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u Woman of 29 years old was admitted to the hospital with complains on spastic pains in low part of abdomen, scanty bloody discharges from vagina, sub fibril temperature of body.
u. What do You like to know from anamnesis of patient?
0000000 1. How long she has complains? 2. Is she married or not? 3. When was her last menstrual period ? 4. Did she have disturbances of menstrual period in the past? 5. Which type of gynecological diseases she had in the past?
u u u u Answer: 1. She is not completely healthy during 6 days already 2. She is married during one year. No any pregnancy was. 3. She does not remember exact date of last menstrual period, but consider, delay of menstruation on one week She did not have disturbances of menstrual period in the past 4. She had pains in abdomen previously and was hospitalized to gynecological department with diagnosis: Acute bilateral adnexitis. It was 1, 5 years ago.
u How You must assess the patient condition on admission?
You should assess general condition, of skin color, indexes of BP, pulse rate , of abdomen form, painful or painless abdomen on palpation , date of abdomen percussion; date of gynecological examination
General condition is satisfactory. Skin is rather pale. Ps rate is 92 beats in one minute, BP 100/ , 100/60 mm of Hg. Abdomen is not enlarged. There is changes of percutory sound in low parts of abdomen. During gynecological examination it was found, that uterus is slight enlarged, painless, left adnexa without problems , but to the right there is a formation 2, 0 sm in diameter , slight painful. Fornex posterior is flattened /
Which type of additional examination You must prescribe in this case?
Common blood, urine analysis; check blood group, RH factor; smear on microscopy; test on chorionic gonadotropins USI of small pelvis organs coagylogram dynamic of hemodynamic indexes
u Date of laboratory investigation: u Concentration of Hb is 96 gr/ l u Erythrocytes 2 mln 900 thousands u L- 6800, u REP 6 mm/ hour u Blood group B ( III) third, Rh positive u Degree of vagina purity is the II
u Test on CH Gonatropins is positive u What is Your assessment of USI date and another methods of examination?
u USI date: u Uterus is normal size, is 0, 9 sm in depth u How it is seen, there is inside endometrium no embryo
u What is Your assessment of USI date and another methods of examination?
What is Your provisional diagnosis?
It is difficult to put diagnosis exactly, but may be it is Ectopic pregnancy?
u u u Differential diagnosis it is necessary to perform with such diseases, as: Beginning early abortion Apoplexy of ovary Torsion of tumor of ovary peduncle Complete early abortion dysfunctional uterine bleeding
u u u Common for present disease and all types of interrupted pregnancy is : delay of menstruation positive test on Ch. Gonadotropins Difference: absence of embryo in uterine cavity; uterus is slight enlarged only; There is no such complains, as nausea, vomiting….
u Apoplexy of ovary, anemic form. Common symptoms: pains in abdomen, u Decreasing of Hb, erythrocytes level, u suddenly, happened symptoms of anemia, hemodinamic indexes u Difference: in cases of apoplexy of ovary there is no delay of menstruation , u Symptoms appear at the middle of menstrual cycle , as a rule.
u Torsion of tumor peduncle: u Common symptoms are: spastic pains in low abdomen: u Some formation in ovary region, that is completely seen during USI u Difference: positive test on pregnancy in our case, moderate character of pains, but for torsion of tumor peduncle more characteristic is very sever pain
u Dysfunctional uterine bleeding. Common symptoms are bloody discharges from vagina, delay of menstruation. u Difference: positive test on pregnancy in our case, spastic character of pains, u some formation in place of adnexa.
Which additional method of examination it is necessary to use for making our diagnosis more exact?
Puncture of fornex posterior.
u. What is particularity of blood, that was receiving from abdominal cavity in our case ?
It was fluid. There is no tendency to coagulation of blood, because it is from abdominal cavity.
What is Your tactic after that?
Laparotomy should be done, because our patient has internal bleeding. If it is possible , laparoscopy.
Which types of operation may be performed in our case?
From which factors surgical tactic depending on?
u u It is possible to perform 2 types of operations: salpingectomy ( removing of tube) salpingotomy – conservative operation on tube. Type of operation depending on the general condition of patient. Bad condition of patient, signs of hemorrhagic shock are contraindications for plastic operation on tube.
What is Your clinic Diagnosis?
My diagnosis is. Wright side ectopic pregnancy. Tubal abortion.
During operation a lot of adherences , surrounding pregnant tube were found. Doctor decided to perform salpingectomy.