Mc Elin T W, Iffy L
Obstet Gynecol Annu. 1976;5:241-91.
In this chapter on ectopic gestation are have attempted to elucidate new and controversial issues in this area. In summary, we identify the following items as "nominative imperatives": I. Meticulous review of the classic etiologic concepts of ectopic gestation indicates that these concepts are no longer tenable although certain of them may be operative in specific instances. Review of certain veterinary work, animal experimentation, and pathologic and clinical observations in primates lends support to the hypothesis that failure of the ovum to implant may be related to delayed (post-midcycle) ovulation followed by shortening of the luteal phase with defective endometrial development and by a bleeding episode that simulates menstruation. II. Review of the literature indicates that the woman who has a tubal pregnancy has about a 50 to 60 percent chance of never becoming pregnant again. Among those who do conceive, at least 10 percent, and possibly more, develop another ectopic gestation. Only one-third of the women who have a tubal pregnancy will ever succeed in delivering a healthy child. Obviously this unhappy prognosis is the basis for many of our recommendations for management. The woman who had had a tubal pregnancy should consider the use of mechanical contraception after the midcycle to prevent recurrent ectopic pregnancy. This is obviously a suggestion based on the etiologic theory that we espouse. The prophylactic use of anti-Rh immunoglobulin is necessary in ectopic gestation in Rh-negative gravidas. III. In terms of the relation of ectopic pregnancy to intrauterine devices, the most authoritative statement than can be found is that of Lehfeldt, who states that the IUD is 99.5 percent effective in preventing intrauterine pregnancy, 95 percent effective in preventing tubal ectopic gestation, and is ineffective against ovarian implantation. Nonetheless, the fact that one in 23 IUD pregnancies is ectopic makes consideration of this diagnosis mandatory. IV. In terms of diagnostic assistance that can be provided by the radiologist, a comprehensive summary of their capabilities is presented. Laparoscopy is considered a valuable aid in establishing the diagnosis of unruptured ectopic pregnancy. A new, highly sensitive radioimmunoassay with specific affinity for the beta subunit of HCG is described that can detect very low levels of HCG when routine pregnancy tests are negative. It appears that this test can be of enormous help in diagnosing the early, unruptured tubal pregnancy. V. In a consideration of the role of conservative operations in the management of tubal pregnancy, we take the position that the modern gynecologist must acknowledge the possibility of conservative operations. It is obvious that success is most likely, when the surgeon is confronted with an early, unruptured ectopic gestation and that the feasibility of a linear salpingostomy must be acknowledged. VI...
在本章关于异位妊娠的内容中，我们试图阐明该领域的新问题和有争议的问题。总之，我们将以下几点视为“命名性必须事项”：一、对异位妊娠经典病因概念的细致回顾表明，这些概念已不再成立，尽管其中某些在特定情况下可能起作用。对某些兽医工作、动物实验以及灵长类动物的病理和临床观察的回顾支持了这样一种假说，即卵子着床失败可能与排卵延迟（月经周期中期后）有关，随后黄体期缩短，子宫内膜发育不良，并伴有类似月经的出血情况。二、文献回顾表明，曾患输卵管妊娠的女性再次怀孕的几率约为50%至60%。在那些成功受孕的女性中，至少10%，甚至可能更多，会再次发生异位妊娠。只有三分之一曾患输卵管妊娠的女性能够成功分娩出健康婴儿。显然，这种不理想的预后是我们许多治疗建议的依据。曾患输卵管妊娠的女性在月经周期中期后应考虑采用机械避孕措施以预防复发性异位妊娠。这显然是基于我们所支持的病因理论提出的建议。对于Rh阴性孕妇的异位妊娠，预防性使用抗Rh免疫球蛋白是必要的。三、关于异位妊娠与宫内节育器的关系，能找到的最权威的说法是莱费尔特的观点，他指出宫内节育器预防宫内妊娠的有效率为99.5%，预防输卵管异位妊娠的有效率为95%，但对卵巢着床无效。尽管如此，每23例宫内节育器妊娠中有1例为异位妊娠这一事实使得必须考虑这一诊断。四、关于放射科医生能提供的诊断帮助，对他们的能力进行了全面总结。腹腔镜检查被认为是诊断未破裂异位妊娠的有价值的辅助手段。描述了一种对人绒毛膜促性腺激素β亚基具有特异性亲和力的新型高灵敏度放射免疫测定法，当常规妊娠试验为阴性时，该方法能检测到极低水平的人绒毛膜促性腺激素。看来这种检测方法对诊断早期未破裂的输卵管妊娠可能有极大帮助。五、在考虑保守手术在输卵管妊娠治疗中的作用时，我们认为现代妇科医生必须承认保守手术的可能性。显然，当外科医生面对早期未破裂的异位妊娠时，成功的可能性最大，并且必须承认线性输卵管造口术的可行性。六、……
