流产异位妊娠(英文)-AbortianandEctopicPregnancy-尧良清.ppt

AbortionandEctopicPregnancy,Liang-QingYaoObstetricsandGynecologyHospitalofFudanUniversity,Abortion,Concept,Apregnancylossbefore28weeksofgestationwhilefetalweightunder1000gramsEarlyAbortion：pregnancylossbefore12gestationalweeksLateAbortion:pregnancylossduring1228gestationalweeksSpontaneousAbortionArtificialAbortion,GeneticdefectMaternalfactors:systematicdisease;genitalorgananomalies;endocrineanomalies;irritation;badhabitImmuneanomaliesEnvironmentalfactors,Etiology,Pathology,Before8weeks:chorionicvilliimmatureFetaldeathbasaldecidualbleedinguterinecontractionexpulsionofalltheproductsofconception,lightbleedingDuring812weeks：withfirmattachmenttothebasaldeciduaPartialexpulsionoftheproductsofconceptionnon-idealuterinecontraction,severebleedingAfter12weeks:placentafullyformed.Uterinecontractionexpulsionofalltheproductsofconception，lightbleeding,Symptoms,Amenorrhea,vaginalbleeding,andabdominalpainEarlyabortion：vaginalbleedingprecedingabdominalpainLateabortion：abdominalpainprecedingvaginalbleeding,TypesofAbortion,ThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionMissedAbortionHabitualAbortionSepticAbortion,ClinicalPresentations,ThreatenedAbortionlightvaginalbleedingwithmildabdominalpaincervicalosclosed,fetalmembranesunbrokentreatmentmightwork,continuepregnancyInevitableAbortionbleedingheavier,abdominalpainmoresevere,orfluidpassedcervicalosopen，pregnancytissuevisibleabortionisinevitable,IncompleteAbortionheavyvaginalbleedingpregnancytissueprotrudingfromthecervicalosuterussmallforthepresumedgestationalweekCompleteAbortionvaginalbleedingdecreasing,abdominalpainalleviatingcervicaloscloseduterusnormalforthepresumedgestationalweek,DifferentStagesofAbortion,threatenedabortioncontinuepregnancyinevitableabortionincompleteabortioncompleteabortion,Diagnosis,HistoryPhysicalExaminationLaboratoryAssessment:ultrasoundpregnancytesthormonelevel:serumprogesterone,Management,ThreatenedAbortionbedrest,sedationantiabortion：progesterone，HCG；VitE；thyroxinesupplementmonitoring：ultrasound；serumHCGwhethertocontinuepregnancyInevitableAbortiononcediagnosed，removethepregnancytissueasquicklyaspossiblesuctioncurettage,IncompleteAbortionperformsuctioncurettagepromptlyifwithheavybleeding：bloodtransfusion；preventiveantibioticuseCompleteAbortionnoretainedproductsofconceptionconfirmedbyultrasound；noinfectionnoneedforspecialmanagement,MissedAbortion,Concept:inuterodeathoftheembryoorfetuswithretainedproductsofconceptionClinicalManifestation:uterineenlargementceasingorfetalmovementdisappearingcervicalosclosed,uterussmallforthepresumedgestationalagenofetalheartbeat;embryonicdemisesuggestedbyultrasoundfindings,Management,bloodroutineexamination,coagulationfunctiontestcorrectingcoagulationdefects：heparin,fibrinogen,etc.sensitizingtheuterus：diethylstilbestroltransfusionpreparation;emptyingtheuterus：before12weeks:suctioncurettageafter12weeks：inductionoflabor,HabitualAbortion,Theoccurrenceof3ormoreconsecutivespontaneousabortionsTheoccurrenceof2spontaneousabortionsisdefinedasrecurrentabortionEarlyabortion：chromosomalabnormalities，immunologicfactors，luteal-phaseinsufficiency,hypothyroidismLateabortion：congenitaluterineanomalies，cervicalincompetence，uterinefibroids,etc.,Management,obtaininformationonetiologyforpriorlossesbeforeconceptiongeneticcounselingcervicalincompetence：cervicalcerclageduring1418weeksofgestationwithunclearcauses：progesteronetherapyuntil10weeksofgestationactiveimmunotherapy：intradermicinjectionoflymphocytes,SepticAbortion,Prolongedbleedingduringabortionorretainedproductsofconceptionleadtointrauterineinfection,whichmightprogressintopelvicinflammatorydisease,peritonitisorevensepsisifnottreatedAntibiotictreatment+Promptevacuationwithoutseverebleeding:managementofinfection,performanceofsuctionandcurettagewithseverebleeding：managementofinfectionwhileapplyingforceps,withsecondarysuctionandcurettage,EctopicPregnancy,Concept,EctopicPregnancy:implantationofthefertilizedovumintissueotherthantheendometriumExtrauterinePregnancyincluding：tubalpregnancy(95),ovarianpregnancy,cornualpregnancy,cervicalpregnancy,abdominalpregnancy,etc.oneofthemaincausesofacuteabdomenanddeath,EtiologyandRiskFactors,tubalinflammation,pelvicinflammationprevioustubalsurgery：forinfertility,tubalpregnancy,etc.IVFfailureofcontraception：currentuseofIUDororalcontraceptivestubalundergrowthordysfunctionotherfactors：endometriosis,hysteromyoma,smoking,etc.,Endingsoftubalpregnancy,abortion：812weeksrupture：1216weekssecondaryabdominalpregnancyChronicectopicpregnancyPersistentectopicpregnancy,PathologyoftheUterus,enlargementandsofteningamenorrheavaginalbleedingtheArias-Stellareactionoftheendometriumbutnochorionicvilli,ClinicalPresentations-Symptoms,AmenorrheaAbdominalpain：time,characteristicsVaginalbleedingFaint/shock,ClinicalPresentations-Signs,GeneralconditionAbdomenexaminationPelvicexamination：cervicalmotiontenderness，sensationofafloatinguterus，adnexalmass,etc.,LaboratoryAssessment,HCG:urinaryHCG；theriseintheserum-HCGlevelover48hours66serumprogesterone：only1.5%25ng/mlultrasound：theemptyuterussign；adnexalcardiacactivityorultrasonographiclucency;presenceofcul-de-sacfluid,culdocentesis：nonclottingbloodlaparoscopy：goldstandard，diagnosistreatmentearlydiagnosismissedin34ofpatientsusewithcaution：toavoidanestheticandsurgicalrisks；medicaltherapyasanoptionUterinecurretage：profusevaginalbleeding;intrauterinepregnancyloss,DifferentialDiagnosis,SurgicalTreatment,Radicaloperation：hemodynamicallyunstable;interstitialpregnancy;tubalruptureConservativeoperation：withwishestoretainpotentialforfertilitymilkingorlinearsalpingostomyMTX,MedicalTreatment,principle：inhibitingproliferationoftrophoblastictissueindication：nocontraindicationtochemotherapy；noruptureorabortion；mass4cm；serum-HCG2000U/L；noobviousinternalbleeding；nodemonstrationofcardiacactivityorembryonicbud,MedicalTreatment,Protocol：MTX150mg，giveaseconddoseonday7ifnecessaryMonitoringtherapeuticeffectiveness：ifdeclineinserumhCGlevelonday725%；15%orsymptomsworseningorinternalbleedingoccurring;2weeksuntilnegative,Expectanttreatment,Painmild，bleedinglight；Noevidenceoftubalrupture；Nointraabdominalbleeding；Serum-HCG1000U/L，andcontinuedeclining;Pregnancymass3cmorundetected；Follow-upreliable,NontubalEctopicPregnancy,CervicalPregnancy,Concept：implantationofthedevelopingconceptusinthecervicalcanalIncidence：1：18000Clinicalfeature：painlessvaginalbleedingDiagnosticcriteria：theuterinesizeiscomparabletothatofanunpregnantone;thepresenceofpregnancytissuerelatedexclusivelytothecervicalcanal；curretageoftheendometrialcavityisnonproductiveofpregnancytissueTreatmentprinciple：transfusionpreparation;curretageorsuctioncurretage;MTXand/oruterinecurretage,OvarianPregnancy,AconditioninwhichanectopicpregnancyimplantswithintheovariancortexDiagnosticcriteria：thefallopiantubeontheaffectedsidemustbeintact；thefetalsacmustoccupythepositionoftheovary；ovariantissuemustbelocatedinthesacwall；theovaryandfetalsacmustbeconnectedtotheuterusbytheovarianligament,OvarianPregnancy,Clinicalpresentations：amenorrhea,abdominalpain,vaginalbleeding，shock,etc.Differentiatedfrom：rupturedcorpusluteum；tubalpregnancyTreatmentpri