Tubal pregnancy

　　Tubal pregnancy is one of the common acute abdominal emergencies in gynecology and obstetrics. When the tubal pregnancy aborts or ruptures acutely, it can cause severe intra-abdominal bleeding. If it is not diagnosed and treated in time, it can be life-threatening.

　　The site of tubal pregnancy is mainly the ampulla, accounting for about 55-60%; followed by the isthmus, accounting for 20-25%; then the fimbria, accounting for 17%; and interstitial pregnancy is the least, only accounting for 2-4%.

　　(1) Chronic salpingitis

　　Chronic salpingitis can cause adhesion of the mucosal folds of the fallopian tube, leading to lumen narrowing, mucosal destruction, loss of epithelial cilia, adhesion around the fallopian tube, tortuous shape, and all these conditions affect the normal operation and passage of the ovum in the fallopian tube, which is the main cause of tubal pregnancy.

　　(2) Abnormal development or function of the fallopian tube
　　Abnormal development of the fallopian tube, such as long fallopian tubes, poor muscle layer development, absence of mucosal cilia, double tubes, additional fimbriae, and so on, can all become causes of tubal pregnancy.

　　The physiological function of the fallopian tube is complex, and the peristalsis of the fallopian tube wall, the activity of cilia, and the secretion of epithelial cells are regulated by estrogen and progesterone. If the balance between the two hormones is disrupted, it will affect the transport of the ovum and lead to tubal pregnancy.

　　(3) Post-tubal surgery
　　Whether the tubal ligation, electrocoagulation, or ring method is used in tubal sterilization surgery, there is a possibility of tubal pregnancy if a fistula or recanalization occurs. Tubal reanastomosis or tubal shaping surgery after tubal sterilization may also cause the disease due to scar tissue narrowing and poor patency of the lumen.

　　(4) Pelvic endometriosis
　　The ectopic pregnancy caused by endometriosis of the uterine tube is mainly due to mechanical factors. In addition, the ectopic endometrium in the pelvic cavity may have a chemotactic effect on the ovum, promoting its implantation outside the uterine cavity.

　　Complications of ectopic pregnancy:

　　1. Abdominal pain:This is the most important symptom of ectopic pregnancy. Abdominal pain is caused by various factors such as the enlargement, rupture of fallopian tubes, and stimulation of the peritoneum by blood. When ruptured, the patient will suddenly feel a tearing pain in the lower abdomen on one side, often accompanied by nausea and vomiting. If the blood is confined to the lesion area, it presents as local lower abdominal pain; if the blood accumulates in the rectouterine凹陷, there is a feeling of坠胀 in the anus; if there is an excessive amount of bleeding, the blood flows from the pelvic cavity to the abdominal cavity, causing the pain to spread from the lower abdomen to the entire abdomen; if the diaphragm is stimulated by the blood, it can cause radiating pain in the scapula.

　　2, Irregular vaginal bleeding:After embryo death, irregular vaginal bleeding often occurs, with dark brown blood, less in amount, and generally does not exceed the amount of menstrual blood, but it does not stop bleeding completely. The difference between ectopic pregnancy bleeding and menstrual blood mainly lies in the different conditions of abdominal pain and vaginal bleeding.

　　3, Amenorrhea:Before the onset of ectopic pregnancy, there is often a short period of amenorrhea or delayed menstruation for several days. However, there are also a few people without obvious amenorrhea, and some people regard slight vaginal bleeding as menstruation. However, this pseudo-menstruation is generally different from the real menstruation, such as less bleeding or darker color, which can be considered as an early symptom of female ectopic pregnancy.

　　4, Shock:Due to acute intra-abdominal hemorrhage, it can cause a decrease in blood volume and severe abdominal pain. Mild cases often have syncope, and severe cases may lead to shock. The severity is proportional to the speed and amount of intra-abdominal bleeding, that is, the more and faster the bleeding, the more rapid and severe the symptoms appear, but it is not proportional to the amount of vaginal bleeding.

　　The clinical manifestations of ectopic pregnancy are related to the implantation site of the ovum in the fallopian tube, whether there is abortion or rupture, the amount of blood in the abdomen, and the onset time. Before the abortion or rupture of ectopic pregnancy, symptoms and signs are not obvious, except for short-term amenorrhea and pregnancy signs, there may be one-sided lower abdominal distension or pain during examination, and the fallopian tube is normal or enlarged. After the abortion or rupture of ectopic pregnancy, the disease is generally divided into acute and chronic types according to the urgency of the condition.

　　(一)Ectopic pregnancy

　　1, Symptoms

　　⑴ Amenorrhea: In addition to the interstitial pregnancy with a longer amenorrhea period, most cases have amenorrhea for 6 to 8 weeks. Generally, abdominal pain and vaginal bleeding occur after amenorrhea, but about 20% of patients report no history of amenorrhea.

　　⑵Abdominal pain: This is the main symptom when the patient seeks medical attention. Abdominal pain is caused by various factors such as the dilation, rupture of the fallopian tube, and stimulation of the peritoneum by blood. When rupturing, the patient suddenly feels a tearing pain in one side of the lower abdomen, often accompanied by nausea and vomiting. If the blood is confined to the lesion area, it manifests as localized lower abdominal pain; if the blood accumulates in the rectouterine pouch, there is a sensation of rectal distension; if the amount of bleeding is excessive, the blood flows from the pelvis to the abdomen, causing the pain to spread from the lower abdomen to the entire abdomen; if the diaphragm is stimulated by the blood, it can cause radiation pain in the scapula.

　　⑶Vaginal bleeding: After embryo death, irregular vaginal bleeding is common, which is dark brown in color, less in amount, and generally does not exceed the amount of menstrual blood, but it does not stop bleeding completely.

　　⑷Syncope and shock: Due to acute intra-abdominal hemorrhage, it can cause a decrease in blood volume and severe abdominal pain. Mild cases often have syncope, and severe cases may lead to shock. The severity is proportional to the speed and amount of intra-abdominal bleeding, that is, the more and faster the bleeding, the more rapid and severe the symptoms appear, but it is not proportional to the amount of vaginal bleeding.

　　2. Signs

　　⑴ In general, when there is a lot of intraperitoneal bleeding, it presents with acute anemia, and with a large amount of bleeding, there may be pale complexion, cold extremities, rapid and weak pulse, and a decrease in blood pressure, which are symptoms of shock. The body temperature is generally normal, slightly lower during shock, and may slightly increase during the absorption of intraperitoneal blood, but not exceeding 38℃.

　　⑵ Abdominal examination shows marked tenderness and rebound pain, especially on the affected side, but the abdominal muscle tension is less than that of板状腹 during peritonitis. When there is a lot of bleeding, percussion may show mobile dullness, and after a long time, blood clots may form. Soft lung masses can be felt in the lower abdomen, and repeated bleeding can cause the mass to increase in size and hardness.

　　⑶ Pelvic examination shows a full posterior fornix, tenderness, and a marked upward or lateral movement of the cervix can cause severe pain. The uterus is slightly larger and softer, and when there is a lot of internal bleeding, the uterus has a floating sensation. A mass can be felt on one side or behind the uterus, with a texture similar to wet wheat dough, unclear boundaries, and marked tenderness. The gestational sac in the isthmus is different from that in other parts of the fallopian tube. The size of the uterus is basically consistent with the menstrual period of amenorrhea, but the contour is not symmetrical. The cornu of the affected side is prominent, and the signs caused by rupture are very similar to those of uterine rupture during pregnancy.

　　(II) Chronic ectopic pregnancy

　　Refers to the long course of illness after the abortion or rupture of tubal pregnancy, with repeated internal bleeding, the condition gradually stabilizes. At this time, the embryo dies, the villi regress, internal bleeding stops, and abdominal pain is somewhat relieved. However, the formed hematoma gradually becomes fibrous and hard, and adheres to surrounding tissues and organs. Patients with chronic ectopic pregnancy may have a history of recurrent postmenstrual bleeding. The clinical characteristics are irregular vaginal bleeding, intermittent abdominal pain, adnexal mass, and low fever. The low fever is caused by the absorption process of intraperitoneal blood. If secondary infection is present, it may manifest as high fever.

　　1. Pregnancy and correct contraception
　　Choose a time when both partners are in good mental and physical condition to get pregnant. If they are not considering becoming parents at the moment, they should practice contraception. Good contraception can fundamentally prevent ectopic pregnancy.
　　2. Treat reproductive system diseases in a timely manner
　　Inflammation is the main cause of fallopian tube stenosis, and procedures such as artificial abortion further increase the likelihood of inflammation and endometrial entry into the fallopian tube, leading to adhesion and stenosis of the fallopian tube, increasing the risk of ectopic pregnancy. Diseases such as uterine fibroids and endometriosis can also change the shape and function of the fallopian tube. Timely treatment of these diseases can reduce the occurrence of ectopic pregnancy.
　　3. Try in vitro fertilization
　　If a woman has had one ectopic pregnancy, the possibility of another can be enough to destroy her confidence in becoming a mother. She can choose in vitro fertilization. After the sperm and egg successfully 'marry' in vitro, the fertilized egg can be returned to the mother's uterus for safe gestation.
　　4. Pay attention to the hygiene of the menstrual period, childbirth, and postpartum period to prevent infections of the reproductive system. As soon as possible after menopause, it is important to clarify the location of pregnancy and to detect ectopic pregnancy in a timely manner.

　　(1) Urine pregnancy test:Simple and quick, positive results can assist in diagnosis, while negative results require waiting for blood β-HCG quantification to exclude the possibility.

　　(2) Blood β-HCG quantification:It is an important method for the early diagnosis of ectopic pregnancy, which can not only assist in diagnosis but also help judge the activity of the embryo to guide treatment. In ectopic pregnancy, the blood β-HCG level is usually lower than that of normal intrauterine pregnancy. Blood β-HCG levels should be monitored after conservative drug treatment or surgery to detect persistent ectopic pregnancy early.

　　(3) Blood progesterone measurement:The level of progesterone in patients with ectopic pregnancy is low, which can also be used as an indicator for the diagnosis of early ectopic pregnancy. The level of progesterone in early pregnancy is relatively stable, such as when the progesterone level is

　　(4) Ultrasound examination:Vaginal ultrasound is superior to abdominal ultrasound, with a diagnostic accuracy rate for ectopic pregnancy of 70-94%. The presence of a gestational sac ("tubal ring") or fetal heartbeat in the fallopian tube can be diagnosed. For those with a history of cesarean section, the scar site on the anterior wall should be observed carefully to avoid missed diagnosis of scar pregnancy. If the serum β-HCG is over 2000 mIU/ml, if it is an intrauterine pregnancy, vaginal ultrasound can detect the gestational sac, otherwise, ectopic pregnancy should be警惕. The liquid dark area in the peritoneal cavity is helpful for diagnosis.

　　(5) Laparoscopic examination:It is the 'gold standard' for diagnosing tubal pregnancy, but it is an invasive method with high costs. It can perform submicroscopic surgery at the same time as the diagnosis is made, avoiding the盲目ness of laparotomy, with less trauma and faster recovery. It is widely used in hospitals with conditions. The specific method can be seen in the 'Laparoscopic Examination' section of this manual.

　　(6) Endometrial pathological examination:For those with abundant vaginal bleeding and ultrasound indicating uneven thickening of the endometrium or with cystic areas, diagnostic curettage can be performed. If villi are found in the刮出物, it can be diagnosed as an intrauterine pregnancy abortion. Otherwise, pathological examination should be sent, as the absence of villi and the presence of decidua can help diagnose tubal pregnancy. For ectopic pregnancy with unclear diagnosis, a serum β-HCG reexamination can be performed 24 hours after curettage. If there is no significant decrease or increase compared to before surgery, it supports the diagnosis. In recent years, with the popularization of assisted reproduction technology, the incidence of composite pregnancy has increased significantly, and high vigilance should be exercised.

　　1. Diet suitable for ectopic pregnancy
　　Supplement protein
　　Protein is an important component of antibodies. If intake is insufficient, the body's resistance will decrease. Within half a month after surgery, 1.5 to 2 grams of protein per kilogram of body weight should be provided, with an approximate daily amount of 100 to 150 grams. Therefore, it is advisable to eat more chicken, lean pork, eggs, dairy products, and legumes, as well as legume products.

　　Supplement water
　　After surgery, due to the body's weakness, sweating is common. Therefore, it is necessary to supplement water and reduce the amount of water evaporation; more water-soluble vitamins are excreted in sweat, especially vitamin C, vitamin B1, and vitamin B2, so it is advisable to eat more fresh vegetables and fruits. This is also conducive to preventing constipation.

　　2. Diet taboos for ectopic pregnancy

　　On the basis of normal diet, fat should be restricted appropriately. Within one week after surgery, fat intake should be controlled at about 80 grams per day. For those with menstrual irregularities, it is forbidden to eat刺激性 food, such as chili, alcohol, vinegar, pepper, ginger, etc., as these foods can cause congestion of the organs, increase the amount of menstruation, and also forbidden to eat cold foods such as crabs, snails, and clams. It is also forbidden to eat cold foods.

　　Therapeutic diet for ectopic pregnancy:

　　槐花苡米粥 (from 'Congshu'): 10g of huaihua (sophora flowers), 30g of job's tears, 20g of winter melon seeds, and appropriate amount of rice. Boil huaihua and winter melon seeds into a decoction, remove the residue, add job's tears and rice to cook into porridge for consumption. This formula has the effect of invigorating the body and removing dampness.

　　Rehmannia Chicken (from 'Yanshan Zhengyao'): 250g of rehmannia, 1 black hen, 150g of sugar. Remove the feathers and clean the intestines and stomach of the hen, finely cut, mix rehmannia and sugar evenly, put them in the hen's belly, steam over water, and do not use salt, vinegar, and other seasonings. This formula has the effect of nourishing yin and clearing heat.

　　Chicken shreds stir-fried wide vegetables: 500g of amaranth, 100g of chicken breast. Clean the amaranth, remove the roots, cut into pieces about 3 cm long, and slice the chicken breast. Put water in the wok, blanch the amaranth first, then drain it; heat the oil in the wok, stir-fry the chicken shreds until they change color, add salt, monosodium glutamate, and clear soup, pour the amaranth in, stir well, and it is ready to eat after boiling for 5 minutes. Amaranth, sweet and cold in nature, clears heat and promotes diuresis, nourishes the blood and cools the blood; chicken breast contains protein and vitamins, which can nourish the liver and strengthen the liver.

　　Shrimp and sea cucumber soup: 150g of sea cucumber, some shrimp, and other seasonings. First, put the sea cucumber in a pot, add water, turn off the fire after boiling with low heat, until it swells and softens, scrape off the internal organs, clean it again, and then blanch it with boiling water until it is fully cooked, cut into cubes; soak the shrimp with huangjiu to soften. Put chicken broth in the pot, add sea cucumber and shrimp, boil for 20 minutes after adding salt. Add monosodium glutamate, white pepper, and starch slurry to thicken, and then serve it in a bowl. Shrimp contains abundant protein, phosphorus, iron, and vitamins, which can tonify the kidney and strengthen yang; sea cucumber fills the essence and helps yang and yin.

　　Garlic flavored turtle soup: 1 round turtle weighing about 200g, boil it in hot water after killing, remove the shell and internal organs, clean it; 20g of peeled garlic, slightly crushed. Place the turtle in a soup bowl, add huangjiu, ginger pieces, scallion pieces, and salt, steam for 20 minutes first, remove ginger and scallions, add garlic, monosodium glutamate, and appropriate amount of water, then steam for another 40 minutes in the steamer, drink the soup and eat the meat. The round turtle, also known as the turtle, contains high-quality protein and essential amino acids, nourishes the liver yin and promotes blood circulation; garlic contains protein, vitamins, minerals, volatile oil, and garlic flavoring, which can promote diuresis and blood circulation.

　　Ginseng and Astragalus Chicken: 1 old hen, 50g of Codonopsis, 50g of Astragalus, 50g of Chinese yam, 50g of jujube, and appropriate amount of huangjiu (yellow wine). Place the slaughtered hen without feathers and internal organs, soaked in huangjiu, the other four ingredients around the chicken, steamed over water, and served in portions. It has the effects of invigorating the body and enriching the blood. It is suitable for tonifying after abortion.

　　Dove and goji soup: 1 dove, 30g of goji, a little salt. Remove the feathers and internal organs of the dove, clean it, put it in a pot with water and goji to stew, add a little salt when it is cooked. Eat the meat and drink the soup, twice a day. It has the effects of invigorating the body, enriching the blood, and tonifying deficiency. It is suitable for body weakness after abortion, as well as symptoms such as qi deficiency, fatigue, and spontaneous sweating due to superficial deficiency after illness.

　　Soybean milk rice porridge: 2 bowls of soybean milk, 50g of rice, and appropriate amount of sugar. Rinse and clean the rice, cook it into porridge with soybean milk, add sugar and adjust the taste after it is cooked. Take it on an empty stomach in the morning every day. It has the effects of harmonizing the spleen and stomach, clearing heat and moistening dryness. It is suitable for the nourishment of body weakness after artificial abortion.

　　Lychee and Jujube Soup: 7 dried lychees and 7 dried jujubes. Boil them together with water and take one dose per day. It has the effects of nourishing the blood and moistening the body. It is suitable for nourishing deficiency of blood and Qi in women and for nourishing the body after abortion.

　　Egg and Jujube Soup: 2 eggs, 10 jujubes, and an appropriate amount of brown sugar. Boil water in a pot, add eggs, and simmer. When the water boils again, add the jujubes and brown sugar, and simmer over low heat for 20 minutes. It has the effects of replenishing the middle energy and nourishing the blood. It is suitable for nourishing deficiency of blood and Qi after anemia and after illness, and after childbirth.

　　Chemical Drugs:

　　Mainly suitable for early ectopic pregnancy, young patients who wish to preserve their fertility.

　　It is generally believed that the following conditions can be adopted:

　　① The diameter of the ectopic pregnancy mass

　　② The ectopic pregnancy has not ruptured or aborted;

　　③ No obvious internal bleeding;

　　④ Blood HCG

　　Surgical Treatment:

　　The treatment principle of ectopic pregnancy is mainly surgical treatment, among which there are two types of surgical methods: one is the resection of the affected fallopian tube; the other is the operation to retain the affected fallopian tube, that is, conservative surgery.

　　Conservative surgery is suitable for young women with the desire to bear children, especially those with the opposite fallopian tube removed or with obvious lesions. In recent years, due to the improvement of diagnostic technology, there has been an increase in the number of ectopic pregnancies diagnosed before abortion or rupture, so the use of conservative surgery has increased significantly compared to the past. The operation method is selected according to the site of fertilization and the condition of the fallopian tube lesions. If it is tubal pregnancy, the pregnancy product can be squeezed out; for ampullary pregnancy, the embryo is removed from the fallopian tube by incision and then sutured; for isthmic pregnancy, the diseased segment is excised and anastomosed end-to-end. The use of microsurgical techniques can improve the pregnancy rate in the future. In addition to open surgery, conservative surgery can also be performed through laparoscopy.

　　Minimally Invasive Treatment:

　　In recent years, minimally invasive laparoscopic technology has become increasingly mature and is widely used in the field of gynecology and obstetrics, making the treatment of ectopic pregnancy also shift from 'large trauma' to 'minimally invasive'. Because of its small surgical trauma, less bleeding, short operation time, fast postoperative recovery, short hospital stay, almost no scar on the abdomen, less pelvic adhesion, mild fallopian tube obstruction, and easier preservation of the fallopian tube, tissue coagulation can prevent the exudation and precipitation of fibrin, and significantly improve the quality of life of patients after surgery.