妇产妊娠合并症1 课件

1、 妊娠合并症山东大学齐鲁医院马玉燕cardiac diseaseIncidenceThe 2nd cause leading to maternal death, the 1st indirect cause of maternal mortality. Overall incidence 14% In the past：rheumatic disease（风湿性心脏病）is predominant；Now： congenital disease（先天性心脏病）Cardiocirculatory changesPrenatal periodMaternal plasma volume（血容量）

2、 increases 3545%Cardiac output（心输出量） increases 3050%, heart rate（心率） rises 1015 bpm, oxygen consumption（氧耗量） increasesThe cardiac moves upward and outward，and presents slightly murmur,which puzzled the diagnosis（心脏移位，出现杂音）Labor/delivery：心脏负担最重的时期Uterine contractions cause a 20% increase in stroke ou

3、tput（心搏量）One uterine contraction may squeeze 250500ml blood into the circulation.In the 3rd stage, about 500 ml blood in the uterine vessels is squeezed into circulatePostpartum periodFluids are reabsorbed from tissue, which cause blood volume increase temporarily and lead to a tendency of heart fai

4、lure.ClassificationCongenital heart diseaseRheumatic heart diseaseCardiac disease induced by preeclampsiaPeripartum cardiomyopathmyocarditisMaternal riskPhysiological changes happened during pregnancy can aggravate underlying cardiac disease and lead to the associated morbidity and mortality.Three d

5、angerous periods: 3234ws gestation，Labor/delivery，3 days after deliveryCongenital cardiac disease左向右分流型：Atrial septal defect（房缺）：1cm2，可耐受妊娠和分娩，较大者，可出现右向左分流，2cm2者，应手术后妊娠Ventricular septal defect（室缺）：1cm2/m2，能耐受妊娠和分娩，较大缺损常伴肺动脉高压，易出现右向左分流Patent ductus arteriosus（动脉导管未闭）：儿童期多已矫治，合并妊娠不多见右向左分流型：for Fallot

6、s syndrome or Eisenmenger syndrome woman，pregnancy is forbidden, the maternal and fetal mortality is 3050%。无分流型：肺动脉口狭窄、主动脉缩窄、Marfan syndrome，母儿病率和死亡率均高，应劝其避孕。Rheumatic diseaseMitral stenosis（二尖瓣狭窄）：病变严重、伴肺动脉高压者易发生肺水肿和心衰，应在妊娠前矫正Mitral regurgitation（二尖瓣关闭不全）：一般能耐受妊娠Aortic stenosis and regurgitation（主动

7、脉瓣关闭不全及狭窄）：关闭不全者多可耐受妊娠，狭窄严重者应手术后妊娠Cardiac disease induced by preeclampsiaDefinition:既往无心脏病症状的妊娠期高血压孕妇，发生以左心衰为主的全心衰竭。合并中重度贫血时更易发生如及时诊断和处理，常能渡过妊娠及分娩，产后病情缓解。Peripartum cardiomypathyDefinition: 既往无心脏病史，在妊娠最后3个月至产后6个月内发生的扩张型心肌病Causes:不明，与妊娠和分娩关系密切Manifestation:主要表现为心衰症状，心脏增大，伴各种心律失常，死于心衰、肺梗死和心律失常再次妊娠可复发病

8、毒感染后13周内出现表现为 各种心律失常，心肌酶升高，心肌受累严重者易发生心衰病情控制好的急性心肌炎可在严密监护下继续妊娠。myocarditisFetal risksSpontaneous abortion, preterm labor, fetal death, FGR/IUGR, high risk for fetal distress and neonatal asphyxia.Drugs toxicityHigh risk for fetal congenital heart diseaseDiagnosis of cardiac diseaseHistory of cardiac

9、disease or rheumatic fever（风湿热）, presentation of abnormal cardiac function.Signs: cyanosis（紫绀）、clubbed fingers（杵状指），持续颈静脉怒张。Diastolic murmurs（舒张期杂音） or rough systolic murmurs（收缩期杂音）EKG：symptomatic and sustained arrhythmias（心律失常），ST段及T波改变。Echocardiogram（超声心动图）:显著的心腔扩大及心脏结构异常。Heart functional classifi

10、cation （以主观功能量为依据）.No limitation of physical activity.Slight limitation,ordinary activity result in fatigue,palpitation, dyspnea or anginal pain.Marked limitation,less-than-ordinary activity causes symptoms.Unable to carry on any activity, symptoms of cardiac insufficiency may be present, even at re

11、st.Heart functional classification （以客观检查手段为依据）Category A：no evidence of cardiovascular disease；Category B：slight cardiovascular diseaseCategory C：moderate diseaseCategory D：severe diseaseDiagnosis of early heart failureSlightly physical activity cause palpitation（心悸）, dyspnea（气短）or anginal pain（心前区

12、疼痛/胸闷）Heart rate110bpm， respiratory rate20/min during rest。夜间常因胸闷而坐起呼吸，或到窗口呼吸新鲜空气。肺底部出现少量持续性湿啰音，咳嗽后不消失。Common complicationscardiac failure Infection:亚急性感染性心内膜炎Hypoxia & cyanosis 缺氧和紫绀Embolism：静脉、肺ManagementDetermination about tolerance of gestationAllow to gestation：心脏病变较轻，心功能-级，既往无心衰史，无其他并发症者Not al

13、low to gestation：心脏病变较重、心功能级或级以上、既往心衰史、肺动脉高压、紫绀型先心病、严重心律失常、活动风湿热、心脏病并发细菌性心内膜炎者Prenatal carePrepregancy counseling and evaluation Prenatal care periodicallyAdmission in 3638 gestational weeksTermination of gestation不宜妊娠者终止妊娠的时机12wtherapeutic abortion1228w引产。28w对顽固性心衰病例，严格监护下行剖宫产术。Prevention of cardia

14、c failure adequate restnutrition, avoid body weight overgain：体重增长10kgavoid/ minimize aggravation：贫血、维生素B族缺乏、心律失常、感染、情绪激动prenatal care intensivelyDrugs：不主张预防性应用洋地黄，常选用地高辛，不要求达到饱和量。Management of cardiac failureSame to nonpregnant woman早期心衰的孕妇，常选用地高辛，不要求达到饱和量。晚期妊娠心衰，先控制心衰，适当放宽剖宫产指征严重心衰，边控制心衰边紧急行剖宫产Labo

15、r/delivery提前选择适宜的分娩方式Vaginal deliveryIndications：心功能III级，胎儿不大，胎位正常，宫颈条件良好Intrapartum managementsAvoid mental and physical distressLabor in left lateral positionMonitor electrocardiogramContinuous fetal heart rate monitoringAssisted delivery in second stagePrevention of postpartum hemorrhageProphylac

16、tic antibioticsCesarean sectionIndications ：胎儿偏大，产道条件不佳，心功能在级及级以上者，应择期剖宫产。麻醉：连续硬膜外阻滞麻醉，麻醉剂中不加肾上腺素，平面不宜过高。严格限制输液量和输液速度。(不宜再妊娠者根据病情及术中情况在与家属和患者沟通决定是否同时行输卵管结扎术。)PuerperiumAdequate rest and intensive monitoring Prophylactic antibioticsBreast feeding is not recommended for the cardiac failure womanIndica

17、tions of cardiac surgery一般不主张在妊娠期手术必须手术时，宜在妊娠12周之前进行，手术前注意保胎及预防感染病例介绍病史患者28岁，停经38周，第1胎第1孕，现有不规律腹痛，胎膜未破。自幼患先心-室间隔缺损。平时能胜任一般体力活动。近一周感乏力，轻微活动后心慌、呼吸困难，夜间有时憋醒，不能平卧。查体HR110/min，R22/min，口唇粘膜轻度紫绀，双肺底闻及少许湿罗音，第3、4肋间闻及3-4级收缩期杂音。子宫大小符合停经周数，LOA，胎头半固定，胎心140/min，有不规律宫缩。骨盆测量正常，宫口未开。超声估测胎儿体重3500g，超声心动图示室间隔肌部缺损0.5cm，

18、右室增大，ECG示窦性心动过速。该病例的诊断是什么1 38周妊娠G1P0,LOA 2.先天性心脏病-室间隔缺损3心功能级应如何处理1.控制心衰2.预防性应用抗菌素3.终止妊娠，以剖宫产为宜理由心衰，胎儿较大，胎头未衔接，宫口未开，有可能产程较长，易再次发生心衰，为防止发生细菌性心内膜炎，应用抗菌素预防。如无心衰症状，规律宫缩，宫口已开大3cm，应如何处理？可在严密监护下经阴分娩。如产程中出现心功能不全，产程进展缓慢，需行剖宫产结束分娩。预防性应用抗菌素Viral hepatitisPhysiological changesMost of the livers functions are not

19、 affected by pregnancy.Some synthetic functions are altered.serum albumin fallsserum levels of Vit K dependent clotting factors and fibrinogen riseserum levels of CH, TG and lipoproteins riseGestations effects妊娠期易感染肝炎病毒，也使原有肝炎病情加重。营养物质消耗增多，肝糖原储备降低多量雌激素、胎儿代谢产物需在肝脏代谢并发症的影响：妊娠呕吐，妊娠期高血压疾病分娩时体力消耗、缺氧，使酸性代

20、谢物质产生增加Maternal risk早孕反应加重preeclampsiaPostpartum hemorrhageMaternal mortalityFetal and neonatal riskFetal deformity、abortion、preterm labor、stillbirth and neonatal deathVertical transmission（垂直传播）:尤以乙型肝炎为甚HBVvertical transmission为主要途径宫内经胎盘传播分娩时接触母血及羊水产后接触母亲唾液或母乳。 母亲产道分泌物、乳汁、羊水HBsAg阳性，血HBeAg阳性，是造成胎儿感染

21、的高危因素HCV：2/3 of C hepatitis in 3rd trimester exists vertical transmission, of which, 1/3 develops chronic hepatitisHAV 、 HDV 、HEV ：rare vertical transmissionDiagnosisDiagnosis of acute hepatitis is difficult1st trimester: hepatitis may be neglected by morning sick.2nd and 3rd trimester: other illnes

22、s also can cause abnormal liver functionDiagnosis cant only be ensured by elevated AST or ALT.Points of diagnosisHistory of exposure or blood products transfusionClinical manifestationIncreased serum ALTTBIL17mol/L，尿胆红素阳性Pathogen testsHBV血清学及病原学检测及意义HBsAg：infectivityHBsAb: immunologic response to in

23、fection or cureHBeAg: high infectivityHBeAb:partial immune response to infection and cureHBcAb-IgM: infectivityHBcAb-IgG: chronic infectionHBV-DNA: infectivityDiagnosis of fulminant hepatitis乙型、乙/丙、乙/丁重叠感染为主要原因。感染戊肝也易发生。Manifestation：severe symptoms of digestive tract；rapidly increased TBIL171mol/L；

24、肝臭，abnormal liver function; tendency to general bleeding；肝性脑病；acute renal failure Identification妊娠剧吐引起的肝损害妊娠期高血压疾病引起的肝损害：终止妊娠后迅速恢复。HELLP syndrome药物性肝损害：氯丙嗪、苯巴比妥类镇静药、红霉素、异烟肼、利福平等Acute fatty liver of pregnancyInduced by pregnancy and resolves after pregnancyMajor risk is maternal death due to rapid li

25、ver failure and its complicationsDiagnosis of AFLPSerum ALT500UB超:肝区弥散的密度增高区，呈雪花状强弱不均MRI见肝大片密度减低区Diagnosis depends on liver biopsyManagement of AFLPSupportive therapyMaternal resuscitation by correction of hypoglycaemia, fluid imbalance, DICTreatment of liver failureIntensive fetal monitoringUrgent

26、deliveryPrevention of postpartum hemorrhage and infectionPreventionHepatitis BMater：乙肝母亲治愈半年后妊娠 Vaccination is the most important in preventing HBVs mother-to-infants transmission.Infants3 routes主动免疫：生后24小时内肌肉注射乙肝疫苗10g，1、6个月再分别注射10g（成功率达75%）。被动免疫：生后立即肌肉注射HBIG 100-200U联合免疫：乙肝疫苗按0、1、6进行，生后6小时肌注HBIG 20

27、0U（成功率95%）Hepatitis A：密切接触7日内肌注丙种球蛋白。Hepatitis C：无特异的免疫方法。减少医源性感染是重要环节。保护易感人群可用丙种球蛋白。抗HCV抗体阳性母亲的婴儿，在l岁前可注射免疫球蛋白。ManagementsManagement of mild hepatitisRestNutritionProtecting the damaged liverPrevent further damage of the liver, such as some foods or drugs Prevent infectionManagement of severe hepat

28、itisTherapy of protecting liver：胰高血糖-胰岛素-葡萄糖，白蛋白，血浆预防及治疗肝昏迷：限制蛋白质摄入，减少氨及毒素的吸收。醋谷胺，氨基酸，ATP，辅酶APrevention and management of DICManagements of renal failure：严格限制入液量，应用利尿剂。防治高血钾。避免应用肾损害的药物Obstetric managements Prenatal management妊娠早期急性肝炎，积极治疗后可继续妊娠。慢性活动性肝炎适当治疗后终止妊娠。妊娠中晚期避免终止妊娠，加强胎儿监护。避免妊娠延期或过期。Injection vitamin K1 2040mg/d.Blood crossmatch.Avoid prolonging labor.Prevention of genital tract laceration and postpartum hemorrhage.CS is appropriate for fulminant hepati