国家级精品课《妇产科学》异位妊娠

异位妊娠EctopicPregnancy,复旦大学附属妇产科医院隋龙,DefinitionandOverview,DefinitionIncidence:onein100pregnanciesTheincresingtendencyInducedfactors:infertilelowersocioeconomicgrouppreviousectopicpregnancy,10-20%salpingitisandtuboplasty,Unruptruedtubalpregnancy(L),CASEONE,ElectrocoagulationandSection,LoopLigature,Whydiditimplantoutsideuterinecavity?,UnclearExplanationofMechanism,Etiology,TubalFactors(salpingitis)ZygoteAbnormalities(chromosomalabnormalities)OvarianFactors(unextrudedovum)ExogenousHormones(progestin-onlyoralcontraceptives)OtherFactors(endometriosis,IUD),ClassificationandSpecificIncidence,TubalPregnancy:99%AbdominalPregnancyCompoundorhysterotrophicpregnancyCervicalPregnancyOtherabnormalpregnancies,LocationsofEctopicPregnancy,55%,25%Isthmic,17%,Interstitial2%,0.5%,0.1%,Veryrare,Ampullary,Fimbrial,AbdominalPregnancy,omentum,Placenta,Tubalpregnancy(99%),Ampullary(55%)Isthmic(25%)Fimbrial(17%)Interstitial(2%)BilateralDistalwithsegmentalabsenceofthetube,OvarianPregnancy(0.5%),OvarianTubo-ovarianAbdominal-ovarian(secondaryabdominalpregnancy),AbdominalPregnancy(0.1%),PrimarySecondaryAbdomino-ovarianTubo-abdominal,CompoundorHeterotrophic,Combinedwithintrauterinepregnancy1in17,00030,000pregnancies,CervicalPregnancy,VeryrareIntraligamentousInthevesicovaginalspaceFollowinghysterectomy:inacervicalstump,inauterinetubeInaprolapseduterinetube(fimbrialorabdominal),OtherdisplacementofPregnancyinUterus,Cornual(角)(OneEx)Angular(畸形角)Withinauterinediverticulum(憩室)Inauterinesacculation(囊)Inarudimentaryhorn(始基角)Intramural(肌壁间),Pathology,LackageofresistancetoinvasionbythetrophoblastMinimaldefenseagainstthepenetratingtrophoblastAbdominalpregnancy:1:15,000pregnanciesMortalityrate:90%Enlargeduterus:circulationandendometriumchanges,EndometrialChangesthebroadligamentortheperitonealcavity.Cervical:ruptureintothecervicalcanalAbdominal:ruptureintotheperitonealcavity,intotheretroperitonealspace,orintoavitalorgan.Ovarian:ruptureintotheperitonealcavityCombined:Thetubalpregnancymayabortorrupture,andtheuterinepregnancymayabort,terminateprematurely,orcontinuetoterm,Ruptureoftubepregnancy,Abortionoftubepregnancy,ClinicalFindings,NospecificsymptomsorsignsarepathognomonicofectopicpregnancyCombinationoffindingsmaybesuggestiveSymptomsofearlypregnancy(amenorrhea,breasttenderness,andnausea)Bleeding(usuallyspotting)DiffuselowerabdominalpainOver16%ofectopicgestationspresentassurgicalemergencies.,Symptoms,Pelvicorlowerabdominalpain:99%Abnormaluterinebleeding:75%Secondaryamenorrhea:68%Generalizedpain:44%Unilaterallowerabdominalpain:33%Subdiaphragmaticpainorsharpshoulderpain:22%Syncope(晕厥):37%Uterinecast:7%,Signs,Abdominaltenderness80%Adnexaltenderness75%.ThepainmaybeexquisitelysevereonpalpationorslightmovementofthecervixanduterusAdnexalmassAunilateraladnexalmass:53%;boggyandpoorlydelineatedUterinechangesnormalsize:71%;6-8weekssize:26%,9-12weekssize:3%Feveronlyabout2%ofpatients,LaboratoryFindings,Pregnancytests-hCGpositivein82.5%ofectopicpregnanciesandnegativeinonly17.5%anegativetestdoesnotruleoutanectopicgestation.HematocritWhitebloodcellcountReticulocytes(网状红细胞).,SpecialExaminations,UtrasonicallyScanningCuldocentesisLaparoscopyDilatationandcurettageExploratorylaparotomy,Culdocentesis,Lithotomyposition,anAllisclamporatenaculumposteriorfornix18-gaugespinalneedlepunctureintheshortestdistanceintothecul-de-sac,DifferentialDiagnosis,Whatkindsofdiseasesshouldbedifferentiated:appendicitissalpingitisrupturedcorpusluteumcystovarianfollicleuterineabortiontwistedovariancysturinarytractdiseasedegeneratingleiomyomasnormalintrauterinepregnancywithotherabdominalorpelvicproblems,EssentialsofDiagnosis,AmenorrheafollowedbyirregularvaginalbleedingAdnexaltendernessormassUltrasonographicevidenceofadnexalmassandnointrauterinegestationPositive-hCG,Complications,About1in1000ectopicpregnanciesresultinmaternaldeathUntreatedormistreatedrupturedectopictubalpregnancy8-12%ofallmaternaldeathsThemajorityofthesedeathsarepreventable.ChronicsalpingitisInfertilityorsterilityIntestinalobstructionandfistulasmaydevelopafterhemoperitoneumandperitonitis,Treatment,EmergencyTreatment:Immediatesurgery,anti-shockmeasures(warm,oxygen,applymoderatelysnugtourniquetsaroundtheupperlegs)Surgicaltreatment:laparoscopictechniques.laparotomyMedicalTreatment:MTX.ItappearsverypromisingSupportiveTreatment:broad-spectrumantibiotics,oralorintravenousirontherapy,ahigh-proteindiet,IndicationsforConservativeDrugTherapy,Nosignsofactiveintra-abdominalbleedingDiameterofmass3cmSerum-hCG2000U/LNoembryonicbloodvesslepoundingNocontraindicationforMTXapplicationNormalliverandkidneyfunctionNormalRBC、WBCcountsandBPC,SamplesbyLaparoscopicsalpinec