09級(jí)-婦產(chǎn)科學(xué)34流產(chǎn)black

1、Abortion（流 產(chǎn)）Zhou hong（周虹）Definition Spontaneous abortion means the termination of pregancy before the 28th completed week of gestation and the fetus weighing less than 1000g.abortionearly abortionlater abortionspontaneous abortioninduced abortionThreated aborionInevitible abortinComplete abortion p

2、lete abortionClassificationMissed abortion habitual abortion septic abortionEarly abortion occurs before 12 weeks late abortion between 12 and 28 weeks Induced abortion Abortion in its various forms is probably the greatest problem in obstetrics and gynaecology. It is often stated that the incidence

3、 of spontaneous abortion is about 15 per cent of pregnancies, but it is extremely difficult to get reliable figures.is plished for therapeutic and elective termination of pregancy.motherenvironmentetiologyfetus1、Chromosomal abnormality：at least 50% of human conceptions are thought to have chromosoma

4、l abnormalities. There are number(abnormal karyotype: aneuploid, euploid) and structure abnormal(rupture，replacement), other factors(drugs, infections) leading genetic abnormal Abortion in these circumstances is a beneficial process and represents a form of natural selection.Etiologychromosomal defe

5、cts(21 three body）anencephaly 2、Mothers factors(1) Endocrine defects：(2) Multiple pregnancy The larger the number of fetuses, the greater the tendency to abortion. This may be due to overdistension of the uterus.It is probably related to failure of the corpus luteum(3) Uterine causesa、Cervical peten

6、ce-may be congenital or acquired due to trauma of previous operations or births. Typically, cervical petence causes mid-trimester abortion preceded by premature rupture of the membranes.(3) Uterine causesb、Double uterus-in its various forms, this is the result of anomalies of fusion of the Mullerian

7、 ducts. The greater the degree of duplication, the more normal is pregnancy c、leiomyoma may sometimes distort the uterine cavity and produce abortion， but pregnancy proceeds without interruption in many women with multiple fibroids.Malformation of the uterusUterus didelphysSaddle form uterusUterus s

8、eptusUterus unicornisfibroidsIntramural myomaSubmucous myomaSubserous myoma(4) Infectionsa、Any severe pyrexial illness may cause abortion.b、Specific infections such as syphilis, brucellosis and listeriosis have been suggested as causes of abortion. Conclusive evidence on these subjects is lacking.(5

9、) PoisonsA number of systemic poisons may cause abortion, particularly cytotoxic drugs.(6) Radiation As with cytotoxic drugs, abortion following radiotherapy is sometimes encountered during treatment for cancer.(7) Maternal systemic disease diabetes mellitus, hypothyroidism, chronic hypertension, ch

10、ronic renal diseases, severe malnutrition etc.(8) bad habitual: tobacco, alcohol(9) Traumas3、ImmunologicalThe rejection of the pregnancy by the mother for immunological reasons would seem theoretically a likely cause of abortion. There is little little information of practical value on this subject

11、so far. The commonest immunological problem encountered in pregnancy is Rhesus iso-immunisation and here abortion sometimes results.4、 Environmental factors: lead, arsenic, benzeneetiology Pathology In spontaneous early abortion, hemorrhage into the deciduas basalis often occurs. Necrosis and inflam

12、mation appear in the region of implantation. The pregnancy es partially or entirely detached and is, in effect, a foreign body in the uterus. Uterine contractions and dilatation of the cervix result in expulsion of most or all of the products of conception. pathologyIn cases of missed abortion, ther

13、e may be partial organization of the blood clot surrounding the conceptus. This results in the formation of a fleshy, nodular, dark red mass called a carneous mole, or blood mole.20clinical featuresamenorrhea vaginal bleedingsuprapubic pain21 According to the different gestational week, the clinical

14、 presentation is different Early abortion (before 12 weeks) The first symptom is bleeding, then abdominal pain Late abortion ( between 12 and 28 weeks) The first symptom is abdominal pain, then appears slight vaginal bleeding.（1）12 weeks：slight bleedingThreatened abortionClinical typesInevitable abo

15、rtionComplete abortion plete abortionDiagnosis and TreatmentThreatened abortionSymptoms:1. Bleeding after amenorrhea2. Usually no uterine contractions and no pain or slight abdominal painSigns:1. Cervix remains closed2. Uterus is expected sizes for datesDiagnosis28 Notices:The key is the embryo is s

16、till aliveThe criterion of pregnancy is going on or not: ultrasonography, hCG, progesteroneThe following condition prompts the pregnancy prognosis is not well: Lower hCG Continue sonography, 710 days after gestational sac appears, not seeing fetal heart Progesterone level in blood 5ng/ml,29 Treatmen

17、t Including psychologic and physicalConfinement to bed Reduce stimulation, apply nutrition Sedatives Hormones(progesterone, hCG) Treatment of the cause Subsequent treatment30Inevitable abortionThe progress of threatened abortion It refers to the state in which bleeding of intrauterine origin occurs

18、before the 28th completed week with continuous and progressive dilatation of the cervix, but without expulsion of the products of conception. Symptoms:a、Increased bleeding-clots often passed.b、Uterine contractions and severe abdominal painc、Vaginal discharge Signs:a、On examination, cervix is found t

19、o be dilating and products projecting. b、The size of uterus is the same as the gestational daysExamination:a. Negative pregnancy urine testsb. Ultrasonography shows no evidence of fetal heart action and perhaps no fetus at all-as in the blighted ovumc. The level of hCG or progesterone is low diagnos

20、is diagnosis Treatmenta. Termination of the pregnancy- D & Cb. Late abortion, the size of uterus is large-giving oxytocin 5u+10% glucose 500ml iv plete abortion plete abortion is the expulsion of some, but not all, of the products of conception before the 28th complete week of gestation.This is ofte

21、n the result of interference (legal or illegal)Symptoms:a、Part of conceptus has been passed or has been removed.b、Bleeding continues and may be severe.c、Vagina may be full of clot and patient may e shocked(hypovolemia) before adequate treatment is started.d、Relieving abdominal painf、Infection may su

22、pervene. Signs: patulous cervix often seeing tissues at the external os (picture) the body of uterus is smaller than the days of gestation Treatment: if diagnosis is made correctly - evacuate the uterus promptly,oxytocin iv blood transfusion if bleeding is brisk antiseptic e.g.Complete abortionCompl

23、ete abortion is the expulsion of all of the products of conception before the 28th complete week of gestation Characteristics:a、Whole conceptus is expelled.b、Slight bleeding and bleeding stops.c、Cessation of paind、Closed of cervix, uterus contracts down to near normal size.e、Negative pregnancy testf

24、、Ultrasonic examination shows no tissue in uterine cavityTreatmentIf the abortion is complete no specific treatment is necessary If the ultrasonic examination shows an empty uterus, curettage may be unnecessary.Differential diagnosis1.Various types of abortion2. Early abortion must be different from

25、 ectopic pregnancy, hydatidiform mole, dysfunctional uterine bleeding etc.Differentiation diagnosistypesthreatened inevitable pletecompletevaginal bleedingslightmildsevereslightnoabdominal pain slightaggravationalleviationnoevacuate of tissuenonopartialtotal os of cervixclosedprobable dilatationdila

26、tation or obstruction of tissueclosed corpusthe same the samesmallernormal ultrasonicalivedeathrudimental tissuenormal cavityhCGpositivesuspiciousnegativenegativetreatmentsprotectioncurettagecurettageno treatmentspecial types of abortion missed abortion habitual abortion or recurrent spontaneous abo

27、rtion septic abortion missed abortion Definition the embryo or fetus dies in utero before the 28th completed week of gestation, but the products of conception are retained Any of the causes of abortion may be responsible. This means the retention in the uterus of a dead conceptus. Clinical presentat

28、ion: amenorrhea slight abdominal pain, companying or not vaginal bleeding Symptoms and signs of pregnancy-e.g. breast enlargement - will regress. Brown vaginal discharge may be present. Signs: closed cervix the size of uterus is smaller than the days of gestation DiagnosisClinical featuressignsHCGul

29、trasound Treatments:1. Determination of coagulation: 1) Routine Blood Test and CT, BT, PT2) Blood fibrinogen, time of thrombinogen, 3P test*If there are some abnormal in these tests, which must be correct firstly then giving the treatments2. Giving estrogen3. 12 weeks: induced abortion (oxytocin, pr

30、ostaglandin )Treatments:Recurrent spontaneous abortion(Habitual abortion) DefinitionHabitual abortion is defined as 3 consecutive spontaneous pregnancy wastages before 28 weeks gestation with a fetus weighing less than 1000g.Characters: every time it appears in the same gestational week its clinical

31、 process is the same as other abortionReasons:Early abortion: genetic,endocrine factors immunological defect etc.Late abortion: cervical petence malformation of uterus etc.genetic,endocrine factors immunological defect etc.cervical petence malformation of uterus etc. petent cervixReasons of petent c

32、ervix:1. Damage of cervix2. Operation of cervix: conization, cauterization, amputation3. Abnormal cervical development4. Other reasonsDiagnosis of petent cervix1. Very clear recurrent abortion in the second trimester2. The 8th dilator can easily insert through cervical canal to cavity when in no conception 3. Ultrasonography: the internal os of cervix in pregnancy is larger than 15mm Treatment1.To find the reasons before pregnancy1) Karyotyping the parents, dete