(婦產(chǎn)科學(xué)課件)06.2Ectopic-圖文

(婦產(chǎn)科學(xué)課件）06.2Ectopic2021/10/10星期日12021/10/10星期日2重慶醫(yī)科大學(xué)附屬第一醫(yī)院牟曉玲Ectopicpregnancy2021/10/10星期日3DefinitionImplantationofthefertilizedovumintissueotherthantheuterinebodycavity2021/10/10星期日42021/10/10星期日5Categories

Tubalpregnancy95%

輸卵管妊娠ovarianpregnancy

卵巢妊娠

abdominalpregnancy

腹腔妊娠cervicalpregnancy

宮頸妊娠2021/10/10星期日6

TubalPregnancy

輸卵管妊娠2021/10/10星期日7Sitesoftubalpregnancyampulla壺腹部(75-80%)isthmus峽部

fimbria傘部

interstitial間質(zhì)部

Theampullaisthemostfrequentlocationoftubalpregnancy2021/10/10星期日8Etiology

anyreasonthatimpedethepassageoffertilizedovumalongthetubetowardtheuterinecavity2021/10/10星期日9Chronicsalpingitis(慢性輸卵管炎）

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

OtherEtiologiesPrevioustubalsurgeryreconstructivesurgery：tubeplasty（輸卵管整形術(shù)）

AbnormalitiesordysfunctionofthetubeexcessivelengthofthetubeIVFFailureofcontraception:currentuseofIUDororalcontraceptives（emergencycontraception）

Pelvicendometriosis,myoma,ovariantumors

（子宮內(nèi)膜異位癥、子宮肌瘤、卵巢腫瘤）2021/10/10星期日11

PathologyThechangeofthetube

輸卵管的變化ThechangeoftheUterus

子宮的變化2021/10/10星期日12ThechangeofthetubeThetubeistoothintoaccommodatethegrowthoffertilizedovumThefertilizedovumpenetratesintothetubalwallThetubalpregnancymayterminatebytubalabortionortubalrupture2021/10/10星期日13Tubalrupture輸卵管妊娠破裂Tubalruptureoccursatabout6weeksinisthmicpregnancy

(thelumenisnarrower)Tubalrupturemayoccuratabout12-16weeksininterstitialportion2021/10/10星期日14BleedingisheavierthantubalabortionIfinvasivetrophoblast(滋養(yǎng)細胞)erodeslargevessel，severeintraperitonealhemorrhage（腹腔內(nèi)出血）occursTubalrupture輸卵管妊娠破裂2021/10/10星期日15Tubalabortion輸卵管妊娠流產(chǎn)Twocategories:completetubalabortionincompletetubalabortion

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

abdominalpain腹痛vaginalbleeding陰道流血

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全身檢查whentheintra-abdominalbleedingisrapidandseverePallor面色蒼白

rapidandfeeblepulse脈搏細弱Hypotention:lowbloodpressure血壓降低2021/10/10星期日22

SignsAbdominalexaminationabdominaltenderness壓痛:diffuseorlocalizedabdominaltendernessispresentinover80%ofectopicpregnancyreboundtenderness反跳痛

Guarding肌緊張2021/10/10星期日23

Signspelvicexamination（trans-vaginalexamination)Vaginal陰道:vaginalbleedingCervix宮頸:motiontenderness宮頸舉擺痛

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

DiagnosisHistoryandPhysicalExam(mostimportant!)Needassistedexaminations1.Pregnancytest：urine/bloodhCG(humanchorionicgonadotropin))2.Ultrasound超聲檢查3.Culdocentesis后穹隆穿刺術(shù)4.D&C（dilationandcurettage）刮宮術(shù)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宮腔空虛Freefluid游離液體

Adnexalmass附件包塊

2021/10/10星期日31Culdocentesisinsertinganeedlethroughtheposteriorfornix(后穹窿)intothecul-de-sac(子宮直腸陷凹)

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(絨毛)identifiesanintrauterinelocationofthepregnancyandrulesoutectopicpregnancy.2021/10/10星期日35DifferentialDiagnosis

Itisimportanttoruleout:uterineabortion宮內(nèi)妊娠流產(chǎn)acuteappendicitis急性闌尾炎Pelvicinflammatorydisease急性盆腔炎torsionofovariantumor卵巢腫瘤扭轉(zhuǎn)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腹腔內(nèi)出血Unstablevitalsignorshock生命體征不平穩(wěn)FailureMedicaltreatment藥物治療失敗2021/10/10星期日40Surgicaltreatment

Radicalvs.Conservativesurgery

根治性vs.保守性Laparotomyvs.Laparoscopy

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