异位妊成：钟刚.ppt

1、Ectopic Pregnancy,Zhong Gang Department of Gynecology and Obstetric Tongji Hospital,Introduction,Pregnancy in any location other than the body of uterus, namely implantation outside of the uterine cavity is considered ectopic. The vast majority of ectopic pregnancies occur in the oviduct 95%. Ectopi

2、c pregnancy appears to have become more common in the last years.,Cause of ectopic pregnancy,Ectopic pregnancy may be caused by any factor that retards the passage of the fertilized egg common ovary to endometrium. The primary risk factor for ectopic pregnancy is a prior history of salpingitis. Wome

3、n with a history of salpingitis have a 6-fold increase in their risk of ectopic pregnancy. Operation on the oviduct have become increasingly important etiologic factors.,Cause of ectopic pregnancy,Intrauterine contraception devices(IUP) prevent all types of pregnancies, although ectopic pregnancies

4、may be reduced relatively less than false impression that they are a risk factor. Age is an important risk factor, women 35 to 44 years old have threefold increase in the rate of ectopic pregnancy compared with women 15 to 24 years old. Other factors,Pathology,The termination of the gestation depend

5、s largely on the location. Pregnancies in the ampulla, particularly the distal portion, frequently abort with minimal signs. Pregnancy in the isthmus usually rupture into the peritoneal cavity or rupture a pregnancy in the interstitial portion of the tube may be rapidly followed by shock. Secondary

6、abdominal pregnancy, which is more common, involves reimplantation somewhere in the abdominal cavity after the pregnancy has been separated from its primary site of implantation such as in tubal abortion.,Pathology,The change of uterus: the uterus usually grows at a normal rate for about six to eigh

7、t weeks, and decidual reaction(without trophoblastic tissue) is commonly found in the endometrium. The arias-stella reaction is not pathogenomic of oviductal pregnancy, but may be found when there is functioning trophoblastic tissue anywhere in the body.,Here is ectopic pregnancy in a fallopian tube

8、 that was excised. This is a medical emergency because of the sudden rupture with hemoperitoneum.,Clinical evaluation of possible ectopic pregnancy,The classic presentation of a patient with an ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding, although all of these symptom

9、s are not always present.,Clinical evaluation of possible ectopic pregnancy,Symtoms of ectopic pregnancy Prevalence% _ Abdominal pain 95-100 Abnormal uterine bleeding 65-85 Amenorrhea 75-95 Syncope 10-18 Dizziness 20-35 Pregnancy symptoms 10-20,Physical finding in tubal pregnancy,Physical examinatio

10、n findings range from a totally normal examination in early unruptured ectopic pregnancy to hypovolemic shock and acute abdomen in cases of ruptured ectopic pregnancy. Fever is not expected, although a mild elevation in temperature in response to intraperitoneal blood may occur. A temperature of gre

11、ater than 38oC may suggest an infectious etiology to a patients symptoms.,Physical finding in tubal pregnancy,Finding prevalence% _ Abdominal tenderness 80-90 Peritoneal signs Ruptured 50 Unruptures 5 Adnexal tenderness 75-90 Unilateral 40-74 Bilateral 50-75 Cervical motion tenderness 50-75 Adnexal

12、mass 30-50 Uterus normal size 70 Enlarged 15-30,Differential diagnosis,Elements of the differeantial diagnosis include complications of an intrauterine pregnancy, nonpregnancy-related gynecologic condition(acute salpingitis, follicular or corpus luteum cyst rupture, or adnexal torsion) and nongyneco

13、logic conditions (e.g.appendicitis).,Diagnostic procedures,Any sexually active women in the reproductive age group who presents with pain, irregular bleeding, and/or amenorrhea should have ectopic pregnancy as a part of the initial diagnosis. Pregnancy test. a negative pregnancy test excludes the po

14、ssibility of ectopic pregnancy. They detect hCG as early as 14 days after conception and are positive in more than 90% of cases of ectopic pregnancy. Serum assays can detect the presence of hCG as early 5 days after conception.,Diagnostic procedures,Pelvic ultrasonography: ultrasonography cannot be

15、relied on to routinely image a pregnancy outside the uterine cavity, but it can identify an intrauterine pregnancy with considerable accuracy.,Ultrasound showing uterus and tubal pregnancy,Same image. Uterus outlined in red, uterine lining in green, ectopic pregnancy yellow. Fluid in uterus at blue

16、circle - sometimes called a pseudosac,Diagnostic procedures,Culdocentesis can aid in the identification of a hemoperitoneum, which in turn, may indicate a ruptured ectopic pregnancy. Nonclotting blood is evidence of which the blood clot has undergone fibrinolysis - positive Aspiration of clear perit

17、oneal fluid(negative culdocentesis) indicates no hemorrhage into the abdominal cavity but does not rule out an unruptured ectopic pregnancy. Aspiration of blood that clots can indicate either penetration of a vessel .,Diagnostic procedures,Laparoscopy The most accurate technique of identifying an ec

18、topic pregnancy is by direct visualization, done most commonly via laparoscopy, even laparotomy. Curettage of the uterine cavity can also help rule out ectopic pregnancy. Identification of chorionic villi in curettings identifies an intrauterine location of the pregnancy and essentially rules out ectopic pregnancy.,A right tubal ectopic pregnancy as seen at laparoscopyThe swollen right tube containing the ectopic pregnancy is on the right at EThe stump of the left tube is seen at L - this woman had a previous tubal ligation,Management of ectopic pregnancy,The traditional managem