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Classification of ectopic pregnancy
Unruptured ectopic pregnancy
Differential diagnosis of tubal abortion
Following signs can help in diagnosis of ectopic pregnancy
Pregnancy in rudimentary uterine horn
Torsion of tumor crus
on the conference of the Department
of Obstetrics and Gynecology with the Course
of Infant and Adolescent Gynecology
“____” _____________200 p.
T.a.The Head of the department, Professor
on the themes singled out for independent study
“Acute gynecologic diseases”
For 5 year students of medical faculty
2 academic hours
Developed by assistant, PhD
I. Scientific and methodical grounds of the theme
Emergency surgery is one of the most actual problems of practical medicine. The quality of surgical aid at acute diseases in obstetrics and gynecology depends on timely diagnostics.
A student must know:
1. Ligamental apparatus of uterus and ovaries.
2. Blood supply of internal genitals.
3. Treatment of hemorrhagic shock.
A student should be able to:
1. Estimate the volume of blood loss.
2. Perform a punction of peritoneal cavity via posterior fornix.
III. Recommendations to the student
Pregnancy is called ectopic when it fertilized ovum implants outside the borders of uterine cavity.
Ectopic is one of the most serious gynecological diseases, because its interruption is followed by considerable intraperitoneal bleeding and needs emergency service.
Etiology. Anatomic changes in tissues of uterine tube that appear in the result of inflammatory processes are the main causes of the violation of ovum transport and ectopic pregnancy. Inflammation of mucous membrane, its edema and presence of inflammatory exudate in acute and chronic stages may cause dysfunction of uterine tubes. After this adhesions and closing of ampular end of the tube are formed. Damaging of muscular layer and changes in innervation of the tube lead to changes of its peristalsis and delay of fertilized ovum passing through it. Considerable anatomic changes in tubal layer or adjacent tissues cause abortions, operative interventions into the organs of true pelvis. Ectopic pregnancy frequently happens in women with genital infantilism, endometriosis, tumor of the uterus and uterine adnexa. Usage of intrauterine contraceptives increases the risk of ectopic pregnancy. There are scientific datas that toxic influence of exudate in tube at its chronic inflammation causes speed-up trophoblast maturing, that's why the proteolitic enzymes activize, and implantation comes before fertilized ovum enters the uterus. In case of the slow development of trophoblast an ovum is implanted in lower uterine (placenta praevia) segments or outside uterine cavity — in its cervix (cervical pregnancy).
^ . Depending on that, where a fertilized ovum has implanted tubal pregnancy, ovarian pregnancy, abdominal pregnancy, pregnancy in rudimentary uterine horn, intraligamentaory (between folds of wide uterine ligament) and cervical pregnancy are distinguished.
In majority of cases (98,5 %) the tubal pregnancy occurs. Interstitial pregnancy happens in interstitial portion of tube, isthmic — in isthmus and ampullar — in ampullar portion. According to clinical duration unruptured and interrupting ectopic pregnancy are distinguished. Interrupting of ectopic pregnancy happens by type of tubal abortion or by type of uterine tube rupture.
Duration of ectopic pregnancy. After implantation of fertilized ovum in woman's organism there appear changes, typical for normal uterine pregnancy: yellow pregnancy body is developed in ovary, decidual membrane is generated in uterine, uterus becomes soft and enlarges under the influence of ovarian hormones. All these signs are typical for pregnancy. The chorionic gonadotropin is also produced. One can find gonadotropin by means of appropriate researches. Pregnancy test is positive. Women have presumptine pregnancy signs: nausea, appetite changes and so on.
A fertilized ovum, that has been implanted into endosalpinx, goes over the same development stages, as in case of uterine pregnancy. The chorion villi are generated. At first they grow into mucous layer of the tube, then, without finding sufficient conditions for development, they grow into its muscular layer. While the size of fertilized ovum increases, the walls of tube stretch. The chorion villi, invading deeper, bring on its destruction. A layer of fibrinoid necrosis is generated. For Werth's figure of speech, "a fertilized ovule digs in tube wall not only nest for oneself, but the grave". The wall of uterine tube can not create favourable conditions for fetal development, that's why within 4-7 weeks interrupting of ectopic pregnancy takes place.
Tubal pregnancy is interrupted for type of uterine tubal rupture or for type of tubal abortion, depending on the method the embryo is going out into abdominal cavity. In case of rupture of uterine tube destruction of its wall takes place in the result not of mechanical tension and rupture, but in the result of corrosion by chorion villi. At pregnancy interrupting for type of tubal abortion exfoliating of the embryo from tube walls and its passing into abdominal cavity through the ampular end takes place.
Difficulty of diagnosis is connected with absence of symptoms which differ ectopic pregnancy from the uterine one. Sometimes women can feel uterine pain in the 'ower part of abdomen. During bimanual research one can palpate the enlarged tube, but sometimes it is not possible to do that because only at the end of the second month the tube reaches the size of an ovum and soft elastic consistence gives no possibility to palpate it distinctly. A differential diagnosis of unruptured ectopic pregnancy is made in case of uterine pregnancy of early terms, cyst, ovary cystoma and hydrosalpinx.
Elastic organ is palpated in case of either ovarian cystoma near the uterine or in case of unruptured tubal pregnancy, in which uterus is not enlarged, reaction to the chorionic gonadotropin (CG) is negative. There is no ischomenia. .;
In case of hydrosalpinx in adnexal region elastic organ is also found, but uterine is not enlarged, women do not complain on ischomenia, reaction on CG is negative.
Diagnosis difficulties appear owing that uterus continues to enlarge because of the development of decidual envelope and hypertrophy of mucose fibres, but uterus falls behind in dimensions typical for the certain pregnancy term.
Tests for chorionical gonadotropin" determination in such cases give a possibility to establish the pregnancy presence, but they don't give answer to the question about its localization. In some cases one can make diagnosis of unruptured ectopic pregnancy with ultrasonic research. In this case embryo is absent in uterine cavity. The diagnosis can be confirmed by means of laparoscopy Urgent hospitalization for complex examination and supervision is necessary in case when there is suspicion for unruptured ectopic pregnancy. The patient has to stay under the careful supervision of medical personnel. One should inform a doctor in case when there appear some changes in woman's state, especially when there are the symptoms typical for internal bleeding.
After entering stationary it is necessary to define blood type, and also rhesus-factor of the patient immediately.
Clinic. In case of tubal abortion exfoliating of an embryo from tube wall
and its passing into abdominal cavity take place. The clinic of tubal abortion is displayed by colicky pain, that is localized in one of iliac parts and irradiates into thigh, rectum and sacrum. Sometimes pain appears in supraclavicular part — frenicus-symptom. If embryo drives out from the tube at once, sometimes it is followed by considerable bleeding, giddiness and loosing of consciousness. Sometimes exfoliating of embryo ceases for a while, pain stops disturbing, however the pain is soon renewed. This can repeat once or twice, then the tubal abortion lasts for a long time. Blood, that outflow from the tube, accumulates in cul-de-sac and causes the feeling of pressure on rectum.
Diagnosis. The diagnosis of tubal abortion is not very simple. Carefully studied past history is of a great importence. Doubtful and probable signs of pregnancy are present. Anaemia'is common due to intensive blood loss, arterial pressure decreases abruptly and pulse accelerates. Abdomen is flatulent, its participation in breathing act is limited. In lateral abdominal parts blunting percussion sound is determined, during palpation there are the symptoms of peritoneal irritation.
During speculum examination is revealed cyanosis of vaginal mucosa and uterine cervix, typical are the secretions, described previously. At bimanual examination one can find that uterus is enlarged, but it does not correspond to menstruation delay term, isthmus allotment is soft, cervix motions are painful. In adnexa region from one side one can palpate an organ of elastic consistence with unclear contours. Back vault is smoothened or even prominent.
^ . In the cases, when there is no considerable intraperitoneal bleeding, tubal abortion should be differentiated with uterine abortion in early term, exacerbation of salpingo-oophoritis, dysfunctional uterine bleeding and cystoma crus torsion.
At uterine abortion there is a permanent colicky pain, that irradiates into lumbar part. Discharge is bright or dark red coloured.
At tubal abortion pain is periodic, colicky, ordinarily it is followed by dizziness, and irradiates into rectum.
When percussion blunting of sound in lateral part of the abdomen is found in ectopic pregnancy and tympan is in case of uterine abortion.
Secretions from vagina in tubal abortion appear after pain attact, they are dark, of poor amount, in case of uterine abortion they are bright red and considerable.
General woman's state in tubal abortion does not correspond to external hemorrhage, but in uterine abortion it does. Bimanual examination in case of tubal abortion gives a possibility to find a formation nearby the uterus, uterus does not correspond to pregnancy term, whereas in case of uterine abortion uterine size correspond to pregnancy term and ovaries are not altered.
There are some differences between the inflammatory process of uterine adnexa and tubal abortion. In case of inflammatory process there are no menses delays, reaction on CG is negative. Unlike tubal abortion pain during this disease appears gradually, there is no dizziness. Pain is not colicky, but permanent.
In case of tubal abortion with a long abortion duration one can observe subfebryle temperature, whereas in case of acute uterine adnexa inflammation temperature is high in most cases. Some blood loss at tubal abortion gives rise to BP lowering, in inflammatory process BP is normal. In case of abortion pulse is higher, temperature rises rarely.
In case of tubal abortion abdomen is slightly flatulent, but soft and painful during palpation on one side, during percussion blunting sound is observed in lateral departments. In case of inflammatory process examination of abdomen gives the identical symptoms, however there is no blunting of percussion sound.
Bloody secretions in inflammatory processes of ovaries can be rarely found. Unlike the secretions of tubal abortion, they are bright, sometimes with purulent admixtures.
During bimanual examination enlargement of uterus with unclear adnexa contours from one side testifies about tubal abortion rather than about inflammation of ovaries, in which uterus is not enlarged and ovaries are palpated as enlarged from both sides. Often in tubal abortion sagging of back vault is found.
In spite of great amount of differences, which give a possibility to make a differential diagnosis between tubal abortion and inflammatory process of ovaries, sometimes it is very hard to distinguish them. US and specially culdocentesis are importent in such case. In case of tubal abortion during puncture blood is received and in inflammatory processes one can get serous or a purulent liquid.
If one couldn't manage to specify diagnosis and the general woman's state is satisfactory, they hold on resolvent and hemostatic therapy during 5-7 days with careful clinical supervision. In tubal abortion all phenomena (colicky character of pain, bloody secretions) progress and at inflammatory process improvement of general state is observed.
Tubal abortion differs from cystoma crus torsion. In case of cystoma torsion there is no menses delay, reaction on chorionic gonadotropic is negative, bloody discharge and signs of internal bleeding are absent. Cystoma torsion is found by abdomen palpation. US and sometimes endoscopy is used as individual method.
Differential diagnosis between tubal abortion and appendicitis. In appendicitis a patient does not complain of menses delay, there are no signs of pregnancy. At tubal abortion pain is periodic, colicky, with one side localization. In appendicitis it apears at first in epigastria, and lateral then it localizes in right iliac region and it is accompanied by nausea and vomiting, that are rare in case of tubal abortion. Bloody excretions and signs of internal bleeding are absent. Palpation of the abdomen in acute appendicitis expresses tensity of the front abdomen, whereas in case of tubal abortion it is insignificant and sometimes it is absent. The Schotkin-Blumberg's and Rovzing signs testifies acute appendicitis while frenicus-symptom is absent. During bimanual examination in case of acute appendicitis uterus and ovaries are not enlarged. If much time has passed since the beginning of the disease, one can not always palpate them because of irritation of pelvic peritoneum. An infiltrate is palpated above and it is not possible to reach it through vagina.
A blood analysis in case of appendicitis gives leucocytosis with shift to the left, there is no anemia, whereas at tubal abortion blood picture is typical for anemia. After all, a culdocentesis can be a diagnostic criterion.
When clear differentiation is impossible, it is necessary to make laparotomy.
Clinic. Tube rupture develops more frequently in that case, when pregnancy
is localized in isthmus or interstitial department. Clinics displays by severe internal bleeding, shock and acute anaemia.
Disease begins after menses delay with acute pain in lower abdomen, which appears suddenly. It is localized in iliac areas and irradiates into rectum and sacrum. This pain is followed by momentary loosing consciousness. After this patient remains adynamic. During the attempt to get up she can lose her consciousness again.
Patient has all signs typical for internal bleeding: acute pallor, cold sweat, coldness of lower limbs, feeling of weakness, sometimes there is a threadlike pulse. The abdomen is flatulent, its participation in breathing act is limited. There is blurting of percussion sound in lateral abdominal region. Palpation of the abdomen is very painful. There are signs of peritoneal irritation.
Diagnosis. During .speculum examination cyanosis of mucous membrane of vagina is found. Bloody excretions are present, though not always. They are dark-coloured and look like coffee-grounds.
At bimanual examination cervical motion is always painful, there appears bulging and acute pain of the posterior pouch. Uterus body is enlarged insignificantly and along its side painful organ with unclear contours can be palpated, sometimes it is pulsatory. One should remember, that it is not always possible to palpate uterus and ovaries because of acute pain during gynecological examination.
At vaginal research such signs are determined:
Gudell’ s sign — soft consistence of cervix
At long blood presence in abdominal cavity its partial resorbtion takes place and transformed bilirubin deposits in skin cells. That's why there appear such signs:
Rare forms of ectopic pregnancy
Ovarian pregnancy, intraligamentous pregnancy, abdominal pregnancy, cervical pregnancy and pregnancy in rudimentary uterine horn belong to the rare forms of ectopic pregnancy.
Ovarian pregnancy. At such localization pregnancy develops either in fc .acle (follicular pregnancy), or upon the ovarian surface. Progressing of pregnancy is followed by pain, peritoneum tension, that covers an ovary. Interrupting comes in early terms. In rare cases pregnancy can reach late terms.
^ is primary and secondary. At primary one fertilized ovum is implanted immediately in abdominal cavity — on peritoneum, omentum, bowels, liver. Secondary abdominal pregnancy develops as a result of reimplantation of fertilized egg in cavity of small pelvis after proceeding from uterine tube by reason of tubal abortion. Abdominal pregnancy can be interrupted in early terms, bringing the picture of acute abdomen, but sometimes it can reach the late terms. A fetus is palpated right under the abdominal wall, its heart beat is clearly auscultated, enlarged uterus is determined separately from the fetus. In-term birth of living child is possible! Operation is in fetus and placenta removal but there appear considerable technical difficulties with compartment of placenta from internal organs.
Intraligamentorus pregnancy. If tubal pregnancy, chorion villi don't grow into the abdominal cavity, but into side of broad ligament of the uterus, separating it, embryo comes into space between leaves oflig. latum uteri and continues to develop between them. Embryo, protected by leaves of the broad ligament, can develop to late terms or even to full-term, however more frequently interruption of such pregnancy in 2-3 months term takes place. At its interrupting a big haematoma accumulates, and if the leaves of the broad ligament are ruined in the result of chorion villi penetrating, bleeding into abdominal cavity can appear.
^ . The rudimentary uterine horn can have junction with the cavity. In that case impregnated ovum is able to come there. Progressing pregnancy doesn't give special symptomatics. During palpation a tumor-like organ, adjacent to uterus is determined, sometimes on a cms. It is mobile and painless. Muscular layer of rudimentary horn is developed insufficiently as compared with miometrium, but it is developed much better in comparison with the uterine tube, that's why pregnancy in rudimentary horn is interrupted in later terms. Bleeding at such localization of ectopic pregnancy is considerable, that's why quick transportation of a woman into medical establishment is necessary. Diagnosis and operation are of particular importance.
Treatment. Just after confirming the diagnosis decision about operative treatment is taken. During hospitalization into stationary patients blood type and rhesus-factor is immediately determined, so that one can stop blood loss and shock. Amount of transfused blood is determined according blood loss and general state of a patient.
The altered uterine tube is removed during the operation. Conservative-plastic operations are made recently for saving of reproductive function of women. In absence of expressed anatomic changes in tube and at satisfactory woman's state embryo is removed from the tube, the tube is sutured. If pregnancy interrupting took place not long ago, blood is not hemolized, and there is a necessity for immediate blood transfusion. The blood, taken from abdominal cavity may be reinfused.
^ is blood effusion into ovary parenchyma, which is followed by bleeding into abdominal cavity.
Apoplexy causes are not clearly determined. It can develop in any day of ovarian-menstrual cycle or after menses delay, but more frequently it can happen in the middle of the cycle. The provoking factors are sexual act, trauma of the abdomen, operative intervention, mechanical pressing of the vessels by pelvis tumor.
Clinic. Disease begins suddenly, with pain frequently in one of the iliac region, which often spreads through the abdomen and irradiates into rectum, inguinal areas, sacrum and legs. The symptoms of internal bleeding appear, shock with loss of consciousness is common. The body temperature is normal. During abdominal palpation it is flatulent, patient can feel pain in lower abdomen in one or both sides.
Diagnosis. Previous diagnosis is made on the basis of carefully taken anamnesis and complaints. Disease onset data of physical and also vaginal examination are taken into consideration.
Bimanual research gives a possibility to set gynecological nature of the disease. Bulding (in case of severe bleeding) and pain of vaginal fornixes is present. Displacement of cervix causes strong pain. Uterus is of normal size, and pain is determined in ovaries region from one side. There is enlarged, cystically changed ovary.
Frequently at apoplexy a diagnosis of ectopic pregnancy is made, because there are no symptoms, typical for apoplexy.
^ is made with ectopic pregnancy and appendicitis. It is necessary because at ectopic pregnancy operative intervention is obligatory, while a apoplexy — not always. During differential diagnostics of ovary apoplexy with ectopic pregnancy one must pay attention to the fact that at apoplexy there are not signs of pregnancy. More frequently ectopic pregnancy appears after menses delay (not always!). Pain in both cases appears abruptly, irradiates into the same areas. In ectopic pregnancy frenicus-symptom is expressed, while apoplexy it happens rarely.
In apoplexy the peritoneal irritation phenomena and symptoms of internal bleeding are not so clearly expressed. However there are no clear criterions, for which one can distinguish ovarian apoplexy from interrupted ectopic pregnancy, especially if it interrupts by tubal rupture type. That's why management has to be determined by patient's general state.
As for differential diagnostics with acute appendicitis, one must remember, that in appendicitis more frequently pain initiate at the epigastric region, there are nausea and vomiting and no signs of internal bleeding. At abdominal examination muscular defancel and positive Schotkin-Blumberg's symptom are observed.
Treatment. At absence of expressed signs of internal bleeding a conservative cure can be applied. We put a cold thind on abdomen, hold haemostatics. After fading of acute phenomena physiotherapy is prescribed.
In case of expressed internal bleeding an operative intervention is indicated. Its volume depends upon the changes which take place in ovaries. If there is a big haematoma, and ovarian tissue is completely blasted by effusions of blood, it should be removed. In case of small haematoma an ovary resection is made.
An abscess rupture takes place spontaneously or in the result of physical trauma.
Clinic. Before abscess perforation there is always patient's health change to the worse — pain reinforces, temperature rises, peritoneum irritation symptoms are intensifying. Just after rupture there appears an acute pain which has a cutting character through the abdomen, collapse, nausea, vomiting, stomach is strained and strongly painful. General patient's state becomes worse, the face features sharpen, breathing becomes frequent and superficial. In the result of bowels paresis abdomen becomes flatulent, peristalsis disappears and meteorism develops.
Diagnosis. During stomach percussion one can find blunting of sound in lateral departments because of exudate presence in abdominal cavity.
During bimanual examination uterus and ovaries palpation is impossible because of acute pain and tension of front abdominal wall and vaginal fornixes bulgeng. Pelvic peritonitis may develop in the result of pyosalpinx rupture. Specification of the diagnosis can be made by means of ultrasonic research and culdocentesis.
Treatment. Cure of patients with purulent process in abdominal cavity is a complicated problem, successful solving of which needs fast and decisive actions. Operative cure with ablating of altered ovaries and following drainage of abdominal cavity is necessary. Laparotomy should be made by lower-middle incision, because this access gives a possibility to make a revision of abdominal cavity organs and its wide drainage, and if it is necessary — peritoneal dialysis. During the operation it is necessary examine appendix because its frequent involving in pathological process. If pathological changes are found appendectomy is done. Removal of purulent mass is technically difficult and needs caution and carefulness, but ablating of purulent formation is obligatory, because drainage, without ablating causes formation of purulent fistulas, those do not heal for a long time. A conservative care of such patients (antibiotics, vitamin therapy, cold on umbilicus) can give a temporary state improvement, but not a convalescence. Disease acquires chronic recidivate character with frequent acutenings. Operative intervention is inevitable anyways, however before operation it is necessary to make out suitable patient's preparation with stimulation of immune system and detoxicaton.
Cystoma cms torsion can happen more often, but sometimes the eras of subserous fibrous myoma can also happen. Quick motions, pregnancy, labor, stormy bowel peristalsis can cause torsion. In the result of torsion trophies of tumor tissue disturb, degenerative changes and necrosis with wall rupture appear in it
Clinic. Complete and incomplete eras torsion may occur. Clinically at eras torsion the symptoms of "acute abdomen" appear. Muscles of anterior abdominal wall tension is expressed on the part of process localization. In case of a big tumor its contours are available for palpation through abdominal wall, and during bimanual examination one can reach a lower tumor pole. Examination is very painful. In incomplete torsion the clinical picture is poor less and all phenomena can temporally vanish if blood supply of the tumor will be renewed.
Treatment. Torsion of tumor'eras needs immediate operation. Protraction with laparotomy gives rise to tumor necrosis, infection, beginning of adhesion's process and accretion of tumor to adjacent organs, that will create additional complications during the operation. An operation volume depends on ovarian tumor type: at benign tumor it is removed; in suspicion of malignization total hysterectomy with omentum resection is indicated.
There is a peculiarity in the operation: clench is laid more proximally from the place of torsion and the tumor is cut off without twisting its crus. It is forbidden to twist the crus because the thrombs those are in crus and also substances of necrotic destruction of the tumor can get into woman's blood.
IV. Control questions and tasks
1. Etiology, pathogenesis and classification of extrauterine pregnancy.
2. Cervical pregnancy. Diagnosis and treatment.
3. What is a cyst peduncle?
4. Surgeon’s strategy by fibromatous node necrosis.
V. List of recommended literature
1. Gynecology. - Stephan Khmil, Zina Kuchma, Lesya Romanchuk. - 2003. -
2. Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-2000.-P.293-299
Approved on Session of Department of Obstetrics and Gynecology with course of Infant and Adolescent Gynecology_________________ protocol No__________
T.a.The Head of Department:_______________ O.A.Andriiets’
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||Application form ХV international scientific conference «Ideas of Academician Vernadskyi and Problems of Regional Sustainable Development»|
«Kremenchuk Plavni». The conference fee does not cover meals and accommodation. For foreign participants the conference fee may be...
|Application form ХІV international scientific conference «Ideas of Academician Vernadskyi, Problems of Research and Evaluation of Regional Sustainable Development»|
«Kremenchutski Plavni». The conference fee does not cover meals and accommodation. The conference fee for foreign participants may...
|M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Rickets|