产科并发症（英文）ppt课件

1、vPremature deliveryPremature deliveryvProlonged pregnancyProlonged pregnancyvPremature Rupture of Premature Rupture of MembranesMembranes( PROM)( PROM)Content Preterm Labor: Labor occurs after 28 weeks but before 37 weeks (ie.196258days) gestation. Infants born during these phase are premature infan

2、ts. The premature infants weight is between 1000 and 2499g. The prognosis of the premature infant is correlated with its gestational age, weight.Definition: Etiology:1.Obstetric complications 产科并发症产科并发症2.Medical complications 内科并发症内科并发症3.Surgical complications 外科并发症外科并发症4.Genital tract anomalies 生殖道

3、畸形生殖道畸形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裂伤裂伤 of cervix or uterus2.Medical complications:Pulmonar

4、y or systemic hypertensionRenal diseaseHeart diseaseInfection: genital tract infection, urinary tract infection, pyelonephritis肾盂肾炎肾盂肾炎, acute systemic infectionHeavy cigarette smokingAlcoholism or drug addictionSevere anemia3.Surgical complications:Conization of cervix宫颈锥切术宫颈锥切术Previous incision in

5、 uterus or cervix ( cesarean delivery剖宫产术剖宫产术)4.Genital tract anomaliesBicornuate双角双角, subseptate纵隔纵隔, or unicormuate单角单角 uterusCongenital cervical incompetency先天性宫先天性宫颈闭合不全颈闭合不全Clinical Finding & Diagnosis1.Symptom and SignUterine contractionsmore than 2 in one-half hour;Vaginal bleeding-bloody

6、 mucous vaginal discharge or “bloody show;Dilatation扩张扩张 and effacement衰退衰退 of cervix-change in dilatation or effacement of at least 1cm or a cervix that is well effaced and dilatated (at least 2 cm);2. Laboratory StudiesCompletely blood count with differentialCervix discharge cultures ：should be se

7、nt for gonorrhea淋病淋病 and chlamydia衣原体衣原体. Fetal fibronectin纤连蛋白纤连蛋白Ffn): negative test is effective at ruling out imminent delivery(within 2 weeks)； positive test Ffn50ng/ml): result is sensitive at predicting preterm birth.分泌物分泌物3. Accessory examination:Ultrasound examination for fetal size, positi

8、on, placenta location，and cervical length. Cervical length30nm: prognosticating premature delivery. Infundibulum漏斗漏斗 length of cervical internal os25% Cervical length or Amniocentesis to ascertain fetal lung maturity, the amnio fluid羊水羊水 be tested for lecithin卵磷卵磷脂脂/ sphingomyelin鞘磷脂鞘磷脂 (L/S) ratio

9、principle: If the fetus is alive, with no PROM 胎膜早破胎膜早破, 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 infan

10、t.Treatment:1. Bed rest：2. Corticosteroids: to accelerate fetal lung maturity Betamethason 倍他米松倍他米松: 12mg IM 1/24 hr 2 doses Dexamethasone地塞米松地塞米松: 6 mg IM 1/12 hr 4 doses3. Antibiotics: no benefit in delaying preterm birth.4. Tocolysis： 4.Tocolysis Tocolytic therapy should be considered in the pati

11、ent with cervical dilation less than 3 cm.(1) Beta-Mimetic Adrenergic Agents肾上腺受体激动肾上腺受体激动剂剂 Ritodrine利托君，利托君， Terbutaline特布他林，特布他林， salbutamol沙丁胺醇：沙丁胺醇：(2) Magnesium sulfate硫酸镁硫酸镁: first line agent for tocolysis;(3) Calcium Channel Blockers钙离子通道拮抗剂钙离子通道拮抗剂; nifedipine硝苯地平硝苯地平(4) Prostaglandin Synth

12、etase Inhibitors前列腺素合成前列腺素合成抑制剂抑制剂 indomethacin吲哚美辛吲哚美辛 Some cases in which preterm labor should not be suppressed. Maternal factors: Fetal factors:Maternal factors:Severe hypertensive diseasePulmonary or cardiac diseaseAdvanced cervical dilationMaternal hemorrhageFetal factors:Fetal death or lethal

13、 anomalyFetal distressIntrauterine infectionTherapy adversely affecting the fetusEstimated fetal weight2500gErythroblastosis fetalisSevere intrauterine growth retardationManner of labor 1. Vaginal delivery: perineum section会阴切开术会阴切开术 2. Cesarean section: abnormal fetal position胎位异常胎位异常 fetal distres

14、s胎儿窘迫胎儿窘迫 maternal hemorrhage孕妇出血孕妇出血 severe maternal complications孕妇孕妇严重的并发症严重的并发症 Case File vA healthy 20-year-old pregnant woman, G1P0 at 29 A healthy 20-year-old pregnant woman, G1P0 at 29 weeksweeks gestation present to the labor and delivery area gestation present to the labor and delivery are

15、a complaining of intermitten abdominal pain. She denies complaining of intermitten abdominal pain. She denies leakage of fluid or bleeding per vagina. Her antenatal leakage of fluid or bleeding per vagina. Her antenatal history has been unremarkable. She has been eating history has been unremarkable

16、. She has been eating and drinking normally. On examination, the fetal heart and drinking normally. On examination, the fetal heart rate tracing reveals a baseline heart rate of 120bpm rate tracing reveals a baseline heart rate of 120bpm and reactive pattern. Uterine contraction are occuring and rea

17、ctive pattern. Uterine contraction are occuring every 3 to 5 min. On pelvic examination, her cervix is 1 every 3 to 5 min. On pelvic examination, her cervix is 1 cm dilated, 90% effaced, and fetal vertex is presenting cm dilated, 90% effaced, and fetal vertex is presenting at -1 station.at -1 statio

18、n. vWhat is the most likely diagnosis?v Preterm labor.vWhat is your next step in management?v Tocolysis, try to identify a cause of the preterm labor, antenatal steroids, and antibiotics.QuestionsPROLONGED PREGNANCY(POSTTERM PREGNANCY)General consideration:vDefinition: v Prolonged pregnancy is defin

19、ed 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. v The maternal risk: Related to extraordinary fetal size:Dysfunctional labor功能妨碍性分娩功能妨碍性分娩Arrested progress of labor 产程停顿产程停顿 Fetopelvic disproportion胎盆不称

20、胎盆不称 Cesarean section 剖宫产剖宫产 Labor trauma 分娩损伤分娩损伤Effect to fetus: Impaired nutritional supply ( weight loss, reduced subcutaneous tissue, scaling脱皮脱皮, parchmentlike skin羊皮纸样皮肤羊皮纸样皮肤)-dysmaturity 成熟妨碍成熟妨碍 Birth injury ( shoulder dystocia肩难产肩难产) Oligohydramnios羊水过少羊水过少 Fetal distress胎儿窘迫胎儿窘迫Meconiurn

21、 aspiration syndroame MAS)胎胎粪吸入综合征粪吸入综合征Asphyxia neonatorum新生儿窒息新生儿窒息ETIOLOGYProlonged pregnancy may relate to:Dysfunction of estrogen/progesteron (E/P) ratio雌孕激素比例失调：雌孕激素比例失调：prostaglandin前前列腺素列腺素, estrogen雌激素雌激素 progestin孕激孕激素素cephalopelvic disproportion头盆不称头盆不称cpd): Fetal deformity胎儿畸形胎儿畸形;Geneti

22、c factors遗传要素遗传要素:placenta sulfatase deficiency胎盘硫酸酯酶胎盘硫酸酯酶PATHOLOGYvPlacenta: normal or hypofunction功能减退功能减退 vAmniotic fluid: vOligohydramnios羊水过少羊水过少vMeconium dye of amniotic fluid羊水粪染羊水粪染vFetus:vFetal macrosomia宏大胎儿宏大胎儿vFetal dysmaturity胎儿成熟妨碍胎儿成熟妨碍vSmall-for-date infant小样儿小样儿Diagnosis: 1. Confir

23、mation 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 p

24、arameters of early pregnancy ( e.g, hCG )2. Judgment of the placental function:Fetal movement count胎动计数胎动计数:Fetal electrical monitor胎儿电子监护胎儿电子监护:Ultrasound examination超声检查超声检查:Urine estrogen/creatinine ratio雌激素和肌酐比雌激素和肌酐比值值 :Amnioscopy羊膜镜检查羊膜镜检查:Treatment: Indication of terminal pregnancy:Cervical m

25、atureFetal weigth4000g, or non reaction pattern of NST, or CST positive (doubtful)Urine estrogen/creatinine ratio decreasedFetal movement OligohydramniosWith eclampsia of pre-eclampsia1. Induced labor: Cervix is mature, bishop score7 When cervix is mature: 人工破膜人工破膜Oxytocin, Prasterone普拉睾酮普拉睾酮Prostag

26、landin前列腺素：前列腺素： propess普贝生普贝生(Dinoprostone Suppositories地诺前列酮栓地诺前列酮栓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.Premature Rupture of Me

27、mbranes( PROM)DEFINITIONvThe fetal membrane rupture happens before labor. Premature rupture of membrane can cause preterm labor, prolapse of umbilical cord, and maternal and fetal infection. vThe less the gestational age, the worse the prognosis of the perinatal infant. Essentials of Diagnosis1. His

28、tory of a gush of fluid from the vagina or watery vaginal discharge;2. Demonstration of amniotic fluid leakage from the cervix.ETIOLOGYvGenital tract pathogenic microorganism upgoing infection:vAmniotic cavity pressure increase:vPressure on fetal membrane is unbalanced;vNutritional factor;vCervical

29、incompetence;vCytokine: Pathology & PathophysiologyvPreterm laborvProlapse of the umbilical cordvPlacenta abruptionvIntrauterine infectionvChorioamnionitisDIAGNOSIS1. SymptomSudden gush of fluid or continued leakageThe color and consistency of the fluid and the presence of Vernix caseosa胎脂胎脂or m

30、econium胎粪胎粪, reduce size of the uterus, and increased prominence of the fetus to palpation.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 th

31、e 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 semen3. Physical examination:To search for other signs for infection.4. Laboratory studies:Complet

32、e blood count with differentialUltrasound examination for fetal size and amniotic fluid indexAmniocentesis to determine fetal lung maturity and the presence of infection5. ChorioamniotisThe most reliable signs of infection include:Fever: the temperature should be checked every 4 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