《流产异位妊娠英文AbortianandEctopicPregnancy尧良清》由会员分享，可在线阅读，更多相关《流产异位妊娠英文AbortianandEctopicPregnancy尧良清（42页珍藏版）》请在金锄头文库上搜索。
1、 Abortion and Ectopic PregnancyLiang-Qing YaoObstetrics and Gynecology Hospital of Fudan University 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
2、Abortion：pregnancy 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 de
3、fectGenetic defectMaternal factors:Maternal factors: systematic disease; genital organ systematic disease; genital organ anomalies; endocrine anomalies; anomalies; endocrine anomalies; irritation; badirritation; bad habithabitImmune anomaliesImmune anomaliesEnvironmental factorsEnvironmental factors
4、EtiologyPathologyuuBefore 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 bleedingco
5、nception, light bleedinguuDuring 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, sev
6、ere bleedingsevere bleedinguuAfter 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,
7、vaginal bleeding , and abdominal 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 Abort
8、ionuuThreatenedThreatened Abortion AbortionuuInevitable AbortionInevitable AbortionuuIncompleteIncomplete Abortion AbortionuuComplete AbortionComplete AbortionMissed AbortionMissed AbortionHabitual Habitual AbortionAbortionSeptic AbortionSeptic AbortionClinical Presentationsn nIncomplete AbortionInc
9、omplete Abortionheavy vaginal bleedingheavy 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 bleed
10、ing decreasing, vaginal bleeding decreasing, 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 con
11、tinue pregnancycontinue pregnancyinevitable abortion incomplete abortioninevitable abortion incomplete abortioncomplete abortioncomplete abortionDiagnosisuuHistoryuuPhysical ExaminationuuLaboratory Assessment:ultrasound pregnancy testhormone level: serum progesteroneBleedingAbdominal PainTissue Expu
12、lsionCervical OsUterusThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionLightMildtoheavyLighttoheavyLighttononeNone/lightIntensifiedRelievedNoneNoneNonePartialCompleteClosedDilatedDilatedorobstructedClosedNormalNormalorslightlysmallSmallNormalorslightlylarge History Pelvic Examin
13、ationManagementn nThreatened AbortionThreatened 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 wheth
14、er to continue pregnancyn nInevitable AbortionInevitable 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 perform suction curet
15、tage promptlypromptlyif with heavy bleedingif with heavy bleeding：blood blood transfusiontransfusion；preventive antibiotic preventive antibiotic useusen nComplete Abortionno retained products of conception no retained products of conception confirmed by ultrasoundconfirmed by ultrasound；no no infect
16、ioninfectionno need for special managementno need for special managementMissed Abortion uuConcept: in utero death of the embryo or Concept: in utero death of the embryo or fetus with retained products of fetus with retained products of conception conception uuClinical Manifestation:Clinical Manifest
17、ation:uterine enlargement ceasing or fetal uterine enlargement ceasing or fetal movement disappearingmovement disappearingcervical os closed, uterus small for the cervical os closed, uterus small for the presumed gestational agepresumed gestational ageno fetal heartbeat ; embryonic demise no fetal h
18、eartbeat ; embryonic demise suggested by ultrasound findingssuggested by ultrasound findingsManagement uublood routine examination, blood routine examination, coagulation function testcoagulation function testuucorrecting coagulation defectscorrecting coagulation defects：heparin, fibrinogen, etc.hep
19、arin, fibrinogen, etc.uusensitizing the uterussensitizing 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：indu
20、ction ofinduction of laborlaborHabitual Abortion uuThe occurrence of 3 or more consecutive The occurrence of 3 or more consecutive spontaneous abortionsspontaneous abortionsuuThe occurrence of 2 spontaneous abortions is The occurrence of 2 spontaneous abortions is defined as recurrent abortiondefine
21、d as recurrent abortionEarly abortionEarly abortion：chromosomal abnormalitieschromosomal abnormalities，immunologic factorsimmunologic factors，luteal-phase insufficiency, luteal-phase insufficiency, hypothyroidismhypothyroidismLate abortionLate abortion：congenital uterine anomaliescongenital uterine
22、anomalies，cervical incompetencecervical incompetence，uterine fibroids, etcuterine fibroids, etc. .Managementobtain information on etiology for prior obtain information on etiology for prior losses before conceptionlosses before conceptiongenetic counselinggenetic counselingcervical incompetencecervi
23、cal incompetence：cervical cervical cerclagecerclage during 14 during 1418 weeks of 18 weeks of gestationgestationwith unclear causeswith unclear causes：progesterone progesterone therapy until 10 weeks of gestationtherapy until 10 weeks of gestationactive immunotherapyactive immunotherapy：intradermic
24、 intradermic injection of lymphocytesinjection of lymphocytesSeptic 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
25、 might progress into pelvic inflammatory disease, progress into pelvic 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 with
26、out severe bleeding: management of infection , performance of suction and infection , 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
27、curettage secondary suction and curettage Ectopic PregnancyConceptuu Ectopic Pregnancy: implantation of the fertilized Ectopic Pregnancy: implantation of the fertilized ovum in tissue other than the endometriumovum in tissue other than the endometriumuuExtrauterine PregnancyExtrauterine Pregnancyinc
28、ludingincluding：tubal pregnancy (95tubal pregnancy (95), ovarian ), ovarian pregnancy,pregnancy, cornual pregnancy, cervical cornual pregnancy, cervical pregnancy, abdominal pregnancy, etc.pregnancy, abdominal pregnancy, etc.one of the main causes of acute abdomen and one of the main causes of acute
29、 abdomen and deathdeathEtiology and Risk Factorstubal inflammation, pelvic tubal inflammation, pelvic inflammation inflammation previous tubal surgeryprevious tubal surgery：for for infertility, tubal pregnancy, etc.infertility, tubal pregnancy, etc.IVFIVFfailure of contraceptionfailure of contracept
30、ion：current current use of IUD or oral contraceptives use of IUD or oral contraceptives tubal undergrowth or dysfunctiontubal undergrowth or dysfunctionother factorsother factors：endometriosis, endometriosis, hysteromyoma, smoking, etc.hysteromyoma, smoking, etc.Endings of tubal pregnancyabortionabo
31、rtion：8 81212 weeksweeks rupturerupture：121216 weeks16 weeks secondary abdominal secondary abdominal pregnancypregnancyChronic ectopic pregnancyChronic ectopic pregnancyPersistent ectopic pregnancyPersistent ectopic pregnancyPathology of the Uterusenlargement and softeningenlargement and softeningam
32、enorrheaamenorrhea vaginal bleeding vaginal bleeding the Arias-Stella reaction of the Arias-Stella reaction of the endometrium but no the endometrium but no chorionic villichorionic villiClinical Presentations-SymptomsAmenorrheaAbdominal pain：time, characteristicsVaginal bleedingFaint/shockClinical
33、Presentations-SignsGeneral conditionAbdomen examinationPelvic examination：cervical motion tenderness，sensation 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 hourshours6
34、666uuserum progesteroneserum progesterone：only only 1.5%1.5%25ng/ml25ng/mluuultrasoundultrasound：the empty uterus 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
35、 fluiduuculdocentesisculdocentesis：nonclotting bloodnonclotting blooduulaparoscopylaparoscopy：gold standardgold standard，diagnosisdiagnosistreatmenttreatment early diagnosis missed in 3early diagnosis missed in 34 4 of patients of patients use with cautionuse with caution：to avoid to avoid anestheti
36、c and surgical risksanesthetic and surgical risks；medical therapy as an optionmedical therapy as an optionuuUterine curretageUterine curretage：profuse profuse vaginal bleeding; intrauterine vaginal bleeding; intrauterine pregnancy losspregnancy lossDifferential DiagnosisEctopic Ectopic pregnancypreg
37、nancyabortionabortionAdnexal Adnexal inflammationinflammationAppendicitisAppendicitisCorpus Corpus luteum luteum ruptureruptureOvary Ovary cyst cyst torsiontorsion1.Amenorrhea1.Amenorrhea2.Abdominal 2.Abdominal painpain3.Bleeding3.Bleeding4.Shock4.Shock 5.Body 5.Body temperaturetemperature6.Pelvic 6
38、.Pelvic examinatioonexaminatioon7.WBC7.WBC8.Hb8.Hb9.HCG9.HCG10.Ultrasound10.Ultrasound11.Culdocentesis11.CuldocentesisSurgical TreatmentRadical operationRadical operation：hemodynamically hemodynamically unstable ; interstitial unstable ; interstitial pregnancy; tubal rupturepregnancy; tubal ruptureC
39、onservative operationConservative operation：with wishes to retain with wishes to retain potential for fertilitypotential for fertility milking or linear milking or linear salpingostomysalpingostomyMTXMTXMedical Treatmentprincipleprinciple：inhibiting proliferation of inhibiting proliferation of troph
40、oblastic tissuetrophoblastic tissueindicationindication：no contraindication to no contraindication to chemotherapy chemotherapy ；no rupture or abortionno rupture or abortion；massmass 4cm4cm；serum serum -HCG -HCG 2000U/L2000U/L；no no obvious internal bleedingobvious internal bleeding；no no demonstrat
41、ion of cardiac activity or demonstration of cardiac activity or embryonic budembryonic budMedical TreatmentProtocolProtocol：MTX150 mgMTX150 mg，give a second give a second dose on day 7 if necessarydose on day 7 if necessaryMonitoring therapeutic effectivenessMonitoring therapeutic effectiveness：if i
42、f decline in serum hCG level on day 7decline in serum hCG level on day 7 25%25%； 15% or symptoms worsening or 15% or symptoms worsening or internal bleeding occurring; 2 weeks internal bleeding occurring; 2 weeks until negativeuntil negativeExpectant treatmentPain mildPain mild，bleeding lightbleedin
43、g light；No evidence of tubal ruptureNo evidence of tubal rupture；No intraabdominal bleedingNo intraabdominal bleeding；Serum Serum -HCG -HCG 1000U/L 1000U/L，and continue and continue declining;declining;Pregnancy massPregnancy mass3cm or undetected3cm or undetected；Follow-up reliableFollow-up reliabl
44、eNontubal Ectopic PregnancyCervical PregnancyConceptConcept：implantation of the developing implantation of the developing conceptus in the cervical canalconceptus in the cervical canalIncidenceIncidence：1 1：1800018000Clinical featureClinical feature：painless vaginal painless vaginal bleedingbleeding
45、Diagnostic criteriaDiagnostic criteria：the uterine size is the uterine size is comparable to that of an unpregnant comparable to that of an unpregnant one; the presence of pregnancy tissue one; the presence of pregnancy tissue related exclusively to the cervical canalrelated exclusively to the cervi
46、cal canal；curretage of the endometrial cavity is curretage of the endometrial cavity is nonproductive of pregnancy tissuenonproductive of pregnancy tissueTreatment principleTreatment principle：transfusion transfusion preparation; curretage or suction preparation; curretage or suction curretagecurret
47、age ; MTX and/or uterine curretage; MTX and/or uterine curretageOvarian PregnancyA condition in which an ectopic pregnancy A condition in which an ectopic pregnancy implants within the ovarian corteximplants within the ovarian cortexDiagnostic criteriaDiagnostic criteria：the fallopian tube on the fa
48、llopian tube on the affected side must be intactthe affected side must be intact；the fetal the fetal sac must occupy the position of the ovarysac must occupy the position of the ovary；ovarian tissue must be located in the ovarian tissue must be located in the sac wallsac wall；the ovary and fetal sac
49、 must be the ovary and fetal sac must be connected to the uterus by the ovarian connected to the uterus by the ovarian ligamentligamentOvarian PregnancyClinical presentations：amenorrhea, abdominal pain, vaginal bleeding，shock, etc.Differentiated from：ruptured corpus luteum；tubal pregnancyTreatment p
50、rinciple：surgical treatmentAbdominal PregnancyThe presence of a pregnancy related to a The presence of a pregnancy related to a peritoneal surface other than fallopian tube, peritoneal surface other than fallopian tube, ovary or broad ligamentovary or broad ligament， 1 1：15000 15000 ClassificationCl
51、assification：primary, secondaryprimary, secondaryClinical presentationsClinical presentations：amenorrhea, abdominal amenorrhea, abdominal pain and vaginal bleedingpain and vaginal bleeding；fetus.fetus.Treatment principleTreatment principle：remove the fetusremove the fetusplacenta managementplacenta
52、managementtransfusion, prevent transfusion, prevent infectioninfectionattached to the attached to the uterus, fallopian tubeuterus, fallopian tubeattached to attached to peritoneum , mesenteriumperitoneum , mesenterium（4 weeks; long 4 weeks; long been deadbeen dead）QuestionsQuestionsuuDescribe the c
53、linical presentations of different Describe the clinical presentations of different stages of abortionstages of abortion？uuSummarize treatment principles of habitual, septic Summarize treatment principles of habitual, septic and missed abortionsand missed abortions？uuWhat conditions should be differ
54、entiated from What conditions should be differentiated from tubal pregnancy their respective differential tubal pregnancy their respective differential pointspoints？uuWhat does laboratory assessment for Ectopic What does laboratory assessment for Ectopic pregnancy includepregnancy include？uuSummarize the treatment for tubal pregnancy and Summarize the treatment for tubal pregnancy and its choiceits choice？uuMissed abortion, cervical pregnancy?Missed abortion, cervical pregnancy?Thank youThank you！
