Вы находитесь на странице: 1из 145

Abortion

Spontaneous Abortion

The most common complication of pregnancy.


Defination
It is defined as delivery occurring before the 20th
completed week of gestation. It implies delivery
of all or any part of the products of conception,
with or without a fetus weighing less than 500
grams.
Early abortion occurs before 12 weeks 3

late abortion between 12 and 20 weeks.


Induced abortion is accomplished for
therapeutic and elective termination of
pregancy.
Abortion in its various forms is probably the
greatest problem in obstetrics and gynaecology.
It is often stated that the incidence of
spontaneous abortion is about 15 per cent of
pregnancies, but it is extremely difficult to get
reliable figures.
4

etiology
fetus

environment mother
Etiology
1 Chromosomal abnormality
at least 10% of human conceptions are thought to
have chromosomal abnormalities. There are
number(abnormal karyotype: aneuploid, euploid)
and structure abnormal(rupture replacement),
other factors(drugs, infections) leading genetic
abnormal
Abortion in these circumstances is a beneficial
process and represents a form of natural selection.
6

2 Maternal factors
(1) Endocrine defects It is
probably related to failure of the
corpus luteum
(2) Multiple pregnancy
The larger the number of fetuses,
the greater the tendency to abortion.
This may be due to overdistension of
the uterus
7

(3) Uterine causes


a Cervical incompetence----may
be congenital or acquired due to trauma
of previous operations or births.
Typically, cervical incompetence causes
mid-trimester abortion preceded by
premature rupture of the membranes
8

b Double uterus----in its various forms,


this is the result of anomalies of fusion of the
Mullerian ducts. The greater the degree of
duplication, the more normal is pregnancy
likely to be.
c leiomyoma may sometimes distort the
uterine cavity and produce abortion but
pregnancy proceeds without interruption in
many women with multiple fibroids.
d Previous scarring of the uterine cavity
following dilatation and curettage
( Asherman's syndrome )
Malformation of the uterus 9

Uterus didelphys Saddle form uterus

Uterus septus Uterus unicornis


10

fibroids Subserous myoma

Submucous myoma Intramural myoma


11

(4) Infections
a Any severe pyrexial illness may cause
abortion.
b Specific infections such as syphilis,
brucellosis and listeriosis have been
suggested as causes of abortion.
Conclusive evidence on these subjects is
lacking.
12

(5) Poisons
A number of systemic poisons may cause
abortion, particularly cytotoxic drugs.
(6) Radiation
As with cytotoxic drugs, abortion following
radiotherapy is sometimes encountered
during treatment for cancer.
13

(7) Maternal systemic disease diabetes


mellitus, hypothyroidism, chronic hypertension,
chronic renal diseases, severe malnutrition etc.
(8) bad habitual: tobacco, alcohol
(9) Traumas
submucous or intramural myomas
etiology 15
3 Immunological
The rejection of the pregnancy by the mother for
immunological reasons would seem theoretically a
likely cause of abortion. There is little little
information of practical value on this subject so far.
The commonest immunological problem encountered
in pregnancy is iso-immunisation and here abortion
sometimes results.

4 Environmental factors:
lead, arsenic, benzene
Pathology
hemorrhage
into the decidua basalis .

Necrosis and inflammation


appear in the area of implantation .
Detached
( the pregnancy becomes partially or entirely ).
Uterine contractions and dilatation of the cervi

(expulsion of most or all of the products of conceptio


17

pathology
In cases of missed abortion, there may be
partial organization of the blood clot
surrounding the conceptus. This results in
the formation of a fleshy, nodular, dark red
mass called a carneous mole, or blood
mole.
18

clinical features
amenorrhea
vaginal bleeding
suprapubic pain
19

According to the different gestational


week, the clinical presentation is different
Early abortion (before 12 weeks)
The first symptom is bleeding, then
abdominal pain
Late abortion ( between 12 and 20 weeks)
The first symptom is abdominal pain, then
appears slight vaginal bleeding
20

1 <8 weeks: slight bleeding


2 8~12 weeks severe
bleeding
3 >12 weeks slight bleeding
Clinical types

Pragnancy
go on
Threatened
abortion Incomplete
Inevitable abortion
abortion
Complete
abortion
Types
Threatened abortion : bleeding ; P45
with or without uterine contractions,
without dilatation of the cervix,
without expulsion of the products of conception.
Inevitable abortion : bleeding
with dilatation of the cervix
without expulsion of the products of conception.
with or without rupture of the membranes
Complete abortion : the expulsion of all of the products of conception
bleeding
with the cervix from dilatation to close
Incomplete abortion : the expulsion of some, but not all, of the products of
conception.
bleeding generally is persistent and is often severe.
Cramps are usually present.
Less than 10 weeks' duration:the fetus and placenta are usually passed together.
After 10 weeks, they may be passed separately with a portion of the products retained in
the uterine cavity.
Types

Missed abortion: the embryo or fetus dies in utero,


the products of conception are retained in utero.

Septic abortion : infection of the uterus and sometimes surrounding structures


fever
malodorous vaginal discharge
pelvic and abdominal pain,
cervical motion tenderness.
Peritonitis and sepsis
Recurrent abortion : 3 or more consecutive pregnancy losses
each with a fetus weighing less than 500 g.

Blighted Ovum: a failed development of the embryo


only a gestational sac, with or without a yolk sac
Laboratory Findings P47

1. Complete Blood Count


Anemic
The white blood cell count
The sedimentation rate
2. Pregnancy Tests
Falling or abnormally low plasma levels of -hCG
an abnormal pregnancy, a blighted ovum, spontaneous abortion, or ectopic pregnancy
Ultrasonography
In threatened abortion : a normal gestational sac and viable embryo.
A poor prognosis: a large or irregular sac,
an eccentric fetal pole,
the presence of a large ( >25% of sac size) retrochorionic bleed,
a slow fetal heart rate ( < 85 bpm) carry a poor prognosis.
In incomplete abortion : the deflated gestational sac
irregular, echogenic material representing placental
tissue in the uterine cavity
In complete abortion : the endometrium appears closely apposed, with no visible
products of conceptio

In missed abortion: an embryo or fetus without heart motion


In blighted ovum an abnormal gestational sac, without a yolk sac or em
Complications
Severe or persistent hemorrhage
Sepsis
Infection,
Intrauterine synechia,
Infertility

Perforation injury to the bowel and bladder


hemorrhage, infection, and fistula formation
( DandC)
Diagnosis

A complete history
A general physical examination
Laboratory findings
Ultrasonography
29

Threatened abortion
Symptoms:
1. Bleeding after amenorrhea
2. Usually no uterine contractions and no
pain or slight abdominal pain
Signs:
1. Cervix remains closed
2. Uterus is expected sizes for dates
30

Notices:
The key is the embryo is still alive
The criterion of pregnancy is going on or
not: ultrasonography, hCG, progesterone
The following condition prompts the
pregnancy prognosis is not well:
Lower hCG
Continue sonography, 7~10 days after
gestational sac appears, not seeing fetal heart
Progesterone level in blood <5ng/ml,
Treatment
31

Including psychologic and physical


bed rest and pelvic rest
Reduce stimulation, apply nutrition
Sedatives
Hormones(, hCG)
Treatment of the cause(progesterone,
hypothyroidism ---Thyroid Tablets)
Subsequent treatment
32

Inevitable abortion
The progress of threatened abortion
It refers to the state in which
bleeding of intrauterine origin occurs
before the 20th completed week with
continuous and progressive dilatation
of the cervix, but without expulsion of
the products of conception.
33
Symptoms:
a Increased bleeding----clots often passed.
b Uterine contractions and severe
abdominal pain
c Vaginal discharge
Signs:
a On examination, cervix is found to be
dilating and products projecting.
b The size of uterus is the same as the
gestational days
34

Examination:
a. Negative pregnancy urine tests
b. Ultrasonography shows no evidence of fetal heart action
and perhaps no fetus at all----as in the blighted ovum
c. The level of hCG or progesterone is low
35

diagnosis
36

diagnosis
37

Treatment
a. Termination of the pregnancy--- D & C

b. Late abortion, the size of uterus is large---

giving oxytocin 5u+10% glucose 500ml iv


38

Incomplete abortion
Incomplete
abortion is the
expulsion of some,
but not all, of the
products of
conception before
the 20th complete
week of gestation.
39
This is often the result of interference
Symptoms:
a Part of conceptus has been passed or
has been removed.
b Bleeding continues and may be severe.
c Vagina may be full of clot and patient
may become shocked(hypovolemia) before
adequate treatment is started.
d Relieving abdominal pain
f Infection may supervene.
Signs: 40

patulous cervix
often seeing tissues at the external os (picture)
the body of uterus is smaller than the days of
gestation

Treatment:
if diagnosis is made correctly ---- evacuate the uterus
promptly,oxytocin iv
blood transfusion if bleeding is brisk
antiseptic

intravenous injection
41
42

Complete abortion
Complete
abortion is the
expulsion of all of
the products of
conception before
the 20th complete
week of gestation
43

Characteristics:
a Whole conceptus is expelled.
b Slight bleeding and bleeding stops.
c Cessation of pain
d Closed of cervix, uterus contracts down to near
normal size.
e Negative pregnancy test
f Ultrasonic examination shows no
tissue in uterine cavity
44

Treatment
If the abortion is complete no
specific treatment is necessary
If the ultrasonic examination
shows an empty uterus, curettage
may be unnecessary.
45

Differential diagnosis
1.Various types of abortion
2. Early abortion must be different from
ectopic pregnancy, hydatidiform
mole, dysfunctional uterine bleeding
etc.
P48
Differentiation diagnosis 46

types threatened inevitable incomplete complete


vaginal
slight mild severe slightno
bleeding
abdominal
slight aggravation alleviation no
pain
evacuate of
no no partial total
tissue
dilatation or
probable
os of cervix closed obstruction closed
dilatation
of tissue
corpus the same the same smaller normal
rudimental normal
ultrasonic alive death
tissue cavity
hCG positive suspicious negative negative
treatments protection curettage curettage no treatment
47

special types of abortion

missed abortion
habitual abortion or recurrent
spontaneous abortion
septic abortion
48

missed abortion
Definition
49

the embryo or fetus dies in utero before the


20th completed week of gestation, but the
products of conception are retained
Any of the causes of abortion may be responsible.
This means the retention in the uterus of a dead
conceptus.
Clinical presentation: 50

amenorrhea
slight abdominal pain, companying or not
vaginal bleeding
Symptoms and signs of pregnancy----e.g.
breast enlargement/nauseated ---- will
regress.
Brown vaginal discharge may be present.
Signs:
closed cervix
the size of uterus is smaller than the
days of gestation
51

Diagnosis
Clinical features
signs
HCG
ultrasound
52

Treatments:
1. Determination of coagulation:
1) Routine Blood Test and
2) Blood fibrinogen, time of thrombinogen, 3P
test

*If there are some abnormal in these tests,


which must be correct firstly then giving the
treatments
53

2. Giving estrogen
3. <12 weeks: curettage (if adhesion is
tightly, giving multiple operation,
avoiding perforation )
>12 weeks: induced abortion
(oxytocin, prostaglandin )
54

Recurrent spontaneous
abortion
(Habitual abortion)
55

Definition
Recurrent abortion is defined as 3
consecutive spontaneous
pregnancy wastages before 20
weeks gestation with a fetus
weighing less than 500g.
56

Characters:
every time it appears in the same
gestational week
its clinical process is the same as
other abortion
57

Reasons:
Early abortion: genetic,endocrine factors
immunological defect etc.
Late abortion: cervical incompetence
malformation of uterus etc.
58

Incompetent cervix
59

Reasons of incompetent cervix:


1. Damage of cervix
2. Operation of cervix: conization,
cauterization, amputation
3. Abnormal cervical development
4. Other reasons
60

Diagnosis of incompetent cervix


1. Very clear recurrent abortion in the
second trimester
2. The 8th dilator can easily insert through
cervical canal to cavity when in no
conception
3. Ultrasonography: the internal os of
cervix in pregnancy is larger than 15mm
Treatment
61

1.To find the reasons before pregnancy


1) Karyotyping the parents, determination of the blood
types
2) Test the ovary function
3) Exam the reproductive system clearly
2.To the reasons
Early abortion: progesterone,
Late abortion: cerclage of cervix (12-18 weeks)
62

septic abortion
63

Definition

Infected abortion is abortion


associated with infection of
the genital organs
Diagnosis 64

Symptoms and signs of abortion


features of sepsis :
malodorous discharge from vaginal and cervix, pelvic and
abdominal pain, marked suprapubic tenderness,
signs of peritonitis, tenderness with movement of the uterus or
cervix, fever of 37.8 40.60C, white blood count elevated
Treatment 65

If the diagnosis is right, the following two


criterion must be obeyed:
1. Controlling infection
2. Prompt evacuation of the products of conception

Notice :
1. severe bleeding
2. slight bleeding
66


Thank You for your Interest
Vocabulary
67
Spontaneous abortion
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Septic abortion
Habitual abortion (recurrent abortion)

Induced abortion
Early abortion
Late abortion
Ectopic pregnancy
Ectopic Pregnancy
Definition
A fertilized ovum implants in an area other
than the endometrial lining of the uterus .

More than 95% of extrauterine pregnancies


occur in the fallopian tube.
Definition
An extrauterine pregnancy (ectopic pregnancy) is
one in which a fertilized ovum implants in an area
other than the uterine cavity
Ectopic pregnancy is a comparatively common,
dangerous and potentially fatal condition.
About 1 in 1000 ectopic pregnancies result in
maternal death. Hemorrhage is the major cause of
maternal death in untreated ruptured ectopic
pregnancy
The incidence is about 1 in 100 pregnancies

At least 99% of extra uterine pregnancies occur in


the uterine tube and the commonest site is the
ampulla

The other locations include ovarian pregnancy(


0.5% , abdominal pregnancy( 0.1% ,
cervical pregnancy, broad ligament pregnancy and
pregnancy in rudimentary horn.etc hepatic
pregnancy
Classification
1. Tubal ( > 95%)
The locations within the tube are as follows: ampullary (55%), isthmic (25%),
fimbrial (17%), interstitial (2%).

2. Other ( < 5% )
Includes : cervical , ovarian , and abdominal ( most abdominal pregnancies are
secondary pregnancies, from tubal abortion or rupture and subsequent
implantation in the bowel, omentum, or mesente

Etiology
1. Tubal Factors
salpingitis ; and in most of these patients, the uninvolved tube is also abnormal.

2. Ovarian Factors
fertilization of an unextruded ovum, transmigration of the ovum into the contralateral
tube with subsequent delayed and faulty implantation, and postmidcycle ovulation and
fertilizatio
3. Other Factors
Intrauterine device ( IUD
Etiology

1. Tubal factores
(1) chronic salpingitis: the most common reason
Endosalpingitis ( : agglutination of the

arborescent folds of the tubal mucosa with


narrowing of the lumen or formation of blind
pockets. multiple previous induced abortion,
tuberculous salpingitis ,

gonorrhea

peritubal adhesions subsequent to postabortal


or puerperal infection, kinking of the tube and
narrowing of the lumen
(2) abnormal tubal anatomy: too long normal
length is 8~14CM hypoplasia of muscular
layer congenital diverticula, or atresia
(3)others tubal surgical, pelvic tumors,
endometriosis
2. Zygote abnormalities
Chromosomal abnormalities, gross
malformation andneural tube defects.
delay passage of the fertilized ovum into the
uterine cavity
3.Ovarian factors: fertilization of an
unextruded ovum, transmigration of the ovum,
post-midcycle ovulation and fertilization
4. Exogenous hormones:
oral contraceptives altered tubal motility,
5.Other factors: in vitro fertilization and
embryo transfer (IVF-ET) , IUD
It is not clear whether the intrauterine
contraceptive device is related to an increased
incidence of ectopic pregnancy.
Pathology
One important aspect of ectopic pregnancy is the
lack of resistance of the endosalpinx to invasion
by the trophoblast thus, implantation occurs
beneath the endosalpinx in the muscle and
connective tissue next to the tubal serosa. There
may be little or no decidual reaction and minimal
defense against the penetrating trophoblast.
Therefore, the trophoblast invades the blood
vessels to cause local hemorrhage.
Tubal pregnancy may terminate in several ways
and the clinical features will vary accordingly.
P53
Pathology
1. Changes and sequels of tubal pregnancy
(1) Tubal Abortion
(2) Tubal Rupture
(3) Secondary Abdominal Pregnancy
(4) others
2. Changes of Uterus
(1) Macroscopic Changes
(2) Changes of Endometrium
1. Tubal abortion.
Often in ampullary. 8~12 weeks gestation, including
complete and incomplete
The ovum separates from the wall of the tube and is
gradually squeezed out the fimbriated end, from which
bleeding takes place. The contractions of the tube during
this process cause colicky abdominal pain.


tubal
abortion
2.Tubal rupture.
Trophoblast erodes through the tube causing massive and
sometimes fatal haemorrhage.
Rupture may be intracapsular or extracapsular.
Isthmic: often occurs at 6-8 weeks gestation ampullary: at 8-
12 weeks
interstitial : at about 3~4 months ,rarely,very dangerous the
reasons are:
A. Misdiagnosis as uterine pregnancy before rupture
B. The result almost is rupture and severe hemorrhage
e.g.
Tubal rupture

3.Secondary abdominal pregnancy


Generally, an abdominal pregnancy is
primary; very rarely, it may be secondary to a
tubal rupture or abortion. There may be
serious effects from invasion of vital organs in
cases of abdominal pregnancy. The incidence of
abdominal pregnancy is one per 15,000
pregnancies; the fetal mortality rate is about
90%.
e.g.
4.Pelvic haematocele.
Slow effusion of blood forms a
large haematoma in the pouch of
Douglas
5.Intraligmentary pregnancy
Occasionally the products of conception
may perforate the tube between the layers
of the broad ligament and continue to grow
there.
6.Mummification of fetus
If ectopic pregnancy is unrecognized the
fetus may be retained in the abdomen. a
lithopedion may be the end result.
1.Macroscopic changes: uterus enlarged,
soften because of the added circulation,
smaller than gestational days
2.changes of endometrium:
Bleeding is of uterine origin and is
caused by en-dometrial involution and
decidual sloughing. Atypical changes in
the endometrium may be suggestive of
ectopic pregnancy.
2. Changes of endometrium:
Decidual reactions: reaction of compact
layer of endometrium
zygote alive typical decidual reaction
manifestations hyperplasia of gland,
high secretion, edema of interstitial,
interstitial cell is large and polygon
zygote death decidua necrosis, ablation,
occasionally expel decidual cast
when floating in the water, there is no
chorion, the surface is granular. No chorion
when examed by microscope, this is the key
point of differential diagnosis of uterine
pregnancy.
2 AriasStella reaction spongy
layer of endometrium gland
characters
endometrial gland hyperplasia and secretion
reaction
nuclear hypertrophy, focal enlargement of
glandular cells, loss of cell boundaries and
stackingof gland cells
significations
It is the endometrium reaction to hormonal
overstimulation.
If AS reaction appears, ectopic pregnancy
should be considered, but its not specificity
3 hyperplasia and secretion
with the death of zygote, the function of
chorion disappears, new ovum regenerates,
endometrium regains normal menstrual cycle,
hyperplasia and secretion happen.
Clinical Findings
Since early diagnosis is crucial, a high
index of suspicion should be maintained
when any pregnant woman in the first
trimester presents with bleeding and/or
abdominal pain
Normal pregnancy / threatened or incomplete abortion / rupture of an
ovarian cyst / ovarian torsion / gastroenteritis / appendicitis /ectopic
pregnanc
Clinical findings
1. Symptoms
Abdominal pain, amenorrhea,
irregular vaginal bleeding
(1) amenorrhea: 6~8 weeks, interstitial
3~4months, about no amenorrhea
(2) Abdominal pain: about 99% complaint,
the most common
(3) Vaginal bleeding: slight, persist or
intermittence
(4) Syncope or shock: according to the
amount of bleeding, not resemble to the
vaginal bleeding
(5) Other symptoms: nausea, vomiting
2. Signs:
(1) General condition: resemble to the amount of
hemorrhage.
Fever is unusual
(2) Signs of abdomen:
shifting dullness (+)
signs of peritoneal irritation (+) on turning
the patient
Diffuse or localized abdominal tenderness is
present in over 80% of ectopic pregnancies.
(3) Pelvic examination:
Vagina: culdesac is fullness, tenderness
Cervix: tenderness, swing pain
Corpus : normal size or enlarged, less than
gestational day , boggy, levitation
Adnexal: tenderness in the affected side,
sometimes touching mass
Interstitial pregnancy the size of uterus is
the same as gestational day, but the uterus is
asymmetry, one cornu is protruding, having
tenderness
2.Clinical Findings-signs

A. Tenderness
over 80% Diffuse or localized abdominal tenderness
over 75% Adnexal and/or cervical motion tenderness

B. Adnexal Mass
30-50% A unilateral adnexal mass is palpated

C. Uterine Changes
The uterus may undergo typical changes of pregnancy, including softening and a slight
increase in size
Diagnostic aids
Gist of diagnosis: Taking history in detail,
combing symptoms, signs and pelvic
examination
1.Pregnancy tests
hCG is positive, it is the most sensitivity index
in diagnosis of pregnancy
Urinary pregnancy test: qualitative
Serum hCG: quantitative
notices:
urine tests are of doubtful value. a positive test
only confirms pregnancy and does not indicate
whether it is intrauterine or extrauterine.
Meanwhile, a negative test does not rule out an
ectopic gestation.
Consecutive testing hCG can be used as a
credibility index in differential diagnosis of
uterine pregnancy, uterine abortion, ectopic
pregnancy.
2.Sonography the very important methods
Characters:
1 enlarge of uterus, no sac in cavity
2 abnormal echo in one side of uterus,
if embryo sac or heart beat can be seen the
diagnosis is confirmed
3 there is no echo character around
uterus if abortion or rupture had happened. If
there is some fluid in the cul-de-sac, diagnosis can
be made.
(4) It needs some time to diagnosis early
pregnancy by sonography. 5~6 weeks
conception appears gestational sac.
What may appear on the sonogram as a
small sac or a collapsed sac may be a blood
clot or decidual cast.
It must combined with consecutive hCG
test.
(5) vaginal sonography had higher accuracy
3. Culdocentesis:
Culdocentesis is the transvaginal passage of a needle
(posterior to the cervix) into the cul-de-sac (pouch of
Douglas) for the purpose of determining whether
free blood is present in the abdomen.
simple, safe, practicality, useful in the diagnosis of
intraperitoneal bleeding
culdocentesis
Methods: Patient is in the dorsal lithotomy
position. A speculum is placed in the vagina and
the posterior lip of the cervix grasped with an
tenaculum. The vagina is cleansed. A needle is
attached to a 10 ml syringe, and with gentle
traction on the cervix, the needle is passed into
the cul-de-sac (pouch of Douglas), whence fluid
can be aspirated.
Aspirating dark red bloody and nonclotting fluid
means positive.
If hemorrhage in peritoneum is more than 50 ml,
the positive results may reach 95%.
Notices
1 negative results cant exclude ectopic
pregnancy: such as unruptured or before abortion
ectopic pregnancy, slight hemorrhage, adhesion of
peritoneum
2 positive results only show
hemoperitoneum, it needs to diagnosis the cause of
bleeding.
4.laparoscopy-Laparoscopy is the most
valuable of all the diagnostic aids.
It is increasingly being used in the diagnosis
of early and unruptured atypical ectopic
pregnancy.
Characters
(1) Swelling and indigo in oviduct
(2) superficial blood vessels is infuriate
(3) hemoperitoneum
(4) rupture of oviduct or hemorrhage in
fimbria
Contraindication:
Severe hemorrhage
Hypovolemic shock

Exploratory laparotomy as soon as possible


5. Dilatation and curettage
Endometria may be variety in ectopic pregnancy, it has
no specificity.
Arias-Stella reaction reinforcing the presumptive
diagnosis of ectopic pregnancy.
Values:
1. Exclude intrauterine pregnancy
When trophoblastic tissue is recovered (usually chorionic
villi), the diagnosis of intrauterine pregnancy is
confirmed.
2. It is usually used in severe vaginal bleeding
Differential diagnosis
1.Appendicitis:
1) pyrexial disease
2) Epigastric, periumbilical, then right lower
quadrant pain; tenderness localizing at
McBurneys point, rebound tenderness.
3) Unrelated to menses
4) Negative -hCG
5) White cell count elevated
2.Salpingitis
1) Pyrexial disease
2) Usually in both lower quadrants pain, with or
without rebound tenderness
3) Hypermenorrhea or metrorrhagia, or both
4) Temperature and pulse 37.2-400C. Pulse
elevated in proportion to fever.
5) Negative -hCG.
6) White cell count elevated
3.Ruptured Corpus Luteum Cyst
1) Unilateral pain
2) NO symptoms or signs of pregnancy
3) Temperature and pulse normal
4) Tenderness over affected ovary. No masses.
Uterus firm and not enlarged
5) Negative -hCG.
6) White cell count normal
4.Uterine Abortion
1) Midline cramps.
2) Longer amenorrhea, then spotting, then brisk
bleeding.
3) To 37.20C if spontaneous; to 400C if induced
(infected).
4) Cervix slightly patulous. Uterus slightly
enlarged, irregularly softened. Tender only with
infection
5) ultrasonography
5.Ectopic Pregnancy
1) Unilateral cramps and tenderness before
rupture. Pain usually precedes bleeding, unlike
threatened abortion where bleeding comes first.
Shoulder-tip pain is common.
2) Some missed period, spotting. Vaginal bleeding
is usually slight in ectopic.
3) Unilateral tenderness, especially on movement
of cervix
4) positive-hCG
5) Red cell count strikingly low if blood loss large.
Treatment
1. Expectant Management
-hCG liters are low ( < 200 mlU/mL ) or decreasing , and the risk
of rupture is low
Treatment
2.Surgical treatment : the principle is
surgery
Indications
Interstitial ectopic pregnancy
Severe intraperitoneal bleeding
Failure of conservative treatment
Old ectopic pregnancy
Require sterilization
Methods: laparotomy or laparoscopy
1. Salpingectomy: very common
2. Conservative surgery
Indications: require pregnancy, contralateral
oviduct had been resected or had pathological
changes
Modes: according to the site of lesion
(1) fimbrial evaculation fimbria
(2) salpingostomy: ampulla
(3) Segmental resection and anastomosis: isthmus
(4) cuneihysterectomy
interstitial
3.Emergency Treatment:
Immediate surgery
Transfusion (autotransfusion)
Rapid entry into the abdomen
Careful, fast exploration of the abdominal
cavity
Remove products of conception, clots, and free
blood, exposing the area of nidation.
salpingectomy
2. Nonsurgical management:
conservative medicine -----killing the embryo
Indications
(1) Intraperitoneal bleeding is less than 300 ml vital
signs is stable
(2) Focus is less than 3cm
(3) Serum -hCG < 2000IU/L
(4) No abortion or rupture in ectopic pregnancy
Contraindications
(1)see fetal heart beat
(2)severe dysfunction of liver and kidney
(3)defect of coagulation
Methotrexate MTX
Inhibiting trophoblast proliferation, destroy
chorion, embryo died
1 systemic administration
local single or multiple muscular injection
2 local administration
by laparoscope, sonography, intubation of
oviduct, injecting MTX 25~50mg to the
pathological site
Effectiveness observation
test hCG regularly, sonography
Failure of treatments
(1)hCG not decrease
(2)mass is still persisting
(3)exacerbation of hemoperitoneum
Others:
Traditional Chinese Medicine
3.Supportive Treatment:
If symptoms and signs of infection are
present, give broad-spectrum antibiotics,
prescribe oral or intravenous iron
therapy (or both), and order a high
protein diet with vitamin and mineral
supplements as soon as the patient is on
oral intake.
Prognosis
Another tubal pregnancy will occur in 10-20% of
patients treated.
Infertility develops in approximately 50% of
patients who have undergone surgery for the
treatment of an ectopic pregnancy, and of these,
about 30% become sterile.
Normal pregnancies are achieved in about 50% of
patients who have one ectopic pregnancy.
The maternal mortality rate due to ectopic
pregnancy in the USA is 1-2%; the perinatal
mortality rate is virtually 100%.
Prevention
Treat salpingitis early and vigorously; perform
D&C promptly for incomplete abortion, avoiding
adhesions. Early diagnosis of unruptured tubal
pregnancy will obviate later extensive surgery.

Most forms of ectopic pregnancy other than tubal


are not preventable.
Vocabulary
Extrauterine pregnancy
Ectopic pregnancy
Ampulla pregnancy
Isthmic pregnancy
Fimbrial pregnancy
Interstitial pregnancy
Ovarian pregnancy
Cervical pregnancy
Abdominal pregnancy
Culdocentesis
Pregnancy test
Laparoscopy
Laparotomy
Ultrasonography
Adnexal mass and tenderness

Positive -hCG -hCG
Thanks