Obstetrics and Gynecology - A.M. Gromova 2000

"Acute Abdomen" in Gynecology
"Acute Abdomen" Associated with Intra-abdominal Bleeding
Ectopic Pregnancy

Under normal conditions, a fertilized egg travels down the fallopian tube into the Uterus, where it implants into the endometrial lining. If the egg's passage is disrupted, it implants outside the uterine cavity, resulting in an Ectopic Pregnancy (graviditas extrauterinae). Potential implantation sites include the fallopian tube (Tubal Pregnancy), the Ovary (Ovarian Pregnancy), a rudimentary uterine horn, the Abdominal cavity (abdominal pregnancy), the isthmic-cervical portion of the uterus (isthmic-cervical pregnancy), and the cervix (cervical pregnancy).

Based on the anatomical segments of the fallopian tube, tubal pregnancies are classified as ampullary, isthmic, or interstitial. Ovarian pregnancy can develop On the surface of the ovary or within the follicle itself. Abdominal pregnancy is subdivided into primary (where implantation initially occurs on the parietal Peritoneum, omentum, or any abdominal organ) and secondary (attachment of the gestational sac within the abdominal cavity following a tubal abortion).

Depending on the clinical course, ectopic pregnancies are distinguished as either progressive or disrupted. Disruption typically occurs via an external rupture of the gestational sac—such as a rupture of the fallopian tube, ovary, or rudimentary uterine horn. The second type of termination is an internal rupture of the gestational sac, commonly known as a tubal abortion, which predominantly occurs when the pregnancy is located in the ampullary section of the tube. In recent years, improved diagnostic capabilities have also led to the identification of a regressing form of ectopic pregnancy.

Etiology AND Pathogenesis

Ectopic pregnancy is most frequently caused by impaired tubal function, often linked to systemic processes of various etiologies. Non-specific infections play a major role, the spread of which is facilitated by intrauterine Procedures. Additionally, chlamydial, tuberculous, and gonococcal infections are of clinical significance. Consequently, the tube may develop kinks, strictures, adhesions of the mucosal folds, and functional alterations reflected by decreased levels of RNA, Glycogen, and Glycoproteins in the tubal secretions. As a result, The transport of the ovum into the uterus is impaired; it becomes trapped in the tube and attaches to its wall. The inflammatory process alters tubal peristalsis, further hindering the egg's progression and contributing to The Development of ectopic pregnancy.

Tubal anomalies (such as diverticula, accessory tubes and ostia, blind tracts, and duplicated lumens) also predispose to ectopic pregnancy. Frequently, ectopic pregnancy arises on the Background of genital infantilism (hypoplasia). In infantilism, the fallopian tubes are elongated and tortuous, their lumens are narrow, and peristalsis is weak. The fertilized egg must travel a relatively long distance, and its progression driven by weak peristalsis is sluggish. During this prolonged journey through a narrow, lengthy tube, the fertilized ovum continues to develop, acquiring trophoblastic properties and implantation capacity. Consequently, it settles in the tube and embeds into its wall.

Excessively prolonged breastfeeding leads to a decrease in tubal contractility. If Fertilization occurs during this period, the ovum will move slowly and may become trapped within the tube.

Ectopic pregnancy frequently occurs against the backdrop of menstrual irregularities, cyclic dysregulation of Pituitary Hormones, estrogens, and progesterone, endocrine disorders, and the development of Endometriosis. This is attributed to hormonal imbalances affecting the neuromuscular apparatus of the tubes. Neuroendocrine dysfunction contributes to reduced tubal contractility and the appearance of antiperistaltic contractions.

Pathological implantation may also be linked to an excessively high biological activity of the fertilized ovum, driven by the Toxic effects of inflammatory byproducts, alcohol, or narcotics. These factors accelerate the shedding of the zona pellucida, promote trophoblast formation, and lead to premature nidation.

Other causes of ectopic pregnancy include postoperative pelvic adhesions, a history of tubal insufflation (pertubation), and tumor-like growths within the tubal lumen or pelvic cavity that can mechanically compress the fallopian tube. Psychological factors also play a certain role.

When a fertilized ovum develops in the isthmic portion of the tube—where the mucosal folds are low—basotropic growth of chorionic villi occurs. These villi secrete Proteolytic Enzymes that rapidly break down the mucosal, muscular, and serosal layers of the tube. Within 4–6 weeks, this results in wall perforation and vascular destruction, terminating the pregnancy via external rupture of the gestational sac. The mechanical factor associated with the stretching of the tube by the growing ovum does not play a significant role in tubal rupture.

However, due to the massive Development of the muscular layer surrounding this specific segment of the tube, the gestation may persist for a longer duration (up to 10–12 weeks). Tubal rupture triggers massive intra-abdominal Hemorrhage, leading to severe anemia.

In cases of ampullary tubal abortion, the fertilized ovum detaches from the tubal wall, expires, becomes infiltrated with Blood, and gradually disintegrates. The tube initiates intensified antiperistaltic movements, expelling the detached ovum into the peritoneal cavity. Ovum detachment is accompanied by bleeding; blood accumulates around the tube or within its lumen. With significant blood loss, blood enters the peritoneal cavity and typically pools in the pouch of Douglas, forming an extrauterine hematoma. In very rare instances, the detached ovum survives and implants within the peritoneal cavity, resulting in an abdominal pregnancy. As a rule, ectopic pregnancies terminate at 5–6 weeks, and less frequently at the end of the second or beginning of the third month.

Ovarian pregnancy is characterized by The formation of the gestational sac within the ovary itself, while the fallopian tube typically remains unchanged. The capsule of the gestational sac is weak, making it prone to rupture and intra-abdominal hemorrhage.

Clinical presentation and Diagnostics

The clinical picture depends on the stage of the ectopic pregnancy, its form of termination (rupture vs. abortion), total blood loss, and the body's systemic response. While an ectopic pregnancy is progressive, standard early Signs of Pregnancy (both subjective and objective) are observed. The cervix is firm, while the isthmic region is softened, albeit not to the same extent as in intrauterine pregnancy. The uterus is softened and gradually enlarges, though its dimensions do not correspond to the gestational age. Its shape remains pear-shaped, lacking the asymmetric bulging of one of the uterine horns typically seen in intrauterine pregnancy.

Palpation reveals a thickened, soft, pregnant tube adjacent to or slightly lateral to the uterus. Such findings may occasionally be misinterpreted by the physician as inflammatory adnexal disease (salpingo-oophoritis). However, in adnexal inflammation, the consistency of the appendages is firmer, tenderness is marked, the condition is frequently bilateral, and it rarely occurs in isolation without involving adjacent Organs and forming adhesions. When diagnostic uncertainties arise (adnexal inflammation vs. progressive tubal pregnancy), the patient is scheduled for a comprehensive workup, 1–2 days of clinical observation, and mild anti-inflammatory therapy (ice to the lower abdomen, autohemotherapy, calcium chloride). A normal Temperature response, stable leukocyte counts over time, and a lack of objective improvement from the therapy point strongly toward ectopic pregnancy.

Positive pregnancy tests, ultrasound diagnostics, and laparoscopy are crucial for establishing the Diagnosis.

Pregnancy tests are based on the detection of human chorionic gonadotropin (hCG) in the patient's serum and urine. Today, biological Methods for determining hCG no longer play a primary role. Immunological assays (slide and capillary tests) and serological methods (such as erythrocyte aggregation inhibition or latex agglutination inhibition) are widely used. Radioimmunoassay for the Quantitative determination of serum ß-hCG exhibits high Specificity.

Ultrasound reveals a slightly enlarged uterus with linear or discrete echoes within the cavity, caused by endometrial hyperplasia and decidual tissue development. No gestational sac is observed within the uterine cavity. Instead, it is visualized in the adnexal region as a rounded Structure whose dimensions correspond to the gestational age. Embryonic Cardiac Activity may occasionally be detected.

Laparoscopy boasts high diagnostic accuracy; however, due to its invasiveness, its use is limited and generally reserved as a confirmatory step in complex diagnostic scenarios. Histological examination of Tissues obtained via endometrial curettage can sometimes provide definitive diagnostic assistance. The absence of chorionic villi in the presence of decidual Changes in the uterine lining strongly indicates an ectopic pregnancy.

Culdocentesis (puncture of the peritoneal cavity via the posterior vaginal fornix) is frequently employed for diagnosis. In ectopic pregnancy, the aspirated blood is dark, non-clotting, and contains small clots. Retrieving such fluid confirms intra-abdominal hemorrhage. However, a negative tap does not rule out a tubal pregnancy, as blood may fail to reach the rectouterine pouch due to adhesions.

Characteristic symptoms of an ectopic pregnancy manifest when a tubal abortion or tubal rupture occurs. Symptoms are significantly more pronounced in tubal rupture than in tubal abortion.

Tubal rupture presents with a sudden, acute onset. The patient experiences a sharp bout of lower abdominal pain accompanied by fainting or near-fainting spells (syncope/presyncope). The pain radiates to the rectum, shoulder, or supraclavicular region (phrenic nerve sign). Due to ongoing hemorrhage, the Skin and visible mucous membranes become pale, the pulse accelerates, and blood pressure drops—manifesting signs of hemorrhagic Shock. Respiration is rapid; in severe cases, vomiting occurs, the skin becomes clammy, and body temperature drops. The abdomen is distended, tender on palpation, with positive peritoneal irritation signs. Abdominal Percussion reveals dullness over areas of accumulated spilled blood. When the patient is turned onto her side, the zones of percussion dullness shift as the pooled blood flows toward the dependent side.

Internal gynecological examination is significantly hindered by severe tenderness. Speculum examination may reveal varying degrees of cyanosis and pallor of the vaginal mucosa and cervix. Bloody discharge from the cervical canal is typically absent; its appearance, associated with the shedding of the decidual lining, usually occurs during the postoperative period. Gentle bimanual examination reveals flattening or bulging of the posterior and one of the lateral vaginal fornices. The uterus is easily displaced. There is an impression that the uterus and the enlarged adnexa on one side are "floating" in free fluid. Varying degrees of tenderness are noted upon displacing the cervix anteriorly, along with exquisite tenderness of the posterior vaginal fornix ("Cullen's/Douglas cry").

In some cases, when a physician has doubts about the correct diagnosis and the patient's condition remains relatively stable, a culdocentesis (puncture of the peritoneal cavity through the posterior vaginal fornix) can be performed. Obtaining dark, non-clotting blood confirms the preliminary diagnosis. In situations where the patient is in a state of hemorrhagic shock, diagnostic culdocentesis is considered inappropriate.

With a tubal abortion, a life-threatening clinical presentation is less common. There is slight pallor of the skin and mucous membranes, but the pulse and blood pressure remain relatively stable. The patient experiences cramping pain accompanied by lethargy or near-fainting. Just like in a tubal rupture, the pain radiates to the rectum, scapula, and neck. Following a pain attack in disrupted ectopic pregnancy, there is scant dark bloody vaginal discharge, which is associated with the shedding of the decidual lining due to decreased sex hormone levels; sometimes particles of the uterine mucosa—which transforms into decidual tissue during ectopic pregnancy—are mixed into the discharge, and occasionally the entire decidual cast is expelled from the uterus.

The clinical picture of a tubal abortion is characterized by the periodicity of symptoms. During an attack, the patient exhibits paleness of the skin and mucous membranes, mild tachycardia with normal or slightly decreased blood pressure. The abdomen is soft and tender in the lower quadrants (more pronounced on the side of the affected fallopian tube). Abdominal wall rigidity is absent. Signs of peritoneal irritation are mild. Percussion dullness is clearly defined. After the attack subsides, the pregnant woman feels almost normal, and clinical signs of pathology are practically absent. The abdomen is soft and non-tender, with no signs of peritoneal irritation.

A gynecological examination reveals cyanosis of the vaginal mucosa and cervix. The uterus is enlarged, but smaller than expected for the gestational age. Enlarged adnexa, often with indistinct contours, are palpated on one side. If an ectopic hematoma forms, it is palpated as a single tender, moderately mobile mass involving the adnexa and uterus. Minor intraperitoneal bleeding does not cause flattening of the vaginal fornices. Therefore, diagnosing a disrupted ectopic pregnancy in the form of a tubal abortion requires culdocentesis.

Because the course of the pathology sometimes lacks distinct clinical signs, a tubal abortion must be differentiated from Ovarian Apoplexy, acute pelvic inflammatory disease, early Spontaneous Abortion, Pelvioperitonitis due to necrosis of uterine fibroids, and torsion of an ovarian tumor pedicle.

Positive pregnancy test results point toward an ectopic pregnancy. Ultrasound examination during the termination of a tubal pregnancy reveals numerous amorphous echoes in the extrauterine space, indicating blood accumulation.

When dark bloody vaginal discharge appears, Diagnostic curettage of the uterine cavity may be performed, followed by histological examination of the retrieved material (in ectopic pregnancy, decidual tissue is found without chorionic villi).

Ovarian, abdominal, and rudimentary uterine horn pregnancies are rare. The clinical picture of an ovarian pregnancy resembles that of a tubal pregnancy. Abdominal pregnancy very rarely reaches advanced gestational ages; full-term abdominal pregnancies have been described. In such cases, the fetus, enclosed in membranes, lies among the Internal Organs, while the Placenta attaches to the tube, peritoneum, or internal organs. The course of an abdominal pregnancy is severe, and the fetus usually dies. The deceased fetus undergoes maceration and aseptic decay or mummification. Due to placental Separation, significant intraperitoneal hemorrhage may occur.

The clinical manifestations of cervical and cervico-isthmic pregnancy include vaginal bleeding against the background of Amenorrhea in the absence of pain. Gynecological examination reveals an eccentric position of the external os and dilation of the cervical vessels. Bimanual examination reveals a soft, barrel-shaped, enlarged cervix and a small, firm uterus. Bleeding increases following the examination.

Treatment

Treatment for patients with ectopic pregnancy is surgical. The choice of Procedure depends on the Location OF THE gestational sac, the degree of blood loss, the patient's general condition, the severity of pathological changes in the affected and contralateral tubes, the patient's age, and her desire for future fertility. Options include tubectomy and microsurgical techniques (salpingostomy in the ampullary or isthmic portion of the tube, segmental resection of the isthmic portion with end-to-end anastomosis).

Tubectomy

Tubectomy is performed in cases of heavy bleeding in the patient, or significant pathological changes in the fallopian tube caused by a disrupted pregnancy or inflammatory processes.

The incision can be made at the surgeon's discretion. The lower midline longitudinal incision is faster to perform, less time-consuming, and provides a better view of the abdominal organs. If technical complications arise during surgery, this incision can easily be extended upward. However, some surgeons prefer a transverse suprapubic pfannenstiel incision of the abdominal wall. Although technically more demanding, it promotes better healing and preserves abdominal wall Muscle Function.

After opening the abdominal cavity, the uterus and the tube containing the gestational sac are exteriorized into the wound, and clamps are applied to the mesosalpinx and the uterotube angle. Once bleeding is controlled, the surgeon can clearly assess the pelvic cavity, remove blood clots, and examine the adnexa and Appendix. The tube and the tubal angle are then excised and reperitonealized using the round ligament.

If the ovary is found to be involved as well, either an ovarian resection is performed, or the adnexa are completely removed.

In early-stage progressive ectopic pregnancy, or in a disrupted ectopic pregnancy with minor tubal damage, laparoscopic salpingostomy can be performed.

Conservative Surgery for Tubal Pregnancy (Salpingostomy)

In a significant number of women with a tubal pregnancy, a conservative plastic surgery can be performed, which involves removing the gestational sac followed by tubal reconstruction (salpingostomy). Such surgery is performed in nulliparous women, in cases of recurrent tubal pregnancy, or when the woman wishes to preserve the fallopian tube.

Contraindications for conservative surgery include:

- significant blood loss;

- significant tubal rupture;

- long-interrupted tubal pregnancy.

This causes irreversible changes in the Uterine tube wall itself and the formation of dense adhesions, making conservative surgery impossible.

The Nature of the surgery depends on the localization of the gestational sac. If it is implanted in the ampullary section of the tube, careful expression can be performed.

When the gestational sac is localized in the interstitial section, the surgery can be performed in two ways: either by excising the segment of the fallopian tube and restoring its patency, or by incising the tube, removing the gestational sac, and subsequently reconstructing the tubal integrity. While tubal patency is preserved in this approach, the epithelial lining is damaged, which subsequently makes the restoration of reproductive function impossible.

Long-term outcomes depend on the clinical course of the ectopic pregnancy, the extent and surgical technique of the operation, and the occurrence of postoperative complications. Between 25% and 50% of operated women remain infertile. The risk of a recurrent ectopic pregnancy ranges from 30% to 48%.

To prevent postoperative Infertility, a phased rehabilitation of menstrual and reproductive function is indicated, particularly in young women. This includes the retrograde administration of medications into the lumen of the unaffected fallopian tube during surgery (Stage I); postoperative antibiotic therapy, hydrotubation with lidase, hydrocortisone, novocaine, and penicillin, as well as iontophoresis with zinc and iodine salts (Stage II). It is advisable to conduct repeat courses of rehabilitation therapy at 3, 6, and 9 months. One year after surgery, spa and sanatorium treatment is recommended (Stage III).