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Abnormal Duration of Pregnancy 妊娠时限异常. 程苾恒 武汉大学人民医院产科. Chapter 1 Spontaneous Abortion 自然流产 Chapter 2 Premature Delivery 早产 Chapter 3 Post-term Pregnancy 过期妊娠. 自然流产. TIPS for Spontaneous abortion. Definition 重点! Epidemilogy Etiology

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Abnormal Duration of Pregnancy 妊娠时限异常


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    1. Abnormal Duration of Pregnancy 妊娠时限异常 程苾恒 武汉大学人民医院产科

    2. Chapter 1 Spontaneous Abortion 自然流产 Chapter 2 Premature Delivery 早产 Chapter 3 Post-term Pregnancy 过期妊娠

    3. 自然流产

    4. TIPS for Spontaneous abortion • Definition 重点! • Epidemilogy • Etiology • Pathology • Manifestation and classification 重点! • Diagnosis 难点! • Therapy 重点!

    5. Definition • Spontaneous abortion: termination of pregnancy before the 28th week of gestation,the weight of fetus less than 1000g • 自然流产:妊娠不足28周,胎儿体重小于1000g而终止者 • <20 weeks from the first day of the last menstrual period or a fetus weighing <500g • 妊娠满20周以前,或体重小于500g (美国) • Miscarriage VS Abortion

    6. Definition • Early abortion <12weeks • Late abortion ≥12weeks~<28weeks • Artificial abortion • Spontaneous abortion

    7. Epidemiology • Incidence: 10%~15%   • 80% of abortions: before the 12th week most of these: before the 8th week  • 流产发生率10~15%,以早期流产居多 • Subclinical abortion 用尿hCG对希望怀孕的妇女进行监测,有62%的受精卵在孕12周之前死亡,其中大多数(92%)流产是亚临床的

    8. Etiology • Embryonic/fetal factors (1)Embryonic factors: inheritance、infection、drugs → chromosome abnormalities in number or structure →early abortion  e.g. trisomy三体 monosomy单体 triploidy三倍体 polyploidy多倍体 translocation易位 (2)Placental abnormalities:villus degeneration、placenta previa

    9. Etiology (一)胚胎(或胎儿)因素 • 胚胎因素 早期流产最常见原因为染色体异常,约占50~60%。染色体数目异常和结构异常由遗传或感染、药物等因素导致未必是坏事! • 胎盘异常 由于滋养层发育不全,胎盘绒毛变性,或胎盘附着位置过低等,可使胎儿胎盘循环障碍,导致流产

    10. Etiology • Maternal factors (1)Systemic diseases (2)Endocrine disorders (3)Genital organ abnormalities:unicornuate uterus、uterine septum、cervical incompetence (4)Emotional disturbance (5)Harmful habits:smoking, alcohol abuse,drug addiction

    11. Etiology (二)母体因素 • 全身性疾病:妊娠期急性传染病,可因病原体或毒素经胎盘侵入,造成胎儿死亡,或因高热、感染引起宫缩导致流产;严重贫血或心衰,致胎儿缺氧死亡;高血压或肾病导致胎盘梗死…… • 内分泌失调:生殖内分泌/代谢内分泌 • 生殖器官疾病:子宫发育不良、子宫肌瘤或畸形;宫颈机能不全

    12. Etiology 4.强烈的精神刺激、外伤或性交:但常仅为诱发因素 5.不良生活习惯 *每天抽10支烟增加流产率1.2倍,每天抽14支烟增加2倍 *喝酒增加流产率:每周喝2次增加2倍,每天喝酒增加3倍 *每天喝5杯以上咖啡略增加流产率

    13. Etiology • Environmental factors:Chemical materials,Physical factors,drugs、lead and radiation  • Immunological factors:The implanted embryo is regarded as an allograft containing foreign antigens which derive from the paternal genome antiphospholipid syndrome-APS

    14. Etiology (三)环境因素 放射线、化学物质 (四)免疫因素 妊娠相当于同种异体移植。危险因素包括配偶的组织相容性抗原、胎儿抗原、血型抗原、母体抗磷脂抗体过多、抗精子抗体存在、孕期中母体封闭抗体不足等

    15. Pathology • 胚胎死亡→底蜕膜出血 →胚胎与蜕膜层分离→排出

    16. Pathology • < 8th week pregnancy villi immature, embryo separate totally • 8-12th week villi mature, implanted closely, embryo separate difficult, expulsion incomplete • > 12th week the placenta is well formed. expulsion of fetus followed by placenta 

    17. Manifestation • Amenorrhea • Lower abdominal pain and uterine cramping • Vaginal bleeding • Cervical dilatation • Extrusion of product of pregnancy • Disappearance of symptoms and signs of pregnancy

    18. Manifestation • 主要症状是停经、阴道出血、腹痛 • 早期流产—先出血后腹痛,且全过程均伴有阴道出血 • 晚期流产—先腹痛后出血,流产过程与早产相似 • 体征因妊周大小、流产过程不同而异。检查子宫大小、宫颈扩张与否、是否破膜、贫血程度等

    19. Classification • Clinical categories actually is general process of spontaneous abortion  continued pregnancy threatened abortion complete abortion inevitable abortion incomplete abortion

    20. Classification

    21. threatened abortion • Slight vaginal bleeding • With or without lower abdominal pain • Cervix is closed • The size of the uterus corresponds to the gestational age • ultrasonograph shows intact pregnant sac and a living fetus • Pregnancy may continue • 阴道少量出血,下腹阵发性隐痛,宫口未开,胎膜未破,子宫大小与孕周相符

    22. inevitable abortion • Vaginal bleeding is increased • Abdominal pain becomes stronger • Cervix is dilated • The size of uterus corresponds with or smaller than the gestational age • rupture of membrane • Pregnancy loss is unavoidable • 出血增多,腹痛加重,或胎膜破裂,宫口扩张,宫口可能有物堵,子宫大小与孕周相符或略小

    23. incomplete abortion • Vaginal bleeding is profuse • Cervix is dilated • Some tissue filling the cervix • Size of the uterus is smaller than gestational age • The product of pregnancy is partial expelled. cervix opening • High risk in infection and shock • 妊娠产物部分排出,部分残留或嵌顿,持续阴道出血、量多,宫口扩张有物堵,子宫小于孕周

    24. complete abortion • Vaginal bleeding cease • Abdominal pain cease • Cervix closes again • Uterus becomes smaller and firmer to normal • everything is expelled • 妊娠产物完全排出,出血、腹痛渐停止消失,宫口关闭,子宫接近正常大小

    25. Special types • Missed abortion:dead embryo retains in the uterus absence of uterine growth,loss of some early pregnancy symptoms,slight bleeding,DIC • 稽留/过期流产:胚胎或胎儿已死亡未能及时?自然排出而滞留宫内。早孕反应消失,子宫小于孕周,胎心、胎动消失 • 胎盘组织可机化与子宫壁粘连导致刮宫困难;如死亡的妊娠物在宫腔内滞留太久,易发生严重的凝血功能障碍

    26. Special types • Septic abortion:Abortion complicated by infection Septic shock、offensive vaginal discharge、lower abdominal pain、tender of lower abdomen or uterus • 流产合并感染:流产过程中合并宫腔感染、全身感染。多见于不全流产出血时间长者。不同病原体混合感染

    27. Special types • 习惯性流产(habitual abortion) three or more times of consecutive spontaneous abortion 自然流产连续发生≥3次,每次流产多发生在同一孕月 • 复发性自然流产(recurrent spontaneous abortion,RSA)spontaneous abortion occurs consecutively two or more times 连续2次或以上的自然流产

    28. Etiology of RSA Early abortion---chromosomal abnormality、 immune or endocrine disorders Later abortion---cervical incompetence、anatomic deformities

    29. Diagnosis (1)History 有无停经史和反复流产的病史 有无早孕反应 阴道流血量及其持续时间 有无腹痛,腹痛的部位、性质、程度 阴道有无水样排液,阴道排液的色、量、味 有无组织排出等

    30. Diagnosis (2)Physical examination • 观察患者全身情况,有无贫血,评估生命体征等 • 妇科检查应在消毒情况下进行 注意点:宫颈口是否扩张、有无组织堵塞、羊膜囊是否膨出 子宫位置、大小是否与停经月份相符合,有无压痛 双侧附件有无包块

    31. Diagnosis (3)Assistant examinations 1.Ultrasonographic scan:确定是否存活,协助判断预后,诊断流产类型 与流产有关的超声现象 1.一个平均直径超过2cm的妊娠囊应该有胚胎出现 2.一个头臀长超过5mm的胚胎应该有胎心搏动 3.卵黄囊出现意味着胚胎存活的机会比较大 4.有绒毛下血肿时,发生流产的机会是30%(即使是有胎心时)

    32. Diagnosis 2.血hCG、孕酮测定 • -hCG定量 • 与孕周、超声检查相关性。 • 测2次,相隔2-3天——增长一倍 • 下降或不变提示异常妊娠 • 孕酮 • <5ng/ml可能预测结局不良 • >25ng/ml提示宫内妊娠存活 • 若已见胎囊,血-HCG水平<1000IU/L,结合血P水平<5ng/mL,几乎可以肯定宫内妊娠已死亡

    33. 实验室和超声的相关性

    34. Differential diagnosis 病 史 妇 科 检 查 • 类 型 出血量 下腹痛 组织排出 宫颈口 子宫大小 • 先兆流产 少 无或轻 无 闭 =孕周 • 难免流产 中→多 加剧 无 扩张 ≤孕周 • 不全流产 少→多 减轻 部分排出 扩张或闭 <孕周 • 完全流产 少→无 无 完全排出 闭 正常或稍大 • 早期自然流产应与异位妊娠、葡萄胎、功血、子宫肌瘤鉴别。

    35. Treatment Principles type-specificity (1)threatened abortion • Rest and forbidden sexual intercourse • Luteal function defect-progesterone • Vitamin E and folic acid • Thyroxine tablets • Mental therapy

    36. 流产心理问题与处理 • 知识方面的告知, 并使之放弃内疚感 • 允许合理的悲痛悲伤和情绪的宣泄 • 给予适当的同情与支持 • 对下次妊娠可能性的介绍 • 建议如何将消息告知同事与亲友 • 建议如何以客观、积极的心态对待这一事件

    37. Treatment (2)inevitable abortion and incomplete abortion • D&C (dilatation and curettage )诊断明确后立即清宫! • Oxytocin/pitocin催产素 • blood transfusion may be required如出血多,甚或伴有休克症状者,应输液输血、纠正休克,注意治疗贫血 • antibiotics:抗生素预防感染 • The tissues removed should be sent for pathologic examination刮出物应送病理检查

    38. (3)complete abortion  no particular treatment

    39. Treatment (4)missed abortion • D&C 诊断明确后立即清宫! • Check coagulation function • Proper dosage of estrogen before operation 戊酸雌二醇口服或苯甲酸雌二醇肌注 • Preparing blood transfusion • Oxytocin

    40. (5)habitual abortion 全面检查,查明原因,针对病因进行治疗 (6)septic abortion • 可发生败血症,血栓性静脉炎、中毒性休克,DIC等严重后果,应予重视 • D&C after antibiotics;出血量多或抗生素未能控制感染时,可在抗感染同时钳出大块残留组织。切不可立时全面搔刮宫腔!

    41. 假如你在坐诊…… • 患者停经50天,阴道出血,你想到什么? • 患者停经50天,阴道淋漓出血,伴有阵发性下腹痛,下一步你打算怎么办? • 患者停经50天,阴道出血伴下腹痛,自述有烂肉样物排出,你对她有什么建议?

    42. 早 产

    43. TIPS Preterm delivery • Definition 重点! • Etiology • Manifestation and diagnosis 重点! • Treatment 难点! • prevention Post-term pregnancy • Definition 重点! • Etiology and pathology • Diagnosis 难点! • Treatment

    44. 定义 • 早产(preterm delivery):妊娠满28周至不足37周(196~258天)间分娩者 • 此时娩出的新生儿称早产儿( premature infant),体重1000~2499克

    45. 所有死亡新生儿中28%为早产(占无畸形儿死亡中的70%)所有死亡新生儿中28%为早产(占无畸形儿死亡中的70%) • 早产新生儿存活主要取决于胎龄,其次为体重 • 早产婴儿死亡率(<32周的小孕周早产儿) 186.4/1000 出生儿 (死亡率是足月产婴儿的75倍) • 孕周小于32周的早产儿,有20%存活不到一年 • 国内占分娩总数5%~15%,约15%早产儿于新生儿期死亡

    46. 不同孕周早产发生率 (1995-2000) • < 28 weeks : 0.82 % • < 32 weeks: 2.2 % • 33-36 weeks: 8.9 % • < 37 weeks: 11.2 IOM Report-July 2006- page 72/2006 Alexander GR et al 2006 (under review)