早孕胎盘绒毛植入.ppt

,9/21/,2000,*,*,*,*,*,*,*,中山市博爱医院,Zhongshan BOAI Hospital,早孕胎盘绒毛植入,侵蚀性葡萄胎：,invasive mole,PSTT,：,placental site trophoblastic tumor,胎物残留：,placental remnant,CIS,：,cancinoma in situ,CIN:cervical intraepithelial neoplasia,病例一,病例二,病例三,病例四,中山市博爱医院妇科,颜友良,早孕绒毛植入,placenta,accreta,i,mplantation of early pregnancy,病例特点一,患者覃,xx,，女，,30,岁，已婚,人流术后,17,天，检查发现宫内异常,1,天，于,3,月,3,日入院,17,天前在外院因“早孕”行人流术，组织物未送病检，过程顺利。,患者月经规则，末次月经,2010-12-30,。,G1P0A1,。,心肺腹部无异常,妇科检查：宫颈光滑，无举痛，子宫前位，增大如孕,2,月大小，质软，无压痛，双附件未及包块，无压痛。,病历特点二,3,月,2,日（入院前一天）：,血,-HCG129,351,mIU/ml,，,B,超：子宫增大，宫内异常回声,3633,，考虑滋养细胞疾病？组织残留物？,血常规、凝血功能、白带常规,+BV,、心电图、胸片无异常。肝功示,ALT 64U/L,，余正常，肾功无异常,入院诊断：,滋养细胞疾病？,依据：,已婚育龄女性，,人流术后,17,天，检查宫内异常。,子宫增大如孕,2,月。,血,-HCG12,9351mIU/ml,，,B,超检查示：子宫增大，宫内异常回声,3633,，考虑滋养细胞疾病？组织残留物？,鉴别诊断,胎物残留？,侵蚀葡萄胎？,绒毛膜癌？,宫腔镜检查,(3,月,4,日,),：,宫深,11cm,，宫颈管光滑，宫腔形态不规则，宫腔右侧见黄色组织物及粘连带如网状。右侧输卵管开口可见，左侧输卵管开口未见，,镜下诊断：,1,、宫腔粘连,2,、胎物残留？,诊刮术，刮出组织物,15g,，见绒毛样组织物，术中出血,10ml,。,治疗经过,第三天,(3,月,6,日,),：,1.,血,-HCG79,290mIU/ml,。,2.,病理：送检绒毛组织物，少数绒毛水肿变性，滋养叶细胞未见明显增生，,3.,阴道三维彩超：子宫增大，宫底后壁类圆形稍高混合回声,4031mm,，内见丰富彩流信号,考虑滋养细胞疾病累及肌壁？组织物残留植入肌壁？,诊疗经过,术后患者阴道流血少，无腹痛。生命体征平稳，腹软，无压痛及反跳痛。,入院第六天,:,血,-HCG 45,406mIU/ml,。,入院第十天,:,血,-HCG 33,747mIU/ml,。,诊断：考虑早孕胎盘植入可能性大，建议患者行介入动脉灌注治疗,.,介入治疗（入院第,12,天）,双侧子宫动脉管径增粗，迂曲显影（左侧优势）,子宫体左侧可见团状血管染色，大小约,3.0*3.0cm,，边缘欠清，未见明显动静脉瘘及血管畸形,微导管分别插至双侧子宫动脉主干后，分别注入氨甲喋呤（总量为,100mg,）后，以庆大霉素混合明胶海绵颗粒（直径约,710-1400um,）适量栓塞，再次腹主动脉下段造影显示双侧栓塞范围及程度满意，双侧子宫动脉未显影。,3,月,17,日（术后第,2,天）,-HCG 3799mIU/ml,3,月,22,日（术后第,7,天）,-HCG 609.43mIU/ml,阴道彩超：子宫底部偏左侧实性略强回声团（栓塞术后）,3024mm,：结合病史考虑胎物浸润肌层可能，周边见少许点状血流信号。,术后情况,时间,子宫大小（,mm,）,内膜厚度（,mm,）,宫底包快大小（,mm,）,-,HCG(mIu/ml),E2(pg/ml),2011.3.17,54*38*53,8.2,33*22,混合性,3799,2011.3.22,56*44*64,7,30*24,实性,609.43,2011.3.30,150,2011.4.14,28.38,2011.4.25,50*40*54,3,25*22,实性,16.05,2011.6.23,45*32*42,4,12*11,混合性,5,2011.7.25,47*37*38,3,15*16,混合性,1.23,2011.9.22,0.67,78.14,2012.2.23,54*34*53,5.6,8*7,混合性,2012.6.27,50*41*48,9,消失,0.78,416.62,问题,1、诊断？,2、处理能否更加完善些？,3、如何预防？,1.,病理基础：子宫粘膜缺乏或缺陷,2.,所有子宫内膜疾病都容易发生胎盘植入,3.,粘膜下子宫肌瘤、子宫瘢痕、子宫肌瘤剔除术后或残角子宫切除术后及有刮宫、徒手剥离胎盘、子宫内膜炎病史,胎盘绒毛植入的,病因,胎盘绒毛植入的临床特点,1.,剖宫产史：,2.,停经后阴道出血：,3.,刮宫术时出现难以控制的大出血：,4.,子宫穿破、腹腔内出血：,1.,子宫切除术 胎盘植入可发生致命性大出血，多需子宫切除术才能奏效,2.,子宫动脉栓塞术,胎盘绒毛植入的处理方法,早孕绒毛植入误诊,1,例,吉林省临江林业局职工医院妇产科宫青,1,临床资料,一般情况,:,患者,女,28,岁,因停经,45 d,在当地卫生院行人工流产术后持续流血半个月,又行消炎、促进宫缩、刮宫治疗,观察,1,周仍有阴道流血,色暗,又行第二次刮宫,阴道持续流血,1,个月,不伴有腹痛,术后,HCG,定性持续阳性,转入本院。发病以来无明显消瘦及咳嗽等症状。既往曾做过,2,次人工流产,足月分娩一胎。入院查体,:,一般情况良好。妇科检查,:,子宫增大约孕,50 d,大小,质软,无明显结节及压痛。,HCG,定量,3,次分别为,386,、,226,和,202 IU L-1(,正常值为,120 IUL-1),。彩色,B,型超声,:,子宫,7.3 cm6.4 cm 5.5 cm,边界欠清,中央有强光团,附件正常。,B,型超声,:,人工流产不全,绒毛膜癌待排出。遂入院后行清宫术,术中探及宫腔,8 cm,宫腔壁无明显突起,刮出少许组织物。病理报告,:,增殖期子宫内膜。临床拟诊绒毛膜癌,征得家属同意行手术治疗。剖腹探查术,:,术中发现子宫增大约孕,50 d,大小,左宫角突起呈紫蓝色结节,约,5 cm3 cm,浆膜完整。双附件正常,流血不明显,切开紫色结节,内部为均匀坏死织。行子宫次全切除加左附件切除术。病理报告,:,左宫角绒毛植入。术后,8 d,痊愈出院。,，（，）,【,】,，；,_,，,【,】,Int J Crit Illn Inj Sci.,2013 Jul;3(3):183-9.doi:10.4103/2229-5151.119197.,Contemporary issues in the management of abnormal placentation duringpregnancyin developing nations:An Indian perspective.,Bajwa SK,1,Singh A,1,Bajwa SJ,2,.,Abstract,The gap between the developed and developing nations with regards to maternal mortality and morbidity may have narrowed but still a lot of dedicated work is required to bridge these differences.Obstetrical haemorrhage is the leading cause of maternal deaths in these developing nations especially in India.The most common causes of this fatal haemorrhage are the placental abnormalities which rarely get detected before delivery.Numerous factors have been incremental in the causation of this abnormal placentalimplantationwith resultant complications.The present article is an attempt to review possible predictors of abnormal placentalimplantation.Also,a genuine attempt has been made to enumerate possible measures to identify the predictors of abnormal placentation duringearly pregnancyand their suitable prevention and management.,KEYWORDS:,Abnormal placentation,haemorrhage,maternal mortality,placenta accreta,placentaincreta,placentapercreta,placentaprevia,BJOG.,2014 Jan;121(2):171-81;discussion 181-2.doi:10.1111/1471-0528.12557.,The antenatal diagnosis ofplacenta accreta.,Comstock CH,1,Bronsteen RA,.,Abstract,The incidence of placental attachment disorders continues to increase with rising caesarean section rates.Antenatal diagnosis helps in the planning of location,timing and staffing of delivery.In at-risk women grey-scale ultrasound is quite sensitive,although colour ultrasound is the most predictive.Magnetic resonance imaging can add information in some limited instances.Patients who have had a previous caesarean section could benefit fromearly(before 10 weeks)visualisation of theimplantationsite.Current data refer only to placentas implanted in the lower anterior uterine segment,usually over a caesarean section scar.2013 Royal College of Obstetricians and Gynaecologists.,KEYWORDS:,Caesarean hysterectomy,caesarean section,colour Doppler ultrasound,magnetic resonance imaging,placenta,placenta accreta,placentaincreta,placentapercreta,scarpregnancy,three-dimensional colour Doppler ultrasound,ultrasound,J Ultrasound Med.,2012 Nov;31(11):1835-41.,Identifying sonographic markers forplacenta accretain the first trimester.,Ballas J,1,Pretorius D,Hull AD,Resnik R,Ramos GA,.,Author information,Abstract,Our study attempted to identify whether sonographic markers forplacenta accretamay be present asearlyas the first trimester.We reviewed 10 cases with pathologically provenaccretaand retrospectively analyzed their first-trimester images.The gestational ages ranged from 8 weeks 4 days to 14 weeks 2 days.Sonographic findings included anechoic placental areas(9 of 10),lowimplantationof the gestational sac(9 of 10),an irregular placental-myometrial interface(9 of 10),andplacentaprevia(7 of 10).Nine patients had at least 1 prior cesarean delivery;3 had additional uterine surgical procedures.One patient underwent hysteroscopic myomectomy.Our case series suggests that signs ofplacenta accretamay be present in the first trimester.,病例四,谢谢！,