An ectopic pregnancy is a pregnancy in which the attachment and further development of the fetal egg occur outside the uterine cavity. This is a dangerous pathology that can lead to serious complications, including life-threatening ones.

Tubal ectopic pregnancy

Causes and risk factors

Various factors that disrupt the process of advancement of a fertilized egg into the uterine cavity or implantation lead to the occurrence of an ectopic pregnancy. These factors include:

• drug stimulation of ovulation;
• endometriosis;
• hormonal types of contraception;
• interruption of pregnancy in history;
• the presence of an intrauterine device;
• delayed sexual development;
• tumors of the internal genital organs;
• previous operations on the ovaries or fallopian tubes;
• malformations of the genital organs;
• inflammatory diseases of the appendages, in particular sexually transmitted diseases;
• Asherman's syndrome (intrauterine synechia).

Patients who once had an ectopic pregnancy have a 10 times greater risk of developing it than healthy women.

Types of disease

Depending on the place of attachment of the fetal egg, an ectopic pregnancy can be:

• pipe;
• ovarian;
• abdominal;
• cervical.

In 99% of all cases of ectopic pregnancy, implantation of the fetal egg occurs in the fallopian tubes. The most rare form is cervical pregnancy.

Symptoms

In the early stages, an ectopic pregnancy manifests itself in the same way as a normal one:

• delayed menstruation;
• engorgement of the mammary glands;
• nausea, especially in the morning;
• weakness;
• change in taste preferences.

When conducting a gynecological examination, you can notice that the size of the uterus lags behind the expected gestational age.

As the fetal egg grows and develops in a place not intended for this, various complications arise that determine the clinical picture of an ectopic pregnancy.

tubal pregnancy

When implanting a fetal egg in the cavity of the fallopian tube, pregnancy usually progresses to 6-7 weeks. Then the fetal egg dies, and the fallopian tubes begin to contract intensely, pushing it into the abdominal cavity. This process is accompanied by bleeding. Blood also enters the abdominal cavity. This termination of an ectopic pregnancy is called a tubal abortion.

The clinical picture of tubal abortion is largely determined by the amount of blood poured into the abdominal cavity. With a slight bleeding, the woman's condition changes little. She usually complains of cramping pains in the lower abdomen and the appearance of dark spotting bloody discharge from the genital tract.

A tubal abortion, accompanied by significant bleeding, is characterized by severe pain that can radiate to the anus. In addition, signs of internal bleeding arise and increase:

• general weakness;
• dizziness;
• tachycardia.

Treatment of ectopic pregnancy is surgical, regardless of the place of implantation of the fetal egg.

In some cases, tubal pregnancy can lead to rupture of the fallopian tube. This condition is accompanied by massive internal bleeding and in 10% of cases is complicated by the development of hemorrhagic shock. The clinical picture of a pipe rupture develops very quickly:

• sharp pain in the lower abdomen, radiating to the anus;
• the appearance of tenesmus (false urge to defecate);
• severe dizziness;
• fainting states;
• pallor of the skin and mucous membranes;
• cold clammy sweat;
• lethargy, apathy;
• frequent pulse of weak filling;
• lowering blood pressure;
• dyspnea.

Ovarian pregnancy

Ovarian pregnancy can progress up to 16-20 weeks, which is associated with the high elasticity of ovarian tissues. However, at a certain point in time, they cease to have time to stretch after the growth of the embryo. The onset of the limit is characterized by pain in the abdomen, painful defecation. Then the ovary ruptures with the development of massive bleeding into the abdominal cavity. The clinical picture is similar to the clinical picture of a fallopian tube rupture.

An ectopic pregnancy is a dangerous pathology that can lead to serious complications, including life-threatening ones.

Abdominal pregnancy

In abdominal pregnancy, the fetus is implanted between the intestinal loops. As it grows, irritation of the nerve endings of the peritoneum occurs, manifested by intense pain in the abdomen.

In the vast majority of cases, during abdominal pregnancy, the death of the fetus occurs, which subsequently undergoes maceration or is impregnated with calcium salts, turning into a petrified fetus.

In abdominal pregnancy, there is always a high risk of rupture of the fetus with the development of severe internal bleeding, accompanied by symptoms traditional for such a condition - weakness, hypotension, tachycardia, pallor of the skin, cold sweat.

In very rare (literally isolated) cases, abdominal pregnancy develops before the end of the term and ends with the birth of a child by caesarean section.

cervical pregnancy

With this type of ectopic pregnancy, the fetal egg is implanted in the cervical canal of the cervix. In the early stages, the disease is asymptomatic or with signs characteristic of a normal uterine pregnancy. Then, for a period of 8-12 weeks, spotting from the genital tract appears. There is no pain involved. Bleeding during cervical pregnancy can have a different intensity: from minor spotting to profuse, life-threatening.

During a gynecological examination, it is noted that the cervix is ​​much larger than the body.

Diagnostics

Diagnosis of an ectopic pregnancy before it is terminated is often difficult. Its presence can be assumed on the basis of the following signs:

• discrepancy between the size of the uterus and the expected gestational age;
• discrepancy between the content of hCG in the blood to the expected gestational age.

In 99% of all cases of ectopic pregnancy, implantation of the fetal egg occurs in the fallopian tubes. The most rare form is cervical pregnancy.

In these cases, an ultrasound examination of the uterus is performed by the transvaginal method, determining the presence of a fetal egg in the uterine cavity.

When interrupting an ectopic pregnancy, in most cases, the diagnosis is not difficult. It is based on a characteristic clinical picture, anamnesis, examination results, ultrasound data (accumulation of fluid in the abdominal cavity, absence of a fetal egg in the uterus).

In doubtful cases, a diagnostic puncture of the posterior vaginal fornix is ​​performed. The presence in the punctate of dark blood that does not form clots confirms a disturbed ectopic pregnancy.

Treatment

Treatment of ectopic pregnancy is surgical, regardless of the place of implantation of the fetal egg.

In tubal pregnancy, a laparoscopic intervention is usually performed, during which the affected fallopian tube and blood that has leaked into the abdominal cavity are removed. When terminating a pregnancy by the type of tubal abortion, it is possible to perform an organ-preserving operation - tubotomy.

In an ovarian pregnancy, an oophorectomy (removal of the ovary) is performed.

The choice of the method of surgical intervention in abdominal pregnancy is determined by several factors - first of all, the place of implantation of the fetal egg and the gestational age.

In cervical pregnancy, hysterectomy is indicated (removal of the body and cervix). The medical literature describes the successful removal of the fetal egg from the cervical canal, followed by suturing the bed of the fetus. However, such operations have a high risk of developing profuse bleeding, so they can only be performed in a hospital, in an extended operating room.

After an ectopic pregnancy, a long course of rehabilitation is indicated with the planning of a new pregnancy no earlier than 6, and preferably 12 months.

Possible complications and consequences

The main complications of ectopic pregnancy:

• hemorrhagic shock;
• posthemorrhagic iron deficiency anemia;
• adhesive process in the small pelvis;
• secondary infertility.

Forecast

With timely diagnosis and treatment, the prognosis is favorable for life.

Patients who once had an ectopic pregnancy have a 10 times greater risk of developing it than healthy women.

Prevention

Prevention of ectopic pregnancy consists of the following activities:

• avoiding casual sex and related sexually transmitted diseases;
• timely detection and treatment of inflammatory diseases of the genitourinary system;
• medical examination at the stage of pregnancy planning;
• abortion prevention (use of contraception);
• after an ectopic pregnancy - a long course of rehabilitation with planning a new pregnancy no earlier than 6, and preferably 12 months.

Video from YouTube on the topic of the article:

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Today I want to present you an article about a unique operation that I had a chance to do. The fact is that we with a team of surgeons managed to help give birth to a woman with a full-term ectopic pregnancy (!)

This is a truly unique case, this simply did not happen in history.

An ectopic pregnancy is a kind of deviation from the norm, when, for one reason or another, a fertilized egg does not reach the uterus and is attached to the fallopian tubes, cervix, to any organ of the abdominal cavity. Most often, the embryo is attached to the fallopian tubes (in 70% of cases).

Naturally, the tubes are not adapted to the bearing of the fetus, and when it increases, they simply burst and spontaneous abortion occurs, severe bleeding and pain.

And there was not a single case in the history of obstetrics and gynecology that a child was carried and born outside the uterus.. It was an axiom. Until the case we encountered.

Below is the full text of an article published in one of the newspapers, which accurately describes everything that happened that day.

« Miraculous birth"

The doctors of the maternity hospital of the National Center for Maternal and Child Welfare performed a unique operation and saved the life of a mother and her child, which grew and developed ... in the abdominal cavity.

- In world practice, there is no description of such cases for a woman to report an ectopic pregnancy up to 37–38 weeks. , - says the head of the department of obstetrics and gynecology of the state medical institute for retraining and advanced training Natalya Kerimova, who led the operating team.

- When I spoke about this incident at a seminar in Austria, which was attended by my colleagues from 23 countries of the world, then silence reigned in the hall after that, which lasted for two or three minutes, and then a heated discussion of this unique case in world practice began, - adds Associate Professor of this department Gulmira Biyalieva.

A 17-year-old woman in labor arrived with an unclear diagnosis. Local doctors examined her on ultrasound, even tried to induce labor, but they could not induce them, and, according to obstetricians and gynecologists, this could not happen in this situation. That is why they sent the woman to the maternity hospital of the National Center.

One of the best ultrasound specialists, having examined a woman, wrote in conclusion: suspicion of an ectopic pregnancy (abdominal) and central placenta previa (improper attachment of the placenta in the uterus).

These two diagnoses are extremely rare in themselves, and each of them poses a mortal danger to life.

- With central placenta previa, immediate surgery is required, as the woman is in pain, and if labor begins, she may die from sudden bleeding , - explains Natalia Ravilievna Kerimova.

- And we are more tuned in to the operation for this particular pathology. But when they entered the abdominal cavity, everyone was just numb. This very placenta turned out to be an ovary, which increased to an incredible size, with a huge number of blood vessels. The ovary turned out to be, figuratively speaking, a refuge for the fetus.

By the time the operation began, the membranes had burst, so the woman experienced severe abdominal pain.

Amniotic fluid spilled into the abdominal cavity. The ovary looked so scary that at first we could not even figure out what was located where. In my more than 25 years of practice, I have seen this for the first time.

The first words of obstetricians-gynecologists after they came to their senses were: urgently call vascular surgeons. But, as Professor Kerimova said, they were sorry to lose this child, because if they were waiting for their colleagues, the baby would definitely die on the background of anesthesia and all the manipulations.

Therefore, obstetricians and gynecologists decided to take the risk and start the operation without waiting for them.

- Of course, we risked a lot, as there was a huge probability of bleeding. Literally centimeter-by-centimetres, the body of a child, entangled in adhesions and abdominal organs, was released.

If we pulled it right away, we could injure the mother's intestines, large vessels and the mesentery of the intestine, which has undergone significant changes due to the pathological proliferation of blood vessels. Our slightest wrong move - and we could lose both the woman and the baby, Karimova explains.

The operating team consisted, without exaggeration, of superspecialists: in addition to Kerimova and Biyaliyeva, it included Marat Zhazhiev, head of the department of pathology of pregnant women, and Eleonora Isaeva, head of the intensive care unit and senior operating sister of the National Center for Maternal and Child Health Lyudmila Agay. But everyone's nerves were on edge.

- We realized that the operation ended successfully when the girl we extracted began to scream loudly. And it seemed that there is nothing more important than this cry, - says Marat Zhazhiev.

First child ever born from an ectopic pregnancy

- This is, of course, a victory for our entire brigade. . The risk might not be worth it.

But, according to Kerimova, they could not miss the chance to save the little man, especially since he clung to life so much. The baby was handed over to neonatologists immediately after birth. Now mother and child are already at home. The child is developing perfectly, absolutely healthy, eats well and even smiles. Mom is fine too.

- We felt much worse after this operation. , - Natalya Ravilievna laughs. - After that, I believed even more that a miracle in medicine exists. And our case is proof of that.”

Rereading these lines, I think again and again that there are no final diagnoses. There is a woman's faith and strength, her highest destiny is to give birth to children, and the body does everything possible to adjust and fulfill its main role.

So never give up and keep believing that everything will work out for you!

If you or someone you know had any interesting, incredible cases, please share in the comments below.

Abdominal pregnancy is one of the varieties of ectopic conception, during which the embryonic component is attached to the abdominal region. Moreover, such a location, due to the growth of the embryo and in the absence of proper diagnosis, can lead to organ rupture and subsequent bleeding.

Features of the abdominal formation of the embryo

A fertilized cell cannot grow and form outside the reproductive organs, i.e. full-term pregnancy is possible only in the uterus. Therefore, any deviation from this norm and the introduction of the egg in other organs leads to serious consequences.

So, pregnancy in the abdominal cavity is characterized by pathological changes when the egg is attached to the peritoneum, liver, spleen or intestines, while the embryo is fed from the bloodstream of the gastrointestinal tract.

There are 2 types of abdominal pregnancy:

• primary - the initial implantation of the egg in the abdominal cavity;
• secondary pathology involves the entry of a viable embryo from the fallopian tube, after tubal fertilization, into the peritoneum.

Regardless of the type of ectopic pregnancy, the pathology threatens the life of the mother, because in connection with the growth of the fetus, there is a danger of organ rupture and subsequent infection, which requires timely treatment.

Causes of abdominal pregnancy

The abdominal attachment of the fetal egg, like any other pregnancy outside the uterus, speaks of a pathological process in the mucosa of the fallopian tubes. The most common risk factors include the following:

• inflammatory reactions and diseases of the reproductive organs;
• the presence of adhesions or violations of the contractile function of the tubes, which lead to the impossibility of movement of the egg;
• congenital anomalies in the anatomy of the reproductive organs;
• diseases of the endocrine system.

The formation of various neoplasms, mucosal damage and endometriosis increase the likelihood of ectopic conception. In addition, artificial insemination and smoking reduce peristalsis in the fallopian tubes, which leads to the implantation of the embryo outside the uterine cavity.

According to statistics, the older the woman's age (over 35 years), the worse the reproductive system functions, the chances of a healthy baby being born are reduced, while the risk of ectopic conception increases significantly. The situation is associated with hormonal changes and with a decrease in the activity of peristalsis of the tubes.

Diagnosis of pregnancy in the peritoneum

It is rather difficult even for qualified specialists to determine abdominal pregnancy before the period of complications. Basically, symptomatic manifestations are caused by normal signs that are characteristic of the initial period of gestation (toxicosis, change in taste preferences, soreness of the mammary glands, etc.). With the help of ultrasound at an early stage, it is also impossible to make an accurate diagnosis, since the clinical picture can be mistaken for a multiple conception or the diagnosis is established as gestation with the presence of formation abnormalities.

Progressive abdominal pregnancy is already characterized by more obvious symptoms, when parts of the fetus can be recognized by palpation of the peritoneum for a period of 8 weeks, there is a strong pain syndrome in the lower abdomen and bleeding.

With an unclear clinical picture, diagnosis includes MRI or computed tomography. The most informative method is laparoscopy, which allows not only to clarify the localization of the embryo in the abdominal cavity, but also to immediately remove it.

Treatment of abdominal pregnancy

Treatment of abnormal attachment of the fetal egg involves only surgical intervention. At an early stage, laparoscopy with minimal intervention or laparotomy in a later period of gestation with dissection of the peritoneal tissues is mainly used.

In the case of timely diagnosis and detection of abnormal fetal development, the prognosis for a woman is more than favorable. If an already developed fetus is identified, the risks for the patient increase, up to death, due to the discovery of heavy bleeding or due to injury to internal organs.

There are isolated stories in medical practice when a woman was able to bear a child in the peritoneum. At the same time, a planned operation to extract the baby was scheduled for an earlier date, and after the baby was placed in boxes for premature babies in order to prevent possible complications associated with an unformed organism.

Approximately 0.3% of patients have an abdominal ectopic pregnancy. This pathological condition is quite dangerous, because it can cause the death of a woman. The doctor makes such a diagnosis in situations where the implantation of the embryo occurs in any organ of the abdominal cavity.

With such a pregnancy, the process of entering nutrients into the zygote, as well as blood supply, occurs due to the vessels that are in the organ where the fetal egg is attached. In most cases, only one embryo develops, although the development of multiple pregnancies is not excluded.

Kinds

Pregnancy ectopic in the abdominal cavity can be primary or secondary. This is determined depending on the stage at which the implantation of the fetal egg occurred. With its initial attachment in this area, a primary ectopic pregnancy is diagnosed, which can also happen after in vitro fertilization.

In the second case, the diagnosis is made if the egg was initially attached to the oviduct, where it grew, but as a result of a tubal abortion, the embryo was abandoned into the abdominal cavity.

As for such a condition as a tubal abortion, it can occur in the period from 4 to 8 weeks. The main symptoms are painful sensations that appear as a result of the contraction of the oviduct, thereby pushing the embryo out. When blood enters the abdominal cavity, the condition becomes more pronounced.

Ectopic abdominal pregnancy on ultrasound. Source: medicine-live.ru

If there is little biological fluid, then the signs of a tubal abortion will be implicit, while the woman will not feel a general deterioration in her condition, the pain will be slight, respectively, it will be almost impossible to suspect that the embryo went into the abdominal cavity. Already in this zone, the attachment of the embryo can be to the spleen, liver, perimetry, omentum, bowel bends.

If implantation has occurred to an internal organ in which the blood circulation process is poorly developed, then spontaneous interruption occurs in the early stages. However, with good nutrition, fetal development can be long. The embryo in the abdominal cavity will very quickly increase its size, this can lead to blood loss and injury to internal organs.

Causes

Doctors identify a wide range of predisposing factors in which a woman can develop an ectopic pregnancy in the abdominal cavity. In particular, they are associated with anomalies in the development and functioning of the oviduct and ovaries.

Here are just some of the reasons for the pathological attachment of the embryo:

• Inflammatory processes in the reproductive organs of a chronic type;
• Previously performed surgical treatment of eggs entering;
• The presence of congenital anomalies in the reproductive organs;
• Damage to the fallopian tubes by endometriosis;
• Increased pressure on the oviduct by neoplasms;
• Incorrectly performed artificial insemination;
• Prolonged wearing of an intrauterine device;
• A history of adrenal and thyroid disease;
• Abuse of alcoholic beverages and smoking;
• Prolonged stay in stressful situations;
• late pregnancy.

As can be seen, there are many predisposing factors for embryo implantation to occur outside the uterine cavity. Therefore, if the pregnancy test showed a positive result, it is necessary to make sure as soon as possible that the egg has attached to the wall of the reproductive organ.

Symptoms

An ectopic pregnancy in the abdominal cavity has the same symptoms at an early stage of development as with normal implantation of the embryo. Accordingly, a woman will feel the following states:

1. No menstrual bleeding;
2. Pregnancy test is positive;
3. Increased hCG levels;
4. Constant sleepiness;
5. Neuropsychic instability;
6. Increase and appearance of soreness in the mammary glands;
7. Change in taste preferences;
8. Inability to tolerate certain odors;
9. Toxicosis and mood swings;
10. Frequent urination.

If a woman goes for an examination to a gynecologist, then during a two-handed examination, the specialist will notice that there is no embryo in the uterine cavity, while the reproductive organ will be slightly hypertrophied, and its size does not correspond to the gestational age.

However, in certain situations it is quite problematic to make a correct diagnosis, since this condition can be confused with congenital anomalies in the structure of the uterus. Also, in situations where a woman has an abdominal ectopic pregnancy, the symptoms of this condition can also be traced in violation of the gastrointestinal tract: there is a feeling of nausea and vomiting appears, there are problems with bowel movements, the development of anemia is not excluded.

In order to confirm the diagnosis, the doctor may inject the hormone oxytocin, but there will be no uterine contractions. A characteristic sign for HMP is the discovery of bleeding from the genital tract during a manual examination.

If a spontaneous interruption of an abdominal ectopic pregnancy occurs, then the woman will have a weak pulse, dizziness will occur, loss of consciousness will occur, nausea and vomiting will appear, blood pressure will decrease, bleeding will open, and severe pain will be present in the abdomen.

Diagnostics

It is very important to diagnose an abdominal ectopic pregnancy in a timely manner, since in a neglected state it can be fatal. You need to go to a doctor who will perform a gynecological examination with mirrors. Next, the patient is assigned a dynamic blood donation to determine the level of hCG.

With an ectopic pregnancy, the rates are quite low, and they also do not correspond to the gestational age. Through ultrasound screening, the absence of a fetal egg in the uterine cavity is detected. Thanks to the lateral x-ray, the abnormal location of the embryo can be detected, which is often removed by diagnostic laparoscopy.

Treatment

The only therapeutic method that can save the patient's life is surgical treatment. It is important to understand that taking cytostatic drugs can cause serious complications, for example, blood poisoning will occur, since the placenta will quickly die.

The operation is performed by laparotomy or laparoscopy. The choice of technique is within the competence of the doctor, and directly depends on the severity of the clinical case and the duration of pregnancy. During the intervention, only the embryo is removed, while not affecting the child's place, since such actions can provoke severe blood loss and death of the patient.

Operation (video)

Complications

In those situations where a woman had a primary abdominal pregnancy and the embryo was not removed in a timely manner, it may die, crumble, or calcify. In the latter case, the long-term preservation of the fetus in the body of a woman, which she may not even know about, is not ruled out. However, infection often occurs, and if the bacteria enter the bladder, intestines, or vagina, fistulas form.

In abdominal ectopic pregnancy, if the fetus is constantly increasing in size, it creates a significant load on the organ to which it was implanted. The outcome of such a situation can be deplorable, since organ rupture is not ruled out, which will cause severe blood loss and death of a woman.

As for the embryo, when it is localized in the abdominal cavity, defects and its development, insufficient blood supply and oxygen starvation are noted. Since there is no protection by the uterine walls, at a long gestation period, this will cause damage to the fetal membrane, after which water enters the abdominal cavity. In this case, emergency hospitalization and surgical intervention are also required.

(Fig. 156) is primary and secondary. It is extremely rare that a primary abdominal pregnancy is noted, that is, a condition when a fetal egg is grafted to one of the abdominal organs from the very beginning (Fig. 157). In recent years, several reliable cases have been described. Primary implantation of the egg on the peritoneum can be proved only in the early stages of pregnancy; c, this is supported by the presence of functioning villi on the peritoneum, the absence of microscopic signs of pregnancy in the tubes and ovary (M. S. Malinovsky).

Rice. 156. Primary abdominal pregnancy (according to Richter): 1 - uterus; 2 - rectum; 3 - fertilized egg.

Secondary abdominal pregnancy develops more often; in this case, the egg is initially grafted in the tube, and then, having got into the abdominal cavity during a tubal miscarriage, it is implanted again and continues to develop. The fetus during late ectopic pregnancy often has certain deformities resulting from unfavorable conditions for its development.

MS Malinovsky (1910), Sittner (1901) believe that the frequency of fetal deformities is exaggerated and is no more than 5-10%.

In abdominal pregnancy in the first months, a tumor is determined, located somewhat asymmetrically and resembling the uterus. Unlike the uterus, the fetus does not shrink at hand during an ectopic pregnancy. If it is possible to determine the uterus separately from the tumor (fetus) during a vaginal examination, the diagnosis is facilitated. But with an intimate fusion of the fetus with the uterus, the doctor easily falls into a mistake and makes a diagnosis of uterine pregnancy. It should be borne in mind that the tumor is most often spherical or irregular in shape, limited in mobility and has an elastic consistency. The walls of the tumor are thin, do not contract on palpation, and parts of the fetus are sometimes surprisingly easily identified when examined with a finger through the vaginal fornix.

If a uterine pregnancy is excluded or the fetus has died, probing of the uterine cavity can be used to clarify its size and position.

Rice. 157. Abdominal pregnancy: 1-chip loops soldered to the fetus; 2 - adhesions; 3 - fruit place; 4-placenta; 5 - uterus.

At first, abdominal pregnancy may not cause any special complaints from the pregnant woman. But as the fetus develops, in most cases, complaints of constant, excruciating pain in the abdomen appear, which are the result of adhesions in the abdominal cavity around the fetal egg, causing reactive irritation of the peritoneum (chronic peritonitis). The pains are aggravated by the movement of the fetus and cause excruciating suffering to the woman. Lack of appetite, insomnia, frequent vomiting, constipation lead to exhaustion of the patient. All of these phenomena are especially pronounced if the fetus, after rupture of the membranes, is in the abdominal cavity, surrounded by intestinal loops that have fused around it. However, there are cases when the pain is moderate.

By the end of pregnancy, the fetus occupies most of the abdominal cavity. Parts of the fetus in most cases are determined under the abdominal wall. On palpation, the walls of the fruiting chamber do not contract under the hand and do not become more dense. Sometimes it is possible to determine a separately lying, slightly enlarged uterus. With a live fetus, its heartbeat and movements are determined. X-ray with filling of the uterus with a contrast mass reveals the size of the uterine cavity and its relationship with the location of the fetus. When carrying an ectopic, in particular abdominal, pregnancy, labor pains appear, but the opening of the pharynx does not occur. The fetus dies. If there is a rupture of the fetus, a picture of acute anemia and peritoneal shock develops. The risk of rupture of the fetus is greater in the first months of pregnancy, and further decreases. Therefore, a number of obstetricians, in an effort to obtain a viable fetus, find it possible, in cases where the pregnancy exceeds VI-VII months and the ball is in a satisfactory condition, to wait with the operation and do it close to the expected date of birth (V. F. Snegirev, 1905 ; A. P. Gubarev, 1925, etc.).

MS Malinovsky (1910), on the basis of his data, believes that the operation at the end of a progressive ectopic pregnancy is technically not more difficult and is accompanied by no less favorable results than in the early months. However, the majority of reputable obstetricians and gynecologists, both domestic and foreign, believe that with any diagnosed ectopic pregnancy, an operation should be performed immediately.

The rupture of the fetus during late pregnancy is a great danger to the life of a woman. Ware indicates that maternal mortality in late ectopic pregnancy was 15%. Timely diagnosis before surgery can reduce mortality in women. A number of cases are described in the literature when the development of an ectopic pregnancy stopped, a falling membrane was released from the uterus, regressive phenomena began and regular menstruation began. The fetus, undergoing encystation in such cases, is mummified or, saturated with calcium salts, petrifies. Such a fossilized fetus (lithopedion) can be in the abdominal cavity for many years. There is even a case of lithopedion staying in the abdominal cavity for 46 years. Sometimes a dead ovum becomes suppurated, and the abscess opens through the abdominal wall into the vagina, bladder, or intestines. Together with pus, parts of the decaying fetal skeleton come out through the formed fistulous opening.

With the modern formulation of medical care, such outcomes of ectopic pregnancy are the rarest exception. On the contrary, cases of timely diagnosis of late ectopic pregnancy began to be published more often.

The operation for a progressive abdominal pregnancy, performed by abdominal surgery, presents significant, and sometimes great difficulties. After opening the abdominal cavity, the wall of the fetus is dissected and the fetus is removed, and then the fetal sac is removed. If the placenta is attached to the posterior wall of the uterus and the leaf of the broad ligament, then its separation does not present great technical difficulties. Ligatures or chipping sutures are applied to bleeding places. If the bleeding does not stop, it is necessary to ligate the main trunk of the uterine artery or the hypogastric artery on the corresponding side.

In case of severe bleeding, before ligation of these vessels, the assistant should press the abdominal aorta to the spine with his hand. The greatest difficulty is the separation of the placenta attached to the intestine and its mesentery or liver. Surgery for late ectopic pregnancy is available only to an experienced surgeon and should include abdominal surgery, removal of the fetus, placenta and bleeding control. The operator must be ready to resect the intestine if the placenta is attached to its walls or mesentery and this becomes necessary during the operation.

In the old days, because of the danger of bleeding during the separation of the placenta attached to the intestines or liver, the so-called marsupialization method was used. At the same time, the edges of the fetal sac or its parts were sutured into the abdominal wound, and a Mikulich tampon was inserted into the cavity of the sac, covering the placenta remaining in the abdominal cavity. The cavity gradually decreased, there was a slow (within 1-2 months) release of the necrotizing placenta.

The method of marsupialization, designed for spontaneous rejection of the placenta, is anti-surgical, under modern conditions it can be used by an experienced operator only as a last resort, and also under the condition that an insufficiently experienced surgeon performs the operation as an emergency. Marsupialization is indicated for an infected fetus.

Mynors (1956) writes that in late ectopic pregnancy the placenta is often left in situ, closing the abdominal wound. At the same time, the placenta is detected during palpation for several months, while Friedman's reaction to pregnancy becomes negative after 5-7 weeks.

During surgery for late progressive ectopic pregnancy, despite the good condition of the patient, it is necessary to prepare in advance for blood transfusion and anti-shock measures.

During the operation, severe bleeding can suddenly occur, and the delay in providing urgent care increases the danger to the woman's life.

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983