妊高症等课件

Section 5 Pregnancy-induced hypertension Syndrome(PIH) 一、Definition: A rise in the MAP above 106mmHg (eg.,140/90mmHg) after 20weeks of pregnancy and (0r) Proteinuria and (or) edema, even convulerion and coma. The hypertension disappears after delivery. PIH is one of important deathly cause of gravida-parturient and perinatal infant. (MAP: mean arterial pressure) 二、Cause of disease: 1. Risk factors for PIH (1)first pregnancy. (2)multiple gestation (3)polyhydramnios (4)hydatidiform mole (5)malnutrition (6)positive family history of PIH (7)psychoactive (8)airtemperature change 2.Pathogenesis theory (1)uterine placenta ischemic theory (2)neurocrine theory (3)immunity theory (4)DIC (5)the others. 三、Pathologic histology changes in the chief organ The baseline pathophysiology changes are all the small arteria spasm in pregnancy women with PIH. 1.Cardiovascular-respiratory examination. There are no specific findings unless congestive heart failure is present. 2.Abdominal examination check for liver tenderness(subcapsular hemorrhage) note if ascites is present. 3. Eyeground examination Check for eyeground of retinopathy of pregnancy and hypertension syndrome 四、Classification This diagnosis requires hypertension and proteinuria with or without edema. Usually, this disease occurs in primigravidas and occurs initially after the twentieth week of pregnancy. 1.Mild. PIH. Recognized when (a) the BP is less than 140/90mmHg; or the Bp is less than 30/15mmHg over baseline value.(b ) proteinuria and (or)edema develops. This definition requires accurate knowledge of the patients blood pressure (BP) reading at prior points in her pregnancy. 2.Moderate Recognized in a patient with hypertension who has an BP greater than 140/90mmHg and less than 160/110mmHg . This increase in BP is combined with appreciable proteinura, while edema of the lower extremities is usually, but not always, present. 3. Severe. Preeclampsia Hypertension exceeding an BP of 160/110mmHg. on at least two occasions 6 hours apart with the patient at bed rest, and proteinuria of greater than 5mg/24h; uaually accompanied by headaches and blurred vision. If right upper quadrant or epigastric. pain. oliguria, pulmonary edama, or visual or cerebral disturbances occur, severe disease is present. Edema of the face, hands, and lower extremities is usually present. Eclampsia. Generalized seizure accompanied by hypertension and proteinuria in a pregnant patient. Other seizure etiologies such as epilepsy, drup withdrawal. Or cardiovascular accident must be excluded. The seizure may occur up to 24 hours into the postpartum period; indeed, the initial eclamptic fit frequently occurs during the postpartum period. Eclamptic seizures do not correlate well with the level of hypertension. 4. Complication of PIH (1)nephric function disorder (acute renal failure) (2)placental abruption (3)intrauterine fetal growth retardation (IUGR) (4)fetal distress (5)hepatic rupture (6)pulmonary edema. (7)cerebral hemorrhage. (8)retinal detachment 五、Diagnosis 1.history (1)past medical history (2)familial inheritance history (3)pregnant history (4)frequently-occuring fector 2.clinical symptom preeclampsia eclampsia With With or without (+) 5g/24h BP 160/110mmHg Severe- PIH without With or without (+) 0.5g/24h BP 150/00mmHg and 160/110mmHg Moderate- PIH withoutWith or without ( )BP 140/90mmHg Or 30/15 over Baseline value Mild-PIH Subjective symptom edemaProteinuria (g) Hypension (mmHg) classification 3.Laboratory tests a: complete blood count(CBC) b: liver enzymes(in normal pregnancy. Serum glutamic- oxaloasetic transaminaseSGOT, SGPT、LDH) c: Uric acid (less than 6mg/100 ml is normal in pregnancy) d: start a 24-hour urine collection for creatinine clearance (130-160ml/min in normal pregnancy) and total protein (less than 300mg/24 hour normal pregnancy) e:Coagulation status with platelet count, PT. PTT. f:Blood urea nitrogen(BUN) and serum creatinine. g: Daily hematocrits. Rising values are ominous. Falling valuves suggest clinical improvement. 六、 Prevention Preliminary examination 1.mABP(MAP) mABP=(systolicBP+diastolic BP 2) 3 2.Roll-over test(ROT) should be performed at 28 to 32 weeks. The patient is placed in the left lateral recumbent position, and BP is taken every 5 minutes until the systolic and diastolic reading are stable. The patient is then rolled flat on her back, and the Bp is taken immediately and at 5-minute intervals. Among patients in whom the diastolic BP increase by more than 20 mmHg, as high as 93 percent will develop preeclampsia. If the diastolic BP increase less than 20 mmHg, Preeclampsia probably will not develop. 七、Therapy 1.Mild. A: Bed rest: Bathroom privileges may be allowed. B:Sedation:Patients are allowed to relax. Help lower blood pressure, and reduce the likelihood of convulsion. C:eating: lower salt, enough protein. 2.Moderate and Severe (1)Anticonvulsive therapy Magnesium sulfate(therapy) is the drug of choice. A:Method a.Loading dose for seizure prophylaxis is 4 to 6g of Mg SO4 IV over 20 minutes and continued at 1-1.5g /hour. b.toxicity reaction. Magnesium toxicity may be signaled by excessive drowsiness and absence of patellar reflexes.muscle weakness. respiratory paralysis and cardiac depression can occur. 10ml of 10% calcium gluconate (or calcium chloride) may be administered IV push in the event of magnesium toxicity, or the infusion can be turned off for 1to 2 hours. (2) sedative therapy. a.Phenobarbital: 30-60mg every hours IM or PO. b. hydroxyzine; 50to 10 mg IM every 4-6 hours. (3) Antihypertensive therapy. a: Indicated only if BP persistently 160/110mmHg. b: Aim for a diastolic BP 90 to 100 mmHg. Avoid overcorrection because normal BP can result in placental hypoperfusion. (4)Diaresis therapy. Indiation: all edema. Heart failure Pulmonary edema Encephaledema. (5) Timely stop pregrancy A:Indication: After the mother with eclampsia has been stabilized for 6-12 hour. After controling the eclampsia for 24-48hour, patient have symptome too. gestational age 36week Although the gestational age of preeclaruporia mother is less than 36 week, her palcental function have deficiened; and her fetus have matured. B: Method induction of labor a favorable cervix a cephatic presentation cesarean section (abdominal delivery) an unfavorable cervix a very premature infant The fetus cannot be monitored directly Section 6 Placerta previa 1.Definition: Placenta previa means that the palcenta develops in the lower uterine segment and either covers or adjoins the internal cervical as. 2.Etiology: specific cause of placenta previa is unknown; however, the following prediposing factors have been implicated. 2.1 Having abnormalities of the uterus Being older in age. Having had other babies Having a prior delivery by cesarean section Smoking cigarettes The placernta will be considerably larger. 3.Calssification The standard classification into complete, partial and marginal placenta previa, is based directly upon the findings at the finally ultrasound or vaginal examination before the treatment of placenta previa. 4. Incidence: Placenta previa complicates about 1:200 pregnancies, of which 10% are usually complete. 5.clinical symptom 5.1 symptom A history of painless vaginal bleeding with the passage of bright red blood during the trimester of pregnancy and in labor . Time of bleeding: complete placenta previa 28w partial placenta previa-between both marginal placenta previa 37-40w. anemia shock Fetus deathy 5.2 sign Sign of anemia and shock Sign of obstetrics. 6.Diagnosis A number of diagnostic techniques have been used in an attempt to localize the placenta. The approximate accuracy rate of vavious techniques is as follows: 6.1: ultrasonography-95 percent 6.2: soft tissue x-ray-85 to 90 percent 6.3 :Transfemoral arteriography-98 percent 6.4 :Isotope scans 90 percent 6.5: Amniography-95 percent. 7.Differential diagnosis 7.1: placental abruption 7.2: placenta velamentous 7.3: blood vessel of placental edge is rupture 7.4: cervical bleeding 7.4.1: cervical poly. 7.4.2: cervical erosion 7.4.3: carcinoma of uterine cevix 7.4.4: condyloma acuminatum. 8.To affect maternal and fetus 8.1: postpartum hernorrhage. 8.2: placenta increta. 8.3: puerperal infection 8.4: premature delivery and high mortality of perinatal infant 9.Management 9.1: Expectant management: gestational age 37w Indication: or weight of fetum 2300g little vaginal bleeding rest in bed Method: administration of oxygen Sedation and hematonic Inhibitor of contraction 9.2 Immediate delivery Cesarean section (abdominal delivery) Vaginal delivery 9.3: correct hypoemia and prevent infection Section 7. Placental abruption 1.Definition: After pregnancy 20w or in labor. Placental abruption occurs when a normal implanted placenta separates from the decidua basalis after the twentieth week of gestation and prior to the third stage of labor. 2.Etiology 2.1: vasculopathy eg: PIH. 2.2: Injury to the abdomen. 2.3: High blood pressure of uterine 3.Classification and pathophysiology changes: 3.1: revealed abruption 3.2: concealed abruption 3.3: mixed hemorrhage *: uteroplacental apoplex consumptive coagulopathy 4.Clinical symptom: Including bleeding from the vagina, severe pain in the abdomen or back, and tenderness of the uterus. Depending on the severity of the bleeding, the another may experience a drop in blood pressure, followed by symptoms of organ failure as her organs are deprived of oxygen. Sometimes, there is no visible vaginal bleeding, instead, the bleeding is said to be “concealed”. In this case, the bleeding is trapped behing the placenta, or there may be bleeding into muscle of the uterus, many patients will have abnormal contractions of the uterus, particullarly extremely hard, prolonged Prolonged contractions. 4.1: Mild: The chief presentence is external hemorrhage. 4.2: Severe: The chief presentence are internal hemorrhage and retroplacental hematoma. 5. Assistant examination: 5.1: ultras onography 5.2: Lab. Examination. 6.Diagmosis: History Symptom and sign: Vaginal bleeding pain uterine tenderness an increase in uterine size amniotic fluid may be bloody shock Assigtant examination 7. Deffirental diagnosis: Placenta previaPlacental abruption Threatened uterine rupture symptome(vaginal bleeding with painless) Painless vaginal bleeding and bright red in color Vaginal bleeding with pain(80%) Or conceal in 20% Vaginal bleeding with severe pain in abdomen and with difficult delivery signFloating high above the brim Placental nurmur shock Uterus is board-like rigidity Pathologic retraction ring Assistant examination Ultrasonography lab. examination shockshock 8:complication of placental abruption 8.1: DIC or coagulation disorder 8.2: postpartum hemorrhage 8.3: acute renal failure 9.Management The first line of treatment involves replacing the mothers lost blood with blood transfusions and fluids given through a needle in a vein. Oxygen will be administered. 9.1: correct shock 9.2: timely stop pregnancy 9.3: prevence of postpartum hernorrhae 9.4: treatment of DIC 9.5: Prevence of acute renal failure Section 8 Multiple Pregnancy Definition: A pregnancy there are two fetuses or more the fetuses. 2. Varieties of twins. Twins may be binovular or uniovular 2.1. Binovular twins: Two ova. Be fertilized. separate gene and distinct placentae Each fetus has its own amnion and chorion. 2.2 Uniovular twins a single ovum be fertilized. Division may occur in the early stage of segmentation or later. 3.Clinical presentation 3.1 gestation period: PIH polyhydramnios fetus deformity placenta previa premature rupture of membranes premature delivery 3.2 delivery period: delayed delivery abnomal fetal position prolapse of cord placental abruption head locking and paragomphosis postpartum hemorrhage Puerperal infection 4.1: Diagnosis of twins 4.1: history early symptoms of pregnancy in late pregnancy, preclampsia is common 4.2: antepartum examination fetal heart sound large size of the uterus 4.3: assistant examination ultrasound apparatus 5.Management of twin pregnancy 5.1: gestation period antenatal care increasing nutrition preventing complication of twins 5.2: delivery period vaginal delivery abdominal delivery All preparations should have been made for the resuscitation and special care of babies of low birth weight. all cases of twin labour should be in hospital units preventing postpartum hemorrhage Section 11: Prolonged Pregnancy (Postterm Pregnancy) 1.Definiton: A pregnancy that lasts more than 42 weeks or 294 days from the date o