英文胎膜早破、胎窘、流产、宫外孕（２０１1，八年制））

nullTopics todayTopics today Premature rupture of membranes Fetal distress Ectopic pregnancy AbortionZhao Aimin MD.PhD.PREMATURE RUPTURE OF MEMBRANES PREMATURE RUPTURE OF MEMBRANES (PROM)DefinitionDefinition PROM is defined as the rupture of the chorioamniotic membrane before the onset of labor IncidenceIncidencePROM occurs in about 10%~15% of all delivery PROM is associated with 10% of term pregnancyCause of PROMCause of PROM The cause of PROM is not clearly undersdood, perhaps associated with the follow factors: Trauma (abdominal striked intensely) Sexual intercourse(particularly in the late gestational weeks) lax of internal os of uterine nullVaginal infection due to bacteria、virus、TOXO、CMV、HPV and HSV,et al STDs sexually transmitted diseases play an important role in the cause of PROM, because such infections are more commonly found in women with PROM than in those without PROM increased of intra-uterine pressure (such as multiple pregnancy and hydraminios) Abnormalities in presentation and position Smoking the risk of PROM is at least doubled in women who smoke during pregnancy Other factors for PROM include the follow Prior PROM A short cervical length Prior preterm delivery Bleeding in early pregancy Clinical manifestation and diagnosisClinical manifestation and diagnosis Fluid passing through the vagina suddenly, and then small amounts of fluid flow through the vagina intermitently, particularly when the increased of abdorminal pressure (cough,sneeze,et al) nullIntermittent urinary leakage is common during pregnancy, especially near term Increased vaginal secretions in pregnancy Perineal moisture Increased cervical discharge Urinary incontinence Vesicovaginal fistula May be mistaken for the fluid Expermental test Expermental test The Nitrazine test uses pH to distinguish amniotic fluid from urine and vaginal secretions, the paper turns dark blue in response to the amniotic fluid. Amniotic fluid is quite alkaline having a pH above 7.0, but vaginal secretions in preganancy usually have pH values of less 6.0 The “fern” testThe “fern” testThe “fern” test is also used to distinguish amniotic fluid from other fluids,and this test is considered more indicative of the rupture of membranes than the Nitrazine test. The amniotic fluid does fern The other fluid does not fern Risk of PROMRisk of PROMThe primary risk of PROM is preterm labor, about 75% patients of PROM is preterm PROM(rupture of menbranes before 37 weeks’ gestational age) Intrauterine infection (chorioamnionitis,30%-50% of cases) Puerperal infection Fetal and Neonatal complicationsFetal and Neonatal complicationsFetal and neonatal pneumonia、sepsis Neonatal respiratory distress syndrone Neurologic dysfunction Intracranial hemorrhage Prolapse of umbilical cord Abruptio placentaEvaluationEvaluation Patients with PROM shoud be hopitalized for evaluation and further management. The factors to be considered in the management of patients with PROM include The gestational age (LMP ultrasound and uterus fundal height measurement) The presence of uterine contractions (abdominal examination) nullThe amount of amniotic fluid (ultrasound) Fetal heart rate (FHR) (FHR monitor) Fetal maturity (L/S or PG) The likelihood of chorioamnionitis (white blood cell count) The likelihood of prolapse of umbilical cord Management Management Patients with PROM shoud be hopitalized and pay attention to the change of FHR carefully If PROM occurs at term (37 weeks’ gestational age or more), awaiting the onset of spontaneous labor for 12-24h shoud be considered, because spontaneous labor will ensue in 90% of patients within 24 hours If the time from PROM to the onset of labor exceeds 24h, induction of labor should be considered by oxytocin nullIf the evaluation suggests intrauterine infection or chorioamnionitis,antibiotic and delivery are indicated and the antibiotic prescribed should have a broad spectrum of coverage If the infant is a preterm breech, and the onset of PROM occurs after 30 weeks’ of gestational, possibly by ceasarean deliverynullIf the gestational age is less 30 weeks’,vaginal deliverly should be chosen nullIf the fetus is significantly preterm and the absence of infection, expectant management is generally chosen patients must be assessed carefully Uterine tenderness daily Electronic fetal monitoring used frequently Fetal movement monitoring by the mother Frequent ultrasound assessment helps to determine amniotic fluid nullFrequently WBC counts,usually daily for several days Antibiotic should be used and antibiotic therapy may prolong the latency period after preterm PROM and improve the perinatal outcomenull To enhance fetal pulmonary matrurity in patients with preterm PROM, corticosteroid therapy(such as betamethasone and dexamethasone) is generally recommended in patients whose gestational age is 34 weeks’ or lessnullFetal distress What is fetal distress? Fetal distress is defined as depletion of oxygen and accumulation of carbon dioxide,leading to a state of “hypoxia and acidosis “during intrauterine life nullEtiology Maternal factors Microvascular ischaemia(PIH) Low oxygen carried by RBC(severe anemia) Acute bleeding(placenta previa, placental abruption) Shock and acute infection obstructed of Utero-placental blood flow nullPlacenta、umbilical factors Obstructed of umbilical blood flow Dysfunction of placenta Fetal factors Malformations of cardiovascular system Intrauterine infectionnullPothogenesis Hypoxia、accumulation of carbon dioxide →leading to acidosis →pH<7.20 FHR be excited →depressed Hyperfunction of intestines wriggle →meconium liquor(amniotic fluid) →aspirated into the lung →fetal or neonatal pneumonia Chronic fetal distress →IUGR(intrauterine groth retardation) nullFHR baseline Bpm 120~160 beats/min FHR Variabilitynullacceleration decelerationnull early deceleration,EDVariable deceleration，VD） Variable deceleration，VD） Late deceleration，VD Late deceleration，VD nullNST(FAT,fetal acceleration test) Non-stress test OCT Oxytocin challenge test CST Contraction stress testnullClinical manifestation Acute fetal distress FHR FHR>160 beats/min( tachycardia) <120 beats/min(bradycardia) Placenta dysfunction → Repeated LD Umbilical factors →VDnullMeconium staining of the amniotic fluid meconium staining divided into gradeI、II、III MAS (meconium aspiration syndrome) causes,or contributes to ,neonatal death in about 10% of babies who aspiratenullFetal movement frequently →decrease and weaken Acidosis FBS(fetal blood sample) pH<7.20 PO2<10mmHg(15~30mmHg) CO2>60mmHg(35~55mmHg)nullChronic fetal distress Determination of placental function FHR monitoring frequently Take care of movement Measurement volume of amniotic fluid by ultrasound amnioscopynullManagement Remove the induced factors actively Correct the acidosis Terminate the pregnancy as soon as possiblenull Indications of termination pregnancy FHR>160 beats/min or <120 beats/min with meconium staining(II~III) Meconium staining grade III with amniotic fluid volume<2cm FHR<100 beats/min continue Repeated LD and severe VD Baseline variability disappear with LD FBS pH<7.20nullEctopic pregnancy Definition Implantation outside of the uterine cavity is termed ectopic pregnancy It is a condition that significantly jeopardizes the mother because catastrophic bleeding may occur when the implanting pregnancy erodes blood vessels or ruptures of the tubal wallnullImplant locations Tubal 95% (80% ampullary portion) Ovarian <1% Abdominal 1-2% Cervical 0.15% Cornual 2% nullEtiology Salpingitis have 6-fold increase the risk of ectopic pregnancy Operation of tubal IUD(intrauterine device) Dysfunction of tubal Orther: endometriosis nullOutcomes of ectopic pregnancy Tubal abortion 8-12 Weeks ampullary portion Rupture of tubal pregnancy 5 weeks isthmic portion Tubal abortion with subsequent implantation on an intraperitoneal structure for example liver pregnancynullClinical manifestation of ectopic pregnancy Amenorrhea 70-80% 6-8 weeks Abdominal and pelvic pain the most common symptom,which is present in nealy all patients. Pain is a result of distented of tubal and irritation of peritoneum by blood Irregular vaginal bleeding results from the sloughing of the decidua Shock result from amount of blood loss Abdominal massnullPhysical findings in tubal pregnancy General findings: Anemic or pale face pulse increased BP decreased T< 38 degreenullAbdominal examination distention and tenderness with or without rebound Decreased bowel sound Shifting dullness positive massnullPelvic examination Slightly open cervix with bleeding Cervical motion tenderness Adnexal tenderness Adnexal mass The uterus size may be normal or enlargednullDiagnostic procedures Typical cases can be determined easy Early ectopic pregnancy or unrupture type difficulty It is nessesary to need assistant examinationnullHCG test 80-100% positive Urinary HCG level Blood HCG level If HCG negative,ectopic pregnancy does not be rule out Type B Utrasound Culdocentesis Aid in the identification of peritoneum bleeding Positive (noncloting blood) ectopic pregnancy may be confirmed Negative ectopic pregnancy does not be depletion nullLaproscopy It is a direct visualization and accurte method to diagnosis ectopic pregnancy Even laproscopy,however,carries 2-5% misdiagnosis rate, because an extremely early tubal pregnancy gestation may not be identified nullPothology of endometriun Curettage of the uterine cavity can also help rule out ectopic pregnancy Identification of chorionic villi in curetting may identify an intrauterine pregnancynullDifferential diagnosis Abortion Acute salpingitis Acute appendicitis Rupture of corpus luteum Torsion of ovarian cystnullTreatment of ectopic pregnancy Surgical treatment Salpingectomy Conservative operation Salpinggostomy Segmantal resection and tubal reanatomosisnullNonsurgical therapy Chinese traditional medicine Chemical therapy Drug:MTX Indication The diameter of the mass <3cm Unrupture Not significantly bleeding HCG level <2000U/LAbortionAbortionnullDefinition Abortion is the termination of a pregnancy before 28 weeks from the first day of the last menstrual period and the fetus weight <1000gnullClassification Early abortion <12W Late abortion 12-28W Spontaneous abortion Artificial abortionnullEtiology Genetic factors Maternal factors Infection systemic factors heart disease sever anemia endocrine Reproductive tract abnormality Immunologic factors Enviromental factors Toxin Radiation smoking aloholnullPathology 1.Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation.null2. The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.null3. Expulsion complete, The decidua is shed during the next few days in the lochial flow.Clinical manifestationClinical manifestationHaemorrhage is usually the first sign and may be significantly if placental separation is incomplete. Pain is usually intermittent, ‘like a small labrur’. It ceases when the abortion is complete.nullThreatened abortionLow abdominal Pain company vaginal bleeding Cervix is closed unrupture of membrane Embryo survivenullInevitable abortionBleeding increased Pain development Ruputure of membrane Cevix dilation Embryo tissue incarcerated in the cervixnullComplete abortion Uterine contractions are felt, the cervix dilates and blood loss continues. The fetus and placenta are expelled complete, the uterus contracts and bleeding stops. No further treatment is needed.nullIncomplete abortion In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled. The placenta remains partly attached and bleeding continues. This abortion must be completed by surgical methods.nullMissed abortion Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as more than two menstrual cycles Recurrent abortion It is a term used when a patient has had two or more consecutive spontaneous abortions Septic abortionnull Treatment of abortion Incomplete abortion Remove the embryo and placenta as soon as possible Negative pressure suction Embryulcia Missed abortion Notice blood clot function prevent DIC Septic abortion Broad-spectrum antibiotics nullRemoval of placental tissue with ovum forceps.null