Abortion Ectopic Pregnancy Hyperemesis Gravidarum Women Hospital , School of Medical, ZheJiang University Yang Xiao Fu

Abortion Spontaneous abortion Artificial 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 Hemorrhage into the decidua basalis Necrosis and inflammation Uterine contractions and cervical dilatation Expulsion of most or all of the products of conception ＜8w 8~12w ＞12w

Clinical Findings Amenorrhea Bleeding Pain

Clinical Findings Threatened Abortion Inevitable Abortion Without cervical dilatation Without extrusion of products of conception Inevitable Abortion Cervical dilatation Without extrusion of products of conception

Clinical Findings Incomplete Abortion Complete Abortion Bleeding severe Incomplete Abortion Expulsion of some, but not all, of the products of conception Complete Abortion Expulsion of all of the products of conception

Clinical Findings Missed Abortion Septic Abortion Embryo or fetus death, products of conception in utero Pain Septic Abortion Infection of the uterus

Clinical Findings Recurrent spontaneous Abortion ≥three times abortion

Laboratory Findings Ultrasonography Pregnancy tests Blood count Gestational sac and viable embryo with heart motion Ultrasonography Pregnancy tests HCG Blood count 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 Dilatation and curettage InevitableAbortion Oxytocin pathological examination Dilatation and curettage InevitableAbortion Oxytocin Ultrasound Antibiotics

Treatment Dilatation and curettage IncompleteAbortion Promptly IncompleteAbortion Blood type and cross-match Fluid infusion Antibiotics

Treatment Products of conception Complete Abortion Ultrasound Bleeding Examine Complete Abortion Ultrasound Bleeding

Treatment DIC Estrogen Missed Abortion Dilatation and curettage(＜12w) Second RU486 and PG(＞12w) Oxytocin

Treatment Cause Recurrent spontaneous Abortion Habitual Abortion Genetic error Anatomic defect Hormonal abnormalities Infection Systemic disease Immunologic factors Cause Recurrent spontaneous Abortion Habitual Abortion Cervical cerclage Progesterone

Treatment Antibiotics Septic Abortion 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 In this short animation, we can see that the sperm enters the follopian tube and meet with the ovum. However, due to some reasons, the fertilized egg is trapped here before it reached the uterus and develops into a misplaced embryo. This misplaced embryo is somewhat like a time bomb because tissues at these abnormal locations for implantation are vulnerable and thin, they cannot support and accommodate the growing embryo. After several weeks , it may rupture and cause massive intraperitoneal bleeding, resulting in a potentially serious situation.

Sites of ectopic pregnancy pregs in fallopian tubes 78% ampulla 12% isthmic 11.1% fimbrial 3.2% ovarian 2.4% interstitial 1.3% abdominal

Etiology Tubal Factors (salpingitis, previous tubal surgery) Tubal dysplasia ART 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 Secondary amenorrhea (68%) 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 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 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 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 Tubal damage 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 ≤4cm 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