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AbortionEctopic PregnancyHyperemesis Gravidarum
Women Hospital , School of Medical, ZheJiang University Yang Xiao Fu
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Abortion
Spontaneous
abortion
Induced
abortion
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Abortion
• Defined as delivery occurring before the 28th completed week of gestation
• Fetus weighing less than 1000g
• US ( before the 20th completed week of gestation)
• Early abortion and late abortion
• 15% of clinically evident pregnancies
• 80% of abortions prior to 12 weeks’ gestation
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• Abnormal karyotype: 50%• Maternal factors: infection (TORCH)
endocrine factors
immunologic factors
maternal systemic disease
anatomic defects
trauma• Toxic factors
Etiology
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anatomic defects
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• Hemorrhage into the decidua basalis
• Necrosis and inflammation
• Uterine contractions and cervical dilatation
• Expulsion of most or all of the products of conception
Pathology
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Clinical Findings
Amenorrhea
Bleeding
Pain
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Clinical Findings
Threatened Abortion
Inevitable Abortion
Without cervical dilatation
Without extrusion of products of conception
Cervical dilatation
Without extrusion of products of conception
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Clinical Findings
Incomplete Abortion
Complete Abortion
Expulsion of some, but not all, of the products of conception
Expulsion of all of the products of conception
Bleeding severe
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Clinical Findings
Missed Abortion
Septic Abortion
Embryo or fetus death, products of conception in utero
Infection of the uterus
Pain
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Clinical Findings
Habitual Abortion
≥three times abortion
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Laboratory Findings
Ultrasonography
Pregnancy tests
Blood count
Gestational sac and viable embryo with heart motion
HCG
Anemic
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Complication
Life threatening
Severe hemorrhage
Infection
Intrauterine synechia
Perforation
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Diagnosis
Medical history
Physical examination
Accessory examination
?
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Threatened Abortion Inevitable
Incomplete Missed
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Treatment
Threatened Abortion
Bed rest
Forbid sexual life
Progesterone
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Treatment
InevitableAbortion
Dilatation and curettage
Oxytocin
Ultrasound
Antibiotics
pathological examination
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Treatment
IncompleteAbortion
Dilatation and curettage
Promptly
Antibiotics
Blood type and cross-match
Fluid infusion
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Treatment
Complete Abortion
Products of conception
Ultrasound
Bleeding
Examine
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Treatment
Missed Abortion
DIC
Oxytocin
Dilatation and curettage
Estrogen
Second
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Treatment
Habitual Abortion
Cause
Progesterone
Genetic error
Anatomic defect
Hormonal abnormalities
Infection
Systemic disease
Immunologic factors
Cervical cerclage
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Treatment
Antibiotics
Cervical cultures
Septic Abortion
Dilatation and curettage
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Ectopic pregnancy
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Definition
A fertilized ovum implants in an area other than the endometrial lining of the uterus.
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Animation of intrauterine implantation
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Animation of ectopic implantation
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Sites of ectopic pregnancy
>95% ectopic
pregs in fallopian
tubes
70% ampulla
12% isthmic
11.1% fimbrial
3.2% ovarian
2.4% interstitial
1.3% abdominal
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Etiology
• Tubal Factors (salpingitis, previous tubal surgery)
• Zygote Abnormalities (chromosomal abnormalities)
• Ovarian Factors (ovum into contralateral tube)
• Exogenous Hormone (oral contraceptives)• Other Factors (endometriosis, IUD)
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Pathology
• Lackage of resistance to invasion by the trophoblast
• Abdominal pregnancy -1:15000 pregnancies
• Enlarged uterus and endometrium changes
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Termination of the pregnancy
Abortion
Rupture
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Temination of the pregnancy
• Tubal:abortion or missed abortion
• Interstitial,Angular,Cornual:rupture into the uterine cavity,the broad ligament or the peritoneal cavity.
• Cervical:rupture into the cervical canal
• Abdominal:rupture into the peritoneal cavity,into the retroperitoneal space
• Ovarian:rupture into the peritoneal cavity
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Clinical Findings
• Symptoms of early pregnancy (amenorrhea, breast tenderness, and nausea)
• Bleeding (usually spotting)
• Diffuse lower abdominal pain
• Over 15% of ectopic pregnant as surgical emergencies.
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Symptoms
Pain• Pelvic or lower abdo
minal pain (99%)• Generalized pain (44
%)• Unilateral lower abd
ominal pain (33%)• Subdiaphragmatic p
ain or sharp shoulder pain (22%)
Abnormal uterine bleeding (75%)
Secondary amenorrhea (68%)
Syncope (37%)
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Signs
• Abdominal tenderness (80%)
• Adnexal tenderness (75%)
• Adnexal mass(a unilateral adnexal mass:53%)
• Uterine changes (normal size:71%,6-8 weeks’ size:26%, 9-12 weeks’ size:3%)
• Fever (only about 2% of patients)
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Laboratory Findings
• Pregnancy tests (postive-82.5%)
• Hematocrit
• White blood cell count
• A negative test does not rule out an ectopic gestation
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Special Examinations
• Utrasonically scanning
• Culdocentesis
• Dilatation and curettage
• Exploratory laparotomy
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Differential Diagnosis
• Appendicitis• Salpingitis• Ruptured corpus luteum c
yst • Uterine abortion• Twisted ovarian cyst• Urinary tract disease• Degenerating leiomyomas
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Essentials of Diagnosis
• Amenorrhea followed by irregular vaginal bleeding
• Adnexal tenderness or mass
• Ultrasonographic evidence of adnexal mass and no intrauterine gestation
• Positive ß-hCG
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Complications
• About I in 1000 ectopic pregnancies result in maternal death
• Untreated or mistreated ruptured ectopic tubal pregnancy 8-12% of all materal deaths
• The majority of these deaths are preventable
Death
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Complications
•Chronic salpingitis•Infertility or sterility•Intestinal obstruction may develop after hemoperitoneum and peritonitis
Tubal damage
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Treatment
• Emergency Treatment
Immediate surgery,anti-shock(warm,oxygen)• Surgical treatment
laparoscopic techniques• Medical treatmemt-MTX• Supportive treatment
antibiotic,iron therapy,
a high-protein diet
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Salpingectomy
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Indications for Conservative Drug Therapy
• No signs of active intra-abdominal bleeding
• Diameter of mass < 3cm• Serum ß-hCG < 2000U/L• No embryonic blood vessle pounding• No contraindication for MTX application• Normal liver and kidney function• Normal RBC count
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Prognosis
• Another tubal pregnancy will occur in 10-20% of patients treated
• Infertility develops in approximately 50% of patients
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Hyperemesis Gravidarum
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Prolonged and severe nausea/ vomiting associated with dehydration, weight loss, or electrolyte disturbances when pregnancy
Definition
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Etiology
•Unknown
•Hormonal, neurologic, metabolic, toxic,
and psychosocial factors (underlying
emotional disorder)
•Degree of biochemical hyperthyroidismh
•The level of beta-HCGlevel o
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• Severe nausea, Waste Away
• Ketonuria, Increased urine specific gravity
• Elevated hematocrit and BUN level
• Hyponatremia,Hypokalemia,Hypochloremia
• Metabolic acidosis
• Wernicke-Korsakoff
• Deficiency of VitaminK
Clinical Findings
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– Urine
– Blood
– Serum Beta-HCG (Molar pregnancy)
– Thyroid function
– Ultrasound
– EKG
– Fundus oculi
Diagnosis and Differential Diagnosis
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• Indication for hospitalization
Intractable emesis, Correction of any
electrolyte abnormalities ,
Hypovolemia
• IV hydration
• Parental nutrition
• Electrolyte supplement
Treatment
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• Vitamin supplementation ( B1 )—— Wernocke’s encephalopathy
• NaHCO3
• Oral feedings
• Terminal pregnancy
Treatment
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