最新妊娠合并内科疾病(英文)-妇科八年制教学课件PPT课件 79页

'妊娠合并内科疾病(英文)-妇科八年制教学课件 CardiovasculardiseasesPulmonarydisordersRenalandurinarytractdisordersGastrointestinaldisordersHematologicaldisordersConnectivetissuedisordersNeurologicalandpsychiatricdisordersEndocrinedisordersDermatologicaldisordersNeoplasticdiseasesInfections HeartdiseasehemodynamicBurdernHeartfunction32-34weeksofpregnancyIntrapartumPuerperium(3dayspostpartum)Interactionbetweenpregnancyandheartdisease ClinicalsignificanceofheartdiseaseinpregnancyMother:heartfailure;infectiveendocarditis;hypoxiaandcyanosis;thrombenbolismBaby:miscarriage（流产）,stillbirth（死产）,fetalgrowthrestriction（生长受限）,fetalandnewborndistress（呼吸窘迫）,pretermdelivery（早产）Increasedcaesareansectionrate（剖宫产）DrugeffectHereditarycongenitalheartdisease（先天性心脏病） ClassificationofHeartDiseaseCongenitalheartdisease（先天性心脏病）Left-torightshuntRight-toleftshuntNon-shuntRheumaticheartdisease（风湿性心脏病）Hypertensiveheartdisease（妊娠期高血压疾病性心脏病）Peripartumcardiomyopathy(PPCM)Myocarditis（心肌炎） Peripartumcardiomyopathy(PPCM)围产期心肌病Dilatedcardiomyopathyoccursduringthelast3monthsofpregnancyto6monthspostpartum(increasedheartsize,decreasedheartfunction)EtiologyunknownNohistoryofcardiovasculardiseaseDiefromheartfailure,arrhythmiaorpulmonaryinfarction50%recover6monthspostpartumRecurinthesuccessivepregnancyClinicalImplications：10-30%offetaldeathTherapyTreatmentforheartfailureHearttransplantation CardiacFunctionSubjectivecapacityClassI:UncompromisedClassII:SlightlycompromisedClassIII:MarkedcompromisedClassIV:SeverelycompromisedObjectiveexaminationA:WithoutobjectivebasisofcardiacdiseaseB:MildcardiacdiseaseaccordingtoobjectiveexamC:Moderate…D:Severe… ManagementTOBEORNOTTOBE？？？Protectthemother’sheart PreconceptionalcounselingPregnancyYESorNO? PreconceptionalcounselingYESMildCardiacfunctionI～IINohistoryofheartfailureNocomplicationNOSevereCardiacfunctionⅢ一ⅣHistoryofheartfailurePulmonaryhypertensionRight-to-leftshuntsSeverearrythmiaActiverheumaticheartdiseaseAcuteMyocarditis,endocarditis>35ywithlonghistoryofcardiacdisease DuringPregnancyDeterminewhetherornotthepregnancyshouldbecontinuedNO:inducedabortionbefore12weeksYES:IntensivecareduringpregnancyEarlydiagnosisandtreatmentofcongestiveheartfailure IntensivecareduringpregnancyDetectcongestiveheartfailureasearlyaspossiblebefore20weeks:1timeper2weeksafter20weeks:1timeperweekHospitalizedat36-38weeks DuringpregnancyHeartfailure----preventionLimitedphysicalactivityControlofbodyweight:increase<12Kg(<0.5Kg/month)Limitedsaltintake:<4-5g/dayPreventriskfactors:infection,anemia,arrhythmia,hypertensivediseasesDynamicobservationofcardiacfunction DuringPregnancyHeartfailure---earlydiagnosisDevelopmentofdyspneaandpalpitationonexertionHeartrate>110bpm;breathrate>20/minNocturnalcoughPersistentbasilarrales DuringpregnancyTreatmentofheartfailureDigoxinDiureticsVesseldilatingagentsTerminationofpregnancy:C-STimingTerminationafterheartfailureiscontrolledC-Swhenheartfailurecouldnotbecontrolled IntrapartummanagementPatternofdeliveryCesareansectionVaginaldeliveryHeartfunctionI-IIVerygoodobstetricalconditionVaginaldelivery----preventheartfailureFirststage:intensivecareandsedationSecondstage:shortenthecourseThirdstage:Addpressureonabdomenpreventpostpartumhemorrhage PuerperiummanagementIntensivecareduringthefirst3daysPreventinfectionBreastfeedingSterilization YesHeartfailurefetaldemisecongenitalheartdiseaseIntensivecareandearlydiagnosisofheartfailureVaginaldeliveryPreventinfectionandpostpartumhemorrhageCanIhaveababy?Whatistheriskformeandmybaby?WhatshouldIdoduringthecourseofpregnancy?BywhichwayshouldIdeliverymybaby?Anyspecialthingtobepaidattentiontoafterbirth? 思考题妊娠合并心脏病哪些情况不宜妊娠？妊娠合并心脏病分娩方式的选择?阴道分娩过程中的注意事项。 Diabetescomplicatingpregnancy妊娠合并糖尿病 DiabetescomplicatingpregnancyGestationaldiabetesmellitus(GDM)andovertdiabetescomplicatingpregnancy(妊娠期糖尿病和显性糖尿病合并妊娠）Diabetespregnancy（糖尿病与妊娠的相互影响）Screeninganddiagnosis（筛查和诊断）Managementofwomencomplicatingdiabetesduringpregnancy（妊娠合并糖尿病的处理） CaseGestationalDiabeticMellitusIncreasedfetalventricularseptumInsulinusedtocontrolbloodglucoselevelC-Sat34weeksforfetaldistressNewbornbabydied1monthafterdelivery DiabetesIncidence:2.9%(1.5—14.0%)Overtdiabetes(糖尿病合并妊娠）GestationaldiabetesmellitusGDM>90%（妊娠期糖尿病） ImpactofpregnancyondiabetesIncreasedglucosedemands---hypoglycemia（低血糖）InsulinresistanceandinsufficiencyInsulinoverdoseafterdelivery MaternalandfetaleffectsMaternaleffectsHypertensivedisorders（高血压）Infection（感染）Ketoacidosis（酮症酸中毒）Spontaneousabortion（自发流产）Polyhydramnios（羊水过多）Dystocia（难产）andC-Sowingtomacrosomia（巨大儿）RecurrentGDM（再次妊娠时复发） MaternalandfetaleffectsFetaleffectsMacrosomia（巨大儿）Fetalgrowthrestriction（胎儿宫内生长受限）Spontaneousabortion&Pretermdelivery（自发流产和早产）Malformation（胎儿畸形） MaternalandfetaleffectsNeonataleffectsRespiratorydistress（呼吸窘迫）HyperinsulinemiaPulmonarySurfactantDelayedpulmonarymaturationHypoglycemia（低血糖） Diagnosis----GDMHistory:family,previouspregnancy,presentpregnancyScreening:50-goralglucosechallengetest（24-28weeks）ConfirmeddiagnosisOGTT:75/100-goralglucosetolerancetest The50gr.GCT(Cutoff>140mg/dl,7.8mmol/L)Sensitivity:93.3%Specificity:38.2%PositivePredictiveValue:78.6%NegativePredictiveValue:70.0% DiagnosticcriteriaforGDM----OGTTMethodCriteria(mmol/L)FPG1hr.2hr.3hr.WHO(75g)5.610.38.66.7Diagnosedwhen2ormorevaluesareabnormalFPG:Fastingplasmaglucose Diagnosis—Overtdiabetespolydipsia（多饮）,polyuria（多尿）,unexplainedweightloss，ketoacidosisRandomplasmaglucose>200mg/dL(11.1mmol/L);fastingglucose>126mg/dL(7mmol/L) StagingA:GDMB:Overtdiabetes,lateonset(after20y),<10yC:Earlyonset(10-19y),diseasecourse10-19yD:onsetbefore10yordiseasecourse>=20y,orretinopathyF:diabeticnephropathyR:proliferativeretinopathyorvitreoushemorrhageH:coronaryheartdiseaseT:kidneytransplantation ManagementPurposeMaintainglucoselevelwithinnormalrangeMinimizefetalandmaternalcomplicationLowerperipartumfetalandneonatalmortality DuringpregnancyDietToprovidethenecessarynutrientsforthemotherandfetusTocontrolglucoselevelsTopreventstarvation30-35kcal/kgofidealbodyweight55%carbohydrate20%protein25%fat3mealsand3snacksdailyIntensifiedmonitoringFastingglucose<3.3-5.6mmol/LPostprandialglucose<6.7mmol/L DuringpregnancyDrugtreatment:InsulinonlyIndividualized AssessmentofmotherGlucose/ketonemonitoring（监测血糖/酮体）Retinalphotograph(眼底)Renalfunction（肾功能）GlycatedHaemoglobin（糖化血红蛋白） Assessmentoffetalwell-beingDailyfetalmovementcountingNSTAFVorbiophysicalprofiles DeliveryWHEN?after38completedweeksFetallungmuturationBefore38weekswhenUnsatisfiedglucosecontrolMaternalcomplication:infection,severepreeclampsia;vasculardieseaseFetaldistressorFGRCautionintheuseofcorticosteroids DeliveryHOW?DiabetesitselfisnottheindicationforC-SC-Swhenindicated:macrosomia,compromisedplacentafunction,etc.Stopsubcutaneousinsulin3hoursbeforeoperation DeliveryVaginaldeliveryClosemonitoringControlthewholecoursewithin12hoursGlucosemonitoring:>5.6mmol/L(100mg/dL) postpartumInsulindosedecrease1/2-1/3afterdelivery NeonatalmanagementTreatedaspretermbaby25%glucoseintake30minutesafterdeliveryPreventcomplications PrognosisMorethan50%womenwithGDMdevelopdiabetesinthefollowing20yearsMoreriskforoffspringtodevelopobesityanddiabetes 思考题糖尿病对母儿的影响糖尿病的筛查确诊方法糖尿病的分娩时机和分娩方式的选择，终止妊娠时注意事项 ViralHepatitisinPregnancy妊娠合并急性病毒性肝炎 ViralHepatitisinPregnancyInteractionbetweenpregnancyandhepatitis（妊娠与肝炎的相互影响）Diagnoseandtreatment（诊断和治疗）Pathwayofmaternal–fetalinfectionandprevention（母-胎感染途径和预防）Differentialdiagnosisofhepaticdisease（与妊娠期肝内胆汁淤积症的鉴别诊断） EpidemiologyofHepatitis0.2billionintheworld,0.13billioninChina10-20%populationwithpositiveHBsAginChina IntroductionTypesofviralHAV,HBV,HCV,HDV,HEV,HGVIncidence:0.8%-17.8%amongpregnantwomenHBVinfectionmoreprevalentinChina ImpactofpregnancyonviralhepatitisCompromiseddefendingabilityofliverHeavierliverburdenMorecomplicatedandsevereconditioninpregnantpatients ImpactofhepatitisonpregnancyEarlyPregnancySeriouspregnancyreactionAbortionMalformation ImpactofhepatitisonpregnancyLatepregnancyHypertensionPostpartumhemorrhagePretermdelivery,fetaldeath,stillbirth ImpactofhepatitisonpregnancyMaternal-fetalinfectionHBV(母婴垂直传播）IntrauterineIntrapartum—mainrouteoftransmissionFetalswallowingingenitaltractMotherbloodleakingintofetalcirculationPostpartum:breastfeeding,salivary DiagnosisHistory:closecontactwithhepatitispatients,bloodtransfusionwithin6monthsClinicalfeatures:gastrointestinalsymptomscan"tbeexplainedbyotherreasons,jaundice,increasedliversizeinfirstandsecondtrimester,pain DiagnosisHBsAg:ActiveHBVinfection;maybeacuteorchronicHBeAg:Highinfectivity,activeviralreplicationHBcAg:Activecopying,undetectableinserumAnti-HBcAgIgM:AcuteHBVinfection(newerandmoresensitiveassaysmayalsobepositiveduringreactivationofchronicinfections)HBV-DNAandDNApolymerase:Directmeasureofinfectivityorreplicativestate;becomingincreasinglyavailableAnti-HBsAg:ImmunetoHBV;maybenaturalimmunityorfollowingvaccinationAnti-HBeAg:Lowornoinfectivity;needonlybemeasuredinchronicHBV ManagementRestNutritionProtectionofliverfunctionPreventinfectionandfurtherdamageFluminanthepatitis（重症肝炎） ObstetricalManagementThefirsttrimesterLighthepatitis:activetreatmentandmaintainingthepregnancyChronicactivehepatitis:terminationaftertreatment ThesecondandthirdtrimesterPreventfromterminationofpregnancyClosemonitoring ManagementDeliveryC-SispreferredVitaminK120-40mgimseveraldaysbeforedeliveryPreventpostpartumhemorrhageFulminanthepatitis（重症肝炎）C-S24hoursafteractivetreatment ManagementPureperium（产褥期）PreventfromdamagingliverfunctionBreastfeeding:StopifHBsAg,HBeAg,anti-HBc,HBV-DNApositive PreventionofneonatalinfectionImmunoprophylaxis4,000among18,000newbornbabieswithHBsAg-positivemotherwillbechronicallyinfectedwithHBVwithoutimmunoprophylaxis ImmunoprophylaxisNeonateActiveimmnoprophylaxis:0,1,6主动免疫30μgHBVvaccineim24hoursafterbirth,10μg1month,6monthPassiveimmnoprophylaxis0,1,3被动免疫HBIG0.5mlsoonafterbirth,0.16ml/kg1month,3monthCombinedimmoprophylaxis联合免疫HBIG0.5mlwithin6hours;3-4weeksafterbirth,+activeimmnoprophylaxis DifferentialdiagnosisIntrahepaticcholestasisofpregnancy（ICP,妊娠期肝内胆汁淤积症）HappenduringlatepregnancyPruritus（瘙痒）Jaundice（黄疸）Cholicacid（胆酸升高）fetaldeath DifferentialdiagnosisAcutefattyliverofpregnancy（妊娠期急性脂肪肝）Latepregnancy,acuteandseverehepaticdisfunction,fatfilledhepaticcellHELLPsyndromeHypertension,hemolysis,BPC,elevatedliverenzymeHyperemesisgravidarum（妊娠剧吐）Lightliverdysfunction,negativevirusmarkerDruginducedhepatitisHistoryofdrugintake 思考题防止新生儿病毒性肝炎的主动与被动免疫病毒性肝炎合并妊娠与妊娠期肝内胆汁淤积症鉴别诊断 ReferenceWilliamsObstetrics,(22nd.ed.),byCunningham,F.GaryMD(ed.),McGraw-HillIncorporated(2005)病理产科学庄依亮，李笑天主编人民卫生出版社2003年妇产科学8年制及7年制临床医学专业用丰有吉,沈铿主编人民卫生出版社2006年 '