双语-流产.ppt

1、Spontaneous abortion,自然流产,教学目的,了解病因和病理变化 熟悉不同发展阶段和处理 掌握几种特殊情况的临床表现,处理原则,教学要求,掌握流产的不同发展阶段和处理 掌握流产一系列过程中各阶段的临床表现及不同阶段的处理原则及鉴别诊断,教学内容,流产的定义 5分钟 流产发生的原因及流产时胎儿、母体的病理变化 5分钟 流产各不同阶段的临床类型及处理 15分钟 习惯性、感染性及过期流产等特殊类型的临床表现、诊断及处理 15分钟 流产的鉴别诊断 5分钟 总结 5分钟,复习,一.Definitions 定义,Spontaneous abortion is defined as a pr

2、egnancy terminating before the 20th completed week (139 days) of gestation. 妊娠不足28周，胎儿体重不足1000克而终止者。 分为早期流产（12周）、晚期流产（12-28周） * Early abortion occurs before 12 weeks and late abortion between 12 and 28 weeks.,Etiology 病因,Chromosomal abnormalities胚胎因素 Maternal systemic disease 母体因素 *全身性疾病 (eg,diabete

3、s , hyperthroidism) *内分泌异常Endocrine factors * 免疫功能异常Immunologic factors *生殖器异常Anatomic defects *创伤刺激 环境因素,三 病 理,胚胎死亡底蜕膜出血胚胎与蜕膜层分离排出。 妊娠8周 妊娠812周 妊娠12周后 底蜕膜反复少量出血,Pathology,Hemorrhage,Necrosis inflammation,Detachment,Abortion,妊娠8周，胎盘绒毛发育未成熟，与底蜕膜联系较松完整排出，出血不多。妊娠812周，胎盘绒毛发育茂盛，与底蜕膜联系较紧胚胎与蜕膜层分离不完整胚胎组织残留出

4、血较多。妊娠12周后，胎盘完全形成先腹痛，后排出胎儿、胎盘，出血不多。若底蜕膜反复少量出血血样胎块肉样胎块、纤维化与子宫壁粘连。,Classification 临床分型,Threatened abortion 先兆 Inevitable abortion 难免 Incomplete abortion 不全 Complete abortion 完全 Missed abortion 稽留 Habitual abortion 习惯性 Septic abortion 感染,Clinical presentations and therapy 临床表现,四 临床表现,主要症状是阴道出血、腹痛。 早期流产

5、先出血后腹痛，且全过程均伴有阴道出血。 晚期流产先腹痛后出血，流产过程与早产相似。 体征因妊周大小、流产过程不同而异。检查子宫大小、宫颈扩张与否、是否破膜、贫血程度等。,五 临床类型,先兆流产(threatened abortion) 阴道少量出血，下腹阵发性隐痛，宫口未开，胎膜未破，子宫大小与妊周相符。,Threatened abortion 先兆流产,The cervix remains closed, although slight bleeding or cramping may be noted. Place the patient at bed rest, interdict in

6、tercourse, and observe the patients progress. Drug therapy is generally ineffective in preventing abortion because so many of these uncertain pregnancies are abnormal. Progesterone use is controversial,The prognosis in the case of threatened abortion is good when all abnormal signsand symptoms disap

7、pear and when resumption of the progress of pregnancy is apparent.Ultrasonography is helpful in the management of threatened abortion by detecting fetal movement of heart beat.This prognostic sign is most reliable after 7 weeks gestation.,五 临床类型,难免流产(inevitable abortion) 出血增多，腹痛加重，宫口扩张，胎膜破裂，子宫大小与妊周相

8、符或略小。,B.Inevitable abortion 难免流产,Pain ( uterine cramping ) and bleeding with an open cervix indicate impending abortion; the expulsion of the uterine contents is imminent.Inevitable and incomplete abortion both require similar therapy.,五 临床类型,不全流产(incomplete abortion) 妊娠产物部分排出，持续阴道出血、量多，宫口扩张，子宫小于妊周。

9、,C.Incomplete abortion 不全流产,Retained tissue is evidenced by continued bleeding, a patulous cervix, and an enlarged, boggy uterus. Bleeding generally is persistent and is often severe enough to constitute frank hemorrhage. Tissue at the external os should beremoved with sponge forceps and examined by

10、 a pathologist. If abortion is complicated or hasoccurred after the first trimester, the patient may require hospitalization.,Type and cross-match for possible blood transfusion if bleeding is brisk or if the initial hemoglobin is less than 100g/L. The oxytocin contracts the uterus, aids in the expu

11、lsion of tissue or clots, and limits blood loss. D&C should be performed for possible retained tissue. Evacuate the uterus promptly.Suction D&C is most effective.,The prognosis for the mother is good if the retained tissue is promptly and completely evacuated.Rh-negative mothers who are candidates f

12、or Rh immune globulin should receive it as soon after the abortion as possible.,五 临床类型,完全流产(complete abortion) 妊娠产物完全排出，出血、腹痛渐停止消失，宫口关闭，子宫接近正常大小。,D.Complete abortion 完全流产,Marked by cessation of pain as well as termination of brisk bleeding. The conceptus be very carefullyexamined for completeness an

13、d for trophoblastic disease. The prognosis is excellent when all products of conception have been removed.,五 临床类型,稽留流产(missed abortion) 胚胎或胎儿已死亡未能自然排出而滞留宫内。早孕反应消失，子宫小于妊周，胎心、胎动消失。流产感染(septic abortion) 流产过程中合并局部感染、全身感染。多见于不全流产出血时间长者。,E.Missed abortion 稽留流产,Missed abortion implies that despite fetal de

14、ath the pregnancy has been retained. Manifested by loss of symptoms of pregnancy and a decrease in uterine size. The embryo or fetus has succumbed,but no tissue is passed. A brownish vaginal discharge The cervix remains firm and closed,and no adnexal abnormality can be identified.,Ultrasonography is

15、 effective for following a pregnancy suspected of being a missed abortion. The quantitative -HCG may decline. In markedly prolonged(4weeks) midtrimester missed abortion,absorption of the products of conception may result in a coagulopathy most notable for a low plasma fibrinogen. The differential di

16、agnosis of missed abnortion includes continued pregnancy,inaccurate dating of a continuing pregnancy,and pelvic tumor without pregnancy.,Currently a more interventional route is usually undertaken, with the uterus being evacuated soon after diagnosis. In the first trimester this is most frequently a

17、ccomplished by suction curettage, whereas in the second trimester evacuation is most frequently accomplished using prostaglandin E suppositories. If evidence of a seriously reduced fibrinogen level, infection, or anemia exists, appropriate therapy must also be instituted.,G.Septic abortion 流产合并感染,Ma

18、nifested by a malodorous discharge from the vagina and cervix, pelvic and abdominal pain,marked suprabubic tenderness,signs of peritonitis,tenderness with movement of the uterus or cervix. Fever Jaundice An elevated white blood count,五 临床类型,习惯性流产(habitual abortion) 自然流产连续发生3次，亦称复发性自然流产。每次流产多发生在同一孕月。

19、 早期流产原因：黄体功能不足、甲减、染色体异常等。 晚期流产原因：宫颈内口松弛、子宫畸形、子宫肌瘤等。,F.Habitual abortion 习惯性流产,Defined as 3 consecutive spontaneous pregnancy wastages.连续自然流产3次或以上者。 Recidive abortion is 2 consecutive spontanous pregnancy wastages. Etiology:Genetic,anatomic abnormalities(cervical incompetence, submucous leiomyomas),六

20、 诊 断,根据病史、临床表现、妇科检查多能确诊，还应区分其类型，决定处理方法。 辅助检查 超、hCG、P等。注意 动态观察,Essentials of diagnosis 诊断要点,Suprapubic pain 下腹痛 Vaginal bleeding 阴道流血 Cervical dilatation 宫颈扩张 Extrusion of products of conception 妊娠物排出 Disappearance of symptoms and signs of pregnancy Negative pregnancy test of quantitative HCG that is

21、 not properly increasing HCG 阳性 Adverse ultrasonic findings(eg,empty gestational sac,fetal disorganization,lack of fetal growth)B超,七 鉴别诊断,病 史 妇 科 检 查 类 型 出血量 下腹痛 组织排出 宫颈口 子宫大小 先兆流产 少 无或轻 无 闭 孕周 难免流产 中多 加剧 无 扩张 孕周 不全流产 少多 减轻 部分排出 扩张或闭 孕周 完全流产 少无 无 完全排出 闭 正常或稍大早期流产应与异位妊娠、葡萄胎、功血、子宫肌瘤鉴别诊断。,八 处 理,处理原则：一经

22、确诊，应根据其不同类型及时进行恰当的处理。先兆流产 卧床休息、禁忌性生活、心理治疗。黄体酮,HCG,Vic E, 孕康口服液等 治疗观察2周，决定下一步处理。,八 处 理,难免流产 一旦确诊，应尽早使胚胎及胎盘组织清出宫腔。 早期流产负压吸宫术。 晚期流产催产素、Ru486，必要时清宫。 不全流产 一旦确诊，应及时清宫。抗休克、预防感染等。 完全流产 如无感染，无须特殊处理。,八 处 理,稽留流产 处理前应检查血常规、PT、KPTT、3P试验等，备血。若凝血功能正常，应用雌激素35天，以提高子宫平滑肌对催产素的敏感性。子宫12孕周者，在超监视下清宫。子宫12孕周者，Ru486、催产素等引产，必

23、要时在超监视下清宫。若凝血功能异常，则纠正后，再行产科处理。,八 处 理,习惯性流产 应在孕前进行必要的相关检查，如卵巢功能、生殖道检查、双方染色体、血型鉴定等。若能纠正者，孕前治疗。 原因不明者，有妊娠征兆可按黄体功能不足给予Loton、hCG治疗，确定妊娠后继续用药超过原流产月份。,八 处 理,习惯性流产 对宫颈内口松弛、子宫畸形、子宫肌瘤者应孕前手术治疗。 对宫颈内口松弛已妊娠者，最好在孕1416周行宫颈内口环扎术，术后严密观察，以免宫颈裂伤。,八 处 理,感染流产 治疗原则 1 阴道出血不多，抗感染23天后清宫； 2 阴道出血多，在抗感染的同时，钳夹宫内残留物，减少出血量，待感染控制后再清宫。 3 合并感染性休克，应积极纠正休克。若感染控制不佳，应行手术治疗，必要时切除子宫。,Differential Diagnosis,Ectopic Pregnancy 异位 妊娠,Hydatidiform Mole 葡萄胎,Could you tell me the classification of spontanous abortion? 流产的类型和特点 处理原则? What are habitual abortion and missed abortion 习惯性流产 稽留流产,RELAX! ANY QUESTION ?,