Gestational conditions Hyperemesis Gravidarum

Unlike the transient nausea and vomiting normally experienced until about the 12th week of pregnancy, hyperemesis gravidarum is severe and unremitting nausea and vomiting that persists after the first trimester. It usually occurs with the first pregnancy and commonly affects pregnant women with conditions that produce high levels of human chorionic gonadotropin, such as hydatidiform mole or multiple pregnancy. This disorder occurs among blacks in about 7 in 1,000 pregnancies and among whites in about 16 in 1,000 pregnancies. The prognosis is good. Causes Several factors may contribute to hyperemesis gravidarum, including:

High or rapidly rising serum levels of hormones such as hCG (human chorionic gonadotropin)secreted by the fetus. Increased estrogen levels Pressure on the stomach and intestines a multiple pregnancy (i.e., twins or more) hydatidiform mole

Signs and Symptoms The patient typically complains of unremitting nausea and vomiting, the cardinal symptoms of hyperemesis gravidarum. The vomitus initially contains undigested food, mucus, and small amounts of bile; later, it contains only bile and mucus; and finally, blood and material that resembles coffee grounds. The patient may report substantial weight loss and eventual emaciation caused by persistent vomiting, thirst, hiccups, oliguria, vertigo, and headache. Inspection may reveal pale, dry, waxy, and possibly jaundiced skin, with decreased skin turgor; a dry and coated tongue; subnormal or elevated temperature; rapid pulse; and a fetid, fruity breath odor from acidosis. The patient may appear confused and delirious. Lassitude, stupor and, possibly, coma may occur. Diagnostic tests

Diagnosis is used to rule out other disorders, such as gastroenteritis, cholecystitis, and peptic ulcer, which produce similar clinical effects. Differential diagnosis also rules out hydatidiform gestation, hepatitis, inner ear infection, food poisoning, emotional problems, and eating disorders. The following test results support a diagnosis of hyperemesis gravidarum:

Serum analysis shows decreased protein, chloride, sodium, and potassium levels and increased blooc urea nitrogen levels. Other laboratory tests reveal ketonuria, slight proteinuria, elevated hemoglobin levels, and an elevated white blood cell count

Treatment The patient with hyperemesis gravidarum may require hospitalization to correct electrolyte imbalance and prevent starvation. I.V. infusions are used to maintain nutrition until she can tolerate oral feedings. She progresses slowly to a clear liquid diet, then a full liquid diet, and finally, small, frequent meals of high-protein solid foods. A midnight snack helps stabilize blood glucose levels. Parenteral vitamin supplements and potassium replacements help correct deficiencies. When persistent vomiting jeopardizes health, antiemetic medications are administered. Currently only meclizine and diphenhydramine are known to have a low risk for teratogenicity. When vomiting stops and electrolyte balance has been restored, the pregnancy usually continues without recurrence of hyperemesis gravidarum. Most patients feel better as they begin to regain normal weight, but some continue to vomit throughout the pregnancy, requiring extended treatment. If appropriate, some patients may benefit from consultations with clinical nurse specialists, psychologists, or psychiatrists.
Prevention

Many of the conditions that lead to hyperemesis are not preventable and it is unknown why some women without those conditions develop hyperemesis. You can try to reduce your nausea during pregnancy by:

Avoiding smells, foods or other things that stimulate nausea Eat frequent small meals Do not allow yourself to get too hungry or too full

Ectopic Pregnancy
Ectopic pregnancy is the implantation of a fertilized ovum outside the uterine cavity. It most commonly occurs in the fallopian tube, but other sites are possible. In whites, ectopic pregnancy occurs in about 1 in 200 pregnancies; in nonwhites, in about 1 in 120. The prognosis for the patient is good with prompt diagnosis, appropriate surgical intervention, and control of bleeding; rarely, in cases of abdominal implantation, the fetus may survive to term. Usually, only 1 in 3 women who experience an ectopic pregnancy give birth to a live neonate in a subsequent pregnancy. Causes An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked it. Pelvic inflammatory disease is the most common of these infections. Endometriosis or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress. Signs and Symptoms Ectopic pregnancy sometimes produces symptoms of normal pregnancy or no symptoms other than mild abdominal pain (the latter is especially likely in abdominal pregnancy), making diagnosis difficult. Typically, the patient reports amenorrhea or abnormal menses (after fallopian tube implantation), followed by slight vaginal bleeding and unilateral pelvic pain over the mass. If the tube ruptures, the patient may complain of sharp lower abdominal pain, possibly radiating to the shoulders and neck. She may indicate that this pain is often precipitated by activities that increase abdominal pressure such as a bowel movement. During a pelvic examination, the patient may report extreme pain when the cervix is moved and the adnexa is palpated. The uterus feels boggy and is tender. Diagnostic tests

Serum pregnancy (human chorionic gonadotropin [HCG] test result shows an abnormally low level of HCG and, when repeated in 48 hours, the level remains lower than the levels found in a normal intrauterine pregnancy. Real-time ultrasonography determines intrauterine pregnancy or ovarian cyst (performed if serum pregnancy test results are positive). Culdocentesis (aspiration of fluid from the vaginal cul-de-sac) detects free blood in the peritoneum (performed if ultrasonography detects absence of a gestational sac in the uterus). Laparoscopy may reveal pregnancy outside the uterus (performed if culdocentesis is positive). Differential diagnosis is used to rule out intrauterine pregnancy, ovarian cyst or tumor, pelvic inflammatory disease (PID), appendicitis, and recent spontaneous abortion. Treatment If culdocentesis shows blood in the peritoneum, laparotomy and salpingectomy are indicated, possibly preceded by laparoscopy to remove the affected falopian tube and control bleeding. Patients who wish to have children can undergo microsurgical repair of the fallopian tube. The ovary is saved, if possible; ovarian pregnancy requires oophorectomy. Nonsurgical, management of ectopic pregnancy involves the use of methotrexate, a chemotherapeutic agent, administered istered orally, I.M., or by local infiltration to destroy remaining trophoblastic tissue and avoid the need for lalaparotomy. Interstitial pregnancy may require hysterectomy; abdominal pregnancy requires a laparotomy to remove the fetus, except in rare cases, when the fetus survives to term or calcifies undetected in the abdominal cavity. Supportive treatment includes transfusion with whole blood or packed red blood cells to replace excessive blood loss, administration of broad-spectrum I.V. antibiotics for sepsis, administration of supplemental iron (given orally or I.M.), and institution of a high-protein diet.
Prevention

Avoiding risk factors for pelvic inflammatory disease , such as multiple sexual partners, intercourse without a condom, and sexually transmitted diseases

Early diagnosis and treatment of STDs Early diagnosis and treatment of salpingitis and PID

Gestational Trophoblastic Disease

Depending on histopathologic changes that occur in the trophoblast cells of the chorionic villi, gestational trophoblastic disease takes one of three forms. The first is hydatidiform mole, a nonmalignant neoplasm that forms on the chorion (the outer layer of the membrane containing amniotic fluid). The second form, commonly called invasive mole (chorioadenoma destruens), is a self-limiting, malignant tumor that occurs when trophoblastic tissue continues to grow and locally invades the uterine myometrium and pelvic blood supply. The third category is choriocarcinoma, a serious, rapidly developing. but rare, carcinoma. Neoplastic trophoblasts proliferate without cystic villi and may metastasize profusely throughout the body. Gestational trophoblastic disease is reported to occur in about 1 in every 2,000 pregnancies. Recent research indicates that the incidence would be much higher if all cases of the disorder were identified. Some cases aren't recognized because the pregnancy is aborted early and the products of conception aren't available for analysis. The incidence is increased in women from low socioeconomic groups, older women, and multiparous women. The incidence is highest in Asian women, especially those from Southeast Asia. With prompt diagnosis and appropriate treatment. the prognosis is usually excellent for patients with hydatidiform or invasive mole; about 10% of patients with hydatidiform mole develop choriocarcinoma. Recurrence is possible in about 2% of patients. Causes Hydatidiform mole is a condition which develops when a pregnancy has many complications. Conception takes place, but placental tissue grows very fast, rather than supporting the growth of a fetus. The result is a tumor, rather than a baby. This is known as a molar pregnancy. Choriocarcinoma is a similar type of growth. In approximately one-half of cases of choriocarcinoma, the preceding factor is hydatidiform mole. However, only 5 - 10% of molar pregnancies are associated with later choriocarcinoma. Therefore, choriocarcinoma remains an uncommon, yet almost always curable, cancer that can be associated with pregnancy. Signs and Symptoms A patient with hydatidiform mole may report vagina, bleeding, ranging from brownish red spotting to bright red hemorrhage. She may report passing tissue that resembles grape clusters. Her history may also include lower abdominal cramps, such as those that accompany

spontaneous abortion, hyperemesis, and signs and symptoms of preeclampsia. On inspection, a uterus that is exceptionally large for the patient's gestational date is detected. On pelvic examination. you may discover grapelike vesicles in the vagina. Palpation may reveal ovarian enlargement due to theca-lutein cysts. Auscultation of the uterus may reveal the absence of fetal heart tones normally noted during a previous visit. A patient with choriocarcinoma typically reports vaginal bleeding. If the disease has metastasized, she may also report hemoptysis, cough, dyspnea, headache, dizzy spells, weakness, paralysis, and rectal bleeding. Occasionally, a patient with choriocarcinoma may exhibit an acute abdomen due to rupture of the uterus, liver, or theca-lutein cyst. On inspection, the uterus may be enlarged, with blood coming through the os. A tumor may be visible in the vagina. Diagnostic tests Radioimmunoassay of HCG levels. performed frequently, can allow early and accurate diagnosis. HCG levels that are extremely elevated for early pregnancy indicate gestational trophoblastic disease. Histologic examination of possible hydatid vesicles is used to confirm the diagnosis. Ultrasonography performed after the third month shows grapelike clusters rather than a fetus. Amniography, a procedure that introduces a water-soluble dye into the uterus, may reveal the absence of a fetus (performed only when the diagnosis is in question). Doppler ultrasonography demonstrates the absence of fetal heart tones. Hemoglobin level and hematocrit, red blood cell count, prothrombin time, partial thromboplastin time, fibrinogen levels, and hepatic and renal function findings are abnormal. White blood cell count and erythrocyte sedimentation rate are increased. Chest X-rays, computed tomography scanning, and magnetic resonance imaging may be used to identify choriocarcinoma metastasis. Lumbar puncture may reveal early cerebral metastasis if HCG is in the cerebrospinal fluid. Differential diagnosis is used to rule out normal pregnancy, threatened abortion, uterine leiomyomas, multiple gestation, and incorrect gestational date Treatment

Gestational trophoblastic disease necessitates uterine aracuation by dilatation and curettage, abdominal hysterectomy, or instrument or suction curettage, depending on uterine size. I.V. oxytocin may be used to promote uterine contractions. Postoperative treatment varies, depending on the amount of blood lost and complications. If no complications develop, hospitalization is usually brief and normal activities can be resumed quickly, as tolerated. Because of the possibility of choriocarcinoma development following hydatidiform mole, scrupulous follow up care is essential. Such care includes monitoring HCG levels once weekly until titers are negative for 3 consecutive weeks; then once monthly for 6 months; then every 2 months for 6 months. It also includes chest X-rays to check for lung metastasis once monthly until HCG titers are negative, then once every 2 months for 1 year. Another pregnancy should be postponed until at least 1 year after all titers and X-ray findings are negative. An oral contraceptive is indicated to prevent pregnancy. Prophylactic chemotherapy with either methotrexate or actinomycin D after evacuation of the uterus has been successful in preventing malignant gestational trophoblastic disease. Chemotherapy with combination therapy and irradiation are used for metastatic choriocarcinoma.
Prevention

Although careful monitoring after the removal of hydatidiform mole or termination of pregnancy may not prevent the development of choriocarcinoma, it is essential in early identification of the condition, which improves outcome. INCOMPETENT CERVIX Incompetent cervix refers to the premature dilatation of the cervix, usually in the fourth or fifth month of pregnancy. It is associated with repeated second-trimester abortions. Possible causes include cervical trauma, infection, congenital cervical or uterine anomalies, or increased uterine volume (as with a multiple gestation). Diagnosis is based on a positive history of repeated, relatively painless and bloodless second-trimester abortions. Serial pelvic examinations early in the second trimester reveal progressive effacement and dilatation of the cervix and bulging of the membranes through the cervical os. If incompetent cervix is suspected, serial ultrasound provides information on dilatation of the internal cervical os before a dilated external os is detected.

Incompetent cervix is managed surgically with a Shirodkar procedure (cerclage)or a modification of it by McDonaldwhich reinforces the weakened cervix by encircling it at the level of the internal os with suture material. A purse-string suture is placed in the cervix in the first trimester or early in the second trimester. Once the suture is in place, a cesarean birth may be planned (to prevent repeating the procedure in subsequent pregnancies), or the suture may be cut at term and vaginal birth permitted. Recent research questions the effectiveness of cerclage in preventing late miscarriage or preterm birth (American College of Obstetricians and Gynecologists [ACOG], 2003). The woman must understand the importance of contacting her physician immediately if her membranes rupture or labor begins. The physician can remove the suture to prevent possible complications.

Abortion
In spontaneous abortion (miscarriage) or induced (therapeutic) abortion, the products of conception are expelled from the uterus before fetal viability (fetal weight of less than 17 oz [about 500 g] and gestation of less than 20 weeks). Up to 15% of all pregnancies and about 30% of first pregnancies end in miscarriage. At least 75% of miscarriages occur during the first trimester. The incidence of legal induced abortions is increasing in the United States. Causes Which are in the main the same as the causes of miscarriage and premature delivery. Abortion may be due to pathological changes in the ovum, the uterus, or its adnexa one or both -- to the physical or nervous condition of the woman, to diseases either inherited or acquired (syphilis, tuberculosis, rheumatism); to any infectious, contagious, or inflammatory disease; to shock, injury, or accident. It may be induced knowingly, willingly, and criminally by the pregnant person herself, or by someone else, with the aid of drugs, or instruments, or both. Signs and Symptoms A patient who has experienced a spontaneous abortion may report a pink discharge for several days or a scant brown discharge for several weeks before onset of cramps and increased vaginal bleeding. She may describe cramps that appear for a few hours, intensify, and occur frequently.

If the patient has expelled the entire contents of the uterus, the cramps and bleeding may subside. However, if any contents remain, cramps and bleeding continue. Diagnostic tests Human chorionic gonadotropin (HCG) in the blood or urine confirmspregnancy; decreased HCG levels suggest spontaneous abortion. Cytologic analysis indicates evidence of products of conception. Laboratory tests reflect decreased hematocrit and hemoglobin levels due to blood loss. Ultrasound examination confirms the presence or absence of fetal heart tones or an empty amniotic sac. The newer vaginal probe technique enables earlier visualization of the gestational sac. Differential diagnosis is done to distinguish spontaneous abortion from cervicitis, ectopic pregnancy, gestational thromboplastic disease, and malignancy. Treatment An accurate evaluation of uterine contents is necessary before planning treatment. The progression of spontaneous abortion can't be prevented, except in those cases caused by an incompetent cervix. Hospitalization is necessary to control severe hemorrhage. Severe bleeding requires transfusion with packed red blood cells or whole blood. Initially, l.V. administration of oxytocin stimulates uterine contractions. If remnants remain in the uterus, dilatation and curettage or dilatation and evacuation (D&E) should be performed. D&E is also used in first-trimester induced abortions. In second-trimester induced abortions, an injection of hypertonic saline solution or of prostaglandin into the amniotic sac or insertion of a prostaglandin vaginal suppository induces labor and expulsion of uterine contents. After a spontaneous or induced abortion, an Rhnegative female with a negative indirect Coombs' test should receive Rh(D) immune globulin (RhoGAM) to prevent future Rh isoimmunization. In a habitual aborter, spontaneous abortion can result from an incompetent cervix. Treatment involves surgical reinforcement of the cervix (cerclage) about 14 to 16 weeks after the last menstrual period. A few weeks before the estimated delivery date, the sutures are removed and the patient waits for the onset of labor. An alternative procedure, especially for the woman

who wants to have more children, is to leave the sutures in place and to deliver the infant by cesarean section.

Placenta Previa
In this disorder, the placenta implants in the lower uterine segment, where it encroaches on the internal cervical os. Placenta previa, one of the most common causes of bleeding during the second half of pregnancy, occurs in about 1 in 200 pregnancies, more commonly in multigravidas than in primigravidas. The placenta may cover all, part, or a fraction of the internal cervical os. Among patients who develop placenta previa in the second trimester of pregnancy, less than 15% have a persistent previa at term. The elongation of the upper and lower uterine segments causes the placenta to be located higher on the uterine wall. Generally, termination of pregnancy is necessary when placenta previa is diagnosed in the presence of heavy maternal bleeding. The maternal prognosis is good if hemorrhage can be controlled; the fetal prognosis depends on gestational age and the amount of blood lost. Causes Placenta previa occurs when the embryo implants in the lower part of the uterus and then grows to cover the exit. Doctors and researchers don't understand why this happens. They hypothesize that the condition may be related to:

Scars in the lining of the uterus (endometrium) A large placenta, such as in multiple pregnancy An abnormally shaped uterus

Signs and Symptoms Typically, a patient with placenta previa reports the onset of painless, bright red, vaginal bleeding after the 20th week of pregnancy. Such bleeding, beginning before the onset of labor, tends to be episodic; it starts without warning, stops spontaneously, and resumes later.

About 7% of all patients with placenta previa are asymptomatic. In these women, ultrasound examination reveals the disorder incidentally. Palpation may reveal a soft, nontender uterus. Abdominal examination using Leopold's maneuvers reveals various malpresentations due to interference with the descent of the fetal head caused by the placenta's abnormal location. Minimal descent of the fetal presenting part may indicate placenta previa. The fetus remains active, however, with good heart tones audible on auscultation. Diagnostic tests Transvaginal ultrasound scanning is used to determine placental position. Pelvic examination (under a double setup [preparations for an emergency cesarean] because of the likelihood of hemorrhage) performed immediately before delivery is used to confirm the diagnosis. In most cases, only the cervix is visualized. Laboratory studies may reveal decreased maternal hemoglobin levels (due to blood loss). Differential diagnosis excludes genital lacerations, excessive bloody show, abruptio placentae, and cervical lesions. Treatment Medical management of placenta previa is intended to assess, control, and restore blood loss; deliver a viable infant; and prevent coagulation disorders. Immediate therapy includes starting an I. V. infusion using a large-bore catheter; drawing blood for hemoglobin and hematocrit levels and for typing and cross matching; initiating external electronic fetal monitoring; monitoring maternal blood pressure, pulse rate, and respirations; and assessing the amount of vaginal bleeding. If the fetus is premature (following determination of the degree of placenta previa and necessary fluid and blood replacement), treatment consists of careful observation to allow the fetus more time to mature. If clinical evaluation confirms complete placenta previa, the patient is usually hospitalized due to the increased risk of hemorrhage. As soon as the fetus is sufficiently mature, or in case of intervening severe hemorrhage, immediate delivery by cesarean section may be necessary.

Vaginal delivery is considered only when the bleeding is minimal and the placenta previa is marginal or when the labor is rapid. Because of possible fetal blood loss through the placenta, a pediatric team should be on hand during such delivery to immediately assess and treat neonatal shock, blood loss, and hypoxia.
Prevention

There are no guidelines for preventing placenta previa. However, if you have it, you need to do the following to prevent bleeding:

Have the condition checked regularly Carefully follow any instructions you are given regarding bed rest and what to do if you have bleeding or contractions

Abruptio Placentae
Abruptio placentae - also called placental abruptionoccurs when the placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage. This disorder may be classified according to the degree of placental separation and the severity of maternal and fetal symptoms. Abruptio placentae is most common in multigravidas - usually in women over age 35 - and is a common cause of bleeding during the second half of pregnancy. A firm diagnosis when there is heavy maternal bleeding generally necessitates termination of the pregnancy. The fetal prognosis depends on the gestational age and amount of blood lost. The maternal prognosis is good if hemorrhage can be controlled. Causes The exact cause is not known; but high blood pressure, heart disease, and arthritis make it more likely. A trauma such as a car accident or a fall may trigger the problem. Cocaine abuse increases the risk. Signs and Symptoms Abruptio placentae produces a wide range of clinical effects, depending on the extent of placental separation and the amount of blood lost from maternal circulation.

A patient with mild abruptio placentae (marginal separation) may report mild to moderate vaginal bleeding, vague lower abdominal discomfort, and mild to moderate abdominal tenderness. Fetal monitoring may indicate uterine irritability. Auscultation reveals strong and regular fetal heart tones. A patient with moderate abruptio placentae (about 50% placental separation) may report continuous abdominal pain and moderate dark red vaginal bleeding. Onset of symptoms may be gradual or abrupt. Vital signs may indicate impending shock. Palpation reveals a tender uterus that remains firm between contractions. Fetal monitoring may reveal barely audible or irregular and bradycardic fetal heart tons. Labor usually starts within 2 hours and often proceeds rapidly. A patient with severe abruptio placentae (70% placental separation) will report abrupt onset of agonizing, unremitting uterine pain (described as tearing or knifelike) and moderate vaginal bleeding. Vital signs indicate rapidly progressive shock. Fetal monitoring indicates an absence of fetal heart tones. Palpation reveals a tender uterus with boardlike rigidity. Uterine size may increase in severe concealed abruptions. Assessment Tip Draw a line at the level of the fundus and check it every 30 minutes. If the level of the fundus increases, suspect abruptio placentae. Diagnostic tests Pelvic examination under double setup (preparations for an emergency cesarean) and ultrasonography are performed to rule out placenta previa. Decreased hemoglobin levels and platelet counts support the diagnosis. Periodic assays for fibrin split products aid in monitoring the progression of abruptio placentae and in detecting DIC. Differential diagnosis excludes placenta previa, ovarian cysts, appendicitis, and degeneration of leiomyomas. Treatment Medical management of abruptio placentae is intended to assess, control, and restore the amount of blood lost; to deliver a viable infant; and to prevent coagulation disorders.

Immediate measures for abruptio placentae include starting an I. V. infusion (by large-bore catheter) of appropriate fluids (lactated Ringer's solution) to combat hypovolemia, inserting a central venous pressure line and an indwelling urinary catheter to monitor fluid status, drawing blood for hemoglobin and hematocrit determination and coagulation studies and for typing and cross matching, starting external electronic fetal monitoring, and monitoring maternal vital signs and vaginal bleeding. After determining the severity of placental abruption and appropriate fluid and blood replacement, prompt delivery by cesarean section is necessary if the fetus is in distress. If the fetus isn't in distress, monitoring continues; delivery is usually performed at the first sign of fetal distress. (If placental separation is severe with no signs of fetal life, vaginal delivery may be performed unless uncontrolled hemorrhage or other complications contraindicate it.) Because of possible fetal blood loss through the placenta, a pediatric team should be ready at delivery to assess and treat the neonate for shock, blood loss, and hypoxia. Complications of abruptio placentae require appropriate treatment. With a complication, such as DIC, for example, the patient needs immediate intervention with heparin, platelets, and whole blood, as ordered, to prevent exsanguination.
Prevention

Avoid drinking, smoking or using other drugs during pregnancy. Get early and continuous prenatal care. Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure also decrease the risk of placenta abruptio.

Premature Rupture of The Membranes

Premature rupture of the membranes is a spontaneous break or tear in the amniotic sac before onset of regular contractions, resulting in progressive cervical dilation. This common abnormality of parturition occurs in nearly 10% of all pregnancies over 20 weeks' gestation, and labor usually starts within 24 hours; more than 80% of these infants are mature. The latent period (between membrane rupture and onset of labor) is generally brief when the membranes rupture near term. When the infant is

premature, the latent period is prolonged, which increases the risk of mortality from maternal infection (amnionitis, endometritis), fetal infection (pneumonia, septicemia), and prematurity. Causes PROM's causes aren't thoroughly understood, but taking certain steps may help reduce your risk. Smoking increases the risk of PROM, so quit now. Get early, regular prenatal care so that certain complications of pregnancy that increase the risk of PROM, such as uncontrolled high blood pressure, can be detected and treated. You also are at increased risk of PROM if you are pregnant with twins Signs and Symptoms A patient who has experienced premature rupture typically reports gushing or leaking of blood-tinged amniotic fluid containing vernix particles. Inspection during sterile speculum examination shows amniotic fluid in the vagina Diagnostic tests A characteristic passage of amniotic fluid confirms the rupture. Slight fundal pressure or Valsalva's maneuver may expel fluid through the cervical os. The following diagnostic tests support the diagnosis:

Alkaline pH of fluid collected from the posterior fornix turns nitrazine paper deep blue. (The presence of blood can give a false-positive result.) Staining the fluid with Nile blue sulfate reveals two categories of cell bodies. Blue-stained bodies represent sheath fetal epithelial cells; orange stained bodies originate in sebaceous glands. Incidence of prematurity is low when more than 20% of cells stain orange. A smear of fluid, placed on a slide and allowed to dry, takes on a fernlike pattern (because of the high sodium and protein content of amniotic fluid). This positive finding confirms that the substance is amniotic fluid. Vaginal probe ultrasonography may be done to yisualize the amniotic sac. Differential diagnosis excludes urinary incontinenre and vaginal infection.

Treatment

Fetal age and the risk of infection are considered in determining the course of treatment for premature rupture of the membranes. In a term pregnancy, if spontaneous labor and vaginal delivery aren't achieved within 24 hours after the membranes rupture, inducement of labor with oxytocin is usually necessary; if inducement fails. cesarean delivery is usually necessary. Cesarean hysterectomy is recommended with gross uterine infection. Management of a preterm pregnancy of less than 34 weeks is controversial; with advanced technology a conservative approach may be effective. With a preterm pregnancy of 28 to 34 weeks, treatment includes hospitalization and observation for signs of infection (maternal leukocytosis or fever and fetal tachycardia) while awaiting fetal maturation. If clinical status suggests infection, baseline cultures and sensitivity tests are appropriate. If these tests confirm infection, labor must be induced, followed by I.V. administration of antibiotics. A culture should also be made of gastric aspirate or a swabbing from the neonate's ear because antibiotic therapy may be indicated for him as well. During delivery, resuscitative equipment and ares thesia should be available. A pediatrician should be present to treat neonatal distress.
Prevention

Unfortunately, there is no way to actively prevent PROM. However, this condition does have a strong link with cigarette smoking and mothers should stop smoking as soon as possible.

Pregnancy-Induced Hypertension
Pregnancy-induced hypertension is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It most often occurs in nulliparous women and may be nonconvulsive or convulsive. Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7 % of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups. Eclampsia, the convulsive form, occurs between 24 weeks' gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease.

About 5% of women with preeclampsia develop eclampsia; of these, about 15% die of eclampsia or its complications. Fetal mortality is high because of the increased incidence of premature delivery. Pregnancy-induced hypertension and its complications are the current most common cause of maternal death in developed countries. Causes No one understands what is the trigger for the development of this condition. However, it seems to strike most often in first pregnancies and becomes less common with subsequent pregnancies. Signs and Symptoms A patient with mild preeclampsia typically reports a sudden weight gain of more than 3 lb (1.4 kg) a week in the second trimester or more than 1 lb (0.5 kg) a week during the third trimester. The patient's history reveals hypertension, as evidenced by elevated blood pressure readings: 140 mm Hg or more systolic, or an increase of 30 mm Hg or more above the patient's normal systolic pressure, measured on two occasions, 6 hours apart; and 90 mm Hg or more diastolic, or an increase of 15 mm Hg or more above the patient's normal diastolic pressure, measured on two occasions, 6 hours apart. Inspection reveals generalized edema, especially of the face. Palpation may reveal pitting edema of the legs and feet. Deep tendon reflexes may indicate hyperreflexia. As preeclampsia worsens, the patient may demonstrate oliguria (urine output of 400 ml/day or less), blurred vision caused by retinal arteriolar spasms, epigastric pain or heartburn, irritability, and emotional tension. She may complain of a severe frontal headache. In severe preeclampsia, blood pressure readings increase to 160/110 mm Hg or higher on two occasions, 6 hours apart, during bed rest. Also, ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage. Preeclampsia can suddenly progress to eclampsia with the onset of seizures. The patient with eclampsia may appear to cease breathing, then suddenly take a deep, stertorous breath and resume breathing. The patient may then lapse into a coma, lasting a few minutes to several hours. Awakening from

the coma, the patient may have no memory of the seizure. Mild eclampsia may involve more than one seizure; severe eclampsia up to 20 seizures. In eclampsia, physical examination findings are similar to those in preeclampsia but more severe. Systolic blood pressure may increase to 180 mm Hg and even to 200 mm Hg. Inspection may reveal marked edema, but some patients exhibit no visible edema. Diagnostic tests Laboratory test findings reveal proteinuria (more than 300 mg/24 hours [1 + ] with preeclampsia, and 5 g/24 hours [5 +] or more with severe eclampsia). Test results may suggest HELLP syndrome. Ultrasonography, stress and nonstress tests, and biophysical profiles aid evaluation of fetal well-being. Differential diagnosis is used to distinguish we disorder from viral hepatitis, idiopathic thrombocytopenia, cholecystitis, hemolytic uremic syndrome peptic ulcer, neuroangiopathic syndrome, appendicitis, kidney stones, pyelonephritis, and gastroenteritis. Treatment Therapy for patients with preeclampsia is intended to halt the progress of the disorder - specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown - and to ensure fetal survival. Some doctors advocate the prompt inducement of labor, especially if the patient is near term; others follow a more conservative approach. Therapy may include:

complete bed rest in the preferred left lateral lying position to enhance venous return antihypertensive drugs, such as methyldopa and hydralazine magnesium sulfate to promote diuresis, reduce blood pressure, and prevent seizures if the patient's blood pressure fails to respond to bed rest and antihypertensives and persistently rises above 160/100 mm Hg or if central nervous system irritability increases.

If these measures fail to improve the patient's condition, or if fetal life is endangered (as determined by stress or nonstress tests and biophysical profiles), cesarean section or oxytocin inducement may be required to terminate the pregnancy.

Emergency treatment of eclamptic seizures consists of immediate administration of magnesium sulfate (I.V. drip), oxygen administration, and electronic fetal monitoring. After the patient's condition Stabilizes, cesarean section may be performed. Adequate nutrition, good prenatal care, and control of preexisting hypertension during pregnancy decrease the incidence and severity of preeclampsia. Early recognition and prompt treatment of preeclampsia can prevent progression to eclampsia.
Prevention

Early identification of women at risk for pregnancy-induced hypertension may help prevent some complications of the disease. Education about the warning symptoms is also important because early recognition may help women receive treatment and prevent worsening of the disease.