异 位 妊 娠 异 位 妊 娠 Ectopic PregnancyEctopic Pregnancy

主讲人： 于 冰单位：山西医科大学第二医院 妇产科教研室

( 宫 外 孕 extrauterine pregnancy)

IntroductionIntroduction

DefinitionEtiology (the most common cause)Pathology (three pathological terminations)Clinical Manifestation (the classic triad)Diagnosis (four ancillary methods)Treatment (the primary treatment)

Definition:Definition:

Pregnancy in any location other than the body of the uterus is considered ectopic.

Incidence: 0.5~1%

图 1 异位妊娠的发生部位

Tubal Pregnancy

壶腹部 (Ampulla) 55~60%

峡部 (Isthmus) 20~25%

伞部 (Fimbria) 少见

间质部 (Interstitial portion) 少见

Chronic salpingitis

pelvic inflammatory disease (PID) 盆腔炎 sexually transmitted disease(STD) 性传播疾病

Prior tubal surgery

tubal sterilization or salpingectomy

绝育 输卵管切除术

Current IUD use:intrauterine device 宫内节育器

History of infertility

EtiologyEtiology

Pathology

一、Terminations of tubal pregnancy

2

1 、输卵管腔 2 、输卵管内血肿 3 、绒毛侵犯管壁 4 、绒毛膜 5 、羊膜

图 2 输卵管妊娠剖面示意图

图 3 输卵管妊娠时孕卵的着床部位 1 、着床于粘膜皱襞内常向管腔破裂 2 、着床于粘膜皱襞间常穿破管壁

（一） Tubal abortion

图 4 输卵管妊娠流产

（二） Rupture of tubal pregnancy

图 5 输卵管妊娠破裂

ampullary pregnancy: 8-12W (abortion,rupture)isthmic pregnancy: 6W (rupture)

interstitial portoion: 4M(rupture)

图 6 间质部妊娠

( 三 )Secondary abdominal pregnancy

图 7 腹腔妊娠 示意图

二、 Uterine changes（一） Enlargement and soft: same as IUP(intrauterine pregnancy) 宫内孕

图 8 输卵管妊娠子宫剖面示意图

（二） Endometrium 子宫内膜

decidual reactiion 蜕膜变

Arias-Stella reaction A-S 反应

proliferative phase 增生期 secretory phase/menstrual period 分泌期或月经期

Clinical Manifestation

一、 Symptoms Amenorrhea Amenorrhea 停经停经

Abdominal pain 腹痛

Vaginal bleeding 阴道出血

Syncope and shock 晕厥与休克

SymptomsAmenorrhea (3/4) mistake uterine bleeding for true menstruation( 月经 ) lack of amenorrhea do not exclude

Abdominal pain(90-100%) due to tubal stretching “tearing”pain with nausea and vomiting pain in the shoulder tenesmus( 里急后重 )

Symptoms

Vaginal bleeding (spotting) external bleeding scanty,dark intermittent or continuous

Syncope and shock acute hemoperitoneum 急性内出血 severe abdominal pain 剧 烈 腹 痛 hemorrhagic shock 失血性休克

（二） （二） SignsSigns

Blood pressure and pulse

hypotension 低血压 hypovolemia 血容量减少

Abdominal examination

Abdominal tenderness with “rebound”

压痛、反跳痛

Shifting dullness 移动性浊音

SignsSigns

Pelvic examinationPelvic examination (on bimanual examination (on bimanual examination 双合双合诊诊 ))

exquisite tenderness , especially on motion exquisite tenderness , especially on motion

of the cervix of the cervix 宫颈触痛宫颈触痛 aadnexal mass aadnexal mass 附件肿物附件肿物 uterine enlargement uterine enlargement 子宫增大子宫增大

Ancillary examination

β-HCG

Ultrasound

Culdocentesis

Laparoscopy

Diagnosis

History

Physical examination

Measurement of β-hCG(human chorionic gonadotropin)

绒毛膜促性腺激素测定

尿β-hCG: false-negative,false-positive血β-hCG(radioimmunoassays)

Ultrasonic Diagnosis 超声诊断

经腹超声 TAS （ Transabdominal Sonography ）

经阴超声 TVS (Transvaginal Sonography)

彩色多普勒超声 CDFI (Colour Doppler Flow Imaging)

图 9 输卵管妊娠经腹超声影像

Culdocentesis 阴道后穹窿穿刺 technique for identifying hemoperitoneum

腹腔积血

图 10 阴道后穹窿穿刺示意图

Laparoscopy 腹腔镜检查

图 11 腹腔镜检查操作示意图

Treatment

Surgical treatment

Non-operative approach

手术治疗 (Surgical Treatment) ： 输卵管切除术 (Salpingectomy)

图 12 输卵管妊娠切除术

图 13 输卵管妊娠术后所见

Preliminary SummaryPreliminary Summary

the most common cause

three pathological terminations

the classic triad

four basic ancillary methods

primary treatment