异常子宫出血规培教学查房讲课.ppt

1、临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,异常子宫出血,（,AUB,）,Abnormal,uterine bleeding,临沂妇女儿童医院妇科,1,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,?,中年女性，,42,岁。,?,3,余年前出现月经量增多，增多至既往,2,倍余，偶感头晕、,乏力不适，患者分别于,2,年半前、,1,年前于当地医院行诊刮,术，术后病理均提示：（宫腔）子宫内膜单纯性增生，输,血治疗,2,次。后

2、间断“中药、黄体酮胶囊”治疗，效果欠,佳。,3,个月前于当地医院复查再次行诊刮术，术后病理示：,（宫腔）子宫内膜单纯性增生伴小灶状复杂性增生。术后,给予“优思明”治疗,2,个月（具体用药情况不详），自行,停药,，阴道流血,20,天来院。,2,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,病例特点,:,?,围绝经期女性。,?,月经紊乱，经量增多,3,年。,?,既往,3,次诊刮，均示：子宫内膜增生。,?,未规范治疗，反复发作。,3,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Chi

3、ldrens Health Care Hospital Of Linyi,住院病史补充,?,患者既往无鼻出血、牙龈反复出血等出血性疾病。,?,发病前未用阿司匹林等抗凝。,?,最近有无避孕药、雌孕激素等药物。,?,未使用抗抑郁药物。,?,否认高血压、糖尿病史。,4,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,体格检查,?,体格检查：,T 37.4,，,P 86,次,/,分，,R 19,次,/,分，,BP,134/84mmHg,，贫血貌，结膜口唇苍白，全身皮肤黏膜无,黄染、出血及皮疹,。,?,专科情

4、况：外阴发育正常；阴道通畅，粘膜光滑；宫颈光,滑，见纳氏囊肿，无触血；子宫后位，正常大小，活动度,可，无压痛，双侧附件区未扪及异常。,5,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,辅助检查,?,2016-11-28,彩超：宫体前壁探及,1.9cm,1.7cm,1.8cm,的低回声团块，子宫内膜厚约,1.0cm,。,?,2016-11-28,血常规：白细胞,:6.43x109/L,血红蛋白,:69g/L,血小板,:323x109/L,中性粒细胞百分比,:64.5%,。,?,2016-09-16,

5、诊刮病理：（宫腔）子宫内膜单纯性增生伴,小灶状复杂性增生。,6,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,入院诊断,?,1,、异常子宫出血,(AUB-O?),?,2,、中度贫血,?,3,、子宫肌瘤,7,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,异,常,子,宫,出,血,的,诊,断,一、患者是,AUB,吗？,二、什么类型？,两个问题,8,2020/3/31,临,沂,市,妇,幼,保,健,院,Wome

6、n&Childrens Health Care Hospital Of Linyi,功血（,DUB,）的概念,?,由于调节生殖的,神经内分泌机制失常,引起的,异常子宫出血,。,?,分为两类：,1,、无排卵性功血,占,85%,青春期、绝经过度期,2,、排卵性功血,多见于育龄期,9,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,正常月经及异常子宫出血,?,正常月经四要素：周期频率、规律性、经期长度、,经量,?,周期频率,21-35,天，经量,5-80ml,，经期,3-7,天,10,2020/3/31,

7、临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,异常子宫出血,?,周期频率：月经频发：,21,天，月经稀发,35,天。,?,规律性：,1,年内周期变化,7,天，,2,次,7,天为不规律月经。,?,经期长度：经期延长,7,天，经期过短,3,天。,?,经量,:,过多,80ml,，过少：,5ml,。,11,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,2009,年中国功血诊断治疗指南,12,2020/3/31,临,沂,市,妇,幼

8、,保,健,院,Women&Childrens Health Care Hospital Of Linyi,2014,年中华医学会根据,FIGO,分类,13,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,的病因及发病机制,?,雌激素撤退性出血或雌激素突破性出血,：,青春期性轴不成熟，无,LH,峰，无排卵；更年期,E2,下降，卵泡发育受阻而不排卵,-,孕激素的缺乏,?,子宫内膜出血自限机制缺陷：组织脆性增加；子,宫内膜脱落不完全；血管结构与功能异常；凝血,与纤溶异常；血管舒张因子异常，,P

9、GE2,增多。,14,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,子宫内膜病理变化,AUB-O,?,子宫内膜增生症,单纯型增生,（,1%,发展为内膜癌）,图,幻灯片,18,复杂型增生,（,3%,发展为内膜癌）,不典型增生,（癌前病变,幻灯片,，,23%,发展为内膜癌,幻灯,片,20,，）,增生期子宫内膜,?,萎缩型子宫内膜,15,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,16,202

10、0/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,17,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,18,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,临床表现,?,子宫不规则出血：,月经周期紊乱、不规律、经期长短不一、经,量不定；,?,无腹痛；,?,失血性贫血，甚至休克。,19,2020/3/31,临,沂,市,

11、妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,辅助检查,1,、血红细胞计数、血凝功能测定,2,、,HCG,3,、,B,超,4,、诊断性刮宫（,D&C,）,5,、宫腔镜,6,、卵巢功能测定（是否无排卵）,?,BBT,?,宫颈粘液评分,?,阴道脱落细胞涂片,?,性激素测定,?,子宫内膜病理,20,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,21,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childre

12、ns Health Care Hospital Of Linyi,22,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,诊断,?,病史、体格检查、辅助检查,23,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,鉴别诊断,?,异常妊娠或妊娠并发症,?,生殖器官肿瘤,?,生殖器官感染,?,性激素类药物使用不当、宫内节育器或异物引起,出血,?,全身性疾病：血液病、肝肾功能衰竭、甲状腺疾,病,24,2

13、020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,的治疗,诊断,止血,止血后治疗,25,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,止血治疗,一、一般治疗,补充营养、输血、抗感染、充分休息,二、药物治疗（功血一线治疗）,绝经过渡期功血以止血、调整周期、减少经,量、防止子宫内膜病变为治疗原则。,三、手术治疗：诊刮,26,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&

14、Childrens Health Care Hospital Of Linyi,AUB-O,止血治疗：,?,（一）药物止血,性激素治疗,8,小时内见效，,2448,小时内出血基本停止，,若,96,小时以上仍不止血，应进一步检查。,1,、联合用药（雌激素,+,孕激素）：第三代口服避孕药,2,、雌激素（急性大出血）仅用于青春期,妊马雌酮、苯甲酸雌二醇、戊酸雌二醇,3,、孕激素,甲羟孕酮、甲地孕酮、炔诺酮,4,、雄激素,5,、其他：非甾体类抗炎药物和其他止血药,27,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of L

15、inyi,药物止血,1:“,内膜萎缩法”,?,高效孕激素,?,口服避孕药,?,其他（棉酚、米非司酮）,适于：,任何年龄、贫血严重,2-3,片,/,日,*7,天,2,片,/,日,*7,天,1,片,/,日,*7,天,妈富隆、达英,35,、优思明等,任何年龄、贫血严重,28,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,药物止血,2:,雌激素内膜修复法,补佳乐,2-4mg/d,维持,减量,止血,撤血,雌激素,血止,补佳乐,4-6mg/q6-8h,雌激素维持量,雌激素剂量递减，,每次减,1/3,维持,3,

16、天,孕,激,素,贫血纠正,青春期、贫血严重,29,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,药物止血,3:,孕激素内膜脱落法,?,黄体酮,20mg/d*3-5,天，肌注,?,微粉化黄体酮,200mg/ d*10-14,天,?,安宫黄体酮,8mg/ d*10-14,天,?,炔诺酮（妇康片）,5mg/ d*10-14,天,?,甲地孕酮（妇宁片）,8mg/ d*10-14,天,?,地屈孕酮（达芙通）,20mg/d*10-14,天,首选纯天然，,嘱：停药后有撤血！,任何年龄、贫血不严重,中华医学会妇产

17、科学分会内分泌组，徐苓,.,功能失调性子宫出血的,药物治疗,.,中国实用妇科与产科杂志,2014,20:199-200,。,可于撤退性出血第,15,天起使用孕激素，连用,10,14,天，酌情用,3,6,个周期,30,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,的药物止血处理,异常子宫出血,器质性,功能性（无排卵）,贫血,不贫血,雌激素“内膜修复”,内膜萎缩（,COC,）,孕激素,hb,80g/l,。,青春期,任何年龄,血栓高危除外,任何年龄,血常规,31,2020/3/31,临,沂,

18、市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,手术止血治疗,?,什么样患者需要刮宫：,?,年龄大于,35,岁,?,药物治疗无效,?,存在子宫内膜癌高危因素,32,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,后续治疗,?,药物治疗：,?,（一）调整月经周期,1,、雌孕激素序贯疗法（人工周期）,用于,青春期,2,、雌孕激素联合法（,COC,）,3,、后半期疗法,?,（三）促排卵，有生育要求。,33,2020

19、/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,后续治疗,?,(,二）左炔诺孕酮宫内释,放系统：含左炔诺孕酮,52mg,，每天释放,20ug,，,持续,5,年，有效率在,90%,以上。,34,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,AUB-O,后续治疗,手术治疗：,1,、子宫内膜切除术,2,、子宫切除术,35,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens

20、Health Care Hospital Of Linyi,该患者怎样治疗，为什么？,?,1,、继续药物治疗？,?,2,、诊刮？,?,3,、宫腔镜检查？,36,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,治疗经过,?,患者入院后因中度贫血，,hb69g/l,，给予去白,悬浮红细胞,2.5,单位输注，复查,hb77g/l,，患者,自觉乏力、头晕等不适消失，行宫腔镜检查术：,宫腔形态正常，内膜不厚，色粉红，可见充血,血管，未见赘生物，双侧输卵管开口可见，行,诊刮术，病理。,37,2020/3/31,临,沂,市,妇,幼,保,健,院,Women&Childrens Health Care Hospital Of Linyi,后续治疗,?,这个患者，我们可选