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

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 IncompleteMissed

Treatment Threatened Abortion Bed rest Forbid sexual life Progesterone

Treatment Inevitable Abortion Dilatation and curettage Oxytocin Ultrasound Antibiotics pathological examination

Treatment Incomplete Abortion 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 abdominal pain (99%) Generalized pain (44%) Unilateral lower abdominal pain (33%) Subdiaphragmatic pain 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 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 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