Внематочная беременность: диагностика, риски и лечение.

Female reproductive system health issue
Overall, ectopic pregnancies annually affect less than 2% of pregnancies worldwide. Detection of ectopic pregnancy is typically by blood tests for human chorionic gonadotropin (hCG) and ultrasound. The rate of ectopic pregnancy is about 11 to 20 per 1,000 live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology. It is the most common cause of death among women during the first trimester at approximately 6 13% of the total. The risk of death among those in the developed world is between 0.1 and 0.3 percent while in the developing world it is between one and three percent. The first known description of an ectopic pregnancy is by Al Zahrawi in the 11th century.

Up to 10% of those with ectopic pregnancy have no symptoms, and one third have no medical signs.

The most common complication is rupture with internal bleeding which may lead to hypovolemic shock. Damage to the fallopian tubes can lead to difficulty becoming pregnant in the future. The woman's other fallopian tube may function sufficiently for pregnancy. After the removal of one damaged fallopian tube, pregnancy remains possible in the future. If both are removed, in vitro fertilization remains an option for women hoping to become pregnant.

Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Vaginal douching is thought by some to increase ectopic pregnancies. However, DES has not been used since 1971 in the United States. The low socioeconomic status may be risk factors for ectopic pregnancy.

An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in everyone who has a positive pregnancy test. Transvaginal ultrasonography has a sensitivity of at least 90% for ectopic pregnancy.]] The combination of a positive pregnancy test and the presence of what appears to be a normal intrauterine pregnancy does not exclude an ectopic pregnancy, since there may be either a heterotopic pregnancy or a "pseudosac", which is a collection of within the endometrial cavity that may be seen in up to 20% of women. If the β hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated as: Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal bleeding. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo tubal transport and alterations in the tubal environment allowing early implantation to occur.

Two percent of ectopic pregnancies occur in the ovary, cervix, or are intra abdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria. While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intra abdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in Third World countries, the diagnosis is most commonly made at 16 to 20 weeks' gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data is unavailable and reliance must be made on anecdotal reports. However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding. With the increase in Cesarean sections performed worldwide, Cesarean section ectopic pregnancies (CSP) are rare, but becoming more common. The incidence of CSP is not well known, however there have been estimates based on different populations of 1:1800–1:2216. CSP are characterized by abnormal implantation into the scar from a previous cesarean section, and allowed to continue can cause serious complications such as uterine rupture and hemorrhage. The diagnosis of CSP is made by ultrasound and four characteristics are noted: (1) Empty uterine cavity with bright hyperechoic endometrial stripe (2) Empty cervical canal (3) Intrauterine mass in the anterior part of the uterine isthmus, and (4) Absence of the anterior uterine muscle layer, and/or absence or thinning between the bladder and gestational sac, measuring less than 5 mm. Given the rarity of the diagnosis, treatment options tend to be described in case reports and series, ranging from medical with methotrexate or KCl to surgical with dilation and curettage, uterine wedge resection, or hysterectomy. allowing for uterine preservation. Recurrence risk for CSP is unknown, and early ultrasound in the next pregnancy is recommended.

A pregnancy in a rudimentary horn refers to a rare and life threatening condition that occurs when a fertilized egg implants inside the small rudimentary horn of a unicornuate uterus, which is a type of congenital uterine abnormality caused by the incomplete development of one of the Müllerian ducts. This type of ectopic pregnancy is often results in rupture of the rudimentary horn between 10 and 15 weeks of gestation, leading to a high risk of morbidity and mortality.

A persistent ectopic pregnancy refers to the continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15–20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic pregnancy to assure their decline, also methotrexate can be given at the time of surgery prophylactically.

Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography. which was developed in the 1980s. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; the developing embryo may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm. Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy, or severe abnormality in any surviving pregnancy. The United States uses a multi dose protocol of methotrexate (MTX) which involves four doses of intramuscular along with an intramuscular injection of folinic acid to protect cells from the effects of the drugs and to reduce side effects. In France, the single dose protocol is followed, but a single dose has a greater chance of failure.

If bleeding has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected fallopian tube and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883. It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%. Autotransfusion of a woman's own blood as drained during surgery may be useful in those who have a lot of bleeding into their abdomen. Published reports that a re implanted embryo survived to birth were debunked as false.

When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, but all fetuses die or are aborted. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died). In 2006–2008 the UK Confidential Enquiry into Maternal Deaths found that ectopic pregnancy is the cause of 6 maternal deaths (0.26/100,000 pregnancies).

Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. The treatment choice does not play a major role; a randomized study in 2013 concluded that the rates of intrauterine pregnancy two years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery. In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over two years is over 90%. Methotrexate does not affect future fertility treatments. The number of oocytes that were retrieved before and after treatment with methotrexate does not change. In case of ovarian ectopic pregnancy, the risk of subsequent ectopic pregnancy or infertility is low. There is no evidence that massage improves fertility after ectopic pregnancy.

The rate of ectopic pregnancy is about 1% and 2% of that of live births in developed countries, though it is as high as 4% in pregnancies involving assisted reproductive technology. In the Catholic Church, there are moral debates on certain treatments. A significant number of Catholic moralists consider use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed. Organisations exist that provide information and support to help those who experience ectopic pregnancy. Studies show that people can experience post traumatic stress, depression, and anxiety for which they would need specialist therapies. Partners can also experience post traumatic stress.

There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy. In July 1999, Lori Dalton gave birth by caesarean section in Ogden, Utah, United States, to a healthy baby girl, Saige, who had developed outside of the uterus. Previous ultrasounds had not discovered the problem. "[Dalton]'s delivery was slated as a routine Caesarean birth at Ogden Regional Medical Center in Utah. When Dr. Naisbitt performed Lori's Caesarean, he was astonished to find Saige within the amniotic membrane outside the womb ." "But what makes this case so rare is that not only did mother and baby survive—they're both in perfect health. The father, John Dalton took home video inside the delivery room. Saige came out doing extremely well because even though she had been implanted outside the womb, a rich blood supply from a uterine fibroid along the outer uterus wall had nourished her with a rich source of blood." In September 1999 an English woman, Jane Ingram (age 32) gave birth to triplets: Olivia, Mary and Ronan, with an extrauterine fetus (Ronan) below the womb and twins in the womb. All three survived. The twins in the womb were taken out first. On May 29, 2008, an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38‑week pregnancy.

Ectopic gestation exists in mammals other than humans. In sheep, it can go to term, with mammary preparation to parturition, and expulsion efforts. The fetus can be removed by caesarean section. Pictures of caesarian section of a euthanized ewe, five days after parturition signs.