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Amniotic Fluid Disorders Normal amniotic fluid increases in amount throughout pregnancy until it reaches its maximum level(l liter) at 38 weeks of gestation.Amniotic fluid normal decrease 38 weeks onwards:800 ml at 40 weeks400 ml at 42 weeks300 ml at 43 weeks

1Disorders of Amniotic Fluid cont .There are two chief abnormalities of amniotic fluid:Polyhydramnious (Hydramnious)Oligohydramnious

21. Polyhydramnious Definition: polyhydramnious is an excess amniotic fluid which exceeds 2000 ml. Incidence: 9 in 1000 pregnancies.Etiology: Majority of polyhydramnios is idiopathic (>60 %) conditions that increase the surface area of the placenta and amnion or disrupt the integument of the fetus or hamper the normal swallowing process of the fetus:

3Polyhydramnious ContDiabetes mellitus, placental tumors, fetal anomalies like esophageal artesia, tracheoesophageal fistula, spinal bifida and anencephaly, RH isoimmunization, multiple gestations are clinical conditions associated with polyhydraminos

4Polyhydramnious ContTypes of Polyhydramnious:Acute PolyhydramniousChronic Polyhydramnious A. Acute Polyhydramnious:Is very rareUsually occurs at about 20 weeksComes on very suddenThe uterus reaches the xiphisternum with in 3 4 days

5Polyhydramnious ContFrequently associated with severe fetal malformations and monozygotic twinsEnds with spontaneous abortion most of the timeSevere abdominal pain is common symptom B. Chronic Polyhydramnious: Is gradual in onsetUsually from 30 weeks of pregnancyIs the most common type

6Recognition:The mother may complain of breathlessness and discomfort: the condition may exacerbate heartburn, indigestion, edema, and varicosities.

7Polyhydramnious ContS/S :On Inspection:The uterus is larger than expectedThe uters is globular in shapeThe abdominal skin appears stretched and shiny marked straegravidarum Obvious superficial blood vessels are seen

8Polyhydramnious ContB. On Palpation: The uterus feels tenseIt is difficult to feel fetal parts(may be balloted b/n two hands)Fluid thrill is presentAbdominal girth increase rapidly(in acute)

9Polyhydramnious ContC. On Auscultation: FHB is difficult to hearD. Ultrasonic Scanning:Confirms polyhydramnious by measuring fluid poolsNB: Investigations are needed to know the cause of the polyhydramnious. 10Polyhydramnious ContAssignment:Definition of Polyhydramnious based on ultrasoundSingle pocket_____ cmAll pockets ________ cm 2. Role of indomethacin in management of polyhydramnious 11Polyhydramnious ContComplications: Maternal ureteric obstructionIncreased fetal mobility leading to unstable lie and malpresentationCord presentation and cord prolapsePremature rupture of membranes (PROM)Placental abruptionPremature labour

12Polyhydramnious ContComplications contIncreased risk of C/SPost partum hemorrhageHigh perinatal mortality rate 13Polyhydramnious ContPolyhydramnious ContManagement:The cause of the condition should be determined if possible.Management depends on:Condition of the fetus and the motherThe cause and degree of polyhydramniousStage of pregnancy

14Polyhydramnious ContMgt of Asymptomatic Polyhydramnious: Managed expectantlyThe woman is not necessarily admitted to hospital but should be advised that if she suspects that her membranes has been ruptured, immediate admission is recommendedBed rest.

15Polyhydramnious ContMgt of Symptomatic Polyhydramnious: Hospital admission for at least 2 weeks.Upright position to relive dyspneaAnti acids to relive heart burnAmniocentesisInduction of labour if worseningDelivery should be hospital

16Polyhydramnious ContNB: Before inducing labour any malpresentation should be checked. While rupturing the membranes, hand should be in cervix for the following reasons: To prevent cord prolapse Feta and maternal distress are avoided To prevent placental abruption 17Polyhydramnious ContBe ready to manage PPH!!!The baby should up sided down at birth and also carefully examined for congenital abnormalities!!!182. Oligohydramnious Definition: Abnormally small amount of amniotic fluid which is less than 300 500 ml at term. Is a rare condition. Causes: Renal agenesis in early pregnancyFetal malformations and PROM in late pregnancy Postterm pregnaancy 19Oligohydramnious Cont Note: The lack of amniotic fluid reduces the intrauterine space and over time causes compression deformities: Squashed looking faceFlattening of the noseMigrognathiaTalipes equine varus Dry and leathery appearance of the skin 20Oligohydramnious Cont S/S:Uterus is small for dates (early)Uterus feels full of fetus (late)Breech presentation is commonFHR is normalSmall columns by ultrasoundManagement: Renal agenesis: Termination of pregnancyPROM: Amino infusion by normal saline

21Premature Rupture of Membranes(PROM)Definition: PROM Defined as spontaneous rupture of membranes at any(formerly 1 hr) time prior to on set of labour. Preterm PROM (PPROM): if < 37 weeksTem PROM: if >37 weeksCauses of PROM:Precise cause is unknown but it is associated with: 22PROM ContCauses of PROM:MalpresentationInfection chorioamnionitisTrauma:Pelvic examinationCoitusIncreased intrauterine pressureMultiple pregnancyPolyhydramnious

23PROM ContSTIsLow soc economic statusIncompetent cervixPossible weak areas in the amnion and chorion 24PROM ContDiagnosis: History: patients often report a leakage or gush of clear fluid from the vagina. Investigations: Sterile speculum examination: Escape of fluid from the cervix may be seen spontaneously or following the pressure from the abdomen valsalva maneuver 25PROM Cont2. Nitrazine paper test: Amniotic fluid is alkalineVaginal secretions are acidic 3. Fern test: The best method; 4. Ultrasound: little or no amniotic fluid will be seen5. Intra amniotic injection of dye26PROM ContManagement of PROM: The two main approaches of management are: Conservative/ expectant andActive

27PROM ContActive Management: is preferred when the risk associated with PROM is greater than that is associated with termination of pregnancy(INFECTION)When GA is less than 37 weeksConfirm diagnosisR/O Chorioamnionitis: fever, thachycardia, purulent vaginal discharge, uterine tenderness( When there is chorioamnionis induction is a must!)

28PROM ContWhen there is no Chorioamnionitis and GA is less than 37 weeks conservative management is favored. Conservative management at Hospital: Purpose: to allow the fetus to reach stage of maturity. Bed restTemperature and pulse 4 hourly

29PROM ContWBC count dailyAvoid digital examU/S weekly to assess amniotic fluid volume & fetal growthSteroids to mature fetal lungs Infection induction is a must

30PROM ContConservative management a home:When all parameters are stableThere is no excessive loss of amniotic fluid No coitus, no douche or vaginal tamponsTemperature every 4 hr by the pt

31PROM ContIf GA is > 37 weeks:Induction of labour in absence of complicationsDangers of PROM:Cord prolapsePreterm labourMalpresentation(breech)Infection(Chorioamnionitis)APH

32PROM ContAssignmentGo to Arbaminch Hospital OB/GYN ward and ask:Antibiotics used to: Prevent infection in woman with PROM including dose.Treat infection in woman with PROM including dose.

33Fetal Growth Abnormalities Intrauterine Growth Restriction (IUGR)Intrauterine Fetal Death (IUFD)

Intrauterine Growth Restriction (IUGR)Definition: IUGR is fetal condition characterized by failure to grow at the expected rate that can result in birth of small for gestational age (SGA) baby. (Estimated wt less than 10th percentile and abdominal circumference less than2.5th percentile). 34IUGR ContCauses: Maternal malnutritionPremature placental agingPlacental infarctsCongenital infectionsEnvironmental hazards (teratogenes, maternal substance abuse etc.)35IUGR ContTypes of IUGR: There are two types of IUGR:Symmetrical(proportional) IUGR and Asymmetrical(Disproportional) IUGR

36IUGR ContSymmetrical IUGR:Occurs when the fetus has experienced early and prolonged nutritional deprivation caused by severe chronic maternal malnutrition, placental insufficiency, intrauterine infection or fetal chromosomal abnormalities. Hypoplastic cell growth and development occursThere is generalized defficency of cell number through out the body in all organ system.

37IUGR ContThe neonate's body and head both appears small.The condition is associated with diminished brain size and permanent mental retardation. II. Asymmetrical IUGR:Results from nutritional deficiencies and placental insufficiency in late pregnancy.Atrophy of pre existing cells occur, resulting in diminished cell size but cell numbers are not reduced.The neonate appears to have disproportionally large head in relation to his body.

38IUGR ContThe body is long and emaciated with little subcutaneous fat, generalized muscle wasting, abdomen is scaphoid I shape, and the skin has poor skin turgor. Postnatal growth and development are rapid, and potential for normal intellectual function is excellent. 39IUGR ContManagement:Check for possible causes and try to treat the causeCheck for the fetal heart rate frequentlyInstruct the mother to count fetal movements by kick chartTermination of pregnancy to get alive baby if The fetus is at high riskFetal lung maturity is adequateGA is > 43 weeks

40B. Intrauterine Fetal Death (IUFD)Death of a fetus in uterus after 28 weeks of pregnancy.Causes:Maternal HTN(Pre eclampsia-eclampsia)Placental abruptionTransplacental infections (Syphilis, typhoid fever)Cord entanglement (rarely)

41IUFD ContRh isoimmunizationMaternal diabetes mellitus (DM)Post term pregnancy (Hypoxia)Severe anemia etcNote:In great number of instance, no cause is foundIn majority of IUFDs, labour starts spontaneously with in 2 weeksInduction of labour should be done at 3 4 weeks to prevent DIC.

42IUFD ContS/S of IUFD:Loss of fetal movementsFHRs are absentNo fetal movements by ultrasoundSpaldings sign - (overlapping skull bones by x-rayRoberts's sign Gas in the heart & great vessels by x- rayExaggeration of fetal spine curvature by x- rayMaceration

43IUFD ContComplications of IUFD:BleedingDIC (>3 weeks in utero)InfectionPsychological traumaManagement:Induction of labour if not started spontaneouslyAntibioticsInvestigate for underlying causes: Rh, syphilis

44IUFD ContAssignment:Write down the degrees(s/s, time span) of maceration of IUFD.45Preterm Labour(PTL) Definition: PTL is defined as labour occurring after 28 weeks but before 37 completed weeks of gestation. Complicates 5 15 % of all pregnancies. The single most important complication of PTL is prematurity and the care of premature infant is costly compared with term infants. Those born prematurely suffer greatly from increased morbidity and mortality. 46PTL Cont.Thus every effort should be made to prevent or inhibit preterm labor. If it can not be inhibited or is best allowed continuing, it should be conducted with the least possible trauma to the mother and infant.

47PTL ContRisk Factors: Race (Black > non back)Low socio economic statusPoor nutrition and low pre pregnancy weightHistory of previous PTL.Second trimester abortionNegative attitude towards pregnancyCurrent pregnancy complications including placenta previa, abruptio placenta, polyhydramnious, Oligohydramnious, 1st trimester pregnancy and multiple pregnancies.

48PTL ContCervical conizationAge 40 yUterine anomaly or fibroids( Tumors) Maternal stressAnemiaCigarette smokingGenital infection or colonizationMedical diseases(anemia, DM, HTN, pyelonephritis, and febrile illness)

49PTL ContDiagnosis of PTL: Signs and symptoms:Uterine contraction 2/10/30Cervical dilation and effacement.Progressive change in the cervixCervical dilatation of 2 cm or moreCervical effacement of 80% or more B. Visual estimates: During speculum exam, if fetal parts or membranes are visible, cervix is 2 cm or more dilated.C. Trans vaginal ultrasound showing: Cervical length (normally 2.5 3 cm)

50PTL ContLaboratory Studies:CBC with differentialsU/A and sensitivityU/S for fetal sizeAmniocentesis forMaturity assessmentBacteriological studyElectrolyte and blod sugar for pt requiring toclysis

51PTL ContManagement:The pt should be observed for - 1 hr to determine appropriate management. See the table on the next slide. 52PTL ContGroupUterine contractions Cxal Dilatation & EffacementDiagnosisManagementINoNo No labourNone IIIYesNo 2Pre term laborHydration & sedation IVNo Yes 3Incompetent CxBed rest, consider cercalage VYesYes 3Pre term laborTocolysis 53PTL Cont1 = two or more contractions per 10 minutes for 30 seconds2 = Dilatation < 4cm and effacement < 80% 3 = Effacement of 80% with dilatation of 2 cm or more changes with observation. 54PTL ContA. Cases in whom PTL should be allowed to continue.:Maternal diseases and disorders: Severe hypertensive disease (Pre eclampsia- eclampsia)Pulmonary or cardiac diseases (Pulmonary edema, ARDS, Valvular heart diseases)Maternal bleeding (APH, DIC)

55PTL Cont2. Fetal Disease and disorders: Fetal deathPolyhydramniousSevere IUGRFetal distressIntrauterine infection (Chorioamnionitis)Erythroblast sis fetalis56PTL Cont3. Miscellaneous: Ruptured membranesBulging membranesCervical dilatation >4 cm and effacement > 80%Mature fetus

57PTL ContB. Cases who need sedation and tocolysis:As for group II in the table above. C. Tocolysis: Group IV and failed group II Pts Approximately 10 30% of pts with PTL are eligible. 58PTL ContCriteria to use tocolysis:The fetus is apparently healthyGA is b/n 28 & 37 weeks)Cervical dilation is < 4 cm & effacement < 80%The membranes are intact 59PTL Cont.Drugs used for tocolysis: First line agents: - drenergics(ritodrine, terbutaline, fenoterol)Magnisum sulphate 2. Second line drugs Antiprostaglandines( Indomethacin, Naperoxen) Calcium channel blokers ( Nifedipine)

60PTL ContDelivery:Vaginal delivery: Wide episiotomyProphylactic forceps) C/S: for LBW and non vertex presentation.

61PTL ContIdentification and prevention of pre term labour: Identification: Prior pre term birthCervical dilatationS/S including:Uterine contractions - Blood stained discharge Pelvic pressure - Pain in the lower back Menstural like cramps

62PTL ContPrevention of PTL: Educate woman at high risk about s/s of preterm laborFollow closely with weekly or biweekly examination 63Prolonged/Postterm/ PregnancyDefinition: Postterm pregnancy is defined as the one that exceeds 294 days/42 weeks from the first date of the last menstrual period. Incidence: 10% of all pregnancies. High in primigravidae. Diagnosis: EDD calculation: do not forget to ask history of hormonal method of contraception.

64Postterm Cont2. Quickening: can be heard from 16 20 weeks (pregnant women should be asked to note the date they felt fetal movement first time).3. Ultrasound: Better if done before 20 weeks of gestation: accuracy with in 5 days n 95 % of cases.4. FHB: heard from 20 weeks onwards5. X-ray 65Postterm ContS/S of Postterm:Diminished liquorReduced fetal movementsAbnormal fetal heart rateMaternal wt lossDecreased uterine sizeMeconium stained liquorAdvanced bone maturation- hard fetal skull

66Postterm ContNote: pregnancy can not be said Postterm without accurate dating. Effects of Postterm:On the mother:AnxietyCPDProlonged labourRisks related to C/S

67Postterm ContB. On the fetus:Placental insufficiency fetal hypoxia fetal distress meconium aspiration IUFD

Mental Retardation Macrosomia- b/s the fetus has longer time to grow in the uterus Birth trauma68Postterm ContAppearance of post mature baby:Hard skull bonesSmall fontanelles with narrow sutureLong finger nailsAbsence of vernix casiosaDry, peeling and cracked skin69Postterm ContFactors increasing Risk:Congenital anomalies:HydrocephalyAnencephalyOlder primigravidaePoor obstetric historyPre-eclampsiaDMPrevious history of big baby 70Postterm ContManagement:Expectant: is appropriate when there are no complication:Rest Biophysical profile Amniotic fluid measurementReassuranceB. Active:ARM/Oxytocin- induction of labour if fail C/S 71Postterm ContAssignment:1. What is bio physical profile: Write its 5 components with detail explanations.2. What is non reassuring fetal heart rate pattern (NRFHRP)

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