(妇产科学课件)06.2Ectopic-图文

(妇产科学课件）06.2Ectopic2021/10/10星期日12021/10/10星期日2重庆医科大学附属第一医院牟晓玲Ectopicpregnancy2021/10/10星期日3DefinitionImplantationofthefertilizedovumintissueotherthantheuterinebodycavity2021/10/10星期日42021/10/10星期日5Categories

Tubalpregnancy95%

输卵管妊娠ovarianpregnancy

卵巢妊娠

abdominalpregnancy

腹腔妊娠cervicalpregnancy

宫颈妊娠2021/10/10星期日6

TubalPregnancy

输卵管妊娠2021/10/10星期日7Sitesoftubalpregnancyampulla壶腹部(75-80%)isthmus峡部

fimbria伞部

interstitial间质部

Theampullaisthemostfrequentlocationoftubalpregnancy2021/10/10星期日8Etiology

anyreasonthatimpedethepassageoffertilizedovumalongthetubetowardtheuterinecavity2021/10/10星期日9Chronicsalpingitis(慢性输卵管炎）

ItisthecommonestcauseoftubalpregnancyInflammationdestroytheepithelium,formingadhesionsin/aroundthetube2021/10/10星期日10

OtherEtiologiesPrevioustubalsurgeryreconstructivesurgery：tubeplasty（输卵管整形术）

AbnormalitiesordysfunctionofthetubeexcessivelengthofthetubeIVFFailureofcontraception:currentuseofIUDororalcontraceptives（emergencycontraception）

Pelvicendometriosis,myoma,ovariantumors

（子宫内膜异位症、子宫肌瘤、卵巢肿瘤）2021/10/10星期日11

PathologyThechangeofthetube

输卵管的变化ThechangeoftheUterus

子宫的变化2021/10/10星期日12ThechangeofthetubeThetubeistoothintoaccommodatethegrowthoffertilizedovumThefertilizedovumpenetratesintothetubalwallThetubalpregnancymayterminatebytubalabortionortubalrupture2021/10/10星期日13Tubalrupture输卵管妊娠破裂Tubalruptureoccursatabout6weeksinisthmicpregnancy

(thelumenisnarrower)Tubalrupturemayoccuratabout12-16weeksininterstitialportion2021/10/10星期日14BleedingisheavierthantubalabortionIfinvasivetrophoblast(滋养细胞)erodeslargevessel，severeintraperitonealhemorrhage（腹腔内出血）occursTubalrupture输卵管妊娠破裂2021/10/10星期日15Tubalabortion输卵管妊娠流产Twocategories:completetubalabortionincompletetubalabortion

2021/10/10星期日16ThechangeoftheUterusenlargementandsofteningamenorrheavaginalbleedingtheArias-Stellareactionoftheendometriumbutnochorionicvilli2021/10/10星期日17SymptomsthreePrimarysymptoms(5-6weeksafterLMP)amenorrhea停经

abdominalpain腹痛vaginalbleeding阴道流血

EarlypregnancysymptomsSyncopeandshock2021/10/10星期日18AmenorrheaAhistoryofamenorrheaabout6-8weeksAbout25%ofpatientshavenoevidentamenorrhea2021/10/10星期日19Abdominalpain

mostfrequent(about95%patientscomplain)abortionortubalrupturemaypresentasacuteorchronicform2021/10/10星期日20Vaginalbleeding

hormonelevelbecomesinadequate,uterinebleedingoccursThebleedingisusuallylessthanmenstrualbleeding2021/10/10星期日21

SignsGeneralexamination全身检查whentheintra-abdominalbleedingisrapidandseverePallor面色苍白

rapidandfeeblepulse脉搏细弱Hypotention:lowbloodpressure血压降低2021/10/10星期日22

SignsAbdominalexaminationabdominaltenderness压痛:diffuseorlocalizedabdominaltendernessispresentinover80%ofectopicpregnancyreboundtenderness反跳痛

Guarding肌紧张2021/10/10星期日23

Signspelvicexamination（trans-vaginalexamination)Vaginal阴道:vaginalbleedingCervix宫颈:motiontenderness宫颈举摆痛

（tendernessespeciallywhenmovingthecervix）Uterus子宫:enlargedcorrespondingwithornotwiththedurationofpregnancyAdnexal附件:adnexalmass/adnexaltenderness2021/10/10星期日24

DiagnosisHistoryandPhysicalExam(mostimportant!)Needassistedexaminations1.Pregnancytest：urine/bloodhCG(humanchorionicgonadotropin))2.Ultrasound超声检查3.Culdocentesis后穹隆穿刺术4.D&C（dilationandcurettage）刮宫术2021/10/10星期日25HistoryandPhysicalExamAnywomeninthereproductiveagegroupwhopresentswithpain,irregularbleeding,and/oramenorrheashouldhaveectopicpregnancyasapartoftheinitialdiagnosis.2021/10/10星期日26Pregnancytest

apositivepregnancytestassociatedwithpainandvaginalbleedingisanabnormalpregnancy,highlysuspectedofectopicpregnancyAnegativepregnancytestexcludesthepossibilityofectopicpregnancy2021/10/10星期日27SerumhCG(Quanlitative定量的)hCG-hormoneproducedbytheplacentaDetectableinplasmaandurinefollowingblastocystimplantation.SingledeterminationnothelpfulBloodlevelsriserapidlyinnomalpregnancy,66%every48hrsHCGwithinadequateincreasemaysuggestectopicpregnancy2021/10/10星期日28UltrasoundThesiteofgestationalsac?Freefluidpresent?Adnexalmass?2021/10/10星期日29Ultrasonography2021/10/10星期日30UltrasonographyEmptyuterus宫腔空虚Freefluid游离液体

Adnexalmass附件包块

2021/10/10星期日31Culdocentesisinsertinganeedlethroughtheposteriorfornix(后穹窿)intothecul-de-sac(子宫直肠陷凹)

2021/10/10星期日32

Culdocentesiscanaidintheidentificationofahemo-peritoneum,whichinturn,mayindicatearupturedectopicpregnancy.Positive:Aspirationofnon-clottingblood（indicatesintra-peritonealhemorrhage）Culdocentesis2021/10/10星期日33Negative:Aspirationwithoutnon-clottingbloodorwithclearperitonealfluidindicatesnohemorrhageintotheabdominalcavitybutdoesnotruleoutectopicpregnancyCuldocentesis2021/10/10星期日34

D&C

Curettageoftheuterinecavitycanalsohelpruleoutectopicpregnancy.Identificationofchorionicvilli(绒毛)identifiesanintrauterinelocationofthepregnancyandrulesoutectopicpregnancy.2021/10/10星期日35DifferentialDiagnosis

Itisimportanttoruleout:uterineabortion宫内妊娠流产acuteappendicitis急性阑尾炎Pelvicinflammatorydisease急性盆腔炎torsionofovariantumor卵巢肿瘤扭转2021/10/10星期日36TreatmentMedicaltreatment:MethotrexateSurgicaltreatment(laparotomy/laparoscopy)2021/10/10星期日37MedicaltreatmentIfthesituationisnotacute,theconservetherapywithmedicinecanbeusednocontra-indicationofmedicaltreatmentectopicpregnancymassdiameter<3cmβ-HCG＜2000U/Lnoruptureoftubalpregnancynoabdominalhemorrhage2021/10/10星期日38MedicaltreatmentMTX(Methotrexate,甲氨蝶呤)hasbeensuccessfullyused.ItisachemotherapydrugtokilltheembryoToxictotrophoblastcells0.4mg/kg/dintramuscular×5days.Requirescompliantpatientandfollow-up2021/10/10星期日39SurgicaltreatmentIndication:abdominalhemorrhage腹腔内出血Unstablevitalsignorshock生命体征不平稳FailureMedicaltreatment药物治疗失败2021/10/10星期日40Surgicaltreatment

Radicalvs.Conservativesurgery

根治性vs.保守性Laparotomyvs.Laparoscopy

剖腹vs.腹腔镜2021/10/10星期日41Conservative:Salpingostomy输卵管造口Smallpregnancyleisonlocatedindistalfallopiantubepreservationoftube5%riskofrecurrence2021/10/10星期日42Radical:Salpingectomy输卵管切除Extractionofthetube2021/10/10星期日43Radical:Salpingectomyectopicpregnancyinafallopiantubet