流產(chǎn)異位妊娠(英文)-Abortian-and-EctopicPregnancy-堯良清課件

1、 Abortion and Ectopic PregnancyLiang-Qing Yao Obstetrics and Gynecology Hospital of Fudan University Abortion and Ectopic AbortionAbortionConcept A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 gramsEarly Abortion：pregnancy loss before 12 gestational weeks Late Abortion:

2、pregnancy loss during 1228 gestational weeks Spontaneous AbortionArtificial AbortionConcept A pregnancy loss beforGenetic defectMaternal factors: systematic disease; genital organ anomalies; endocrine anomalies; irritation; bad habitImmune anomaliesEnvironmental factorsEtiologyEtiologyPathologyBefor

3、e 8 weeks: chorionic villi immature Fetal deathbasal decidual bleeding uterine contractionexpulsion of all the products of conception, light bleedingDuring 812 weeks：with firm attachment to the basal deciduaPartial expulsion of the products of conception non-ideal uterine contraction, severe bleedin

4、gAfter 12 weeks: placenta fully formed. Uterine contraction expulsion of all the products of conception，light bleedingPathologyBefore 8 weeks: choriSymptomsAmenorrhea, vaginal bleeding , and abdominal painEarly abortion：vaginal bleeding preceding abdominal painLate abortion：abdominal pain preceding

5、vaginal bleedingSymptomsAmenorrhea, vaginal blTypes of AbortionThreatened AbortionInevitable AbortionIncomplete AbortionComplete AbortionMissed AbortionHabitual AbortionSeptic AbortionTypes of AbortionThreatened AbClinical PresentationsThreatened Abortion light vaginal bleeding with mild abdominal p

6、aincervical os closed, fetal membranes unbrokentreatment might work , continue pregnancy Inevitable Abortion bleeding heavier, abdominal pain more severe, or fluid passedcervical os open，pregnancy tissue visibleabortion is inevitableClinical PresentationsThreatenIncomplete Abortionheavy vaginal blee

7、dingpregnancy tissue protruding from the cervical osuterus small for the presumed gestational week Complete Abortionvaginal bleeding decreasing, abdominal pain alleviatingcervical os closeduterus normal for the presumed gestational week Incomplete AbortionDifferent Stages of Abortionthreatened abort

8、ion continue pregnancyinevitable abortion incomplete abortioncomplete abortionDifferent Stages of AbortiontDiagnosisHistoryPhysical ExaminationLaboratory Assessment:ultrasound pregnancy testhormone level: serum progesteroneDiagnosisHistoryBleedingAbdominal PainTissue ExpulsionCervical OsUterusThreat

9、ened AbortionInevitable AbortionIncomplete AbortionComplete AbortionLightMild to heavyLight to heavyLight to noneNone/lightIntensifiedRelievedNoneNoneNonePartialCompleteClosedDilatedDilated or obstructedClosedNormalNormal or slightly smallSmallNormal or slightly large History Pelvic ExaminationBleed

10、ingAbdominal PainTissue EManagementThreatened Abortionbed rest, sedationanti abortion：progesterone，HCG；Vit E；thyroxine supplement monitoring：ultrasound；serum HCG whether to continue pregnancyInevitable Abortiononce diagnosed，remove the pregnancy tissue as quickly as possible suction curettage Manage

11、mentThreatened AbortionIncomplete Abortionperform suction curettage promptlyif with heavy bleeding：blood transfusion；preventive antibiotic useComplete Abortionno retained products of conception confirmed by ultrasound；no infectionno need for special managementIncomplete AbortionMissed Abortion Conce

12、pt: in utero death of the embryo or fetus with retained products of conception Clinical Manifestation:uterine enlargement ceasing or fetal movement disappearingcervical os closed, uterus small for the presumed gestational ageno fetal heartbeat ; embryonic demise suggested by ultrasound findingsMisse

13、d Abortion Concept: in utManagement blood routine examination, coagulation function testcorrecting coagulation defects：heparin, fibrinogen, etc.sensitizing the uterus： diethylstilbestroltransfusion preparation; emptying the uterus： before 12 weeks: suction curettage after 12 weeks：induction of labor

14、Management blood routine examiHabitual Abortion The occurrence of 3 or more consecutive spontaneous abortionsThe occurrence of 2 spontaneous abortions is defined as recurrent abortionEarly abortion：chromosomal abnormalities，immunologic factors，luteal-phase insufficiency, hypothyroidismLate abortion：

15、congenital uterine anomalies，cervical incompetence，uterine fibroids, etc.Habitual Abortion The occurrenManagementobtain information on etiology for prior losses before conceptiongenetic counselingcervical incompetence：cervical cerclage during 1418 weeks of gestationwith unclear causes：progesterone t

16、herapy until 10 weeks of gestationactive immunotherapy：intradermic injection of lymphocytesManagementobtain information oSeptic Abortion Prolonged bleeding during abortion or retained products of conception lead to intrauterine infection, which might progress into pelvic inflammatory disease, perito

17、nitis or even sepsis if not treatedAntibiotic treatment + Prompt evacuationwithout severe bleeding: management of infection , performance of suction and curettagewith severe bleeding：management of infection while applying forceps, with secondary suction and curettage Septic Abortion Prolonged blEcto

18、pic PregnancyEctopic PregnancyConcept Ectopic Pregnancy: implantation of the fertilized ovum in tissue other than the endometriumExtrauterine Pregnancyincluding：tubal pregnancy (95), ovarian pregnancy, cornual pregnancy, cervical pregnancy, abdominal pregnancy, etc.one of the main causes of acute ab

19、domen and deathConcept流產(chǎn)異位妊娠(英文)-Abortian_and_EctopicPregnancy-堯良清課件Etiology and Risk Factorstubal inflammation, pelvic inflammation previous tubal surgery：for infertility, tubal pregnancy, etc.IVFfailure of contraception：current use of IUD or oral contraceptives tubal undergrowth or dysfunctionothe

20、r factors：endometriosis, hysteromyoma, smoking, etc.Etiology and Risk FactorstubalEndings of tubal pregnancyabortion：812 weeks rupture：1216 weeks secondary abdominal pregnancyChronic ectopic pregnancyPersistent ectopic pregnancyEndings of tubal pregnancyaborPathology of the Uterusenlargement and sof

21、teningamenorrhea vaginal bleeding the Arias-Stella reaction of the endometrium but no chorionic villiPathology of the UterusenlargeClinical Presentations-SymptomsAmenorrheaAbdominal pain：time, characteristicsVaginal bleedingFaint/shockClinical Presentations-SymptomClinical Presentations-SignsGeneral

22、 conditionAbdomen examinationPelvic examination：cervical motion tenderness，sensation of a floating uterus ，adnexal mass, etc.Clinical Presentations-SignsGeLaboratory Assessment HCG: urinary HCG；the rise in the serum -HCG level over 48 hours66serum progesterone：only 1.5%25ng/mlultrasound：the empty ut

23、erus sign；adnexal cardiac activity or ultrasonographic lucency ; presence of cul-de-sac fluidLaboratory Assessment HCG: uriculdocentesis：nonclotting bloodlaparoscopy：gold standard，diagnosistreatment early diagnosis missed in 34 of patients use with caution：to avoid anesthetic and surgical risks；medi

24、cal therapy as an optionUterine curretage：profuse vaginal bleeding; intrauterine pregnancy lossculdocentesis：nonclotting blooDifferential DiagnosisEctopic pregnancyabortionAdnexal inflammationAppendicitisCorpus luteum ruptureOvary cyst torsion1.Amenorrhea2.Abdominal pain3.Bleeding4.Shock 5.Body temp

25、erature6.Pelvic examinatioon7.WBC8.Hb9.HCG10.Ultrasound11.CuldocentesisDifferential DiagnosisEctopic Surgical TreatmentRadical operation：hemodynamically unstable ; interstitial pregnancy; tubal ruptureConservative operation：with wishes to retain potential for fertility milking or linear salpingostom

26、yMTXSurgical TreatmentRadical operMedical Treatmentprinciple：inhibiting proliferation of trophoblastic tissueindication：no contraindication to chemotherapy ；no rupture or abortion；mass4cm；serum -HCG 2000U/L；no obvious internal bleeding；no demonstration of cardiac activity or embryonic budMedical Tre

27、atmentprinciple：inhMedical TreatmentProtocol：MTX150 mg，give a second dose on day 7 if necessaryMonitoring therapeutic effectiveness：if decline in serum hCG level on day 725%； 15% or symptoms worsening or internal bleeding occurring; 2 weeks until negativeMedical TreatmentProtocol：MTX1Expectant treat

28、mentPain mild，bleeding light；No evidence of tubal rupture；No intraabdominal bleeding；Serum -HCG 1000U/L，and continue declining;Pregnancy mass3cm or undetected；Follow-up reliableExpectant treatmentPain mild，Nontubal Ectopic PregnancyNontubal Ectopic PregnancyCervical PregnancyConcept：implantation of

29、the developing conceptus in the cervical canalIncidence：1：18000Clinical feature：painless vaginal bleedingDiagnostic criteria：the uterine size is comparable to that of an unpregnant one; the presence of pregnancy tissue related exclusively to the cervical canal；curretage of the endometrial cavity is

30、nonproductive of pregnancy tissueTreatment principle：transfusion preparation; curretage or suction curretage ; MTX and/or uterine curretageCervical PregnancyConcept：implOvarian PregnancyA condition in which an ectopic pregnancy implants within the ovarian cortexDiagnostic criteria：the fallopian tube

31、 on the affected side must be intact；the fetal sac must occupy the position of the ovary；ovarian tissue must be located in the sac wall；the ovary and fetal sac must be connected to the uterus by the ovarian ligamentOvarian PregnancyA condition iOvarian PregnancyClinical presentations：amenorrhea, abdominal pain, vaginal bleeding，shock, etc.Differentiated from：ruptured corpus luteum；tubal