產(chǎn)科并發(fā)癥英文實(shí)用教案

1、Premature deliveryProlonged pregnancyPremature Rupture of Membranes( PROM)Content第1頁(yè)/共44頁(yè)第一頁(yè)，共45頁(yè)。第2頁(yè)/共44頁(yè)第二頁(yè)，共45頁(yè)。 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

2、 1000 and 2499g. The prognosis of the premature infant is correlated with its gestational age, weight.Definition: 第3頁(yè)/共44頁(yè)第三頁(yè)，共45頁(yè)。Etiology:1.Obstetric complications 產(chǎn)科并發(fā)癥2.Medical complications 內(nèi)科并發(fā)癥3.Surgical complications 外科(wik)并發(fā)癥4.Genital tract anomalies 生殖道畸形第4頁(yè)/共44頁(yè)第四頁(yè)，共45頁(yè)。1.Obstetric compl

3、ications: Severe hypertensive state or pregnancy Anatomic disorder of the placenta( abruptio placentae, placenta previa) Premature rupture of membranes Polyhydramnios or oligohydramnios Multiple pregnancy Previous laceration（裂傷） of cervix or uterus第5頁(yè)/共44頁(yè)第五頁(yè)，共45頁(yè)。2.Medical complications: Pulmonary

4、or systemic hypertension Renal disease Heart disease Infection: genital tract infection, urinary tract infection, pyelonephritis腎盂腎炎, acute systemic infection Heavy cigarette smoking Alcoholism or drug addiction Severe anemia第6頁(yè)/共44頁(yè)第六頁(yè)，共45頁(yè)。3.Surgical complications:Conization of cervix宮頸錐切術(shù)Previous

5、 incision in uterus or cervix ( cesarean delivery剖宮產(chǎn)術(shù))4.Genital tract anomaliesBicornuate雙角, subseptate縱隔(zngg), or unicormuate單角 uterusCongenital cervical incompetency先天性宮頸閉合不全第7頁(yè)/共44頁(yè)第七頁(yè)，共45頁(yè)。Clinical Finding & Diagnosis1.Symptom and SignUterine contractionsmore than 2 in one-half hour;Vaginal

6、 bleeding-bloody mucous vaginal discharge or “bloody show”;Dilatation擴(kuò)張(kuzhng) 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);第8頁(yè)/共44頁(yè)第八頁(yè)，共45頁(yè)。2. Laboratory StudiesCompletely blood count with differentialC

7、ervix discharge cultures ：should be sent for gonorrhea淋病(ln bng) 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.分泌物第9頁(yè)/共44頁(yè)第九頁(yè)，共45頁(yè)。3. Accessory exam

8、ination:Ultrasound examination for fetal size, position, placenta location，and cervical length. Cervical length30nm: prognosticating premature delivery. Infundibulum漏斗(ludu) length of cervical internal os25% Cervical length or Amniocentesis to ascertain fetal lung maturity, the amnio fluid羊水 be test

9、ed for lecithin卵磷脂/ sphingomyelin鞘磷脂 (L/S) ratio第10頁(yè)/共44頁(yè)第十頁(yè)，共45頁(yè)。 principle: If the fetus is alive, with no PROM 胎膜(ti m)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, somet

10、hing must be done to elevate the survival rate of the premature infant.Treatment:第11頁(yè)/共44頁(yè)第十一頁(yè)，共45頁(yè)。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(d si m sn): 6 mg IM 1/12 hr 4 doses3. Antibiotics: no benefit in delaying

11、 preterm birth.4. Tocolysis：第12頁(yè)/共44頁(yè)第十二頁(yè)，共45頁(yè)。 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(dòng)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

12、) 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(hchng)抑制劑 indomethacin吲哚美辛第13頁(yè)/共44頁(yè)第十三頁(yè)，共45頁(yè)。 Some cases in which preterm labor should not be suppressed. Maternal factors: Fetal factors:Maternal factors: Severe hypertensive disease Pulmonary or cardiac

13、 disease Advanced cervical dilation Maternal hemorrhage第14頁(yè)/共44頁(yè)第十四頁(yè)，共45頁(yè)。Fetal factors: Fetal death or lethal anomaly Fetal distress Intrauterine infection Therapy adversely affecting the fetus Estimated fetal weight2500g Erythroblastosis fetalis Severe intrauterine growth retardation第15頁(yè)/共44頁(yè)第十五頁(yè)，

14、共45頁(yè)。Manner of labor 1. Vaginal delivery: perineum section會(huì)陰切開(kāi)術(shù) 2. Cesarean section: abnormal fetal position胎位異常 fetal distress胎兒(ti r)窘迫 maternal hemorrhage孕婦出血 severe maternal complications孕婦嚴(yán)重的并發(fā)癥 第16頁(yè)/共44頁(yè)第十六頁(yè)，共45頁(yè)。Case File A healthy 20-year-old pregnant woman, G1P0 at 29 weeks gestation presen

15、t 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

16、 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.第17頁(yè)/共44頁(yè)第十七頁(yè)，共45頁(yè)。 What is the most likely diagnosis? Preterm labor. What is your next step in management? Tocolysis

17、, try to identify a cause of the preterm labor, antenatal steroids, and antibiotics.Questions第18頁(yè)/共44頁(yè)第十八頁(yè)，共45頁(yè)。PROLONGED PREGNANCY(POSTTERM PREGNANCY)第19頁(yè)/共44頁(yè)第十九頁(yè)，共45頁(yè)。General consideration: Definition: Prolonged pregnancy is defined as pregnancy that has reached 42 weeks of completed gestation fr

18、om the first day of the LMP or 40 weeks gestation from the time of conception. 第20頁(yè)/共44頁(yè)第二十頁(yè)，共45頁(yè)。 The maternal risk: Related to extraordinary fetal size:Dysfunctional labor功能障礙性分娩Arrested progress of labor 產(chǎn)程停止(tngzh) Fetopelvic disproportion胎盆不稱 Cesarean section 剖宮產(chǎn) Labor trauma 分娩損傷第21頁(yè)/共44頁(yè)第二十一頁(yè)

19、，共45頁(yè)。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(zhng i) Birth injury ( shoulder dystocia肩難產(chǎn)) Oligohydramnios羊水過(guò)少 Fetal distress胎兒窘迫Meconiurn aspiration syndroame （MAS)胎糞吸入綜合征Asphyxia neonatorum新生兒窒息第

20、22頁(yè)/共44頁(yè)第二十二頁(yè)，共45頁(yè)。ETIOLOGYProlonged pregnancy may relate to:Dysfunction of estrogen/progesteron (E/P) ratio雌孕激素比例失調(diào)：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(yn s):placenta sulfatase deficiency胎盤硫酸酯酶第23頁(yè)/共44頁(yè)第二十三頁(yè)，共45頁(yè)。P

21、ATHOLOGY Placenta: normal or hypofunction功能減退 Amniotic fluid: Oligohydramnios羊水過(guò)少 Meconium dye of amniotic fluid羊水糞染 Fetus: Fetal macrosomia巨大(jd)胎兒 Fetal dysmaturity胎兒成熟障礙 Small-for-date infant小樣兒第24頁(yè)/共44頁(yè)第二十四頁(yè)，共45頁(yè)。Diagnosis: 1. Confirmation of gestational age: by referring to records of : Mecial

22、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 )第25頁(yè)/共44頁(yè)第二十五頁(yè)，共45頁(yè)。

23、2. Judgment of the placental function:Fetal movement count胎動(dòng)計(jì)數(shù):Fetal electrical monitor胎兒電子監(jiān)護(hù)(jinh):Ultrasound examination超聲檢查:Urine estrogen/creatinine ratio雌激素和肌酐比值 :Amnioscopy羊膜鏡檢查:第26頁(yè)/共44頁(yè)第二十六頁(yè)，共45頁(yè)。Treatment: Indication of terminal pregnancy: Cervical mature Fetal weigth4000g, or non reaction

24、pattern of NST, or CST positive (doubtful) Urine estrogen/creatinine ratio decreased Fetal movement Oligohydramnios With eclampsia of pre-eclampsia第27頁(yè)/共44頁(yè)第二十七頁(yè)，共45頁(yè)。1. Induced labor: Cervix is mature, bishop score7 When cervix is mature: 人工(rngng)破膜Oxytocin, Prasterone普拉睪酮Prostaglandin前列腺素： propes

25、s普貝生(Dinoprostone Suppositories地諾前列酮栓）第28頁(yè)/共44頁(yè)第二十八頁(yè)，共45頁(yè)。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.第29頁(yè)/共44頁(yè)第二十九頁(yè)，共45頁(yè)。Premat

26、ure Rupture of Membranes( PROM)第30頁(yè)/共44頁(yè)第三十頁(yè)，共45頁(yè)。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 in

27、fant. 第31頁(yè)/共44頁(yè)第三十一頁(yè)，共45頁(yè)。Essentials of Diagnosis1. History of a gush of fluid from the vagina or watery vaginal discharge;2. Demonstration of amniotic fluid leakage from the cervix.第32頁(yè)/共44頁(yè)第三十二頁(yè)，共45頁(yè)。ETIOLOGY Genital tract pathogenic microorganism upgoing infection: Amniotic cavity pressure increa

28、se: Pressure on fetal membrane is unbalanced; Nutritional factor; Cervical incompetence; Cytokine: 第33頁(yè)/共44頁(yè)第三十三頁(yè)，共45頁(yè)。Pathology & Pathophysiology Preterm labor Prolapse of the umbilical cord Placenta abruption Intrauterine infection Chorioamnionitis第34頁(yè)/共44頁(yè)第三十四頁(yè)，共45頁(yè)。DIAGNOSIS1. Symptom Sudden

29、 gush of fluid or continued leakage The 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.第35頁(yè)/共44頁(yè)第三十五頁(yè)，共45頁(yè)。2. Sterile speculum examination Pooling: the collection of amniotic fluid in

30、 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;第36頁(yè)/共44頁(yè)第三十六頁(yè)，共45頁(yè)。3. Physical exami

31、nation: To search for other signs for infection.4. Laboratory studies: Complete blood count with differential Ultrasound examination for fetal size and amniotic fluid index Amniocentesis to determine fetal lung maturity and the presence of infection第37頁(yè)/共44頁(yè)第三十七頁(yè)，共45頁(yè)。5. ChorioamniotisThe most relia

32、ble signs of infection include: Fever: the temperature should be checked every 4 hours Maternal leukocytosis: daily leukocyte count and differential. An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infection Uterine tenderness: check every 4 hours Tachycardia: either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.第38頁(yè)/共44頁(yè)第三十八頁(yè)，共45頁(yè)。Influence on Mother and FetusInfluence on mother:Infection;Placenta abruptionInfluence on fetus:Premature deliveryrespiratory distress syndrome of newborn新生兒呼吸窘迫(jingp)綜合