Tubal pregnancy

Introduction to tubal pregnancy The disease refers to the fertilization of the egg in the ampulla of the fallopian tube. The fertilized egg is blocked in the fallopian tube for some reasons, and the implantation and development of a part of the fallopian tube occurs, and the tubal pregnancy occurs. The ampullary pregnancy is the most, accounting for 50 to 70%; followed by the isthmus, accounting for 30 to 40%; the umbrella and interstitial parts are the least, accounting for 1-2%. After abortion or rupture of the tubal pregnancy, the clinical phenomenon is obvious. Before the tubal pregnancy has not broken, there are generally no obvious symptoms. Some patients have early pregnancy reaction, that is, loss of appetite, nausea and vomiting, partial eclipse, etc. Some patients have a paroxysmal lower abdominal pain, and the double uterus has no obvious swelling. Large or slightly swollen, with a mass on one side, tenderness, suspected tubal pregnancy and further related to the auxiliary examination to confirm the diagnosis, due to the above characteristics no obvious history of menopause, no history of infertility, a small amount of vaginal bleeding mistakenly considered the intrauterine device Side effects, so the rate of misdiagnosis is high, misdiagnosis increases the risk of the disease. basic knowledge The proportion of illness: 0.028% Susceptible people: women Mode of infection: non-infectious Complications: shock, retroperitoneal space bleeding, persistent tubal pregnancy

Causes of tubal pregnancy

Fallopian tube inflammation chronic salpingitis (35%):

Fallopian tube inflammation Chronic salpingitis, tubal intima due to inflammatory adhesions to form a stenosis, tubal tortuous or inflammatory adhesions around the fallopian tube, often obstructing the pregnant egg, salpingitis not only causes morphological changes, but also the fallopian tube endometrial cilia often have defects, The ability of the fallopian tube to move is reduced, affecting the migration of pregnant eggs.

Tubal dysplasia or malformation of tubal dysplasia (25%):

Tubal dysplasia or malformed tubal dysplasia, the wall muscle fiber development is poor or lacking, the endometrial cilia is lacking, its shape is thinner than the normal fallopian tube, and the curve is spiral, longer than normal, twists and turns, hindering the passage of pregnant eggs . Developmental malformations are porous, diverticulum, double oviduct or another underdeveloped fallopian tube, which is a parasitic fallopian tube.

Endometriosis of the fallopian tube (25%):

Endometriosis of the fallopian tube Endometrial tissue can invade the interstitial part of the fallopian tube, thickening the interstitial part, stenosis or obstruction is one of the causes of tubal pregnancy. It is suggested that the fallopian tube, ovary, pelvic cavity The endometrium may have some chemotaxis to the fertilized egg, which induces the implantation of the fertilized egg outside the uterine cavity.

1. Tumor compression or traction in the pelvic cavity can make the fallopian tube become thinner and longer, twisting and twisting, hindering the passage of pregnant eggs.

2, birth control measures and ectopic pregnancy IUD can cause ectopic pregnancy, is a concern and controversy. In 1965, Li Pu first reported IUD users, have a higher ectopic pregnancy, most scholars believe that Inert or active IUD can effectively prevent intrauterine pregnancy, partially prevent tubal pregnancy, but can not prevent ovarian pregnancy. In recent years, the incidence of ectopic pregnancy has increased significantly.

Re-canalization after sterilization, newborn umbrella, technical errors, etc. can form tubal pregnancy.

3, Chlamydia infection is a separate important factor in ectopic pregnancy, when the Chlamydia antibody titer is 1:16, the relative risk is 2.91 titer 1:64 is 3.0.

[pathological changes]

1. Changes and outcomes of tubal pregnancy

In tubal pregnancy, due to the lack of a complete decidua in the fallopian tube, after implantation of the pregnant egg, its villus is destroyed by proteolytic enzymes, directly invading the muscular layer of the wall, destroying the microvascular of the muscular layer, causing bleeding, blood injection and ovulation layer and Between the surrounding tissues, the pregnant eggs are surrounded by a layer of muscle fibers and connective tissue. Different outcomes can occur with different implantation sites.

(1) Tubal pregnancy abortion: more occurs in the tubal ampulla, its growth and development multi-directional bulging, due to the fragile tissue, often rupture in 6 to 12 weeks of pregnancy, bleeding causes the pregnant egg to fall into the lumen, due to proximity The umbrella end is easily squeezed into the abdominal cavity. If the embryo is completely stripped into the abdominal cavity, the amount of bleeding is often small, and the fallopian tube is completely aborted. Sometimes the embryo remains in the fallopian tube after the embryo is separated, the blood fills the lumen, and the fallopian tube hematoma is formed. After the embryo is dead. Most of them are absorbed, but can also form blood tubers of the fallopian tube. For example, the tubal hematoma is mechanized. After the hemoglobin subsides, the meat-like blocks can also be formed. When the ampulla is not fully aborted, the nourishing leaf cells can be used for a long time. Still preserves vitality, and can continue to erode the fallopian tube tissue. This bleeding, due to repeated bleeding, blood condenses around the umbrella end and the fallopian tube, forming a hematoma around the fallopian tube. Finally, due to more bleeding, the blood in the abdominal cavity is more concentrated in the uterus rectal fossa. Post-uterine hematoma.

(2) Fallopian tube rupture: more occurs in the isthmus of the fallopian tube. Due to the narrowing of the lumen, the gestation of the egg yolk erodes the muscular layer and the serosa to the wall, and finally penetrates the wall to form the fallopian tube. Tubal pregnancy abortion, due to rupture of the capsule, no major vascular injury, only bleeding from the villus stripping, so the course is slow, recurrent, but rarely life-threatening major bleeding, but the tubal pregnancy rupture, can cause the fallopian tube wall Larger blood vessel laceration, blood directly into the abdominal cavity, bleeding is often more serious, can be life-threatening, but there are only damage to smaller vein branches or damage to larger arterial branches, due to internal bleeding caused by hypotension, resulting in decreased bleeding, thrombosis Temporary hemostasis, isthmus rupture occurs earlier, can occur in the first week of conception (pregnancy eggs have implantability 3 to 6 days after fertilization), so there is no history of amenorrhea, and clinical ectopic pregnancy symptoms have occurred The embryo implanted in the interstitial part can develop until 3 to 4 months before it begins to rupture. At this time, the symptoms are like uterine rupture and the bleeding is extremely serious. In the case of persistent cases, it is often impossible to distinguish between abortion type and rupture type. Because the two types are often staggered, it is often encountered in the clinical stage that after the tubal incomplete abortion, the fallopian tube rupture occurs due to the continued growth and development of the residual villi.

(3) secondary abdominal pregnancy: when the tubal pregnancy is ruptured or aborted, the fetus has been discharged from the perforation or umbrella end, while the placenta still adheres to the wall or grows outward from the rupture, attached to the uterus, fallopian tube, broad ligament, basin Walls and other places to form a secondary abdominal pregnancy, such as the rupture between the two layers of the broad ligament peritoneum, the embryo continues to grow can develop into a wide ligament pregnancy or extraperitoneal pregnancy, another type of abdominal pregnancy.

(4) advanced tubal pregnancy: individual tubal pregnancy can also grow to the third trimester of pregnancy.

(5) Pelvic hematoma and infection: The hematoma accumulated in the rectal fossa of the uterus can gradually become a layer of connective tissue and adhere to the surrounding adjacent organs through the connective tissue reaction of the peritoneum.

(6) Embryo or fetal degeneration: Some tubal pregnancy may be due to spontaneous degeneration, which occurs in the mucosal folds of the oviduct in the ampulla of the fallopian tube, not invading the wall, and some invade the wall muscle layer, but due to nutrition Obstruction, early embryonic death, self-degeneration without obvious clinical symptoms, and found in laparotomy for other reasons in the future.

(7) Others: Sometimes the tubal pregnancy is a twin, and the contralateral fallopian tube may also have blood due to uterine effusion, and individual tubal pregnancy coexists with intrauterine pregnancy.

2, changes in the endometrium

During tubal pregnancy, the uterine muscle is affected by endocrine, hypertrophy and hypertrophy, making the uterus larger than normal, and softer, but less than the amenorrhea month. The more significant change is the decidual change of the endometrium shortly after fertilization. The existence is related to the survival of the pregnant egg. The fetus of the tubal pregnancy often only survives for a short period of time. After the death of the fetus, the uterine decidua often falls off (triangle), which is called uterine tube type, or is fine fragments falling off. In many cases, the degenerative changes in the uterus cause the diaphragm to decompose before it is discharged. Some people think that 50% of cases have true cast-out.

Degenerative secretion: After the fallopian tube pregnancy, some of the villi can still survive for a period of time, and some of the villi are deep into the muscular layer of the fallopian tube, which is closely connected with the mother. Therefore, the degeneration process of the corpus luteum is slower than that in the normal pregnancy, so the new follicle The maturity is also postponed. In the process of luteal degeneration, the decidual membrane gradually decreases with the sex hormones, showing various degenerative processes and even atrophy, but the endometrial secretion of the decidua is extremely developed, so it remains in the process of degradation. The phenomenon of secretion activity.

Regeneration: The endometrium of degenerative secretion gradually regenerates after a certain period of time. The interstitial density gradually becomes loose, the glandular duct is round or elliptical, the glandular epithelial cells are cylindrical, and the nucleus is arranged neatly, located at the bottom or the center of the cell. Most of them are proliferative period membranes, but if they are carefully examined, there are still very small parts of degenerative secretion images, so the endometrial images of ectopic pregnancy are diverse, with sex hormone concentration, progesterone and estrogen ratio The length of development of the pregnant egg and the development time of the pregnant egg are related.

Tubal pregnancy prevention

Pay attention to the hygiene during menstruation, maternity and puerperium, and prevent infection of the reproductive system. If it has already occurred, you should go to the hospital for infusion, blood transfusion, and immediately perform laparotomy.

Tubal pregnancy complications Complications, shock, retroperitoneal space, hemorrhage, persistent tubal pregnancy

Can be complicated by major bleeding, shock and so on.

Tubal pregnancy symptoms Common symptoms Acute abdominal pain Lower abdomen rebound pain Lower abdomen fall pain Vaginal bleeding Menstruation syncope Shock nausea

After abortion or rupture of the tubal pregnancy, the clinical phenomenon is obvious.

1, symptoms

(1) Abdominal pain: Patients often come to see a doctor because of sudden abdominal pain. The incidence rate is more than 90%. It often starts with severe pain in the lower abdomen of the affected side, such as tearing, which may affect the whole abdomen. The degree and nature of pain and internal bleeding The amount and speed are related. If it is ruptured, the amount of internal bleeding is much and rapid, and the peritoneum is stimulated to produce severe pain, and it can spread to the whole abdomen. If it is a tubal abortion, the bleeding is less, slower, and the abdominal pain is often limited to the lower abdomen or one side. Pain The degree is also mild. In a few cases, the amount of bleeding is high. The blood flows to the upper abdomen, irritating the diaphragm, causing pain in the upper abdomen and shoulders. It is often misdiagnosed as upper abdominal abdomen, such as repeated rupture or abortion, which can cause internal bleeding repeatedly. Or a small number of internal bleeding and not treated in time, blood agglutination in the lowest part of the pelvic cavity (uterine rectal fossa), causing severe pain in the anus.

(2) amenorrhea: tubal pregnancy often have amenorrhea, the length of amenorrhea, mostly related to the fallopian tube pregnancy site, pregnancy in the isthmus or ampulla of the amenorrhea date, often around 6 weeks, the symptoms of abdominal pain, rarely more than 2 to 3 months In the menstrual regular women, the menstrual period of several days, the phenomenon of internal bleeding, should consider whether it is tubal pregnancy, tubal interstitial pregnancy, due to thicker surrounding muscle layer, often rupture in 3 to 4 months of pregnancy, so Have a long amenorrhea, ask the history, should ask in detail the amount of menstruation, quality, duration of days compared with previous menstruation, do not mistake the vaginal bleeding for a menstrual period, a few of the fallopian tube pregnancy of the chorionic tissue produced by the chorionic gonads Hormones are not enough to cause the endometrium to respond to amenorrhea without amenorrhea.

(3) irregular vaginal bleeding: after the fallopian tube pregnancy, causing endocrine changes, followed by degeneration and necrosis of the endometrium, the aponeurosis is fragmented or completely discharged, causing uterine bleeding, bleeding is often irregular, Dark brown, after the removal of the lesion (surgery or drugs), can be completely stopped, there are a few cases of vaginal bleeding, bloodshed in addition to endometrial exfoliation, it is believed to come from the fallopian tube.

(4) syncope and shock: patients with abdominal pain, often have dizziness, vertigo, cold sweat, palpitations, and even syncope, the degree of syncope and shock is related to the speed and amount of bleeding.

(5) History of infertility: There is often a history of primary or secondary infertility. Among the 2822 cases reported by Shanghai, 66.28% were infertile.

2, signs

(1) Systemic examination: body temperature is generally normal, may be slightly lower during shock, when the internal bleeding is absorbed, the body temperature can be slightly higher, and generally does not exceed 38 ° C, blood pressure drops during internal bleeding, the pulse becomes faster, weaker, pale.

(2) Abdominal examination: Abdominal tenderness, obvious rebound tenderness, most prominent on the disease side, abdominal muscle stiffness 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 bleeding There may be signs of mobile dullness, hemorrhage may occur in patients with slow bleeding or late treatment, and semi-substantial feeling may be felt in the abdomen, and there is a tender mass.

(3) vaginal examination: there is often a small amount of bleeding in the vagina, from the uterine cavity, the vaginal sputum is often full, tender, the cervix has obvious lifting pain, when the cervix is up or gently touched to the left and right, the patient is feeling severe Pain, more internal bleeding, check the uterus has a sense of floating, the uterus is normal or slightly larger, slightly softer, one side of the uterus can touch the swollen fallopian tube, the later treatment time, can be touched in the uterus rectal fossa The semi-substantial mass, the longer the time, the hardening of the blood packet.

The patient's hemoglobin and red blood cell values are related to the amount of internal bleeding and the time of examination. When acute internal bleeding begins, hemoglobin measurement is often normal, because blood is concentrated at that time, blood is diluted after 1 to 2 days, hemoglobin is decreased; or bleeding continues, hemoglobin continues Decreased, so hemoglobin can be repeatedly measured when the patient is closely observed, for comparison, the number of white blood cells is often as high as 10 × 109 / L.

Tubal pregnancy check

First, the abdominal B-ultrasound

As an image diagnosis technology, ultrasonography has the advantages of simple operation, strong intuitiveness, no damage to the human body, and repeated examination. However, the ultrasound image is complex, and the technicians and experience of the inspectors are quite different. The misdiagnosis rate can be reached. 9.1%.

1. Intrauterine image: no gestational sac in the uterus, no fetal bud and fetal heartbeat, but the incidence of false gestational sac is about 20%, which is due to pregnancy-induced endometrial decidualization and a small amount in the uterine cavity. The blood is stored, the outline is unclear, the level is not complete, the edge is irregular, does not increase with the pregnancy, and sometimes shrinks, and careful observation can be identified.

2, the side of the uterus or / and uterine rectum sag characteristics: the uterus outsourcing block is generally composed of gestational sac, hematoma and surrounding adhesions.

(1) Before the rupture of the tubal pregnancy, a hypoechoic area with irregular shape and blurred edges was observed at the side of the palace. The gestational sac developed to a certain extent, and a circular or elliptical sac dark area was seen in the hypoechoic area. Even the intra-vial bud and the original fetal heartbeat can be seen, which is a solid evidence for the diagnosis of ectopic pregnancy. It is reported that the former accounted for 20% and the fetal heartbeat accounted for 12%.

(2) When a tubal pregnancy abortion occurs, the blood flows out from the umbrella end of the fallopian tube, and a small amount of free liquid is seen in the uterine side mass and the uterine rectum, and there is no echo or low echo dark area.

(3) When the tubal pregnancy rupture occurs, the gestational sac escapes early through the fallopian tube rupture. Due to the high echo zone mass near the bleeding palace, the internal echo distribution is disordered, the echo is enhanced, and the gestational sac is in the hematoma. Very few cases can be seen. The gestational sac echo, even the fetal bud and the original fetal heart beat, such as long rupture time, repeated bleeding to form an enlarged para-palgal mass, internal echo disorder, different intensity of reflection, edge thickening, clinically seen Old ectopic pregnancy.

3, tubal interstitial pregnancy before the pregnant egg penetrates into the muscle layer, it can be seen that the gestational sac is surrounded by thickening muscle layer, its sound image is similar to uterine residual angle pregnancy, the two are more difficult to identify.

Second, the determination of chorionic gonadotropin

The technique for measuring chorionic gonadotropin has been greatly improved in the past 10 years. The hCG subunit radioimmunoassay can correctly measure early pregnancy. It is a better method for diagnosing ectopic pregnancy, and the secret cells in the villi are secreted. Chorionic gonadotropin, due to the oviduct mucosa, the muscle layer is extremely thin, can not supply the nutrients required for villous cells, the ectopic pregnancy has a lower concentration of -hCG in plasma, and the -hCG radioimmunoassay can measure the ninth day of pregnancy. The presence or absence of eggs, in the early pregnancy, the amount of -hCG increased by 1.2 times every 1.2 to 2.2 days, while 86.6% of ectopic pregnancy, the doubling time is slow, and the absolute value of -hCG is also lower than normal pregnancy.

Third, the posterior puncture

For the current diagnosis of ectopic pregnancy, a widely used method, such as extraction of pus or serous fluid, can rule out tubal pregnancy, but if the liquid is not extracted, can not rule out tubal pregnancy, such as a lump hard, not easy to extract the contents, Before puncture, you can inject a little saline first, and then pump it. If the salt water is reddish brown and mixed with small blood clots, it can be confirmed as an old hematoma. If the extracted blood is mistakenly inserted into the vein, place it. Blood coagulation after a short time, not caused by tubal pregnancy.

In order to further improve the diagnostic value of posterior malleolar puncture, the sputum puncture blood can be compared with the peripheral venous blood. The former has a slower erythrocyte sedimentation rate and is a reliable basis for thrombocytopenia, regardless of the abortion of the tubal pregnancy, regardless of the duration of the attack. For the time being, the erythrocyte sedimentation rate of the puncture blood was significantly slower, with an average slow rate of 12.1 mm; platelets were also significantly reduced, with an average of 100,000 less. On the contrary, the blood transfusion and platelet blood of the blood vessels and the peripheral blood vessels were almost identical.

Fourth, laparoscopic

General ectopic pregnancy can be diagnosed by the above examinations. Laparoscopy is of great value for atypical cases. The relationship between ectopic pregnancy and surrounding organs and adhesion status can be observed in detail. In some cases, surgery can be performed at the same time.

Laparoscopic findings: Tumor-like part of the tubal pregnancy is tumor-like, dark red, bulging, surface vascular hyperplasia, such as hemorrhage in the abdominal cavity, dark field of view, clot attachment, observation of the pregnancy is slightly difficult The abdominal cavity can be fully washed with physiological saline to make the visual field clear, and the implantation site can be easily observed. At the same time, the blood and blood clots in the abdominal cavity can be quickly sucked to ensure a good visual field.

Fifth, diagnostic curettage

With the use of diagnostic curettage to observe changes in the endometrium, only the aponeurosis and no villus are seen, and intrauterine pregnancy can be ruled out.

In addition, in ectopic pregnancy, endometrial atypical hyperplasia is similar to endometrial cancer, accounting for about 10 to 25%, glandular height is curved, serrated, cytoplasm foam, nuclear staining, uneven Etc., such as excessive secretion of endometrium, the so-called Aris-Starley reaction also has a certain diagnostic significance, but patients have a long period of uterine bleeding, the endometrium has even returned to non-pregnant state, so Diagnostic curettage has significant limitations in the diagnosis of ectopic pregnancy.

Six, uterine fallopian tube lipiodol angiography

It has a certain value in the pre-diagnosis diagnosis of tubal pregnancy, that is, before the fallopian tube is not ruptured, the uterine lipiodol angiography has the following characteristics:

1. The uterus is flaring and expanding from the original triangle to a sphere.

2, can not see the neck tube.

3, remove the catheter of iodized oil, the contrast agent does not flow out.

The above 3 points are the same as those of intrauterine pregnancy, and have the following characteristics different from intrauterine pregnancy.

1. There is no elephant defect in the uterus.

2, the edge of the uterine cavity is uneven.

Diagnosis of tubal pregnancy

diagnosis

Typical cases have acute abdominal pain, short-term amenorrhea and irregular vaginal bleeding, and there are many primary or secondary infertility history; the affected side of the tubal swelling and tenderness during the examination; hemorrhagic shock occurs when the internal bleeding is frequent, and the diagnosis is still suspicious. An auxiliary examination method can be used for diagnosis.

Before the tubal pregnancy has not broken, there are generally no obvious symptoms. Some patients have early pregnancy reaction, that is, loss of appetite, nausea and vomiting, partial eclipse, etc. Some patients have a paroxysmal lower abdominal pain, and the double uterus has no obvious swelling. Large or slightly swollen, with a mass on one side, tenderness, suspected tubal pregnancy and further related to the auxiliary examination to confirm the diagnosis, due to the above characteristics no obvious history of menopause, no history of infertility, a small amount of vaginal bleeding mistakenly considered the intrauterine device Side effects, so the rate of misdiagnosis is high, misdiagnosis increases the risk of the disease. The key to early diagnosis is that gynaecologists and women health workers are highly vigilant in thinking. 1 After the placement of IUD, irregular vaginal bleeding, lower abdomen Pain, with or without history of menopause, should be used to treat IUD side effects, exclude ectopic pregnancy, make necessary examinations, and inform patients to self-monitoring, such as abdominal pain or stool pain should be followed up, falling out of tissue Brought by the doctor after the examination to send pathological examination for decidual tissue; 2 belt pregnancy abortion surgery empty, should review pregnancy test and B-ultrasound In order to diagnose clearly before rupture.

Differential diagnosis

1, early pregnancy abortion

Abortion abdominal pain is more moderate, the site is mostly in the lower abdomen, paroxysmal, generally vaginal bleeding, vaginal bleeding is consistent with the symptoms of systemic blood loss, no tenderness or slight tenderness in the abdomen, generally no rebound pain, no moving dullness Vaginal examination of the cervix without pain, after the sputum is not full, the size of the uterus is consistent with the number of menopause, no lumps around the uterus, for those who have children or more bleeding, can explain with the patient and family members, a diagnostic curettage.

2, acute salpingitis

No amenorrhea history and early pregnancy, no shock sign, elevated body temperature, abdominal muscle tension, tenderness on both sides of the lower abdomen, vaginal examination is not full, uterus is normal, the attachments on both sides are often thickened, mass and tenderness Sometimes the side is prominent, the puncture can sometimes take out pus, the white blood cells and neutral classification are high, the pregnancy test is negative, especially hemorrhagic salpingitis, not only the lower abdomen tenderness rebound, and sometimes mobile dullness, After puncture, fresh blood can be extracted. It is difficult to identify before operation. It is often diagnosed after laparotomy. However, it is reported that most patients have a history of recent abortion, hCG is negative, such as internal bleeding (more than 1200ml) Exploratory laparotomy is also necessary, showing thickening of the fallopian tube, congestion and edema, see blood flowing from the umbrella end, the pathology is acute inflammation, no fluff.

3, acute appendicitis

No amenorrhea and early pregnancy, no vaginal bleeding, abdominal pain mostly from the upper abdomen, and then confined to the lower right abdomen, often accompanied by nausea, vomiting, no internal bleeding symptoms, examination of right lower abdominal muscle tension, appendix point tenderness rebound, no movement Voiced voice, vaginal examination of the cervix without pain, uterus normal, if the spread of appendicitis spread to the right fallopian tube or a wider range, there may be tenderness on the right side of the attachment, or bilateral tenderness, otherwise there is no obvious attachment on both sides of the pregnancy test Negative, high body temperature, increased white blood cell count.

4, ovarian cyst tumor pedicle torsion

There is a history of abdominal mass, such as reverse self-remission, abdominal pain is transient; after the formation of intracapsular hemorrhage after twisting, abdominal pain is persistent, but tenderness, rebound pain is limited to the mass of the mass and its surroundings, no moving dullness, Vaginal examination of the uterus has tender cysts, no history of amenorrhea and early pregnancy, no history of vaginal bleeding, but it should be noted that early pregnancy often promotes the existing ovarian tumor pedicle torsion.

5, yellow body rupture

Most occur in the premenstrual period, and often occurs after sexual intercourse, without amenorrhea and early pregnancy, no vaginal bleeding, abdominal pain and nature and the same as tubal pregnancy rupture, negative pregnancy test.

6, chocolate cyst rupture

The disease occurs mostly in young women, prone to spontaneous rupture, causing acute abdominal pain, but no amenorrhea and early pregnancy, no vaginal bleeding, past history may have progressive dysmenorrhea, a history of pelvic mass.

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