Premature Delivery Premature Rupture of Membrane Prolonged Pregnancy, Multiple Pregnancy

1. Premature Delivery Premature Rupture of MembraneProlonged Pregnancy, Multiple Pregnancy Women Hospital , School of Medical, ZheJiang University Yang Xiao Fu

2. Preterm labour

3. Preterm labour • Defined as delivery after gestation 28 completed weeks till 37 weeks (196-258 days). Birth weight 1000g - 2449g • Preterm labour makes up 5% - 15% of total number of delivery • Can the lower limit of preterm labour be brought earlier to 20 weeks gestation?

4. Classification • Spontaneous preterm labor • Preterm prematurely ruptured membranes • Preterm birth for medical and obstetrical indications

5. Diagnosis of preterm labour • Labour occurring between gestation 28 completed weeks and 37 weeks • regular uterine contraction:≥ 4 times in 20 minutes or 8 times in 60 minutes • cervical shortening of ≥ 80% • progressivecervical dilatation of 1cm and above

6. Prediction of preterm labour • Ultrasound assessing cervical length and internal os funnel formation, when internal os funnel is longer than the total cervical length by 25%, or total cervical length <2.5cm, indicating high possibility of preterm labour

8. Treatment • Bed rest • Corticosteroids • Tocolysis • Antibiotics • Conduct of labor ＆ delivery

9. Treatment • Tocolysis ß-adrenergic receptor agonists magnesium sulfate atosiban calcium-channel blockers prostaglandin inhibitors

10. Premature rupture of membrane

11. Premature rupture of membrane • Membrane rupture occurring before labour, known as premature rupture of membrane (PROM) • Occurring after 37 completed weeks gestation, is called premature rupture of membrane at term • Occurring before 37 weeks gestation, called preterm premature rupture of membrane (PPROM)

12. Etiology • Maternal infection • Hydramnios • Cervical incompetency • Nutritional deficit • Others(amniocentesis, sexual behavior)

13. Clinical Findings and Diagnosis • Sudden gush of fluid or continued leakage • Amniotic fluid in the posterior fornix • Nitrazine test • Ferning • IGFBP-1 • Amnioscopy • Ultrasound

14. Effect to mother and fetus • Feto-maternal infection • Placenta abruptio • Premature infant: 30% - 40% of premature labour is associated with premature rupture of membrane • Cord prolapse, cord compression • Poor fetal lung development and fetal compression syndrome

15. Treatment • Term pregnancy without amnionitis expectment management labor induction

16. Treatment • Preterm pregnancy without amnionitis expectment management best rest antibiotics tocolysis corticosteroids termination of pregnancy

17. Post-term pregnancy Prolonged pregnancy

18. Prolonged pregnancy • Gestation at or beyond 42 weeks gestation (>=294 days), known as post-term pregnancy • Important factor for fetal distress, meconium aspiration syndrome, maturation disturbance syndrome, newborn asphysia, perinatal death, macrosomia and dystocia

19. Diagnosis • Determine gestational age • Calculation based on last menstrual period • Calculation based on ovulation • Ultrasound examination to ascertain gestation age • Period of manifestation of early pregnancy symptoms, quickening • First trimester pelvic examination assessing uterine size

20. Diagnosis • Assess placental function • Fetal movement count • Fetal electronic monitoring • Fetal biophysical profile (Ultrasound) • amnioscopy

21. Management • Prevent post-term labour, effectively manage at term • Decide appropriate mode of delivery based on integrated analysis of placental function, estimated fetal weight, cervical effacement, etc • Preinduction cervical ripening • Induced labour • Caesarean section • Neonatal resuscitation

22. Multiple pregnancy

23. Multiple pregnancy • Conception of 2 or more fetuses in the same intra-uterine pregnancy • Incidence of multiple pregnancy: 1:80n-1 (n represents number of fetus in a single pregnancy)

24. Dizygotic twin • Dizygotic twin makes up 70% of twin pregnancy • Associated with ovulation induction, multi-embryo intrauterine transplantation and genetic factors • Two separate ova being fertilized forming two zygotes, each genetic compositions is not identical, hence the differences in both fetuses

25. Dizygotic twin • The placentas are usually dichorionic, can be fused together, but each has own independent blood circulation • Two amniotic cavities • two layers of amniotic membrane • two layer of chorionic membrane

26. Monozygotic twin • Monozygotic twin makes up approximately 30% of twin pregnancy • Unclear cause, higher incidence in older pregnant women • Single fertilized ovum differentiating into two fetuses, thus gender, blood type and other phenotypes are identical • As the fertilized ovum differentiates at different times, forming 4 types

27. Diamniotic dichorionic monozygotic twin • Differentiate within 72 hours of fertilization • Form two independent fertilized ova and two amniotic sac, two layers of chorionic membranes and two layers amniotic membranes within the amniotic sacs • Maybe single or two placentas • Makes up approximately 30% of monozygotic twins

29. Diamniotic monochorionic monozygotic twin • Differentiation occurs from 72 hours to 8 days of fertilization • One layer of chorionic membranes and two layers of amniotic membranes within two amniotic sacs • Single placenta • Makes up 68% of monozygotic twins

32. Monoamniotic monochorionic monozygotic twin • Differentiation within 9-13 days after fertilization • Both fetuses share a single amniotic cavity • Single placenta • Makes up 1% - 2% of monozygotic twins

36. Conjoined twin • Differentiation after 13 days of fertilization, during which the primitive embryo has formed, the body cannot completely differentiate into two separate bodies, thus leading to different types of conjoined twins • Incidence is 1/1500 of monozygotic twins

37. Conjoined twin

39. TRAPS

41. Complication • Pregnant women • Anaemia • Hypertensin in pregnancy • Hydramnios and Premature rupture of membrane • Placental abruption • Uterine atony • Postpartum hemorrhage

42. Complication • Perinatal infant • Preterm labor • Abnormity of umbilical cord • Head-locking • Anomaly • Selective FGR • TTTS

43. Management • Treatment of pregnancy • Monozygotic twin laser/RFA • Indication for termination of pregnancy • Timing of pregnancy termination • Treatment in delivery

44. THANKS