Progressive tubal pregnancy
Until the moment of interruption, the pathology mimics a normal early intrauterine pregnancy. The patient may be bothered by delayed menstruation, changes in taste and smell, and breast engorgement. Symptoms of an «acute abdomen» are completely absent.
Gynecological examination reveals cyanosis of the vaginal mucosa and cervix. However, the uterine body is smaller than it should be for the estimated gestational age. Specific signs of intrauterine pregnancy (Piskacek's, Horwitz-Hegar's, and Genter's signs) are most often not determined. A painful, spindle-shaped mass may be palpated in the adnexal region, although in early terms the tube is slightly enlarged and may not be palpable.
Interruption by the type of tubal abortion
The condition changes dramatically when the fallopian tube begins to contract. This leads to partial or complete detachment of the gestational sac and the effusion of blood into the abdominal cavity. The severity of the clinical picture directly depends on the volume of blood loss.
- Up to 500 ml: the general condition is minimally affected, pain is aching, and diagnosis is difficult due to scanty symptoms.
- More than 500 ml: severe abdominal pain occurs, radiating to the right clavicle, interscapular region, and hypochondrium (phrenic nerve sign). Weakness, nausea, and dizziness appear. The «vanka-vstanka» sign is characteristic — the inability to find a comfortable position due to diaphragmatic irritation while lying down and loss of consciousness when sitting up.
During a bimanual examination, the cervix is softened, the external os is closed, and cervical motion is painful. A thickened tube or peritubular hematoma is palpated laterally or posteriorly to the uterus — a limited-mobility retort-shaped or ovoid mass without clear contours.
Fallopian tube rupture
The catastrophe develops against a background of complete well-being and is accompanied by acute intraperitoneal hemorrhage. Sharp pain occurs in the lower abdomen, radiating to the rectum. Tenesmus and loose stools join.
Objectively, a picture of hemorrhagic shock is observed: skin pallor with an icteric tinge, cold sweat, apathy, pronounced tachycardia, shortness of breath, and a drop in blood pressure. The abdomen is acutely tender, with signs of peritoneal irritation and dullness to percussion in dependent areas (the border shifts when changing body position).
During a gynecological examination, bloody discharge is often absent. Two striking signs are revealed:
- «Floating uterus» sign — excessive mobility of the enlarged and softened uterus.
- «Cullen's sign of Douglas» (Cry of Douglas) — sharp tenderness and bulging of the posterior vaginal fornix due to blood accumulation in the rectouterine pouch.
Cervical pregnancy
A rare but extremely dangerous form in which the growing chorion invades the muscular layer of the cervix, destroying it and damaging blood vessels.
Its main feature is the absence of pain syndrome. The main complaint of patients is bloody discharge from the cervical canal (ranging from scanty to profuse) occurring after delayed menstruation.
Upon examination, the cervix is shortened, barrel-shaped, and sharply cyanotic. The external os is slightly open, and the tissue of the gestational sac may be determined beyond it.
Caution: Palpation should be performed with utmost care, as it can provoke massive hemorrhage. Sometimes the diagnosis is made only during an attempted artificial abortion of a suspected intrauterine pregnancy, when the removal of the gestational sac does not stop the profuse bleeding.
Key diagnostic methods
A comprehensive approach is used to confirm the diagnosis, as isolated data may be inaccurate.
- Hormonal diagnostics: blood levels of β-hCG increase more slowly than in a normal pregnancy and do not correspond to the gestational age. Evaluated strictly in dynamics.
- Pelvic ultrasound: indirectly reveals thickening of the endometrium without a gestational sac in the uterus, fluid accumulation behind the uterus, and a heterogeneous mass in the projection of the adnexa.
- Culdocentesis (puncture through the posterior fornix): allows obtaining non-clotting blood with small clots. The method is losing relevance with the availability of laparoscopy and can give false-negative results (in case of adhesions, small blood volume, or needle blockage).
- Laparoscopy: the most accurate method. It allows visual assessment of the pelvic organs, revealing a purple-cyanotic thickened tube and dark blood flowing from the fimbrial end.
Briefly: answers to topical questions
What forms of ectopic pregnancy exist depending on the localization of the gestational sac?
Depending on the site of implantation of the gestational sac, tubal, ovarian, abdominal, cervical, and other rare forms of pregnancy are distinguished.
- Tubal pregnancy — the most frequent form, which is subdivided into ampullary, isthmic, and interstitial (intramural).
- Ovarian pregnancy — develops directly in the ovary.
- Abdominal pregnancy — localized in the abdominal cavity.
- Cervical pregnancy — implantation occurs in the cervical canal.
- Pregnancy in a rudimentary uterine horn — occurs with organ malformations.
- Heterotopic pregnancy — simultaneous combination of intrauterine and tubal pregnancy.
Casuistic forms also include multiple, bilateral tubal, and pregnancy in the stump of a removed tube.
What risk factors and etiological causes lead to the development of an ectopic pregnancy?
The development of an ectopic pregnancy is caused by slowed advancement of the fertilized egg through the fallopian tube and increased trophoblast activity. The following groups of risk factors and causes are distinguished:
- Inflammatory and surgical factors — adnexal inflammation, adhesions, previous surgeries on the tubes and abdominal organs.
- Hormonal disorders — use of progesterone drugs, hormonal contraception, use of IVF.
- Factors disrupting peristalsis — intrauterine devices, endometriosis, endocrine diseases, stress, prolonged lactation.
- Anatomical features — genital infantilism, tumors of the uterus and adnexa.
- External migration of the ovum — gamete entering the tube from the opposite side.
- Trophoblastic factor — premature proteolytic activity of the trophoblast.
What types of surgical operations are performed for tubal pregnancy?
For tubal pregnancy, radical and organ-sparing (conservatively plastic) surgical interventions are performed.
- Radical surgeries — include salpingectomy (tubectomy), which consists of removing the fallopian tube. When the gestational sac is localized in the interstitial section, excision of the utero-tubal corner is additionally performed.
- Organ-sparing surgeries — aim to preserve reproductive function and include the following types:
- «Milking» the gestational sac (milking) — used only for localization in the ampullary section.
- Tubotomy — a longitudinal incision of the fallopian tube over the location of the gestational sac followed by its removal.
- Resection of the fallopian tube segment — removal of the affected area of the tube.
The «Three P» rule in fallopian tube rupture: Pressure drop (shock), Floating uterus, Piercing «Cry of Douglas» (pain upon palpation of the fornix).
Class and exam questions
Does a negative pregnancy test rule out an ectopic location of the gestational sac?
No, it does not rule it out. Interruption of any pregnancy leads to the death of the chorion and cessation of hCG production, so the test may show a negative result.
What is the phrenic nerve sign and why does it occur?
This is the radiation of pain to the right hypochondrium, right clavicle, or interscapular region. The symptom is caused by irritation of the phrenic nerve by blood spilled into the abdominal cavity.
In which cases is diagnostic curettage performed?
The method is used exclusively for differential diagnosis with incomplete spontaneous abortion or dysfunctional uterine bleeding. In ectopic pregnancy, the scraping will reveal decidual tissue without chorionic villi.
What else to study on this topic
- Differential diagnosis of conditions with blood accumulation in the abdominal cavity (ovarian apoplexy, menstrual blood reflux, organ rupture).
- Rare forms of ectopic pregnancy: ovarian, abdominal, in a rudimentary horn.
- Anamnesis collection and risk factors (chronic adnexitis, ovulation induction, progestogens, abortions).
- Causes of false-positive and false-negative results in culdocentesis.
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