Labor and PROM早产和早产胎膜早破

nullPreterm Labor and Premature Rupture of Membranes早产及早产胎膜早破 Preterm Labor and Premature Rupture of Membranes早产及早产胎膜早破 Objectives目的 Objectives目的 Define PTL and PROM and describe their significance定义早产和胎膜早破并描述其重要性 List risk factors associated with PTL and PROM描述与早产和胎膜早破相关的危险因素 Outline initial evaluation of PTL and PROM略述对早产和胎膜早破的初步评估 Describe management of PTL and PROM描述早产和胎膜早破的处理 Discuss neonatal GBS prevention strategies讨论新生儿GBS感染的预防措施Preterm Labor早产 Preterm Labor早产 Incidence发生率 11.6% of all deliveries占全部妊娠的11.6% Rate é since 1980自从1980年发生率上升 Definition定义 Uterine contractions (>3 in 30 min)宫缩（30分钟内大于3次） Presence of cervical change出现宫颈改变 Before 37 weeks gestation发生在妊娠37周前 Risk Factors for Preterm Labor早产的危险因素Risk Factors for Preterm Labor早产的危险因素Historical病史 Prior preterm birth既往早产史 Maternal age孕妇的年龄 Low SES低社会经济状况 Race种族 Known uterine anomalies已知的子宫结构异常 Trauma外伤Current Pregnancy目前妊娠 孕妇感染 Maternal infections bacteriuria菌尿症 pyelonephritis肾盂肾炎 genital tract (BV)生殖道（细菌性阴道病） pneumonia肺炎 Preterm PROM早产胎膜早破 Uterine distention子宫张力过大 twins, polyhydramnios双胎妊娠，羊水过多Prevention in High Risk Groups 高危组的预防 Prevention in High Risk Groups 高危组的预防 Educational programs, targeted social support:教育项目，有目的的社会支持： no decrease in preterm delivery rate不降低早产率 Home uterine activity monitoring家庭子宫活动监测 variable success; no consistent benefit成功率存在差异，无一致认可的优点 Assessment of cervical length (by U/S)宫颈长度的评估（超声） May be helpful in risk stratification在评估危险可能有助 Screening for & treating BV筛查和治疗细菌性阴道病 documented reduction in preterm birth证实可减少早产 Fetal Fibronectin胎儿纤维结合蛋白Fetal Fibronectin胎儿纤维结合蛋白Present in vagina before 20 wks, then absent until labor妊娠20周前在阴道内出现，随后至临产消失 Detection in vaginal secretions > 24 weeks: >24周阴道分泌物可检出 Increased risk of delivery within 7 days增加7日内分娩的危险 PPV of 79%, NPV of 83%阳性预测值79%，阴性预测值83% Higher rates of false positives if test done within 24 hours of digital exam若24h内指检，可引起较高的假阳性率 Role for screening yet to be determined该项检查的作用尚不肯定PROM胎膜早破 PROM胎膜早破 Rupture of membranes at least one hour before onset of labor至少临产1小时以前胎膜破裂 2-17% of pregnancies (average 8%)发生率 2-17%（平均8% 20-40% before 37 weeks (PPROM)妊娠37周前发生率20-40%（早产胎膜早破） Precise etiology uncertain确切病因不详 Multiple risk factors, similar to PTL与早产类似，多种危险因素 Infection often plays a role感染通常发挥一定作用Evaluation of PTL/PROM 早产/早产胎膜早破的评估 Evaluation of PTL/PROM 早产/早产胎膜早破的评估 Four questions:四个问题： 1. Is the patient in labor? 孕妇是否临产? 2. Are the membranes ruptured?胎膜是否破裂? 3. Is the fetus preterm?胎儿是否早产? 4. What risk factors are present?存在什么危险因素? Patient History患者病史 Patient History患者病史 Detailed history of “labor”详细的临产病史 History of fluid leakage液体流出的病史 Dating of pregnancy核对妊娠日期 Review history for risk factors回顾危险因素病史 History of other medical problems其他医疗问题的病史 Assessment of social history and home support评价社会史和家庭支持情况Physical Exam体格检查 Physical Exam体格检查 Maternal vitals: signs of infection?孕妇的生命体征:感染的征象? General physical exam全身体格检查 Fetal heart rate pattern胎心率类型 Contraction pattern宫缩类型 Fetal size and presentation胎儿大小和胎位 NO digital cervical exam if membrane rupture suspected若疑胎膜早破,不行宫颈指检 Sterile Speculum Exam 消毒后窥具检查 Sterile Speculum Exam 消毒后窥具检查 Assess for membrane rupture:对胎膜早破进行评价 Pooling of fluid in vagina阴道液 Nitrazine and fern test硝嗪试纸及羊齿试验 Assess cervix visually检查宫颈 Obtain cervical cultures获取宫颈培养 Obtain wet prep for vaginitis, if no ROM若无胎膜破裂，获湿片检查阴道炎 Obtain GBS culture of outer vagina and rectum获取外部阴道和直肠B组链球菌培养 Additional Tests其他检查 Additional Tests其他检查 CBC, urinalysis全血细胞记数，尿液 Evaluate for maternal infection评价孕妇感染 Amniocentesis羊水穿刺 Assess fetal lung maturity评估胎肺成熟度 Ultrasound超声 Assess amniotic fluid index评估羊水指数 Determine (+/- 3 weeks) gestational age确定胎龄（+/- 3周） Transvaginal scan for cervical length经阴道行宫颈长度测定 Cervicovaginal swab for fetal fibronectin宫颈阴道拭子胎儿纤维结合蛋白Fetal Fibronectin 胎儿纤维结合蛋白 Fetal Fibronectin 胎儿纤维结合蛋白 Present in vagina before 20 wks, then absent until labor妊娠２０周前在阴道中出现，随后消失直至临产 Detection in vaginal secretions > 24 weeks:超过24周在阴道分泌物中检测出： Increased risk of delivery within 7 days增加了7日内分娩的危险 PPV of 79%, NPV of 83%阳性预测值为79%，阴性预测值为83% Higher rates of false positives if test done within 24 hours of digital exam如果在阴道指检２４小时内进行检测，假阳性率较高 Role for screening yet to be determined该项筛查的作用尚未确定 Initial Management初步处理 Initial Management初步处理 Consider:考虑： Condition of the fetus胎儿情况 Imminence of delivery紧急分娩 Availability of local resources局部资源的有效性 Availability of safe transport to referral center 安全转运至转诊中心的可行性 Maternal transport <32-34 weeks decreases neonatal mortality by 60%妊娠32至34周前将孕妇转诊，新生儿病率可降低60% Management of Preterm Labor 早产的处理 Management of Preterm Labor 早产的处理 Traditional first steps传统的初步处理步骤 Bed rest卧床休息 Hydration补液 Treat underlying conditions对引起早产的情况进行治疗 Neither proven beneficial 两者均未证实有效Corticosteroids in PTL 早产的皮质类固醇治疗Corticosteroids in PTL 早产的皮质类固醇治疗Effectively reduce RDS, IVH, and infant mortality at 24-34 weeks gestation妊娠24至34周，皮质类固醇可有效预防肺透明膜病，脑室内出血并减少婴儿死亡率 Criteria: 24-34 weeks gestation +：妊娠24至34周+ no contraindication to 24-48h delay in delivery对于延迟分娩24至48小时无禁忌 no contraindication to steroids对类固醇无禁忌 Betamethasone 12 mg IM, 2 doses q24h倍他米松：12毫克肌注2次，间隔24小时 Dexamethasone 6 mg IM, 4 doses q12h地塞米松：6毫克肌注4次，间隔12小时 Tocolytics宫缩抑制治疗Tocolytics宫缩抑制治疗 No evidence to support long-term suppression of labor缺乏能长期抑制临产的证据 Can be effective for 24-48 hours有效抑制宫缩24至48小时 allows time for maternal transfer or administration of steroids争取时间转运孕妇或使用皮质类激素 Candidates for Tocolysis 宫缩抑制治疗选择标准Candidates for Tocolysis 宫缩抑制治疗选择标准No contraindications to drug对药物无禁忌 No contraindications to prolonging pregnancy无延长妊娠的禁忌 Fetus currently healthy目前胎儿健康 Clear diagnosis of preterm labor明确诊断为早产 Cervix <4 cm dilatation宫颈扩张小于4cm Gestational age between 24 - 34 weeks妊娠24至34周 之间Terbutaline特布它林Terbutaline特布它林Available for IV, SQ, or PO use可静脉、皮下注射或口服 IV: start at 0.01 mg/min静脉：以0.01毫克/分钟的速率开始 Increase by 0.005 mg/min q10min每10分钟以0.005毫克/分钟的速率增加 Maximum dose 0.025 mg/min最大剂量0.025毫克/分钟 SQ: 0.25 mg single dose皮下注射：单次皮下注射0.25毫克 May repeat every 1 to 4 hours可以每1至4小时重复 PO: 2.5 to 5 mg every 3-4 hours口服：每3至4小时口服2.5至5毫克 No evidence to support oral dosing无证据支持口服剂量 Ritodrine羟苄羟麻黄碱 Ritodrine羟苄羟麻黄碱 Only FDA approved tocolytic是唯一经FDA批准的宫缩抑制剂 Only available for IV use仅可以静脉形式使用的制剂 Begin infusion at 0.1 mg per minute开始治疗时，以0.1毫克/分钟输入 Increase by 0.05 mg/min q10min until labor suppressed每10分钟增加0.05毫克/分钟直至宫缩被抑制 Max dose 0.35 mg/min最大剂量0.35毫克/分钟 May titrate downward once labor stopped宫缩停止后，可降低滴速 Duration: 12-24 hours维持时间：12至14小时 Beta-Agonist Side Effects β激动剂的副作用 Beta-Agonist Side Effects β激动剂的副作用 Maternal孕妇 Palpitations, chest pain, dyspnea心悸、胸痛、呼吸困难 Anxiety, headaches, tremor, nausea精神紧张、头痛、震颤、恶心 Pulmonary edema - High doses of drug and overuse of IV fluid肺水肿—药物剂量过大和静脉补液量过多 Minimize by using lowest effective dose减少用以抑制宫缩的最低有效剂量 Fetal胎儿 Fetal tachycardia胎儿心动过速 Magnesium Sulfate硫酸镁 Magnesium Sulfate硫酸镁 IV bolus of 4-6 grams followed by 1-4 gram per hour infusion予以4～6克负荷量，然后每小时输入1～4克维持 Therapeutic level = 5.5-7.5 mg/dl治疗剂量=5.5～7.5mg/dl Oral forms not effective口服制剂无效 Duration of therapy guidedby response根据反应指导治疗时间 Unnecessary to wean不必要时停止 Magnesium side Effects 硫酸镁的副作用 Magnesium side Effects 硫酸镁的副作用 Maternal孕妇 Flushing, warmth, sweating, headache, nausea, palpitations出汗、发热、面色潮红、恶心、呕吐、头痛和心悸 Respiratory arrest with toxic levels (>15 mg/dl)中毒水平会造成呼吸骤停（大于15mg/dl Loss of patellar reflexes is early sign (>8 mg/dl)膝腱反射消失是早期体征（大于8mg/dl） Antidote = Calcium gluconate拮抗剂=葡萄糖酸钙 One gram IV over 3 minutes葡萄糖酸钙1g静脉注射，>3分钟 No significant intrauterine fetal effects对宫内胎儿无明显不良影响 Empiric Use of Antibiotics 经验性抗生素治疗 Empiric Use of Antibiotics 经验性抗生素治疗 In PTL with intact membranes:早产临产胎膜完整的孕妇 Conflicting results in delaying preterm birth对于延迟早产，结论存在争议 No short or long-term benefits demonstrated已证实无短期或长期益处Premature ROM早产胎膜早破 Premature ROM早产胎膜早破 Management based on gestational age, estimated fetal size, and lung maturity根据孕周、估计的胎儿大小和胎肺成熟度处理 Fetus >36 weeks or >2500 g胎儿大于36周或体重大于2500g Manage as term PROM按足月胎膜早破处理 Fetus <32 weeks or <2500 g胎儿小于32周或体重体重小于2500g Manage as PPROM按早产胎膜早破处理 Fetus 32-36 weeks: clinical judgement胎儿32—36周：临床判断 Consider amniocentesis for lung maturity考虑行羊水穿刺行胎肺成熟度检查 PPROM早产胎膜早破 PPROM早产胎膜早破 Delivery likely within 12-24 hours可能于12～24小时内分娩 Consult with perinatologist请围产医学家会诊 Plan site of delivery计划分娩的地点 Tocolytics and/or corticosteroids宫缩抑制剂和/或皮质类固醇 Antibiotics for Group B streptococcus针对B组链球菌的抗生素治疗 Avoid digital cervical exams避免宫颈指检PPROM早产胎膜早破 PPROM早产胎膜早破 Expectant management if delivery not imminent:如果分娩并并非即将发生，采用期待疗法： No digital exam unless labor begins除非临产开始，否则不应行指检 Follow for signs of infection随诊感染的征象 Corticosteroids if fetus 24-34 weeks如果胎儿24至34周，使用皮质类固醇 Antibiotics controversial in prolonging latency采用抗生素延缓早产的潜伏期尚存在争议Term PROM足月胎膜早破 Term PROM足月胎膜早破 Expectant management vs. induction?期待疗法还是引产？ 90% spontaneous labor within 48 hrs. 90%48小时内自然临产 Induce if signs of infection如果出现感染征象则引产 Prostaglandins for unfavorable cervix若宫颈不成熟，予以前列腺素 Early oxytocin decreases infection rate without increasing cesarean delivery rate尽早使用催产素引产以减少感染，但不增加剖宫产率 Delivery of the Premature Fetus 早产儿的分娩Delivery of the Premature Fetus 早产儿的分娩Limit maternal narcotics when possible尽可能限制孕妇使用麻醉药镇痛药 Anticipate malpresentations预先发现先露异常 Anticipate delivery at <10 cm dilatation宫颈扩张少于10厘米时即可分娩 Elective cesarean delivery not supported by evidence据证不支持选择性剖宫产 Alert neonatal care team of impending delivery紧急分娩时，需有机敏的新生儿治疗小组 Group B Streptococcus B组链球菌 Group B Streptococcus B组链球菌 Intrapartum antibiotics lower rate of early-onset (<7 days) neonatal sepsis产间抗生素治疗可降低早期出现的（小于7天）新生儿感染的发生率 CDC, AAP, and ACOG differ on patient selection疾病控制中心、美国儿科学会和美国妇产科协会在患者的选择上不同 Screening approach - culture all patients at 35-37 weeks & treat positives筛查：妊娠35～37周所有患者的培养和治疗阳性患者 Risk factor approach - treat only if risk factors present or if cultures unavailable危险因素途径：如果危险因素存在或如果不能培养，只能治疗 GBS Risk Factors B组链球菌的危险因素 GBS Risk Factors B组链球菌的危险因素 Prenatal产前 Previous GBS infected infant既往出现B组链球菌感染胎儿 GBS bacteriuria during current pregnancy目前妊娠期间发现B组链球菌尿 Intrapartum产间 Maternal temp more than 38 C (100.4 F)孕妇体温超过摄氏38度（华氏100.4度） Gestational age < 37 weeks妊娠少于37周 Ruptured membranes > 18 hours破膜时间超过18小时Management Based on GBS Screening Cultures 根据B组链球菌筛查培养进行处理 Management Based on GBS Screening Cultures 根据B组链球菌筛查培养进行处理 Anogenital culture on all patients at 35-37 weeks (collected without speculum)对所有孕35-37周孕妇作肛门生殖道细菌培养(收集时不用窥具) Offer antibiotics to all with positive culture when labor begins临产时,对所有培养阳性的孕妇使用抗生素 Those with prior GBS infant or GBS bacteriuria should be treated既往出现B组链球菌感染胎儿或B组链球菌尿孕妇，应进行治疗 Management Based GBS on Risk Factors 根据B组链球菌危险因素进行处理 Management Based GBS on Risk Factors 根据B组链球菌危险因素进行处理 Intrapartum antibiotics offered to all women who develop risk factor during labor对所有临产期间出现危险因素的孕妇进行抗生素治疗 No routine antenatal cultures不行产前常规培养 Treat all with previous GBS infant or GBS bacteriuria during this pregnancy本次妊娠期间对所有既往B组链球菌感染胎儿或B组链球菌尿孕妇，应进行治疗 GBS Prophylaxis B组链球菌的预防性治疗 GBS Prophylaxis B组链球菌的预防性治疗 Preferred agent首选药物 Penicillin G - 5million units IV, then 2.5 million units IV q4h until delivery青霉素G 5百万单位静脉注射，此后每四小时静脉注射青霉素250万单位直到分娩 Alternate可选 Ampicillin 2 g initially, then 1 gm IV q4h初始时2g氨苄青霉素，然后每4小时予以1g If penicillin allergic若对青霉素过敏 Clindamycin 900 mg IV q8h林可霉素900毫克每8小时静脉注射一次 Erythromycin 500 mg IV q6h红霉素500毫克每6小时静脉注射一次 Newborn Management新生儿处理 Newborn Management新生儿处理 Symptoms of sepsis or <35 weeks出现症状或孕周少于35周 Full sepsis evaluation and antibiotics行全面感染评估和抗生素治疗 Baby asymptomatic and >35 weeks新生儿无症状和大于35周 Intrapartum antibiotics < 4 hours:产间接受预防性治疗小于4小时: Limited sepsis evaluation (CBC, blood culture) and close observation for 48 hours有限的评估感染方法（全血细胞计数, 血培养），并严密观察病情变化48小时 Intrapartum antibiotics > 4 hours:产间抗生素治疗超过4小时: Observation for at least 48 hours观察至少48小时 Summary Summary总结 Preterm delivery rates are increasing早产率正在增加 Risk factors predict less than 50% of cases少于50%病例危险因素的预测 Initial evaluation directed at possible causes初步评估直接针对可能的病因 Tocolytics can prolong pregnancy for short time, allowing time for transfer or steroids宫缩抑制剂可短时间延长妊娠,争取时间转运孕妇或使用皮质类固醇 Management of PTL or PROM varies based on gestational age, availability of tertiary care早产或胎膜早破应根据不同的孕周及三级保健中心的可行性进行处理 ALSO课程网址ALSO课程网址 中文 http://also.china-obgyn.net 英文 http://www.aafp.org/also.xml