妇产科_异位妊娠

异 位 妊 娠 Ectopic Pregnancy,(宫 外 孕 extrauterine pregnancy),Introduction,Definition Etiology (the most common cause) Pathology (three pathological terminations) Clinical Manifestation (the classic triad) Diagnosis (four ancillary methods) Treatment (the primary treatment),Definition:,Pregnancy in any location other than the body of the uterus is considered ectopic. Incidence: 0.51%,图1 异位妊娠的发生部位,Tubal Pregnancy,壶腹部(Ampulla) 5560% 峡部(Isthmus) 2025% 伞部(Fimbria) 少见 间质部(Interstitial portion) 少见,Chronic salpingitis pelvic inflammatory disease (PID)盆腔炎 sexually transmitted disease(STD)性传播疾病 Prior tubal surgery tubal sterilization or salpingectomy 绝育 输卵管切除术 Current IUD use:intrauterine device 宫内节育器 History of infertility,Etiology,Pathology,一、Terminations of tubal pregnancy,2,1、输卵管腔 2、输卵管内血肿 3、绒毛侵犯管壁 4、绒毛膜 5、羊膜,图2 输卵管妊娠剖面示意图,图3 输卵管妊娠时孕卵的着床部位 1、着床于粘膜皱襞内常向管腔破裂 2、着床于粘膜皱襞间常穿破管壁,（一）Tubal abortion,图4 输卵管妊娠流产,（二）Rupture of tubal pregnancy,图5 输卵管妊娠破裂,ampullary pregnancy: 8-12W (abortion,rupture) isthmic pregnancy: 6W (rupture) interstitial portoion: 4M(rupture),图6 间质部妊娠,(三)Secondary abdominal pregnancy,图7 腹腔妊娠 示意图,二、Uterine changes,（一）Enlargement and soft: same as IUP(intrauterine pregnancy) 宫内孕,图8 输卵管妊娠子宫剖面示意图,（二）Endometrium 子宫内膜 decidual reactiion 蜕膜变 Arias-Stella reaction A-S反应 proliferative phase 增生期 secretory phase/menstrual period 分泌期或月经期,Clinical Manifestation,一、 Symptoms,Amenorrhea 停经 Abdominal pain 腹痛 Vaginal bleeding 阴道出血 Syncope and shock 晕厥与休克,Symptoms Amenorrhea (3/4) mistake uterine bleeding for true menstruation(月经) lack of amenorrhea do not exclude Abdominal pain(90-100%) due to tubal stretching “tearing”pain with nausea and vomiting pain in the shoulder tenesmus(里急后重),Symptoms Vaginal bleeding (spotting) external bleeding scanty,dark intermittent or continuous Syncope and shock acute hemoperitoneum 急性内出血 severe abdominal pain 剧 烈 腹 痛 hemorrhagic shock 失血性休克,（二） Signs,Blood pressure and pulse hypotension 低血压 hypovolemia 血容量减少 Abdominal examination Abdominal tenderness with “rebound” 压痛、反跳痛 Shifting dullness 移动性浊音,Signs Pelvic examination (on bimanual examination 双合诊) exquisite tenderness , especially on motion of the cervix 宫颈触痛 aadnexal mass 附件肿物 uterine enlargement 子宫增大,Ancillary examination,-HCG,Ultrasound,Culdocentesis,Laparoscopy,Diagnosis,History,Physical examination,Measurement of -hCG (human chorionic gonadotropin) 绒毛膜促性腺激素测定,尿-hCG: false-negative,false-positive 血-hCG(radioimmunoassays),Ultrasonic Diagnosis 超声诊断 经腹超声 TAS （Transabdominal Sonography） 经阴超声 TVS (Transvaginal Sonography) 彩色多普勒超声 CDFI (Colour Doppler Flow Imaging),图9 输卵管妊娠经腹超声影像,Culdocentesis 阴道后穹窿穿刺 technique for identifying hemoperitoneum 腹腔积血,图10 阴道后穹窿穿刺示意图,Laparoscopy 腹腔镜检查,图11 腹腔镜检查操作示意图,Treatment,Surgical treatment Non-operative approach,手术治疗(Surgical Treatment)： 输卵管切除术(Salpingectomy),图12 输卵管妊娠切除术,图13 输