persistent tubal pregnancy
Introduction
Introduction to persistent tubal pregnancy Persistent tubal pregnancy refers to the survival of trophoblast cells after conservative surgery or drug treatment of tubal pregnancy. Human chorionic gonadotropin (HCG) still maintains a certain level without decreasing or even rising. The viable trophoblasts can still be around. Tissue destruction, causing intra-abdominal hemorrhage, is a new complication after the increase in conservative treatment of tubal pregnancy in recent years. basic knowledge The proportion of illness: 0.001% Susceptible people: good for adult women Mode of infection: non-infectious Complications: anemia
Cause
Causes of persistent tubal pregnancy
(1) Causes of the disease
Increased likelihood of persistent fallopian tube pregnancy in the following situations:
1 less than 7 weeks of menopause, fallopian tube mass <2cm;
2 preoperative blood HCG>3000mU/ml or progesterone>35mg/ml;
3 HCG rise >1000mU/ml 24 hours before surgery;
4 Laparoscopic conservative surgery has a slightly increased risk compared with open surgery.
(two) pathogenesis
It is generally believed that during conservative operation of tubal pregnancy, the trophoblast cells have penetrated into the muscularis of the wall, or because the lesions are too large to be removed, no small lesions or non-ruptured lesions were found during surgery, and when tubal extruding was performed, The trophoblast cells are left in the lumen, allowing the trophoblasts to continue to grow and a persistent tubal pregnancy.
P>Continuous ectopic pregnancy: Due to the increasing incidence of ectopic pregnancy and significant improvement in diagnostic methods, the treatment of ectopic pregnancy is gradually transformed from thorough surgical treatment to conservative treatment of surgery or drugs, therefore, The occurrence of persistent ectopic pregnancy (PEP) after conservative treatment; the incidence of PEP is 3% to 20%, which is characterized by the presence of trophoblast survival after conservative fallopian tube therapy, HCG Still maintain the original level, and there are irregular vaginal bleeding, due to the destruction of surrounding tissues by trophoblast cells, even intra-abdominal hemorrhage can continue to occur. In rare cases, fallopian tube choriocarcinoma can occur, conservative fallopian tube surgery, such as linear fallopian tube Open surgery, partial salpingectomy, especially after umbrella compression, because the trophoblast cells have been pressed into the wall muscle layer or the lesions are large, it may not be completely removed during laparoscopic or laparotomy surgery. complication.
Prevention
Persistent fallopian tube pregnancy prevention
How to completely remove the pregnancy during conservative surgery is the key to prevent persistent tubal pregnancy. The incision should be in the center of the most prominent part of the fallopian tube to avoid leakage of pregnancy. Some people inject saline into the incision to make the pregnancy If you rush out, you can also use methotrexate before or after surgery to prevent it, or 10 to 25 mg of methotrexate in the embryo implantation before the end of surgery.
Complication
Persistent tubal pregnancy complications Complications anemia
The main complication is hemorrhagic anemia, and severe cases can cause anemia.
Symptom
Persistent tubal pregnancy symptoms Common symptoms Pelvic mass abdominal pain ectopic pregnancy vaginal bleeding bleeding
The main performance is lower abdominal pain after conservative surgery, occasionally continue bleeding in the abdominal cavity, for menopause, abdominal pain, vaginal bleeding, pelvic mass.
Monitoring of blood -HCG is the basis for the diagnosis of persistent tubal pregnancy. Blood -HCG should be measured immediately after conservative surgery for tubal pregnancy, and then measured 2 to 3 times a week until <15mU/ml, if postoperative Continuous monitoring of blood -HCG weekly <15%, the possibility of persistent tubal pregnancy is very high, such as 12 days after surgery, blood -HCG decreased <10% can determine the diagnosis.
If patients have abdominal pain or intra-abdominal hemorrhage after conservative surgery, they should be alert to the occurrence of persistent tubal pregnancy.
Examine
Continuous tubal pregnancy check
Serum -HCG monitoring; conservative surgery, such as linear fallopian tube or umbrella compression, HCG fall to the normal range of time varies, up to 30 days, an average of 8 to 12 days For example, 12 days after surgery, serum HCG value only drops within 10% of the preoperative period, the diagnosis can be established, so continuous monitoring with serum HCG before and after treatment is of great significance for the diagnosis of PEP, B-ultrasound found pelvic cavity Lumps, etc., if necessary, laparoscopy can be used to assist diagnosis.
Diagnosis
Diagnosis and diagnosis of persistent tubal pregnancy
Differential diagnosis:
1. There are many high-risk factors in ectopic pregnancy. There are many types in clinical, some are more common and rare, and there are various diagnostic methods. Different methods should be used for identification in different periods. Differentiation should be analyzed from different angles. In order to distinguish from many diseases, in terms of abdominal pain, it is very important to distinguish other diseases of the fallopian tube.
2. Salpingitis, tubal empyema, fallopian tube ovarian abscess, pelvic inflammatory disease annex inflammation is a relatively common gynecological disease, occurred in pregnant women, but in 1993, Yip L et al reported a 20-year-old woman due to acute abdominal pain and loss of consciousness Emergency admission, surgical exploration for acute suppurative salpingitis combined with intrauterine pregnancy, given a large number of intravenous antibiotics to cure, the article suggests that pregnancy should be given adequate and thorough treatment.
In 1993, Cowan RK et al reported a case of suspected pelvic inflammatory disease at the time of initial diagnosis. In the further evaluation, the patient was found to have a state of shock, so it was suggested that any non-specific symptoms and signs should be carefully and carefully examined. In the same year, Westfall MD also reported a case. Similar to the case of PID and toxic shock syndrome, it is indicated that after acute abdomen, the posterior iliac puncture is performed. When there is serous purulent liquid, bacterial culture can further confirm the diagnosis.
Chlamydia trachomatis is an important cause of acute and chronic salpingitis, accounting for more than half of pelvic inflammatory disease.
In 1991, Wallace TM reported a patient with acute abdominal pain. The double-conspiratory examination showed tenderness in the pelvis and secretions in the vagina.
In addition, the patient has ascites and a mass near the pelvis. This mass is very similar to a malignant tumor. The surgical specimen is severe lymphoid follicular salpingitis. The large net and the posterior peritoneal lymph nodes also have obvious lymphoid follicular hyperplasia. Chlamydia trachomatis is a classic. Immunohistochemical monoclonal antibody test confirmed.
3. Fallopian tube torsion and infarction: The cause of tubal torsion and infarction is unclear, which may be related to its excessive length. Because of its long movement and large curvature, although it occurs mostly in the end of pregnancy, in the early pregnancy, the mid-term occurs. There are reports.
In addition, there are some records in adolescents or near middle age, it is estimated that 10% to 20% of patients occur during pregnancy.
Due to sudden severe pain in the lower abdomen, it should be differentiated from appendicitis, ectopic pregnancy, ovarian cyst pedicle torsion, clinically often sudden right lower abdominal pain, then nausea, vomiting, leukocytosis and tenderness on the disease side, reversal can not be alleviated Invasion of blood flow and siltation, laparoscopic identification or further surgical exploration is required.
If the operation is performed, the blood supply should be blocked first to prevent the embolus from falling off. The attachment removal, simple fallopian tube resection, and preservation of the ovaries are determined according to the situation.
