Download Placenta previa

Pre-term pre-labor rupture of the
membranes
-PPROM
-occurs before 37 weeks' gestation,
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-pre-labour rupture of the membranes :
where rupture of the fetal membranes
occurs without the onset of spontaneous
uterine activity resulting in cervical
dilatation.
-PPROM affects 2% of pregnancies.
- Placental abruption is associated with
PPROM
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-17–34% recurrence rate in subsequent
pregnancies of affected women
-It may be associated with cervical
incompetence (although it is likely that
uterine contractions accompany the
rupture of membranes with this
condition).
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-There is a strong association
between PPROM and maternal
vaginal colonization with potentially
pathogenic micro-organisms
-the incidence of sub clinical
chorioamnionitis said to be around
30% Infection may both precede or
follow PPROM.
Risks of PPROM
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labour, resulting in a preterm birth
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chorioamnionitis, which may be followed by fetal and
maternal systemic infection if not treated promptly
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oligohydramnios if prolonged PPROM occurs, with
associated fetal problems including pulmonary hypoplasia
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psychosocial problems resulting from uncertain fetal
and neonatal outcome and long term hospitalization
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cord prolapse
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malpresentation associated with prematurity
• primary antepartum haemorrhage.
Management
-management of this condition remains
controversial.
-Psychological consideration of the
woman's, and her partner's, circumstances
- If PPROM is suspected
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- the woman will be admitted to the labour suite
-a careful history is taken
- rupture of the membranes confirmed by a sterile
speculum examination of any pooling of liquor in
the posterior fornix of the vagina.
-Very wet sanitary towels over a 6 hrs period,
urine leakage should be excluded
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a positive Nitrazine test should not be
considered
- a fetal fibronectin immunoenzyme test
confirming rupture of the membranes
-ultrasound scanning .
-Digital vaginal examination should be
avoided to reduce the risk of introducing
infection.
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- Assess the fetal condition from the fetal
heart rate (an infected fetus may have a
tachycardia) and maternal infection screen.
-temperature and pulse, should be recorded.
-uterine tenderness and purulent or
offensively smelling vaginal discharge,
should be observed
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-If the woman has a gestation of less than 32
weeks, the fetus condition normal ,no signs of
APH or labor, she will be managed as :
-hospitalization
- frequent ultrasound scans to check the growth of
the fetus and the extent and complications of any
oligohydramnios.
- corticosteroids as soon as PPROM is confirmed.
-tocolytic drugs will be considered to prolong the
pregnancy.
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- presence of vaginal infection should be
treated with antibiotics and prophylactic
antibiotics erythromycin seems to be the
drug of choice for most women .
HROM:it is a hind water leakage , and the
pregnancy may proceed with no further
complications
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-Treated by amnioinfusion .
- If membranes rupture before 24 weeks of
gestation the outlook is not good; the fetus
is likely has both problems caused by
oligohydramnios or to those caused by preterm birth.
-termination of the pregnancy
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If the woman is more than 32 weeks'
pregnant, the fetus appears to be
compromised and APH or intervening
labour is suspected or confirmed,
-The mode of birth will be decided either
induction of labour or caesarean section
Malignant disease in pregnancy
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-Incidence 1 in 1000–1500 pregnancies .
- The most common malignancies
associated with pregnancy are,: cervix,
ovary, breast, melanoma, leukemia,
lymphoma and colorectal carcinoma.
women with delayed childbearing liable
for cancer .
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- Pregnancy may adversely affect the course
of the disease, and cancer in the mother can
metastasize to the placenta and fetus,
melanoma being the most likely to do so.
-If cancer is discovered before pregnancy ,it
should be treated and followed up before
pregnancy is attempted
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-when cancer discovered during pregnancy
leads dilemmas.
- The options involve balancing the effects
of the treatment, the disease and birth on
both the mother and her fetus.
-If the woman is in early pregnancy, her
first dilemma may be whether or not to
continue with the pregnancy
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If she continues, the next dilemma will be
whether to treat the disease during the
pregnancy or await birth
-as both chemotherapy and radiation
therapy may have toxic effects, particularly
on the fetus
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- Surgery is the treatment least likely to
affect the pregnancy adversely, particularly
if it takes place in later pregnancy, but it
may not be the treatment of first choice .
-Elective pre-term birth is often favored by
medical practitioners
Obesity and failure to gain weight
in pregnancy
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-the value of frequent routine weighing of all
pregnant women in predicting various perinatal
outcomes.
- women who have a poor diet and their fetuses
are at greater risk than well-nourished women
-Weight is no more than a very crude indicator of
a woman's health status in pregnancy
Obesity :
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- the midwife's observation of a very obese
woman, or a very thin one, should alert her to
some of the risks such women may face during
pregnancy and the longer term risks to both
women and their children
-A woman who starts pregnancy while obese, or
puts on an excessive amount of weight during
pregnancy, appears to be at greater risk of:
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*hypertensive disturbances, including
pregnancy-induced hypertension .
* at greater risk of gestational diabetes
* both of these conditions make her more
likely to be delivered by caesarean section.
*at increased risk of urinary tract infection.
* uncertain fetal position.
*postpartum hemorrhage.
*thrombophlebitis.
*more likely to give birth to a large for
gestational age infant
*at greater risk of shoulder dystocia .
*evidence of a relationship between maternal
obesity and perinatal mortality.
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* The woman is also more prone to wound
infection following operative delivery. *Obesity
may also be associated with malnourishment from
essential nutrient deficiency.
* Obesity is, an important risk factor for maternal
death.
-excessive weight increase during pregnancy
being a greater risk factor for of hypertensive
disorders
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- its sudden onset may signal occult
oedema. If such weight gain is noted by the
woman or the midwife it is important to
take the woman's blood pressure and test
her urine for protein.
-Once oedema has been excluded, the
midwife should discuss the woman's diet
with her.
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- as early in their pregnancy as possible, or
even before, and at regular intervals
thereafter. Midwives should discuss diet,
nutrition, life style, exercise and the reasons
why excessive weight gain in pregnancy is
undesirable
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-There is no advantage to dieting during
pregnancy (and strict dieting may be dangerous).
- Referral to a dietician may be helpful.
-Blood pressure measurements should always be
taken accurately with a correctly sized cuff.
- gestational diabetes and urinary tract infection
should be screened .
- Frequent routine weighing
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- The midwife should also bear in mind that
obesity can be a symptom of another
disease, such as:
- hypothyroidism
-polycystic ovarian syndrome
-Cushing's disease, and in such cases diet
will have only a minimal effect on weight
Failure to gain weight
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-the midwife may observe that a woman
appears to be thin during her pregnancy. -Detailed discussion should attempt to elicit
the quality and quantity of the woman's diet
and her weight pattern over previous years.
-Some women are naturally very slim and
remain so because of :
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*genetic factors
*a high metabolic rate.
Result: going on to produce a healthily
sized baby.
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-a medical disorder such as
*a malabsorption condition
*starvation
*anorexia nervosa.
* bulimia, or both.
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-she is at greater risk of :
1-anaemia
2- intrauterine growth restriction
3- birth asphyxia .
4- perinatal death.
Note: Bulimia may be wrongly diagnosed
as hyperemesis gravidarum.
The midwife's role:
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-will depend on the cause.
-She should always involve the medical practitioner
because of the risk of intrauterine growth restriction
-admitted to, a clinical psychologist or psychiatrist.
-Dietary discussion and advice, including the use of
supplements such as multivitamins and referral to a
dietician
- discuss with the woman, Quality of nutrition, than
quantity
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Problems associated with pregnancy
following assisted conception
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Couples who achieve pregnancy following
assisted conception may be at greater risk of
complications during the pregnancy than those
who conceive naturally
The cause of the fertility problem may be: a
medical problem that is aggravated by pregnancy.
It is also known that with some forms of assisted
conception there is an increased rate of:
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multiple pregnancy
- the risk of pre-eclampsia
- preterm labor.
-Women who undergo assisted conception
are likely to be an older age group, either
having previously tried for some time to
conceive a baby naturally or having fertility
problems because of their increased age.
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- Increased maternal age has slight associations
with multiple pregnancy and pre-eclampsia, and
the older a woman is the more liable to develop a
medical problem such as essential hypertension or
diabetes mellitus, or a gynecological problem such
as fibroids.
‘precious pregnancy’, need appropriate care
&intervention.