節(jié)默克診療學(xué)第十八章婦科與產(chǎn)科對(duì)照版本

1、默克診療手冊(cè) 默克診療手冊(cè) 第十八章 第十八章 婦產(chǎn)科疾病 婦產(chǎn)科疾病 第 249 節(jié) 正常妊娠和分娩 正常妊娠和分娩概述妊娠的第一個(gè)臨床癥狀是停經(jīng),同時(shí)也是懷孕婦女就醫(yī)的首要原因.育齡婦女如既往月經(jīng)周期規(guī)則,停經(jīng)超過一周者就應(yīng)懷疑妊娠.同時(shí)還可伴有乳房脹滿感及惡心,嘔吐等早孕反應(yīng),其中乳房的改變是由于妊娠期體內(nèi)高水平的雌,孕激素刺激乳房腺體的進(jìn)一步發(fā)育.受精卵形成后 10 天,合體滋養(yǎng)細(xì)胞開始合成并釋放人絨毛膜促性腺激素(hCG),后

2、者引起惡心,嘔吐.而卵巢黃體在 hCG 的刺激下持續(xù)分泌水平很高的雌,孕激素以維持妊娠.許多婦女在此期間易感疲勞,少數(shù)在妊娠初期有腹脹的感覺. 妊娠通常從末次月經(jīng)的第一天起按周數(shù)來計(jì)算.如一個(gè)婦女的月經(jīng)周期是規(guī)則的且排卵發(fā)生在月經(jīng)周期的第14 天,那么其孕周要比胎齡多 2 個(gè)星期左右；如果月經(jīng)周期不規(guī)則,則兩者的差別大于 2 周或不滿 2 周.通常停經(jīng) 2周即孕周達(dá) 6 周時(shí),子宮已開始相應(yīng)增大.盆腔觸診可觸及因妊娠而增大的子宮.子宮增

3、大變軟,宮頸更柔軟,同時(shí)由于妊娠期間血供增加而呈藍(lán)紫色.受孕后用酶聯(lián)免疫法測(cè)定血或尿中的 hCG 通常為陽性,該方法快捷易行,且敏感度高.只要尿中 hCG 含量達(dá)50mIU/ml,用酶聯(lián)免疫的方法行孕檢即可呈陽性,而在有停經(jīng)史前往往尿中hCG 就已達(dá)此水平.用放免法可檢測(cè)出[General] The first sign of pregnancy and the first reason most pregnant women see

4、a physician is missing a menstrual period. If a patient's periods are usually regular and she is sexually active, missing a period for >= 1 wk is presumptive evidence of pregnancy. Breast engorgement and naus

5、ea with occasional vomiting may also be noted. The engorgement is caused by increased levels of estrogen (primarily) and progesterone and is an extension of premenstrual breast engorgement. Nausea and vomiting may

6、be caused by human chorionic gonadotropin (hCG) and estrogen, which the syncytial cells of the placenta begin to produce in increasing amounts 10 days after fertilization. The corpus luteum in the ovary is stimulated by

7、 hCG to continue secreting high levels of estrogen and progesterone to maintain the pregnancy. Many women become fatigued at this time, and an occasional patient notices abdominal enlargement (bloating) very early in he

8、r pregnancy.Pregnancies are usually dated in weeks, starting from the first day of the last menstrual period. Thus, if the patient's periods were regular and if ovulation occurred on day 14 of the cycle, obstetric d

9、ates are about 2 wk longer than embryologic dates. If the patient's periods are irregular, the difference is more or less than 2 wk. Usually, 2 wk after missing a period, the patient is considered to be 6 wk pregnan

10、t, and the uterus is correspondingly enlarged.Pelvic examination detects uterine enlargement compatible with pregnancy. The cervix is softer, and the uterus is irregularly softened and enlarged. The cervix usually becom

11、es bluish to purple, apparently because blood supply to the uterus is increased.Blood or urine tests are usually positive. Enzyme-linked immunosorbent assay (ELISA) for hCG can quickly and easily detect even small quan

12、tities of this hormone in urine. Some of the most sensitive pregnancy tests using this method (eg, ICON, TestPack) can provide positive results in about 1/2 h with hCG levels as low as 50 mIU/mL of urine; such levels o

13、ften occur several days 默克診療手冊(cè) 默克診療手冊(cè) 第十八章 第十八章 婦產(chǎn)科疾病 婦產(chǎn)科疾病 第 249 節(jié) 正常妊娠和分娩 正常妊娠和分娩病例可觀察到宮內(nèi)孕囊及胎心搏動(dòng).孕16~20 周時(shí)可自感胎動(dòng).對(duì)于月經(jīng)規(guī)則的婦女(月經(jīng)周期為28 天),孕期可持續(xù) 266 天(從受精日算起)或 280 天(從末次月經(jīng)算起).NÖagele 規(guī)則將末次月經(jīng)的月份-3,日期+7 得到預(yù)產(chǎn)期.但這僅是計(jì)算分娩日期的一

14、種粗略的方法,僅≤10%的產(chǎn)婦在預(yù)產(chǎn)期分娩,50%的產(chǎn)婦在孕39~41 周時(shí)分娩,而 90%的產(chǎn)婦則于孕38~42 周時(shí)結(jié)束妊娠.產(chǎn)婦必須明了妊娠在孕 38~42 周終止都是正常的. 我們通常用胎次和產(chǎn)次來表示妊娠分娩史.每次妊娠為一個(gè)胎次(多胎妊娠為一個(gè)胎次),產(chǎn)次表示分娩的次數(shù).胎次又分為早產(chǎn)胎次和流產(chǎn)胎次.前者是指妊娠周數(shù)＞20 周,后者是指孕周＜20 周時(shí)終止.我們一般用 4 個(gè)數(shù)字來表示產(chǎn)次：第一個(gè)數(shù)字是表示足月產(chǎn)數(shù)(37 周

15、以后),第二個(gè)數(shù)字表示早產(chǎn)數(shù)(＞20 周及＜37 周),第三個(gè)數(shù)字表示流產(chǎn)數(shù),第四個(gè)數(shù)字表示目前存活的子女?dāng)?shù).如一個(gè)婦女足月產(chǎn)一次,雙胎妊娠早產(chǎn)一次,流產(chǎn)兩次,即產(chǎn)次為 5次,胎次為 1-1-2-3.生 理 學(xué) 妊娠期間,母體的各系統(tǒng)器官都發(fā)生了生理性變化,而這樣的變化大多在分娩后恢復(fù)正常. pregnancy can be detected within the uterus at about 5 to 6 wk (4 wk aft

16、er ovulation) with ultrasonography. Fetal cardiac motion may first be observed at about 5 to 6 wk with real-time ultrasound scanning and is observed at 7 to 8 wk in > 95% of cases. The pregnant woman usually begins

17、to feel fetal movement between 16 and 20 wk.Pregnancy is considered to last 266 days from the time of conception or 280 days from the first day of the last menstrual period if periods are regular at 28 days. Nägel

18、e's rule calculates the estimated delivery date by subtracting 3 mo from the first day of the last menstrual period and adding 7 days. This calculation is only approximate; 20 and < 37 wk); the 3rd, the number o

19、f abortions; and the 4th, the number of living children. Thus, a woman who is pregnant and has had one term delivery, one set of twins born at 32 wk, and two abortions is gravida 5, para 1-1-2-3.Physiology Pregnancy ca