Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company LOG,浙大医学院附属妇产科医院产科,Company LOGO,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Abortion,Abortion,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 28 weeks gestation,Definition,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 & the incidence of chromosomal anomalies decrease,Inheritance,Infection,Drug,EtiologyEmbryo factor,F9-1,F9-1,Mother factors,Systemic disease,Endocrine abnormalities,Anomaly of immunity,Disease of reproduction organ-,Uterine defects,Stimulus of trauma,Etiology,Mother factorsEtiology,Maternal factors,Nutrition,Dietary deficiency of any one nutrients not important cause,Drug use and environmental factor,Tobacco,Alcohol,Caffeine,Chemical agent(benzene,lead,et al),X-ray,Radiation,Environmental toxins,Maternal factorsNutrition,Pathology,Dead of embryo or fetus,Bleeding of decidua basalis,Embryo or fetus out of uterus,Pathology Dead of embr,Clinical symtoms,Suppressed menstruation,Abdominal pain,Vaginal bleeding,Embryo discharge,Shock infection,Clinical symtomsSuppressed men,Categories of spontaneous abortion,Threatened abortion,Inevitable abortion,Complete or incomplete abortion,Missed abortion,Habitual,abortion,Categories of spontaneous abor,Threatened abortion,Definition,Any bloody vaginal discharge or bleeding during 1,st,half of pregnancy,Bleeding is frequently slight, but may persist for days or weeks,Frequency,Extremely common (one out of four or five pregnant women),Prognosis,Approximately will abort,Risk of preterm delivery, low birth weight, perinatal death,Risk of malformed infant does not appear to be increased,Threatened abortionDefinition,Symptoms,Usually bleeding begins first,Cramping abdominal pain follows a few hours to several days later,Presence of bleeding & pain, Poor prognosis for pregnancy continuation,Slight bleeding persists for weeks,Vaginal sonography,Serial serum quantitative hCG,Serum progesterone, can help ascertain if the fetus is alive & its location,Threatened abortion,Threatened abortion,Symptoms Threatened abortionTh,Threatened abortion,Vaginal sonography,Gestational sac(+) & hCG 1000mIU/ml, gestation is not likely to survive, If any doubt(+), check the serum hCG level at intervals of 48hrs, if not increase more than 65%, almost always hopeless,Serum progesterone value 5 ng/ml, dead conceptus,Ectopic pregnancy should be considered if gestational sac or,fetus are not identified,Threatened abortion,Inevitable abortion,Gross rupture of membrane,evidenced by leaking amnionic fluid, in the presence of cervical dilatation, but no tissue passed,Placenta (in whole or in part) is retained in the uterus, Uterine contractions begin promptly or infection develops,The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitable,Inevitable abortionGross ruptu,Complete abortion,Following complete detachment & expulsion of the conceptus,The internal cervical os closes,Incomplete abortion,Expulsion of some but not all of the products of conception,The internal cervical os remains open & allows passage of blood,The fetus & placenta may remain entirely in utero or may partially extrude through the dilated os, Remove retained tissue without delay,Complete or incomplete abortion,Complete or incomplete abortion,Complete abortion Complete or,Retention of dead products of conception in uteri for several days or weeks,Many women have no symptoms except persistent amenorrhea,Uterus remain stationary in size, but mammary changes usually,regress uterus become smaller,Serious coagulation defect occasionally develop after prolonged retention of fetus,Missed abortion,Missed abortion,Retention of dead products of,Definition : Three or more consecutive spontaneous abortions,Clinical investigation of recurrent miscarriage,Parental cytogenetic analysis,Lupus anticoagulant & anticardiolipin antibodies assays,Postconceptional evaluation,Serial monitoring of,hCG,from missed mens period,Maternal serum,assessment,(GA16-20wks),Amniocentesis, fetal karyotype,Prognosis,Depends on potential underlying etiology & number of prior losses,Recurrent abortion,Habitual abortion,Definition : Three or more con,Clinical groups and identification,Vaginal bleeding,Abdomina-l pain,Embryo discharge,Os uteri,Uterine size,Threatened abortion,few,light,no,close,Correspond,Inevitable abortion,more,severe,no/incarc-eration,open,Small,Incomplete abortion,More,hard to arrest,severe,Incomplete discharge,open,small,Complete abortion,Few,arrest automatic,improve,Complete discharge,close,small,Clinical groups and identifica,妇产科学ppt课件流产（英文版）,Management,Diagnose in time,patient history,clinical symptoms,Lab test and image,：,Bus,HCG,，,E,P,，,HPL,Manage according to the type of abortion,ManagementDiagnose in time,Threatened abortion,general management,：,Lying in bed,，,forbidding coition,，,relaxation,Etiologic management,Treatment,Progesterone (IM) or synthetic progestational agent (PO or IM),Lack of evidence of effectiveness,Often results in no more than a missed abortion,Adjustment according to patient,s condition,Threatened abortion,Inevitable abortion,Discharge the pregnancy tissue as early as possible once diagnosed.,Take in drugs to promote uterine contraction,Dilatation and curettage(D&C),Antibiotic,Inevitable abortion,Incomplete abortion,Suction curettage , D&C,Antishock,Prevention of infection,Complete abortion,No need to manage.,Incomplete abortion,Missed abortion,Lab test:blood Rt,blood coagulation function,Preparation using estrogen,Cross-matching of blood,Discharge of embryo or fetus,Missed abortion,habitual abortion,：,Treatment aim directly at etiology,habitual abortion ：,妇产科学ppt课件流产（英文版）,妇产科学ppt课件流产（英文版）,Abortion complicating with infection,Principle,：,First control the infection, then curettage,Abortion complicating with inf,Ectopic Pregnancy,HuWenSheng,Womens Hospital,School of Medicine,Zhejiang University,Ectopic PregnancyHuWenSheng,Definition,Ectopic pregnancy,:,The zygote nidation at abnormal site outside the lumen of uterus.,The most common site,of occurrence,is within a,f,allopian tube, however, ectopic pregnancies can occur in the,ovary, the,abdomen,and in,the lower portion of the uterus (the,cervix,),DefinitionEctopic pregnancy:,Ectopics happen in about,1% of all pregnancies,Ectopic Pregnancy is a common, life,threatening condition affecting one in 100 pregnancies,Ectopics happen in about 1% of,Classification,Tubal pregnancy,(96-98%),ampullary,(mid) portion of the fallopian tube (80-90%),isthmic,(area closer to uterus) portion of the fallopian tube (5-10%),fimbrial (,distal end away from uterus) portion of the fallopian tube (5%),cornual,(within the uterine muscle) portion of the fallopian tube (1-2%),Abdominal,(1-2%) primary/secondary,(tubo-abdominal/abdomino-ovarian),Ovarian,(0.5-1%),Cervical,(less than 0.5%),Heterotopic,(combination of ectopic + intrauterine pregnancy),ClassificationTubal pregnancy,Uncommon Ectopics,Intraligamentous pregnancy (in broad ligament),Angular pregnancy (inside the uterotubal attachment),Pregnancy in a rudimentary horn of uterus,Intraural pregnancy (in myometrium),Vaginal pregnancy,Multiple tubal pregnancy,Uncommon EctopicsIntraligament,Tubal Pregnancy,Tubal Pregnancy,Tubal Pregnancy,Is a pregnancy that grows in the fallopian tube, not the uterus,If the pregnancy continues,and the tube ruptures, there may be life-threatening intraabdominal bleeding,Even with the modern practice of medicine, the rupture of the tubal ectopic pregnancy is still one of the leading causes of gynecological deaths,Tubal PregnancyIs a pregnancy,Etiology,Pelvic inflammatory disease (PID) or Salpingitis 6 -10 times higher risk.,Mainly invasion of gonorrhea or chlamydia from the cervix up to the uterus and tubes causes an intense inflammatory response and scar tissue adhesions in the tube and may damage the cilia of the fallopian tube,Previous tubal surgery,Dysfunction or malformation of the tube,Assisted reproductive technology ,In vitro fertilization 2-5% of pregnancies are conected with IVF,History of IUD use,Pelvic,adhesions, pelvic tumors,Endometriosis,EtiologyPelvic inflammatory di,Outcome of tubal pregnancy,1.,Tubal abortion,Outcome of tubal pregnancy1.Tu,2.,Rupture of tubal pregnancy,Most common in tubal pregnancy loaded in interstitial portion,2.Rupture of tubal pregnancy,3.,Persistent ectopic pregnancy,4. Secondary intraperitoneal pregnancy,3. Persistent ectopic pregna,Symptoms,Amenorrhoea,Vaginal bleeding,Abdominal pain （,One-sided pain in abdomen,/,Shoulder-tip pain,),Apopsychia and shock that not correspond to the volume of vaginal bleeding,Clinical manifestations,SymptomsClinical manifestation,Physical signs,Shock signs,Abdominal signs：Tenderness and rebound,tenderness at lower abdominal part；,Shifting dullness;,Sign of mass,Pelvic signs,Physical signs,Auxiliary examination,Blood HCG,B-ultrasound examination,Abdominal paracentesis/,culdocentesis,Laparoscope,Diagnostic curettage,Auxiliary examinationBlood HCG,Tubal Pregnancy at USG,Ultrasound showing uterus and tubal pregnancy,2D scan,Uterus outlined in red,Uterine lining in green,Ectopic pregnancy yellow,Fluid in uterus at blue circle is called a pseudogestational sac,Tubal Pregnancy at USGUltrasou,Diagnosis,Early diagnosis of an ectopic pregnancy is critically important,There is no uniformly accepted diagnostic 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,blood in CD),Sometimes dilatation and curettage (exclude intrauterine,p,regnancy or incomplete abortion,),DiagnosisEarly diagnosis of an,Abortion,Acute salpingitis,Acute appendicitis,Rupture of corpus luteum,Torsion of pedicle of oval cyst,Rupture of oval cyst,Differential diagnosis,AbortionDifferential diagnos,Principles,Generous hemorrhage complicating with shock:,Emergency operation,Otherwise: synthetic assessment; appropriate treatment,Management,PrinciplesManagement,Management,Expectant management,-,proportion of all ectopics will 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 treatment, (methotrexate),given by injection,;,in form of systemic or local administration,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,ManagementExpectant management,Criteria for Expectant Management,Decreasing hCG titers (less than 1,0,00 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 healthy woman,Absence of fetal heart tones,PZ,Criteria for Expectant Managem,Methotrexate Treatment,Anti-metabolite drug,Inexpensive, easy to obtain, well tolerated,folic acid antagonist,The initial dose regimen,MTX (1 mg/kg IM ) or single IM dose of 50 mg/square meter,Dont exceed 4 doses,70-95% efficiency of cases treated,Methotrexate TreatmentAnti-me,Operation,Salpingectomy,Cutting the tube out,Salpingotomy,Making an incision on the tube and removing the pregnancy,Choosing operation modes according to patient,s condition.,OperationSalpingectomy Cutting,Other types of EP,Ovarian pregnancy,Abdominal pregnancy,Broad ligment pregnancy,Cervical pregnancy,Other types of EPOvarian pregn,A right tubal ectopic pregnancy seen at laparoscopy,The swollen right tube containing the ectopic pregnancy is on the right at E,The stump of the left tube is seen at L - this woman had a previous tubal ligation,A right tubal ectopic pregnanc,Close view of the,same ectopic,After laparoscopic resection of the tube, the tubal stump is seen at S,Close view of the After laparo,Right tubal ectopic,pregnancy in 11 th,week of gestation,Same situation after rupture,Right tubal ectopicSame situat,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,Laparoscopist must try to remo,The first step of this technique involves making a linear slit into the fallopian tube over the ectopic with a monopolar needle tip.,The first step of this techniq,Hyperemesis Gravidarum,Prolonged and severe nausea/ vomiting associated with dehydration, weight loss, or electrolyte disturbances when pregnancy。,1.0 of 1000 pregnancies。,Hyperemesis Gravidarum,Cause,：,Hormonal, neurological, metabolic, toxic, and psychosocial factors (underlying emotional disorder),Degree of biochemical hyperthyroidism,The level of beta-HCG,Cause：,Lab :,Ketonuria,Increased urine specific gravity,Elevated hematocrit and BUN level,Hyponatremia,Hypokalemia,Hypochloremia,Metabolic alkalosis,Lab :,Check,：,Urine,Blood (CBC/DC, electrolyte, ABG),Serum Beta-HCG,Thyroid function,Hyperthyroidism,Transient hyperthyroidism : self-limiting,Resolving by 18 weeks,Sonar,Check：,妇产科学ppt课件流产（英文版）,Management,（Severity of Symptom）,Indication for hospitalization,Intractable emesis,Correction of any electrolyte abnormalities,Hypovolemia,IV hydration,Anti-emetic drug (ex: Metoclopramide),Parental nutrition,Electrolyte supplement,Management （Severity of Sympto,Vitamin supplementation (thiamine B1),Wernockes encephalopathy,Oral feedings,Slowly when tolerated,Starting with clear liquids and progressing to a bland solid diet consisting of small, carbohydrate-rich meals,Avoidance of fatty and spicy foods,妇产科学ppt课件流产（英文版）,