1、流产,上海交通大学附属第六人民医院 陶敏芳 2010-11-11,流产1、妊娠不足28w2、胎儿体重不足1000g而终止者,定义 Definition,Abortion:The pregnancy terminates at the gestational age less than 28 weeks,the weight of fetal is less than 1000g,分类 Types1.时间分类早期流产 Early Abortion:12weeks晚期流产 Late Abortion:12-28weeks2 流产方式分类自然流产 Spontaneous Abortion(incid
2、ence rate 10%-15%)most of cases occur in early pregnancy人工流产 Artificial Abortion,流产Abortion,病因 Etiology,1遗传基因缺陷Genitic gene defect 染色体异常50%-60%发生早期流产 Chromosomal abnormities cause at least half of these early abortion 数目异常 三体、X单体、三倍体及四倍体 结构异常 断裂、倒置、缺失和易位,病因 Etiology,2.母体因素 Maternal factors 全身性疾病 Phy
3、sical diseases such as infections,anemia,Heart Failure,chronic nephritis,hypertension 生殖器官异常 Reproductive organs such as malformation of uterus,myoma of uterus,incompetent cervix 内分泌异常 Endocrine abnormalities such as hypothyroidism,severe diabetes mellitus,luteal insufficiency 不良习惯 Bad habits such a
4、s excessive smoking,alcoholism,excessive coffee,drug创伤刺激 Trauma stimulationsuch as severe shock,uterine trauma,stess,anxiety,fear,sadness,病因 Etiology,3.免疫功能异常Immunological factors Much attention has focused on the immune system as important in recurrent pregnancy loss4.环境因素Enviroment conditions chem
5、ical pollute,x-ray,noising and so on,早期流产 Early Abortion Embryo die first,hemorrhea in deciduas occurs then,uterine contraction follows,and the content is discharged.8w Complete,less bleeding 8-12w Incomplete,more bleeding晚期流产 Late Abortion Abdominal pain occurs,accompanied with vaginal bleeding,the
6、n discharge the fetal and placenta.,病理 Pathology,临床表现 Clinical Presentations,主要症状Symptoms 停经后阴道流血、腹痛。阴道排出组织物 Menolipsis,Vaginal bleeding and abdomen ache.早期流产 Early Abortion:12weeks vaginal bleeding abdomen ache 晚期流产 Late Abortion:12-28weeks abdomen ache vaginal bleeding 体征Signs 根据妊娠月份及流产过程不同而不同,先兆流
7、产 Threatened Abortion 要点:流血少,腹痛轻or无,妊娠物未排出 妇科检查宫口未开,未破膜,子宫大小与停经周数相符 处置:希望继续妊娠者:休息,禁性生活,酌情用药 不希望继续妊娠者:人工流产或引产,临床类型Types of Abortion,2.难免流产 inevitablle abortion 指流产不可避免,怎样处理均不能使妊娠继续处置:原则:一旦确诊,尽早排出妊娠物 药物治疗:缩宫素 10u 静滴 5%GS 500ml 手术治疗:早期流产:吸宫、刮宫术 晚期流产:钳刮术,临床类型Types of abortion,3.不全流产 Incomplete Abortion
8、指妊娠产物已部分排出体外,尚有部分残留于宫腔内,由难免流产发展而来 要点:阴道出血持续不止,妇科检查宫颈口已扩张,妊娠物堵塞宫口处置:一经确诊,应及时行吸宫术或钳刮术 有休克者,输血输液,抗生素预防感染 出血时间长需加抗生素,临床类型Types of abortion,4.完全流产 Complete Abortion All is expelled out of uterus,bleeding stops,and abdominal ache cease要点:阴道流血渐止,腹痛渐消失,宫口闭,子宫接近正常大小。超声示宫腔内无组织物残留。处置:一般无特殊处理 注意:如不能确定,应按不全流产处理,
9、以再作一次刮宫为宜,临床类型Types of Abortion,pregnancy Threatened abortion incomplete abortion inevitable abortion complete abortion,发展过程 The process,The process of abortion,三种特殊情况的流产,稽留流产Missed Abortion 习惯性流产Habitual Abortion 流产合并感染Septic Abortion,稽留流产 Missed Abortion 指胚胎或胎儿已死亡滞留在宫腔内尚未自然排出者 The dead fetal retai
10、ns in uterus要点:胚胎或胎儿死亡,子宫缩小,早孕反应消失 妇科检查宫口未开,子宫较停经周数小胚胎死亡过长:1、胎盘机化与宫壁粘连 2、消耗凝血因子,出血,DIC,稽留流产 Missed Abortion 指胚胎或胎儿已死亡滞留在宫腔内尚未自然排出者 The dead fetal retains in uterus处置:出血及凝血功能检查,定血型作输血准备 1、一般治疗:如凝血功能障碍,应纠正后再行处理 2、药物治疗:凝血功能正常 雌激素 5-10mg tid 3-5d 缩宫素10u+5%GS 500ml 米索 0.6mg pv q12h 利凡诺 50-100mg 3、手术治疗:刮宫
11、(子宫12w),习惯性流产 Habitual Abortion指自然流产连续发生3次或以上者复发性自然流产(recurrent abortion)指自然流产连续发生2次特点:Abortion is often in same gestational week.病因:Early abortion is because of chromosomal abnormities,immunological abnormal,luteal dysfunction,hypothyroidism.Late abortion is because of malformation of uterus,dysfun
12、ction of cervical os,myoma of uterus,预防为主,寻找病因是防治的主要措施 孕前染色体核型、血型、免疫检查相关抗体、丈夫精液、卵巢功能、生殖道检查、内分泌检查。孕早期全面检查,孕中期流产月份保胎,产前早期入院待产无明显原因者孕后可按先兆流产药物治疗 对于宫口松弛者则在孕前行内口修补术 或在妊娠1416 周行宫颈内口环扎术,习惯性流产的处理,流产合并感染septic abortion 定义:流产过程中,若阴道流血时间过长、有组织残留于宫腔内或非法堕胎等,有可能引起宫腔内感染,严重时感染可扩展到盆腔、腹腔乃至全身,并发盆腔炎、腹膜炎、败血症及感染休克等,称为流产合
13、并感染要点:妊娠或人流史;感染体征;宫腔内常有组织物。各类流产均可发生,在不全流产中最常见处置原则:一、积极控制感染 二、尽快清除宫腔内残留物,1.病史采集:(l)停经史,3月(2)腹痛:程度不同,可无,下腹正中(3)阴道出血:一定有 量取决于孕周、妊娠物是否排出、排出时间长短(4)过去史,诊断 Diagnosis,2.查体(消毒后)子宫与孕周一致性、宫口扩张、妊娠物、胎膜是否破 附件压痛、增厚、包块3.辅助检查(l)妊娠试验:尿HCG 连续测定血HCG的动态变化 HCG:合体滋养细胞产生 着床即排卵后6天滋养细胞形成 1天后测出,以后倍增,诊断 Diagnosis,3.辅助检查(2)B超:对
14、鉴别诊断与确定流产类型有实际价值 孕囊出现时间,了解有无孕囊,胚胎大小、是否存活(3)其他检查:孕激素等有助判断先兆流产的预后 孕酮:排卵后由黄体产生,LH峰后6-8天达峰值,经前4天降至卵泡水平(4)病理,诊断 Diagnosis,鉴别诊断 Differential Diagnosis,鉴别诊断 Differential Diagnosis,早期流产应与以下疾病鉴别 异位妊娠:不规则出血、患侧腹痛、超声、HCG 葡萄胎:不规则出血、子宫异常大、超声宫内弥散光点、HCG 功血:不规则出血、子宫不大、超声无孕囊、HCG 子宫肌瘤:不规则出血、无停经、子宫大而硬、超声、HCG 阴道宫颈疾病引起的出血,谢谢,