異位妊娠專題知識

異位妊娠

EctopicPregnancy復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院隋龍第1頁DefinitionandOverviewDefinitionIncidence:onein100pregnanciesTheincresingtendencyInducedfactors:infertilelowersocioeconomicgrouppreviousectopicpregnancy,10-20%salpingitisandtuboplasty第2頁Unruptruedtubalpregnancy(L)CASEONE第3頁ElectrocoagulationandSection第4頁LoopLigature第5頁Whydiditimplantoutsideuterinecavity?UnclearExplanationofMechanism第6頁EtiologyTubalFactors(salpingitis

)ZygoteAbnormalities(chromosomalabnormalities)OvarianFactors(unextrudedovum)ExogenousHormones(progestin-onlyoralcontraceptives)OtherFactors(endometriosis,IUD)第7頁ClassificationandSpecificIncidenceTubalPregnancy:99%AbdominalPregnancyCompoundorhysterotrophicpregnancyCervicalPregnancyOtherabnormalpregnancies第8頁

LocationsofEctopicPregnancy55%25%Isthmic17%Interstitial2%<0.5%0.1%VeryrareAmpullaryFimbrial第9頁第10頁

AbdominalPregnancyomentumPlacenta第11頁Tubalpregnancy

(99%)Ampullary(55%)Isthmic(25%)Fimbrial(17%)Interstitial(2%)BilateralDistalwithsegmentalabsenceofthetube第12頁OvarianPregnancy

(<0.5%)OvarianTubo-ovarianAbdominal-ovarian(secondaryabdominalpregnancy)第13頁AbdominalPregnancy

(0.1%)PrimarySecondaryAbdomino-ovarianTubo-abdominal第14頁CompoundorHeterotrophicCombinedwithintrauterinepregnancy1in17,000～30,000pregnancies第15頁CervicalPregnancyVeryrareIntraligamentousInthevesicovaginalspaceFollowinghysterectomy:inacervicalstump,inauterinetubeInaprolapseduterinetube(fimbrialorabdominal)第16頁OtherdisplacementofPregnancyinUterusCornual(角)(OneEx)Angular(畸形角)Withinauterinediverticulum(憩室)Inauterinesacculation(囊)Inarudimentaryhorn(始基角)Intramural(肌壁間)第17頁PathologyLackageofresistancetoinvasionbythetrophoblastMinimaldefenseagainstthepenetratingtrophoblastAbdominalpregnancy:1:15,000pregnanciesMortalityrate:90%Enlargeduterus:circulationandendometriumchanges第18頁EndometrialChanges&VaginalBleedingBleeding←endometrialinvolutionandsloughofdeciduaAtypicalendometrialchangesarenotdiagnosticofectopicpregnancyTheArias-Stellareaction(hormonaloverstimulation)Occasionally,endometrialtissuemaybepassedasaso-calleddecidualcast

Notrophoblasticcells第19頁TerminationofthePregnancyTubal:abortionormissedabortionInterstitial,Angular,Cornual:ruptureintotheuterinecavity;thebroadligamentortheperitonealcavity.Cervical:ruptureintothecervicalcanalAbdominal:ruptureintotheperitonealcavity,intotheretroperitonealspace,orintoavitalorgan.Ovarian:ruptureintotheperitonealcavityCombined:Thetubalpregnancymayabortorrupture,andtheuterinepregnancymayabort,terminateprematurely,orcontinuetoterm第20頁RuptureoftubepregnancyAbortionoftubepregnancy第21頁第22頁ClinicalFindingsNospecificsymptomsorsignsarepathognomonicofectopicpregnancyCombinationoffindingsmaybesuggestiveSymptomsofearlypregnancy(amenorrhea,breasttenderness,andnausea)Bleeding(usuallyspotting)DiffuselowerabdominalpainOver16%ofectopicgestationspresentassurgicalemergencies.第23頁

SymptomsPelvicorlowerabdominalpain:99%Abnormaluterinebleeding:75%Secondaryamenorrhea:68%Generalizedpain:44%Unilaterallowerabdominalpain:33%Subdiaphragmaticpainorsharpshoulderpain:22%Syncope(暈厥):37%Uterinecast:7%第24頁SignsAbdominaltenderness－80%Adnexaltenderness－75%.ThepainmaybeexquisitelysevereonpalpationorslightmovementofthecervixanduterusAdnexalmass－Aunilateraladnexalmass:53%;boggyandpoorlydelineatedUterinechanges－normalsize:71%;6-8weeks'size:26%,9-12weeks'size:3%Fever－onlyabout2%ofpatients第25頁LaboratoryFindingsPregnancytests－β-hCGpositivein82.5%ofectopicpregnanciesandnegativeinonly17.5%※anegativetestdoesnotruleoutanectopicgestation.HematocritWhitebloodcellcountReticulocytes(網(wǎng)狀紅細(xì)胞).第26頁第27頁SpecialExaminationsUtrasonicallyScanningCuldocentesis

Laparoscopy

Dilatationandcurettage

Exploratorylaparotomy第28頁Culdocentesis

LithotomypositionanAllisclamporatenaculumposteriorfornix18-gaugespinalneedlepunctureintheshortestdistanceintothecul-de-sac第29頁第30頁DifferentialDiagnosisWhatkindsofdiseasesshouldbedifferentiated:■appendicitis■salpingitis■rupturedcorpusluteumcyst■ovarianfollicle■uterineabortion■twistedovariancyst■urinarytractdisease■degeneratingleiomyomas■normalintrauterinepregnancywithotherabdominalorpelvicproblems第31頁EssentialsofDiagnosisAmenorrheafollowedbyirregularvaginalbleedingAdnexaltendernessormassUltrasonographicevidenceofadnexalmassandnointrauterinegestationPositive-hCG第32頁ComplicationsAbout1in1000ectopicpregnanciesresultinmaternaldeathUntreatedormistreatedrupturedectopictubalpregnancy→8-12%ofallmaternaldeathsThemajorityofthesedeathsarepreventable.ChronicsalpingitisInfertilityorsterilityIntestinalobstructionandfistulasmaydevelopafterhemoperitoneumandperitonitis第33頁TreatmentEmergencyTreatment:

Immediatesurgery,anti-shockmeasures(warm,oxygen,applymoderatelysnugtourniquetsaroundtheupperlegs)Surgicaltreatment:

laparoscopictechniques.laparotomyMedicalTreatment:MTX.ItappearsverypromisingSupportiveTreatment:broad-spectrumantibiotics,oralorintravenousirontherapy,ahigh-proteindiet第34頁Ind