PREGNANCY PREGNANCY INTERRUPTINGINTERRUPTING

N. BahnijN. Bahnij

Pregnancy interrupting – spontaneous preterm interrupting of pregnancy:

• To 12 weeks of pregnancy – early spontaneous abortion

• 13-22 weeks – late spontaneous abortion

• 22-36 weeks – preterm labor

Causes of Preterm BirthCauses of Preterm BirthMaternal infection• chronic tonsillitis• urinary tract infection• TORCH – infection• viral infection• chronic inflammatory diseases of the female sexual organs (vaginatis, bacterial vaginosis)Amnionic Fluid Infection• Chorioamnionic infection Maternal endocrine disorders: • ovarian hormonal insufficiency - patients with the late menarche, irregular menstrual cycle, genital

infantilism, infertility;• adrenal impairment – hyperandrogeny• thyroid gland impairment - hypothoroidism• Organic cervical dilation (cervical incomoetence), abnormal uterine developmentMedical and Obstetrical Complications• placental abruption, placental previa• pregnancy induced hypertension• multiple pregnancy• polyhydramniosLifestyle Factors• cigarette smoking, • poor nutrition, and poor weight gain during pregnancy, • use of drugs such as cocaine or alcohol have been reported to play important roles in the incidence

and outcome of low-birth weight infants;• low maternal age• poverty• short stature • occupational factors• psychological stress in the mother.

Classification of spontaneous abortion:Classification of spontaneous abortion:

• Threatened abortion• Initial abortion• Inevitable abortion• Incomplete abortion• Complete abortion

DIAGNOSIS AND TREATMENT OF DIAGNOSIS AND TREATMENT OF DIFFERENT TYPES OF ABORTIONSDIFFERENT TYPES OF ABORTIONS

Threatened abortionSigns – lover abdominal pain.In bimanual examination – cervix is

closed, enlargement of the uterus corresponds with gestational period

Management – conservative.

Initial abortionInitial abortion

Signs – lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period

Management – conservative.

Inevitable abortionInevitable abortion

Signs – cramp abdominal pain thanks to uterine contractions, bloody vaginal discharge till profuse hemorrhage.

In bimanual examination – cervix is dilated, products of conception are presented on cervical channel, enlargement of the uterus doesn’t correspond with gestational period – smaller

Management –surgical – uterine curettage.

Complete abortion – all products Complete abortion – all products of conception are expelled out of of conception are expelled out of

uterusuterus

Signs - lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is dilated or closed, enlargement of the uterus doesn’t correspond with gestational period – smaller.

Management –surgical – uterine curettage

Incomplete abortion – retention of Incomplete abortion – retention of some conceptus inside the uterussome conceptus inside the uterus

Signs – lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is dilated, enlargement of the uterus doesn’t correspond with gestational period – smaller, some products of conception should be expelled out.

Management –surgical – uterine curettage

Conservative treatment in the case of Conservative treatment in the case of threatened and initial abortion in early threatened and initial abortion in early

termsterms

• Bed rest• Sedative drugs – Valeriannae, Persen,

Novopaside.• Spasmolitics – No-Spani, Papaverini hydrochloride• Analgetics – Analgin, Baralgin• Progesterone – Utrogestan – 100 mg twice a day,

Duphastone – 10 mg 2-3 times a day, Progesterone 10-25 mg in a day

• Chorionic Gonadotropin Hormone• Vitamines – vit. E 200 mg per os, folic acid – 0,4

mg in a day

Conservative treatment in the case of Conservative treatment in the case of threatened and initial abortion in late threatened and initial abortion in late

terms (after 16 weeks)terms (after 16 weeks)

• Bed rest• Sedative drugs – Valeriannae, Persen,

Novopaside.• Spasmolitics – No-Spani, Papaverini hydrochloride• Tokolotic agents: Magnesii sulfatis 40 ml 25 % in

400 ml isotonic solution, b2- adrenomimetics (2 ml ginipral in 500 ml isotonic solution).

• Progesterone – Utrogestan – 100 mg twice a day, Duphastone – 10 mg 2-3 times a day.

Cervical incompetenceCervical incompetence

Accounts for about 15 to 20 percent of all pregnancy losses during the second trimester.

Premature effacement (shortening of the vaginal portion of the cervix and thinning of the walls) and dilation of the cervix is not caused by structural weakness in the cervix itself.

The weakness can result from a number of conditions, most due to prior injury to the cervix or resulting from an inherited physical condition of the cervix.

The cervix dilates without contractions or pain, sometimes opening completely. The dilation results in the amniotic membranes bulging through the opening and eventually rupturing, often before the baby can survive outside of the uterus. This irritates the uterus and brings on pregnancy interrupting.

Symptoms of Cervical IncompetenceSymptoms of Cervical Incompetence

• Women with incompetent cervix typically present with "silent" cervical dilation (i.e., with minimal uterine contractions) between 16 and 22 weeks of gestation. They present with significant cervical dilation (1 cm or more) and minimal symptoms.

Diagnosis of Cervical IncompetenceDiagnosis of Cervical Incompetence

Diagnosis is made by:• medical history,• physical exam, • and ultrasound study.

UUltrasoundltrasound findings findings• Funneling of the cervix with the changes in

forms T, Y, V, U (correlation between the length of the cervix and the changes in the cervical internal os).

• Cervix length < 25 mm• Internal cervical os more than 10 mm • Protrusion of the membranes. • Presence of fetal parts in the cervix or

vagina.

Funneling of the cervix with the changes Funneling of the cervix with the changes in forms T, Y, V, Uin forms T, Y, V, U

Treatment of Cervical IncompetenceTreatment of Cervical Incompetence• Surgical procedure called cerclage (stitching the

cervix closed). One or more stitches are placed around or through the cervix to keep it tightly closed.

• This is usually performed after 12 till 16 weeks of pregnancy, the time after which a woman is least likely to miscarry for other reasons - but it is not done if there is rupture of the membranes or infection.

• This procedure is carried out under general anaesthetic.

• After surgery, the mother is carefully monitored to check for infection and contractions, which are sometimes brought on by the procedure. After hospital discharge, the patient may remain on bedrest in order to remove any pressure on the cervix and increase the chance of retaining the pregnancy until the baby is viable. The cerclage is usually removed just before childbirth so that the patient can give birth vaginally.

A Shirodkar suture using Merselene tape at A Shirodkar suture using Merselene tape at the level of the internal os is the treatment the level of the internal os is the treatment

available.available.

McDonald suture with #4 mersilk at the level McDonald suture with #4 mersilk at the level of the internal osof the internal os

Preterm labor - is the term used to define infants who are born between 22 and 37 weeks of gestation with the weight 500 – 2500 gram and length 25 - 48 cm

Clinical classification of preterm laborClinical classification of preterm labor

•Threatened preterm labor

•Initial preterm labor

•Inevitable preterm labor

Signs and Symptoms of Preterm LaborSigns and Symptoms of Preterm Labor

Threatened preterm labor is characterized by:• symptoms of pelvic pressure, low back pain;• increase uterine tone; • absence of cervical effacement and dilation in vaginal

examination.

Initial preterm labor is characterized by:• irregular crampy – like painful uterine contractions;• presence of cervical effacement and dilation of the cervix

till 3-4 cm in vaginal examination;• amniotic fluid gush is present very often.

Inevitable preterm labor is characterized by:• regular uterine contractions;• cervical dilation more than 3-4 cm.

Peculiarities of Preterm labor duration:Peculiarities of Preterm labor duration:

• Preterm Ruptured Membranes• Known risk factors for preterm rupture of the membranes

include:1. preceding preterm labor; 2. occult amnionic fluid infection;3. multiple fetuses;4. abruptio placentae. • Uterine contractions abnormalities: uterine inertia, uterine

hyperactivity, discoordination.• Precipitatous preterm labor as a result of cervical

incompetence.• Vaginal bleeding as a result of placental abruption or placenta

previa is most common complication in labor.• Fetal hypoxia is more common in labor• Infectious complications are very common in labor

(chorionamnionitis) and postpartum period (endometritis, phlebitis).

Diagnosis of preterm labor includesDiagnosis of preterm labor includes::

• To learn the cause of preterm labor and its elimination.

• To estimate gestational age of pregnancy and probable fetal weight, its lie, presentation, visus.

• To diagnose uterine activity (presence or absence regular uterine contractions).

• To perform vaginal examination for learning cervical effacement and dilation, preterm ruptured membranes and to put correct diagnose of the preterm labor stage.

Management of preterm laborManagement of preterm labor

1. Expectant Management - nonintervention or expectant management, in which nothing is done and spontaneous labor is simply awaited

2. Active Management - intervention that may include corticosteroids, given with or without tocolytic agents to arrest preterm labor in order that the corticosteroids have sufficient time to induce fetal maturation.

Indications for expectant managementIndications for expectant management::

• threatened and initial preterm labor;• intact membranes; • gestational age of pregnancy till 36 weeks of

gestation;• satisfactory maternal and fetal conditions;• cervical dilation till 2-4 cm;• absence of infection, regular uterine contractions,

serious obstetric and extragenital pathology. • 28-34 weeks of pregnancy with preterm ruptured

membranes, absence of regular uterine contractions and infection.

• 28-34 weeks of gestation, intact membranes, 100 % cervical effacement and cervical dilation till 3-4 cm.

Expectant Management of Preterm labor in Expectant Management of Preterm labor in the case of Ruptured amniotic membranes:the case of Ruptured amniotic membranes:

1. One sterile speculum examination is performed to identify fluid coming from the cervix or pooled in the vagina. Demonstration of visible fluid or a positive Nitrazine test is indicative of ruptured membranes. Attempts are made to visualize the extent of cervical effacement and dilatation, but a digital examination is not performed. A cervicovaginal specimen is taken and culture sent for Neisseria gonorrhoeae.

2. Ultrasound examination is performed to help confirm gestational age, and assess amniotic fluid volume.

3. If the gestational age is 34 completed weeks or less and there are no other maternal or fetal indications for delivery, the woman is observed closely in Labor and Delivery, with continuous fetal heart rate monitoring

4. If there is no evidence of fetal jeopardy, or if labor does not begin, the woman is transferred to the High Risk Pregnancy Unit for close observation for signs of labor, infection, or fetal jeopardy.

5. General blood analysis – twice a day determination of leucocytes number, urine, vaginal smear, bacteriological examination once a 5 days.

6. To 34 weeks of pregnancy for 24-48 hours Inhibiting preterm labor drugs are prescribed - b-adrenergic inhibitors: 2 ml ginipral is dissolved in 500 ml isotonic solution with the rate 10 drops per minute.

7. Accelerated Maturation of Pulmonary Function - Dexamethasone, 6 mg, is given intramuscularly every 12 hours for 4 doses for enhancement of fetal maturation.

8. Antimicrobial Therapy in the case of infection.

Indications for active management:Indications for active management:

• preterm ruptured membranes;• regular uterine contractions;• presence of infection;• fetal jeopardy, hypoxia;• severe maternal diseases;• birth defects of the fetus;• obstetric complications of pregnancy (severe

pregnancy induced hypertension, polyhydramnios).Vaginal delivery is indicated in cephalic

presentations, cesarean section is performed in the case of breech presentation and transverse lie.

Expectant Management of Preterm labor in Expectant Management of Preterm labor in the case of Intact amniotic membranes:the case of Intact amniotic membranes:

• 1) Bed Rest• 2) Calcium Channel-blocking Drugs• Smooth muscle activity, including myometrium, is directly related to free calcium within the

cytoplasm, and a reduction in calcium concentration inhibits contraction. – Nifedipine, izoptine – 10 mg sublingualis every 15 minutes during 1 hour, after 20 mg three times a day.

• 3) Beta-adrenergic Receptor Agonists• There are two classes of b-adrenergic receptors: b1-receptors, dominant in the heart and intestines;

and b2-receptors, dominant in the myometrium, blood vessels, and bronchioles. A number of compounds generally similar in structure to epinephrine have been evaluated in the search for one that ideally would provide optimal stimulation of myometrial b2-receptors and thus inhibit uterine contractions while simultaneously causing few adverse effects from stimulation of receptors elsewhere.

• 1. Ritodrine – 1 g is dissolved in 250-400 ml isotonic solution and is prescribed invtravenously slowly during 4-12 hours.

• 2. Bricanil (Terbutaline) 0.5 mg is dissolved in 250-400 ml isotonic solution. Toxicity—especially maternal pulmonary edema and glucose intolerance—have been evident with its use (Angel and associates, 1988).

• 3. Partusistene (Fenoterol, Berotek) - 0.5 mg is dissolved in 250-400 ml isotonic solution and prescribed slowly i/v.

• 4. 2 ml (10 mkg) ginipral is dissolved in 500 ml isotonic solution with the rate 10 drops per minute. • 4 ) Magnesium Sulfate – is not prescribed nowadays• 5) Prostaglandin Inhibitors• Antiprostaglandin agents may act by inhibiting the synthesis of prostaglandins or by blocking the

action of prostaglandins on target organs. Several drugs are known to block this system, including aspirin and other salicylates, indomethacin, naproxen, and sulindac.

• Unfortunately, prostaglandin synthase inhibitors may adversely affect the fetus, and this has prevented widespread use of these agents for tocolysis. Complications include closure of the ductus arteriosus, necrotizing enterocolitis, and intracranial hemorrhage (Norton and co-workers, 1993).

• 6) Atosiban - a nonapeptide oxytocin analog. Atosiban has been shown to be a competitive oxytocin-vasopressin antagonist capable of inhibiting oxytocin-induced uterine contractions.

• 7 ) Nitric Oxide Donor Drugs• Nitric oxide is a potent endogenous smooth-muscle relaxant in the vasculature, the gut, and the

uterus. Nitroglycerin is an example of a nitric oxide donor drug.

Accelerated Maturation of Pulmonary FunctionAccelerated Maturation of Pulmonary Function

Glucocorticoid Therapy – is recommended till 34 weeks for gestation

• The mechanism by which betamethasone or other corticosteroids are currently thought to reduce the frequency of respiratory distress involves induction of proteins that regulate biochemical systems within type II cells in the fetal lung that produce surfactant (Ballard and Ballard, 1995). The reported physiological effects of glucocorticoids on the developing lungs include increased alveolar surfactant, compliance, and maximal lung volume.

• betamethasone (12 mg intramuscularly in two doses 24 hours apart) to prevent respiratory distress in the subsequently delivered preterm infant.

• dexamethasone, 6 mg intramuscularly every 12 hours - 24 mg all dose between 22 and 34 weeks.

• Repeated dose of hormones is not indicated.

Intrapartum ManagementIntrapartum Management

In general, the more immature the fetus, the greater the risks from labor and delivery.

• Labor. Whether labor is induced or spontaneous, abnormalities of fetal heart rate and uterine contractions should be sought, preferably by continuous electronic monitoring.

• Delivery. Novadays, for relaxation of vaginal outlet, a liberal

episiotomy and Pudendal anesthesia by 0.25 % Novocaine are not performed.

Perineal protective maneuvers don’t apply.