Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pregnancy-specific diseases

Similar presentations


Presentation on theme: "Pregnancy-specific diseases"— Presentation transcript:

1 Pregnancy-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 examination Chao Gu M.D., Ph.D. Dept of Ob/Gyn OB/GYN Hospital, Fudan University

2 CASE 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 diagnosis of 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.

3 CASE 1 What are the classification of hypertension in pregnancy?
Gestational hypertension Preeclampsia Eclampsia Superimposed preeclampsia on chronic hypertension Chronic hypertension in 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.

4 CASE 1 What is the definition of various types of hypertension ?
Chronic hypertension in pregnancy BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease or Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum Gestational hypertension Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy No proteinuria BP returns to normal before 12 weeks postpartum Final 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.

5 CASE 1 What is the definition of various types of hypertension ?
Preeclampsia BP 140/90 mm Hg after 20 weeks' gestation Proteinuria 300 mg/24 hours or 1+ dipstick Increased certainty of preeclampsia BP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Serum creatinine >1.2 mg/dL unless known to be previously elevated Platelets < 100,000/ L Microangiopathic hemolysis—increased LDH Elevated serum transaminase levels—ALT or AST Persistent headache or other cerebral or visual disturbance 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.

6 CASE 1 What is the definition of various types of hypertension ?
Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia Superimposed Preeclampsia On Chronic Hypertension New-onset proteinuria mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ L in women with hypertension and proteinuria before 20 weeks' gestation 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.

7 CASE 1 What is the management? Evaluation Severity Gestational age
Presence of preeclampsia Outpatient Hospitalization Termination of pregnancy is the only cure for preeclampsia

8 CASE 1 What is the management?
High-risk chronic hypertension iassociated maternal and peri-natal complications, superimposed pre-eclampsia abruptio placentae Careful 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

9 INDICATION OF MAGNESIUM SULFATE
CASE 1 INDICATION OF MAGNESIUM SULFATE Control eclampsia convulsions Prevent preeclampsia develop into eclampsia

10 The uses of magnesium sulfate
CASE 1 The uses of magnesium sulfate DAY 1: loading dose: 25% MgSO4 20ml+10% GS 20ml IV in 5-10min Maintenance dose: 25% MgSO4 60ml+5%GS 1000ml IV in 10h Day 2 to 24h Postpartum 25% MgSO4 60ml+5% GS 1000ml IV in 10 h

11 CASE 1 Contraindication as follow : absent or very sluggish knee jerk
a respiratory rate below 16/min a urinary output of less than 100ml in the preceding 4 hours (25ml/hr)

12 CASE 1 Indications of Antihypertensive drugs 130-140/85-100 mmhg。
BP ≥150/100mmhg, <160/110mmhg,Oral。 BP ≥ 160/或/110mmhg,IV。 Control to / mmhg。

13 CASE 1 What are the antihypertensive drugs commonly use in pregnancy?
Labetalol combined alpha- and beta-adrenoceptor blocker. Nifedipine Calcium Channel Blockers Nifedipine Beta-blockers Methyldopa Sodium nitroprusside Hydralazine ACEI (血管紧张素转换酶抑制剂) can’t use!!! 胎儿生长受限(fetal growth restriction,FGR ARDS

14 CASE 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 gestation preeclampsia 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.

15 CASE 2 A 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.

16 CASE 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 enzymeprofile High alkaline phosphatase is a marker of cholestasis Slightly high transaminases (AST, ALT) differentiate it from viral hepatitis Bilirubin 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).

17 CASE 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.

18 CASE 2 Therapeutic Principle Company Logo
Bed rest, left lateral position Drug Adenosylmethionine 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

19 CASE 2 Termination of pregnancy Company Logo
Jaundice (+) 36 weeks of gestation Jaundice (-) 37 weeks of gestation Significantly decreased placental function or Fetal distress Immediately Cesarean section Company Logo

20 Case 3 30 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+

21 CASE 3 Hyperemesis Gravidarum
What is the patient’s likely diagnosis? Hyperemesis Gravidarum Nausea (70%) and vomiting (60%) common in 1st trimester, Hyperemesis = fluid and electrolyte imbalance and nutritional deficiency Persistent and severe vomiting More severe in: Multiple gestation Hydatidiform mole Without treatment can lead to CNS disturbance, liver and renal failure

22 CASE 3 Presentation Severe nausea and vomiting Dehydration Weight loss
Ketosis Ptyalism (unable to swallow saliva)

23 CASE 3 Diagnosis Consider other causes e.g. UTI, gastritis, ketoacidosis, peptic ulceration, Addison’s disease, pancreatitis Investigations: 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 sensitivity USS (if not done yet) Weight

24 Serious Complications
CASE 3 Serious Complications Wernicke syndrome (Wernicke 脑病):Vit B1 deficiency A 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 deficiency Company Logo

25 INDICATIONS FOR TERMINATION OF PREGNANCY
CASE 3 INDICATIONS FOR TERMINATION OF PREGNANCY Continuing jaundice Continuing proteinuria Fever continuing over 38 ° C Tachycardia (≥ 120 beats / min) Wernicke syndrome appears

26 CASE 4 19 year old G1 P0+0 39 weeks - antenatal care outside your area
Contractions 3-4 in 10 minutes Excessive weight gain during pregnancy Recent generalized oedema A 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.  

27 CASE 4 On Examination Facial & generalised oedema +++
Admission BP = 164/102 (repeat 160/100) Urine = +++ protein VE : Cervix = 4 cm dilated, 100% effaced, station ‘0’, membranes intact - contractions 3-4 in 10 mins, - baseline FHR = 140bpm - normal variability, - no decelerations A 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.  

28 CASE 4 What concerns you about with this situation?
likely to have severe pre-eclampsia  both fetal & maternal risks such as risk of ECLAMPSIA intracranial haemorrhage risk of pulmonary oedema (iatrogenic fluid overload) hepatorenal failure Likely 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.

29 CASE 2 Full Blood Count What lab investigations would you order?
(Coagulation) Group & Save for X-match Urea, Creatinine & Electrolytes Liver Function Tests Urate MSU (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.

30 CASE 4 What other data do you need at this point?
her handheld antenatal records Antenatal records, any ultrasounds

31 CASE 4 Would you give antihypertensive and/or magnesium
sulphate at this point? Antihypertensives –persistent systolic BP >160mmHg should be treated Magnesium 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 symptoms Magnesium 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…..

32 CASE 4 30 MINUTES LATER… While awaiting laboratory results, you are called urgently to delivery suite The patient has a grand mal seizure that lasts about 1 minute CTG shows a fetal bradycardia of 80 bpm after the seizure

33 WHAT WOULD YOU DO AT THIS POINT?
CASE 4 WHAT WOULD YOU DO AT THIS POINT? CALL FOR HELP +++++ INITIATE BASIC ABCs remember left lateral tilt!! ‘A’ – airway can’t be inserted during a fit ‘C’ – includes x2 large bore cannulae Initiate unit ‘Eclampsia protocol’ DO NOT NURSE IN THE DARK!! Give loading dose MgSO4 (…what dose?) Foley catheter/fluid balance Keep NBM – review need to treat BP CALL FOR HELP +++++ EMPHASISE IMPORTANCE OF BASIC ABCs (IN THAT ORDER!!) Turn patient on her side Check 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 ends Initiate ‘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/hr Place Foley catheter, monitor input and output (4 hourly assessment of output is adequate Patient to have nothing by mouth IV N Saline or Hartman’s at 80 –85 ml/hr or 1mg/kg/hr Group & save (if not already done) Does hypertension itself need treating? (In this case - not at present = 150/100)

34 CASE 4 How would you deliver when stable - LSCS versus induction with vaginal delivery? Labour induction can usually be considered if: gestation >32 weeks cervix reasonably favourable (i.e. delivery likely within 12 hours) – cervix is often favourable in pre-eclampsia fetal 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

35 CASE 4 After the seizure... Meticulous attention to fluid balance -
intake / output assessed hourly 4g loading dose MgSO4 then infusion at 1-2 g/hr Total IV fluids limited to 80-85ml/hr or 1 ml/kg/hr Foley catheter Your 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.

36 CASE 4 Fetal bradycardia recovers with control of seizures, oxygen and left lateral positioning Contracting 4-5 in 10; lasting seconds ARM - meconium-staining FHR = 160bpm with decreased variability Consultant Anaesthetist / Obstetrician and theatre aware of situation BP = 180/110 The 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.

37 CASE 4 What would you do next? Control Blood Pressure
Analgesia as appropriate Control of blood pressure needed Appropriate analgesia is required (consider epidural )

38 CASE 4 Are 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.

39 CASE 4 How would you control the blood pressure?
can you name 2 drugs you could consider using? SL Nifedepine IV 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 situation An epidural will also help to lower blood pressure (provided platelets are OK) . Anaesthestist may also consider insertion of a long-line for CVP monitoring.

40 CASE 2 What are the signs of magnesium toxicity? IN ORDER
loss of reflexes somnolence respiratory depression paralysis finally cardiac arrest

41 Calcium gluconate 1g IV over 3 minutes
CASE 4 What is the antidote for magnesium toxicity? Calcium gluconate 1g IV over 3 minutes (10mls 10% calcium gluconate)

42 Stop MgSO4 until reflexes return
CASE4 What action should be taken for absent reflexes? Stop MgSO4 until reflexes return

43 CASE 4 What action should be taken for
respiratory depression / somnolence? Stop MgSO4 Give O2 Recovery position (as reduced level of consciousness) Monitor closely

44 THE BLOOD RESULTS RETURN…
CASE 4 THE BLOOD RESULTS RETURN… Observations BP 140/95 Pulse - 90bpm Resp rate - 12/min Temp °C Urine output 30ml over past hour Blood results Hb 12.0g/dl WBC 21x109 Platelets 185x109 Coagulation normal / LFTs Normal Magnesium level is therapeutic After 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.

45 CASE 4 The patient has another grand mal seizure
Case Presentation BP The patient has another grand mal seizure What 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 toxicity consider another neuroleptic if seizures continue despite second bolus General 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.

46 CASE 2 Would you deliver – if so how?
once stable, delivery by urgent LSCS may be appropriate after this 2nd fit (assuming vaginal delivery is not imminent)

47 CASE 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 fit Should antibiotics be started ? NO - unless there are other overt signs of infection Her 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

48 CASE 4 Does she have HELLP syndrome?
NO – HELLP typically presents with: Haemolysis Elevated Liver enzymes (ALT/AST) Low Platelets No. 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

49 CASE 4 The delivery… and then? Case Presentation BP
VE confirms cervix 7cm dilated Oxytocin augmentation Normal delivery within 1 hour Healthy 3.8kg baby boy Apgars = 6 (1 min) + 9 (5 min) Placenta delivered & appears intact No uterine atony or perineal trauma Repeat 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

50 CASE 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-delivery Continue the MgSO4 for another 24 hours and then review. May be required 48 hours. More than 40% of all eclampsia occurs post-delivery. 


Download ppt "Pregnancy-specific diseases"

Similar presentations


Ads by Google