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1. 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 weeks 400 ml at 42 weeks 300 ml at 43 weeks 1

2. Disorders of Amniotic Fluid cont …. There are two chief abnormalities of amniotic fluid: Polyhydramnious ( Hydramnious ) Oligohydramnious 2

3. 1. 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: 3

4. Polyhydramnious Cont… Diabetes mellitus, placental tumors, fetal anomalies like esophageal artesia , tracheoesophageal fistula, spinal bifida and anencephaly, RH isoimmunization , multiple gestations are clinical conditions associated with polyhydraminos 4

5. Polyhydramnious Cont… Types of Polyhydramnious: Acute Polyhydramnious Chronic Polyhydramnious A. Acute Polyhydramnious: Is very rare Usually occurs at about 20 weeks Comes on very sudden The uterus reaches the xiphisternum with in 3 – 4 days 5

6. Polyhydramnious Cont… Frequently associated with severe fetal malformations and monozygotic twins Ends with spontaneous abortion most of the time Severe abdominal pain is common symptom B. Chronic Polyhydramnious: Is gradual in onset Usually from 30 weeks of pregnancy Is the most common type 6

7. Recognition: The mother may complain of breathlessness and discomfort: the condition may exacerbate heartburn, indigestion, edema, and varicosities. 7 Polyhydramnious Cont…

8. S/S : On Inspection: The uterus is larger than expected The uters is globular in shape The abdominal skin appears stretched and shiny marked straegravidarum Obvious superficial blood vessels are seen 8 Polyhydramnious Cont…

9. B. On Palpation: The uterus feels tense It is difficult to feel fetal parts(may be balloted b/n two hands) Fluid thrill is present Abdominal girth increase rapidly(in acute) 9 Polyhydramnious Cont…

10. C. On Auscultation: FHB is difficult to hear D. Ultrasonic Scanning: Confirms polyhydramnious by measuring fluid “pools’’ NB : Investigations are needed to know the cause of the polyhydramnious. 10 Polyhydramnious Cont…

11. Assignment: Definition of Polyhydramnious based on ultrasound Single pocket_____ cm All pockets ________ cm 2. Role of indomethacin in management of polyhydramnious 11 Polyhydramnious Cont…

12. Complications: Maternal ureteric obstruction Increased fetal mobility leading to unstable lie and malpresentation Cord presentation and cord prolapse Premature rupture of membranes (PROM) Placental abruption Premature labour 12 Polyhydramnious Cont…

13. Complications cont… Increased risk of C/S Post partum hemorrhage High perinatal mortality rate 13 Polyhydramnious Cont…

14. Polyhydramnious Cont… Management: The cause of the condition should be determined if possible. Management depends on: Condition of the fetus and the mother The cause and degree of polyhydramnious Stage of pregnancy 14

15. Polyhydramnious Cont… Mgt of Asymptomatic Polyhydramnious: Managed expectantly The woman is not necessarily admitted to hospital but should be advised that if she suspects that her membranes has been ruptured, immediate admission is recommended Bed rest. 15

16. Polyhydramnious Cont… Mgt of Symptomatic Polyhydramnious: Hospital admission for at least 2 weeks. Upright position to relive dyspnea Anti acids to relive heart burn Amniocentesis Induction of labour if worsening Delivery should be hospital 16

17. Polyhydramnious Cont… NB: 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 17

18. Polyhydramnious Cont… Be ready to manage PPH!!! The baby should up sided down at birth and also carefully examined for congenital abnormalities!!! 18

19. 2. 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 pregnancy Fetal malformations and PROM in late pregnancy Postterm pregnaancy 19

20. Oligohydramnious Cont… Note : The lack of amniotic fluid reduces the intrauterine space and over time causes compression deformities: Squashed looking face Flattening of the nose Migrognathia Talipes equine varus Dry and leathery appearance of the skin 20

21. Oligohydramnious Cont… S/S: Uterus is small for dates (early) Uterus feels full of fetus (late) Breech presentation is common FHR is normal Small columns by ultrasound Management: Renal agenesis: Termination of pregnancy PROM: Amino infusion by normal saline 21

22. Premature 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 weeks Tem PROM: if >37 weeks Causes of PROM: Precise cause is unknown but it is associated with: 22

23. PROM Cont… Causes of PROM: Malpresentation Infection – chorioamnionitis Trauma: Pelvic examination Coitus Increased intrauterine pressure Multiple pregnancy Polyhydramnious 23

24. PROM Cont… STIs Low soc economic status Incompetent cervix Possible weak areas in the amnion and chorion 24

25. PROM Cont… Diagnosis: 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 25

26. PROM Cont… 2. Nitrazine paper test: Amniotic fluid is alkaline Vaginal secretions are acidic 3. Fern test: The best method; 4. Ultrasound: little or no amniotic fluid will be seen 5. Intra amniotic injection of dye 26

27. PROM Cont… Management of PROM: The two main approaches of management are: Conservative/ expectant and Active 27

28. PROM Cont… Active Management : is preferred when the risk associated with PROM is greater than that is associated with termination of pregnancy(I NFECTION ) When GA is less than 37 weeks Confirm diagnosis R/O Chorioamnionitis : fever, thachycardia , purulent vaginal discharge, uterine tenderness( When there is chorioamnionis induction is a must!) 28

29. PROM Cont… When 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 rest Temperature and pulse 4 hourly 29

30. PROM Cont… WBC count daily Avoid digital exam U/S weekly to assess amniotic fluid volume & fetal growth Steroids to mature fetal lungs Infection – induction is a must 30

31. PROM Cont… Conservative management a home: When all parameters are stable There is no excessive loss of amniotic fluid No coitus, no douche or vaginal tampons Temperature every 4 hr by the pt 31

32. PROM Cont… If GA is > 37 weeks: Induction of labour in absence of complications Dangers of PROM: Cord prolapse Preterm labour Malpresentation (breech) Infection( Chorioamnionitis ) APH 32

33. PROM Cont… Assignment Go 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. 33

34. Fetal 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 10 th percentile and abdominal circumference less than2.5 th percentile). 34

35. IUGR Cont… Causes: Maternal malnutrition Premature placental aging Placental infarcts Congenital infections Environmental hazards ( teratogenes , maternal substance abuse etc.) 35

36. IUGR Cont… Types of IUGR: There are two types of IUGR: Symmetrical(proportional) IUGR and Asymmetrical(Disproportional) IUGR 36

37. IUGR Cont… Symmetrical 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 occurs There is generalized defficency of cell number through out the body in all organ system. 37

38. IUGR Cont… The 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. 38

39. IUGR Cont… The 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. 39

40. IUGR Cont… Management: Check for possible causes and try to treat the cause Check for the fetal heart rate frequently Instruct the mother to count fetal movements by kick chart Termination of pregnancy to get alive baby if The fetus is at high risk Fetal lung maturity is adequate GA is > 43 weeks 40

41. B. Intrauterine Fetal Death (IUFD) Death of a fetus in uterus after 28 weeks of pregnancy. Causes: Maternal HTN(Pre eclampsia-eclampsia) Placental abruption Transplacental infections (Syphilis, typhoid fever…) Cord entanglement (rarely) 41

42. IUFD Cont… Rh – isoimmunization Maternal diabetes mellitus (DM) Post term pregnancy (Hypoxia) Severe anemia etc Note: In great number of instance, no cause is found In majority of IUFDs, labour starts spontaneously with in 2 weeks Induction of labour should be done at 3 – 4 weeks to prevent DIC. 42

43. IUFD Cont… S/S of IUFD: Loss of fetal movements FHRs are absent No fetal movements by ultrasound Spalding’s sign - (overlapping skull bones by x-ray Roberts's sign – Gas in the heart & great vessels by x- ray Exaggeration of fetal spine curvature by x- ray Maceration 43

44. IUFD Cont… Complications of IUFD: Bleeding DIC (>3 weeks in utero) Infection Psychological trauma Management: Induction of labour if not started spontaneously Antibiotics Investigate for underlying causes: Rh , syphilis … 44

45. IUFD Cont… Assignment: Write down the degrees(s/s, time span) of maceration of IUFD. 45

46. Preterm 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. 46

47. PTL 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. 47

48. PTL Cont… Risk Factors: Race (Black > non back) Low socio economic status Poor nutrition and low pre pregnancy weight History of previous PTL. Second trimester abortion Negative attitude towards pregnancy Current pregnancy complications including placenta previa, abruptio placenta, polyhydramnious, Oligohydramnious, 1 st trimester pregnancy and multiple pregnancies. 48

49. PTL Cont… Cervical conization Age <18y or >40 y Uterine anomaly or fibroids( Tumors) Maternal stress Anemia Cigarette smoking Genital infection or colonization Medical diseases(anemia, DM, HTN, pyelonephritis , and febrile illness) 49

50. PTL Cont… Diagnosis of PTL: Signs and symptoms: Uterine contraction 2/10/30” Cervical dilation and effacement. Progressive change in the cervix Cervical dilatation of 2 cm or more Cervical 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) 50

51. PTL Cont… Laboratory Studies: CBC with differentials U/A and sensitivity U/S for fetal size Amniocentesis for Maturity assessment Bacteriological study Electrolyte and blod sugar for pt requiring toclysis 51

52. PTL Cont… Management: The pt should be observed for ½ - 1 hr to determine appropriate management. See the table on the next slide. 52

53. PTL Cont… Group Uterine contractions Cxal Dilatation & Effacement Diagnosis Management I No No No labour None III Yes No 2 Pre term labor Hydration & sedation IV No Yes 3 Incompetent Cx Bed rest, consider cercalage V Yes Yes 3 Pre term labor Tocolysis 53

54. PTL Cont… 1 = two or more contractions per 10 minutes for 30 seconds 2 = Dilatation < 4cm and effacement < 80% 3 = Effacement of 80% with dilatation of 2 cm or more changes with observation. 54

55. PTL Cont… A. 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) 55

56. PTL Cont… 2. Fetal Disease and disorders: Fetal death Polyhydramnious Severe IUGR Fetal distress Intrauterine infection ( Chorioamnionitis ) Erythroblast sis fetalis 56

57. PTL Cont… 3. Miscellaneous: Ruptured membranes Bulging membranes Cervical dilatation >4 cm and effacement > 80% Mature fetus 57

58. PTL Cont… B. 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. 58

59. PTL Cont… Criteria to use tocolysis: The fetus is apparently healthy GA is b/n 28 & 37 weeks) Cervical dilation is < 4 cm & effacement < 80% The membranes are intact 59

60. PTL 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) 60

61. PTL Cont… Delivery: Vaginal delivery: Wide episiotomy “Prophylactic” forceps) C/S : for LBW and non vertex presentation. 61

62. PTL Cont… Identification and prevention of pre term labour: Identification: Prior pre term birth Cervical dilatation S/S including: Uterine contractions - Blood stained discharge Pelvic pressure - Pain in the lower back Menstural like cramps 62

63. PTL Cont… Prevention of PTL: Educate woman at high risk about s/s of preterm labor Follow closely with weekly or biweekly examination 63

64. Prolonged/Postterm/ Pregnancy Definition: 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. 64

65. Postterm Cont… 2. 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 onwards 5. X-ray 65

66. Postterm Cont… S/S of Postterm: Diminished liquor Reduced fetal movements Abnormal fetal heart rate Maternal wt loss Decreased uterine size Meconium stained liquor Advanced bone maturation- hard fetal skull 66

67. Postterm Cont… Note: pregnancy can not be said Postterm without accurate dating. Effects of Postterm: On the mother: Anxiety CPD Prolonged labour Risks related to C/S 67

68. Postterm Cont… B. 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 trauma 68

69. Postterm Cont… Appearance of post mature baby: Hard skull bones Small fontanelles with narrow suture Long finger nails Absence of vernix casiosa Dry, peeling and cracked skin 69

70. Postterm Cont… Factors increasing Risk: Congenital anomalies: Hydrocephaly Anencephaly Older primigravidae Poor obstetric history Pre-eclampsia DM Previous history of big baby 70

71. Postterm Cont… Management: Expectant: is appropriate when there are no complication: Rest Biophysical profile Amniotic fluid measurement Reassurance B. Active: ARM/ Oxytocin - induction of labour if fail C/S 71

72. Postterm Cont… Assignment: 1. What is bio physical profile: Write its 5 components with detail explanations. 2. What is non reassuring fetal heart rate pattern (NRFHRP) 72