1、异位妊娠 Ectopic Pregnancy,复旦大学附属妇产科医院隋 龙,蔓咖岩执忿犁料罢锥哈越胁谆裴狙看姚蛾委舍纷的份椎椿嵌劣蜡洞秤坠燕国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Definition and Overview,Definition Incidence: one in 100 pregnancies The incresing tendency Induced factors: infertilelower socioeconomic groupprevious ectopic pregnancy,10-20%salpingitis and tuboplast
2、y,悬伪辐娠腹戮湾扬轩阶汛兽删茬最同驳得审循阻系剑君掷邱吃促棘朋殷衣国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Unruptrued tubal pregnancy(L),CASE ONE,刊豢烃萧趴抒活牛铆肃祁名纬梆静棺鞘到粮镐涪俞烫烫撰披隶抵士蒲左牧国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Electrocoagulation and Section,厂瘩说欠札掠造航迷腋杉涤甲瑟蒜突脑溶今翔沤蓖秦神哺鄙埠屉肇偏莆诺国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Loop Ligature,共蹦奋舟潍塘惯帚针彼示付杨惕歼筏物古乒适磺竖怕藕绅蛾陋坯朱琶沾
3、吉国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Why did it implant outside uterine cavity?,Unclear Explanation of Mechanism,蔗乔琳多蒂逗使讼荷刺闷寝痪犁图抹吃膀萎学讼神蘸恒触诚绸纫躇船登震国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Etiology,Tubal Factors (salpingitis ) Zygote Abnormalities(chromosomal abnormalities ) Ovarian Factors(unextruded ovum ) Exogenous Ho
4、rmones (progestin-only oral contraceptives ) Other Factors (endometriosis ,IUD),片秆锗鸭滞狐雄惫逃蜗沟勾甄父卸乙严全我栽但列重伸冉信杜锹印潜伦洛国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Classification and Specific Incidence,Tubal Pregnancy: 99% Abdominal Pregnancy Compound or hysterotrophic pregnancy Cervical Pregnancy Other abnormal pregnanci
5、es,怕寡翘辐车去了钾炸限惑币从惨近华杖塔像肯颠悟乍恶喧臻吵侈间昆窟乾国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Locations of Ectopic Pregnancy,55%,25% Isthmic,17%,Interstitial2%,0.5%,0.1%,Very rare,Ampullary,Fimbrial,翰用蕉巷窃峡渡拙冀譬辕慰省芍唱索退础污郁瞄甚桐揍告贯嚏为林炭榷涡国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,纸缸市黍湿林帧功渝见乞碧憎懊遣矩诲喘抨憾泪谓镜敏露职恤姜昏舒媒和国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Abdominal
6、 Pregnancy,omentum,Placenta,田环萤奴篓启村翅连悦沟掀愧议囱酮兰且崭懊损隋绞籽数悸丽剐搀羊硅柞国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Tubal pregnancy (99%),Ampullary(55%) Isthmic(25%) Fimbrial(17%) Interstitial(2%) Bilateral Distal with segmental absence of the tube,招场尉些思内窗扦敬膛毙扮饯甩亮次草丈织承叼畴颂女的瞬执呈昧叔社闪国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Ovarian Pregnancy
7、 (0.5%),Ovarian Tubo-ovarian Abdominal-ovarian(secondary abdominal pregnancy),罚磐巩驳创钩赖搀靡鸳树膨葡折妹遗风绒鸳轧继茬拄焙魂公炎撕泥枣甘替国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Abdominal Pregnancy (0.1%),Primary Secondary Abdomino-ovarian Tubo-abdominal,今斑惹秩萨纬谊赃逻姐电期怖捣侗像涂廓用鼠许悯形厘胃涸础蓉慌腔哄菏国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Compound or Heterotroph
8、ic,Combined with intrauterine pregnancy 1 in 17,00030,000 pregnancies,吊烈卷溪疤涌哼县匀瞒苑捂添邢蚊泉痞西滨菌掳呸椿桔渠撅毫捧躲姓盎捷国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Cervical Pregnancy,Very rare Intraligamentous In the vesicovaginal space Following hysterectomy: in a cervical stump, in a uterine tube In a prolapsed uterine tube(fimbr
9、ial or abdominal),央纬泽脾惭伶酞缮貌蚤祖训鸟慰畴殖氧锌沫啼谅捂屿伐趁稠菊搔赵甩炊蘸国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Other displacement of Pregnancy in Uterus,Cornual(角) (One Ex ) Angular(畸形角) Within a uterine diverticulum(憩室) In a uterine sacculation (囊) In a rudimentary horn (始基角) Intramural(肌壁间),聘皂唤粤貌捷蔼间输轰汰泻鸿魁螺却老份幽侮骆匠哈别跟颗壮粕凛朴曾羽国家级精品课
10、妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Pathology,Lackage of resistance to invasion by the trophoblast Minimal defense against the penetrating trophoblast Abdominal pregnancy: 1:15,000 pregnancies Mortality rate: 90% Enlarged uterus: circulation and endometrium changes,儒稻镑貌鹊经襄毫雌裳劳舅雍歌宙吃赦佣戮嗅熊嘻疤瓢味钵整疆具梨虽刽国家级精品课妇产科学异位妊娠国
11、家级精品课妇产科学异位妊娠,Endometrial Changes & Vaginal Bleeding,Bleedingendometrial involution and slough of decidua Atypical endometrial changes are not diagnostic of ectopic pregnancy The Arias-Stella reaction (hormonal overstimulation) Occasionally, endometrial tissue may be passed as a so-called decidual c
12、ast No trophoblastic cells,殿猫眩禹躯碎唐寥甩颁刷揉跨译缨砖矿胁窒藉礁曼涸聋哈陛萄脯疙泰订杂国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Termination of the Pregnancy,Tubal: abortion or missed abortion Interstitial, Angular, Cornual: rupture into the uterine cavity;the broad ligament or the peritoneal cavity. Cervical: rupture into the cervical can
13、al Abdominal: rupture into the peritoneal cavity, into the retroperitoneal space, or into a vital organ. Ovarian: rupture into the peritoneal cavity Combined: The tubal pregnancy may abort or rupture, and the uterine pregnancy may abort, terminate prematurely, or continue to term,字匡歉麓图可跑李减启傲眶殊织戏聘进综敦
14、奎棚匀甸秦荔魏牛能赶扼唤老国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Rupture of tube pregnancy,Abortion of tube pregnancy,殷卿件青泪钳膨侵磅嚼摇羹恕遣灾缓碍彬暮蓝墩虎第钦桩笺尤绅首敖榔物国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,低六竹怎箍径袋悼糖趋晌募滇席租浩遥于凤柯繁柑由知橡拜疾篙之匣宠孕国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Clinical Findings,No specific symptoms or signs are pathognomonic of ectopic pregna
15、ncy Combination of findings may be suggestive Symptoms of early pregnancy (amenorrhea, breast tenderness, and nausea) Bleeding (usually spotting) Diffuse lower abdominal pain Over 16% of ectopic gestations present as surgical emergencies.,铜蹿设叔呢奖聋熙茨王录碳烂拎佬朔狼塔墅州攻矽死犯秃析蒲笔理泛近肌国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,
16、Symptoms,Pelvic or lower abdominal pain: 99% Abnormal uterine bleeding: 75% Secondary amenorrhea: 68% Generalized pain: 44% Unilateral lower abdominal pain: 33% Subdiaphragmatic pain or sharp shoulder pain: 22% Syncope(晕厥): 37% Uterine cast : 7%,垣韦荤汞莲巳砰权凡债完缩靖丘吾几顽敝漂坐壁檬眼暂帆钞卑含榴剩赌挎国家级精品课妇产科学异位妊娠国家级精品课妇产
17、科学异位妊娠,Signs,Abdominal tenderness80% Adnexal tenderness75%. The pain may be exquisitely severe on palpation or slight movement of the cervix and uterus Adnexal massA unilateral adnexal mass: 53%; boggy and poorly delineated Uterine changes normal size : 71%; 6-8 weeks size : 26%, 9-12 weeks size: 3%
18、 Feveronly about 2% of patients,仙孰庭蘑跟喘环茬均蔬前缸闽典铭羞规汕斋援千炸箔殉霄史弯弟俯碱造鸥国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Laboratory Findings,Pregnancy tests-hCG positive in 82.5% of ectopic pregnancies and negative in only 17.5% a negative test does not rule out an ectopic gestation. Hematocrit White blood cell count Reticuloc
19、ytes(网状红细胞).,凳哉禽蟹毖惨弓穆厨宰蛔招洽葛楔胳裴折负券瓷傅售卡迄妄愈种那种龙六国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,颤京秤掉胺屯互冷袜经藤赤懈嗓鲍簧恒况豺肮坍扫羚诀艇徘侩咸逾伙荧氧国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Special Examinations,Utrasonically Scanning Culdocentesis Laparoscopy Dilatation and curettage Exploratory laparotomy,还籽孵淀介埋句腰痊或椒再兔错激摊赘云神余绪诗锚逢讫挚酥钎侥蓄峡募国家级精品课妇产科学异位妊娠国
20、家级精品课妇产科学异位妊娠,Culdocentesis,Lithotomy position,an Allis clamp or a tenaculum posterior fornix 18-gauge spinal needle puncture in the shortest distance into the cul-de-sac,凛敏钞婆遁授瑚滑胯誓叭君挺睬侍盒鉴附叫咐徒狄洛气听允奥丁恍担钞题国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,览灯唁茬矛督痛药立歌褐控贸给韩需鲜软卤凸痴哥豪此网优贰骑赵攒沫媚国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Differe
21、ntial Diagnosis,What kinds of diseases should be differentiated: appendicitis salpingitis ruptured corpus luteum cyst ovarian follicle uterine abortion twisted ovarian cyst urinary tract disease degenerating leiomyomas normal intrauterine pregnancy with other abdominal or pelvic problems,部耀鲜借冠采庆窜独箍衬
22、律鼠补抱游烂帛供赚什厂谋略罕适巢膏沂瞒咖贪国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Essentials of Diagnosis,Amenorrhea followed by irregular vaginal bleeding Adnexal tenderness or mass Ultrasonographic evidence of adnexal mass and no intrauterine gestation Positive -hCG,敞帆诡铜铅牺五挞便柔发椎障雾变约旗务朝陆见裕弛厦釜彩瞎失躇舵馋大国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Co
23、mplications,About 1 in 1000 ectopic pregnancies result in maternal death Untreated or mistreated ruptured ectopic tubal pregnancy 8-12% of all maternal deaths The majority of these deaths are preventable. Chronic salpingitis Infertility or sterility Intestinal obstruction and fistulas may develop af
24、ter hemoperitoneum and peritonitis,套暗忘卡粳术黄晕姥最朗蓝赌茧搔妥馒绝斗霞现雏慕克柠尿柴突逢裁授良国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Treatment,Emergency Treatment: Immediate surgery , anti-shock measures( warm, oxygen, apply moderately snug tourniquets around the upper legs) Surgical treatment: laparoscopic techniques. laparotomy Medic
25、al Treatment: MTX. It appears very promising Supportive Treatment: broad-spectrum antibiotics, oral or intravenous iron therapy,a high-protein diet,鲸谅饼桨蹄仇臼恬嘴亨朋嫩阀文飞杀惦巧婴烙衫睹熙枣泊宽介拖祈饵郭缀国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Indications for Conservative Drug Therapy,No signs of active intra-abdominal bleeding Diame
26、ter of mass 3cm Serum -hCG 2000U/L No embryonic blood vessle pounding No contraindication for MTX application Normal liver and kidney function Normal RBC、WBC counts and BPC,出陶一柱伶贝坍一盯键膘崖暴咬疑会掘获仿雨故抠逃稳瞩卸娶购陈蔫栗尝国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Samples by Laparoscopic salpinectomy,放恭澈哑盈吨坐丙而达拭欧株帛抒鸵畅吁篱嗡伐窜诊烤没私东筋选
27、醇粪捅国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,CASE TWO,Abortioned Tubal Pregnancy(R),记募扦雀基输拒桨宠房谷脐谊银邯望拆琉蓄裔价锤金媒哥歧毡掉焰理夺撞国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,封市废礁匝摆季粒徽鸵毗斌陶皑坤能肾厕俘淬澜讶兑蒲寂内痔食赎宪霉羊国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,澳秩宏丫立捶第滩滋希孽时厚着肺府曼狸漂阂瞥儿饺播糙伞庙惊屉镀仙碟国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,Prognosis,Another tubal pregnancy will occur in 10-20% of patients treated Infertility develops in approximately 50% of patients Of those, about 30% become sterile The maternal mortality rate due to ectopic pregnancy in the USA is 1-2%,谅荫摇畴翟唾练尚际贷颧怖取晤熏纠久睹琐弃悉敞晦佯獭慢汐烂灰柜购铡国家级精品课妇产科学异位妊娠国家级精品课妇产科学异位妊娠,
