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患者34岁。妊娠46~(+2)周,于1988年5月13日入院待产。末次月经为1987年6月21日。停经53天曾有腹痛及阴道少量流血。停经4个月感胎动,日渐频繁,胎动时腹痛难忍,以上腹部为甚,呈进行性加重,伴头晕、乏力、纳差。月经初潮14岁,既往月经规律,孕5产4,无难产史。查体:T36.5℃,P112次/分,R24次/分,Bp13.3/8kPa。呈贫血貌。腹部隆起大于足月妊娠,胎动明显,胎头位于右季肋下,呈肩右前位,胎儿肢体表浅,胎心音正常。妇科检查:子宫如孕4个月大小,宫底轮廓不清,按压呈海绵状感。实验室检查:Hb80g╱L。入院诊断:①腹腔妊娠46~(+3)周,横位;②轻度贫血。
Patient 34 years old. Pregnancy 46 ~ (+2) weeks, on May 13, 1988 admission to be produced. The last menstruation was June 21, 1987. Menopause 53 days had abdominal pain and a small amount of vaginal bleeding. 4 months after menopause, a sense of fetal movement, increasing frequency, abdominal pain during fetal movement unbearable, more than the abdomen was progressive aggravated, with dizziness, fatigue, anorexia. Menstrual age 14 years old, the previous menstrual cycle, pregnancy 5 4, no history of dystocia. Physical examination: T36.5 ℃, P112 times / min, R24 times / min, Bp13.3 / 8kPa. Is anemic appearance. Abdominal bulge than full-term pregnancy, fetal movement significantly, the fetal head is located in the right quarter under the ribs, was the right anterior shoulder, fetal limbs superficial, fetal heart sound normal. Gynecological examination: the uterus, such as 4-month-old pregnant size, unclear outline of the bottom of the palace, was pressed like a sponge-like feeling. Laboratory examination: Hb80g ╱ L. Admission diagnosis: ① abdominal pregnancy 46 ~ (+3) weeks, horizontal; ② mild anemia.