_medical complications of pregnancy妊娠内科合并症课件

Medical Complications of Pregnancy 妊娠期合并症 Objectives目 的 Describe selected medical emergencies exclusive to pregnancy描述仅在妊娠出现的医 疗急症 Describe selected medical conditions that can cause serious complications in pregnancy描述 可能危及生命的妊娠合并症 Formulate a plan for diagnosis and treatment of these conditions制定诊断及治疗的计划 Conditions Exclusive to Pregnancy仅在妊娠 出现的症状 Severe pre-eclampsia 严重子痫前期 Eclampsia子痫 HELLP syndromeHELLP综合 征 Acute fatty liver of pregnancy (AFLP)妊 娠期急性脂肪肝 Conditions That Complicate Pregnancy使妊娠复杂化的症 状 Deep venous thrombosis (DVT)深静脉血栓 Pulmonary embolism (PE) 肺栓塞 Disseminated intravascular coagulation (DIC)弥漫性血 管内凝血 Human immunodeficiency virus (HIV) infection HIV感 染 Hypertensive Disorders of Pregnancy 妊娠相关高血压症 Pregnancy Induced Hypertension妊高症 PIH无蛋白尿 (no proteinuria) HELLP Syndrome HELLP综合征 Chronic Hypertension (Elevated BP prior to 20 weeks)慢性高血 压（妊娠前20周 血压升高） 6-8% of all gestations 妊娠的 6-8% Preeclampsia 子痫前期 (proteinuria +/- edema)蛋白 尿水肿 Eclampsia 子痫 Severe Preeclampsia 严重子痫前期 Pre-Eclampsia子痫前期 Classic Triad:经典三联征 FHypertension (140/90)高血压 FProteinuria (1+ or 300 mg/24h)蛋白尿 FGeneralized edema (least reliable)广泛性水肿 Hypertension and proteinuria must be present on two occasions 6 hr apart高血压和蛋白尿需在 至少间隔6小时、二次以上 Rapid weight gain is supportive evidence 体重迅速增加支持诊断 Diagnostic Criteria for Severe Preeclampsia 严重先兆子痫的诊断标准 Headaches 头痛 Visual Disturbances 视力紊乱 Pulmonary Edema 肺水肿 Hepatic Dysfunction 肝功异常 RUQ or Epigastric Pain 右上腹或上腹痛 Oliguria少尿 Elevated Creatinine肌酐酐上升 Proteinuria of 5 g or more in 24 hrs 24小时时尿蛋白5g以上 Thrombocytopenia or hemolysis 血栓性血小板减少或溶血 Systolic BP收缩压 160 to 180 mm Hg Diastolic BP舒张压 110 mm Hg Risk Factors for Preeclampsia 先兆子痫的危险因素 Nulliparity Maternal age 40 Twin gestation Family history of pre- eclampsia or eclampsia Chronic hypertension Chronic renal disease Antiphospholipid syndrome Diabetes mellitus Angiotensin gene T235 初产妇 母年龄超过40岁 双胎 以前妊娠有先兆子痫 慢性高血压 慢性肾病 抗磷脂综合征 糖尿病 血管紧张素T235基因 Prevention: No Proven Benefit 预防：尚未证明获益 Correct nutritional deficiencies改善营养缺乏 F Magnesium镁 FZinc锌 FOmega 3 fatty acids 欧米茄3脂肪酸 Change prostacyclin / thromboxane balance: 改变前列环素/血栓烷的平衡 FAspirin阿斯匹林 Clinical Course of Preeclampsia 子痫前期临床病程 Eyes Arteriolar Spasm Retinal Hemorrhage Papilledema Transient Scotomata Respiratory System Pulmonary Edema ARDS Liver Subcapsular Hemorrhage Hepatic Rupture Hematopoietic System HELLP Syndrome DIC CNS Seizures Intracranial Hemorrhage CVA Encephalopathy Pancreas Ischemic Pancreatitis Kidneys Acute Renal Failure Uteroplacental Circulation IUGR Abruption Fetal Compromise Fetal Demise Clinical Course of Preeclampsia子痫前期临床病程 中枢神经系统 子痫发作 颅内出血 脑血管意外 脑水肿 Pancreas胰腺 Ischemic Pancreatitis 缺血性胰腺炎 Kidneys肾脏 Acute Renal Failure 急性肾功能衰竭 子宫胎盘循环 胎儿生长受限 早剥 胎儿受损 胎儿死亡 眼睛 小动脉痉挛 视网膜出血 视乳头水肿 一过性的盲点 呼吸系统 肺水肿 ARDS 肝脏 包膜下出血 肝脏破裂 造血系统 HELLP综合征 DIC Management of Severe Preeclampsia 严重先兆子痫的处理 Admit to hospital, monitor closely at bedrest 住院卧床休息，密切监测 Treatment goals:治疗的目标 FPrevent seizures预防抽搐 FLower BP to prevent cerebral hemorrhage降压预防脑出血 FExpedite delivery, balancing maternal condition and fetal maturity 提前分娩，权衡母情况与胎儿成熟的状况 Maternal Evaluation对母亲的评估 Vitals, neuro checks, and DTRs q15-60 min. until stable生命体征、神经系统的检查，深腱反射每15-60 分钟一次，直至稳定 Foley catheter - output and dipstick protein hourly foley尿管每小时计量排量和蛋白量 External monitoring NST 外检测NST Labs: Blood count, BUN, creatinine, AST, ALT, LDH, electrolytes and uric acid 实验室：血常规、BNU、肌 酐、肝酶、电解质、尿酸 Meds: MgSO4 IV; BP meds for diastolic 110 药物 ：静脉硫酸镁，若舒张压110用降压药 Magnesium Sulfate硫酸镁 Preferred anticonvulsant 抗抽搐首选 Slows neuromuscular conduction and decreases CNS irritability减慢神经肌肉的传导 、降低中枢神经系统的激惹性 No significant effects on blood pressure对血 压无显著影响 4-6 gram IV load, followed by infusion of 1-3 grams / hour静脉4-6克，然后每小时1-3克 Magnesium Levels硫酸镁浓度 Normal Therapeutic Loss of patellar reflex Somnolence Respiratory depression Paralysis Cardiac arrest mg/dl 1.3 to 2.6 4 to 8 8 to 10 10 to 12 12 to 17 15 to 17 30 to 35 Antidote is calcium gluconate one gram IV over 3 minutes 拮抗剂是葡萄糖酸钙拮抗剂是葡萄糖酸钙1g1g缓慢（缓慢（ 3 3 分钟以上）静脉注射分钟以上）静脉注射 正常 治疗浓度 膝腱反射消失 嗜睡 呼吸窘迫 麻痹 心跳骤停 Antihypertensive Medication 抗高血压药物 Goal: Maternal diastolic 90-110 mm Hg 目标：母亲舒张压90-110 Choices of parenteral agent静脉用药选择 FBeta blockers (labetalol)贝塔阻滞剂 FVasodilators (hydralazine)扩血管药物 Oral alternatives (slower onset) 口服替代药（起效慢） FCalcium channel blockers (nifedipine) F钙离子拮抗剂（尼非地平） FMethyldopa (Aldomet)甲基多巴 33-34 weeks大于34周 Delivery引产 Delivery Decisions - Severe Preeclampsia 严重子痫前期分娩判断 Maternal deterioration?母亲情况恶化？ Severe IUGR?严重胎儿生长受限 Fetal compromise?胎儿窘迫 In labor?已在分娩过程？ 34 weeks gestation?孕期34周 28-32周 Corticosteroids糖皮质激素 Antihypertensive drugs抗高血压药 Daily evaluation of maternal and fetal conditions until 33-34 Weeks每天评估母婴情况直至33到 34周 Yes Delivery within 24 hours 24H内引产 Amniocentesis羊穿 Immature fluid不成熟羊水 Corticosteroids糖皮质激素 Deliver 48 hours later 48H 后引产 Mature fluid成熟羊水 No Adapted from University of Tennessee, Memphis, management plan for patients with severe preeclampsia, Sibai, BM, in Obstetrics: Normal and Problem Pregnancies, 3rd Edition, Gabbe, SG, Niebyl, JR, Simpson, JL. Delivery Decisions for Severe Preeclampsia II严重先兆子痫的分娩决策 Vaginal delivery preferred倾向于阴道分娩 Cesarean delivery for剖宫产用于 FContinuous seizures or other emergency连续抽搐或其它 急症 FFetal distress胎儿窘迫 FUnfavorable cervix宫颈不成熟 FSevere prematurity很早的早产 Anesthesia麻醉 Epidural vs. general硬膜外或全麻 Postpartum Management产后处理 Improvement usually rapid after delivery 产后常很快地改 善 Risk of seizure greatest in first 24 hours 在产后24小时内 抽搐的危险最大 Magnesium continued for 24 hrs 连续使用硫酸镁24H Continue monitoring serum MgSO4 levels, BP, urine output 监测硫酸镁、血压及尿量 Watch for signs of fluid overload 注意水负荷过重的体征 Eclampsia 子痫 Appearance of seizures in a patient with preeclampsia先兆子痫的患者发生抽搐 Etiology uncertain病因不清 Fcerebral edema, ischemia possible causes脑水肿、缺血可 能是原因 BP often significantly elevated, but in 20% can be normal (diastolic 1.2 mg/dl FLDH 600 IU/L Liver enzymes肝酶 FAST (SGOT) 70 IU/L Platelet count血小板计数 F 35年龄35岁 Weight 80 kg体重超过 80kg Multiparity多产 Family history of VTE家族史 Deficiencies:缺陷 FAntithrombin抗凝血酶 FProtein C蛋白C FProtein S蛋白S Gene variants:基因变异 FFactor V Leiden FProthrombin凝血素 Lupus anticoagulant狼疮抗凝 血剂 Clinical Presentation of DVT DVT 的临床表现 75% antepartum - 51% by 15 weeks 产前75%，51%15周 Swelling and discomfort of the leg腿疼痛及肿胀 Calf circumference difference 2 cm小腿周径差值 2cm Signs of superficial phlebitis浅表静脉炎的体征 Positive Homans sign may be present Homan征非特异性 Consider anti- coagulation therapy考虑抗凝 Impedance plethysmography阻抗容积描记术 Ultrasound超声 Meets diagnostic criteria for DVT符合 诊断标准 Equivocal不确定 Begin anti- coagulation therapy开始抗 凝治疗 Repeat ultrasound vs. IPG vs. abdominal shielded venography重复检 查或腹部遮盖的静脉造影 Meets diagnostic criteria for DVT符合 诊断标准 Begin anti- coagulation therapy开始抗 凝治疗 Equivocal 不确定 DVT Diagnosis Pulmonary Embolism (PE)肺栓塞 Majority occur postpartum2/3发生于产后 Mild dyspnea and tachycardia progressing to cardiopulmonary collapse表现各异；从轻度的呼吸 困难及心动过速到心肺虚脱 Treat (O2, hemodynamic support) and evaluate simultaneously治疗（吸氧、血液动力学的支持、复 苏（ABCS）及评估同时进行 ABG will show decreased PO2 ( 100,000保持血小板100000 FMaintain fibrinogen (from FFP or cryoprecipitate) 保持纤 维蛋白原 150 mg/dl FAvoid heparin if patient actively bleeding如果病人有活动 性出血则避免使用肝素 HIV in Pregnancy妊娠HIV感染 Goal: decrease vertical transmission 目标：降低垂 直感染 FCan be decreased from 25% to 2% with antepartum treatment如果妥善处理可以由25%危险性降低为2% Risk factors for transmission传播的危险因素 FHigh viral load (1000 copies per ml)高病毒载量 FLower CD4 count低CD4计数 FProlonged rupture of membranes破膜时间延长 FPremature birth or low birth weight早产或者低体重 Can be transmitted by breast feeding可以皆有哺乳 传播 HIV Antivirals in Pregnancy 孕期抗病毒药 Current recommendations: (August 2000)目前推荐 FZDV 100mg 5x/d beginning 14-34 weeks由14-34周开始每 五天ZDC100mg FIn labor: ZDV 2mg/kg IV over one hour, followed by 1 mg/kg/hr infusion 临产时： 1小时静脉ZDV2mg/kg，接着1 mg/kg/hr 持续 FPostpartum: ZDV 2 mg/kg po 4x/d for infant 产后婴儿ZDV 每四天2 mg/kg 口服 nadjust dose if less than 34 weeks at birth如果出生时小于34周应 调整剂量 HIV De