11妊娠合并内科疾病(英文)-陈晓军.ppt
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11妊娠合并内科疾病(英文)-陈晓军.ppt
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MEDICALCOMPLICATIONSINPREGNANCY妊娠合并内科疾病,陈晓军复旦大学附属妇产科医院,Cardiovasculardiseases,Pulmonarydisorders,Renalandurinarytractdisorders,Gastrointestinaldisorders,Hematologicaldisorders,Connectivetissuedisorders,Neurologicalandpsychiatricdisorders,Endocrinedisorders,Dermatologicaldisorders,Neoplasticdiseases,Infections,HeartDiseases,Diabetes,Hepatitis,Disease,HeartDiseaseinPregnancy,妊娠合并心脏病,Heartdiseaseinpregnancy,Interactionbetweenheartdiseaseandpregnancy(心脏病与妊娠的相互影响)Peripartumcardiomyopathy,PPCM(围产期心肌病)Medicaltreatmentofpregnantwomencomplicatedwithheartdisease(妊娠合并心脏病的治疗),Iwantababy,27yearsoldAtrialseptaldefect1cmFeeldiscomfortonlyafterordinaryactivity,CanIhaveababy?
Whatistheriskformeandmybaby?
WhatshouldIdoduringthecourseofpregnancy?
BywhichwayshouldIdeliverymybaby?
Anyspecialthingtobepaidattentiontoafterbirth?
HeartDisease,Incidence:
1-4%ofpregnanciesOneoftheleadingcausesofmaternaldeath(8.3%)Deathrate0.6%-2.7%,Heartdisease,hemodynamicBurdern,Heartfunction,32-34weeksofpregnancyIntrapartumPuerperium(3dayspostpartum),Interactionbetweenpregnancyandheartdisease,Clinicalsignificanceofheartdiseaseinpregnancy,Mother:
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),ClassificationofHeartDisease,Congenitalheartdisease(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,CardiacFunction,SubjectivecapacityClassI:
UncompromisedClassII:
SlightlycompromisedClassIII:
MarkedcompromisedClassIV:
SeverelycompromisedObjectiveexaminationA:
WithoutobjectivebasisofcardiacdiseaseB:
MildcardiacdiseaseaccordingtoobjectiveexamC:
ModerateD:
Severe,Management,TOBEORNOTTOBE,?
Protectthemothersheart,Preconceptionalcounseling,PregnancyYESorNO?
Preconceptionalcounseling,YESMildCardiacfunctionIIINohistoryofheartfailureNocomplication,NOSevereCardiacfunction一HistoryofheartfailurePulmonaryhypertensionRight-to-leftshuntsSeverearrythmiaActiverheumaticheartdiseaseAcuteMyocarditis,endocarditis35ywithlonghistoryofcardiacdisease,DuringPregnancy,DeterminewhetherornotthepregnancyshouldbecontinuedNO:
inducedabortionbefore12weeksYES:
IntensivecareduringpregnancyEarlydiagnosisandtreatmentofcongestiveheartfailure,IntensivecareduringpregnancyDetectcongestiveheartfailureasearlyaspossiblebefore20weeks:
1timeper2weeksafter20weeks:
1timeperweekHospitalizedat36-38weeks,Duringpregnancy,Heartfailure-preventionLimitedphysicalactivityControlofbodyweight:
increase12Kg(0.5Kg/month)Limitedsaltintake:
4-5g/dayPreventriskfactors:
infection,anemia,arrhythmia,hypertensivediseasesDynamicobservationofcardiacfunction,DuringPregnancy,Heartfailure-earlydiagnosisDevelopmentofdyspneaandpalpitationonexertionHeartrate110bpm;breathrate20/minNocturnalcoughPersistentbasilarrales,Duringpregnancy,TreatmentofheartfailureDigoxinDiureticsVesseldilatingagentsTerminationofpregnancy:
C-STimingTerminationafterheartfailureiscontrolledC-Swhenheartfailurecouldnotbecontrolled,Intrapartummanagement,PatternofdeliveryCesareansectionVaginaldeliveryHeartfunctionI-IIVerygoodobstetricalconditionVaginaldelivery-preventheartfailureFirststage:
intensivecareandsedationSecondstage:
shortenthecourseThirdstage:
Addpressureonabdomenpreventpostpartumhemorrhage,Puerperiummanagement,Intensivecareduringthefirst3daysPreventinfectionBreastfeedingSterilization,YesHeartfailurefetaldemisecongenitalheartdiseaseIntensivecareandearlydiagnosisofheartfailureVaginaldeliveryPreventinfectionandpostpartumhemorrhage,CanIhaveababy?
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,Diabetescomplicatingpregnancy,Gestationaldiabetesmellitus(GDM)andovertdiabetescomplicatingpregnancy(妊娠期糖尿病和显性糖尿病合并妊娠)Diabetespregnancy(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),Case,GestationalDiabeticMellitusIncreasedfetalventricularseptumInsulinusedtocontrolbloodglucoselevelC-Sat34weeksforfetaldistressNewbornbabydied1monthafterdelivery,Diabetes,Incidence:
2.9%(1.514.0%)Overtdiabetes(糖尿病合并妊娠)GestationaldiabetesmellitusGDM90%(妊娠期糖尿病),Impactofpregnancyondiabetes,Increasedglucosedemands-hypoglycemia(低血糖)InsulinresistanceandinsufficiencyInsulinoverdoseafterdelivery,Maternalandfetaleffects,MaternaleffectsHypertensivedisorders(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),Maternalandfetaleffects,FetaleffectsMacrosomia(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),Maternalandfetaleffects,NeonataleffectsRespiratorydistress(呼吸窘迫)HyperinsulinemiaPulmonarySurfactantDelayedpulmonarymaturationHypoglycemia(低血糖),Diagnosis-GDM,History:
family,previouspregnancy,presentpregnancyScreening:
50-goralglucosechallengetest(24-28weeks)ConfirmeddiagnosisOGTT:
75/100-goralglucosetolerancetest,The50gr.GCT(Cutoff140mg/dl,7.8mmol/L),Sensitivity:
93.3%Specificity:
38.2%,PositivePredictiveValue:
78.6%NegativePredictiveValue:
70.0%,DiagnosticcriteriaforGDM-OGTT,MethodCriteria(mmol/L)FPG1hr.2hr.3hr.WHO(75g)5.610.38.66.7Diagnosedwhen2ormorevaluesareabnormalFPG:
Fastingplasmaglucose,DiagnosisOvertdiabetes,polydipsia(多饮),polyuria(多尿),unexplainedweightloss,ketoacidosisRandomplasmaglucose200mg/dL(11.1mmol/L);fastingglucose126mg/dL(7mmol/L),Staging,A:
GDMB:
Overtdiabetes,lateonset(after20y),=20y,orretinopathyF:
diabeticnephropathyR:
proliferativeretinopathyorvitreoushemorrhageH:
coronaryheartdiseaseT:
kidneytransplantation,Management,PurposeMaintainglucoselevelwithinnormalrangeMinimizefetalandmaternalcomplicationLowerperipartumfetalandneonatalmortality,Duringpregnancy,DietToprovidethenecessarynutrientsforthemotherandfetusTocontrolglucoselevelsTopreventstarvation30-35kcal/kgofidealbodyweight55%carbohydrate20%protein25%fat3mealsand3snacksdailyIntensifiedmonitoringFastingglucose3.3-5.6mmol/LPostprandialglucose6.7mmol/L,Duringpregnancy,Drugtreatment:
InsulinonlyIndividualized,Assessmentofmother,Glucose/ketonemonitoring(监测血糖/酮体)Retinalphotograph(眼底)Renalfunction(肾功能)GlycatedHaemoglobin(糖化血红蛋白),Assessmentoffetalwell-being,DailyfetalmovementcountingNSTAFVorbiophysicalprofiles,Delivery,WHEN?
after38completedweeksFetallungmuturationBefore38weekswhenUnsatisfiedglucosecontrolMaternalcomplication:
infection,severepreeclampsia;vasculardieseaseFetaldistressorFGRCautionintheuseofcorticosteroids,Delivery,HOW?
DiabetesitselfisnottheindicationforC-SC-Swhenindicated:
macrosomia,compromisedplacentafunction,etc.Stopsubcutaneousinsulin3hoursbeforeoperation,Delivery,VaginaldeliveryClosemonitoringControlthewholecoursewithin12hoursGlucosemonitoring:
5.6mmol/L(100mg/dL),postpartum,Insulindosedecrease1/2-1/3afterdelivery,Neonatalmanagement,Treatedaspretermbaby25%glucoseintake30minutesafterdeliveryPreventcomplications,Prognosis,Morethan50%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,ViralHepatitisinPregnancy,Interactionbetweenpregnancyandhepatitis(妊娠与肝炎的相互影响)Diagnoseandtreatment(诊断和治疗)Pathwayofmaternalfetalinfectionandprevention(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),EpidemiologyofHepatitis,0.2billionintheworld,0.13billioninChina10-20%populationwithpositiveHBsAginChina,Introduction,TypesofviralHAV,HBV,HCV,HDV,HEV,HGVIncidence:
0.8%-17.8%amongpregnantwomenHBVinfectionmoreprevalentinChina,Impactofpregnancyonviralhepatitis,CompromiseddefendingabilityofliverHeavierliverburdenMorecomplicatedandsevereconditioninpregnantpatients,Impactofhepatitisonpregnancy,EarlyPregnancySeriouspregnancyreactionAbortionMalformation,Impactofhepatitisonpregnancy,LatepregnancyHypertensionPostpartumhemorrhagePretermdelivery,fetaldeath,stillbirth,Impactofhepatitisonpregnancy,Maternal-fetalinfectionHBV(母婴垂直传播)IntrauterineIntrapartummainrouteoftransmissionFetalswallowingingenitaltractMotherbloodleakingintofetalcirculationPostpartum:
breastfeeding,salivary,Diagnosis,History:
closecontactwithhepatitispatients,bloodtransfusionwithin6monthsClinicalfeatures:
gastrointestinalsymptomscantbeexplainedbyotherreasons,jaundice,increasedliversizeinfirstandsecondtrimester,pain,Diagnosis,HBsAg:
ActiveHBVinfection;maybeacuteorchronicHBeAg:
Highinfectivity,activeviralreplicationHBcAg:
Activecopying,undetectableinserumAnti-HBcAgIgM:
AcuteHBVinfection(newerandmoresensitiveassaysmayal
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- 11 妊娠 合并 内科 疾病 英文 陈晓军
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