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

2. Abortion
Spontaneous
abortion
Artificial
abortion

3. 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

4. Etiology Abnormal karyotype: 50% Maternal factors: infection (TORCH)
endocrine factors
immunologic factors
maternal systemic disease
anatomic defects
trauma
Toxic factors

5. anatomic defects

6. 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

7. Clinical Findings
Amenorrhea
Bleeding
Pain

8. 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

9. 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

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

11. Clinical Findings
Recurrent spontaneous Abortion
≥three times abortion

12. Laboratory Findings Ultrasonography Pregnancy tests Blood count
Gestational sac and viable embryo with heart motion
Ultrasonography
Pregnancy tests
HCG
Blood count
Anemic

13. Complication Life threatening Severe hemorrhage Infection
Intrauterine synechia
Perforation

14. Diagnosis
Medical history
Physical examination ?
Accessory examination

15. Threatened Abortion
Inevitable
Incomplete
Missed

16. Treatment
Threatened Abortion
Bed rest
Forbid sexual life
Progesterone

17. Treatment Dilatation and curettage InevitableAbortion Oxytocin
pathological examination
Dilatation and curettage
InevitableAbortion
Oxytocin
Ultrasound
Antibiotics

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

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

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

21. 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

22. Treatment Antibiotics Septic Abortion Dilatation and curettage
Cervical cultures

23. Ectopic pregnancy

24. Definition
A fertilized ovum implants in an area other than the endometrial lining of the uterus.

25. Animation of intrauterine implantation

26. 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.

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

28. Etiology Tubal Factors (salpingitis, previous tubal surgery)
Tubal dysplasia
ART
Exogenous Hormone (oral contraceptives)
Other Factors (endometriosis, IUD)

29. Pathology Lackage of resistance to invasion by the trophoblast
Abdominal pregnancy -1:15000 pregnancies
Enlarged uterus and endometrium changes

30. Termination of the pregnancy
Abortion
Rupture

31. 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

32. 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.

33. 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%)

34. 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)

35. Laboratory Findings Pregnancy tests (postive-82.5%) Hematocrit
White blood cell count
A negative test does not rule out an ectopic gestation

36. Special Examinations Utrasonically scanning Culdocentesis
Dilatation and curettage
Exploratory laparotomy

38. Differential Diagnosis
Appendicitis
Salpingitis
Ruptured corpus luteum cyst
Uterine abortion
Twisted ovarian cyst
Urinary tract disease
Degenerating leiomyomas

39. 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

40. Complications
About I in 1000 ectopic pregnancies result in maternal death
Untreated or mistreated ruptured ectopic tubal pregnancy % of all materal deaths
The majority of these deaths are preventable
Death

41. Complications Tubal damage Chronic salpingitis
Infertility or sterility
Intestinal obstruction may develop after hemoperitoneum and peritonitis
Tubal damage

42. 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

43. Salpingectomy

44. 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

45. Prognosis
Another tubal pregnancy will occur in 10-20% of patients treated
Infertility develops in approximately 50% of patients

46. Hyperemesis Gravidarum

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

48. Etiology
Unknown
Hormonal, neurologic, metabolic, toxic, and psychosocial factors (underlying emotional disorder)
Degree of biochemical hyperthyroidismh
The level of beta-HCGlevel o

49. 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

50. Diagnosis and Differential Diagnosis
Urine
Blood
Serum Beta-HCG (Molar pregnancy)
Thyroid function
Ultrasound
EKG
Fundus oculi

51. Treatment Indication for hospitalization
Intractable emesis, Correction of any
electrolyte abnormalities , Hypovolemia
IV hydration
Parental nutrition
Electrolyte supplement

52. Treatment Vitamin supplementation（ B1 ）——Wernocke’s encephalopathy
NaHCO3
Oral feedings
Terminal pregnancy