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1、LATER PREGNANCY COMPLICATIONS,Premature delivery Prolonged pregnancy Premature Rupture of Membranes ( PROM),Content,PRETERM LABOR 早 产,Preterm Labor: Labor occurs after 28 weeks but before 37 weeks (ie.196258days) gestation. Infants born during these phase are premature infants. The premature infants
2、 weight is between 1000 and 2499g. The prognosis of the premature infant is correlated with its gestational age, weight.,Definition:,Etiology:,1.Obstetric complications 产科并发症 2.Medical complications 内科并发症 3.Surgical complications 外科并发症 4.Genital tract anomalies 生殖道畸形,1.Obstetric complications: Sever
3、e hypertensive state or pregnancy Anatomic disorder of the placenta( abruptio placentae, placenta previa) Premature rupture of membranes Polyhydramnios or oligohydramnios Multiple pregnancy Previous laceration（裂伤） of cervix or uterus,2.Medical complications: Pulmonary or systemic hypertension Renal
4、disease Heart disease Infection: genital tract infection, urinary tract infection, pyelonephritis肾盂肾炎, acute systemic infection Heavy cigarette smoking Alcoholism or drug addiction Severe anemia,3.Surgical complications: Conization of cervix宫颈锥切术 Previous incision in uterus or cervix ( cesarean deli
5、very剖宫产术) 4.Genital tract anomalies Bicornuate双角, subseptate纵隔, or unicormuate单角 uterus Congenital cervical incompetency先天性宫颈闭合不全,Clinical Finding & Diagnosis,1.Symptom and Sign Uterine contractionsmore than 2 in one-half hour; Vaginal bleeding-bloody mucous vaginal discharge or “bloody show”; Dilat
6、ation扩张 and effacement消退 of cervix-change in dilatation or effacement of at least 1cm or a cervix that is well effaced and dilatated (at least 2 cm);,2. Laboratory Studies Completely blood count with differential Cervix discharge cultures ：should be sent for gonorrhea淋病 and chlamydia衣原体. Fetal fibro
7、nectin纤连蛋白（Ffn): negative test is effective at ruling out imminent delivery(within 2 weeks)； positive test （Ffn50ng/ml): result is sensitive at predicting preterm birth.分泌物,3. Accessory examination: Ultrasound examination for fetal size, position, placenta location，and cervical length. Cervical leng
8、th30nm: prognosticating premature delivery. Infundibulum漏斗 length of cervical internal os25% Cervical length or Amniocentesis to ascertain fetal lung maturity, the amnio fluid羊水 be tested for lecithin卵磷脂/ sphingomyelin鞘磷脂 (L/S) ratio,principle: If the fetus is alive, with no PROM 胎膜早破, fetal distres
9、s , or the severe pregnancy complications，the uterine contraction should be inhibited to prolong the gestational age. If premature delivery is unavoidable, something must be done to elevate the survival rate of the premature infant.,Treatment:,1. Bed rest： 2. Corticosteroids: to accelerate fetal lun
10、g maturity Betamethason 倍他米松: 12mg IM 1/24 hr 2 doses Dexamethasone地塞米松: 6 mg IM 1/12 hr 4 doses 3. Antibiotics: no benefit in delaying preterm birth. 4. Tocolysis：,4.Tocolysis Tocolytic therapy should be considered in the patient with cervical dilation less than 3 cm. (1) Beta-Mimetic Adrenergic Ag
11、ents肾上腺受体激动剂 Ritodrine利托君， Terbutaline特布他林， salbutamol沙丁胺醇： (2) Magnesium sulfate硫酸镁: first line agent for tocolysis; (3) Calcium Channel Blockers钙离子通道拮抗剂; nifedipine硝苯地平 (4) Prostaglandin Synthetase Inhibitors前列腺素合成抑制剂 indomethacin吲哚美辛,Some cases in which preterm labor should not be suppressed. Mat
12、ernal factors: Fetal factors: Maternal factors: Severe hypertensive disease Pulmonary or cardiac disease Advanced cervical dilation Maternal hemorrhage,Fetal factors: Fetal death or lethal anomaly Fetal distress Intrauterine infection Therapy adversely affecting the fetus Estimated fetal weight2500g
13、 Erythroblastosis fetalis Severe intrauterine growth retardation,Manner of labor 1. Vaginal delivery: perineum section会阴切开术 2. Cesarean section: abnormal fetal position胎位异常 fetal distress胎儿窘迫 maternal hemorrhage孕妇出血 severe maternal complications孕妇严重的并发症,Case File,A healthy 20-year-old pregnant woman
14、, G1P0 at 29 weeks gestation present to the labor and delivery area complaining of intermitten abdominal pain. She denies leakage of fluid or bleeding per vagina. Her antenatal history has been unremarkable. She has been eating and drinking normally. On examination, the fetal heart rate tracing reve
15、als a baseline heart rate of 120bpm and reactive pattern. Uterine contraction are occuring every 3 to 5 min. On pelvic examination, her cervix is 1 cm dilated, 90% effaced, and fetal vertex is presenting at -1 station.,What is the most likely diagnosis? Preterm labor. What is your next step in manag
16、ement? Tocolysis, try to identify a cause of the preterm labor, antenatal steroids, and antibiotics.,Questions,PROLONGED PREGNANCY (POSTTERM PREGNANCY),General consideration:,Definition: Prolonged pregnancy is defined as pregnancy that has reached 42 weeks of completed gestation from the first day o
17、f the LMP or 40 weeks gestation from the time of conception.,The maternal risk: Related to extraordinary fetal size: Dysfunctional labor功能障碍性分娩 Arrested progress of labor 产程停止 Fetopelvic disproportion胎盆不称 Cesarean section 剖宫产 Labor trauma 分娩损伤,Effect to fetus: Impaired nutritional supply ( weight lo
18、ss, reduced subcutaneous tissue, scaling脱皮, parchmentlike skin羊皮纸样皮肤)-dysmaturity 成熟障碍 Birth injury ( shoulder dystocia肩难产) Oligohydramnios羊水过少 Fetal distress胎儿窘迫 Meconiurn aspiration syndroame （MAS)胎粪吸入综合征 Asphyxia neonatorum新生儿窒息,ETIOLOGY,Prolonged pregnancy may relate to: Dysfunction of estrogen/
19、progesteron (E/P) ratio雌孕激素比例失调：prostaglandin前列腺素, estrogen雌激素 progestin孕激素 cephalopelvic disproportion头盆不称（cpd): Fetal deformity胎儿畸形; Genetic factors遗传因素:placenta sulfatase deficiency胎盘硫酸酯酶,PATHOLOGY,Placenta: normal or hypofunction功能减退 Amniotic fluid: Oligohydramnios羊水过少 Meconium dye of amniotic f
20、luid羊水粪染 Fetus: Fetal macrosomia巨大胎儿 Fetal dysmaturity胎儿成熟障碍 Small-for-date infant小样儿,Diagnosis:,1. Confirmation of gestational age: by referring to records of : Mecial history: LMP, the exact time of conception, ovulate time, et al; Clinical expression: early pregnancy reaction, quickening time, gy
21、necological examination in first trimester, et al; Laboratory tests: ultrasound: examination, and clinical parameters of early pregnancy ( e.g, hCG ),2. Judgment of the placental function: Fetal movement count胎动计数: Fetal electrical monitor胎儿电子监护: Ultrasound examination超声检查: Urine estrogen/creatinine
22、 ratio雌激素和肌酐比值 : Amnioscopy羊膜镜检查:,Treatment:,Indication of terminal pregnancy: Cervical mature Fetal weigth4000g, or non reaction pattern of NST, or CST positive (doubtful) Urine estrogen/creatinine ratio decreased Fetal movement Oligohydramnios With eclampsia of pre-eclampsia,1. Induced labor: Cerv
23、ix is mature, bishop score7 When cervix is mature: 人工破膜 Oxytocin, Prasterone普拉睾酮 Prostaglandin前列腺素： propess普贝生(Dinoprostone Suppositories地诺前列酮栓）,3. Cesarean section: Failure of induced labor; Arrested progress of labor; Fetal distress; Disposition; Large fetus; Amniotic fluid is abnormal; Pregnancy
24、complications; Fetal compromise : breech presentation, et al.,Premature Rupture of Membranes ( PROM),DEFINITION,The fetal membrane rupture happens before labor. Premature rupture of membrane can cause preterm labor, prolapse of umbilical cord, and maternal and fetal infection. The less the gestation
25、al age, the worse the prognosis of the perinatal infant.,Essentials of Diagnosis,1. History of a gush of fluid from the vagina or watery vaginal discharge; 2. Demonstration of amniotic fluid leakage from the cervix.,ETIOLOGY,Genital tract pathogenic microorganism upgoing infection: Amniotic cavity p
26、ressure increase: Pressure on fetal membrane is unbalanced; Nutritional factor; Cervical incompetence; Cytokine:,Pathology & Pathophysiology,Preterm labor Prolapse of the umbilical cord Placenta abruption Intrauterine infection Chorioamnionitis,DIAGNOSIS,1. Symptom Sudden gush of fluid or continued
27、leakage The color and consistency of the fluid and the presence of Vernix caseosa胎脂or meconium胎粪, reduce size of the uterus, and increased prominence of the fetus to palpation.,2. Sterile speculum examination Pooling: the collection of amniotic fluid in the posterior fornix ; Nitrazine test: the nit
28、razine paper turns blue, demonstrating an alkaline PH (7.0-7.25); Ferning : Fluid from the posterior fornix is placed on a slide and allowed to air-dry. Amniotic fluid will form a fernlike pattern of crystallization; Be care of false negative result: vaginal infections, presence of blood or semen,3.
29、 Physical examination: To search for other signs for infection. 4. Laboratory studies: Complete blood count with differential Ultrasound examination for fetal size and amniotic fluid index Amniocentesis to determine fetal lung maturity and the presence of infection,5. Chorioamniotis The most reliabl
30、e signs of infection include: Fever: the temperature should be checked every 4 hours Maternal leukocytosis: daily leukocyte count and differential. An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infection Uterine tenderness: check every 4 h
31、ours Tachycardia: either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.,Influence on Mother and Fetus,Influence on mother: Infection; Placenta abruption Influence on fetus: Premature deliveryrespiratory distress syndrome of newborn新生儿呼吸窘迫综合症 Chorioamnionitis绒毛膜羊膜炎aspiration pneumonitis
32、of newborn新生儿吸入性肺炎，septicemia败血症 prolapse of cord脐带脱垂fetal distress,Treatment,1.Expectant management: is appropriate for those whose gestational age between 28 and 35 weeks, without chorioamnionitis General management: bed rest, hydration, clean, patients temperature, heart rate, contraction, vagina
33、l leakage, blood leukocyte count, et al. Antibiotic: Tocolysis: Corticosteroids:,2. Chorioamnionitis (1) delivery: If chorioamnionitis is present in the patient with PROM, the patient should be actively delivered regardless of gestational age. (2) Broad-spectrum antibiotics,3. Term pregnancy without chorioamnionitis: (1) Expectant management: Waiting for patient to go into labor spontaneously; (2) Active management: Induction of labor with an agent such as oxytocin;,Thank you!,