Evidence Abased Diagnosis Of Ectopic Pregnancy

Background: In recent years, the incidence of ectopic pregnancy is rising in United States, from 1970 to 1995 the ratio of the ectopic pregnancy and normal pregnancy increased from 1:222 to l: 51 and in domestic, the ratio increased from l: 167 ~ 322 in 1970 to 1:56 to 63 in 1995. The main reasons of ectopic pregnancy include: 1) infection; 2) the dysfunction of fallopian tube; 3) endocrine factors such as luteal insufficiency; 4) tubal surgery; 5) embryos migration; 6)Intrauterine IUD; 7) estrogen and progesterone containing the contraceptives; 8) sexually transmitted diseases; 9) smoking. Ectopic pregnancy is the leading cause of death for maternal in early pregnancy. In British, from1997 to 1999 there was 13 maternals died of ectopic pregnancy. Despite of the decline in the mortality rate, in the early pregnancy phase, 80% of maternal death is attributed to ectopic pregnancy, so early diagnosis and treatment of ectopic pregnancy is essential. What is the mean of early diagnosis of ectopic pregnancy? Although there is not a clear and uniform criteria, it is generally considered that fetal block still remains and is confined in the fallopian tube, no rupture. Because the signs and symptoms are not obvious, ectopic pregnancy is often missed by patients and physicians. Over the past 20 years, with the improvement of sensitivity of the serum human chorionic gonadotropin (β-hCG), the constant studies of progesterone, the wider use of transvaginal ultrasound and laparoscopic technology, ectopic pregnancy is diagnosed more accurately and early and is often treated with conservative method. Clinical Practice indicates that the conservative treatment of ectopic pregnancy has a better outcome, a higher cure rate compared with surgical treatment. After the treatment, the proportion of Tubal restoring to normal and the rate of normal pregnancy again is also quite high.. But it is difficult to identify between the early ectopic pregnancy and normal pregnancy, it is easy to misdiagnose and miss diagnosis, resulting in delayed treatment. The current methods of diagnosis for ectopic pregnancy include serum HCG, progesterone, vaginal ultrasound, curettage and puncture of posterior fornix. However any of these methods alone can not effectively diagnose ectopic pregnancy. Although the studies showed that the serum HCG of the ectopic pregnancy is lower and increases more slowly compared to normal pregnancy. Since the clearance of serum HCG in blood plasma is slow, and most of hospitals get the results the day after the day drawing the blood, the only use of blood HCG in the diagnosis of ectopic pregnancy is unmeaningful and can only give a reference to clinicians. The pelvic mass examined by ultrasonography is an important basis by which doctors diagnose and treat ectopic pregnancy. In most cases, however, ultrasound is used to exclude normal pregnancy. First, whether intrauterine or early ectopic pregnancy there is a "blind spot" in ultrasound examination. Secondly, the individual differences of the gestational age and the development of embryo exist, which interfere the clinical judgement. Thirdly, Because of the lack of relatively fixed anatomic pelvic position of tubal like uterine and the interference of other organs of the echo reflection, such as intestine , even if there is accurate gestational age, we can not identify ectopic pregnancy via the existence of embryo block echo without the tube audio-visual reflection yet. Therefore, the author wanted to follow the evidence-based medicine and combine the biochemical indicators and the ultrasonography indicators to provides better diagnosis bases of ectopic pregnancy for cliniciansObjective: to combine the biochemical indicators and the ultrasonography indicators to provides better diagnosis bases of ectopic pregnancy for clinicians.Methods:①to raise questions: How to use the limited clinical materials to accuratly diagnose the ectopic pregnancy has been a difficult problem for gynaecologist problems.②to find evidence from medical research : we choosed 40 cases of ectopic pregnancy patients confirmed by surgery and pathology, and samplied 30 cases of normal intrauterine pregnancy who required abortion and we ultimately saw the sac as a control group .the two groups were divided into five groups by the number of days of menopause. Each was asked about the history in detail, underwent gynaecological examination, ultrasound examination and detection of human chorionic gonadotropin, and statistically analyzed the results at last .③we got the evidence from literatures.Results:①Except for menopause 4 to 5 weeks group, the serum HCG of the ectopic pregnancy groups were significantly lower than that of normal pregnancy, and serum HCG doubling time significantly delayed, which showed a platform phase after six weeks. The available evidence from Literatures shows that if HCG increases less than 66% every 48-hour, it is more likely to be ectopic pregnancy.②The ultrasound image of ectopic pregnancy can be divided into four kinds: A. Neither the inside nor outside of the uterine saw the sac; B. tubal ring; C. annex mass; D. heart-throb. We can not diagnose ectopic pregnancy by any typies except for the ultrasonic pulse of the heart, and the specificity of annex mass is the lowest. Most of ectopic pregnancy broke or miscarriaged before we can see the pulse of heart under the ultrasound. Only about 20 percent of ectopic pregnancy can be seen the heart beat under ultrasound, so it is not reliable to diagnose ectopic pregnancy by ultrasound alone.③When we can see the sac under ultrasound, the reference range of HCG is about 1800 IU / L in our hospital, which is consistent with the third international standards.④If the patients with endometrial thickness greater than 1.1 cm, it is likely to be normal intrauterine pregnancy; if the patients with endometrial thickness less than 1.1 cm, it is likely to be ectopic pregnancy.Conclusions:①The combination of vaginal ultrasound and blood HCG is the most sensitive and specificial detection method on the diagnosis of ectopic pregnancy;②When we highly suspected ectopic pregnancy ,and the condition of the patient is not not serious the referral time shoud be set up in the 48-hour intervals;③when the blood HCG is more than 1800 ~ 6500 IU / L, and we did not see the intrauterine pregnancy sac under vaginal ultrasound ,it is more possible of ectopic pregnancy;④The conservative treatment of ectopic pregnancy should strictly abide by international standards.