1、Abortion and Ectopic Pregnancy,Liang-Qing YaoObstetrics and Gynecology Hospital of Fudan University,Abortion,Concept,A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 gramsEarly Abortion：pregnancy loss before 12 gestational weeks Late Abortion: pregnancy loss during 1228 ge
2、stational weeks Spontaneous Abortion Artificial Abortion,Genetic defectMaternal factors:systematic disease; genital organ anomalies; endocrine anomalies; irritation; bad habitImmune anomaliesEnvironmental factors,Etiology,Pathology,Before 8 weeks: chorionic villi immatureFetal deathbasal decidual bl
3、eeding uterine contractionexpulsion of all the products of conception, light bleedingDuring 812 weeks：with firm attachment to the basal decidua Partial expulsion of the products of conception non-ideal uterine contraction, severe bleedingAfter 12 weeks: placenta fully formed. Uterine contraction exp
4、ulsion of all the products of conception，light bleeding,Symptoms,Amenorrhea, vaginal bleeding , and abdominal painEarly abortion：vaginal bleeding preceding abdominal pain Late abortion：abdominal pain preceding vaginal bleeding,Types of Abortion,Threatened Abortion Inevitable Abortion Incomplete Abor
5、tion Complete AbortionMissed 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 Abortionbleeding heavier, abdominal pai
6、n 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 all
7、eviating cervical os closed uterus normal for the presumed gestational week,Different Stages of Abortion,threatened abortion continue pregnancyinevitable abortion incomplete abortioncomplete abortion,Diagnosis,HistoryPhysical ExaminationLaboratory Assessment:ultrasound pregnancy test hormone level:
8、serum progesterone,Management,Threatened Abortion bed rest, sedation anti abortion：progesterone，HCG；Vit E；thyroxine supplement monitoring：ultrasound；serum HCG whether to continue pregnancyInevitable Abortion once diagnosed，remove the pregnancy tissue as quickly as possible suction curettage,Incomple
9、te Abortion perform suction curettage promptly if with heavy bleeding：blood transfusion；preventive antibiotic useComplete 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 wit
10、h 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, coagulat
11、ion function test correcting coagulation defects：heparin, fibrinogen, etc. sensitizing the uterus： diethylstilbestrol transfusion preparation; emptying the uterus：before 12 weeks: suction curettageafter 12 weeks：induction of labor,Habitual Abortion,The occurrence of 3 or more consecutive spontaneous
12、 abortions The occurrence of 2 spontaneous abortions is defined as recurrent abortionEarly abortion：chromosomal abnormalities，immunologic factors，luteal-phase insufficiency, hypothyroidism Late abortion：congenital uterine anomalies，cervical incompetence，uterine fibroids, etc.,Management,obtain infor
13、mation on etiology for prior losses before conception genetic counseling cervical incompetence：cervical cerclage during 1418 weeks of gestation with unclear causes：progesterone therapy until 10 weeks of gestation active immunotherapy：intradermic injection of lymphocytes,Septic Abortion,Prolonged ble
14、eding during abortion or retained products of conception lead to intrauterine infection, which might progress into pelvic inflammatory disease, peritonitis or even sepsis if not treatedAntibiotic treatment + Prompt evacuation without severe bleeding: management of infection , performance of suction
15、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 endometriumExtrauterine Pregnancyincluding：tubal pregnancy (95), ovarian p
16、regnancy, 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
17、 or oral contraceptives tubal undergrowth or dysfunction other factors：endometriosis, hysteromyoma, smoking, etc.,Endings of tubal pregnancy,abortion：812 weeks rupture：1216 weekssecondary abdominal pregnancyChronic ectopic pregnancy Persistent ectopic pregnancy,Pathology of the Uterus,enlargement an
18、d softening amenorrheavaginal bleeding the Arias-Stella reaction of the endometrium but no chorionic villi,Clinical Presentations-Symptoms,AmenorrheaAbdominal pain：time, characteristicsVaginal bleedingFaint/shock,Clinical Presentations-Signs,General conditionAbdomen examinationPelvic examination：cer
19、vical motion tenderness，sensation of a floating uterus ，adnexal mass, etc.,Laboratory Assessment,HCG: urinary HCG；the rise in the serum -HCG level over 48 hours66serum progesterone：only 1.5%25ng/mlultrasound：the empty uterus sign；adnexal cardiac activity or ultrasonographic lucency ; presence of cul
20、-de-sac fluid,culdocentesis：nonclotting bloodlaparoscopy：gold standard，diagnosistreatmentearly diagnosis missed in 34 of patients use with caution：to avoid anesthetic and surgical risks；medical therapy as an optionUterine curretage：profuse vaginal bleeding; intrauterine pregnancy loss,Differential D
21、iagnosis,Surgical Treatment,Radical operation：hemodynamically unstable ; interstitial pregnancy; tubal ruptureConservative operation：with wishes to retain potential for fertility milking or linear salpingostomyMTX,Medical Treatment,principle：inhibiting proliferation of trophoblastic tissueindication
22、：no contraindication to chemotherapy ；no rupture or abortion；mass4cm；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 necessaryMonitoring therapeutic effectiveness：if decline in s
23、erum hCG level on day 725%； 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 mass3cm or undetected； Follow-up r
24、eliable,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
25、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 th
26、e ovarian cortexDiagnostic 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 pre
27、sentations：amenorrhea, abdominal pain, vaginal bleeding，shock, etc.Differentiated from：ruptured corpus luteum；tubal pregnancyTreatment principle：surgical treatment,Abdominal Pregnancy,The presence of a pregnancy related to a peritoneal surface other than fallopian tube, ovary or broad ligament， 1：15
28、000 Classification：primary, secondary Clinical presentations：amenorrhea, abdominal pain and vaginal bleeding；fetus. Treatment principle：remove the fetusplacenta managementtransfusion, prevent infectionattached to the uterus, fallopian tubeattached to peritoneum , mesenterium（4 weeks; long been dead）
29、,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！,
