流产异位妊娠(英文)AbortianandEctopicPregnancy尧良清
流产、异位妊娠-精品医学课件
病 因etiology
输卵管结构和功能异常
➢ 慢性输卵管炎症Chronic salpingitis 输卵管黏膜炎——淋菌、沙眼衣原体 输卵管周围炎——流产、产后感染 结节性输卵管峡部炎
➢ 输卵管功能异常：发育不良、内分泌、精神
输卵管手术史：不孕手术、输卵 管妊娠手术等；
辅助生殖； 避孕失败：IUD、避孕药； 其他：内异症、子宫肌瘤等。
21-三体综合症
唐氏综合征
病
因
胚胎因素：胚胎染色体异常是早期流产发生的主 要原因
数目异常、结构异常
母体因素
全身性疾病、内分泌异常、免疫功能异常、生殖 器异常、创伤刺激、烟酒等不良生活习惯
父亲因素：精子的染色体异常可以导致自然流产 环境因素：辐射、铅、砷、苯、甲醛等
纵膈子宫
粘膜下肌瘤
输卵管壶腹部妊娠 ampullary pregnancy
输卵管间质部妊娠 interstitial pregnancy
腹腔妊娠 abdominal pregnancy
子宫残角妊娠 Pregnancy of rudimentary horn
Why did it implant outside uterine cavity?
自然流产 spontaneous abortion
假如你是一名大夫……
女，28岁，平时月经规则，现停经8周 ，有恶心呕吐。昨有少量阴道流血，轻微 腹痛。检查：宫颈着色、口闭，宫体前位 ，如孕2月大小，质软，活动，无压痛， 附件未及，尿HCG（+），B超见宫内孕囊 ，并见胎心搏动。
临床诊断为？
妊娠时限
25
治疗
复发性流产
查明原因，若能纠正者应于妊娠前治疗； 原因不明，补充黄体酮或HCG； 保胎至妊娠10周或超过以往流产的月份； 卧床休息，禁止性生活； 宫口松弛，于妊娠14-18周行宫颈内口环扎术。
流产、异位妊娠(英文)-Abortian-and-EctopicPregnancy-尧良清
Pathology
Before 8 weeks: chorionic villi immature
➢ Fetal death→basal decidual bleeding →uterine contraction→expulsion of all the products of conception, light bleeding
➢ Early abortion：vaginal bleeding preceding abdominal pain
➢ Late abortion：abdominal pain preceding vaginal bleeding
Types of Abortion
Threatened Abortion Inevitable Abortion Incomplete Abortion Complete Abortion
Etiology
➢ Genetic defect ➢ Maternal factors:
systematic disease; genital organ anomalies; endocrine anomalies; irritation; bad habit
➢ Immune anomalies ➢ Environmental factors
➢ Early Abortion：pregnancy loss before 12 gestational weeks
➢ Late Abortion: pregnancy loss during 12～28 gestational weeks
➢ Spontaneous Abortion ➢ Artificial Abortion
Abortion and Ectopic Pregnancy
流产异位妊娠(英文)-AbortianandEctopicPregnancy-尧良清
Clinical Presentations
Threatened Abortion ➢ light vaginal bleeding with mild abdominal
pain ➢ cervical os closed, fetal membranes unbroken ➢ treatment might work , continue pregnancy
➢ Early abortion：vaginal bleeding preceding abdominal pain
➢ Late abortion：abdominal pain preceding vaginal bleeding
Types of Abortion
Threatened Abortion Inevitable Abortion Incomplete Abortion Complete Abortion
Abortion and Ectopic Pregnancy
Liang-Qing Yao
Obstetrics and Gynecology Hospital of Fudan University
Abortion
Concept
A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 grams
inevitable abortion
incomplete abortion
complete abortion
Diagnosis
History
异位妊娠(ectopic pregnancy)(1)
概述异位妊娠（ectopic pregnancy）是指受精卵在子宫体腔以外的任何部位着床，俗称宫外孕。
根据受精卵再子宫体腔外种植部位的不同可以分为：输卵管妊娠（tubal pregnancy）、卵巢妊娠（ovarian pregnancy）、腹腔妊娠（abdominal pregnancy）、阔韧带妊娠（broad ligament pregnancy）、宫颈妊娠（cervical pregnancy）。
其中以输卵管妊娠最常见，约占95%以上，以壶腹部妊娠为最多，占50～70％；其次为峡部，占30～40％；伞部、间质部最少见，占1～2％。
病因一、输卵管炎症是异位妊娠的主要原因。
慢性输卵管炎，输卵管内膜因炎症粘连形成狭窄部，输卵管曲折或输卵管周围有炎症粘连，常使孕卵受阻。
输卵管炎不仅引起形态上的变化，且使输卵管内膜纤毛常有缺损，输卵管蠕动能力降低，影响孕卵移行。
二、输卵管发育不良或畸形、功能不良输卵管发育不良者，其壁之肌纤维发育差或缺乏，内膜纤毛缺乏，其外形较正常输卵管细薄，并弯曲呈螺旋状，较正常为长。
发育畸形者有多孔、憩室、双输卵管口或另有一发育不全的输卵管，为副输卵管。
输卵管功能包括蠕动、纤毛活动、上皮细胞的分泌等受雌、孕激素的调节，若调解失败，可影响受精卵俄的正常运行。
此外，精神因素引起输卵管痉挛和蠕动异常，干扰受精卵运送。
三、输卵管的子宫内膜异位症子宫内膜组织可侵入输卵管间质部，使间质部增厚，管腔狭窄或阻塞为输卵管妊娠原因之一。
有人提出，异位于输卵管、卵巢、盆腔的子宫内膜，对受精卵可能有某些趋化作用，诱发受精卵在宫腔以外的位置着床。
四、盆腔内肿瘤子宫肌瘤或卵巢肿瘤压迫输卵管，可使输卵管变细变长，迂回曲折，阻碍孕卵通过。
五、节育措施与异位妊娠宫内节育器是否会引起异位妊娠，是一个人们关注和争议的问题。
1965年李普首先报告了IUD使用者，有较高的异位妊娠。
多数学者认为惰性或活性IUD能有效的防止宫内妊娠，部分防止输卵管妊娠，而不能防止卵巢妊娠。
异位妊娠(Ectopic+pregnancy)
（四）诊断
• 未发生流产或破裂时，临床表现不明 显，诊断较困难，往往须采用辅助检 查才能确诊； • 流产或破裂后，多数患者临床表现典 型，诊断多无困难。
辅助检查：
1.HCG测定 2.超声诊断 3.阴道后穹隆穿刺 4.腹腔镜检查 5.子宫内膜病理检查
(五) 鉴别诊断
• • • • • 流产 急性输卵管炎 黄体破裂 卵巢囊肿蒂扭转 急性阑尾炎
输卵管妊娠
流产
急性输卵 管炎 无
急性阑尾 炎 无
黄体破裂
卵巢囊 肿蒂扭 转 无
停经
多有
有
多无
腹痛
突然撕裂样 剧痛，自下 腹一侧开始 向全腹扩散
量少，暗红 色，可有蜕 膜组织或管 型排出 程度与外出 血不成正比 正常，时有 低热
下腹中央阵 发性坠痛
两下腹持 续性腹痛
持续性疼 痛，从上 腹开始， 经脐周转 至右下腹
（1）输卵管切除术：尤其适用于输卵 管妊娠内出血并发休克的急症患者。 （2）保守性手术：保留患侧输卵管手 术,适用于有生育要求的妇女。
2、药物治疗：
（1）化学药物治疗 （2）中药治疗
（1）化学药物治疗
• 适于早期异位妊娠，要求保存生育能力的 患者。 • 治疗机理：抑制滋养细胞增生，破坏绒毛， 使胚胎组织坏死、脱落、吸收而免于手术。
3）陈旧性宫外孕 4）继发性腹腔妊娠
（二）病理
2.子宫的变化
月经停止来潮 子宫增大变软 子宫内膜呈蜕膜反应
（三）临床表现
1.症状：1）停经
2）腹痛 3）阴道流血 4）晕厥与休克 5）腹部包块
2 体征
1）一般情况：贫血貌，休克表现。 2）腹部检查：下腹压痛、反跳痛。 3）盆腔检查：来自 宫腔的少量出血，后穹隆 饱满，触痛，宫颈举痛或摇摆痛，子宫稍大 而软，子宫一侧或其后方可触及肿块，触痛 明显。
Ectopic pregnancy 异位妊娠
Ectopic pregnancy 异位妊娠【DEFINITION:】In a normal pregnancy, the fertilized egg enters the uterus 子宫and settles into the uterine lining 子宫内膜where it has plenty of room to divide and grow.however,under some abnormal circumstances, the embryo ['ɛmbrɪo] implants outside the uterine cavity, so that an ectopic pregnancy ,or eccysis,happens.【LOCATION:】Most ectopic pregnancies occur in the Fallopian tube [fə'ləupiən]输卵管. but implantation can also occur in the cervix 子宫颈，ovary 卵巢and abdomen 腹腔.Tips：in most cases, ectopic pregnancies are dangerous for the mother, since internal haemorrhage内出血is a life-threatening complication. so an ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.【SIGNS AND SYMPTOMS:】（Early symptoms are either absent or subtle）--Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp 痉挛，绞痛).--Pain while urinating 排尿--Pain and discomfort, usually mild.--Vaginal bleeding 阴道出血[və'dʒaɪnl], usually mild.This is due to the falling progesterone 黄体酮[pro'dʒɛstə'ron] levels.--Internal bleeding (hematoperitoneum 腹腔积血[,peritəu'ni:əm]) is due to hemorrhage from the affected tube.【CAUTION：】Ectopic pregnancy can mimic 酷似，呈现...症状symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic [,ɡainikə'lɔdʒik]妇科的problems.If doctors misdiagnose it ,the rupture of the Fallopian tube with internal haemorrhage may lead to hypovolaemic shock失血性休克，even death.【DIGNOSIS:】①An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound 超声诊断showing a gestational sac 孕囊[dʒe'steiʃənəl] with fetal 胎儿的['fitl] heart in the fallopian tube is clear evidence of ectopic pregnancy.②A laparoscopy 腹腔镜检查or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube.③Culdocentesis后穹窿穿刺[,kʌldəusen'ti:sis], in which fluid is retrieved from the space separating the vagina阴道[və'dʒaɪnə] and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus 子宫['jutərəs] and in front of the rectum直肠. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy.【TREATMENT:】--medical :Early treatment of an ectopic pregnancy with methotrexate(MTX ,一种抗癌药物) is a viable 可行的alternative to surgical treatment.If administered early in the pregnancy, MTX terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications 禁忌症include liver, kidney, or blood disease, as well as an ectopic mass > 3.5 cm.--surgical:If hemorrhage has already occurred, surgical intervention may be necessary.However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.。
9流产、异位妊娠、过期妊娠
三 病理 （一） 胎盘 过期妊娠的胎盘有两种类型。 胎盘功能正常：除重量略有增加外， 胎盘外观和镜检均与妊娠足月胎盘相 似。
胎盘功能减退： 胎盘绒毛内血管床减少，间质纤维化增加，合 体细胞小结增加，某些合体细胞小结断裂、脱 落，绒毛表面出现缺损，缺损部位由纤维蛋白 沉积填补并在纤维蛋白沉积表面出现钙化灶， 绒毛上皮与血管基底膜增厚。 另外有绒毛间血栓、胎盘梗死、绒毛周围纤维 素或胎盘后血肿增加等胎盘老化现象，使物质 交换与转运能力下降。
一 病因
（一）遗传基因缺陷：引起早期流产的主要原因 遗传基因缺陷： 母体方面的因素： （二）母体方面的因素：
全身性疾病 生殖器官疾病 内分泌功能失调 不良习惯 吸烟 酗酒 饮咖啡 海洛因等 其他：创伤（手术创伤、外伤、情感创伤） 其他：创伤（手术创伤、外伤、情感创伤） （三）免疫因素 母儿血型不合 1 2 3 4 5
第九章 妊娠时限异常 第一节 自然流产
主讲 蔡娱飞 课件制作 蔡娱飞
第一节 自然流产 （spontaneous abortion）
妊娠不足28周 概 念：妊娠不足 周，胎儿体重不足 1000g者，称流产。 者 称流产。 流产发生在12周以前者称早期流产 流产发生在 周以前者称早期流产 (early abortion) 发生于12周至不足 周至不足28周者称晚期流产 发生于 周至不足 周者称晚期流产 (late abortion) 自然流产(spontaneous abortion) 自然流产 人工流产(artificial abortion) 人工流产
第Ⅲ期 为胎儿全身因粪染历 时较长广泛着色，指 (趾)甲和皮肤呈黄色， 脐带和胎膜呈黄绿色。 此期胎儿已经历和渡过Ⅱ期危 险阶段，其预后反较Ⅱ期好。
3、胎儿生长受限 小样儿可与过期妊娠 共存，后者更增加胎儿 的危险性。
流产、异位妊娠-Abortian-and-EctopicPregnancy-尧良清
Incomplete Light to Abortion heavy
Relieved
Partial
Dilated or Small obstructed
Complete Light to none None Abortion
➢ Missed Abortion ➢ Habitual Abortion ➢ Septic Abortion
Clinical Presentations
Threatened Abortion ➢ light vaginal bleeding with mild abdominal
pain ➢ cervical os closed, fetal membranes unbroken ➢ treatment might work , continue pregnancy
Incomplete Abortion ➢ heavy vaginal bleeding ➢ pregnancy tissue protruding
from the cervical os ➢ uterus small for the presumed
gestational week
Complete Abortion ➢ vaginal bleeding decreasing,
Abortion and Ectopic Pregnancy
Liang-Qing Yao
Obstetrics and Gynecology Hospital of Fudan University
Abortion
Concept
A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 grams
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presumed gestational week
Different Stages of Abortion
threatened abortion continue pregnancy
Etiology
➢ Genetic defect ➢ Maternal factors:
systematic disease; genital organ anomalies; endocrine anomalies; irritation; bad habit
➢ Immune anomalies ➢ Environmental factors
During 8～12 weeks：with firm
attachment to the basal decidua ➢ Partial expulsion of the products of
conception→ non-ideal uterine contraction, severe bleeding
Ectopic Pregnancy
Concept
Ectopic Pregnancy: implantation of the fertilized ovum in tissue other than the endometrium
Extrauterine Pregnancy
➢ including：tubal pregnancy (95％), ovarian pregnancy, cornual pregnancy, cervical pregnancy, abdominal pregnancy, etc.
➢ genetic counseling ➢ cervical incompetence：cervical cerclage
during 14～18 weeks of gestation ➢ with unclear causes：progesterone therapy
until 10 weeks of gestation ➢ active immunotherapy：intradermic injection
inevitable abortion
incomplete abortion
complete abortion
Diagnosis
History
Physical Examination
Laboratory Assessment:
➢ ultrasound ➢ pregnancy test ➢ hormone level: serum progesterone
➢ Missed Abortion ➢ Habitual Abortion ➢ Septic Abortion
Clinical Presentations
Threatened Abortion ➢ light vaginal bleeding with mild abdominal
pain ➢ cervical os closed, fetal membranes unbroken ➢ treatment might work , continue pregnancy
transfusion preparation; emptying the uterus：
➢ before 12 weeks: suction curettage ➢ after 12 weeks：induction of labor
Habitual Abortion
The occurrence of 3 or more consecutive spontaneous abortions
After 12 weeks: placenta fully formed.
➢ Uterine contraction→ expulsion of all the products of conception，light bleeding
Symptoms
Amenorrhea, vaginal bleeding , and abdominal pain
Normal or slightly large
Management
Threatened Abortion
➢ bed rest, sedation ➢ anti abortion：progesterone，HCG；
Vit E；thyroxine supplement ➢ monitoring：ultrasound；serum
of lymphocytes
Septic Abortion
Prolonged bleeding during abortion or retained products of conception lead to intrauterine infection, which might progress into pelvic inflammatory disease, peritonitis or even sepsis if not treated
Incomplete Abortion ➢ heavy vaginal bleeding ➢ pregnancy tissue protruding
from the cervical os ➢ uterus small for the presumed
gestational week
Complete Abortion ➢ vaginal bleeding decreasing,
Antibiotic treatment + Prompt evacuation ➢ without severe bleeding: management of
infection , performance of suction and curettage ➢ with severe bleeding：management of infection while applying forceps, with secondary suction and curettage
➢ no need for special management
Missed Abortion
Concept: in utero death of the embryo or fetus with retained products of conception
Clinical Manifestation: ➢ uterine enlargement ceasing or fetal movement
Management
blood routine examination, coagulation function test
correcting coagulation defects： heparin, fibrinogen, etc.
sensitizing the uterus： diethylstilbestrol
The occurrence of 2 spontaneous abortions is defined as recurrent abortion
➢ Early abortion：chromosomal abnormalities， immunologic factors，luteal-phase insufficiency, hypothyroidism
Abortion and Ectopic Pregnancy
Liang-Qing Yao
Obstetrics and Gynecology Hospital of Fudan University
Abortion
Concept
A pregnancy loss before 28 weeks of gestation while fetal weight under 1000 grams
Pathology
Before 8 weeks: chorionic villi immature
➢ Fetal death→basal decidual bleeding →uterine contraction→expulsion of all the products of conception, light bleeding
disappearing ➢ cervical os closed, uterus small for the
presumed gestational age ➢ no fetal heartbeat ; embryonic demise
suggested by ultrasound findings
➢ Late abortion：congenital uterine anomalies，cervical incompetence，uterine fibroids, etc.
Management
➢ obtain information on etiology for prior losses before conception
➢ perform suction curettage promptly ➢ if with heavy bleeding：blood
transfusion；preventive antibiotic use
Complete Abortion
➢ no retained products of conception confirmed by ultrasound；no infection
➢ Early Abortion：pregnancy loss before 12 gestational weeks
➢ Late Abortion: pregnancy loss during 12～28 gestational weeks