胎膜早破
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Pregnancy complication Department of gynaecology and obstetrics
Early pregnancy complication Late pregnancy complication
Late pregnacy complication
preterm labor premature rupture of membranes （ prom ） prolonged pregnancy RH isoimmunization other blood group incompatiblities Management of the pregnancy with isoimmunization
Premature rupture of membranes
Rupture of the membrant may happen at any time during pregnancy 1.the fetus is preterm pretem premature rupture of membraned （ PROM ） 2.24hour elapse between rupture of the membrands and the onset of labor ， the problem is one of prolonged premature rupture of the membranes
Etiology Pathology and pathophysiology Clinical findings Treatment
Etiology
Diseases and disorders associated with premature rupture of the membranes Meternal infection Intrauterine infection Cervical incompetency Multiple previous pregnancies Hydramnios Nutritional deficit Decreased tensile strength of membranes Familial history of prematuere rupture of membrance
Etiology Pathology and pathophysiology Clinical findings Treatment
Pathology and pathophysiology Preterm labor
prolapse of the cord
PROM Intrauterine infection
Placental abruption,
Pathology and pathophysiology amnionitis
endomyometritis
puerperal sepsis
Etiology Pathology and pathophysiology Clinical findings Treatment
Clinical findings
Symptoms sterile speculum examination physical examination laboratory studies amnionitis
1.Symptoms the patient usually reports a sudden gush of fluid or continued leekage additional symptom include : the color and consistency of the fluid the presence of flecks of vernix or meconium reduced size of the uterus increased prominece of the fetus to palpation.
2.sterile speculum examination differentiating PROM from hydrorrhea gravidarum,vaginitis, increased vaginal secretions,and urinary incontinence.
A pooling The collection of amniotic fluid in the posterior fornix
B nitrazine test A sterile cotton-tipped swab should be used to collect fluid from the posterior fornix apply it to nitrazine paper. the nitrazine paper will turn blue ,demonstrating an alkaline PH(7.07.25) in the presence of amniotic fluid
C ferning A drop of fluid from the posterior fornix should be placed on a slide and allowed to air-dry.amniotic fluid will from a fernlike pattern of crystallization.
3 physical examination 1). Once PROM is confirmed ,a careful Physical examination should be done to search for other signs of infection 2).Given the risk of infection,there is no indication for digital cervical examination if the patient is in early labor 3).the serile specululm exam is sufficient to distinguish between early and advanced labor.
4 laboratory studies
1Initial laboratory include a complete blood count with differential. 2 urine collected by catheterization for urinalysis,culture,and sensitivity tesing,
3 ultrasound examination for fetal size and amniotic fluid index
5.amnionitis the most reliable signs of infection include the following 1.fever- the temperature should be checked every 4h 2.maternal leukocytosis –a white blood cell count of more than 16.000/ul(16*10^9/l) is considered alarming 3.uterine tenderness-check every 4 h 4.tachycardia –either maternal pulse >100b/s,or fetal heart rate >160b/m-is worrisome. 5.foulsmelling amniotic fluid
complicate the diagosis of amnionitis : 1.frequent fundal examinations may cause uterine tenderness. 2.corticosteroid administration may cause mild leukocytosis (increase of 20-25%) 3. labor is assocated with leukocytosis.
If daignosis of amnionitis is equivocal, amniocentesis may be performed to search for bona fide evidence In all cases of amnionitis,it is safer for the fetus to be delivered than to be retainded in utero.
Etiology Pathology and pathophysiology Clinical findings Treatment
Treatment
Depends on several factors Gestational age the presence or absence of amnionitis 1.amnionitis 2.term pregnancy without amnionitis 3. preterm pregnancy without amnionitis
1.amnionitis if amnionitis is present in the patient with PROM the patient should be actively deliveried regardless of gestational age . broad –spectrum antibiotics should be started to treat the amnionitis if the patient is not in labor ,labor should be induced to expedit delivery.
2 term pregnancy without amnionitis The term pregnancy with PROM in the absence of anmionitis can be managed expectantly or actively .
expectant management entails noninterventin while waiting for the patient to go into laboar spontaneously .
active management entails induction of labor with an agent such as pitocin .
if the patient does not go into labor within 6-12h after PROM, labor should be induced to minimize the risk of infection
3 preterm pregnancy without amnionitis The principles of managing the preterm PROM Patient are similar to those of the preterm labor patient . the key difference is the much increased risk of developing amnionitis associated with preterm
1.pregnancies beyond 33-34week s’ EGA Can be managed as a term pregnancy because there is no evidence that antibiotics ,corticosteroids ,or tocolytics improve outcome in these patients .as long as these patients show no signs of amnionitis they can be managed expectantly.
2.Pregnancies prior to 24weeks’EGA with PROM have extremely low rates of fetal salvage with considerable materanl risk.furthermore ,at this early gestational age ,steroids,tocolytics and antibiotics have no proven benefit.these patient should be managed with expectant management or active termination
3.for pregnancies with PROM Between 24-32weeks’EGA,several interventions have been shown to prolong pregnancy and improve outcome .after amnionitis has been ruled out and a specimen of anmiotic fluid from vagianl pool collection or amniocentesis is sent for determination of fetal lung maturity ,management should consist of the following interventions
A antibiotics B corticosteroids C tocolytics
A antibiotics . -as an important treatment for prterm PROM. .in contrast to preterm labor where antibiotics have shown nobenefit in prolonging pregnancy .antibiotics appear to be effective in prolonging the latency period in patients with preterm PROM .
they have also been shown to decrease the infection rate in these patients .a number of well –designed studies have shown improved neonatal outcomes with antibiotics alone and with antibiotics combined with corticosteroid therapy .
corticosteroids the use of steroids in PROM patients prior to 32wekks’EGA in the absence of intraamniotic infection.in this patient porulation, corticosteroids have been shown decrease the rate of respiratory distress syndrome, necrotizing enterocolitis,and inraventricular hemorrhage.
tocolytics ,if at any time the patient shows sings of chorioamnionitis ,she should be delivered the use of tocolytics in the preterm PROM patient should be limited to 48h duration,to permit administration of corticosteroids and antibiotics .
if after starting these interventions the fetal lung profile return as mature,they should be abandoned and the patient should be delivered
essentials of diagnosis 1.history of a gush of fliud from the vagian or watery vaginal discharge 2. demonstration of amniotic fluid leakage from the cervix
Early pregnancy complication Late pregnancy complication
Late pregnacy complication
preterm labor premature rupture of membranes （ prom ） prolonged pregnancy RH isoimmunization other blood group incompatiblities Management of the pregnancy with isoimmunization
Premature rupture of membranes
Rupture of the membrant may happen at any time during pregnancy 1.the fetus is preterm pretem premature rupture of membraned （ PROM ） 2.24hour elapse between rupture of the membrands and the onset of labor ， the problem is one of prolonged premature rupture of the membranes
Etiology Pathology and pathophysiology Clinical findings Treatment
Etiology
Diseases and disorders associated with premature rupture of the membranes Meternal infection Intrauterine infection Cervical incompetency Multiple previous pregnancies Hydramnios Nutritional deficit Decreased tensile strength of membranes Familial history of prematuere rupture of membrance
Etiology Pathology and pathophysiology Clinical findings Treatment
Pathology and pathophysiology Preterm labor
prolapse of the cord
PROM Intrauterine infection
Placental abruption,
Pathology and pathophysiology amnionitis
endomyometritis
puerperal sepsis
Etiology Pathology and pathophysiology Clinical findings Treatment
Clinical findings
Symptoms sterile speculum examination physical examination laboratory studies amnionitis
1.Symptoms the patient usually reports a sudden gush of fluid or continued leekage additional symptom include : the color and consistency of the fluid the presence of flecks of vernix or meconium reduced size of the uterus increased prominece of the fetus to palpation.
2.sterile speculum examination differentiating PROM from hydrorrhea gravidarum,vaginitis, increased vaginal secretions,and urinary incontinence.
A pooling The collection of amniotic fluid in the posterior fornix
B nitrazine test A sterile cotton-tipped swab should be used to collect fluid from the posterior fornix apply it to nitrazine paper. the nitrazine paper will turn blue ,demonstrating an alkaline PH(7.07.25) in the presence of amniotic fluid
C ferning A drop of fluid from the posterior fornix should be placed on a slide and allowed to air-dry.amniotic fluid will from a fernlike pattern of crystallization.
3 physical examination 1). Once PROM is confirmed ,a careful Physical examination should be done to search for other signs of infection 2).Given the risk of infection,there is no indication for digital cervical examination if the patient is in early labor 3).the serile specululm exam is sufficient to distinguish between early and advanced labor.
4 laboratory studies
1Initial laboratory include a complete blood count with differential. 2 urine collected by catheterization for urinalysis,culture,and sensitivity tesing,
3 ultrasound examination for fetal size and amniotic fluid index
5.amnionitis the most reliable signs of infection include the following 1.fever- the temperature should be checked every 4h 2.maternal leukocytosis –a white blood cell count of more than 16.000/ul(16*10^9/l) is considered alarming 3.uterine tenderness-check every 4 h 4.tachycardia –either maternal pulse >100b/s,or fetal heart rate >160b/m-is worrisome. 5.foulsmelling amniotic fluid
complicate the diagosis of amnionitis : 1.frequent fundal examinations may cause uterine tenderness. 2.corticosteroid administration may cause mild leukocytosis (increase of 20-25%) 3. labor is assocated with leukocytosis.
If daignosis of amnionitis is equivocal, amniocentesis may be performed to search for bona fide evidence In all cases of amnionitis,it is safer for the fetus to be delivered than to be retainded in utero.
Etiology Pathology and pathophysiology Clinical findings Treatment
Treatment
Depends on several factors Gestational age the presence or absence of amnionitis 1.amnionitis 2.term pregnancy without amnionitis 3. preterm pregnancy without amnionitis
1.amnionitis if amnionitis is present in the patient with PROM the patient should be actively deliveried regardless of gestational age . broad –spectrum antibiotics should be started to treat the amnionitis if the patient is not in labor ,labor should be induced to expedit delivery.
2 term pregnancy without amnionitis The term pregnancy with PROM in the absence of anmionitis can be managed expectantly or actively .
expectant management entails noninterventin while waiting for the patient to go into laboar spontaneously .
active management entails induction of labor with an agent such as pitocin .
if the patient does not go into labor within 6-12h after PROM, labor should be induced to minimize the risk of infection
3 preterm pregnancy without amnionitis The principles of managing the preterm PROM Patient are similar to those of the preterm labor patient . the key difference is the much increased risk of developing amnionitis associated with preterm
1.pregnancies beyond 33-34week s’ EGA Can be managed as a term pregnancy because there is no evidence that antibiotics ,corticosteroids ,or tocolytics improve outcome in these patients .as long as these patients show no signs of amnionitis they can be managed expectantly.
2.Pregnancies prior to 24weeks’EGA with PROM have extremely low rates of fetal salvage with considerable materanl risk.furthermore ,at this early gestational age ,steroids,tocolytics and antibiotics have no proven benefit.these patient should be managed with expectant management or active termination
3.for pregnancies with PROM Between 24-32weeks’EGA,several interventions have been shown to prolong pregnancy and improve outcome .after amnionitis has been ruled out and a specimen of anmiotic fluid from vagianl pool collection or amniocentesis is sent for determination of fetal lung maturity ,management should consist of the following interventions
A antibiotics B corticosteroids C tocolytics
A antibiotics . -as an important treatment for prterm PROM. .in contrast to preterm labor where antibiotics have shown nobenefit in prolonging pregnancy .antibiotics appear to be effective in prolonging the latency period in patients with preterm PROM .
they have also been shown to decrease the infection rate in these patients .a number of well –designed studies have shown improved neonatal outcomes with antibiotics alone and with antibiotics combined with corticosteroid therapy .
corticosteroids the use of steroids in PROM patients prior to 32wekks’EGA in the absence of intraamniotic infection.in this patient porulation, corticosteroids have been shown decrease the rate of respiratory distress syndrome, necrotizing enterocolitis,and inraventricular hemorrhage.
tocolytics ,if at any time the patient shows sings of chorioamnionitis ,she should be delivered the use of tocolytics in the preterm PROM patient should be limited to 48h duration,to permit administration of corticosteroids and antibiotics .
if after starting these interventions the fetal lung profile return as mature,they should be abandoned and the patient should be delivered
essentials of diagnosis 1.history of a gush of fliud from the vagian or watery vaginal discharge 2. demonstration of amniotic fluid leakage from the cervix
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