What Is a Tubal Pregnancy?

Tubal pregnancy is the most common ectopic pregnancy, where fertilized eggs are planted in the fallopian tubes. Ampulla pregnancy is the most common, accounting for 50% to 70%; followed by the isthmus, accounting for 30% to 40%; umbrella and interstitial are the least common, accounting for 1% to 2%. Menopause, abdominal pain, and irregular vaginal bleeding are the main symptoms.

Basic Information

Visiting department

Obstetrics and Gynecology

Multiple groups

Women who have undergone conservative treatment of tubal pregnancy

Common locations

oviduct

Common causes

Complications of conservative treatment of tubal pregnancy

Common symptoms

Lower abdominal pain, menopause, abdominal pain, vaginal bleeding, pelvic mass, etc.

Causes of tubal pregnancy

The exact cause is unknown, and may be related to the following factors.

Tubal abnormalities

Chronic salpingitis can cause luminal fold adhesion and partial obstruction; appendicitis, pelvic tuberculosis, peritonitis, and endometriosis can cause adhesions around the fallopian tube, tubal distortion and stiffness, resulting in tubal stenosis, partial obstruction or abnormal peristalsis; The pulling and compression of pelvic tumors force the fallopian tubes to become slender, tortuous, or partially blocked or narrowed; the fallopian tube adhesion separation, recanalization, and severe adhesions after the ostomy stoma or surgical site scarring, tubal sterilization The formation or recanalization of the posterior fistula can delay or prevent the fertilized eggs from entering the uterine cavity, thereby implanting the fallopian tube and causing tubal pregnancy. In addition, when the fallopian tube is underdeveloped, the fallopian tube is slender and tortuous, the muscular layer is poorly developed, and the mucosal cilia are lacking, which can affect the normal operation of the fertilized egg.

2. Fertilized eggs swim

The egg is fertilized on one side of the fallopian tube and implanted after entering the contralateral fallopian tube through the uterine cavity (walking inside the fertilized egg); or swimming in the abdominal cavity and being picked up by the contralateral fallopian tube (walking outside the fertilized egg). Long, fertilized egg development increases, so the contralateral fallopian tube is planted to produce a fallopian tube pregnancy.

3. Contraception failure

An intrauterine device (IUD) has an increased chance of a tubal pregnancy during pregnancy when pregnancy fails. When using low-dose progestin contraceptives, tubal peristalsis can be abnormal. If ovulation is not inhibited, tubal pregnancy can occur. If an emergency contraceptive containing a large amount of estrogen is used for contraception, the pregnancy rate of tubal pregnancy is increased.

4. Other

Fallopian tube pregnancy can also occur with infertility treatment with assisted reproduction techniques. Endocrine abnormalities and mental stress can also cause tubal peristalsis or spasm and tubal pregnancy.

Clinical manifestations of tubal pregnancy

Symptoms

(1) Abdominal pain In the beginning, severe pain in the lower abdomen of the affected side, such as tearing, may spread to the entire abdomen. The degree of pain is related to the nature and amount and speed of internal bleeding. If it is ruptured, the internal bleeding volume is large and rapid, which stimulates the peritoneum and produces severe pain, which can spread to the entire abdomen. If it is a fallopian tube abortion, there is less bleeding and slower, abdominal pain is often limited to the lower abdomen or one side, and the pain is also mild. In a few cases, there is a large amount of bleeding. The blood flows to the upper abdomen, which stimulates the diaphragm and produces pain in the upper abdomen and shoulders. It is often misdiagnosed as epigastric acute abdomen. Such as repeated rupture or miscarriage, internal bleeding can be repeatedly caused. Those who suffered a large or multiple small internal bleeding and did not treat it in time, the blood aggregated in the lowest part of the pelvic cavity (uterine rectal fossa), causing severe anal pain.

(2) Amenorrhea There are often amenorrhea in tubal pregnancy. The length of menopause is mostly related to the location of the tubal pregnancy. The date of amenorrhea for those who are pregnant in the isthmus or ampulla often shows symptoms of abdominal pain around 6 weeks, rarely exceeding 2 to 3 months. In women who have regular menstrual periods, if there are internal bleeding in the menstrual period for several days, they should consider whether they are tubal pregnancy. The tubal interstitial pregnancy, due to the thicker muscle tissue surrounding the rupture often occurs in 3 to 4 months of pregnancy, so there is a longer amenorrhea.

(3) Irregular bleeding in the vagina After the termination of tubal pregnancy, it causes endocrine changes, followed by degenerative changes and necrosis of the endometrium, and the decidua is fragmented or completely discharged, causing uterine bleeding. Bleeding is often irregular, dark brown, and can only be stopped after the lesion has been removed (surgery or medication).

(4) Syncope and shock Patients with abdominal pain often have dizziness, dazzle, cold sweats, palpitations, and even syncope. The degree of syncope and shock is related to the rate and amount of bleeding.

(5) History of infertility Often there is a history of primary or secondary infertility.

2. Signs

(1) Whole body examination The body temperature is generally normal, and may be slightly lower during shock. When internal bleeding is absorbed, the body temperature may be slightly higher, but generally does not exceed 38 ° C. With internal bleeding, blood pressure drops, pulses become faster, weaker, and pale.

(2) Examination of the abdomen There is tenderness in the abdomen, which shows obvious rebound pain, most notably the diseased side. Abdominal muscle rigidity is lighter than general peritonitis, showing that bloody peritoneal irritation caused by internal bleeding is different from general infectious peritonitis. When there is a large amount of intra-abdominal hemorrhage, hematoma may occur in patients with slow dullness signs or bleeding later, and a semi-substantial sensation and tenderness in the abdomen can be felt in the abdomen.

(3) Vaginal examination There is often a small amount of bleeding in the vagina, which comes from the uterine cavity. The posterior vaginal fornix is often full and tender. The cervix has obvious lifting pain, that is, when the cervix is gently moved upward or left and right, the patient feels severe pain. In those with more internal bleeding, the uterus often feels floating when examined. The uterus is normally large or slightly larger and slightly softer. One side of the uterus may touch the enlarged fallopian tubes. Patients who are late for treatment can touch the semi- parenchymal mass at the uterine rectal fossa. The longer the time, the harder the mass becomes.

Tubal pregnancy test

(A) B-mode ultrasound

Ultrasound has become one of the main methods for diagnosis of tubal pregnancy. A typical sonogram is: no pregnancy sac is seen in the uterus, and the endometrium is thickened; a mixed mass with unclear boundaries and uneven echo is seen on the side of the uterus, and sometimes the pregnancy sac, germ, and primitive Cardiac pulsation is direct evidence of tubal pregnancy, and there is fluid in the rectum and uterine depression. Reported in the literature, the accuracy of ultrasound is 77% to 92%. With the application of color ultrasound, three-dimensional ultrasound, and transvaginal ultrasound, the diagnostic accuracy continues to increase.

(Two) determination of chorionic gonadotropin

Using hCG subunit radioimmunoassay can accurately determine early pregnancy and is a better method for diagnosing ectopic pregnancy. Synaptic cells in the villus secrete chorionic gonadotropin. Due to the extremely thin mucosa and muscular layer of the fallopian tubes, they cannot provide the nutrients needed by the villous cells. The ectopic pregnancy has a low -hCG concentration in the plasma and a -hCG release The presence or absence of pregnant eggs on the 9th day can be measured. In the early stages of normal pregnancy, the amount of -hCG doubles every 1.2 to 2.2 days, while the doubling time of 86.6% of ectopic pregnancy is slow, and the absolute value of -hCG is also lower than that of normal pregnancy.

(Three) abdominal puncture

Including transvaginal posterior fornix puncture and transabdominal wall puncture, it is a simple and reliable diagnostic method. If fluid is not withdrawn, tubal pregnancy cannot be ruled out. If the mass is hard and it is not easy to extract the contents, you can inject a small amount of normal saline before puncturing, and then suction. If the saline is reddish brown and mixed with small blood clots, it can be confirmed as old hematoma. Tubal pregnancy is not condensed. In order to further improve the diagnostic value of posterior fornix puncture, it is also possible to compare the posterior fornix puncture blood with peripheral venous blood. The former reduces blood sedimentation, which is a reliable basis for thrombocytopenia. Regardless of tubal pregnancy miscarriage or rupture, and regardless of the duration of its onset, the erythrocyte sedimentation rate of the posterior fornix puncture blood was significantly slower, an average of 12.1 mm slower; platelets were also significantly reduced, an average of 100,000 less. In contrast, erythrocyte sedimentation and platelets are almost identical to those of peripheral blood vessels. When there is a large amount of bleeding and mobile dullness is positive, it can be punctured directly through the lower abdominal wall.

(D) Laparoscopy

Application of laparoscopy in atypical cases is of great value, and the relationship and adhesion status of ectopic pregnancy and surrounding organs can be observed in detail. In some cases, surgery can be performed at the same time. Laparoscopic findings: Tubal-shaped implantation site of the fallopian tube was tumor-like, dark red, swollen, and vascular proliferation on the surface.

(E) Diagnostic curettage

With the help of diagnostic curettage to observe the changes in the endometrium, only decidua and no villi are seen, which can exclude intrauterine pregnancy. In addition, in ectopic pregnancy, the endometrium is atypical hyperplasia similar to endometrial cancer changes accounted for 10% to 25%. The glands are highly curved, jagged, foamy cytoplasm, densely stained nuclei, and uneven, such as hypersecretory endometrium, the so-called Ares-Staley reaction also has certain diagnostic significance.

The first two tests are non-invasive and easy to accept, and the latter three tests are minimally invasive. It is more difficult to accept asymptomatic early tubal pregnancy or those who are suspected of retaining intrauterine pregnancy. The American Association of Obstetricians and Gynecologists (ACOG, 2004) judges asymptomatic early fallopian tube pregnancy based on the results of the first two tests. The clinical decisions proposed are for reference:

1. Comprehensive analysis of vaginal ultrasound when serum -HCG 1500U / L

(1) Results of vaginal B-ultrasound: A pregnancy sac, germ, or primitive heart tube pulsation can be seen outside the uterus to diagnose tubal pregnancy.

(2) Results of vaginal B-ultrasound No pregnancy sac in the uterus, and a lump in the appendix can be considered for fallopian tube pregnancy; no pregnancy sac, etc in the uterus, no lumps in the appendix, the blood -HCG and vaginal B can be repeated after two days ultra. If no pregnancy sac is seen in the uterus and the serum -HCG value is increased or unchanged, tubal pregnancy can also be considered.

2. Serum -HCG 1500U / L, vaginal B-ultrasound results showed no pregnancy sac, etc. in the uterus and the uterus, and there was no mass in the accessory area. Repeated detection of blood -HCG and vaginal B-ultrasound after 3 days

(1) If the -HCG value has not doubled or decreased, and the vaginal B-ultrasound has not seen an intrauterine pregnancy sac, etc. It is considered that there is no possibility of survival even if the intrauterine pregnancy is performed, and it can be treated according to tubal pregnancy.

(2) If the -HCG value doubles, you can wait for a vaginal B-ultrasound to see the pregnancy sac in or near the uterus.

Differential diagnosis of tubal pregnancy

Early pregnancy abortion

Abdominal pain caused by miscarriage is relatively mild, mostly in the center of the lower abdomen, paroxysmal, and usually a large amount of vaginal bleeding. The vaginal bleeding is more or less consistent with the symptoms of systemic blood loss, and sometimes villous discharge is seen. There is no tenderness or slight tenderness in the abdomen, generally no rebound pain, no moving dullness. Vaginal examination of the cervix showed no pain, the posterior fornix was not full, the size of the uterus was consistent with the number of menopause months, and there was no mass next to the uterus. Hematuria was negative for HCG. B ultrasound showed a pregnancy sac in the uterine cavity, or villi were seen in excluded tissues.

2. Acute salpingitis

There is no history of amenorrhea and early pregnancy, and there is no shock sign. The temperature rises, the abdominal muscles are tense, and there are tenderness on both sides of the lower abdomen. The vault is not full after vaginal examination, the uterus is normal, and there are often thickening, masses, and tenderness at the appendages on both sides, sometimes on one side. A posterior dome puncture can sometimes draw pus. High white blood cells and neutral classification, negative pregnancy test. In particular, hemorrhagic salpingitis not only has lower abdominal tenderness and rebound tenderness, but sometimes mobile dullness can also occur. The posterior fornix puncture can draw fresh blood, which is difficult to distinguish before surgery, and the diagnosis is often made after laparotomy.

3. Acute appendicitis

No amenorrhea and early pregnancy, no vaginal bleeding. Abdominal pain usually starts from the upper abdomen and is then limited to the right lower abdomen. It is often accompanied by nausea, vomiting, and no internal bleeding symptoms. Check the right lower abdominal muscles for tension, appendiculum tenderness, rebound tenderness, and no moving dullness. Vaginal examination of the cervix showed no pain, and the uterus was normal. The pregnancy test is negative, fever may be present, and the white blood cell count is increased.

4. Ovarian cyst pedicle twist

There is a history of abdominal mass. If the torsion is relieved, the abdominal pain is transient; if intra-cystic hemorrhage is formed after torsion, the abdominal pain is persistent, but tenderness and rebound pain are limited to the mass around and around the mass. No mobile dullness. Vaginal examination has tenderness cysts next to the uterus. There is no history of amenorrhea and early pregnancy, no history of vaginal bleeding, but it should be noted that early pregnancy often promotes the reversal of an existing ovarian tumor pedicle.

5. Rupture of the corpus luteum

Mostly occur in the premenstrual period, and often after sexual intercourse, without amenorrhea and early pregnancy, no vaginal bleeding, abdominal pain and signs of pregnancy and rupture of tubal pregnancy, negative pregnancy test, B-ultrasound examination see the mass in the annex area.

6. Chocolate cyst rupture

The disease mostly occurs in young women and is prone to spontaneous rupture, causing acute abdominal pain, but without amenorrhea and early pregnancy, and without vaginal bleeding. Past history may include progressive dysmenorrhea and a history of pelvic mass. Examination revealed tenderness and rebound pain in the lower abdomen, tender palpable nodules in the uterine sacral ligament, tenderness in the attachment area of the affected side, and the previously found mass disappeared. B-ultrasound showed a posterior dome effusion, which could puncture chocolate-like liquid.

Tubal pregnancy treatment

For the treatment of tubal pregnancy, the main method has always been surgery. In the past more than 10 years, due to the development of high-sensitivity radioimmunoassay -hCG and high-resolution B-ultrasound and laparoscopy, the early diagnosis rate of ectopic pregnancy has increased significantly, so it is generally used clinically. Conservative surgery and medication.

Surgical treatment

(1) Fallopian tube resection Regardless of whether it is a miscarriage or a ruptured fallopian tube pregnancy, salpingectomy can stop bleeding in time and save lives. In women who have children who are no longer planning to have children, they can also perform contralateral fallopian tube ligation. In women who need to retain fertility, salpingectomy should also be performed if the fallopian tube lesions are too large and the laceration is too long, which damages the mesentery and blood vessels, and / or the vital signs are severe. In conservative surgery, the fallopian tube is bleeding and it cannot be controlled. The fallopian tube should be removed immediately.

(2) Conservative surgery In principle, the tubal pregnancy is removed, and the anatomy and function of the tubal are retained as much as possible to create conditions for future intrauterine pregnancy. Young woman, this fallopian tube pregnancy is the first pregnancy; no child has had one side of the fallopian tube removed. Salpingotomy should be performed to remove the embryo.

Laparoscopy and laparotomy can be used for the above-mentioned various operations. Laparoscopy is more intuitive and can be performed under direct vision. Laparoscopy is less invasive but requires related equipment and operators. Skilled technology.

2. Drug treatment

Methotrexate is mainly used for unruptured tubal pregnancy, intact tubal serosa, no active bleeding, diameter of tubal pregnancy product <3 ~ 4cm, blood in the abdominal cavity <100ml, -hCG <3000mIU / ml, vital signs Stable, young and fertile. Medication methods: MTX is taken orally and is rarely used clinically; MTX is injected intramuscularly; MTX-CF regimen, formyl tetrahydrofolate (CF), CF can reverse the adverse effects of MTX, which is the most commonly used method at present; MTX local injection, under ultrasound Guided into the gestational sac with MTX; or injected directly into the fallopian tube under laparoscopy. Abdominal pain, vital signs, and adverse drug reactions must be closely observed during drug therapy. And -hCG and B ultrasound were used to monitor the local situation of fallopian tubes.

Prognosis of tubal pregnancy

If the fallopian tube rupture can be diagnosed in time, the prognosis is good. Interstitial pregnancy rupture can be effective if diagnosed and rescued in time. Most patients with ectopic pregnancy urgently need to understand the fertility problems in the future. Patients with ectopic pregnancy caused by organic or functional lesions have an increased chance of infertility in the future.