Normally, a fertilized egg migrates from the fallopian tube to the uterine cavity, where it settles and slowly develops into a fetus. More than 90% of ectopic pregnancies occur in the fallopian tube. Such a fertilized egg will not only fail to develop into a normal fetus, but will also act like a time bomb and cause danger.
Abdominal pain: cramping pain in the lower abdomen, a sensation of defecation, sometimes severe pain, accompanied by cold sweat. In case of rupture, the patient feels a sudden tearing pain in one side of the lower abdomen, often accompanied by nausea and vomiting.
Menopause: Before miscarriage or rupture of tubal pregnancy, the symptoms and signs are not obvious. The fallopian tube is normal or enlarged on examination.
Vaginal bleeding: often a small amount of bleeding.
Syncope and shock: Due to acute intra-abdominal bleeding, it can cause decreased blood volume and severe abdominal pain, often syncope in mild cases and shock in severe cases.
Other symptoms: there can be nausea, vomiting and frequent urination. Symptoms of ectopic pregnancy are often atypical, and some patients experience shock due to hemorrhage, pallor and decreased blood pressure.
Under normal circumstances, when a woman is pregnant and the embryo is implanted in the uterine cavity, it is called an intrauterine pregnancy, but if it is implanted somewhere outside the uterine cavity, it is called an ectopic pregnancy, which is also known medically as ectopic pregnancy. The most common site of ectopic pregnancy is the fallopian tube and, to a lesser extent, the ovaries and cervix. An ectopic pregnancy is formed when the egg that survived the tubal pregnancy is shed in the abdominal cavity and occasionally continues to grow in the abdominal viscera, such as the greater omentum. If the implanted egg separates from the wall and flows into the abdominal cavity, tubal pregnancy is aborted; if the chorionic villi of the egg rupture through the wall, tubal pregnancy is ruptured; both can cause intra-abdominal bleeding, but the latter is more serious, often leading to shock and even life-threatening due to massive internal bleeding.
What are the manifestations of ectopic pregnancy? Women of childbearing age, with menstrual periods, sometimes accompanied by early pregnancy reactions such as anorexia and nausea, suggesting pregnancy but with sudden onset of lower abdominal pain, persistent or recurrent, which may be accompanied by nausea, vomiting, anal drop and other discomforts; in severe cases, patients may be pale, have cold sweats, chills in the limbs, or even fainting and shock. Some patients have irregular vaginal bleeding, which is usually less than the amount of menstruation (note that this should never be mistaken for menstruation). Therefore, the typical symptoms of ectopic pregnancy can be summarized into three major symptoms, namely: menopause, abdominal pain and vaginal bleeding.
I. Etiology: The most common factor causing tubal pregnancy is tubal inflammation. As a result of inflammation, the tubal adhesions are twisted or the lumen is narrowed, or the endometrial cilia are defective, so that the peristalsis of the fallopian tube is weakened and the fertilized egg cannot be transported to the uterus normally, but instead, it lays in the fallopian tube. Others are due to dysplasia or malformation of the fallopian tubes, overly long fallopian tubes or diverticula. The rest of the cases can be due to pressure from tumors in the neighboring organs, which can displace or deform the fallopian tubes, or ectopic endometrium in the fallopian tubes, etc. These cases are rare.
Once the fertilized egg has settled in the fallopian tube, it starts to develop. The thin wall of the fallopian tube is eroded by the villi, and as the embryo develops, it expands and then ruptures, causing massive bleeding and, in severe cases, shock, which can be life-threatening if not rescued in time. When a tubal pregnancy does not rupture or is not aborted, it is often overlooked because there are no special manifestations. However, when severe abdominal pain occurs, the tubal pregnancy has often ruptured and intra-abdominal bleeding has occurred. Therefore, early diagnosis of ectopic pregnancy is very important.
First of all, for women with chronic pelvic inflammatory disease or infertility secondary to abortion, a pregnancy test should be performed promptly after 6 to 8 weeks of menopause (some menstrual periods may last only a few days), and if the test result is positive, further ultrasound examination should be performed to determine the site of fertilized egg implantation. If lower abdominal pain occurs suddenly after menopause, you should be alert and go to the hospital immediately. If the pain is severe and there are signs of shock such as a drop in blood pressure, you should not move around, but stay in bed and contact the hospital emergency room as soon as possible to get the fastest possible treatment. Women who have repeated abortions or a history of ectopic pregnancy are relatively more likely to suffer from ectopic pregnancy. Then the factors of the onset of ectopic pregnancy.
1, repeated abortions: With the changing traditional concept, premarital sex is becoming increasingly common, and repeated abortions are prone to ectopic pregnancy. At present, the incidence of ectopic pregnancy has increased 5 to 6 times compared to the 1980s. The greater the number of abortions, the greater the chance of ectopic pregnancy. Therefore, whether or not they have children, women should do a good job of contraception to prevent ectopic pregnancy attacks.
2, chronic pelvic inflammatory disease: chronic pelvic inflammatory disease, especially tubal inflammatory disease is another important factor in the development of ectopic pregnancy, women should not ignore this common gynecological disease. The reason is that tubal infection can narrow the lumen and make it difficult for the fertilized egg to enter the uterine cavity, so it has to “set up camp” in the fallopian tube or ovary. This is why any woman of childbearing age should pay attention to her personal hygiene and stop having an unclean sex life. This will reduce the occurrence of pelvic inflammatory disease and minimize the incidence of ectopic pregnancy.
3. IUD: According to medical textbooks, about 3% of women with IUDs still get pregnant, therefore, even with IUDs, the symptoms of abdominal pain should be considered ectopic pregnancy. As for the diarrhea manifestation, it is due to the intestinal tract stimulated by intra-abdominal bleeding, which causes diarrhea due to accelerated intestinal peristalsis. Therefore, once a woman of childbearing age has abdominal pain, she must first exclude ectopic pregnancy as a potentially fatal risk.
4. History of ectopic pregnancy: Women with a history of ectopic pregnancy have a high risk of recurrence of ectopic pregnancy, but interestingly, recurrence of ectopic pregnancy usually occurs in the contralateral fallopian tube. Therefore, once again, women who are ready to have a baby must do a good job of contraception.
5. IVF: Normal pregnancy can lead to ectopic pregnancy, and likewise IVF can also lead to ectopic pregnancy. According to statistics, the likelihood of ectopic pregnancy in IVF is 5-8%. This is because when the fertilized egg is placed in the uterine cavity on the third day, it has to wait 3 to 4 days to find the right “soil”. During this time, the endometritis and other factors may disrupt the uterine cavity and the fertilized egg may take up residence in the fallopian tube, leading to ectopic pregnancy. Therefore, women who are ready to do IVF should be treated for gynecological diseases beforehand to prevent ectopic pregnancy and improve the pregnancy rate.
6, tubal inflammation: about 60% of patients with tubal pregnancy have a history of tubal inflammation. Repeated episodes of chronic tubal inflammation cause adhesion of the mucosal folds of the fallopian tubes, narrowing of the lumen, damage to the cilia, or distortion of the fallopian tubes due to inflammation and adhesion of the surrounding tissues, which cannot move normally, all of which can hinder the normal operation of the fertilized egg, so that the fertilized egg cannot reach the uterine cavity as scheduled and is laid in the fallopian tube.
7. Abnormal development of the fallopian tubes or after tubal surgery: long fallopian tubes, lack of mucous membrane cilia, or post-tubal ligation or tubalplasty may cause tubal pregnancy.
8. Wandering of the pregnant egg: the egg is ovulated on one side of the ovary, but after fertilization it migrates through the uterine or abdominal cavity to the opposite fallopian tube, which is called wandering of the pregnant egg. As the egg grows during the migration process, tubal pregnancy occurs when it cannot pass through the fallopian tube, i.e., when it lays in the fallopian tube.
9. Women with pelvic endometriosis or with intrauterine devices may also have an increased incidence of tubal pregnancy.
Abdominal pregnancy: If the pregnant egg lays and develops in the abdominal cavity, it is an abdominal pregnancy. Most often, this is secondary to a ruptured tubal pregnancy or miscarriage, where the embryo of the pregnancy falls into the abdominal cavity and continues to grow on the peritoneum or on the surface of other organs. In very few patients, abdominal pregnancy is primary. This means that the oocytes are fertilized and grow implanted directly in the abdominal cavity. The incidence of abdominal pregnancy is 1:15,000 deliveries. Intraligamentous pregnancy, ovarian pregnancy. These are very rare ectopic pregnancies.
Therefore, ectopic pregnancy is completely preventable by taking safe and effective contraceptive measures, eliminating impure sex and treating gynecological diseases such as pelvic inflammatory disease in a timely manner. If women of childbearing age experience symptoms such as vaginal bleeding, abdominal pain, diarrhea and shock, they must be alert to ectopic pregnancy and go to the hospital for diagnosis and treatment in time to minimize its risk.
II. Clinical diagnosis.
Modern medical name of the disease. Abbreviated as ectopic pregnancy, also known as ectopic pregnancy. It refers to pregnancy outside the body cavity of the uterus, with tubal pregnancy being the most common. Clinical manifestations include menopause, early pregnancy reaction, abdominal pain or episodes of small abdominal pain, vaginal bleeding, intra-abdominal bleeding, anemia, shock and other symptoms.
The symptoms and signs of acute ectopic pregnancy are typical, and most patients can be diagnosed in time; if there is difficulty in diagnosis, necessary auxiliary examinations should be performed.
(I) Posterior fornix aspiration As blood in the abdominal cavity is most likely to accumulate in the rectal recess of the uterus, it can be aspirated by posterior fornix aspiration even if the amount of blood is not much. A positive result is obtained by using an 18-gauge needle to puncture the posterior fornix of the vagina into the recto-uterine recess and drawing out dark red non-coagulated blood, indicating the presence of intra-abdominal blood accumulation.
(b) Pregnancy test When the embryo is alive or the trophoblast is viable, the syncytial cells secrete hCG and the pregnancy test can be positive. Since the level of hCG in ectopic pregnancy is lower than that in normal pregnancy, the general method of hCG determination has a low positive rate.
(c) Ultrasound diagnosis In early tubal pregnancy, the ultrasound image shows an enlarged uterus with an empty cavity and a hypoechoic zone in the parametrium. This image is not an acoustic feature of tubal pregnancy and the possibility of early intrauterine pregnancy with a gestational corpus luteum needs to be excluded. The diagnosis of ectopic pregnancy is very important with ultrasound detection of the gestational sac and fetal heartbeat, which can be diagnosed if the pregnancy is located outside the uterus; if the gestational sac is located inside the uterus, ectopic pregnancy can mostly be excluded. early diagnosis of interstitial pregnancy is clinically important with ultrasound, which can show protrusion of the uterine horn on one side, localized myometrial thickening, and an obvious gestational sac inside.
(iv) Laparoscopy Laparoscopy can be used when available and necessary.
(v) Endometrial pathological examination Diagnostic curettage is only indicated in patients with high vaginal bleeding, with the aim of excluding intrauterine pregnancy. The uterine discharge should be routinely sent for pathological examination. If villi are seen in the section, intrauterine pregnancy can be diagnosed; if only meconium without villi is seen, ectopic pregnancy should be considered, but the diagnosis cannot be confirmed.
III. Treatment
Application of anti-cancer drugs
1.Indications.
(1) Non-ruptured tubal pregnancy with a gestational sac less than 3 cm in diameter, 100 ml of intra-abdominal free fluid, and B-HCG less than 1000 u.
(2) No heart, liver, kidney or blood abnormalities.
(3) Certain special conditions, such as horn pregnancy, cervical pregnancy.
2. Contraindications.
(1)Obvious symptoms of internal bleeding.
(2) “B” ultrasound indicates fetal heartbeat.
(3) B-HCG greater than 1000mIU/L.
(4) Severe liver and kidney damage (MTX) does not work urine alkaline.
3, the main drugs: aminomethyl disulfiram (MTX) and tetrahydrofolic acid; 5-fluorouracil.
4, the method of administration: intravenous systemic drug, through the laparoscope in the umbilical end of the drug, the uterine cavity or pelvic injection of drugs.
All of these should be done in the hospital under the supervision of a physician.
Use of Mifepristone
Using its anti-pregnancy principle.
Chemical drugs
It is mainly indicated in young patients with early ectopic pregnancy who require preservation of fertility.
It is generally considered to be used when the following conditions are met.
(i) the tubal pregnancy mass is <3 cm in diameter
(ii) the tubal pregnancy has not ruptured or miscarried
(iii) no significant internal bleeding
Chemotherapy is usually administered systemically or locally. The mechanism of treatment is to inhibit the proliferation of trophoblast cells and destroy the villi, so that the embryonic tissue can be necrosed, shed and absorbed without surgery. The common dose is 0.4mg/kg.d, injected intramuscularly, for 5 days as a course of treatment. The application of chemotherapy may not be successful in every case. Therefore, B-mode ultrasound and HCG should be used for close monitoring during the treatment period and attention should be paid to the changes in the patient’s condition and the toxic side effects of the drug.
If the HCG decreases and is negative for 3 times in a row, abdominal pain is relieved or disappears, and vaginal bleeding is reduced or stopped 14 days after the drug is administered, it is considered effective. If the condition does not improve or even acute abdominal pain or tubal rupture occurs, surgery should be performed immediately. Local medication can be injected directly into the pregnancy capsule of the fallopian tube by puncture under B-type ultrasound guidance, or the pregnancy capsule of the fallopian tube can be punctured under direct laparoscopic view, and the medication can be injected into it after aspirating part of the capsule fluid.
IV. Surgical treatment
The principle of treatment for ectopic pregnancy is mainly surgical treatment, of which there are two types of surgical treatment: one is to remove the affected fallopian tube; the other is to preserve the affected fallopian tube, i.e. conservative surgery.
Conservative surgery is suitable for young women with fertility requirements, especially if the contralateral fallopian tube has been removed or has obvious lesions. In recent years, due to improved diagnostic techniques, more tubal pregnancies have been diagnosed before miscarriage or rupture, so the use of conservative surgery has increased significantly compared to the past. In the case of umbilical pregnancy, extrusion of the pregnancy product is possible; in the case of abdominal pregnancy, the tube is incised to remove the embryo and then sutured; in the case of isthmus pregnancy, the lesioned segment is excised and end-to-end anastomosis is performed. The use of microsurgical techniques may improve the rate of subsequent pregnancies. In addition to open surgery, conservative surgery can also be performed laparoscopically.
Surgical treatment The principle of treatment for tubal pregnancy is primarily surgical, and surgery is usually performed once the diagnosis is confirmed. Young women who have a need for fertility in the opposite fallopian tube can undergo conservative surgery to preserve the tube and its function if the opposite fallopian tube has been removed or has obvious lesions. In the case of cystic pregnancy, an incision is performed to remove the pregnant egg from the isthmus. The management of interstitial tubal pregnancy can be performed by hysterectomy or total hysterectomy depending on the lesion. In recent years, laparoscopic diagnosis and treatment of tubal pregnancy has been carried out at home and abroad, and autologous blood transfusion is one of the effective measures to rescue acute ectopic pregnancy, especially in the absence of blood source, and the recovery of intra-abdominal blood must meet the following conditions: < 12 weeks of gestation, unbroken membranes, bleeding time < 24 hours, uncontaminated microscopic red blood cell rupture rate < 30%.
V. Minimally invasive treatment of ectopic pregnancy
In recent years, the minimally invasive laparoscopic technology has become increasingly mature and widely used in the field of obstetrics and gynecology, so that the treatment of ectopic pregnancy is also moving from “massively invasive” to “minimally invasive”. It is easier to preserve the fallopian tubes because of its small surgical trauma, less bleeding, shorter operation time, quicker postoperative recovery, shorter hospital stay, almost no scar in the abdomen, less pelvic adhesions and slight tubal obstruction. The tissue coagulation wound can prevent the exudation and deposition of fibrin, and obviously improve the quality of life of patients after surgery. It is very popular among patients.
The most advanced laparoscopy in the world, which uses cold light source to provide illumination, inserts a laparoscopic lens (3-10mm in diameter) into the abdominal cavity and uses digital camera technology to transmit the images captured by the laparoscope lens to the posterior signal processing system through optical fibers and displays them in real time on a special monitor. The doctor then uses the images of the patient’s organs from different angles displayed on the monitor screen to analyze the patient’s condition and perform the surgery with special laparoscopic instruments.
During the operation, only three small holes of 0.5 to 1 cm are opened in the patient’s abdomen. After recovery, only one to three 0.5-1 cm linear scars, the size of a keyhole, are left in the abdominal cavity, making it a less invasive and less painful operation. The most crucial thing is that the fallopian tubes can be effectively preserved, with a tubal preservation rate of 95.65%, creating favorable conditions for future fertility, which is ideal for women with fertility requirements.