Symptoms of ectopic pregnancy

Symptoms of ectopic pregnancy are determined by signs of the underlying disease and developing complications, which include the following conditions: pregnancy. Violation of the menstrual cycle, pain syndrome, intra-abdominal hemorrhage.

In urgent gynecology, a practical doctor most often encounters an impaired tubal pregnancy (tube rupture or tubal abortion) having a variety of clinical manifestations: from mildly expressed symptoms to vivid signs of internal bleeding.

Pregnancy, broken by the type of rupture of the tube, usually does not present diagnostic difficulties. The main requirement that life poses to practical doctors is not so much the ability to deliver the correct diagnosis, as the ability to quickly and clearly provide adequate emergency assistance.

In the overwhelming majority of cases, a doctor of any specialty, and not just a gynecologist, successfully determines the nature of the disease on the basis of the following data. A sharp beginning against the background of the general well-being, which some women (not all!) Are preceded by a delay in regular menstruation from one day to several weeks. Sudden sharp pains in the lower abdomen on the right or left, which radiate into the anus, into the sub- and supraclavicular area, shoulder or scapula, in the hypochondrium. The pains are accompanied by nausea or vomiting, dizziness up to loss of consciousness, sometimes with a thin stool. The general condition of the patient progressively worsens until the development of severe degrees of hemorrhagic shock. In some patients, this takes several hours, others - 20-30 minutes, depending on the rate of bleeding and the initial state of the body of women.

Objective examination usually gives every reason to confirm internal bleeding. The patient is more often hindered, less often shows signs of anxiety. Skin and visible mucous membranes are pale, limbs are cold, breathing is often superficial. Tachycardia, pulse of weak filling, arterial pressure lowered. The tongue is moist, not coated. The abdomen can be somewhat swollen, the muscle tension of the anterior abdominal wall is absent. When palpation, soreness is observed in the lower abdomen, especially on the side of the lesion. Here the symptoms of irritation of the peritoneum are revealed. With percussion. As a rule, they find dullness in the sloping places of the abdomen.

Doing an internal gynecological examination, do not exert excessive effort to clarify the shape, size, consistency of the uterus and appendages. Because of the sharp pain, this can not be done, and unnecessary suffering is not indifferent to the patient, they can contribute to increased bleeding and shock. Careful examination gives enough reason to confirm the correct diagnosis. When viewed with mirrors, you can detect a different degree of cyanosis or pallor of the vaginal mucosa and exocervix. Bloody discharge from the cervical canal is absent, the appearance associated with the detachment of the decidua is usually found later, even in the postoperative period. A careful bimanual examination reveals a flattening or protrusion of the posterior and one of the lateral arches. Uterus easily shifts, as it were, "floating" in a free fluid.

In some cases, if the doctor remains in doubt about the correctness of the diagnosis, and the patient's condition remains relatively satisfactory, one can resort to a puncture of the rectal-uterine cavity through the posterior vaginal vault. The use of this manipulation in such situations in connection with accessibility, simplicity, speed of execution and high information content is fully justified.

Interrupting the ectopic pregnancy as an internal rupture of the fetus, or tubal abortion, in contrast to the rupture of the tube presents significant diagnostic difficulties. This variant of abortion is characterized by a slow course, lasting from several days to several weeks. Periodically renewed partial detachment of the fetal egg from the fetus is accompanied by a small (20-30 ml) or moderate (100-200 ml) bleeding into the lumen of the tube and into the abdominal cavity, which does not have a noticeable effect on the general condition of the patient. However, at any time, bleeding can become significant or profuse, which, of course, clarifies - the clinical picture, but significantly worsens the patient's condition. Interruption of pregnancy, which began as an internal rupture of the fetus, always carries a threat of transition into the external rupture, accompanied by increased bleeding. All this makes the doctor to speed up the implementation of diagnostic measures, and they can be carried out only in a hospital that has all the conditions for an emergency operation.

It should be emphasized that carefully collected history provides invaluable assistance in the diagnosis of tubal abortion. Only based on the history, you can give a correct interpretation of the objective research data and outline the necessary amount of additional laboratory and hardware diagnostic methods.

On what should be paid special attention in the collection of information from patients. With suspicion of internal rupture of the embryo? First, a history of the patient: the presence in the past of ectopic pregnancy, inflammatory processes of internal genital organs, abortion, infertility, appendectomy, the use of contraceptives and inducers of ovulation. Secondly, the information on the beginning and features of the course of the present disease.

It is known that the main symptoms of pregnancy, interrupted by the type of internal rupture of the embryo, are represented by the following triad: delay in menstruation. Pain in the abdomen, spotting from the vagina. However, clinical practice shows that the combination of all three signs is observed no more than half of the patients. In our 226 women with tubal abortion, a similar combination was found only in 46% of cases. Unfortunately, this triad, and especially the separately presented symptom, is not pathognomonic for tubal abortion. All of them occur in many other gynecological and extragenital diseases, which greatly complicates the diagnosis and causes the doctor to take into account the slightest nuances of manifestation of the disease.

The leading symptom of tubal abortion is pain. It occurs in almost all patients. The causes of pain in tubal abortion, and therefore its nature, are manifold. Pain can appear as a result of a hemorrhage into the lumen of the tube, which leads to its overextension and anti-peristaltic contractions. Blood can pour into the abdominal cavity, or accumulate in the rectum-uterine cavity, or along the lateral canal of the corresponding side to spread to the upper abdominal cavity, irritating certain areas of the peritoneum. Bleeding can stop, then resume with unpredictable force and frequency.

Pain in tubal abortion most often occurs paroxysmally for no apparent reason against the background of general well-being, localized in the lower abdomen, sometimes its intensity is more pronounced on the side of the affected tube. Some women associate the onset of pain with an act of defecation. The pain lasts from a few minutes to several hours, sometimes acquiring a cramping character, may not have irradiation or give to the anus, shoulder, scapula. Clavicle. Sometimes women complain of pain in the hypochondrium, both independent and appearing when forced breathing.

Attacks may be accompanied by weakness, dizziness, darkening in the eyes, the appearance of cold sweat, nausea, less often - vomiting, sometimes with a liquid stool.

Pain, as a rule, is not accompanied by an increase in body temperature. However, in some women subfebrile condition may be observed, which is explained by the absorption of the outflow of blood. A significant temperature rise may appear later due to infection.

In cases of ongoing intraperitoneal bleeding, the intensity of pain increases, the general condition of the patient worsens, and the doctor finds a disease clinic similar to the symptoms of a pipe rupture. However, this is not always the case. More often attacks of pain completely stop. The woman again feels quite healthy and therefore can not seek medical help until the next attack. In some cases, with a generally satisfactory condition, there is a feeling of heaviness in the lower abdomen or a feeling of a foreign body pressing on the anus.

The second place in the frequency of symptoms of tubal abortion is occupied by complaints of spotting from the genital tract. Usually, bloody discharge from the vagina appears a few hours after the attack of pain, they are due to the rejection of the decidual shell as a result of a drop in the level of sex hormones. The main distinguishing feature of bloody discharge during tubal abortion is their persistent nature, which can not be affected by any medication; bleeding does not stop even after curettage of the uterine mucosa. The amount of blood lost is insignificant, often scarce; color - dark, can be almost black or brown. In rare cases, scraps of decidual tissue leave with blood.

The third symptom of tubal abortion, which a woman can indicate, is a delay in menstrual intercourse. In case of delay of the next monthly woman can consider herself pregnant, which greatly facilitates the diagnosis. However, this symptom is not determinative, since bloody discharge in connection with the termination of pregnancy can begin on or next day of the expected menstruation and disguise its absence. Moreover, the termination of pregnancy can occur in the early stages, even before the possible onset of the next monthly.

The data of objective examination largely depend on the time of its conduct. If the examination of the patient occurs during or immediately after the attack of pain, the clinical picture will be more pronounced. If after the attack a few days have passed, objective data may not be convincing. Each repeated attack increases the volume of characteristic objective signs, but does not add health to the woman, so it is irrational to build a calculation on a long wait.

At the time of the attack, the patient is pale skin and mucous membranes, a moderate tachycardia against a background of normal or slightly reduced figures of blood pressure. The abdomen is soft, not swollen, painful on palpation in the lower parts of the affected uterine tube. There are also more or less pronounced symptoms of irritation of the peritoneum in the absence of tension in the muscles of the abdominal wall. Dullness of the percussion tone is not often detected.

If after the attack some time has passed, the patient can feel quite healthy, have the usual color, skin and mucous membranes. There are no changes in the cardiovascular system. The abdomen is soft, painless on palpation in all parts. There are no signs of irritation of the peritoneum. When examining the vagina and cervix with the help of mirrors, one can observe loosening and cyanosis of the mucosa and characteristic bloody discharge from the cervical canal. In a bimanual study, palpable closed external sores, increased, respectively, or less than the expected time of the pregnant uterus. At very early termination of pregnancy the uterus can have normal sizes. Ambiguous data indicating changes in appendages. The violation of tubal pregnancy leads to a one-sided increase in the appendages. However, when internal investigation is often found enlarged appendages on both sides, which is due to the presence of the preceding inflammatory process. The form of palpable appendage formation can be various: sausage-like or retort-like with clear contours due to the formation of hematosalpinx, or an indefinite form without clear contours when peritubar hematoma forms. If a clogging hematoma is organized, then the adnexal formation is palpated in a single conglomerate with the uterus. Whatever the form and size of the formation, its mobility is rather limited, and palpation is always painful. The closer the study is to the time of the attack, the more painful it is. In tubal abortion, accompanied by a mild bleeding, the vaginal vaults can remain high. Increased blood loss leads to a flattening of the lateral or posterior fornix. Completing the internal research, you need to carefully, but persistently move the uterus to the bosom: with even a small amount of blood in the rectum-uterine space, the tension of the sacro-uterine ligaments causes severe pain.

Thus, the data of an objective survey are so diverse that the correct interpretation of them is extremely difficult even in comparison with a well-collected anamnesis. Of course, if the patient has a combination of all three characteristic complaints in tubal abortion (delayed menstrual pain with appropriate irradiation, dark spotting discharge from the vagina) with the presence of soreness and symptoms of irritation of the peritoneum in the lower abdomen against the background of normal body temperature, with one-sided increase appendages, then the diagnosis of tubal abortion becomes obvious. However, such a picture of the disease is not always observed. A considerable number of patients do not have all the symptomatic tubal abortion, and the symptoms are often devoid of typical signs. In this case - tubal abortion is masked for other gynecological and extragenital diseases: the beginning of a maternal miscarriage of early terms, apoplexy of the ovary. Acute inflammation of the appendages, pelvioperitonitis, malnutrition of the subserous nodes of the uterine myoma, torsion of the ovarian tumor, appendicitis.

Differential diagnosis of tubal abortion is based on the features of the clinical course of these diseases and the use of additional research methods.

Symptoms of recurrent uterine miscarriage consist of complaints of cramping or pulling pains in the lower abdomen, bright bloody discharge from the vagina after delay in menstruation; signs of internal bleeding are absent; the external cervical cervix is ajar; the uterus corresponds to the period of delay of the menstrual period. The degree of anemia is adequate to external bleeding.

Symptoms of ovarian apoplexy and tubal abortion have many common features and differential diagnosis of them is quite complicated.

The leading symptom of acute inflammation of the uterine appendages, as well as an abnormal ectopic pregnancy, is pain, but the pain characteristics are not the same. In the inflammatory process, the pain symptom grows gradually, accompanied by an increase in body temperature; there are no signs of internal bleeding. Violation of the menstrual cycle, often observed in the inflammatory process, can simulate the symptom of bloody discharge in tubal abortion, but the color of the blood during inflammation usually has a bright tint. With a vaginal examination, a normal uterus is defined, the appendages are often enlarged from both sides, the vaults are high.

The disturbance in feeding of the subserous uterine fibroids is accompanied by a pain symptom, which arises quite sharply, but without signs of internal bleeding. Differentiate the myoma of the uterus from the pericardial hematoma with a broken tubal pregnancy. The clogging hematoma, together with the tube and the uterus, can represent a single conglomerate, which has some similarity with uterine myoma. However, myoma borders are more distinct and its mobility is usually preserved.

To twist the legs of the ovarian tumor is characterized by a sharp beginning: pain in the right or left ileal regions, nausea, vomiting. There are no signs of internal bleeding. Symptoms of irritation of the peritoneum may occur. Data. Internal examination is rather specific: normal size of the uterus, round elastic consistency, painful formation in the appendages, high vaginal vaults, usual type of vaginal discharge.

With appendicitis, pain appears in the epigastric region, then descends into the right iliac, accompanied by vomiting, an increase in body temperature. There are no symptoms of internal bleeding. Bleeding from the vagina is not. Soreness, tension of the muscles of the abdominal wall, symptoms of irritation of the peritoneum in the right iliac region. With internal examination, the uterus and appendages are unchanged. A very characteristic picture of white blood: leukocytosis, neutrophilia with a shift of the formula to the left.

Pipe ectopic pregnancy, broken by the type of internal rupture of the fetus, can occur under the masks of not only these diseases. Sometimes women are unsuccessfully treated by therapists about "cholecystitis" or go to an infectious disease hospital with "colitis", or find themselves in the urological department with "urolithiasis". Which confirms the reputation of tubal abortion as one of the most insidious diseases.

Signs of pregnancy:

• delay in men for 1-4 weeks;
• engorgement of mammary glands;
• change in taste, olfactory and other sensations, characteristic of pregnancy;
• symptoms of early gestosis (nausea, vomiting);
• positive immunological reactions to pregnancy.

Violation of the menstrual cycle:

• Spotting spotting from the genital tract: after a delay of the monthly, with the beginning of the next monthly, before the onset of the next monthly.

Pain syndrome:

• unilateral cramping or persistent pain in the lower abdomen;
• sudden intense pain in the lower abdomen;
• peritoneal symptoms in the lower abdomen of varying severity;
• Irradiation of pain in the rectum, perineum, lower back.

Signs of intra-abdominal hemorrhage:

• tachycardia, lowering blood pressure;
• dullness of percussion sound in the sloping sections of the abdomen;
• a positive symptom of Kulenkampf (the presence of signs of irritation of the peritoneum in the absence of local muscle tension in the lower abdomen);
• symptom "vanka-vstanka" (in the horizontal position the patient is a positive two-sided "frenicus-symptom", in the vertical position - dizziness, loss of consciousness);
• decrease in hemoglobin, erythrocyte, hematocrit.

Signs of a general condition disorder:

• weakness, dizziness, short-term loss of consciousness;
• nausea, single reflex vomiting;
• flatulence, single liquid stool.

Gynecological examination data

1. Cyanotic coloration of the mucous membrane of the vagina and cervix.
2. The size of the uterus is less than the expected duration of pregnancy.
3. One-sided increase and soreness of the uterine appendages.
4. Hanging of the vaginal vaults.
5. "Douglas Scream" - a sharp soreness in the movements of the cervix.
6. Positive symptom of Promptov (soreness in movement for the cervix in combination with painless finger research of the rectum).

[1], [2], [3]