1、浙大医学院附属妇产科医院产科浙大医学院附属妇产科医院产科Company LOGOAbortion Company LOGDefinition Abortion:Pregnancy terminated before 28 weeks gestation with fetal weight 1000 gram.Early abortion：pregnancy terminated before 12 weeks gestation Late abortion：pregnancy terminated between 12 and 28 weeks gestationCompany LOGEtio
2、logyEmbryo factor Chromosomal anomaly is the chief agent.More than 80 percent of abortions occur in the first 12 weeks of pregnancyAt least half result from chromosomal anomaliesAfter the first trimester,both the abortion rate&the incidence of chromosomal anomalies decreaseuInheritanceuInfectionuDru
3、gCompany LOGF9-1Company LOGMother factors Systemic disease Endocrine abnormalities Anomaly of immunity Disease of reproduction organ-Uterine defects Stimulus of traumaEtiologyCompany LOGMaternal factorsNutritionDietary deficiency of any one nutrients not important causeDrug use and environmental fac
4、torTobaccoAlcoholCaffeineChemical agent(benzene,lead,et al)X-rayRadiationEnvironmental toxinsCompany LOGPathology Dead of embryo or fetus Bleeding of decidua basalis Embryo or fetus out of uterusCompany LOGClinical symtomsSuppressed menstruationAbdominal painVaginal bleedingEmbryo dischargeShock inf
5、ectionCompany LOGCategories of spontaneous abortionThreatened abortionInevitable abortionComplete or incomplete abortionMissed abortionHabitual abortionCompany LOGThreatened abortionDefinition Any bloody vaginal discharge or bleeding during 1st half of pregnancyBleeding is frequently slight,but may
6、persist for days or weeksFrequencyExtremely common(one out of four or five pregnant women)PrognosisApproximately will abortRisk of preterm delivery,low birth weight,perinatal death Risk of malformed infant does not appear to be increased Company LOGSymptoms Usually bleeding begins firstCramping abdo
7、minal pain follows a few hours to several days laterPresence of bleeding&pain Poor prognosis for pregnancy continuationSlight bleeding persists for weeks Vaginal sonographySerial serum quantitative hCGSerum progesterone can help ascertain if the fetus is alive&its locationThreatened abortionThreaten
8、ed abortionCompany LOGThreatened abortionVaginal sonography Gestational sac(+)&hCG 1000mIU/ml gestation is not likely to survive If any doubt(+),check the serum hCG level at intervals of 48hrs if not increase more than 65%,almost always hopelessSerum progesterone value 5 ng/ml dead conceptusEctopic
9、pregnancy should be considered if gestational sac or fetus are not identified Company LOGInevitable abortionGross rupture of membrane,evidenced by leaking amnionic fluid,in the presence of cervical dilatation,but no tissue passed Placenta(in whole or in part)is retained in the uterus Uterine contrac
10、tions begin promptly or infection developsThe gush of fluid is accompanied by bleeding,pain,or fever,abortion should be considered inevitableCompany LOGComplete abortion Following complete detachment&expulsion of the conceptusThe internal cervical os closesIncomplete abortionExpulsion of some but no
11、t all of the products of conception The internal cervical os remains open&allows passage of bloodThe fetus&placenta may remain entirely in utero or may partially extrude through the dilated os Remove retained tissue without delay Complete or incomplete abortionComplete or incomplete abortionCompany
12、LOGRetention of dead products of conception in uteri for several days or weeksMany women have no symptoms except persistent amenorrheaUterus remain stationary in size,but mammary changes usually regress uterus become smallerSerious coagulation defect occasionally develop after prolonged retention of
13、 fetus Missed abortionMissed abortionCompany LOGDefinition:Three or more consecutive spontaneous abortionsClinical investigation of recurrent miscarriageParental cytogenetic analysisLupus anticoagulant&anticardiolipin antibodies assaysPostconceptional evaluationSerial monitoring of hCG from missed m
14、ens period Maternal serum assessment(GA16-20wks)Amniocentesis fetal karyotype PrognosisDepends on potential underlying etiology&number of prior lossesRecurrent abortionHabitual abortionCompany LOGClinical groups and identificationVaginal bleedingAbdomina-l painEmbryo dischargeOs uteriUterine sizeThr
15、eatened abortionfewlightnocloseCorrespondInevitable abortionmoresevereno/incarc-erationopenSmallIncomplete abortionMore,hard to arrestsevereIncomplete dischargeopensmallComplete abortionFew,arrest automaticimproveComplete dischargeclosesmallCompany LOGCompany LOGManagementDiagnose in time patient hi
16、story clinical symptoms Lab test and image：Bus,HCG，E,P，HPLManage according to the type of abortion Company LOGThreatened abortionu general management：Lying in bed，forbidding coition，relaxationuEtiologic managementTreatment Progesterone(IM)or synthetic progestational agent(PO or IM)Lack of evidence o
17、f effectivenessOften results in no more than a missed abortionuAdjustment according to patients condition Company LOGInevitable abortion Discharge the pregnancy tissue as early as possible once diagnosed.uTake in drugs to promote uterine contractionuDilatation and curettage(D&C)uAntibiotic Company L
18、OGIncomplete abortion Suction curettage,D&C Antishock Prevention of infectionComplete abortion No need to manage.Company LOGMissed abortion Lab test:blood Rt,blood coagulation function Preparation using estrogen Cross-matching of blood Discharge of embryo or fetusCompany LOGhabitual abortion：Treatme
19、nt aim directly at etiologyCompany LOGCompany LOGCompany LOGAbortion complicating with infection Principle：First control the infection,then curettage浙大医学院附属妇产科医院产科浙大医学院附属妇产科医院产科Company LOGOEctopic PregnancyHuWenShengWomens HospitalSchool of MedicineZhejiang UniversityCompany LOGDefinitionEctopic pre
20、gnancy:The zygote nidation at abnormal site outside the lumen of uterus.The most common site of occurrence is within a fallopian tube,however,ectopic pregnancies can occur in the ovary,the abdomen and in the lower portion of the uterus(the cervix)Company LOGEctopics happen in aboutEctopics happen in
21、 about 1%of all pregnancies1%of all pregnanciesEctopic Pregnancy is a common,lifeEctopic Pregnancy is a common,lifethreatening condition affecting threatening condition affecting one in 100 pregnanciesone in 100 pregnanciesCompany LOGClassificationTubal pregnancy(96-98%)ampullary(mid)portion of the
22、fallopian tube(80-90%)isthmic(area closer to uterus)portion of the fallopian tube(5-10%)fimbrial(distal end away from uterus)portion of the fallopian tube(5%)cornual(within the uterine muscle)portion of the fallopian tube(1-2%)Abdominal(1-2%)primary/secondary(tubo-abdominal/abdomino-ovarian)Ovarian(
23、0.5-1%)Cervical(less than 0.5%)Heterotopic(combination of ectopic+intrauterine pregnancy)Company LOGUncommon EctopicsIntraligamentous pregnancy (in broad ligament)Angular pregnancy (inside the uterotubal attachment)Pregnancy in a rudimentary horn of uterusIntraural pregnancy (in myometrium)Vaginal p
24、regnancyMultiple tubal pregnancyCompany LOG Tubal PregnancyCompany LOGTubal PregnancyIs a pregnancy that grows in the fallopian tube,not the uterusIf the pregnancy continues and the tube ruptures,there may be life-threatening intraabdominal bleedingEven with the modern practice of medicine,the ruptu
25、re of the tubal ectopic pregnancy is still one of the leading causes of gynecological deaths Company LOGEtiologyPelvic inflammatory disease(PID)or Salpingitis 6-10 times higher risk.Mainly invasion of gonorrhea or chlamydia from the cervix up to the uterus and tubes causes an intense inflammatory re
26、sponse and scar tissue adhesions in the tube and may damage the cilia of the fallopian tube Previous tubal surgery Dysfunction or malformation of the tubeAssisted reproductive technology In vitro fertilization 2-5%of pregnancies are conected with IVFHistory of IUD usePelvic adhesions,pelvic tumorsEn
27、dometriosis Company LOGOutcome of tubal pregnancy1.Tubal abortion Company LOG2.2.Rupture of tubal pregnancy Most common in tubal pregnancy loaded in interstitial portionCompany LOG 3.Persistent ectopic pregnancy 4.Secondary intraperitoneal pregnancyCompany LOGSymptomsAmenorrhoea Vaginal bleeding Abd
28、ominal pain（One-sided pain in abdomen/Shoulder-tip pain)Apopsychia and shock that not correspond to the volume of vaginal bleeding Clinical manifestationsCompany LOGPhysical signsShock signsAbdominal signs：Tenderness and rebound tenderness at lower abdominal part；Shifting dullness;Sign of massPelvic
29、 signsCompany LOGAuxiliary examinationBlood HCGB-ultrasound examinationAbdominal paracentesis/culdocentesis LaparoscopeDiagnostic curettageCompany LOGTubal Pregnancy at USGUltrasound showing uterus and tubal pregnancy2D scanUterus outlined in redUterine lining in greenEctopic pregnancy yellowFluid i
30、n uterus at blue circle is called a pseudogestational sac Company LOGDiagnosisEarly diagnosis of an ectopic pregnancy is critically important There is no uniformly accepted diagnostic protocol HistoryPhysical examination (pain,adnexal mass,enlarged uterus)Transvaginal or transabdominal ultrasound Qu
31、antitative hormone tests (HCG,-hCG,progesterone)Occasionally culdocentesis (thin needle is inserted at the topof the vagina,between the uterus and the rectum,to check forblood in CD)Sometimes dilatation and curettage (exclude intrauterine pregnancy or incomplete abortion)Company LOG Abortion Acute s
32、alpingitis Acute appendicitis Rupture of corpus luteum Torsion of pedicle of oval cyst Rupture of oval cyst Differential diagnosisCompany LOGPrinciplesGenerous hemorrhage complicating with shock:Emergency operation Otherwise:synthetic assessment;appropriate treatmentManagementCompany LOGManagementEx
33、pectant managementExpectant management-proportion of all ectopics will not progress to tubal rupture,but will regress spontaneously and be slowly absorbedLevel of hCG must falling and a woman becomes clincally well.Situation needs daily hCG,TVS.If hCG increases or sonographic findings are suspicious
34、 active management Medical treatmentMedical treatment (methotrexate)(methotrexate)given by injection;in form of systemic or local administrationOpen surgery(laparotomy)Open surgery(laparotomy)-involves a 5-8 cm incision at the top of the pubic hairlineThe affected tube is brought out and either salp
35、ingotomy or ectomy is performedCompany LOGCriteria for Expectant Management Decreasing hCG titers(less than 1000 mIU/mL)No evidence of rupture or significant bleeding Ectopic mass with size less than 3 cm Highly motivated patient with strong desire to avoid both surgery and medical managementHemodyn
36、amically stable healthy woman Absence of fetal heart tones Company LOGMethotrexate TreatmentAnti-metabolite drugAnti-metabolite drugInexpensive,easy to obtain,well toleratedInexpensive,easy to obtain,well toleratedfolic acid antagonistfolic acid antagonistThe initial dose regimen The initial dose re
37、gimen MTX(1 mg/kg IM)or single IM dose of 50 mg/square meter MTX(1 mg/kg IM)or single IM dose of 50 mg/square meter DonDont exceed 4 doses t exceed 4 doses 70-95%efficiency of cases treated70-95%efficiency of cases treatedCompany LOGOperationSalpingectomy Cutting the tube outSalpingotomy Making an i
38、ncision on the tube and removing Making an incision on the tube and removing the pregnancythe pregnancy Choosing operation modes according to patient Choosing operation modes according to patients condition.s condition.Company LOGOther types of EPOvarian pregnancyAbdominal pregnancyBroad ligment pre
39、gnancyCervical pregnancyCompany LOGA right tubal ectopic pregnancy seen at laparoscopyThe swollen right tube containing the ectopic pregnancy is on the right at EThe stump of the left tube is seen at L-this woman had a previous tubal ligation Company LOGClose view of the same ectopic After laparosco
40、pic resection of the tube,the tubal stump is seen at S Company LOGRight tubal ectopicpregnancy in 11 thweek of gestation Same situation after ruptureCompany LOGLaparoscopist must try to remove the ectopic pregnancy,preserve the fallopian tube,and early send the patient home Diagnostic LSK picture be
41、lowDIAGNOSIS&TREATMENT OPERATIVE LAPAROSCOPIC SURGERYCompany LOGThe first step of this technique involves making a linear slit into the fallopian tube over the ectopic with a monopolar needle tip.Hyperemesis Gravidarum Prolonged and severe nausea/vomiting associated with dehydration,weight loss,or e
42、lectrolyte disturbances when pregnancy。1.0 of 1000 pregnancies。Company LOGCause：Hormonal,neurological,metabolic,toxic,and psychosocial factors(underlying emotional disorder)Degree of biochemical hyperthyroidismThe level of beta-HCGCompany LOG Lab :KetonuriaIncreased urine specific gravity Elevated h
43、ematocrit and BUN levelHyponatremiaHypokalemiaHypochloremiaMetabolic alkalosisCompany LOGCheck：UrineBlood(CBC/DC,electrolyte,ABG)Serum Beta-HCG Thyroid functionHyperthyroidism Transient hyperthyroidism:self-limiting Resolving by 18 weeks Sonar Company LOGCompany LOGManagement（Severity of Symptom）Ind
44、ication for hospitalization Intractable emesisCorrection of any electrolyte abnormalities HypovolemiaIV hydration Anti-emetic drug(ex:Metoclopramide)Parental nutrition Electrolyte supplement Company LOGVitamin supplementation(thiamine B1)Wernockes encephalopathyOral feedings Slowly when tolerated Starting with clear liquids and progressing to a bland solid diet consisting of small,carbohydrate-rich meals Avoidance of fatty and spicy foods
