(上海交大)妇产科学(双语)全套课件

1、ABRUPTIO PLACENTAEDefinitionAbruptio Placentae( placental abruption): premature separation of the normally implanted placenta from the uterine wall.EtiologyMechanism: hemorrhage into the decidua basalis, leading to premature placental separation and further bleeding.Associated factors:Maternal hyper

2、tensionSudden decompression of the uterusMaternal cocaine use traumaClassificationComplete separation: no vaginal bleedingPartial separation :vaginal bleeding will be apparentMarginal separation : vaginal bleeding will be apparent diagnosisClassic clinical presentation: vaginal bleedingTender uterus

3、Uterine contractionsFetal distressCoagulation abnormalitiesHypofibrinogenemiaIncreaseing levels of fibrin degradation productsdecreasing platelet count Increasing prothrombin time and partial thromboplastin timeDecreasing other serum clotting factorsUltrasonography: relatively large retroplacental c

4、lots may be detectedPlacental examination The extent of placental abruption of the maternal surface of the placenta on which a clot is detect at the time of delivery.ManagementMaintain hemodynamic stabilization ( Transfusion therapy)Crystalloid transfusionWhole blood therapyComponent therapyCorrect

5、coagulation statusDeliveryWhen the fetus is mature,vaginal delivery is preferable unless there is evidence of fetal distress or hemodynamic instability.When the fetus is not mature and placental abruption is limited,observation with close monitoring of both fetal and maternal status.Cardiovascular C

6、omplicationsLiu WeiDepartment of Ob & GyRen Ji hospital General ConsiderationCause of mother death The 2nd causeIncidence 1%-4%General ConsiderationAntenatal cardiovascular changesBlood volume increase by 40%-60% Peaking at 32 34 weeks the expansion in plasma volume is greater than that expansion of

7、 red cell mass.Cardiac output Increase by 40%-50% Peaking at 20-24 weeksGeneral ConsiderationBlood pressure Decrease in the first trimester Rise to prepregnancy levels in the third trimesterHeart size Ventricular chamber size is increased Systolic function is unchanged.General ConsiderationIntrapart

8、um cardiovascular changesFirst-stage labor 300ml 500ml(each contraction) Cardiac output(maternal pain, anxiety) Second-stage labor Lung circulation(bearing-down efforts to expel the fetus) Venous return(after fetus is deliveried) Placental circulation is lost (after placenta is deliveried)General Co

9、nsiderationPostpartumCirculating blood volume(Placental circulation is lost)Circulating blood volume further(mobilization of extravascular fluid into the vascular system)Types of Cardiovascular ComplicationCongenital heart disease先心: the most frequentLeft to right shunting左向右分流型Atrial septal defect

10、(ASD)房缺: most common asymptomatic (most patients); pulmonary blood flow(lesion 2cm2) pulmonary hypertension Eisenmengers syndromeVentricular septal defect (VSD)室缺 tolerated (small lesion); left ventricular hypertrophy pulmonary hypertension biventricular hypertrophyTypes of Cardiovascular Complicati

11、onPatent ductus arteriosus (PDA)动脉导管未闭 rare (early surgical repair); hemodynamic consequence are similar to VSDRight to left shunting右向左分流型Tetralogy of Fallot法洛氏四联征Pulmonary stenosis, right ventricular hypertrophy, large ventricular septal defect and overriding aortathe most common cyanotic lesion c

12、omplicating pregnancyTypes of Cardiovascular ComplicationNon-shuntingPulmonary stenosis Not usually progressiveAortic stenosis rare; its outcome is badMarfans syndrome (genetic disorder) Myxomatous degeneration of the heart valves; mitral and cystic medial necrosis（囊性中层坏死） of the aorta (aneurysms动脉瘤

13、) death rate: 4%-50%Types of Cardiovascular ComplicationRheumatic heart diseaseMitral stenosis is the most common lesion.Severe lesion with pulmonary hypertension pulmonary edema hear failure: terminate the pregnancyHeart disease caused by preeclampsia Left heart failure (increased blood pressure an

14、d cardiac muscle ischemia)Types of Cardiovascular ComplicationPeripartum cardiomyopathyCongestive cardiomyopathy (during the late stage of pregnancy (3 months) or within the first 6 months postpartum)Absence of other causes of heart failureIts etioloty is uncertainManifestations: symptoms caused by

15、heart failure and embolismThe risk of maternal mortality is 30%-50%.Types of Cardiovascular ComplicationMyocarditis 心肌炎Manifestation: arrhythmia心律失常Sequelae of myocarditis心肌炎后遗症: more commonEffects on fetusPreterm labor, fetal death, fetal distressDrug usedInherited problem Ventricular septal defect

16、 (VSD): 22% Marfans syndrome: 50%Diagnosis Etiology diagnosis congenital or rheumatic or preeclampsia or peripartum cardiomyopathyAnatomy diagnosis ASD or VSD or PDA or mitral stenosis or mitral regurgitationPathophysiology diagnosis pulmonary hypertension or Eisenmengers syndrome or arrhythmiaFunct

17、ional classification Class: IIVDiagnosismore significant signsHistory: palpitation(心悸), short breath, heart diseaseOrthopnea (端坐呼吸), chest pain, expectoration of blood (咯血)Cyanosis紫绀, diastolic murmur舒张期杂音ArrhythmiaEnlargement of heart (chest x-ray film)Echocardiogram: chamber enlarge, hypertrophy,

18、abnormality of valve Functional classification of heart diseaseNew York Heart Association (NYHA)Class I: asymptomaticClass II: symptoms with normal activityClass III: symptoms with less than normal activityClass IV: symptoms at restRevised guidelineAccording to the result of objective testing (chest

19、 x-ray, EKG, echocardiogram)early diagnosis of heart failurePalpitation and short breath with less than normal activityHR110, R20 at restOrthopnea at nightPersistent wet rale in lung Judgment of safety of pregnancyConception should be prevented if:Severe heart diseaseFunctional classification: class

20、 III-IVHistory of heart failurePulmonary hypertensionRight to left shuntingSevere arrhythmiarheumatic fever风湿热Combined valve diseaseAcute myocarditisTreatment Antenatal treatmentTermination of pregnancy: Terminate before 12 weeks (cases not suitable to pregnancy)Antenatal supervise: regular and inte

21、nsive and early (early pregnancy)Prevention of heart failuresufficient restweigh controlpreventing infection, correcting anemia and arrhythmiaTreatmentTreatment of heart failureCardiotonic强心: digoxinVascular dilationDiuretic利尿Caesarean sectionTreatmentIntrapartum treatmentMethod of delivery: CSFirst

22、 stagecalm down, ataractic(镇静剂), oxygen supplementSecond stageOperative vaginal deliveryThird stagePreventing postpartum hemorrhagePuerperiumPreventing infectionENDCEREBRALVASCULAR DISEASEDr. LU, QINCHIDEPARTMENT OF NEUROLOGYREN JI HOSPITALSHANGHAI JIAO TONG UNIVERSITYSCHOOL OF MEDICINETel: 58752345

23、-3094Email: qinchiluCerebral vascular DiseaseDefinition of term:The term cerebrovascular disease designates any abnormality of the brain resulting from a pathologic process of the blood vessels. Sudden loss of neurological function is the hallmark of cerebrovascular disease. Cerebrovascular disease

24、is the third most common cause of death and the most common disabling neurologic disorder in western civilized countries where an increasing proportion of people survive to old age. Shanghai is entering the aging societyIts incidence increases with age and is somewhat higher in men than in women.Ris

25、k factors for strokeSystolic or diastolic hypertensionDiabeticsHypercholesterolemiaHeart disease (afib)Cigarette smoking Heavy alcohol consumptionHigh homocystineOral contraceptive useThe major types of cerebrovascular diseaseCerebral ischaemia and infarctionTransient Ischemic AttacksAtherosclerotic

26、 thrombosisLacunesEmbolismHemorrhageHypertensive hemorrhageRuptured aneurysms and vascular malformationsOtherI、Cerebral ischaemia and infarctionAnatomy and pathologyThe principal pathological process under consideration here is the occlusion of arteries supplying the brain. The two internal carotid

27、arteries and the basilar artery form the Circle of Willis at the base of the brain, which acts as an efficient anatomotic device in the event of occlusion of arteries proximal to it. Anatomy and pathologyOcclusion leads to sudden severe ischaemia in the area of brain tissue supplied by the occluded

28、artery, and recovery depends upon rapid lysis or fragmentation of the occluding material:Reversal of neurological function within minutes or hours gives rise to the clinical picture of a transient ischaemic attack.Anatomy and pathologyWhen the neurological deficit lasts longer than 24 hours, it may

29、be called a reversible ischaemic neurological deficit ( RIND ) if it recovers completely in a few days,or a completed stroke if there is a persistent deficit.Sometimes recovery is very slow and incomplete.Neurological symptoms and signs The loss of function that the patient notices, and which may be

30、 apparent on examination, entirely depends on the area of brain tissue involved in the ischaemic process. Neurological symptoms and signsThe following suggest middle cerebral territory:Dysphasia;Dyslexia, dysgraphia, dyscalculia;Loss of use of contralateral face and arm;Loss of feeling in contralate

31、ral face and arm. Neurological symptoms and signsThe following suggests anterior cerebral territory:Loss of use and/ or feeling in the contralateral leg.The following suggests posterior cerebral territory:Development of a contralateral homonymous hemianopia.Neurological symptoms and signsThe followi

32、ng suggests a deep-seated lesion affecting the internal capsule which is supplied by small perforating branches of the middle and posterior cerebral arteries close to their origins:Complete loss of motor and sensory function throughout the whole of the contralateral side of the body with a homonymou

33、s hemianopia.Neurological symptoms and signsThe following suggests ophthalmic artery territory (the ophthalmic artery arises from the internal carotid artery just below the Circle of Willis):Monocular loss of vision. Neurological symptoms and signsThe following suggest vertebro-basilar territory:dou

34、ble vision( 3,4,6);facial numbness(5);facial weakness(7);vertigo (8);dysphagia (9, 10);dysarthria ( 9, 10, 12);ataxia;drop attacks;motor or sensory loss in both arms or legs.1. Transient Ischemic Attacks(TIA)Definition of termCurrent opinion holds that TIAs are brief, reversible episodes of focal, n

35、onconvulsive ischaemic neurologic disturbance, Consensus has been that their duration should be less than 24 h.Clinical pictureTransient Ischaemic Attacks can reflect the involvement of any cerebral artery. The loss of function entirely depends on the influenced artery.It may last a few seconds or u

36、p to 12 to 24 h, Most of them last 2 to 15 min.There are only a few attacks or several hundred.Between attacks, the neurologic examination may disclose no abnormalities.A stroke may occur after numerous attacks have occurred over a period of weeks or months.Differential diagnosis of TIAsTransient ep

37、isodes, indistinguishable from TIAs, are known to occur in patients with Seizure,Migraine,Transient global amnesia,and occasionally in patients with multiple sclerosis, meningioma, glioblastoma ,metastatic brain tumors situated in or near the cortex ,and even with subdural hematoma.2. Cerebral throm

38、bosisMost cerebrovascular disease can be attributed to atheroscleroses and chronic hypertension; until ways are found to prevent or control them, vascular disease of the brain will continue to be a major cause of morbidity.PathogenesisPathogenesis of Ischemic neuronal death Ischemia Excitatory amino

39、 acid receptors Borderzone or penumbra Programmed cell deathClinical picture In general, evolution of the clinical phenomena in relation to cerebral thrombosis is more variable than that of embolism and hemorrhage. The loss of function that the patient notices, and which may be apparent on examinati

40、on, entirely depends on the area of brain tissue involved in the ischaemic process.(above)Clinical pictureIn more than half of patients, the main part of the stroke is preceded by minor signs or one or more transient attacks of focal neurologic dysfunction. The final stroke may be preceded by one or

41、 two attacks or a hundred or more brief TIAs, and stroke may follow the onset of the attacks by hours, weeks, or, rarely, months.The most occurrence of the thrombotic stroke is during sleep.The patient awakens paralyzed. Either during the night or in the morning.Unaware of any difficulty, he may ari

42、se and fall helplessly to the floor with the first step.Clinical pictureAssociated symptomsSeizures accompany the onset of stroke in a small number of cases (10-50%); in other instances, they follow the stroke by weeks to years. The presence of seizures does not definitively distinguish embolic from

43、 thrombotic strokes, but seizure at the onset of stroke may be more common with embolus.Clinical pictureAssociated symptomsHeadache occurs in about 25% of patients with ischaemic stroke, possibly because of the acute dilation of collateral vessels.Laboratory FindingsCT Scan or MRI: A CT scan or MRI

44、should be obtained routinely to distinguish between infarction and hemorrhage as the cause of stroke, to exclude other lesions (eg, tumor, abscess) that can mimic stroke, and to localize the lesion. CT is usually preferred for initial diagnosis because it is widely available and rapid and can readil

45、y make the critical distinction between ischaemia and hemorrhage.Lumbar Puncture: This should be performed in selected cases to exclude subarachnoid hemorrhage.Laboratory FindingsCerebral Angiography: Intra-arterial angiography is used to identify operable extracranial carotid lesions in patients wi

46、th anterior circulation TIAs who are good surgical candidates. It also can be used for intra-arterial thrombolysis ( r-tPA)Magnetic resonance angiography (MRA) may detect stenosis of large cerebral arteries, aneurysms, and other vascular lesion, but its sensitivity is generally inferior to that of c

47、onventional angiography.Differential DiagnosisVascular disorders are mistaken for ischaemic stroke include intracerebral hemorrhage, subdural or epidural hematoma , and subarachnoid hemorrhage from rupture of an aneurysm or vascular malformation. These condition can often be distinguished by a histo

48、ry of trauma or of excruciating headache at onset, a more marked depression of consciousness, or by the presence of neck stiffness on examination. They can be excluded by CT scan or MRI.Differential DiagnosisDifferential Diagnosis: Other structural brain lesion such as tumor or abscess can also prod

49、uce focal cerebral symptoms of acute onset. Brain abscess is suggested by concurrent fever, and both abscess and tumor can usually be diagnosed by CT scan or MRI. Metabolic disturbances, particularly hypoglycemia and hyperosmolar nonketotic hyperglycemia, may present in stroke like fashion. The seru

50、m glucose level should therefore be determined in all patients with apparent stroke. Treatment of Cerebral Thrombosis and Transient Ischemic AttacksThe current treatment of it may be divided into four parts:Management in the acute phaseMeasures to restore the circulation and arrest the pathologic pr

51、ocess 1. Thrombolytic agents ( t-PA only for completed stroke,w/in 36hrs ) 2.Anticoagulant drugs ( Heparin, LMWH & warfarin) 3. Antiplatelet drugs ( Aspirin or Clopidogrel, Dipyridamole or Ticlopidine ) 4.Difibrase 5. Neuroprotective agents: barbiturates, opioid antagonist naloxone,Manitol Treatment

52、Treatment of cerebral edema and raised intracranial pressureAcute surgical revascularization Surgery for symptomatic carotid stenosis Carotid endarterectomy, intralumenal stents, extracranial-intracranial bypassPhysical therapy and rehabilitation Measures to prevent further strokes and progression o

53、f vascular disease.TreatmentSince the primary objective in the treatment of atherothrombotic disease is prevention , efforts to control the risk factors must continue. AspirinHypotensive agentsOversedation should be avoidedSystemic hypotension, severe anemia should be treated promptlyParticular care

54、 should be taken to maintain the systemic blood pressure, oxygenation and intracranial blood flow during surgical procedures, especially in elderly patient.Course and PrognosisWhen the patient is seen early in the cerebral thrombosis, it is difficult to give an accurate prognosis.As for the eventual

55、 or long-term prognosis of the neurologic deficit , there are many possibilities.It must be mentioned that having had one thrombotic stroke, the patient is at risk in the ensuing months and years of having a stroke at the same or another site, especially if there is hypertension or diabetes mellitus

56、.3.Embolic infarctionThis is one of the most common cause of stroke. In most cases of cerebral embolism, the embolic material consists of a fragment that has broken away from a thrombus within the heart. Embolism due to fat, tumor cells, fibrocartilage, amniotic fluid, or air is a rare occurrence an

57、d seldom enters into the differential diagnosis of stroke.Clinical PictureOf all strokes, those due to cerebral embolism develop most rapidly.The embolus strikes at any time of the day or night. Getting up to go to the bathroom is a time of danger.The neurologic picture will depend on the artery inv

58、olved and the site of obstruction.Clinical PictureIt is important to repeat that an embolus may produce a severe neurologic deficit that is only temporary; symptoms disappear as the embolus fragments. In other words , embolism is a common cause of a single evanescent stroke that may reasonably be ca

59、lled a prolonged TIA. Also as already pointed out, several emboli can give rise to two or three transient attacks of differing pattern or , rarely , of almost identical pattern.Causes of cerebral embolism:Cardiac originNoncardiac originUndetermined originLaboratory FindingsNot infrequently the first

60、 sign of myocardial infarction is the occurrence of embolism; therefore it is advisable that an ECG and echocardiogram be obtained in all patients with stroke of uncertain origin.Prolonged study of heart rhythm with Holter monitoring should be undertaken. Laboratory FindingsIn some 30 percent of cas