1、产科并发症专题知产科并发症专题知识讲座识讲座vPremature deliveryPremature deliveryvProlonged pregnancyProlonged pregnancyvPremature Rupture of Premature Rupture of MembranesMembranes(PROM)(PROM)Content产科并发症专题知识讲座2产科并发症专题知识讲座3 Preterm Labor:Preterm Labor:Labor occurs after 28 weeks but before 37 Labor occurs after 28 weeks
2、 but before 37 weeks(ie.196258days)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 pro
3、gnosis of the premature infant is The prognosis of the premature infant is correlated with its gestational age,weight.correlated with its gestational age,weight.Definition:产科并发症专题知识讲座4Premature infantMature infant产科并发症专题知识讲座5Etiology:1.Obstetric complications 产科并发症产科并发症2.Medical complications 内科并发症内
4、科并发症3.Surgical complications 外科并发症外科并发症4.Genital tract anomalies 生殖道畸形生殖道畸形产科并发症专题知识讲座61.Obstetric complications:vSevere hypertensive state or pregnancyvAnatomic disorder of the placenta(abruptio placentae,placenta previa)vPremature rupture of membranes vPolyhydramnios or oligohydramniosvMultiple pr
5、egnancyvPrevious laceration（裂伤）（裂伤）of cervix or uterus产科并发症专题知识讲座72.Medical complications: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 dr
6、ug addictionvSevere anemia产科并发症专题知识讲座83.Surgical complications:vConization of cervix宫颈锥切术宫颈锥切术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专题知识
7、讲座9Clinical Finding&Diagnosis1.Symptom and SignvUterine contractionsmore than 2 in one-half 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 dila
8、tated(at least 2 cm);产科并发症专题知识讲座102.Laboratory StudiesvCompletely blood count with differentialvCervix 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（Ffn
9、50ng/ml):result is sensitive at predicting preterm birth.分泌物分泌物产科并发症专题知识讲座113.Accessory examination:vUltrasound 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
10、length or vAmniocentesis to ascertain fetal lung maturity,the amnio fluid羊水羊水 be tested for lecithin卵磷脂卵磷脂/sphingomyelin鞘磷脂鞘磷脂(L/S)ratio产科并发症专题知识讲座12 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
11、 to prolong the gestational age.If premature delivery is unavoidable,something must be done to elevate the survival rate of the premature infant.Treatment:产科并发症专题知识讲座131.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
12、 mg IM 1/12 hr 4 doses3.Antibiotics:no benefit in delaying preterm birth.4.Tocolysis：产科并发症专题知识讲座14 4.Tocolysis Tocolytic 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
13、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 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专题知识讲座15 Some cases in which preterm labor should not be suppressed.Maternal factors:Feta
14、l factors:Maternal factors:vSevere hypertensive diseasevPulmonary or cardiac diseasevAdvanced cervical dilationvMaternal hemorrhage产科并发症专题知识讲座16Fetal factors:vFetal death or lethal anomalyvFetal distressvIntrauterine infectionvTherapy adversely affecting the fetusvEstimated fetal weight2500gvErythro
15、blastosis fetalisvSevere intrauterine growth retardation产科并发症专题知识讲座17Manner 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 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 产科并发症专题知识讲座18Case Fil
16、e 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 and delivery area weeks gestation present to the labor and delivery area complaining of intermitten abdominal pain.She denies complaining of intermitten abdominal p
17、ain.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.She has been eating and drinking normally.On examination,the fetal heart and drinking normally.On
18、 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 reactive pattern.Uterine contraction are occuring every 3 to 5 min.On pelvic examination,her cervix is 1 ev
19、ery 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 station.产科并发症专题知识讲座19 vWhat is the most likely diagnosis?Preterm labor.vWhat is your next step in management?Tocolysis,try
20、to identify a cause of the preterm labor,antenatal steroids,and antibiotics.Questions产科并发症专题知识讲座20PROLONGED PREGNANCY(POSTTERM PREGNANCY)产科并发症专题知识讲座21General consideration:vDefinition:Prolonged pregnancy is defined as pregnancy that has reached 42 weeks of completed gestation from the first day of t
21、he LMP or 40 weeks gestation from the time of conception.产科并发症专题知识讲座22 The maternal risk:Related to extraordinary fetal size:vDysfunctional labor功能障碍性分娩功能障碍性分娩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专题知识讲座23Effect to
22、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(shoulder 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
23、生儿窒息新生儿窒息产科并发症专题知识讲座24ETIOLOGYProlonged 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 progestin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
24、胎盘硫酸酯酶胎盘硫酸酯酶产科并发症专题知识讲座25PATHOLOGYvPlacenta: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 macrosomia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专题知识讲座26Diagnosis:1.Confirmation of gestational age:by r
25、eferring to records of:vMecial history:LMP,the exact time of conception,ovulate time,et al;vClinical expression:early pregnancy reaction,quickening time,gynecological examination in first trimester,et al;vLaboratory tests:ultrasound:examination,and clinical parameters of early pregnancy(e.g,hCG)产科并发
26、症专题知识讲座272.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:产科并发症专题知识讲座28Treatment:Indication of terminal pregnancy:vCervical maturevFetal weig
27、th4000g,or non reaction pattern of NST,or CST positive(doubtful)vUrine estrogen/creatinine ratio decreasedvFetal movement OligohydramniosvWith eclampsia of pre-eclampsia产科并发症专题知识讲座291.Induced 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vProstagland
28、in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）产科并发症专题知识讲座30Premature Rupture of Membranes(PROM)产科并发症专题知识讲座32DEFINITIONvThe fetal membrane rupture happens before labor.Premature rupture of membrane can cause preterm labor,prolapse of umbilical cord,and maternal and fetal infection.v
29、The less the gestational age,the worse the prognosis of the perinatal infant.产科并发症专题知识讲座33Essentials of Diagnosis1.History of a gush of fluid from the vagina or watery vaginal discharge;2.Demonstration of amniotic fluid leakage from the cervix.产科并发症专题知识讲座34ETIOLOGYvGenital tract pathogenic microorga
30、nism upgoing infection:vAmniotic cavity pressure increase:vPressure on fetal membrane is unbalanced;vNutritional factor;vCervical incompetence;vCytokine:产科并发症专题知识讲座35Pathology&PathophysiologyvPreterm laborvProlapse of the umbilical cordvPlacenta abruptionvIntrauterine infectionvChorioamnionitis产科并发症
31、专题知识讲座36DIAGNOSIS1.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.产科并发症专题知识讲座372.Sterile speculum examinationvPoolingPooling:th
32、e collection 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 crys
33、tallization;产科并发症专题知识讲座383.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产科并发症专题知识讲座
34、395.ChorioamniotisThe 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 int
35、ra-amniotice infectionvUterine tendernessUterine tenderness:check every 4 hoursvTachycardiaTachycardia:either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.产科并发症专题知识讲座40Influence on Mother and FetusInfluence on mother:vInfection;vPlacenta abruptionInfluence on fetus:vPremature deliveryr
36、espiratory distress syndrome 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产科并发症专题知识讲座41Treatment1.Expectant management:is appropriate for those whose gestational age between 28 and
37、 35 weeks,without chorioamnionitisvGeneral management:bed rest,hydration,clean,patients temperature,heart rate,contraction,vaginal leakage,blood leukocyte count,et al.vAntibiotic:vTocolysis:vCorticosteroids:产科并发症专题知识讲座422.Chorioamnionitis (1)delivery:If chorioamnionitis is present in the patient wit
38、h PROM,the patient should be actively delivered regardless of gestational age.(2)Broad-spectrum antibiotics产科并发症专题知识讲座433.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;产科并发症专题知识讲座44产科并发症专题知识讲座45
