妊娠合并内科疾病(英文)妇科八年制教学课件-2-2

1、MEDICAL COMPLICATIONS IN PREGNANCY妊娠合并内科疾病陈晓军复旦大学附属妇产科医院Cardiovascular diseasesPulmonary disordersRenal and urinary tract disordersGastrointestinal disordersHematological disordersConnective tissue disordersNeurological and psychiatric disordersEndocrine disordersDermatological disordersNeoplastic d

2、iseasesInfectionsHeart DiseasesDiabetesHepatitisDiseaseHeart Disease in Pregnancy妊娠合并心脏病Heart disease in pregnancyInteraction between heart disease and pregnancy（心脏病与妊娠的相互影响）Peripartum cardiomyopathy, PPCM (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）I want

3、a baby27 years oldAtrial septal defect 1cmFeel discomfort only after ordinary activityCan 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 birth?Heart DiseaseIncide

4、nce:1-4% of pregnancies One of the leading causes of maternal death (8.3%)Death rate 0.6%-2.7%Heart diseasehemodynamic BurdernHeart function32-34 weeks of pregnancyIntrapartumPuerperium (3 days postpartum)Interaction between pregnancy and heart diseaseClinical significance of heart disease in pregna

5、ncyMother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolismBaby: miscarriage（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）Increased caesarean section rate （剖宫产）Drug effectHereditary congenital heart disease

6、 （先天性心脏病）Classification of Heart DiseaseCongenital heart disease （先天性心脏病）Left-to right shuntRight-to left shuntNon-shuntRheumatic heart disease （风湿性心脏病）Hypertensive heart disease（妊娠期高血压疾病性心脏病）Peripartum cardiomyopathy (PPCM)Myocarditis （心肌炎）Peripartum cardiomyopathy (PPCM) 围产期心肌病Dilated cardiomyopat

7、hy occurs during the last 3 months of pregnancy to 6 months postpartum (increased heart size, decreased heart function)Etiology unknownNo history of cardiovascular diseaseDie from heart failure, arrhythmia or pulmonary infarction50% recover 6 months postpartumRecur in the successive pregnancyClinica

8、l Implications ：10-30% of fetal deathTherapy Treatment for heart failureHeart transplantationCardiac FunctionSubjective capacityClass I: UncompromisedClass II: Slightly compromisedClass III: Marked compromisedClass IV: Severely compromisedObjective examinationA: Without objective basis of cardiac di

9、seaseB: Mild cardiac disease according to objective examC: Moderate D: Severe ManagementTO BE OR NOT TO BE？ Protect the mothers heartPreconceptional counselingPregnancy YES or NO ?Preconceptional counselingYESMild Cardiac function IIINo history of heart failure No complicationNOSevere Cardiac functi

10、on 一History of heart failurePulmonary hypertensionRight-to-left shuntsSevere arrythmiaActive rheumatic heart diseaseAcute Myocarditis, endocarditis35y with long history of cardiac diseaseDuring PregnancyDetermine whether or not the pregnancy should be continuedNO: induced abortion before 12 weeksYES

11、:Intensive care during pregnancyEarly diagnosis and treatment of congestive heart failureIntensive care during pregnancy Detect congestive heart failure as early as possible before 20 weeks: 1 time per 2 weeksafter 20 weeks : 1 time per weekHospitalized at 36-38 weeksDuring pregnancyHeart failure -

12、prevention Limited physical activityControl of body weight: increase 12Kg (0.5Kg / month)Limited salt intake: 110 bpm; breath rate 20/min Nocturnal coughPersistent basilar ralesDuring pregnancyTreatment of heart failureDigoxinDiuretics Vessel dilating agentsTermination of pregnancy:C-S TimingTermina

13、tion after heart failure is controlledC-S when heart failure could not be controlledIntrapartum managementPattern of deliveryCesarean sectionVaginal deliveryHeart function I-IIVery good obstetrical conditionVaginal delivery- prevent heart failureFirst stage: intensive care and sedationSecond stage:

14、shorten the courseThird stage: Add pressure on abdomen prevent postpartum hemorrhagePuerperium managementIntensive care during the first 3 daysPrevent infectionBreast feedingSterilizationYesHeart failure fetal demise congenital heart diseaseIntensive care and early diagnosis of heart failureVaginal

15、deliveryPrevent infection and postpartum hemorrhage 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 birth?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。Diabet

16、es complicating pregnancy妊娠合并糖尿病Diabetes complicating pregnancyGestational diabetes mellitus (GDM) and overt diabetes complicating pregnancy(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）Screening and diagnosis（筛查和诊断）Management of women complicating diabetes during pregnancy（妊娠合并糖尿病的处理）Case Gestat

17、ional Diabetic MellitusIncreased fetal ventricular septumInsulin used to control blood glucose levelC-S at 34 weeks for fetal distressNewborn baby died 1 month after deliveryDiabetesIncidence: 2.9% (1.5 14.0%)Overt diabetes (糖尿病合并妊娠）Gestational diabetes mellitus GDM 90%（妊娠期糖尿病）Impact of pregnancy on

18、 diabetesIncreased glucose demands-hypoglycemia （低血糖）Insulin resistance and insufficiencyInsulin overdose after deliveryMaternal and fetal effectsMaternal effectsHypertensive disorders （高血压）Infection （感染）Ketoacidosis （酮症酸中毒） Spontaneous abortion （自发流产）Polyhydramnios （羊水过多）Dystocia （难产） and C-S owing

19、 to macrosomia （巨大儿）Recurrent GDM （再次妊娠时复发）Maternal and fetal effectsFetal effectsMacrosomia （巨大儿）Fetal growth restriction （胎儿宫内生长受限）Spontaneous abortion & Preterm delivery （自发流产和早产）Malformation （胎儿畸形）Maternal and fetal effectsNeonatal effectsRespiratory distress （呼吸窘迫）Hyperinsulinemia Pulmonary Sur

20、factant Delayed pulmonary maturationHypoglycemia （低血糖）Diagnosis-GDMHistory: family, previous pregnancy, present pregnancyScreening: 50-g oral glucose challenge test （24-28 weeks）Confirmed diagnosisOGTT: 75/100-g oral glucose tolerance testThe 50 gr. GCT (Cutoff 140 mg/dl, 7.8mmol/L)Sensitivity: 93.3

21、%Specificity: 38.2%Positive Predictive Value: 78.6 %Negative Predictive Value : 70.0 %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 glucoseDiagnosisOvert diabetespolydipsia （多

22、饮）, polyuria （多尿）, unexplained weight loss，ketoacidosisRandom plasma glucose 200 mg/dL(11.1 mmol/L); fasting glucose126mg/dL (7 mmol/L)StagingA: GDMB: Overt diabetes, late onset (after 20y), =20y, or retinopathyF: diabetic nephropathyR: proliferative retinopathy or vitreous hemorrhage H: coronary he

23、art disease T: kidney transplantation ManagementPurposeMaintain glucose level within normal rangeMinimize fetal and maternal complicationLower peripartum fetal and neonatal mortality During pregnancyDietTo provide the necessary nutrients for the mother and fetusTo control glucose levelsTo prevent st

24、arvation30-35kcal/kg of ideal body weight55% carbohydrate20% protein25% fat3 meals and 3 snacks dailyIntensified monitoringFasting glucose 3.3-5.6mmol/LPostprandial glucose 5.6mmol/L (100mg/dL)postpartum Insulin dose decrease 1/2 -1/3 after deliveryNeonatal managementTreated as preterm baby25% gluco

25、se intake 30 minutes after deliveryPrevent complicationsPrognosisMore than 50% women with GDM develop diabetes in the following 20 yearsMore risk for offspring to develop obesity and diabetes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Viral Hepatitis in Pregnancy 妊娠合并急性病毒性肝炎Viral Hepatitis in P

26、regnancyInteraction between pregnancy and hepatitis（妊娠与肝炎的相互影响）Diagnose and treatment （诊断和治疗）Pathway of maternal fetal infection and prevention（母-胎感染途径和预防）Differential diagnosis of hepatic disease （与妊娠期肝内胆汁淤积症的鉴别诊断）Epidemiology of Hepatitis0.2 billion in the world, 0.13billion in China10-20% populat

27、ion with positive HBsAg in ChinaIntroductionTypes of viral HAV, HBV, HCV, HDV, HEV, HGVIncidence: 0.8%-17.8% among pregnant womenHBV infection more prevalent in ChinaImpact of pregnancy on viral hepatitisCompromised defending ability of liverHeavier liver burdenMore complicated and severe condition

28、in pregnant patientsImpact of hepatitis on pregnancyEarly PregnancySerious pregnancy reactionAbortionMalformationImpact of hepatitis on pregnancyLate pregnancyHypertensionPostpartum hemorrhagePreterm delivery, fetal death, stillbirthImpact of hepatitis on pregnancyMaternal - fetal infection HBV (母婴垂

29、直传播）IntrauterineIntrapartummain route of transmissionFetal swallowing in genital tractMother blood leaking into fetal circulationPostpartum: breastfeeding, salivaryDiagnosisHistory: close contact with hepatitis patients, blood transfusion within 6 monthsClinical features: gastrointestinal symptoms c

30、ant be explained by other reasons, jaundice, increased liver size in first and second trimester, painDiagnosisHBsAg: Active HBV infection; may be acute or chronic HBeAg: High infectivity, active viral replication HBcAg: Active copying, undetectable in serumAnti-HBcAg IgM: Acute HBV infection (newer

31、and more sensitive assays may also be positive during reactivation of chronic infections) HBV-DNA and DNA polymerase: Direct measure of infectivity or replicative state; becoming increasingly available Anti-HBsAg: Immune to HBV; may be natural immunity or following vaccination Anti-HBeAg: Low or no

32、infectivity; need only be measured in chronic HBV ManagementRestNutritionProtection of liver functionPrevent infection and further damageFluminant hepatitis （重症肝炎）Obstetrical ManagementThe first trimesterLight hepatitis: active treatment and maintaining the pregnancyChronic active hepatitis: termina

33、tion after treatmentThe second and third trimesterPrevent from termination of pregnancyClose monitoringManagementDeliveryC-S is preferredVitamin K1 20-40mg im several days before delivery Prevent postpartum hemorrhageFulminant hepatitis（重症肝炎） C-S 24 hours after active treatmentManagementPureperium （产褥期）Prevent from damaging liver functionBreast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positivePrevention of neonatal infectionImmunoprophylaxis4,000 among 18,000 new born babies w