1.Clinical data
1.1 General data
The age of onset in this group ranged from 17 to 43 (average 27.8) years. There were 28 cases with pregnancy history, accounting for 84.8%, 5 cases without pregnancy history, accounting for 15.2%; 22 cases with abortion history, 8 cases with cesarean section history, 5 cases with infertility; 16 cases with intrauterine device, 7 cases with bilateral tubal ligation, 6 cases with instrumental contraception and pharmacological contraception, 4 cases without contraception (one of them had bilateral tubal removal for two ectopic pregnancies); 3 cases with repeated ectopic pregnancies.
In this group, there were 20 cases with clear history of menopause, 28 cases with lower abdominal pain, 8 cases with anal swelling, 23 cases with vaginal bleeding, 13 cases with cervical pain, 10 cases with pelvic masses on gynecological examination, 3 cases with no symptoms; 30 cases with positive urinary chorionic gonadotropin, 2 cases with weak positivity and 1 case with negative; 18 cases with pelvic fluid, 13 cases with adnexal masses and 3 cases with no echo in the uterus on ultrasound examination. There were 9 cases of misdiagnosed appendicitis, 7 cases of ruptured corpus luteum, 5 cases of hemorrhagic salpingitis, 2 cases of pelvic inflammatory disease, 2 cases of preterm abortion, 2 cases of early pregnancy, 1 case of gonorrhea, 1 case of dysmenorrhea, 1 case of ovarian cyst torsion, 1 case of intestinal obstruction, 1 case each of gastroenteritis and colitis.
1.2 Misdiagnosis of diseases and diagnosis and treatment
1.2.1 Misdiagnosis as surgical disorders
One case was misdiagnosed as intestinal obstruction: manifested as abdominal pain, nausea and vomiting, with a history of previous abdominal surgery and gas-fluid flat on abdominal dialysis, diagnosed as intestinal obstruction and admitted to surgery. Later, shock appeared and a small amount of vaginal bleeding was found, gynecological consultation was requested, and non-coagulated blood was withdrawn by posterior vault aspiration, which was transferred to emergency gynecological surgery and confirmed as ectopic pregnancy.
1.2.2 Misdiagnosis as gynecological disorder
Seven cases were misdiagnosed as ruptured corpus luteum, all of which had irregular vaginal bleeding, sudden lower abdominal pain and anal cramping; ultrasound examination showed hypoechoic light mass in the adnexal area on one side. The possibility of ectopic pregnancy was overlooked because two cases had bilateral tubal ligation and four cases had intrauterine device contraception. In 5 cases, ectopic pregnancy was confirmed by caesarean section and in 2 cases by laparoscopic exploration.
Four cases were misdiagnosed as intrauterine pregnancy: one case was diagnosed as intrauterine pregnancy due to menopause, small amount of vaginal bleeding, positive urinary HCG and ultrasound suggesting no echo in the uterus, two cases of preterm abortion, which were treated with fetal preservation, followed by sudden lower abdominal pain and posterior vault aspiration with non-coagulated blood; one case was considered as early pregnancy due to menopause, positive urinary HCG and ultrasound suggesting no echo in the uterus, and abortion was performed, and the aspirate was sent for pathological examination, which showed metaplasia-like The ultrasound examination indicated pelvic mass and peritoneal fluid, and non-coagulated blood was extracted by posterior vault aspiration; one case had vaginal bleeding and abdominal pain after a pharmacological abortion in a private clinic due to menopause and positive urine HCG, and non-coagulated blood was extracted by posterior vault aspiration, and dissection was performed in all four cases. Ectopic pregnancy.
Five cases of hemorrhagic tubal infection were misdiagnosed: all patients in this group had vaginal bleeding with lower abdominal pain. three cases had a history of menopause, and one of them had bilateral tubal ligation. Ultrasound examination showed liquid dark areas in the pelvis and no mass in the adnexal area. She was treated with anti-infection and hemostasis, but her symptoms were not relieved. She was treated with anti-infection and hemostasis, but her symptoms did not relieve. gynecologic examination showed painful cervical lifting, non-coagulated blood from posterior vault aspiration, and positive urine pregnancy test. 2 cases of ruptured tubal pregnancy and bleeding were found during the exploratory laparotomy, and 3 cases of tubal pregnancy and miscarriage were found during the laparoscopic exploration.
Two cases were misdiagnosed as pelvic inflammatory disease: both cases were seen in private clinics without ultrasound and gynecological examination, and were diagnosed as early pregnancy only on the basis of positive urine pregnancy test, and drug abortion was performed.
One case was misdiagnosed as ovarian tumor torsion: the patient had no history of menopause and presented only with abdominal pain with nausea and vomiting, ultrasound suggested a pelvic mass, and ectopic pregnancy was detected by caesarean section.
The patient had no obvious history of menopause, vaginal bleeding with no abdominal pain, and ultrasound examination showed no significant abnormalities in the intrauterine and ectopic areas. Five days later, due to sudden onset of left lower abdominal pain, the patient had a 4-cm mixed mass in the right adnexal area on repeat ultrasound. 266.4 mIU/mL of THCG was detected and laparoscopic investigation confirmed abortion of tubal jugular pregnancy.
One case of misdiagnosis of dysmenorrhea: the patient was 17 years old, complained of irregular vaginal bleeding with menstrual flow, withheld medical history and denied having sexual history, the emergency physician also did not do other related tests and considered it as dysmenorrhea, and gave symptomatic treatment for pain relief. A laparoscopic investigation was performed to confirm the pregnancy in the right fallopian tube.
1.2.3 Misdiagnosis as medical disorders
One case was misdiagnosed as gastroenteritis due to abdominal pain, nausea and vomiting, and post-acute feeling; and one case was misdiagnosed as colitis due to abdominal pain, diarrhea with low-grade fever. In both cases, conservative treatment was ineffective, followed by increased abdominal pain and pallor, and abdominal puncture was performed after consultation with obstetrics and gynecology to draw out non-coagulated blood.
2.Results
All 33 cases in this group were treated surgically, and the reports were confirmed by medical examination. Among the 33 cases, 30 were tubal pregnancies, 2 were ovarian pregnancies, and 1 was a residual angle pregnancy. The maximum amount of blood accumulated in the abdominal cavity was 1500 ml and the minimum was about 300 ml. All 33 cases were discharged from the hospital.
3. Discussion
3.1 Reasons for misdiagnosis
The 16 cases in this group were with intrauterine device, which did not attract the attention of the first doctor. The vaginal bleeding of ectopic pregnancy with device is often mistaken as a side effect of IUD and not taken seriously. In fact, sterilization is not an absolutely safe measure. In fact, sterilization is not an absolutely safe measure. The reason may be that the tubal ligation is too tight or too loose, causing fistula or recanalization, which may lead to the chance of conception, and postoperative tubal adhesions, tortuous and narrowing, which may obstruct the movement of the fertilized egg and cause the egg to settle in the fallopian tube. In this group, 7 cases had tubal ligation, 4 cases were misdiagnosed as appendicitis, 2 cases were misdiagnosed as ruptured corpus luteum, and 1 case was misdiagnosed as hemorrhagic tubal inflammation.
3.1.2 Insufficient awareness of atypical ectopic pregnancy
The clinical manifestations are diverse because of the different pregnancy sites, rupture size, amount of internal bleeding and tolerance. The atypical ones are easily confused with other acute abdominal diseases, especially those first diagnosed in internal medicine and surgery, and doctors pay too much attention to the gastrointestinal symptoms such as nausea and vomiting, abdominal pain and diarrhea, and anal swelling, while ignoring the history of menstruation and vaginal bleeding and considering this disease unilaterally. In this group, 9 cases were misdiagnosed as appendicitis due to right lower abdominal pain, 1 case was misdiagnosed as gastroenteritis due to abdominal pain and diarrhea, 1 case was misdiagnosed as colitis due to abdominal pain and diarrhea with hypothermia, and 1 case was misdiagnosed as intestinal obstruction due to abdominal pain and nausea and vomiting.
3.1.3 Insufficient understanding of the requirements for the implementation of medication abortion and abortion
The discharge after abortion should be seen as villi tissue, and if no villi tissue is seen, the discharge should be routinely sent for pathological examination.
3.1.4 Lack of detailed medical history, careless physical examination, and over-reliance on a certain auxiliary examination
In this group, 5 cases were misled by the first physician because they were unmarried and denied the history of sexual life. 4 cases were misdiagnosed as acute appendicitis, and ectopic pregnancy was diagnosed intraoperatively; 1 case was misdiagnosed as dysmenorrhea, and later the diagnosis was confirmed by a gynecological consultation due to the gradual aggravation of abdominal pain. Therefore, we must be patient and explain to unmarried women and repeatedly ask them in order to obtain the true situation. In one case of this group, the aspirate was sent to pathological examination after abortion, and the result of the pathological examination showed metaphase-like changes, which was consistent with early pregnancy, misleading the young clinician to think that it was intrauterine early pregnancy, and the pathologist’s report was inaccurate, so the clinician did not carefully analyze the pathological report and only saw the result consistent with early pregnancy, but did not continue monitoring and examination, resulting in misdiagnosis and delaying the best time for treatment.
3.1.5 Insufficient attention to relevant examination results
Urine pregnancy test or blood HCG measurement is commonly used to diagnose early pregnancy. The HCG is positive when the embryo is alive or the trophoblast is still viable, but in ectopic pregnancy, the level is usually lower than that of normal pregnancy, and its multiplication within 48 hours is often less than 66%, so it is important to monitor the blood HCG after 48 hours, and ectopic pregnancy cannot be completely excluded when the HCG is negative [3,4,5]. ultrasound examination can identify intrauterine and ectopic pregnancy with a sensitivity of 77% to 92% [6], but it is necessary The sensitivity of ultrasound examination is 77-92% [6], but only if fetal heart, yolk sac and germ are seen, otherwise dynamic monitoring is required. In our group, two cases were misdiagnosed due to the absence of intrauterine echogenicity on ultrasound examination when considering intrauterine pregnancy with preterm abortion treated with fetal preservation machine.
3.2 Countermeasures to prevent misdiagnosis of ectopic pregnancy
① Raise the alertness to the above misdiagnosed diseases, and pay attention to differentiate ectopic pregnancy from other internal bleeding diseases and acute abdomen when considering ectopic pregnancy, and take detailed medical history, especially menstrual history. Patients with no history of menopause should not hastily rule out ectopic pregnancy, and those with significantly reduced menstrual flow or irregular vaginal bleeding with abdominal pain should be alerted to ectopic pregnancy, even if sterilization or intrauterine device has been performed.
② For drug abortion and induced abortion, preoperative ultrasound examination should be performed to confirm the diagnosis of intrauterine pregnancy, and the aspirate should be carefully examined for villi during abortion, and sent for pathological examination if necessary; the drug abortion should be strictly managed, and the patient should be kept in hospital for observation during the administration of drugs, so that villi can be seen in the discharge.
③For women of childbearing age, abdominal pain, anemia, shock and syncope should be ruled out first, ultrasonography, dynamic determination of blood and urine HCG, and laparotomy or posterior vault aspiration for suspected internal bleeding should be performed, especially posterior vault aspiration is more significant for the confirmation of ectopic pregnancy.
④Summarize the characteristics of symptoms and signs in patients with ectopic pregnancy, and do the necessary auxiliary tests to improve the accuracy of preoperative diagnosis.
⑤ For abdominal pain, ultrasound suggesting large pelvic and abdominal fluid or pelvic masses, emergency dissection or laparoscopic investigation can be performed to further clarify the diagnosis so as not to delay the condition.
⑥Surgical excision of tissues should be routinely sent for pathological examination after surgery to further verify the correctness of clinical diagnosis.