Ectopic pregnancy

　　The fallopian tube is the most common site of extrauterine pregnancy. When the fallopian tube pregnancy has an acute attack of abortion or rupture, it can cause severe intra-abdominal hemorrhage. If it is not diagnosed and treated in time, it can be life-threatening. The incidence of fallopian tube pregnancy is the highest in the ampulla, accounting for 55-60%, followed by the isthmus, accounting for 20-25%, then the fimbria, accounting for 17%, and the least in the interstitial part, only accounting for 2-4%.

　　(One) Chronic salpingitis

　　Chronic salpingitis can cause adhesion of the mucosal folds of the fallopian tube, leading to stenosis of the lumen, destruction of the mucosa, loss of epithelial cilia, adhesion around the fallopian tube, and tubular torsion. These conditions affect the normal operation and passage of the ovum in the fallopian tube, and are the main causes of tubal pregnancy.

　　(Two) Abnormal development or function of the fallopian tube

　　Abnormal development of the fallopian tube, such as excessive length, poor muscle layer development, lack of mucosal cilia, bilobed fallopian tubes, additional fimbriae, etc., can all be causes of tubal pregnancy. The complex physiological function of the fallopian tube, including the peristalsis of the fallopian tube wall, the activity of cilia, and the secretion of epithelial cells, are regulated by estrogens and孕激素. If there is a imbalance between the two hormones, it will affect the transport of the ovum and lead to tubal pregnancy.

　　(Three) Post-tubal surgery

　　Whether by ligation, electrocoagulation, or ring suture methods, tubal sterilization can lead to tubal pregnancy if there is a formation of fistula or recanalization. Tubal sterilization and reconstruction after sterilization or tubal shaping surgery can also cause stenosis and poor patency due to scars, leading to disease.

　　(Four) Pelvic endometriosis

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

　　The common complications of ectopic pregnancy are pelvic inflammatory disease. Pelvic inflammatory diseases are a group of diseases caused by inflammation of the female upper reproductive tract, including endometritis, salpingitis, salpingo-ovarian abscess, and pelvic peritonitis. Most of them are mainly manifested by pain, accounting for more than 90%. Since the pelvic organs are mainly innervated by visceral nerves, the pain sensation is often inaccurately localized, and the inflammation itself is not only limited to a single pelvic organ, so sometimes it is difficult to determine the exact location of the inflammation in clinical practice, whether it is the fallopian tube or ovary, etc. Sometimes, the inflammation confined around the fallopian tube and ovary is called adnexitis.

　　Clinical symptoms include lower abdominal pain with fever, and if the condition is severe, chills, high fever, anorexia, and other symptoms may occur. During peritonitis, symptoms such as nausea, vomiting, and abdominal distension may occur in the digestive system. If an abscess forms, there may be lower abdominal masses and local pressure and stimulation symptoms. If the mass is located in the front, there may be urinary system symptoms. If it is located at the back, there may be symptoms of rectal irritation, such as diarrhea, urgency, and difficulty defecating.

　　Patients present with an acute illness appearance, elevated body temperature, increased heart rate, possible muscle tension, tenderness, and rebound tenderness in the lower abdomen. Gynecological examination may show a large amount of purulent discharge from the cervix, marked tenderness in the fornix, and possible distension and fluctuation in the posterior fornix, suggesting the presence of a pelvic abscess. The cervix is congested and tender, the uterus is tender and movement is limited, and there is marked tenderness on both sides of the uterus. If it is a simple salpingitis, the fallopian tube may be palpable with thickening and marked tenderness. If it is an abscess, a palpable mass with marked tenderness and fluctuation may be felt. When there is parametritis, palpation may reveal unilateral or bilateral patchy thickening, or significant edema and thickening of the uterine fundus ligaments, with marked tenderness.

　　The clinical manifestations of ectopic pregnancy are related to the implantation site of the embryo 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, both symptoms and signs are not obvious, except for short-term amenorrhea and pregnancy symptoms, there may be unilateral lower abdominal distension and pain, and the fallopian tube is normal or enlarged during examination. After the abortion or rupture of ectopic pregnancy, the condition is generally divided into acute and chronic types according to the urgency of the disease.

　　One. Ectopic Pregnancy

　　1. Symptoms

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

　　⑵ Abdominal Pain: Abdominal pain is the most prominent symptom when patients seek medical attention. Abdominal pain is caused by various factors, including dilatation, rupture of the fallopian tube, and stimulation of the peritoneum by blood. During rupture, patients suddenly feel a tearing pain in one side of the lower abdomen, often accompanied by nausea and vomiting. If the blood is confined to the area of the lesion, it presents as localized lower abdominal pain; if the blood accumulates in the rectouterine pouch, there may be a sensation of rectal prolapse; if there is excessive bleeding, the blood flows from the pelvis to the abdomen, and the pain spreads from the lower abdomen to the entire abdomen; if the diaphragm is stimulated by the blood, it can cause radiation pain in the scapula.

　　⑶ Vaginal Bleeding: After embryonic death, irregular vaginal bleeding is common, characterized by a deep brown color, small amount, usually not exceeding the amount of menstrual blood, but persistent.

　　⑷ Syncope 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, while severe cases may develop shock. The severity is proportional to the speed and amount of intra-abdominal bleeding, meaning the more and faster the bleeding, the more rapid and severe the symptoms will appear, but not proportional to the amount of vaginal bleeding.

　　2. Signs and Symptoms

　　⑴ In general cases, with a large amount of intra-abdominal bleeding, it presents with acute anemia appearance. With massive bleeding, there may be pale complexion, cold extremities, rapid and weak pulse, and decreased blood pressure, among other symptoms of shock. The body temperature is generally normal, slightly lower during shock, and may slightly increase during the absorption of intra-abdominal blood, but not exceeding 38℃.

　　(⑵ Abdominal examination: There is marked tenderness and rebound pain in the lower abdomen, especially on the affected side. However, the abdominal muscle tension is less than that of the rigid abdomen in peritonitis. When there is a lot of bleeding, percussion shows mobile dullness. After a long time, blood clots are formed. Soft masses can be felt in the lower abdomen. Repeated bleeding causes the mass to increase in size and become hard.

　　(⑶ Pelvic examination: The posterior fornix of the vagina is full and tender, the cervix has obvious lifting pain. When the cervix is gently lifted or moved to the left and right, it can cause severe pain. The uterus is slightly larger and soft. 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 flour, unclear boundaries, and marked tenderness. The gestational sac in the isthmus is different from that in other parts of the fallopian tube pregnancy. The size of the uterus is basically consistent with the menstrual period of amenorrhea, but the contour of the uterus is not symmetrical. The cornual part of the affected side is prominent, and the signs caused by rupture are very similar to those of uterine rupture during pregnancy.

　　Second, chronic ectopic pregnancy

　　It refers to the long course of illness after the abortion or rupture of ectopic pregnancy, with the condition gradually stabilizing due to repeated internal bleeding. At this time, the embryo dies, the villi regress, internal bleeding stops, abdominal pain is somewhat relieved, but the blood clot formed gradually becomes hard and adheres to the surrounding tissues and organs. Patients with chronic ectopic pregnancy can inquire about a history of recurrent postmenstrual bleeding. The clinical characteristics are irregular vaginal bleeding, intermittent abdominal pain, adnexal mass, and low fever. Low fever is caused by the absorption process of intraperitoneal blood. If secondary infection is present, it is manifested as high fever.

　　In recent years, the incidence of ectopic pregnancy has shown an increasing trend. This is an important issue facing us. Although the exact etiology of the disease is not yet fully clear, many related factors are clear. Reducing the high-risk factors can achieve the purpose of prevention.

　　(1) Strengthen the publicity and social governance of the prevention and treatment of sexually transmitted diseases.

　　(2) When placing an intrauterine contraceptive device, performing induced abortion, and other intrauterine manipulations, it is crucial to strictly follow the standard operating procedures and infection prevention measures.

　　(3) Early treatment should be given to pelvic soft tissue infection, and it should be cured completely in one go.

　　(4) Actively treat endometriosis.

　　(5) After using ovulation induction drugs, if there is a suspicion of early pregnancy, or if assisted reproduction is successful, ectopic pregnancy and twin pregnancy should be excluded in a timely manner.

　　(6) Publicize the dangers of smoking, prohibit drug abuse, quit smoking and drinking, and effectively prevent the occurrence of ectopic pregnancy.

　　(7) Those who have had multiple dilatation and curettage should be vigilant during subsequent pregnancy and should have an ultrasound examination to see if the embryo is 'living' in the uterus. Once an abnormality is found, appropriate measures should be taken immediately.

　　(8) Do not simply confirm that vaginal bleeding after pregnancy is a common sign of threatened miscarriage, do not act on your own, and be sure to go to the hospital to find out the truth to avoid accidents.

　　(9) Contraception methods should be used strictly and in accordance with the instructions on the drug package of each brand of birth control pills.

　　(10) It is very important to have pre-pregnancy checks to prevent ectopic pregnancy, because if there are pathogenic factors such as cervical inflammation, pelvic inflammation, etc. found before pregnancy, the condition can be controlled first before conception.

　　The symptoms and signs of ectopic pregnancy are typical, and most patients can make a timely diagnosis. When there is difficulty in diagnosis, necessary auxiliary examinations should be carried out.

　　1. Posterior fornix puncture or abdominal puncture

　　Since blood is most likely to accumulate in the cul-de-sac of the uterus and rectum, even with a small amount of blood, it can be aspirated through the posterior fornix. A 18-gauge long needle is inserted into the cul-de-sac of the uterus and rectum through the posterior fornix of the vagina to aspirate dark red unclotted blood, which is a positive result, indicating the presence of blood in the abdominal cavity. When there is a lot of bleeding, it can be directly punctured through the lateral abdominal wall.

　　2. Pregnancy test

　　When the embryo is viable or the trophoblast is active, the syncytiotrophoblast secretes hCG, and the pregnancy test may be positive. Due to the lower level of HCG in patients with ectopic pregnancy compared to normal pregnancy, the positive rate of general HCG testing methods is low, and more sensitive β-HCG radioimmunoassay or monoclonal antibody enzyme-linked immunosorbent assay should be used for detection.

　　3. Ultrasound diagnosis

　　During early tubal pregnancy, B-ultrasound imaging shows enlargement of the uterus, but the uterine cavity is empty, and there is a hypoechoic area adjacent to the uterus. This kind of image is not the ultrasonic imaging characteristic of tubal pregnancy and needs to exclude the possibility of early intrauterine pregnancy accompanied by corpus luteum. The use of ultrasound to detect gestational sac and fetal heart movement is very important for the diagnosis of ectopic pregnancy. If the gestational sac is located outside the uterus, it can be diagnosed as ectopic pregnancy; if the gestational sac is located inside the uterus, it can usually exclude ectopic pregnancy. Early B-ultrasound diagnosis of interstitial pregnancy has important clinical significance, showing prominence of one uterine horn and local thickening of the myometrium with a distinct gestational sac.

　　4. Laparoscopy

　　Laparoscopy can be adopted when conditions and necessity permit.

　　5. Endometrial pathological examination

　　Diagnostic curettage is only applicable to patients with heavy vaginal bleeding, the purpose is to exclude intrauterine pregnancy. The products of uterine cavity should be routinely sent for pathological examination. If villi are seen in the slices, it can be diagnosed as intrauterine pregnancy. If only decidua is seen without villi, although it should be considered as ectopic pregnancy, it cannot be diagnosed.

　　Patients with ectopic pregnancy have weak physique, and attention should be paid to their diet, strengthened nutrition, and appropriate diet plays a very important role in the recovery and health care of the disease. Therefore, the following points should be noted in the diet of patients with ectopic pregnancy:

　　1. It is recommended to supplement nutrition and eat more foods rich in protein and vitamins to maintain smooth defecation. Due to anemia, it is advisable to eat more foods rich in iron such as spinach, mushrooms, pork liver, and jujube. During MTX chemotherapy, it is advisable to eat soft foods without bones or thorns, rinse the mouth frequently, and strictly prevent the occurrence of oral ulcers. During high fever, it is advisable to eat high-calorie and easily digestible foods, eat small and frequent meals, drink plenty of water, and pay attention to rinsing the mouth.

　　2. It is not recommended to eat aquatic products that have abortifacient effects. Many aquatic products have the function of promoting blood circulation and softening hardness, which may cause bleeding and miscarriage in early pregnancy when consumed. For example, crabs, although delicious, are cold in nature and have the function of promoting blood circulation and removing blood stasis. The crab claws, in particular, have a significant abortifacient effect and the function of nourishing yin and benefiting the liver and kidneys. For most people, it is a dish rich in nutrition and nourishing the body, but the turtle is salty and cold in nature, with strong functions of promoting blood circulation and dispersing blood stasis, thus it has the abortifacient effect. The abortifacient power of turtle shell is stronger than that of turtle meat; seaweed is salty and cold in nature, with the function of softening hardness, dispersing knots, and resolving phlegm and blood stasis, thus it also has the abortifacient effect.

　　3. Do not eat slippery foods. Rice seed, also known as Coix Seed, is a type of plant seed that can be used both as medicine and as food. Its nature is slippery, and pharmacological experiments have shown that Coix Seed has an exciting effect on the uterine muscle, promoting uterine contraction, and thus has the potential to induce abortion; Portulaca oleracea, also known as melon seed vegetable, is both a medicine and can be eaten as a vegetable. However, it is cool and slippery, and experimental evidence shows that Portulaca oleracea juice also has a significant exciting effect on the uterus, increasing the frequency and intensity of uterine contractions, which is easy to cause abortion.

　　4. Do not eat apricots and杏仁. Apricots are sour and hot, have the effect of滑胎, due to the heavy pregnancy qi and heat, it is generally followed by the principle of 'clear before childbirth', and the hot nature and滑胎 characteristics of apricots are a great taboo for pregnant women. Almonds contain a highly toxic substance hydrogen cyanide, which can cause tissue asphyxiation and death. Eating 7~10 almonds can be fatal to children, so to avoid the toxic substances passing through the placental barrier and affecting the fetus, pregnant women should avoid eating almonds.

　　5. Do not eat black fungus. Although black fungus is popular for its nourishing and stomach-soothing effects, it also has the function of promoting blood circulation and removing blood stasis, which is not conducive to the stability and growth of the embryo, so it should be avoided. For cervical pregnancy, do not eat hawthorn, as hawthorn has the effects of promoting blood circulation, removing blood stasis, and contracting the uterus, so it should be avoided.

　　The common western medical treatment methods for ectopic pregnancy include surgical treatment and non-surgical treatment:

　　(One) Surgical Treatment

　　For patients with severe internal hemorrhage and shock, active correction of shock, blood volume supplementation, and surgical rescue should be carried out. Rapidly open the abdominal cavity, remove the diseased fallopian tube, use a round forceps to clamp the fallopian tube mesentery quickly to control bleeding, accelerate fluid infusion, and continue surgery after the blood pressure rises.

　　(Two) Non-surgical Treatment

　　(1) Expectant Therapy: No clinical symptoms or mild clinical symptoms; the diameter of the mass in ectopic pregnancy

　　(2) Chemotherapy: Suitable for those without obvious abdominal pain, the maximum diameter of the mass is 3.5~5.0cm, and β-hCG

　　(3) Interventional Therapy: After angiography, methotrexate is slowly injected into the uterine artery, and the uterine artery is embolized with absorbable gelatin sponge particles after perfusion is completed. After embolization, closely observe the vital signs of the patient, and re-examine blood β-hCG and ultrasound weekly. Due to its high cost, it is currently only used in the treatment of some special types of ectopic pregnancy.