妇产科笔记.docx
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妇产科笔记.docx
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妇产科笔记
1Whatdoesplacentaconsistofandwhatisfunctionofplacenta?
Amnion羊膜,Chorionfrondosum叶状绒毛膜,Deciduabasalis底蜕膜
1.metabolism
ExchangeofO2andCO2,nutritivefactorsandwaste
2.Defensive:
Limited.IgM,virus,drug
3.Endocrine
1)hCG,hPL(humanplacentallactogen)人胎盘生乳素,estrogen,progesterone,Oxytocinase缩宫素酶:
灭活缩宫素受体、维持妊娠,CytokinesandGrowthFactors
4.Immunitytolerance
2Describethechangesofcardiovascularsysteminpregnancy
1.Heart:
moveupward,hypertrophyofcardiacmuscle
2.CardiacOutput
increaseby30%(from10weeks),peakat32nd–34th
3.Bloodpressure
firstandsecondtrimester:
Bp↓
thirdtrimester:
Bp↑
Supinehypotensivesyndrome妊娠仰卧位低血压综合征:
仰卧位时下腔静脉受压,venousreturn减少—>CO减少—>vagusn兴奋(舒张外周血管)—>BP降低
3Whatareprerequisitesforimplantation?
1)Disappearanceofzonapellucida
2)Formationofsyncytiotrophoblast
3)Adequateprogesterone
4)Synchronizeddevelopmentofblastocystandendometrium
4describelaboratoryexaminationsfordiagnosisofearlypregnancy
1.β-HCG
1)UrineHCGtest:
+or–
2)Bloodβ-HCG受精后8-10天可以在孕妇血清中检测到hCG升高
2.Ultrasonography
1)Enlargementofuterus
2)Gestationalsac妊娠囊—-早期妊娠的超声图像标志
3)Embryoorfetalpulse
3.Othertests
1)Progesteronetest
2)Cervicalmucusexamination
Basalbodytemperature(BBT)36.9-37.2(36.3-37.2)是指人经过6—8小时的睡眠以后,比如在早晨从熟睡中醒来,体温尚未受到运动饮食或情绪变化影响时所测出的体温。
基础体温通常是人体一昼夜中的最低体温
5whatisfetallie,fetalpositionandfetalpresentation?
fetallie胎产式:
therelationshipofthelongaxisofthefetustothelongaxisofthemother:
Longitudinallie(Parallel),Transverselie,crosses
fetalposition胎方位:
therelationshipofthepointofdirectionofthepresentingparttooneofthe4quadrantsofthepelvisortothetransversediameterofthematernalpelvis.胎儿先露部的指示点与母体骨盆的关系
fetalpresentation胎先露:
theportionofthefetusthatdescendsfirstthroughthebirthcanal
6whatisHegar’ssign?
Itisdemonstratedasasofteningintheconsistencyoftheuterus,andtheuterusandcervixseemtobetwoseparateregions.因为宫颈变软,子宫狭部极软—>双合诊检查时感觉宫颈和宫体似不相连。
从4-6周开始—>12thweekofpregnancy
7Whatisthemonitoringmethodforsafetyoffetus?
1)Fetalmovement:
3-5/hour
2)Fetalheart
3)Electronic fetal monitoring(EFM)
4)Ultrasound
5)Amnioticfluid
6)Placentalfunction
7)Maturity
Whatismechanismoflabor?
Whatconsistsofmechanismoflabor?
胎儿先露部随骨盆各平面的不同形态,被动进行的一连串适应性转动,以其最小径线通过产道的全过程Aseriesofcharacteristicchangesinfetalposition(orcardinalmovements)inrelationtothematernalpelvis,Thesespontaneousadjustmentsaremadetoeffectefficientpassagethroughthepelvisasthefetusdescends.
Engagement*衔接:
胎头双顶径进入骨盆入口平面,颅骨的最低点接近or达到坐骨棘水平
Descent下降
Flexion俯屈
Internalrotation内旋转:
到中骨盆(前后径长)右外45
Extension仰伸:
到阴道外口
Externalrotation外旋转左外45(回原位)—>左外45(右肩出)—>右外45(左肩出)
Howtoassessifplacentahaveseparated?
子宫体变硬呈球形,胎盘剥离后降至子宫下段,下段被扩张,子宫体呈狭长形被推向上,子宫底升高达脐上
剥离的胎盘降至子宫下段,阴道口外露的一段脐带自行延长
阴道少量流血
用手掌尺侧在产妇耻骨联合上方轻压子宫下段时,子宫体上升而外露的脐带不再回缩
Howtoassesstheonsetoflabor?
Painfuluterinecontraction有规律且逐渐增强的子宫收缩,持续时间30s+,间歇5-6min
effacementanddilationofthecervix进行性宫颈管消失,宫口扩张
Descentoffetalpresentation胎先露下降
异位妊娠
Tomaster:
1.Theclinicalfeaturesandvariousauxiliarydiagnosticmethodsoftubalpregnancy,andstrivetoachieveearlydiagnosis
Amenorrhea,Vaginalbleeding,Abdominalorpelvicpain,Painradiatingtotheshoulder,syncope,andshock。
Abdominaltendernessandreboundtenderness
Pelvicexamination:
Nonspecific
Cervicalmotiontenderness宫颈举痛(uptotwothirds)
Atenderadnexalmass(10%to50%)
⏹Ultrasonography
⏹Serialquantitativeβ-hCGmeasurements(BSU)正常hcg每48小时翻倍
⏹Culdocentesis后穹窿穿刺
⏹Laparoscopy腹腔镜
⏹Serumprogesteronelevels孕酮<5ng/mL
⏹uterinesamplingviamanualvacuumextractionorcurettage
2.Thetreatmentprinciplesoftubalpregnancyandtounderstandtheurgencyoftreatment
⏹Observation
⏹Laparoscopy:
Salpingostomy(输卵管吻合术),Salpingotomy(输卵管开窗术),Salpingectomy(输卵管切除术)
⏹Laparotomy剖腹手术
⏹MedicalmanagementwithMTX抑制滋养细胞(未破裂,<=3cm,ß-hCG<2000U/L)
Persistentectopicpregnancy:
Diagnosedbyaplateauingorrisingβ-hCGconcentrationfollowingconservativesurgicaltherapy;Laparoscopic~3%,MostEasilyTreatedWithMTX
Tounderstand:
thedefinitionandclassificationofectopicpregnancy
Theimplantationofafertilizedovumoutsideoftheendometrialcavity,Theleadingcauseofmaternaldeathinthefirsttrimester。
Tubalpregnancy(mostcommon,>95%),Cervicalpregnancy,Ovarianpregnancy,Abdominalpregnancy
流产
Conceptofabortion:
Terminationofpregnancybefore28weeksgestationorDeliveryofafetusofweightlessthan1000grams
Classificationofabortion:
InducedAbortion:
intentionalmedicalorsurgicalterminationofapregnancy;SpontaneousAbortion:
apregnancythatendsonit'sown
Clinicalmanifestation,diagnosis,differential
⏹Vaginalbleeding
⏹maybelightorheavy,constantorirregular.
⏹Abdominalpain
vEarlyabortion(12周前—vaginalbleedingbeforeabdominalpain
vLateabortion—abdominalpainbeforvaginalbleeding
妊高症
ClassificationanddefinitionsofHypertensivedisorderscomplicatingpregnancy
PathophysiologyofPE/eclampsia
阶段一Trophoblastsfailtocompletelyremodeltheuterinespiralarteries.Remodelingeitherabsentorlimitedtothesuperficialportionofthearterylocatedinthedecidua,ratherthanextendingintotheinnerthirdofthemyometrium.
阶段二causesplacentalhypoxia,placentareleasingfactors,,causingvasculardamage.Perfusionisreducedtoeverymaternalorgan.血管痉挛
RiskfactorsforPE
●初产妇primiparity
●孕妇年龄≥40岁
●多胎妊娠multifetal
●子痫前期病史previousPE
●子痫前期家族史(母亲或姐妹)
●慢性高血压或/和慢性肾脏病史
●IVF-ET术后妊娠体外受精invitrofertilization
●糖尿病史
●肥胖(孕前BMI≥25kg/m2)
●系统性红斑狼疮SLE
●血栓病史thrombophilia
OldandnewdiagnosiscriteriaofPE
Old:
Bloodpressuregreaterthanorequalto140mmHgsystolicor90mmHgdiastolicrecordedontwoseparateoccasionsatleast4hoursapartafterthe20thweekgestationinapreviouslynormotensivewomanandresolvingcompletelyby12weekspostpartum,andproteinuriagreaterthanorequalto300mgina24hoursurinecollection.
ComplicationsofPE
●Placentaabruption
●Postpartumhemorrhage
●DIC
●Increasesrisksofcesareansection
●Pretermdelivery
●FGR胎儿生长受限
●Intrapartumfetaldistressorstillbirth
●Increasesbothmaternalandneonatalmorbidityandmortality
●etc.
TreatmentofPE
⏹Controlofmaternalbloodpressure:
α,β-adrenergicblockerLabetalol
Calciumchannelblocker:
Nifedipine,Nimoldipine,Nicardipine
α-adrenergicblockerPhentolamine
DirectperipheralarteriolarvasodilationMethyldopa
ProducerofNitricoxideNitroglycerin
DirectperipheralvasodilationSodiumnitroprusside
⏹Preventionofconvulsion:
Magnesiumsulfate,抑制Ach释放
⏹Initiationofdelivery:
促胎肺成熟dexamethasone5mg(orbetamethasone
preventionofPE:
LowdoseofAspirin,补钙
难产
1.Thedefinitionandclassificationofdystosia
Dystocialiterallymeansdifficultlaboranditischaracterizedbyabnormallyslowprogressoflabor
Itistheconsequenceoffourdistinctabnormalitiesthatmayexistsinglyorcombination
2.Howtodealwithuterineinertiaduringthefirststageoflabor?
Concordantgeneralmanagement
physicalmethods:
amniotomy
drugs:
oxitocin、diazepine
c-section
Mis-matchsedative:
pethidine
c-section
PID诊断标准
⏹Minimumcriteria
⏹Uterusoradnextenderness
⏹Cervicalmotiontenderness
⏹Additionalcriteria
⏹T>=38.3
⏹Purulentdischarge
⏹Leucocyteinsecretion
⏹G+andchalymidiaexist
⏹ESR
⏹CRP(+)
⏹Specificcriteria
⏹Biopsyofendometrium
⏹Imagingtest
⏹Laproscopy
Myoma
©Menorrhagiaandprolongedmenstrualperiod
©Lowerabdomenmass
©Increasedvaginaldischarge
©Pelvicpressure
■Urinaryfrequency
■Boweldifficulty
■(Constipation)
©Others
■pelvicpain
■Spontaneousabortion
■Infertility
©Apalpableabdominaltumour
©Pelvicexamination:
■Uterus
•enlargedandirregular
•hard
诊断:
©History
©Bimanualexamination
©Ultrasonography(B–ultrasoundexamination)
©Hysteroscopy,Laparoscopy
手术指征:
Menorrhagia,leadtoanemia;Havepressuresymptoms;Growsrapidly;Failureofmedicaltreatment;Infertility;Recurrentabortion
DifferentialContents
Benignneoplasms
Malignantneoplasms
History
longclinicalcourse,graduallyenlarge
Shortclinicalcourse,rapidlyenlarge
Featuresofneoplasm
Oftenunilateral,movable,cystic,smooth
Oftenbilateral,solidorsemisolid,irregularity,fixed
Ascites
none
Oftenasciteswithmalignantcells
Generalcondition
generallygoodcondition
cachexia
B-Ultrasound
darkfluidechoarea,intracysticdiaphragm间隔光带,definedboundary
Mixedstrongpointswithindarkfluidarea,poorboundary
CA125(>50y)
<35U/ml
>35U/ml
掌握早期、中期及晚期妊娠的诊断要点。
2amenorrhea停经,停经10日以上应高度怀疑妊娠
②morningsickness早孕反应,停经6周左右出现畏寒、头晕、流涎、乏力、嗜睡、食欲缺乏、喜食酸物、厌恶油腻、恶心、晨起呕吐等症状,12周多自行消失
3频frequency,nocturia,前倾增大的子宫在盆腔内压迫膀胱所致
4房改变,自觉乳房胀痛,出现蒙氏结节Montgomerytubercles
⑤妇科检查,阴道黏膜和宫颈阴道部充血呈紫红色,出现黑加征hegar
掌握枕先露的分娩机转。
Engagement
Descendent
Flexion
Internalrotation
Extension
Externalrotation
掌握分娩的临床经过及其处理。
①firststageoflabor第一产程又称宫颈扩张期,从开始出现规律宫缩至宫口开全,初产妇约需11-12小时,经产妇约需6-8小时latent,activephase
②第二产程又称胎儿娩出期,从宫口开全至胎儿娩出。
初产妇约需1-2(3)小时,经产妇多在数分钟完成
③第三产程又称胎盘娩出期,从胎儿娩出至胎盘娩出,约需5-15分钟,不应超过30分钟
4.产后2h易出血
输卵管妊娠的处理原则及了解其处理的紧迫性。
妊娠高血压综合征的防治原则。
流产的不同阶段的病理和处理。
①若胎膜未破,胎儿存活、无胎儿窘迫,无严重妊娠合并症及并发症时,应设法抑制宫缩,尽可能延长孕周
②若胎膜已破,早产不可避免时,应设法提高早产儿存活率
③具体包括三个方面:
一般治疗;药物治疗;分娩处理
子宫肌瘤的治疗原则和手术指征。
手术指征:
Menorrhagia,leadtoanemia;Havepressuresymptoms;Growsrapidly;Failureofmedicaltreatment;Infertility;Recurrentabortion
子宫内膜癌的治疗原则。
治疗:
早期患者以手术治疗为主,晚期则采用手术、放射、药物等综合治疗
包括:
①手术治疗;②放疗;③化疗;④孕激素治疗
卵巢肿瘤的并发症。
①蒂扭转torsionofpedicle;②破裂;③感染;④恶变
卵巢肿瘤的治疗原则。
葡萄胎处理原则:
及时清宫
绒毛膜癌的病理特点:
有绒毛结构的:
侵蚀性葡萄胎
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