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LATER PREGNANCY COMPLICATIONS

LATER PREGNANCY COMPLICATIONS. DONGMEI HU Department Gynecology & Obstetrics Zhujiang Hospital South Medical University. Content. Premature delivery Prolonged pregnancy Premature Rupture of Membranes ( PROM). PRETERM LABOR 早 产. Definition: . Preterm Labor:

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LATER PREGNANCY COMPLICATIONS

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  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 早 产

  4. Definition: 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.

  5. Premature infant Mature infant

  6. 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

  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（裂伤）of cervix or uterus

  8. 2.Medical complications: • Pulmonary or systemic hypertension • Renal 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

  9. 3.Surgical complications: • Conization of cervix宫颈锥切术 • Previous incision in uterus or cervix ( cesarean delivery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

  10. Clinical Finding & Diagnosis 1.Symptom and Sign • Uterinecontractions—more than 2 in one-half hour; • Vaginal bleeding-bloody mucous vaginal discharge or “bloody show”; • Dilatation扩张and effacement消退ofcervix-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淋病 and chlamydia衣原体. • Fetal fibronectin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

  12. 3. Accessory examination: • Ultrasoundexamination for fetal size, position, placenta location，and cervical length. Cervical length>30nm: prognosticating premature delivery. Infundibulum漏斗length of cervical internal os>25% 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

  13. Treatment: principle:If the fetus is alive, with no PROM 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.

  14. 1. Bed rest： 2. Corticosteroids:to accelerate fetal lung 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：

  15. 4.TocolysisTocolytic 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

  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 weight≥2500g • Erythroblastosis fetalis • Severe intrauterine growth retardation

  18. 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

  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

  24. Effect to fetus: • Impaired nutritional supply ( weight loss, 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

  25. ETIOLOGY Prolonged pregnancy may relate to: • Dysfunction of estrogen/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↓

  26. PATHOLOGY • Placenta: normal or hypofunction功能减退 • Amniotic fluid: • Oligohydramnios羊水过少 • Meconium dye of amniotic fluid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

  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胎动计数: • Fetal electrical monitor胎儿电子监护: • Ultrasound examination超声检查: • Urine estrogen/creatinine ratio雌激素和肌酐比值: • Amnioscopy羊膜镜检查:

  29. Treatment: Indication of terminal pregnancy: • Cervical mature • Fetal weigth≥4000g, 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 score>7 • 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）

  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胎脂or meconium胎粪, 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新生儿呼吸窘迫综合症 • Chorioamnionitis绒毛膜羊膜炎→aspiration pneumonitis of newborn新生儿吸入性肺炎，septicemia败血症 • prolapse of cord脐带脱垂→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, patient’s 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. Thank you!

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