Name: Hua.

Sex: Female.

Age: 32 years.

0ccupation: A saleswoman.

Chief Complaint: Continuous colporrhagia for 26 days, accompanied with paroxysmal pain of right lower abdomen.

History of Present Illness: Twenty-six days ago, the patient got colporrhagia without any obvious causes, accompanied with a pain in her right low abdomen. It's an irregular, continuous colporrhagia and occurring in drops, the blood was fresh red in colour and less in amount. The pain occurred paroxysmally and was a sharp prickling pain. Then she went to a maternity and child-care centre for treatment. Through examination of diagnostic uterine curettage and urine pregnancy test, it was diagnosed as " Heterotopie Pregnancy. " Then she was treated with intravenous dripping some antibiotics and hemostats, but the treatment couldn't prevent the colporrhagia from occurring continuously. Then she was sent to the department of gynaecology and obstetrics of a hospital. During the period of being in the hospital, she had been treated with intravenous dripping "MTX, CF" and some hemostats, some supporting drugs. After more than 10 days' treatment, the abdominal pain couldn't be relieved effectively, the eolporrhagia occurred continuously yet. Furthermore, through 3 times of examinantion of ultrasonogram B, it was found that the hematocele in the pelvic cavity progressively became more and more. Meanwhile the patient got dizziness, fatigue, lassitude, and limpness of limbs, excessive sweat and so on. Then the gynaecologists in the hospital decided to treat the illness with an operation after they consulted about the case with a consultant from Shanghai. But the patient and her family refused the operation firmly and came here for treatment on October 18, 1999. After the illness came on,the patient lost her appetite slowly and got bad sleeping, while her defecation and urination were all normal all along. There wasn't other complaint.

Menstrual and Obstetrical Histories:

14¡Á[(5-7)¡Â27]¡Á1999-9-2; 4-2-2-1.

Physical Examination: The patient was conscious with a sallow complexion. The forehead, palms and the underside of the feet were all covered with a layer of cold sweat. The pulse was rapid, thready and soggy, the tongue was dark red with a thick layer of white fur. The respiratory sounds in lungs were clear, no rales could be heard. HR was 94 beats/min. The cardiac rhythm was regular, there weren't systolic and diastolic murmur. The abdomen was soft and flat. There was tenderness in the right lower abdomen, there weren't rebound tenderness and muscular tension. Gynecological examination showed there was a soft mass whose size was 5.0cm¡Á5.0cm with tenderness in the right side d oviduct, it's clearly divided from the contiguous tissues; the uterus was soft and slightly enlarged with lifting pain of uterine cervix; there were fullness and prominent tenderness over the posterior fornix; the vagina was unobstructed and there was some fresh red blood in it. There wasn't other abnormal sign.

Lab Test: Urine pregnancy test is positive. The result of HCG was 3.6gg/ml.

Examination of Diagnostic Uterine Curettage: It showed the endometria were extensively proliferous.

Examination of Ultrasonogram B: There was a mass of mixed echo whose size was 4.4cm¡Á4. lcm in the right adnexal area. Opaque dark area of fluid whose depth was 2.8cm was seen in iliac fossa, there was opaque dark area of fluid in the Douglas' cul-de sac and the uterovesical pouch too, the depth was separately 1.7cm and 1.5cm. There was no abnormal sign else. All these signs showed there were right adnexal mass and pelvic hydrops.

Diagnosis: Heterotopic Pregnancy (Ruptured Type).

Differentiation: This disease,in TCM, belongs to the category of"syndrome of blood stasis in lower abdomen. "It was caused by the accumulated heat evil and blood stasis in the meridian of lower abdomen which obstructed the adnexal meridian and disturbed the normal functional activities of pelvic organs. As a result of it, the accumulated heat evil disturbed the normal functional activities of the fertilized egg when the fertilized egg was formed, furthermore, the blood stasis obstructed the necessary passage for the fertilized egg to move into the uterus. So that the fertilized egg couldn't move into the uterus as normal, then it was out of the uterus and teratogenously grew into a pathologic adnexal mass. In order to take nourishment, the mass extended itself into the meridian around it. When the adjacent blood vessels were hurt by it, there appeared a continuous colporrhagia and pelvic hydrops; when the adjacent meridian was obstructed by it, there appeared blood stasis and qi-stagnation and the patient got a paroxysmal abdominal pain; after many days of bleeding, the healthy qi was extra consumed, and then the patient got lassitude, fatigue and limpness of limbs ; after Yin and blood were all extra consumed, the patient got the sallow complexion, dizziness and excessive sweat.

Therapeutic Principle: It's cardinal therapy to pare the mass, strike the blood stasis and dredge the obstructed meridian; it's auxiliary therapy to eliminate the damp heat from the lower-Jiao, invigorate qi and nourish the blood.

Recipe:

BieJia,Fresh-water Turtle Shell 30g (to be decocted earlier)

MuLi,Oyster Shell 30g (to be decocted earlier)

ShengHuangQi,Raw Milkvetch Root 30g

DangGui,Chinese Angelica Root 10g

ShuiZhi, Leech 5g

DiBieChong,Ground Beetle 5g

DangShen,Pilose Asiabell Root 30g

BaiShao,White Peony Root 20g

XiaKuCao,Prunella Spike 30g

LongDanCao,Gentian Root 15g

NiuXi,Achyranthes Root 20g

ChiShao,Red Peony Root 15g

TuFuLing, Smilax Glabra Rhizome 25g

ZhiGanCao,Prepared Liquorice Root 10g

TaoRen,Peach Seed 15g

All the above drugs were to be decocted in water for oral taking, 5 doses were prescribed. Hot and greasy food was forbidden during the treatment. In the same period, she was told to take the capsule for wrecking mass.

Recipe:

UuPo, Amber

A' Wei, Asafetida

(Each herb was taken just the proper amount. )

All the above drugs were to be ground into powder, the 2 kinds of powder should be mixed together, filling the large-sized capsules with the mixed powder. She was told to take 2 pieces of the capsule each time, 3 times a day in morning, afternoon and evening separately.

Effect Observation: During the treatment, the patient got a spasmodic pain in the deep part of her vagina. Meanwhile the colporrhagia got less and less day by day, the occurring of co1porrhagia became from continuous to intermittent in frequency and from fresh red to dark brown in colour. Furthermore, the pain in the right lower abdomen was relieved greatly. After taking the decoction, reexamination of ultrasonogram B showed the opaque dark area of fluid in iliac fossa and uterovesical pouch disappeared at all, the depth of the opaque dark area of fluid in the Douglas' culde-sac became 1.0cm. The mass of mixed echo in the right adnexal area was there yet, but its size reduced to 4.4cm¡Á2.5cm. It showed there was an adnexal mass accompanied with a little of pelvic hydrops. All these signs showed the hematocele in the pelvic cavity had been slowly absorbed into the deep tissues of perineum and the hematocele became prominently less than before, the adnexal mass had been smashed by the used herbs, it had been atrophing, it became obviously smaller than hefore. In addition, physical examination showed the pulse was thready and taut, the tongue was red with a greasy layer of white fur. There weren't dizziness, lassitude, fatigue and excessive sweat. While she got a bad appetite yet. All these signs showed the blood stasis had been mostly removed while the pathogenic phlegm and heat evil got entangled each other so firmly that they couldn't be removed easily. Then it's necessary to increase the LongDanCao,Gentian Root in the original recipe from 15g to 25g,omit 20g of BaiShao, White Peony Root and add 12g of DanLanXing, Arisaema with Bile in order to reinforce clearing away heat and eliminating pathogenic phlegm. The other herbs in the original recipe weren't changed. She was told to take 5 doses of this changed prescription. All the drugs were to be decocted in water for oral taking. The dietetic restraint and taking the capsule for wrecking mass were all as same as before.

After taking the decoction, the patient came back for reexamination on October 29,1999. She told me her appetite got better and the abdominal pain disappeared at all, the spasmodic pain in the deep part of her vagina disappeared too, there weren't co1porrhagia any longer. She felt she was very energetic. Physical

examination showed the pulse was thready and uneven, the tongue was red with a thin layer of white fur. Reexamination of ultrasonogram B showed there was no longer the opaque dark area of fluid in the pelvic cavity. The right adnexal mass became a thin and narrow cord, whose size was 4.4cm X 1.5cm. All these signs showed the hematocele in the pelvic cavity had been absorbed completely, the adnexal mass had been atrophing into a fibrosis, which would disappear soon. But the damp-heat hadn't been removed completely. Then it's necessary to omit 12g of DanNanXing, Arisaema with Bile, add 25g of DiGuPi, Wolfberry Bark in the 2nd prescription. She was told to take 5 doses of this prescription, all the drugs were to be decoeted in water for oral taking. The dietetic restraint and taking the capsule for wrecking I mass were all as same as before.

After taking the decoction, all the uncomfortable sensation disappeared. Reexamination of ultrasonogram B showed the right adnexal mass became a longer and narrower cord, which had nearly merged into the right adnexal tissues and could hardly been found. There was no hydrops in the pelvic cavity. All these signs showed the original adnexal mass had atrophied into fibrosis completely. This illness had been cured completely too. After 2 years' follow-up, the patient was well all along. Then it's ending.