Download Pathological duration of pregnancy, labor and postpartum period

Pathological duration of pregnancy, labor
and postpartum period
Prepared by N. Bahniy
The main causes of hemorrhages in
the first half of pregnancy
 Spontaneous
abortion
 Ectopic pregnancy
 Hytadidiform 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 28 cm.
Classification of abortions

Spontaneous
 Induced






According to clinical duration spontaneous
abortion is divided:
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.
DIAGNOSIS AND TREATMENT OF DIFFERENT
TYPES OF ABORTIONS
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 abortion
Signs – 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 –surgical – 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 –surgical – uterine curettage
Missed Abortion
Is the retention of a failed intrauterine
pregnancy for an extended period.
 These patients present with an absence of
uterine growth and may have lost some of
the early symptoms of pregnancy,
presented of dark bloody discharge
 Although
unusual,
disseminated
intravascular coagulopathy (DIG) can
occur.
Management –surgical – uterine curettage

Importance of uterine curettage
Necessary to remove the products
of conception and prevent further
bleeding and infection.
Conservative treatment in the case
of threatened and initial abortion







Bed rest
Sedative drugs – Valeriannae,
Persen,Novopaside.
Spasmolitics – No-Spani, Papaverini
hydrochloride
Analgetics – Analgin, Baralgin
Progesterone – Utrogestan, Duphastone,
Progesterone
Chorionic Gonadotropin Hormone
Vitamines – vit. E
Stages of uterine curettage
Anesthesia - 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
Induced Abortion:

Elective (Voluntary) - is the interruption of
pregnancy before 12 weeks of pregnancy
(before viability) at the request of the woman
but not for reasons of impaired maternal health
or fetal disease.
 Therapeutic - termination of pregnancy before
22 weeks of pregnancy ( before viability) for
the purpose of safeguarding the health of the
mother.
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
By localization:
 Tubal – isthmic,
interstitial,ampullary
 Ovarian
 Abdominal
 Broad-Ligament
pregnancy
 Cervical
By clinical duration:
 Progressive
 Ruptured - Tubal
rupture, Tubal abortion
Clinical signs of Ectopic Pregnancy

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
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Presence of Presumptive (nausea, vomiting) and
Probable (amenorrhea) signs of pregnancy
Irregular vaginal bleeding results from the
sloughing of the decidua from the endometrial
lining. It is scanty, dark brown, and may be
intermittent or continuous.
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 mass
 Enlarged 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
Diagnostic procedures
Complete blood count
 Positive urinary test fir estimation of
chorionic gonadotropin (hCG) levels
 Ultrasonography
 Culdocentesis
 Curettage of the uterine cavity can also
rule out ectopic pregnancy

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 pregnancy
Surgical - Laparoscopy and laparotomy
 linear salpingostomy
 segmentai resection
 Salpingectomy
Medical - Methotrexate, a folinic acid antagonist,
has been successfully used to treat ectopic
pregnancy via the oral, IM, or by direct injection
into the ectopic gestational sac.
Success is greatest 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
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.
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 of Hydatidiform Mole
Vacuum aspiration
 Digital removal
 Curettage by sharp curette

The two causes of hemorrhage in the
second half of pregnancy require
greatest attention, because of the
associated maternal and fetal morbidity
and mortality rates.
They are:
 placenta previa
 abruptio placentae
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.
PLACENTA PREVIA
Clinical findings and Diagnosis

Painless bleeding It almost always
ceases spontaneously, unless digital
examination or other trauma occurs.

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
 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
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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
Idiopathic preterm labor
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.
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.
Causes of Postpartum Hemorrhage
uterine atony
 genital tract trauma
 bleeding from the placental site (retained
placental tissue, low placental
implantation, placental adherence,
uterine inversion)
 coagulation disorders


Uterine atony is called as total absence of
uterine contractions into the external irritation.
 Uterine hypotony is called as presence of
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.
Use of oxytocic drugs
Oxytocin
Ergometrine/
Methylergometrine
15-methyl
Prostaglandin F2α
Dose and route
IV: Infuse 20 units in IM or IV (slowly): 0.2 IM: 0.25 mg
1 L IV fluids at 60
mg
drops per minute
IM: 10 units
Continuing dose
IV: Infuse 20 units in Repeat 0.2 mg IM
1 L IV fluids at 40
after 15 minutes
drops per minute
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 5 doses (Total 1.0
IV fluids containing
mg)
oxytocin
8 doses (Total 2 mg)
Precautions/
Contrain-dications
Do not give as an IV
bolus
Asthma
Pre-eclampsia,
hypertension, heart
disease
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

Predisposing factors for Bleeding from placental
implantation cite
1.
Retained placental tissue – avulsed
cotyledon, succentuariate lobe
2.Abnormally adherent – accreta, increta,
percreta.
Abnormal placenta adherent
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):
the placental villi are attached into the basal layer placenta adhaerens;
the 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
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.
3. Manual removal of the placenta confirms the diagnosis
of different types of abnormal placental adherence.
 In the case of partial placental adherence it stops
bleeding, but in the case of placenta accreta, increta and
percrata it increases bleeding. Attempts at manual
removal are futile. That’s why in these cases manual
removal of the placenta should be stopped immediately
and hysterectomy should be performed.
1.
Management of bleeding from placental cite
1) placental separation signs are absent – manual
separation and removal of the placenta and
exploration of the uterine cavity, uterine massage,
uterine contracting drugs are prescribed;
2) complete and partial placenta adherens - manual
separation and removal of the placenta;
3) placenta accreta, increta and percreta – hysterectomy.
With
more
extensive
involvement,
however,
hemorrhage becomes profuse as manual removal of
the placenta is attempted.
DISSEMINATED INTRAVASCULAR
COAGULOPATHY (DIC)
DIC is the pathological complex, which is
characterized by blood clotting that has
been
leading
to
microcirculation
blockade by fibrin in the main human
organs
(lungs,
kidneys,
liver).
Dysfunction of these organs is the result
of their damage. In the end of this
process thrombohemorrhagic disorders
have been developed.
Classification DIC syndrome

By clinical duration:
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Acute
Subacute
Chronic
By stages:
I stage – hypercoagulation;
II stage – hypocoagulation without generalizing
fibrinolysis activation;
III stage – hypocoagulation with generalizing
fibrinolysis activation;
IV stage – total fibronolysis.
Clinical manifestation
Hemorrhages into skin and mucous
membranes;
 Hemorrhages
from the places of
injections, incisions, uterus.
 Necrosis of some areas of skin and
mucous membranes;
 Central nervous system impairment;
 Acute
renal,
liver,
pulmonary
insufficiency.

General principles of DIC treatment

Heparin, fibrinogen are contraindicated .
 Proteolytic enzymes inhibitors in the dose of 10
mg/kg/hour .
 Early and quick introduction of fresh frozen donor’s
plasma . Initially the dose of intravenous introduction is
6-12 ml/kg. After it dose is 300-400 ml each 6-8 hours.
 Stimulation of vascular-thrombocytes link of hemostasis
(dicinone, etamsilat).
 Transamacha acid usage – in the dose 500-750 mg on
0,9 % NaCl. This medicine inhibits plasmine activity,
stabilizes coagulate factors and fibrin.
Blood loss determination
Hematocrit, %
Blood loss
volume, ml
44 – 40
500
38 – 32
1000
30 – 22
< 22
Algover’s
index
Blood
loss
volume, %
out
of
circulating
blood volume
0,8 and <
10 %
0,9 – 1,2
20 %
1,3 – 1,4
30 %
1,5 and >
40 %
1500
> 1500
Hemorrhagic shock is a very serious
complication in the case of pathological
hemorrhage.
 Physiological blood loss during labor is
0, 5 % out of female weight.
 If blood loss predominate physiological
one, hemorrhagic shock have been
occurred.

Classification of hemorrhagic shock
Stage
ypovolemia
stage
I
Mild
H Circulating
blood
volume
deficiency
Bloo %
d loss,
from
ml
body
weight
10 %20%
Moderate
1,0 –
Ps – 90-100 beats
1,5 % per min;
1000
Arterial
blood
pressure (BP) - >100
mm Hg;
Central
Venous
pressure (CVP) – 80100 mm Hg;
Diuresis – N.
500
–
II
Hemodynamics
data,
diuresis
20%-
1000
30%
1,5
1500
,
2,0
%
Ps – 120 beats per
min;
BP - <100 mm Hg;
CVP – < 60 mm Hg;
Diuresis – < 50 ml
per hour (oligouria)
III
Severe
30%-
1500,
– 2000
2,0
–
40%
2,5
%
IV
Considerable
40% and >
2000,
and >
>
2,5
%
Ps – 140 beats per
min;
BP - < 70 mm Hg;
CVP – < 40 mm Hg;
Diuresis – < 30 ml
per hour (anuria)
Ps – 140 beats per
min;
BP – < 50 mm Hg;
CVP – 0;
Diuresis– anuria
INTERM restoration of the circulating blood
volume – is the main step in the treatment of
acute blood loss.
Human organism should be survived in the
case of 2/3-erythrocytes volume loss, but it
doesn’t survive in the case of 1/3 plasma
volume loss. That’s why it should be
remembered that in considerable blood loss
the first step is the transfusion not only blood,
but also crystalloids.
Transfusion therapy in obstetrics
hemorrhages
Blood
loss
10-20 %
5001000ml
20-30 %
10001500 ml
30-40 %
15002000 ml
40-and >
> 2000 ml
Volume
of
infusion
2500 ml
Crystalloids
Refortan,
Gelofusin
Stabisol
Freshfrozen
plasma
10-15 ml/
kg
10 ml /kg
-
-
10 ml /kg
10 ml /kg
5 - 10 ml
/kg
-
7 ml/kg
7 ml/kg
10 - 15 ml 200 ml
/kg
10 - 20 ml
/kg
7 ml/kg
10 ml /kg
15 - 20 ml
/kg
30 ml /kg
3000 ml
4000 ml
> 6000
ml
Albumin
Erythro(10-20 %) massa
200 ml
5 ml /kg
Aspects in pathogenesis of hypertensive
disorders in pregnancy
1. Generalized vasospasm.
2. Hypovolemia.
3. Hemoconcentration.
4. Disseminated intravascular coagulopathy.
5. Metabolic impairment as result of hypoxia.
6.Organ dysfunction – renal, hepatic, cardiac and
pulmonary, hematological, cerebral problems.
7. Placental dysfunction because the vasospastic
changes.
Classification of PIH
1. Hypertensive disorders during
pregnancy.
2. Edema during pregnancy.
3. Proteinuria during pregnancy.
4. Mild preeclampsia.
5. Moderate preeclampsia.
6. Severe preeclampsia.
7. Eclampsia.
Hypertension
In pregnancy is generally defined as
a diastolic blood pressure of 90 mm
Hg or greater, as a systolic blood
pressure at or above 140 mm Hg at
two estimations with the interval 4
hours or 160/110 mm Hg at once.
Preeclampsia
Is defined as the development of
hypertension with proteinuria or
edema (or both).
Clinical signs of severe
preeclampsia

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
General edema
weight gain exceeds more than 900 g in a
week
cerebral or visual disturbances such as
headache and scotomata
pulmonary edema or cyanosis
epigastric or right upper quadrant pain,
evidence of hepatic dysfunction
Oligouria (less than 500 ml/ day)
Assessment of different stages of PIH
severity
Mild
preeclampsia
Symptom of
evaluation
Moderate
preeclampsia
Edema
Light,
on + abdomen
lower
extremitas
Diastolic blood pressure
90-99
Hg
Proteinuria
in
collection sample
a
Severe
preeclampsia
Considerabl
e
mm 100-110 mm > 110 mm
Hg
Hg
24hours < 0,3 g / L
0,3-5 g / L
5 g/ L
TREATMENT

1. Bed rest. Preferably with as much of the
time as possible spent in a lateral decubitus
position. In this position, cardiac function and
uterine blood flow are maximized and maternal
blood pressures in most cases are normalized.
This improves uteroplacental function, allowing
normal fetal growth and metabolism.
 Ambulatory treatment has no place in the
management of PIH.
 Bed-rest throughout the greater part of the day
is essential.
Mild preeclampsia –
expectant management
Sedative drugs for normalization of
status of central nervous system:
 Droperidol – 2 ml IM,
 Seduxen – 2 ml IM.
 These drugs should be combined with
Droperidol – 0,25 % - 2ml IM or IV
Antihypertensive therapy eliminates vasospasm of
macro- and microcirculation.
It is started if BP > 150/100 mmHg

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



Methyldopa – a2 adrenoagonists, false neurotransmission
in the dose 250-500 mg 3- 4 time a day – FIRST-LINE
DRUG
Labetalol – a- and b- adrenergic blockers – in the dose
100-400 mg 2-3 times per day (10-20 mg IV every 10
minutes till 300 mg) –SECOND-LINE DRUG
Atenolol – b1- adrenergic blockers in the dose 25-100 mg
once a day
Metoprolol - b1- adrenergic blockers in the dose 12,5-50
mg 2 times per day
Nifedipine – calcium-channel blocker – in the dose 10 mg
po q 4-8 hours;
Hydralazine – miometrial vasodilator (if diastolic pressure
is repeatedly above 110 mm Hg ) An initial dose of 5 mg
given every 10 minutes till 20 mg until suitable blood
pressure is achieved.
Spasmolytic agents – No-spani 2 % - 2-4 ml IM,
Papaverine hydrochloride – 2 % - 2-4 ml IM,
Plathyphillinum – 0,2 % - 2, 0 – twice a day, Dibasol – 1 %
2-4 ml IM or IV, Euphyllinum – 2,4 % 10, 0 IV.
Magnesium Sulfate
It is used when diastolic pressure is >
110 mm Hg
 It is used to arrest and prevent the
convulsions of eclampsia
 It
has
spasmolytic,
sedative,
antihypertensive and anticonvulsant
effects.

Limitated intravenous fluid therapy
under control of blood volume,
hematocrit, diuresis.
Primarily saline (lactated Ringer’s,
isotonic solution)should be given at a
rate of 60-125 ml per hour
Complications of preeclapsia
Maternal – placenta abruption, cerebral
hemorrhage, renal and liver insufficiency,
disseminated
intravascular
coagulopathy,
adrenal
insufficiency,
eclampsia.
 Fetal – intrauterine growth retardation,
intranatal fetal death, infant morbodity
and mortality.

ECLAMPSIA
 Is
characterized typically by those
same abnormalities as severe
preeclampsia with the addition of
convulsions.
PROTOCOL FOR TREATING
ECLAMPSIA



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

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
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
Turn patient on the side,
Establish airways and administer oxygen
Pulmonary ventilation – elimination of hypoxia
Magnesial therapy.
Immediate delivery within 3 to 6 hours. Continue to administer
magnesium for at least 24 hours after delivery or last convulsion.
Attention! In the case if severe preeclampsia and eclampsia
three catheters should be inserted obligatory:
1 – into central vein - v. subclavia for a fluid therapy and
controlling of central venous pressure;
2 – into urinary bladder for controlling of diuresis per hour;
3 – transnasal catheterisation of stomach for prevention of
Mendelson’s syndrome.\
Hypotensive therapy – if DBP > 110 mm Hg
Schemes of magnesium administration in the
case of severe preeclampsia and eclampsia
Intravenous administration of Magnesium
Sulfate – 4 gram 16 ml 25 % during 5
minutes very slowly (it is dissolved in 34
.
ml isotonic solution).
Maintenance dose is 1g-2g/hour (7,
5gramm – 30 ml 25 % solution is
dissolved in 220 ml isotonic solution – 3,
33 % Magnesial solution)