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(妇产科学课件)06.2 Ectopic

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(妇产科学课件)06.2 Ectopic(妇产科学课件)06.2EctopicCategoriesTubalpregnancy95%输卵管妊娠ovarianpregnancy卵巢妊娠abdominalpregnancy腹腔妊娠cervicalpregnancy宫颈妊娠TubalPregnancy输卵管妊娠Sitesoftubalpregnancyampulla壶腹部(75-80%)isthmus峡部fimbria伞部interstitial间质部TheampullaisthemostfrequentlocationoftubalpregnancyEtio...

(妇产科学课件)06.2 Ectopic
(妇产科学课件)06.2EctopicCategoriesTubalpregnancy95%输卵管妊娠ovarianpregnancy卵巢妊娠abdominalpregnancy腹腔妊娠cervicalpregnancy宫颈妊娠TubalPregnancy输卵管妊娠Sitesoftubalpregnancyampulla壶腹部(75-80%)isthmus峡部fimbria伞部interstitial间质部TheampullaisthemostfrequentlocationoftubalpregnancyEtiologyanyreasonthatimpedethepassageoffertilizedovumalongthetubetowardtheuterinecavityChronicsalpingitis(慢性输卵管炎)ItisthecommonestcauseoftubalpregnancyInflammationdestroytheepithelium,formingadhesionsin/aroundthetubeOtherEtiologiesPrevioustubalsurgeryreconstructivesurgery: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)PathologyThechangeofthetube输卵管的变化ThechangeoftheUterus子宫的变化ThechangeofthetubeThetubeistoothintoaccommodatethegrowthoffertilizedovumThefertilizedovumpenetratesintothetubalwallThetubalpregnancymayterminatebytubalabortionortubalruptureTubalrupture输卵管妊娠破裂Tubalruptureoccursatabout6weeksinisthmicpregnancy(thelumenisnarrower)Tubalrupturemayoccuratabout12-16weeksininterstitialportionBleedingisheavierthantubalabortionIfinvasivetrophoblast(滋养细胞)erodeslargevessel,severeintraperitonealhemorrhage(腹腔内出血)occursTubalrupture输卵管妊娠破裂Tubalabortion输卵管妊娠流产Twocategories:completetubalabortionincompletetubalabortionThechangeoftheUterusenlargementandsofteningamenorrheavaginalbleedingtheArias-StellareactionoftheendometriumbutnochorionicvilliSymptomsthreePrimarysymptoms(5-6weeksafterLMP)amenorrhea停经abdominalpain腹痛vaginalbleeding阴道流血EarlypregnancysymptomsSyncopeandshockAmenorrheaAhistoryofamenorrheaabout6-8weeksAbout25%ofpatientshavenoevidentamenorrheaAbdominalpainmostfrequent(about95%patientscomplain)abortionortubalrupturemaypresentasacuteorchronicformVaginalbleedinghormonelevelbecomesinadequate,uterinebleedingoccursThebleedingisusuallylessthanmenstrualbleedingSignsGeneralexamination全身检查whentheintra-abdominalbleedingisrapidandseverePallor面色苍白rapidandfeeblepulse脉搏细弱Hypotention:lowbloodpressure血压降低SignsAbdominalexaminationabdominaltenderness压痛:diffuseorlocalizedabdominaltendernessispresentinover80%ofectopicpregnancyreboundtenderness反跳痛Guarding肌紧张Signspelvicexamination(trans-vaginalexamination)Vaginal阴道:vaginalbleedingCervix宫颈:motiontenderness宫颈举摆痛(tendernessespeciallywhenmovingthecervix)Uterus子宫:enlargedcorrespondingwithornotwiththedurationofpregnancyAdnexal附件:adnexalmass/adnexaltendernessDiagnosisHistoryandPhysicalExam(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HistoryandPhysicalExamAnywomeninthereproductiveagegroupwhopresentswithpain,irregularbleeding,and/oramenorrheashouldhaveectopicpregnancyasapartoftheinitialdiagnosis.Pregnancytestapositivepregnancytestassociatedwithpainandvaginalbleedingisanabnormalpregnancy,highlysuspectedofectopicpregnancyAnegativepregnancytestexcludesthepossibilityofectopicpregnancySerumhCG(Quanlitative定量的)hCG-hormoneproducedbytheplacentaDetectableinplasmaandurinefollowingblastocystimplantation.SingledeterminationnothelpfulBloodlevelsriserapidlyinnomalpregnancy,66%every48hrsHCGwithinadequateincreasemaysuggestectopicpregnancyUltrasoundThesiteofgestationalsac?Freefluidpresent?Adnexalmass?UltrasonographyUltrasonographyEmptyuterus宫腔空虚Freefluid游离液体Adnexalmass附件包块Culdocentesisinsertinganeedlethroughtheposteriorfornix(后穹窿)intothecul-de-sac(子宫直肠陷凹)Culdocentesiscanaidintheidentificationofahemo-peritoneum,whichinturn,mayindicatearupturedectopicpregnancy.Positive:Aspirationofnon-clottingblood(indicatesintra-peritonealhemorrhage)CuldocentesisNegative:Aspirationwithoutnon-clottingbloodorwithclearperitonealfluidindicatesnohemorrhageintotheabdominalcavitybutdoesnotruleoutectopicpregnancyCuldocentesisD&CCurettageoftheuterinecavitycanalsohelpruleoutectopicpregnancy.Identificationofchorionicvilli(绒毛)identifiesanintrauterinelocationofthepregnancyandrulesoutectopicpregnancy.DifferentialDiagnosisItisimportanttoruleout: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TreatmentMedicaltreatment:MethotrexateSurgicaltreatment(laparotomy/laparoscopy)MedicaltreatmentIfthesituationisnotacute,theconservetherapywithmedicinecanbeusednocontra-indicationofmedicaltreatmentectopicpregnancymassdiameter<3cmβ-HCG<2000U/LnoruptureoftubalpregnancynoabdominalhemorrhageMedicaltreatmentMTX(Methotrexate,甲氨蝶呤)hasbeensuccessfullyused.ItisachemotherapydrugtokilltheembryoToxictotrophoblastcells0.4mg/kg/dintramuscular×5days.Requirescompliantpatientandfollow-upSurgicaltreatmentIndication:abdominalhemorrhage腹腔内出血Unstablevitalsignorshock生命体征不平稳FailureMedicaltreatment药物治疗失败SurgicaltreatmentRadicalvs.Conservativesurgery根治性vs.保守性Laparotomyvs.Laparoscopy剖腹vs.腹腔镜Conservative:Salpingostomy输卵管造口Smallpregnancyleisonlocatedindistalfallopiantubepreservationoftube5%riskofrecurrenceRadical:Salpingectomy输卵管切除ExtractionofthetubeRadical:SalpingectomyectopicpregnancyinafallopiantubethatwasexcisedLaparoscopy腹腔镜recommendedapproachandpreferredsurgeryMinimallyinvasive微创的,unlikelaparotomyLessbloodloss术中出血,lesstransfusions输血,lessrecoverytime术后恢复,lesspost-oprativepain术后疼痛Fewcontraindications:Unstablepatient(hemodynamincinstability)LaparoscopyRighttubalectopicpregnancyisseenatlaparoscopyTheswollenrighttubecontainingtheectopicpregnancySalpingectomyorSalpingostomySummaryEctopicpregnancyisacommon,treatableproblemPrimarypresentation:Amenorrhea;Abdominalpain;VaginalbleedingSensitivehCGassaycombinedwithultrosoundallowearlydetectionanddiagnosisSurgicalandmedicaloptionsexist
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