Your SlideShare is downloading. ×
不孕症        遺傳諮詢            2
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

不孕症 遺傳諮詢 2

507

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
507
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. 人工流產的臨床考量      何師竹 台中榮民醫院婦產部
  • 2. 人工流產的母體合併症 (官方手術說明書)
    • 感染:極少數感染會造成子宮內膜炎、輸卵管炎、骨盆腔炎症或流產後敗血症,甚至會因而感染造成休克死亡。
    •  不完全流產:容易發炎或造成大量出血。
    •  出血:嚴重失血以致造成肺栓塞、腦部受損、心臟停止甚至死亡。
    •  組織傷害:極少數,但情況嚴重時甚至須緊急施以腹腔鏡或剖腹手術探查:
    • 1. 子宮頸裂傷:可能造成日後受孕困難、子宮頸閉鎖不全甚至早產。
    • 2. 子宮內膜受損:少數會因子宮內膜腔沾黏造成阿休曼式症候群,術後子宮腔積血、經血量少、甚至無月經;或日後造成不孕症及復發性流產。
  • 3. 人工流產的母體合併症 (官方手術說明書)
    • 3. 子宮穿孔 :造成腸道損傷併發腹膜炎、腹腔膿瘍或併發腹內出血,嚴重可至休克 死亡 。
    • 4. 子宮破裂
    • 5. 神經損傷
    •  嚴重出血時需要輸血,伴隨 輸血的危險 包括:
    • 1. 感染 2. 溶血性輸血反應
    • 3. 血量負荷過大、鬱血性心衰竭、肺水腫、輸血性抗宿主反應等合併症。
    •  與麻醉有關之併發症 :藥物過敏反應、神經作用、心跳過緩或停止,休克。
  • 4. 人工流產對長期身心健康上的後果 Long-Term Physical and Psychological Health Consequences of Induced Abortion:Review of the Evidence OBSTETRICAL AND GYNCOLOGICAL SURVEY 2007 V58:67
    • One can presume that abortion is most often chosen as a response to a crisis or unintended pregnancy. The high prevalence of history of induced abortion means that even small positive or negative effects on long-term health could influence the lives of many women and their families.
    Abortion rate  1996 U.S.A. 23 / 1000 #  Women Age 15 to 44 # 26% all recognized pregnancy 1995 Canada 16/1000 England 15/1000 Sweden 18/1000 Netherland 6/1000
  • 5. Obstetric Ethics : (the fetus as a patient) 胎兒也是產科醫師的病人
    •  The pregnant women has beneficence-based obligations to the fetus because she is its moral fiduciary . She is expected to protect and promote the best interests of her fetus.
    • 孕婦是胎兒的法定代理人,有嘉惠胎兒的義務,被預期會保護及促進胎兒的權益。
  • 6. Obstetric Ethics : (the fetus as a patient) 胎兒也是產科醫師的病人
    • The physician also has beneficence-based obligation to the fetus,
    • to protect and promote its interests.
    • 醫師也有嘉惠胎兒的義務,會保護及促進胎兒的權益。
    • The beneficence model :
    • prevention of premature death, disease, handicapping conditions,
    • and unnecessary pain and suffering.
    • 嘉惠原則:預防其提早死亡、疾病、殘障及不必要的受苦。
  • 7. 優生保健法 第三章 人工流產及結紮手術 第九條 懷孕婦女經診斷或證明有左列情事之一者,得依其自願, 施行人工流產。
    • ﹟ 一、 本人或其配偶患有礙優生之 遺傳性、傳染性疾病或精神病者
    • ﹟ 二、本人或其配偶之 四等親以內之血親 患有礙優生之 遺傳性病者
    •  三、有醫學上理由,足以認定懷孕或分娩有招致 生命危險或有害
    • 身體或精神健康者。
    • ﹟ 四、有醫學上理由,足以認定 胎兒有畸型發育之虞者
    • 五、因被強姦、誘姦或與 依法不得結婚 相姦而受孕者
    • 六、因懷孕或生產, 將影響其心理健康或家庭生活者
    • 本項 佔台灣 95% 的人工流產
    • 有配偶者,依前項第六款規定,施行人工流產應得配偶之同意
  • 8.
    • Prenatal diagnosis 產前診斷
    • Genetic counseling 遺傳諮詢
    • Screening 篩檢
    為「優生」施行的流產涉及 :
  • 9. 非引導性的遺傳諮詢與同意書 Informed consent and Nondirective genetic counseling
    • Disclosure by the physician to the patient of adequate information 醫生提供足夠資訊
    • 2. Understanding of that information by the patient 病患對資訊充分了解
    • 3. A voluntary decision by the patient to authorize or refuse clinical managemant 病患自主決定授權或拒絕處置
  • 10. Ethical and legal considerations in screening, detection, and management of fetal anomalies
    • to provide emotional support to the stressed pregnant woman in circumstances of ;    在下列情況提供孕婦情緒支持
    • Screening 篩檢
    • confirmatory testing 確定檢查結果
    • giving bad news 給壞消息
    • making abortion decisions 作流產的決定
    • making management decisions after viability 留存胎兒的處置決定
    • to help the pregnant woman make informed
    • management decisions based on her values and goals .
    • 以幫助孕婦根據她的價值觀與目標,做出正式的處置決定
    產科醫師的責任 Duty of the obstetrician
  • 11. 產前診斷及發現異常之諮商的兩難情況(一) Dilemma in Prenatal Diagnosis and Counselling After Disclosure ( I )
    • Small Neural tube defect? 小的神經管缺陷
    • MSAFP↑Normal level II ultrasound, normal karyotype
    • AFAFP ↑, AF Acetylcholinesterase ↑
    • Grand multiple pregnancy 超高胎數的懷孕
    • Third Trimester prenatal diagnosis 妊娠後期診斷
    • Preference of discolosure of the sex of fetus
    • 是 否告知胎兒性別
  • 12.
        • 無腦兒
        • 全水腦(空腦症)
        • 嚴重複雜性心臟疾病合併心臟衰竭
        • 致死性遺傳性胎兒多囊性腎臟
        • 雙側性腎臟發育缺失
        • 致死性骨骼發育異常
        • 甲型致死性地中海型貧血
        • 其他致死性遺傳或代謝疾病
    妊娠 24 週以後合法中止懷孕適應症
  • 13.      內發現,宜於足月產後矯治     Detectable in Utero but Best Corrected After Delivery at Term
    • Esophageal, duodenal, jejunoileal, and anorectal atresias.
    • Meconium peritonitis ( localized lesion without fetal ascites ) .
    • Small intact omphalocele.
    • Uncomplicated gastroschistis.
    • Unilateral multicystic dysplastic kidney
    • Small intact myelomeningocele & spina bifida..
    • Small sacrococcygeal teratoma.
    • Ovarian cysts.
  • 14. 唇腭裂的產前照護 Obstetrical ManagementAntepartum for Cleft Lip and Palate
    • Careful survey by Ultrasonography 詳細超音波
    • Karyotyping : controversial 染色體
    • Follow up once a month 每月追蹤
    • Polyhydramnios 羊水量
    • Missed additional defect 是否遺漏其他異常
    • Standand obstetrical care if no other anomalies 標準產科照護
    • Delivery at a tertiary center 醫學中心生產
    • Respiratory & Feeding problems 處置呼吸及餵食問題
  • 15. 需提前娩出子宮外作矯治 May Require Induced Preterm Delivery for Early Correction Ex Utero
    • Obstructive hydronephrosis.
    • Obstructive hydrocephalus.
    • Amniotic band malformation complex.
    • Complicated gastroschisis or ruptured omphalocele.
  • 16. 產前診斷及發現異常之諮商的兩難情況(二) Dilemma in Prenatal Diagnosis and Counselling after Disclosure ( II )
    • 45,X ; 47,XYY ; 47,XXY 、 XX-male 性染色體異常
    • Androgen insensitivity 雄性素不敏感(無反應器)
    • Trisomy Mosacism 鑲嵌性染色體
    • Inherited balanced translocation 遺傳性染色體平衡轉位
  • 17. 篩檢唐氏症的代價太高? The Cost of Choice: A Price Too High in the Triple Screen for Down Syndrome.   Elkins,et al. Clinical Obs/Gynecology, V36:532-540
    • Some fetal anomalies clearly bring greatly diminished life expectancy ( ancephaly and trisomy 13 or 18). Other fetal conditions ( Tay-Sachs disease or AIDS) lead to extreme infant suffering.
    • These are vastly different from Down’s syndrome , the discovery of Genetic traits, rather than disorders , would not be seen as important enough to warrant such extensive screening.
    •             
  • 18. 篩檢唐氏症的代價太高? The Cost of Choice: A Price Too High in the Triple Screen for Down Syndrome.
    • We argued against attaching a price tag to persons with Down’s syndrome. Determining cost effectiveness is franght with difficulties. 唐氏症並非預期生命短(無腦兒、第13、18對染色體3倍等),亦非嬰兒嚴重受苦(代謝異常、愛滋病等),所以可視為遺傳上的變異而非疾病。我們反對將生命加以標價。
  • 19. 產前診斷及中止懷孕所引發的倫理議題 Ethical problems raised by prenatal diagnosis and TOP
    • 難下終止懷孕的決定
    • ◎ minor anomaliy
    • ◎ 誰知孩子的未來?
    • ◎ 滑坡理論
    • 擔心異常兒童在‘優生社會’的處境。
    • 允許醫師決定生死,使醫師的角色不合理。
    • 女性懷孕過程充滿壓力,將造成心理上的後遺症,破壞孕期及出生後的親子關係。
    • 部分醫事人員承認終止懷孕比兒童虐待好。
  • 20. 國人有更多的兩難 More dilemma in our practice
    •     The tradition of sexual discrimation is still strong 性別偏見仍強
    •     No consensus about the ‘beginning of human life’ 對生命起源無共識
    •     The legal status of fetus is ambiguous.
    •     胎兒法律地位未明
    •    
        Human diginity and rights are the consecrated and inviolable gift of creator to mankind . Medicine is an art of healing which take place in object with knowing, feeling, willing and endowed right .    人類的尊嚴與權利是造物主所授予神聖不可侵犯的禮物。醫學是醫治的藝術,施之予有知、情、意及賦有人權的個體身上。

×