Ruptura de l'embaràs ectòpic i sagnat precoç de l'embaràs¶

Un embaràs ectòpic es produeix quan un òvul fecundat s'implanta i comença a créixer fora de la cavitat principal de l'úter, més freqüentment dins de la trompa de Fal·lopi estreta (del 95 al 97% dels casos, conegut com a embaràs tubàric), o més rarament a l'ovari, el coll uterí, la còrnia uterina o una cesària prèvia. Com que la trompa de Fal·lopi només fa 1 a 4 mil·límetres (0,04 a 0,16 polzades) d'amplada i no té una paret muscular gruixuda, l'embrió en creixement i els vasos sanguinis placentaris inevitablement s'estiren i s'erosionen a través de la paret tubàrica, normalment entre 5 i 10 setmanes d'embaràs (sovint abans que la pacient sàpiga que està embarassada). Quan la trompa de Fal·lopi es trenca, les branques de gran flux de les artèries uterines i ovàriques aboquen 1.000 a 2.500 mil·lilitres (de 2 a 5 pintes) de sang directament a la cavitat abdominal (hemoperitoneu) amb poc o cap sagnat vaginal visible. L'embaràs ectòpic trencat és la causa número u de mort materna en el primer trimestre del món, que requereix un transport immediat en ambulància per a la cirurgia laparoscòpica d'emergència i la transfusió de sang.

Fes això ara¶

1. Truqueu immediatament al vostre número d'emergència local si una persona embarassada (o potencialment embarassada) té dolor pèlvic unilateral combinat amb marejos, desmais, pell pàl·lida o dolor a la punta de l'espatlla. Truqueu al 911 als Estats Units i al Canadà, 112 a tota la Unió Europea, 999 al Regne Unit o consulteu-ho tot. números d'emergència. Digueu clarament al despatxador: "Sospita d'embaràs ectòpic trencat amb hemorràgia interna i xoc", de manera que la tripulació de l'ambulància prepara líquids intravenosos i avisa el quiròfan obstètric de l'hospital.
2. Lay the person flat on her back (or tilted slightly onto her left side) and do NOT let her stand or walk. Standing upright or sitting on the toilet when over a liter of blood has pooled inside the abdomen causes blood pressure to crash immediately (orthostatic syncope), leading to sudden loss of consciousness, head trauma on bathroom floors, and cardiac arrest. Keep her lying down on the bed or floor until paramedics lift her onto a stretcher.
3. No donar estrictament RES per via oral (sense aigua, menjar ni analgèsics). Un embaràs ectòpic trencat només es pot aturar al quiròfan amb anestèsia general. Mantingueu el pacient estrictament res per la boca (NPO) perquè no vomiti i inhali el contingut de l'estómac als pulmons durant la intubació endotraqueal d'emergència. A més, no donar mai aspirina, ibuprofè o naproxè, que perjudiquen la coagulació plaquetària i empitjoren l'hemorràgia interna.
4. Never insert tampons, never douche, and never press down on the lower abdomen. If vaginal bleeding is present, place a clean external sanitary pad (maternity pad) in the underwear so doctors can estimate external blood loss by counting how many pads are soaked per hour. Do not press or palpate the lower belly: firm pressure on an unruptured or leaking tubal pregnancy can burst the distended fallopian tube and trigger catastrophic arterial bleeding.
5. Keep the patient warm with blankets and monitor her pulse and breathing every 3 to 5 minutes. Cover her with a warm blanket and place insulation underneath her if she is lying on a tile floor. Preventing hypothermia (core temperature below \(35^\circ\text{C}\) or \(95^\circ\text{F}\)) is critical because cold blood loses its ability to clot. If she becomes unconscious, roll her onto her left side in the lateral recovery position to keep her airway clear.
6. Confirm pregnancy status if unknown and gather medical history for paramedics. Note the first day of her last normal menstrual period (LMP), whether she has an intrauterine device (IUD / coil) or a prior tubal ligation ("tubes tied"), any history of prior ectopic pregnancy or pelvic inflammatory disease, and her Rh blood type (if known). Tell paramedics immediately if she has experienced pain while trying to open her bowels or urinate, which is a classic sign of liquid blood pooling in the pelvic Pouch of Douglas.

First-trimester bleeding and acute pelvic pain clinical decision tree¶

Use this triage flowchart for any female of reproductive age (from puberty to menopause, roughly ages 12 to 52) presenting with lower abdominal pain or vaginal bleeding.

flowchart TD
    Start["Female of Reproductive Age (12 to 52 yrs) with:<br/>Positive Pregnancy Test, Missed/Late Period, OR Irregular Spotting<br/>PLUS Pelvic/Abdominal Pain or Vaginal Bleeding"] --> RedFlagCheck{"Are ANY Ruptured Ectopic / Shock Red Flags Present?<br/>1. Dizziness, lightheadedness, or fainting (syncope)<br/>2. Sharp pain at the tip of the shoulder (Kehr's sign)<br/>3. Severe or worsening one-sided (unilateral) lower belly pain<br/>4. Pain/pressure when trying to pass stool or urinate<br/>5. Pale, cold, clammy skin or fast pulse (>100 bpm)<br/>6. Soaking >= 2 maxi pads per hour for 2 hours"}

    RedFlagCheck -->|"YES: Any single red flag present"| Emergency911["CRITICAL SURGICAL EMERGENCY (Suspected Ruptured Ectopic / Hemorrhage):<br/>1. Call 911 / 112 / 999 Immediately<br/>2. Lay flat on back (or left side if nauseated/unconscious); DO NOT let walk<br/>3. Keep Strictly Nothing by Mouth (NPO) for emergency surgery<br/>4. Keep warm with blanket; use external sanitary pad only"]

    RedFlagCheck -->|"NO: Hemodynamically stable,<br/>no fainting, no shoulder pain"| PainVsBleed{"What symptoms are present right now?"}

    PainVsBleed -->|"Mild-to-moderate one-sided pelvic ache<br/>OR dark brown 'prune-juice' spotting"| UrgentSameDay["HIGH RISK FOR UNRUPTURED ECTOPIC PREGNANCY:<br/>Go to Emergency Department or Early Pregnancy Assessment Unit (EPAU) TODAY<br/>Requires same-day Transvaginal Ultrasound + Quantitative Serum beta-hCG<br/>Do NOT wait for a routine prenatal appointment next week"]

    PainVsBleed -->|"Midline menstrual-like cramping<br/>with pink/red vaginal bleeding"| MiscarriageEval["Possible Threatened, Incomplete, or Complete Miscarriage:<br/>Contact OB/GYN or Early Pregnancy Clinic within 24 hours for Ultrasound<br/>and Rh(D) Blood Type check (Anti-D / RhoGAM needed within 72 hrs if Rh-negative)<br/>Go to ER immediately if pain shifts to one side or bleeding increases"]

    PainVsBleed -->|"Painless light spotting only<br/>around expected period date"| LightSpotEval["Possible Implantation Bleeding, Cervical Ectropion, or Subchorionic Hematoma:<br/>Avoid tampons and sexual intercourse; schedule prompt ultrasound<br/>to confirm an intrauterine pregnancy (IUP) inside the uterus"]

Comparing causes of first-trimester bleeding and pelvic pain¶

Because up to 20 to 25 percent of all pregnancies experience some vaginal spotting or bleeding during the first 12 weeks, distinguishing a life-threatening ectopic pregnancy from a miscarriage or harmless subchorionic hematoma saves lives.

Anatomia i fisiopatologia: per què una trompa de Fal·lopi trencada sagna tan ràpid¶

Per entendre per què una dona amb un embaràs ectòpic trencat pot passar de caminar i parlar a una aturada cardíaca total en menys de 45 minuts, considereu l'anatomia de la pelvis femenina:

1. Per què la trompa de Fal·lopi no pot estirar-se com l'úter: l'úter humà normal té una paret muscular llisa gruixuda i de diverses capes (miometri) dissenyada per expandir-se 500 vegades en volum durant 9 mesos. En canvi, la trompa de Fal·lopi (ampula i istme) és un conducte muscular delicat i prim com un cabell revestit de cilis microscòpics l'única feina dels quals és escombrar un òvul fecundat a l'úter durant 3 o 5 dies. Quan l'embrió s'enganxa a la trompa de Fal·lopi, les cèl·lules invasores del trofoblast (que estan programades per endinsar-se en els vasos sanguinis materns profunds per construir una placenta) ** s'enfonsen directament a través de la paret fina de paper de la trompa de Fal·lopi** i toquen directament les branques tubàriques de l'artèria uterina i l'artèria ovàrica.
2. Subministrament de sang arterial dual en vasodilatació de l'embaràs: durant l'embaràs primerenc, les hormones maternes augmenten el flux sanguini pèlvic i la producció cardíaca. Com que la trompa de Fal·lopi es troba al llarg d'una arcada arterial alimentada per ambdós extrems (per l'artèria uterina des de l'artèria ilíaca interna a la part media i per l'artèria ovàrica directament de l'aorta abdominal lateralment), una llàgrima a través de la trompa de Fal·lopi obre un brot arterial bidireccional d'alta pressió a la cavitat peritoneal lliure.
3. Per què passa el signe de Kehr (dolor a la punta de l'espatlla): no hi ha res dolent amb l'articulació de l'espatlla del pacient. Quan de \(500\text{ a }1.500\text{ mil·lilitres}\) de sang líquida surten de la pelvis i la dona s'estira plana (o es recolza en un sofà), la gravetat fa que la sang líquida càlida flueixi cap amunt pels canals paracòlics i s'agrupi directament sota el diafragma muscular (la cúpula del múscul abdominal que separa el pit). La part inferior del diafragma està innervada pel nervi frènic, que s'origina al coll a les arrels nervioses de la columna cervical C3, C4 i C5. Com que les mateixes arrels nervioses C3, C4 i C5 també subministren la pell a la part superior de l'espatlla i la clavícula (nervis supraclaviculars), el cervell interpreta erròniament la irritació de la sang diafragmàtica com a dolor agut i punxant just a la punta de l'espatlla.
4. Why "Bathroom Fainting" and Rectal Pressure happen (Pouch of Douglas pooling): When the woman is upright or sitting, blood pools in the lowest gravity pocket of the female pelvis: the rectouterine pouch (Pouch of Douglas / posterior cul-de-sac), which sits immediately in front of the rectum. Blood distending this space presses directly on the rectum and pelvic parasympathetic nerves, giving the woman a sudden, intense urge that she "needs to have a bowel movement." She walks into the bathroom, sits on the toilet, and strains, which drops venous return to her heart and causes immediate syncopal collapse on the bathroom floor.

Hidden traps: Why you can still have an ectopic pregnancy with an IUD, "tubes tied," or after "getting your period"¶

Three common misunderstandings delay emergency care every day:

1. "She just had her period last week, so she cannot be pregnant"¶

Up to 30 percent of patients diagnosed with a ruptured ectopic pregnancy report that they had what they thought was a normal or slightly light menstrual period 1 to 3 weeks earlier. In reality, when an ectopic pregnancy implants in the fallopian tube, it produces lower-than-normal levels of human chorionic gonadotropin (\(\beta\text{-hCG}\)) and progesterone, causing the lining of the empty uterus to slough and bleed right around the time a period was due. Any female of reproductive age with acute unilateral pelvic pain, shoulder pain, or unexplained fainting must have a urine or blood pregnancy test immediately, regardless of her menstrual history.

2. "She has an IUD (Intrauterine Device / Coil) or had a Tubal Ligation ('Tubes Tied')"¶

While intrauterine devices (such as Mirena, Kyleena, Liletta, or Copper ParaGard IUDs) and surgical tubal sterilization are over 99 percent effective at preventing pregnancy inside the uterus, if a rare pregnancy DOES occur while an IUD is in place or after a prior tubal ligation, there is a 15 to 50 percent chance that the pregnancy is an ECTOPIC pregnancy in the fallopian tube. Having an IUD or tied tubes actually places a pregnant patient in the highest possible risk category for tubal rupture.

3. Major medical risk factors for ectopic pregnancy¶

While roughly 50 percent of all women diagnosed with an ectopic pregnancy have ZERO known risk factors, the risk is significantly elevated in patients with: - A previous ectopic pregnancy (10% to 25% recurrence risk). - Previous Pelvic Inflammatory Disease (PID) or prior Chlamydia trachomatis or Neisseria gonorrhoeae infection (which leaves microscopic scar adhesions inside the delicate cilia of the fallopian tube). - Prior fallopian tube surgery, tubal ligation reversal, appendectomy (especially ruptured appendix), endometriosis, or pelvic surgery. - In Vitro Fertilization (IVF) and Assisted Reproductive Technology (ART): Including a rare condition called a heterotopic pregnancy, where one embryo implants normally inside the uterus AND a second twin embryo implants simultaneously inside the fallopian tube (occurring in roughly 1 in 100 to 1 in 1,000 IVF pregnancies). - Cigarette smoking (nicotine and cotinine paralyze the rhythmic beating of fallopian tube cilia, slowing embryo transport).

How to evaluate external vaginal bleeding volume and the Rh-Negative (Anti-D / RhoGAM) 72-hour rule¶

If a first-trimester patient is having visible vaginal bleeding (whether from an ectopic pregnancy or a miscarriage), doctors need two critical pieces of information:

1. Counting maxi pads per hour (The "2 Pads Per Hour for 2 Hours" Hemorrhage Rule)¶

• Place a standard full-size external sanitary pad (maxi pad) in the underwear (never use a tampon or menstrual cup, which traps blood inside the vagina and can introduce bacteria through an open cervix).
• Emergency Hemorrhage Threshold: If vaginal bleeding is heavy enough to completely soak through 2 or more full-size maxi pads per hour for 2 consecutive hours (or 1 pad every 15 to 30 minutes), or if the patient passes blood clots larger than a golf ball or lemon (\(4\text{ to }5\text{ centimeters}\) / \(1.5\text{ to }2\text{ inches}\)), call 911 / 112 / 999 immediately.
• If grey or pink solid tissue is passed: If the patient passes solid tissue during a suspected miscarriage, gently place the tissue into a clean glass jar or plastic container (or wrap it in a damp clean paper towel inside a sealed plastic bag) and bring it to the hospital so pathologists can inspect it for chorionic villi (confirming an intrauterine miscarriage rather than an ectopic pregnancy).

2. The Rh-Negative Blood Type Rule (Anti-D Immunoglobulin / RhoGAM)¶

If the pregnant woman has Rh-negative blood (\(A\text{-negative}, B\text{-negative}, AB\text{-negative}, \text{or } O\text{-negative}\)) and has an ectopic pregnancy, a threatened or complete miscarriage, or abdominal trauma, fetal Rh-positive red blood cells can enter her bloodstream and sensitize her immune system to attack future babies (hemolytic disease of the fetus and newborn). - Be sure to ask the hospital or Early Pregnancy Assessment Unit whether she requires an intramuscular injection of Anti-D immunoglobulin (RhoGAM) within 72 hours of the start of bleeding or surgery (following national guidelines from ACOG in the United States, RCOG/NICE in the United Kingdom, and SOGC in Canada).

What happens at the hospital: Transvaginal ultrasound, the hCG Discriminatory Zone, and treatment¶

Knowing how hospital emergency physicians and obstetricians diagnose and treat an ectopic pregnancy helps partners and families understand what is happening:

1. Point-of-Care FAST Ultrasound and Transvaginal Ultrasound (TVUS): Within minutes of ambulance arrival for an unstable patient, emergency doctors place an ultrasound probe on the abdomen (FAST exam: Focused Assessment with Sonography in Trauma) looking at Morison's pouch (between the liver and right kidney) and the pelvic cul-de-sac. Seeing dark liquid blood in Morison's pouch confirms at least \(500\text{ to }1,000\text{ milliliters}\) of free blood in the abdomen and triggers immediate transfer to the operating room without waiting for lab work. In stable patients, a high-resolution transvaginal ultrasound checks the uterus and adnexa for a gestational sac, yolk sac, or a "tubal ring" / "ring of fire" mass next to the ovary.
2. Quantitative Serum \(\beta\text{-hCG}\) and the Discriminatory Zone: Doctors draw blood to measure the exact numerical level of beta-human chorionic gonadotropin (\(\beta\text{-hCG}\)). Once serum \(\beta\text{-hCG}\) reaches the discriminatory zone of \(1,500\text{ to }3,500\text{ mIU/mL}\) (\(IU/L\)), a normal healthy pregnancy inside the uterus should almost always be visible on transvaginal ultrasound; an empty uterus combined with a \(\beta\text{-hCG}\) above \(3,500\text{ mIU/mL}\) (or a \(\beta\text{-hCG}\) that fails to rise appropriately over 48 hours in a "Pregnancy of Unknown Location" [PUL]) strongly points to an ectopic pregnancy.
3. Surgical vs. Medical Treatment:
4. Emergency Laparoscopic Surgery (Salpingectomy or Salpingostomy): Required for every ruptured ectopic pregnancy, any patient with hemodynamic instability, free peritoneal blood, severe pain, or a fetal heartbeat inside the fallopian tube. Surgeons remove the ruptured fallopian tube (salpingectomy) or open the tube to remove the pregnancy (salpingostomy) and transfuse O-negative or crossmatched blood. (Having one fallopian tube removed still leaves 70 to 85 percent of normal natural fertility via the remaining healthy tube).
5. Medical Management with Intramuscular Methotrexate (Only for Stable, Unruptured Ectopics): If an ectopic pregnancy is caught early before it ruptures, and the patient is completely stable with minimal pain and a small unruptured mass, doctors can often avoid surgery by giving an intramuscular injection of methotrexate (a folate antagonist that stops rapidly dividing placental cells so the body safely reabsorbs the pregnancy over 2 to 6 weeks). Critical post-methotrexate warning: Even after receiving a methotrexate shot, the fallopian tube remains fragile and can still rupture 3 to 14 days later; if a patient who received methotrexate develops sudden severe abdominal pain, shoulder-tip pain, or dizziness at home, call 911 / 112 / 999 immediately.

Rare non-tubal ectopic locations that rupture with catastrophic bleeding¶

While 95 to 97 percent of ectopic pregnancies implant in the main ampulla or isthmus of the fallopian tube, about 3 to 5 percent implant in unusual anatomical sites where diagnosis is harder and internal hemorrhage can be even more violent:

• Interstitial (Cornual) Ectopic Pregnancy (2% to 4% of ectopics): Implants in the proximal segment of the fallopian tube that tunnels directly through the thick muscular wall of the uterus, right where the uterine and ovarian arteries anastomose. Because the surrounding uterine muscle is thicker than the outer fallopian tube, an interstitial pregnancy can grow until 8 to 14 weeks of gestation before suddenly exploding through the uterine horn, causing rapid exsanguination with a mortality rate up to 2 to 5 times higher than standard tubal pregnancies.
• Embaràs de la cicatriu per cesària (CSP): s'implanta directament al defecte fibrós microscòpic (nínxol) d'una cicatriu prèvia de la cesària del segment inferior. A mesura que la placenta creua la cicatriu prima cap a la bufeta urinària, pot provocar una ruptura uterina catastròfica del primer o segon trimestre o una hemorràgia de l'espectre de la placenta accreta.
• Embaràs ectòpic cervical, ovàric i abdominal: implantació dins del canal endocervical (provocant hemorràgia vaginal torrencial indolora), a la superfície de l'ovari o directament sobre el revestiment peritoneal o la serosa intestinal dins de la cavitat abdominal.

Preguntes freqüents¶

Fonts revisades¶

• American College of Obstetricians and Gynecologists (ACOG, Estats Units): Practice Bulletin No. 193: Tubal Ectopic Pregnancy i Practice Bulletin No. 200: Early Pregnancy Loss.
• National Institute for Health and Care Excellence (NICE, Regne Unit) i Royal College of Obstetricians and Gynecologists (RCOG, Regne Unit): Embaràs ectòpic i avortament involuntari: diagnòstic i gestió inicial (NG126, actualitzat el 2023) i Directriu Green-top núm. 21 i gestió de l'embaràs.
• Society of Obstetricians and Gynaecologists of Canada (SOGC, Canada): Clinical Practice Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Non-Tubal Ectopic Pregnancies.
• Organització Mundial de la Salut (OMS): Gestió de les complicacions en l'embaràs i el part: sagnat vaginal en l'embaràs precoç i protocols quirúrgics d'embaràs ectòpic trencats.

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