妇科急腹症腹痛急课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,ectopic pregnancy,extrauterine 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 bowelsthe abdomen rigidity and tenderness、rebound tenderness.,pass water,fainted on the spot,blood 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 pregnancy 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,an unusually high rate of ectopic pregnancy(1 in 28 deliveries).,e,tiology:,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 pregnancy,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 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 missed 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,，,(,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 and 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710,cm,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 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,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,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 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38,c,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（）；,ultrasound to help with the diagnosis.,a cotton swab to determine which organism is causing the infection.Expesially,a gonococcus,a 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,treatments of Gyneacologic Acute Abdomen（3）,保守：,异位妊娠流产,黄体破裂,急性盆腔炎药物控制有效,ectopic pregnancy,medical,treatment,指征：,a.,妊娠囊3,cm,b.,未破裂或流产型,c.,无明显内出血,d.-HCG3000u/L,保守治疗,异位妊娠流产 黄体破裂 急性盆腔炎,中药治疗 止血 支持治疗,化疗药物 抗炎 足量广谱,抗炎 抗生素,A right tubal ectopic pregnancy as seen at laparoscopyThe swollen right tube containing the ectopic pregnancy is on the right at EThe stump of the left tube is seen at L-this woman had a previous tubal ligation,Close view of the same ectopic,After laparoscopic resection of the tube,the tubal stump is seen at S,Ovarian ectopic pregnancyOvary is the white structure in the middlePregnancy implanted on the far right side of the ovary at the XBleeding and clotted blood are seen here around the ovaryOvarian pregnancies are quite rare,This ovary is dark and enlarged from hemorrhage following torsion.Torsion of the ovary is uncommon but may occur in adults in conjunction with benign ovarian cysts or neoplasms and in children or infants spontaneously.It leads to a presentation like that of acute appendicitis,but an adnexal mass may be palpable.,Torsion of the ovary,病史,输卵管 黄体 流产 卵巢囊肿 急性输 急性阑 妊娠 破裂 蒂扭转 卵管炎 尾炎,停经 多有 多 有 无 无 无,腹痛 突然撕裂 突发下 下腹中央 突发下 两下腹持 转移性 样一侧向 腹一侧 阵发坠痛 腹一侧 续性疼痛 右下腹痛 全腹,阴道 少，暗红 无或如 少至多 无 无 无 流血 蜕膜管型 月经量 鲜红血块 组织,体检,输卵管 黄体 流产 卵巢囊肿 急性输 急性阑 妊娠 破裂 蒂扭转 卵管炎 尾炎 休克 程度与 无或轻 程度与 无 无 无 外出血 外出血 不成比例 成比例 体温 正常 正常 正常 稍高 升高 升高 或稍高,PV,宫颈举痛 宫颈举痛 宫口开,卵巢肿物 一附件 肛查右侧 宫旁后穹 有时有 子宫大 边缘清晰 压痛 高位压痛,隆包块 包块 而软 蒂触痛,辅助检查,输卵管 黄体 流产 卵巢囊肿 急性输 急性阑 妊娠 破裂 蒂扭转 卵管炎 尾炎,WBC,正常 正常 正常 稍高 升高 升高 或稍高,Hb,下降 下降 正常 正常 正常 正常后穹隆 不凝血 血液 阴性 阴性 渗液 阴性 穿刺 或脓液,-HCG,阳性 阴性 阳性 阴性 阴性 阴性,B,超 一侧附件 一附件 宫内 肿物 两附件包 子宫双附,包块妊娠 包块 妊娠囊 块或充血 件无异常 囊游离液 游离液,治疗,输卵管 流产 急性输 急性阑 黄体 卵巢囊肿 妊娠 卵管炎 尾炎 破裂 蒂扭转,紧急手术 清宫,支持治疗 手术 保守 紧急,手术,保守,手术 敏感抗菌素,手术,肿物剥除,药物 手术,急腹症病例,395739。沈*，29岁，停经80天，阴道不规则出血6天，量少，02.1.5入院。平素月经5-6/40-50天，量中无痛经。,LMP01.10.14.,停经50多天，微感恶心呕吐，未就诊。10几天前出现阴道不规则出血持续6天，色暗，微感下腹坠胀不适。门诊尿（+），,B,超：右附件厚，宫内未见妊娠囊。今日复诊,B,超：右卵巢内侧包块1.6*1.5*1.4,cm，,中心囊腔0.5,cm。,诊断：右输卵管间质部妊娠,急腹症病例,4012429。李*，22岁，尿痛20天，下腹痛20天，加重3天，03.3.8入院。20天前无明显诱因尿痛，阴道分泌物增多，程脓性，无异味。外院以尿道炎、阴道炎甲硝唑、罗红霉素治疗6天好转。12天前月经来潮后出现下腹痛，无发烧。校医院给左克、甲硝唑治疗又好转。3天前腹痛加剧，今晨37.8度。,B,超：双附件囊实性包块，粘连。,诊断：急性淋球菌性盆腔炎。,急腹症病例,4002680。钱*，31岁。停经40天后不规则阴道出血伴下腹痛8天，02.6.28入院。平时月经7/30天。,LMP02.5.10，7,天干净。6月10日阴道少量出血1天，6月20日开始阴道出血，时多时少，伴下腹胀痛。6月26日北大医院尿（+），今日我院B,超：子宫前位5.7*5.9*4.9,cm，,回声不均，内膜回声中等1.0,cm,T,环正，左附件不规则不均中低回声肿块6.7*5.3*4.2,cm，,卵巢被包在其内，右卵巢（-）。子宫后非纯囊液3.2,cm，,前方液5.2,cm。,诊断：左输卵管壶腹部妊娠。,急腹症病例,395737。李*，29岁，停经53天，下腹隐痛伴少量阴道出血2天，02.1.5入院。平素月经5-6/30天，,LMP01.11.13，,停经43天尿（+），2天前情绪激动后出现下腹隐痛，持续性，伴少许阴道出血色红，无恶心呕吐，无发热。外院,B,转我院,B,超：左侧靠近子宫处可见中等回声团1.9,cm。,诊断：左侧输卵管妊娠。,急腹症病例,384279。马*，40岁，下腹痛一天,01.3.3入院。月经3/30天，中等无痛经。,LMP01.2.10，,昨8,AM,无明显诱因左下腹痛，发展至全腹。剧烈伴里急后重。急诊查尿（-），抗炎留观。今日发烧38.5度，未进食，呕吐2次，为胃内容物。,诊断：急性盆腔炎，不全肠梗阻。,急腹症病例,394347。吴*，28岁，腹痛伴头晕乏力12小时，01.11.29入院。平素月经规律，,LMP01.11.3,经量正常。今晨同房后突然右下腹痛剧烈，肛门坠胀，继之腹痛向全腹扩散，头晕乏力，无恶心、呕吐及畏寒发热。急诊,B,超：盆腔囊实性包块，盆腔积液。,诊断：黄体破裂出血，宫内妊娠。急腹症病例,4005055。纪*，30岁，下腹痛11小时，02.8.31入院。11小时前同房后下腹轻微隐痛，逐渐加重为持续性剧痛，伴恶心，呕吐胃内容物两次，肛门坠胀感，无腹泻，无阴道流血，无发烧。我院尿（-），,B,超：左卵巢6.1*6.4*5.3,cm，,内有囊腔5.2,cm，,考虑卵巢囊肿蒂扭转入院。,诊断：左输卵管妊娠完全流产。,急腹症病例,396006。管*，32岁，停经3个月，阴道出血2月余，下腹痛2天，02.1.11入院。平素月经规律，,LMP01.9,月末，2月前阴道淋漓出血，两天前量增多，同月经量，下腹隐痛，右侧重，无肛门坠胀，有头晕乏力，20天前外院行取环术。我院门诊,B,超：子宫充血，右侧宫外孕包块，盆腔少量积液。尿（,）。,诊断：右输卵管妊娠。,Thank you!,