abortion
Introduction
Introduction to abortion Abortion is called abortion after 28 weeks of gestation and less than 1000g of fetal weight. Abortion occurs before 12 weeks of gestation and is called early abortion. It occurs in the second trimester of pregnancy to less than 28 weeks. Abortion is divided into spontaneous abortion and abortion. This section is limited to spontaneous abortion. The incidence of spontaneous abortion accounts for about 15% of all pregnancies, most of which are early abortions. There are also two special types of abortion: missed abortion and habitual abortion. basic knowledge The proportion of illness: 0.025% Susceptible population: pregnant women Mode of infection: non-infectious Complications: bacterial infections pelvic inflammatory disease hemorrhagic shock
Cause
Cause of abortion
Chromosomal abnormalities (12%):
Chromosomal abnormalities include abnormal chromosome numbers, such as monomer, trisomy, and polyploid; structural abnormalities such as breaks, deletions, and translocations can cause abortion, and some people have studied chromosomes in spontaneous abortion and therapeutic abortion and found that they are in spontaneous abortion. The nucleus-type abnormalities accounted for 60%, and the karyotype abnormalities were accompanied by a structural abnormality such as the fetus or placenta, and the fetuses with normal karyotype abortion were normal.
Endocrine disorders (20%):
Excessive estrogen and progesterone deficiency are also causes of early abortion. Because of the placenta formation in place of pregnancy luteal function during the 12-14 weeks of gestation, endocrine disorders are easy to occur, especially in the corpus luteum. In addition, thyroxine is absent. Cellular oxidation processes are impeded, and hyperthyroidism and diabetes are prone to miscarriage.
Abnormal placenta and endocrine insufficiency (10%):
Decidual inflammation in early pregnancy can cause hemorrhage or hyperplasia of the decidua, villus epithelial cells and decidual cells are dissolved, blood vessels in the villi are blocked, affecting the absorption and transport of nutrients, so that the pregnant eggs are separated from the attachment, bleeding and abortion In addition, if the large infarction in the placenta can reduce the function of the placenta, affecting the survival of the fetus; and placenta previa, placental villus edema degeneration caused by abortion is not uncommon, maternal blood -hCG, hPL, P, E2, estrone after pregnancy If these hormone values decrease during early pregnancy, 50% will abort.
Blood type incompatibility (5%):
Due to the previous pregnancy or blood transfusion, the Rh factor and the incompatible ABO blood group factor produce antibodies in the mother. The pregnancy enters the fetus from the placenta and the red blood cells aggregate to produce hemolysis, resulting in miscarriage.
Neurological factors (10%):
Such as fright, severe mental stimulation, etc. can also lead to miscarriage, in recent years through research, noise and vibration have a certain impact on human reproduction.
Maternal systemic disease (10%):
1, severe acute infectious diseases and infectious diseases: such as lobar pneumonia, many with high fever leading to uterine contractions, or / and embryo death can cause miscarriage.
2, chronic diseases: severe anemia, heart disease, heart failure can cause fetal hypoxia, suffocation and death; chronic nephritis, severe hypertension can cause infarction or early stripping of the placenta and cause miscarriage.
3, malnutrition or drug poisoning: such as vitamin deficiency, especially vitamin E - the lack of tocopherol, mercury, lead, alcohol and morphine and other chronic poisoning, can cause miscarriage.
Genital diseases, uterine malformations, such as double-horned uterus, uterine cavity mediastinum, often abortion, but uterine dysplasia is often the cause of infertility, in addition, such as uterine fibroids, especially the submucosal muscles that develop into the uterine cavity Tumors or ovarian cysts incarcerated in the orbital cavity can affect the development of the fetus and cause miscarriage. The relaxation of the uterus is one of the common causes of habitual abortion. In recent years, about 14% of patients with intrauterine adhesions have been found. After abortion, adhesion causes the uterine cavity to shrink, deformation and endometrial area to decrease, and hardening, affecting embryo development.
Prevention
Abortion prevention
To prevent and avoid miscarriage, the following points should be noted:
1. Acute infectious diseases must be cured after a period of recovery, and patients with chronic diseases should be treated until the condition is stable and approved by a specialist before they can become pregnant.
2, for couples who have had a history of abortion, should go to the hospital in time to check the cause of miscarriage, no matter which side of the couple has problems, they should be treated in time, and then the child is cured.
3, pregnant women, to avoid exposure to harmful chemicals, such as benzene, mercury, radiation, etc., should be less early in the public places to avoid viral and bacterial infections, if pregnant women are sick, in a timely manner under the guidance of a doctor Take medication, don't use it at your own risk.
4, early pregnancy (12 weeks pregnant) In addition to pay attention to food hygiene and avoid excessive fatigue, but also to avoid excessive tension, to maintain emotional stability, to the fetus, the first 3 months of pregnancy not to the same room, if examined, fetal development abnormalities When the doctor thinks that the curettage should be performed, the patient should not delay, so as to avoid excessive blood loss (even shock, death) or the formation of internal genital inflammation affecting future birth. It should be noted that most of the aborted embryos are generally born with defects. Naturally eliminated, must not be lost due to small, endangering the health of pregnant women.
Have a history of abortion to prevent abortion:
1. Contraception should be taken within half a year after abortion, and pregnancy should be repeated after half a year to reduce the occurrence of miscarriage.
2, to do genetic testing, both couples accept chromosome examination.
3, do blood type identification including Rh blood type system.
4, there is a loose internal uterus can do internal suture.
5, the use of drugs for luteal insufficiency treatment time exceeds the pregnancy period of the previous abortion.
6, those with hypothyroidism, to maintain normal thyroid function and then pregnant, also take anti-A low drug during pregnancy.
7, pay attention to rest, avoid sexual intercourse, emotional stability, and the rules of life.
8, the man to do the inspection of the reproductive system, the treatment of bacteriosis, and then the wife to conceive.
9. Avoid contact with toxic and radioactive materials.
10. Computer workers should work less than 20 hours a week, and rest for four weeks after abortion.
Spontaneous abortion is a misfortune for pregnant women, but in a sense, spontaneous abortion is a way for human beings to continually optimize themselves. It is also a choice for gestating new life. The survival of the fittest is the law of nature, accounting for more than 50% of abortion. Chromosomal abnormalities Early abortion of the fetus will reduce the birth of the deformed child. Therefore, the cause should be ascertained as possible before the miscarriage, and blind fetus should not be blinded.
Complication
Abortion complications Complications, bacterial infection, pelvic inflammatory disease, hemorrhagic shock
1, large blood loss sometimes inevitable abortion or incomplete abortion can cause severe blood loss, and even shock, so should be actively treated, various measures can be carried out simultaneously, intravenous or intramuscular injection of oxytocin or pituitary vasopressin 10U, strive to give patients blood transfusion, in In the absence of a blood bank, the medical staff or their families can be mobilized to donate blood. If blood is not available for a while, dextran can be temporarily instilled intravenously. At the same time, the curettage is given. After the fetal embryo tissue is removed, the bleeding often stops, even if there is In the presence of infection, large pieces of embryonic tissue should also be removed, and then conditions should be actively created for blood transfusion.
2, infection of all types of abortion can be combined with infection, occurred in more than abortion, infection often occurs in abortion surgery with a device that is not strictly disinfected; device damage to the cervix; or uterine cavity infection, surgical abortion or natural After abortion, it can cause infection spread. In addition, after abortion (natural or artificial abortion), it does not pay attention to hygiene. Premature sexual intercourse can cause infection. Infectious pathogens are often mixed with various bacteria, anaerobic and aerobic bacteria. It has been reported that anaerobic bacteria can account for 60-80% of the majority.
The infection can be confined to the uterine cavity, or spread around the uterus, forming salpingitis, tubal oophoritis, pelvic connective tissue inflammation and even beyond the reproductive organs to form peritonitis, sepsis.
Patients with chills and fever, abdominal pain, vaginal bleeding, sometimes odorous secretions, uterus and attachment tenderness, uterine relapse, leukocytosis and other inflammatory manifestations, severe cases can occur septic shock, can do blood, cervical or uterine secretions Smear, culture (aerobic and anaerobic bacteria), B-ultrasound examination of the uterine cavity with or without tissue residue.
Symptom
Symptoms of abortion Common symptoms Pregnant women with small abdominal pain, vaginal bleeding, uterine shift, urine pregnancy test, positive lower abdomen, pain, pelvic sag, pelvic weight, heavy feeling
First, the main symptoms of abortion are bleeding and abdominal pain
1, vaginal bleeding: abortion within 3 months of pregnancy, the beginning of the villus and aponeurosis separation, blood sinus opening, that is, began to bleed, when the embryos are all stripped and discharged, the uterus strongly contracted, the sinusoids closed, bleeding stopped, so early abortion The whole process is accompanied by vaginal bleeding. In the late abortion, the placenta has formed. The abortion is similar to that of premature delivery and full-term birth. Generally, there is not much bleeding.
2, abdominal pain: early abortion begins to bleed, there is blood in the uterine cavity, especially blood clots, stimulating uterine contractions, persistent lower abdominal pain, late abortion, first paroxysmal uterine contractions, and then placenta stripping, so there is before vaginal bleeding stomach ache.
Abdominal pain and bleeding are mostly progressive, related to clinical progress and progress.
Second, the clinical classification of abortion
Most of the abortions have a certain development process. Although some stages are not obvious in clinical performance, and they do not necessarily develop in order, there are generally several processes, namely clinical classification: threatened abortion, inevitable abortion, incomplete abortion and complete Abortion, expired abortion is another special case of abortion development, habitual abortion is named after its repeated abortion, but the two still contain the above clinical classification in the abortion process.
1, threatened abortion (threatened abortion): the performance of abortion, but after the treatment of miscarriage, may continue to pregnancy to full-term, often occurs in early pregnancy, only a small amount of vaginal bleeding, accompanied by mild intermittent uterine contractions, At the time of examination, the uterine cervix did not open, the amniotic sac did not rupture, the uterus was in line with the menopause month, and the pregnancy test was positive.
2, inevitable abortion or inevitable abortion (inevitable abortion): the above process, but the embryo continues to separate from the uterine wall, bleeding time, bleeding increased, more than normal menstrual flow, and blood clots, paroxysmal lower abdomen pain For sputum or swell, check the uterus mouth gradually open, the pregnancy month is larger, some amniotic sac has bulged or ruptured; some embryonic tissue is blocked in the cervical canal and even exposed in the cervix, Abortion is bound to happen, and pregnancy can no longer continue.
3, incomplete abortion (imcomplete abortion): often occurs in the late pregnancy (after 10 weeks), the placenta is developing or has formed, the fetus and part of the placenta are discharged during abortion, the entire placenta or part of the placenta is still attached to the uterine wall, the uterus can not Very good contraction, so that the vaginal bleeding is very much, the residual placenta can form placental polyps for a long time, repeated bleeding, and easy to induce infection.
4, complete abortion (complete abortion): through aura and inevitable abortion process, in a short time, the embryonic tissue is completely discharged, bleeding, abdominal pain stops.
5, missed abortion (missed abortion): also known as expired abortion or stillbirth, refers to embryo death and still stay in the uterine cavity, and pregnancy products are generally discharged within 1 to 2 months after the symptoms are generated, therefore, all It is stipulated that the embryos have not been naturally discharged 2 months after the embryo ceases to develop, which is called missed abortion. Most pregnant women have early abortion threatened abortion. After that, the uterus no longer grows up, but gradually shrinks, and it is not as soft as normal pregnancy. The positive becomes negative, the placenta is mechanically adhered to the uterine wall, and it is not easy to be separated. On the other hand, due to insufficient sex hormones, the uterine contractility is reduced, and it is difficult to discharge and the uterine cavity is reserved. After the embryo dies, the placenta dissolves, and the lysozyme is released into the mother blood. Circulation, causing blood clotting in microvessels, consuming a large number of clotting factors, the longer the time of uterine cavity is reserved, the greater the possibility of causing coagulation dysfunction. In recent years, B-ultrasound is widely used in clinical practice, and the fetal sac can be explored after 6 to 7 weeks of menopause. , fetal buds, such as suspected and embryos stop development, can be observed with B-ultrasound, timely diagnosis and treatment, it is suggested that the use of the term abortion now, but Clinically, there are also symptoms that are not obvious, and have not caused the patient's attention. The embryonic death of the embryo at the time of diagnosis is longer.
6, habitual abortion (habitual abortion): more than three consecutive spontaneous abortion is called habitual abortion, and abortion often occurs in the same month, and the process of abortion can experience the aforementioned clinical classification.
Examine
Abortion check
First, ultrasound diagnosis: generally in the 5 to 6 weeks of pregnancy can be seen in the fetal sac, 6 to 7 weeks of pregnancy can be seen fetal buds, transvaginal probes than the abdomen, when there is no clinical signs of abortion, ultrasound examination can be found wilted pregnant eggs, The fetal sac >20mm yolk sac or fetal sac >25mm without fetal buds is the wilted pregnant egg, the image only sees a large ectal sac in the anechoic zone.
What kind of abortion can be diagnosed:
1, threatened abortion: ultrasound examination due to a small amount of bleeding, the side of the fetal sac is surrounded by no echo zone, the amount is not much but clear; severe uterine cavity has a large amount of blood, sometimes visible fetal membrane and palace wall stripping, There is no echo zone behind the membrane, and the fetal bud can be seen according to different pregnancy periods, and the original fetal heart beats.
2, inevitable abortion: ultrasound performance: 1 fetal cyst deformation, fetal sac moved down, or amniotic fluid has flowed out; 2 intrauterine or cervical canal has been opened, embryonic products moved down in the uterine or cervical canal, such as the membrane If it is not broken, the cystic dark area is seen in the cervical canal or the vagina; 3 the fetus has died and there is no fetal heartbeat.
3, incomplete abortion: ultrasound performance: 1 uterus slightly larger; 2 uterine cavity has irregular light group or small dark area.
4, complete abortion: ultrasound image: 1 normal size of the uterus or slightly larger; 2 see the regular intrauterine wave in the uterine cavity, no irregular light group.
5, missed abortion: In recent years, the application of ultrasound can detect embryo death in time, no need to wait for 2 months to diagnose, so in recent years it has been proposed to use "fetal death within the palace", ultrasound performance: 1 uterus less than gestational weeks; 2 not seen Fetal heart beat or fetal movement; 3 intrauterine echo disorder, difficult to distinguish the placenta or fetal structure.
Second, vaginal cytology
1. The appearance of chorionic zygote cells in smear tends to occur abortion. The chorionic corpuscle cells are cell clusters of different sizes, the cytoplasm is alkaline, contains different numbers of deeply stained large nuclei, and is often red, white blood cells. Surrounded by, it is characterized by it.
2. Nuclear pyknosis index: The increase of nuclear pyknosis index in vaginal smear during pregnancy indicates progesterone deficiency. The reason is that ovarian corpus luteum insufficiency leads to poor development of endometrium and decidua, which leads to defects in nourishing leaves. One is the defect of nourishing the leaf itself. The deficiency of lutein can be recovered naturally or recovered after treatment. If the nourishing leaf is a large piece of abnormality, it is the defect of the primary fertilized egg or the separation or decidua secondary to the nourishing leaf. The defects, abortion will be inevitable, the prognosis of the above two cases is different, but the nuclear pyknosis index is increased, so the nuclear pyknosis index can not identify two different situations, only the continuous observation of nuclear deflation changes make sense .
Third, cervical mucus crystallization: estrogen can produce cervical mucus crystallization, and progesterone has an inhibitory effect on crystallization, therefore, the examination of cervical mucus crystallization during pregnancy, can be measured the prognosis of abortion.
Fourth, basal body temperature: early pregnancy should maintain a high temperature curve, lasting about 16 weeks, gradually normal, there is abortion aura, such as basal body temperature and normal pregnancy, the prognosis is good, if the pregnancy is lower than normal pregnancy, the prognosis is poor.
V. Hormone determination: due to abortion caused by endocrine abnormalities, hormones can be determined according to different conditions, such as suspected luteal insufficiency, the dynamic changes of progesterone can be measured, and appropriate methods can be selected for treatment.
Diagnosis
Abortion diagnosis
diagnosis
First, you should first determine whether abortion
1. Detailed medical history: whether there is a history of menopause, whether there is vaginal bleeding, blood flow, nature, whether accompanied by abdominal pain and other discharges.
(1) The amount of uterine bleeding during abortion is generally higher than that of ectopic pregnancy; unlike other abnormal pregnancy, ectopic pregnancy is mostly vaginal bleeding; the bleeding of hydatidiform mole is often dark red, and can also repeatedly bleed, and even a large number of vagina Bleeding, such as careful examination, sometimes blister-like tissue can be found in the blood, dysfunctional uterine bleeding occurs at the two ends of the reproductive age, and it occurs in people over 40 years of age often have a history of menopause, although the vagina bleeds a lot, However, there is no abdominal pain, and there are few other discharges. In such cases, combined with the history of pregnancy and the presence or absence of contraception, it is not difficult to distinguish. If in doubt, it is feasible to diagnose the curettage, and pathological examination can confirm the diagnosis; Conducive to treatment, many cases of abortion, indeed misdiagnosed as dysfunctional uterine bleeding, uterine fibroids patients without significant menopause history and menorrhagia and infertility history, check the uterus, such as can touch the muscle nucleus, the diagnosis is more clear.
(2) bleeding from the last menstrual period: the time from the last menstruation to the beginning of vaginal bleeding, often in the ectopic pregnancy; and in abortion, the mole is longer.
(3) The color of the blood flowing out: the beginning of the abortion is bright red, the time is dark red or brown, the ectopic pregnancy is often a small amount, the color is reddish or brown; the hydatidiform mole is often dark red.
(4) Abdominal pain: abortion, grape abdominal pain is generally light, paroxysmal, mostly in the lower abdomen, ectopic pregnancy is a side of the lower abdomen severe pain, can spread to the whole abdomen, gradually reduced after 1 to 2 days, dysfunctional uterine bleeding There is no pain in the lower abdomen, and uterine fibroids may have a feeling of pelvic weight or pain.
(5) Understand the phenomenon of early pregnancy and the cause of abortion after menopause, such as sex life, weight bearing, tourism, etc.
2, double diagnosis: pay attention to the location, size, shape, hardness of the uterus, whether the uterine isthmus is particularly soft, as if the uterus body and the uterine neck lose continuity; both sides of the attachment with no mass or tenderness, resistance; cervix Whether there is erosion, bleeding, with or without cervical polyps; and must identify whether the bleeding is from the uterus, if abortion, then blood must be from the uterus.
3. Auxiliary inspection.
Second, determine what kind of abortion
The performance of various abortions is different, and the treatment principles are different. Therefore, it is necessary to determine which abortion.
The amount of vaginal bleeding is small, the uterus is not open, and the uterus is in accordance with the menopause month. It is a threatened abortion, the uterus is enlarged, the amniotic sac is prominent, or has been ruptured. The vaginal bleeding is very large, which is inevitable abortion and bleeding. Excretion of part of the tissue, the uterus is less than the menopause month, for abortion, there is a history of threatened abortion, the uterus is not open, the amount of bleeding at the beginning, after the embryonic tissue is discharged, the vaginal bleeding is rapidly reduced or stopped, the uterus is closed, the uterus is contracted Good, for complete abortion, the uterus is less than the menopause month, and the pregnancy test is negative, it is an expired abortion.
Habitual abortion
First of all, understand the reasons for abortion, emphasizing the simultaneous diagnosis of couples, not only to check the woman, but also to pay attention to the male factor. The conditional hospitals have established genetic eugenics consultation clinics, and the diagnosis and treatment of habitual abortion is one of the important contents.
1. Ask in detail about past pregnancy history, past medical history, family genetic history, and family history of suspicious genetic history.
2. Perform a systemic examination and a gynecological examination.
3, carry out the necessary tests and auxiliary examinations, the man: semen routine, blood type, chromosomes, etc., the woman: vaginal cell smear, cervical score, basal body temperature, blood type, chromosome, B-ultrasound to check the uterus development with or without deformity.
4. Further inspection according to the situation:
(1) suspected uterine malformation in addition to B ultrasound, feasible hysterosalpingography, hysteroscopy, laparoscopy.
(2) suspected endocrine abnormalities, examination of fasting blood glucose, combined with basal body temperature endometrial pathology and radioimmunoprogesterone, LH, FSH, PRL, E2, T3, T4, TSH, 17-OH, 17-Cu, etc. If necessary, the brain CT can be used to understand whether the pituitary gland has microadenomas.
(3) suspected special infection can be checked for cytomegalovirus, toxoplasma, and chlamydia.
(4) Those with a history of adverse environmental exposure, SLE, micronucleus, chromosome aberration rate check.
(5) If the suspected ABO blood group is not suitable, further check the antibody titer. For example, during the pregnancy, the antibody titer is changed, and the titer is decreased after receiving the treatment.
Third, with or without abortion complications
Abortion must be differentiated from functional uterine bleeding, tubal pregnancy, hydatidiform mole, uterine fibroids, and chorionic epithelial cancer. In addition, various types of abortion should be identified in order to confirm the diagnosis and choose different treatments according to different types.
