BMedicalComplicationsofPregnancy妊娠內(nèi)科合并癥

1、1會(huì)計(jì)學(xué)BMedicalComplicationsofPregnancy妊娠內(nèi)科合并癥妊娠內(nèi)科合并癥Conditions That Complicate Pregnancy使使妊娠復(fù)雜化的癥狀妊娠復(fù)雜化的癥狀 Deep venous thrombosis (DVT)深靜脈血栓 Pulmonary embolism (PE)肺栓塞 Disseminated intravascular coagulation (DIC)彌漫性血管內(nèi)凝血 Human immunodeficiency virus (HIV) infection HIV感染Pregnancy Induced Hypertension妊

2、高癥PIH無蛋白尿(no proteinuria)HELLP SyndromeHELLP綜合綜合征征Chronic Hypertension (Elevated BP prior to 20 weeks)慢性高慢性高血壓（妊娠前血壓（妊娠前20周周血壓升高）血壓升高）6-8% of all gestations妊娠的妊娠的6-8%Preeclampsia 子癇前期(proteinuria +/- edema)蛋白尿水腫Eclampsia子癇子癇Severe Preeclampsia嚴(yán)重子癇前期嚴(yán)重子癇前期Diagnostic Criteria for Severe Preeclampsia嚴(yán)重

3、先兆子癇的診斷標(biāo)準(zhǔn)嚴(yán)重先兆子癇的診斷標(biāo)準(zhǔn)Headaches 頭痛頭痛Visual Disturbances 視力紊亂視力紊亂Pulmonary Edema 肺水腫肺水腫Hepatic Dysfunction 肝功異常肝功異常RUQ or Epigastric Pain右上腹或上腹痛右上腹或上腹痛Oliguria少尿少尿Elevated Creatinine肌酐上升肌酐上升Proteinuria of 5 g or more in 24 hrs24小時(shí)尿蛋白小時(shí)尿蛋白5g以上以上Thrombocytopenia or hemolysis血栓性血小板減少或溶血血栓性血小板減少或溶血Systolic

4、 BP收縮壓收縮壓 160 to 180 mm HgDiastolic BP舒張壓舒張壓 110 mm Hg初產(chǎn)婦初產(chǎn)婦母年齡超過母年齡超過40歲歲雙胎雙胎以前妊娠有先兆子癇以前妊娠有先兆子癇慢性高血壓慢性高血壓慢性腎病慢性腎病抗磷脂綜合征抗磷脂綜合征糖尿病糖尿病血管緊張素血管緊張素T235基因基因Clinical Course of Preeclampsia 子癇前期臨床病程子癇前期臨床病程EyesArteriolar SpasmRetinal HemorrhagePapilledemaTransient ScotomataRespiratory SystemPulmonary EdemaA

5、RDSLiverSubcapsular HemorrhageHepatic RuptureHematopoietic SystemHELLP SyndromeDICCNSSeizuresIntracranial HemorrhageCVAEncephalopathyPancreasIschemic PancreatitisKidneysAcute Renal FailureUteroplacental CirculationIUGRAbruptionFetal CompromiseFetal DemiseClinical Course of Preeclampsia子癇前期臨床子癇前期臨床病程

6、病程中樞神經(jīng)系中樞神經(jīng)系統(tǒng)統(tǒng)子癇發(fā)作顱內(nèi)出血腦血管意外腦水腫Pancreas胰腺胰腺Ischemic Pancreatitis缺血性胰腺炎Kidneys腎臟腎臟Acute Renal Failure急性腎功能衰竭子宮胎盤循環(huán)子宮胎盤循環(huán)胎兒生長受限早剝胎兒受損胎兒死亡眼睛眼睛小動(dòng)脈痙攣視網(wǎng)膜出血視乳頭水腫一過性的盲點(diǎn)呼吸系呼吸系統(tǒng)統(tǒng)肺水腫ARDS肝臟肝臟包膜下出血肝臟破裂造血系統(tǒng)造血系統(tǒng)HELLP綜合征DICAntidote is calcium gluconate one gram IV over 3 minutes正常正常治療濃度治療濃度膝腱反射消失膝腱反射消失嗜睡嗜睡呼吸窘迫呼吸窘迫麻痹

7、麻痹心跳驟停心跳驟停33-34 weeks大于34周Delivery引產(chǎn)引產(chǎn)Delivery Decisions - Severe Preeclampsia嚴(yán)重子癇前期分娩判斷嚴(yán)重子癇前期分娩判斷Maternal deterioration?母親情況惡化？Severe IUGR?嚴(yán)重胎兒生長受限Fetal compromise?胎兒窘迫In labor?已在分娩過程？34 weeks gestation?孕期34周28-32周Corticosteroids糖皮質(zhì)激素Antihypertensive drugs抗高血壓藥Daily evaluation of maternal and fetal

8、 conditions until 33-34 Weeks每天評(píng)估母嬰情況直至33到34周YesDelivery within 24 hours24H內(nèi)引產(chǎn)內(nèi)引產(chǎn)Amniocentesis羊穿羊穿Immature fluid不成熟羊不成熟羊水水Corticosteroids糖皮質(zhì)激糖皮質(zhì)激素素Deliver 48 hours later 48H后引產(chǎn)后引產(chǎn)Mature fluid成熟羊成熟羊水水NoAdapted from University of Tennessee, Memphis, management plan for patients with severe preeclampsi

9、a, Sibai, BM, in Obstetrics: Normal and Problem Pregnancies, 3rd Edition, Gabbe, SG, Niebyl, JR, Simpson, JL.Consider anti-coagulation therapy考慮抗凝Impedance plethysmography阻抗容積阻抗容積描記術(shù)描記術(shù)Ultrasound超聲超聲Meets diagnostic criteria for DVT符合診斷標(biāo)準(zhǔn)Equivocal不確定Begin anti-coagulation therapy開始抗凝治療Repeat ultraso

10、und vs. IPG vs. abdominal shielded venography重復(fù)檢查或腹部遮蓋的靜脈造影Meets diagnostic criteria for DVT符合診斷標(biāo)準(zhǔn)Begin anti-coagulation therapy開始抗凝治療Equivocal不確定DVT DiagnosisInitial evaluation supports diagnosis of PE (ABC, CXR, ECG)實(shí)施檢查ABC, CXR, ECGSymptoms/risk factors suggesting PE癥狀或高危因素提示可能PEAnti-coagulation

11、therapy抗凝療法Intermediate中度可能Normal正常V/QLow probability低可能High probability高可能Begin heparin 肝素Pulmonary angiogram肺血管造影Emboli present有血栓Emboli absent無血栓No therapy不治療Pregnancy Induced Hypertension妊高癥PIH無蛋白尿(no proteinuria)HELLP SyndromeHELLP綜合綜合征征Chronic Hypertension (Elevated BP prior to 20 weeks)慢性高慢性高血壓（妊娠前血壓（妊娠前20周周血壓升高）血壓升高）6-8% of all gestations妊娠的妊娠的6-8%Preeclam