AbortionEctopic PregnancyHyperemesis 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

• Abnormal karyotype: 50%• Maternal factors: infection (TORCH)

endocrine factors

immunologic factors

maternal systemic disease

anatomic defects

trauma• Toxic factors

Etiology

anatomic defects

• Hemorrhage into the decidua basalis

• Necrosis and inflammation

• Uterine contractions and cervical dilatation

• Expulsion of most or all of the products of conception

Pathology

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

Expulsion of some, but not all, of the products of conception

Expulsion of all of the products of conception

Bleeding severe

Clinical Findings

Missed Abortion

Septic Abortion

Embryo or fetus death, products of conception in utero

Infection of the uterus

Pain

Clinical Findings

Habitual Abortion

≥three times abortion

Laboratory Findings

Ultrasonography

Pregnancy tests

Blood count

Gestational sac and viable embryo with heart motion

HCG

Anemic

Complication

Life threatening

Severe hemorrhage

Infection

Intrauterine synechia

Perforation

Diagnosis

Medical history

Physical examination

Accessory examination

?

Threatened Abortion Inevitable

Incomplete Missed

Treatment

Threatened Abortion

Bed rest

Forbid sexual life

Progesterone

Treatment

InevitableAbortion

Dilatation and curettage

Oxytocin

Ultrasound

Antibiotics

pathological examination

Treatment

IncompleteAbortion

Dilatation and curettage

Promptly

Antibiotics

Blood type and cross-match

Fluid infusion

Treatment

Complete Abortion

Products of conception

Ultrasound

Bleeding

Examine

Treatment

Missed Abortion

DIC

Oxytocin

Dilatation and curettage

Estrogen

Second

Treatment

Habitual Abortion

Cause

Progesterone

Genetic error

Anatomic defect

Hormonal abnormalities

Infection

Systemic disease

Immunologic factors

Cervical cerclage

Treatment

Antibiotics

Cervical cultures

Septic Abortion

Dilatation and curettage

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 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%)

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

• Pregnancy tests (postive-82.5%)

• Hematocrit

• White blood cell count

• A negative test does not rule out an ectopic gestation

Special Examinations

• Utrasonically scanning

• Culdocentesis

• Dilatation and curettage

• Exploratory laparotomy

Differential Diagnosis

• Appendicitis• Salpingitis• Ruptured corpus luteum c

yst • 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

• 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

Complications

•Chronic salpingitis•Infertility or sterility•Intestinal obstruction may develop after hemoperitoneum and peritonitis

Tubal damage

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

Prolonged and severe nausea/ vomiting associated with dehydration, weight loss, or electrolyte disturbances when pregnancy

Definition

Etiology

•Unknown

•Hormonal, neurologic, metabolic, toxic,

and psychosocial factors (underlying

emotional disorder)

•Degree of biochemical hyperthyroidismh

•The level of beta-HCGlevel o

• 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

– Urine

– Blood

– Serum Beta-HCG (Molar pregnancy)

– Thyroid function

– Ultrasound

– EKG

– Fundus oculi

Diagnosis and Differential Diagnosis

• 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

Treatment