1、产科并发症英1vPremature deliveryPremature deliveryvProlonged pregnancyProlonged pregnancyvPremature Rupture of Premature Rupture of MembranesMembranes(PROM)(PROM)Content产科并发症英2产科并发症英3 Preterm Labor:Preterm Labor:Labor occurs after 28 weeks but before 37 Labor occurs after 28 weeks but before 37 weeks(ie.1
2、96258days)gestation.weeks(ie.196258days)gestation.Infants born during these phase are Infants born during these phase are premature infants.premature infants.The premature infants weight is between The premature infants weight is between 1000 and 2499g.1000 and 2499g.The prognosis of the premature i
3、nfant is The prognosis of the premature infant is correlated with its gestational age,weight.correlated with its gestational age,weight.Definition:产科并发症英4Etiology: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 生殖道畸形生
4、殖道畸形产科并发症英51.Obstetric complications:vSevere hypertensive state or pregnancyvAnatomic disorder of the placenta(abruptio placentae,placenta previa)vPremature rupture of membranes vPolyhydramnios or oligohydramniosvMultiple pregnancyvPrevious laceration（裂伤）（裂伤）of cervix or uterus产科并发症英62.Medical compl
5、ications:vPulmonary or systemic hypertensionvRenal diseasevHeart diseasevInfection:genital tract infection,urinary tract infection,pyelonephritis肾盂肾炎肾盂肾炎,acute systemic infectionvHeavy cigarette smokingvAlcoholism or drug addictionvSevere anemia产科并发症英73.Surgical complications:vConization of cervix宫颈
6、锥切术宫颈锥切术vPrevious incision in uterus or cervix(cesarean delivery剖宫产术剖宫产术)4.Genital tract anomaliesvBicornuate双角双角,subseptate纵隔纵隔,or unicormuate单角单角 uterusvCongenital cervical incompetency先天性宫颈闭先天性宫颈闭合不全合不全产科并发症英8Clinical Finding&Diagnosis1.Symptom and SignvUterine contractionsmore than 2 in one-half
7、 hour;vVaginal bleeding-bloody mucous vaginal discharge or“bloody show”;vDilatation扩张扩张 and effacement消退消退 of cervix-change in dilatation or effacement of at least 1cm or a cervix that is well effaced and dilatated(at least 2 cm);产科并发症英92.Laboratory StudiesvCompletely blood count with differentialvC
8、ervix discharge cultures：should be sent for gonorrhea淋病淋病 and chlamydia衣原体衣原体.vFetal 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.分泌物分泌物产科并发症英103.Accessory examination:vU
9、ltrasound examination for fetal size,position,placenta location，and cervical length.Cervical length30nm:prognosticating premature delivery.Infundibulum漏斗漏斗 length of cervical internal os25%Cervical length or vAmniocentesis to ascertain fetal lung maturity,the amnio fluid羊水羊水 be tested for lecithin卵磷
10、脂卵磷脂/sphingomyelin鞘磷脂鞘磷脂(L/S)ratio产科并发症英11 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
11、survival rate of the premature infant.Treatment:产科并发症英121.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：产科并发症英13 4.Tocolysis Tocoly
12、tic therapy should be considered in the patient with cervical dilation less than 3 cm.(1)Beta-Mimetic Adrenergic Agents肾上腺受体激动剂肾上腺受体激动剂 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;nifedi
13、pine硝苯地平硝苯地平(4)Prostaglandin Synthetase Inhibitors前列腺素合成抑制剂前列腺素合成抑制剂 indomethacin吲哚美辛吲哚美辛产科并发症英14 Some cases in which preterm labor should not be suppressed.Maternal factors:Fetal factors:Maternal factors:vSevere hypertensive diseasevPulmonary or cardiac diseasevAdvanced cervical dilationvMaternal h
14、emorrhage产科并发症英15Fetal factors:vFetal death or lethal anomalyvFetal distressvIntrauterine infectionvTherapy adversely affecting the fetusvEstimated fetal weight2500gvErythroblastosis fetalisvSevere intrauterine growth retardation产科并发症英16Manner of labor 1.Vaginal delivery:perineum section会阴切开术会阴切开术 2
15、.Cesarean section:abnormal fetal position胎位异常胎位异常 fetal distress胎儿窘迫胎儿窘迫 maternal hemorrhage孕妇出血孕妇出血 severe maternal complications孕妇严重的并发症孕妇严重的并发症 产科并发症英17Case File vA healthy 20-year-old pregnant woman,G1P0 at 29 A healthy 20-year-old pregnant woman,G1P0 at 29 weeks gestation present to the labor a
16、nd delivery area weeks gestation present to the labor and delivery area 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 be
17、en unremarkable.She has been eating history has been unremarkable.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 an
18、d reactive pattern.Uterine contraction are occuring and reactive 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
19、 vertex is presenting at-1 station.at-1 station.产科并发症英18 vWhat is the most likely diagnosis?Preterm labor.vWhat is your next step in management?Tocolysis,try to identify a cause of the preterm labor,antenatal steroids,and antibiotics.Questions产科并发症英19PROLONGED PREGNANCY(POSTTERM PREGNANCY)产科并发症英20Ge
20、neral consideration:vDefinition: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.产科并发症英21 The maternal risk:Related to extraordinary fetal size:vDysfunctional labor功能障碍性分娩功能障碍性
21、分娩vArrested progress of labor 产程停止产程停止v Fetopelvic disproportion胎盆不称胎盆不称v Cesarean section 剖宫产剖宫产v Labor trauma 分娩损伤分娩损伤产科并发症英22Effect to fetus:v 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 成熟障碍成熟障碍v Birth injury(shoulde
22、r dystocia肩难产肩难产)v Oligohydramnios羊水过少羊水过少 v Fetal distress胎儿窘迫胎儿窘迫vMeconiurn aspiration syndroame（MAS)胎粪吸胎粪吸入综合征入综合征vAsphyxia neonatorum新生儿窒息新生儿窒息产科并发症英23ETIOLOGYProlonged pregnancy may relate to:vDysfunction of estrogen/progesteron(E/P)ratio雌孕激素比例失调雌孕激素比例失调：prostaglandin前列腺素前列腺素,estrogen雌激素雌激素 pro
23、gestin孕激素孕激素vcephalopelvic disproportion头盆不称头盆不称（cpd):vFetal deformity胎儿畸形胎儿畸形;vGenetic factors遗传因素遗传因素:placenta sulfatase deficiency胎盘硫酸酯酶胎盘硫酸酯酶产科并发症英24PATHOLOGYvPlacenta:normal or hypofunction功能减退功能减退 vAmniotic fluid:Oligohydramnios羊水过少羊水过少Meconium dye of amniotic fluid羊水粪染羊水粪染vFetus:Fetal macroso
24、mia巨大胎儿巨大胎儿Fetal dysmaturity胎儿成熟障碍胎儿成熟障碍Small-for-date infant小样儿小样儿产科并发症英25Diagnosis:1.Confirmation of gestational age:by referring to records of:vMecial history:LMP,the exact time of conception,ovulate time,et al;vClinical expression:early pregnancy reaction,quickening time,gynecological examinatio
25、n in first trimester,et al;vLaboratory tests:ultrasound:examination,and clinical parameters of early pregnancy(e.g,hCG)产科并发症英262.Judgment of the placental function:vFetal movement count胎动计数胎动计数:vFetal electrical monitor胎儿电子监护胎儿电子监护:vUltrasound examination超声检查超声检查:vUrine estrogen/creatinine ratio雌激素和
26、肌酐比值雌激素和肌酐比值:vAmnioscopy羊膜镜检查羊膜镜检查:产科并发症英27Treatment:Indication of terminal pregnancy:vCervical maturevFetal weigth4000g,or non reaction pattern of NST,or CST positive(doubtful)vUrine estrogen/creatinine ratio decreasedvFetal movement OligohydramniosvWith eclampsia of pre-eclampsia产科并发症英281.Induced
27、labor:Cervix is mature,bishop score7 When cervix is mature:人工破膜人工破膜vOxytocin,vPrasterone普拉睾酮普拉睾酮vProstaglandin前列腺素前列腺素：propess普贝生普贝生(Dinoprostone Suppositories地诺地诺前列酮栓前列酮栓）产科并发症英293.Cesarean section:vFailure of induced labor;vArrested progress of labor;vFetal distress;vDisposition;vLarge fetus;vAmni
28、otic fluid is abnormal;vPregnancy complications;vFetal compromise:breech presentation,et al.产科并发症英30Premature Rupture of Membranes(PROM)产科并发症英31DEFINITIONvThe fetal membrane rupture happens before labor.Premature rupture of membrane can cause preterm labor,prolapse of umbilical cord,and maternal and
29、 fetal infection.vThe less the gestational age,the worse the prognosis of the perinatal infant.产科并发症英32Essentials of Diagnosis1.History of a gush of fluid from the vagina or watery vaginal discharge;2.Demonstration of amniotic fluid leakage from the cervix.产科并发症英33ETIOLOGYvGenital tract pathogenic m
30、icroorganism upgoing infection:vAmniotic cavity pressure increase:vPressure on fetal membrane is unbalanced;vNutritional factor;vCervical incompetence;vCytokine:产科并发症英34Pathology&PathophysiologyvPreterm laborvProlapse of the umbilical cordvPlacenta abruptionvIntrauterine infectionvChorioamnionitis产科
31、并发症英35DIAGNOSIS1.SymptomvSudden gush of fluid or continued leakagevThe color and consistency of the fluid and the presence of Vernix caseosa胎脂胎脂or meconium胎粪胎粪,reduce size of the uterus,and increased prominence of the fetus to palpation.产科并发症英362.Sterile speculum examinationvPoolingPooling:the colle
32、ction of amniotic fluid in the posterior fornix;vNitrazine test:Nitrazine test:the nitrazine paper turns blue,demonstrating an alkaline PH(7.0-7.25);vFerning:Ferning:Fluid from the posterior fornix is placed on a slide and allowed to air-dry.Amniotic fluid will form a fernlike pattern of crystalliza
33、tion;产科并发症英373.Physical examination:vTo search for other signs for infection.4.Laboratory studies:vComplete blood count with differentialvUltrasound examination for fetal size and amniotic fluid indexvAmniocentesis to determine fetal lung maturity and the presence of infection产科并发症英385.Chorioamnioti
34、sThe most reliable signs of infection include:vFever:Fever:the temperature should be checked every 4 hoursvMaternal leukocytosisMaternal leukocytosis:daily leukocyte count and differential.An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infe
35、ctionvUterine tendernessUterine tenderness:check every 4 hoursvTachycardiaTachycardia:either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.产科并发症英39Influence on Mother and FetusInfluence on mother:vInfection;vPlacenta abruptionInfluence on fetus:vPremature deliveryrespiratory distress sy
36、ndrome of newborn新生儿呼吸窘迫综合症新生儿呼吸窘迫综合症vChorioamnionitis绒毛膜羊膜炎绒毛膜羊膜炎aspiration pneumonitis of newborn新生儿吸入性肺炎，新生儿吸入性肺炎，septicemia败血症败血症vprolapse of cord脐带脱垂脐带脱垂fetal distress产科并发症英40Treatment1.Expectant management:is appropriate for those whose gestational age between 28 and 35 weeks,without chorioamn
37、ionitisvGeneral management:bed rest,hydration,clean,patients temperature,heart rate,contraction,vaginal leakage,blood leukocyte count,et al.vAntibiotic:vTocolysis:vCorticosteroids:产科并发症英412.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产科并发症英423.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;产科并发症英43产科并发症英44
