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LATER PREGNANCY COMPLICATIONS

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Title: LATER PREGNANCY COMPLICATIONS


1
LATER PREGNANCY COMPLICATIONS
DONGMEI HU Department Gynecology
Obstetrics Zhujiang Hospital South Medical
University
2
Content
  • Premature delivery
  • Prolonged pregnancy
  • Premature Rupture of Membranes ( PROM)

3
PRETERM LABOR ? ?
4
Definition
  • 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 weight is between
    1000 and 2499g.
  • The prognosis of the premature infant is
    correlated with its gestational age, weight.

5
Premature infant
Mature infant
6
Etiology
  • 1.Obstetric complications
  • ?????
  • 2.Medical complications
  • ?????
  • 3.Surgical complications
  • ?????
  • 4.Genital tract anomalies
  • ?????

7
  • 1.Obstetric complications
  • Severe hypertensive state or pregnancy
  • Anatomic disorder of the placenta( abruptio
    placentae, placenta previa)
  • Premature rupture of membranes
  • Polyhydramnios or oligohydramnios
  • Multiple pregnancy
  • Previous laceration(??) of cervix or uterus

8
  • 2.Medical complications
  • Pulmonary or systemic hypertension
  • Renal disease
  • Heart disease
  • Infection genital tract infection, urinary tract
    infection, pyelonephritis????, acute systemic
    infection
  • Heavy cigarette smoking
  • Alcoholism or drug addiction
  • Severe anemia

9
  • 3.Surgical complications
  • Conization of cervix?????
  • Previous incision in uterus or cervix ( cesarean
    delivery????)
  • 4.Genital tract anomalies
  • Bicornuate??, subseptate??, or unicormuate??
    uterus
  • Congenital cervical incompetency?????????

10
Clinical Finding Diagnosis
  • 1.Symptom and Sign
  • Uterine contractionsmore than 2 in one-half
    hour
  • Vaginal bleeding-bloody mucous vaginal discharge
    or bloody show
  • Dilatation?? and effacement?? of cervix-change in
    dilatation or effacement of at least 1cm or a
    cervix that is well effaced and dilatated (at
    least 2 cm)

11
  • 2. Laboratory Studies
  • Completely blood count with differential
  • Cervix discharge cultures should be sent for
    gonorrhea?? and chlamydia???.
  • Fetal fibronectin????(Ffn)
  • negative test is effective at ruling out
    imminent delivery(within 2 weeks)
  • positive test (Ffngt50ng/ml) result is
    sensitive at predicting preterm birth.???

12
  • 3. Accessory examination
  • Ultrasound examination for fetal size, position,
    placenta location,and cervical length.
  • Cervical lengthgt30nm prognosticating
    premature delivery.
  • Infundibulum?? length of cervical internal
    osgt25 Cervical length or
  • Amniocentesis to ascertain fetal lung maturity,
    the amnio fluid?? be tested for lecithin???/
    sphingomyelin??? (L/S) ratio

13
principle If the fetus is alive, with
no PROM ????, 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
14
  • 1. Bed rest
  • 2. Corticosteroids to accelerate fetal lung
    maturity
  • Betamethason ????
  • 12mg IM 1/24 hr 2 doses
  • Dexamethasone????
  • 6 mg IM 1/12 hr 4 doses
  • 3. Antibiotics no benefit in delaying preterm
    birth.
  • 4. Tocolysis

15
  • 4.Tocolysis Tocolytic therapy should be
    considered in the patient with cervical dilation
    less than 3 cm.
  • (1) Beta-Mimetic Adrenergic Agentsß????????
  • Ritodrine???, Terbutaline????,
    salbutamol????
  • (2) Magnesium sulfate??? first line agent for
    tocolysis
  • (3) Calcium Channel Blockers????????
  • nifedipine????
  • (4) Prostaglandin Synthetase Inhibitors?????????
  • indomethacin????

16
  • Some cases in which preterm labor
    should not be suppressed.
  • Maternal factors
  • Fetal factors
  • Maternal factors
  • Severe hypertensive disease
  • Pulmonary or cardiac disease
  • Advanced cervical dilation
  • Maternal hemorrhage

17
  • Fetal factors
  • Fetal death or lethal anomaly
  • Fetal distress
  • Intrauterine infection
  • Therapy adversely affecting the fetus
  • Estimated fetal weight2500g
  • Erythroblastosis fetalis
  • Severe intrauterine growth retardation

18
  • Manner of labor
  • 1. Vaginal delivery
  • perineum section?????
  • 2. Cesarean section
  • abnormal fetal position????
  • fetal distress????
  • maternal hemorrhage????
  • severe maternal complications????????

19
Case File
  • A healthy 20-year-old pregnant woman, 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 reveals 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.

20

Questions
  • What is the most likely diagnosis?
  • Preterm labor.
  • What is your next step in management?
  • Tocolysis, try to identify a cause of
    the preterm labor, antenatal steroids, and
    antibiotics.

21
PROLONGED PREGNANCY (POSTTERM PREGNANCY)
22
General consideration
  • Definition
  • 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.

23
  • The maternal risk
  • Related to extraordinary fetal size
  • Dysfunctional labor???????
  • Arrested progress of labor ????
  • Fetopelvic disproportion????
  • Cesarean section ???
  • Labor trauma ????

24
  • Effect to fetus
  • Impaired nutritional supply ( weight loss,
    reduced subcutaneous tissue, scaling??,
    parchmentlike skin??????)----dysmaturity
  • ????
  • Birth injury ( shoulder dystocia???)
  • Oligohydramnios????
  • Fetal distress????
  • Meconiurn aspiration syndroame (MAS)???????
  • Asphyxia neonatorum?????

25
ETIOLOGY
  • Prolonged pregnancy may relate to
  • Dysfunction of estrogen/progesteron (E/P)
    ratio????????prostaglandin????, estrogen???? ?
    progestin????
  • cephalopelvic disproportion????(cpd)
  • Fetal deformity????
  • Genetic factors????placenta sulfatase
    deficiency???????

26
PATHOLOGY
  • Placenta normal or hypofunction????
  • Amniotic fluid
  • Oligohydramnios????
  • Meconium dye of amniotic fluid????
  • Fetus
  • Fetal macrosomia????
  • Fetal dysmaturity??????
  • Small-for-date infant???

27
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
    )

28
  • 2. Judgment of the placental function
  • Fetal movement count????
  • Fetal electrical monitor??????
  • Ultrasound examination????
  • Urine estrogen/creatinine ratio????????
  • Amnioscopy?????

29
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

30
  • 1. Induced labor
  • Cervix is mature, bishop scoregt7
  • When cervix is mature ????
  • Oxytocin,
  • Prasterone????
  • Prostaglandin????
  • propess???(Dinoprostone
    Suppositories??????)

31
  • 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.

32
Premature Rupture of Membranes ( PROM)
33
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 gestational age, the worse the
    prognosis of the perinatal infant.

34
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.

35
ETIOLOGY
  • Genital tract pathogenic microorganism upgoing
    infection
  • Amniotic cavity pressure increase
  • Pressure on fetal membrane is unbalanced
  • Nutritional factor
  • Cervical incompetence
  • Cytokine

36
Pathology Pathophysiology
  • Preterm labor
  • Prolapse of the umbilical cord
  • Placenta abruption
  • Intrauterine infection
  • Chorioamnionitis

37
DIAGNOSIS
  • 1. Symptom
  • Sudden gush of fluid or continued leakage
  • The color and consistency of the fluid and the
    presence of Vernix caseosa??or meconium??, reduce
    size of the uterus, and increased prominence of
    the fetus to palpation.

38
  • 2. Sterile speculum examination
  • Pooling 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

39
  • 3. 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

40
  • 5. Chorioamniotis
  • The most reliable 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 hours
  • Tachycardia either maternal pulse ?100bpm or
    fetal heart ?160 bpm is suspicious.

41
Influence on Mother and Fetus
  • Influence on mother
  • Infection
  • Placenta abruption
  • Influence on fetus
  • Premature delivery?respiratory distress syndrome
    of newborn??????????
  • Chorioamnionitis???????aspiration pneumonitis of
    newborn????????,septicemia???
  • prolapse of cord?????fetal distress

42
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,
    vaginal leakage, blood leukocyte count, et al.
  • Antibiotic
  • Tocolysis
  • Corticosteroids

43
  • 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

44
  • 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

45
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