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

Placental
Intrauterine
abruption,
infection
 Pathology and
pathophysiology
amnionitis

puerperal
sepsis
endomyometritis
 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(7.0-
7.25) 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