妊娠合并内科疾病（英文）妇科八年制教学课件

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 diseases Pulmonary disorders Renal and urinary tract disorders Gastrointestinal disorders Hematological disorders Connective tissue disorders Neurological and psychiatric disorders Endocrine disorders Dermatological disorders Neoplastic diseases Infections Heart Diseases Diabetes Hepatitis Disease Heart Disease in Pregnancy 妊娠合并心脏病 Heart disease in pregnancy n Interaction between heart disease and pregnancy（心脏病与妊娠的相互影响 ） n 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 a baby n 27 years old n Atrial septal defect 1cm n Feel discomfort only after ordinary activity 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? Heart Disease n Incidence:1-4% of pregnancies n One of the leading causes of maternal death (8.3%) n Death rate 0.6%-2.7% Heart disease hemodynamic Burdern Heart function 32-34 weeks of pregnancy Intrapartum Puerperium (3 days postpartum) Interaction between pregnancy and heart disease Clinical significance of heart disease in pregnancy n Mother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolism n Baby: 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） n Increased caesarean section rate （剖宫产 ） n Drug effect n Hereditary congenital heart disease （先天 性心脏病） Classification of Heart Disease n Congenital heart disease （先天性心脏病） JLeft-to right shunt LRight-to left shunt KNon-shunt n Rheumatic heart disease （风湿性心脏病） n Hypertensive heart disease（妊娠期高血压 疾病性心脏病） n Peripartum cardiomyopathy (PPCM) n Myocarditis （心肌炎） Peripartum cardiomyopathy (PPCM) 围产期心肌病 n Dilated cardiomyopathy occurs during the last 3 months of pregnancy to 6 months postpartum (increased heart size, decreased heart function) n Etiology unknown n No history of cardiovascular disease n Die from heart failure, arrhythmia or pulmonary infarction n 50% recover 6 months postpartum n Recur in the successive pregnancy n Clinical Implications ： 10-30% of fetal death n Therapy n Treatment for heart failure n Heart transplantation Cardiac Function Subjective capacity n Class I: Uncompromised n Class II: Slightly compromised n Class III: Marked compromised n Class IV: Severely compromised Objective examination n A: Without objective basis of cardiac disease n B: Mild cardiac disease according to objective exam n C: Moderate n D: Severe Management nTO BE OR NOT TO BE ？ Protect the mothers heart Preconceptional counseling n Pregnancy YES or NO ? Preconceptional counseling YES Mild Cardiac function I II No history of heart failure No complication NO n Severe n Cardiac function 一 n History of heart failure n Pulmonary hypertension n Right-to-left shunts n Severe arrythmia n Active rheumatic heart disease n Acute Myocarditis, endocarditis n 35y with long history of cardiac disease During Pregnancy Determine whether or not the pregnancy should be continued n NO: induced abortion before 12 weeks n YES: n Intensive care during pregnancy Early diagnosis and treatment of congestive heart failure n Intensive care during pregnancy Detect congestive heart failure as early as possible n before 20 weeks: 1 time per 2 weeks n after 20 weeks : 1 time per week n Hospitalized at 36-38 weeks During pregnancy n Heart failure - prevention n Limited physical activity n Control of body weight: increase 110 bpm; breath rate 20/min n Nocturnal cough n Persistent basilar rales During pregnancy n Treatment of heart failure n Digoxin n Diuretics n Vessel dilating agents n Termination of pregnancy: n C-S n Timing n Termination after heart failure is controlled n C-S when heart failure could not be controlled Intrapartum management n Pattern of delivery n Cesarean section n Vaginal delivery n Heart function I-II n Very good obstetrical condition n Vaginal delivery- prevent heart failure n First stage: intensive care and sedation n Second stage: shorten the course n Third stage: Add pressure on abdomen prevent postpartum hemorrhage Puerperium management n Intensive care during the first 3 days n Prevent infection n Breast feeding n Sterilization n Yes n Heart failure fetal demise congenital heart disease n Intensive care and early diagnosis of heart failure n Vaginal delivery n Prevent infection and postpartum hemorrhage n Can I have a baby? n What is the risk for me and my baby? n What should I do during the course of pregnancy? n By which way should I delivery my baby? n Any special thing to be paid attention to after birth? 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。 Diabetes complicating pregnancy 妊娠合并糖尿病 Diabetes complicating pregnancy n Gestational 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） n Screening and diagnosis（筛查和诊断） MManagement of women complicating diabetes during pregnancy（妊娠合并糖尿 病的处理） Case n Gestational Diabetic Mellitus n Increased fetal ventricular septum n Insulin used to control blood glucose level n C-S at 34 weeks for fetal distress n Newborn baby died 1 month after delivery Diabetes n Incidence: 2.9% (1.5 14.0%) n Overt diabetes (糖尿病合并妊娠） n Gestational diabetes mellitus GDM 90%（妊娠期糖尿病） Impact of pregnancy on diabetes n Increased glucose demands- hypoglycemia （低血糖） n Insulin resistance and insufficiency n Insulin overdose after delivery Maternal and fetal effects n Maternal effects n Hypertensive disorders （高血压） n Infection （感染） n Ketoacidosis （酮症酸中毒） n Spontaneous abortion （自发流产） n Polyhydramnios （羊水过多） n Dystocia （难产） and C-S owing to macrosomia （巨大儿） n Recurrent GDM （再次妊娠时复发） Maternal and fetal effects n Fetal effects n Macrosomia （巨大儿） n Fetal growth restriction （胎儿宫内生长受限） n Spontaneous abortion fasting glucose126mg/dL (7 mmol/L) Staging n A: GDM n B: Overt diabetes, late onset (after 20y), =20y, or retinopathy n F: diabetic nephropathy n R: proliferative retinopathy or vitreous hemorrhage n H: coronary heart disease n T: kidney transplantation Management n Purpose n Maintain glucose level within normal range n Minimize fetal and maternal complication n Lower peripartum fetal and neonatal mortality During pregnancy n Diet n To provide the necessary nutrients for the mother and fetus n To control glucose levels n To prevent starvation n 30-35kcal/kg of ideal body weight n 55% carbohydrate n 20% protein n 25% fat n 3 meals and 3 snacks daily n Intensified monitoring n Fasting glucose 5.6mmol/L (100mg/dL) postpartum n Insulin dose decrease 1/2 -1/3 after delivery Neonatal management n Treated as preterm baby n 25% glucose intake 30 minutes after delivery n Prevent complications Prognosis n More than 50% women with GDM develop diabetes in the following 20 years n More risk for offspring to develop obesity and diabetes 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 Viral Hepatitis in Pregnancy 妊娠合并急性病毒性肝炎 Viral Hepatitis in Pregnancy n Interaction between pregnancy and hepatitis（妊娠与肝炎的相互影响） n Diagnose and treatment （诊断和治疗 ） MPathway of maternal fetal infection and prevention（母 -胎感染途径和预防 ） n Differential diagnosis of hepatic disease （与妊娠期肝内胆汁淤积症的 鉴别诊断） Epidemiology of Hepatitis n 0.2 billion in the world, 0.13billion in China n 10-20% population with positive HBsAg in China Introduction n Types of viral HAV, HBV, HCV, HDV, HEV, HGV n Incidence: 0.8%-17.8% among pregnant women n HBV infection more prevalent in China Impact of pregnancy on viral hepatitis n Compromised defending ability of liver n Heavier liver burden n More complicated and severe condition in pregnant patients Impact of hepatitis on pregnancy n Early Pregnancy n Serious pregnancy reaction n Abortion n Malformation Impact of hepatitis on pregnancy n Late pregnancy n Hypertension n Postpartum hemorrhage n Preterm delivery, fetal death, stillbirth Impact of hepatitis on pregnancy n Maternal - fetal infection HBV (母婴垂直传播） n Intrauterine n Intrapartummain route of transmission n Fetal swallowing in genital tract n Mother blood leaking into fetal circulation n Postpartum: breastfeeding, salivary Diagnosis n History: close contact with hepatitis patients, blood transfusion within 6 months n Clinical features: n gastrointestinal symptoms cant be explained by other reasons, n jaundice, increased liver size in first and second trimester, pain Diagnosis L HBsAg: Active HBV infection; may be acute or chronic L HBeAg: High infectivity, active viral replication L HBcAg: Active copying, undetectable in serum L 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 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 Management n Rest n Nutrition n Protection of liver function n Prevent infection and further damage n Fluminant hepatitis （重症肝炎） Obstetrical Management n The first trimester JLight hepatitis: active treatment and maintaining the pregnancy LChronic active hepatitis: termination after treatment n The second and third trimester n Prevent from termination of pregnancy n Close monitoring Management n Delivery n C-S is preferred n Vitamin K1 20-40mg im several days before delivery n Prevent postpartum hemorrhage n Fulminant hepatitis（重症肝炎） C-S 24 hours after active treatment Management n Pureperium （产褥期） n Prevent from damaging liver function n Breast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positive Prevention of neonatal infection n Immunoprophylaxis n 4,000 among 18,000 new born babies with HBsAg-positive mother will be chronically infected with HBV without immunoprophylaxis Imm