ECTOPIC(课件).ppt

ECTOPIC PREGNANCY（异位妊娠）,Definition,ectopic pregnancy(extra uterine pregnancy)refers to:implantation(种植)of the fertilized ovum(受精卵)outside the uterine cavity,Incidence:,year other country our country 1970 1:222 1:167322 1989 1:51 1:5693,Categories,Female internal organs,uterus,ovary,ovary,Fallopian tube,Fallopian tube,Positions of ectopic pregnancy,tubal pregnancy 95%ovarian pregnancy abdominal pregnancycervical pregnancybroad ligment pregnancy,Categories,TUBAL PREGNANCY,the site of tubal pregnancy:ampulla(78%)isthmus infundibulum interstitial portion,Etiology,for any reason there is delay in the passage of the fertilized ovum along the tube,Chronic salpingitis(慢性输卵管炎)Previous tubal surgeryTubal abnormalities or dysfunction Assisted reproductive technologiesContraception failureOthers,Etiology,A.Chronic salpingitis,The common cause of tubal pregnancy mucous membrane inflammation(输卵管粘膜炎)Perisalpingitis(输卵管周围炎)destroy the ciliated(纤毛)epithelium epithelial folds adhesions obstruct tubal lumen,B.Previous tubal surgery tubal ligation(结扎术)、tubal reanastomosis(吻合术)、infertility tubal surgery C.tubal abnormalities or dysfunction excessive length of the tube congenital diverticula(憩室)accessory ostia(输卵管附伞),hypoplasia,D.Assisted reproductive techniques 5%E.Contraception failure IUDF.Others:pelvic endometriosis myoma ovarian tumors,Tubal pathologyUterine changes,Pathology,Tubal pathology,The embedding of the embryo in the uterus is different from that in the tube decidua and muscle thick/thinit is easy for the trophoblast(滋养层)to erode into the decidua and muscle of tube.ultimately penetrates a tubal wall or artery,local bleeding occurs,Tubal pathology,Tubal pathology categories,Tubal abortionTubal rupture Old ectopic pregnancy(陈旧性宫外孕)Secondary abdominal pregnancy(继发性腹腔妊娠),Tubal pathology,Tubal abortion,the common mode of terminationampulla8th-12th week,Blastocyst胚泡,Tubal pathology,Tubal abortion,Tubal pathology,tubal abortion,complete,incomplete,pelvic hematocele（血肿）,diffuse intraperitoneal hemorrhage,Tubal rupture,6th week in isthmus pregnancy 4th month in interstitial portion,Tubal pathology,Bleeding is heavy and continuous,Tubal rupture,Tubal pathology,Old ectopic pregnancy,Hematoma rounding the dead embryo organize and adhere to the connected tissue.,Tubal pathology,Secondary abdominal pregnancy,Occasionallyafter the tubal abortion or rupturethe embryo is alive and grow,Tubal pathology,uterus increases in size,softendometrium undergoes decidual change decidual change（蜕膜样变）decidua cast（蜕膜管型）“Arias-Stella”(A-S)reaction all kinds of pathologic types,Uterine changes,uterine pathology,Symptoms,three essential symptoms:Amenorrhea(停经)Abdominal painVaginal bleeding(阴道出血)Others,clinical manifestation,Amenorrhea,A history of amenorrhea about 6-8 weeks before vaginal bleeding occurs in about 80%of patients.2030%patients have no clear missed period.,symptoms,Abdominal pain,the most common 95%When tubal rupture,clinical features may present as acute or chronic formdull or vaguebursting、sharp、tearing shoulder pain,symptoms,Vaginal bleeding,why bleeding decidua irregularless than menstrual bleeding,symptoms,others,Syncope(晕厥)and shockPelvic mass,symptoms,Signs,General examination Abdominal examination Pelvic examination,clinical manifestation,General examination,Acute anemia(贫血)Rapid pulseFalling blood pressure,signs,Abdominal examination,TendernessRebound tendernessShifting dullness(移动性浊音)Pelvic cavity mass,signs,Pelvic examination,Vaginal:bleeding Cervix:pain Uterus:soft and slightly enlarged Adnexa:tenderness or mass,signs,Diagnosis,Symptoms Signs Special examinations,Special examinations,Pregnancy test-hCGUltrasoundCuldocentesis(后穹窿穿刺术)Laparoscopy(腹腔镜)D&C,diagnosis,Pregnancy test,Urine/Blood hCG Urine hCG-qualitative Negative:can not exclude ectopic pregnancy Positive:can not verify ectopic pregnancyBlood hCG-quantitative hCG level is lower,diagnosis,Ultrasound,great value no GS in the uterus an indefinite mixed mass fluid collection in pelvic and abdomen,diagnosis,GS胚囊,Culdocentesis,Abdominal bleeding,diagnosis,Laparoscopy,Gold standard Both diagnosis and treatment,diagnosis,D&C,no villus found decidual changes or Arias-Stella reaction,distinguish intrauterine pregnancy,diagnosis,Differential Diagnosis,uterine abortion acute appendicitis salpingitis ruptured corpus luteum cyst torsion of ovarian tumor,Table Differential Diagnosis,Treatment,Surgical treatmentMedical treatmentExpectent treatment,Surgical treatment,patients situation is unstable the diagnosis is unclearhigh hCG or big massfollowing up difficultlytaboo of medicine treatment,treatment,salpingectomy(输卵管切除术)-emergency operation conservative surgery-preserve the affected tube,surgery,Salpingectomy,lesion,surgery,conservative surgery,surgery,Medical treatment,MTX and MifepristonConditions:no rupture diameter of mass 3c-HCG2000U/L no obvious abdominal hemorrhage,treatment,Expectant treatment,Strict condition:pain slight,little bleedingno rupture or abortion-HCG1000U/Ldiameter of mass 3cmno abdominal hemorrhageeasy to follow up,treatment,