ectopic pregnancy
Introduction
Introduction to ectopic pregnancy An abnormal pregnancy process in which the pregnant egg is implanted outside the uterine cavity. Also known as "ectopic pregnancy." Tubal pregnancy is the most common. The cause is often due to inflammation of the tubal lumen or surrounding, causing poor lumen patency, hindering the normal operation of the pregnant egg, allowing it to stay in the fallopian tube, implantation, development, leading to abortion or rupture of the tubal pregnancy. There are often no obvious symptoms before abortion or rupture, but also menopause, abdominal pain, and a small amount of vaginal bleeding. After rupture, it manifests as acute severe abdominal pain, recurrent episodes, vaginal bleeding, and even shock. The clinical manifestations of tubal pregnancy and the implantation of pregnant eggs in the fallopian tube, whether there is abortion or rupture, the amount of blood in the abdominal cavity and the onset time. Before the abortion or rupture of the tubal pregnancy, the symptoms and signs are not obvious. In addition to short-term menstruation and pregnancy performance, there is sometimes a lower abdominal pain, and the fallopian tube is normal or swollen. basic knowledge The proportion of illness: 0.03% Susceptible people: good for pregnant women Mode of infection: non-infectious Complications: amenorrhea, abdominal pain, shock
Cause
Etiology of ectopic pregnancy
Tubal pregnancy is one of the common acute abdomen in obstetrics and gynecology. When the tubal pregnancy is aborted or ruptured, it can cause severe bleeding in the abdominal cavity. If it is not diagnosed in time, it can be life-threatening.
The incidence of tubal pregnancy is the largest in the ampulla, accounting for 55-60%; followed by the isthmus, accounting for 20-25%; once again, the umbrella end, accounting for 17%; the interstitial pregnancy is the least, accounting for only 2-4%.
Chronic salpingitis (25%):
Chronic salpingitis can cause adhesions of the fallopian tube mucosa, leading to stenosis of the lumen, mucosal destruction, loss of epithelial cilia, adhesion around the fallopian tube, and distortion of the tubular shape. The above conditions affect the normal operation and passage of the oviduct in the fallopian tube, which is the main cause of tubal pregnancy. .
Fertilized egg travel (20%):
After the fertilized egg is fertilized on one side of the fallopian tube, it can swim to the contralateral fallopian tube along the umbrella end. Due to the prolonged time, it has the ability to implant under the uterine cavity, and what symptoms are formed in the ectopic pregnancy of ectopic pregnancy.
Pelvic tumors (8%):
Compression or traction of the pelvic tumor causes the fallopian tube to be displaced or deformed, hindering the passage of the fertilized egg, which is also the cause of the ectopic pregnancy and the cause of the symptoms of the ectopic pregnancy.
Tubal dysplasia (20%):
Oviduct development or dysfunction of tubal dysplasia such as excessive fallopian tube, muscular dysplasia, lack of mucociliary, double-tube fallopian tube, extra umbrella, etc., can be the cause of tubal pregnancy. The physiological function of the fallopian tube is complex. The peristalsis of the fallopian tube wall, the activity of cilia and the secretion of epithelial cells are regulated by estrogen and progesterone. For example, the imbalance between the two hormones will affect the delivery of the pregnant egg and the tubal pregnancy.
Tubal sterilization after fallopian tube surgery, whether by ligation, electrocoagulation or looping, such as the formation of fallopian tube fistula or recanalization, may lead to tubal pregnancy, tubal sterilization after recanalization or fallopian tubeplasty, but also due to scar The cavity is narrow and the patency is poor and the disease is caused.
Pelvic endometriosis Endometriosis caused by tubal pregnancy is mainly caused by mechanical factors. In addition, the endometrium of the pelvic cavity may have a chemotactic effect on the pregnant egg, prompting it to be outside the uterine cavity. Bring the bed.
Prevention
Ectopic pregnancy prevention
The primary principle of preventing ectopic pregnancy is to actively prevent and treat pelvic inflammatory disease and reduce the incidence of chronic salpingitis. Secondly, patients with a history of tubal surgery should be closely monitored during pregnancy, and they should be pregnant under the guidance of a doctor. Women with contraceptive contraception should be regularly checked as required, and pelvic inflammatory disease should be detected and treated promptly. Those with genital tumors should be clear about the location and nature of the tumor, and follow the doctor's advice to treat the tumor reasonably in order to obtain the best reproductive prognosis.
For patients with suspected ectopic pregnancy, it is recommended to be admitted to the hospital, try to stay in bed, have less activity, light diet, ensure smooth urination, and do well in the patient's ideological work, explain the knowledge about ectopic pregnancy to help patients establish confidence in fighting disease. . Patients with ectopic pregnancy hemorrhagic shock, first open the vein, oxygen, blood transfusion, infusion anti-shock, and actively prepare for surgery. Postoperative attention to monitoring vital signs, when conditions are available, to receive ECG monitoring, continue to inhale oxygen, help patients recover soon.
Complication
Ectopic pregnancy complications Complications, amenorrhea, abdominal pain, shock
Usually accompanied by amenorrhea, abdominal pain, irregular vaginal bleeding, shock.
Symptom
Symptoms of ectopic pregnancy Common symptoms Pale pale and severe pain Abortion Early pregnancy Abdominal pain Limbs Cold and abdominal pain Low fever Abdominal disgusting Nasal rectal fossa effusion
Clinical manifestation
The clinical manifestations of tubal pregnancy and the implantation of pregnant eggs in the fallopian tube, whether there is abortion or rupture, the amount of blood in the abdominal cavity and the onset time.
Before the abortion or rupture of the tubal pregnancy, the symptoms and signs are not obvious. In addition to short-term menstruation and pregnancy performance, there is sometimes a lower abdominal pain, and the fallopian tube is normal or swollen.
After abortion or rupture of tubal pregnancy, it is generally divided into acute and old types according to the severity of the disease.
( 1) Acute ectopic pregnancy
1, symptoms
(1) Stop menstruation except for interstitial pregnancy, menopause time is longer, most of them stop menstruating for 6 to 8 weeks, usually after abdominal menstruation, abdominal pain, vaginal bleeding and other symptoms, but about 20% of patients complained that there is no history of menopause.
(2) Abdominal pain is the main symptom of the patient at the time of treatment. Abdominal pain is caused by various factors such as tubal enlargement, rupture and blood stimulation of the peritoneum. When the rupture occurs, the patient feels a side of the lower abdomen tear-like pain, often accompanied by nausea and vomiting. The area is characterized by local pain in the lower abdomen; when the blood accumulates in the uterus rectum, the anus has a sense of bulging; the amount of bleeding is excessive, and the blood flows from the pelvic cavity to the abdominal cavity, and the pain spreads from the lower abdomen to the whole abdomen; when the blood stimulates the diaphragm, Causes radiation pain in the shoulder blades.
(3) vaginal bleeding after embryo death, often irregular vaginal bleeding, dark brown, less, generally not more than menstrual flow, but dripping is not clean.
(4) syncope and shock due to acute intra-abdominal hemorrhage, can cause blood volume reduction and severe abdominal pain, light often have syncope, severe shock, the severity is proportional to the rate of intra-abdominal bleeding and bleeding, that is, the more the more urgent, The more rapid and severe the symptoms appear, but not proportional to the amount of vaginal bleeding.
2, signs
(1) In general, when there is more intra-abdominal hemorrhage, it is characterized by acute anemia. When there is a lot of bleeding, there are pale complexion, cold and cold limbs, rapid and weak pulse and blood pressure drop. The body temperature is normal, slightly lower during shock, and the blood in the abdominal cavity can be absorbed. Slightly elevated, but not more than 38 ° C.
(2) Abdominal examination has obvious tenderness and rebound tenderness in the lower abdomen, especially in the affected side, but the abdominal muscle tension is lighter than that in the peritonitis. When there is more bleeding, there is a mobile dullness in the percussion, which forms a blood coagulation after a long time. Block, the lower abdomen can touch the soft lungs, repeated bleeding makes the mass enlarge and hard.
(3) pelvic examination of the vagina after fullness, tenderness, the cervix has obvious pain, when the cervix is gently lifted or shaken to the left and right, it can cause severe pain, the uterus is slightly large and soft, the internal bleeding is often, the uterus has a sense of floating, the uterus One side or the rear can touch the lump, which is like a wet flour group. The boundary is unclear and the tenderness is obvious. The interstitial pregnancy is different from other parts of the tubal pregnancy. The size of the uterus is basically consistent with the menopause month, but the uterus contour is not symmetrical. The angle of the affected side of the uterus is prominent, and the signs caused by the rupture are like the uterus rupture.
(two) old ectopic pregnancy
It refers to the long course of tubal pregnancy after abortion or rupture. After repeated internal hemorrhage, the condition gradually stabilizes. At this time, the embryo is dead, the villi are degenerated, the internal hemorrhage stops, the abdominal pain is relieved, but the hematoma formed gradually becomes hard and hard, and the surrounding tissue and Organ adhesions, old ectopic pregnancy patients can consult the history of repeated internal bleeding after menopause, its clinical features are irregular vaginal bleeding, paroxysmal abdominal pain, attachment lumps and low fever, low fever is caused by intra-abdominal blood absorption process, such as combined secondary infection , it is characterized by high fever.
Examine
Examination of ectopic pregnancy
(1) urine pregnancy test: simple, fast, positive can assist in diagnosis, negative patients need to be excluded from blood -HCG.
(2) Quantification of blood -HCG: It is an important method for early diagnosis of ectopic pregnancy. In addition to assisting diagnosis, it can also help determine the activity of embryos to guide treatment. In ectopic pregnancy, blood -HCG values are usually lower than normal intrauterine pregnancy. After conservative drug therapy or surgery, blood beta-HCG levels are monitored for early detection of persistent ectopic pregnancy.
(3) blood progesterone determination: ectopic pregnancy patients with low progesterone levels, can also be used as an indicator for the diagnosis of early ectopic pregnancy. Progesterone levels in early pregnancy are relatively stable. For example, progesterone <45 nmol/L (15 ng/ml) at 8 weeks of pregnancy suggests ectopic pregnancy or luteal dysplasia with a sensitivity of 95%. There is overlap between normal and abnormal pregnancy serum progesterone levels. It is difficult to determine the absolute threshold between them for reference only. Progesterone is listed as a routine monitoring indicator for ectopic pregnancy in developed countries.
(4) Ultrasound examination: vaginal ultrasound is superior to abdominal ultrasound. The accuracy of ectopic pregnancy diagnosis is 70-94%. The gestational sac ("fallopian tube ring") or fetal heartbeat can be diagnosed in the fallopian tube. Those with a history of cesarean section should focus on the scar on the anterior wall to avoid missing scar pregnancy. Serum -HCG exceeds 2000mIU/ml. If it is intrauterine pregnancy, vaginal ultrasound can detect gestational sac, otherwise it should be alert to ectopic pregnancy. The pelvic and abdominal fluid dark area is helpful for diagnosis.
(5) Laparoscopy: It is the "gold standard" for the diagnosis of tubal pregnancy, but it is an invasive method, and the cost is high. The diagnosis can be performed at the same time as microscopic surgery, avoiding the blindness of open surgery and less trauma. It is quick to recover and is widely used in hospitals with conditions. See the Laparoscopy section of this manual for specific methods.
(6) Endometrial pathological examination: more vaginal bleeding, ultrasound suggesting endometrial heterogeneity thickening or accompanied by cyst area, feasible diagnostic curettage, scraping material with villi, can be diagnosed as intrauterine pregnancy abortion, otherwise Send a pathological examination, such as pathology only see the decidua without fluff to help diagnose tubal pregnancy. For ectopic pregnancy with unknown diagnosis, serum -HCG can be reviewed 24 hours after curettage, which is supported by the diagnosis without a significant decrease or increase before surgery. In recent years, the popularity of assisted pregnancy technology has led to a marked increase in the incidence of composite pregnancy (Heterotopic pregnancy) and should be highly vigilant.
Diagnosis
Diagnosis of ectopic pregnancy
diagnosis
Before the abortion or rupture of the tubal pregnancy, the clinical manifestations are not obvious, and the diagnosis is difficult. The auxiliary examination should be combined to confirm the diagnosis as early as possible.
Differential diagnosis
Tubal pregnancy needs to be differentiated from intrauterine pregnancy abortion, acute appendicitis, acute salpingitis, corpus luteum rupture and ovarian cyst torsion.
