Spontaneous abortion

Introduction Spontaneous abortion refers to the pregnancy that terminates spontaneously before 28 weeks, and the weight of the fetus is less than 1000g. This definition is based on the abortion period set by the World Health Organization in 1966. At present, there are many controversies about the duration of abortion. Some countries limit the period of abortion to 25 weeks or even 20 weeks. Because in the developed countries, the gestational age is more than 20 weeks, and the newborns weighing 600-700g survive because of adequate treatment. opportunity. However, according to the actual situation in China, the abortion period is still limited to 28 weeks ago. Clinically, abortion occurs before 12 weeks of gestation, which is called early abortion; in the 12 weeks, the latter is called late abortion. Spontaneous abortion is a common disease in gynecology. If it is not treated in time, it may leave genital inflammation or injury, or endanger the health of pregnant women due to major bleeding, and even threaten life. In addition, spontaneous abortion is also easily confused with certain gynecological diseases, and should be identified.

Cause

(1) Causes of the disease:

There are many reasons for spontaneous abortion, which can be divided into embryonic factors and maternal factors. Common causes of early abortion are embryonic chromosomal abnormalities, endocrine abnormalities in pregnant women, genital malformations, reproductive tract infections, local or systemic immune abnormalities in the genital tract, etc.; and late abortions are caused by factors such as cervical insufficiency and maternal and child blood group incompatibility.

1. Embryo chromosomal abnormalities: Chromosomal abnormalities are the most common cause of spontaneous abortion. Domestic and foreign literature reports that 46% to 54% of spontaneous abortions are associated with embryonic chromosomal abnormalities. According to Warburton et al, the earlier the abortion occurs, the higher the frequency of embryonic chromosomal abnormalities. Chromosomal abnormalities include quantitative abnormalities and structural abnormalities. In the quantitative abnormalities, the stained trisomy ranked first, accounting for 52%. Except for the No. 1 stained trisomy, no trisomy was found, and all three bodies were found, of which 13,16 The 18th, 21st and 22nd chromosomes are the most common, 16 trisomy is about 1/3; the second is 45, X monomer, about 19%, is the more common chromosomal abnormality after the trisomy, such as survival. Turner syndrome is formed after full-term delivery. Triploids often coexist with vesicular degeneration of the placenta. Fetuses with incomplete vesicular blocks can develop into triploid or chromosome 16 trisomy, with abortion earlier, a few survivors, and multiple deformities after continued development. There are no live births, there are very few tetraploid live births, and most of them have very early abortions. Abnormal chromosomal structural abnormalities are mainly chromosomal translocations (3.8%), chimeras (1.5%), etc. Chromosomal inversions, deletions and overlaps have also been reported.

From an epidemiological perspective, the incidence of abortion increases as women age. Therefore, some people think that embryonic chromosomal abnormalities may be related to the age of pregnant women, but studies have shown that except for the trisomy 21 and the maternal age, the other three are not related to the mother's age.

2. Mother factor:

(1) Chromosome abnormalities in couples: As early as 1960, Schmiel et al. found that habitual abortion was associated with chromosomal abnormalities in couples. Domestic and foreign literature reports that the frequency of chromosomal abnormalities in couples with habitual abortion is 3.2%, of which the more common are chromosome translocations, accounting for 2%, and the Robertsonian translocations accounting for 0.6%. Domestic data show that the frequency of chromosomal abnormalities in recurrent abortion couples is 2.7%.

(2) Endocrine factors:

1 luteal dysfunction: luteal phase progesterone peak is less than 9ng / ml, or endometrial biopsy and menstrual time synchronization difference of more than 2 days can be diagnosed as luteal dysfunction. High concentration of progesterone can prevent uterine contraction and keep the uterus in a relatively static state; insufficient progesterone secretion can cause poor decidual reaction in pregnancy, affecting implantation and development of pregnant eggs, leading to miscarriage. There are two ways to progesterone during pregnancy. One is produced by the corpus luteum and the second is the secretion of placental trophoblast cells. After 6-8 weeks of gestation, the progesterone production of the ovarian corpus luteum is gradually reduced, and then the progesterone is replaced by the placenta. If the two are connected, the miscarriage is easy to occur. Insufficient secretion of progesterone is closely related to abortion. Chlamydial dysfunction occurs in 23% to 60% of cases of habitual abortion.

2 Polycystic ovary: It has been found that the incidence of polycystic ovary in habitual abortion can be as high as 58%, and 56% of patients have high secretion of LH. It is believed that the high concentration of LH in polycystic ovary may lead to the premature completion of the second meiosis of the egg cell, thereby affecting the fertilization and implantation process.

3 hyperprolactinemia: high levels of prolactin can directly inhibit the proliferation and function of corpus luteum cells. The main clinical manifestations of hyperprolactinemia are amenorrhea and lactation. When prolactin is at the upper limit of normal, it can manifest as luteal insufficiency.

4 Diabetes: A prospective study by Milis et al showed that patients with diabetes who had good glycemic control during early pregnancy (within 21 days) had no difference in the incidence of miscarriage compared with non-diabetic groups. However, the incidence of abortion in patients with poor glycemic control can be as high as 15% to 30%. In addition, hyperglycemia in early pregnancy may be a risk factor for embryo malformation.

5 Thyroid function: In the past, hypothyroidism or hyperthyroidism was thought to be related to abortion, but this view has been controversial.

3. Anatomical factors of reproductive organs:

(1) uterine malformation: uterine malformations such as single-horned uterus, double-horned uterus, double uterus, uterine mediastinum, etc., can affect uterine blood supply and intrauterine environment caused by miscarriage.

(2) Asherman syndrome: intrauterine adhesions and fibrosis caused by intrauterine trauma (such as excessive curettage), infection or placental residue. Endometrial resection or submucosal myomectomy under hysteroscopy can also cause intrauterine adhesions. Insufficiency of the endometrium can affect embryo implantation and lead to recurrent miscarriage. Hysteroscopy contributes to the diagnosis of the intrinsic. Romer et al used hysteroscopy to examine a group of cases and found that the incidence of intrauterine adhesions in patients with incomplete abortion and expired abortion was about 20%, and recurrent abortion cases were as high as 50%.

(3) Cervical dysfunction: Cervical dysfunction is the main cause of abortion in the middle and late stages. Cervical dysfunction is anatomically characterized by a short cervical canal or a loose internal cervix. Due to the anatomical defects, as the uterus increases with the progress of pregnancy, the uterine pressure increases. Most patients have painless cervical tube regression, uterine dilatation, amniotic sac protrusion, and membrane rupture in the middle and late pregnancy. Eventually a miscarriage occurred. Cervical dysfunction is mainly caused by local cervical trauma (delivery, surgical midwifery, cesarean section, cervical conization, Manchester surgery, etc.), congenital cervical dysplasia is rare; in addition, exposure to diethylstilbestrol during embryonic period can also cause cervical dysplasia .

(4) Others: Uterine tumors can affect the uterine environment and cause miscarriage.

4. Reproductive tract infections: Some chronic infections of the reproductive tract are considered to be one of the causes of early abortion. Pathogens that cause recurrent miscarriage are often persistent in the reproductive tract and the mother rarely produces symptoms, and the pathogen can directly or indirectly cause embryonic death. Retrograde infection of the reproductive tract usually occurs before 12 weeks of gestation. During this period, the placenta merges with the aponeurosis to form a mechanical barrier, and with the progress of pregnancy, the anti-infective capacity of amniotic fluid is gradually enhanced, and the chance of infection is reduced.

(1) Bacterial infection: Brucella and campylobacter infection can cause abortion of animals (bovine, pig, sheep, etc.), but it is not certain in humans. Some people think that Listeria monocytogens has a certain relationship with related abortion, but lacks definite evidence.

(2) Chlamydia trachomatis: The literature reports that the infection rate of Chlamydia trachomatis during pregnancy is 3% to 30%, but whether it directly leads to abortion is inconclusive.

(3) Mycoplasma: The positive rate of mycoplasma in the cervix and flow products of abortion patients is high, and serologically support mycoplasma hominis and ureaplasma urealyticlum are related to abortion.

(4) Toxoplasma: Abortion caused by Toxoplasma infection is sporadic, and the relationship with habitual abortion has not been fully proved.

(5) viral infection: cytomegalovirus (cytomegalovirus) through the placenta can affect the fetus, causing cardiovascular system and nervous system malformation, death or miscarriage. The incidence of herpes simplex infection in the first half of pregnancy can be as high as 70%, even if there is no miscarriage, it is easy to affect the fetus and newborn. The incidence of abortion in patients with rubella virus infection is higher in early pregnancy. Human immunodeficiency virus (HIV) infection is closely related to abortion. Temmerman et al reported that HIV-1 antibody positive is an independent factor related to abortion.

5. Immunity factors: Abortion caused by immune factors, especially recurrent abortion, habitual abortion can be divided into two types, namely autoimmune type and allotype. Autoimmune types usually detect various autoantibodies from patients, mainly antiphospholipid antibodies. Allogeneic patients are screened for etiology and exclude common causes, so it is also called unexplained habitual abortion; this is mainly related to poor physiological immune response during pregnancy, lack of immunosuppressive factors or blocking factors, and ultimately embryos suffer. Immune damage leads to miscarriage.

(1) Autoimmune type: Autoimmune habitual abortion is mainly related to antiphospholipide antibody in patients. Some patients may be accompanied by thrombocytopenia and thromboembolism. These patients may be called early antiphospholipid antibodies. Antiphospholipide antibody syndrome. In addition, autoimmune habitual abortion is also associated with other autoantibodies.

Antiphospholipid antibody component: Antiphospholipid antibody is an autoimmune antibody, including lupus anticoagulant factor (LAC), anticardiolipin antibody (ACL), antiphosphatidylserine antibody (APSA), antiphosphatidylinositol antibody (APIA), antiphospholipid ethanolamine antibody (APEA), and antiphosphatidic acid antibody (APAA). Several antibodies can be detected simultaneously in various autoimmune diseases; among them, anti-cardiolipin antibodies and lupus anticoagulant factors are the most representative and clinical significance. There are three types of anticardiolipin antibodies: IgG, IgA, IgM; among them, IgG is most clinically significant.

(2) Immune type: Modern reproductive immunology believes that pregnancy is a successful semi-allogous transplantation process. Pregnant women develop a series of adaptive changes due to the autoimmune system, thus showing immune tolerance to intrauterine embryo transfer. No rejection occurs, allowing pregnancy to continue.

Susceptible genes or monomers: In recent years, some scholars believe that patients with habitual abortion may have susceptibility genes or monomers. According to genetic theory, there are clinical susceptibility genes or monomers in the human genome; moreover, this susceptibility gene or monomer may exist in or closely linked to other genes in the HLA complex, including abortion susceptibility genes or singles. The parent of the body is in a low-reaction state to the embryonic antigen and does not stimulate the maternal immune system to produce a blocking factor. There are differences in the locations or locations of susceptibility genes or monomers reported by national scholars, which may be related to the racial specificity of HLA.

(3) Local uterine immunity: The current study shows that there is a significant adaptive response in the uterine decidua during normal pregnancy, and NK cell subpopulations undergo phenotypic conversion, that is, from CD56 CD16-type (killing type) to CD56 CD16. Type (secretory) is the main type, secretory NK cells can secrete some cytokines, such as TGF-, etc. These cytokines exert immunological or immunosuppressive effects on the local immune regulation of the uterus. Our study found that patients with habitual abortion have insufficient local physiological immune response, and NK cells are still mainly killing type, which may be directly related to the pathogenesis of the disease.

6. Other:

(1) Chronic wasting disease: Tuberculosis and malignant tumors often lead to early abortion and threaten the lives of pregnant women. High fever can cause uterine contraction; anemia and heart disease can cause fetal placental unit hypoxia; chronic nephritis, high blood pressure can cause infarction of the placenta.

(2) Malnutrition: Severe malnutrition can directly lead to miscarriage. Now more emphasis on the balance of various nutrients, such as vitamin E deficiency can also cause miscarriage.

(3) Mental and psychological factors: severe mental stimulation such as anxiety, nervousness and intimidation can lead to miscarriage. It has also recently been found that noise and vibration also have a certain impact on human reproduction.

(4) Smoking and drinking: In recent years, the number of women of childbearing age who smoke, drink, or even take drugs has increased; these factors are high risk factors for miscarriage. Excessive drinking of coffee during pregnancy also increases the risk of miscarriage. There is no definitive basis to prove that the use of contraceptives is associated with miscarriage. However, there have been reports of intrauterine contraceptives failing to increase the incidence of infective abortion.

(5) Environmentally toxic substances:

1 Mercury: Mercury can be present in the form of metallic mercury, inorganic mercury and organic mercury compounds. The teratogenic effects of mercury have been confirmed in animal experiments, with malformations of dysplasia and eye defects, as well as cleft lip and palate, rib fusion and maxillofacial deformities. A survey of occupational exposure to mercury found that the incidence of spontaneous abortion, stillbirth and congenital defects was twice as high as that of the control group. The mechanism of mercury teratogenicity and abortion may be related to genetic material damage. Mercury can bind to nuclear proteins to cause chromosomal changes. It can also cause damage to DNA molecules caused by increased free radicals in cells, and can also cause damage to cell spindles and affect cells. The normal division.

2 Cadmium: Cadmium has a significant adverse effect on the development of offspring. Exposure to cadmium in animals during pregnancy can cause embryos to absorb, die, and deform. The most common sites of deformity are the brain, limbs, and bones. The toxic mechanism of cadmium on embryos is related to the inhibition of cell growth and division by cadmium, which mainly inhibits the synthesis of DNA and protein, which blocks the incorporation of thymidine. In DNA, reducing DNA synthesis may be the result of inhibition of thymidine activating enzyme activity.

3 Lead: Lead can affect the fetus through the placenta. A large number of animal experiments have shown that lead can cause abnormalities in the fetal litter of experimental animals, mainly neurological defects. The teratogenic effect of lead on humans is also obvious. Exposure of pregnant women to excessive lead can cause fetal abortion and death, and can also lead to an increase in the incidence of birth defects in offspring. The teratogenic mechanism of lead may be related to the damage of germ cell DNA and chromosomes; damage to the spindle of the cell, affecting cell mitosis; entry into the mitochondria affects the tricarboxylic acid cycle; lead causes uterine muscle excitability, leading to miscarriage.

4 Arsenic: Animal experiments show that arsenic deficiency can affect the growth and reproduction of animals. High concentrations of arsenic have teratogenic effects. The types of teratogenesis include central nervous system defects, eye defects, and cleft lip and palate fusion. Inorganic arsenic can increase the amount of arsenic in breast milk, and can cause fetal malformation and miscarriage through the placenta. The mechanism of teratogenicity and abortion is to interfere with the development of visceral yolk sac.

5 chloroprene: causes embryo death.

6 Vinyl Chloride: Causes an increase in the incidence of miscarriage and malformation.

Dichloro-diphenyl-trichloro-ethane (DDT): can increase the incidence of spontaneous abortion and low birth weight infants.

(2) Pathogenesis:

Under normal conditions, various negatively charged phospholipids are located in the inner layer of the lipid bilayer of the cell membrane and are not recognized by the immune system; once exposed to the body's immune system, various antiphospholipid antibodies can be produced. Antiphospholipid antibodies are not only a strong clotting active substance, but also activate platelets and promote blood clotting, leading to platelet aggregation and thrombosis. At the same time, it can directly cause damage to vascular endothelial cells, aggravate thrombosis, local thromboembolism in placental circulation, and placental infarction. The fetus died in the palace, causing miscarriage. Recent studies have also found that antiphospholipid antibodies may directly bind to trophoblast cells, thereby inhibiting trophoblast function and affecting the placental implantation process.

It is currently known that trophoblastic HLA-G antigen expression may play an important role in this immune regulation process. In addition, in the maternal serum of normal pregnancy, there are one or several blocking factors that can suppress immune recognition and immune response, also known as blocking antibodies, and immunosuppressive factors, while patients with habitual abortion These factors are lacking in the body, and therefore, the embryo is rejected by the mother's immune attack.

1. Blocking factor: The blocking factor is a group of IgG type anti-spouse lymphocyte cytotoxic antibodies. It is generally believed that the blocking factor can directly act on the maternal lymphocytes and bind to the surface specific antigen of the trophoblast cells, thereby blocking the immune recognition and immune response between the mother and the child, and blocking the cytotoxic effect of the maternal lymphocytes on the trophoblast cells. . It is also believed that the blocking factor may be an anti-idiotypic antibody directed against T lymphocyte or B lymphocyte surface specific antigen receptor (BCR/TCR), thereby preventing maternal lymphocytes from reacting with embryonic target cells. In vitro, blocking factors can inhibit mixed lymphocyte reaction (MLR).

2. HLA antigen: The relationship between homozygous habitual abortion and HLA antigen compatibility has been controversial for decades. In recent years, it has been found that HLA-G antigen may play an important role in the pathogenesis of habitual abortion. In addition, some progress has been made in the study of susceptibility genes or monomers for habitual abortion.

HLA-G: As early as the 1970s, some scholars suggested that habitual abortion may be related to the compatibility of couple HLA antigens. It is believed that HLA antigens are incompatible between couples and mothers during normal pregnancy, and the paternal HLA antigens carried by the embryos can stimulate the maternal immune system and produce a blocking factor. Studies on the compatibility of HLA antigens mainly involve the A and B sites of HLA class I antigen molecules and the DR and DQ sites of HLA class II antigen molecules. However, after more than 20 years of research, it is still difficult to determine the exact relationship between HLA antigen compatibility and habitual abortion. In recent years, with the improvement of the level of molecular biology detection, people have found that patients with habitual abortion do not necessarily have increased HLA compatibility between couples or mothers. However, it was found that the expression of HLA-G antigen may be involved in the onset of habitual abortion.

It is generally believed that trophoblast cells do not express classical HLA class I antigen molecules by themselves. In recent years, most scholars have demonstrated that trophoblasts can express a class of non-canonical HLA-I antigens that specifically bind to W6/32 and 2m antibodies and have a lower molecular weight. This HLA class I antigen has now been named the HLA-G antigen. It was observed that the level of HLA-G expressed by trophoblasts gradually decreased with the progress of pregnancy, indicating that the expression of HLA-G gene is regulated by extraembryonic tissues. It is currently believed that the main role of trophoblast cells in expressing HLA-G antigen is to regulate the local immune response of the uterus placenta. HLA-G can cause an inhibitory immune response, which has a protective effect on the fetus and can inhibit the maternal immune system from attacking the fetal placenta. Although some scholars have suggested that habitual abortion may be related to abnormal expression of trophoblastic HLA-G; however, the exact mechanism is still unclear and needs further study.

an examination

Related inspection

Irregular antibody screening eugenics eugenics four tests urine pregnancy latex agglutination inhibition test IgG anti-B-potency determination

1. Detailed observation of vaginal bleeding and abdominal pain, vaginal secretions and other traits. Physical examination: whether there is anemia, blood pressure, pulse condition. Gynecological examination of the cervix is open or not open, pregnancy products in the cervix and vagina are discharged from the uterus, and the size of the uterus is consistent with the gestational age.

2. Auxiliary examination: B-ultrasound can determine whether the embryo or fetus is alive or not according to whether there is a gestational sac in the uterus, whether there is fetal heart reflex and fetal movement. Incomplete abortion and missed abortion can also be determined. Quantification of -HCG and other hormones such as blood progesterone can help determine the prognosis of threatened abortion.

Differential diagnosis

1. Tubal pregnancy:

(1) Menopause time: Except for the longer period of menopause in the tubal interstitial, the history of menopause is 6-8 weeks, and 20%~30% of patients have no obvious history of menopause. The irregular vaginal bleeding may be mistaken for the last menstrual period. Or because menstruation only expires for a few days, it is not considered to be menopause. The menstrual period of abortion can be longer.

(2) vaginal bleeding and color: There are many vaginal bleeding in the tubal pregnancy, the color is dark brown, the amount is small, generally does not exceed the amount of menstruation, dripping endless, may be accompanied by decidual tube type or aponeurosis fragments, vaginal bleeding Can be stopped after the lesion is removed. In the case of abortion, the amount of vaginal bleeding generally increases from less to less, starting with a bright red, and if the bleeding time is long, it turns dark red or brown.

(3) Abdominal pain: Before the abortion or rupture of the tubal pregnancy, it often manifests as a pain or soreness in one side of the lower abdomen. When abortion or rupture occurs, the patient suddenly has a tear in the lower abdomen, often accompanied by nausea and vomiting. Severe cases may cause syncope, shock, and may be accompanied by frequent intentions and anal bulging discomfort. The abdominal pain of abortion is paroxysmal, and the lower abdomen is in the middle, ranging from mild fall pain to obvious spastic pain.

(4) Gynecological examination: When the tubal is pregnant, the posterior vaginal fornix is full, there is tenderness, and the cervical pain is obvious. This is one of the main features of tubal pregnancy. The uterus is slightly larger and softer. When there is a lot of internal bleeding, check the uterus for a sense of floating. The side of the uterus or the rear of the uterus can touch the unclear mass of the border, and the tenderness is obvious.

(5) Auxiliary inspection:

1 After the vaginal iliac puncture, the dark red is not coagulated, which can help diagnose the tubal pregnancy;

2 urine pregnancy test is positive, but the patient's HCG level is significantly lower than the intrauterine pregnancy; 3B type ultrasound examination found that the uterus is enlarged but the uterine cavity is empty, the hypoechoic area appears next to the palace, and the germ and the original cardiac tube beat, can be diagnosed For tubal pregnancy; 4 laparoscopy helps to improve the accuracy of ectopic pregnancy diagnosis.

2. Hydatidiform mole:

(1) Menopause time: Most patients have a history of menopause for 2 to 4 months, with an average of 12 weeks.

(2) vaginal bleeding: hydatidiform moles are characterized by irregular vaginal bleeding, often dark red, the amount of uncertainty, intermittent, during which there may be repeated large bloodshed, most patients with anemia appearance, carefully examined sometimes in the blood flowing out A blister sample can be found to help confirm the diagnosis.

(3) Abdominal pain: When the hydatidiform mole grows rapidly and the uterus accumulates blood to make the uterus increase rapidly, it can cause paroxysmal pain in the lower abdomen and is generally tolerable. Hydatid is often accompanied by intermittent bleeding after paroxysmal lower abdominal pain.

(4) gynecological examination: the uterus is significantly larger than the menopause month, the texture is very soft, the uterus, such as pregnancy 5 months old, can not touch the carcass, can not hear the fetal heart, can not feel fetal movement, should be suspected of hydatidiform mole.

(5) Auxiliary inspection:

1 Chorionic gonadotropin (HCG) assay: During normal pregnancy, trophoblasts begin to secrete HCG on day 6 after implantation of the fertilized egg. As the pregnancy progresses, the serum HCG value gradually increases, reaching a peak at 8 to 10 weeks of gestation. The serum HCG value gradually decreased afterwards. However, in the case of hydatidiform mole, the trophoblast cells are highly proliferating, producing a large amount of HCG. The serum HCG value is usually higher than the normal pregnancy value of the corresponding gestational age, and the HCG continues to rise after 12 weeks of menopause. This difference can be used as an auxiliary diagnosis.

2B type ultrasound examination: it is an important auxiliary examination method for diagnosing hydatidiform mole. It shows that the uterus is significantly larger than the menopause month, no gestational sac, no fetal heartbeat motility, and the uterine cavity is filled with heterogeneous dense or short strip echo. "Snow-like", when the blisters are large, the echogenic area is "honeycomb". The wall of the uterus is thin, but the echo is continuous, and there is no focal translucent area. Occasionally, the ovarian flavin cysts on both sides or one side are measured, which are multi-room, thin in the wall, and partially separated in the inside. Color Doppler ultrasonography showed abundant uterine artery blood flow, but no blood flow or only sparse "star-like" blood flow signal in the myometrium.

3 Ultrasound Doppler examination: the fetal heart can not hear the fetal heart, only the uterine blood flow murmur can be heard, and the normal pregnancy can hear the fetal heart at the earliest 6 to 7 weeks of pregnancy.

3. Dysfunctional uterine bleeding: can also occur in women of childbearing age.

(1) Menopause time: due to the disorder of the menstrual cycle, sometimes mistaken for menopause.

(2) vaginal bleeding: common symptoms are irregular vaginal bleeding, characterized by menstrual cycle disorders, menstrual cycle length, bleeding volume for a long time, or even a lot of bleeding, lasting 2 to 3 weeks or more, not easy to stop.

(3) Abdominal pain: There is no abdominal pain during dysfunctional uterine bleeding. In the case of miscarriage, there is often lower abdominal pain.

(4) Gynecological examination: There are no organic lesions in the internal and external reproductive organs.

(5) Auxiliary examination: negative pregnancy test; diagnostic curettage, sent pathological examination, no pregnancy or pregnancy endometrial changes, can rule out miscarriage.

4. Uterine fibroids:

(1) Menopause time: The patient has no obvious history of menopause.

(2) vaginal bleeding: uterine fibroids typically have menorrhagia, shortened menstrual cycle, prolonged menstruation and infertility; submucosal fibroids with necrosis, there may be persistent irregular vaginal bleeding or bloody purulent drainage.

(3) Abdominal pain: usually no abdominal pain, acute abdominal pain occurs when the subserosal fibroids are reversed, abdominal pain is severe with fever when the fibroids are red, and submucosal fibroids secondary infection can cause lower abdominal pain. Common symptoms include lower abdomen bulge, back pain, and menstrual period.

(4) gynecological examination: intermuscular fibroids uterus increased, the texture is hard, the surface has irregular fibroid nodules; subserosal fibroids can touch the hard, globular mass and the uterus have fine pedicles, good activity Submucosal fibroids uterus uniform enlargement, sometimes cervical dilatation, fibroids located in the cervical canal or prolapse to the vagina, red, parenchy, smooth surface of the ball, accompanied by exudate or superficial ulcer formation on the surface of the infection, and There is purulent drainage. If the fibroids have a cystic change, the texture becomes soft and it is easy to be misdiagnosed as a pregnant uterus.

(5) Auxiliary examination: negative pregnancy test; B-mode ultrasound examination showed a round hypoechoic fibroid, and can determine whether the fibroids have degeneration.

5. Pregnancy with cervical erosion or polyp bleeding: This type of bleeding is not accompanied by lower abdominal pain, less blood but bright red. Speculum examination showed active bleeding at the cervical erosion or polyp. The size of the uterus is consistent with the month of pregnancy. B-mode ultrasound showed no abnormal signs.

6. The common point of choriocarcinoma and threatened abortion is that both are women of childbearing age, with vaginal bleeding and uterine enlargement. Choriocarcinoma vaginal bleeding occurs in the mole, abortion or full-term delivery, prone to lung, vaginal, brain and other parts of the transfer. The uterus is enlarged, soft and irregular in shape. Endometrial histological examination showed a large number of nourishing cells, hemorrhage, necrosis, and no villus structure can confirm the diagnosis. B-mode ultrasound showed no signs of pregnancy in the uterine cavity. When the transfer is suspected, further X-ray films and CT examinations will be taken to assist in the diagnosis.

7. Pregnancy corpus luteum rupture: sudden menstrual pain on the lower abdomen after menopause, no vaginal bleeding, no shock or mild shock. Gynecological examination of the cervix pain, tenderness in the attachment area on one side. After the iliac puncture, dark red was not coagulated, and B-mode ultrasonography revealed a low echo zone in the attachment area on one side.

8. Membrane-like menstruation: menstrual period of abdominal pain or menstrual period for several days, with menstrual blood excretion of membrane-like tissue, easily misdiagnosed as miscarriage. Negative pregnancy test, the discharge of tissue to the pathological examination for the endometrium, no villus can be diagnosed.

9. Pregnancy with cervical cancer: manifested as irregular vaginal bleeding, or often bloody secretions, especially vaginal examination or bleeding after sexual intercourse, gynecological examination and cervical biopsy for cancer, can be diagnosed.

10. Cervical pregnancy: a history of menopause and a history of early pregnancy, beginning with a small amount of irregular vaginal bleeding or only a history of bloody secretions. Subsequently, the amount of bleeding gradually increases, which may be intermittent vaginal bleeding, or sudden sudden massive bleeding leading to shock, a large number of bleeding often occurs within 3 months of pregnancy. The amount of bleeding is more than that of intrauterine pregnancy. When the hematoma forms at the bottom of the broad ligament, there is abdominal pain. Gynecological examination: the cervix is significantly enlarged, soft and coloring, and the change of the size and hardness of the palace is not obvious. With the development of pregnancy, the cervix is conical, the outer edge of the cervix is thin and congested, the outer mouth is invaginated, the internal cervix is closed, and the vaginal bleeding comes from the cervical canal and flows out through the small hole. B-mode ultrasound examination: the uterus is normal or slightly larger, there is no gestational sac in the uterine cavity, the cervical canal is enlarged and thickened, and the gestational sac can be confirmed in the cervical canal. Diagnostic criteria for cervical pregnancy:

1 The site of the placenta attachment must have a cervical gland;

2 placenta and the wall of the cervix should be closely attached;

3 all or most of the placenta tissue below the internal cervix;

4 no intrauterine pregnancy.

11. Red degeneration of uterine fibroids: more common in pregnancy, a history of uterine fibroids, manifested as severe pain in the lower abdomen with high fever, check the rapid increase of fibroids. Gynecological examination of the uterus has tenderness, and can touch the painful mass, B-mode ultrasound examination of the uterine muscle wall with degenerative fibroids echo.

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