Abnormal Duration of Pregnancy ??????

1
Abnormal Duration of Pregnancy ??????
??? ??????????
2

• Chapter 1 Spontaneous Abortion
• ????
• Chapter 2 Premature Delivery
• ??
• Chapter 3 Post-term Pregnancy
• ????

3
????
4
TIPS for Spontaneous abortion

• Definition
  ??!
• Epidemilogy
• Etiology
• Pathology
• Manifestation and classification ??!
• Diagnosis ??!
• Therapy
  ??!

5
Definition

• Spontaneous abortion termination of pregnancy
  before the 28th week of gestation,the weight of
  fetus less than 1000g
• ????????28?,??????1000g????
• lt20 weeks from the first day of the last
  menstrual period or a fetus weighing lt500g
• ???20???,?????500g (??)
• Miscarriage VS Abortion

6
Definition

• Early abortion
• lt12weeks
• Late abortion
• 12weekslt28weeks
• Artificial abortion
• Spontaneous abortion

7
Epidemiology

• Incidence 1015  
• 80 of abortions before the 12th week
• most of these before the 8th week 
• ?????1015,???????
• Subclinical abortion
• ???hCG ????????????,?62??????12?????,??
  ???(92)???????

8
Etiology

• Embryonic/fetal factors
• (1)Embryonic factors inheritance?infection?drugs
  ? chromosome abnormalities in number or structure
  ?early abortion
•  e.g. trisomy?? monosomy?? triploidy???
  polyploidy??? translocation??
• (2)Placental abnormalitiesvillus
  degeneration?placenta previa

9
Etiology

• (?)??(???)??
• ???? ???????????????,??5060??????????????????
  ????????? ?????!
• ???? ?????????,??????,??????????,??????????,????

10
Etiology

• Maternal factors
• (1)Systemic diseases
• (2)Endocrine disorders
• (3)Genital organ abnormalitiesunicornuate
  uterus?uterine septum?cervical incompetence
• (4)Emotional disturbance
• (5)Harmful habitssmoking,
• alcohol abuse,drug addiction

11
Etiology

• (?)????
• ?????????????,?????????????,??????,??????????????
  ????????,???????????????????
• ??????????/?????
• ??????????????????????????

12
Etiology

• 4.?????????????????????
• 5.??????
• ???10???????1.2?,???14????2?
• ??????????2???2?,??????3?
• ???5???????????

13
Etiology

• Environmental factorsChemical materials,Physical
  factors,drugs?lead and radiation 
• Immunological factorsThe implanted embryo is
  regarded as an allograft containing foreign
  antigens which derive from the paternal genome
• antiphospholipid syndrome-APS

14
Etiology

• (?)???? ????????
• (?)???? ??????????????????????????????????????????
  ???????????????????????????

15
Pathology

• ??????????
• ????????????

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Pathology

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

18
Manifestation

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

19
Manifestation

• ???????????????
• ??????????,???????????
• ??????????,?????????
• ?????????????????????????????????????????

20
Classification

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

21
Classification
22

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
• ??????,???????,????,????,?????????

23
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
• ????,????,?????,????,???????,????????????

24
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
• ????????,???????,?????????,???????,??????

25
complete abortion

• Vaginal bleeding cease
• Abdominal pain cease
• Cervix closes again
• Uterus becomes smaller and firmer to normal
• everything is expelled
• ????????,??????????,????,????????

26
Special types

• Missed abortiondead embryo retains in the uterus
• absence of uterine growth,loss of some early
  pregnancy symptoms,slight bleeding,DIC
• ??/?????????????????????????????????,??????,?????
  ??
• ??????????????????????????????????,????????????

27
Special types

• Septic abortionAbortion complicated by infection
• Septic shock?offensive vaginal discharge?lower
  abdominal pain?tender of lower abdomen or uterus
• ??????????????????????????????????????????????

28
Special types

• ?????(habitual abortion) three or more times of
  consecutive spontaneous abortion
• ????????3?,????????????
• ???????(recurrent spontaneous abortion,RSA)spontan
  eous abortion occurs consecutively two or more
  times
• ??2?????????

29

• Etiology of RSA
• Early abortion---chromosomal
  abnormality? immune or endocrine disorders
• Later abortion---cervical incompetence?anatomic
  deformities

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Diagnosis

• (1)History
• ?????????????
• ??????
• ???????????
• ????,???????????
• ????????,??????????
• ???????

31
Diagnosis

• (2)Physical examination
• ????????,????,???????
• ?????????????
• ?????????????????????????
• ?????????????????,????
• ????????

32
Diagnosis

• (3)Assistant examinations
• 1.Ultrasonographic scan??????,??????,??????
• ??????????
• 1.????????2cm???????????
• 2.???????5mm??????????
• 3.??????????????????
• 4.???????,????????30(???????)

33
Diagnosis

• 2.?hCG?????
• ?-hCG??
• ????????????
• ?2?,??2-3?????
• ???????????
• ??
• lt5ng/ml????????
• gt25ng/ml????????
• ?????,??- HCG??lt1000IU/L,???P??lt5ng/mL,???????????
  ??

34
??????????
LMP????? ??? ???? ??? ???? ?? ?-hCG IU/L
lt 5 ? ? ????? 1800
5 - 6 ? ??? ??????? 1800 - 3500
7 ? ?? 5-10mm ??????,???? gt20,000
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Differential diagnosis

• ?
  ? ? ? ? ?
• ? ? ??? ??? ???? ??? ????
• ???? ? ??? ? ?
  ??
• ???? ??? ?? ? ??
  ??
• ???? ??? ?? ???? ???? lt??
• ???? ??? ? ???? ?
  ?????
• ???????????????????????????

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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

38
?????????

• ???????, ????????
• ???????????????
• ??????????
• ???????????
• ??????????????
• ???????????????????

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Treatment

• (2)inevitable abortion and incomplete abortion
• DC (dilatation and curettage )?????????!
• Oxytocin/pitocin???
• blood transfusion may be required????,?????????,??
  ????????,??????
• antibiotics???????
• The tissues removed should be sent for pathologic
  examination?????????

40

• (3)complete abortion 
• no particular treatment

41
Treatment

• (4)missed abortion
• DC ?????????!
• Check coagulation function
• Proper dosage of estrogen before operation
• ????????????????
• Preparing blood transfusion
• Oxytocin

42

• (5)habitual abortion
• ????,????,????????
• (6)septic abortion
• ??????,????????????,DIC?????,????
• DC after antibiotics???????????????,????????????
  ???????????????!

43
??????

• ????50?,????,??????
• ????50?,??????,????????,??????????
• ????50?,????????,?????????,?????????

44
? ?
45
TIPS

• Preterm delivery
• Definition ??!
• Etiology
• Manifestation and diagnosis ??!
• Treatment ??!
• prevention
• Post-term pregnancy
• Definition ??!
• Etiology and pathology
• Diagnosis ??!
• Treatment

46
??

• ??(preterm delivery)???28????37?(196258?)????
• ????????????( premature infant),??10002499?

47

• ????????28???(?????????70)
• ??????????????,?????
• ???????(lt32????????) 186.4/1000 ???
  (??????????75?)
• ????32?????,?20??????
• ???????515,?15??????????

48
????????? (1995-2000)

• lt 28 weeks 0.82
• lt 32 weeks 2.2
• 33-36 weeks 8.9
• lt 37 weeks 11.2

IOM Report-July 2006- page 72/2006 Alexander GR
et al 2006 (under review)
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??

• ????
• ????(premature rupture of membranes)???????(chorio
  amnionitis)3040
• 20??????????????????,??????????????????
• 609??????????,??????????????,??????
• ???????????,????????????????
• ?????????? B???????????????????????????

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• 2. ????????????
• Meis(1995,1998)??
• 28?????????????,1/4????,1/4????????????????
• 72?????,???????

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• 3. ???????????
• ????
• ????
• ????
• ????
• ??????

54

• 4. ???????
• cervical incompetence
• uterine spetum
• bicornuate uterus

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• 5. ????
• ???2-5????????,1.2-2??????
• ?????????????(?????)??????Vit
  C????(???????)?????????????
• ??????????????,?????????

56
?????????

• ?????
• 16000??????,?????,?????????????????3?
• ??2???,1/3??????
• 70????????????????????

57

• ????????????
• ?????????????????????????
• ????????
• ??????2916??,24??28??????,24???????3.5cm
• 16-24????????35????????Yost(2004)??????????2-4cm,
  ??35????????

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• ????
• ?????????
• ????????,??????,????????
• Lams(1994) ????????????,??24???????

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• ????????(Fetal Fibronectin,fFN)
• ???,??????????????,?????????
• ??20???????????????,22-35????,36??????
• ???????,gt50ng/ml???
• ????????????,?????????????????,24h?????
• ???????????fFN??,?????????
• Swamy(2001)404???,?22-34?????,?????30,?????41

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• ???
• ??????????????????????????????????????
  ?????????7????????24-28?????4???32?????
• ?????????37??????

61
???????
62

• ????(threatened premature labor)
  ???28w?????10?????????,??????
• ???? ???28w???37w,??????(20???4??60??
  8?,??30s),?????? 75,????2cm??

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• Regular abdominal painstaking(contractions)and/or
  backache
• Cervical dilatation and effacement
• Vaginal discharge (fluid or blood)
• Fetal heart rate monitoring

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??????
????????????????????
Iams, Obstet Gynecol 1994 Berghella Am J Ob Gyn
1997 Hartmann, Obstet Gynecol 1999 Guzman Am J
Ob Gyn 1999 Gomez Am J Ob Gyn 2001
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fFN
2436?????????fFN??gt50ng/ml
66
????

• lt34??,????????????????,???????,??????????
• ?????????????,??????????????
• ??????
• 24? 20
• 25? 50
• ??????4
• 34??,????

67
??

• ?????????????????????

68
????
?????????? ?????????(??????????????????) ????? ??
???(?????????????)
New ACOG Treatment Guidelines Gynecology and
Obstetrics 2004 Edition
69
????

• (?)?????( Tocolysis )
• 1?ß2?????
• ß???? ß1????,??
• ß2?????,??,???
• ??ß2????,????????,cAMP?,??Ca2?,???????

70

• ????
• ???(??????)??
• ????(???)2.4-4.8mg q6-8h

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• ????????,??????,???,????,???,?????(24-48h?),????,
  ????
• ?????????????????????????????????????????????????
  ?????????????????
• ????????????????????
• ????HR?BP?????????????????

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• 2????????????????,??Ca2???
• ????????
• ???gt16?/min
• ???gt25ml/h
• ???10GS 10ml 10 ?????10ml iv

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• 3????? Ca2???,????
• ????????(???)10mg q8h
• ????????????????
• ???MgSO4????????????
• ????????????N-??????,??????

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• 4?PG??????????(???)
• ???????????------- ?????
• ?????? -------????
• ????????????34?????(1??)

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????

• (?)???(antibiotics)
• ??????????????,?????????????????????
• (1)??????????????,??????????????
• (2)?????????????????????????

76
?????

• (?)?????( Corticosteroid )
• ?????????,???????????????????????????????
• ?? ???? ????

77
?????

• ???????
• ?????????,??????????
• ???????????????????,?????????
• ??lt34?????????????????????????????????????34?????
  ?????

78
?????

• ???????
• 1?????(vaginal delivery)
• ?????? ??????
• 2????(cesarean section)
• ??????????,?????????
• ???????????

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??

• 1????????????,?????,??PROM
• 2???????,?????/?????
• 3???????????14-18????(cerclage)

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? ?? ?
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??

• ????(post-term pregnancy)
• ??????,???????42??(294?)????
• ???3-15

84
????
? ?
? ?
? ?
??
?37?
?40????
?42?
??????????? ??????????????????????????????-3,??
7 ???3????2?(??????,?????)
85
??

• 1??/??????????????
• 2?????????????
• 3????????
• 4??????????????

86
? ?

• ?????????????
• BW gt 4000g 25
• BW gt 4500g 5.4
• ?????????????10-20
• ???????
• ????????
• ????????
• ??????????

87
??????

• 1??????????????????????????????
• ?????????
• ???????35?
• ????13?
• ????4?
• 2?????????

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????????

• 1???LMP????????(28?)?,??42?(294?)
• 2???????????280?
• ? ??????
• ? ????28???????14?
• ? ??????
• ? IVF???

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• 3?B?
• 20?????????????
• 5-12?????????CRL
• 12-20????BPD/???FL
• 4??????????????????????????????
• 5??????????HCG????

90
??????????

• 1?????????????
• ??10?/12h
• ??lt10?/12h?????gt50
• 2???????
• NST 1-2?/?
• OCT ?????
• B?

91

• 3?B?1-2?/? Manning??
• ??????????????NST
• 4??E3?E3/Cr??????
• ?? E3/Crlt10
• E3lt10mg

92

• 5??????
• ????(??????)
• ?????????

93
??

• ??????
• ????
• ???????????
• ??lt10??NST????,OCT?????
• ?E3/Cr?
• ???????
• ???????????

94

• ?????????????
• ??/???????
• 1?????????(preinduction cervical ripening)
• (1) ???????Bishop ??
• (2) ???????
• ????
• ???
• PGE2
• COOK??

95

• 2???
• ??Bishop ??gt7?
• ??????????

96

• 3???/????????
• (1)???????
• (2)???????????????
• (3)????
• (4)????????????
• ?????PH???????
• (5)??????????????,????????,?????????

97

• ?????
• ??????
• ????
• ??????
• ???
• ????
• ????
• ???/???GDM?ICP?PIH
• ????
• ????

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THANKS