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1、妇科急腹症 Gyneacologic Acute Abdomen 以腹部疼痛为主要症状的一组妇科急症。 腹痛是这三种疾病的主要症状 急：发病突然，症状重，危及生命,ectopic pregnancyextrauterine pregnancy,torsion of the ovarian pedicle twisted ovarian cysts,acute pelvic inflammatory disease,a ruptured ovarian lutia,Endomitriosis,story,Acute abdominal pain wanted to give bowels the
2、 abdomen rigidity and tenderness、rebound tenderness. pass water fainted on the spotblood presure was zero,Diagnosis?,ectopic pregnancy,Ectopic Pregnancy,Definition: Ectopic pregnancy is defined as pregnancy outsied the uterine cavity Most common site of occurrence is the fallopian tube,tubal pregnan
3、cy 88.5% ovarian pregnancy 4.5% cervical pregnancy 0.7% pregnancy in rudimentary horn 1.5% pregnancy in interstitial 4.8% abdominal pregnancy,4,7,8,6,3,1,2,5,the UK : 0.25-1% getting more common. In Finland, tripled between 1966 and 1985 in the US , a four-fold rise between 1970 and 1983. In Jamaica
4、, an unusually high rate of ectopic pregnancy (1 in 28 deliveries).,etiology:,受精卵着床于子宫体腔以外。或因为输卵管结构异常，或受精卵行走异常。,FACTORS,输卵管结构异常 受精卵行走异常 Pelvic inflammatory disease Advancing age Tubal surgery DES exposure Previous ectopic， repeated IVF and ovulation induction Previous termination 经宫腔或腹腔向对侧 of pregna
5、ncy 输卵管移行 输卵管发育不良或功能异常 smoke IUD Intrauterine device usage 肌瘤，卵巢肿物，EM,Salpingitisadhesions of the tubal wall, retards the passage of the fertilized egg Ectopic pregnancy。,输卵管的变化,部位 壶腹部 峡部 间质部 解剖 管腔宽 窄 较窄 肌层 较厚 薄 很厚 停经 8-12周 6周 4个月 表现 流产 破裂 破裂,abdominal pain of ectopic pregnancy,tubal rupture: sharp
6、colicky pain tubal abortion:隐痛、胀痛,伴随症状,Straining at stool faintness and shock amenorrhea or menstrual period delayed spotting type bleeding 掉出蜕膜管型,子宫的变化：,子宫稍大 内膜蜕膜反应 胚胎死亡：蜕膜剥离出血 Arias-Stell反应,sumerize the Symptoms,Lower abdominal pain and Abnormal uterine bleeding approximately 1-2 weeks after the m
7、issed menstrual period “异位妊娠最容易诊断，异位妊娠最不易诊断”,体检,全身：贫血貌，面色苍白，血压下降，脉搏弱，快。四肢冰冷； 腹部：拒按，腹膜刺激征，全腹压痛、反跳痛重，肌紧张轻(tenderness, rebound tenderness and muscular rigidity)，移动性浊音（） 妇科：后穹隆饱满，宫颈着色，举痛，摇摆痛，子宫略大，软，可有飘浮感，一侧附件区触及不规则包块，压痛明显。,内科 外科 急性胃肠炎 阑尾炎 中毒性痢疾 肠梗阻 输尿管结石 胆囊炎 脾破裂,辅助检查,Urine pregnancy test-may be negative
8、 ， (Serial serum B-hCG testing )hCG(Human Chorionic gonadotropin),culdocentesis：抽出血，15分钟不凝固。Ultrasound ： 宫腔空虚，输卵管部位出现妊娠囊和异常回声团，子宫前、后有液性暗区可助诊。子宫内膜：为排除宫内妊娠流产，可刮宫。送病理。血常规，Hb进行性下降。可以血液浓缩。腹腔镜：是Gyneacology Acute Abdomen诊断和治疗手段，可进可退。,Same case as above. Detailed view of ectopic.,Ultrasound showing uterus a
9、nd tubal pregnancy,Same image. Uterus outlined in red, uterine lining in green, ectopic pregnancy yellow. Fluid in uterus at blue circle - sometimes called a “pseudosac“,Same image. Tubal pregnancy circled in red, 4.5 mm fetal pole (between cursors) in green, pregnancy yolk sac blue.,another case,新婚
10、夫妇 acute abdominal pain, vomitting, 肌紧张、压痛、反跳痛不明显 B超盆腔里有个占位,torsion of the ovarian pedicle twisted ovarian cysts 卵巢囊肿蒂扭转,Torsion of the ovarian pedicle twisted ovarian cysts,好发因素 瘤蒂长：游离,活动度大 中等大小：约710cm 重心偏的肿瘤,病 理,静脉回流受阻肿瘤充血 肿瘤坏死 血管破裂 动脉受阻 破裂 瘤体增大 感染 瘤内出血,？,？,卵巢囊肿蒂扭转的腹痛,突发一侧下腹剧疼（sudden excruciating
11、pain)，阵发性加重，与体位改变有关。 伴随症状 伴恶心，呕吐，腹膜牵引绞窄所致。 伴腰疼 可能有卵巢肿瘤的病史,体检,全身：急性痛苦面容，但血压正常腹部：软，腹膜刺激征局限于下腹一侧，压痛重，反跳痛和肌紧张轻或者无。 妇科：子宫一侧可扪及肿物，张力大，与子宫之间压痛明显（蒂）。 辅助检查 B超示附件区肿物,acute Pelvic Inflammatory Disease(PID),acute Pelvic Inflammatory Disease(PID) Pelvic inflammatory disease (PID) is the term used to describe an
12、infection of any of a womans pelvic organs, including the uterus, ovaries or fallopian tubes. Acute PID comes on suddenly and is apt to be more severe.,PID is caused by bacteria.,产后或流产后感染 or certain operations, such as a dilation and curettage (D and C) which cause the cervix opening to the uterus,
13、to widen temporarily intrauterine device (IUD) for contraception 通液术、造影术、宫腔镜 Douching also increases the risk of PID intercourse during menstrual period. 阑尾炎，腹膜炎 慢性盆腔炎急性发作,病 理,黏膜：急性子宫内膜炎 肌层：急性子宫肌炎 急性输卵管炎，输卵管积脓，输卵管卵巢脓肿 浆膜：卵管周围炎 急性盆腔结缔组织炎 腹膜：急性盆腔腹膜炎 全身：败血症及脓毒血症,Symptoms with acute pelvic inflammatory
14、disease,两侧下腹或下腹持续性顿痛，逐渐加重。 伴随症状 伴发烧，体温38c以上，或低热。 伴脓白带，有臭味。 any abnormal menstrual bleeding or a vaginal discharge 伴局部压迫刺激症状，前方膀胱刺激症状，后方直肠刺激症状 有宫腔操作的手术史，或经期产后不卫生。,体 检,全身： often accompanied by fever. 腹部：腹膜刺激征。 妇科：宫颈举痛，摇摆痛，宫口有脓性分泌物，子宫略大，压痛，双附件增厚，压痛 Diagnostic and Test Procedures血象：WBC高，中性粒细胞比例高；尿妊娠试验（）
15、； ultrasound to help with the diagnosis. a cotton swab to determine which organism is causing the infection.Expesially a gonococcusa laparoscopic exam,treatments of Gyneacologic Acute Abdomen（1）,紧急手术： 异位妊娠破裂salpingectomy 卵巢囊肿蒂扭转 巧囊破裂 黄体破裂休克 脓肿破裂,treatments of Gyneacologic Acute Abdomen（2）,暂缓手术： 异位妊娠流产 salpingectomy or Conservative surgical treatment 壶腹部切开取出 伞部挤压出expression of the pregnancy from the tube 峡部切除断端吻合术 卵巢囊肿蒂扭转有缓解 黄体破裂 急性盆腔炎保守治疗无效、脓肿形成,
