婦產(chǎn)科學(xué)課件：異位妊娠（英文版）

EctopicPregnancyDefinitionAnygestationinwhichimplantationoccursatalocationotherthantheuterinecavity.Incidence:approximately1~2%ofconceptionsAccountsfor10%ofpregnancy-relatedmaternaldeathsCategorytubalpregnancy(95%ofectopicpregnancy)ovarianpregnancyabdominalpregnancybroadligamentpregnancycervicalpregnancycesareanscarpregnancypregnancyinrudimentaryhorn(子宮殘角妊娠）

TubalpregnancyTubalPregnancySites:ampullaportionmostcommonisthmicportionfimbrialportionInterstitialportionrareEtiologychronicsalpingitisprevioustubalpregnancyortubalsurgeryabnormalitiesorDysfunctionassistedreproductivetechnique(ART)failureofcontraceptionChronicsalpingitisThefertilizedovumgetstrappedalongthetube.infectionoftubalmucousmembrane(輸卵管黏膜炎）destroytheciliated纖毛epitheliumgonococcus淋球菌,Chlamydia衣原體peripheraltubalinfection(輸卵管周圍炎）adhesionsofepitheliumAbortion,deliveryprevioustubalpregnancyorsurgerychanceofarelapseabout10%withprevioustubalpregnancyIncidenceof10~20%withprevioustubalsurgerytuballigation（結(jié)扎術(shù)）tubalrepair(reconstructivesurgery)

AbnormalitiesorDysfunctionexcessivelengthofthetubelessdevelopmentoftubalmusclelackofcilium纖毛congenitaldiverticula(憩室)dysfunctionduetoendocrinedisorderanxiety,depressionARTFirstIVF-ETin1975endedupwithectopicpregnancy.1~5%inallARTpregnancymigrationoftransferredembryointothetubesqueezedintothetubebythecontractionofuterusmostpatientsofARTcombinedwithabnormaltubalPathologynocompletedeciduanarrowlumenandthinmusclefertilizedovumburrowsintothethintubalmusclefertilizedovumgrowsanddistendsthetubePathologyOutcomesoftubalpregnancyTubalabortionRuptureoftubalpregnancy

Obsoleteectopicpregnancy陳舊性宮外孕SecondaryabdominalpregnancyTubalabortionoccursmostinampullaabout8th-12thweektwocategories:completetubalabortionincompletetubalabortionrecurrentinvasionoftubalwallbytrophoblastrepeatedhemorrhagebloodcollectedinthePouchofDouglasmayformapelvichematoma.TubalabortionRuptureoftubalpregnancymostlyoccursinisthmicpregnancisduetothesmalldiameterofthisportionofthetubeabout6weeksgestationinvasionofmuscleandserousmembrane漿膜usuallyspontaneousprofusehemorrhageinshorttimeshockseverepainRuptureoftubalpregnancyRuptureoftubalpregnancyIfimplantationisintheinterstitialportion,ruptureisoftendelayedatthe12th-16thweek.duetothethickmuscleonthetubewallseverehemorrhagehypovolemicshockObsoleteectopicpregnancyInabortionorruptureoftubalpregnancyrecurrentinternalhemorrhageOrganizationofhematoma血腫機(jī)化AdhesionwithtissuesaroundLastingandcalcification鈣化lithopedion石胎Secondaryabdominalpregnancyafterabortionorruptureoftubalpregnancyembryoexpelled,mostlydeadembryoaliveoccasionallyimplantsagainatbroadligamentorinabdominalcavity2010湘雅醫(yī)院2.18kg重的腹腔妊娠寶寶王雅奇PathologyUteruschangesuterusenlargementandsoftendecidualization蛻膜化ofendometriumThedeciduawillshedafterthedeathoftheembryo,andmaybepassedinfragmentsorintactasadeciduacast蛻膜管型NovilliortrophoblasticcellUteruschangelongafterembryodeathproliferativephaseArias-Stella”(A-S)reactionalivevillisecretoryphaseClinicalmanifestationsamenorrheaabdominalpainvaginalbleedingsyncope(暈厥）andshockabdominalmassAmenorrheausuallythehistoryofamenorrheaabout6-8weeksmaybelongerhistoryininterstitialpregnancyIrregularvaginalbleedinginectopicpregnancymaybemistakenbymenstruationAbdominalpainthemostcommonclinicalcomplaining(95%)one-sidelowerabdominaldullpainasthedevelopmentofthefertilizedovumtear-likepainwhenabortionorruptureoccursradiatingpainVaginalbleedingroughly60%~80%ofcasesirregularusuallyspotting,lessthanmenstrualbleedingcontainingdecidualcastorfratmentsSignsGeneralexaminationwhentheinternalbleedingisrapidandsevere:acuteanemia,pallorrapidandfeeblepulselowbloodpressureAbdominalexaminationpressurepain&reboundtendernessadnexalmasssometimesambulantsonant（移動性濁音）positivePelvicexaminationvaginalbleedingcervix:tendernessespeciallyonmovingthecervix

宮頸舉痛或搖擺痛themostimportantsignoftubalpregnancyuterus:softandslightlyenlargedadnexa:fullnessoranindefinitetendermass,sizevariesDiagnosishistory&symptomssignspelvicexaminationspecialexaminationSpecialexaminationhCGtestProgesteronetestUltrasonographyCuldocentesis(后穹隆穿刺術(shù))DiagnositiccurettagehCGtestbloodorurinehCGImportantforearlydiagnosisthevalueofbloodhCGusuallylessthanintrauterinenormalpregnancycontinuedetectionofhCGduplicationtime>7days,verysuspiciousProgesteronetestLowprogesteronevaluebetween10~25ng/ml,ectopicpregnancy<5ng/ml,abortionorectopicpregnancy>25ng/ml,littlepossibilityofectopicpregnancyUltrasonographydistinguishnormalpregnancyfromectopicpregnancyemptyuterus,nogestationalsacadnexalmasshCGtestandultrasoundcomplementeachanotherhCG>2000U/L&nogestationalsacinuterusCuldocentesisSimpleandreliableSuspiciousinternalbleedinginsertinganeedlethroughtheposteriorfornixintothepouchofDouglasblooddoesnotcoagulateectopicpregnancycannotbeexludedifnegativeDifferentialDiagnosisthreatenedorincompleteabortionultrasonographyruptureofcorpusluteumacuteappendicitisacutepelvicinflammatorydiseaseovariantorsionhCGnegativeTreatmentMedicaltreatmentSurgicaltreatmentMedicaltreatmentIndications:nocontraindicationofmedicaltreatmentnoruptureoftubalpregnancydiameterofgestationalsac≤４cmBloodhCG<2000U/LnoobviousinternalbleedingContraindictions:UnstablegeneralconditionRuptureortubalpregnancydiameterofgestationalsac>４cmor>3.5cmwithheartbeatMedicaltreatmentMTX(methotrexate)suppresstheproliferationoftrophoblastdamagethevillileadtothedeath,abscissionandabsorptionoftheembryoTreatmentplan0.4mg/(kg.d)i.m.*5days50mg/m21timeMeasurehCGon4thans7thday,repeatwhenhCGdecrease<15%tillhCG<51U/LLocaltreatment:injectionintogestationalsacMedicaltreatmentWithclosemonitorhCG+UltrasonographyAfter14daysoftreatmentthevalueofbloodhCGshouldbenegativefor3testslessornoabdominalpainlessornovaginalbleedingSur