Download L10 Ectopic-and-Molar-Pregnancy-Pregnancy

Pregnancy Complications
Flip class-Monday
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Nausea and vomiting, Constipation, GERD during pregnancy
Rh D Alloimmunization
DM and GDM in pregnancy
HTN, Pre-eclampsia and eclampsia in pregnancy
VTE in pregnancy
UTI in pregnancy
Induction of Labor and Labor analgesia
Postpartum Hemorrhage, Preterm Labor, Antenatal Glucocorticoid and
PPROM Preterm Premature Rupture of Membranes
• Ectopic and molar pregnancy
DM during pregnancy & Gestational DM
• GDM
• Diagnosis of diabetes at 24 to 28 weeks of gestation
• Overt DM
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Diagnosis at the first prenatal visit
A1C ≥6.5 percent
A fasting glucose ≥126 mg/dL
A1C is 5.7 to 6.4 percent
• Two hour 75 gram oral glucose tolerance test (GTT)
Range of diagnostic criteria for gestational
diabetes
Approach
Two step (100gram load)
Two step (75gram load)
One step (75gram load)
Criteria*
Fasting mg/dL
One-hour
mg/dL
Two-hour
mg/dL
Three-hour
mg/dL
Carpenter and
Coustan
95 (5.3
mmol/L)
180 (10.0
mmol/L)
155 (8.6
mmol/L)
140 (7.8
mmol/L)
NDDG
105 (5.8
mmol/L)
190 (10.6
mmol/L)
165 (9.2
mmol/L)
145 (8.0
mmol/L)
CDA
95 (5.3
mmol/L)
191 (10.6
mmol/L)
160 (8.9
mmol/L)
WHO
92 to 125 (5.1
to 6.9 mmol/L)
180 (10.0
mmol/L)
153 to 199 (8.5
to 11 mmol/L)
IADPSG
92 to 125 (5.1
mmol/L)
180 (10.0
mmol/L)
153 (8.5
mmol/L)
• These thresholds are for diagnosis of gestational diabetes. Diagnosis of
overt diabetes and diabetes in pregnancy are based on different criteria
(eg, IADPSG: fasting blood glucose ≥126 mg/dL [7.0 mmol/L] is consistent
with overt diabetes; WHO: two-hour glucose ≥200 mg/dL [11.1 mmol/L]
following a 75-gram oral glucose load is consistent with diabetes in
pregnancy).
• NDDG: National Diabetes Data Group;
• CDA: Canadian Diabetes Association;
• WHO: World Health Organization;
• IADPSG: International Association of Diabetes and Pregnancy Study
Groups.
Diagnostic criteria for the 100-gram three-hour GTT to diagnose gestational diabetes mellitus
Plasma or serum glucose level
Carpenter/Coustan
Plasma level
National Diabetes Data Group
mg/dL
mmol/L
mg/dL
mmol/L
Fasting
95
5.3
105
5.8
One hour
180
10.0
190
10.6
Two hours
155
8.6
165
9.2
Three hours
140
7.8
145
8.0
100-gram oral glucose load is given in the morning to a patient who has fasted overnight for at least 8 hours.
Glucose concentration greater than or equal to these values at TWO or more time points is a positive test.
Two different classification schemes of GDM based upon results of the three-hour GTT results have been
proposed. The Fourth International Workshop-Conference on Gestational Diabetes GTT values cited above are
based upon the Carpenter and Coustan modification of earlier values. They are lower than those proposed by
the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus and the National Diabetes Data
Group (NDDG), which used cutoff values of 105, 190, 165, and 145 mg/dL (5.8, 10.6, 9.2, and 8.0 mmol/L),
respectively. The values are lower because the thresholds derived from the older Somogyi-Nelson method of
glucose analysis were corrected to account for the enzymatic assays currently in use.
ADA criteria for the diagnosis of diabetes
1. A1C ≥6.5 percent. The test should be performed in a laboratory using a method that is NGSP certified
and standardized to the DCCT assay.*
OR
2. FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least eight hours.*
OR
3. Two-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test should be performed as
described by the World Health Organization, using a glucose load containing the equivalent of 75-gram
anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose
≥200 mg/dL (11.1 mmol/L).
Risk factors
• Pregnant women with any of the following characteristics appear
• Personal history of impaired glucose tolerance or gestational diabetes in a previous
pregnancy
• Member of one of the following ethnic groups, which have a high prevalence of type 2
diabetes: Hispanic-American, African-American, Native American, South or East Asian, Pacific
Islander
• Family history of diabetes, especially in first degree relatives
• Prepregnancy weight ≥110 percent of ideal body weight or BMI >30 kg/m2, significant weight
gain in early adulthood and between pregnancies, or excessive gestational weight gain
• Maternal age >25 years of age
• Previous delivery of a baby >9 pounds (4.1 kg)
• Previous unexplained perinatal loss or birth of a malformed infant
• Maternal birthweight >9 pounds (4.1 kg) or <6 pounds (2.7 kg)
• Glycosuria at the first prenatal visit
• Medical condition/setting associated with development of diabetes, such as metabolic
syndrome, polycystic ovary syndrome (PCOS), current use of glucocorticoids, hypertension
Timing of screening/testing
• 1st first prenatal
• In the absence of early screening/testing or if
early screening/testing is negative, universal screening is performed
at 24 to 28 weeks of gestation
Management
• Medical nutritional therapy,
• Self-monitoring of blood glucose levels
• Awakening and one or two hours after each meal
• Insulin therapy, when needed rather than oral anti-hyperglycemic agents during
pregnancy
• Glyburide or metformin is a reasonable alternative for women who refuse to take, or are
unable to comply with, insulin therapy.
• metformin results in a lower rate of macrosomia than use of glyburide, metformin users are more
likely to require supplemental insulin to maintain euglycemia than glyburide users. The long-term
effects of transplacental passage of oral anti-hyperglycemic agents are not known.
• Target: 95/130-140/120
• Initiate: 95/13-140/120
• fasting BG ≥95 mg/dL/one-hour postprandial BG ≥130 to 140 mg/dL/two-hour BG >120 mg/dL
• Women with GDM be tested postpartum and that they receive screening at least every
three years thereafter
HTN in pregnancy
• Preeclampsia-eclampsia
• Syndrome of new onset of hypertension and either proteinuria or end-organ
dysfunction most often after 20 weeks of gestation in a previously
normotensive woman
• Eclampsia is diagnosed when seizures have occurred.
• Chronic (preexisting) hypertension
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≥140 mmHg and/ ≥90 mmHg
Antedates pregnancy,
Present before the 20th week of pregnancy,
Persists longer than 12 weeks postpartum.
Criteria for the diagnosis of preeclampsia
Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart
after 20 weeks of gestation in a previously normotensive patient
If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation within minutes is
sufficient
and
Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3
Dipstick ≥1+ if a quantitative measurement is unavailable
In patients with new-onset hypertension without proteinuria, the new onset of any of the following is diagnostic
of preeclampsia:
Platelet count <100,000/microliter
Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease
Liver transaminases at least twice the normal concentrations
Pulmonary edema
Cerebral or visual symptoms
HTN in pregnancy
• Preeclampsia-eclampsia superimposed upon chronic hypertension
• Gestational hypertension
• elevated blood pressure first detected after 20 weeks of gestation in the
absence of proteinuria or other diagnostic features of preeclampsia.
• May progress to pre-eclampsia
• May progress to chronic HTN
HTN in pregnancy
• Treatment of severe hypertension: ok
• mild to moderate hypertension: not ok
• Angiotensin converting enzyme inhibitors, angiotensin II receptor
blockers, and direct renin inhibitors are contraindicated at all stages
of pregnancy
Chronic (preexisting) hypertension
• uncomplicated mild primary hypertension:
• Not initiating antihypertensive
• Initiate or resume antihypertensive
• ≥150 mmHg/ 95 to 99 mmHg
• lower pressures and signs of hypertensive end-organ damage
• Antihypertensive therapy
• methyldopa or labetalol
• A long-acting calcium channel blocker (eg, nifedipine) can be added if needed.
• Target: 140 to 150 mmHg/ 90 to 100 mmHg.
Preeclampsia
• avoiding antihypertensive therapy for mild hypertension associated with preeclampsia
• Treatment of severe hypertension to prevent maternal cerebrovascular complications.
• Initiate antihypertensive at ≥150/ ≥100 mmHg.
• Initiate treatment at a lower threshold in younger women whose baseline blood pressure was low,
and in those with symptoms that may be attributable to elevated blood pressure (eg, headache,
visual disturbances, chest discomfort).
• American College of Obstetricians and Gynecologists (ACOG)
• Treatment at ≥160 mm Hg.
• Acute blood pressure therapy
• labetalol IV or hydralazine IV.
• Target blood pressure goal is systolic pressure of 140 to 150 mmHg and diastolic pressure
of 90 to 100 mmHg.
Options for breastfeeding mothers
• Beta-blockers and alpha/beta-blockers
• Propranolol, metoprolol, and labetalol
• have the lowest transfer into milk
• Calcium channel blockers
• Diltiazem, nifedipine, nicardipine, and verapamil
• The American Academy of Pediatrics (AAP) compatible
• Angiotensin converting enzyme (ACE) inhibitors
• Captopril and enalapril
• AAP compatible
• Diuretics
• AAP compatible
Eclampsia
• Occurrence of new-onset, generalized, tonic-clonic seizures or coma in a woman
with preeclampsia.
• Preeclampsia/eclampsia remains a common cause of maternal morbidity and
death
• Clinical presentation and findings
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hours before the initial seizure
Hypertension (75 percent)
Headache (persistent frontal or occipital headaches or thunderclap headaches) (66 percent)
Visual disturbances (scotomata, loss of vision [cortical blindness], blurred vision, diplopia,
visual field defects [eg, homonymous hemianopsia], photophobia) (27 percent)
• Right upper quadrant or epigastric pain (25 percent)
• Asymptomatic (25 percent)
• Ankle clonus is also a common finding
Eclampsia
• Management
• If the seizure is witnessed, maintaining airway patency and preventing
aspiration are the initial priority
• Prevention of maternal hypoxia and trauma
• Treatment of severe hypertension, if present
• Prevention of recurrent seizures
• Evaluation for prompt delivery
Eclampsia
• Management
• Treatment of severe hypertension, if present
• to prevent stroke, which accounts for 15 to 20 percent of deaths from eclampsia.
• Initiating: ≥160 mmHg /105 to 110 mmHg????
• Drug choice and dose, and target blood pressure are the same as in preeclampsia
Eclampsia
• Management
• Prevention of recurrent seizures
• The anticonvulsive drug of choice is magnesium sulfate.
• Safer and more effective than phenytoin, diazepam, or lytic cocktail
(ie,chlorpromazine, promethazine and pethidine) for prevention of recurrent seizures in
eclampsia
• Loading dose
• 6 g intravenously over 15 to 20 minutes
• Maintenance dose
• 2 g / hr
• Management of persistent seizures
• Diazepam and lorazepam
Eclampsia
• Management
• Delivery Only curative treatment
• Cesarean delivery is a reasonable option for women less than 32 to 34 weeks
of gestation with an unfavorable cervix.
Prevention of Rh(D) alloimmunization in
pregnancy
• Rh(D)-negative pregnant women
• Antibody screen at the 1st prenatal visit.
• Negative
• repeat screen at 28 weeks of gestation is optional
• Noninvasive fetal RHD genotyping is the standard approach in some
countries
Prevention of Rh(D) alloimmunization in
pregnancy
• Rh(D)-negative Pregnants whose fetus is/may Rh(D)-positive:
• Administration of anti-D immunoglobulin early in the third trimester
• 300 micrograms at 28 weeks of gestation
• 100 to 120 micrograms at 28 and 34 weeks
Prevention of Rh(D) alloimmunization in
pregnancy
• Antenatal anti-D immunoglobulin
• Increased risk of fetomaternal hemorrhage
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miscarriage,
abortion,
ectopic pregnancy,
multifetal reduction,
amniocentesis,
chorionic villus sampling,
blunt abdominal trauma,
external cephalic version,
antepartum bleeding, and
fetal death.
300 micrograms as soon as possible within 72 hours of the event
Prevention of Rh(D) alloimmunization in
pregnancy
• Ongoing risk for fetomaternal hemorrhage
• Repeat dosing
• chronic placental abruption or placenta previa with intermittent vaginal
bleeding
• Serial determinations of the maternal indirect Coombs every three weeks
with repeat dosing if it is found to be negative.
Prevention of Rh(D) alloimmunization in
pregnancy
• Anti-D immunoglobulin within 72 hours of delivery of an Rh(D)positive infant
• 300 micrograms
• Additional doses
• Excessive fetomaternal hemorrhage
• If inadvertently omitted after delivery
• as soon as possible
• Partial protection is afforded with administration within 13 days of the birth
• May be an effect as late as 28 days after delivery
Prevention of Rh(D) alloimmunization in
pregnancy
• Management of pregnancies complicated by alloimmunization
• intrauterine fetal transfusions
• Investigational
• maternal plasmapheresis
• intravenous immune globulin therapy
Ectopic and molar pregnancy
• Definition
• Extrauterine pregnancy.
• Fallopian tube (98 percent)
• Symptoms
• Abdominal pain
• Vaginal bleeding
• > 50 percent of women are asymptomatic
• Evaluation
• transvaginal ultrasound (TVUS) examination
• Quantitative human chorionic gonadotropin (hCG) level
• measured serially every 48 to 72 hours
• hCG discriminatory zone
• Mostly 1500 to 2000 IU/L
• hCG is below the discriminatory zone
• Serial hCG is rising abnormally (does not increase by at least 53 percent in 48 hours OR
doubling in 72 hr
• Diagnosis is made based upon the hCG pattern.
• hCG is above the discriminatory zone
• Diagnosis by ultrasound
Diagnosis Algorithm
• The fetal pole
• Thickening on the margin of the
yolk sac of a fetus during
pregnancy.
• Usually identified
• 8 weeks with abdominal US
• 6 weeks with vaginal ultrasound
imaging
• Quite normal for the fetal pole to
not be visible until about 9 weeks
• Between 5 ½ to 6 ½ weeks, a fetal pole
or even a fetal heartbeat may be
detected by vaginal ultrasound.
• yolk sac attaches outside the
developing embryo
• Connected to the umbilical cord by
a yolk stalk.
• Acts as the preliminary circulatory
system and is eventually absorbed into
the gut of the embryo.
adnexal mass
• An adnexal mass is a lump in tissue of the adnexa of uterus
• structures closely related structurally and functionally to the uterus such as
the ovaries, fallopian tubes, or any of the surrounding connective tissue.
• Adnexal masses can be benign or cancerous, and they can be categorized as
simple or complex
The higher the hCG,
The higher the rate of failure
• MTX treatment optimal
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Hemodynamically stable
Have no renal, hepatic, or hematologic disorders
Able and willing to comply with post-treatment monitoring
Pretreatment serum hCG concentration less than 5000 mIU/mL
Tubal size of less than 3 to 4 cm and no fetal cardiac activity (these are not
independent predictors of MTX treatment success)
• Tubal pregnancy If treated with MTX
• single-dose over multiple-dose regimen
• Interstitial pregnancy
• Multi-dose regimen
• Surgery
• Urgent surgical treatment
• Women preference
Treatment overview
• Ruptured ectopic pregnancy or if patient is hemodynamically unstable
• Surgery is necessary
• Patients with ectopic pregnancy who are clinically stable
• both surgery and methotrexate therapy may be appropriate first-line therapy
if unruptured ectopic pregnancy
http://www.dynamed.com/topics/dmp~AN~T115772/Ectopic-pregnancy#Treatment
Treatment overview
• Surgery
• laparoscopy is often the preferred method
• options include
• salpingectomy or salpingostomy
• At least as effective as intramuscular methotrexate in women with
unruptured ectopic pregnancies (level 2 [mid-level] evidence)
• single dose of methotrexate following salpingostomy may prevent persistent
ectopic pregnancy in women with unruptured ectopic pregnancy (level 2
[mid-level] evidence)
http://www.dynamed.com/topics/dmp~AN~T115772/Ectopic-pregnancy#Treatment
Treatment overview
• Medical treatment with methotrexate
• No studies found comparing intramuscular methotrexate to placebo
• 3 different dosing protocols
• single-dose regimen of intramuscular methotrexate may not be as effective in
eliminating ectopic pregnancy as laparoscopic salpingostomy (level 2 [mid-level]
evidence)
• 2-dose regimen reported to be successful in 87% of cases (level 3 [lacking direct]
evidence)
• multiple-dose methotrexate not clearly more effective than single-dose methotrexate for
ectopic pregnancy (level 2 [mid-level] evidence)
• multi-dose intramuscular methotrexate not clearly more effective than surgical
management in hemodynamically stable women with ectopic pregnancy (level 2 [midlevel] evidence)
http://www.dynamed.com/topics/dmp~AN~T115772/Ectopic-pregnancy#Treatment
Treatment overview
• expectant management
• Patient is asymptomatic,
• evidence of spontaneous resolution is occurring, and
• patient accepts the risk of rupture
• Spontaneous resolution reported to occur in 48%-88% of ectopic
pregnancies
http://www.dynamed.com/topics/dmp~AN~T115772/Ectopic-pregnancy#Treatment
Homework
• What is the prevalence of ectopic pregnancy among Jordanians?
• PMID: 21077507
• 1/180-1/150
Molar pregnancy
• Gestational trophoblastic disease GTD
• Benign
• Hydatidiform mole
• Complete mole
• Karyotype diploid
• Partial mole
• Karyotype triploid
• Malignant
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Invasive mole,
Choriocarcinoma,
Placental site trophoblastic tumor, and
Epithelioid trophoblastic tumor.
Molar pregnancy
• Risk factors
• Extremes of maternal age
• ≤15 and >35 years
• History of previous mole
• S&S
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Elevated serum hCG
Vaginal bleeding,
Pelvic discomfort.
Enlarged uterus
Molar pregnancy
• Diagnosis
• Serum hCG
• hCG is high as >100,000 mIU/mL
• Pelvic ultrasound
Karyotype triploid
Karyotype Diploid
Treatment
• Uterine evacuation + suction curettage rather than medication-only
• Medications
• (misoprostol, mifepristone, oxytocin)
• age ≥40 years and have completed childbearing
• Hysterectomy rather than uterine evacuation
• Patients at high risk for GTN (neoplasia)
• Hysterectomy
• Prophylactic chemotherapy
• MTX or actinomycin D
• Follow-up of treatment
• Serial weekly serum hCG
• Reliable contraception during the entire interval of hCG monitoring.
• Rh(D) immune globulin
• Patients who are Rh(D)-negative should receive anti-Dimmune globulin at the time of treatment
because the Rh(D) factor is expressed on trophoblast.
Treatment
• Suction dilatation and curettage is the preferred treatment
• (Strong recommendation).
• Monitor for malignant postmolar gestational trophoblastic disease after surgical
management of molar pregnancy
• (Strong recommendation).
• Serial monitoring of human chorionic gonadotropin (hCG) to screen for postmolar
gestational trophoblastic disease is preferred over routine prophylactic chemotherapy
after evacuation of molar pregnancy in patients for whom follow-up is likely, although
prophylactic chemotherapy may decrease risk of postmolar gestational trophoblastic
disease in high-risk patient, especially if poor follow-up is likely
• (Weak recommendation).
• After diagnosis of molar pregnancy, advise patient to use contraception and avoid
pregnancy until hCG levels remain low (documented remission) for 6-12 months
• (Strong recommendation).
Preterm Labor
• Early signs and symptoms
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Non-specific
Menstrual-like cramping;
mild, irregular contractions;
low back ache;
pressure sensation in the vagina;
vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie,
mucus plug, bloody show)
Preterm births
• Early (<34 week)
• Late (34 to 36 weeks)
• Spontaneous
• 70-80%
• Preterm labor 40-50%
• PPROM 20-30%
• Initiated by a clinician
Preterm Labor
• Diagnosis
• Regular painful uterine contractions accompanied by cervical
dilation and/or effacement (cervix stretches and gets thinner).
• 34-35 weeks of gestation is the threshold at which perinatal morbidity and
mortality are too low to justify the potential maternal and fetal complications
and costs associated with inhibition of preterm labor, which only results in
short-term delay in delivery
Preterm Labor
• Discharge home
• ≥34 weeks of gestation,
• Without progressive cervical dilation and effacement after an observation
period of four to six hours
• Fetal well-being is confirmed
• <34 weeks of gestation+cervical length <3 cm
• transvaginal ultrasound
• analysis of cervicovaginal fetal fibronectin
Management
• Antenatal corticosteroid therapy for reduction of neonatal morbidity
and mortality from preterm delivery
• Tocolytic drugs for up to 48 hours to delay delivery so
that betamethasone given to the mother can achieve its maximum
fetal effect.
• Magnesium sulfate for pregnancies at 24 to 32 weeks of gestation.
• In utero exposure to magnesium sulfate provides neuroprotection against
cerebral palsy and other types of severe motor dysfunction in offspring born
preterm.
• Antibiotic therapy has no role in the treatment of acute preterm labor
in the absence of a documented infection or GBS prophylaxis
Inhibition of acute preterm labor
• Tocolytics to delay in delivery for 48 hours
• So that antenatal corticosteroids can be administered and achieve their
maximal effect;
• Allow safe transport of the mother, if indicated, to a facility that can provide
an appropriate level of neonatal care if the patient delivers preterm; and
• prolong pregnancy when there are underlying, self-limited causes of labor,
such as abdominal surgery, that are unlikely to cause recurrent preterm labor.
Inhibition of acute preterm labor
• 24 to 32 weeks of gestation
• Indomethacin as first-line therapy for labor inhibition
• C/I
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maternal platelet dysfunction or bleeding disorder,
hepatic dysfunction,
gastrointestinal ulcerative disease,
renal dysfunction, or
asthma
Gestations over 32 weeks and caution against their use for more than 72 hours because
of concern about premature narrowing or closure of the ductus arteriosus
• Nifedipine
• 24 to 32 weeks + C/I to Indomethacin
• Terbutaline
Inhibition of acute preterm labor
• 32 to 34 weeks of gestation
• Nifedipine as the first-line therapy
• terbutaline
• avoid concurrent use of tocolytic drugs
Inhibition of acute preterm labor
• Less effective tocolytic drugs
• Oxytocin receptor antagonists
• Atosiban
• Magnesium sulfate
• Nitric oxide donors
• Ineffective
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bedrest,
hydration,
sedatives,
antibiotics, and
progesterone supplementation
Threatened abortion
Postpartum Hemorrhage
• Definition
• ≥500 mL after vaginal birth or
• ≥1000 mL after cesarean delivery.
• Primary PPH occurs in the first 24 hours after delivery
• Secondary PPH occurs 24 hours to 12 weeks after delivery
• Causes
• atony,
• trauma, and
• acquired or congenital coagulation defects
Postpartum Hemorrhage
• Management
• Depending on the cause and whether the patient has had a vaginal birth or
cesarean delivery.
• Traumatic, hemorrhaging lesions are managed surgically
• Coagulopathy is managed medically, with replacement of blood products.
• Atony depends on the route of delivery
PPROM
• Membrane rupture before the onset of uterine contractions
• Preterm Premature Rupture of Membranes
• Prelabor rupture of membranes
• before 370/7thsweeks of gestation.
• 3%
• 30% of preterm births
PPROM
• Risk factors
• Similar to those for preterm labor
• Strong association
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PPROM in a previous pregnancy,
genital tract infection,
antepartum bleeding, and
cigarette smoking
Risk factors for preterm birth
Risk factors for preterm birth
PPROM
• The diagnosis of PPROM is clinical,
• Visualization of amniotic fluid in the vagina of a woman who presents
with a history of leaking fluid.
• Laboratory tests (eg, Nitrazine and fern or Amnisure) are used for
confirmation in cases of clinical uncertainty.
Pregnancy complications associated with
preterm premature rupture of membranes
(PPROM)
• (A) Typical ferning pattern of dried amniotic fluid (400).
(B, C) Urine and amniotic fluid can be distinguished by microscopic
examination of a droplet of the fluid spread and dried on a
microscope slide. The proteins in amniotic fluid give the appearance
of ferning (B) that is not observed with urine (C).
(D) Ferning pattern from amniotic fluid.
CDC algorithm for screening for GBS in PROM
before 37 weeks of gestation
PPROM management
• Expeditious delivery
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intrauterine infection,
abruptio placentae,
nonreassuring fetal testing, or
a high risk of cord prolapse is present or suspected
PPROM management
• Stable patients with PPROM <34 weeks
• Expectant management
• + A course of antenatal corticosteroids to enhance fetal lung maturation in
pregnancies less than 34 weeks of gestation
• +Prophylactic antibiotics
• ampicillin 2 g intravenously every 6 hours for 48 hours, followed by amoxicillin (500 mg orally
three times daily or 875 mg orally twice daily) for an additional five days.
• one dose of azithromycin (one gram orally) at the time of admission and repeat the dose five
days later.
• Confirmed gestational age
• Delivery at ≥34 weeks of gestation without assessment of pulmonary maturity
• Gestational age is uncertain
• Confirm lung maturity before delivery
• delivery at 36 weeks, assuming the mother and fetus are stable
Antenatal Glucocorticoid
• Improvement in neonatal lung function by enhancing maturation
• Reduces the incidence of
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respiratory distress syndrome,
intraventricular hemorrhage,
necrotizing enterocolitis,
sepsis, and
neonatal mortality by approximately 50 percent.
Antenatal Glucocorticoid
• Administration of antenatal corticosteroids to pregnant woman
• 23 to 34 weeks of gestation
• Increased risk of preterm delivery within the next seven days
• Rupture membranes or
• Receiving tocolysis for active preterm labor,
• Delivery for maternal or fetal indications is anticipated within the next seven days.
Antenatal Glucocorticoid
• 230/7ths weeks of gestation the lower limit
• Earlier administration in the 22nd week is reasonable if aggressive
neonatal intervention is planned
Antenatal Glucocorticoid
• A course of antenatal corticosteroids consists
• betamethasone 12 mg IM every 24 hours for two doses
• Dexamethasone 4 doses of 6 mg IM 12 hours apart.
Antenatal Glucocorticoid
• Women delivered at 340/7ths to 386/7ths
• Theoretical long-term hazards of steroid administration, particularly adverse
neurodevelopment
• Cesarean delivery at 340/7ths to 366/7ths weeks
• May give first course of antenatal corticosteroids
• 340/7ths to 366/7ths weeks who have already received a course of antenatal
corticosteroids, or who are expected to deliver vaginally, or whose
likelihood of delivery within the next seven days is uncertain, we suggest
not administering a course of antenatal corticosteroids
• Repeat courses of steroids have not be studied after 34 weeks, transient
tachypnea of the newborn is less common after labor and vaginal birth,
and most women with threatened preterm labor do not deliver preterm.
• Inadequate data
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number of courses that are safe for the fetus,
the appropriate time interval between courses,
the optimal dose for repeated courses of therapy, or
the full ramifications of the single course approach to therapy
• Single course of salvage (rescue, booster)
• Risk of delivery within the next seven days,
• More than two weeks have elapsed since the initial course of antenatal
corticosteroid therapy,
• Gestational age at administration of the initial course was <28 weeks of gestation
• Two dose course is also reasonable.
Induction of Labor
• Techniques for stimulating uterine contractions to accomplish delivery
prior to the onset of spontaneous labor.
• Indicated
• Continuing the pregnancy is thought to be associated with greater
maternal or fetal risk than intervention to deliver the pregnancy
• Avoid elective induction of labor at term
• Modified Bishop scoring system
• ≥8 suggests the chances of having a vaginal delivery are good and the cervix is
considered favorable or ripe for induction.
• ≤6 the chances of having a vaginal delivery are low and the cervix is considered
unfavorable or unripe for induction.
Induction of Labor
• Women with favorable cervices
• Oxytocin with early rather than amniotomy alone
• Artificial rupture of membranes (AROM)
• low-dose oxytocin protocol
• Oxytocin alone without amniotomy is also reasonable
• High-dose oxytocin regimens
• Decrease the time from admission to vaginal delivery,
• Does not appear to decrease the incidence of cesarean delivery
• Higher rate of tachysystole than low-dose regimes
Oxytocin infusion protocols
Regimen
Starting
dose,
milliunits/
minute
Low-dose
Alternative low-dose
0.5 to 1
1 to 2
High-dose
6
Alternative high-dose
4
Dosage
interval,
minutes
Incremental increase,
milliunits/minute
1
2
6
The incremental increase
should be reduced to 3
milliunits/minute if
hyperstimulation is present,
and reduced to 1
milliunit/minute if
recurrent hyperstimulation.
Some clinicians limit to a
maximum cumulative dose
of 10 units and a maximum
duration of six hours.
4
30 to 40
15 to 30
15 to 40
15
Side effects of oxytocin
• Maternal
• cardiovascular instability
•
•
•
•
hypotension,
tachycardia,
myocardial ischemia,
arrhythmias
• Nausea, vomiting, headache, and flushing
• Rarely, large doses have caused water retention, leading to hyponatremia.
• Neonatal
• Hyperbilirubinemia?
Ripening the unfavorable cervix prior to induction
• Two major techniques
• Mechanical (physical) interventions
• Insertion of catheters or cervical dilators
• Application of cervical ripening agents
• Prostaglandins
• Misoprostol (Cytotec®)
• PGE1 analog
• 100 mcg and 200 mcg tablets, breakable
• Oral and vaginal routes
• Dinoprostone
• PG E2
• for vaginal insertion, and tablet for oral administration
Labor analgesia
Labor analgesia
• Low concentrations of the local
anesthetics bupivacaine and ropivacaine produce greater sensory
than motor block
• Fentanyl and sufentanil are used interchangeably to provide labor
analgesia
• Provide only about 90 minutes of pain relief.
• Do not provide reliable analgesia for the late first stage or second stage of
labor.
• Combination of fentanyl or sufentanil and a low concentration of
bupivacaine or ropivacaine.
Labor analgesia
• Epinephrine
• Potentiate analgesia
• Decrease local anesthetic requirements,
• Enhances motor block,
• Cesarean delivery under neuraxial anesthesia
• Local anesthetic + epinephrine