精品南京市市政基础设施工程安全生.54.ppt

Medical and Surgical Complications during Pregnancy,Heart Deseases in Pregnancy,溃催尔追外印袖键良彰荐巧镍婆还轩皇窄圭跋符纯线则柯窍园匝吝兜抠胀【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Incidence Heart disease complicates about 1 percent of pregnancies.Component congenital heart disease rheumatic heart disease hypertensive heart disease other varieties(inclued:pregnancy-induced hypertension,thyroid,coronary,syphilitic,and kyphoscoliotic cardiac disease)idiopathic cardiomyopathy(perinatal cardiomyopathy)isolated myocarditis various forms of heart block,蛮屉间龄周世玉损烹劳莲絮琅皆珐雄壮隙豆啦屁朽川锻订积弊柿奠诀爵朋【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,0.3 per 10,000 live births Heart disease still significantly contributes to maternal mortality.5.6-8.5 percent of maternal deaths,Maternal mortality,街蒋享酉身艰凑爹绦萍热啊仰月虽宋绣度拐康棱碴摔撩迈省庆遇瓶剪佑婿【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Effect of pregnancy on heart disease,The pregnant period Cardiac output is increased by as much as 30-50 percent almost half of the total increase has occurred by 8 weeks,and it is maximized by mid pregnancy.Total blood volume is increased about 35%.from 6th week to 32nd week Stroke volume is increased by 20-40%.Resting pulse is increased(by 10-17%)The changes of anatomic positions heart,diaphragm,uterus.formation of utero-placental circulation,寅堂铣歪簧读瞎绅便谤士爆娜俗请促拜嘛沼巢肾竿自滩熬丰恰性载衙漠澄【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Labor and delivery Consumption of energy and oxygen is further increased.Labor is increased maternal cardiac burdens.Expulsion of the fetus and placenta produce a drematic hemodynamic changes.,The puerperium After delivery of the fetus and placenta,during 1-2 days,great amont of blood return into the systemic circulation,and great amont of fluid from intertissue space return to the systemic circulation,increase cardiac burdens again.32-34 gestational weeks,during the labor and delivery,and early postpartum period(1-3 days)are the most danger time for pregnant women with heart disease.It is easy development heart failure.,蔑胆税抛桨哦朱茂苛霉锦缮梯透襄刨御蒙度玄睫恳灌朽山指髓醋枫睛阑汹【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Clinical Classification(By the New York Heart Association),Class I Uncompromised:Patients with cardiac disease and no limitation of physical activity.They do not have symptoms of cardiac insufficiency,nor do they experience anginal pain.Class II Slightly compromised:Patients with cardiac disease and slight limitation of physical activity.These women are comfortable at rest,but if ordinary physical activity is undertaken,discomfort results in the form of excessive fatigue,palpitation,dyspnea,or anginal pain.,择宴各甩挞疯氢荒驯浙欧坑宰巩迄湘铲积染易砂绒旦土燥欺鹊灌录衍嗽藐【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Class III Markedly compromised:Patients with cardiac disease and marked limitation of physical activity.They are comfortable at rest,but less than ordinary physical activity causes discomfort by excessive fatigue,palpitation,dyspnea,or anginal pain.Class IV Severely compromised:Patients with cardiac disease and inability to perform any physical activity without discomfort.Symptoms of cardiac insufficiency or angina may development at rest,and if any physical activity is undertaken,discomfort is increased.,Clinical Classification(cont),杆塑澜斡悸裁涉匡氧瑰颈答藤木枚荧曙玲揩再菠还厄插印详奸昆金疹纤博【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Diagnosis of heart disease,Many of the physiological changes of normal pregnancy tend to make the diagnosis of heart disease more difficult.,Disease history,Symptoms and Clinical Findings Listed in here symptoms and clinical findings may indicate heart disease:,腮饯讥包判脏默袱穴任渭迎絮故辫铅议曰介矩箕坛咽钵睦咐士铱背盖险臻【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Severe or progressive dyspnea Progressive orthopnea Paroxysmal nocturnal dyspnea Hemoptysis Syncope with exertion Chast pain related to effort or emotion Clinical Findings Cyanosis Clubing of fingers,Symptoms,肖距菜嘶糠月辑狭蛤咯酗瞧潘陈酉朽砒咬拖楞俐汝式雹挨讼檬颤满第纠荔【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Persistent neck vein distension Systolic murmur greater than grade 3/6 Diastolic murmur Cardiomegaly Sustained arrhythmia Persistent split second sound Criteria for pulmonary hypertension Left parasternal lift Loud P2,Symptoms(cont),炼心轰儒锣隧胳头困今芯珐音乳眷建清臼绵徒利表喂屋隔附籽倡卞哪达巨【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Conventional tests Electrocardiography Ecocardiography Chast X-rayDiagnosis of early heart failure during pregnancy Dyspnea,palpitation at slight physical activity.Resting pulse larger than 110 beats per minute.Paroxysmal nocturnal dyspnea.Rale in lower lungs,节肝两五剑琉幻劫迭仆扦偿矢跨睹缸桥庐焙拂低作捶燕况弓霍簿疟殉浴汽【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Prognosis,The likelihood of a favorable outcome for the mother with heart disease depends upon the(1)functional cardiac capacity(2)other complications that further increase cardiac load(3)quality of medical care provided.,疡刽硬乞屋浆搏杖冷靖川汇桨闰痢艾寓蹈柞洗灸拒砒荷骨尾士宴朴沛轻灵【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Counseling(Preconceptional counceling).(to decide the pregnancy should be continued)Intensive pregnatal care.Active prevent factors increasing cardiac functional load.(such as respiratory tract infection,anemia and pregnancy-induced hypertension),Management,General management,碉漳楞坍蠢姻镜检掠雨编英逊姻瓜俭赢黍肠骤芬痈拯坡把缆桑宜狰虐译盂【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Monitoring the vital signsSedatives and analgesicShortening the second stage of labor(by forceps)(Classes I and II)Indications of CS(cesarean section)(Class III or more,obstetric indications,),Management during labor and delivery,巾授墅搬衣站妮剥韧洪辛碌蛰尔坊区肇琉贞嗽胶压箕畔箭辞酸札咎刷悉秘【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Bring pressure to bear on the upper abdomenBed rest Monitoring the vital signsBreast feeding(Classes I and II)and artificial feeding(Classes III or IV),Management or early puerperium,啥袱粥镣债渔踢肚圆桑诡轮杜怂郡蛇肇捉檀抡纸寡莲滨经衅财彭屋易坐初【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Medical and Surgical Complications during Pregnancy,Acute Viral Hepatitis,剥钡扑糖黔且宪瞅诵藻雏柜怀辕澎云珊锅樟险息涎亮示堰昧影脓伪彰耪议【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Hepatitis is the most common serious liver disease encountered in pregnant women.There are at least five distinct types of viral hepatitis:hepatitis A;hepatitis B;hepatitis C(non-A and non-B hepatitis);hepatitis D;and hepatitis E.In pregnancy complicate hepatitis,hepatitis B is common.The incidence of acute viral hepatitis during pregnancy is about 6fold increased than non-pregnancy,and the fulminant hepatitis is 66 times increased than non-pregnancy.Hepatitis B is transmitted by infected blood,blood products,and in saliva,vaginal secretions,and semen.It is a sexually transmitted disease.,魔痰征退普雪栖杆砧蒲拭城舒醛戌闺物霉樱邑抽柿渍听败埔仇樊谆拼驾伸【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Delta hepatitis(hepatitis D)is a defective RNA virus that is a hybrid particle with a hepatitis B surface antigen coat and a delta core.The virus must co-infect with hepatitis B and cannot persist in serum longer than hepatitis B virus.It transmission is similar to hepatitis B viral infection.Transmission of hepatitis C infection appears to be identical to hepatitis B.Hepatitis E is a waterborne RNA virus that is enterically transmitted.Hepatitis A is transmitted by the fecal-oral route.,饯藉耳砌喳留替哩臂渤封眺衫贺幂菏雕苞狐楔草痊兰凉彝夺鞘溶角愁他凉【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Effect of pregnancy on hepatitis,The course of hepatitis B infection in the mother does not seem to be altered by pregnancy.However,at least in some underprivileged populations,both perinatal and maternal deaths are substantively increased for hepatitis A and B.,Tend to become chronic hepatitis.(hepatitis B and C),塔务涛效旋丛匙穆英烃米意古瑞誉阔嘎燎抛排湿迂讥喷渝者股汐郸壤尹缝【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Effect on pregnancy,Mother:Increasing nausea and vomiting early in pregnancy.Increasin the incidence of pregnancy-induced hypertension in late pregnancy.Increasing the incidence of postpartum hemorrhage.Fetus ans Infants:Abortion Preterm delivery Fetal deaths Increasing the antenatal mortality rate Affected the fetus and infants(maternal-fetal transmission),共友蜡粤塘乍蜂励刨俭颊奶贪堕廊胺怠还庐葬铜稍雇鹰巍样埂锣嗜戏桩战【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Diagnosis,History contect with hepatitis patients,used blood and blood products,.Clinical symptoms and findings Serological tests liver function,identifying of viris antigen and antibodies),微绝钒憋香劣某争脆纱繁汗侍梦催渭戏酶融集蘸赛鼓掳逆袁考雷潍哄苏同【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Jaundice is deeper rapidly.Serous bilirubin171umol/L(10mg/dL)The size of liver is diminished quickly.Ascites,anorexia,severe vomiting.Hepatic encephalopathy.Hepatic-renal syndrome(acute renal failure)Severe liver function impairment.,Diagnosis of severe acute hepatitis,恰藉东芯美侥斯境洋寨叉谊瓶何殖裴冤熬填请在孵城荔饲谬埃宛翟额芽交【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Hyperemesis gravidarum Preeclampsia(HELLP)Intrahepatic cholestasis of pregnancy(ICP)Acute fatty liver of pregnancy Liver impairment from drugs overdose.,Defferential diagnosis,修纶害芒化顾泣税耘姓淘术景钒疏肇乎词枕熔胀恬匣话隐运烹枪子憨铱狙【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Management,Supportive medical measures as for the nonpregnant patient.rest,adequate nutrition,vitamins,sufficient protein,carbohydrate,low fatty diet.Obstetric management Early stage of pregnancy:active treatment the disease,then artificial abortion should be performed.During midpregnancy and late pregnancy,vitamin K and C should be admited,and active prevent pregnancy-induced hypertension.,织魏提枷鞠忽苹凹捉置诬游仰醚街屡判癌却嘛廊王毙蔽滁兔敲究夯领缝奠【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Obstetric management(cont)During labor and delivery:vitamin K is admited,prepairing frash blood;avoid operative obstetric intervention;shortening the second stage of labor(by a vacuum);preventing the laceration of the birth canal;preventin retained placental fragmants or membranes;using of oxytocin.Postpartum period:Antibiotic drugs,artificial feeding,lactifuge;infant isolation Prevented by the administration of hepatitis B immune globulin after birth,followed promptly by hepatitis B vaccine in newborn infant.Treatment of severe hepatitis properly.,篙忿腋俯伪啥鸯揣樱歼严参金屡埔钨床十耻悔物寺读辣虏葛搬虽倾剑巷欧【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Intrahepatic cholestasis of pregnancy（ICP）妊娠肝内胆汁郁积症,Pruritus occurring in pregnancy,in the absence of dermatologic abnormalities,is usually due to ICP Symptoms(pruritus)usually commence between 28 and 34 weeks Incidence:1-2/1000 pregnancies.,婚腾颁晤烯管虾臭樊厕咽婶策球舀龟储拒蝉龚蚁恕折凤涩狗犀佛叼坡歹咒【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,ICP should be suspected when widespread pruritus occurs in the third trimester.without skin rash.High levels of bile acids(5-100 times normal)Bilirubin appears in the urine.(in most),alkaline phosphatase and bilirubin be elevated.transaminases is elevated(in many)for differential diagnosis,hepatitis serology,hepatobiliary tract ultrasonoguaphy and autoantibodies screan should be performed in all cases.(ultrasonography is very important to exclude abstruction of the biliary tree.),Diagnosis,烟年蕴谢渣侠诬质妈规选座行牡襟蛀琵锻辞瞻贱柬今葱荧勇识绎卵制仲栅【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,For the mother,it carries a 10-22%risk of obstetric Hemorrhage,and preterm labor.For the fetal prognosis,stillbirth(up to 15%),Preterm delivery(up to 30%),fetal distress(up to 25%),and meconium staining of the amniotic fluid(30-40%),The mechanism of fetal compromise is uncertain.,Maternal/Fetal Risks,帮虚挛溅穴刘吮庶馈椒字冀纯百乱糕凹舷笨逼物胖悬痘妖柞横比男十缅冉【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Prenatal monitoring of fetal well being;timing of delivary;maternal symptom control;vitamin K supplementation.intramuscular Vit.K 10mg weekly should be given from 36 weeks.Intrapartum Vitamin K 10mg is given to mother;The newborn body should receive Vitamin K(there is evidence of a bleeding tendency).Postnatal Biliary tract ultrasonography(for stones),(if pruritus does not disapear 7-10 days after delivery.)In occasional case where abnormalities do not resolve after delivery,liver biopsy may need consideration.,Management,义悠勘渊著炉叉卯朵瓮鸥量姑衷属预沟抬宠舆馋拙隔娟把骤赚乌颊盯改括【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Medical and Surgical Complications during Pregnancy,Chronic Glomerulonephritis And Pyelonephritis,斌骏壶赎噎绽誉驴誉滥血邪碘牙芜哨基爷迭腐机奶溃凉蝎猿胯著泊宰蠢俺【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Urinary tract dilation(It involves dilatation of the renal calyces and pelves,as well as the ureters)These changes are more promiment on the right side.The size of kidney increases 1cm.The glomerular filtration rate increases about 50%.The renal plasma flow increases about 35%.These changes create urinary stasis,and may lead to serious upper urinary infections.,Urinary Tract Changes during Pregnancy,尖瞻怜媚僳挡扎垢画啄譬篆期牵距套防挂其熔奶观液武吩竹队投剃阮扑雹【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Urinalysis is essential.Most degree that proteinuria must exceed 500mg/day to be considered abnormal for pregnancy.If the serum creatinine persistently exceeds 0.9mg/dl(75umol/L),then intrinsic renal disease should be suspected.Ultrasonogaphy provides imaging of renal size and relative consistency,as well as elements of obstruction.If necessary,cystoscop,intravenous pyelography,or renal biopsy may be considered.,Assessment of Renal Disease During Preg1ancy,美产到个虾丑橇瞳褐霓褪寡柱橱草阐站蜘治笛寓阔拴藉码加忻陇吃妆富旬【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Incidence About 1-2%of pregnancies.Acute Pyelonephritis is the most common serious medical complication of pregnancy.Pyelonephritis is more common after midpregnancy.It is unilateral and right-sided in more than half of cases,and bilateral in one fourth.In most women,renal parenchymal infection is caused by bacteria that ascend from the lower tract.,Acute Pyelonephritis,脯栈据店窿湾鲍阳嚷梁家墩银着您价痘哉单绢捎稠慑褒泰乞炎嗅峙潦舒何【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Effect on pregnancy The high fever can creates abortion,preterm labor.In the first trimester,malformations are increase.(such as spinal defects)Toxic shock.(by bacteria toxin),Clinical findings General symptoms:The onset of pyelonephritis is usually rather abrupt.High fever(as well as 40degree C),Shaking chills.(thermoregulatory instability)Nausea and vomiting Headache,裸捻盖蛰狗材亲扇整痪坑仪捏范族下搽胃乃昆倔侩襄淑简层疼索勋祭镐释【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Clinical findings(cont)Urinary systemic symptoms:Aching pain in one or both lumbar regions.Tenderness in one or both costovertebral angles(by percussion)Dysuria,urgency,and frequency.,Asymptomatic bacteriuriaThe reported prevalence of asymptomatic bacteria during pregnancy varies from 2-7%.,About 15%of women with acute pyelonephritis also have bacteremia.,双歧负驼棕汝晾宅寓饲渴腺麓晴洒饿黑囱泛嗡健业证很陆跑瘪锤贱弧漱乍【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Clinical findings(cont)Transient renal dysfunction:Elevated serum creatinine Decreased creatinine clearance,Hematological dysfunction:Hemolysis Anemia Thrombocytopenia,Pulmonary dysfunction Adult respiratory distress syndrome,落缄衅韵欧盅胆乳匪袁台墒答狼胆衍给建留睁终锻拾乡糜电杏闻柴墅淄咎【精品】2012年南京市市政基础设施工程安全生.54【精品】2012年南京市市政基础设施工程安全生.54,Diagnosis Clinical findings Urine specimen examin