婦產(chǎn)科學(xué)教學(xué)課件：Abortion

1、浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOGO Abortion 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Definition 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

2、28 weeks gestation 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Etiology Embryo factor Chromosomal anomaly is the chief agent. More than 80 percent of abortions occur in the first 12 weeks of pregnancy At least half result from chromosomal anomalies After the first trimester, both the abortion rate Sign

3、 of mass Pelvic signs 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Auxiliary examination Blood HCG B-ultrasound examination Abdominal paracentesis/ culdocentesis Laparoscope Diagnostic curettage 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Tubal Pregnancy at USG Ultrasound showing uterus and tubal pregnancy

4、 2D scan Uterus outlined in red Uterine lining in green Ectopic pregnancy yellow Fluid in uterus at blue circle is called a pseudogestational sac 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Diagnosis Early diagnosis of an ectopic pregnancy is critically important There is no uniformly accepted diagnost

5、ic protocol History Physical examination (pain, adnexal mass, enlarged uterus) Transvaginal or transabdominal ultrasound Quantitative hormone tests (HCG, -hCG, progesterone) Occasionally culdocentesis (thin needle is inserted at the top of the vagina, between the uterus and the rectum, to check for

6、blood in CD) Sometimes dilatation and curettage (exclude intrauterine pregnancy or incomplete abortion) 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Abortion Acute salpingitis Acute appendicitis Rupture of corpus luteum Torsion of pedicle of oval cyst Rupture of oval cyst Differential diagnosis 浙大醫(yī)學(xué)院附屬婦

7、產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Principles Generous hemorrhage complicating with shock: Emergency operation Otherwise: synthetic assessment; appropriate treatment Management 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Management Expectant managementExpectant management - - proportion of all ectopics w

8、ill not progress to tubal rupture, but will regress spontaneously and be slowly absorbed Level of hCG must falling and a woman becomes clincally well. Situation needs daily hCG, TVS. If hCG increases or sonographic findings are suspicious active management Medical treatmentMedical treatment (methotr

9、exate) (methotrexate) given by injection ;in form of systemic or local administration Open surgery (laparotomy)Open surgery (laparotomy) - - involves a 5-8 cm incision at the top of the pubic hairline The affected tube is brought out and either salpingotomy or ectomy is performed 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院

10、附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Criteria 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 management Hemodynamically stable

11、healthy woman Absence of fetal heart tones 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Methotrexate Treatment Anti-metabolite drugAnti-metabolite drug Inexpensive, easy to obtain, well toleratedInexpensive, easy to obtain, well tolerated folic acid antagonistfolic acid antagonist The initial dose regim

12、en The initial dose regimen 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 treated 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Operat

13、ion Salpingectomy Cutting the tube out Salpingotomy Making an incision 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. 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)

14、學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Other types of EP Ovarian pregnancy Abdominal pregnancy Broad ligment pregnancy Cervical pregnancy 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG A right tubal ectopic pregnancy seen at laparoscopy The swollen right tube containing the ectopic pregnancy is on the right at E The stu

15、mp of the left tube is seen at L - this woman had a previous tubal ligation 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Close view of the same ectopic After laparoscopic resection of the tube, the tubal stump is seen at S 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Right tubal ectopic pregnancy in 11 th w

16、eek of gestation Same situation after rupture 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Laparoscopist must try to remove the ectopic pregnancy, preserve the fallopian tube, and early send the patient home Diagnostic LSK picture below DIAGNOSIS & TREATMENT OPERATIVE LAPAROSCOPIC SURGERY 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科

17、浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG The 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 electrolyte disturbances when preg

18、nancy。 1.0 of 1000 pregnancies。 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Cause： Hormonal, neurological, metabolic, toxic, and psychosocial factors (underlying emotional disorder) Degree of biochemical hyperthyroidism The level of beta-HCG 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Lab : Ketonuria Incr

19、eased urine specific gravity Elevated hematocrit and BUN level Hyponatremia Hypokalemia Hypochloremia Metabolic alkalosis 浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科浙大醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院產(chǎn)科 Company LOG Check： Urine Blood (CBC/DC, electrolyte, ABG) Serum Beta-HCG Thyroid function Hyperthyroidism Transient hyperthyroidism : self-limiting Resolving by 18 weeks Sonar 浙大醫(yī)學(xué)院