异 位 妊 娠 Ectopic Pregnancy(宫 外 孕 extrauterine pregnancy)IntroductionlDefinitionlEtiology (the most common cause)lPathology (three pathological terminations)lClinical Manifestation (the classic triad)lDiagnosis (four ancillary methods)lTreatment (the primary treatment)Definition:Pregnancy in any location other than the body of the uterus is considered ectopic.Incidence: 0.51%图1 异位妊娠的发生部位Tubal Pregnancy壶腹部(Ampulla) 5560%峡部(Isthmus) 2025%伞部(Fimbria) 少见间质部(Interstitial portion) 少见Chronic salpingitispelvic inflammatory disease (PID)盆腔炎sexually transmitted disease(STD)性传播疾病Prior tubal surgerytubal sterilization or salpingectomy绝育 输卵管切除术Current IUD use:intrauterine device 宫内节育器History of infertility EtiologyEtiologyPathology一、Terminations of tubal pregnancy21、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Symptoms Amenorrhea (3/4) mistake uterine bleeding for true menstruation(月经)lack of amenorrhea do not excludeAbdominal pain(90-100%)due to tubal stretching “tearing”pain with nausea and vomiting pain in the shoulder tenesmus(里急后重)SymptomsVaginal bleeding (spotting)external bleedingscanty,darkintermittent or continuousSyncope and shockacute hemoperitoneum 急性内出血severe abdominal pain 剧 烈 腹 痛hemorrhagic shock 失血性休克（二） SignsBlood pressure and pulsehypotension 低血压hypovolemia 血容量减少Abdominal examinationAbdominal tenderness with “rebound”压痛、反跳痛Shifting dullness 移动性浊音SignsSignsPelvic examinationPelvic examination(on bimanual examination (on bimanual examination 双合诊双合诊) )exquisite tenderness , especially on motion exquisite tenderness , especially on motion of the cervix of the cervix 宫颈触痛宫颈触痛aadnexalaadnexal mass mass 附件肿物附件肿物uterine enlargement uterine enlargement 子宫增大子宫增大Ancillary examination-HCG UltrasoundCuldocentesisLaparoscopyDiagnosisHistoryPhysical examinationMeasurement of -hCG (human chorionic gonadotropin) 绒毛膜促性腺激素测定 尿-hCG: false-negative,false-positive血-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TreatmentSurgical treatmentNon-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 Summarythe most common cause three pathological terminations the classic triad four basic ancillary methods primary treatment