 years old, was admitted with a diagnosis of “incomplete abortion.” History: 1 birth, 2 abortions without complications. Last menstruation 2.5 months ago. Medical history: a mini-abortion was performed at the place of residence in the area during pregnancy 6 weeks (ultrasound No. 1, UDPJ = 14mm). Due to incessant bleeding, ultrasound No. 2 was performed - hematometer, and observation was continued. After 5 days, ultrasound No. 3 shows the remains of the fertilized egg in the left horn. Sent to Kazan, where outpatient ultrasound No. 4 showed “signs of arteriovenous malformation that may have arisen as a result of melting of the myometrium by aggressive chorion.” Sent to hospital. Bimanual: the neck is formed, the pharynx is closed. The body of the uterus in anterversio-flexio is slightly larger than normal size, dense, painless. Appendages without features. The vaults are free. The discharge is bloody and moderate. The diagnosis of incomplete abortion is confirmed and curettage of the uterine cavity is performed. No elements of chorionic tissue were found in the scraping. An ectopic pregnancy is suspected. Ultrasound No. 5 (cito) - the body of the uterus is 60× 46× 58 mm, in the left corner, in the interstitial part of the fallopian tube, a liquid formation with a diameter of 6 mm is visualized. HCG test = 522.8 IU\ml. Clinical diagnosis: interstitial pregnancy. Laparotomy. It turned out: the body of the uterus is slightly enlarged, the left corner is bulging, cyanotic. Appendages unchanged. The angle in the softest area was opened and the chorion was discovered. A left-sided tubectomy with angle resection was performed. The defect is sutured. Recovery. The observation demonstrates the difficulty of diagnosis in the early stages, and only a comprehensive dynamic examination made it possible to establish the interstitial localization of the fetal egg before surgery (according to V.S. Gruzdev, Fig. 1, paragraph 2).

Observation 6. K., 32 years old, was delivered by ambulance at 20.10 with a picture of an “acute abdomen”. History: 3 births, 2 abortions - without complications. Against the backdrop of the next menstruation, an IUD was inserted. After 3 weeks, pain in the lower abdomen and bloody discharge from the genital tract appeared in the evening. The next morning, the pain and bleeding intensified. In the evening I called an ambulance. Objectively: the state is of moderate severity, conscious, answers questions adequately, but inhibited. Blood pressure 80/60 mm Hg, pulse 98 per minute, weak filling. Breathing is smooth, without shortness of breath. On palpation, the abdomen is sharply painful in the lower parts, the Shchetkin-Blumberg symptom is positive. Percussion in the abdominal cavity was determined by the presence of free fluid. Bimanual: the vagina is free, the cervix is cylindrical, the pharynx is closed, the tip of the finger can pass through. The body of the uterus cannot be clearly identified due to severe pain. The posterior arch is protruded and painful. Ultrasound (cito) - uterine body 42× 40×52 mm, in retroversion-flexio, IUD in the uterine cavity, endometrium 8 mm. Posterior to the uterus is a heterogeneous structure 90x51 mm containing an anechoic component with a diameter of 5.7 mm. Clinical diagnosis: acute abdomen, suspected ectopic pregnancy, terminated as an external rupture. Hemorrhagic shock of 1-2 degrees. Emergency laparotomy. It turned out that there was 700 ml of dark blood with clots in the abdominal cavity. The body of the uterus is enlarged until 6-7 weeks of pregnancy. The left tube is sharply expanded in the area of the tube angle with a bluish bulge and a defect. A left-sided tubectomy was performed with excision of the left angle of the uterus. The defect is sutured. Infusion therapy. The postoperative period was without complications. Recovery. Interesting observation: the difficulty of diagnosing interstitial pregnancy before surgery and its fatal danger due to heavy bleeding due to external rupture were once again confirmed.

Observation7. This observation is of particular interest, since there was a combination of an anomaly in the development of the uterus (bicornuate uterus, incomplete form) with interstitial localization of the fertilized egg in one of the horns.

T., 36 years old, was admitted for an induced abortion at will at 8 weeks. History: 4 births - without any peculiarities, no abortions. HCG - 4280 IU/ml. Bimanual: the cervix is cylindrical, one, the pharynx is slit-like, closed. The body of the uterus is two-horned, each horn measuring up to 6 weeks of pregnancy. The appendages are not palpable. The vaults are free. The discharge is serous. Probing: the probe goes freely into both horns to a depth of 9 cm. Expansion of the cervical canal to No. 12. An abundant scraping containing no chorionic tissue was obtained from each horn. Histologically: gravid endometrium, decidual tissue, no chorionic villi. Ultrasound: bicornuate uterus. In the left horn there is a formation resembling a fertilized egg with an embryo. KTR= 19 mm. Clinical diagnosis: interstitial localization of the fetal egg in the left horn of the uterus. Laparotomy. It turned out that the body of the uterus is divided into 2 halves. In the left corner there is a blue-purple formation 5x6 cm. The appendages are unchanged. Taking into account the age and the presence of 3 living children, a high supravaginal amputation of the uterine body without appendages was performed. Recovery. Macropreparation (kept in the museum of the department): the body of the uterus consists of 2 horns, which in their lower part merge into a single body of the uterus (incomplete form). The angle of the left horn is increased due to the protrusion of a bluish-purple formation with the presence of fluctuation. On the frontal section, two almost identical uterine cavities with a smooth surface are clearly visible, merging in the lower section into a single cavity. In the left horn, in the projection of the interstitial part of the tube, there is a fertilized egg with a diameter of 2.5×3 cm with well-defined chorionic tissue. The walls of the angle are thinned to 1-1.5 mm, there is hemorrhage around. The interest of the observation is in the rare combination of two pathologies and in diagnosing the localization of the fetal egg before surgery.

So, looking back at everything “present”, we can state that in the obstetrics and gynecology clinic prof. V.S. Gruzdev adhere to the recommendations of academician L.S. when surgically treating interstitial pregnancy. Persianinov, namely: tubectomy with angle resection or supravaginal amputation of the uterine body. In diagnostics, in combination with the use of ultrasound, today it is possible to recognize the interstitial localization of the fetal egg before laparotomy, provided that women apply in the early stages. The latter circumstance obliges the obstetrician-gynecologist to examine women in such cases with special care.

“Medicine was not born today, nor yesterday, and that the state of this science is only a moment, a stage in its constant movement forward.” (Tadeusz Kelanowski)

Diagnostics. It is known that the diagnosis of “pregnancy” is made based on the identification of 3 groups of signs: doubtful, probable, and reliable. The terms speak for themselves. In the recent past, the final diagnosis was made only at a later date when reliable signs were identified. There are only 4 of them: detecting parts of the fetus, its movements, listening to the heartbeat and identifying the fetal skeleton. Today, identifying these signs using ultrasound has become possible in the early stages of pregnancy. A.N. Strizhakov et al. in the book “Ultrasound Diagnostics in the Obstetric Clinic” (M., 1990, pp. 14-19) they indicate that the heartbeat of the embryo can be seen at 3-4 weeks of pregnancy, and a little later - parts of the fetus and its movements. In their opinion, at a period of “5-6 weeks from the first day of the last menstruation,” pregnancy can be reliably diagnosed. Therefore, the algorithm of the doctor’s diagnostic actions was noticeably more specific: delayed menstruation - positive hCG test - examination by a doctor, preliminary diagnosis - ultrasound - final diagnosis, choice of therapeutic measures. Ultrasound examination in this algorithm acquires special importance, since in addition to confirming the diagnosis, it allows the doctor to find out the location of the fetal egg. Keeping this in mind, it is possible to routinely identify any ectopic localization, including in the interstitial part of the fallopian tube. As the above analysis of observations showed, this is possible with a friendly examination of the patient by a clinician and an ultrasound specialist. In passing, we note that the majority of women were admitted to the hospital for artificial termination of pregnancy. We also consider it necessary to warn the reader about a possible error in diagnosing pregnancy due to the special picture of necrotic and remalational changes in small fibromatous nodes.

There are 4 known diagnostic criteria for ultrasound for interstitial pregnancy: an empty uterine cavity, the fertilized egg is visualized separately from the uterine cavity, a thin layer of myometrium surrounding the fertilized egg and the “interstitial line” - a hyperechoic zone separating the fertilized egg from the uterine cavity (Ackerman TE, Levi CS, Dashefsky SM, Interstitial line: sonography finding in interstitial cornual ectopic pregnancy. Radiology 1993;189:83-7 Timor-Tritsch et al).

Unfortunately, the diagnosis of ectopic pregnancy is still difficult. According to Chan et al. (2003), at the first examination the diagnosis was erroneous in 41.7% of patients. In this regard, laparoscopy, which has become firmly established in practice, can be considered a promising method. Hysteroscopy in combination with tuboscopy with appropriate technical support gives great hope (N.L. Piganova - “Tuboscopy: diagnostic and therapeutic use.” Obstetrics and Gynecology, 1994, No. 6, pp. 11-13.)

Treatment. So far, the main method of treatment for interstitial localization of the ovum remains surgical in various modifications: evacuation of the ovum (cornuostomy), tubectomy with resection of the uterine angle, resection of the uterine angle followed by tube transplantation (at the woman’s request), defundation, supravaginal amputation of the uterine body. The laparosurgical method should be considered promising, allowing for maximum preservation of the integrity of the uterus and its tubes in the early stages.

With the development of chemotherapy, the possibility of non-operative treatment of ectopic pregnancy has become possible. For the first time, T. Tanaka (1982) proposed treating interstitial pregnancy with methotrexate. Treatment with prostaglandin F2α, actinomycin D, etc. is possible. A.A Semendyaev (“Gynecology”, 2001, vol. 3, no. 4, pp. 152-154) believes that methotrexate provides a cure in 80.1-95.7% of patients , and restoration of tubal patency in 50-75% of observed women. He proposed a combined method for treating tubal pregnancy: “kneading” or “squeezing out” the fertilized egg, followed by the administration of imozimase. Subsequently, lavage of the fallopian tubes and hydrotubation with a 1% solution of methylene blue. In all 38 women, he obtained 100% preservation of the fallopian tubes and their patency. A year later, 9 had intrauterine pregnancy.

Indications for non-operative treatment are the size of the ovum less than 3 cm and the hCG level less than 3500 IU/l. Conditions include stability of hemodynamic parameters, the possibility of repeat visits, and patient compliance. Unfortunately, conservative treatment does not completely exclude surgical intervention. Therefore, the opinion of scientists is still ambiguous. A.N. Strizhakov et al. in their monograph (1998), they consider drug treatment of tubal pregnancy unpromising due to the fact that the specific frequency of diagnosing progressive pregnancy “does not exceed 5-8% of all ectopic nidations.” However, N.L. Piganova, in the above-mentioned work, refers to F Risquez et al. (1993) who used “...tuboscopy to visualize tubal pregnancy and even to wash out the ovum.” It can be assumed that transcervical hysteroscopy in combination with tuboscopy will allow the introduction of drugs into the fertilized egg, localized in the interstitial part of the fallopian tube.

We will conclude with this review of the most interesting and insufficiently studied interstitial localization of the ovum with hope for the prospect of its early diagnosis and rational choice of treatment in each individual case. We fully agree with the opinion of V.V. Abramchenko that “often the main problem in the development of maternal and child health care is not the lack of basic knowledge, but the inability to apply this knowledge in organizing proper care for mothers and children” (“Clinical Perinatology.” St. Petersburg, 1998, p. 15).

Non medicamentis, sed medici mente curator egrotus - the patient is treated not with drugs, but with the mind of a doctor.

Prof. L.A. Kozlov, head gin. dept. KMU S.G. Khairutdinova, Ph.D., Ass. N.V. Yakovlev, Art. 6th year G.O. Cleveland. - Department of Obstetrics and gynek. No. 1 KSMU (head-prof. A.A. Khasanov).

During the normal course of pregnancy, the fertilized egg attaches to the wall of the uterus, where further development of the embryo occurs.

Implantation of the fertilized egg into the mucous membrane of the ovary, fallopian tube, or abdominal cavity is called an ectopic pregnancy.

Types of ectopic pregnancy

According to the place of attachment of the fertilized egg, ectopic pregnancy can be tubal, ovarian, cervical and abdominal.

Types of ectopic pregnancy

Tubal ectopic pregnancy

Tubal pregnancy occurs in 98% of ectopic pregnancies.

This type of ectopic pregnancy occurs due to the fact that the fertilized egg does not move along the fallopian tube to exit into the uterine cavity and gain a foothold there, but is implanted into the wall of the tube itself.

Tubal pregnancy can develop in different parts of the fallopian tube, and according to this it is divided into ampullary (accounts for 80% of all cases of tubal pregnancies), isthmic (accounts for 13% of the total number of tubal pregnancies), interstitial (accounts for 2%) and fimbrial (accounts for 5%).

In ampullary tubal pregnancy, rupture of the fallopian tube usually occurs somewhat later than in other cases, somewhere around 8-12 weeks, since this part of the tube is the widest and the fetus can reach large sizes until it becomes cramped and will rupture the fallopian tube. Less common, but still possible, is another outcome - tubal abortion.

Isthmic tubal pregnancy most often ends in tubal rupture at an early stage, at about 4-6 weeks of pregnancy, since the isthmus of the fallopian tube is its narrowest part. After the tube ruptures, the egg is released into the abdominal cavity.

With interstitial tubal pregnancy, pregnancy can develop up to 4 months (14-16 weeks), since the myometrium of this section of the fallopian tube can stretch to large sizes. It is this section of the fallopian tube that connects directly to the uterus; it has a developed blood supply network, so rupture of the tube is accompanied by large blood loss, which can be fatal. If the uterus is significantly damaged, extirpation (removal) is prescribed.

In fimbrial tubal pregnancy, the fetus develops at the exit of the fallopian tube (in the fimbriae - villi).

Any type of tubal ectopic pregnancy ends in termination and is expressed by rupture of the fallopian tube or detachment of the fertilized egg from the wall of the fallopian tube and its expulsion into the abdominal cavity with subsequent death of the fetus (this process is called tubal abortion).

Ovarian ectopic pregnancy

Ovarian pregnancy occurs in approximately 1% of women among the total number of women with an ectopic pregnancy.

An ovarian ectopic pregnancy occurs when a sperm fertilizes an egg that has not yet been released from the dominant follicle or the fertilized egg attaches to the ovary instead of moving through the tubes towards the uterine cavity.

Thus, ovarian pregnancy is divided into two forms: intrafollicular - when implantation occurs inside the follicle, and epiophoral - when implantation occurs on the surface of the ovary.

Cervical pregnancy

Pregnancy in the cervical canal of the uterus is quite rare, namely 0.1% of all cases of ectopic pregnancy. During cervical pregnancy, the fertilized egg penetrates the mucous membrane of the cervix.

There is also a cervical-isthmus type of pregnancy, when the fertilized egg attaches to the isthmus of the uterus.

Cervical pregnancy can develop up to the 2nd trimester of pregnancy.

Abdominal pregnancy

This is a rare case of ectopic pregnancy. Abdominal pregnancy can be primary or secondary.

During primary abdominal pregnancy, fertilization of the egg and the implantation of the fertilized egg itself occurs in the abdominal cavity.

During a secondary abdominal pregnancy, fertilization occurs in the fallopian tube, and then the fertilized egg is released into the abdominal cavity, where it attaches to the internal organ of the peritoneum (liver, spleen, etc.). Secondary abdominal pregnancy is a consequence of tubal abortion, thus, an interrupted tubal pregnancy develops into another type of ectopic pregnancy.

An abdominal pregnancy is extremely rarely carried to term, but if the fetus manages to attach to tissues with good blood circulation, the child is born as a result of such pregnancy, but with defects and soon dies.

As a result of abdominal pregnancy, the mother’s organs adjacent to the developing fetus are also greatly affected, which is extremely dangerous for the woman’s life.

Ectopic pregnancy in the rudimentary uterine horn

Pregnancy in a rudimentary uterine horn is a fairly rare phenomenon, which is also usually classified as an ectopic type, since the fetus attaches to the wall of the defective uterus and leads to miscarriage with rupture of the uterine horn.

This only happens in women with a congenital anomaly of the anatomical structure of the uterus, when even during the formation and development of her own reproductive system, while in the womb of her mother, there was a failure in the formation of the internal genital organs (this happened somewhere at 13-14 weeks of embryonic development ).

Each of the types of pregnancy described above cannot result in the birth of a healthy child, since the fetus cannot develop normally and reach its full maturity; it will not have enough nutrients or space for development.

An ectopic pregnancy ends either in abortion (spontaneous or mechanical), or, in case of untimely diagnosis, in surgical intervention and/or rupture of the tissues of the reproductive organs.

Symptoms of ectopic pregnancy

Usually, with an ectopic pregnancy, all the signs of a normal pregnancy remain: delayed menstruation, morning sickness, breasts are full and painful, there is an unusual taste in the mouth, weakness is felt in the body, and the pregnancy test shows two lines. Moreover, the hCG level can increase at a normal pace, but if the dynamics of the hCG level show a slow increase in the hCG level (i.e., the hCG level increases more slowly than 50% every 2 days), then this is the first sign of an ectopic pregnancy.

In general, the first signs of an ectopic pregnancy in the early stages are prolonged spotting, spotting pain in the place where the ectopic pregnancy develops, nagging pain in the lower abdomen or pain that radiates to the lower back or anus.

In later stages, the main signs of ectopic pregnancy include increasing pain that cannot be tolerated, increased body temperature, and loss of consciousness from painful shock. This condition is typical for organ rupture and heavy blood loss.

It is possible to accurately determine whether a pregnancy is ectopic only with the help of an ultrasound.

A diagnostic doctor, using special equipment to scan the pelvic organs, will examine the uterine cavity to determine whether a fertilized egg has settled in it. If the fertilized egg was not detected in the uterus, visualization of fluid in the abdominal cavity and/or in the retrouterine space, and blood clots is noted, then such a pregnancy will be designated as ectopic.

Causes of ectopic pregnancy

An ectopic pregnancy can develop for various reasons. Below are the causes of ectopic pregnancy according to the specific type of ectopic pregnancy.

Causes of tubal pregnancy

This usually occurs due to a violation of the peristalsis of the fallopian tube, that is, due to a violation of its ability to contract, or due to other processes that impede the patency of the fallopian tubes (with adhesions, tumors, disruption of the structure of the fimbriae, bending of the tube, underdevelopment of the tubes (genital infantilism ) etc.)

Thus, untimely treatment of inflammatory diseases of the tubes (salpingitis, hydrosalpinx, for example) or previous operations on the fallopian tubes are usually the reasons for the development of tubal pregnancy.

Causes of ovarian pregnancy

After the dominant follicle ruptures, the egg meets the sperm while still in the ovary. Further, the fertilized egg, for one reason or another, does not continue its movement to the uterine cavity, but is attached to the ovary.

The cause of such a failure during pregnancy may be a previous infectious disease of the uterine appendages or inflammation of the endometrium, obstruction of the fallopian tubes, endocrine and genetic disorders, etc.

Causes of cervical pregnancy

Cervical pregnancy occurs due to the fact that the fertilized egg cannot attach to the wall of the uterus. Implantation of the fertilized egg to the wall of the cervical canal occurs due to a previous mechanical abortion or cesarean section, the formation of adhesions in the uterine cavity, fibroids, and due to various anomalies in the development of the uterus.

Causes of abdominal pregnancy

Abdominal pregnancy develops with obstruction of the fallopian tubes and other acquired or congenital pathologies.

Typically, abdominal pregnancy is a consequence of the release of a fertilized egg into the abdominal cavity after a rupture of the fallopian tube (after a tubal abortion).

Consequences of ectopic pregnancy

An ectopic pregnancy that is not diagnosed in time can lead to rupture of the fallopian tube and further surgical removal (for tubal pregnancy), ovary (for ovarian pregnancy), large blood loss and removal of the uterus (for cervical pregnancy) and even death.

Treatment of ectopic pregnancy

There are two ways to treat ectopic pregnancy: medication and surgery.

Drug treatment means taking a drug (usually an injection of Methotrexate) that causes the death of the fetus with its further resorption. This way, you can save the fallopian tube or ovary, which will make it possible to get pregnant normally and give birth to a child in the future.

Surgical treatment means curettage of the fetus and/or removal of its attachment site (fallopian tube, ovary or uterine horn).

There are two ways to access the pelvic organs - laparoscopic and laparotomy.

Laparotomy- this is an incision in the anterior abdominal wall, as in a conventional operation, and laparoscopy is small punctures of the abdomen, through which all manipulations take place.

Laparoscopy is a modern type of surgical intervention, after which no scars remain, and the postoperative recovery period is minimized

For tubal ectopic pregnancy, two types of surgical intervention using laparoscopic access are possible - salpingotomy or tubotomy (a conservative type of operation in which the fetal egg is removed while preserving the fallopian tube) and salpingectomy or tubectomy (a radical type of operation in which the fallopian tube is removed along with the fetus ).

But preservation of the fallopian tube is possible only at the progressive stage of ectopic pregnancy, that is, when the attachment of the fertilized egg has occurred, but the rupture or strong stretching of the tube wall has not yet occurred.

Also, to decide whether to leave the fallopian tube, the surgeon must consider the following factors:

does the patient want more children in the future (usually women who already have children do not want to take risks in the future, but the likelihood of a repeat ectopic pregnancy is very high, they tell the doctor that this pregnancy was not wanted anyway and they do not intend to have more children) ;
the presence and degree of structural changes in the wall of the fallopian tube (for example, strong stretching of the wall of the tube by the growing fetus), the condition of the epithelium and fimbriae of the tube, the severity of the adhesive process (most often the condition of the tube is so poor that it will not be able to fully perform its functions in the future, such a tube cannot participate in the normal course of pregnancy, and the likelihood of an ectopic pregnancy is so great that there is no point in leaving it);
whether the ectopic pregnancy is repeated for a given tube (as a rule, if an ectopic pregnancy is repeated in the same fallopian tube, it is removed, since the subsequent development of an abnormal pregnancy in the same tube is inevitable);
whether a reconstructive plastic surgery was previously performed to restore the patency of this fallopian tube (if “yes, such an operation was once performed on this tube,” then its preservation is not carried out, it is no longer suitable);
the area where the fertilized egg is attached (when a fertilized egg is implanted into the wall of the interstitial section of the fallopian tube - the narrowest part - usually no operation is performed to preserve the tube);
the condition of the second fallopian tube (if there is no second tube or if its condition is worse than that of the woman being operated on, a decision is made to leave the tube so that the woman has a chance to become pregnant in the future).

If there is heavy internal bleeding, the only way to save a woman’s life is laparotomy (removal of the fallopian tube).

After removal, restoration of the fallopian tube is not carried out, since the tube tends to contract, which helps the fertilized egg move from the ovary towards the uterine cavity, which is not possible with the implantation of an artificial section of the tube.

For ovarian ectopic pregnancy, treatment includes removal of the fertilized egg and wedge resection of the ovary (in this case, the ovary is preserved and restores its functions over time) or, in a critical case, oophorectomy (removal of the ovary).

Cervical pregnancy poses the greatest danger to a woman. Previously, the only way to treat cervical pregnancy was considered to be extirpation or hysterectomy (removal of the uterus), since the tissues in this area contain many blood vessels and nodes, and any operation is fraught with large blood loss, and the risk of death is very high. But modern medicine is aimed at preserving the uterus, so gentle treatment methods are used - medical abortion (using methotrexate injection) if an ectopic pregnancy is detected at an early stage, and if an ectopic pregnancy is diagnosed late and severe bleeding begins, hemostatic measures are carried out (cervical tamponade with a Foley catheter, applying a circular suture to the cervix or ligating the internal iliac arteries, etc.), and then removing the fertilized egg.

Treatment of abdominal pregnancy is a complex operation to remove the fetus from the peritoneum. Depending on the complexity of the case, surgical intervention can be either laparoscopic or laparotomy.

Take a urine test for hCG to confirm pregnancy, and after 2-3 days take this test again to track changes in hCG;
Contact your gynecologist with a complaint about bloody discharge from the genital tract or abdominal pain (if any), providing the results of a urine test for hCG as proof of your pregnancy;
Get an ultrasound to determine the type of pregnancy (uterine or ectopic);
In the event of an ectopic pregnancy, re-visit your gynecologist to receive medication treatment (in the early stages) or a referral for surgery (in an emergency when the ectopic pregnancy was detected late).

A case from obstetric practice

In my obstetric practice, there was a case when menstruation seemed to come on time or with a slight delay, and before menstruation the test showed a negative result, but immediately after it, the pregnancy test shows, although pale, a second line, and the hCG level also confirms pregnancy. And after a while, the woman’s pregnancy is determined by ultrasound to be ectopic.

It is assumed that the first test could not yet detect pregnancy, and the bleeding was not a normal monthly menstruation, it was a reaction of the endometrium to an unusual pregnancy.

The pregnancy developed in the fallopian tube and, unfortunately, the surgeon was forced to remove it; it was of little use for further use. Two years after this incident, this young woman came to see me again; she was carrying a child under her heart, who is now quickly running up the stairs on the playground.

And in my practice there are dozens or even hundreds of such cases of pregnancy occurring in the presence of only one tube (even if it is narrow-passing), and this is great!

A. Berezhnaya, obstetrician-gynecologist

Self-diagnosis and self-medication during ectopic pregnancy are unacceptable.

This leads to its untimely detection, and as a consequence, to extensive internal bleeding and even death.

A woman can only assume that the pregnancy is ectopic, but she cannot treat it independently without the help of specialists.

At the first signs or suspicions, for the sake of your own health, contact a gynecologist. This will save you the opportunity to become a happy mother in the future.

Be healthy and sensible!

Interstitial pregnancy. Pregnancy in the interstitial (intramural) part of the fallopian tube, as a rule, is interrupted in the early stages by the type of tube rupture, which is always accompanied by severe bleeding. In extremely rare cases, interstitial tubal pregnancy persists up to 16-17 weeks. and severe bleeding after termination of pregnancy is extremely dangerous for a woman’s life. This happens due to the fact that near the angle of the uterus there are more branches of the uterine artery than in the peripheral part of the fallopian tube, and if it ruptures in this area, severe bleeding begins.

Clinical manifestations of disorders of such pregnancy are reduced mainly to the picture of acute intra-abdominal bleeding. Mizhzvyazkova pregnancy. Implanted on the mesenteric side of the fallopian tube, the fertilized egg melts the wall of the tube with the villi of its trophoblast and flows between the leaves of the broad ligament of the uterus. Further growth of the uterus can go in two directions - towards the anterior leaf of the broad ligament of the uterus and towards its posterior leaf. Midterm pregnancy is usually terminated early. The fetus usually dies. In this case, a hematoma forms between the leaves of the broad ligament of the uterus, the size of which depends on the duration of pregnancy and the size of the vessels that burst. The proximity of a midsection hematoma to the rectum and impaired tissue permeability at the time of termination of pregnancy can lead to infection of the hematoma. The clinical picture in this case may be different. In some cases, the picture of bleeding comes to the fore, in others - of an acute inflammatory disease. Ovarian pregnancies are usually terminated early. The clinical picture depends on the intensity of bleeding. If it is small, then a hematoma can form.

The clinical picture of prolonged bleeding into the abdominal cavity does not differ from that which occurs during acute termination of a tubal pregnancy. Abdominal pregnancy. A feature of this form of ectopic pregnancy is that the peritoneum in the place where the amniotic sac is attached is not able to create a continuous capsular membrane, as a result of which the fetal sac initially remains “open”. Subsequently, the capsule for the “open” part of the amniotic sac is the peritoneum of the abdominal organs, omentum, intestinal loops, etc.. Abdominal pregnancy termination occurs in most cases in late stages and is always accompanied by a clinical picture of shock, acute abdomen, and growing anemia. Sometimes an infection can occur, and then the clinical picture resembles an inflammatory process and becomes acute or protracted.

In some cases, it is possible to carry the pregnancy to term. Pregnancy in the rudimentary uterine horn. Termination of such a pregnancy most often occurs in the 3-5th month. It is possible to carry the pregnancy to term. The clinical picture during termination of pregnancy in the rudimentary uterine horn differs from the termination of tubal and other forms of ectopic pregnancy by very heavy bleeding. Bilateral tubal pregnancy in its pathological and clinical picture does not differ significantly from ordinary unilateral tubal pregnancy. During surgery for tubal pregnancy on one side, the doctor requires increased attention to the appendages of the other side.

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