1、 ABORTION 流 產1 Case presentation A woman, 26y, G2P0, menstruation: 5-6/28dChief complaint: 6 weeks of menopause, vaginal spotting for 3 days with slight lower abdominal pain 停經6周，少量陰道流血3天，伴輕微下腹疼痛Pregnancy test (Urine HCG)：positive 尿妊娠試驗: 陽性 What is happening? Managements? Take history - Physical exa

2、mination - Assistant detection Diagnosis - Differential diagnosis - Treatment 2 Normal/Abnormal PregnancyNormal Pregnancy：normal duration normal location 正常妊娠：正常時限，正常位置Abnormal Pregnancy: abnormal duration abnormal location 異常妊娠：異常時限，異常位置3 Definition 定義Abortion：spontaneous termination of pregnancy b

3、efore the 28th week of gestation, the weight of fetus less than 1000g流產：妊娠不足28周、胎兒體重不足1000g 而終止者 early abortion (before 12th week) 早期流產 late abortion (12th 28th week) 晚期流產 4 Incidence 發生率 frequency of spontaneous abortion is about 30% 自然流產占全部妊娠的30%左右Approximately 80% is occurring during the first 12

4、 weeks of pregnancy，in which 2/3 are clinically silent miscarriages 80%以上為早期流產；其中2/3 為隱性流產5Etiology 病因6 hysteroscope 宮腔鏡7正常宮腔子宮縱隔宮腔粘連子宮粘膜下肌瘤Etiology 病因8PATHOLOGY 病理The process of abortion is the separation and expulsion of pregnancy tissue from uterus 流產是妊娠物從子宮壁剝離、然后排 出子宮的過程death of the embryo 胚胎死亡

5、hemorrhage in the decidua basalis 底蛻膜出血c. uterine contraction & cervical dilatation 子宮收縮、宮頸擴張pregnancy tissue detach & exclude 妊娠物剝離、排出9 clinical presentations 臨床表現 amenorrhea 停經 vaginal bleeding 陰道流血 lower abdominal pain 腹痛10 Clinical categories 臨床類型threatened abortion 先兆流產inevitable abortion 難免流產i

6、ncomplete abortion 不全流產complete abortion 完全流產special forms: missed abortion 稽留流產 recurrent abortion 重復性流產 septic abortion 流產伴感染 11 A. threatened abortion 先兆流產 symptoms : slight vaginal bleeding 少量陰道流血 with or without lower abdominal pain 輕微下腹痛 signs：cervix remains closed 宮頸口未開prognosis: After treatm

7、ent or rest, some pregnancies may continue 預后：部分可繼續妊娠12Symptoms : vaginal bleeding increases more 陰道流血增多 abdominal pain is stronger 腹痛加重signs: cervical dilatation 宮頸口擴張 sometimes cervical os is blocked by tissues 有時可見胚胎組織堵塞于宮頸口Prognosis: pregnancy loss is unavoidable 預后：流產不可避免B. inevitable abortion

8、難免流產13C. incomplete Abortion 不全流產the products of conception are partially expelled 妊娠物部分排出vaginal bleeding is profuse - maybe threatened to life 大量陰道流血，可能危及生命 abdominal pain is stronger - paroxysmal cramp 腹痛加重，陣發性腹痛14D. complete Abortion 完全流產the products of conception are expelled in total 妊娠物已經完全排出

9、vaginal bleeding ceases 陰道流血停止abdominal pain ceases 腹痛消失15 Different stage of abortionstage of abortionhistorypelvic examination vaginal bleedingabdominal pain passage of tissues cervical osthreatened abortionslightabsent or mildabsent closedinevitable abortionmoderate or heavyincreasein intensityab

10、sent dilatedincomplete abortionmoderateor heavydecreasein intensitypartial dilated or blocked by tissuescomplete abortionslight orabsent absentcomplete closed 16 Assistant Examination 輔助檢查 A. pregnancy test (-hCG test) 妊娠試驗-hCG: pregnant or not -hCG檢測確定妊娠urine -HCG: qualitative 定性 serum -HCG: quanti

11、tative 定量Serial -HCG test: Abnormal levels of serum -HCG are predictive of an abnormal pregnancy 血-HCG值下降或低于正常提示異常妊娠17 Assistant Examination 輔助檢查 B. Ultrasonography 超聲檢查Intrauterine pregnancy or not 確定宮內妊娠viable pregnancy or not 判斷胚胎是否存活residual of conception tissue or not 宮腔有無妊娠物殘留 1819先兆流產：孕囊和胚芽Ul

12、trasonography 超聲檢查難免流產：孕囊不規則不全流產：妊娠物殘留 完全流產：無殘留Diagnosis 診斷A. History a missed period amount and duration of vaginal bleeding characteristic of abdominal pain B. SignsGeneral condition (vital signs)Pelvic examinationC. Assistant examinationpregnancy test Ultrasonography 20Differential Diagnosis 鑒別診斷

13、ectopic pregnancy 異位妊娠hydatidiform mole 葡萄胎pelvic inflammatory disease 急性盆腔炎dysfunctional uterine bleeding 功血21Treatment 治療 A. Threatened abortiontaking rest 休息Progesterone, HCG 孕激素或HCG保胎治療observe the progress 觀察病情變化22Treatment 治療 B. Inevitable & incomplete abortion D&C (dilatation and curettage) 清宮

14、術 oxytocin be given 縮宮素 blood transfusion may be required 必要時補液輸血 antibiotics: risk of infection 預防感染23Treatment 治療 C. complete abortionNo particular management 不需特殊處理Observation for bleeding 觀察陰道流血情況Ultrasound examination 證實宮內無組織殘留24A. Missed abortion 稽留流產Fetus dies and still remains in the uterus

15、定義：胚胎死亡未排出Clinical Presentations 表現：胚胎停止生長（超聲及血HCG）；早孕反應消失D&C 清宮術Large dosage of estrogen before operation 清宮術前大劑量激素治療Three special forms 三種特殊類型25B. Recurrent abortion 重復性流產Consecutive loss of three or more pregnancies 定義：連續發生3次及3次以上的自然流產Common cause 常見病因：染色體異常、子宮異常（子宮畸形、宮 腔粘連、宮頸機能不全等）Cause therapy 病因治療Three special forms 三種特殊類型26C. Septic abortion 流產合并感染Definition: abortion complicated by infectionManifestation: fever, malodorous discharge, cervix pain 臨床表現：發熱、分泌物臭、腹痛、宮頸舉痛Antibiotics; remove infectious tissues