产科并发症英文ppt课件.ppt

LATER PREGNANCY COMPLICATIONSLATER PREGNANCY COMPLICATIONSvPremature deliveryPremature deliveryvProlonged pregnancyProlonged pregnancyvPremature Rupture of Premature Rupture of MembranesMembranes( PROM)( PROM)ContentPRETERM LABOR早早 产 Preterm Labor: Labor occurs after 28 weeks’ but before 37 weeks’ (ie.196~258days) gestation. Infants born during these phase are premature infants. The premature infant’s weight is between 1000 and 2499g. The prognosis of the premature infant is correlated with its gestational age, weight.Definition: Etiology:1.Obstetric complications 产科并发症产科并发症2.Medical complications 内科并发症内科并发症3.Surgical complications 外科并发症外科并发症4.Genital tract anomalies 生殖道畸形生殖道畸形1.Obstetric complications: Severe hypertensive state or pregnancyAnatomic disorder of the placenta( abruptio placentae, placenta previa)Premature rupture of membranes Polyhydramnios or oligohydramniosMultiple pregnancyPrevious laceration〔裂伤〕〔裂伤〕 of cervix or uterus2.Medical complications:Pulmonary or systemic hypertensionRenal diseaseHeart diseaseInfection: genital tract infection, urinary tract infection, pyelonephritis肾盂肾炎肾盂肾炎, acute systemic infectionHeavy cigarette smokingAlcoholism or drug addictionSevere anemia3.Surgical complications:Conization of cervix宫颈锥切术宫颈锥切术Previous incision in uterus or cervix ( cesarean delivery剖宫产术剖宫产术)4.Genital tract anomaliesBicornuate双角双角, subseptate纵隔纵隔, or unicormuate单角单角 uterusCongenital cervical incompetency先天性宫先天性宫颈闭合不全颈闭合不全Clinical Finding & Diagnosis1.Symptom and SignUterine contractions—more than 2 in one-half hour;Vaginal bleeding-bloody mucous vaginal discharge or “bloody show〞〞;Dilatation扩张 and effacement衰退衰退 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 StudiesCompletely blood count with differentialCervix discharge cultures ：：should be sent for gonorrhea淋病淋病 and chlamydia衣原体衣原体. Fetal fibronectin纤连蛋白〔纤连蛋白〔Ffn): negative test is effective at ruling out imminent delivery(within 2 weeks)；； positive test 〔〔Ffn>50ng/ml): result is sensitive at predicting preterm birth.分泌物分泌物3. Accessory examination:Ultrasound examination for fetal size, position, placenta location，，and cervical length. Cervical length>30nm: prognosticating premature delivery. Infundibulum漏斗漏斗 length of cervical internal os>25% Cervical length or Amniocentesis to ascertain fetal lung maturity, the amnio fluid羊水羊水 be tested for lecithin卵磷卵磷脂脂/ sphingomyelin鞘磷脂鞘磷脂 (L/S) ratio principle: If the fetus is alive, with no PROM 胎膜早破胎膜早破, fetal distress , 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￿rest1.￿Bed￿rest：：2.￿Corticosteroids:￿to￿accelerate￿fetal￿2.￿Corticosteroids:￿to￿accelerate￿fetal￿lung￿maturitylung￿maturity￿￿￿￿Betamethason￿￿￿￿￿Betamethason￿倍他米松倍他米松:￿:￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿12mg￿IM￿1/24￿hr￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿12mg￿IM￿1/24￿hr￿×2￿doses×2￿doses￿￿￿￿￿￿￿￿￿￿Dexamethasone￿￿￿￿￿￿￿￿￿￿Dexamethasone地塞米松地塞米松:￿:￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿6￿mg￿IM￿1/12￿hr￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿6￿mg￿IM￿1/12￿hr￿×￿4￿doses×￿4￿doses3.￿Antibiotics:￿no￿benefit￿in￿delaying￿3.￿Antibiotics:￿no￿benefit￿in￿delaying￿preterm￿birth.preterm￿birth.4.￿Tocolysis4.￿Tocolysis：： 4.Tocolysis Tocolytic therapy should be considered in the patient with cervical dilation less than 3 cm.(1) Beta-Mimetic Adrenergic Agentsβ肾上腺受体激上腺受体激动剂 Ritodrine利托君，利托君， Terbutaline特布他林，特布他林， salbutamol沙丁胺醇：沙丁胺醇：(2) Magnesium sulfate硫酸硫酸镁: first line agent for tocolysis;(3) Calcium Channel Blockers钙离子通道拮抗离子通道拮抗剂; nifedipine硝苯地平硝苯地平(4) Prostaglandin Synthetase Inhibitors前列腺素合成前列腺素合成抑制抑制剂 indomethacin吲哚美辛美辛 Some cases in which preterm labor should not be suppressed. Maternal factors: Fetal factors:Maternal factors:Severe hypertensive diseasePulmonary or cardiac diseaseAdvanced cervical dilationMaternal hemorrhageFetal factors:Fetal death or lethal anomalyFetal distressIntrauterine infectionTherapy adversely affecting the fetusEstimated fetal weight≥2500gErythroblastosis fetalisSevere intrauterine growth retardationManner of labor 1. Vaginal delivery: perineum section会阴切开术会阴切开术 2. Cesarean section: abnormal fetal position胎位异常胎位异常 fetal distress胎儿窘迫胎儿窘迫 maternal hemorrhage孕妇出血孕妇出血 severe maternal complications孕妇孕妇严重的并发症严重的并发症 Case File vA healthy 20-year-old pregnant woman, G1P0 at 29 A healthy 20-year-old pregnant woman, G1P0 at 29 weeks’ gestation present to the labor and delivery area weeks’ gestation present to the labor and delivery area complaining of intermitten abdominal pain. She denies complaining of intermitten abdominal pain. She denies leakage of fluid or bleeding per vagina. Her antenatal leakage of fluid or bleeding per vagina. Her antenatal history has been unremarkable. She has been eating history has been unremarkable. She has been eating and drinking normally. On examination, the fetal heart and drinking normally. On examination, the fetal heart rate tracing reveals a baseline heart rate of 120bpm and rate tracing reveals a baseline heart rate of 120bpm and reactive pattern. Uterine contraction are occuring every reactive pattern. Uterine contraction are occuring every 3 to 5 min. On pelvic examination, her cervix is 1 cm 3 to 5 min. On pelvic examination, her cervix is 1 cm dilated, 90% effaced, and fetal vertex is presenting at -dilated, 90% effaced, and fetal vertex is presenting at -1 station.1 station. vWhat is the most likely diagnosis?v Preterm labor.vWhat is your next step in management?v Tocolysis, try to identify a cause of the preterm labor, antenatal steroids, and antibiotics.QuestionsPROLONGED PREGNANCY(POSTTERM PREGNANCY)General consideration:vDefinition: v Prolonged pregnancy is defined as pregnancy that has reached 42 weeks of completed gestation from the first day of the LMP or 40 weeks’ gestation from the time of conception. v  The maternal risk: Related to extraordinary fetal size:Dysfunctional labor功能妨碍性分娩功能妨碍性分娩Arrested progress of labor 产程停顿产程停顿 Fetopelvic disproportion胎盆不称胎盆不称 Cesarean section 剖宫产剖宫产 Labor trauma 分娩损伤分娩损伤Effect to fetus: Impaired nutritional supply ( weight loss, reduced subcutaneous tissue, scaling脱皮脱皮, parchmentlike skin羊皮纸样皮肤羊皮纸样皮肤)----dysmaturity 成熟妨碍成熟妨碍 Birth injury ( shoulder dystocia肩难产肩难产) Oligohydramnios羊水过少羊水过少 Fetal distress胎儿窘迫胎儿窘迫Meconiurn aspiration syndroame 〔〔MAS)胎粪胎粪吸入综合征吸入综合征Asphyxia neonatorum新生儿窒息新生儿窒息ETIOLOGYProlonged pregnancy may relate to:Dysfunction of estrogen/progesteron (E/P) ratio雌孕激素比例失雌孕激素比例失调：：prostaglandin前前列腺素列腺素, estrogen雌激素雌激素↓ → progestin孕激孕激素素↑cephalopelvic disproportion头盆不称〔盆不称〔cpd): Fetal deformity胎儿畸形胎儿畸形;Genetic factors遗传要素要素:placenta sulfatase deficiency胎胎盘硫酸硫酸酯酶↓PATHOLOGYvPlacenta: normal or hypofunction功能减退功能减退 vAmniotic fluid: vOligohydramnios羊水过少羊水过少vMeconium dye of amniotic fluid羊水粪染羊水粪染vFetus:vFetal macrosomia宏大胎儿宏大胎儿vFetal dysmaturity胎儿成熟妨碍胎儿成熟妨碍vSmall-for-date infant小样儿小样儿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, gynecological 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胎动计数胎动计数:Fetal electrical monitor胎儿电子监护胎儿电子监护:Ultrasound examination超声检查超声检查:Urine estrogen/creatinine ratio雌激素和肌酐比雌激素和肌酐比值值 :Amnioscopy羊膜镜检查羊膜镜检查:Treatment: Indication of terminal pregnancy:Cervical matureFetal weigth≥4000g, or non reaction pattern of NST, or CST positive (doubtful)Urine estrogen/creatinine ratio decreasedFetal movement OligohydramniosWith eclampsia of pre-eclampsia1. Induced labor: Cervix is mature, bishop score>7 When cervix is mature: 人工破膜人工破膜Oxytocin, Prasterone普拉睾酮普拉睾酮Prostaglandin前列腺素：前列腺素： propess普贝生普贝生(Dinoprostone Suppositories地诺前列酮栓〕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 complications;Fetal compromise : breech presentation, et al.Premature Rupture of Membranes( PROM)DEFINITIONvThe fetal membrane rupture happens before labor. Premature rupture of membrane can cause preterm labor, prolapse of umbilical cord, and maternal and fetal infection. vThe less the gestational age, the worse the prognosis of the perinatal infant. Essentials of Diagnosis1.￿History￿of￿a￿gush￿of￿fluid￿from￿the￿1.￿History￿of￿a￿gush￿of￿fluid￿from￿the￿vagina￿or￿watery￿vaginal￿discharge;vagina￿or￿watery￿vaginal￿discharge;2.￿Demonstration￿of￿amniotic￿fluid￿leakage￿2.￿Demonstration￿of￿amniotic￿fluid￿leakage￿from￿the￿cervix.from￿the￿cervix.ETIOLOGYvGenital tract pathogenic microorganism upgoing infection:vAmniotic cavity pressure increase:vPressure on fetal membrane is unbalanced;vNutritional factor;vCervical incompetence;vCytokine: Pathology & PathophysiologyvPreterm laborvProlapse of the umbilical cordvPlacenta abruptionvIntrauterine infectionvChorioamnionitisDIAGNOSIS1. SymptomSudden gush of fluid or continued leakageThe color and consistency of the fluid and the presence of Vernix caseosa胎脂胎脂or meconium胎粪胎粪, reduce size of the uterus, and increased prominence of the fetus to palpation.2. Sterile speculum examinationPooling: the collection of amniotic fluid in the posterior fornix ;Nitrazine test: the nitrazine 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.￿￿Physical￿examination:3.￿￿Physical￿examination:To￿search￿for￿other￿signs￿for￿infection.To￿search￿for￿other￿signs￿for￿infection.4.￿￿Laboratory￿studies:4.￿￿Laboratory￿studies:Complete￿blood￿count￿with￿differentialComplete￿blood￿count￿with￿differentialUltrasound￿examination￿for￿fetal￿size￿and￿Ultrasound￿examination￿for￿fetal￿size￿and￿amniotic￿fluid￿indexamniotic￿fluid￿indexAmniocentesis￿to￿determine￿fetal￿lung￿Amniocentesis￿to￿determine￿fetal￿lung￿maturity￿and￿the￿presence￿of￿infectionmaturity￿and￿the￿presence￿of￿infection5.￿￿Chorioamniotis5.￿￿ChorioamniotisThe￿most￿reliable￿signs￿of￿infection￿include:The￿most￿reliable￿signs￿of￿infection￿include:Fever:￿the￿temperature￿should￿be￿checked￿Fever:￿the￿temperature￿should￿be￿checked￿every￿4￿hoursevery￿4￿hoursMaternal￿leukocytosis:￿daily￿leukocyte￿count￿Maternal￿leukocytosis:￿daily￿leukocyte￿count￿and￿differential.￿An￿increase￿in￿the￿white￿and￿differential.￿An￿increase￿in￿the￿white￿blood￿cell￿count￿or￿neutrophil￿count￿may￿blood￿cell￿count￿or￿neutrophil￿count￿may￿indicate￿the￿presence￿of￿intra-amniotice￿indicate￿the￿presence￿of￿intra-amniotice￿infectioninfectionUterine￿tenderness:￿check￿every￿4￿hoursUterine￿tenderness:￿check￿every￿4￿hoursTachycardia:￿either￿maternal￿pulse￿Tachycardia:￿either￿maternal￿pulse￿﹥100bpm￿100bpm￿or￿fetal￿heart￿or￿fetal￿heart￿﹥160￿bpm￿is￿suspicious.160￿bpm￿is￿suspicious.Influence on Mother and FetusInfluence on mother:Infection;Placenta abruptionInfluence on fetus:Premature delivery→respiratory distress syndrome of newborn新生儿呼吸窘迫新生儿呼吸窘迫综合症合症Chorioamnionitis绒毛膜羊膜炎毛膜羊膜炎→aspiration pneumonitis of newborn新生儿吸入性肺炎，新生儿吸入性肺炎，septicemia败血症血症prolapse of cord脐带脱垂脱垂→fetal distressTreatment1.Expectant management: is appropriate for those whose gestational age between 28 and 35 weeks, without chorioamnionitisGeneral management: bed rest, hydration, clean, patient’s temperature, heart rate, contraction, vaginal 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;。