流產(chǎn)、異位妊娠(英文)-Abortian_and_EctopicPregnancy-堯良清.ppt

AbortionandEctopicPregnancy Liang QingYaoObstetricsandGynecologyHospitalofFudanUniversity Abortion Concept Apregnancylossbefore28weeksofgestationwhilefetalweightunder1000gramsEarlyAbortion pregnancylossbefore12gestationalweeksLateAbortion pregnancylossduring12 28gestationalweeksSpontaneousAbortionArtificialAbortion GeneticdefectMaternalfactors systematicdisease genitalorgananomalies endocrineanomalies irritation badhabitImmuneanomaliesEnvironmentalfactors Etiology Pathology Before8weeks chorionicvilliimmatureFetaldeath basaldecidualbleeding uterinecontraction expulsionofalltheproductsofconception lightbleedingDuring8 12weeks withfirmattachmenttothebasaldeciduaPartialexpulsionoftheproductsofconception non idealuterinecontraction severebleedingAfter12weeks placentafullyformed Uterinecontraction expulsionofalltheproductsofconception lightbleeding Symptoms Amenorrhea vaginalbleeding andabdominalpainEarlyabortion vaginalbleedingprecedingabdominalpainLateabortion abdominalpainprecedingvaginalbleeding TypesofAbortion ThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionMissedAbortionHabitualAbortionSepticAbortion ClinicalPresentations ThreatenedAbortionlightvaginalbleedingwithmildabdominalpaincervicalosclosed fetalmembranesunbrokentreatmentmightwork continuepregnancyInevitableAbortionbleedingheavier abdominalpainmoresevere orfluidpassedcervicalosopen pregnancytissuevisibleabortionisinevitable IncompleteAbortionheavyvaginalbleedingpregnancytissueprotrudingfromthecervicalosuterussmallforthepresumedgestationalweekCompleteAbortionvaginalbleedingdecreasing abdominalpainalleviatingcervicaloscloseduterusnormalforthepresumedgestationalweek DifferentStagesofAbortion threatenedabortioncontinuepregnancyinevitableabortionincompleteabortioncompleteabortion Diagnosis HistoryPhysicalExaminationLaboratoryAssessment ultrasoundpregnancytesthormonelevel serumprogesterone Management ThreatenedAbortionbedrest sedationantiabortion progesterone HCG VitE thyroxinesupplementmonitoring ultrasound serumHCG whethertocontinuepregnancyInevitableAbortiononcediagnosed removethepregnancytissueasquicklyaspossiblesuctioncurettage IncompleteAbortionperformsuctioncurettagepromptlyifwithheavybleeding bloodtransfusion preventiveantibioticuseCompleteAbortionnoretainedproductsofconceptionconfirmedbyultrasound noinfectionnoneedforspecialmanagement MissedAbortion Concept inuterodeathoftheembryoorfetuswithretainedproductsofconceptionClinicalManifestation uterineenlargementceasingorfetalmovementdisappearingcervicalosclosed uterussmallforthepresumedgestationalagenofetalheartbeat embryonicdemisesuggestedbyultrasoundfindings Management bloodroutineexamination coagulationfunctiontestcorrectingcoagulationdefects heparin fibrinogen etc sensitizingtheuterus diethylstilbestroltransfusionpreparation emptyingtheuterus before12weeks suctioncurettageafter12weeks inductionoflabor HabitualAbortion Theoccurrenceof3ormoreconsecutivespontaneousabortionsTheoccurrenceof2spontaneousabortionsisdefinedasrecurrentabortionEarlyabortion chromosomalabnormalities immunologicfactors luteal phaseinsufficiency hypothyroidismLateabortion congenitaluterineanomalies cervicalincompetence uterinefibroids etc Management obtaininformationonetiologyforpriorlossesbeforeconceptiongeneticcounselingcervicalincompetence cervicalcerclageduring14 18weeksofgestationwithunclearcauses progesteronetherapyuntil10weeksofgestationactiveimmunotherapy intradermicinjectionoflymphocytes SepticAbortion Prolongedbleedingduringabortionorretainedproductsofconceptionleadtointrauterineinfection whichmightprogressintopelvicinflammatorydisease peritonitisorevensepsisifnottreatedAntibiotictreatment Promptevacuationwithoutseverebleeding managementofinfection performanceofsuctionandcurettagewithseverebleeding managementofinfectionwhileapplyingforceps withsecondarysuctionandcurettage EctopicPregnancy Concept EctopicPregnancy implantationofthefertilizedovumintissueotherthantheendometriumExtrauterinePregnancyincluding tubalpregnancy 95 ovarianpregnancy cornualpregnancy cervicalpregnancy abdominalpregnancy etc oneofthemaincausesofacuteabdomenanddeath EtiologyandRiskFactors tubalinflammation pelvicinflammationprevioustubalsurgery forinfertility tubalpregnancy etc IVFfailureofcontraception currentuseofIUDororalcontraceptivestubalundergrowthordysfunctionotherfactors endometriosis hysteromyoma smoking etc Endingsoftubalpregnancy abortion 8 12weeksrupture 12 16weekssecondaryabdominalpregnancyChronicectopicpregnancyPersistentectopicpregnancy PathologyoftheUterus enlargementandsofteningamenorrheavaginalbleedingtheArias Stellareactionoftheendometriumbutnochorionicvilli ClinicalPresentations Symptoms AmenorrheaAbdominalpain time characteristicsVaginalbleedingFaint shock ClinicalPresentations Signs GeneralconditionAbdomenexaminationPelvicexamination cervicalmotiontenderness sensationofafloatinguterus adnexalmass etc LaboratoryAssessment HCG urinaryHCG theriseintheserum HCGlevelover48hours 66 serumprogesterone only1 5 25ng mlultrasound theemptyuterussign adnexalcardiacactivityorultrasonographiclucency presenceofcul de sacfluid culdocentesis nonclottingbloodlaparoscopy goldstandard diagnosis treatmentearlydiagnosismissedin3 4 ofpatientsusewithcaution toavoidanestheticandsurgicalrisks medicaltherapyasanoptionUterinecurretage profusevaginalbleeding intrauterinepregnancyloss DifferentialDiagnosis SurgicalTreatment Radicaloperation hemodynamicallyunstable interstitialpregnancy tubalruptureConservativeoperation withwishestoretainpotentialforfertility milkingorlinearsalpingostomy MTX MedicalTreatment principle inhibitingproliferationoftrophoblastictissueindication nocontraindicationtochemotherapy noruptureorabortion mass 4cm serum HCG 2000U L noobviousinternalbleeding nodemonstrationofcardiacactivityorembryonicbud MedicalTreatment Protocol MTX150mg giveaseconddoseonday7ifnecessaryMonitoringtherapeuticeffectiveness ifdeclineinserumhCGlevelonday7 25 15 orsymptomsworseningorinternalbleedingoccurring 2weeksuntilnegative Expectanttreatment Painmild bleedinglight Noevidenceoftubalrupture Nointraabdominalbleeding Serum HCG 1000U L andcontinuedeclining Pregnancymass 3cmorundetected Follow upreliable NontubalEctopicPregnancy CervicalPregnancy Concept implantationofthedevelopingconceptusinthecervicalcanalIncidence 1 18000Clinicalfeature painlessvaginalbleedingDiagnosticcriteria theuterinesizeiscomparabletothatofanunpregnantone thepresenceofpregnancytissuerelatedexclusivelytothecervicalcanal curretageoftheendometrialcavityisnonproductiveofpregnancytissueTreatmentprinciple transfusionpreparation curretageorsuctioncurretage MTXand oruterinecurretage OvarianPregnancy AconditioninwhichanectopicpregnancyimplantswithintheovariancortexDiagnosticcriteria thefallopiantubeontheaffectedsidemustbeintact thefetalsacmustoccupythepositionoftheovary ovariantissuemustbelocatedinthesacwall theovaryandfetalsacmustbeconnectedtotheuterusbytheovarianligament OvarianPregnancy Clinicalpresentations amenorrhea abdominalpain vaginalbleeding shock etc Differentiatedfrom rupturedcorpusluteum tubalpregnancyTreatmentpr