Ectopic pregnancy is one of the most common gynecologic emergencies. In recent years, it has shown a gradual increase with the increase of uterine operations and various sexually transmitted diseases. Early diagnosis can reduce hemorrhagic shock, avoid excessive tubal damage, preserve reproductive function and reduce complications, so early diagnosis and treatment of ectopic pregnancy is especially important.
1. Early diagnosis of ectopic pregnancy
(1) Ectopic pregnancies are likely to occur in the following groups
(i) those who have previously suffered from pelvic inflammatory disease, ectopic pregnancy or endometriosis.
(ii) Patients with ovarian tumors.
(iii) those who have undergone tubal reconstruction or connection surgery and have failed to use intrauterine contraceptive devices
(iv) women with infertility who have received artificial reproductive treatment and become pregnant.
(2) Clinical manifestations of ectopic pregnancy.
(1) Symptoms: Patients with ectopic pregnancy often have symptoms of menopause, discomfort and distension in one side of the lower abdomen and vaginal bleeding before rupture or miscarriage occurs. In some young patients, there is no obvious abdominal discomfort due to poor sensitivity. In 20% to 30% of patients, there is no obvious history of menopause, and irregular vaginal bleeding is mistaken for menstruation. However, such bleeding is often less than normal menstruation and irregular, and does not clean up as expected, so irregular vaginal bleeding symptoms are the most common in clinical practice. If patients with irregular vaginal bleeding can be routinely screened, the early diagnosis rate of ectopic pregnancy can be greatly improved.
(2) Physical signs: before rupture or miscarriage occurs in patients with ectopic pregnancy, the vital signs are stable, the general condition is still acceptable, the uterus is slightly larger and softer on gynecological examination, and there may be thickening or palpation of distended fallopian tubes in the affected adnexal area.
(3) Common auxiliary tests for ectopic pregnancy: early ectopic pregnancy is not clinically obvious and difficult to diagnose, so auxiliary tests are needed to confirm the diagnosis.
Blood B-HCG quantitative immunoassay: <3.1 μg/L is considered negative for pregnancy, >5.0 U/L is considered probable for conception, and >10.0 U/L basically confirms pregnancy. In women, elevated blood β-HCG can be measured 7-10 days after conception, and β-HCG can rise to 100 U/L 14 days after conception. in normal intrauterine pregnancy, its value increases rapidly before 8 weeks of pregnancy, and blood β-HCG rises ≥66% every 48 hours. Therefore, in patients with suspected ectopic pregnancy, continuous measurement of blood β-HCG should be done to dynamically observe its growth rate. If the rise at 48 hours is lower than normal, the possibility of ectopic pregnancy should be highly alerted. Very few patients with asymptomatic early ectopic pregnancy have normal trophoblast function and the initial blood β-HCG rise curve is the same as that of normal intrauterine pregnancy. If it is difficult to determine this with continuous blood β-HCG measurement, it is often combined with other diagnostic methods to make a comprehensive judgment.
Measurement of blood progesterone: within 6 weeks of gestation, progesterone is mainly derived from the ovarian corpus luteum. Low blood progesterone levels in patients with ectopic pregnancies are well recognized, but their values are interspersed with those of a proportion of intrauterine pregnancies. Blood progesterone alone cannot be used to distinguish ectopic pregnancy from intrauterine pregnancy. Further testing of patients with low blood progesterone levels can significantly improve the early diagnosis of ectopic pregnancy.
Ultrasound examination: Ultrasound examination includes abdominal and negative. Abdominal ultrasound can affect its resolution because of factors such as intestinal gas, obesity and underfilled bladder in patients. Transvaginal ultrasound is an intracavitary ultrasound with significantly higher resolution than transabdominal ultrasound.
Diagnostic scraping: clinically, diagnostic scraping is neither a routine test for ectopic pregnancy nor is it specific, but it still has its clinical significance. Its main purpose is to exclude intrauterine pregnancy.
Posterior vault aspiration: for patients with suspected intra-abdominal bleeding. In some early stages of tubal pregnancy miscarriage, intra-abdominal bleeding, even if small, can be aspirated by posterior vault aspiration because it tends to accumulate in the rectal recess.
Laparoscopy: This test not only serves as the gold standard for the diagnosis of ectopic pregnancy, but can also play a therapeutic role in the case of a definite diagnosis. It is indicated for the identification of acute abdominal conditions of unknown origin and early ectopic pregnancy.
Among the above mentioned ectopic pregnancy auxiliary diagnostic methods, ultrasound and blood β-HCG are indispensable tests for the diagnosis of ectopic pregnancy. More than 90% of patients with early ectopic pregnancy can be diagnosed clinically through these two tests, and the rest of them can be used clinically or combined according to local conditions and patient’s specific situation.
2.Treatment of early ectopic pregnancy
(1) Non-surgical treatment: Conservative treatment of ectopic pregnancy depends on the early diagnosis of ectopic pregnancy. Experts believe that non-surgical treatment will become the preferred treatment for ectopic pregnancy, and surgical treatment will only be used as a remedial measure when non-surgical treatment fails. Non-surgical treatment includes pharmacological treatment and anticipatory therapy.
(2) Pharmacological treatment: It is mainly applied to young patients with early tubal pregnancy, in good condition and requiring preservation of fertility. It is generally considered that this method can be used for those who meet the following conditions.
(i) There are no contraindications to pharmacological treatment.
(ii) The tubal pregnancy has not ruptured or miscarried.
(iii) The diameter of the tubal pregnancy mass is ≤3 cm.
④Blood β-HCG < 2000 IU/L.
⑤No obvious internal bleeding.
(6) Certain special cases, such as horn pregnancy and cervical pregnancy.
(3) Expectant therapy: A small number of tubal pregnancies may be spontaneously aborted or absorbed, and the symptoms are mild without surgery or drug treatment. Expectant therapy is indicated for.
(i) mild pain and minimal bleeding.
(ii) Reliable follow-up.
(iii) No evidence of tubal pregnancy rupture.
④Blood β-HCG <1000 U/L and continues to decline.
⑤ tubal pregnancy mass <3 cm or not explored.
⑥No intra-abdominal bleeding. Vital signs and changes in abdominal pain should be noted during the expectant process, and ultrasound and blood β-HCG monitoring should be performed.
(4) Surgical treatment.
(1) Conservative surgery: for young women with fertility requirements. If the contralateral fallopian tube has been removed or has obvious lesions, conservative surgery is feasible.
(2) Laparoscopic surgery: laparoscopic techniques have been widely used in gynecological clinics. Ectopic pregnancy is the most suitable indication for laparoscopy.
(iii) Radical surgery: it is suitable for patients with internal bleeding complicated by shock or without fertility requirements.
(5) Chinese medicine evidence-based treatment
Unbroken type: invigorate blood circulation, remove blood stasis, eliminate Y and kill embryos. Ectopic pregnancy Formula II: Danshen 15g, Radix Paeoniae 15g, Peach kernel 9g, Trigonella 9g, Curcuma 9g.
Broken shock type: Returning Yang to save the offspring, activating Blood circulation and eliminating blood stasis.
Broken type unstable type: Promoting Blood circulation and eliminating blood stasis, complemented by benefiting Qi. Ectopic pregnancy Ⅰ formula: Salvia miltiorrhiza 15g, Radix Paeoniae Alba 15g, Peach kernel 9g, Radix Codonopsis Pilosulae 15g, Radix Astragali 15g, Radix Glycyrrhiza Uralensis 6g. should be prepared for resuscitation shock and surgery at any time.
Mass type: breaking stasis and eliminating Y. Ectopic pregnancy Formula II: Salvia miltiorrhiza 15g, Radix et Rhizoma Paeoniae 15g, Momordica charantia 9g, Salviae Miltiorrhiza 9g, Curcuma longa 9g.