1、LATER PREGNANCY COMPLICATIONS第1頁，共44頁。Premature deliveryProlonged pregnancyPremature Rupture of Membranes( PROM)Content第2頁，共44頁。PRETERM LABOR早 產(chǎn)第3頁，共44頁。 Preterm Labor: Labor occurs after 28 weeks but before 37 weeks (ie.196258days) gestation. Infants born during these phase are premature infants. T

2、he premature infants weight is between 1000 and 2499g. The prognosis of the premature infant is correlated with its gestational age, weight.Definition: 第4頁，共44頁。Etiology:1.Obstetric complications 產(chǎn)科并發(fā)癥2.Medical complications 內(nèi)科并發(fā)癥3.Surgical complications 外科并發(fā)癥4.Genital tract anomalies 生殖道畸形第5頁，共44頁。

3、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（裂傷） of cervix or uterus第6頁，共44頁。2.Medical complications:Pulmon

4、ary or systemic hypertensionRenal diseaseHeart diseaseInfection: genital tract infection, urinary tract infection, pyelonephritis腎盂腎炎, acute systemic infectionHeavy cigarette smokingAlcoholism or drug addictionSevere anemia第7頁，共44頁。3.Surgical complications:Conization of cervix宮頸錐切術(shù)Previous incision

5、in uterus or cervix ( cesarean delivery剖宮產(chǎn)術(shù))4.Genital tract anomaliesBicornuate雙角, subseptate縱隔, or unicormuate單角 uterusCongenital cervical incompetency先天性宮頸閉合不全第8頁，共44頁。Clinical Finding & Diagnosis1.Symptom and SignUterine contractionsmore than 2 in one-half hour;Vaginal bleeding-bloody mucous vagi

6、nal discharge or “bloody show”;Dilatation擴(kuò)張 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);第9頁，共44頁。2. Laboratory StudiesCompletely blood count with differentialCervix discharge cultures ：should be sent for

7、 gonorrhea淋病 and chlamydia衣原體. Fetal fibronectin纖連蛋白（Ffn): negative test is effective at ruling out imminent delivery(within 2 weeks)； positive test （Ffn50ng/ml): result is sensitive at predicting preterm birth.分泌物第10頁，共44頁。3. Accessory examination:Ultrasound examination for fetal size, position, pl

8、acenta location，and cervical length. Cervical length30nm: 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第11頁，共44頁。 princi

9、ple: 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.Treatmen

10、t:第12頁，共44頁。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 doses3. Antibiotics: no benefit in delaying preterm birth.4. Tocolysis：第13頁，共44頁。 4.Tocolysis Tocolytic therapy should be considered in the pa

11、tient with cervical dilation less than 3 cm.(1) Beta-Mimetic Adrenergic Agents腎上腺受體激動劑 Ritodrine利托君， Terbutaline特布他林， salbutamol沙丁胺醇：(2) Magnesium sulfate硫酸鎂: first line agent for tocolysis;(3) Calcium Channel Blockers鈣離子通道拮抗劑; nifedipine硝苯地平(4) Prostaglandin Synthetase Inhibitors前列腺素合成抑制劑 indometha

12、cin吲哚美辛第14頁，共44頁。 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第15頁，共44頁。Fetal factors:Fetal death or lethal anomalyFetal distressIntrau

13、terine infectionTherapy adversely affecting the fetusEstimated fetal weight2500gErythroblastosis fetalisSevere intrauterine growth retardation第16頁，共44頁。Manner of labor 1. Vaginal delivery: perineum section會陰切開術(shù) 2. Cesarean section: abnormal fetal position胎位異常 fetal distress胎兒窘迫 maternal hemorrhage孕婦

14、出血 severe maternal complications孕婦嚴(yán)重的并發(fā)癥 第17頁，共44頁。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 unremarka

15、ble. 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

16、 at -1 station.第18頁，共44頁。 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.Questions第19頁，共44頁。PROLONGED PREGNANCY(POSTTERM PREGNANCY)第20頁，共44頁。General consideration:Defi

17、nition: 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. 第21頁，共44頁。 The maternal risk: Related to extraordinary fetal size:Dysfunctional labor功能障礙性分娩Arrested progress of labor

18、 產(chǎn)程停止 Fetopelvic disproportion胎盆不稱 Cesarean section 剖宮產(chǎn) Labor trauma 分娩損傷第22頁，共44頁。Effect to fetus: Impaired nutritional supply ( weight loss, reduced subcutaneous tissue, scaling脫皮, parchmentlike skin羊皮紙樣皮膚)-dysmaturity 成熟障礙 Birth injury ( shoulder dystocia肩難產(chǎn)) Oligohydramnios羊水過少 Fetal distress胎兒窘

19、迫Meconiurn aspiration syndroame （MAS)胎糞吸入綜合征Asphyxia neonatorum新生兒窒息第23頁，共44頁。ETIOLOGYProlonged pregnancy may relate to:Dysfunction of estrogen/progesteron (E/P) ratio雌孕激素比例失調(diào)：prostaglandin前列腺素, estrogen雌激素 progestin孕激素cephalopelvic disproportion頭盆不稱（cpd): Fetal deformity胎兒畸形;Genetic factors遺傳因素:pla

20、centa sulfatase deficiency胎盤硫酸酯酶第24頁，共44頁。PATHOLOGYPlacenta: normal or hypofunction功能減退 Amniotic fluid: Oligohydramnios羊水過少M(fèi)econium dye of amniotic fluid羊水糞染Fetus:Fetal macrosomia巨大胎兒Fetal dysmaturity胎兒成熟障礙Small-for-date infant小樣兒第25頁，共44頁。Diagnosis: 1. Confirmation of gestational age: by referring

21、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

22、)第26頁，共44頁。2. Judgment of the placental function:Fetal movement count胎動計(jì)數(shù):Fetal electrical monitor胎兒電子監(jiān)護(hù):Ultrasound examination超聲檢查:Urine estrogen/creatinine ratio雌激素和肌酐比值 :Amnioscopy羊膜鏡檢查:第27頁，共44頁。Treatment: Indication of terminal pregnancy:Cervical matureFetal weigth4000g, or non reaction pattern

23、 of NST, or CST positive (doubtful)Urine estrogen/creatinine ratio decreasedFetal movement OligohydramniosWith eclampsia of pre-eclampsia第28頁，共44頁。1. Induced labor: Cervix is mature, bishop score7 When cervix is mature: 人工破膜Oxytocin, Prasterone普拉睪酮Prostaglandin前列腺素： propess普貝生(Dinoprostone Supposito

24、ries地諾前列酮栓）第29頁，共44頁。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.第30頁，共44頁。Premature Rupture of Membranes( PROM)第31頁，共44頁。DEFINITIONThe

25、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. 第32頁，共44頁。Essentials of Diagnosis1. History of a gush of fl

26、uid from the vagina or watery vaginal discharge;2. Demonstration of amniotic fluid leakage from the cervix.第33頁，共44頁。ETIOLOGYGenital tract pathogenic microorganism upgoing infection:Amniotic cavity pressure increase:Pressure on fetal membrane is unbalanced;Nutritional factor;Cervical incompetence;Cy

27、tokine: 第34頁，共44頁。Pathology & PathophysiologyPreterm laborProlapse of the umbilical cordPlacenta abruptionIntrauterine infectionChorioamnionitis第35頁，共44頁。DIAGNOSIS1. SymptomSudden gush of fluid or continued leakageThe color and consistency of the fluid and the presence of Vernix caseosa胎脂or meconium

28、胎糞, reduce size of the uterus, and increased prominence of the fetus to palpation.第36頁，共44頁。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 t

29、he 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第37頁，共44頁。3. Physical examination:To search for other signs for infection.4. Laboratory stud

30、ies:Complete blood count with differentialUltrasound examination for fetal size and amniotic fluid indexAmniocentesis to determine fetal lung maturity and the presence of infection第38頁，共44頁。5. ChorioamniotisThe most reliable signs of infection include:Fever: the temperature should be checked every 4

31、 hoursMaternal leukocytosis: daily leukocyte count and differential. An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infectionUterine tenderness: check every 4 hoursTachycardia: either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.第39頁，共4