Case 1
Pregnant woman, female, 28 years old, due to "pregnancy 39+6 weeks, abdominal distension and abdominal pain 1 1 hour, abnormal fetal monitoring for 2 hours." Admission. Pregnancy 2 gives birth to 0, induced abortion 1 time.
Current disease history
Menstruation is normal, the last menstrual period is 20 19 10.02, and the expected date of delivery is July 9, 2020. Natural conception, intrauterine pregnancy confirmed by color Doppler ultrasound in February; Early pregnancy reactions such as mild nausea and vomiting occurred in the first trimester. There is no history of exposure to poisons and radioactive substances in the first trimester, no history of vaginal bleeding and contraception, and no history of cold medicine. From the fourth month of pregnancy, a standardized prenatal examination was conducted, and there were no abnormalities in NT, eugenics, G6PD, thalassemia screening, hepatitis B, syphilis, AIDS, hepatitis C, liver and kidney function, Down's screening, OGTT and GBS screening. Early TSH 4. 184 iu/ml, TPOAb 1 19.5IU/ml. I suggested seeing a doctor in endocrinology department, but I didn't follow the instructions. Four-dimensional color Doppler ultrasound showed strong echo focus of fetal left ventricle, and there was no headache, dizziness, dizziness, blurred vision and edema of lower limbs in the third trimester. 65438+ At 0: 00 a.m. on the day of admission, there was swelling pain in the lower abdomen without inducement, and at 8: 00 a.m., there was a little vaginal bleeding, dark red and no vaginal running water. Consciously, the fetal movement was normal, and the outpatient fetal heart monitoring showed that the baseline fluctuation of fetal heart was 164- 178 beats/min, with slight variation. Plan "1. Pregnancy 2, pregnancy 0, pregnancy 39+6 weeks, LOA threatened labor 2. Abnormal fetal monitoring "will be admitted to the hospital. Weight gain during pregnancy is about 17kg.
anamnesis
In the past, he was in good health, denied the history of chronic diseases such as hypertension and diabetes, denied the history of infectious diseases such as hepatitis and tuberculosis, and denied the history of surgical trauma and blood transfusion. No history of drug and food allergy.
physical examination
T: 37.0p: 86 beats/min, R: 20 beats/min, BP: 1 12/77mmhg, weighing 80kg, height 15 1cm. Body mass index is 26.9 1. Breathing sounds in both lungs are clear, rales cannot be heard, heart rate is 86 beats/min, and murmurs cannot be heard rhythmically. Abdominal bulge such as gestational age (thick abdominal wall fat), abdominal muscles are soft, without tenderness and rebound pain. Liver, spleen and tendons are not up to standard. There is no edema in both lower limbs.
Expert situation
The uterus is 34cm high, the abdominal circumference is 1 10cm, and the fetus comes out first and has entered the basin. Fetal position LOA, fetal heart sound 170 beats/min, irregular rules. It is estimated that the fetal weight is about 3700g g. Female examination: there is no abnormality in vulva, and a small amount of dark red secretion can be seen. Vaginal diagnosis: the cervix is not open, the cervical canal is reduced by 40%, the cervix is in the middle, in the middle, S-2, and the fetal membrane exists. The cervical vertebra score is 4 points.
accessory examination
White blood cell count. ): 10.33 * 10 9/L, platelet count (PLT): 276.00 * 10 9/L, red blood cell count (RBC. ): 4. 19 * 6544.
COVID-19 nucleic acid negative;
Outpatient fetal monitoring: Baseline 164- 178 times/minute, slightly changed. NST is suspicious.
Changes of sinus heart rate and t wave in electrocardiogram.
Color Doppler ultrasound: biparietal diameter 99mm, head circumference 356mm, abdominal circumference 365mm, femur length 75 mm, fetal weight estimated by ultrasound 40 18 587 g ... fetal heart rate 148 beats/min. Amniotic fluid index is 67mm, and the sound transmission is acceptable. Placenta is 36mm thick, located in the middle and upper part of the anterior wall of uterus, with patchy strong echo inside. CDFI: U-shaped impression can be seen on the skin of fetal neck, CDFI shows color ring sign, and umbilical artery blood flow spectrum RI 0.58, PI 0.85, S/D 2.38.
Ultrasonic prompt:
1, late intrauterine pregnancy, single live fetus, head position.
2. Placenta II, normal position.
3, the amount of amniotic fluid is slightly less.
4. Umbilical cord around neck 1 circle.
Biophysics score: respiratory movement:1; Fetal movement: 2 points; Muscle tension: 2 points; Amniotic fluid: 1. Total score: 6.
be hospitalized
After oxygen inhalation, glucose+vitamin C intravenous drip and left lateral lying position, fetal heart monitoring showed no response.
Considering the emergency of fetal distress, a live baby boy weighing 3970 grams was taken out during cesarean section under combined spinal-epidural anesthesia. During the operation, amniotic fluid * * * 100ml, amniotic fluid degree III (viscous granular), umbilical cord around the neck 1 week, A's score 1 minute, 7 points (breathing, muscle strength and skin color), 5 points, 9 points (muscle strength),/kloc-0. No bacterial growth was found in amniotic fluid culture after operation. Pathology of placenta showed acute umbilical cord inflammation and acute chorioamnionitis (II), and no obvious abnormality was found in placenta. The parturient was discharged on the fifth day after operation, and was discharged after 15 days of treatment for meconium aspiration syndrome and NICU asphyxia. The overall situation is acceptable.
Case 2
Pregnant woman, female, 33 years old, was admitted to the hospital because of "menopause 38+ 1 week, abnormal fetal heart monitoring 4+ hours". Three pregnancies, two deliveries and two full-term deliveries are not special.
Current disease history
The menstrual regularity of pregnant women, the last menstruation is 20191015, and the expected date of delivery is August 22, 2020. There was no obvious early pregnancy reaction in the first trimester, no contact with toxic and radioactive substances, no history of miscarriage protection and leucorrhea. Didn't check NT and eugenics in the first three months; There are standardized prenatal examinations in the second and third trimesters. There were no abnormalities in thyroid function, four-dimensional color Doppler ultrasound, G6PD, thalassemia, OGTT, IDT, NIPT, liver and kidney function and GBS screening during pregnancy. There was no dizziness, blurred vision, edema of lower limbs and other discomfort in the third trimester. In these two days, the fetal movement of pregnant women was reduced by half, and there was no discomfort such as abdominal pain, abdominal distension, vaginal bleeding and bleeding. When monitoring fetal heart in outpatient department, the baseline of fetal heart is flat and the acceleration of fetal movement is not obvious. She was admitted as "/kloc-0". Abnormal fetal heart monitoring II. Pregnancy 3, LOA of intrauterine pregnancy 38+ 1 week ". Weight gain during pregnancy is about 13kg.
anamnesis
In the past, he was in good health, denied the history of chronic diseases such as hypertension and diabetes, denied the history of infectious diseases such as hepatitis and tuberculosis, and denied the history of surgical trauma and blood transfusion. No history of drug and food allergy.
physical examination
T: 36.6p: 95p/min r: 20p/min BP:117/87mmhg weight 73kg height 160cm. Breathing sounds in both lungs are clear, rales cannot be heard, heart rate is 95 beats/min, and murmurs cannot be heard rhythmically. Abdominal bulge such as gestational age, abdominal muscle weakness, no tenderness and rebound pain. Liver, spleen and tendons are not up to standard. There is no edema in both lower limbs.
Professional situation
The uterus is 33cm high, and its abdominal circumference is 104cm. It is estimated that the fetal weight is 3.5kg, and the head is exposed first and has entered the basin. Fetal position LOA, fetal heart sound 140 beats/min, no contractions. Vaginal examination: the cervical canal disappeared by 30%, the quality was medium, the cervix was centered, the cervix 1 finger, presenting first, S-2, fetal membrane preservation, and the Bishop score of cervix was 3 points.
accessory examination
There were no abnormalities in blood routine, coagulation function and liver and kidney function.
Electrocardiogram: sinus rhythm, normal electrocardiogram;
The fetal color ultrasound showed that the biparietal diameter of the fetus was 94m, the head circumference was 334mm, the abdominal circumference was 35 1mm, the femur was 73mm, the estimated weight was 35 12 5 13g, the amniotic fluid index was 100mm, the placenta was attached to the middle and upper part of the anterior wall of the uterus, and the placenta was grade II with a thickness of 37mm.
Color Doppler ultrasound of fetal middle cerebral artery: the blood flow velocity of fetal middle cerebral artery is 36cm/s, S/D is 2.7, and RI is 0.64. The peak systolic velocity of fetal umbilical artery blood flow was 66 cm/s, S/D was 2.2, and RI was 0.55. RI(MCA)/RI(UmA)& gt； 1; Fetal heart monitoring showed that the baseline of fetal heart was flat, the acceleration of fetal movement was not obvious, and NST was suspicious.
be hospitalized
OCT examination was performed, and the fetal monitoring showed no response during intravenous drip, and the deceleration was prolonged for 3 minutes. Considering the emergency of fetal distress, a live baby boy weighing 3300g was taken out during cesarean section under combined spinal-epidural anesthesia. During the operation, the amniotic fluid was * * * 200ml, the amniotic fluid was ⅲ degree, the length of umbilical cord was 55cm, the neonatal A's score was 1 minute, 9 points, 5 points,1minute, and the umbilical cord blood PH value was 7.37. The puerpera recovered well without fever after operation. Postoperative placental pathology: acute chorioamnionitis (stage I)
The newborn was transferred to NICU for treatment and discharged for 4 days, generally in good condition.
Case 3
A 32-year-old pregnant woman was admitted to the hospital because of "pregnancy 37+ 1 week, abdominal distension 1 day, vaginal bleeding 1 hour". 2 births pregnant 1. 20 1 1 Cesarean section of full-term pregnancy due to oligohydramnios, single live baby girl, live, 2900g.
Current disease history
The menstrual regularity of pregnant women, the last menstrual period is 2019165438+128 October, and the expected date of delivery is 5 September 2020. More than 40 days after menopause, it was diagnosed as intrauterine pregnancy by color Doppler ultrasound. There was no exposure to poison and radioactive substances in the first three months. NT, thyroid function, IDT, G6PD, thalassemia screening, liver and kidney function, electrocardiogram, mid-term Down syndrome screening, NIPT, four-dimensional color Doppler ultrasound, OGTT screening, GBS without complaint; MTHFR showed CT type and received folic acid supplementation. In the second trimester, it is suggested that HB 99g/l and ferritin in moderate anemia are low, and they are normal after oral iron treatment. There was no dizziness, blurred vision, edema of lower limbs and other discomfort in the third trimester. Pregnancy 37+ 1 week, amniotic fluid index 22 1 mm by color Doppler ultrasound, and 1: 30 on the day of admission. No obvious reason for leucorrhea, large amount, dark red, abdominal distension, no abdominal pain, came to the hospital. I intend to "1". Placental abruption; 2. Scare the uterus; 3. Premature rupture of membranes; 4. Pregnancy 2, delivery 1, pregnancy 37+ 1 week, left anterior occipital threatened labor. Weight gain during pregnancy is about 8.5kg.
physical examination
T 36.3 P 76 times/min R 20 times/min BP 124/72mmHg height 158cm weight 66Kg. No abnormality was found in cardiopulmonary auscultation. Abdominal bulge, such as gestational age, shows a transverse surgical scar about 1.5 cm long at pubic symphysis; Abdominal muscle tension is high, without tenderness and rebound pain. The height of the uterus is 34 cm and the abdominal circumference is 95 cm. Contraction can be felt without obvious intermission. The estimated fetal weight is 3200g, and the fetal heart rate 140 beats/min is uniform. Female examination: dark red blood was seen in vulva, dark red amniotic fluid was seen in vaginal orifice, accompanied by blood clot, the cervix was centered and soft, the regression rate was 60%, the cervix 1 finger, S-2. When the fetal head is pushed up, dark red amniotic fluid can be seen. The PH test paper changed color. Do not touch the umbilical cord pulse. The cervical vertebra score was 6, and there was no edema in both lower limbs.
accessory examination
Normal urine routine, coagulation and liver and kidney function; D- dimer (d-d):16.75 mg/l;
Color Doppler ultrasound: biparietal diameter 93mm, head circumference 336mm, abdominal circumference 365mm, femur length 73mm, and fetal weight estimated by ultrasound 3762549 g. Fetal heart rate 134 beats/min. Amniotic fluid index 2 12mm, poor sound transmission. Placenta is 36mm thick and located in the middle and upper part of the posterior wall of uterus, with patchy strong echo inside. CDFI: No obvious impression was found on the fetal neck skin, and the umbilical artery blood flow spectrum RI 0.42, PI 0.57, S/D 1.7.
Ultrasonic prompt:
1, late intrauterine pregnancy, singleton live fetus, LOA.
2. Placenta II, normal position.
3. Amniotic fluid volume is normal, and amniotic fluid transmission is poor.
be hospitalized
A live baby girl, with a weight of 3 120g, underwent emergency cesarean section under general anesthesia with tracheal intubation. Intraoperative bloody amniotic fluid * * * 1200ml, placenta and fetal membrane have been stripped 1/2. The score of newborn A is 1 minute and 2 seconds. Give her positive airway pressure for 5 minutes and 9 seconds, 65438. The puerpera recovered well without fever after operation. The newborn was transferred to NICU for treatment and discharged for 4 days, generally in good condition. Postoperative pathology showed acute chorioamnionitis stage I.
discuss
The first two cases are chronic fetal distress, which is related to fecal contamination of amniotic fluid and oligohydramnios. The third is acute fetal distress, which is caused by premature rupture of membranes and placental abruption. Postoperative pathology showed acute chorioamnionitis, and placenta and umbilical cord caused fetal distress. Three cases of electronic fetal heart monitoring showed that the baseline of fetal heart was normal, but there was no acceleration, variation and no response. It all happens before delivery, and it is impossible to give birth through vagina in a short time. Timely termination of pregnancy by cesarean section can improve the prognosis of newborns and reduce the occurrence of long-term complications.
Fetal stress is a series of pathological conditions and comprehensive symptoms caused by intrauterine hypoxia and acidosis, which endangers the health and life of the fetus and is related to pregnant women, fetus, placenta, umbilical cord, amniotic fluid, anesthesia and other factors. It is very critical and important to identify the high-risk factors causing fetal distress before delivery and deal with them in time. Therefore, an important goal of fetal monitoring is to find and deal with acute fetal distress early, improve the prognosis of newborns and reduce the occurrence of long-term complications.
The basic pathology of fetal distress is a series of pathophysiological changes caused by ischemia and hypoxia. When the fetus is in distress, the hemodynamic changes of the heart first appear in hypoxia. At the initial stage of hypoxia, sympathetic nerves are excited, the secretion of catecholamine and cortisol in adrenal gland is increased, blood pressure is increased, heart rate is accelerated, and the blood flow in the fetus is redistributed, so that the blood flow of important organs such as heart and brain remains normal, while the blood flow of kidneys and other organs is obviously reduced. If hypoxia continues to develop, it will turn into vagus nerve excitement, arteriovenous blood vessels will expand, effective circulating blood volume will decrease, ischemia and hypoxia of important organs such as heart and brain will increase, and organ function will decrease; The central nervous system function is inhibited, fetal movement is reduced, and the baseline variation of fetal heart is reduced.