Transcript Abortion Ectopic Pregnancy Hyperemesis Gravidarum Women Hospital , School of Medical,

Abortion
Ectopic Pregnancy
Hyperemesis Gravidarum
Women Hospital , School of Medical,
ZheJiang University
Yang Xiao Fu
Abortion
Spontaneous
abortion
Induced
abortion
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
Etiology
• Abnormal karyotype: 50%
• Maternal factors: infection (TORCH)
endocrine factors
immunologic factors
maternal systemic disease
anatomic defects
trauma
• Toxic factors
anatomic defects
Pathology
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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
Clinical Findings
Amenorrhea
Bleeding
Pain
Clinical Findings
Threatened
Abortion
Inevitable
Abortion
Without cervical dilatation
Without extrusion of
products of conception
Cervical dilatation
Without extrusion of
products of conception
Clinical Findings
Incomplete
Abortion
Complete
Abortion
Bleeding
severe
Expulsion of some, but
not all, of the products of
conception
Expulsion of all of the
products of conception
Clinical Findings
Missed
Abortion
Embryo or fetus death,
products of conception in
utero
Pain
Septic
Abortion
Infection of the uterus
Clinical Findings
Habitual
Abortion
≥three times
abortion
Laboratory Findings
Ultrasonography
Gestational sac and
viable embryo with
heart motion
Pregnancy tests
HCG
Blood count
Anemic
Complication
Life
threatening
Infection
Intrauterine
synechia
Perforation
Severe
hemorrhage
Diagnosis
Medical history
Physical
examination
Accessory
examination
?
Threatened Abortion
Incomplete
Inevitable
Missed
Treatment
Threatened
Abortion
Bed rest
Forbid sexual life
Progesterone
Treatment
Dilatation and
curettage
Inevitable
Abortion
Oxytocin
Ultrasound
Antibiotics
pathological
examination
Treatment
Dilatation and
curettage
Incomplete
Abortion
Blood type and
cross-match
Fluid infusion
Antibiotics
Promptly
Treatment
Products of
conception
Complete
Abortion
Ultrasound
Bleeding
Examine
Treatment
DIC
Estrogen
Missed
Abortion
Dilatation and
curettage
Oxytocin
Second
Treatment
Habitual
Abortion
Genetic error
Cause
Anatomic defect
Hormonal abnormalities
Infection
Systemic disease
Immunologic factors
Cervical cerclage
Progesterone
Treatment
Septic
Abortion
Antibiotics
Dilatation and
curettage
Cervical cultures
Ectopic pregnancy
Definition
A fertilized ovum implants in an area
other than the endometrial lining of
the uterus.
Animation of intrauterine
implantation
Animation of ectopic implantation
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
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)
Pathology
• Lackage of resistance to invasion by the
trophoblast
• Abdominal pregnancy -1:15000
pregnancies
• Enlarged uterus and endometrium
changes
Termination of the pregnancy
Abortion
Rupture
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
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.
Symptoms
Pain
• Pelvic or lower
abdominal pain (99%)
• Generalized pain
(44%)
• Unilateral lower
abdominal pain (33%)
• Subdiaphragmatic
pain or sharp
shoulder pain (22%)
Secondary
amenorrhea (68%)
Abnormal uterine
bleeding (75%)
Syncope (37%)
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)
Laboratory Findings
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Pregnancy tests (postive-82.5%)
Hematocrit
White blood cell count
A negative test does not rule out an
ectopic gestation
Special Examinations
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Utrasonically scanning
Culdocentesis
Dilatation and curettage
Exploratory laparotomy
Differential Diagnosis
• Appendicitis
• Salpingitis
• Ruptured corpus luteum
cyst
• Uterine abortion
• Twisted ovarian cyst
• Urinary tract disease
• Degenerating leiomyomas
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
Complications
Death
• 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
Complications
Tubal damage
•Chronic salpingitis
•Infertility or sterility
•Intestinal obstruction
may develop after
hemoperitoneum and
peritonitis
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
Salpingectomy
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
Prognosis
• Another tubal pregnancy will occur in
10-20% of patients treated
• Infertility develops in approximately
50% of patients
Hyperemesis Gravidarum
Definition
Prolonged and severe
nausea/ vomiting
associated with
dehydration, weight
loss, or electrolyte
disturbances when
pregnancy
Etiology
• Unknown
• Hormonal, neurologic, metabolic, toxic,
and psychosocial factors (underlying
emotional disorder)
• Degree of biochemical hyperthyroidismh
• The level of beta-HCGlevel o
Clinical Findings
• Severe nausea, Waste Away
• Ketonuria, Increased urine specific gravity
• Elevated hematocrit and BUN level
• Hyponatremia,Hypokalemia,Hypochloremia
• Metabolic acidosis
• Wernicke-Korsakoff
• Deficiency of VitaminK
Diagnosis and Differential
Diagnosis
– Urine
– Blood
– Serum Beta-HCG (Molar pregnancy)
– Thyroid function
– Ultrasound
– EKG
– Fundus oculi
Treatment
• Indication for hospitalization
Intractable emesis, Correction of any
electrolyte abnormalities ,
Hypovolemia
• IV hydration
• Parental nutrition
• Electrolyte supplement
Treatment
• Vitamin supplementation（ B1 ）——
Wernocke’s encephalopathy
• NaHCO3
• Oral feedings
• Terminal pregnancy