妇产科笔记.docx

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