Early symptoms of ectopic pregnancy

Subjective signs of progressive tubal pregnancy

At the initial stage, before tubal rupture or tubal abortion occurs, the patient experiences the same changes as in normal gestation. Clinically, three variants of the course are distinguished: progressive pregnancy, tubal abortion, and tubal rupture. In the progressive variant, the following are observed:

• Doubtful signs: delayed menstruation, nausea, vomiting, altered taste preferences and smell.
• Probable signs: breast tenderness, expression of colostrum droplets upon pressure on the nipples.
• The home pregnancy test shows a positive result.

Physical examination findings

During an objective examination, the doctor can identify a number of specific markers. Speculum examination reveals cyanosis of the vaginal mucosa, cervix, and labia minora.

Bimanual vagino-abdominal examination determines:

• Lag in uterine size: the organ is slightly enlarged, the isthmus is softened, but the dimensions of the uterus are smaller than expected for the current estimated gestational age.
• Ovoid mass: an elongated, slightly tender structure is palpated in the region of the right or left adnexa.
• Displacements behind the cervix upon palpation remain painless.
• The vaginal fornices are deep, and the discharge is mucous in character.

Additional diagnostics: Ultrasound and hCG

Instrumental and laboratory methods are used to confirm the diagnosis:

1. Transvaginal sonography (TVS): the gestational sac is not visualized in the uterine cavity, and a inhomogeneous mass is detected in the projection of the adnexa (separately from the ovary). In the very early stages, the method may yield diagnostic errors.
2. Blood test for hCG: the quantitative content of the $\beta$-subunit of human chorionic gonadotropin is evaluated dynamically. In ectopic localization, the hormone level is below normal and does not demonstrate adequate growth (in a normal intrauterine pregnancy, the indicator doubles every 2 days).
3. Laparoscopy: used for precise visualization in complex cases.

Pregnancy of unknown location

Sometimes a situation arises where the hCG test is positive, but ultrasound shows no signs of either an intrauterine or an ectopic pregnancy.

If the $\beta$-hCG level reaches 1000 IU/L and higher, and the gestational sac is not visible either inside the uterus or outside it on transvaginal ultrasound, a diagnosis of pregnancy of unknown location is established. In this case, a strict management tactic is indicated: repeat transvaginal pelvic ultrasound and monitoring of serum $\beta$-hCG (free beta-subunit) exactly 48 hours later.

Pathogenesis of termination and outcomes

Progressive tubal pregnancy inevitably terminates. Chorionic villi invade the tubal wall and secrete proteolytic enzymes. This leads to melting, thinning of the wall, and opening of blood vessels.

• Fallopian tube rupture: accompanied by bleeding into the abdominal cavity.
• Tubal abortion: the gestational sac detaches and is expelled into the abdominal cavity. In a complete abortion, it is entirely expelled, dies, and undergoes mummification or calcification. If the expulsion stops, an “old” ectopic pregnancy is formed — the gestational sac is surrounded by blood clots and a dense capsule, which may closely adhere to the visceral and parietal peritoneum.

Features of surgical treatment

The main method of treatment for tubal pregnancy remains surgical. The classic intervention is salpingectomy (removal of the tube). It includes mobilization of the uterine end of the tube with clamping of the isthmus, sequential hemostasis of the mesosalpinx (mesosalpinx), tubal resection, and peritonealization of the stump. To cover the stump, a loop is formed from the round ligament of the uterus (lig. teres uteri) and sutured to the uterine horn with a continuous catgut suture.

With stable hemodynamics, early gestation, and the desire to preserve reproductive function, tubotomy (removal of the gestational sac with preservation of the tube) or conservative therapy with methotrexate is possible. However, these methods do not replace emergency surgery in the presence of a full-blown picture of intra-abdominal hemorrhage.

Class and exam questions

What else to study on this topic

• Clinical presentation of a terminated ectopic pregnancy (symptoms of intra-abdominal hemorrhage).
• Complications of intrauterine contraception: expulsion, pelvic inflammatory disease (PID), and uterine bleeding.
• Management tactics for patients who develop an intrauterine pregnancy while using an IUD.
• Technique of stump peritonealization in case of a deficiency of mesosalpinx tissues during salpingectomy.
• Indications and contraindications for medical treatment with methotrexate.

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.