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AbortionandEctopicPregnancy

Liang-QingYao

ObstetricsandGynecologyHospitalofFudanUniversity

AbortionandEctopic1AbortionAbortion2ConceptApregnancylossbefore28weeksofgestationwhilefetalweightunder1000gramsEarlyAbortion：pregnancylossbefore12

gestationalweeksLateAbortion:pregnancyloss

during12～28

gestationalweeksSpontaneousAbortionArtificialAbortionConceptApregnancylossbefor3GeneticdefectMaternalfactors:systematicdisease;genitalorgananomalies;endocrineanomalies;irritation;bad

habitImmuneanomaliesEnvironmentalfactorsEtiology

Etiology

4PathologyBefore8weeks:

chorionicvilliimmature

Fetaldeath→basaldecidualbleeding→uterinecontraction→expulsionofalltheproductsofconception,lightbleedingDuring8～12

weeks：withfirmattachmenttothebasaldeciduaPartialexpulsionoftheproductsofconception→non-idealuterinecontraction,severebleedingAfter12

weeks:

placentafullyformed.

Uterinecontraction→expulsionofalltheproductsofconception，lightbleedingPathologyBefore8weeks:chori5SymptomsAmenorrhea,vaginalbleeding,andabdominalpainEarlyabortion：vaginalbleedingprecedingabdominalpainLateabortion：abdominalpainprecedingvaginalbleedingSymptomsAmenorrhea,vaginalbl6TypesofAbortionThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionMissedAbortionHabitualAbortionSepticAbortionTypesofAbortionThreatenedAb7ClinicalPresentationsThreatenedAbortionlightvaginalbleedingwithmildabdominalpaincervicalosclosed,fetalmembranesunbrokentreatmentmightwork,continuepregnancyInevitableAbortionbleedingheavier,abdominalpainmoresevere,orfluidpassedcervicalosopen，pregnancytissuevisibleabortionisinevitableClinicalPresentationsThreaten8IncompleteAbortionheavyvaginalbleedingpregnancytissueprotrudingfromthecervicalosuterussmallforthepresumedgestationalweekCompleteAbortionvaginalbleedingdecreasing,abdominalpainalleviatingcervicaloscloseduterusnormalforthepresumedgestationalweekIncompleteAbortion9DifferentStagesofAbortionthreatenedabortion

continuepregnancyinevitableabortionincompleteabortioncompleteabortionDifferentStagesofAbortiont10DiagnosisHistoryPhysicalExaminationLaboratoryAssessment:ultrasoundpregnancytesthormonelevel:serumprogesteroneDiagnosisHistory11BleedingAbdominalPainTissueExpulsionCervicalOsUterusThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionLightMildtoheavyLighttoheavyLighttononeNone/lightIntensifiedRelievedNoneNoneNonePartialCompleteClosedDilatedDilatedorobstructedClosedNormalNormalorslightlysmallSmallNormalorslightlylargeHistoryPelvicExaminationBleedingAbdominalPainTissueE12ManagementThreatenedAbortionbedrest,sedationantiabortion：progesterone，HCG；VitE；thyroxinesupplementmonitoring：ultrasound；serumHCG→whethertocontinuepregnancyInevitableAbortiononcediagnosed，removethepregnancytissueasquicklyaspossiblesuctioncurettage

ManagementThreatenedAbortion13IncompleteAbortionperformsuctioncurettagepromptlyifwithheavybleeding：bloodtransfusion；preventiveantibioticuseCompleteAbortionnoretainedproductsofconceptionconfirmedbyultrasound；noinfectionnoneedforspecialmanagementIncompleteAbortion14MissedAbortion

Concept:inuterodeathoftheembryoorfetuswithretainedproductsofconceptionClinicalManifestation:uterineenlargementceasingorfetalmovementdisappearingcervicalosclosed,uterussmallforthepresumedgestationalagenofetalheartbeat;embryonicdemisesuggestedbyultrasoundfindingsMissedAbortionConcept:inut15Managementbloodroutineexamination,coagulationfunctiontestcorrectingcoagulationdefects：heparin,fibrinogen,etc.sensitizingtheuterus：

diethylstilbestroltransfusionpreparation;emptyingtheuterus：

before12weeks:suctioncurettage

after12weeks：inductionof

laborManagementbloodroutineexami16HabitualAbortion

Theoccurrenceof3ormoreconsecutivespontaneousabortionsTheoccurrenceof2spontaneousabortionsisdefinedasrecurrentabortionEarlyabortion：chromosomalabnormalities，immunologicfactors，luteal-phaseinsufficiency,hypothyroidismLateabortion：congenitaluterineanomalies，cervicalincompetence，uterinefibroids,etc.HabitualAbortionTheoccurren17Managementobtaininformationonetiologyforpriorlossesbeforeconceptiongeneticcounselingcervicalincompetence：cervicalcerclageduring14～18weeksofgestationwithunclearcauses：progesteronetherapyuntil10weeksofgestationactiveimmunotherapy：intradermicinjectionoflymphocytesManagementobtaininformationo18

SepticAbortion

Prolongedbleedingduringabortionorretainedproductsofconceptionleadtointrauterineinfection,whichmightprogressintopelvicinflammatorydisease,peritonitisorevensepsisifnottreatedAntibiotictreatment+Promptevacuationwithoutseverebleeding:managementofinfection,performanceofsuctionandcurettagewithseverebleeding：managementofinfectionwhileapplyingforceps,withsecondarysuctionandcurettage

SepticAbortion

Prolongedbl19EctopicPregnancyEctopicPregnancy20Concept

EctopicPregnancy:implantationofthefertilizedovumintissueotherthantheendometriumExtrauterinePregnancyincluding：tubalpregnancy(95％),ovarianpregnancy,

cornualpregnancy,cervicalpregnancy,abdominalpregnancy,etc.oneofthemaincausesofacuteabdomenanddeathConcept21流產(chǎn)異位妊娠(英文)-AbortianandEctopicPregnancy課件22EtiologyandRiskFactorstubalinflammation,pelvicinflammationprevioustubalsurgery：forinfertility,tubalpregnancy,etc.IVFfailureofcontraception：currentuseofIUDororalcontraceptivestubalundergrowthordysfunctionotherfactors：endometriosis,hysteromyoma,smoking,etc.EtiologyandRiskFactorstubal23Endingsoftubalpregnancyabortion：8～12

weeks

rupture：12～16weeks

secondaryabdominalpregnancyChronicectopicpregnancyPersistentectopicpregnancyEndingsoftubalpregnancyabor24PathologyoftheUterusenlargementandsofteningamenorrhea

vaginalbleedingtheArias-StellareactionoftheendometriumbutnochorionicvilliPathologyoftheUterusenlarge25ClinicalPresentations-SymptomsAmenorrheaAbdominalpain：time,characteristicsVaginalbleedingFaint/shockClinicalPresentations-Symptom26ClinicalPresentations-SignsGeneralconditionAbdomenexaminationPelvicexamination：cervicalmotiontenderness，sensationofafloatinguterus，adnexalmass,etc.ClinicalPresentations-SignsGe27LaboratoryAssessmentHCG:urinaryHCG；theriseintheserumβ-HCGlevelover48

hours﹤66％serumprogesterone：only1.5%﹥25ng/mlultrasound：theemptyuterussign；adnexalcardiacactivityorultrasonographiclucency;presenceofcul-de-sacfluidLaboratoryAssessmentHCG:uri28culdocentesis：nonclottingbloodlaparoscopy：goldstandard，diagnosis＋treatment

earlydiagnosismissedin3％～4％ofpatientsusewithcaution：toavoidanestheticandsurgicalrisks；medicaltherapyasanoptionUterinecurretage：profusevaginalbleeding;intrauterinepregnancylossculdocentesis：nonclottingbloo29DifferentialDiagnosisEctopicpregnancyabortionAdnexalinflammationAppendicitisCorpusluteumruptureOvarycysttorsion1.Amenorrhea2.Abdominalpain3.Bleeding4.Shock

5.Bodytemperature6.Pelvicexaminatioon7.WBC8.Hb9.HCG10.Ultrasound11.CuldocentesisDifferentialDiagnosisEctopic30SurgicalTreatmentRadicaloperation：hemodynamicallyunstable;interstitialpregnancy;tubalruptureConservativeoperation：withwishestoretainpotentialforfertility－milkingorlinearsalpingostomy＋MTXSurgicalTreatmentRadicaloper31MedicalTreatmentprinciple：inhibitingproliferationoftrophoblastictissueindication：nocontraindicationtochemotherapy；noruptureorabortion；mass≤4cm；serumβ-HCG＜2000U/L；noobviousinternalbleeding；nodemonstrationofcardiacactivityorembryonicbudMedicalTreatmentprinciple：inh32MedicalTreatmentProtocol：MTX150mg，giveaseconddoseonday7ifnecessaryMonitoringtherapeuticeffectiveness：ifdeclineinserumhCGlevelonday7≤25%；＜15%orsymptomsworseningorinternalbleedingoccurring;2weeksuntilnegativeMedicalTreatmentProtocol：MTX133ExpectanttreatmentPainmild，bleedinglight；Noevidenceoftubalrupture；Nointraabdominalbleeding；Serumβ-HCG﹤1000U/L，andcontinuedeclining;Pregnancymass﹤3cmorundetected；Follow-upreliableExpectanttreatmentPainmild，34

NontubalEctopicPregnancy

NontubalEctopicPregnancy35CervicalPregnancyConcept：implantationofthedevelopingconceptusinthecervicalcanalIncidence：1：18000Clinicalfeature：painlessvaginalbleedingDiagnosticcriteria：theuterinesizeiscomparabletothatofanunpregnantone;thepresenceofpregnancytissuerelatedexclusivelytothecervicalcanal；curretageoftheendometrialcavityisnonproductiveofpregnancytissueTreatmentprinciple：transfusionpreparation;curretageorsuctioncurretage

;MTXand/oruterinecurretageCervicalPregnancyConcept：impl36OvarianPregnancyAconditioninwhichanectopicpregnancyimplantswithintheovariancortexDiagnosticcriteria：thefallopiantubeontheaffectedsidemustbeintact；thefetalsacmustoccupythepositionoftheovary；ovariantissuemustbelocatedinthesacwall；theovaryandfetalsacmustbeconnectedtotheuterusbytheovarianligamentOvarianPregnancyAconditioni37OvarianPregnancyClinicalpresentations：amenorrhea,abdominalpain,vaginalbleeding，shock,etc.Differentiatedfrom：rupturedcorpusluteum；tubalpregnancyTreatmentprinciple：surgicaltreatmentOvarianPregnancyClinicalpres38AbdominalPregnancyThepresenceofapregnancyrelatedtoaperitonealsurfaceotherthanfallopiantube,ovaryorbroadligament，1：15000Classification：primary,secondaryClinicalpresentations：amenorrhea,abdominalpainandvaginalbleeding；fetus.Treatmentprinciple：removethefetus＋placentamanagement＋transfusion,preventinfection－attachedtotheuterus,fallopiantube－attachedtoperitoneum,mesenterium（﹤4weeks;longbeendead）AbdominalPregnancyThepresenc39流產(chǎn)異位妊娠(英文)-AbortianandEctopicPregnancy課件40QuestionsDescribetheclinicalpresentationsofdifferentstagesofabortion？Summarizetreatmentprinciplesofhabitual,septicandmissedabortions？Whatconditionsshouldbedifferentiatedfromtubalpregnancytheirrespectivedifferentialpoints？WhatdoeslaboratoryassessmentforEctopicpregnancyinclude？Summarizethetreatmentfortubalpregnancyanditschoice？Missedabortion,cervicalpregnancy?QuestionsDescribetheclinical41Thankyou！Thankyou！42

AbortionandEctopicPregnancy

Liang-QingYao

ObstetricsandGynecologyHospitalofFudanUniversity

AbortionandEctopic43AbortionAbortion44ConceptApregnancylossbefore28weeksofgestationwhilefetalweightunder1000gramsEarlyAbortion：pregnancylossbefore12

gestationalweeksLateAbortion:pregnancyloss

during12～28

gestationalweeksSpontaneousAbortionArtificialAbortionConceptApregnancylossbefor45GeneticdefectMaternalfactors:systematicdisease;genitalorgananomalies;endocrineanomalies;irritation;bad

habitImmuneanomaliesEnvironmentalfactorsEtiology

Etiology

46PathologyBefore8weeks:

chorionicvilliimmature

Fetaldeath→basaldecidualbleeding→uterinecontraction→expulsionofalltheproductsofconception,lightbleedingDuring8～12

weeks：withfirmattachmenttothebasaldeciduaPartialexpulsionoftheproductsofconception→non-idealuterinecontraction,severebleedingAfter12

weeks:

placentafullyformed.

Uterinecontraction→expulsionofalltheproductsofconception，lightbleedingPathologyBefore8weeks:chori47SymptomsAmenorrhea,vaginalbleeding,andabdominalpainEarlyabortion：vaginalbleedingprecedingabdominalpainLateabortion：abdominalpainprecedingvaginalbleedingSymptomsAmenorrhea,vaginalbl48TypesofAbortionThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionMissedAbortionHabitualAbortionSepticAbortionTypesofAbortionThreatenedAb49ClinicalPresentationsThreatenedAbortionlightvaginalbleedingwithmildabdominalpaincervicalosclosed,fetalmembranesunbrokentreatmentmightwork,continuepregnancyInevitableAbortionbleedingheavier,abdominalpainmoresevere,orfluidpassedcervicalosopen，pregnancytissuevisibleabortionisinevitableClinicalPresentationsThreaten50IncompleteAbortionheavyvaginalbleedingpregnancytissueprotrudingfromthecervicalosuterussmallforthepresumedgestationalweekCompleteAbortionvaginalbleedingdecreasing,abdominalpainalleviatingcervicaloscloseduterusnormalforthepresumedgestationalweekIncompleteAbortion51DifferentStagesofAbortionthreatenedabortion

continuepregnancyinevitableabortionincompleteabortioncompleteabortionDifferentStagesofAbortiont52DiagnosisHistoryPhysicalExaminationLaboratoryAssessment:ultrasoundpregnancytesthormonelevel:serumprogesteroneDiagnosisHistory53BleedingAbdominalPainTissueExpulsionCervicalOsUterusThreatenedAbortionInevitableAbortionIncompleteAbortionCompleteAbortionLightMildtoheavyLighttoheavyLighttononeNone/lightIntensifiedRelievedNoneNoneNonePartialCompleteClosedDilatedDilatedorobstructedClosedNormalNormalorslightlysmallSmallNormalorslightlylargeHistoryPelvicExaminationBleedingAbdominalPainTissueE54ManagementThreatenedAbortionbedrest,sedationantiabortion：progesterone，HCG；VitE；thyroxinesupplementmonitoring：ultrasound；serumHCG→whethertocontinuepregnancyInevitableAbortiononcediagnosed，removethepregnancytissueasquicklyaspossiblesuctioncurettage

ManagementThreatenedAbortion55IncompleteAbortionperformsuctioncurettagepromptlyifwithheavybleeding：bloodtransfusion；preventiveantibioticuseCompleteAbortionnoretainedproductsofconceptionconfirmedbyultrasound；noinfectionnoneedforspecialmanagementIncompleteAbortion56MissedAbortion

Concept:inuterodeathoftheembryoorfetuswithretainedproductsofconceptionClinicalManifestation:uterineenlargementceasingorfetalmovementdisappearingcervicalosclosed,uterussmallforthepresumedgestationalagenofetalheartbeat;embryonicdemisesuggestedbyultrasoundfindingsMissedAbortionConcept:inut57Managementbloodroutineexamination,coagulationfunctiontestcorrectingcoagulationdefects：heparin,fibrinogen,etc.sensitizingtheuterus：

diethylstilbestroltransfusionpreparation;emptyingtheuterus：

before12weeks:suctioncurettage

after12weeks：inductionof

laborManagementbloodroutineexami58HabitualAbortion

Theoccurrenceof3ormoreconsecutivespontaneousabortionsTheoccurrenceof2spontaneousabortionsisdefinedasrecurrentabortionEarlyabortion：chromosomalabnormalities，immunologicfactors，luteal-phaseinsufficiency,hypothyroidismLateabortion：congenitaluterineanomalies，cervicalincompetence，uterinefibroids,etc.HabitualAbortionTheoccurren59Managementobtaininformationonetiologyforpriorlossesbeforeconceptiongeneticcounselingcervicalincompetence：cervicalcerclageduring14～18weeksofgestationwithunclearcauses：progesteronetherapyuntil10weeksofgestationactiveimmunotherapy：intradermicinjectionoflymphocytesManagementobtaininformationo60

SepticAbortion

Prolongedbleedingduringabortionorretainedproductsofconceptionleadtointrauterineinfection,whichmightprogressintopelvicinflammatorydisease,peritonitisorevensepsisifnottreatedAntibiotictreatment+Promptevacuationwithoutseverebleeding:managementofinfection,performanceofsuctionandcurettagewithseverebleeding：managementofinfectionwhileapplyingforceps,withsecondarysuctionandcurettage

SepticAbortion

Prolongedbl61EctopicPregnancyEctopicPregnancy62Concept

EctopicPregnancy:implantationofthefertilizedovumintissueotherthantheendometriumExtrauterinePregnancyincluding：tubalpregnancy(95％),ovarianpregnancy,

cornualpregnancy,cervicalpregnancy,abdominalpregnancy,etc.oneofthemaincausesofacuteabdomenanddeathConcept63流產(chǎn)異位妊娠(英文)-AbortianandEctopicPregnancy課件64EtiologyandRiskFactorstubalinflammation,pelvicinflammationprevioustubalsurgery：forinfertility,tubalpregnancy,etc.IVFfailureofcontraception：currentuseofIUDororalcontraceptivestubalundergrowthordysfunctionotherfactors：endometriosis,hysteromyoma,smoking,etc.EtiologyandRiskFactorstubal65Endingsoftubalpregnancyabortion：8～12

weeks

rupture：12～16weeks

secondaryabdominalpregnancyChronicectopicpregnancyPersistentectopicpregnancyEndingsoftubalpregnancyabor66PathologyoftheUterusenlargementandsofteningamenorrhea

vaginalbleedingtheArias-StellareactionoftheendometriumbutnochorionicvilliPathologyoftheUterusenlarge67ClinicalPresentations-SymptomsAmenorrheaAbdominalpain：time,characteristicsVaginalbleedingFaint/shockClinicalPresentations-Symptom68ClinicalPresentations-SignsGeneralconditionAbdomenexaminationPelvicexamination：cervicalmotiontenderness，sensationofafloatinguterus，adnexalmass,etc.ClinicalPresentations-SignsGe69LaboratoryAssessmentHCG:urinaryHCG；theriseintheserumβ-HCGlevelover48

hours﹤66％serumprogesterone：only1.5%﹥25ng/mlultrasound：theemptyuterussign；adnexalcardiacactivityorultrasonographiclucency;presenceofcul-de-sacfluidLaboratoryAssessmentHCG:uri70culdocentesis：nonclottingbloodlaparoscopy：goldstandard，diagnosis＋treatment

earlydiagnosismissedin3％～4％ofpatientsusewithcaution：toavoidanestheticandsurgicalrisks；medicaltherapyasanoptionUterinecurretage：profusevaginalbleeding;intrauterinepregnancylossculdocentesis：nonclottingbloo71DifferentialDiagnosisEctopicpregnancyabortionAdnexalinflammationAppendicitisCorpusluteumruptureOvarycysttorsion1.Amenorrhea2.Abdominalpain3.Bleeding4.Shock

5.Bodytemperature6.Pelvicexaminatioon7.WBC8.Hb9.HCG10.Ultrasound11.CuldocentesisDifferentialDiagnosisEctopic72SurgicalTreatmentRadicaloperation：hemodynamicallyunstable;interstitialpregnancy;tubalruptureConservativeoperation：withwishestoretainpotentialforfertility－milkingorlinearsalpingostomy＋MTXSurgicalTreatmentRadicaloper73MedicalTreatmentprinciple：inhibitingproliferationoftrophoblastictissueindication：nocontraindicationtochemotherapy；noruptureorabortion；mass≤4cm；serumβ-HCG＜2000U/L；noobviousinternalbleeding；nodemonstrationofcardiacactivityorembryonicbudMedicalTreatmentprinciple：inh74MedicalTreatmentProtocol：MTX150mg，giveaseconddoseonday7ifnecessaryMonitoringtherapeuticeffectiveness：ifdeclineinserumhCGlevelonday7≤25%；＜15%orsymptomsworseningorinternalbleedingoccurring;2weeksuntilnegativeMedicalTreatmentProtocol：MTX175ExpectanttreatmentPainmild，bleedinglight；Noevidenceoftubalrupture；Nointraabdominalbleeding；Serumβ-HCG﹤1000U/L，andcontinuedeclining;Pregnancymass﹤3cmorundetected；Follow-upreliableExpectanttreatmentPainmild，76

NontubalEctopicPregnancy

No

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