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, menstrual irregularities, pain syndrome, intra-abdominal bleeding.

In emergency gynecology, the general practitioner most often encounters a disrupted tubal pregnancy (ruptured tube or tubal abortion), which has a variety of clinical manifestations: from mild symptoms to clear signs of internal bleeding.

Pregnancy, disrupted by the type of tubal rupture, usually does not present diagnostic difficulties. The main requirement that life presents to practicing doctors is not so much the ability to make a correct diagnosis, but the ability to quickly and clearly provide adequate emergency care.

In the vast majority of cases, a doctor of any specialty, and not just a gynecologist, can successfully determine the nature of the disease based on the following data. Acute onset against the background of general well-being, which in some women (not all!) is preceded by a delay in the next menstruation from one day to several weeks. Sudden sharp pains in the lower abdomen on the right or left, which radiate to the anus, to the sub- and supraclavicular region, shoulder or shoulder blade, to the hypochondrium. The pain is accompanied by nausea or vomiting, dizziness up to loss of consciousness, sometimes loose stools. The general condition of the patient progressively worsens up to the development of severe degrees of hemorrhagic shock. In some patients this takes several hours, in others - 20-30 minutes, depending on the rate of bleeding and the initial condition of the woman's body.

An objective examination usually gives all the grounds for confirming internal bleeding. The patient is often inhibited, less often shows signs of anxiety. The skin and visible mucous membranes are pale, the extremities are cold, breathing is rapid and shallow. Tachycardia, the pulse is weak, blood pressure is low. The tongue is moist, not coated. The abdomen may be slightly distended, there is no tension in the muscles of the anterior abdominal wall. Palpation reveals pain in the lower abdomen, especially on the affected side. Symptoms of peritoneal irritation are also revealed here. Percussion usually reveals dullness in the sloping parts of the abdomen.

When performing an internal gynecological examination, do not make excessive efforts to clarify the shape, size, consistency of the uterus and appendages. This cannot be done due to severe pain, and unnecessary suffering is not indifferent to the patient, it can contribute to increased bleeding and shock. Careful examination provides sufficient grounds for confirming the correct diagnosis. When examining with mirrors, you can detect varying degrees of cyanosis or pallor of the mucous membrane of the vagina and exocervix. Bloody discharge from the cervical canal is absent, their appearance, associated with detachment of the decidual membrane, is usually detected later, in the postoperative period. Careful bimanual examination reveals flattening or protrusion of the posterior and one of the lateral fornices. The uterus is easily displaced, as if "floating" in free fluid.

In some cases, if the doctor still has doubts about the correctness of the diagnosis, and the patient's condition remains relatively satisfactory, it is possible to resort to a puncture of the recto-uterine pouch through the posterior vaginal fornix. The use of this manipulation in such situations is fully justified due to its availability, simplicity, speed of execution and high information content.

Termination of an ectopic pregnancy by the type of internal rupture of the fetal receptacle, or tubal abortion, unlike a rupture of the tube, presents significant diagnostic difficulties. This type of termination of pregnancy is characterized by a slow course, lasting from several days to several weeks. Periodically resuming partial detachment of the ovum from the fetal receptacle 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. Termination of pregnancy that began by the type of internal rupture of the fetal receptacle always carries a threat of transition to an external rupture, accompanied by increased bleeding. All of the above makes the doctor speed up diagnostic measures, and they can only be carried out in a hospital setting that has all the conditions for an emergency operation.

It should be emphasized that a carefully collected anamnesis provides invaluable assistance in diagnosing tubal abortion. Only based on the anamnesis can one correctly interpret the data of an objective study and outline the necessary volume of additional laboratory and hardware diagnostic methods.

What should be paid special attention to when collecting information from patients with suspected internal rupture of the fetal receptacle? Firstly, to the patient's medical history: the presence of a past ectopic pregnancy, inflammatory processes of the internal genital organs, abortions, infertility, appendectomy, use of contraceptives and ovulation inducers. Secondly, to information about the onset and features of the course of the present disease.

It is known that the main symptoms of pregnancy interrupted by internal rupture of the fetal receptacle are represented by the following triad: delayed menstruation, abdominal pain, bloody vaginal discharge. However, clinical practice shows that a combination of all three signs is observed in no more than half of patients. In the 226 women with tubal abortion that we observed, such a combination was found in only 46% of cases. Unfortunately, the specified triad, and even more so the separately presented symptom, are not pathognomonic for tubal abortion. All of them are found in many other gynecological and extragenital diseases, which significantly complicates diagnostics and forces the doctor to take into account the slightest nuances of the disease manifestation.

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

Pain during tubal abortion most often occurs paroxysmally without apparent cause 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 the act of defecation. The pain lasts from several minutes to several hours, sometimes acquiring a cramping character, may not have irradiation or radiate to the anus, shoulder, shoulder blade. collarbone. Sometimes women complain of pain in the hypochondrium, both independent and appearing with forced breathing.

Attacks may be accompanied by weakness, dizziness, darkening of the eyes, cold sweat, nausea, less often vomiting, and sometimes loose stools.

Pain is usually not accompanied by an increase in body temperature. However, some women may experience subfebrile temperature, which is explained by the absorption of the spilled blood. A significant increase in temperature may appear later due to the addition of an infection.

In cases of ongoing intra-abdominal bleeding, the intensity of pain increases, the patient's general condition worsens, and the doctor discovers clinical features of the disease similar to the symptoms of a ruptured tube. However, this is not always the case. More often, the attacks of pain stop completely. The woman again feels completely healthy and therefore may not seek medical help until the next attack. In some cases, with a generally satisfactory condition, a feeling of heaviness in the lower abdomen or a sensation of a foreign body pressing on the anus remains.

The second most common symptom of tubal abortion is complaints of bloody discharge from the genital tract. Usually, bloody discharge from the vagina appears several hours after an attack of pain, it is caused by the rejection of the decidual membrane as a result of a drop in the level of sex hormones. The main distinguishing feature of bloody discharge during a tubal abortion is its persistent nature, which does not respond to any medical treatment; bleeding does not stop even after scraping the mucous membrane of the uterus. The amount of blood lost is insignificant, often scanty; the color is dark, can be almost black or brown. In rare cases, scraps of decidual tissue come off along with the blood.

The third symptom of tubal abortion that a woman may indicate is a delay in menstruation. In the case of a delay in the next menstruation, a woman may consider herself pregnant, which significantly simplifies diagnosis. However, this symptom is not decisive, since bloody discharge due to termination of pregnancy may begin on time or the next day of the expected menstruation and mask its absence. Moreover, termination of pregnancy may occur in the early stages, even before the possible onset of the next menstruation.

The objective examination data largely depend on the time of its implementation. If the patient is examined during or immediately after an attack of pain, the clinical picture will be more clearly expressed. If several days have passed since the attack, the objective data may be inconclusive. Each repeated attack increases the volume of characteristic objective signs, but does not add to the woman's health, so it is irrational to rely on a long wait.

During the attack, the patient has pale skin and mucous membranes, moderate tachycardia against the background of normal or slightly reduced blood pressure. The abdomen is soft, not distended, painful on palpation in the lower sections and on the side of the affected fallopian tube. More or less pronounced symptoms of peritoneal irritation are also determined there against the background of the absence of tension in the muscles of the abdominal wall. Dullness of percussion tone is not often detected.

If some time has passed since the attack, the patient may feel quite healthy, have normal skin and mucous membrane color. There are no changes in the cardiovascular system. The abdomen is soft, painless on palpation in all areas. There are no signs of peritoneal irritation. When examining the vagina and cervix with mirrors, loosening and cyanosis of the mucous membrane and characteristic bloody discharge from the cervical canal can be detected. During a bimanual examination, a closed external os is palpated, the uterus is enlarged accordingly or less than the expected period of pregnancy. In case of a very early termination of pregnancy, the uterus may be of normal size. Data indicating a change in the appendages are ambiguous. Disruption of tubal pregnancy leads to a unilateral enlargement of the appendages. However, during an internal examination, enlarged appendages are often found on both sides, which is explained by the presence of a previous inflammatory process. The shape of the palpated appendage may be varied: sausage-shaped or retort-shaped with clear contours due to the formation of hematosalpinx, or of an indefinite shape without clear contours in the case of the formation of a peritubal hematoma. If a subuterine hematoma is organized, the appendage is palpated in a single conglomerate with the uterus. Whatever the shape and size of the formation, its mobility is quite limited, and palpation is always painful. The closer to the moment of the attack the examination is carried out, the more painful it is. In case of tubal abortion, accompanied by moderate bleeding, the vaginal fornices may remain high. Increased blood loss leads to flattening of the lateral or posterior fornix. When completing the internal examination, it is necessary to carefully but persistently shift the uterus to the pubis: in the presence of even a small amount of blood in the rectouterine space, tension of the uterosacral ligaments causes sharp pain.

Thus, the objective examination data are so diverse that their correct interpretation is extremely difficult even in comparison with a well-collected anamnesis. Of course, if the patient has a combination of all three typical complaints of tubal abortion (delayed menstruation, pain with corresponding irradiation, dark spotting vaginal discharge) with the presence of soreness and symptoms of peritoneal irritation in the lower abdomen against the background of normal body temperature, with a unilateral increase in appendages, then the diagnosis of tubal abortion becomes obvious. However, such a picture of the disease is not always observed. A significant number of patients do not have the entire symptom complex of tubal abortion, and the symptoms that are present are often devoid of typical signs. In this case, tubal abortion is disguised as other gynecological and extragenital diseases: early uterine miscarriage, ovarian apoplexy. acute inflammation of the appendages, pelvic peritonitis, impaired nutrition of the subserous nodes of uterine fibroids, torsion of the ovarian tumor pedicle, appendicitis.

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

Symptoms of the beginning of a uterine miscarriage consist of complaints of cramping or nagging pain in the lower abdomen, bright bloody discharge from the vagina after a delay in menstruation; signs of internal bleeding are absent; the external os of the cervix is slightly open; the uterus corresponds to the period of delay in menstruation. The degree of anemia is adequate to external bleeding.

The symptoms of ovarian apoplexy and tubal abortion have many common features and their differential diagnosis is quite complex.

The leading symptom of acute inflammation of the uterine appendages, as well as of a disrupted ectopic pregnancy, is pain, but the characteristics of the pain are not the same. During the inflammatory process, the pain symptom increases gradually, accompanied by an increase in body temperature; there are no signs of internal bleeding. Menstrual irregularities, often observed during the inflammatory process, can simulate the symptom of bloody discharge during a tubal abortion, but the color of the blood during inflammation usually has a bright shade. During a vaginal examination, the uterus is determined to be of normal size, the appendages are often enlarged on both sides, the vaults are high.

The disruption of the nutrition of the subserous uterine myoma is accompanied by a painful symptom that occurs quite acutely, but without signs of internal bleeding. It is necessary to differentiate uterine myoma from a retrouterine hematoma in case of a disrupted tubal pregnancy. A uterine hematoma together with the tube and uterus can represent a single conglomerate that has some similarity with uterine myoma. However, the myoma has clearer boundaries and its mobility is usually preserved.

Torsion of the ovarian tumor stalk is characterized by an acute onset: pain in the right or left iliac region, nausea, vomiting. There are no signs of internal bleeding. Symptoms of peritoneal irritation may appear. Data from an internal examination are quite specific: normal uterine size, a round elastic painful formation in the appendages, high vaginal vaults, normal vaginal discharge.

With appendicitis, pain appears in the epigastric region, then descends to the right iliac region, accompanied by vomiting and an increase in body temperature. There are no symptoms of internal bleeding. There is no bleeding from the vagina. Pain, tension of the abdominal wall muscles, symptoms of peritoneal irritation in the right iliac region. During internal examination, the uterus and appendages are unchanged. The white blood picture is quite characteristic: leukocytosis, neutrophilia with a shift in the formula to the left.

Tubal ectopic pregnancy, disrupted by the type of internal rupture of the fetal receptacle, can proceed under the masks of not only the above-mentioned diseases. Sometimes women are unsuccessfully treated by therapists for "cholecystitis" or end up in an infectious diseases hospital with "colitis", or end up in a urology department with "urolithiasis", which confirms the reputation of tubal abortion as one of the most insidious diseases.

Signs of pregnancy:

• delay of menstruation by 1-4 weeks;
• engorgement of the mammary glands;
• changes in taste, smell and other sensations characteristic of pregnancy;
• symptoms of early gestosis (nausea, vomiting);
• positive immunological reactions to pregnancy.

Menstrual cycle disorders:

• spotting bloody discharge from the genital tract: after a missed period, with the onset of the next period, before the onset of the next period.

Pain syndrome:

• one-sided cramping or constant pain in the lower abdomen;
• sudden intense pain in the lower abdomen;
• peritoneal symptoms in the lower abdomen of varying severity;
• irradiation of pain to the rectum, perineum, lower back.

Signs of intra-abdominal bleeding:

• tachycardia, decreased blood pressure;
• dullness of percussion sound in the sloping parts of the abdomen;
• positive Kulenkampf's sign (the presence of signs of peritoneal irritation in the absence of local muscle tension in the lower abdomen);
• "Tumbler-toy" symptom (in a horizontal position the patient has a positive bilateral "phrenicus symptom", in a vertical position - dizziness, loss of consciousness);
• decrease in hemoglobin, red blood cell, and hematocrit levels.

Signs of a general health disorder:

• weakness, dizziness, short-term loss of consciousness;
• nausea, single reflex vomiting;
• flatulence, single loose 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 gestational age.
3. Unilateral enlargement and soreness of the uterine appendages.
4. Overhanging vaginal vaults.
5. "Douglas' cry" is a sharp pain when moving the cervix.
6. Positive Promptov's sign (pain when moving the cervix in combination with painless digital examination of the rectum).

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