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Pregnancy With Internal Medical Diseases Yinglin Liu( 刘颖琳 ) MD&PhD, Department of Gyn & Obs The 2 nd  Affiliated Hospital ...
Emphasis <ul><li>Pregnancy complicated with: </li></ul><ul><li>Heart Disease(HD) </li></ul><ul><li>Viral Hepatitis </li></...
Key points <ul><li>Clinical manifestation, diagnosis, and management </li></ul><ul><li>Influence between disease & pregnan...
Part One  Cardiovascular Diseases
Pregnancy complicated with Heart Disease Incidence of pregnancies:1-4% Death rate:  0.6%-2.7% 2nd leading cause of materna...
Influence 0f Pregnancy on Cardiovascular system <ul><li>During Pregnancy(32-34wks) </li></ul><ul><li>During Labor </li></u...
Hemodynamic and respiratory change of normal pregnancy <ul><li>Blood volume:  ↑   25-50%   32-36wks </li></ul><ul><li>CO: ...
During labor <ul><li>First stage:   </li></ul><ul><li>Each ut. Con.  CO ↑24% </li></ul><ul><li>extrudes 500 ml  CVP↑ </li>...
During labor <ul><li>Second stage:   </li></ul><ul><li>Bearing down effort  Pulmonary pressure ↑ </li></ul><ul><li>Congeni...
During labor <ul><li>Third stage: </li></ul><ul><li>After placenta elimination-> </li></ul><ul><li>placental cir. disappea...
Puerperium <ul><li>First 3 days </li></ul><ul><li>Retension fluid go back to circulation </li></ul><ul><li>Uterus shrinks ...
The types of Heart Disease Complication Pregnancy <ul><li>I. Congenital heart disease </li></ul><ul><li>Ⅱ . Rheumatic hear...
Congenital heart disease With large L-to-R shunt:  pulmonary artery hypertension ,  right-left shunt , cyanosis Blood shun...
Rheumatic heart disease <ul><li>Mitral stenosis </li></ul><ul><li>Aortic stenosis </li></ul><ul><li>Mitral or aortic insuf...
Heart Disease of hypertensive disorder complicating pregnancy <ul><li>Heart burthen   </li></ul><ul><li>coronary artery s...
Peripartum cardiomyopathy  (PPCM) <ul><li>Cause :  unknown.(viral infection, genetic factors, autoimmunity, mal-nutrition,...
PPCM <ul><li>50% recover 6 months postpartum </li></ul><ul><ul><li>Recur in the successive pregnancy </li></ul></ul><ul><u...
Myocarditis and Sequelaes <ul><li>Symptoms may occur after viral infection: enteric virus , Coxsackie virus , Rubella viru...
Influence of Heart Diseases on Fetuses <ul><li>Abortion, premature labour, fetal death, FGR(fetal growth retardation) and ...
Symptoms & signs of normal pregnancy mimicking HD <ul><li>Symptoms </li></ul><ul><li>Palpitation, dyspnea / orthopnea, eas...
Diagnosis  of Heart Disease   <ul><li>History </li></ul><ul><li>Sypmtoms :  physical dyspnea, emptysis ,  orthopnea ,  pal...
Functional Classification of Heart Disease  –  subjective sym. <ul><li>Class I: NO limitation to normal active life </li><...
Clinical Classification  –   objective detection <ul><li>Class A : No evidence of cardiovascular diseas </li></ul><ul><li>...
According To The Patients ’  Ability To Cope With Pregnancy <ul><li>Conditions allowable for pregnancy : </li></ul><ul><li...
Common complication <ul><li>Heart failure </li></ul><ul><li>Subacute infective endocarditis </li></ul><ul><li>Hypoxia & Cy...
Diagnosis Of The Early Cardiac Failure <ul><li>Stuffy, palpitation, short-breath  after slight physical activity, nocturna...
Management <ul><li>Prepregnancy </li></ul><ul><li>During Pregnancy </li></ul><ul><li>Therapeutic abortion </li></ul><ul><l...
Prevention of cardiac failure <ul><li>Quiet & rest (>10hrs/d) </li></ul><ul><li>Nutrition:  pro.& Vit  , sodium & fat  ....
To choose suitable birth way <ul><li>Trial labour : classⅠ~Ⅱof cardiac function, moderate fetal size, normal fetal positio...
Management During Delivery <ul><li>1 st  stage:  sedatives ;  surveillance (BP, P,R,HR); O 2 ; digitalis;  antibiotics  </...
Management During Puerperium <ul><li>Careful observation ( first 3 days ) </li></ul><ul><li>Antibiotics ( 7 days after lab...
Heart Surgery <ul><li>Should not be done during pregnancy   </li></ul><ul><li><12 weeks of gestation </li></ul><ul><li>Pre...
Part Two  Acute Viral Hepatitis
 
 
Physiological Changes of Liver During Pregnancy <ul><li>Blood flow, size </li></ul><ul><li>AST/ALP </li></ul><ul><li>ALP, ...
The Effect Of Pregnancy On Hepatitis <ul><li>More nutrition is needed </li></ul><ul><li>Hyperemesis gravidarum  </li></ul>...
The Effect Of Viral Hepatitis On Pregnancy: For Gravidas  <ul><li>Mortality ↑18.3% </li></ul><ul><li>Worsen pregnant react...
The Effect Of Viral Hepatitis On Pregnancy: For Fetuses <ul><li>Malformation </li></ul><ul><li>Abortion </li></ul><ul><li>...
Materno-Fetal Transmission (HBV) <ul><li>Intrauterine infection  (9.1%~36.7%) </li></ul><ul><li>Impaired placental barrier...
Diagnosis <ul><li>History </li></ul><ul><li>Symptoms </li></ul><ul><li>Sign </li></ul><ul><li>Laboratory examination:  HBs...
<ul><li>HBsAg : Active HBV infection; may be acute or chronic  </li></ul><ul><li>HBeAg : High infectivity, active viral re...
Differential Diagnosis <ul><li>Hyperemesis gravidarum: ketosurine (+) </li></ul><ul><li>Hypertensive disorder complicating...
Viral hepatitis ICP Acute fatty liver of pregnancy HELLP syndrome Hyperemesis gravidarum Drug induced hepatitis onset All ...
Management Of Hepatitis <ul><li>Slight type:  nutrition & rest </li></ul><ul><li>Severe type: </li></ul><ul><li>Liver prot...
Obstetric Management  <ul><li>1 st  trimester  :  artificial abortion </li></ul><ul><li>2 nd  / 3 rd  trimester :  avoid o...
Prevention <ul><li>Enhence peripartum health care: surveillance, nutrition, serological screening </li></ul><ul><li>Prophy...
HBV Immunoprophylaxis <ul><li>Active immunity:  HB vac (vaccine)  30   μ g   im. (<24hr, 10  μ g  1st, 6 th month) </li></...
Part III  Diabetes Mellitus
Gestational Diabetes Mellitus(GDM) <ul><li>Definition:   It is the first time for D.M. to be found just during pregnancy. ...
Effects of Pregnancy on Diabetes <ul><li>Placentas ->E3, HPL,…↑->antagonize insulin: </li></ul><ul><li>Latent D.M. ->appar...
Effects of Diabetes on Pregnancy  (Gravidas) <ul><li>Natural abortion ↑ 15%~30%. </li></ul><ul><li>EPH-syn. 3-5 times ↑ </...
Effects of Diabetes on Pregnancy  (Fetuses) <ul><li>Fetal macrosomia: 25%~40%. </li></ul><ul><li>FGR: 21%. </li></ul><ul><...
Effects of Diabetes on Pregnancy  (Neonates) <ul><li>Respiratory distress syndrome (RDS) :  mothers Glu. ↑ ->   fetuses  -...
Minor adverse health effects for offspring  in GDM Birth Wt (g) 3303 ±64 3649 ±51    3849 ±72  <0.01 Macrosomia(%) 8 36 47...
Diagnosis <ul><li>History </li></ul><ul><li>Laboratory examination : </li></ul><ul><li>Fasting blood sugar   ≥5.8 mmol/L  ...
White grouping class description A Abnormal OGTT treat only by diet therapy B Onset at age 20years or older and duration o...
Management <ul><li>Ⅰ .   To Estimate the Patients ’  Ability to Cope With Pregnancy: </li></ul><ul><li>Class D, F, R -> ar...
Standard of blood glucose controled Time blood glucose fasting blood glucose 3.3~5.6mmol/L two hours after meal 4.4~6.7mmo...
Management <ul><li>Ⅲ . Medicinal therapy </li></ul><ul><li>Oral heparopen ->pass placenta->fetal damage. </li></ul><ul><li...
Management  (Ⅴ. Termination of pregnancy) <ul><li>Timing </li></ul><ul><li>If blood glucose remain normal, pregnancy can b...
Management  (During labour & puerperium) <ul><li>Blood glucose and electrolytic level must be kept  normal.  (Glucose 4g +...
Low-dosage constant insulin infusion for the intrapartum period blood-glucose (mg/100ml ) Insulin dosage ( U/h ) fluids ( ...
Management of Neonates <ul><li>Treat them as preterm infants! </li></ul><ul><li>Prevention  of  hypoglycemia(<2.22mmol/L),...
Prognosis <ul><li>tendency to recur next pregnancy </li></ul><ul><li>the risk of typeⅡ diabetes rise </li></ul><ul><li>dev...
Key points <ul><li>Clinical manifestation, diagnosis, and management of  Pregnancy With Internal Medical Diseases (HD, Vir...
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Transcript of "4 pregnancy complications"

  1. 1. Pregnancy With Internal Medical Diseases Yinglin Liu( 刘颖琳 ) MD&PhD, Department of Gyn & Obs The 2 nd Affiliated Hospital of Sun Yat-sen University
  2. 2. Emphasis <ul><li>Pregnancy complicated with: </li></ul><ul><li>Heart Disease(HD) </li></ul><ul><li>Viral Hepatitis </li></ul><ul><li>Gestational diabetes mellitus(GDM) </li></ul>
  3. 3. Key points <ul><li>Clinical manifestation, diagnosis, and management </li></ul><ul><li>Influence between disease & pregnancy(mothers & fetuses) </li></ul><ul><li>Types of Heart Disease </li></ul><ul><li>Diagnosis of early heart failure(HF) </li></ul><ul><li>Maternal-fetal transmission of hepatitis B virus </li></ul><ul><li>Definition of GDM </li></ul>
  4. 4. Part One Cardiovascular Diseases
  5. 5. Pregnancy complicated with Heart Disease Incidence of pregnancies:1-4% Death rate: 0.6%-2.7% 2nd leading cause of maternal mortality: 8.3%
  6. 6. Influence 0f Pregnancy on Cardiovascular system <ul><li>During Pregnancy(32-34wks) </li></ul><ul><li>During Labor </li></ul><ul><li>Puerperium (first 3 days) </li></ul>
  7. 7. Hemodynamic and respiratory change of normal pregnancy <ul><li>Blood volume: ↑ 25-50% 32-36wks </li></ul><ul><li>CO: ↑ 30-50% 20-30wks </li></ul><ul><li>HR: ↑ 10-25bpm </li></ul><ul><li>Vascular resistance: ↓ 40-50% </li></ul><ul><li>O 2 consumption: ↑ 15-30% </li></ul><ul><li>Tidal volume : ↑ 40% </li></ul>
  8. 8. During labor <ul><li>First stage: </li></ul><ul><li>Each ut. Con. CO ↑24% </li></ul><ul><li>extrudes 500 ml CVP↑ </li></ul><ul><li>blood to peripheral cir. </li></ul><ul><li>MAP ↑ 10% </li></ul><ul><li>(MAP: mean arterial pressure) </li></ul>
  9. 9. During labor <ul><li>Second stage: </li></ul><ul><li>Bearing down effort Pulmonary pressure ↑ </li></ul><ul><li>Congenital heart dis. </li></ul><ul><li>Blood shunt(L->R) -> Blood shunt(R->L) </li></ul>
  10. 10. During labor <ul><li>Third stage: </li></ul><ul><li>After placenta elimination-> </li></ul><ul><li>placental cir. disappears 500ml blood evacuated u. contracts enter circulation </li></ul><ul><li>2. u. shrinks -> intra-abd. pressure ↓ -> blood accumulated in visera </li></ul>
  11. 11. Puerperium <ul><li>First 3 days </li></ul><ul><li>Retension fluid go back to circulation </li></ul><ul><li>Uterus shrinks further </li></ul>
  12. 12. The types of Heart Disease Complication Pregnancy <ul><li>I. Congenital heart disease </li></ul><ul><li>Ⅱ . Rheumatic heart disease </li></ul><ul><li>Ⅲ . Cardiovascular disease of hypertensive disorder complicating pregnancy </li></ul><ul><li>Ⅳ . Peripartum cardiomyopathy,PPCM </li></ul><ul><li>Ⅴ . Myocarditis </li></ul>
  13. 13. Congenital heart disease With large L-to-R shunt: pulmonary artery hypertension , right-left shunt , cyanosis Blood shunt only from L to R / No blood shunt Blood shunt from R to L Noncyanotic Cyanotic Atrial septal defect, ventricular septal defect, Patent ductus arteriosus Pulmonary stenosis, Coartation of aorta, Marfan’s syndrom Tetralogy of Fallot Eisenmenger’s syndrom . Withstand hemodynamic change of pregnancy and labor with small shunt Pregnancy is contraindicated
  14. 14. Rheumatic heart disease <ul><li>Mitral stenosis </li></ul><ul><li>Aortic stenosis </li></ul><ul><li>Mitral or aortic insufficiency </li></ul><ul><li>And combinations of those above </li></ul>
  15. 15. Heart Disease of hypertensive disorder complicating pregnancy <ul><li>Heart burthen  </li></ul><ul><li>coronary artery spasm </li></ul><ul><li>systemic arterial spasm </li></ul><ul><li>retention of water and sodium </li></ul><ul><li>viscosity of blood ↑ </li></ul><ul><li>Contraction force weaken ↓ cardiac muscle ischemic hypoxia </li></ul><ul><li>systemic arterial spasm </li></ul>
  16. 16. Peripartum cardiomyopathy (PPCM) <ul><li>Cause : unknown.(viral infection, genetic factors, autoimmunity, mal-nutrition, etc), no cardiac history before pregnancy. </li></ul><ul><li>Period : late trimester ~ 6 months after delivery </li></ul><ul><li>Symptoms&signs (HF) : dyspnea, palpitation, cough, emptysis, orthopnea, chest pain, hepatomegaly, edema, organic embolism, dyspnea , thoracalgia , edema , hepatomegaly ect </li></ul><ul><li>X-ray : dilatation of heart, pulmonary congestion </li></ul><ul><li>Echo-CG, ECG : Heart chambers dilatation ,left ventricular hypertrophy, S-T seg. abnormal T wave </li></ul><ul><li>HF, pulmonary infarction or arrhythmia may cause death. </li></ul>
  17. 17. PPCM <ul><li>50% recover 6 months postpartum </li></ul><ul><ul><li>Recur in the successive pregnancy </li></ul></ul><ul><ul><li>Clinical Implications : 10-30% of fetal death </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><ul><li>Treatment for heart failure </li></ul></ul></ul><ul><ul><ul><li>Heart transplantation </li></ul></ul></ul>
  18. 18. Myocarditis and Sequelaes <ul><li>Symptoms may occur after viral infection: enteric virus , Coxsackie virus , Rubella virus , cytomegalovirus </li></ul><ul><li>History of respiratory tract or alimentary infection, fatigue, palpitation, dyspnea, uncomfortable on anterior chest </li></ul><ul><li>Lab.test:CRP ↑ , SR ↑ , enzyme, Ab ↑ (3wks) </li></ul><ul><li>Abnormal ECG </li></ul><ul><li>Even heart failure after two-three weeks of infection </li></ul><ul><li>Not cure with disease for six months——myocarditis sequelae </li></ul><ul><li>Acute myocarditis cured——keep on pregnancy </li></ul>
  19. 19. Influence of Heart Diseases on Fetuses <ul><li>Abortion, premature labour, fetal death, FGR(fetal growth retardation) and fetal distress  , mortality  </li></ul><ul><li>Drugs (digoxin) can pass through the placentas and is danger for the fetuses. </li></ul><ul><li>Genetic problem </li></ul><ul><li>Increased caesarean section rate </li></ul>
  20. 20. Symptoms & signs of normal pregnancy mimicking HD <ul><li>Symptoms </li></ul><ul><li>Palpitation, dyspnea / orthopnea, easy fatigability, dizziness, nocturnal cough </li></ul><ul><li>Signs </li></ul><ul><li>Displacement of apex </li></ul><ul><li>Sinus tachycardia </li></ul><ul><li>S1 of apex / S2 on PV ↑ & split , systolic murmur, third heart sound </li></ul><ul><li>Prominent jugular venous pulsations </li></ul>
  21. 21. Diagnosis of Heart Disease <ul><li>History </li></ul><ul><li>Sypmtoms : physical dyspnea, emptysis , orthopnea , palpitation </li></ul><ul><li>Signs : ≥ Ⅱ dia. mur. or≥ III sys. mur, dia. gallop rhythm,pericardial friction rub,alternating pulse, cyanosis, clubbing of fingers, persistent neck vein distention </li></ul><ul><li>ECG : serious arrhythmia (auricular fibrillation or flutter, AVB), abnormal ST </li></ul><ul><li>X-ray: Cardiomegaly </li></ul><ul><li>Echocardiography : movement and construction </li></ul>
  22. 22. Functional Classification of Heart Disease – subjective sym. <ul><li>Class I: NO limitation to normal active life </li></ul><ul><li>Class II: Slight limitation of physical activity </li></ul><ul><li>Class III: Marked limitation of physical activity </li></ul><ul><li>Class IV: Complete limitation of physical activity </li></ul>
  23. 23. Clinical Classification – objective detection <ul><li>Class A : No evidence of cardiovascular diseas </li></ul><ul><li>Class B : minimal cardiovascular disease according to examination </li></ul><ul><li>Class C : Moderate cardiovascular disease </li></ul><ul><li>Class D : Severe cardiovascular disease </li></ul>
  24. 24. According To The Patients ’ Ability To Cope With Pregnancy <ul><li>Conditions allowable for pregnancy : </li></ul><ul><li>Cardiac function is I or II, slight types </li></ul><ul><li>Conditions unsuitable for pregnancy : </li></ul><ul><li>Severe types, class III or IV, history of HF, pulmonary hypertension, R to L shunt, severe arrhythmia, active rheumatic HD, combined valvar HD, Bac.endocarditis, acute myocarditis, enlargement of heart . </li></ul><ul><li>>35ys, long history . </li></ul>
  25. 25. Common complication <ul><li>Heart failure </li></ul><ul><li>Subacute infective endocarditis </li></ul><ul><li>Hypoxia & Cyanosis </li></ul><ul><li>Venous & pulmonary embolism </li></ul>
  26. 26. Diagnosis Of The Early Cardiac Failure <ul><li>Stuffy, palpitation, short-breath after slight physical activity, nocturnal cough; </li></ul><ul><li>HR>110 bpm at rest, R>20 times/min; </li></ul><ul><li>Paroxysmal nocturnal dyspnea/ Orthopnea may be the very early symptoms; </li></ul><ul><li>Persistent basilar rales , even after couph. </li></ul>
  27. 27. Management <ul><li>Prepregnancy </li></ul><ul><li>During Pregnancy </li></ul><ul><li>Therapeutic abortion </li></ul><ul><li>Antenatal examination </li></ul><ul><li>Prevention of cardiac failure </li></ul>
  28. 28. Prevention of cardiac failure <ul><li>Quiet & rest (>10hrs/d) </li></ul><ul><li>Nutrition: pro.& Vit  , sodium & fat  . weigh gain<10kg, limited salt intake: <4-5g after 16 weeks, fluid replacement limited in 500~1000ml/d , drop velocity <60ml/h </li></ul><ul><li>Therapy of inducement: prevention of URI.; correct anemia & arrhythmia; therapy of EPH-syn; m ultiple and small amounts ( 150~200ml ) blood transfused if needed </li></ul><ul><li>Therapy of cardiac failure: digoxin (0.25mg, Bid), 2~3d  qd. Diuretics. Vessel dilating agents. </li></ul><ul><li>Cesaren section. Timing is important. </li></ul><ul><li>Observe </li></ul>
  29. 29. To choose suitable birth way <ul><li>Trial labour : classⅠ~Ⅱof cardiac function, moderate fetal size, normal fetal position, cervical condition is good enough. </li></ul><ul><li>Cesaren section : class Ⅲ~Ⅳ of cardiac function, large fetal size, obstetric condition is not so good. </li></ul>
  30. 30. Management During Delivery <ul><li>1 st stage: sedatives ; surveillance (BP, P,R,HR); O 2 ; digitalis; antibiotics </li></ul><ul><li>2 nd stage : Bearing down effort should be avoid -- episiotomy , elective forceps and vacuums extraction </li></ul><ul><li>3 rd stage : Sand bag, Oxytocin ( ergometrine should be avoid ) </li></ul><ul><li>Who has torpidity labor or cephalopelvic disproportion or grade heart function should undergo cesarean section </li></ul>
  31. 31. Management During Puerperium <ul><li>Careful observation ( first 3 days ) </li></ul><ul><li>Antibiotics ( 7 days after labour ) </li></ul><ul><li>Breast feeding should be avoid in some patients( III or IV cardiac function ) : </li></ul><ul><li>natrii sulfas , not estrogen </li></ul><ul><li>Contraception and sterilization ( 1 week after labour ) </li></ul>
  32. 32. Heart Surgery <ul><li>Should not be done during pregnancy </li></ul><ul><li><12 weeks of gestation </li></ul><ul><li>Prevention of abortion & infection </li></ul>
  33. 33. Part Two Acute Viral Hepatitis
  34. 36. Physiological Changes of Liver During Pregnancy <ul><li>Blood flow, size </li></ul><ul><li>AST/ALP </li></ul><ul><li>ALP, fibrinogen↑, Coagulative factors ↑ , </li></ul><ul><li>A/G  </li></ul>
  35. 37. The Effect Of Pregnancy On Hepatitis <ul><li>More nutrition is needed </li></ul><ul><li>Hyperemesis gravidarum </li></ul><ul><li>The liver burden  (maternal & fetal metabolism). </li></ul><ul><li>Endocrine change (estrogen  ) </li></ul><ul><li>Hypertensive disorder complicating pregnancy,ICP,AFLP </li></ul><ul><li>During labor </li></ul><ul><li>Postpartum hemorrhage </li></ul><ul><li>Maternal mortality rate elevated </li></ul>
  36. 38. The Effect Of Viral Hepatitis On Pregnancy: For Gravidas <ul><li>Mortality ↑18.3% </li></ul><ul><li>Worsen pregnant reaction </li></ul><ul><li>Hypertensive disorder complicating pregnancy↑ (Aldosterone) </li></ul><ul><li>Postpartum hemorrhage , DIC↑ (coagulative factors  ) </li></ul>
  37. 39. The Effect Of Viral Hepatitis On Pregnancy: For Fetuses <ul><li>Malformation </li></ul><ul><li>Abortion </li></ul><ul><li>Premature labor </li></ul><ul><li>Fetal demise / still birth </li></ul><ul><li>Fetal malfromation </li></ul><ul><li>Perinatal mortality ↑ 46 ‰ </li></ul><ul><li>Perinatal transmission </li></ul>
  38. 40. Materno-Fetal Transmission (HBV) <ul><li>Intrauterine infection (9.1%~36.7%) </li></ul><ul><li>Impaired placental barrier, penetrability  , leakage </li></ul><ul><li>During delivery (40%~60%) </li></ul><ul><li>Mother’s blood or vaginal secretion </li></ul><ul><li>Postpartum </li></ul><ul><li>Sweat, saliva & milk </li></ul>
  39. 41. Diagnosis <ul><li>History </li></ul><ul><li>Symptoms </li></ul><ul><li>Sign </li></ul><ul><li>Laboratory examination: HBsAg, HBeAg, HBVDNA, HBc-IgM </li></ul>
  40. 42. <ul><li>HBsAg : Active HBV infection; may be acute or chronic </li></ul><ul><li>HBeAg : High infectivity, active viral replication </li></ul><ul><li>HBcAg : Active copying, undetectable in serum </li></ul><ul><li>Anti-HBcAg IgM : Acute HBV infection (newer and more sensitive assays may also be positive during reactivation of chronic infections) </li></ul><ul><li>HBV-DNA and DNA polymerase: Direct measure of infectivity or replicative state; becoming increasingly available </li></ul><ul><li>Anti-HBsAg : Immune to HBV; may be natural immunity or following vaccination </li></ul><ul><li>Anti-HBeAg : Low or no infectivity; need only be measured in chronic HBV </li></ul>
  41. 43. Differential Diagnosis <ul><li>Hyperemesis gravidarum: ketosurine (+) </li></ul><ul><li>Hypertensive disorder complicating pregnancy: hypertension, proteinuria, edema, renal function  . HELLP Syn. </li></ul><ul><li>AFLP (Acute fatty liver of pregnancy) </li></ul><ul><li>Liver lesion caused by medicine: wintermin, luminal, erythromycin, rimifon, </li></ul>
  42. 44. Viral hepatitis ICP Acute fatty liver of pregnancy HELLP syndrome Hyperemesis gravidarum Drug induced hepatitis onset All time Late Late Late Early All time Inducement - - - PIH - Drug use symptoms Gastrointestinal, jaundice pruritus-jaundice epigastric pain, vomiting, acute liver failure epigastric pain, jaundice, bleeding Prolonged vomiting Jaundice and prutitus after drug intake Lab findings Hepatitis virus positive Cholic acid  serum bilirubin  urine bilirubin(-) Hemolysis, coagulopathy, BPC  Water, salt and ph imbalance acidophil  Hepatic disfunction Light-severe light Acute and severe severe light light pathology Hepatocyte damage Intrahepatic cholestasis Fat filled in cytoplasm ischemia light light fetus Malformation,demise distress death death light light prognosis prolonged Recover after delivery poor Recover after delivery recover Recover
  43. 45. Management Of Hepatitis <ul><li>Slight type: nutrition & rest </li></ul><ul><li>Severe type: </li></ul><ul><li>Liver protection ( glucagon-insulin-glucose ) </li></ul><ul><li>Prevention & therapy of hepatic coma, DIC & renal failure </li></ul>
  44. 46. Obstetric Management <ul><li>1 st trimester : artificial abortion </li></ul><ul><li>2 nd / 3 rd trimester : avoid operation & drug, fetal surveillance, prevention of EPH-syndrome </li></ul><ul><li>During labor : Vit K, fresh blood; avoid bleeding; oxytocin; antibiotics </li></ul><ul><li>serious case --- Cesarean section 24hrs after </li></ul><ul><li>Puerperium : antibiotics; Stop Breast feeding ( HBVDNA /HBeAg+ in milk) disuse estrogen </li></ul>
  45. 47. Prevention <ul><li>Enhence peripartum health care: surveillance, nutrition, serological screening </li></ul><ul><li>Prophylaxis of HAV:  -globulin 2~3 ml im. within 7 days </li></ul><ul><li>Prophylaxis of HCV: diminish nosocomial transmission. γ - globulin </li></ul>
  46. 48. HBV Immunoprophylaxis <ul><li>Active immunity: HB vac (vaccine) 30 μ g im. (<24hr, 10 μ g 1st, 6 th month) </li></ul><ul><li>Passive immunity: HBIG 0.5ml im.(just born), 0.16ml/kg (1, 3 months) </li></ul><ul><li>Combined immunity: </li></ul><ul><li>active immunity plus HBIG 0.5ml im.(<24hr after birth) </li></ul>
  47. 49. Part III Diabetes Mellitus
  48. 50. Gestational Diabetes Mellitus(GDM) <ul><li>Definition: It is the first time for D.M. to be found just during pregnancy. </li></ul><ul><li>Diagnostic standard : </li></ul><ul><li>① At least two values are abnormal in OGTT (oral glucose tolerance test). (5.6-10.3-8.6-6.7mmol/l) ② Fasting plasma glucose ≥5.8 mmol/L (105mg/dl) twice. </li></ul>
  49. 51. Effects of Pregnancy on Diabetes <ul><li>Placentas ->E3, HPL,…↑->antagonize insulin: </li></ul><ul><li>Latent D.M. ->apparent type </li></ul><ul><li>Situation -> worse ->coma </li></ul><ul><li>More and more insulin is needed to be used. </li></ul>
  50. 52. Effects of Diabetes on Pregnancy (Gravidas) <ul><li>Natural abortion ↑ 15%~30%. </li></ul><ul><li>EPH-syn. 3-5 times ↑ </li></ul><ul><li>Infection ↑ (WBC function ↓) </li></ul><ul><li>Prolonged labor and postpartum hemorrhage </li></ul><ul><li>Hydramnios and macrosomia </li></ul><ul><li>Ketoacidosis </li></ul>
  51. 53. Effects of Diabetes on Pregnancy (Fetuses) <ul><li>Fetal macrosomia: 25%~40%. </li></ul><ul><li>FGR: 21%. </li></ul><ul><li>Premature labour: 10%~25% </li></ul><ul><li>Fetal malformation: 6%~8% </li></ul><ul><li>Perinatal death rate ↑ </li></ul>
  52. 54. Effects of Diabetes on Pregnancy (Neonates) <ul><li>Respiratory distress syndrome (RDS) : mothers Glu. ↑ -> fetuses -> Insulin ↑ -> antagonize the glucocorticoid (promote synthesis of surfactant) -> surfactant ↓ . </li></ul><ul><li>Neonatal hypoglycemia: </li></ul><ul><li>intrauterine Glu. ↑ -> fetuses’ Insulin ↑ -> after birth -> no Glu. -> hypoglycemia </li></ul>
  53. 55. Minor adverse health effects for offspring in GDM Birth Wt (g) 3303 ±64 3649 ±51 3849 ±72 <0.01 Macrosomia(%) 8 36 47 <0.01 C-S 5 10 14 <0.01 Hypoglycemia 2 28 52 <0.01 Hypocalcemia 0 4 7 <0.01 Hyperbilirubinemia 15 23 21 <0.01 Polycythemia 0 7 11 <0.01 Cord C-Pep 1.18±0.1 2.07±0.12 2.98±0.22 <0.01 Cord Glu 100±3.6 103±2.9 114±5.5 <0.01 Normal GDM DM P
  54. 56. Diagnosis <ul><li>History </li></ul><ul><li>Laboratory examination : </li></ul><ul><li>Fasting blood sugar ≥5.8 mmol/L at least twice can be diagnosed as D.M. </li></ul><ul><li>Screening test — Glu.50g ->1hr.plasma glucose ≥7.8 mmol/L (140mg/dl) . </li></ul><ul><li>OGTT -- Glu.75g ->0, 1, 2, 3hrs (5.6, 10.3, 8.6, 6.7 mmol/L ) </li></ul><ul><li>2 values↑->GDM; 1 values↑->GIGT </li></ul>
  55. 57. White grouping class description A Abnormal OGTT treat only by diet therapy B Onset at age 20years or older and duration of less than 10 years C Onset at age 10-19 years or duration of 10-19years D Onset before 10 years of age, duration over 20 years, exudative retinopathy E Calcification of pelvic cavity vasculopathy by X-ray F Nephropathy R proliferative retinopathy RF proliferative retinopathy and Nephropathy G Many pregnancy failure H coronary heart disease T Prior renal transplantation
  56. 58. Management <ul><li>Ⅰ . To Estimate the Patients ’ Ability to Cope With Pregnancy: </li></ul><ul><li>Class D, F, R -> artificial abortion </li></ul><ul><li>Ⅱ . Dietotherapy </li></ul><ul><li>Balance diet: supply = consumption </li></ul><ul><li>With adequate proportion of various components (pro., Glucose, fat, vit, mineral) </li></ul>
  57. 59. Standard of blood glucose controled Time blood glucose fasting blood glucose 3.3~5.6mmol/L two hours after meal 4.4~6.7mmol/L at night Before three meals 4.4~6.7mmol/L 3.3~5.8mmol/L
  58. 60. Management <ul><li>Ⅲ . Medicinal therapy </li></ul><ul><li>Oral heparopen ->pass placenta->fetal damage. </li></ul><ul><li>Insulin is the only drug to be used in gravidas. The dosage should be moderated according to the blood glucose. </li></ul><ul><li>32~33 weeks : dosage reach maximum </li></ul><ul><li>postpartum dosage: 1/2 ~ 1/3 of maximum </li></ul><ul><li>Ⅳ . Materno-fetal Surveillance </li></ul>
  59. 61. Management (Ⅴ. Termination of pregnancy) <ul><li>Timing </li></ul><ul><li>If blood glucose remain normal, pregnancy can be prolonged as long as usual. </li></ul><ul><li>Cesaren section: blood glucose can’t be controlled ideally, serious EPH-syn., severe infection, FGR, fetal distress . Stop insulin 3 hours before operation </li></ul><ul><li>Amnionic fluid should be detected the indexs of fetal maturity by amniocentesis </li></ul>
  60. 62. Management (During labour & puerperium) <ul><li>Blood glucose and electrolytic level must be kept normal. (Glucose 4g + 1 U.) Glucose monitoring: >5.6mmol/L (100mg/dL) </li></ul><ul><li>Labour and fetal monitoring maintain in whole period(  12hrs) . Vaginal delivery </li></ul><ul><ul><li>Control the whole course within 12 hours </li></ul></ul><ul><li>Epidural anesthesia </li></ul><ul><li>After labour, dose of Insulin  1/2(< 24 hrs) </li></ul><ul><li>Puerperium: prevention of postpartum hemorrhage & infection. insulin requirements recover at progestation dose post partum1~2weeks </li></ul>
  61. 63. Low-dosage constant insulin infusion for the intrapartum period blood-glucose (mg/100ml ) Insulin dosage ( U/h ) fluids ( 125ml/h ) <100 0 5%dextrose/lactated Ringer’s solution 100~140 1.0 5%dextrose/lactated Ringer’s solution 141~180 1.5 Normal saline 181~220 2.0 Normal saline >220 2.5 Normal saline dilution is 25U regular insulin in 250ml normal saline, administerd intravenously
  62. 64. Management of Neonates <ul><li>Treat them as preterm infants! </li></ul><ul><li>Prevention of hypoglycemia(<2.22mmol/L), hypocalcemia, jaundice & RDS . </li></ul><ul><li>Feeding them with 25% Glucose solusion. </li></ul><ul><li>(beginning from 30 minutes after birth.) </li></ul>
  63. 65. Prognosis <ul><li>tendency to recur next pregnancy </li></ul><ul><li>the risk of typeⅡ diabetes rise </li></ul><ul><li>develop obesity and type Ⅱ diabetes easily in adult </li></ul>
  64. 66. Key points <ul><li>Clinical manifestation, diagnosis, and management of Pregnancy With Internal Medical Diseases (HD, Viral Hepatitis, GDM) </li></ul><ul><li>Influence between disease & pregnancy(mothers & fetuses) </li></ul><ul><li>3 danger phases in pregnancy with HD </li></ul><ul><li>Types of Heart Disease </li></ul><ul><li>Diagnosis, prophylaxis/treatment of early HF </li></ul><ul><li>Maternal-fetal transmission of hepatitis B virus </li></ul><ul><li>Definition of GDM </li></ul>
  65. 67. [email_address] Mobile: 13711663380
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