Pre-term pre-labor rupture of the membranes -PPROM -occurs before 37 weeks' gestation,

-pre-labour rupture of the membranes : where rupture of the fetal membranes occurs without the onset of spontaneous uterine activity resulting in cervical dilatation. -PPROM affects 2% of pregnancies. - Placental abruption is associated with PPROM

-17–34% recurrence rate in subsequent pregnancies of affected women -It may be associated with cervical incompetence (although it is likely that uterine contractions accompany the rupture of membranes with this condition).

-There is a strong association between PPROM and maternal vaginal colonization with potentially pathogenic micro-organisms -the incidence of sub clinical chorioamnionitis said to be around 30% Infection may both precede or follow PPROM.

Risks of PPROM labour, resulting in a preterm birth chorioamnionitis, which may be followed by fetal and maternal systemic infection if not treated promptly oligohydramnios if prolonged PPROM occurs, with associated fetal problems including pulmonary hypoplasia psychosocial problems resulting from uncertain fetal and neonatal outcome and long term hospitalization cord prolapse

malpresentation associated with prematurity primary antepartum haemorrhage. Management -management of this condition remains controversial. -Psychological consideration of the woman's, and her partner's, circumstances

- If PPROM is suspected - the woman will be admitted to the labour suite -a careful history is taken - rupture of the membranes confirmed by a sterile speculum examination of any pooling of liquor in the posterior fornix of the vagina. -Very wet sanitary towels over a 6 hrs period, urine leakage should be excluded

a positive Nitrazine test should not be considered - a fetal fibronectin immunoenzyme test confirming rupture of the membranes -ultrasound scanning. -Digital vaginal examination should be avoided to reduce the risk of introducing infection.

- Assess the fetal condition from the fetal heart rate (an infected fetus may have a tachycardia) and maternal infection screen. -temperature and pulse, should be recorded. -uterine tenderness and purulent or offensively smelling vaginal discharge, should be observed

-If the woman has a gestation of less than 32 weeks, the fetus condition normal,no signs of APH or labor, she will be managed as : -hospitalization - frequent ultrasound scans to check the growth of the fetus and the extent and complications of any oligohydramnios. - corticosteroids as soon as PPROM is confirmed. -tocolytic drugs will be considered to prolong the pregnancy.

- presence of vaginal infection should be treated with antibiotics and prophylactic antibiotics erythromycin seems to be the drug of choice for most women. HROM:it is a hind water leakage, and the pregnancy may proceed with no further complications

-Treated by amnioinfusion. - If membranes rupture before 24 weeks of gestation the outlook is not good; the fetus is likely has both problems caused by oligohydramnios or to those caused by pre- term birth. -termination of the pregnancy

If the woman is more than 32 weeks' pregnant, the fetus appears to be compromised and APH or intervening labour is suspected or confirmed, -The mode of birth will be decided either induction of labour or caesarean section

Malignant disease in pregnancy -Incidence 1 in 1000–1500 pregnancies. - The most common malignancies associated with pregnancy are,: cervix, ovary, breast, melanoma, leukemia, lymphoma and colorectal carcinoma. women with delayed childbearing liable for cancer.

- Pregnancy may adversely affect the course of the disease, and cancer in the mother can metastasize to the placenta and fetus, melanoma being the most likely to do so. -If cancer is discovered before pregnancy,it should be treated and followed up before pregnancy is attempted

-when cancer discovered during pregnancy leads dilemmas. - The options involve balancing the effects of the treatment, the disease and birth on both the mother and her fetus. -If the woman is in early pregnancy, her first dilemma may be whether or not to continue with the pregnancy

If she continues, the next dilemma will be whether to treat the disease during the pregnancy or await birth -as both chemotherapy and radiation therapy may have toxic effects, particularly on the fetus

- Surgery is the treatment least likely to affect the pregnancy adversely, particularly if it takes place in later pregnancy, but it may not be the treatment of first choice. -Elective pre-term birth is often favored by medical practitioners

Obesity and failure to gain weight in pregnancy -the value of frequent routine weighing of all pregnant women in predicting various perinatal outcomes. - women who have a poor diet and their fetuses are at greater risk than well-nourished women -Weight is no more than a very crude indicator of a woman's health status in pregnancy

Obesity : - the midwife's observation of a very obese woman, or a very thin one, should alert her to some of the risks such women may face during pregnancy and the longer term risks to both women and their children -A woman who starts pregnancy while obese, or puts on an excessive amount of weight during pregnancy, appears to be at greater risk of:

*hypertensive disturbances, including pregnancy-induced hypertension. * at greater risk of gestational diabetes * both of these conditions make her more likely to be delivered by caesarean section. *at increased risk of urinary tract infection. * uncertain fetal position.

*postpartum hemorrhage. *thrombophlebitis. *more likely to give birth to a large for gestational age infant *at greater risk of shoulder dystocia. *evidence of a relationship between maternal obesity and perinatal mortality.

* The woman is also more prone to wound infection following operative delivery. *Obesity may also be associated with malnourishment from essential nutrient deficiency. * Obesity is, an important risk factor for maternal death. -excessive weight increase during pregnancy being a greater risk factor for of hypertensive disorders

- its sudden onset may signal occult oedema. If such weight gain is noted by the woman or the midwife it is important to take the woman's blood pressure and test her urine for protein. -Once oedema has been excluded, the midwife should discuss the woman's diet with her.

- as early in their pregnancy as possible, or even before, and at regular intervals thereafter. Midwives should discuss diet, nutrition, life style, exercise and the reasons why excessive weight gain in pregnancy is undesirable

-There is no advantage to dieting during pregnancy (and strict dieting may be dangerous). - Referral to a dietician may be helpful. -Blood pressure measurements should always be taken accurately with a correctly sized cuff. - gestational diabetes and urinary tract infection should be screened. - Frequent routine weighing

- The midwife should also bear in mind that obesity can be a symptom of another disease, such as: - hypothyroidism -polycystic ovarian syndrome -Cushing's disease, and in such cases diet will have only a minimal effect on weight

Failure to gain weight -the midwife may observe that a woman appears to be thin during her pregnancy. -- Detailed discussion should attempt to elicit the quality and quantity of the woman's diet and her weight pattern over previous years. -Some women are naturally very slim and remain so because of :

*genetic factors *a high metabolic rate. Result: going on to produce a healthily sized baby.

-a medical disorder such as *a malabsorption condition *starvation *anorexia nervosa. * bulimia, or both.

-she is at greater risk of : 1-anaemia 2- intrauterine growth restriction 3- birth asphyxia. 4- perinatal death. Note: Bulimia may be wrongly diagnosed as hyperemesis gravidarum.

The midwife's role: -will depend on the cause. -She should always involve the medical practitioner because of the risk of intrauterine growth restriction -admitted to, a clinical psychologist or psychiatrist. -Dietary discussion and advice, including the use of supplements such as multivitamins and referral to a dietician - discuss with the woman, Quality of nutrition, than quantity

Problems associated with pregnancy following assisted conception

Couples who achieve pregnancy following assisted conception may be at greater risk of complications during the pregnancy than those who conceive naturally The cause of the fertility problem may be: a medical problem that is aggravated by pregnancy. It is also known that with some forms of assisted conception there is an increased rate of:

multiple pregnancy - the risk of pre-eclampsia - preterm labor. -Women who undergo assisted conception are likely to be an older age group, either having previously tried for some time to conceive a baby naturally or having fertility problems because of their increased age.

- Increased maternal age has slight associations with multiple pregnancy and pre-eclampsia, and the older a woman is the more liable to develop a medical problem such as essential hypertension or diabetes mellitus, or a gynecological problem such as fibroids. ‘precious pregnancy’, need appropriate care &intervention.