妊娠合并内科疾病(英文)妇科八年制教学课件

1、妊娠合并内科疾病(英文)妇科八年制教学MEDICAL COMPLICATIONS IN PREGNANCY妊娠合并内科疾病妊娠合并内科疾病(英文)妇科八年制教学Cardiovascular diseasesPulmonary disordersRenal and urinary tract disordersGastrointestinal disordersHematological disordersConnective tissue disordersNeurological and psychiatric disordersEndocrine disordersDermatologic

2、al disordersNeoplastic diseasesInfections妊娠合并内科疾病(英文)妇科八年制教学Heart DiseasesDiabetesHepatitis妊娠合并内科疾病(英文)妇科八年制教学Disease妊娠合并内科疾病(英文)妇科八年制教学Heart Disease in Pregnancy妊娠合并心脏病妊娠合并心脏病妊娠合并内科疾病(英文)妇科八年制教学Heart disease in pregnancynInteraction between heart disease and pregnancy（心脏病与妊娠的相互影响）nPeripartum cardio

3、myopathy, PPCM (围产期心肌病围产期心肌病)Medical treatment of pregnant women complicated with heart disease （妊娠合并心脏病的治疗）妊娠合并内科疾病(英文)妇科八年制教学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 dur

4、ing the course of pregnancy? By which way should I delivery my baby? Any special thing to be paid attention to after birth?妊娠合并内科疾病(英文)妇科八年制教学Heart DiseasenIncidence:1-4% of pregnancies nOne of the leading causes of maternal death (8.3%)nDeath rate 0.6%-2.7%妊娠合并内科疾病(英文)妇科八年制教学Heart diseasehemodynami

5、c BurdernHeart function32-34 weeks of pregnancyIntrapartumPuerperium (3 days postpartum)Interaction between pregnancy and heart disease妊娠合并内科疾病(英文)妇科八年制教学Clinical significance of heart disease in pregnancynMother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolismnBaby: misc

6、arriage（流产）, still birth （死产）, fetal growth restriction （生长受限）, fetal and newborn distress （呼吸窘迫）, preterm delivery （早产）nIncreased caesarean section rate （剖宫产）nDrug effectnHereditary congenital heart disease （先天性心脏病）妊娠合并内科疾病(英文)妇科八年制教学Classification of Heart DiseasenCongenital heart disease （先天性心脏病）

7、JLeft-to right shuntLRight-to left shuntKNon-shuntnRheumatic heart disease （风湿性心脏病）nHypertensive heart disease（妊娠期高血压疾病性心脏病）nPeripartum cardiomyopathy (PPCM)nMyocarditis （心肌炎）妊娠合并内科疾病(英文)妇科八年制教学Peripartum cardiomyopathy (PPCM) 围产期心肌病nDilated cardiomyopathy occurs during the last 3 months of pregnanc

8、y 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 postpartumnRecur in the successive pregnancynClinical Implications ：10-30% of fetal deathnTh

9、erapy nTreatment for heart failurenHeart transplantation妊娠合并内科疾病(英文)妇科八年制教学Cardiac FunctionSubjective capacitynClass I: UncompromisednClass II: Slightly compromisednClass III: Marked compromisednClass IV: Severely compromisedObjective examinationnA: Without objective basis of cardiac diseasenB: Mild

10、 cardiac disease according to objective examnC: Moderate nD: Severe 妊娠合并内科疾病(英文)妇科八年制教学ManagementnTO BE OR NOT TO BE？n Protect the mothers heart妊娠合并内科疾病(英文)妇科八年制教学Preconceptional counselingnPregnancy YES or NO ?妊娠合并内科疾病(英文)妇科八年制教学Preconceptional counselingnYESnMild nCardiac function IIInNo history o

11、f 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 disease妊娠合并内科疾病(英文)妇科八年制教学During PregnancyDet

12、ermine whether or not the pregnancy should be continuednNO: induced abortion before 12 weeksnYES:nIntensive care during pregnancyEarly diagnosis and treatment of congestive heart failure妊娠合并内科疾病(英文)妇科八年制教学nIntensive care during pregnancy Detect congestive heart failure as early as possible nbefore 2

13、0 weeks: 1 time per 2 weeksnafter 20 weeks : 1 time per weeknHospitalized at 36-38 weeks妊娠合并内科疾病(英文)妇科八年制教学During pregnancynHeart failure - prevention nLimited physical activitynControl of body weight: increase 12Kg (0.5Kg / month)nLimited salt intake: 110 bpm; breath rate 20/min nNocturnal coughnPe

14、rsistent basilar rales妊娠合并内科疾病(英文)妇科八年制教学During pregnancynTreatment of heart failurenDigoxinnDiuretics nVessel dilating agentsnTermination of pregnancy:nC-S nTimingnTermination after heart failure is controllednC-S when heart failure could not be controlled妊娠合并内科疾病(英文)妇科八年制教学Intrapartum managementnP

15、attern of deliverynCesarean sectionnVaginal deliverynHeart function I-IInVery good obstetrical conditionnVaginal delivery- prevent heart failurenFirst stage: intensive care and sedationnSecond stage: shorten the coursenThird stage: Add pressure on abdomen prevent postpartum hemorrhage妊娠合并内科疾病(英文)妇科八

16、年制教学Puerperium managementnIntensive care during the first 3 daysnPrevent infectionnBreast feedingnSterilization妊娠合并内科疾病(英文)妇科八年制教学nYesnHeart failure fetal demise congenital heart diseasenIntensive care and early diagnosis of heart failurenVaginal deliverynPrevent infection and postpartum hemorrhage

17、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 should I delivery my baby?nAny special thing to be paid attention to after birth?妊娠合并内科疾病(英文)妇科八年制教学思考题n妊娠合并心脏病哪些情况不宜妊娠？n妊娠合并心脏病分娩方式的选择?n阴道分娩过程中的注意事项。妊娠合并内科疾病(英文)妇科八年制教学妊娠合并内科疾病(英文)

18、妇科八年制教学Diabetes complicating pregnancy妊娠合并糖尿病妊娠合并内科疾病(英文)妇科八年制教学Diabetes complicating pregnancynGestational diabetes mellitus (GDM) and overt diabetes complicating pregnancy(妊娠期糖尿病和显性糖尿病合并妊娠）MDiabetes pregnancy（糖尿病与妊娠的相互影响）nScreening and diagnosis（筛查和诊断）MManagement of women complicating diabetes dur

19、ing pregnancy（妊娠合并糖尿病的处理）妊娠合并内科疾病(英文)妇科八年制教学Case nGestational Diabetic MellitusnIncreased fetal ventricular septumnInsulin used to control blood glucose levelnC-S at 34 weeks for fetal distressnNewborn baby died 1 month after delivery妊娠合并内科疾病(英文)妇科八年制教学DiabetesnIncidence: 2.9% (1.5 14.0%)nOvert diab

20、etes (糖尿病合并妊娠）nGestational diabetes mellitus GDM 90%（妊娠期糖尿病）妊娠合并内科疾病(英文)妇科八年制教学Impact of pregnancy on diabetesnIncreased glucose demands-hypoglycemia （低血糖）nInsulin resistance and insufficiencynInsulin overdose after delivery妊娠合并内科疾病(英文)妇科八年制教学Maternal and fetal effectsnMaternal effectsnHypertensive

21、disorders （高血压）nInfection （感染）nKetoacidosis （酮症酸中毒） nSpontaneous abortion （自发流产）nPolyhydramnios （羊水过多）nDystocia （难产） and C-S owing to macrosomia （巨大儿）nRecurrent GDM （再次妊娠时复发）妊娠合并内科疾病(英文)妇科八年制教学妊娠合并内科疾病(英文)妇科八年制教学Maternal and fetal effectsnFetal effectsnMacrosomia （巨大儿）nFetal growth restriction （胎儿宫内

22、生长受限）nSpontaneous abortion & Preterm delivery （自发流产和早产）nMalformation （胎儿畸形）妊娠合并内科疾病(英文)妇科八年制教学Maternal and fetal effectsnNeonatal effectsnRespiratory distress （呼吸窘迫）nHyperinsulinemia Pulmonary Surfactant Delayed pulmonary maturationnHypoglycemia （低血糖）妊娠合并内科疾病(英文)妇科八年制教学妊娠合并内科疾病(英文)妇科八年制教学Diagnos

23、is-GDMnHistory: family, previous pregnancy, present pregnancynScreening: 50-g oral glucose challenge test （24-28 weeks）nConfirmed diagnosisnOGTT: 75/100-g oral glucose tolerance test妊娠合并内科疾病(英文)妇科八年制教学The 50 gr. GCT (Cutoff 140 mg/dl, 7.8mmol/L)nSensitivity: 93.3%nSpecificity: 38.2%nPositive Predict

24、ive Value: 78.6 %nNegative Predictive Value : 70.0 %妊娠合并内科疾病(英文)妇科八年制教学Diagnostic criteria for GDM - OGTTMethod 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 glucose妊娠合并内科疾病(英文)妇科八年制教学DiagnosisOvert diabetesnpolydips

25、ia （多饮）, polyuria （多尿）, unexplained weight loss，ketoacidosisnRandom plasma glucose 200 mg/dL(11.1 mmol/L); fasting glucose126mg/dL (7 mmol/L)妊娠合并内科疾病(英文)妇科八年制教学StagingnA: GDMnB: Overt diabetes, late onset (after 20y), =20y, or retinopathynF: diabetic nephropathynR: proliferative retinopathy or vitre

26、ous hemorrhage nH: coronary heart disease nT: kidney transplantation 妊娠合并内科疾病(英文)妇科八年制教学ManagementnPurposenMaintain glucose level within normal rangenMinimize fetal and maternal complicationnLower peripartum fetal and neonatal mortality 妊娠合并内科疾病(英文)妇科八年制教学During pregnancynDietnTo provide the necessa

27、ry nutrients for the mother and fetusnTo control glucose levelsnTo prevent starvationn30-35kcal/kg of ideal body weightn55% carbohydraten20% proteinn25% fatn3 meals and 3 snacks dailynIntensified monitoringnFasting glucose 3.3-5.6mmol/LnPostprandial glucose 5.6mmol/L (100mg/dL)妊娠合并内科疾病(英文)妇科八年制教学pos

28、tpartum nInsulin dose decrease 1/2 -1/3 after delivery妊娠合并内科疾病(英文)妇科八年制教学Neonatal managementnTreated as preterm babyn25% glucose intake 30 minutes after deliverynPrevent complications妊娠合并内科疾病(英文)妇科八年制教学PrognosisnMore than 50% women with GDM develop diabetes in the following 20 yearsnMore risk for of

29、fspring to develop obesity and diabetes妊娠合并内科疾病(英文)妇科八年制教学思考题n糖尿病对母儿的影响n糖尿病的筛查确诊方法n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妊娠合并内科疾病(英文)妇科八年制教学妊娠合并内科疾病(英文)妇科八年制教学Viral Hepatitis in Pregnancy 妊娠合并急性病毒性肝炎妊娠合并内科疾病(英文)妇科八年制教学Viral Hepatitis in PregnancynInteraction between pregnancy and hepatitis（妊娠与肝炎的相互影响）nDiagnose

30、 and treatment （诊断和治疗）MPathway of maternal fetal infection and prevention（母-胎感染途径和预防）nDifferential diagnosis of hepatic disease （与妊娠期肝内胆汁淤积症的鉴别诊断）妊娠合并内科疾病(英文)妇科八年制教学Epidemiology of Hepatitisn0.2 billion in the world, 0.13billion in Chinan10-20% population with positive HBsAg in China妊娠合并内科疾病(英文)妇科八年

31、制教学妊娠合并内科疾病(英文)妇科八年制教学IntroductionnTypes of viral HAV, HBV, HCV, HDV, HEV, HGVnIncidence: 0.8%-17.8% among pregnant womennHBV infection more prevalent in China妊娠合并内科疾病(英文)妇科八年制教学Impact of pregnancy on viral hepatitisnCompromised defending ability of livernHeavier liver burdennMore complicated and se

32、vere condition in pregnant patients妊娠合并内科疾病(英文)妇科八年制教学Impact of hepatitis on pregnancynEarly PregnancynSerious pregnancy reactionnAbortionnMalformation妊娠合并内科疾病(英文)妇科八年制教学Impact of hepatitis on pregnancynLate pregnancynHypertensionnPostpartum hemorrhagenPreterm delivery, fetal death, stillbirth妊娠合并内科

33、疾病(英文)妇科八年制教学Impact of hepatitis on pregnancynMaternal - fetal infection HBV (母婴垂直传播）nIntrauterinenIntrapartummain route of transmissionnFetal swallowing in genital tractnMother blood leaking into fetal circulationnPostpartum: breastfeeding, salivary妊娠合并内科疾病(英文)妇科八年制教学DiagnosisnHistory: close contac

34、t with hepatitis patients, blood transfusion within 6 monthsnClinical features: ngastrointestinal symptoms cant be explained by other reasons,n jaundice, increased liver size in first and second trimester, pain妊娠合并内科疾病(英文)妇科八年制教学DiagnosisL HBsAg: Active HBV infection; may be acute or chronic L HBeAg

35、: 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 reactivation of chronic infections) L HBV-DNA and DNA polymerase: Direct measure of infectivity or replicative

36、 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 HBV 妊娠合并内科疾病(英文)妇科八年制教学ManagementnRestnNutritionnProtection of liver functionnPrevent infection and further dama

37、genFluminant hepatitis （重症肝炎）妊娠合并内科疾病(英文)妇科八年制教学Obstetrical ManagementnThe first trimesterJLight hepatitis: active treatment and maintaining the pregnancyLChronic active hepatitis: termination after treatment妊娠合并内科疾病(英文)妇科八年制教学nThe second and third trimesternPrevent from termination of pregnancynClo

38、se monitoring妊娠合并内科疾病(英文)妇科八年制教学ManagementnDeliverynC-S is preferrednVitamin K1 20-40mg im several days before delivery nPrevent postpartum hemorrhagenFulminant hepatitis（重症肝炎） C-S 24 hours after active treatment妊娠合并内科疾病(英文)妇科八年制教学ManagementnPureperium （产褥期）nPrevent from damaging liver functionnBreast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positive妊娠合并内科疾病(英文)妇科八年制教学Prevention of neonatal infectionnImmunoprophylaxisn4,000 among 18,000 ne