10級大5上婦產(chǎn)科學(xué)06-1abortion

1、AbortionDepartment of Obstetrics and Gynecology, the Second Affiliated Hospital，Chongqing Medical UniversityDefinitionTermination of pregnancy prior to 28th week gestation or the weight of fetus less than 1000g CategoryBy the way of terminationspontaneous abortion (自然流產(chǎn)） artificial abortion （人工流產(chǎn)）By

2、 the time of terminationearly abortion (12th week gestation)clinically silent miscarriages (chemical pregnancy生化妊娠): occurs before next menstrual cyclelate abortion (12th 28th week gestation)Incidence31% of all conceptions abort spontaneously after implantation80% occur as early abortionEtiologyFeta

3、l factorsMaternal factorsPaternal factorsEnvironmental factorsFetal factorsChromosomal abnormalities (number or structure)Most common in early abortion, 50%60%Autosomal trisomies 常染色體三體(chromosome 13,16,18,21 or 22)Maternal factorsSystemic diseaseSevere infection (TORCH), feverAnemiaHeart failureUte

4、rine defects Uterus deplex 雙子宮, uterus bicornis 雙角子宮Large and multiple fibroidsEndocrine disordersCorpus luteum insufficiencyHypo-thyroidismImmunologic factorsPhysical and mental traumaSmoking, alcoholic, drugsPathologyDeath of embryo Hemorrhage in deciduaSeparation of placental villi from deciduaUt

5、erine contractionExpulsion of fetusEarly abortion before 8 weeksPathologyEarly abortion between 812 weeksAdvanced development of placental villiCloser with deciduaExpulsion pleteRetained pregnant productsSevere hemorrhagePathologyLate abortion Complete development of placentaAbdominal pain followed

6、by expulsion of fetus and placenta Lithopedion (石胎）Clinical manifestationAmenorrhea 停經(jīng)Vaginal bleedingCrampy （痙攣） abdominal painOccurs after vaginal bleeding in early abortionOccurs before vaginal bleeding in late abortionClinical categoryThreatened abortionInevitable abortion plete abortionComplete

7、 abortionThreatened abortionSlight vaginal bleedingSlight lower abdominal painCervix close, unruptured membraneThe size of the uterus corresponds to the gestational agePregnancy test: HCG positiveUltrasonography: normal gestational sac and viable embryoProgesterone: prognosisTreatmentBed restSedativ

8、e drugsProgesteroneCorpus luteum insufficiency1020mgHCGPsychological therapy Clinial observationInevitable abortionVaginal bleeding increases Abdominal pain es strongerMembrane ruptureCervical os dilated The size of uterus correspond with or smaller than the gestational ageTreatmentComplete expulsio

9、n of pregnant productsSuction curettage （清宮術(shù)） may be requiredoxytocin （縮宮素） in late abortionThe tissues removed should be sent for pathologic examination (chromosomal examination if possible)Antibiotics to reduce the risk of infection plete abortionRetained pregnant products in uterine cavity or inc

10、arceration嵌頓 at cervical osProfuse vaginal bleedingCervical os （宮頸口） is dilatedSize of the uterus is smaller than the gestational ageTreatmentCurettage as soon as possibleAnti-shock therapyBlood transfusion if necessaryAntibiotics to prevent infectionComplete abortionVaginal bleeding ceaseAbdominal

11、pain ceaseCervix closed againUterus of nearly non-pregnant sizeTreatmentUltrasonography: no visible products of conceptionNo sign of infection no particular management neededProcess of spontaneous abortionThreatened abortionPregnancy continuesInevitable abortion plete abortionComplete abortionDiffer

12、ential diagnosisCategoryHistoryExaminationVaginal bleedingAbdominal painTissue expulsionCervical osSize of uterusThreatened abortionslightslight or nonenone closecorrespond to gestational ageInevitable abortionmild to heavyheavynone dilatedcorrespond to or smaller plete abortionslight to heavyslight

13、partdilated or obstruction with tissuesmaller than gestational ageComplete abortionslight to nonenoneallclosesame with non-pregnant or bigger DiagnosisHistoryAmenorrhea, morning sickness, vaginal bleeding (volume and lasting time), expulsion of gestational products, abdominal pain (sites, degree), f

14、everSignsSigns of anemiaSigns of infectionVaginal examination (with caution when threatened abortion suspicious)hCG testultrasonographyDifferential diagnosisectopic pregnancyPregnancy test: positiveNo products of conception in uterushydatidiform mole （葡萄胎） HCG positiveLab test (DNA analysis, immunoh

15、istochemistry)dysfunctional uterine bleeding Pregnancy test: negativeSpecial conditions of abortionMissed abortionRecurrent spontaneous abortion (RSA)Septic abortionMissed abortionDeath of fetus or embryo occursRetention （殘留） of products of conception in uterine cavityDisappear of morning sicknessCl

16、osed cervical osUterus smaller than gestational ageTreatmentCoagulation （凝血） function test, be aware of DICCurettage (before 12th week gestation) combined with usage of oxytocinCorrect coagulation disorder before curettageUse large dosage of estrogen before operation to increase the sensitivity of u

17、terus to oxytocinPreparation for blood transfusionInduced abortion using oxytoxin or mifepristone （米非司酮） misoprostol （米索前列醇） (after 12th week gestation)RSASequential spontaneous abortion (three or more)Pregnancies are with the same sexual partnerMostly early abortionLate abortionAbnormal uterusCervical dysfunctionTreatmentScreening the etiologyIndividual medical management Chromosome examination of parents & Genetic counseling or prenatal diagnosisCerclage of cervix between 1418 weeks of gestationSupply of proge