1、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
2、,Neoplastic diseases,Infections,Heart Diseases,Diabetes,Hepatitis,Disease,Heart Disease in Pregnancy,妊娠合并心脏病,Heart disease in pregnancy,Interaction between heart disease and pregnancy（心脏病与妊娠的相互影响） Peripartum cardiomyopathy, PPCM(围产期心肌病) Medical treatment of pregnant women complicated with heart dise
3、ase （妊娠合并心脏病的治疗）,I want a baby,27 years old Atrial septal defect 1cm 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
4、 after birth?,Heart Disease,Incidence:1-4% of pregnancies One of the leading causes of maternal death (8.3%) Death rate 0.6%-2.7%,Heart disease,hemodynamic Burdern,Heartfunction,32-34 weeks of pregnancy Intrapartum Puerperium (3 days postpartum),Interaction between pregnancy and heart disease,Clinic
5、al significance of heart disease in pregnancy,Mother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolism 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） Increased caesarean section rate （剖宫产）
6、Drug effect Hereditary congenital heart disease （先天性心脏病）,Classification of Heart Disease,Congenital heart disease （先天性心脏病） Left-to right shunt Right-to left shunt Non-shunt Rheumatic heart disease （风湿性心脏病） Hypertensive heart disease（妊娠期高血压疾病性心脏病） Peripartum cardiomyopathy (PPCM) Myocarditis （心肌炎）,Pe
7、ripartum cardiomyopathy (PPCM) 围产期心肌病,Dilated cardiomyopathy occurs during the last 3 months of pregnancy to 6 months postpartum (increased heart size, decreased heart function) Etiology unknown No history of cardiovascular disease Die from heart failure, arrhythmia or pulmonary infarction 50% recov
8、er 6 months postpartum Recur in the successive pregnancy Clinical Implications ：10-30% of fetal death Therapy Treatment for heart failure Heart transplantation,Cardiac Function,Subjective capacity Class I: Uncompromised Class II: Slightly compromised Class III: Marked compromised Class IV: Severely
9、compromised Objective examination A: Without objective basis of cardiac disease B: Mild cardiac disease according to objective exam C: Moderate D: Severe ,Management,TO BE OR NOT TO BE,？,Protect the mothers heart,Preconceptional counseling,Pregnancy YES or NO ?,Preconceptional counseling,YES Mild Ca
10、rdiac function III No history of heart failure No complication,NO Severe Cardiac function 一 History of heart failure Pulmonary hypertension Right-to-left shunts Severe arrythmia Active rheumatic heart disease Acute Myocarditis, endocarditis 35y with long history of cardiac disease,During Pregnancy,D
11、etermine whether or not the pregnancy should be continued NO: induced abortion before 12 weeks YES: Intensive care during pregnancy Early diagnosis and treatment of congestive heart failure,Intensive care during pregnancyDetect congestive heart failure as early as possible before 20 weeks: 1 time pe
12、r 2 weeks after 20 weeks : 1 time per week Hospitalized at 36-38 weeks,During pregnancy,Heart failure - prevention Limited physical activity Control of body weight: increase 12Kg (0.5Kg / month) Limited salt intake: 4-5g/day Prevent risk factors: infection, anemia, arrhythmia, hypertensive diseases
13、Dynamic observation of cardiac function,During Pregnancy,Heart failure-early diagnosis Development of dyspnea and palpitation on exertion Heart rate 110 bpm; breath rate 20/min Nocturnal cough Persistent basilar rales,During pregnancy,Treatment of heart failure Digoxin Diuretics Vessel dilating agen
14、ts Termination of pregnancy: C-S Timing Termination after heart failure is controlled C-S when heart failure could not be controlled,Intrapartum management,Pattern of delivery Cesarean section Vaginal delivery Heart function I-II Very good obstetrical condition Vaginal delivery- prevent heart failur
15、e First stage: intensive care and sedation Second stage: shorten the course Third stage: Add pressure on abdomenprevent postpartum hemorrhage,Puerperium management,Intensive care during the first 3 days Prevent infection Breast feeding Sterilization,Yes Heart failure fetal demise congenital heart di
16、sease Intensive care and early diagnosis of heart failure Vaginal delivery Prevent infection and postpartum hemorrhage,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 attenti
17、on to after birth?,思考题,妊娠合并心脏病哪些情况不宜妊娠？ 妊娠合并心脏病分娩方式的选择? 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,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） Diabetes pregnancy（糖尿病与妊娠的相互影响） Screening and diagnosis（筛查和诊断）
18、 Management of women complicating diabetes during pregnancy（妊娠合并糖尿病的处理）,Case,Gestational Diabetic Mellitus Increased fetal ventricular septum Insulin used to control blood glucose level C-S at 34 weeks for fetal distress Newborn baby died 1 month after delivery,Diabetes,Incidence: 2.9% (1.5 14.0%) O
19、vert diabetes (糖尿病合并妊娠） Gestational diabetes mellitus GDM 90%（妊娠期糖尿病）,Impact of pregnancy on diabetes,Increased glucose demands-hypoglycemia （低血糖） Insulin resistance and insufficiency Insulin overdose after delivery,Maternal and fetal effects,Maternal effectsHypertensive disorders （高血压） Infection （感
20、染） Ketoacidosis （酮症酸中毒） Spontaneous abortion （自发流产） Polyhydramnios （羊水过多） Dystocia （难产） and C-S owing to macrosomia （巨大儿） Recurrent GDM （再次妊娠时复发）,Maternal and fetal effects,Fetal effects Macrosomia （巨大儿） Fetal growth restriction （胎儿宫内生长受限） Spontaneous abortion & Preterm delivery （自发流产和早产） Malformati
21、on （胎儿畸形）,Maternal and fetal effects,Neonatal effects Respiratory distress （呼吸窘迫） Hyperinsulinemia Pulmonary Surfactant Delayed pulmonary maturation Hypoglycemia （低血糖）,Diagnosis-GDM,History: family, previous pregnancy, present pregnancy Screening: 50-g oral glucose challenge test （24-28 weeks） Confi
22、rmed diagnosis OGTT: 75/100-g oral glucose tolerance test,The 50 gr. GCT (Cutoff 140 mg/dl, 7.8mmol/L),Sensitivity: 93.3% Specificity: 38.2%,Positive Predictive Value: 78.6 % Negative Predictive Value : 70.0 %,Diagnostic criteria for GDM - OGTT,Method Criteria (mmol/L) FPG 1 hr. 2 hr. 3 hr. WHO (75
23、g) 5.6 10.3 8.6 6.7Diagnosed when 2 or more values are abnormal FPG: Fasting plasma glucose,DiagnosisOvert diabetes,polydipsia （多饮）, polyuria （多尿）, unexplained weight loss，ketoacidosis Random plasma glucose 200 mg/dL(11.1 mmol/L);fasting glucose126mg/dL (7 mmol/L),Staging,A: GDM B: Overt diabetes, l
24、ate onset (after 20y), =20y, or retinopathy F: diabetic nephropathy R: proliferative retinopathy or vitreous hemorrhage H: coronary heart disease T: kidney transplantation,Management,Purpose Maintain glucose level within normal range Minimize fetal and maternal complication Lower peripartum fetal an
25、d neonatal mortality,During pregnancy,Diet To provide the necessary nutrients for the mother and fetus To control glucose levels To prevent starvation 30-35kcal/kg of ideal body weight 55% carbohydrate 20% protein 25% fat 3 meals and 3 snacks daily Intensified monitoring Fasting glucose 3.3-5.6mmol/
26、L Postprandial glucose 6.7mmol/L,During pregnancy,Drug treatment:Insulin onlyIndividualized,Assessment of mother,Glucose / ketone monitoring （监测血糖/酮体） Retinal photograph (眼底) Renal function （肾功能） Glycated Haemoglobin （糖化血红蛋白）,Assessment of fetal well-being,Daily fetal movement counting NST AFV or bi
27、ophysical profiles,Delivery,WHEN? after 38 completed weeks Fetal lung muturation Before 38 weeks when Unsatisfied glucose control Maternal complication: infection, severe preeclampsia; vascular diesease Fetal distress or FGR Caution in the use of corticosteroids,Delivery,HOW? Diabetes itself is not
28、the indication for C-S C-S when indicated: macrosomia, compromised placenta function, etc. Stop subcutaneous insulin 3 hours before operation,Delivery,Vaginal delivery Close monitoring Control the whole course within 12 hours Glucose monitoring: 5.6mmol/L (100mg/dL),postpartum,Insulin dose decrease
29、1/2 -1/3 after delivery,Neonatal management,Treated as preterm baby 25% glucose intake 30 minutes after delivery Prevent complications,Prognosis,More than 50% women with GDM develop diabetes in the following 20 years More risk for offspring to develop obesity and diabetes,思考题,糖尿病对母儿的影响 糖尿病的筛查确诊方法 糖尿
30、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,Interaction between pregnancy and hepatitis（妊娠与肝炎的相互影响） Diagnose and treatment （诊断和治疗） Pathway of maternal fetal infection and prevention（母-胎感染途径和预防） Differential diagnosis of hepatic disease （与妊娠期肝内胆汁淤积症
31、的鉴别诊断）,Epidemiology of Hepatitis,0.2 billion in the world, 0.13billion in China 10-20% population with positive HBsAg in China,Introduction,Types of viralHAV, HBV, HCV, HDV, HEV, HGV Incidence: 0.8%-17.8% among pregnant women HBV infection more prevalent in China,Impact of pregnancy on viral hepatit
32、is,Compromised defending ability of liver Heavier liver burden More complicated and severe condition in pregnant patients,Impact of hepatitis on pregnancy,Early Pregnancy Serious pregnancy reaction Abortion Malformation,Impact of hepatitis on pregnancy,Late pregnancy Hypertension Postpartum hemorrha
33、ge Preterm delivery, fetal death, stillbirth,Impact of hepatitis on pregnancy,Maternal - fetal infection HBV (母婴垂直传播） Intrauterine Intrapartummain route of transmission Fetal swallowing in genital tract Mother blood leaking into fetal circulation Postpartum: breastfeeding, salivary,Diagnosis,History
34、: close contact with hepatitis patients, blood transfusion within 6 months Clinical features: gastrointestinal symptoms cant be explained by other reasons,jaundice, increased liver size in first and second trimester, pain,Diagnosis,HBsAg: Active HBV infection; may be acute or chronic HBeAg: High inf
35、ectivity, active viral replication HBcAg: Active copying, undetectable in serum Anti-HBcAg IgM: Acute HBV infection (newer and more sensitive assays may also be positive during reactivation of chronic infections) HBV-DNA and DNA polymerase: Direct measure of infectivity or replicative state; becomin
36、g increasingly available,Anti-HBsAg: Immune to HBV; may be natural immunity or following vaccination Anti-HBeAg: Low or no infectivity; need only be measured in chronic HBV,Management,Rest Nutrition Protection of liver function Prevent infection and further damage Fluminant hepatitis （重症肝炎）,Obstetri
37、cal Management,The first trimester Light hepatitis: active treatment and maintaining the pregnancy Chronic active hepatitis: termination after treatment,The second and third trimester Prevent from termination of pregnancy Close monitoring,Management,Delivery C-S is preferred Vitamin K1 20-40mg im se
38、veral days before delivery Prevent postpartum hemorrhage Fulminant hepatitis（重症肝炎） C-S 24 hours after active treatment,Management,Pureperium （产褥期） Prevent from damaging liver function Breast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positive,Prevention of neonatal infection,Immunoprophylaxis
39、4,000 among 18,000 new born babies with HBsAg-positive mother will be chronically infected with HBV without immunoprophylaxis,Immunoprophylaxis,Neonate Active immnoprophylaxis: 0, 1, 6 主动免疫 30g HBV vaccine im 24 hours after birth, 10 g 1month, 6 month Passive immnoprophylaxis 0, 1, 3 被动免疫 HBIG 0.5ml
40、 soon after birth, 0.16ml/kg 1 month, 3 month Combined immoprophylaxis 联合免疫 HBIG 0.5ml within 6 hours ; 3-4 weeks after birth, + active immnoprophylaxis,Differential diagnosis,Intrahepatic cholestasis of pregnancy （ICP, 妊娠期肝内胆汁淤积症） Happen during late pregnancy Pruritus （瘙痒） Jaundice （黄疸） Cholic acid
41、 （胆酸升高） fetal death,Differential diagnosis,Acute fatty liver of pregnancy （妊娠期急性脂肪肝） Late pregnancy, acute and severe hepatic disfunction, fat filled hepatic cell HELLP syndromeHypertension, hemolysis, BPC, elevated liver enzyme Hyperemesis gravidarum （妊娠剧吐）Light liver dysfunction, negative virus marker Drug induced hepatitisHistory of drug intake,思考题,防止新生儿病毒性肝炎的主动与被动免疫 病毒性肝炎合并妊娠与妊娠期肝内胆汁淤积症鉴别诊断,Reference,Williams Obstetrics,(22nd. ed.) , by Cunningham,F. Gary MD(ed.), McGraw-Hill Incorporated (2005) 病理产科学 庄依亮，李笑天主编 人民卫生出版社 2003年 妇产科学 8年制及7年制临床医学专业用 丰有吉, 沈铿主编 人民卫生出版社 2006年,
