LATER PREGNANCY COMPLICATIONS,Premature deliveryProlonged pregnancyPremature Rupture of Membranes( PROM),Content,PRETERM LABOR早 產,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.,Definition:,Etiology:,1.Obstetric complications 產科并發癥2.Medical complications 內科并發癥3.Surgical complications 外科并發癥4.Genital tract anomalies 生殖道畸形,1.Obstetric complications: Severe hypertensive state or pregnancyAnatomic disorder of the placenta( abruptio placentae, placenta previa)Premature rupture of membranes Polyhydramnios or oligohydramniosMultiple pregnancyPrevious laceration（裂傷） of cervix or uterus,2.Medical complications:Pulmonary or systemic hypertensionRenal diseaseHeart diseaseInfection: genital tract infection, urinary tract infection, pyelonephritis腎盂腎炎, acute systemic infectionHeavy cigarette smokingAlcoholism or drug addictionSevere anemia,3.Surgical complications:Conization of cervix宮頸錐切術Previous incision in uterus or cervix ( cesarean delivery剖宮產術)4.Genital tract anomaliesBicornuate雙角, subseptate縱隔, or unicormuate單角 uterusCongenital cervical incompetency先天性宮頸閉合不全,Clinical Finding & Diagnosis,1.Symptom and SignUterine contractionsmore than 2 in one-half hour;Vaginal bleeding-bloody mucous vaginal discharge or “bloody show”;Dilatation擴張 and effacement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);,2. Laboratory StudiesCompletely blood count with differentialCervix discharge cultures ：should be sent for gonorrhea淋病 and chlamydia衣原體. Fetal fibronectin纖連蛋白（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,3. Accessory examination:Ultrasound examination for fetal size, position, placenta location，and cervical length. Cervical length30nm: prognosticating premature delivery. Infundibulum漏斗 length of cervical internal os25% Cervical length or Amniocentesis to ascertain fetal lung maturity, the amnio fluid羊水 be tested for lecithin卵磷脂/ sphingomyelin鞘磷脂 (L/S) ratio,principle: If the fetus is alive, with no PROM 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 survival rate of the premature infant.,Treatment:,1. Bed rest：2. Corticosteroids: to accelerate fetal lung maturity Betamethason 倍他米松: 12mg IM 1/24 hr 2 doses Dexamethasone地塞米松: 6 mg IM 1/12 hr 4 doses3. Antibiotics: no benefit in delaying preterm birth.4. Tocolysis：,4.Tocolysis Tocolytic therapy should be considered in the patient with cervical dilation less than 3 cm.(1) Beta-Mimetic Adrenergic Agents腎上腺受體激動劑 Ritodrine利托君， Terbutaline特布他林， salbutamol沙丁胺醇：(2) Magnesium sulfate硫酸鎂: first line agent for tocolysis;(3) Calcium Channel Blockers鈣離子通道拮抗劑; nifedipine硝苯地平(4) Prostaglandin Synthetase Inhibitors前列腺素合成抑制劑 indomethacin吲哚美辛,Some cases in which preterm labor should not be suppressed. Maternal factors: Fetal factors:Maternal factors:Severe hypertensive diseasePulmonary or cardiac diseaseAdvanced cervical dilationMaternal hemorrhage,Fetal factors:Fetal death or lethal anomalyFetal distressIntrauterine infectionTherapy adversely affecting the fetusEstimated fetal weight2500gErythroblastosis fetalisSevere intrauterine growth retardation,Manner of labor 1. Vaginal delivery: perineum section會陰切開術 2. Cesarean section: abnormal fetal position胎位異常 fetal distress胎兒窘迫 maternal hemorrhage孕婦出血 severe maternal complications孕婦嚴重的并發癥,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.,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.,Questions,PROLONGED PREGNANCY(POSTTERM PREGNANCY),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.,The maternal risk: Related to extraordinary fetal size:Dysfunctional labor功能障礙性分娩Arrested progress of labor 產程停止 Fetopelvic disproportion胎盆不稱 Cesarean section 剖宮產 Labor trauma 分娩損傷,Effect to fetus: Impaired nutritional supply ( weight loss, reduced subcutaneous tissue, scaling脫皮, parchmentlike skin羊皮紙樣皮膚)-dysmaturity 成熟障礙 Birth injury ( shoulder dystocia肩難產) Oligohydramnios羊水過少 Fetal distress胎兒窘迫Meconiurn aspiration syndroame （MAS)胎糞吸入綜合征Asphyxia neonatorum新生兒窒息,ETIOLOGY,Prolonged pregnancy may relate to:Dysfunction of estrogen/progesteron (E/P) ratio雌孕激素比例失調：prostaglandin前列腺素, estrogen雌激素 progestin孕激素cephalopelvic disproportion頭盆不稱（cpd): Fetal deformity胎兒畸形;Genetic factors遺傳因素:placenta sulfatase deficiency胎盤硫酸酯酶,PATHOLOGY,Placenta: normal or hypofunction功能減退 Amniotic fluid: Oligohydramnios羊水過少Meconium dye of amniotic fluid羊水糞染Fetus:Fetal macrosomia巨大胎兒Fetal dysmaturity胎兒成熟障礙Small-for-date infant小樣兒,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 ),2. Judgment of the placental function:Fetal movement count胎動計數:Fetal electrical monitor胎兒電子監護:Ultrasound examination超聲檢查:Urine estrogen/creatinine ratio雌激素和肌酐比值 :Amnioscopy羊膜鏡檢查:,Treatment:,Indication of terminal pregnancy:Cervical matureFetal weigth4000g, or non reaction pattern of NST, or CST positive (doubtful)Urine estrogen/creatinine ratio decreasedFetal movement OligohydramniosWith eclampsia of pre-eclampsia,1. Induced labor: Cervix is mature, bishop score7 When cervix is mature: 人工破膜Oxytocin, Prasterone普拉睪酮Prostaglandin前列腺素： propess普貝生(Dinoprostone Suppositories地諾前列酮栓）,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.,Premature Rupture of Membranes( PROM),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.,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.,ETIOLOGY,Genital tract pathogenic microorganism upgoing infection:Amniotic cavity pressure increase:Pressure on fetal membrane is unbalanced;Nutritional factor;Cervical incompetence;Cytokine:,Pathology & Pathophysiology,Preterm laborProlapse of the umbilical cordPlacenta abruptionIntrauterine infectionChorioamnionitis,DIAGNOSIS,1. SymptomSudden gush of fluid or continued leakageThe color and consistency of the fluid and the presence of Vernix caseosa胎脂or meconium胎糞, reduce size of the uterus, and increased prominence of the fetus to palpation.,2. Sterile speculum examinationPooling: 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,3. Physical examination:To search for other signs for infection.4. Laboratory studies:Complete blood count with differentialUltrasound examination for fetal size and amniotic fluid indexAmniocentesis to determine fetal lung maturity and the presence of infection,5. ChorioamniotisThe most reliable signs of infection include:Fever: the temperature should be checked every 4 hoursMaternal leukocytosis: daily leukocyte count and differential. An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infectionUterine tenderness: check every 4 hoursTachycardia: either maternal pulse 100bpm or fetal heart 160 bpm is sus