妊娠合并內科疾病(英文)婦科八年制教課件

1、medical complications in pregnancy妊娠合并內科疾病陳曉軍復旦大學附屬婦產科醫(yī)院cardiovascular diseasespulmonary disordersrenal and urinary tract disordersgastrointestinal disordershematological disordersconnective tissue disordersneurological and psychiatric disordersendocrine disordersdermatological disordersneoplastic d

2、iseasesinfectionsheart diseasesdiabeteshepatitisdiseaseheart disease in pregnancy妊娠合并心臟病妊娠合并心臟病heart disease in pregnancyninteraction between heart disease and pregnancy（心臟病與妊娠的相互影響）nperipartum cardiomyopathy, ppcm (圍產期心肌病圍產期心肌病)medical treatment of pregnant women complicated with heart disease （妊娠合

3、并心臟病的治療）i want a babyn27 years oldnatrial septal defect 1cmnfeel discomfort only after ordinary activity can i have a baby? what is the risk for me and my baby? what should i do during the course of pregnancy? by which way should i delivery my baby? any special thing to be paid attention to after bi

4、rth?heart diseasenincidence:1-4% of pregnancies none of the leading causes of maternal death (8.3%)ndeath rate 0.6%-2.7%heart diseasehemodynamic burdernheart function32-34 weeks of pregnancyintrapartumpuerperium (3 days postpartum)interaction between pregnancy and heart diseaseclinical significance

5、of heart disease in pregnancynmother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolismnbaby: miscarriage（流產）, still birth （死產）, fetal growth restriction （生長受限）, fetal and newborn distress （呼吸窘迫）, preterm delivery （早產）nincreased caesarean section rate （剖宮產）ndrug effectnhere

6、ditary congenital heart disease （先天性心臟?。ヽlassification of heart diseasencongenital heart disease （先天性心臟病）jleft-to right shuntlright-to left shuntknon-shuntnrheumatic heart disease （風濕性心臟?。﹏hypertensive heart disease（妊娠期高血壓疾病性心臟?。﹏peripartum cardiomyopathy (ppcm)nmyocarditis （心肌炎）peripartum cardiomyo

7、pathy (ppcm) 圍產期心肌病ndilated cardiomyopathy occurs during the last 3 months of pregnancy to 6 months postpartum (increased heart size, decreased heart function)netiology unknownnno history of cardiovascular diseasendie from heart failure, arrhythmia or pulmonary infarctionn50% recover 6 months postpa

8、rtumnrecur in the successive pregnancynclinical implications ：10-30% of fetal deathntherapy ntreatment for heart failurenheart transplantationcardiac functionsubjective capacitynclass i: uncompromisednclass ii: slightly compromisednclass iii: marked compromisednclass iv: severely compromisedobjectiv

9、e examinationna: without objective basis of cardiac diseasenb: mild cardiac disease according to objective examnc: moderate nd: severe managementnto be or not to be？ protect the mothers heartpreconceptional counselingnpregnancy yes or no ?preconceptional counselingnyesnmild ncardiac function iiinno

10、history of heart failure nno complication non severe n cardiac function 一一n history of heart failuren pulmonary hypertensionn right-to-left shuntsn severe arrythmian active rheumatic heart diseasen acute myocarditis, endocarditisn 35y with long history of cardiac diseaseduring pregnancydetermine whe

11、ther or not the pregnancy should be continuednno: induced abortion before 12 weeksnyes:nintensive care during pregnancyearly diagnosis and treatment of congestive heart failurenintensive care during pregnancy detect congestive heart failure as early as possible nbefore 20 weeks: 1 time per 2 weeksna

12、fter 20 weeks : 1 time per weeknhospitalized at 36-38 weeksduring pregnancynheart failure - prevention nlimited physical activityncontrol of body weight: increase 12kg (0.5kg / month)nlimited salt intake: 110 bpm; breath rate 20/min nnocturnal coughnpersistent basilar ralesduring pregnancyntreatment

13、 of heart failurendigoxinndiuretics nvessel dilating agentsntermination of pregnancy:nc-s ntimingntermination after heart failure is controllednc-s when heart failure could not be controlledintrapartum managementnpattern of deliveryncesarean sectionnvaginal deliverynheart function i-iinvery good obs

14、tetrical conditionnvaginal delivery- prevent heart failurenfirst stage: intensive care and sedationnsecond stage: shorten the coursenthird stage: add pressure on abdomen prevent postpartum hemorrhagepuerperium managementnintensive care during the first 3 daysnprevent infectionnbreast feedingnsterili

15、zationnyesnheart failure fetal demise congenital heart diseasenintensive care and early diagnosis of heart failurenvaginal deliverynprevent infection and postpartum hemorrhage ncan i have a baby?nwhat is the risk for me and my baby?nwhat should i do during the course of pregnancy?nby which way shoul

16、d i delivery my baby?nany special thing to be paid attention to after birth?思考題n妊娠合并心臟病哪些情況不宜妊娠？n妊娠合并心臟病分娩方式的選擇?n陰道分娩過程中的注意事項。diabetes complicating pregnancy妊娠合并糖尿病diabetes complicating pregnancyngestational diabetes mellitus (gdm) and overt diabetes complicating pregnancy(妊娠期糖尿病和顯性糖尿病合并妊娠）mdiabetes

17、 pregnancy（糖尿病與妊娠的相互影響）nscreening and diagnosis（篩查和診斷）mmanagement of women complicating diabetes during pregnancy（妊娠合并糖尿病的處理）case ngestational diabetic mellitusnincreased fetal ventricular septumninsulin used to control blood glucose levelnc-s at 34 weeks for fetal distressnnewborn baby died 1 month

18、 after deliverydiabetesnincidence: 2.9% (1.5 14.0%)novert diabetes (糖尿病合并妊娠）ngestational diabetes mellitus gdm 90%（妊娠期糖尿?。﹊mpact of pregnancy on diabetesnincreased glucose demands-hypoglycemia （低血糖）ninsulin resistance and insufficiencyninsulin overdose after deliverymaternal and fetal effectsnmatern

19、al effectsnhypertensive disorders （高血壓）ninfection （感染）nketoacidosis （酮癥酸中毒） nspontaneous abortion （自發(fā)流產）npolyhydramnios （羊水過多）ndystocia （難產） and c-s owing to macrosomia （巨大兒）nrecurrent gdm （再次妊娠時復發(fā)）maternal and fetal effectsnfetal effectsnmacrosomia （巨大兒）nfetal growth restriction （胎兒宮內生長受限）nspontane

20、ous abortion & preterm delivery （自發(fā)流產和早產）nmalformation （胎兒畸形）maternal and fetal effectsnneonatal effectsnrespiratory distress （呼吸窘迫）nhyperinsulinemia pulmonary surfactant delayed pulmonary maturationnhypoglycemia （低血糖）diagnosis-gdmnhistory: family, previous pregnancy, present pregnancynscreening

21、: 50-g oral glucose challenge test （24-28 weeks）nconfirmed diagnosisnogtt: 75/100-g oral glucose tolerance testthe 50 gr. gct (cutoff 140 mg/dl, 7.8mmol/l)nsensitivity: 93.3%nspecificity: 38.2%npositive predictive value: 78.6 %nnegative predictive value : 70.0 %diagnostic criteria for gdm - ogttmeth

22、od criteria (mmol/l) fpg 1 hr. 2 hr. 3 hr.who (75 g) 5.6 10.3 8.6 6.7diagnosed when 2 or more values are abnormalfpg: fasting plasma glucosediagnosisovert diabetesnpolydipsia （多飲）, polyuria （多尿）, unexplained weight loss，ketoacidosisnrandom plasma glucose 200 mg/dl(11.1 mmol/l); fasting glucose126mg/

23、dl (7 mmol/l)stagingna: gdmnb: overt diabetes, late onset (after 20y), =20y, or retinopathynf: diabetic nephropathynr: proliferative retinopathy or vitreous hemorrhage nh: coronary heart disease nt: kidney transplantation managementnpurposenmaintain glucose level within normal rangenminimize fetal a

24、nd maternal complicationnlower peripartum fetal and neonatal mortality during pregnancyndietnto provide the necessary nutrients for the mother and fetusnto control glucose levelsnto prevent starvationn30-35kcal/kg of ideal body weightn55% carbohydraten20% proteinn25% fatn3 meals and 3 snacks dailyni

25、ntensified monitoringnfasting glucose 3.3-5.6mmol/lnpostprandial glucose 5.6mmol/l (100mg/dl)postpartum ninsulin dose decrease 1/2 -1/3 after deliveryneonatal managementntreated as preterm babyn25% glucose intake 30 minutes after deliverynprevent complicationsprognosisnmore than 50% women with gdm d

26、evelop diabetes in the following 20 yearsnmore risk for offspring to develop obesity and diabetes思考題n糖尿病對母兒的影響n糖尿病的篩查確診方法n糖尿病 的分娩時機和分娩方式的選擇，終止妊娠時注意事項viral hepatitis in pregnancy 妊娠合并急性病毒性肝炎viral hepatitis in pregnancyninteraction between pregnancy and hepatitis（妊娠與肝炎的相互影響）ndiagnose and treatment （診斷

27、和治療）mpathway of maternal fetal infection and prevention（母-胎感染途徑和預防）ndifferential diagnosis of hepatic disease （與妊娠期肝內膽汁淤積癥的鑒別診斷）epidemiology of hepatitisn0.2 billion in the world, 0.13billion in chinan10-20% population with positive hbsag in chinaintroductionntypes of viral hav, hbv, hcv, hdv, hev,

28、hgvnincidence: 0.8%-17.8% among pregnant womennhbv infection more prevalent in chinaimpact of pregnancy on viral hepatitisncompromised defending ability of livernheavier liver burdennmore complicated and severe condition in pregnant patientsimpact of hepatitis on pregnancynearly pregnancynserious pr

29、egnancy reactionnabortionnmalformationimpact of hepatitis on pregnancynlate pregnancynhypertensionnpostpartum hemorrhagenpreterm delivery, fetal death, stillbirthimpact of hepatitis on pregnancynmaternal - fetal infection hbv (母嬰垂直傳播）nintrauterinenintrapartummain route of transmissionnfetal swallowi

30、ng in genital tractnmother blood leaking into fetal circulationnpostpartum: breastfeeding, salivarydiagnosisnhistory: close contact with hepatitis patients, blood transfusion within 6 monthsnclinical features: ngastrointestinal symptoms cant be explained by other reasons,n jaundice, increased liver

31、size in first and second trimester, paindiagnosisl hbsag: active hbv infection; may be acute or chronic l hbeag: high infectivity, active viral replication l hbcag: active copying, undetectable in seruml anti-hbcag igm: acute hbv infection (newer and more sensitive assays may also be positive during

32、 reactivation of chronic infections) l hbv-dna and dna polymerase: direct measure of infectivity or replicative state; becoming increasingly available j anti-hbsag: immune to hbv; may be natural immunity or following vaccination j anti-hbeag: low or no infectivity; need only be measured in chronic h

33、bv managementnrestnnutritionnprotection of liver functionnprevent infection and further damagenfluminant hepatitis （重癥肝炎）obstetrical managementnthe first trimesterjlight hepatitis: active treatment and maintaining the pregnancylchronic active hepatitis: termination after treatmentnthe second and thi

34、rd trimesternprevent from termination of pregnancynclose monitoringmanagementndeliverync-s is preferrednvitamin k1 20-40mg im several days before delivery nprevent postpartum hemorrhagenfulminant hepatitis（重癥肝炎） c-s 24 hours after active treatmentmanagementnpureperium （產褥期）nprevent from damaging liver functionnbreast feeding: stop if hbsag, hbeag, anti-hbc, hbv-dna positiveprevention of neonatal infectionnimmunoprophylaxisn4,000 among 18,000 new born babies with