Abnormal
Uterine
Action
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Page 1
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INTRODUCTION
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Normal labour is characterized
by coordinated uterine
contractions associated by
progressive dilatation of cervix
( more than 1 cm/hr) and
descent of the fetal head.
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Page 2
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DEFINITION
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Any deviation of the normal
pattern of uterine contractions
affecting the course of labour is
designated as disorder or
abnormal uterine action.
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Page 3
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ETIOLOGY
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• Advance age of mother.
• Prolonged pregnancy.
• Over distension of uterus due to twins or
hydromnios.
• Psychological factors.
• Contracted pelvis.
• Malpresentation.
• Injudicious administration of sedatives analgesics
and
oxytotics.
• Premature attempt at vaginal delivery or
instrumental
vaginal delivery under light
anesthesia.
Page 4
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CLASSIFICATION
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A.Over-efficient uterine action
• Precipitate labour: in
absence of obstruction
• Excessive contraction and
retraction: in
presence of obstruction
B.Inefficient uterine action
• Hypotonic inertia
• Hypertonic inertia
* Colicky uterus
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* Hyperactive
lower uterine segment
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• Constriction
(contraction) ring
C.Cervical dystocia
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Page 5
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PRECIPITATE
LABOUR
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• A Labour
is called precipitate when the
combined duration of the first and
second stage of labour is less then two
hours.
• Labour
is short as the rate of cervical
dilatation is 5cm/hr. more in nulliparous
women.
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Page 6
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ETIOLOGY
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• It is
more common in multiparous when
there are:
* strong
uterine contractions
* small
sized baby
* roomy(no
plenty of space) pelvis
* minimal
soft tissue resistance
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Page 7
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COMPLICATIONS
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• Maternal-
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Extensive
laceration of the cervix, vagina and
perineum(to
the extent of complete perineal
tear)
PPH due
to uterine hypotonia
Inversion
of uterus
Uterine
rupture
Infection
Amniotic fluid embolism
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•
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Fetal-
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Intra cranial stress and hemorrhage
Birth injuries
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Page 8
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MANAGEMENT
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• Patient
who had previous precipitate
labour should be hospitalized before
expected date of delivery as she is more
prone to repeated precipitate labour.
• the uterine
contractions may be
suppressed by administering Mgso4
during contractions.
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Page 9
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• Episiotomy: to avoid perineal
lacerations
and intracranial haemorrhage.
• Induction
of labour by low rupture of
membrane.
• Delivery
of head should be controlled &
careful conduction of delivery may be
done.
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Page 10
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EXCESSIVE
UTERINE
CONTRACTION AND
RETRACTION
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• This type
of uterine contraction is
predominantly due to obstructed labour
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Page 11
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Physiological
Retraction Ring
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• It is a line of demarcation
between the upper and lower
uterine segment present during normal labour
and cannot
usually be felt abdominally.
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Pathological Retraction Ring (Bandl’s ring)
* It is the
rising up retraction ring during obstructed labour
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due to
marked retraction and thickening of the upper uterine
segment while the relatively passive lower segment
is
markedly stretched and thinned to accommodate
the foetus.
*The Bandl’s
ring is seen and felt abdominally as a
transverse groove that may rise to or above
the symphysis
pubis.
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Page 12
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Page
13
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CLINICAL
FEATURES
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• Patient
is suffering from continuous pain and
discomfort and become restless
• Feature
of exhaustion and keto acidosis are
evident
• Abdominal
palpation reveals
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– Upper
segment is hard and tender and lower
segment is distended and tender
– Pathological
retraction ring is placed obliquely
between the umbilicus and symphysis pubis and
rises upward in course of time
– Round
ligament may be felt on either side
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Page 14
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– Fetal parts not well defined
– F.H.S.
is usually absent
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• Internal
examination reveals
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– Vagina
dry and hot, discharge is offensive
– Cervix
fully dilated
– Membranes
are absent
– Cause
of obstructed labour
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Page 15
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MANAGEMENT
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• Internal
inversion is contraindicated
• Correction
of dehydration and keto
acidosis by infusion of ringer’s solution
• Adequate
pain relief
• Parenteral
antibiotic
• Cesarean
delivery is done majority of the
cases
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Page 16
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UTERINE INERTIA
(hypotonic activity)
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• Uterine
inertia is a common type of disordered
uterine contractions and may complicate any
stage of labour.
• The intensity
of uterine contraction is diminished
duration is shortened, good relaxation in between
contractions and the intervals are increased.
• General
pattern of uterine contraction of labour is
maintained but intrauterine pressure during
contraction hardly rises above 25 mm
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Page 17
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• Patient feels less pain during
uterine
contractions.
• Less hardening
of the uterus during contraction
• Uterus
become relaxed after the contraction.
• Internal
examination reveals:-
a.Over dilatation of cervix.
b.Associated presence of contracted pelvis,
malposition, deflexed head or
Malpresentation.
c.Membranes usually remains intact.
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Page 18
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DIAGNOSIS
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Effect
on the Mother and
Fetus
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• Mother:
maternal exhaustion
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• Fetus:
fetal distress.
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Page 19
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MANAGEMENT
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Contemplating vaginal delivery
A.General measures:
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1.To keep
up the moral of the patient.
2.Posture
of the patient is changed (left lateral position)
supine position is avoided.
3.To empty
the bladder by catheterization if needed.
4.To maintain
the hydration by infusion of RL solution.
5. Adequate
pain relief by intramuscular pethedine 100mg
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Page 20
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B. Active measures:
• acceleration
of uterine contraction by lower
rupture of membrane followed by Oxytocin
drip.
• Oxytocin
is to be continued till 1 hr after
delivery.
• if cervical
dilatation remains unsatisfactory
and fetal distress appears, caesarian
section should be done.
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Page 21
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HYPERTONIC
UTERINE INERTIA
(Inco-ordinate Uterine Action)
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• the hypertonic
state of uterus arises
from any of the conditions such as
spastic lower uterine segment ,colicky
uterus , contraction , constriction ring
or generalized uterine contraction of
the uterus and all the states are
collectively called incordinate uterine
action
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Page 22
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TYPES
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• Colicky
uterus: incoordination of the
different parts of the uterus in
contractions.
• Hyperactive
lower uterine segment: so
the dominance of the upper segment is
lost.
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Page 23
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CLINICAL
FEATURES
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The condition
is more common in primigravidae and
characterised by:
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• Labour is
prolonged.
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• Uterine
contractions are irregular and more painful. The
pain is felt before and throughout the contractions
with
marked low backache often in occipito-posterior
position.
• High resting
intrauterine pressure in between uterine
contractions detected by tocography (normal
value is 5-10
mmHg).
• Slow cervical
dilatation .
• Premature
rupture of membranes.
• Foetal
and maternal distress.
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Page 24
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MANAGEMENT
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A. General
measures: as hypotonic inertia.
B. Medical
measures:
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– Analgesic
and antispasmodic as pethidine.
– Epidural
analgesia may be of good benefit.
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C. Caesarean
section is indicated in:
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– Failure
of the previous methods.
– Disproportion.
– Foetal
distress before full cervical dilatation.
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Page 25
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CONSTRICTION
(CONTRACTION) RING
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• It is
a persistent localized annular spasm
of the circular uterine muscles.
• It occurs
at any part of the uterus but
usually at junction of the upper and lower
uterine segments.
• It can
occur at the 1st, 2nd or 3 rd stage
of labour.
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Page 26
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ETIOLOGY
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Unknown
but the predisposing factors are:
* Malpresentations
and malpositions.
* Clumsy
intrauterine manipulations under
light anaesthesia.
* Improper
use of oxytocin e.g.
> use of oxytocin in hypertonic inertia.
>IM injection of oxytocin.
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Page 27
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DIAGNOSIS
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• The condition
is more common in
primigravidae and frequently preceded by
colicky uterus.
• The exact
diagnosis is achieved only by
feeling the ring with a hand introduced into
the uterine cavity.
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Page 28
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COMPLICATION
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• Prolonged
1st stage: if the ring occurs at
the level of the internal os.
• Prolonged
2nd stage: if the ring occurs
around the foetal neck.
• Retained
placenta and postpartum
haemorrhage: if the ring occurs in the 3rd
stage (hour- glass contraction).
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Page 29
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Pathological
Retraction
Ring
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Occurs in
prolonged 2nd stage.
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Always between
upper and lower
uterine
segments.
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Rises up.
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Felt and
seen abdominally.
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The uterus
is tonically retracted, tender
and the
foetal parts cannot be felt.
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Constriction Ring
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Occurs in
the 1st, 2nd or 3rd stage.
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At any level
of the uterus.
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Does not
change its position.
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Felt only
vaginally.
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The uterus
is not tonically retracted and
the foetal
parts can be felt.
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Maternal
distress and foetal distress or
death.
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Relieved
only by delivery of the foetus.
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Maternal
and foetal distress may not be
present.
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May be relieved
by anaesthetics or
antispasmodics.
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Page 30
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www.freelivedoctor.com
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MANAGEMENT
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• In the
1st stage: Pethidine may be of
benefit.
• In the
2nd stage: Deep general
anaesthesia and amyl nitrite inhalation are
given to relax the constriction ring:
• In the
3rd stage: Deep general
anaesthesia and amyl nitrite inhalation are
given followed by manual removal of the
placenta.
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Page 31
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CERVICAL
DYSTOCIA
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• Failure
of the cervix to dilate within a
reasonable time in spite of good
regular uterine contractions.
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Page 32
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TYPES
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A. Functional (primary):
> In
spite of the absence of any organic
lesion and the well effacement of the
cervix, the external os fails to dilate.
> This
may be due to lack of softening of the
cervix during pregnancy or cervical spasm
resulted from overactive sympathetic tone
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Page 33
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B.
Organic (secondary) due to:
> Cervical
scarring related to previous
amputation, cone biopsy, extensive
cauterisation or obstetric trauma.
> Organic
lesions as cervical myoma or
carcinoma.
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Page 34
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COMPLICATIONS
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• Annular
detachment of the cervix:
surprisingly the bleeding from the cervix is
minimal because of fibrosis and avascular
pressure necrosis leading to thrombosis of
the vessels before detachment.
• Rupture
uterus.
• Postpartum
hemorrhage: particularly if
cervical laceration extends upwards
tearing the main uterine vessels.
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Page 35
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MANAGEMENT
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A. Organic dystocia:
> Caesarean
section is the management of
choice.
B.Functional dystocia:
Pethidine and antispasmodics: may be
effective
Caesarean section: if medical treatment
fails or foetal distress developed.
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Page 36
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PREMATURE RUPTURE OF
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MEMBRANES
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(PROM)
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Page 37
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Definition
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PROM is defined as the rupture
of the chorioamniotic membrane
before the onset of labor
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Page 38
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Incidence
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PROM occurs in about
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10%~15% of all delivery
PROM is associated with 10%
of term pregnancy
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Page 39
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Cause of PROM
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Trauma (abdominal striked intensely)
Sexual intercourse(particularly in the late
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gestational weeks)
Vaginal infection
due to
bacteria 、 virus 、 TOXO 、 CMV 、 HPV and
HSV,et al
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Smoking
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Page 40
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Other :
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Prior PROM
A short
cervical length
Prior preterm
delivery
Bleeding
in early pregancy
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Page 41
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Mothers:
(1) Infection
: intrauterine
puerperal
(2) Placental
abruption
(3) Preterm
delivery
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Page 42
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Infants:
(1) Preterm
Baby and their Complications :
(RDS / Fetal and Neurologic dysfunction
Intracranial hemorrhage)
(2) neonatal
pneumonia 、 sepsis
(3) Pulmonary
hypoplasia and fetal
compression syndrone
(4) Prolapse
or compression of umbilical cord
(5) Abruptio
placenta
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Page 43
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Clinical manifestation
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(1) Fluid
passing through the vagina
suddenly, and then small amounts of fluid
flow through the vagina intermitently,
particularly when the increased of
abdorminal pressure (cough,sneeze,et al)
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Page 44
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(2) Free flowing amniotic fluid
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(3) Fever
/ heart rate of mother and
infants ↑ / WBC and
CRP ↑/ Uterine
tenderness on palpation
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Page 45
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Vaginal speculum exam.:
leakage of amniotic fluid
(2) PH determination
of vaginal fluid
(3) The
“fern” test
(4) Aminoscopy
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Diagnosis
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(1)
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Page 46
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Management
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PROM at term:
(1) Awaiting the onset of spontaneous
labor for 12-24h
(2) Termination of pregnancy after 24
hours
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PROM before term:
Termination of pregnancy
(1) Evidence of fetal pulmonary maturation
(2) Evidence of inturine infection
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Page 47
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Expectant therapy
Indication :
(1) Evidence of fetal pulmonary inmaturation
(2) Without evidence of inturine infection
Management:
(1)To enhance fetal pulmonary maturation
(2) Antibiotic
(3) Tocolysis
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