妊娠内科合并症课件.ppt

1、妊娠内科合并症妊娠内科合并症Objectives目目 的的 Describe selected medical emergencies exclusive to pregnancy描述仅在妊娠出现的医描述仅在妊娠出现的医疗急症疗急症 Describe selected medical conditions that can cause serious complications in pregnancy描述描述可能危及生命的妊娠合并症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

2、及治疗的计划制定诊断及治疗的计划2020/11/3Conditions Exclusive to Pregnancy仅在妊娠仅在妊娠出现的症状出现的症状 Severe pre-eclampsia严重子痫前期 Eclampsia子痫 HELLP syndromeHELLP综合征 Acute fatty liver of pregnancy(AFLP)妊妊娠期急性脂肪肝娠期急性脂肪肝Conditions That Complicate Pregnancy使妊娠复杂化的症使妊娠复杂化的症状状 Deep venous thrombosis(DVT)深静脉血栓 Pulmonary embolism(PE

3、)肺栓塞 Disseminated intravascular coagulation(DIC)弥漫性血管内凝血 Human immunodeficiency virus(HIV)infection HIV感染2020/11/3Hypertensive Disorders of Pregnancy妊娠相关高血压症妊娠相关高血压症Pregnancy Induced Hypertension妊高症PIH无蛋白尿(no proteinuria)HELLP SyndromeHELLP综合征综合征Chronic Hypertension(Elevated BP prior to 20 weeks)慢性高

4、血慢性高血压（妊娠前压（妊娠前20周周血压升高）血压升高）6-8%of all gestations妊娠的妊娠的6-8%Preeclampsia 子痫前期(proteinuria+/-edema)蛋白尿水肿Eclampsia子痫子痫Severe Preeclampsia严重子痫前期严重子痫前期2020/11/3Pre-Eclampsia子痫前期子痫前期 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 Hyperte

5、nsion and proteinuria must be present on two occasions 6 hr apart高血压和蛋白尿需在高血压和蛋白尿需在至少间隔至少间隔6小时、二次以上小时、二次以上 Rapid weight gain is supportive evidence 体重迅速增加支持诊断2020/11/3Diagnostic Criteria for Severe Preeclampsia严重先兆子痫的诊断标准严重先兆子痫的诊断标准Headaches 头痛头痛Visual Disturbances 视力紊乱视力紊乱Pulmonary Edema 肺水肿肺水肿Hepa

6、tic Dysfunction 肝功异常肝功异常RUQ or Epigastric Pain右上腹或上腹痛右上腹或上腹痛Oliguria少尿少尿Elevated Creatinine肌酐上升肌酐上升Proteinuria of 5 g or more in 24 hrs24小时尿蛋白小时尿蛋白5g以上以上Thrombocytopenia or hemolysis血栓性血小板减少或溶血血栓性血小板减少或溶血Systolic BP收缩压收缩压 160 to 180 mm HgDiastolic BP舒张压舒张压 110 mm Hg2020/11/3Risk Factors for Preeclam

7、psia先兆子痫的危险因素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初产妇初产妇母年龄超过母年龄超过40岁岁双胎双胎以前妊娠有先兆子痫以前妊娠有先兆子痫慢性高血压慢性高血压慢性肾病慢性肾病抗磷脂综合征抗磷脂综合征糖尿病糖尿病血管紧

8、张素血管紧张素T235基因基因2020/11/3Prevention:No Proven Benefit预防：尚未证明获益预防：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2020/11/3Clinical Course of Preeclampsia 子痫前期临床病程子痫前期临床病程EyesArteriolar SpasmRe

9、tinal HemorrhagePapilledemaTransient ScotomataRespiratory SystemPulmonary EdemaARDSLiverSubcapsular HemorrhageHepatic RuptureHematopoietic SystemHELLP SyndromeDICCNSSeizuresIntracranial HemorrhageCVAEncephalopathyPancreasIschemic PancreatitisKidneysAcute Renal FailureUteroplacental CirculationIUGRAb

10、ruptionFetal CompromiseFetal Demise2020/11/3Clinical Course of Preeclampsia子痫前期临床病程子痫前期临床病程中枢神经系统中枢神经系统子痫发作颅内出血脑血管意外脑水肿Pancreas胰腺胰腺Ischemic Pancreatitis缺血性胰腺炎Kidneys肾脏肾脏Acute Renal Failure急性肾功能衰竭子宫胎盘循环子宫胎盘循环胎儿生长受限早剥胎儿受损胎儿死亡眼睛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呼吸系统肺水肿ARDS肝脏肝脏包膜下出血肝脏破裂造血系统造血系统HELLP综合征DIC2020/

11、11/3Management of Severe Preeclampsia严重先兆子痫的处理严重先兆子痫的处理 Admit to hospital,monitor closely at bedrest 住院卧床休息，密切监测住院卧床休息，密切监测 Treatment goals:治疗的目标治疗的目标FPrevent seizures预防抽搐预防抽搐FLower BP to prevent cerebral hemorrhage降压预防脑出血降压预防脑出血FExpedite delivery,balancing maternal condition and fetal maturity提前分娩，

12、权衡母情况与胎儿成熟的状况提前分娩，权衡母情况与胎儿成熟的状况2020/11/3Maternal Evaluation对母亲的评估对母亲的评估 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尿管每小时计量排量和蛋白量 External monitoring NST 外检测NST Lab

13、s: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2020/11/3Magnesium Sulfate硫酸镁硫酸镁 Preferred anticonvulsant 抗抽搐首选抗抽搐首选 Slows neuromuscular conduction and decreases CNS irritability减慢神经肌肉的传导、减慢神经肌肉的

14、传导、降低中枢神经系统的激惹性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2020/11/3Magnesium Levels硫酸镁浓度硫酸镁浓度NormalTherapeuticLoss of patellar reflexSomnolenceRespiratory depressionParalysisCardiac arrestmg/dl1.3 to 2.64 to 88

15、 to 1010 to 1212 to 1715 to 1730 to 35Antidote is calcium gluconate one gram IV over 3 minutes正常正常治疗浓度治疗浓度膝腱反射消失膝腱反射消失嗜睡嗜睡呼吸窘迫呼吸窘迫麻痹麻痹心跳骤停心跳骤停2020/11/3Antihypertensive Medication抗高血压药物抗高血压药物 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)

16、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2020/11/333-34 weeks大于34周Delivery引产引产Delivery Decisions-Severe Preeclampsia严重子痫前期分娩判断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Fet

17、al 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YesDelivery within 24 hours24H内引产内引产Amniocentesis羊穿羊穿Immature fluid不成熟羊水不成熟羊水Corticosteroids糖皮质激素糖皮质激素Deli

18、ver 48 hours later 48H后引产后引产Mature fluid成熟羊水成熟羊水NoAdapted 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.2020/11/3Delivery Decisions for Severe Preeclampsia II严

19、重先兆子痫的分娩决策 Vaginal delivery preferred倾向于阴道分娩倾向于阴道分娩 Cesarean delivery for剖宫产用于剖宫产用于FContinuous seizures or other emergency连续抽搐或其它连续抽搐或其它急症急症FFetal distress胎儿窘迫胎儿窘迫FUnfavorable cervix宫颈不成熟宫颈不成熟FSevere prematurity很早的早产很早的早产 Anesthesia麻醉麻醉Epidural vs.general硬膜外或全麻硬膜外或全麻2020/11/3Postpartum Management产后处

20、理产后处理 Improvement usually rapid after delivery 产后常很快地改产后常很快地改善善 Risk of seizure greatest in first 24 hours 在产后在产后24小时内小时内抽搐的危险最大抽搐的危险最大 Magnesium continued for 24 hrs 连续使用硫酸镁连续使用硫酸镁24H Continue monitoring serum MgSO4 levels,BP,urine output监测硫酸镁、血压及尿量监测硫酸镁、血压及尿量 Watch for signs of fluid overload 注意水负

21、荷过重的体征注意水负荷过重的体征2020/11/3Eclampsia 子痫子痫 Appearance of seizures in a patient with preeclampsia先兆子痫的患者发生抽搐先兆子痫的患者发生抽搐 Etiology uncertain病因不清病因不清Fcerebral edema,ischemia possible causes脑水肿、缺血可脑水肿、缺血可能是原因能是原因 BP often significantly elevated,but in 20%can be normal(diastolic 90)血压常升高，但20%的患者并不高（舒张压 1.2 m

22、g/dlFLDH 600 IU/L Liver enzymes肝酶肝酶FAST(SGOT)70 IU/L Platelet count血小板计数血小板计数F100,000 per mm3 FUsed to classify severity用以判断严重性2020/11/3Management of HELLP HELLP的处理的处理 Similar to severe preeclampsia:同于子痫前期同于子痫前期FStabilize motherFEvaluate fetus for compromiseFDetermine optimal timing/route of deliver

23、yFUse CEFM and manage BP and fluid statusF稳定母亲稳定母亲F评估胎儿是否受损评估胎儿是否受损F确定合适的分娩时间及方式确定合适的分娩时间及方式F使用连续胎心电子监护及处理血压及液体的状况使用连续胎心电子监护及处理血压及液体的状况 All women should receive MgSO4 while symptomatic or in labor 所有的孕妇在有症状或临产时都使用硫酸镁所有的孕妇在有症状或临产时都使用硫酸镁2020/11/3HELLP:New Treatments新治疗新治疗 Dexamethasone 10 mg IV q12h w

24、hen platelets 100,000血小板100000时候静脉地塞米松10mg每12h Platelets for active bleeding,or if 20,000 活动性出血或者板20000输注血小板 Plasmapheresis:limited success,but not routinely recommended 血浆置换：有限的成功率但并不被常规推荐2020/11/3Acute Fatty Liver of Pregnancy妊娠期急性脂肪肝妊娠期急性脂肪肝(AFLP)Occurs in one of 7,000-16,000 pregnancies发生率发生率1/7

25、00016,000妊娠妊娠 Presents in third trimester:于妊娠晚期发生：于妊娠晚期发生：FVomiting呕吐呕吐(76%),abdominal pain腹痛腹痛(43%)FAnorexia厌食厌食(21%),jaundice黄疸黄疸(16%)May progress to liver failure,including ascities and renal failure 可进展为肝衰、腹水、肾衰和脑病可进展为肝衰、腹水、肾衰和脑病 Differential includes HELLP,acute hepatitis,or toxin-induced liver

26、 damage 鉴别诊断鉴别诊断FHELLP、肝炎、毒素引起的肝损伤、肝炎、毒素引起的肝损伤2020/11/3Diagnosis of AFLP 诊断诊断 SGOT(AST)elevated,but 500 IU/LAST升高，但常升高，但常500IU/L Bilirubin elevated,but 5 mg/dl胆红素升高，胆红素升高，但常但常 35年龄年龄35岁岁 Weight 80 kg体重超过体重超过80kg Multiparity多产多产 Family history of VTE家族史 Deficiencies:缺陷FAntithrombin抗凝血酶FProtein C蛋白CFP

27、rotein S蛋白S Gene variants:基因变异FFactor V LeidenFProthrombin凝血素 Lupus anticoagulant狼疮抗凝血剂2020/11/3Clinical Presentation of DVT DVT 的临床表现的临床表现 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

28、脉炎的体征 Positive Homans sign may be present Homan征非特异性2020/11/3Consider anti-coagulation therapy考虑抗凝Impedance plethysmography阻抗容积描记术阻抗容积描记术Ultrasound超声超声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

29、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 Diagnosis2020/11/3Pulmonary Embolism(PE)肺栓塞肺栓塞 Majority occur postpartum2/3发生于产后发生于产后 Mild dyspnea and tachycardia progressing to cardiopulmonary collapse表现各异；从轻度的呼吸表现各异；从轻度的呼吸困难及心动过速到心肺虚脱困难及心动过速到心肺虚脱

30、 Treat(O2,hemodynamic support)and evaluate simultaneously治疗（吸氧、血液动力学的支持、复治疗（吸氧、血液动力学的支持、复苏（苏（ABCS）及评估同时进行）及评估同时进行 ABG will show decreased PO2(100,000保持血小板100000FMaintain fibrinogen(from FFP or cryoprecipitate)保持纤维蛋白原 150 mg/dlFAvoid heparin if patient actively bleeding如果病人有活动性出血则避免使用肝素2020/11/3HIV i

31、n Pregnancy妊娠妊娠HIV感染感染 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

32、low birth weight早产或者低体重 Can be transmitted by breast feeding可以皆有哺乳传播2020/11/3HIV Antivirals in Pregnancy孕期抗病毒药孕期抗病毒药 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ZDC100mgFIn labor:ZDV 2mg/kg IV over one hour,followed by 1 mg/kg/hr infusion 临产时：1小时静脉ZDV2mg

33、/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2020/11/3HIV Delivery Management HIV分娩的分娩的管理管理 If viral load 1000 per ml,elective cesarean decreases transmission 如果病毒载量1000/ml，剖宫产可降低感染几率FSchedule for end of

34、38th week计划于38周末 If labor or ROM,cesarean does not reduce risk若果已经临产或破膜，则剖宫产不降低危险 Consider prophylactic antibiotics in all cesarean deliveries 在所有剖宫产都应该预防性使用抗生素 Decision must be individualized个性化作出决定2020/11/3Antenatal Screening for HIV生前筛查生前筛查HIV Multiple groups support universal screening 多组均支持筛查 I

35、n women at high risk,repeat testing in 3rd trimester indicated在高危女性，妊娠晚期重复检查是必须的2020/11/3Summary总结总结 Multiple medical challenges can evolve during pregnancy孕孕期可有多种内科问题存在期可有多种内科问题存在 Key to diagnosis is clinical vigilance+appropriate lab or imaging studies诊断的关键是有临床的警惕性、诊断的关键是有临床的警惕性、适当的化验或影像学的检查适当的化验或影像学的检查 Clinical challenge is balancing maternal and fetal well-being临床上的挑战是如何平衡母儿的安全临床上的挑战是如何平衡母儿的安全 Consultation of value in difficult cases在疑难的病例会在疑难的病例会诊重要诊重要 Universal HIV testing strongly recommended强烈推荐全体HIV检测2020/11/3