【医学ppt课件】早产

LATERPREGNANCYCOMPLICATIONS DONGMEIHUDepartmentGynecology ObstetricsZhujiangHospitalSouthMedicalUniversity PrematuredeliveryProlongedpregnancyPrematureRuptureofMembranes PROM Content PRETERMLABOR早产 PretermLabor Laboroccursafter28weeks butbefore37weeks ie 196 258days gestation Infantsbornduringthesephaseareprematureinfants Theprematureinfant sweightisbetween1000and2499g Theprognosisoftheprematureinfantiscorrelatedwithitsgestationalage weight Definition Prematureinfant Matureinfant 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 ClinicalFinding Diagnosis 1 SymptomandSignUterinecontractions morethan2inone halfhour Vaginalbleeding 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 Ffn 50ng ml resultissensitiveatpredictingpretermbirth 分泌物 3 Accessoryexamination Ultrasoundexaminationforfetalsize position placentalocation andcervicallength Cervicallength 30nm prognosticatingprematuredelivery Infundibulum漏斗lengthofcervicalinternalos 25 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 24hr 2dosesDexamethasone地塞米松 6mgIM1 12hr 4doses3 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 FetaldeathorlethalanomalyFetaldistressIntrauterineinfectionTherapyadverselyaffectingthefetusEstimatedfetalweight 2500gErythroblastosisfetalisSevereintrauterinegrowthretardation 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 G1P0at29weeks gestationpresenttothelaboranddeliveryareacomplainingofintermittenabdominalpain Shedeniesleakageoffluidorbleedingpervagina Herantenatalhistoryhasbeenunremarkable Shehasbeeneatinganddrinkingnormally Onexamination thefetalheartratetracingrevealsabaselineheartrateof120bpmandreactivepattern Uterinecontractionareoccuringevery3to5min Onpelvicexamination hercervixis1cmdilated 90 effaced andfetalvertexispresentingat 1station Whatisthemostlikelydiagnosis Pretermlabor Whatisyournextstepinmanagement Tocolysis trytoidentifyacauseofthepretermlabor antenatalsteroids andantibiotics Questions PROLONGEDPREGNANCY POSTTERMPREGNANCY Generalconsideration Definition Prolongedpregnancyisdefinedaspregnancythathasreached42weeksofcompletedgestationfromthefirstdayoftheLMPor40weeks gestationfromthetimeofconception 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 CervicalmatureFetalweigth 4000g ornonreactionpatternofNST orCSTpositive doubtful Urineestrogen creatinineratiodecreasedFetalmovementOligohydramniosWitheclampsiaofpre eclampsia 1 Inducedlabor Cervixismature bishopscore 7Whencervixismature 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 Pathology Pathophysiology PretermlaborProlapseoftheumbilicalcordPlacentaabruptionIntrauterineinfectionChorioamnionitis DIAGNOSIS 1 SymptomSuddengushoffluidorcontinuedleakageThecolorandconsistencyofthefluidandthepresenceofVernixcaseosa胎脂ormeconium胎粪 reducesizeoftheuterus andincreasedprominenceofthefetustopalpation 2 SterilespeculumexaminationPooling thecollectionofamnioticfluidintheposteriorfornix Nitrazinetest 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 eithermaternalpulse 100bpmorfetalheart 160bpmis