产科 并发症.ppt

LATERPREGNANCYCOMPLICATIONS,PrematuredeliveryProlongedpregnancyPrematureRuptureofMembranes(PROM),Content,PRETERMLABOR早产,PretermLabor:Laboroccursafter28weeksbutbefore37weeks(ie.196258days)gestation.Infantsbornduringthesephaseareprematureinfants.Theprematureinfantsweightisbetween1000and2499g.Theprognosisoftheprematureinfantiscorrelatedwithitsgestationalage,weight.,Definition:,Etiology:,1.Obstetriccomplications产科并发症2.Medicalcomplications内科并发症3.Surgicalcomplications外科并发症4.Genitaltractanomalies生殖道畸形,1.Obstetriccomplications:SeverehypertensivestateorpregnancyAnatomicdisorderoftheplacenta(abruptioplacentae,placentaprevia)PrematureruptureofmembranesPolyhydramniosoroligohydramniosMultiplepregnancyPreviouslaceration（裂伤）ofcervixoruterus,2.Medicalcomplications:PulmonaryorsystemichypertensionRenaldiseaseHeartdiseaseInfection:genitaltractinfection,urinarytractinfection,pyelonephritis肾盂肾炎,acutesystemicinfectionHeavycigarettesmokingAlcoholismordrugaddictionSevereanemia,3.Surgicalcomplications:Conizationofcervix宫颈锥切术Previousincisioninuterusorcervix(cesareandelivery剖宫产术)4.GenitaltractanomaliesBicornuate双角,subseptate纵隔,orunicormuate单角uterusCongenitalcervicalincompetency先天性宫颈闭合不全,ClinicalFindingVaginalbleeding-bloodymucousvaginaldischargeor“bloodyshow”;Dilatation扩张andeffacement消退ofcervix-changeindilatationoreffacementofatleast1cmoracervixthatiswelleffacedanddilatated(atleast2cm);,2.LaboratoryStudiesCompletelybloodcountwithdifferentialCervixdischargecultures：shouldbesentforgonorrhea淋病andchlamydia衣原体.Fetalfibronectin纤连蛋白（Ffn):negativetestiseffectiveatrulingoutimminentdelivery(within2weeks)；positivetest（Ffn50ng/ml):resultissensitiveatpredictingpretermbirth.分泌物,3.Accessoryexamination:Ultrasoundexaminationforfetalsize,position,placentalocation，andcervicallength.Cervicallength30nm:prognosticatingprematuredelivery.Infundibulum漏斗lengthofcervicalinternalos25%CervicallengthorAmniocentesistoascertainfetallungmaturity,theamniofluid羊水betestedforlecithin卵磷脂/sphingomyelin鞘磷脂(L/S)ratio,principle:Ifthefetusisalive,withnoPROM胎膜早破,fetaldistress,ortheseverepregnancycomplications，theuterinecontractionshouldbeinhibitedtoprolongthegestationalage.Ifprematuredeliveryisunavoidable,somethingmustbedonetoelevatethesurvivalrateoftheprematureinfant.,Treatment:,1.Bedrest：2.Corticosteroids:toacceleratefetallungmaturityBetamethason倍他米松:12mgIM1/24hr2dosesDexamethasone地塞米松:6mgIM1/12hr4doses3.Antibiotics:nobenefitindelayingpretermbirth.4.Tocolysis：,4.TocolysisTocolytictherapyshouldbeconsideredinthepatientwithcervicaldilationlessthan3cm.(1)Beta-MimeticAdrenergicAgents肾上腺受体激动剂Ritodrine利托君，Terbutaline特布他林，salbutamol沙丁胺醇：(2)Magnesiumsulfate硫酸镁:firstlineagentfortocolysis;(3)CalciumChannelBlockers钙离子通道拮抗剂;nifedipine硝苯地平(4)ProstaglandinSynthetaseInhibitors前列腺素合成抑制剂indomethacin吲哚美辛,Somecasesinwhichpretermlaborshouldnotbesuppressed.Maternalfactors:Fetalfactors:Maternalfactors:SeverehypertensivediseasePulmonaryorcardiacdiseaseAdvancedcervicaldilationMaternalhemorrhage,Fetalfactors:FetaldeathorlethalanomalyFetaldistressIntrauterineinfectionTherapyadverselyaffectingthefetusEstimatedfetalweight2500gErythroblastosisfetalisSevereintrauterinegrowthretardation,Manneroflabor1.Vaginaldelivery:perineumsection会阴切开术2.Cesareansection:abnormalfetalposition胎位异常fetaldistress胎儿窘迫maternalhemorrhage孕妇出血severematernalcomplications孕妇严重的并发症,CaseFile,Ahealthy20-year-oldpregnantwoman,G1P0at29weeksgestationpresenttothelaboranddeliveryareacomplainingofintermittenabdominalpain.Shedeniesleakageoffluidorbleedingpervagina.Herantenatalhistoryhasbeenunremarkable.Shehasbeeneatinganddrinkingnormally.Onexamination,thefetalheartratetracingrevealsabaselineheartrateof120bpmandreactivepattern.Uterinecontractionareoccuringevery3to5min.Onpelvicexamination,hercervixis1cmdilated,90%effaced,andfetalvertexispresentingat-1station.,Whatisthemostlikelydiagnosis?Pretermlabor.Whatisyournextstepinmanagement?Tocolysis,trytoidentifyacauseofthepretermlabor,antenatalsteroids,andantibiotics.,Questions,PROLONGEDPREGNANCY(POSTTERMPREGNANCY),Generalconsideration:,Definition:Prolongedpregnancyisdefinedaspregnancythathasreached42weeksofcompletedgestationfromthefirstdayoftheLMPor40weeksgestationfromthetimeofconception.,Thematernalrisk:Relatedtoextraordinaryfetalsize:Dysfunctionallabor功能障碍性分娩Arrestedprogressoflabor产程停止Fetopelvicdisproportion胎盆不称Cesareansection剖宫产Labortrauma分娩损伤,Effecttofetus:Impairednutritionalsupply(weightloss,reducedsubcutaneoustissue,scaling脱皮,parchmentlikeskin羊皮纸样皮肤)-dysmaturity成熟障碍Birthinjury(shoulderdystocia肩难产)Oligohydramnios羊水过少Fetaldistress胎儿窘迫Meconiurnaspirationsyndroame（MAS)胎粪吸入综合征Asphyxianeonatorum新生儿窒息,ETIOLOGY,Prolongedpregnancymayrelateto:Dysfunctionofestrogen/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cephalopelvicdisproportion头盆不称（cpd):Fetaldeformity胎儿畸形;Geneticfactors遗传因素:placentasulfatasedeficiency胎盘硫酸酯酶,PATHOLOGY,Placenta:normalorhypofunction功能减退Amnioticfluid:Oligohydramnios羊水过少Meconiumdyeofamnioticfluid羊水粪染Fetus:Fetalmacrosomia巨大胎儿Fetaldysmaturity胎儿成熟障碍Small-for-dateinfant小样儿,Diagnosis:,1.Confirmationofgestationalage:byreferringtorecordsof:Mecialhistory:LMP,theexacttimeofconception,ovulatetime,etal;Clinicalexpression:earlypregnancyreaction,quickeningtime,gynecologicalexaminationinfirsttrimester,etal;Laboratorytests:ultrasound:examination,andclinicalparametersofearlypregnancy(e.g,hCG),2.Judgmentoftheplacentalfunction:Fetalmovementcount胎动计数:Fetalelectricalmonitor胎儿电子监护:Ultrasoundexamination超声检查:Urineestrogen/creatinineratio雌激素和肌酐比值:Amnioscopy羊膜镜检查:,Treatment:,Indicationofterminalpregnancy:CervicalmatureFetalweigth4000g,ornonreactionpatternofNST,orCSTpositive(doubtful)Urineestrogen/creatinineratiodecreasedFetalmovementOligohydramniosWitheclampsiaofpre-eclampsia,1.Inducedlabor:Cervixismature,bishopscore7Whencervixismature:人工破膜Oxytocin,Prasterone普拉睾酮Prostaglandin前列腺素：propess普贝生(DinoprostoneSuppositories地诺前列酮栓）,3.Cesareansection:Failureofinducedlabor;Arrestedprogressoflabor;Fetaldistress;Disposition;Largefetus;Amnioticfluidisabnormal;Pregnancycomplications;Fetalcompromise:breechpresentation,etal.,PrematureRuptureofMembranes(PROM),DEFINITION,Thefetalmembranerupturehappensbeforelabor.Prematureruptureofmembranecancausepretermlabor,prolapseofumbilicalcord,andmaternalandfetalinfection.Thelessthegestationalage,theworsetheprognosisoftheperinatalinfant.,EssentialsofDiagnosis,1.Historyofagushoffluidfromthevaginaorwateryvaginaldischarge;2.Demonstrationofamnioticfluidleakagefromthecervix.,ETIOLOGY,Genitaltractpathogenicmicroorganismupgoinginfection:Amnioticcavitypressureincrease:Pressureonfetalmembraneisunbalanced;Nutritionalfactor;Cervicalincompetence;Cytokine:,PathologyNitrazinetest:thenitrazinepaperturnsblue,demonstratinganalkalinePH(7.0-7.25);Ferning:Fluidfromtheposteriorfornixisplacedonaslideandallowedtoair-dry.Amnioticfluidwillformafernlikepatternofcrystallization;Becareoffalsenegativeresult:vaginalinfections,presenceofbloodorsemen,3.Physicalexamination:Tosearchforothersignsforinfection.4.Laboratorystudies:CompletebloodcountwithdifferentialUltrasoundexaminationforfetalsizeandamnioticfluidindexAmniocentesistodeterminefetallungmaturityandthepresenceofinfection,5.ChorioamniotisThemostreliablesignsofinfectioninclude:Fever:thetemperatureshouldbecheckedevery4hoursMaternalleukocytosis:dailyleukocytecountanddifferential.Anincreaseinthewhitebloodcellcountorneutrophilcountmayindicatethepresenceofintra-amnioticeinfectionUterinetenderness:checkevery4hoursTachycardia:eithermaternalpulse100bpmorfetalheart160bpmissuspicious.,InfluenceonMotherandFetus,Influenceonmother:In