There are four factors that influence the progress and final outcome of labor.

1. The powers (the contractions or forces of the uterus)

- The uterine contraction : The main power during labor and last for the whole puerperal process.
- The characteristics of the uterine contraction:rhythmic, symmetrical and polar, Brachystasis(of
the uterine muscle fibers)
- There have other powers: vContraction of levator ani muscle(It is very important in the internal
rotation of the fetus) and Maternal efforts( abdominal and diaphragmatic muscle which is useful
in the second stage of labor cooperating with uterine contractions)
2. The passage (the bony and soft tissues of the maternal pelvis)
- Bony pelvis : inlet pelvis, mid-pelvis, and outlet pelvis
- pelvic soft tissues: The isthmus, Cervix, The levator ani muscles(help in the forward rotation of
the presenting part during labor), and The anatomy of the uterus and the vagina may influence
the progress of labor(vaginal septa or constrictions, which should be noted prior to the onset of
labor)
3. The fetus : Whether the fetus can be delivered successfully or not lying on the fetal size, position
and existing abnormality. Such as occipito presentation(the chin is near to the chest, it easy to
rotate(internal and external rotation) and frank beech presentation are a good fetal
presentation, position, and lie.
4. Psychological factors
- Prenatal education classes
- Be supported psychologically as well as
- physically
- Be encouraged to participate in prenatal exercise classes
- Learn various psychoprophylactic techniques
- A high level of anxiety during pregnancy has been associated with decreased uterine activity and
with longer and dysfunctional labor.

the differential diagnosis of benign and malignant ovarian tumor.

Benign ovarian tumor
- Features:
1. Slow growth
2. The patient has no discomfort
- Special circumstances:
1. Torsion of tumor pedicle can cause severe
abdominal pain
2. Too large tumor can cause compression
Symptoms
-PV: on one or both sides of the uterus ,smooth surface, clear boundaries ,active mass
Malignant ovarian tumor
- Early asymptomatic
- Rapid growth and rapid transfer
- Late stage: Symptoms such as bloating, enlarged abdomen, anorexia, nausea and vomiting, or
difficulty in defecation
- PV: Fixed solid masses and nodules are touched on one or both sides of the uterus
- PE: Ability to touch the abdominal mass with moving dullness
 Estrogen to uterus
- Estrogen to endometrium: proliferative phase.The Proliferative stage due to estrogen :
grandular epithelium of uterus(both increase in number and activity)
- Glandular epithelium of uterus:increased in number and activity estrogen
- Smooth muscle: The proliferation sensitive to oxytocin
- Cervical mucus: thin, amount increase, viscosity increase, relax of os.
Estrogen enhances and maintains the mucous membrane that lines the
uterus. It also regulates the flow and thickness of uterine mucus secretions.

Perimonopause : from the menstrual disorder to 1 year after after monopause

Function of ovary :
- Fertility (Reproduction function): produce oocyte >embryo>baby
- Endocrine function : produce sexual hormones(estrogen, progesterone, androgen)
- The changes of ovarian cycle
• follicles development and maturation> ovulation>formation and regression of corpus luteum
• endocrine changes that occur during menstrual cycle

Primordial follicle(basic reproductive unit): 1~2 million after birth>0.3~0.4 million during puberty

Ovulation definition :
• Expel both the ovum and cumulus oophorus, granulosa as well as some follicular fluid into the
abdominal cavity.
• Common in the 14th day before next menses
• Theca interna cells has LH-R, secret large amount of estrogen

Hormones production by ovary (follicular secretion)

- Before ovulation, follicle only secrete estrogen
- But after ovulation, the corpus luteum secrete progesterone and estrogen
- The ovary interstitial cells and hillar cells can secrete androgen

Both estrogen and progesterone are steroids hormone

Periodic change of sexual hormones

Proliferative stage due to estrogen : grandular epithelium of uterus(both increase in number and
activity)
Secretory phase due to progesterone :
Grandular epithelium of uterus (secretion, lose and edematous)
 How to detect if patient have ovulation or not?
- Cervical mucus influenced by estrogen : temperature normal, thin, amount is large, viscosity
low, relaxed of os.
- Cervical mucus influenced by progesterone: temperature slightly increase, thicken, amount is
less, closed os.

The physiologic functions of sexual hormone :

Estrogen :
- Hypothalamus : negative feedback
- Pituitary : positive feedback Endometrium: proliferative phase
- Glandular epithelium of uterus:increased in number and activity estrogen
- Smooth muscle: proliferation sensitive to oxytocin
- Oviduct: ciliated cell(increase),secretory cell(increase), and contraction
- Cervical mucus: thin, amount increase, viscosity increase, relax of os
- Vaginal cells: intermediate cells superficial cells thick
- Breast: duct
- Metabolism: retention of water and Na+,
Ca + + sediment in bone
- Temperature: no

- Ovary: improve follicular

Progesterone
- Hypothalamus : inhibit follicular development
- Ovary: negative feedback
- Endometrium: secretory phase
- Glandular epithelium of uterus: secretion, loose and edematous progesterone
- Smooth muscle: inhibit contraction
- Oviduct: ciliated cell (decrease), secretory cell(decrease), and relaxing
- Cervical mucus: thicker, closed os, and amount decrease
- Vaginal cells: basal cells intermediated shedding
- Breast: lobules, alveoli
- Metabolism: catabolism of protein expel Na+ water
- Temperature: slightly increase

Uterine cycle :
1. Endometrium
• Proliferative phase
- Uterine glands draw out
- Functional layer increased rapidly in thickness
- Glandular epithelial cell is cuboidal, column
• Secretive-phase
- Endometrium vascularized
- slightly edematous, vacuole
- Gland coiled and tortuous, secrete fluid
• Menstrual phase
 - Ednometrium thinner
- Focal necrosis of endometrium and spiral artery spasm

Definition of mestruation : menstruation is the periodic vaginal bleeding that occurs with the shedding
of the uterine mucosa, with regular ovulation and secreting estrogen and progesterone by ovary. It’s the
manifestation of ovarian functions

Normal menstruation
- menarche: the age of onset of menstruation, <15y
- menstrual cycle: the interval between the periods, about 21~35days, average 28d
- the duration of flow: 2~8d, average 4~6 days
- the amount of flow (measured by the number of used sanitary pads): less than 80 mL
- the characters of flow: dark red, tissue debris, cervical mucus, exfoliated vaginal epithelia.
prostaglandins, fibrinolysin→not containing clots
- Some women have discomfortable: diarrhea, pelvic pain

Neuroendocrine system :HPOA

Feedback
- Estrogen : positive and negative feedback
- Progesterone: negative feedback

Chapter 2
 The essential conditions of implantation
1)Zona pellucida disappear
2)Syncytiotrophoblast formed
3)Blastomere development assorts with endometrium
4)Enough progesterone
Inner cell mass developed to embryo, trophoblast developed to placenta
Endometrial receptivity : 20-24th of menstruation
Other factors: early pregnancy factor, cAMP

Developing Characteristics:
- Describe the growth of the fetus in units of 4 weeks’ gestational age, beginning with the first day
of the last menstrual period (LMP)
- Using crown-rump lengths to estimate gestational age
- 8 weeks:external ears, nose, fingers and toes are identifiable but featureless, head is flexed on
the thorax， ultrasonography can see primal heart flicker
- 12 weeks: eyelid fused, neck had formed, external genitals formed but Undifferentiated
- 16 weeks: external genitals can be differentiated, skin transparent red
- 20 weeks:skin become opaque, fine hair covers body( lanugo), auscultate fetal heart beat by
stethoscope, quickening
- 24 weeks: fat deposit, skin wrinkled, eyelid separated, eyebrows and fingernails present, after
delivery infant has the chance of survive (note : only after 24weeks the baby has change to
survive, before that, the chance is low)
- 28 weeks:eyes open, scalp hair growing, lungs can capable of breathing, but surfactant content
is low
 - 32 weeks: toenails present, if born 5/6 survive
- 36 weeks: able to cry , suck and survive
- 40 weeks: fetus mature

Chapter 3(abortion)
ABORTION AND ECTOPIC PREGNANCY

A. ABORTION
GENERAL CONSIDERATION
 Definition :
 Abortion (miscarriage): the fetus is not viable after delivery
 Abortion is defined as delivery occurring before the 28 th completed week of
gestation, with a fetus weighing less than 1000 grams
 By the way of termination and time of termination :
 Spontaneous abortion 10%-15% (up to 31%)
o Early abortion : <12 weeks gestation, 2/3 early abortion is clinically
silent miscarriage (chemical pregnancy)
o Late abortion : ≥ 12 weeks gestation (12-27)
o Fetal loss rate between 8-28 weeks gestation 3%
 Artificial abortion
 Incidence (ppt lama)
 10-15% of all conceptions abort spontaneously after implantation
 80% occurs as early abortion
Etiology
 Embryonic factors (most common)
 Genetic abnormality  most common cause (for early abortion)
 Chromosomal anomalies 2/3 early abortion
o Autosomal trisomies (50%): trisomy: -13, -16, -18, -21, -22
o 45 X monosomies
o Triploids, tetraploids
 Maternal factors
 General maternal factors:
 Systemic diseases: DM, hypothyroidism, SLE
 Infection: TORCH (toxoplasma, others, Rubella virus,
Cytomegalovirus, herpes virus)
 Smoking and alcohol consumption
  Age
 Serious stress, a sudden physical or emotional shock
 Local maternal factors:
 Uterine abnormalities

 Cervical incompetence
o Mostly caused by trauma
o Happens in Mid semester of pregnancy (week 13-28)
o Sudden unexpected rupture of membranes
 Submucous fibroids, mostly happens in late 30s year old women
 Intrauterine adhesions, result from trauma of facial layer of
endometrium from previous operation or infection
 Endocrine disorder
o Immunologic disorders
 Father’s factors
 Environmental factors
Pathology
 Hemorrhage into the decidua basalis
 Necrosis and inflammation in the area of implantation
 Pregnancy partially/entirely detached
 Early abortion: fetus died before expulsion
 Late abortion: fetal heartbeat could be heard before expulsion
 Uterine contraction and dilatation of the cervix  expulsion of most/all of the
products of conception
Clinical findings
 Amenorrhea
 Vaginal bleeding
 Abdominal pain
Clinical types and Management (treatment)
1. Threatened abortion
 Characteristics :
 Slight vaginal bleeding before 28th gestational week (1st semester)
 With or without lower abdominal pain, (cramp might be noticed)
 Vaginal examination: a closed cervix
 25%-50% result in loss of pregnancy
 Management:
 Ultrasonic examination:
o Whether the fetus is present
o Whether the fetus is alive (94%)
o Normal gestation sac and viable embryo
 Reassurance
  No need for admission to hospital
 Bed rest is not necessary (it does not improve prognosis)
 Pelvic test
 Patient should not have sex

2. Inevitable abortion
It happens when threatened abortion become more severe and it leads to inevitable
abortion
 Characteristics:
 More vaginal bleeding (blood is more than threatened abortion)
 Lower abdominal pain and back pain
 Vaginal discharge-rupture of membranes is noticed
 Vaginal examination: cervix partially dilated
 Open cervix
 Chorionic villi is the evidence of pregnancy tissue
 Management :
 Evacuation of the uterus by suction D&C (dilution and curettage)
 Tissues should be sent for pathologic evaluation and/or chromosome test
 Insert an intravenous line (if bleeding is heavy)
 Take blood for cross-matching and blood grouping
 Antibiotics should be used (if bleeding lasts for several days)
 Prognosis for mother is good if the retained tissue is promptly and
completely evacuated
3. Incomplete abortion
 Characteristics :
 Vaginal bleeding persistent and severe
 Cramp-like pain
 Products of conception partially passed from the uterine cavity
 >10 weeks, retained placenta affects contraction of uterus  hemorrhagic
shock
 Vaginal examination:
o Cervical dilatation
o Uterus smaller than the period of amenorrhea would suggest
 Management :
 Evacuation of the uterus by suction D&C should be promptly performed
(under appropriate pain control)
 A type and cross-match for possible transfusion
 Insert an intravenous line (it’s best when the bleeding has stopped or at the
minimum amount)
 Use antibiotics to avoid sepsis, renal and hepatic failure, DIC, and even
death
  Tissue should be sent for pathologic evaluation
 Late treatment can lead to overwhelming sepsis
4. Complete abortion
 Characteristics :
 Passage of the entire conceptus
 Bleeding and pain abate (slight bleeding continue for a short period of time)
 Vaginal examination:
o Cervix closes
o Normal-sized uterus

 Management
 Ultrasonic examination: no tissue is retained in uterus
 Products of conception should be examined
 No need for other treatment

Special types of abortion :

1. Missed abortion
 Characteristics :
 Fetus has died but is retained in the uterus
 Symptoms of pregnancy disappear
 Coagulation problems
 Fetus and placenta are removed surgically (ASAP)
 Management :
 Confirm the diagnosis by ultrasound
 Evacuate the retained products of conception surgically
 A type and cross-match for possible transfusion
 Minimize the risk of sepsis and DIC (when a patient is Rh(-) and does not
have Rh antibodies, prophylactic RhD antibiotics immunoglobulin should be
administered)
 Reduce the extent of hemorrhage, (and reduce degree of pain that
accompanies spontaneous explosive process)
2. RSA (recurrent spontaneous abortion)
 Characteristics :
 3 or more successive spontaneous abortion
 Same sex partner
 Two successive 1st – trimester abortion or a single 2nd – trimester abortion
need an evacuation for the cause(s)
 Etiology :
 o Early RSA: chromosomal anomalies, submucous fibroids,
intrauterine adhesions, antiphospholipid syndrome (APS), luteal
insufficiency, hypothyroidism
o Late RSA: cervical incompetence, septate uterus
 Management:
 Rule out the presence of systemic disorders (DM, SLE, Thyroid disease)
 Paternal and maternal chromosomes should be evaluated
 Hysteroscopy or hysterography should be performed to evaluate the uterine
cavity
 Rule out the presence of TORCH, Mycoplasma, and Treponema
 Cervical incompetence is managed by cercalage at the level of internal os
during 12-14 gestational week
3. Septic abortion
 Etiology :
 Long-time vaginal bleeding
 Products of conception retained in the uterus
 Criminal abortion-trauma to the cervix or upper vagina

 Clinical manifestations:
 Fever
 Malodorous vaginal discharge
 Pelvic and abdominal pain
 Cervical motion tenderness
 Intrauterine infection  peritonitis, sepsis, or septic shock
 Management :
 Principle : evacuate the retained products of conception surgically as soon
as the infection is controlled
 Intravenous antibiotic therapy
o Antibiotics agents should provide for both anaerobic and aerobic
coverage
 A D&C should be done
 A hysterectomy may be needed if the infection does not respond to
treatment
 CBC (complete blood count), urinalysis, endometrium cultures, blood
culture, chest X-ray and abdominal X-ray to rule out uterine perforation, all
of those should be obtain

Diagnosis
 History :
 Amenorrhea, RSA
  Morning sickness, vaginal bleeding
 Expelling fluid or pregnant tissue through vagina
 Abdominal pain
 Fever, vaginal discharge
 Physical examination:
 T, P, R, BP (vital sign)
 Signs of anemia or infection
 Gynecology examination help to determine clinical type of abortion
(put 2 fingers into vagina and the other hand touch/slightly press the lower abdomen to
feel the uterus, and see whether there is any mass or tenderness in the pelvic)
 Cervix closed or dilated
 Products of conception in the cervical canal
 Uterus smaller than the gestational week
 Auxiliary examination:
 Ultrasonography : incomplete abortion, missed abortion (necessary)
 Urinary/serum hCG testing
 Serum progesterone testing
 Lab findings include :
 complete blood count, If significant bleeding has occurred the patient will be
anemic, Both WBC count and sedimentation rate may be elevated even without
presence of infection
 Pregnancy test is very essential for spontaneous abortion, following the
abnormally low plasma level of β-hCG are predictive of abnormal pregnancy,
either Blighted ovum, spontaneous abortion, or ectopic pregnancy
 USG is necessary for diagnosis of spontaneous abortion. Transvaginal ultrasound
is helpful in documenting the intrauterine pregnancy as early as 4 to 5 weeks
gestation. USG can determine which pregnancy is healthy/viable and which
pregnancy that will lead to miscarriage. In threatened abortion, USG will review
the normal gestational sac and viable embryo.
 Based on Ultrasound, In incomplete abortion the gestational sac is depleted and
irregular, placenta tissue is thin, endometrium appears very close with no visible
product of conception.
 Embryo/Fetus without hard motion is considered as missed abortion.
 Abnormal gestational sac without Yolk sac Or embryo is considered as blighted
ovum.
 Ectopic pregnancy may cause similar symptoms of miscarriage, such as
menstrual abnormality, abdominal or Pelvic pain. USG can virtually exclude an
ectopic pregnancy by documenting Intrauterine pregnancy
 Hyditidiform mole usually end in abortion before 5 months
Differential diagnosis
Chapter 4- ECTOPIC GESTATION
General consideration
 Ectopic pregnancy: a fertilized ovum implants outside of the endometrial cavity
 Occur in 1 of every 80 spontaneously conceived pregnancies
 The most common cause of maternal mortality in the 1 st trimester
 Early appropriate treatment and prevention are necessary
Classification and incidence
 >95% implant in fallopian tube
 Ampullary 80%, (may be during 8-12 weeks)
 Isthmic 12%
 Fimbrial 6%
 Interstitial 2% (interstitial tissue pregnancies are the last rupture usually at 12-16 weeks)
Less common sites of ectopic implantation
 Ovary
 Uterine cervix
 Rudimentary uterine horn
 Broad ligament
 Peritoneal cavity
Etiology
 Tubal factors:
 Salpingitis, 5-10 times more common
 Tubal pregnancy
 Tubal sterilization
 Ovarian factor:
 Fertilization of an unextruded ovum
 Other factors
 IUD

Pathology
The natural history of untreated ectopic pregnancy
 Changes of fallopian tube:
 Rupture of tubal pregnancy
 Tubal abortion
 Pregnancy resorption
 Old ectopic pregnancy : pelvic hematoma or lithopedion
 Abdominal pregnancy
 Changes of uterus:
 Endometrial involution
 Decidual sloughing
 Atypical changes in the endometrium
 Arias-Stella reaction
Clinical findings – Symptoms
 Classic triad symptoms:
 Pelvic or abdominal pain (100% of patients)
 Bleeding (75% of patients)
 Amenorrhea
 Other symptoms
 Syncope
 Decidual cast
 Abdominal mass
 There are 3 possible clinical presentation of ectopic pregnancy:
1. Acutely rupture ectopic pregnancy
 Has experience of ectopic pregnancy before will most likely to have
intraperitoneal hemorrhage
 Present with severe abdominal pain and dizziness
 May complain ipsilateral shoulder pain
 There may be sign of hemodynamic instability with tachycardia, diaphoresis,
HT, and even loss of consciousness
 May not have mass in uterine cavity
 Slightly enlarge globular uterus
 Uterine pregnancy test (+)
 Need surgery Tx
 Ultrasound: empty uterus and free fluid in peritoneal cavity
2. Probable ectopic pregnancy in a symptomatic woman
 Lower pelvic pain
 Vaginal spotting blood with or without amenorrhea
 Tenderness of abdomen along with cervical motion tenderness
 The diagnosis of ectopic pregnancy may be confirmed by the absence IUP
on ultrasound with β-hCG sufficient to identify an IUP
  Even though patient has reasonable stable vital sign, surgical therapy and
evaluation are generally indicated.
3. Possible ectopic pregnancy (most common)
 Patient has lack of symptoms, so the awareness of risk factors is important
 Lower abdominal pain
 Amenorrhea or the presence of abnormal menstruation period is obtained
75%-90% of ectopic pregnancy
 Abnormal vaginal bleeding is seen in over ½ of patients, ranging from
spotting to equivalent of normal menstrual period.
 Low hCG level
 Mostly has adnexal mass
 Uterus soft, with normal size or slightly enlarge
 Ultrasound: thickened endometrium shape

Clinical findings – Signs

 Tenderness
 Abdominal tenderness, >80%
 Adnexal and/or cervical motion tenderness, >75%
 Unilateral adnexal mass, 1/3-1/2
 Uterine changes:
 Softening
 Slight increase in size
Laboratory findings
 Hematocrit
 White blood count-leukocytosis
 Pregnancy test:
 Abnormal serial titers of serum β-hCG, 2/. (-)  may not rule out an aborted
ectopic pregnancy
 (+) and gestational sac is not visible by transvaginal ultrasound  pregnancies
of unknown location (PUL)
 β-hCG ≥3500 U/L + PUL, likely to have an ectopic pregnancy
 β-hCG <3500 U/L + PUL, serial titers shows continuous increase  use
ultrasound to determine the location of pregnancy
 β-hCG <3500 U/L + PUL, serial titers shows no increase or increase slowly 
diagnostic D&C
Diagnosis
 Ultrasound (most important) (gold standard for diagnosis)
 Document the presence or absence of an intrauterine pregnancy (IUP)
 β-hCG ≥3500 U/L + ultrasound: empty uterine cavity  ectopic pregnancy
 Presence of an adnexal mass with an empty uterus
  Distinguish a normal IUP from a blighted ovum, incomplete abortion, or
complete abortion
 Laparoscopy
 Definitive diagnosis is difficult
 A desired, potentially viable IUP  D&C is contraindicated
 D&C
 Confirm or exclude IUP in the case of an undesired pregnancy, chorionic villi
 Culdocentesis
 Transvaginal passage of a needle into the posterior cul-de-sac
 Determine whether free blood is present in the abdomen
 (+)  laparoscopy or laparotomy should be performed immediately
 Non-clotting blood could be from a ruptured ectopic, or a hemorrhagic corpus
luteum
 (-)  may not rule out an intact ectopic pregnancy
Differential diagnosis
 Gynecologic problems
 Threatened or incomplete abortion
 They all have amenorrhea, bleeding, and pain. But ultrasound and D&C
can be used to distinguish them. If gestational sac is present in
ultrasound and endometrium tissue contains the pregnant conception
seen in D&C, ectopic pregnancy is excluded
 Usually the spontaneous abortion has severe vaginal bleeding and
ectopic pregnancy is only spotting blood and abdominal pain is not the
same. Before abortion or rupture of ectopic pregnancy there is no pain
or very moderate pain. But for incomplete abortion the abdominal pain
is severe
 Ruptured corpus luteum cyst
 Can be differentiated by laparoscopy
 Acute pelvic inflammatory disease
 this will have abdominal pain but the pregnant test is (-) and there is no
gestational sac in uterine cavity
 Adnexal torsion
 There will be mass in adnexal area but pregnancy test (-), in pelvic
examination there will be tension spot
 Degenerating leiomyoma (especially in pregnancy)
 Non-gynecologic problems
 Acute appendicitis
 Pyelonephritis
 Pancreatitis
Management
1. Surgical treatment
 Indications of surgery
 Hemodynamically unstable  laparotomy
(stable patient usually use laparoscopy, which is the gold standard for ectopic
pregnancy)
 Suspected for intraperitoneal bleeding
 Progression of ectopic pregnancy (e.g. serum β-hCG >3000 U/L or continuous
increase, fetal heartbeat and/or big adnexal mass could be detected by
ultrasound)
 Difficult to follow up the patient
 Medical management fails or is contraindicated
 Persistent ectopic pregnancy
 Conservative operations
 Indication : young women who have the desire of fertility, esp. the uninvolved
tube is abnormal or removed already
 Operations:
o Partial salpingectomy
o Salpingotomy
o Salpingostomy
 10%-20% risk of residual trophoblastic tissue
 Repeat hCG titers 3 to 7 days postoperatively to confirm that no hormone-
producing cells remain behind
 If repeat hCG titers fail to decline appropriately (decline by 50% in 1 day after
operation, or decline by 90% in 12 days after operation) persistent ectopic
pregnancy 3.9%-11% Methotrexate (MTX) therapy is needed
 Radical operations
 Indications : no desire of fertility, emergency patient suffering from
intraperitoneal bleeding complicated with shock, the uninvolved tube is normal
 Operations:
o Interstitial pregnancy: corneal wedge resection and salpingectomy
(hysterectomy)
o Other tubal pregnancy : salpingectomy
2. Medical management
 Methotrexate (MTX) : a folinic acid antagonist
 Mechanism : destroy proliferating trophoblast and result in necrosis of the embryonic
tissue
 MTX should only be used when diagnosis of ectopic pregnancy is definite and IUP is
ruled out
 Indications:
 Rule out contraindication of MTX
  Stable patient (no evidence of rupture or intraperitoneal bleeding)
 Diameter of gestational sac < 4cm
 Serum β-hCG <2000 U/L
 Persistent ectopic pregnancy after conservative operations
 Contraindications:
 Unstable vital signs
 Rupture of tubal pregnancy
 Diameter of gestational sac ≥4cm, or ≥3.5cm with detected fetal heartbeat
 Being allergic to MTX, chronic liver disease, hematological system disease, active
lung disease, immune deficiency, peptic ulcer, etc.
 Systemic administration : in divided dose of 50mg/m2 intramuscularly
 Evaluation:
 Return on day 4 and 7 for repeat hCG determination
 Titers fall at least a 15%  followed at weekly intervals to verify at least a 15%
decline every 7 days until the titers are undetectable
 Of the titers plateau or fall too slowly, another divided dose of MTX may be
given
 If the patient becomes more symptomatic or if hCG titers increase during
therapy, surgical intervention is required
 Local application : use ultrasound-guided puncture or laparoscopy to inject MTX into the
gestational sac

3. Expectant management
 Indications :
 Stable, reliable, relatively asymptomatic patients
 The diagnosis is not certain serum β-hCG titers are <1500U/L and declining
 Patient should be told that about 20% of ectopic pregnancies with hCG≤1000U/L will
experience severe sequelae
 Must be carefully followed with serial hCG testing and monitoring

Chapter 5(preterm labor)

Differential diagnosis

Treatment

- Bed rest in lateral decubitus position n Hydration →Adequate hydration + bed rest → 20%
uterine contractions cease
- Corticosteroids
 Accelerate fetal lung maturity
For women at risk of preterm delivery between 24 and 34 weeks’ EGA
Dexamethasone 6 mg IM every 12h for a total of 4 doses
- Tocolysis :
ØBeta-mimetic adrenergic agents
ØMagnesium sulfate
ØCalcium channel blocker
ØProstaglandin synthetase inhibitors
ØOxytocin receptor antagonists - atosiban
- Antibiotics

Postterm labor

Didferential diagnosis

Treatment

labor should be induced by: (vaginal dlivery or Csection)

Artificial rupture of membranes

lOxytocin 2.5 IU+ 5% GS 500 ml ivgtt

PROM at term

- Monitor maternal and fetal conditions: temperature, heart rate (mother/fetal), contraction of
the uterus, ultrasound (volume of the fluid), electronic monitoring (NST, OST, CST)
- Administration of antibiotics after 12 hours S Intrauterine infection risk increase as the time
- Induction of labor after 2~12 hours
- Cervix is mature, use oxytocin
- Cervix is immature, use prostaglandin first

PPROM

*(expectant theraphy) management :

Monitoring

Promote maturity of fetal lung (use dexamethasone)

Prevention of infection (use antibiotics)

Suppress contraction

*termination of pregnancy

Placenta previa

Differential diagnosis :

Placental abruption

Cervical disease

Rupture of velamentous placental vessel

Management :

- Expectant Treatment (in Preterm+No persistent active bleeding)

Inhibit contractions

Correct anemia

Prevent infection

Fetal lung maturity

Close observation in an obstetrical unit

Tocolytic administration limited to 48hrs

The woman must be fully informed the possibility of recurrent bleeding

- Delivery (vaginal or Csection)

Vaginal : in spotting bleeding

Csection : heavy bleeding

Placenta abruption

Differential diagnosis

Placenta previa

Cervical disease
Rupture of velamentous placental vessel

Management

- Expectant theraphy : in case of The fetus is alive & No evidence of compromise

Close observation in an obstetrical unit Fetal lung maturity

Immediate intervention is available

- Delivery ASAP :

Vaginal: mild

Csection: severe

Postpartum hemorrhage

Differential diagnosis

Management :

Identification of etiology is most important

Balance the use of less invasive techniques with the need to control the bleeding and achieve
hemostasis

Less invasive methods should be used initially

Preservation of life requires more aggressive interventions

Transfusion theraphy

Massive transfusion 10 or more units of packed RBCs within 24hrs

RBCs :FFP(fresh frozen plasma): PLTs=1:1:1
Fibrinogen/Cryoprecipitate Tranexamic Acid
Summary of management :

- A designated multidisciplinary response team A staged PPH protocol (guidelines & massive
transfusion protocol)
- Maintaining hemodynamic stability while simultaneously identifying and treating the cause
- Uterotonic agents should be the first-line treatment for PPH caused by uterine atony
- If failed, promptly change to other interventions Less invasive methods should be used initially If
unsuccessful, preservation of life may require more aggressive interventions (hysterectomy)
Inevitable abortion
differential diagnosis : Threatened abortion, incomplete abortion, complete abortion, ectopic
pregnancy, molar pregnancy and so on.
Treatment : curettage promptly

Cervical cancer
Differential diagnosis : Benign lesions:cervical polyp, cervical myoma,cervical tuberculosis
Treatment Operation, Chemotherapy,Radiotherapy

ectopic pregnancy,
Including abortion, ovarian torsion, acute appendicitis, acute PID, rupture of ovarian cyst
the risk factors of the diseases : chronic salpingitis, previous tubal pregnancy or tubal surgery, Tubal
abnormalities or dysfunction, assisted reproductive technique (ART), failure of contraception, smoking,
and advanced age.
Principle of treatment : Medicine ,operation ，expectation treatment
Management : 1) Continuously monitor vital signs through ECG monitoring.
2) Adequate resuscitation with packed red cells and intravenous fluid
3) Medical management with MTX :
Ø If the patient becomes more symptomatic or if hCG titers increase during therapy, surgical
intervention is required.
Ø Effective contraception should be initiated and continued for at least 3 months after the decrease in
hCG titers is observed.
Indicationsof MTX :
Absolute
ü Hemodynamically stable without active bleeding or signs of hemoperitoneum.
ü Nonlaparoscopic diagnosis.
ü Patient desires future fertility.
ü General anesthesia poses a significant risk
ü Patient is able to return for follow-up care
ü No contraindications to MTX
4) surgery
Ø Laparotomy is the preferred surgical approach for woman who are hemodynamically unstable
because rapid access to the bleeding site is critical.
Ø For hemodynamically stable patients, laparoscopy (when available) is the preferred surgical approach.

ovarian torsion
Differential diagnosis: ectopic pregnancy, rupture of ovarian cyst.
Treatment: Once ovarian torsion is diagnosed, laparotomy should be performed as soon as possible.

rupture of ovarian cyst

Differential diagnosis: Including ovarian torsion, ectopic pregnancy, acute appendicitis, and acute PID.
Treatment: The laparotomy should be performed immediately if the rupture of ovarian cyst is
suspected.
acute PID
Differential diagnosis: Acute appendicitis, ectopic pregnancy, ovarian torsion, and rupture of ovarian
cyst.
Treatment: Antibiotic treatment is the main therapy, surgery can be chosen if necessary. The treatment
principles are empirical, broad-spectrum, in time and individual.

Uterine leimyoma
Differential diagnosis:
• Fibroma:
One of ovarian sex cord stromal tumor; Middle-aged women, more often on one side Sometimes with
pleural fluid or ascites
PE: Round, smooth surface and solid mass. Ultrasound can not diagnoses
Surgery and Biopsy
• Serous carcinoma:
One of the ovarian epithelial tumor
Middle-aged and elderly women;
Bloating , gastrointestinal symptoms, loss weight
PE: Solid fixed mass with uneven surface, more common on both sides; Cachexia
Tumor marker(CA125 HE4)
B-ultrasound: mixed echo in the enlarged ovary with plentiful blood signal, unclear mass boundary
CT MRI
• Krukenberg tumor :
A metastatic tumor; stomach or colon
Bloating, Gastrointestinal symptoms, loss weight
PE: Solid fixed mass with uneven surface, more common on both sides; Cachexia
Tumor marker(CA125 CA 199)
B-ultrasound: mixed echo in the enlarged ovary with plentiful blood signal, unclear mass boundary
CT MRI Colonoscopy Gastroscopy
• Mesenteric mass:
One of intestinal tumor
No specific symptoms or signs
PE: The lump surface is smooth and easily move Ultrasound、CT 、MRI and tumor marker are no
specific Easily misdiagnosed as ovary cancer;
Sometimes need surgery to confirm

Ovarian cyst
Differential diagnosis:
- Mesanginl cyst :
Fertile woman;
Long course; Generally no symptoms of oppression; No gastrointestinal symptoms ;benign tumor;
Diagnosis based on intraoperative exploration
PE: normal sized uterus; no cervical motion tenderness, mobile, tenderness mass in the adnexa.
Rebound pain(-); muscle tension(-)
Tumor marker (-)
B-ultrasound: low echo area in both sides adnexa without blood signal
- Chocolate cyst :
Fertile woman;
No dysmenorrhea, no other symptoms in generally. Infertility issues?.
PE: enlarged uterus. cystic masses in the appendages on both sides, tenderness, lack of mobility, and
close adhesion to surrounding tissues.
Ca 125 slightly high. B-ultrasound:mixed echo area in ovarin.
- Subserous myoma:
Fertile women;
No symptoms, Often physical examinations have found that it does not cause menstrual changes and
occasionally shows symptoms of oppression
PE: The attachment area has hard and solid masses, movable, and the surface is smooth
Tumor marker (-)
B-ultrasound: Ultrasound prompts solid hypoechoic mass of pelvis.no blood signal
- Ovarian cancer:
Postmenopausal women;
Gastrointestinal symptoms, loss weight, abdominal mass
PE: Solid fixed mass with uneven surface, often no tenderness
Tumor marker(CA125 HE4)
B-ultrasound: mixed echo in the enlarged ovary with blood signal
CT MRI

Ovarian cancer:Yolk Sac Tumor (endodermal sinus tumor)

Differential diagnosis:
 Fibroma:
One of ovarian sex cord stromal tumor;
Middle-aged women, more often on one side Sometimes with pleural fluid or ascites PE:Round, smooth
surface and solid mass. Ultrasound can not diagnoses
Surgery and Biopsy
Serous carcinoma:
One of the ovarian epithelial tumor
Middle-aged and elderly women; Bloating,Gastrointestinal symptoms, loss weight PE: Solid fixed mass
with uneven surface, more common on both sides;Cachexia
Tumor marker(CA125 HE4)
B-ultrasound: mixed echo in the enlarged ovary with plentiful blood signal, unclear mass boundary
CT MRI Colonoscopy Gastroscopy
Krukenberg tumor :
A metastatic tumor; stomach or colon Bloating,Gastrointestinal symptoms, loss weight PE: Solid fixed
mass with uneven surface, more common on both sides;Cachexia
Tumor marker(CA125 CA 199)
B-ultrasound: mixed echo in the enlarged ovary with plentiful blood signal, unclear mass boundary
CT MRI
Treatment:
First: Antibiotics
Second: surgery and intraoperative frozen pathological examination
Surgical approach: open abdomen
Scope of operation&Whether to retain fertility?
It’s Depend on the intraoperative frozen pathological examination
coelomic epithelial origin(80-85%):complete staging surgery for ovarian cancer
Germ cell origin(10-15%):ill-sided attachment and omentum
Third:chemotherapy drug:BEP 3-4courses

Ovulatory dysfunction (AUB-O)

Differential diagnosis
1) Systemic disease:
Hematologic system disease, failure of liver or kidney, hyperthyroidism or
hypothyroidism
2) Abnormal pregnancy or complications of pregnancy:
Abortion, ectopic pregnancy, retained placenta
3) Genital disease: endometritis, salpingitis, cervical and endometrial polyps
4) Genital tumors: carcinoma of endometrium, cervix, myomas, ovarian tumor
5) Genital injury: vaginal injury, foreign body in vagina.
6) Misuse of sexual hormone drugs.
7) IUD

Differential diagnosis
In different age, the differential diagnosis is different!!!
Puberty → hematologic system disease
Reproductive age → pregnancy induced disease
Premenopause → tumor
Management
1) General treatment: Iron, vitamine C, protein, antibiotic, rest.
2) Medicine : the first-line therapy.
Objectives: Conversion from prolilferative to secretary endometrium.
Principles:
Puberty and reproductive age: hemostasis, regulate cycles, promote ovulation.
Premenopause: hemostasis, regulate cycles, prevent endometrial from malignant
change.
(1) Hemostasis
1Combined use (oral contraceptive)
-- Slight bleeding: combination low-dose oral contraceptive, the first day of menses×21days.
-- Severe bleeding:combination high-dose oral contraceptive pills(1# q8h), have effects within 8 hours;
bleeding stop in 24~48 hours; 72h after bleeding stop, reduce the doses of drugs, 1# q12h; 72h without
bleeding, reduce the doses of drugs again, 1# qd, lasting for 21 days from the first day the bleeding stop.
Commonly used in reproductive age or puberty !!!
2 Estrogen
-- Recovery of endometrium
-- Acute severe bleeding: Progynova (estradiol valerate) 2mg/4-6 hours, bleeding is controlled within
48~72 h; reduce about 1/3 of doses of drug, every 72h with no bleeding, then continue for 21 days with
maintain dose (2 mg), The last 7~10 days, adding dydrogesterone 10mg/d.
-- Contraindication: hypercoagulability or thrombus
Commonly use in puberty !!!
3Progesterone
-- Convert endometrium, base on estrogen
-- Slight bleeding: dydrogesterone 10mg bid for 10 days.
-- Severe bleeding: dydrogesterone 10mg once every 6-12hours, bleeding is controlled within 48~72 h;
reduce about 1/3 of doses of drug, every 72h with no bleeding, until maintaining dose of 10mg bid.
Commonly use in perimenopausal women !!!
Regulate cycles: 3~6 courses
1Estrogens followed by progesterone : Conjugated estrogen 1.25mg or estradiol 2mg qd ×21days, 10
days later adding progestone.
2Combination (oral contraceptives) : Oral contraceptive: the 5th day of menses, every night 1 pill for 21
days, stop for 7 days
3Progesterone alone : From the 15th day of menses, adding dydrogesterone (10mg/d) or MPA
(10mg/d), for 10~14 days.

(3) Promote ovulation

1Clomiphene: the 5th of menses 50-100mg qd×5d
2HCG: promote ovulation
3HMG(human menopausal gonadotropin) and FSH: development of follicle 4HCG+HMGm
Surgery
(1) D&C (Dilation and curettage): acute severe bleeding, risk factor for malignant diseases.
(2) Hysterectomy: medicine has no effect, in premenopausal stage, with no desire of reproduction.
(3) Endometrial ablation: laser, roller ball, NovaSure, necrosis of endometrium, premenopause, no
desire of reproduction in young women.

Endometrial carcinoma
Differential diagnosis:
• Dysfunctional uterine bleeding during menopausal transition period
• Atrophic vaginitis
• Submucous myoma
• Endometrial ployp
• Cervical carcinoma, uterine sarcoma
• Senile chronic endometritis and pyometra
Treatment:
Surgery : radical hysterectomy and bilateral adnexectomy, pelvic and para-aortic lymphadenectomy
Radiotherapy
Progestogen medroxyprogesterone
Chemotherapy

Endometritis
Differential diagnosis:
• Pelvic tumors
• Pelvic inflammatory disease
• Adenomyosis
• Dysmenorrhea
Treatment :
• Observation
• Analgesic therapy
• Medicine: pseudopregnancy pseudomenopause gestrinone. other therapy: mifepristone
• surgery
Gestational thropoblastic (HM)
Differential diagnosis
1) Abortion
Have the symptoms of amenorrhea and vaginal bleeding. Ultrasound.
2) Twin pregnancy
Uterus enlargement, hyperemesis gravidarum, preeclampsia. No bleeding, Ultrasound.
3) Caesarean scar pregnancy
Have the symptoms of amenorrhea and vaginal bleeding. Ultrasound.
Treatment
1) Suction Curettage
When diagnosis is confirmed, molar pregnancy should be terminated.
2) Prophylactic chemotherapy
• The use of prophylactic chemotherapy at the time of molar evacuation is controversial.
3) Surgery

Gestational throphoblastic neoplasia (GTN)

Chemotherapy :
Single-agent chemotherapy: MTX or dactinomycin, low risk
Combined chemotherapy: EMA-CO, high risk
Surgery Assisted therapy
Radiotherapy

Intrahepatic cholestasis of pregnancy

General treatment
S Monitoring fetal heart beat and movement
S Electronic fetal monitoring every week after 34 weeks’ gestation
S Monitoring liver function, serum bile acid (every 1~2 weeks)
Medical management
S Ursodeoxycholic acid (UDCA) : First-line drug, Relieve itching, Decrease serum bile acid level, Liver
function detect every 1-2 weeks
S S-adenosylmethionine (SAMe): Second-line drug
S Dexamethasone: unclear
Termination of pregnancy : Slight ICP: 37~38 weeks; Sever ICP: 34~37 weeks.