异位妊娠专题知识

异位妊娠

EctopicPregnancy复旦大学附属妇产科医院隋龙第1页DefinitionandOverviewDefinitionIncidence:onein100pregnanciesTheincresingtendencyInducedfactors:infertilelowersocioeconomicgrouppreviousectopicpregnancy,10-20%salpingitisandtuboplasty第2页Unruptruedtubalpregnancy(L)CASEONE第3页ElectrocoagulationandSection第4页LoopLigature第5页Whydiditimplantoutsideuterinecavity?UnclearExplanationofMechanism第6页EtiologyTubalFactors(salpingitis

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

LocationsofEctopicPregnancy55%25%Isthmic17%Interstitial2%<0.5%0.1%VeryrareAmpullaryFimbrial第9页第10页

AbdominalPregnancyomentumPlacenta第11页Tubalpregnancy

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

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

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

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

SymptomsPelvicorlowerabdominalpain:99%Abnormaluterinebleeding:75%Secondaryamenorrhea:68%Generalizedpain:44%Unilaterallowerabdominalpain:33%Subdiaphragmaticpainorsharpshoulderpain:22%Syncope(晕厥):37%Uterinecast:7%第24页SignsAbdominaltenderness－80%Adnexaltenderness－75%.ThepainmaybeexquisitelysevereonpalpationorslightmovementofthecervixanduterusAdnexalmass－Aunilateraladnexalmass:53%;boggyandpoorlydelineatedUterinechanges－normalsize:71%;6-8weeks'size:26%,9-12weeks'size:3%Fever－onlyabout2%ofpatients第25页LaboratoryFindingsPregnancytests－β-hCGpositivein82.5%ofectopicpregnanciesandnegativeinonly17.5%※anegativetestdoesnotruleoutanectopicgestation.HematocritWhitebloodcellcountReticulocytes(网状红细胞).第26页第27页SpecialExaminationsUtrasonicallyScanningCuldocentesis

Laparoscopy

Dilatationandcurettage

Exploratorylaparotomy第28页Culdocentesis

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

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

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