流产、异位妊娠(英文)-Abortian_and_EctopicPregnancy-尧良清

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1、流产、异位妊娠流产、异位妊娠(英文英文)-)-Abortian_and_EctopicPrAbortian_and_EctopicPregnancy-egnancy-尧良清尧良清AbortionConceptuu A pregnancy loss before 28 weeks A pregnancy loss before 28 weeks of gestation while fetal weight of gestation while fetal weight under 1000 gramsunder 1000 gramsEarly AbortionEarly Abortion：pr

2、egnancy loss pregnancy loss before 12before 12 gestational weeks gestational weeks Late Abortion:pregnancy lossLate Abortion:pregnancy loss during 12during 122828 gestational weeks gestational weeks SpontaneousSpontaneous Abortion AbortionArtificiaArtificial Abortionl AbortionGenetic defectGenetic d

3、efectMaternal factors:Maternal factors:systematic disease;genital organ anomalies;systematic disease;genital organ anomalies;endocrine anomalies;irritation;badendocrine anomalies;irritation;bad habithabitImmune anomaliesImmune anomaliesEnvironmental factorsEnvironmental factorsEtiologyPathologyuuBef

4、ore 8 weeks:Before 8 weeks:chorionic villi immaturechorionic villi immature Fetal deathFetal deathbasal decidual bleedingbasal decidual bleeding uterine uterine contractioncontractionexpulsion of all the products of expulsion of all the products of conception,light bleedingconception,light bleedingu

5、uDuring 8During 81212 weeksweeks：with firm with firm attachment to the basal deciduaattachment to the basal deciduaPartial expulsion of the products of Partial expulsion of the products of conceptionconception non-ideal uterine contraction,non-ideal uterine contraction,severe bleedingsevere bleeding

6、uuAfter 12After 12 weeks:weeks:placenta fully placenta fully formed.formed.Uterine contractionUterine contraction expulsion of all the expulsion of all the products of conceptionproducts of conception，light bleedinglight bleedingSymptomsuuAmenorrhea,vaginal Amenorrhea,vaginal bleeding,and abdominal

7、bleeding,and abdominal painpainEarly abortionEarly abortion：vaginal vaginal bleeding preceding bleeding preceding abdominal painabdominal painLate abortionLate abortion：abdominal pain preceding abdominal pain preceding vaginal bleedingvaginal bleedingTypes of AbortionuuThreatenedThreatened Abortion

8、AbortionuuInevitable AbortionInevitable AbortionuuIncompleteIncomplete Abortion AbortionuuComplete AbortionComplete AbortionMissed AbortionMissed AbortionHabitual Habitual AbortionAbortionSeptic AbortionSeptic AbortionClinical Presentationsn nIncomplete AbortionIncomplete Abortionheavy vaginal bleed

9、ingheavy vaginal bleedingpregnancy tissue protruding pregnancy tissue protruding from the cervical osfrom the cervical osuterus small for the presumed uterus small for the presumed gestational week gestational week n nComplete AbortionComplete Abortionvaginal bleeding decreasing,vaginal bleeding dec

10、reasing,abdominal pain alleviatingabdominal pain alleviatingcervical os closedcervical os closeduterus normal for the uterus normal for the presumed gestational week presumed gestational week Different Stages of Abortionthreatened abortion threatened abortion continue pregnancycontinue pregnancyinev

11、itable abortion incomplete abortioninevitable abortion incomplete abortioncomplete abortioncomplete abortionDiagnosisuuHistoryuuPhysical ExaminationuuLaboratory Assessment:ultrasound pregnancy testhormone level:serum progesteroneBleedingAbdominal PainTissue ExpulsionCervical OsUterusThreatenedAborti

12、onInevitableAbortionIncompleteAbortionCompleteAbortionLightMildtoheavyLighttoheavyLighttononeNone/lightIntensifiedRelievedNoneNoneNonePartialCompleteClosedDilatedDilatedorobstructedClosedNormalNormalorslightlysmallSmallNormalorslightlylarge History Pelvic ExaminationManagementn nThreatened AbortionT

13、hreatened Abortionbed rest,bed rest,sedationsedationanti abortionanti abortion：progesteroneprogesterone，HCGHCG；Vit EVit E；thyroxine supplement thyroxine supplement monitoringmonitoring：ultrasoundultrasound；serum serum HCG whether to continue pregnancyHCG whether to continue pregnancyn nInevitable Ab

14、ortionInevitable Abortiononce diagnosedonce diagnosed，remove the remove the pregnancy tissue as quickly as possible pregnancy tissue as quickly as possible suction curettagesuction curettage n nIncomplete Abortionperform suction curettage promptlyperform suction curettage promptlyif with heavy bleed

15、ingif with heavy bleeding：blood blood transfusiontransfusion；preventive antibiotic usepreventive antibiotic usen nComplete Abortionno retained products of conception no retained products of conception confirmed by ultrasoundconfirmed by ultrasound；no infectionno infectionno need for special manageme

16、ntno need for special managementMissed Abortion uuConcept:in utero death of the embryo or fetus Concept:in utero death of the embryo or fetus with retained products of conception with retained products of conception uuClinical Manifestation:Clinical Manifestation:uterine enlargement ceasing or fetal

17、 movement uterine enlargement ceasing or fetal movement disappearingdisappearingcervical os closed,uterus small for the cervical os closed,uterus small for the presumed gestational agepresumed gestational ageno fetal heartbeat;embryonic demise no fetal heartbeat;embryonic demise suggested by ultraso

18、und findingssuggested by ultrasound findingsManagement uublood routine examination,blood routine examination,coagulation function testcoagulation function testuucorrecting coagulation defectscorrecting coagulation defects：heparin,fibrinogen,etc.heparin,fibrinogen,etc.uusensitizing the uterussensitiz

19、ing the uterus：diethylstilbestroldiethylstilbestroluutransfusion preparation;emptying transfusion preparation;emptying the uterusthe uterus：before 12 weeks:suction curettagebefore 12 weeks:suction curettage after 12 weeksafter 12 weeks：induction ofinduction of laborlaborHabitual Abortion uuThe occur

20、rence of 3 or more consecutive spontaneous The occurrence of 3 or more consecutive spontaneous abortionsabortionsuuThe occurrence of 2 spontaneous abortions is defined as The occurrence of 2 spontaneous abortions is defined as recurrent abortionrecurrent abortionEarly abortionEarly abortion：chromoso

21、mal abnormalitieschromosomal abnormalities，immunologic factorsimmunologic factors，luteal-phase insufficiency,luteal-phase insufficiency,hypothyroidismhypothyroidismLate abortionLate abortion：congenital uterine anomaliescongenital uterine anomalies，cervical cervical incompetenceincompetence，uterine f

22、ibroids,etcuterine fibroids,etc.Managementobtain information on etiology for prior losses obtain information on etiology for prior losses before conceptionbefore conceptiongenetic counselinggenetic counselingcervical incompetencecervical incompetence：cervical cervical cerclagecerclage during 14durin

23、g 1418 weeks of gestation18 weeks of gestationwith unclear causeswith unclear causes：progesterone therapy progesterone therapy until 10 weeks of gestationuntil 10 weeks of gestationactive immunotherapyactive immunotherapy：intradermic injection intradermic injection of lymphocytesof lymphocytesSeptic

24、 Abortion uuProlonged bleeding during abortion or Prolonged bleeding during abortion or retained products of conception lead to retained products of conception lead to intrauterine infection,which might intrauterine infection,which might progress into pelvic inflammatory disease,progress into pelvic

25、 inflammatory disease,peritonitis or even sepsis if not treatedperitonitis or even sepsis if not treateduuAntibiotic treatment+Prompt Antibiotic treatment+Prompt evacuationevacuationwithout severe bleeding:management of without severe bleeding:management of infection,performance of suction and infec

26、tion,performance of suction and curettagecurettagewith severe bleedingwith severe bleeding：management of management of infection while infection while applying forcepsapplying forceps,with,with secondary suction and curettage secondary suction and curettage Ectopic PregnancyConceptuu Ectopic Pregnan

27、cy:implantation of the fertilized ovum Ectopic Pregnancy:implantation of the fertilized ovum in tissue other than the endometriumin tissue other than the endometriumuuExtrauterine PregnancyExtrauterine Pregnancyincludingincluding：tubal pregnancy(95tubal pregnancy(95),ovarian pregnancy,),ovarian preg

28、nancy,cornual pregnancy,cervical pregnancy,abdominal cornual pregnancy,cervical pregnancy,abdominal pregnancy,etc.pregnancy,etc.one of the main causes of acute abdomen and deathone of the main causes of acute abdomen and deathEtiology and Risk Factorstubal inflammation,pelvic tubal inflammation,pelv

29、ic inflammation inflammation previous tubal surgeryprevious tubal surgery：for for infertility,tubal pregnancy,etc.infertility,tubal pregnancy,etc.IVFIVFfailure of contraceptionfailure of contraception：current current use of IUD or oral contraceptives use of IUD or oral contraceptives tubal undergrow

30、th or dysfunctiontubal undergrowth or dysfunctionother factorsother factors：endometriosis,endometriosis,hysteromyoma,smoking,etc.hysteromyoma,smoking,etc.Endings of tubal pregnancyabortionabortion：8 81212 weeksweeks rupturerupture：121216 weeks16 weeks secondary abdominal secondary abdominal pregnanc

31、ypregnancyChronic ectopic pregnancyChronic ectopic pregnancyPersistent ectopic pregnancyPersistent ectopic pregnancyPathology of the Uterusenlargement and softeningenlargement and softeningamenorrheaamenorrhea vaginal bleeding vaginal bleeding the Arias-Stella reaction of the Arias-Stella reaction o

32、f the endometrium but no the endometrium but no chorionic villichorionic villiClinical Presentations-SymptomsAmenorrheaAbdominal pain：time,characteristicsVaginal bleedingFaint/shockClinical Presentations-SignsGeneral conditionAbdomen examinationPelvic examination：cervical motion tenderness，sensation

33、 of a floating uterus，adnexal mass,etc.Laboratory Assessment uuHCG:urinary HCGHCG:urinary HCG；the rise in the rise in the serum the serum -HCG level over 48-HCG level over 48 hourshours6666uuserum progesteroneserum progesterone：only only 1.5%1.5%25ng/ml25ng/mluuultrasoundultrasound：the empty uterus

34、the empty uterus signsign；adnexal cardiac activity or adnexal cardiac activity or ultrasonographic lucency;ultrasonographic lucency;presence of cul-de-sac fluidpresence of cul-de-sac fluiduuculdocentesisculdocentesis：nonclotting bloodnonclotting blooduulaparoscopylaparoscopy：gold standardgold standa

35、rd，diagnosisdiagnosistreatmenttreatment early diagnosis missed in 3early diagnosis missed in 34 4 of patients of patients use with cautionuse with caution：to avoid to avoid anesthetic and surgical risksanesthetic and surgical risks；medical therapy as an optionmedical therapy as an optionuuUterine cu

36、rretageUterine curretage：profuse profuse vaginal bleeding;intrauterine vaginal bleeding;intrauterine pregnancy losspregnancy lossDifferential DiagnosisEctopic Ectopic pregnancypregnancyabortionabortionAdnexal Adnexal inflammationinflammationAppendicitisAppendicitisCorpus Corpus luteum luteum rupture

37、ruptureOvary Ovary cyst cyst torsiontorsion1.Amenorrhea1.Amenorrhea2.Abdominal 2.Abdominal painpain3.Bleeding3.Bleeding4.Shock4.Shock 5.Body 5.Body temperaturetemperature6.Pelvic 6.Pelvic examinatioonexaminatioon7.WBC7.WBC8.Hb8.Hb9.HCG9.HCG10.Ultrasound10.Ultrasound11.Culdocentesis11.CuldocentesisSu

38、rgical TreatmentRadical operationRadical operation：hemodynamically hemodynamically unstable;interstitial unstable;interstitial pregnancy;tubal rupturepregnancy;tubal ruptureConservative operationConservative operation：with wishes to retain with wishes to retain potential for fertilitypotential for f

39、ertility milking or linear milking or linear salpingostomysalpingostomyMTXMTXMedical Treatmentprincipleprinciple：inhibiting proliferation of inhibiting proliferation of trophoblastic tissuetrophoblastic tissueindicationindication：no contraindication to no contraindication to chemotherapy chemotherap

40、y；no rupture or abortionno rupture or abortion；massmass 4cm4cm；serum serum -HCG-HCG 2000U/L2000U/L；no no obvious internal bleedingobvious internal bleeding；no demonstration of no demonstration of cardiac activity or embryonic budcardiac activity or embryonic budMedical TreatmentProtocolProtocol：MTX1

41、50 mgMTX150 mg，give a second dose give a second dose on day 7 if necessaryon day 7 if necessaryMonitoring therapeutic effectivenessMonitoring therapeutic effectiveness：if if decline in serum hCG level on day 7decline in serum hCG level on day 7 25%25%；15%or symptoms worsening or internal 15%or sympt

42、oms worsening or internal bleeding occurring;2 weeks until negativebleeding occurring;2 weeks until negativeExpectant treatmentPain mildPain mild，bleeding lightbleeding light；No evidence of tubal ruptureNo evidence of tubal rupture；No intraabdominal bleedingNo intraabdominal bleeding；Serum Serum -HC

43、G-HCG 1000U/L 1000U/L，and continue and continue declining;declining;Pregnancy massPregnancy mass3cm or undetected3cm or undetected；Follow-up reliableFollow-up reliableNontubal Ectopic PregnancyCervical PregnancyConceptConcept：implantation of the developing implantation of the developing conceptus in

44、 the cervical canalconceptus in the cervical canalIncidenceIncidence：1 1：1800018000Clinical featureClinical feature：painless vaginal bleedingpainless vaginal bleedingDiagnostic criteriaDiagnostic criteria：the uterine size is the uterine size is comparable to that of an unpregnant one;the comparable

45、to that of an unpregnant one;the presence of pregnancy tissue related presence of pregnancy tissue related exclusively to the cervical canalexclusively to the cervical canal；curretage of curretage of the endometrial cavity is nonproductive of the endometrial cavity is nonproductive of pregnancy tiss

46、uepregnancy tissueTreatment principleTreatment principle：transfusion transfusion preparation;curretage or suction curretagepreparation;curretage or suction curretage ;MTX and/or uterine curretageMTX and/or uterine curretageOvarian PregnancyA condition in which an ectopic pregnancy A condition in whi

47、ch an ectopic pregnancy implants within the ovarian corteximplants within the ovarian cortexDiagnostic criteriaDiagnostic criteria：the fallopian tube on the the fallopian tube on the affected side must be intactaffected side must be intact；the fetal sac must the fetal sac must occupy the position of

48、 the ovaryoccupy the position of the ovary；ovarian tissue ovarian tissue must be located in the sac wallmust be located in the sac wall；the ovary and the ovary and fetal sac must be connected to the uterus by the fetal sac must be connected to the uterus by the ovarian ligamentovarian ligamentOvaria

49、n PregnancyClinical presentations：amenorrhea,abdominal pain,vaginal bleeding，shock,etc.Differentiated from：ruptured corpus luteum；tubal pregnancyTreatment principle：surgical treatmentAbdominal PregnancyThe presence of a pregnancy related to a peritoneal The presence of a pregnancy related to a perit

50、oneal surface other than fallopian tube,ovary or broad surface other than fallopian tube,ovary or broad ligamentligament，1 1：15000 15000 ClassificationClassification：primary,secondaryprimary,secondaryClinical presentationsClinical presentations：amenorrhea,abdominal pain amenorrhea,abdominal pain and

51、 vaginal bleedingand vaginal bleeding；fetus.fetus.Treatment principleTreatment principle：remove the fetusremove the fetusplacenta placenta managementmanagementtransfusion,prevent infectiontransfusion,prevent infection attached to the uterus,fallopian tubeattached to the uterus,fallopian tube attache

52、d to peritoneum,attached to peritoneum,mesenteriummesenterium（4 weeks;long been dead4 weeks;long been dead）QuestionsQuestionsuuDescribe the clinical presentations of different stages of Describe the clinical presentations of different stages of abortionabortion？uuSummarize treatment principles of ha

53、bitual,septic and Summarize treatment principles of habitual,septic and missed abortionsmissed abortions？uuWhat conditions should be differentiated from tubal What conditions should be differentiated from tubal pregnancy their respective differential pointspregnancy their respective differential poi

54、nts？uuWhat does laboratory assessment for Ectopic pregnancy What does laboratory assessment for Ectopic pregnancy includeinclude？uuSummarize the treatment for tubal pregnancy and its Summarize the treatment for tubal pregnancy and its choicechoice？uuMissed abortion,cervical pregnancy?Missed abortion,cervical pregnancy?Thank youThank you！结束语结束语谢谢大家聆听！谢谢大家聆听！43