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,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Abortion and Ectopic Pregnancy,Liang-Qing Yao,Obstetrics and Gynecology Hospital of Fudan University,Abortion,Concept,A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 grams,Early Abortion,：,pregnancy loss before 12,gestational weeks,Late Abortion: pregnancy loss,during 12,28,gestational weeks,Spontaneous,Abortion,Artificia,l Abortion,Genetic defect,Maternal factors:,systematic disease; genital organ anomalies; endocrine anomalies; irritation; bad,habit,Immune anomalies,Environmental factors,Etiology,Pathology,Before 8 weeks:,chorionic villi immature,Fetal death,basal decidual bleeding,uterine contraction,expulsion of all the products of conception, light bleeding,During 8,12,weeks,：,with firm attachment to the basal decidua,Partial expulsion of the products of conception,non-ideal uterine contraction, severe bleeding,After 12,weeks:,placenta fully formed.,Uterine contraction,expulsion of all the products of conception,，,light bleeding,Symptoms,Amenorrhea, vaginal bleeding , and abdominal pain,Early abortion,：,vaginal bleeding preceding abdominal pain,Late abortion,：,abdominal pain preceding vaginal bleeding,Types of Abortion,Threatened,Abortion,Inevitable Abortion,Incomplete,Abortion,Complete Abortion,Missed Abortion,Habitual,Abortion,Septic Abortion,Clinical Presentations,Threatened Abortion,light vaginal bleeding with mild abdominal pain,cervical os closed, fetal membranes unbroken,treatment might work , continue pregnancy,Inevitable Abortion,bleeding heavier, abdominal pain more severe, or fluid passed,cervical os open,，,pregnancy tissue visible,abortion is inevitable,Incomplete Abortion,heavy vaginal bleeding,pregnancy tissue protruding from the cervical os,uterus small for the presumed gestational week,Complete Abortion,vaginal bleeding decreasing, abdominal pain alleviating,cervical os closed,uterus normal for the presumed gestational week,Different Stages of Abortion,threatened abortion,continue pregnancy,inevitable abortion incomplete abortion,complete abortion,Diagnosis,History,Physical Examination,Laboratory Assessment:,ultrasound,pregnancy test,hormone level: serum progesterone,Bleeding,Abdominal Pain,Tissue Expulsion,Cervical Os,Uterus,Threatened Abortion,Inevitable Abortion,Incomplete,Abortion,Complete Abortion,Light,Mild to heavy,Light to heavy,Light to none,None/light,Intensified,Relieved,None,None,None,Partial,Complete,Closed,Dilated,Dilated or obstructed,Closed,Normal,Normal or slightly small,Small,Normal or slightly large,History Pelvic Examination,Management,Threatened Abortion,bed rest,sedation,anti abortion,：,progesterone,，,HCG,；,Vit E,；,thyroxine supplement,monitoring,：,ultrasound,；,serum HCG whether to continue pregnancy,Inevitable Abortion,once diagnosed,，,remove the pregnancy tissue as quickly as possible,suction curettage,Incomplete Abortion,perform suction curettage promptly,if with heavy bleeding,：,blood transfusion,；,preventive antibiotic use,Complete Abortion,no retained products of conception confirmed by ultrasound,；,no infection,no need for special management,Missed Abortion,Concept: in utero death of the embryo or fetus with retained products of conception,Clinical Manifestation:,uterine enlargement ceasing or fetal movement disappearing,cervical os closed, uterus small for the presumed gestational age,no fetal heartbeat ; embryonic demise suggested by ultrasound findings,Management,blood routine examination,coagulation function test,correcting coagulation defects,：,heparin, fibrinogen, etc.,sensitizing the uterus,：,diethylstilbestrol,transfusion preparation; emptying the uterus,：,before 12 weeks: suction curettage,after 12 weeks,：,induction of,labor,Habitual Abortion,The occurrence of 3 or more consecutive spontaneous abortions,The occurrence of 2 spontaneous abortions is defined as recurrent abortion,Early abortion,：,chromosomal abnormalities,，,immunologic factors,，,luteal-phase insufficiency, hypothyroidism,Late abortion,：,congenital uterine anomalies,，,cervical incompetence,，,uterine fibroids, etc,.,Management,obtain information on etiology for prior losses before conception,genetic counseling,cervical incompetence,：,cervical,cerclage,during 14,18 weeks of gestation,with unclear causes,：,progesterone therapy until 10 weeks of gestation,active immunotherapy,：,intradermic injection of lymphocytes,Septic Abortion,Prolonged bleeding during abortion or retained products of conception lead to intrauterine infection, which might progress into pelvic inflammatory disease, peritonitis or even sepsis if not treated,Antibiotic treatment + Prompt,evacuation,without severe bleeding: management of infection , performance of suction and curettage,with severe bleeding,：,management of infection while,applying forceps, with secondary suction and curettage,Ectopic Pregnancy,Concept,Ectopic Pregnancy: implantation of the fertilized ovum in tissue other than the endometrium,Extrauterine Pregnancy,including,：,tubal pregnancy (95,), ovarian pregnancy,cornual pregnancy, cervical pregnancy, abdominal pregnancy, etc.,one of the main causes of acute abdomen and death,Etiology and Risk Factors,tubal inflammation, pelvic inflammation,previous tubal surgery,：,for infertility, tubal pregnancy, etc.,IVF,failure of contraception,：,current use of IUD or oral contraceptives,tubal undergrowth or dysfunction,other factors,：,endometriosis, hysteromyoma, smoking, etc.,Endings of tubal pregnancy,abortion,：,8,12,weeks,rupture,：,12,16 weeks,secondary abdominal pregnancy,Chronic ectopic pregnancy,Persistent ectopic pregnancy,Pathology of the Uterus,enlargement and softening,amenorrhea,vaginal bleeding,the Arias-Stella reaction of the endometrium but no chorionic villi,Clinical Presentations-Symptoms,Amenorrhea,Abdominal pain,：,time, characteristics,Vaginal bleeding,Faint/shock,Clinical Presentations-Signs,General condition,Abdomen examination,Pelvic examination,：,cervical motion tenderness,，,sensation of a floating uterus,，,adnexal mass, etc.,Laboratory Assessment,HCG: urinary HCG,；,the rise in the serum,-HCG level over 48,hours,66,serum progesterone,：,only 1.5%25ng/ml,ultrasound,：,the empty uterus sign,；,adnexal cardiac activity or ultrasonographic lucency ; presence of cul-de-sac fluid,culdocentesis,：,nonclotting blood,laparoscopy,：,gold standard,，,diagnosis,treatment,early diagnosis missed in 3,4,of patients,use with caution,：,to avoid anesthetic and surgical risks,；,medical therapy as an option,Uterine curretage,：,profuse vaginal bleeding; intrauterine pregnancy loss,Differential Diagnosis,Ectopic pregnancy,abortion,Adnexal inflammation,Appendicitis,Corpus luteum rupture,Ovary cyst torsion,1.Amenorrhea,2.Abdominal pain,3.Bleeding,4.Shock,5.Body temperature,6.Pelvic examinatioon,7.WBC,8.Hb,9.HCG,10.Ultrasound,11.Culdocentesis,Surgical Treatment,Radical operation,：,hemodynamically unstable ; interstitial pregnancy; tubal rupture,Conservative operation,：,with wishes to retain potential for fertility,milking or linear,salpingostomy,MTX,Medical Treatment,principle,：,inhibiting proliferation of trophoblastic tissue,indication,：,no contraindication to chemotherapy,；,no rupture or abortion,；,mass,4cm,；,serum,-HCG,2000U/L,；,no obvious internal bleeding,；,no demonstration of cardiac activity or embryonic bud,Medical Treatment,Protocol,：,MTX150 mg,，,give a second dose on day 7 if necessary,Monitoring therapeutic effectiveness,：,if decline in serum hCG level on day 7,25%,； ,15% or symptoms worsening or internal bleeding occurring; 2 weeks until negative,Expectant treatment,Pain mild,，,bleeding light,；,No evidence of tubal rupture,；,No intraabdominal bleeding,；,Serum,-HCG 1000U/L,，,and continue declining;,Pregnancy mass,3cm or undetected,；,Follow-up reliable,Nontubal Ectopic Pregnancy,Cervical Pregnancy,Concept,：,implantation of the developing conceptus in the cervical canal,Incidence,：,1,：,18000,Clinical feature,：,painless vaginal bleeding,Diagnostic 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 nonproductive of pregnancy tissue,Treatment principle,：,transfusion preparation; curretage or suction curretage,; MTX and/or uterine curretage,Ovarian Pregnancy,A condition in which an ectopic pregnancy implants within the ovarian cortex,Diagnostic criteria,：,the fallopian tube 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 ligament,Ovarian Pregnancy,Clinical presentations,：,amenorrhea, abdominal pain, vaginal bleeding,，,shock, etc.,Differentiated from,：,ruptured corpus luteum,；,tubal pregnancy,Treatment principle,：,surgical treatment,Abdominal Pregnancy,The presence of a pregnancy related to a peritoneal surface other than fallopian tube, ovary or broad ligament,，,1,：,15000,Classification,：,primary, secondary,Clinical presentations,：,amenorrhea, abdominal pain and vaginal bleeding,；,fetus.,Treatment principle,：,remove the fetus,placenta management,transfusion, prevent infection,attached to the uterus, fallopian tube,attached to peritoneum , mesenterium,（,4 weeks; long been dead,）,Questions,Describe the clinical presentations of different stages of abortion,？,Summarize treatment principles of habitual, septic and missed abortions,？,What conditions should be differentiated from tubal pregnancy their respective differential points,？,What does laboratory assessment for Ectopic pregnancy include,？,Summarize the treatment for tubal pregnancy and its choice,？,Missed abortion, cervical pregnancy?,Thank you,！,
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