Cardiac Disease Complicating Pregnancy 妊娠合并心脏病

CardiacDiseaseComplicatingPregnancy

妊娠合并心脏病RenjiHospitalLinJianhua(林建华）上海市产科心脏病监护中心

ReviewAntepartum

cardiovascularchangeBloodvolume:increase45%Cardiacoutput::increase,fluctuation,plateaubetween28-34weeksBloodpressure:Decline,vascularresistance:HypercoagulabilityHeart:enlargedIntrapartumcardiovascularchangeFirststagelabor:SecondstagelaborincreasecardiacoutputandworkloadofheartPostpartumcardiovascularchangeRiskofFluidvolumeoverloadThekindsofcardiacdiseaseswithpregnancyCongenitalheartdiseases:Atrial

septaldefect(ASD)Ventricularseptaldefect(VSD)Patentductus

arteriosus(PDA)TetralogyofFallot(F4)AorticstenosisPulmonarystenosisMarfan’ssyndromeEisenmenger’ssyndromeAcquiredheartdisease:RheumaticheartdiseaseHeartdiseasewithpregnantinducedhypertensionPeripartum

cardiomyopathy(PPCM)myocarditisdiagnosisHistorySymptomsandsignsECG(electrocardiography)24HourHOLTEREchocardiographyChestradiographyLeft-heartcatheterizationTheheartfunctionalclassificationTheNewYorkHeartAssociation(NYHA)guidelineClassI:asymptomaticClassII:symptomaticwithnormalactivity,exertionClassIII:symptomaticwithlessthannormalactivityClassIV:symptomaticatrestReliesonsubjectiveIndicationofpregnancy:HeartdiseasewithclassIandclassIINoheartfailurehistoryLife-threateningcardiacdiseasesreversedbycorrectivesurgeryContraindicationofpregnancy:HeartdiseasewithclassIIIandclassIVHeartfailurehistoryPulmonaryhypertensionMitralstenosisEisenmenger’s

syndromeEF<40%managementClassIandIISpecialattentionforpreventionandearlyrecognitionofheartfailureInfectionprevention(commoncold,bacterialendocarditis)CanVaginaldeliveryRelieffrompainandapprehensionClassIIIandIV:TheimportantquestioninthesewomeniswhetherpregnancyshouldbeundertakenBeconsiderinterruptionifearlyenoughBedrestorhospitalizationifcontinuedEpiduralanalgesiaforlaboranddeliveryCesareansectionKeywordsThekindsofcardiacdiseasesTheheartfunctionalclassificationContraindicationofpregnancygestationaldiabetesmellitus（GDM)

妊娠期糖尿病LinJianhua林建华ClassificationGestationaldiabetes:diagnosedduringpregnancyOvertdiabetesduringpregnancytohavediabetesbeforepregnancyDMisametabolicdisordercharacterizedbyhyperglycemiaThecauseofDMismultifactorial(genetic,immune,environmental,viral,)GDM:2.9%inChian(1997)3%-10%inUSA(1999)Effectsofpregnancyonglucosemetabolism/diabetes1.Diataryhabitschanges2.Insulinloadincrease3.Anti-insulinhormonesfromplacentaprolactinestrogenprogesterone

insulinaseMaternaleffectsGlucosuriaHyperglycemiaDiabetesketoacidosisInfectionPIH/PreeclampsiaNephropathy(肾病），retinopathy(视网膜病）Neuropathy（神经病）Fetal/neonataleffectsAbortionPretermdeliveryCongenitalanomalies,malformationsMacrosomiaHydramnios(羊水过多）RespiratorydistressHypoglycemia,HypocalcemiaHyperbilirubinemia(高胆红素血症）Polycythemia(红细胞增多症）diagnosisHistory,familialhistoryofdiabetesSymptoms:

polydipsia,polyuria,unexplainedweightlossAllpregnacywomenshouldbescreenedforGDMbetween24-28weeks’gestatiobn

glucosechallengetest[GCT])measuringtheplasmaorserumglucoseconcentration1houraftera50-goralglucoseloadoralglucosetolerancetest(OGTT)onthatsubsetofwomenexceedingtheglucosethresholdvalue(>140mg/dL/7.8mmol/L)onGCT.Oralglucosetolerancetest:WHO(1985):75g-2-hourOGTTUSA(1994):100g-3-hourOGTTThereisnotaconsensus-100g-O-hour<5.8mmol/L1-hour<10.6mmol/L2-hour<9.2mmol/L3-hour<8.1mmol/LBediagnosedIfanytwoormoreserumglucosevaluesmeetorexceedTextBook（6th）

-75gO-hour<5.6mmol/L1-hour<10.3mmol/L2-hour<8.6mmol/L3-hour<6.7mmol/LWhite’sclassificationofDMinpregnancyA:GDMB:onsetat≧20yearsofageordurationof<10yearsC:onsetat10-19yearsofageordurationof10-19yearsD:onsetat<10yearsofageordurationof≧20yearsoranyonsetordurationwithbackgroundretinopathyorhypertensiononlyF:Nephropathy(>500mgproteinperdayat<20weeksofpregnancyH:Arterioscleroticheartdisease,clinicallyevidentR:proliferativediabeticretinophyorvitreoushemorrhageT:historyofrenaltransplantManagmentEducationStandarddietarytoprovidethenecessarynutrientstocontrolglucoseleveltopreventstarvationketosisdailycaloricintake:30Kcal/Kg/Day+300-500calExerciseInsulintherapyMonitorofbloodglucoselevelObstetricalmanagementmaternalevaluationFetalevaluationgrowthanddevelopment,well-being(NST.CST,BPS)

intrapartum

managmentPostpartumconsequencesKeywordsglucosechallengetest[GCT])oralglucosetolerancetest(OGTT)ManagementAcuteViralHepatitis

withpregnancy

急性病毒性肝炎LinJianhua林建华Viralinfection:HepatitisAHepatitisBHepatitisCHepatitisDHepatitisEHepaticphysiology:Performmetabolicprocessesproteinsynthesis,metabolismofcarbohydrates,lipids,andaminoacidsBiotransformationofdifferentcompoundsSynthesisofFg,PT,clottingfactors,,,,,,

Pregnancy–relatedchanges:Albumin:20%decreaseBilirubin:nochangeAKP:increaseClottingfactors:increaseSerumtransaminase:nochangeTotalprotein:slight

decrease(dilutional)HepatitisABeusuallyspreadbyconsumingfoodwatercontaminatedbyfecesandsewageBysexualcontactThroughbloodexposureHepatitisB:TransmittedviacontaminatedneedlesbloodproductsdirectmucosalcontactwithcontaminatedbodilyfluidsVerticaltransmissionfrommothertochild(antapartum,intrapatum,postpatum)HepatitisC:transfusionwithblood,bloodproducts,OrgandonationrecipientTransvenousdrugabuse,Tatooing,（纹身）Hemodialysis(血透)OccupationalexposuretobloodproductsVerticaltransmissionfrommothertochildHepatitisE:Spreadbyfecal-oraltransmission,Self-limiting,Diagnosis1.history2.incubationperiod:A:14-40daysB:30-110daysC:50daysE:15-65days3.symptoms:malaise,fever,jaundice,fatigue,,,,,,4.s