孕妇阴道流血的病因及诊治Word文档格式.docx

孕妇阴道流血的病因及诊治Word文档格式.docx

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DeputyEditor

VanessaABarss,MD

Disclosures

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.

Literaturereviewcurrentthrough:

Mar2014.|Thistopiclastupdated:

一月6,2014.

INTRODUCTION 

— 

Vaginalbleedingisacommoneventatallstagesofpregnancy.Thesourceisvirtuallyalwaysmaternal,ratherthanfetal.Bleedingmayresultfromdisruptionofbloodvesselsinthedecidua（ie,pregnancyendometrium）orfromdiscretecervicalorvaginallesions.Thecliniciantypicallymakesaprovisionalclinicaldiagnosisbaseduponthepatient'

sgestationalageandthecharacterofherbleeding（lightorheavy,associatedwithpainorpainless,intermittentorconstant）.Laboratoryandimagingtestsarethenusedtoconfirmorrevisetheinitialdiagnosis.

Anoverviewoftheetiologyandevaluationofvaginalbleedinginpregnantwomenwillbereviewedhere.Specificcausesofbleedingandtheirmanagementarediscussedindetailseparately.（Seeindividualtopicreviewsoneachsubject）.

FIRSTTRIMESTERBLEEDING

Overview 

Vaginalbleedingiscommoninthefirsttrimester,occurringin20to40percentofpregnantwomen.Itmaybeanycombinationoflightorheavy,intermittentorconstant,painlessorpainful.Thefourmajorsourcesofbleedinginearlypregnancyare:

●Ectopicpregnancy

●Miscarriage（threatened,inevitable,incomplete,complete）

●Implantationofthepregnancy

●Cervical,vaginal,oruterinepathology（eg,polyps,inflammation/infection,trophoblasticdisease）

Bleedingrelatedtomiscarriageisthemostcommoncauseoffirsttrimesterbleeding（prevalenceofmiscarriage15to20percentofpregnancies）.Althoughbleedingmaybeheavy,onlyabout1percentofexpectantlymanagedwomenrequirebloodtransfusion[1].Ectopicpregnancyismuchlesscommon（prevalenceofectopicpregnancy:

2percentofpregnancies）,butthemostseriousetiologyoffirsttrimesterbleedingasruptureoftheextrauterinepregnancyisalife-threateningcomplication;

therefore,thisdiagnosismustbeexcludedineverypregnantwomanwithbleeding.

Evaluation 

Theexactetiologyofuterinebleedinginthefirsttrimesteroftencannotbedetermined;

thegoaloftheevaluationistomakeadefinitivediagnosiswhenpossibleandexcludethepresenceofseriouspathologyintheremainingcases（algorithm1）.Ectopicpregnancyisparticularlyimportanttoexcludesinceitcanbelife-threatening.Thus,thefirststepinevaluationistodeterminewhetherthepatienthashadanultrasoundexamination,aswellastheresultsofthetest.Priordocumentationthatthepregnancyisinthenormalintrauterinelocationimmediatelynarrowsthedifferentialdiagnosis,althoughthepossibilitythatthepriorultrasoundmayhavemissedaheterotopicpregnancy（ie,oneintrauterineandoneextrauterinepregnancy）oracornual（interstitial）ectopicpregnancyshouldalwaysbeconsidered.Ifindoubt,considerhavinganexperiencedsonographerrepeattheultrasoundexamination.Itisalsoimportanttodeterminewhetherthepatientishemodynamicallyunstablesothatsupportivemeasuresandtreatmentcanberapidlyinitiated.

History 

Theextentofbleedingshouldbedetermined:

isthewomanpassingbloodclotsoristhebloodsoakingthroughherclothes?

Doesshefeellightheaded?

Doesshehavesignificantpelvicpainorcramping?

Hasshepassedanytissue?

Ifsheanswersyestothesequestions,thenectopicpregnancyandmiscarriagearemuchmorelikelydiagnosesthanimplantationbleedingorcervicovaginaldisease（eg,polyps,cervicitis,cancer）.Ontheotherhand,itisimportanttorememberthatthepresenceofonlylight,intermittent,painlessbleedingdoesnotexcludethepossibilityofalife-threateningunderlyingdisorder,suchasectopicpregnancy.

Whatisthepatient'

smedicalhistory?

Apasthistoryofectopicpregnancyorriskfactorsforectopicpregnancy（eg,historyofpelvicinflammatorydisease,presenceofanintrauterinecontraceptivedevice,adnexalsurgery）increasestheprobabilityofthisdisorder.（See"

Incidence,riskfactors,andpathologyofectopicpregnancy"

.）

Ahistoryoftwoormoreconsecutivemiscarriagesoraconditionassociatedwithmiscarriage（eg,parentalchromosomaltranslocation,maternalantiphospholipidsyndrome,uterineanomaly）suggestsbleedingmayberelatedtoimpendingpregnancyloss.（See"

Spontaneousabortion:

Riskfactors,etiology,clinicalmanifestations,anddiagnosticevaluation"

Useofassistedreproductivetechniquestoachieveconceptionincreasestheriskofheterotopicpregnancy.（See"

Abdominalpregnancy,cesareanscarpregnancy,andheterotopicpregnancy"

Physicalexamination 

Orthostaticchangesinbloodpressureorpulseareindicativeofseverebloodlossrequiringsupportivecareandrapidtreatment.However,occasionally,youngpregnantwomencanhavemassivebleedingwithoutdemonstratingtachycardiaorhypotension.Careshouldbetakentoavoidunnecessarydelayinthemanagementofsuchpatients.

Anytissuethepatienthaspassedshouldbeexamined.Patientsmaymistakebloodclotfortheproductsofconception.Ifthetissuerepresentsapartialorcompletemiscarriage,thefetalmembranes,frondsindicativeofplacentalvilli,oranintactfetusshouldbevisibleuponcarefulexamination.Visualizationofvillicanbefacilitatedbyfloatingtheproductsofconceptioninwater（picture1A-B）.

Thepatient'

sabdomenshouldbeexaminedbeforeperforminganinternalexamination.Itisbesttobeginbyexaminingthequadrantwherethepatientisexperiencingtheleastpain.Gentlepercussionispreferredtodeeppalpationsinceitcauseslesspainandguarding.Midlinepainismoreconsistentwithmiscarriage,whilelateralpainismoreconsistentwithectopicpregnancy.Nongynecologiccausesofpainarealsotobeconsidered.（See"

Approachtoabdominalpainandtheacuteabdomeninpregnantandpostpartumwomen"

Theclinicianshoulddeterminewhetheruterinesizeisappropriatefortheestimatedgestationalage.Thesize-gestationalagecorrelationislearnedbyexperienceandisoftendescribedintermsoffruit（eg,6-to8-weeksize=smallpear,8-to10-weeksize=orange,10-to12-weeksize=grapefruit）.Theuterusremainsapelvicorganuntilapproximately12weeksofgestation,whenitbecomessufficientlylargetopalpatetransabdominallyjustabovethesymphysispubis.Thenormaluterusisnontender,smooth,andfirm.

Ifthepregnancyisatorbeyond10to12weeksofgestation,ahandheldDopplerdevicecanbeusedtocheckthefetalheartbeat.Thefetalheartrateusuallycanbeeasilydistinguishedfromthematernalheartratesincethefetalheartrateistypicallyintherangeof110to160beatsperminute;

however,thedifferenceinmaternalandfetalheartratescanbeminimalifthemotherhastachycardia[2].Dopplerconfirmationoffetalcardiacactivityisreassuring,asitindicatesbleedingisnotrelatedtofetaldemiseandunlikelytoberelatedtoanectopicpregnancy.Ontheotherhand,lossofapreviouslydetectedfetalheartbeatshouldraisesuspicionthatfetaldemisehasoccurred.However,inabilitytodetectfetalheartmotionbyDoppler,particularlyinthefirsttrimester,maymerelyreflectthedifficultyinblindlyfindingthelocationofthetinyfetalheart.

Aftertheabdominalexamination,thepatientisplacedinthelithotomyposition.Theexternalgenitaliaareexaminedtoassessthevolumeandsourceofbleedingandthenaspeculumisinsertedintothevagina.Ifbloodclots,productsofconception,orbotharepresent,theycanberemovedwithgauzespongesonaspongeforceps.Thistissueisexaminedasdescribedaboveand,byconvention,sentforpathologicexaminationtoconfirmthepresenceofproductsofconceptionandtoexcludegestationaltrophoblasticdisease.Theutilityofroutinehistopathologicalexaminationisquestionable,asitrarelysuggeststheunderlyingcauseofthepregnancyfailureorestablishesadiagnosisofgestationaltrophoblasticdisease[3].However,pathologistscansometimesdiagnoseentitiesthataretheprobablecauseofthelossorassociatedwithrecurrence.Theseincludemassivechronicintervillositis,massiveintervillousfibrindeposition,maternalvasculitis,findingssuggestiveofsomechromosomalanomalies（eg,triploidy,sometrisomies）,andsepticabortion.

Speculumexaminationmayrevealasourceofbleedingunrelatedtopregnancy;

insuchcases,furtherevaluationdependsuponthenatureoftheabnormality:

●Vaginallaceration（see"

Evaluationandmanagementoflowergenitaltracttraumainwomen"

）

●Vaginalneoplasm（see"

Vaginalcancer"

●Vaginalwarts（see"

Condylomataacuminata（anogenitalwarts）"

●Vaginaldischarge（see"

Approachtowomenwithsymptomsofvaginitis"

●Cervicalpolyps,fibroids,ectropion（see"

Congenitalcervicalanomaliesandbenigncervicallesions"

●Mucopurulentcervicaldischargeorfriabilityattheendocervicalos（see"

Acutecervicitis"

●Cervicalneoplasm（see"

Invasivecervicalcancer:

Epidemiology,riskfactors,clinicalmanifestations,anddiagnosis"

Visualizationofthecervicaloshelpstodistinguishbetweenathreatenedandanimpending/inevitablemiscarriage.Directvisualizationofthegestationalsacinadilatedcervixisgenerallysufficienttodiagnoseanimpending/inevitablemiscarriageclinically.Thecervixwillusuallyalsobeopenwithanincompleteorarecentcompletemiscarriage.Anopeninternalcervicaloswilladmitasmallinstrument,suchasacotton-tippedswab.Ultrasoundcanprovideadditionalinformationinthesecases,suchasw