Presentation on theme: "Pregnancy-specific diseases"— Presentation transcript:
1Pregnancy-specific diseases 同学们，今天我给大家示教的内容是妇科病史及体格检查。Hai,everybody,today,I will introduce some contents about Gynecological history and Physical examinationChao Gu M.D., Ph.D. Dept of Ob/GynOB/GYN Hospital, Fudan University
2CASE 1 What is your next step? A 35 year old lady at 32 weeks of gestation in her first pregnancy goes to your office for a minor upper respiratory tract infection. Incidentally, her blood pressure is found to be 155/90 mmHg with a pulse rate of 85/min. The cardiovascular examination and chest examinations are otherwise unremarkable. The size of uterus is appropriate for gestational age.What is your next step?Repeat another blood pressure measurement to ascertain the diagnosisof hypertension complicating pregnancy.In general, hypertension in pregnancy can be defined as a blood pressure greater than 140 mmHg systolic and 90 mmHg diastolic on at least 2 occasions 6 hours apart.
3CASE 1 What are the classification of hypertension in pregnancy? Gestational hypertensionPreeclampsiaEclampsiaSuperimposed preeclampsia on chronic hypertensionChronic hypertension in pregnancyIn general, hypertension in pregnancy can be defined as a blood pressure greater than 140 mmHg systolic and 90 mmHg diastolic on at least 2 occasions 6 hours apart.
4CASE 1 What is the definition of various types of hypertension ? Chronic hypertension in pregnancyBP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease orHypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartumGestational hypertensionSystolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancyNo proteinuriaBP returns to normal before 12 weeks postpartumFinal diagnosis made only postpartum.In general, hypertension in pregnancy can be defined as a blood pressure greater than 140 mmHg systolic and 90 mmHg diastolic on at least 2 occasions 6 hours apart.
5CASE 1 What is the definition of various types of hypertension ? PreeclampsiaBP 140/90 mm Hg after 20 weeks' gestationProteinuria 300 mg/24 hours or 1+ dipstickIncreased certainty of preeclampsiaBP 160/110 mm HgProteinuria 2.0 g/24 hours or 2+ dipstickSerum creatinine >1.2 mg/dL unless known to be previously elevatedPlatelets < 100,000/ LMicroangiopathic hemolysis—increased LDHElevated serum transaminase levels—ALT or ASTPersistent headache or other cerebral or visual disturbanceIn general, hypertension in pregnancy can be defined as a blood pressure greater than 140 mmHg systolic and 90 mmHg diastolic on at least 2 occasions 6 hours apart.
6CASE 1 What is the definition of various types of hypertension ? EclampsiaSeizures that cannot be attributed to other causes in a woman with preeclampsiaSuperimposed Preeclampsia On Chronic HypertensionNew-onset proteinuria mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestationA sudden increase in proteinuria or blood pressure or platelet count < 100,000/ L in women with hypertension and proteinuria before 20 weeks' gestationIn general, hypertension in pregnancy can be defined as a blood pressure greater than 140 mmHg systolic and 90 mmHg diastolic on at least 2 occasions 6 hours apart.
7CASE 1 What is the management? Evaluation Severity Gestational age Presence of preeclampsiaOutpatientHospitalizationTermination of pregnancy is the only cure for preeclampsia
8CASE 1 What is the management? High-risk chronic hypertension iassociated maternal and peri-natal complications,superimposed pre-eclampsiaabruptio placentaeCareful monitoring for proteinuria and renal function.Hospitalization should be considered if the blood pressure is not under control.Anti-hypertensive drugs should be considered.Once pre-eclampsia is diagnosed, hospitalization is indicated,progress rapidly to multi-system involvement, including eclampsia
9INDICATION OF MAGNESIUM SULFATE CASE 1INDICATION OF MAGNESIUM SULFATEControl eclampsia convulsionsPrevent preeclampsia develop into eclampsia
10The uses of magnesium sulfate CASE 1The uses of magnesium sulfateDAY 1：loading dose： 25% MgSO4 20ml＋10% GS 20ml IV in 5-10minMaintenance dose: 25% MgSO4 60ml＋5%GS 1000ml IV in 10hDay 2 to 24h Postpartum25% MgSO4 60ml＋5% GS 1000ml IV in 10 h
11CASE 1 Contraindication as follow : absent or very sluggish knee jerk a respiratory rate below 16/mina urinary output of less than 100ml in the preceding 4 hours (25ml/hr)
12CASE 1 Indications of Antihypertensive drugs 130-140/85-100 mmhg。 BP ≥150/100mmhg, <160/110mmhg，Oral。BP ≥ 160/或/110mmhg,IV。Control to/ mmhg。
13CASE 1 What are the antihypertensive drugs commonly use in pregnancy? Labetalol combined alpha- and beta-adrenoceptor blocker.Nifedipine Calcium Channel Blockers NifedipineBeta-blockersMethyldopaSodium nitroprussideHydralazineACEI (血管紧张素转换酶抑制剂) can’t use!!!胎儿生长受限（fetal growth restriction，FGRARDS
14CASE 1 Termination of pregnancy Too early --- Can fetus survive？ Complication ？Too late ---Can mother survive？ Complication？preeclampsia patient has no response following medical management for hours .preeclampsia patient after 34 weeks of gestationpreeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and matured fetus.preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and immatured fetus, use Dexamethasone to promote fetal lung maturity before the termination of pregnancy. Eclampsia control over 2h.
15CASE 2A 26-year-old female at 32 weeks of gestation presented to the clinic with complaints of generalized itching. Patient reported no rash or skin changes. She denied any change in detergent, soaps, or perfumes. She denied nausea and vomiting .There was no history of any drug intake or previous allergies. There was no fever or any other medical illness. On physical examination, there were no rashes apparent on her skin and only some excoriations were there from itching. Laboratory investigations revealed slightly elevated serum transaminases and bilirubin levels, Alkaline phosphatase levels were much higher than normal.
16CASE 2 What is the patient’s likely diagnosis? Intrahepatic Cholestasis of Pregnancy. (ICP)What is the cause of the patient’s generalized itching?Increased serum bile salts and accumulation of bile salts in the dermis of the skin are responsible for generalized itching.Generalized pruritus in pregnancy and a characteristic enzymeprofileHigh alkaline phosphatase is a marker of cholestasisSlightly high transaminases (AST, ALT) differentiate it from viral hepatitisBilirubin is high due to intrahepatic obstruction as a result of cholestasis.. (It is also high late in normalpregnancy due to the influx of placental alkaline phosphatase, But incholestasis the level may be 4 times the normal reference range).
17CASE 2 Intrahepatic cholestasis of pregnancy (ICP) benign disorder that occurs in the second or third trimester and resolves spontaneously after delivery.Cholestasis of pregnancy is a condition in which the normal flow of bile from the gall bladder is impeded, leading to accumulation of bile salts in the body.
18CASE 2 Therapeutic Principle Company Logo Bed rest, left lateral positionDrugAdenosylmethionine 腺苷蛋氨酸Ursodeoxycholic acid 熊去氧胆酸Dexamethasone 地塞米松Phenobarbital 苯巴比妥NST (Nonstress Test)Company Logo
19CASE 2 Termination of pregnancy Company Logo Jaundice (+) 36 weeks of gestationJaundice (-) 37 weeks of gestationSignificantly decreased placental function orFetal distress ImmediatelyCesarean sectionCompany Logo
20Case 330 years old First pregnancy 8 weeks gestation by LMP Persistent vomiting for past week Unable to tolerate food or fluids for past 24 hours Passing little urine Urien ketones 3+
21CASE 3 Hyperemesis Gravidarum What is the patient’s likely diagnosis?Hyperemesis GravidarumNausea (70%) and vomiting (60%) common in 1st trimester, Hyperemesis = fluid and electrolyte imbalance and nutritional deficiencyPersistent and severe vomitingMore severe in:Multiple gestationHydatidiform moleWithout treatment can lead to CNS disturbance, liver and renal failure
22CASE 3 Presentation Severe nausea and vomiting Dehydration Weight loss KetosisPtyalism (unable to swallow saliva)
23CASE 3DiagnosisConsider other causes e.g. UTI, gastritis, ketoacidosis, peptic ulceration, Addison’s disease, pancreatitisInvestigations:FBC (raised haematocrit)U&E (hyponatraemia, hypokalemia, hypouraemia)LBP (raised transaminases, found in up to 50% cases)TFTs (thyrotoxicosis)Urinalysis and MSU for culture and sensitivityUSS (if not done yet)Weight
24Serious Complications CASE 3Serious ComplicationsWernicke syndrome （Wernicke 脑病）：Vit B1 deficiencyA type of brain damage in which the initial symptoms appear.Abnormal gait and eye movements.Psychiatric disorder, includes dementia and psychosis.coagulation disorder （凝血功能障碍）：Vit K deficiencyCompany Logo
25INDICATIONS FOR TERMINATION OF PREGNANCY CASE 3INDICATIONS FOR TERMINATION OF PREGNANCYContinuing jaundiceContinuing proteinuriaFever continuing over 38 ° CTachycardia (≥ 120 beats / min)Wernicke syndrome appears
26CASE 4 19 year old G1 P0+0 39 weeks - antenatal care outside your area Contractions 3-4 in 10 minutesExcessive weight gain during pregnancyRecent generalized oedemaA 19 year old G1P0 presents to delivery suite at 39 weeks gestation by LMP with contractions every three minutes. She is booked for delivery elsewhere and is visiting relatives in your area. She is blood group A Rhesus positive and rubella immune. In taking her history, she tells you that her pregnancy has been uncomplicated except for an urinary tract infection in the first trimester. She has gained 21kg with this pregnancy and has complained of generalized oedema to her GP. She has no allergies, and her only medication was prenatal folate until 12 weeks. She has no other medical problems. Her other lab test results are unremarkable.
27CASE 4 On Examination Facial & generalised oedema +++ Admission BP = 164/102 (repeat 160/100)Urine = +++ proteinVE : Cervix = 4 cm dilated, 100% effaced,station ‘0’, membranes intact- contractions 3-4 in 10 mins,- baseline FHR = 140bpm- normal variability,- no decelerationsA 19 year old G1P0 presents to delivery suite at 39 weeks gestation by LMP with contractions every three minutes. She is booked for delivery elsewhere and is visiting relatives in your area. She is blood group A Rhesus positive and rubella immune. In taking her history, she tells you that her pregnancy has been uncomplicated except for an urinary tract infection in the first trimester. She has gained 21kg with this pregnancy and has complained of generalized oedema to her GP. She has no allergies, and her only medication was prenatal folate until 12 weeks. She has no other medical problems. Her other lab test results are unremarkable.
28CASE 4 What concerns you about with this situation? likely to have severe pre-eclampsia both fetal & maternal risks such asrisk of ECLAMPSIAintracranial haemorrhagerisk of pulmonary oedema (iatrogenic fluid overload)hepatorenal failureLikely to have pre-eclampsia with all its’ attendant risk to mother and fetus. In particular will need to be aware of maternal risks of hypertension (and resulting end organ damage – such as intracranial haemorrhage and hepatorenal failure), ECLAMPSIA and iatrogenic fluid overload during and after labour.
29CASE 2 Full Blood Count What lab investigations would you order? (Coagulation)Group & Save for X-matchUrea, Creatinine & ElectrolytesLiver Function TestsUrateMSU (inc Gram Stain)Consider full blood count (inc platelet count), biochemistry profile (urea & electrolytes, uric acid, LFTs), baseline clotting screen (??is this necessary at present if platelets >100??). Consider Group & Save.
30CASE 4 What other data do you need at this point? her handheld antenatal recordsAntenatal records, any ultrasounds
31CASE 4 Would you give antihypertensive and/or magnesium sulphate at this point?Antihypertensives –persistent systolic BP >160mmHg should be treatedMagnesium Sulphate – most units would start MgSO4 at this stage (ref MAGPIE study)Antihypertensive – probably not at this stage. MAP is below 125 (actually 120) and no symptomsMagnesium sulphate – since the MAGPIE study many units would put this patient onto magnesium. The study itself suggested benefit even in cases with BP 140/90 and only protein 1+. In the UK we have tended to treat moderately severe (such as this case) or severe pre-eclampsia.… IN THIS CASE NEITHER IS GIVEN……. IN THIS CASE, NEITHER IS GIVEN…..
32CASE 430 MINUTES LATER…While awaiting laboratory results, you are called urgently to delivery suiteThe patient has a grand mal seizure that lasts about 1 minuteCTG shows a fetal bradycardia of 80 bpmafter the seizure
33WHAT WOULD YOU DO AT THIS POINT? CASE 4WHAT WOULD YOU DO AT THIS POINT?CALL FOR HELP +++++INITIATE BASIC ABCsremember left lateral tilt!!‘A’ – airway can’t be inserted during a fit‘C’ – includes x2 large bore cannulaeInitiate unit ‘Eclampsia protocol’DO NOT NURSE IN THE DARK!!Give loading dose MgSO4 (…what dose?)Foley catheter/fluid balanceKeep NBM – review need to treat BPCALL FOR HELP +++++EMPHASISE IMPORTANCE OF BASIC ABCs (IN THAT ORDER!!)Turn patient on her sideCheck AIRWAY (you cannot insert an airway during the fit!!)Give oxygen and Protect airway (have suction available)SPONTANEOUS BREATHING should re-establish after the fit endsInitiate ‘eclampsia protocol’:DO NOT NURSE IN THE DARK!!!Establish appropriate IV access (ideally two large bore cannulae)Load with MgSO4, 4-6 gms intravenously over 20 min. and begin infusion at 1-2 gm/hrPlace Foley catheter, monitor input and output (4 hourly assessment of output is adequatePatient to have nothing by mouthIV N Saline or Hartman’s at 80 –85 ml/hr or 1mg/kg/hrGroup & save (if not already done)Does hypertension itself need treating? (In this case - not at present = 150/100)
34CASE 4How would you deliver when stable - LSCS versus induction with vaginal delivery?Labour induction can usually be considered if:gestation >32 weekscervix reasonably favourable (i.e. delivery likely within 12 hours) – cervix is often favourable in pre-eclampsiafetal condition stable (i.e. no severe IUGR)The treatment after an eclamptic seizure includes delivery. If the eclamptic patient is not in labour, induction can begin after magnesium sulphate has been loaded and the patient stabilized. Proceed with induction if at least 32 weeks estimated gestational age and if the cervix is reasonably favourable (i.e. reasonable chance of delivery within 12 hours). Many patients with pre-eclampsia/eclampsia are rather easily induced and labour rapidly
35CASE 4 After the seizure... Meticulous attention to fluid balance - intake / output assessed hourly4g loading dose MgSO4 then infusion at 1-2 g/hrTotal IV fluids limited to 80-85ml/hr or 1 ml/kg/hrFoley catheterYour patient is admitted to the HDU, given a 4 gm IV loading dose of MgSO4, and started on a MgSO4 infusion at 1-2 gm/hr. A Foley catheter is inserted, and her urine output is carefully monitored. IV fluid at 85ml/hr is commenced (N Saline or Hartman’s). Amniotomy is done and a fetal scalp electrode applied. The amniotic fluid shows scant, thin meconium.
36CASE 4Fetal bradycardia recovers with control of seizures, oxygen and left lateral positioningContracting 4-5 in 10; lasting secondsARM - meconium-stainingFHR = 160bpm with decreased variabilityConsultant Anaesthetist / Obstetrician and theatre aware of situationBP = 180/110The fetal bradycardia recovers with control of her seizure, oxygen, and position change. Her baseline rate is now 160bpm and there is decreased variability. The obstetric theatre team is alerted and is on standby. Consultant is informed and is on the way in to review. Her blood pressure now is 180/110 (MAP = 133). She is having contractions every two to three minutes lasting seconds.
37CASE 4 What would you do next? Control Blood Pressure Analgesia as appropriateControl of blood pressure neededAppropriate analgesia is required (consider epidural )
38CASE 4Are you worried about her blood pressure?YES – in this case, BP>180/110 puts maternal CNS at risk (intracranial haemorrhage)Yes. Blood pressures that equal or exceed 160/110 (MAP persistently above 125) should be treated with antihypertensive agents to avoid maternal central nervous system damage. The goal is to lower the blood pressure to a diastolic of about 90 to 100mmHg.
39CASE 4 How would you control the blood pressure? can you name 2 drugs you could consider using?SL NifedepineIV hydralazine (bolus +/- infusion)IV Labetalol in an initial dose of 20 mg intravenously is one option.IV Hydralazine 5 to 10 mg intravenously every 20 minutes is the alternative choice. It's duration of action is several hours. Adequate blood pressure control is often achieved with one or two doses.Oral Nifedipine can be used to treat pregnancy induced hypertension but works unpredictably and can cause dramatic falls in blood pressure (esp. if taken sublingually). It is thus less useful in this acute situationAn epidural will also help to lower blood pressure (provided platelets are OK) .Anaesthestist may also consider insertion of a long-line for CVP monitoring.
40CASE 2 What are the signs of magnesium toxicity? IN ORDER loss of reflexessomnolencerespiratory depressionparalysisfinally cardiac arrest
41Calcium gluconate 1g IV over 3 minutes CASE 4What is the antidote for magnesium toxicity?Calcium gluconate 1g IV over 3 minutes(10mls 10% calcium gluconate)
42Stop MgSO4 until reflexes return CASE4What action should be taken for absent reflexes?Stop MgSO4 until reflexes return
43CASE 4 What action should be taken for respiratory depression / somnolence?Stop MgSO4Give O2Recovery position (as reduced level of consciousness)Monitor closely
44THE BLOOD RESULTS RETURN… CASE 4THE BLOOD RESULTS RETURN…Observations BP 140/95Pulse - 90bpmResp rate - 12/minTemp °CUrine output 30ml over past hourBlood results Hb 12.0g/dlWBC 21x109Platelets 185x109Coagulation normal / LFTs NormalMagnesium level is therapeuticAfter receiving medication, her blood pressure is now 140/95, pulse 90bpm, respirations 12/min, and temperature 37.8 degrees C. Her urine output over the past hour has been 30ml. You receive her blood results and find the following: haemoglobin = 120 gm/l, haematocrit = 36%, WBC = 21x109 and liver enzymes are normal. Her platelet count is 185 x109. Her magnesium level is 7 mg/dl (normal = 4 to 8mg/dl). Her clotting and fibrinogen levels are also normal.
45CASE 4 The patient has another grand mal seizure Case Presentation BPThe patient has another grand mal seizureWhat would you do next?general supportive measures (ABCs)second bolus MgSO4 (2g) should be given even if levels are therapeutic, as long as no signs of toxicityconsider another neuroleptic if seizures continue despite second bolusGeneral supportive measures (ABCs)Women already on magnesium sulphate prophylaxis who have seizures may still receive an additional bolus of two grams if they show no signs of magnesium toxicity.A second neuroleptic agent should generally be used in the woman who continues to seize in spite of therapeutic magnesium levels and a second bolus. In this uncommon situation, diazepam, a short acting barbiturate or phenytoin may need to be used.Involve senior anaesthetic help as GA, paralysis and ventilation would be required for prophylaxis or status epilepticus.
46CASE 2 Would you deliver – if so how? once stable, delivery by urgent LSCS may be appropriateafter this 2nd fit (assuming vaginal delivery is not imminent)
47CASE 4 Is she septic ? Should antibiotics be started ? (T = 37.8°C WCC = 21 x 109)NO - WCC and pyrexia are more likely related to the grand mal fitShould antibiotics be started ?NO - unless there are other overt signs of infectionHer elevated white blood cell count and mild pyrexia are likely related to the seizures (if there are no overt signs of infection).Antibiotics are probably not required
48CASE 4 Does she have HELLP syndrome? NO – HELLP typically presents with:HaemolysisElevated Liver enzymes (ALT/AST)Low PlateletsNo. H – haemolysis EL – elevated liver enzymes LP – low platelets.One would look for haemolytic anaemia, elevated ALT and AST with low platelets to diagnose HELLP syndrome.Commoner in multips and may respond to high-dose steroids
49CASE 4 The delivery… and then? Case Presentation BP VE confirms cervix 7cm dilatedOxytocin augmentationNormal delivery within 1 hourHealthy 3.8kg baby boyApgars = 6 (1 min) + 9 (5 min)Placenta delivered & appears intactNo uterine atony or perineal traumaRepeat vaginal examination shows her to be 7cm dilated. With oxytocin augmentation, she progresses rapidly to a normal vaginal delivery of a 3.8kg baby boy with Apgars of six (1) and nine (5). The placenta delivers spontaneously and appears intact. She has no uterine atony, no perineal trauma, and no postpartum haemorrhage
50CASE 4 Post-delivery When would you discontinue MgSO4? continue for minimum 24 hours post-delivery(possibly 48 hours if recovery is protracted)More than 40% of all eclampsia occurs post-deliveryContinue the MgSO4 for another 24 hours and then review. May be required 48 hours. More than 40% of all eclampsia occurs post-delivery.