妇产科笔记.docx

1、妇产科笔记1 What does placenta consist of and what is function of placenta?Amnion羊膜，Chorion frondosum叶状绒毛膜，Decidua basalis底蜕膜1. metabolismExchange of O2 and CO2 ，nutritive factors and waste2. Defensive：Limited. IgM, virus, drug 3. Endocrine1) hCG，hPL(human placental lactogen )人胎盘生乳素，estrogen，progesterone

2、，Oxytocinase缩宫素酶：灭活缩宫素受体、维持妊娠，Cytokines and Growth Factors4. Immunity tolerance2 Describe the changes of cardiovascular system in pregnancy1. Heart: move upward, hypertrophy of cardiac muscle2. Cardiac Output increase by 30%(from 10 weeks), peak at 32nd 34th3. Blood pressure first and second trimest

3、er: Bp third trimester: Bp Supine hypotensive syndrome妊娠仰卧位低血压综合征：仰卧位时下腔静脉受压，venous return减少CO减少vagus n兴奋(舒张外周血管)BP降低3 What are prerequisites for implantation?1) Disappearance of zona pellucida2) Formation of syncytiotrophoblast3) Adequate progesterone 4) Synchronized development of blastocyst and e

4、ndometrium4 describe laboratory examinations for diagnosis of early pregnancy1. -HCG 1) Urine HCG test : + or 2) Blood -HCG受精后8-10天可以在孕妇血清中检测到hCG升高2. Ultrasonography1) Enlargement of uterus2) Gestational sac妊娠囊-早期妊娠的超声图像标志3) Embryo or fetal pulse3. Other tests1) Progesterone test2) Cervical mucus ex

5、aminationBasal body temperature (BBT) 36.9-37.2 (36.3-37.2)是指人经过68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5 what is fetal lie, fetal position and fetal presentation?fetal lie胎产式：the relationship of the long axis of the fetus to the long axis of the mother：Longitudinal lie（Para

6、llel）， Transverse lie，crossesfetal position胎方位： the relationship of the point of direction of the presenting part to one of the 4 quadrants of the pelvis or to the transverse diameter of the maternal pelvis.胎儿先露部的指示点与母体骨盆的关系fetal presentation胎先露：the portion of the fetus that descends first through t

7、he birth canal 6 what is Hegars sign?It is demonstrated as a softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions. 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12th week of pregnancy7 What is the monitoring method for safety of fetus?1) Fetal movement: 3-5/h

8、our2) Fetal heart3) Electronicfetalmonitoring (EFM)4) Ultrasound5) Amniotic fluid6) Placental function7）MaturityWhat is mechanism of labor? What consists of mechanism of labor? 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A series of characteristic changes in fetal position（ or cardinal movements ）i

9、n relation to the maternal pelvis，These spontaneous adjustments are made to effect efficient passage through the pelvis as the fetus descends.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Internal rotation内旋转：到中骨盆(前后径长)右外45Extension仰伸：到阴道外口External rotation外旋转 左外45(回原位)左外45(右肩出)右外45

10、(左肩出)How to assess if placenta have separated ?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How to assess the onset of labor?Painful uterine contraction有规律且逐渐增强的子宫收缩，持续时间30s+，间歇5-6mineffacement and dilation of the cervix进行性宫颈管消失，

11、宫口扩张Descent of fetal presentation 胎先露下降异位妊娠To master: 1.The clinical features and various auxiliary diagnostic methods of tubal pregnancy, and strive to achieve early diagnosisAmenorrhea，Vaginal bleeding ，Abdominal or pelvic pain ，Pain radiating to the shoulder, syncope, and shock。Abdominal tenderne

12、ss and rebound tendernessPelvic examination:NonspecificCervical motion tenderness 宫颈举痛 ( up to two thirds )A tender adnexal mass (10% to 50%) Ultrasonography Serial quantitative-hCG measurements （BSU）正常hcg每48小时翻倍 Culdocentesis 后穹窿穿刺 Laparoscopy 腹腔镜 Serum progesterone levels 孕酮 5 ng/mL uterine sampli

13、ng via manual vacuum extraction or curettage 2. The treatment principles of tubal pregnancy and to understand the urgency of treatment 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 Medical management with MTX抑制滋养细胞（未破裂，=3cm，-hCG95%)，Cervic

14、al pregnancy，Ovarian pregnancy，Abdominal pregnancy流产Concept of abortion：Termination of pregnancy before 28 weeks gestation or Delivery of a fetus of weight less than 1000 grams Classification of abortion：Induced Abortion: intentional medical or surgical termination of a pregnancy ；Spontaneous Aborti

15、on: a pregnancy that ends on its own Clinical manifestation, diagnosis,differential Vaginal bleeding may be light or heavy, constant or irregular. Abdominal painv Early abortion(12周前vaginal bleeding before abdominal painv Late abortionabdominal pain befor vaginal bleeding 妊高症Classification and defin

16、itions of Hypertensive disorders complicating pregnancyPathophysiology of PE/eclampsia 阶段一Trophoblasts fail to completely remodel the uterine spiral arteries. Remodeling either absent or limited to the superficial portion of the artery located in the decidua, rather than extending into the inner thi

17、rd of the myometrium.阶段二causes placental hypoxia，placenta releasing factors，, causing vascular damage. Perfusion is reduced to every maternal organ.血管痉挛Risk factors for PE 初产妇 primiparity 孕妇年龄40岁 多胎妊娠 multifetal 子痫前期病史 previous PE 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 in vitro fertilization

18、糖尿病史 肥胖（孕前BMI25kg/m2 ） 系统性红斑狼疮 SLE 血栓病史 thrombophiliaOld and new diagnosis criteria of PEOld: Blood pressure greater than or equal to 140 mm Hg systolic or 90 mm Hg diastolic recorded on two separate occasions at least 4 hours apart after the 20th week gestation in a previously normotensive woman an

19、d resolving completely by 12 weeks postpartum, and proteinuria greater than or equal to 300 mg in a 24 hours urine collection. Complications of PE Placenta abruption Postpartum hemorrhage DIC Increases risks of cesarean section Preterm delivery FGR 胎儿生长受限 Intrapartum fetal distress or stillbirth Inc

20、reases both maternal and neonatal morbidity and mortality etc.Treatment of PE Control of maternal blood pressure：,-adrenergic blocker Labetalol Calcium channel blocker ：Nifedipine，Nimoldipine，Nicardipine -adrenergic blocker Phentolamine Direct peripheral arteriolar vasodilation MethyldopaProducer of

21、 Nitric oxide NitroglycerinDirect peripheral vasodilation Sodium nitroprusside Prevention of convulsion：Magnesium sulfate，抑制Ach释放 Initiation of delivery：促胎肺成熟dexamethasone 5mg (or betamethasoneprevention of PE ：Low dose of Aspirin，补钙难产1.The definition and classification of dystosia Dystocia literall

22、y means difficult labor and it is characterized by abnormally slow progress of laborIt is the consequence of four distinct abnormalities that may exist singly or combination 2.How to deal with uterine inertia during the first stage of labor ?Concordant general management physical methods：amniotomy d

23、rugs：oxitocin、diazepine c-sectionMis-match sedative：pethidine c-sectionPID诊断标准 Minimum criteria Uterus or adnex tenderness Cervical motion tenderness Additional criteria T = 38.3 Purulent discharge Leucocyte in secretion G+ and chalymidia exist ESR CRP (+) Specific criteria Biopsy of endometrium Ima

24、ging test Laproscopy Myoma Menorrhagia and prolonged menstrual period Lower abdomen mass Increased vaginal discharge Pelvic pressure Urinary frequency Bowel difficulty (Constipation) Others pelvic pain Spontaneous abortion Infertility A palpable abdominal tumour Pelvic examination： Uterus enlarged a

25、nd irregular hard诊断： History Bimanual examination Ultrasonography (Bultrasound examination) Hysteroscopy，Laparoscopy手术指征：Menorrhagia, lead to anemia；Have pressure symptoms；Grows rapidly；Failure of medical treatment；Infertility；Recurrent abortionDifferential Contents Benign neoplasms Malignant neopla

26、sms History long clinical course, gradually enlargeShort clinical course, rapidly enlargeFeatures of neoplasm Often unilateral, movable, cystic, smooth Often bilateral, solid or semisolid, irregularity, fixed Ascites none Often ascites with malignant cells General condition generally good condition

27、cachexia B-Ultrasound dark fluid echo area, intracystic diaphragm间隔光带, defined boundary Mixed strong points within dark fluid area, poor boundary CA125 (50y) 35U /ml 掌握早期、中期及晚期妊娠的诊断要点。2 amenorrhea停经，停经10日以上应高度怀疑妊娠morning sickness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freque

28、ncy, 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Montgomery tubercles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。EngagementDescendentFlexionInternal rotationExtensionExternal rotation掌握分娩的临床经过及其处理。first stage of labor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, active phase第二产程又称胎儿娩出期，从

29、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。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，尽可能延长孕周若胎膜已破，早产不可避免时，应设法提高早产儿存活率具体包括三个方面：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, lead to anemia；Have pressure symptoms；Grows rapidly；Failure of medical treatment；Infertility；Recurrent abortion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：手术治疗；放疗；化疗；孕激素治疗卵巢肿瘤的并发症。蒂扭转torsion of pedicle；破裂；感染；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