Abortion

流产流产

Ⅰ. Definition

Abortion is termination of pregnancy bfore Abortion is termination of pregnancy bfore 28 weeks of gestation and the fetal weight i28 weeks of gestation and the fetal weight is less tan 1000g.s less tan 1000g.

Abortion : spontaneous: 10%~18%Abortion : spontaneous: 10%~18%

artificialartificial The early abortion: occurs before 12wThe early abortion: occurs before 12w The late abortion: occurs after 12w The late abortion: occurs after 12w The miscariage abortion: occurs in 13~28w The miscariage abortion: occurs in 13~28w

2.Etiology

(1)Heredity factors(1)Heredity factors

Abnormal gene is the commonest cause of Abnormal gene is the commonest cause of Spontaneous abortion.Spontaneous abortion.

Abnomalities of chromosomes:Abnomalities of chromosomes:

number: autosomal trisomies polyploidynumber: autosomal trisomies polyploidy

structural: monosomy Xstructural: monosomy X

Early abortion 50%~60% is caused by chroEarly abortion 50%~60% is caused by chromosomal abnormalities. mosomal abnormalities.

(2)Toxic factors: (2)Toxic factors:

lead, mercury, DDT, radiation, X-raylead, mercury, DDT, radiation, X-ray (3)Maternal factors(3)Maternal factors (4)Immunologic factors(4)Immunologic factors

Blood type in compatibility between motBlood type in compatibility between mother and fatus.her and fatus.

Imcompatibilily due to ABO, Rh Imcompatibilily due to ABO, Rh

①the general diseases

Acute infections(systemic or local)Acute infections(systemic or local) virus infectionvirus infection hypertension, typhoid, pneumonia, heart hypertension, typhoid, pneumonia, heart

disease, nephritisdisease, nephritis bacteria, toxin and virus get into fetal blood bacteria, toxin and virus get into fetal blood

circulation by placenta.circulation by placenta.

②endocrine disorder

Hyper- or hypothyroidism (hyroidism)Hyper- or hypothyroidism (hyroidism)

hypofunction of corpus luteumhypofunction of corpus luteum

③the genital disease

A.uterine deformityA.uterine deformity

double uterusdouble uterus

hypoplasia uterihypoplasia uteri

longitadinal uterine septumlongitadinal uterine septum B.pelvic tumor(myoma, ovarian tumor)B.pelvic tumor(myoma, ovarian tumor) C.cervical incompetence, lacerationC.cervical incompetence, laceration

④abdominal operation during the pregnancy

3.Pathologic change Most commonly, necrotic changes occur in Most commonly, necrotic changes occur in

the decidual tissue about the placentation sitthe decidual tissue about the placentation site and result in hemorrhage into this area. As e and result in hemorrhage into this area. As bleeding continues, the sac and the placenta bleeding continues, the sac and the placenta become detached from the uterine wall and become detached from the uterine wall and are expelled by uterine contractions.are expelled by uterine contractions.

Early pregnancy: abortion is completeEarly pregnancy: abortion is complete 8~12w: abortion is incomplete 8~12w: abortion is incomplete

4.Clinical classification and feature

(1) Threatened abortion(1) Threatened abortion (2)Inevitable abortion(2)Inevitable abortion (3)Incomplete abortion(3)Incomplete abortion (4)complete abortion(4)complete abortion (5)Missed abortion(5)Missed abortion (6)Habitual abortion (6)Habitual abortion (7)Septic abortion(infect abortion)(7)Septic abortion(infect abortion)

Differential diagnosis of varied abortions

Threatened Inevitable Imcomplete CompleteHistory Bleeding Slight Middle→ severa Slight→ severa Slight→no Abdominal pain No/slight Aggravate Decrese NoTissues areexpelled

No No Yes(partial) Complete

Gynecologic examination Cervical os Close Open Open/tissue blochk Close Uterine size Consistent with =/slight small < =/slight largerPregnancy test + +/- +/- +/-Treatmentprinciple

Protect fetus Curettage Curettage no

(5)Missed abortion

It is that pregnancy has been retained for 2 It is that pregnancy has been retained for 2 months or more following death of the fetus.months or more following death of the fetus.

The abnormally protracted retention of a The abnormally protracted retention of a dead fetus in uterus in over 2 months that dead fetus in uterus in over 2 months that don’t expelled.don’t expelled.

Missed abortion is manifested by loss of Missed abortion is manifested by loss of symptoms of pregnancy and decrease in symptoms of pregnancy and decrease in uterine size.uterine size.

The embryo or fetus has been dead at least The embryo or fetus has been dead at least 2 months but no tissue is passed.2 months but no tissue is passed.

Middle pregnancy, no fetal movement and Middle pregnancy, no fetal movement and fetus heart tones.fetus heart tones.

The cervix closed. The cervix closed.

(6)Habitual abortion(recurrent)

Recurrent, or habitual, is the sequential 3 or Recurrent, or habitual, is the sequential 3 or more spontaneous abortion.more spontaneous abortion.

Every abortion times is or not same month Every abortion times is or not same month of pregnancy. of pregnancy.

Early cause

①①hypofunction of corpus luteumhypofunction of corpus luteum ②②emotion factor nervous factoremotion factor nervous factor ③③hypopituitarismhypopituitarism ④④chromosomal abonormalitieschromosomal abonormalities

Late abortion

(1)incompetence of the cervix(1)incompetence of the cervix (2)congenital anomalies of the uterus(2)congenital anomalies of the uterus (3)myomas of the uterus(3)myomas of the uterus (4)blood type incompatibility between moth(4)blood type incompatibility between moth

er and fetuser and fetus

5. Diagnosis

(1)History

①①amenorrhea, recurrent abortion symptomamenorrhea, recurrent abortion symptoms of pregnancys of pregnancy

②②the degree of abdominal pain, vaginal blthe degree of abdominal pain, vaginal bleedingeeding

③③the products of gestation were expelled othe products of gestation were expelled or not r not

(2)Examination

①①general examination: temperature , pulse, general examination: temperature , pulse, respiration, blood pressure.respiration, blood pressure.

②②vaginal examination: vaginal examination:

uterine size: compared to the expected uterine size: compared to the expected

date of pregnancydate of pregnancy

cervical os: open or closecervical os: open or close

uterine tendenessuterine tendeness

(3)ancillary examination

①①pregnancy test: HCG<625IU/L→abortionpregnancy test: HCG<625IU/L→abortion ②②measurement of HPLmeasurement of HPL

5~10w: hpl≤0.01mg/L5~10w: hpl≤0.01mg/L ③ ③ measurement of E2(estroid)measurement of E2(estroid)

E2<740pmol/LE2<740pmol/L ④④measurement of pregnanediolmeasurement of pregnanediol

24h urinary<15.6μ/24h, 95%→abortion24h urinary<15.6μ/24h, 95%→abortion 　　　　

⑤⑤B-ultrasoundB-ultrasound

differential of varieties of abortiondifferential of varieties of abortion

gestation sac, embryo status, fetal heart tones, gestation sac, embryo status, fetal heart tones, fetus movementfetus movement

Incompetence of the cervix, cervical os>19mIncompetence of the cervix, cervical os>19mm and have history of abortionm and have history of abortion

Normal pregnancyNormal pregnancy

incomplete septiincomplete septicc

threatened inevitable infectionthreatened inevitable infection

proceed completeproceed complete

delaieddelaied

treatmenttreatment

miised habitual miised habitual

6. Treatment

(1)Threatened abortion Principle: protect fetus treatmentPrinciple: protect fetus treatment ①①place the patient at bed restplace the patient at bed rest

forbid sexual intercourseforbid sexual intercourse ②②drugdrug

folic acid 5mg tid. Po.folic acid 5mg tid. Po.

If corpus luteum or low of uterine pregnanediol proIf corpus luteum or low of uterine pregnanediol progesterone 20mg Qd. Im.gesterone 20mg Qd. Im.

VE 30~50mg Qd po.VE 30~50mg Qd po.

Seditive: valium 2.5mg po. Seditive: valium 2.5mg po.

(2)Inevitable and incomplete abortion At once D&C(curettage) dilatationAt once D&C(curettage) dilatation if bleeding is brisk blood transfusionif bleeding is brisk blood transfusion

oxytosin 5~10u iv/imoxytosin 5~10u iv/im incomplete abortion antibiotic used for incomplete abortion antibiotic used for

preventive infection preventive infection

tissue examination by a pathologisttissue examination by a pathologist

(3)Complete abortion

When the uterus is empty, there are no need When the uterus is empty, there are no need for further interference.for further interference.

(4)Missed abortion

After diagnosis of it ,as soon as expelled prAfter diagnosis of it ,as soon as expelled product of conception is necessary.oduct of conception is necessary.

Because the fetus dead, placenta release thrBecause the fetus dead, placenta release thrombocinatse into blood circulation ease occombocinatse into blood circulation ease occure in coagulability.lead to disseminated inture in coagulability.lead to disseminated intravascular coagulation(DIC)ravascular coagulation(DIC)

①①examination:examination:

bleeding and coagulation timebleeding and coagulation time

placenta countplacenta count

fibrinogen levelfibrinogen level

thrombinogenthrombinogen

②②leveral uterine sentitionleveral uterine sentition

DES(diethylstibestrol)5~10mg tid po 5dDES(diethylstibestrol)5~10mg tid po 5d ③③before curettage, preparey bloodbefore curettage, preparey blood

during opreation: oxytocin 10u im/ivduring opreation: oxytocin 10u im/iv

over than 3 month of pregnancy artificial over than 3 month of pregnancy artificial inducte. inducte.

(5)Habitual abortion The first should be examinatin cause of habitual abortThe first should be examinatin cause of habitual abort

ion and treatment.ion and treatment. 1)rest, increase nutrition, VB,VC,VE…1)rest, increase nutrition, VB,VC,VE… 2)medical treatment: hypofunction of corpus luteum--2)medical treatment: hypofunction of corpus luteum--

progesteroneprogesterone 3)surgical treatment:3)surgical treatment:

① ①correction of congenital anomalies of correction of congenital anomalies of

uterus,removed of myomasuterus,removed of myomas

② ②repair of the incompetent cervix.12~20wrepair of the incompetent cervix.12~20w

(7)abortion complication infection(septic abortion)

Symptoms:temperature ↑, pulse↑, abdominaSymptoms:temperature ↑, pulse↑, abdominal pain, marked suprapubic tenderness sighs l pain, marked suprapubic tenderness sighs of peritonitis(guarding indentfy)marke tendof peritonitis(guarding indentfy)marke tenderness of uterus and uterine adnexa.erness of uterus and uterine adnexa.

Severas:pelvic-peritonitis, septicemia, (endoSeveras:pelvic-peritonitis, septicemia, (endotoxic shock) intoxication shocktoxic shock) intoxication shock

(8)Septic abortion

The principle of treatment:The principle of treatment:

bleeding is a few: first treat infection with bleeding is a few: first treat infection with

broad-spectrum antibiotissbroad-spectrum antibiotiss

second D&Csecond D&C

bleeding is sever: we are eryher contract infectbleeding is sever: we are eryher contract infection or curettage. ion or curettage.

※※The producte of conception from the cervThe producte of conception from the cervix are removed with a sponge holder.ix are removed with a sponge holder.

Don’t used curette to curettage curettage uteDon’t used curette to curettage curettage uterine wall prevent infectionrine wall prevent infection

avoid hematogeous dissemination od the infavoid hematogeous dissemination od the infection. ection.