Persistent ectopic pregnancy

　　1. Etiology

　　The possibility of persistent fallopian tube pregnancy increases under the following conditions: (1) less than 7 weeks of amenorrhea, fallopian tube mass of 3000 mU/ml or progesterone > 35 mg/ml; (2) HCG rising > 1000 mU/ml within 24 hours before surgery; (3) the risk of laparoscopic conservative surgery is slightly higher than that of laparotomy.

　　2. Pathogenesis

　　It is generally believed that during conservative surgery for fallopian tube pregnancy, trophoblastic cells have penetrated deeply into the muscular layer of the tube wall, or due to the extensive range of the lesion, they were not completely removed. Small lesions or non-ruptured lesions were not found during surgery, and trophoblastic cells were left in the lumen during fallopian tube extrusion, causing the trophoblastic cells to continue to grow, leading to persistent ectopic pregnancy.

　　Persistent ectopic pregnancy: Due to the increasing incidence of ectopic pregnancy and significant improvements in diagnostic methods, the treatment of ectopic pregnancy has gradually shifted from radical surgical treatment to conservative surgical or drug treatment. Therefore, persistent ectopic pregnancy (PEP) has occurred after conservative treatment. The incidence of PEP is 3% to 20%. Its characteristics include the survival of trophoblastic cells after conservative treatment of ectopic pregnancy, the maintenance of HCG levels at the original level, and irregular vaginal bleeding. Due to the destruction of trophoblastic cells on surrounding tissues, intra-abdominal hemorrhage may continue to occur. In extremely rare cases, choriocarcinoma of the fallopian tube may occur. Conservative fallopian tube surgery, such as fallopian tube linear incision, partial fallopian tube resection, especially after aneurysmal compression of the ostium, due to the trophoblastic cells having been pressed into the muscular layer of the tube wall or the lesion being extensive, there is a possibility that the lesion is not completely removed during laparoscopic or exploratory laparotomy surgery, leading to this complication.

　　Persistent ectopic pregnancy refers to the condition where trophoblastic cells survive after conservative surgery or drug treatment for ectopic pregnancy, with human chorionic gonadotropin (HCG) levels remaining at a certain level without decline or even rising. The surviving trophoblastic cells can still cause damage to surrounding tissues, leading to intra-abdominal hemorrhage. This can lead to hemorrhagic anemia, shock, and in severe cases, anemia-related heart disease. There is also a possibility of adhesion of peritoneal surrounding tissues.

　　The main symptoms are lower abdominal pain after conservative surgery, occasionally with continued bleeding in the abdomen, amenorrhea, abdominal pain, vaginal bleeding, and pelvic mass.

　　Monitoring of serum β-HCG is the basis for diagnosing persistent tubal pregnancy. After conservative surgery for tubal pregnancy, serum β-HCG should be immediately measured as the initial value, and measured 2-3 times a week thereafter until it is less than 15mU/ml. If the serum β-HCG decreases by less than 15% per week after surgery, the possibility of persistent tubal pregnancy is very high. If the serum β-HCG decreases by less than 10% 12 days after surgery, the diagnosis can be confirmed.

　　If the patient has abdominal pain or intra-abdominal bleeding after conservative surgery, they should be more vigilant about the occurrence of persistent tubal pregnancy.

　　How to completely remove the gestational tissue during the operation is the key to preventing persistent tubal pregnancy. The incision should be made at the center of the most prominent part of the fallopian tube to avoid missing the gestational tissue. Some people inject normal saline near the incision to flush out the gestational tissue in one piece. It is also possible to use methotrexate for prevention before or after surgery, or 10-25mg of methotrexate locally at the site of embryo implantation before the end of surgery.

　　Prognosis:Patients with persistent tubal pregnancy have a smaller chance of pregnancy than those with a single ectopic pregnancy, and the possibility of a second ectopic pregnancy is greater. After conservative surgery for the previous tubal pregnancy, the narrowing of the fallopian tube can lead to incomplete patency and a second ectopic pregnancy. Drug treatment can also cause scar or nodule formation at the site of embryo implantation, leading to incomplete patency and a second ectopic pregnancy. In addition, infertile patients who have had tubal pregnancy and undergone tubal resection or conservative surgery can also experience repeated ectopic pregnancy after embryo transfer, in vitro fertilization, or gamete intrafallopian transfer.

　　Serum β-HCG monitoring; after conservative surgery, such as tubal linear incision or ostium compression, the time required for HCG to decrease to the normal range varies, with the longest reaching 30 days, on average 8-12 days. If the serum HCG value only decreases by less than 10% of the preoperative level 12 days after surgery, the diagnosis can be established. Therefore, continuous monitoring of serum HCG before and after treatment is of great significance for the diagnosis of PEP. Ultrasound examination for pelvic mass and other findings, and laparoscopic examination can be performed to assist in diagnosis if necessary.

　　What kind of food is good for the body with persistent tubal pregnancy: The diet should be light and balanced, pay attention to nutritional balance, eat more vegetables and fruits, and avoid spicy and stimulating foods. The patient's diet should be light and easy to digest, eat more vegetables and fruits, and balance the diet properly, paying attention to adequate nutrition. In addition, patients should also pay attention to avoiding spicy, greasy, and cold foods.

　　1. Prevention:How to completely remove the pregnancy material during conservative surgery is the key to preventing persistent ectopic pregnancy. The incision should be at the center of the most prominent part of the fallopian tube to avoid missing the pregnancy material. Some people inject normal saline next to the incision to wash out the pregnancy material in one piece. It can also be used before or after surgery to apply methotrexate to prevent it or 10-25mg of methotrexate locally at the site of embryo implantation before the end of surgery.

　　2. Western Medicine Treatment:Persistent ectopic pregnancy can still be treated with surgery, drug therapy, and expectant therapy. More than half of the patients need to undergo surgery again. The surgical method can be selected according to the condition and the requirement for fertility. The resection of the fallopian tube or conservative surgery can be adopted. For patients with stable conditions and no obvious internal hemorrhage, drug therapy is more appropriate. The drug treatment method is the same as that for ectopic pregnancy. A few patients have no symptoms, the blood β-HCG level is not high, and it decreases slowly, and expectant therapy can be adopted.

　　The treatment for persistent ectopic pregnancy includes expectant therapy, drug therapy, and surgical treatment, among which surgical methods are more common due to the varying conditions of patients and different requirements for fertility, so the surgical methods are also inconsistent. For example, resection of the fallopian tube, partial resection of the fallopian tube, and total resection of the fallopian tube. For those with no symptoms or significant symptoms, drug treatment is used, such as low-dose methotrexate (MTX), which has minor side effects, but most patients can tolerate it without the need for calcium folinate (formyl tetrahydrofolate calcium) to avoid a second operation. Some patients can recover spontaneously through expectant therapy, therefore, the treatment of PEP should be individualized.

　　3. Traditional Chinese Medicine Treatment

　　(1) Prescription: Salvia miltiorrhiza 30g, Paeonia lactiflora 10g, Prunus persica 10g, Borneol 10g, Myrrha 10g. Boil 300ml of water, take in two doses. Add ginseng for those with weakness, and add Yuanhu for severe pain, and at the same time, rescue shock, transfuse blood, infuse fluid, oxygenate, keep warm, and maintain systolic pressure around 12kpa.

　　(2) 15g of Brucea javanica, 15g of Brucea unifera, 15g of Cupressus funebris, 10 large dried dates with the kernel removed, mixed evenly, ground into fine powder, wrapped in gauze, placed on the lower abdomen, and externally heated. Or with 0.6g of musk, 6g of camphor, 9g of dragon's blood, 9g of rosin, 9g of silver bead. The last four herbs are ground into fine powder, spread on a cloth, and melted with fire, finally adding musk and externally applied to the mass at the lower abdomen.