Interrupted tubal pregnancy (Abortus tubarius. Metrorrhagia profusa in cavo abdominis)

To recognize interrupted (broken) ectopic pregnancy early period in typical cases it is not difficult. The result of the germination villi pipe walls latter is broken or the egg is released from anularea the end of the pipe into the abdominal cavity. In either case occurs, as a rule, intra-abdominal hemorrhage. At break of a pipe bleeding usually stops, and increases, when the pipe as abortion bleeding often (sometimes only for a while) is terminated due to the closure of the lumen of the tube clots and thrombosis last broken vessels. Blood in the abdominal cavity doesn't come formed in a pipe blood clots form a blood tumor pipe (haematosalpinx). At break of a pregnant tubes in some cases may be formed Samotechnaya tumor, but such cases are rare.
The severity of symptoms of ectopic pregnancy depends on the amount of blood that is shed abroad in the abdominal cavity, and rate of blood loss.
The pipeline is usually accompanied by phenomena of a shock: there is a sudden and sharp cutting pain in the stomach, accompanied by a faint, pale face, cold sweat, the pulse is small, easily compressible, rapid (up to 120 beats per minute and more). These phenomena indicate the onset of a stroke. The appearance of the patient, in which there was a break of a pregnant tube, very typical. Visible mucous membrane pale color. With continued internal bleeding phenomena anemia usually grow. The sick person has traces of fear, pupils dilated, frequent breathing, interrupted, the surface; there is pain in the shoulder region, the so-called "frankus-symptom". Pain in the shoulder and shoulder blade due to irritation of the streamed blood sensitive fibers and endings phrenic nerve. Tongue wet, clean, neoplasty. When drawn, and raised up the language well expressed sublingual veins that appear empty white cords (symptom of "language") (O. P. Army). The body temperature is usually normal or below normal, but in some cases (most often in those where the violation of pregnancy has some limitations) can be increased. Temperature increase does not speak for infection, i.e. it can be caused by absorption by the peritoneum proteins streamed blood. At the time of rupture of the stomach is swollen, but not tense, slightly painful to palpation, especially in the lower part. Symptom Shchetkina - Blomberg positive.
Percussion stomach in place projection of ectopic pregnancy can be determined unilaterally dulling the sound, changing with the change of body position. Blood picture is typical for secondary anemia (reduction of hemoglobin and erythrocytes). In the case of fresh bleeding in the abdomen leukocytosis has only at the first hours, and later a WBC count falls to normal levels. Only in cases of known limitation of the number of leukocytes may be improved.
The sed rate is accelerating, as in intrauterine pregnancy.
When vaginal study reveals slight bleeding coffee or chocolate brown, opastnosti or vypechennoe one or more codes. Uterus seems slightly increased, but the form in which it is usually flat. Characteristic testovatoj (softening), characteristic of a normal pregnancy, the uterus does not have. In the field of appendages often palpable tumor with unclear contours, sedentary, mild consistency; often it is located at the rear of the uterus. Sometimes because of the resistance of the vaults and the sharp pain to contribute the tumor is not possible.
The differential diagnosis first of all should be excluded perivous intrauterine pregnancy (incomplete abortion or fleshy skidding). When viewed emitted particles ovum we should strive to find the villi. The resulting fabric histologically must be investigated, because on the possibility for simultaneously ectopic and intrauterine pregnancy.
Diagnostic scraping with histological examination of a scraping valid in the absence of contraindications (fever, leukocytosis, and painful vaginal examination).
If a scraping missing items chorion and found only one decidual tissue, the more likely it is possible to assume the presence of ectopic pregnancy, if the operation curettage of the uterine cavity produced not earlier than in 50-60 days after the former last menstrual period (if women conventional type of the menstrual cycle).
In this period of pregnancy square development Vorsin ovum is already significant (at development of pregnancy inside the uterus) and the elements of the chorion clearly detected in the scraping. But in the early stages of pregnancy the absence of chorionic villi in the scraping may not indicate the presence of ectopic pregnancy, as this cannot be ruled out unnoticed full miscarriage when available intrauterine pregnancy occurred before scraping.
The differential diagnosis should be borne in mind internal bleeding from other authorities (for example, from the ovary); in such cases, as with ectopic pregnancy, shows chrevosechenie. The clinical picture for ectopic pregnancy can be mixed with the phenomena arising from the twisting legs tumors of the ovary, with perforated peritonitis on the basis of ulcers of the stomach and intestines, with rupture of the walls of pyosalpinx and pours out its contents into the abdominal cavity, with appendicitis in acute stage and inflammatory diseases of the uterine appendages.
You should also exclude bowel obstruction (in the presence of pregnancy), which is often accompanied by a number of characteristics observed at the broken ectopic pregnancy.
We should not forget about the possibility of internal bleeding from other causes (rupture of the spleen and its vessels, which took place in the clinic in 1956, ruptured liver, eating villi uterus walls and so on).
It should be emphasized that the difficult situation of the patient when interrupted ectopic pregnancy is caused not only by the blood, how much peritoneal shock. This circumstance should be taken into account surgeon at carrying out of certain interventions.
Anamnesis, clinical picture, data, vaginal, and in some cases rectal examination methods, supplemented by laboratory results, help in adjustment and recognition of the disease. To rely only on words of the patient, that she is a virgin and not to use any methods and means of inspection in no event it is impossible, because such tactics can lead to serious errors.
X-ray diagnostics for ectopic pregnancy is possible only at a later date.
In difficult cases, the diagnosis of ectopic pregnancy is specified with a trial puncture through the posterior vaginal vault. It should be borne in mind that when fresh intra-abdominal hemorrhage back set is not always protruding, as in the patient lying poured out the blood evenly spreads to the abdominal cavity. Occasionally lifting the upper division of the body of the patient, reach movement of blood in the back dopasowa space. So when the patient is on an examination table with her legs, bent at the hip and knee joints and divorced aside, the head end of a trunk it should be lifted.
Puncture (trial puncture) produce thick needle of length not less than 12 cm, obliquely cut at the end. A needle is placed on the syringe in 12-20 cm3. The puncture is made either in the mirrors under the control of, or a finger; the latter by some authors (M. S. Malinovsky) is not recommended, as it is more dangerous and less technically convenient than puncture back arch under visual control.
Before puncture disinfect vulva and vagina. Mandatory catheterization of the bladder.
Vagina impose elaboate mirror and lift the back lip of the cervix capture bullet two pairs of pliers. Back set, some distance of 1-2 cm from the back lip of the cervix, strictly on the middle line make vCal needle to a depth of 3-4 see Then syringe nakazyvaet the blood accumulated in the pelvis. You should not make vCal in the side arches because of the danger of hurting large vessel or the ureter (Fig. 47).


Fig. 47. Puncture through the posterior vaginal vault.


On the same principle make a puncture on the finger. For this purpose two fingers of the left hand is introduced into the posterior vaginal vault underneath the cervix and outline the place of wkola. Then on the fingers needle, which are injected in the planned place. Puncture through the back of the vault is intra-abdominal surgery. So when it runs careful observance of aseptic and antiseptic rules, or may make the infection from the outside. It is unacceptable to make a puncture through the front arch, even if the tumor is located in front dopasowa space, as there is a danger of injury to the bladder.
In the presence of ectopic pregnancy in obtained by puncture blood usually find tiny clots. In order to get better, blood from a syringe poured on a white plate. The presence in the blood clots speaks for the presence of haemorrhage in the abdominal cavity. Even more clearly visible blood clots while pouring it from the syringe into a glass filled with saline. In cases where the blood does not contain them, does not exclude the possibility that she received from a vein of the uterus. In doubtful cases received punctate should do smears for microscopic examination.
More specific clinical picture are cases of Violation of ectopic pregnancy with education samotechny blood tumor (Haematocele retrouterina circumscripta). In these cases out a thorough survey of the patient States that she had an attack of acute pain, once or repeatedly. The patient usually informs about delay of menstruation (but the delay may sometimes not be), the attack of acute pain in the abdomen, accompanied by dizziness and vomiting and emergence from the uterus dark color bleeding in small numbers. Soon, however, the pain being replaced stupid, and the patient feels only the heaviness in the stomach. In the future, dizziness disappears and the condition of the patient improves. During examination of the patient with such clinical picture is observed: wet and clean language, paleness visible integument and mucous membranes, the body temperature is normal and low grade. Pulse Ochsen within 100 beats per minute. The abdominal wall is often strained and painful. With the feeling of stomach in the lower divisions defined tumor without clear contours, slightly painful, soft-elastic consistence. The upper border of the tumor is usually located above the fold, sometimes reaching the navel and rises even higher, depending on the degree of haemorrhage; the tumor has an irregular shape. When vaginal examination found that codes (the back and one side) are sealed and protruding through the specified tumor, which is located in the pelvis and rises. The wall of the vagina over the tumor mobile. The body of the uterus usually somewhat increased, shifted to the side, top and front. To probe appendages fails. However, it is not always typical picture samotechny tumors.
In some cases there is a high body temperature, rapid pulse, tongue is coated. These signs indicate infection and the possibility of festering tumors. When distributing festering tumors in the tissue between the vagina and rectum is a threat ulcer perforation in the rectum.
More or less similar clinical picture is observed in cases of impaired (interrupted) ectopic pregnancy with limited bleeding in and around the fallopian tubes (Haematocele peritubaria). At these slowly flowing forms of light space between individual strokes longer. Themselves strokes are not as intense. Reaction from the abdominal wall minor; percutere, there is a small quiet place projection tubes. When vaginal examination found degteobraznogo emphasis, enlarged uterus, flat shape and shifted slightly to the side; at the side of the uterus defined tumor pipes, having kolbasova or recontouring form dense or elastic consistence, sedentary, usually coming in dopasowa space and sometimes biased toward the front.
In table. 8-14 are differential diagnostic differences between tubal pregnancy and uterine cancer, ovarian apoplexy, acute stage of appendectomy, chronic inflammation of the uterine appendages, peritonitis, between samotechny blood tumor and retroflection gravid uterus and, finally, are the hallmarks violated ectopic pregnancy and bowel obstruction in the presence of pregnancy.