I. Overview
Normally, when a woman becomes pregnant the fertilized egg is laid and grows in the uterine cavity. However, for various reasons, the fertilized egg may also be laid outside the uterus, resulting in an ectopic pregnancy. When an ectopic pregnancy occurs, the woman may experience menopause at first, but since the fertilized egg is not in its normal location, a series of problems may occur as the gestational sac grows larger, including abdominal pain, vaginal bleeding, and even death due to hemorrhagic shock, thus posing a serious health risk to the woman. At present, ectopic pregnancy is an important acute abdominal condition causing damage to the female reproductive system and even death, and the incidence is increasing, which can be as high as 5.8%-8.1%, mostly seen in women aged 20-35, and 86% of ectopic pregnancies will rupture and bleed. Therefore, early diagnosis and proper treatment are very important.
II. Etiology
The occurrence of ectopic pregnancy is mainly related to the following factors:
1. Reproductive system infection, especially tubal infection, is the number one killer of ectopic pregnancy. Inflammation of the fallopian tubes can be divided into tubal mucositis and peri-tubal inflammation. Tubal mucositis is the destruction and adhesion of the mucosa in the lumen of the tube due to inflammation, which can narrow the lumen and damage the cilia, thus leading to obstruction of the fertilized egg and its implantation in the area. Peritubal inflammation is mainly in the plasma membrane or plasma muscle layer of the fallopian tube, which often causes adhesions and distortions around the fallopian tube and weak peristalsis of the tube wall, thus affecting the fertilized egg.
2, history of abortion, repeated abortions can damage the intrauterine environment, damage the mucosa and facilitate the growth of pathogens.
3, history of gynecological surgery and intrauterine device.
4. Contraceptive pills, etc. The drugs can affect the peristalsis of the fallopian tubes and delay the entry of the fertilized egg into the uterus, which can lead to ectopic implantation of the fertilized egg.
III. Clinical manifestations
The main manifestations of ectopic pregnancy are lower abdominal pain, vaginal bleeding, menopause, and in severe cases, hemorrhagic shock.
Diagnosis
It is not difficult to diagnose ectopic pregnancy based on the clinical manifestations, ultrasound and serum β-HCG test. Ectopic pregnancy can be diagnosed if a woman of childbearing age has a history of menopause, abdominal pain, vaginal bleeding and other symptoms; ultrasound indicates a mass in the adnexal area or accompanied by abdominal fluid; elevated blood HCG and serum β-HCG>16.2ug/L.
V. Treatment
1.Conservative treatment
Mainly refers to the use of drugs to necrotize the pregnancy sac, and now the commonly used drugs include oral mifepristone and methotrexate. Mifepristone can antagonize progesterone and make the progesterone-dependent fetal sac necrotic and miscarriage occurs. Methotrexate interferes with DNA synthesis, inhibits the proliferation of trophoblast cells and causes their death, thus stopping the development of the ectopic embryo.
Advantages: conservative treatment, relatively simple, easy to operate, high acceptance rate, non-invasive, low side effects, and an efficiency of about 70-90%. It is suitable for those with small gestational sacs and unruptured gestational sacs, and its efficacy is certain. Disadvantages: there is a high incidence of persistent ectopic pregnancy after treatment, long treatment period, narrow indications, etc.
2.Surgical treatment
There are two methods: open and laparoscopic: open requires epidural anesthesia and treatment such as tubal removal and tubal windowing. Open surgery also has problems such as unclean intraoperative resection. Laparoscopy, operated under general anesthesia, is relatively less invasive and, like intrapelvic treatment, is gradually replacing surgical treatments such as open. The problems with the operation are the high risk of anesthesia and trauma, and the removal of the fallopian tubes is not suitable for those with fertility requirements.
3.Interventional treatment.
(1) Vascular interventional therapy is to cut a small incision of 2mm in the root of the thigh under local anesthesia, puncture the femoral artery, insert the catheter into the uterine artery super-selectively, perform methotrexate infusion and unilateral or bilateral uterine artery embolization with gelatin sponge to destroy the sac by cutting off the nutritional supply of the sac, and the necrotic material of the sac can be absorbed by itself.
Vascular interventions deliver drugs directly to the follicle, with small amount of drugs and large local concentration, with few side effects; small trauma, immediate hemostasis, and killing the follicle at the same time, with reliable efficacy and clinical efficiency of 89-100%; high rate of re-pregnancy, almost no effect on the fallopian tube, postoperative tubal patency rate of 66-91.67%, low complications, and ipsilateral re-ectopic pregnancy rate of about The ectopic pregnancy rate on the same side is about 8.3%.
(2) Non-vascular intervention: It refers to the insertion of a specially designed catheter into the affected fallopian tube through the vagina, cervix and uterine cavity under X-ray examination, followed by injection of methotrexate and other drugs, so as to achieve the purpose of treating tubal pregnancy.
Non-vascular interventional treatment of ectopic pregnancy does not require incision, no trauma, no pain, no anesthesia, and only a few catheters and guidewires are needed to deliver drugs to the inside and around the pregnancy sac to directly kill the embryonic tissue, with a small amount of drugs and minimal side effects, with an efficiency of 77.8-100%. Most of the fallopian tubes are open and do not affect future pregnancies. This is of great importance for those who have fertility requirements.
(3) Interventional treatment under ultrasound. Under ultrasound guidance, the pregnancy sac is punctured with a fine needle, the amniotic fluid is withdrawn and diluted methotrexate is injected to kill the embryo. This method is simple and easy, only a needle is needed, there is little pain, and the drug is delivered directly into the pregnancy sac to destroy it, the effect is complete, the efficiency is about 90% or more, and there is little side effect. However, it is not suitable for patients whose masses are too large or who have already ruptured and bled.
In conclusion, interventional treatment has now become the treatment of choice for ectopic pregnancy, and as long as there is no hemorrhage or shock, there is a chance for interventional treatment.