ectopicpregnancyextrauterinepregnancytorsionoftheovarianpedicletwistedovariancystsacutepelvicinflammatorydiseasearupturedovarianlutiaEndomitriosisstoryAcuteabdominalpainwantedtogivebowelstheabdomenrigidityandtenderness、reboundtenderness.passwaterfaintedonthespotbloodpresurewaszeroDiagnosis?ectopicpregnancy

EctopicPregnancy

Definition:EctopicpregnancyisdefinedaspregnancyoutsiedtheuterinecavityMostcommonsiteofoccurrenceisthefallopiantube

tubalpregnancy88.5%

ovarianpregnancy4.5%

cervicalpregnancy0.7%

pregnancyinrudimentaryhorn1.5%

pregnancyininterstitial4.8%

abdominalpregnancy47863125theUK:0.25-1%gettingmorecommon.InFinland,tripledbetween1966and1985intheUS,afour-foldrisebetween1970and1983.InJamaica,anunusuallyhighrateofectopicpregnancy(1in28deliveries).

etiology:受精卵著床于子宮體腔以外?；蛞?yàn)檩斅压芙Y(jié)構(gòu)異常，或受精卵行走異常。FACTORS

輸卵管結(jié)構(gòu)異常受精卵行走異常

PelvicinflammatorydiseaseAdvancingage

TubalsurgeryDESexposure

Previousectopic，repeatedIVFandovulationinduction

Previoustermination經(jīng)宮腔或腹腔向?qū)?cè)

ofpregnancy輸卵管移行

輸卵管發(fā)育不良或功能異常smoke

IUDIntrauterinedeviceusage

肌瘤，卵巢腫物，EM

Salpingitis→adhesionsofthetubalwall,→retardsthepassageofthefertilizedegg→Ectopicpregnancy。輸卵管的變化部位壺腹部峽部間質(zhì)部解剖管腔寬窄較窄肌層較厚薄很厚停經(jīng)8-12周6周4個(gè)月表現(xiàn)流產(chǎn)破裂破裂a(bǔ)bdominalpainofectopicpregnancytubalrupture:sharpcolickypaintubalabortion:隱痛、脹痛伴隨癥狀Strainingatstoolfaintnessandshockamenorrheaormenstrualperioddelayedspottingtypebleeding掉出蛻膜管型子宮的變化：子宮稍大內(nèi)膜蛻膜反應(yīng)胚胎死亡：蛻膜剝離→出血Arias-Stell反應(yīng)sumerizetheSymptoms

LowerabdominalpainandAbnormaluterinebleedingapproximately1-2weeksafterthemissedmenstrualperiod“異位妊娠最容易診斷，異位妊娠最不易診斷”體檢全身：貧血貌，面色蒼白，血壓下降，脈搏弱，快。四肢冰冷；腹部：拒按，腹膜刺激征，全腹壓痛、反跳痛重，肌緊張輕(tenderness,reboundtendernessandmuscularrigidity)，移動(dòng)性濁音（＋）婦科：后穹隆飽滿，宮頸著色，舉痛，搖擺痛，子宮略大，軟，可有飄浮感，一側(cè)附件區(qū)觸及不規(guī)則包塊，壓痛明顯。內(nèi)科外科

急性胃腸炎闌尾炎

中毒性痢疾腸梗阻

輸尿管結(jié)石

膽囊炎

脾破裂輔助檢查

Samecaseasabove.Detailedviewofectopic.UltrasoundshowinguterusandtubalpregnancySameimage.Uterusoutlinedinred,uterineliningingreen,ectopicpregnancyyellow.Fluidinuterusatbluecircle-sometimescalleda"pseudosac"Sameimage.Tubalpregnancycircledinred,4.5mmfetalpole(betweencursors)ingreen,pregnancyyolksacblue.

anothercase新婚夫婦acuteabdominalpain,vomitting,肌緊張、壓痛、反跳痛不明顯B超盆腔里有個(gè)占位torsionoftheovarianpedicletwistedovariancysts卵巢囊腫蒂扭轉(zhuǎn)

Torsionoftheovarianpedicletwistedovariancysts好發(fā)因素

瘤蒂長(zhǎng)：游離,活動(dòng)度大

中等大?。杭s7－10cm

重心偏的腫瘤病理靜脈回流受阻→腫瘤充血腫瘤壞死

血管破裂→動(dòng)脈受阻→破裂

瘤體增大感染

瘤內(nèi)出血？？卵巢囊腫蒂扭轉(zhuǎn)的腹痛

突發(fā)一側(cè)下腹劇疼（suddenexcruciatingpain)，陣發(fā)性加重，與體位改變有關(guān)。伴隨癥狀伴惡心，嘔吐，腹膜牽引絞窄所致。伴腰疼可能有卵巢腫瘤的病史體檢全身：急性痛苦面容，但血壓正常

腹部：軟，腹膜刺激征局限于下腹一側(cè)，壓痛重，反跳痛和肌緊張輕或者無。婦科：子宮一側(cè)可捫及腫物，張力大，與子宮之間壓痛明顯（蒂）。

輔助檢查B超示附件區(qū)腫物acutePelvicInflammatoryDisease(PID)acutePelvicInflammatoryDisease(PID)Pelvicinflammatorydisease(PID)isthetermusedtodescribeaninfectionofanyofawoman'spelvicorgans,includingtheuterus,ovariesorfallopiantubes.AcutePIDcomesonsuddenlyandisapttobemoresevere.PIDiscausedbybacteria.產(chǎn)后或流產(chǎn)后感染orcertainoperations,suchasadilationandcurettage(DandC)whichcausethecervixopeningtotheuterus,towidentemporarily

intrauterinedevice(IUD)forcontraception通液術(shù)、造影術(shù)、宮腔鏡DouchingalsoincreasestheriskofPIDintercourseduringmenstrualperiod.闌尾炎，腹膜炎慢性盆腔炎急性發(fā)作病理黏膜：急性子宮內(nèi)膜炎肌層：急性子宮肌炎

急性輸卵管炎，輸卵管積膿，輸卵管卵巢膿腫

漿膜：卵管周圍炎急性盆腔結(jié)締組織炎

腹膜：急性盆腔腹膜炎全身：敗血癥及膿毒血癥

Symptomswithacutepelvicinflammatorydisease兩側(cè)下腹或下腹持續(xù)性頓痛，逐漸加重。

伴隨癥狀

伴發(fā)燒，體溫38c以上，或低熱。

伴膿白帶，有臭味。anyabnormalmenstrualbleedingor

avaginaldischarge

伴局部壓迫刺激癥狀，前方－膀胱刺激癥狀，后方－直腸刺激癥狀

有宮腔操作的手術(shù)史，或經(jīng)期產(chǎn)后不衛(wèi)生。體檢

treatmentsofGyneacologicAcuteAbdomen（1）緊急手術(shù)：異位妊娠破裂salpingectomy卵巢囊腫蒂扭轉(zhuǎn)巧囊破裂黃體破裂休克膿腫破裂treatmentsofGyneacologicAcuteAbdomen（2）暫緩手術(shù)：異位妊娠流產(chǎn)salpingectomy

orConservativesurgicaltreatment壺腹部－切開取出傘部－擠壓出expressionofthepregnancyfromthetube峽部－切除斷端吻合術(shù)卵巢囊腫蒂扭轉(zhuǎn)有緩解黃體破裂急性盆腔炎保守治療無效、膿腫形成treatmentsofGyneacologicAcuteAbdomen（3）保守：異位妊娠流產(chǎn)黃體破裂急性盆腔炎藥物控制有效ectopicpregnancymedicaltreatment指征：a.妊娠囊<3cmb.未破裂或流產(chǎn)型c.無明顯內(nèi)出血d.β-HCG<3000u/L保守治療異位妊娠流產(chǎn)黃體破裂急性盆腔炎中藥治療止血支持治療化療藥物抗炎足量廣譜抗炎抗生素

CloseviewofthesameectopicAfterlaparoscopicresectionofthetube,thetubalstumpisseenatS

Thisovaryisdarkandenlargedfromhemorrhagefollowingtorsion.Torsionoftheovaryisuncommonbutmayoccurinadultsinconjunctionwithbenignovariancystsorneoplasmsandinchildrenorinfantsspontaneously.Itleadstoapresentationlikethatofacuteappendicitis,butanadnexalmassmaybepalpable.Torsionoftheovary

病史輸卵管黃體流產(chǎn)卵巢囊腫急性輸急性闌

妊娠破裂蒂扭轉(zhuǎn)卵管炎尾炎停經(jīng)多有多有無無無

腹痛突然撕裂突發(fā)下下腹中央突發(fā)下兩下腹持轉(zhuǎn)移性

樣一側(cè)向腹一側(cè)陣發(fā)墜痛腹一側(cè)續(xù)性疼痛右下腹痛

全腹陰道少，暗紅無或如少至多無無無

流血蛻膜管型月經(jīng)量鮮紅血塊

組織

體檢輔助檢查治療急腹癥病例

395739。沈*，29歲，停經(jīng)80天，陰道不規(guī)則出血6天，量少，02.1.5入院。平素月經(jīng)5-6/40-50天，量中無痛經(jīng)。LMP01.10.14.停經(jīng)50多天，微感惡心嘔吐，未就診。10幾天前出現(xiàn)陰道不規(guī)則出血持續(xù)6天，色暗，微感下腹墜脹不適。門診尿（+），B超：右附件厚，宮內(nèi)未見妊娠囊。今日復(fù)診B超：右卵巢內(nèi)側(cè)包塊1.6*1.5*1.4cm，中心囊腔0.5cm。診斷：右輸卵管間質(zhì)部妊娠急腹癥病例

4012429。李*，22歲，尿痛20天，下腹痛20天，加重3天，03.3.8入院。20天前無明顯誘因尿痛，陰道分泌物增多，程膿性，無異味。外院以尿道炎、陰道炎甲硝唑、羅紅霉素治療6天好轉(zhuǎn)。12天前月經(jīng)來潮后出現(xiàn)下腹痛，無發(fā)燒。校醫(yī)院給左克、甲硝唑治療又好轉(zhuǎn)。3天前腹痛加劇，今晨37.8度。B超：雙附件囊實(shí)性包塊，粘連。診斷：急性淋球菌性盆腔炎。急腹癥病例

4002680。錢**，31歲。停經(jīng)40天后不規(guī)則陰道出血伴下腹痛8天，02.6.28入院。平時(shí)月經(jīng)7/30天。LMP02.5.10，7天干凈。6月10日陰道少量出血1天，6月20日開始陰道出血，時(shí)多時(shí)少，伴下腹脹痛。6月26日北大醫(yī)院尿（+），今日我院B超：子宮前位5.7*5.9*4.9cm，回聲不均，內(nèi)膜回聲中等1.0cm,T環(huán)正，左附件不規(guī)則不均中低回聲腫塊6.7*5.3*4.2cm，卵巢被包在其內(nèi)，右卵巢（-）。子宮后非純囊液3.2cm，前方液5.2cm。診斷：左輸卵管壺腹部妊娠。急腹癥病例395737。李*，29歲，停經(jīng)53天，下腹隱痛伴少量陰道出血2天，02.1.5入院。平素月經(jīng)5-6/30天，LMP01.11.13，停經(jīng)43天尿（+），2天前情緒