A 25-year-old patient was taken by ambulance to the gynecological department with complaints of severe cramping pains in the lower abdomen. Menstruation from 13 years old, after 4 days, after 22 days, regular, painless, moderate. The last normal period was 3 months ago. Pregnancy -5: 2 births and 3 abortions at will without complications. A month ago, the patient in the hospital underwent a medical abortion at a period of 8 weeks. At the time of the alleged menstruation, aching pains in the lower abdomen appeared, which intensified, turned into cramping. On objective examination, the tongue is moist and clean. The abdomen is soft, painful in the lower parts. There are no symptoms of peritoneal irritation. On vaginal examination: the external os of the cervix is closed. The body of the uterus is enlarged to the size of a man's fist, of a very soft consistency. On both sides of the uterus, formations of a densely elastic consistency are determined. Preliminary diagnosis? A ) Беременность 12 недель. Аборт в ходу/Жүктілік 12 апта. Түсік жасалуда / Pregnancy 12 weeks. Abortion is in progress B ) Внематочная беременность, прервавшаяся по типу трубного аборта/ Жатырдан тыс жүктілік тубальды түсікпен тоқтатылды /Ectopic Pregnancy terminated by tubal abortion C ) Пузырный занос / Көпіршікті тығын/ Molar pregnancy D ) ДМК/ жатырдан дисфункционалды қан кету/ dysfunctional uterine bleeding E ) Аденомиоз/ аденомиоз/ adenomyosis One correct answer
ectopic pregnancy tubal abortion bilateral adnexal mass clinical presentation
Answer: B) Ectopic pregnancy terminated by tubal abortion
Reasoning through the clinical clues
| Finding | Significance |
|---|---|
| Last normal period 3 months ago | Suggests an ongoing pregnancy process |
| Medical abortion 1 month ago at 8 weeks | Raises concern - was that abortion complete? Or was there a concurrent/new ectopic? |
| Cramping lower abdominal pain at expected menses | Classic symptom of tubal abortion (intermittent, colicky) |
| Cervical os closed | Rules out "abortion in progress" (option A), which would have a dilated os with products in the canal |
| Uterus enlarged and very soft | The uterus is enlarged due to hormonal stimulation (decidual reaction from ectopic hCG), not an intrauterine pregnancy |
| Bilateral adnexal formations of densely elastic consistency | This is the key finding - bilateral hematosalpinx or bilateral adnexal masses from ectopic implantation |
| No peritoneal irritation signs | Argues against frank rupture; tubal abortion presents with intermittent bleeding into the peritoneal cavity rather than massive hemorrhage |
| Tongue moist, abdomen soft | No signs of hemodynamic instability or acute peritonism - consistent with tubal abortion, not rupture |
Why the other options are wrong
- A (Pregnancy 12 weeks, abortion in progress): The os is closed. In an abortion in progress, the os is dilated with products of conception in the cervical canal. Also, uterine size and bilateral adnexal masses don't fit.
- C (Molar pregnancy): Molar pregnancy typically presents with a uterus large for dates, very high hCG, absence of a fetal heartbeat, and characteristic "snowstorm" appearance on ultrasound. No adnexal masses bilaterally.
- D (Dysfunctional uterine bleeding): DUB is a diagnosis of exclusion with no structural cause. The bilateral adnexal masses and history don't fit.
- E (Adenomyosis): Adenomyosis causes a diffusely enlarged, boggy uterus with dysmenorrhea, but does not explain bilateral adnexal formations in an acute presentation like this.
Pathophysiology of tubal abortion
A 32-year-old woman complains of constant bursting pains in the lower abdomen, mostly on the right. From the anamnesis: a year ago she was sick with salpingitis, she was treated on her own, did not go to the doctor again, chlamydia was detected during the initial visit to the doctor, the husband did not receive treatment. Vaginally: the uterus is in the correct position, normal size, firm, painless. The appendages on the left are pasty, sensitive on examination. On the right, a formation is palpable, sharply painful on palpation, measuring approximately 2.5 * 5.0. Over the past 2 days, the temperature has risen to 38 degrees. Your preliminary diagnosis: A ) ХСО Сальпингооофорит/ССО Сальпингооофорит/ Salpingo-oophoritis B ) ХСО Пиосальпинкс/ ССО Пиосальпинкс/ Piosalpinx C ) ХСО Гидросальпинкс/ ССОГидросальпинкс/ Hydrosalpinx D ) ХСО Пиоовар/ССО Пиоовар/ Pioovar E ) ХСО Абсцесс яичника/ССО Аналық без абсцессі/ Ovarian abscess
pyosalpinx vs hydrosalpinx vs tubo-ovarian abscess clinical differentiation pelvic inflammatory disease
Answer: B) Chronic salpingo-oophoritis - Pyosalpinx (ХСО Пиосальпинкс)
Systematic Analysis of the Clinical Clues
| Finding | Interpretation |
|---|---|
| History of chlamydial salpingitis, self-treated, untreated husband | Persistent/recurrent ascending infection - classic setup for tubal complications |
| Constant bursting pain, mostly right | Distension of a fluid/pus-filled tube causes this characteristic "bursting" or pressure-like quality |
| Right adnexal mass, sharply painful, 2.5 × 5.0 cm | Elongated, tubular dimensions - this is the shape of a fallopian tube, not an ovary |
| Fever 38°C over 2 days | Active infection/inflammation - indicates purulent (not serous) content |
| Left appendages pasty, sensitive | Chronic inflammatory changes on the left without discrete mass formation |
| Uterus normal size, firm, painless | No endometritis; infection confined to adnexa |
Why Pyosalpinx (B) and not the others?
Pathophysiology Summary
"Collections of pus may accumulate within the ovary and tube (tubo-ovarian abscess) or tubal lumen (pyosalpinx)... The tubal lumen fills with purulent exudate that may leak out of the fimbriated end."
"Internal echoes within the distended fluid-filled tube represent fluid debris or layered pus (pyosalpinx). As active infection subsides, the pus undergoes proteolysis, becoming serous fluid and forms a hydrosalpinx."