LATER PREGNANCY COMPLICATIONS

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LATER PREGNANCY COMPLICATIONS
DONGMEI HU Department Gynecology
Obstetrics Zhujiang Hospital South Medical
University
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Content

• Premature delivery
• Prolonged pregnancy
• Premature Rupture of Membranes( PROM)

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PRETERM LABOR ? ?
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Definition

• Preterm Labor
• Labor occurs after 28 weeks but before 37
  weeks (ie.196258days) gestation.
• Infants born during these phase are
  premature infants.
• The premature infants weight is between
  1000 and 2499g.
• The prognosis of the premature infant is
  correlated with its gestational age, weight.

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Premature infant
Mature infant
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Etiology

• 1.Obstetric complications
• ?????
• 2.Medical complications
• ?????
• 3.Surgical complications
• ?????
• 4.Genital tract anomalies
• ?????

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• 1.Obstetric complications
• Severe hypertensive state or pregnancy
• Anatomic disorder of the placenta( abruptio
  placentae, placenta previa)
• Premature rupture of membranes
• Polyhydramnios or oligohydramnios
• Multiple pregnancy
• Previous laceration(??) of cervix or uterus

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• 2.Medical complications
• Pulmonary or systemic hypertension
• Renal disease
• Heart disease
• Infection genital tract infection, urinary tract
  infection, pyelonephritis????, acute systemic
  infection
• Heavy cigarette smoking
• Alcoholism or drug addiction
• Severe anemia

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• 3.Surgical complications
• Conization of cervix?????
• Previous incision in uterus or cervix ( cesarean
  delivery????)
• 4.Genital tract anomalies
• Bicornuate??, subseptate??, or unicormuate??
  uterus
• Congenital cervical incompetency?????????

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Clinical Finding Diagnosis

• 1.Symptom and Sign
• Uterine contractionsmore than 2 in one-half
  hour
• Vaginal bleeding-bloody mucous vaginal discharge
  or bloody show
• Dilatation?? and effacement?? of cervix-change in
  dilatation or effacement of at least 1cm or a
  cervix that is well effaced and dilatated (at
  least 2 cm)

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• 2. Laboratory Studies
• Completely blood count with differential
• Cervix discharge cultures should be sent for
  gonorrhea?? and chlamydia???.
• Fetal fibronectin????(Ffn)
• negative test is effective at ruling out
  imminent delivery(within 2 weeks)
• positive test (Ffngt50ng/ml) result is
  sensitive at predicting preterm birth.???

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• 3. Accessory examination
• Ultrasound examination for fetal size, position,
  placenta location,and cervical length.
• Cervical lengthgt30nm prognosticating
  premature delivery.
• Infundibulum?? length of cervical internal
  osgt25 Cervical length or
• Amniocentesis to ascertain fetal lung maturity,
  the amnio fluid?? be tested for lecithin???/
  sphingomyelin??? (L/S) ratio

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principle If the fetus is alive, with
no PROM ????, 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.
Treatment
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• 1. Bed rest
• 2. Corticosteroids to accelerate fetal lung
  maturity
• Betamethason ????
• 12mg IM 1/24 hr 2 doses
• Dexamethasone????
• 6 mg IM 1/12 hr 4 doses
• 3. Antibiotics no benefit in delaying preterm
  birth.
• 4. Tocolysis

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• 4.Tocolysis Tocolytic therapy should be
  considered in the patient with cervical dilation
  less than 3 cm.
• (1) Beta-Mimetic Adrenergic Agentsß????????
• Ritodrine???, Terbutaline????,
  salbutamol????
• (2) Magnesium sulfate??? first line agent for
  tocolysis
• (3) Calcium Channel Blockers????????
• nifedipine????
• (4) Prostaglandin Synthetase Inhibitors?????????
  
• indomethacin????

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• Some cases in which preterm labor
  should not be suppressed.
• Maternal factors
• Fetal factors
• Maternal factors
• Severe hypertensive disease
• Pulmonary or cardiac disease
• Advanced cervical dilation
• Maternal hemorrhage

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• Fetal factors
• Fetal death or lethal anomaly
• Fetal distress
• Intrauterine infection
• Therapy adversely affecting the fetus
• Estimated fetal weight2500g
• Erythroblastosis fetalis
• Severe intrauterine growth retardation

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• Manner of labor
• 1. Vaginal delivery
• perineum section?????
• 2. Cesarean section
• abnormal fetal position????
• fetal distress????
• maternal hemorrhage????
• severe maternal complications????????

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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 unremarkable. 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 at -1
  station.

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Questions

• 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.

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PROLONGED PREGNANCY(POSTTERM PREGNANCY)
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General consideration

• Definition
• 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.

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• The maternal risk
• Related to extraordinary fetal size
• Dysfunctional labor???????
• Arrested progress of labor ????
• Fetopelvic disproportion????
• Cesarean section ???
• Labor trauma ????

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• Effect to fetus
• Impaired nutritional supply ( weight loss,
  reduced subcutaneous tissue, scaling??,
  parchmentlike skin??????)----dysmaturity
• ????
• Birth injury ( shoulder dystocia???)
• Oligohydramnios????
• Fetal distress????
• Meconiurn aspiration syndroame (MAS)???????
• Asphyxia neonatorum?????

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ETIOLOGY

• Prolonged pregnancy may relate to
• Dysfunction of estrogen/progesteron (E/P)
  ratio????????prostaglandin????, estrogen???? ?
  progestin????
• cephalopelvic disproportion????(cpd)
• Fetal deformity????
• Genetic factors????placenta sulfatase
  deficiency???????

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PATHOLOGY

• Placenta normal or hypofunction????
• Amniotic fluid
• Oligohydramnios????
• Meconium dye of amniotic fluid????
• Fetus
• Fetal macrosomia????
• Fetal dysmaturity??????
• Small-for-date infant???

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Diagnosis

• 1. Confirmation 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 parameters of early pregnancy ( e.g, hCG
  )

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• 2. Judgment of the placental function
• Fetal movement count????
• Fetal electrical monitor??????
• Ultrasound examination????
• Urine estrogen/creatinine ratio????????
• Amnioscopy?????

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Treatment

• Indication of terminal pregnancy
• Cervical mature
• Fetal weigth4000g, or non reaction pattern of
  NST, or CST positive (doubtful)
• Urine estrogen/creatinine ratio decreased
• Fetal movement Oligohydramnios
• With eclampsia of pre-eclampsia

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• 1. Induced labor
• Cervix is mature, bishop scoregt7
• When cervix is mature ????
• Oxytocin,
• Prasterone????
• Prostaglandin????
• propess???(Dinoprostone
  Suppositories??????)

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• 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.

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Premature Rupture of Membranes( PROM)
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DEFINITION

• The 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.

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Essentials of Diagnosis

• 1. History of a gush of fluid from the vagina or
  watery vaginal discharge
• 2. Demonstration of amniotic fluid leakage from
  the cervix.

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ETIOLOGY

• Genital tract pathogenic microorganism upgoing
  infection
• Amniotic cavity pressure increase
• Pressure on fetal membrane is unbalanced
• Nutritional factor
• Cervical incompetence
• Cytokine

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Pathology Pathophysiology

• Preterm labor
• Prolapse of the umbilical cord
• Placenta abruption
• Intrauterine infection
• Chorioamnionitis

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DIAGNOSIS

• 1. Symptom
• Sudden gush of fluid or continued leakage
• The color and consistency of the fluid and the
  presence of Vernix caseosa??or meconium??, reduce
  size of the uterus, and increased prominence of
  the fetus to palpation.

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• 2. Sterile speculum examination
• Pooling 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 the 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

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• 3. Physical examination
• To search for other signs for infection.
• 4. Laboratory studies
• Complete blood count with differential
• Ultrasound examination for fetal size and
  amniotic fluid index
• Amniocentesis to determine fetal lung maturity
  and the presence of infection

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• 5. Chorioamniotis
• The most reliable signs of infection include
• Fever the temperature should be checked every 4
  hours
• Maternal leukocytosis daily leukocyte count and
  differential. An increase in the white blood cell
  count or neutrophil count may indicate the
  presence of intra-amniotice infection
• Uterine tenderness check every 4 hours
• Tachycardia either maternal pulse ?100bpm or
  fetal heart ?160 bpm is suspicious.

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Influence on Mother and Fetus

• Influence on mother
• Infection
• Placenta abruption
• Influence on fetus
• Premature delivery?respiratory distress syndrome
  of newborn??????????
• Chorioamnionitis???????aspiration pneumonitis of
  newborn????????,septicemia???
• prolapse of cord?????fetal distress

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Treatment

• 1.Expectant management is appropriate for those
  whose gestational age between 28 and 35 weeks,
  without chorioamnionitis
• General management bed rest, hydration, clean,
  patients temperature, heart rate, contraction,
  vaginal leakage, blood leukocyte count, et al.
• Antibiotic
• Tocolysis
• Corticosteroids

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• 2. Chorioamnionitis
• (1) delivery
• If chorioamnionitis is present in the
  patient with PROM, the patient should be actively
  delivered regardless of gestational age.
• (2) Broad-spectrum antibiotics

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• 3. Term pregnancy without chorioamnionitis
• (1) Expectant management
• Waiting for patient to go into labor
  spontaneously
• (2) Active management
• Induction of labor with an agent such
  as oxytocin

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Thank you!