受精卵在子宫体腔以外着床称异位妊娠.ppt

Normallocationofpregnancy,Ectopicpregnancy,Pregnancyinanylocationotherthanthebodyoftheuterus（子宫）isconsideredectopicpregnancy.,受精卵在子宫体腔以外着床称异位妊娠，习惯上称宫外孕(extrauterinepregnancy)。,tubalpregnancyovarianpregnancycervicalpregnancyabdominalpregnancybroadligamentpregnancy,4,3,1,2,1,2,3,4,5,5,异位妊娠以输卵管妊娠最常见,Fallopiantubepregnancyisacommonectopicpregnancy,壶腹部(Ampulla)最多见峡部(Isthmus)次之伞部(Fimbria)少见间质部(Interstitialportion)少见,Tubalpregnancyposition,Etiologyoftubalpregnancy,Fristpart,Ectopicpregnanciesareusuallycausedbyconditionsthatobstructorslowthepassageofafertilizedovum(egg)throughthefallopiantubetotheuterus.,Keywords,Etiology1、输卵管炎症(Tubalinfection),Etiology1、输卵管炎症(Tubalinfection)2、输卵管手术史(Previoustubalsurgery)3、输卵管发育异常（Congenitaltubalabnormalities)4、辅助生殖技术(ART)5、宫内节育器(IUD)6、其他（Pelvictumors、endometriosis),Pathologyoftubalpregnancy,输卵管管腔狭小，管壁薄且缺乏粘膜下组织，其肌层远不如子宫肌壁厚与坚韧，妊娠时不能形成完好的蜕膜，不利于胚胎的生长发育。,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,Secondpart,着床于粘膜皱襞间向管壁穿破破裂,种植在粘膜皱襞内向管腔破裂流产,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,ampullarypregnancy:8-12W(abortion,rupture)isthmicpregnancy:6W(rupture)interstitialportion:4M(rupture),输卵管妊娠破裂Tubalrupture,输卵管妊娠流产Tubalabortion,继发性腹腔妊娠Secondaryabdominalpregnancy,Theoutcomeoftubalpregnancy,陈旧性宫外孕OldEctopicPregnancy,Tubalabortion,Tubalrupture,长期反复的内出血所形成的盆腔血肿若不消散，血肿便可机化变硬，并与周围组织粘连，临床上称为“陈旧性宫外孕”。,继发性腹腔妊娠Secondaryabdominalpregnancy,Thechangeofuterus,子宫增大变软，子宫内膜出现蜕膜反应。Enlargementandsoft:sameasIUP(intrauterinepregnancy),输卵管妊娠子宫剖面示意图,蜕膜变A-S反应：可能为甾体激素过度刺激引起的子宫内膜过度增生和分泌反应。镜下见内膜腺体上皮细胞增生、增大细胞边界不清，腺细胞排列成团突入腺腔，细胞极性消失，细胞核肥大、深染，胞浆有泡。增生期改变分泌反应,胚胎死亡后子宫内膜多种形态学改变,排出组织无绒毛，组织学检查无滋养细胞。,Symptomsoftubalpregnancy,Amenorrhea(停经)Vaginalbleeding(阴道流血)Abdominalpain(腹痛)典型症状为停经后腹痛与阴道流血。,Amenorrhea,mistakeuterinebleedingfortruemenstruationlackofamenorrheadonotexclude,Abdominalpain-majorsymptom,duetotubalstretching“tearing”painwithnauseaandvomiting肛门坠胀痛painintheshoulder,Vaginalbleeding(spotting),scanty,spottingintermittentorcontinuous,Syncopeandshock(晕厥、休克),acutehemoperitoneum急性内出血severeabdominalpain剧烈腹痛hemorrhagicshock失血性休克,出血多时,与阴道流血不成正比,Physicalsignsoftubalpregnancy,Generalconditions:贫血、休克体征Abdominalexamination:血腹征、腹部包块Pelvicexamination:宫颈举痛、后穹隆饱满、子宫漂浮感,一侧附件包块，有压痛,easyordifficulty,？,未发生流产或破裂时，临床表现不明显。,Diagnosisoftubalpregnancy,HistorySymptomsPhysicalsignsAssistedexaminations,-HCG,Ultrasound,Culdocentesis,Laparoscopy,Endometrium,Assistedexaminations,pregnancy？,妊娠试验Pregnancytest，HCG-test,尿-hCG简单快速，适用于急症患者。血-hCG定量准确，可协助诊断和保守治疗的疗效判断。血-hCG阴性一般可排除异位妊娠。,异位妊娠患者腹腔积血。早期妊娠期盆腔疼痛患者右上腹斜矢状面扫查显示肝肾四周与大量腹腔积血一致的液体（箭号）。,活的异位妊娠。（A）经腹部横切面扫查图像显示邻近子宫（UT）的左侧妊娠囊（箭号），与左侧卵巢（UTO）分界清。,超声诊断,血-HCG测定与B超配合诊断宫外孕,血-HCG18KU/L时,若阴道B超未见宫内妊娠囊,高度怀疑。,腹腔是否有内出血,阴道后穹隆穿刺（Culdocentesis）,无内出血或出血很少，血肿位置高，直肠子宫陷凹有粘连。,阳性说明血腹的存在，阴性见于:,腹腔镜检查（laparoscopy）金标准,可明确诊断并了解异位妊娠的部位、性质、病灶大小、毗邻关系（有无粘连）、内出血情况等。,适用于：原因不明的急腹症鉴别输卵管妊娠未破裂或流产的早期,子宫内膜病理检查,目的在于排除同时合并宫内妊娠流产。,Dilatationandcurettage,Assistedexaminations,Endometrium,major,鉴别诊断,输卵管妊娠,急性阑尾炎,卵巢肿瘤蒂扭转,黄体破裂,流产,急性输卵管炎,Treatmentoftubalpregnancy,药物治疗Medicaltreatment,手术治疗Surgicaltreatment,期待疗法Expectanttreatment,Expectanttreatment,条件：（1）疼痛轻微（2）随诊可靠（3）无输卵管妊娠破裂依据（4）血-hCG1000U/L，且继续下降（5）输卵管包块直径3cm或未探及（6）无明显内出血,Medicaltreatment,适应于早期输卵管妊娠，要求保留输卵管的患者（1）输卵管妊娠未发生破裂或流产（2）输卵管包块直径4cm（3）血-hCG2000U/L（4）无明显内出血（5）无药物禁忌症,1.Methotrexate（氨甲蝶呤）hasbecomepopularinselectedcasesofectopicpregnancy.2.TraditionalChinesemedicine(中药）,疗效的监测和判断,血-hCG监测：,疗效判断：,显效无效,治疗第四天和第7天检测,及时发现,Surgicaltreatment,Surgeryisthemostcommonmanagementofanectopicpregnancy.,紧急处理（EmergencyTreatment）：内出血并发休克的患者，输血、输液抗休克同时紧急手术。,手术适应症,生命体征不稳定或有腹腔内出血,诊断不明确,异位妊娠有进展,随诊不可靠者,期待疗法或药物治疗禁忌证者,手术途