Fallopian tube rupture is a violation of the integrity of the fallopian tube, which occurs during ectopic pregnancy. The destruction of the organ wall is accompanied by bleeding of varying intensity, the development of acute anemia and an increase in the symptoms of hemorrhagic shock. The acute abdominal clinic comes out on top. The diagnosis is made taking into account the anamnesis, in which there is a delay in menstruation. Gynecological examination, puncture of the posterior vaginal arch and diagnostic laparoscopy are performed. To eliminate the consequences of rupture of the fallopian tube, its removal is necessary, conservative therapy is aimed at combating shock.
O00.1 Tubal pregnancy. Rupture of the (fallopian) tube due to pregnancy
Tubal pregnancy often ends with spontaneous abortion, but in 48% of cases there is a rupture of the fallopian tube. The risk increases with implantation of the fetal egg closer to the isthmic part, attachment in the ampullary part is rarely accompanied by severe tissue damage. Currently, there is an increase in the frequency of ectopic pregnancy, passing into the rupture of the oviduct. This is associated with the prevalence of pelvic inflammatory diseases. The probability of developing pathology is higher in women under 25 years of age.
Rupture of the oviduct is diagnosed at 4-6 weeks of tubal pregnancy. With localization in the interstitial department, the interruption may occur a month later. The provoking factors contributing to the ectopic attachment of the fetal egg and the destruction of the oviduct are:
- Acute salpingitis. After a single inflammation, ectopic pregnancy is diagnosed in 6% of cases, after three episodes of adnexitis, tubal attachment of the egg is observed in 22% of women. With inflammation, the structure of tissues changes, they become loose, peristalsis is disturbed, adhesions form.
- Operations on appendages. Rupture of the fallopian tube may occur after surgical treatment of obstruction, salpingostomy. The probability of pathology increases in patients who have undergone sterilization by electrocoagulation. Less often, the condition is observed 2-3 years after tubal ligation.
- Adhesive process in the pelvis. With endometriosis, chronic inflammation, and surgeries, adhesions form that disrupt the patency of the fallopian tubes, change their configuration and anatomical position.
- Anomalies of development. With diverticula or hypoplasia of the fallopian tubes, the walls of the organs are initially defective, the structure of the mucous membrane is disturbed. The advancement of the egg is difficult, after abnormal implantation, a rupture is possible.
Normally, fertilization of an egg occurs in the ampullary part of the oviduct. Then it is directed to the uterine cavity with the help of peristalsis of the muscle layer of tissues and the movement of the cilia of the epithelium. If there is an obstacle in the way, the progress of the embryo becomes difficult or stops. When staying in the tube for up to 7 days, an invasion into the mucous membrane of the oviduct occurs.
Chorionic villi germinate under the epithelium, and the fetal egg sinks into it, forming a fecundity. The inner capsule becomes the mucous membrane, the outer – the wall of the tube. The chorion forms a layer of fibrinous necrosis. The gradual increase in the embryo stretches the tissues, they thin out. When the critical size is reached, the fallopian tube ruptures, which is accompanied by the death of the fetal egg, followed by intense bleeding into the abdominal cavity.
When a large vessel is damaged, massive blood loss and hemorrhagic shock are observed. When the tube wall breaks, facing towards the wide binding of the uterus, blood accumulates between its leaves. A small amount may leak into the pelvis, so there is an aggravation of shock with minimal symptoms of peritoneal irritation.
The condition develops suddenly. The appearance of signs of pipe rupture is preceded by a delay in menstruation. Pathology occurs 5-6 weeks after the start of the last menstruation. The severity of symptoms depends on the intensity of bleeding into the abdominal cavity, not related to the size of the defect.
Paroxysmal pain in the lower abdomen develops against the background of normal well-being. It has no clear localization, is displaced to the left or right iliac region, gives into the perineum, lower back or upper thighs. In women with a low threshold of sensitivity, pain is accompanied by dizziness, short-term loss of consciousness. Sometimes it bothers reflex nausea, vomiting and hiccups. Urination is delayed, less frequent.
Intestinal irritation causes diarrhea, false urges. Symptoms of shock appear. The pregnant woman turns pale, becomes sluggish, her pupils dilate. The lips acquire a bluish hue, cold sweat appears on the face. The heartbeat quickens, the pulse gradually weakens. Blood pressure is low and continues to drop rapidly. Shortness of breath worries.
A typical sign of a ruptured fallopian tube is bloating. During breathing or changing the position of the body, the pain increases, so the patient is almost motionless, breathing is shallow. Unlike infectious peritonitis, there is no tension of the abdominal wall muscles. Sometimes, after the first attack, the pain almost completely subsides, and later resumes with greater force.
Hemorrhagic shock is possible. Against the background of untimely treatment, a fatal outcome is observed in 15-30% of cases. With the loss of 15% of CBV, stage 1 of hemorrhagic shock develops, blood pressure is about 100 mm Hg. For stage 2, blood loss up to 30% is typical, hypotension up to 80-90 millimeters Hg., tachycardia 110-120 beats / min. Stage 3 is characterized by loss of 30-40% of blood, confusion, pallor of the skin, cyanosis appears.
When more than 40% of the volume of circulating blood is poured out, stage 4 of shock develops. Vital functions are depressed, consciousness is absent, arterial and central venous pressure is not determined, the pulse is not palpable. Severe irreversible changes appear in the internal organs, which lead to death.
An examination of a patient with an acute abdominal clinic is carried out by an obstetrician-gynecologist. The surgeon’s help is necessary for the differential diagnosis of gynecological pathology with acute appendicitis, diverticulitis, peritonitis and other conditions. The gynecologist differentiates the rupture of the fallopian tube with tubal abortion, torsion of the cyst leg, ovarian apoplexy and peritonitis. The following survey methods are used:
- Gynecological examination. Causes increased abdominal pain, is carried out carefully so as not to increase bleeding. Cyanosis of the entrance to the vagina is noted, spotting may appear on the second day. Displacement of the cervix is painful. Through one of the lateral arches, the formation of a testy consistency is palpated. The posterior arch is bulging, extremely painful.
- Laboratory diagnostics. To determine the severity of the condition and the severity of anemia, a general blood test is required. HCG research is performed only with the erased clinical picture.
- Culdocentesis. Puncture of the posterior vaginal arch is performed with an unexpressed clinical picture of an oviduct rupture. They get dark scarlet blood with small clotted grains. Bright red blood without signs of clotting indicates a vessel injury. In severe shock, the method is not used.
- Ultrasound of the pelvis. The uterus of normal size is determined. It is impossible to diagnose the rupture of the oviduct directly with ultrasound, an indirect sign of pathology is the accumulation of fluid in the pelvis.
- Diagnostic laparoscopy. There is a large amount of dark blood in the abdominal cavity. The uterus is not enlarged, when examining the appendages, a rupture of the fallopian tube, a bleeding vessel is found. Usually, immediately after the pathology is detected, therapeutic measures are carried out.
Treatment of fallopian tube rupture
With symptoms of an acute abdomen and suspected violation of the integrity of the tube, a woman is urgently hospitalized in the department of gynecology. Treatment is aimed at maintaining vital functions, stopping internal bleeding and eliminating the effects of shock. The operation is performed in the first hours after admission. Drug therapy is carried out after surgery or simultaneously with it.
The goal of conservative treatment for fallopian tube rupture is to maintain blood volume and hemoglobin concentration, and to prevent hemorrhagic shock. Intravenously, colloidal and crystalloid solutions, plasma and blood substitutes are prescribed. Symptomatic therapy aimed at maintaining breathing and blood pressure is necessary. With a high risk of infection, broad-spectrum antibiotics are administered.
Laparotomic or laparoscopic access is used to stop abdominal bleeding. Restoration of the integrity of the fallopian tube is impossible, the organ is removed, the stump is bandaged. The tubal angle of the uterus is not excised. If the fetal egg is localized in the interstitial part, with incessant bleeding, extirpation of the uterus may be required. Blood clots are extracted from the abdominal cavity, rinsing with saline is performed.
Prognosis and prevention
When performing surgical treatment of rupture of the fallopian tube before the development of hemorrhagic shock, the prognosis is favorable. In other cases, wait-and-see tactics and delayed intervention aggravate the woman’s condition and increase the risk of death. With a diagnosed tubal pregnancy without signs of interruption, methotrexate treatment can be used to prevent rupture.
It is possible to prevent tubal pregnancy with rupture of the oviduct by preventing and timely treatment of pelvic inflammatory pathologies. With hydrosalpinx or hematosalpinx, removal of the fallopian tube is recommended. Prevention of ectopic pregnancy and rupture of the tube in adhesive disease by hydrotubation, the use of vitreous, aloe and lidase is ineffective, equated to placebo.