pathological duration of pregnancy, labor and postpartum period prepared by n. bahniy
TRANSCRIPT
Pathological duration of pregnancy, labor and postpartum period
Prepared by N. BahniyPrepared by N. Bahniy
The main causes of hemorrhages in the first half of pregnancy
Spontaneous abortionEctopic pregnancyHytadidiform Mole
Abortion is the termination of a pregnancy before viability, typically defined as 22 weeks from the first day of the last normal menstrual period or a fetus weighing less than 500 g and its height is less than 25 cm.
Classification of abortions
Spontaneous Induced Clinically: Threatened Initial Inevitable Completed Incomplete Missed
Causes of spontaneous abortions
1. Maternal Infections – Listeria, Mycoplasma hominis, Ureaplasma
urealyticum, Toxoplasmosis,Rubella, Cytomegalovirus. Endocrine factors - luteal phase inadequacy,
HyperthyroidismDiabetes Mellitus Environmental factors Uterine abnormalities 2. Paternal - chromosomal abnormality in either parent.3. Fetal - genetic abnormalities of the conceptus,
approximately half of which are autosomal trisomies.
Threatened abortion
Signs – lover abdominal pain.
In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period
Management – conservative.
Initial abortion
Signs – lover abdominal pain, bloody vaginal discharge.
In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period
Management – conservative.
Inevitable abortionSigns – cramp abdominal pain
thanks to uterine contractions, bloody vaginal discharge till profuse hemorrhage.
In bimanual examination – cervix is dilated, products of conception are presented on cervical channel, enlargement of the uterus doesn’t correspond with gestational period – smaller
Management –surgical – uterine curettage.
Complete abortion – all products of conception are expelled out of uterus
Signs - lover abdominal pain, bloody vaginal discharge.
In bimanual examination – cervix is dilated or closed, enlargement of the uterus doesn’t correspond with gestational period – smaller.
Management–uterine curettage
Incomplete abortion – retention of some conceptus inside the uterus
Signs – lover abdominal pain, bloody vaginal discharge.
In bimanual examination – cervix is dilated, enlargement of the uterus doesn’t correspond with gestational period – smaller, some products of conception should be expelled out.
Management–uterine curettage
Missed Abortion - retention of a failed intrauterine pregnancy for an extended period. Absence of uterine
growth and may have lost some of the early symptoms of pregnancy, presented of dark bloody discharge
Although unusual, DIC can occur.
Management –surgical – uterine curettage
Conservative treatment in the case of threatened and initial abortion
Bed rest Sedative drugs Spasmolitics – No-Spani,
Papaverini hydrochloride Analgetics – Analgin, Baralgin Progesterone – Utrogestan,
Duphastone,Endomerin Chorionic Gonadotropin
Hormone Vitamines – vit. E Hemostatics – Tranexamic
acid
Stages of uterine curettageAnesthesia - paracervical block or
general. Bimanual examination Disinfection of perineal region Speculum insertion Grasping the cervix for anterior lip
with a toothed tenaculum. Uterine probing- to identify the
status of the internal os and to confirm uterine size and position.
Dilation of the cervix by Hehar’s dilators
Uterine curettage by sharp curette
ECTOPIC PREGNANCY
Implantation outside of the uterine cavity is termed as ectopic pregnancy
!Ectopic pregnancy is the leading cause of maternal mortality in the first trimester
Etiology of ectopic pregnancy
1.Mechanical Factors - prevent or retard passage of the fertilized ovum into the uterine cavity include the following.
1. Salpingitis, 2. Peritubal adhesions subsequent to postabortal or puerperal infection 3. Developmental abnormalities of the tube, especially diverticula,
hypoplasia. 4. Previous ectopic pregnancy. 5. Previous operations on the tube, either to restore patency 6. Multiple previous induced abortions. 7. Tumors that distort the tube, such as uterine myomas, adnexal masses.2.Functional Factors - that delay passage of the fertilized ovum into the
uterine cavity. 1. External migration of the ovum 2. Menstrual reflux 3. Altered tubal motility 4. Cigarette smoking at the time of conception 3.Increased Receptivity of Tubal Mucosa to Fertilized Ovum. 4.Assisted Reproduction. 5.Failed Contraception.
Classification of ectopic pregnancy
According to localization: Tubal – isthmic, interstitial,ampullary Ovarian Abdominal Broad-Ligament pregnancy CervicalAccording to clinical duration: Progressive Ruptured - Tubal rupture, Tubal abortion
Clinical signs of Ectopic Pregnancy Presence of Presumptive
and Probable signs of pregnancy
Irregular dark brown vaginal bleeding
Pain – from light to severe Syncope Dizziness Urge to defecate Signs of internal hemorrhage
- peritoneal irritation, shock
Pelvic examination in ectopic pregnancy
Unilateral or bilateral exquisite tenderness especially on motion of the cervix
Adnexal massEnlarged uterus Tenderness and painful of the posterior
fornix
Signs of internal hemorrhages which provoke hypovolemic shock are the more prominent the more closely fertilized ovum localized near the uterus
Culdocentesis – is the simplest technique for identifying hemoperitoneum
Bloody fluid that
does not clot result
of hemoperitoneum resulting from an ectopic pregnancy
Management of ectopic pregnancySurgical: linear salpingostomy segmentai resection Salpingectomy
Medical - Methotrexate, folinic acid antagonist: if the gestation is less than 6 weeks, the tubal mass is not more than 3.5 cm in diameter, and the fetus is not alive
Signs of cervical pregnancy uterine bleeding without
cramping after a period of amenorrhea
softened cervix disproportionally enlarged to a size equal to or larger than the corpus
complete confinement and firm attachment of the products of conception to the endocervix, snug internal cervical os.
MANAGEMENT CERVICAL PREGNANCY
HYSTERECTOMY EMBOLIZATION
of A. UTERINAE
Hydatidiform Mole
Is an abnormal conceptus with loss of villus vascularity and without an embryo or fetus.
Most of symptoms are presented thanks to markedly elevated hCG levels.
Signs of Hydatidiform Mole Vaginal bleeding with molar
elements Preeclampsia In pelvic exam - uterus
larger than expected, Ovarian enlargement due to bilateral theca lutein cysts
Ultrasonography – “snow-storm” appearance
Treatment – vacuum aspiration, utreine curretage
BLEEDING IN THE SECOND HALF OF PREGNANCY - PLACENTA PREVIA
Definition: abnormal location of the placenta over, or in close proximity to, the internal cervical os.
Placenta previa can be categorized as: complete or total - if the entire cervical os is covered; partial - if the margin of the placenta extends across
part but not all of the internal os; marginal , if the edge of the placenta lies adjacent to the
internal os; low lying - if the placenta is located near but not directly
adjacent to the internal os till 6 cm.
Etiology of placenta previa - abnormal vascularization
Clinical findings and Diagnosis
Painless bleeding Ultrasonography
has been of enormous benefit in localizing the placenta.
Careful vaginal examination – in labor.
Management of patients with placenta previa during pregnancy
Initial hospitalization with hemodynamic stabilization, followed by expectant management until fetal maturity has occurred.
Bed rest Vitamins – for increasing of vascular strenght:
Rutin, Ascorutin, Ca Bloodstoping agents – Vicasol, Dicinon,
Tranexam Smasmolytics in the case of pregnancy
interruption
Management of patients with placenta previa in labor
Complete – cesarean section;
Partial, marginal, low lying - artificial rupture of the membranes and oxytocin induction of labor.
If the hemorrhage exceeds 250-300ml – immediate cesarean section
PLACENTAL ABRUPTION - premature separation of the normally implanted placenta from the uterine wall.
Etiology: when there is hemorrhage into the decidua basalis, leading to premature placental separation and further bleeding. The cause for this bleeding is not known.
Patients at risk: Maternal hypertension Multiply pregnancy Polyhidramnios External trauma Preterm prematurely ruptured membranes Cigarette smoking Cocaine abuse Uterine leiomyoma,
Clinical findings and Diagnosis External bleeding can be profuse or
there may be no external bleeding (concealed hemorrhage)
Uterine tenderness Back pain Fetal distress Uterine hypertonus or high-
frequently contractions Dead fetus when placenta is totally
shared. Coagulation disorders Ultrasonography can help in
diagnosis
Management of Placental Abruption
When the fetus is mature - hemodynamic stabilization and delivery by cesarean section. In the second stage of labor – immediate delivery by forceps application, vacuum, total breech extraction.
When the fetus is immature and blood loss is < 250 ml – very close observation, coupled with facilities for immediate intervention, can be practiced.
Couvelaire uterus – Uteroplacental Apoplexy
Differential characteristics between placenta previa and abruptio placentaeCharacteristics Placenta previa Abruptio PlacentaMagnitude of blood loss Variable Variable
Duration Often ceases within 1-2 hours
Usually continues
Abdominal discomfort None Can be severe, pain
Fetal heart rate patternon electronic monitoring
Absent Tachycardia, then bradycardia; loss ofvariability; decelerations frequentlypresent; intrauterine demise not rare
Coagulation defects Rare Associated, but infrequent; DIG oftensevere when present Cocaine use
Associated history None Abdominal trauma;maternal hypertension;multiple gestation; polyhydramnios
HEMORRHAGE IN THE THIRD STAGE OF LABOR AND EARLY PUERPERAL PERIOD
Postpartum hemorrhage is defined as blood loss in excess of physiologic blood loss at the time of vaginal delivery – 0,5% from body weight.
Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage.
Postpartum hemorrhage after delivery of placenta during the first two hours is called as hemorrhage in early puerperal stage.
Mechanisms of Hemorrhage stopping after placental
separation
uterine contractions – calibers of ruptured vessels decreases during uterine contractions;
formation of thrombs, especially in the region of placental site;
torsion of thin septs in which vessels are situated.
Causes of Postpartum Hemorrhage
uterine atonygenital tract trauma bleeding from the placental site (retained
placental tissue, low placental implantation, placental adherence, uterine inversion)
coagulation disorders
Predisposing factors for uterine atony
1. Overdistended uterus – multiple fetuses, Hydramnios, distention with clots.
2. Anesthesia or analgesia – halogenated agents, conducted analgesia with hypertension.
3. Exhausted myometrium – rapid labor, prolonged labor, oxytocin or prostaglandin stimulation.
4. Chorionamnionitis.4. Previous uterine atony.
Uterine atony - total absence of uterine contractions into the external irritation.
Uterine hypotony - inadequate uterine contractions on the external irritation. In the pauses between uterine contractions a uterus is soft.
But blood form clots in the case of uterine hypo- or atony. These clots are stored in the uterine cavity that’s why a uterus is enlarged in sizes.
CONTRICTILE DRUGS
OxytocinErgometrine/ Methyl-ergometrine
15-methyl Prostaglandin F2α
Dose and route IV: Infuse 20 units in 1 L IV fluids at 60 drops per minute IM: 10 units
IM or IV (slowly): 0.2 mg
IM: 0.25 mg
Continuing dose IV: Infuse 20 units in 1 L IV fluids at 40 drops per minute
Repeat 0.2 mg IM after 15 minutes If required, give 0.2 mg IM or IV (slowly) every 4 hours
0.25 mg every 15 minutes
Maximum dose Not more than 3 L of IV fluids containing oxytocin
5 doses (Total 1.0 mg)
8 doses (Total 2 mg)
Precautions/Contrain-dications
Do not give as an IV bolus
Pre-eclampsia, hypertension, heart disease
Asthma
PABAL – I/V BOLUS
ОXYTOCIN ANALOG 1мл – 100 мкг
карбетоцину Діє через 3 хв 1 ін’єкція на 6 годин
MISOPROSTOL
Acts in 30min and last 4-6 hours
FIGO – 1000мкг
Hemorrhages prevention !!!!
Tranexamic acid
Antifibrinilytic
50 mg/ml
15-20 mg/kg
REMESTIP - VASOKONSTRICTOR
0,2 -1, 0 MG every 4-6 hours i/v bolus Effect - 5-10 min
Ligation of uterine arteries, ovarian arteries, a. iliaca interna
Hysterectomy
Antishock garment
Predisposing factors for Genital tract trauma
1. Complicated vaginal delivery.2. Cesarean section or hysterectomy, forceps or
vacuum.3. Uterine rupture; risk increased by: previously
scarred uterus, high parity, hyperstimulation, obstructed labor, intrauterine manipulation.
4. Large episiotomy, including extensions.5. Lacerations of the perineum, vagina or cervix.
Diagnosis and management of Genital Tract Trauma
Diagnosis – speculum inspection
Management - ligation and suturing of all ruptures of the vagina, cervix and perineum. In the case of uterine rupture – hysterectomy should be performed
Bleeding from placental implantation cite
1. Retained placental tissue – avulsed cotyledon, succentuariate lobe
2. Abnormally adherent – accreta, increta, percreta.
Abnormal placenta adherent- any implantation of the placenta in which there is abnormally firm adherence to the uterine wall thanks to partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer (Nitabush’s membrane):
placental villi are attached into the basal layer - placenta adhaerens;
placental villi are attached to the myometrium - placenta accreta;
extensive growth of placental tissue into the uterine muscle itself – placenta increta;
complete invasion through the sickness of the uterine muscle to the serosa or beyond – placenta percreta.
Classification of abnormal placental adherence
Complete or total placenta accreta will not cause bleeding because the placenta remains attached
Partial ( the abnormal adherence involves a few to several cotyledons)
Focal (the abnormal adherence involves a single cotyledon) type may cause profuse bleeding, as the normal part of the placenta separates and the myometrium cannot contract sufficiently to occlude the placental site vessels.
Clinical findings, Diagnosis, Management
1. Absence of the signs of placental separation during 30 minutes.
2. External bleeding – in the case of partial adherence, absence of the bleeding – in the case of total placenta accreta.
In the case of placental adherence bleeding stop, but in the case of placenta accreta, increta and percrata increase.
That’s why in these cases manual removal of the placenta should be stopped immediately and hysterectomy should be performed
DIC - syndrome
Prothrombin complex concentrate
Recombinant VII clotting factorRecombinant VII clotting factor
80-90 80-90 mgmg//kgkg Fresh frozen plasma
Proteolytic enzymes inhibitors – KONTRYCAL, GORDOX
Preeclampsia
Is defined as the development of hypertension with proteinuria or edema (or both).
Assessment of different stages of PIH severity
Symptom of evaluation
Mildpreeclampsia
Moderate preeclampsia
Severepreeclampsia
Edema Light, on lower extremitas
+ abdomen Considerable
Diastolic blood pressure 90-99 mm Hg
100-110 mm Hg
> 110 mm Hg
Proteinuria in a 24hours collection sample
< 0,3 g / L 0,3-5 g / L 5 g/ L
ECLAMPSIA
Is characterized typically by those same abnormalities as severe preeclampsia with the addition of convulsions.