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Medical Complication in Pregnancy

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????????????????????????????????????????????????????????? ????????? ... Fatique, Dyspnea, Headache, PICA. Symptoms : Pallor, Glossitis, Chelitis, Koilonychia ... – PowerPoint PPT presentation

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Title: Medical Complication in Pregnancy


1
Medical Complication in Pregnancy
  • Associate Professor Doctor Atiwut Kamudhamas
  • Department of Obstetrics and Gynecology
  • Faculty of Medicine Thammasat University

2
Contents
  • Gestational diabetes mellitus
  • Iron deficiency anemia
  • Thalassemia
  • Cardiovascular disease

3
Gestational Diabetes mellitus
4
Outline
  • Definition
  • Epidemiology
  • Pathogenesis
  • Classification
  • Screening test
  • Risk Assessment for Detecting GDM
  • Management in GDM

5
Diabetes Mellitus
  • ??????????????????????????????????????????????????
    ??????? ??????????????????????????????????????????
    ?? ??????????????????????????? post prandial
    ???? fasting ??????????????? ????? ketosis ???
    ????????????????????????
  • ????????????????????????????????? 2 ??????
  • - gestational diabetes (GDM) ????????????????????
    ??????????????
  • - pregestational diabetes ?????????????????????
    ??????????????

6
Epidemiology
  • ??????????????????????????????????????????????????
    ?????????
  • ??????????? 2-3 ????????????????????????????
  • ??????????????????????????????????????
  • ?????????????????? 2 ???????????????

7
Pathogenesis
  • ??????????????????????
  • - Estrogen ??? Progesterone ?????
    ???????????????????? beta cell ??????????
    ??????????????? insulin ????????? ????? FBS
    ????????????????????????????
  • ???????????????????????
  • - ???????????????????????????? insulin
    ???????????? ?????????????? ??? HPL ?????????
    prolactin, cortisol, glucagon ???????????????????
    ???????????????? insulin ????????? (diabetogenic
    effect) ?????????????????? insulin ????????????
    ??????????????????

8
Classification of GDM
9
GDM
  • Class A1 (chemical DM) ??????????????
  • Class A2 (overt DM) ?? fasting hyperglycemia

10
Diagnostic test
  • One-step approach OGTT
  • Two-step approach
  • - 50g GCT 140 mg/dl (80)
  • - 100g OGTT 130 mg/dl (90)
  • Selective screening ????????????? high risk
    ????????
  • Universal screening ????????????????????????????
    ????

11
Risk Assessment for Detecting GDM
  • High risk ???????????????? ??????? 1 ?????????
  • - ??????????? 35 ??
  • - ???? ( ?????????????? ideal weight ?????? 20 )
  • - ????????????????????
  • - ??????????????????????????????
  • - ?????????????????????????????? ????
    ????????????????????????? 4000g
  • - ?????????????????
  • ???????????????????????????? ???????????????????
    ??????????????? GA 24-28 wks. ????????????????????
    GDM

12
Risk Assessment for Detecting GDM
  • Moderate risk
  • - ????????????????????????????????
  • ????????????? GA 24-28 wks.
  • Low risk (????????????????)
  • - ???????????? 25 ??
  • - ???????????????????????????????????????????????
    ?
  • - ?????????????????????????
  • - ???????????????????????????????????????????????
    ???????????????
  • (BMI ???????? 26 kg/m2)
  • - ????????????????????????????????
  • - ???????????????????????????????????
  • ????????????????????????

13
Diagnosis
  • Hx
  • - ???????????????????????????
  • - ?????????????????????????????????? ????
    ??????????????? gt 4,000 g, ??????????????????
    ??????????????????????????????
  • PE
  • - ???????????
  • - ????????????????? ?????????????????
  • - ???????????????????????????? ? ??????????
    ???????????????????????????
  • Ix
  • - ?????????????????????
  • - ????????????????????????????? ??????? OGTT

14
Oral glucose tolerance test
  • 100-gram OGTT (3hr)
  • ??????????????????????????????????????????????????
    ???? 2 ????????? ? GDM
  • ?????????? 1 ??? ?????????????????? 1 ????? ? pt.
    1/3 ?? GDM ????????????
  • 75-gram OGTT
  • ???????????????????????????? ?????????????????????
    ?????????????????

15
Diagnostic criteria
16
??????????????????????????????
  • ????????????????????????????
  • ???????? diabetic ketoacidosis ???????
  • ???????????????????????????????? ????
    retinopathy, nephropathy

17
??????????????????????????????
  • ???????
  • Hypoglycemia
  • Hyperglycemia
  • ???????????????
  • ????????????????????????????????????????
  • ???????????
  • ??????????????????????????????????
  • ??????????????????
  • ????????????????????????????????????

18
???????????????????????????????????????????
  • Neonatal hypoglycemia
  • ????????????????????
  • ?????????????????????
  • ???????????? RDS ???????
  • ????????? (macrosomia)
  • ??????????????????
  • Neonatal hypocalcemia
  • Hypomagnesemia
  • Polycythemia
  • Hyperbilirubinemia
  • Renal vein thrombosis
  • Cardiomyopathy

19
Management in GDM
  • ????????????????????????????????????
  • ???????????????????????????
  • ???????????????????
  • ????????????????????????????????

20
??????????????????????????????????
  • ??????????????
  • ??????????????????????????
  • ?????????????????????

21
?????????????????????????????????
  • ???????????
  • ??????????????????????????????????????????????????
    ???????????????
  • ??????????????????????????????????????????
  • ???????????????????????????????????????????
    ketonuria ???? ????????????????

22
?????????????????????????????????
  • ???????????????????????? 30 kcal/kg/day
  • ????????????? ideal body weight
  • ???????????????????????????????????? 1,800-2,000
    kcal
  • CBHProteinLipid 552025
  • ???????????????? 4 ???? ????????? 25303015
  • ????????????????? ???????? ?????
  • ???????????????????????????????????????????????

23
????????????????????????????????????
  • Cardiovascular-conditioning (aerobic exercise)
  • ??????????????????????????????????????????????????
    ??????????
  • ???????????????????????

24
????????????????????????????????????
  • ???????????? ??????????????????? ?????????
  • ????????????????????
  • ???????????????
  • ????????????????????????????? (hypoglycemia)
    ???????
  • ???????????????????? FBS gt 105 mg/dl
    ??????????????????????????????????

25
????????????????????????????????????
  • ???????????????????? Overt DM
  • ????????????????????? ????????????????????????????
    ??????
  • ??? intermediate short-acting insulin
    (mix-split dose) ?????????? 2/3 ?????????? 1/3
    ????????
  • ????????????????????????? ????????????????????????
    ????????? ????????? 1 ?????

26
????????????????????????????????????
  • ???????????????????????? ?????????????????????????
    ????????????? ?????????????????????????????
  • ??????????????????????????????????????????????????
    ??

27
?????????????????????????????????????
28
????????????
??????????????????????????????
  • Diabetic ketoacidosis (DKA)
  • BS 200-250 mg/dl
  • Dehydration
  • Hyponatremia

29
Diabetic ketoacidosis
  • Treatment
  • IV fluid 2 lines 1,000 cc/hr ? BS
  • lt 250 mg/dl ? 5 DW
  • Insulin IV Bolus RI 10-20 u then RI drip 5-10
    u/hr
  • Potassium
  • Within 2-4 hr
  • Should not gt 30-40 mEq/hr
  • Bicarbonate ? in severe acidosis (pH lt 7.0) ?
    off when pH gt 7.2

30
??????????????????????????????
  • ??????????????????? GDM ??????????????????????????
    ? ??????????????????????? ???????????????????
  • ????????????? PIH

31
Management in overt DMin first trimester
  • ????????????????????????????????????
  • ???????????????????????????????????????????????
    ???????? ???????? ???????????????????????
  • ?????????????????????????????????????????????????
    ????????????????????????????
  • ??????????????????????????????
  • ???????????????????????????????? ultrasonography

32
Management in overt DMin second trimester
  • ???? MSAFP ?????????????? 16-20 ???????
    ?????????????????????????????
  • ??????????????????????????? ?????????????? 18-20
    ??????? ?????????????????????????? neural tube
    defect
  • ???? fetal echocardiogram ?????????????? 20-22
    ??????? ??????????????????????????????

33
Management in overt DMin third trimester
  • ????????????????? ????????????????????????????????
    ???????????????
  • ?????????????????????????????????????????? ?
  • ????????????????????????????????????????????????
  • ????????????????????????????????
    ????????????????? vasculopathy ???????????????????
    ?

34
??????????????????????????????
  • ???????? Fetal movement count ????????????????
    28-30 ???????
  • GDM ???? non stress test (NST) 1 ?????/wk
  • Overt DM ???? NST 2 ?????/wk ????? nonreactive
    test ?????????????????? biphysical profile (BPP)
  • ?????????????? doppler ultrasound
    ???????????????????????????? vasculopathy

35
??????????????????????????????
  • ???????????????????????????
  • ????????????? DM ?? delayed lung maturity
  • ??????????????????????? GA 38 wks. ??????????? GA
    ??????
  • ?????????????
  • L/S ratio (Lecithin/sphingomyelin) gt2
  • Foam stability test or Shake test
  • PG level (phosphatidylglycerol level) gt3

36
???????
  • ??????????????????????????????????????????????????
    ?????????? ??????????????????????? 38 ???????
    (??????????????????????????)
  • ?????????????????????????????? ??????????????????
    ß-sympathomimetic
    (tocolytic) ?????????????????ketoacidosis
    ???????????????????? ??????? MgSO4 ???
  • ?????? corticosteroid ????????????????????????????
    ?????????????????
  • ?????????????????????????????? ???? severe
    preeclampsia ??????????????????????????????????

37
???????????
  • ????????????????????? ???????????????????????????
    ?
  • ?????????????????? gt 4500 g ??????????????????????
    ????
  • ??????????????????????????????????????????????????
    ???????????????????????????????????????????

38
?????????????????????
  • Regular insulin ????????????????????? 0.5-2 U/hr
    ??????? glucose ????????????????????? 5-10 g/hr
  • RI 8-10 U ?????? 5 D/NSS 100-120 ml/hr
  • DTX ??? ? 1-4 ??. ?????????? 70-120 mg/dl
  • ??????????????????????????????????? ??????? 5
    D/NSS
  • ???????????????????????????????????. ?????????
    ??????????? sc.
  • ??????????????????????????????????????????????????
    ??????????????????????????????????????
  • ?????????????????????????????????????????????

39
???????????????????
  • ??????????????????????????????????????????????????
    ? ?????????????????????
  • ?????????? RDS
  • ?????????????????????? ????? 1 ??.????????
    ???????????? 4 ??????? ???????? 24 ??. ??? lt 40
    mg/dl ??????????
  • ?????????????????????
  • ???????????????? ??????? ?????????????????
    glucose tolerance

40
????????????
  • ???????????????????????????????????????????????
    ????????????????????? ????????????????????????????
    ?
  • ??????????????????????????????????
    ??????????????????????????????? (???????????????)
  • ????????????????????????????? ???????????????????
    ????????????????

41
????????????
  • ??????????????????? estrogen ?????????
  • ?????????????????????????????????????????
  • Progestin-only pill,Norplant ??????? carbohydrate
    metabolism ????
  • ?????????????? IUD ?????????????????
  • ??????????????????? ?????????????????? Barrier
    methods
  • ??????????????? ????????????????????????????

42
?????????????
  • ?????????????????????????????????????? DM (type
    2) ???????
  • GDM ??????????????????????????????????? 22-28 ??
    ????????? 50 ??????? 75 g OGTT 6-8 wk.
    ????????
  • ??????????????????????????

43
Iron deficiency anemia
44
Iron metabolism
45
Iron contents in the body
  • Ferritin ? Storage form
  • Transferrin ? Transporting form
  • Hemoglobin, Myoglobin, Fe-containing enzymes

46
Iron-deficiency Anemia
  • Most common cause of anemia during pregnancy ?
    75
  • Signs
  • Fatique, Dyspnea, Headache, PICA
  • Symptoms
  • Pallor, Glossitis, Chelitis, Koilonychia

47
Symptoms
Chelitis
koilonychia
Glossitis
48
Iron-deficiency Anemia
  • 3 stages of Iron-deficiency
  • Depletion of iron stores
  • no anemia
  • serum ferritin ?
  • Erythropoiesis defect
  • RBC morphology ? not change
  • Plasma iron, transferrin ?
  • TIBC ?
  • Anemia stage
  • Hypochromic microcytic anemia

49
Laboratory investigation
  • CBC ? hypochromic microcytic
  • Iron study
  • Free erythrocyte protoporphyria ?
  • Bone marrow smear ? ? iron

50
Iron study in iron deficiency anemia
  • Serum ferritin levels lt 15 ng/ml (100 ? 60
    ng/ml)
  • Transferrin levels lt 15 (35-50)
  • TIBC levels gt 400 ?g/dl (330 ? 30
    ?g/dl)
  • Plasma iron levels lt 30 ng/ml (115 ? 50
    ng/ml)

51
Treatment
  • Oral administration
  • Parenteral administration

52
Iron requirements for pregnancy
  • Required 1,000 mg for gestational with single
    fetus
  • 500 mg for maternal Hb mass expansion
  • 300 mg for fetus and placenta
  • 200 mg shed through the gut, urine, and skin
  • Iron daily requirements 6-7 mg
  • Iron daily intake 30-60 mg
  • (60-100 mg for twins)
  • Iron daily intake for Iron-deficiency anemia 200
    mg

53
Oral administration
54
Oral administration
  • In Thammasat University hospital
  • Use Ferrous fumarate
  • 1 tab of Ferrous fumarate give 60 mg of elemental
    iron.
  • For normal pregnancy ? 1 tab OD
  • For pregnancy with iron-deficiency anemia ? 1 tab
    tid (200 mg/day)

55
Oral administration
  • Increase reticulocyte count ? 5-10 d
  • Increase Hb 1g/wk
  • Give 500 mg Vit C ? Increase Iron absorption
  • Oral therapy should be continued for 3-6 months
  • S/E nausea, vomiting, abdominal pain,
  • diarrhea, constipation

56
Parenteral administration
  • IV or IM
  • Treat for woman cant take oral iron preparations
  • - malabsorption syndrome
  • - intolerance to S/E
  • Hb lt 8.5 g/dl

57
Thalassemia
58
Hemoglobinopathies
  • Quality defects
  • Structural hemoglobin variants
  • Hb E ?-globin variant
  • missence mutation of 26th codon from GAG to
  • AAG ( Glutamic to Lysine )
  • Hb Constant Spring ?-globin variant
  • Chain termination mutation of a2-globin gene
    from
  • UAA (Stop codon) to CAA
    (Glutamine)
  • longer and unstable
  • Quantity defects
  • Thalassemia

59
Definition
  • Thalassemia is caused by globin gene mutation
    which are characterized by impaired production of
    one or more of the normal globin peptide chains.
  • Abnormal synthesis rates may result in
    ineffective erythropoiesis, hemolysis, and
    varying degrees of anemia.

60
Thalassemias
  • Two major forms
  • - Impaired production or stability of a-peptide
    chains, causing a-thalassemia
  • - Impaired production or stability of ß-peptide
    chains,causing ß-thalassemia.
  • Inheritance is autosomal recessive.

61
Autosomal recessive Inheritance
  • Rr Rr

RR
Rr
Rr
rr
25 25 25
25
Carrier (Thalassemia minor)
Normal
Disease (Thalassemia major)
62
Incidence of thalassemia
  • Thalassemia belt
  • mediteranian, middle-east, India, south-east
    asia
  • Most common genetic disease in Thailand
  • Thalassemia disease 1
  • ?-thal trait 20-30
  • HbE 13
  • ?-thal trait 3-9
  • HbCS 4

63
Globin gene
64
Molecular basis
?
65
Types of hemoglobin
  • HbA (?2?2) 95
  • HbA2 (?2?2) lt3.5
  • HbF (?2?2) lt2
  • Hb Gower 1 (?2?2)
  • Hb Gower 2 (?2?2)
  • Hb Portland (?2?2)

66
Alpha-thalassemias
  • In normal, there are a-globin 4 gene, 2 locus



  • 2 types
  • - a-thalassemia 1 ( a0-thalassemia )
  • - a-thalassemia 2 ( a-thalassemia )

67
Alpha-thalassemias
  • In most populations, the a-globin chain cluster
    or gene loci are duplicated on chromosome 16.

68
?-Thalassemia
  • ?0- Thalassemia ß0thal , no ?-globin protein
  • ?- Thalassemia ßthal , some ?-globin protein
  • Mechanism of gene mutation
  • Point mutation

69
Most common Thalassemia in Thailand
  • Hb Barts hydrops fetalis
  • 2. Homozygous ?-thalassemia
  • 3. ?-thalassemia/HbE
  • 4. Hb H disease
  • 5. Homozygous Hb Constant Spring

70
Hb Barts hydrops fetalis
  • Deletion of all four ? -globin chain genes
    (--/--) characterizes homozygous a-thalassemia 1
  • Genetic from maternal and paternal (--/??)
  • Without ? -globin chains ? hemoglobin Bart (?? 4)
  • Fetus is affected ? Severe anemia, lack of O2,
    heart failure, hydrops fetalis
  • Maternal complications Preeclampsia, Pre and
    Post-partum hemorrhage, dystonia
  • Fetal blood sampling found Hb Barts (?4)
  • (Normal fetus HbF (a2?2) )

71
Hb Barts hydrops fetalis
72
Homozygous ?-Thalassemia
  • ?-thalassemia major or Cooley anemia
  • At birth ? HbF ? ? no symptom
  • ?-globin? ? ?-globin precipitate into RBC
  • RBC lysis lead to severe anemia (Hb 3-4 g/dl),
    Hepatosplenomegaly, jaundice, slow growth and
  • bone change (Thalassemia facies)
  • Blood transfusion Iron chelator
  • Complication congestive heart failure
  • cirrhosis
  • DM
  • Sterility

73
?-thalassemia/HbE
  • Variation in degree of anemia ( moderate to
    severe )
  • Hb 2.5- 12.5 g/dL
  • Chronic anemia
  • Thalassemia facies
  • Hepatosplenomegaly
  • Complication Respiratory tract infections
  • Congestive heart failure
  • Epilepsy
  • Amenorrhea
  • Infertile

74
HbH disease
  • Mild to moderate severe.
  • Not necessary to have blood transfusion.
  • If patients have infection, acute hemolysis and
    anemia may be occurred rapidly.

75
Homozygous Hb Constant Spring
  • Mild severe
  • Not necessary to have blood transfusion

76
Thalassemia facies
77
Thalassemia peripheral blood smear
Hypochromic microcytic, Anisocytosis,
Poikilocytosis
Target cells, Acanthocytes, Spherocytes,
Schistocytes, Ovalocytes
78
Thalassemia peripheral blood smear
Nucleated RBC
Basophillic stripping
79
Solution for Thalassemia
  • Community information
  • Population screening
  • Genetic counseling
  • Prenatal diagnosis
  • Termination of affected pregnancy

80
Screening method
  • Red cell indices
  • MCV lt 80 fl
  • MCH lt 27 pg
  • One tube osmotic fragility test (OF)
  • normal RBC complete hemolysis in 0.36 NSS
  • Thalassemia trait or Homozygous HbE partial
    hemolysis
  • ?-Thal trait positive 90
  • ?-Thal 1 trait positive 93
  • Iron-deficiency positive
  • ?-Thal 2 trait HbCS negative
  • False positive 5

81
Screening method
  • Dichlorophenol-indophenol precipitation test
    (DCIP)
  • Degrade and precipitate HbE HbH (unstable
    hemoglobin)

82
Confirmatory method
  • Hemoglobin electrophoresis
  • Abnormal screening method
  • Method Cellulose acetate, Citrate agar or
    Agarose gel,
  • Isoelectric focusing (IEF),
    HPLC
  • ?-Thal trait HbA2 gt 3.5
  • ?-Thal trait normal Hb typing but ?MCV ?MCH
  • Genetic Analysis
  • PCR
  • Southern blot analysis

83
Prenatal diagnosis
  • Specimen collection
  • Chorionic villous sampling
  • GA 10-14 wk
  • Detected mutation of globin gene
  • Amniocentesis
  • GA 16-20 wk
  • Chromosome analysis
  • Fetal blood sampling
  • GA gt 18 wk
  • DNA-based analysis or Hb electrophoresis
  • 4. Ultrasonogram
  • Hb Barts hydrops fetalis at GA gt 20 wk

84
Perinatal care
  • Maintain Hb level between 7 10 g/dl
  • Blood transfusion
  • Iron chelating
  • Folate supplement
  • Terminate in hydrops fetalis
  • Fetal health assessment

85
Cardiovascular disease in pregnancy
86
Outline
  • Physiological conditions with heart disease in
    pregnancy
  • Diagnosis of heart disease
  • General management

87
???????????????????????
  • ??????????????????????? ?????????????? 1-2
    ??????????????????????? ????
  • - ?????? 80-85 ????????????????????? ??????????
    90 ???? mitral stenosis
  • - ?????? 10-15 ?????????????????????
  • -?????? 2 ?????????????????????????????????

88
Physiological changes
of pregnancy
  • Blood volume ? 40-50 (1,500 ml)
  • Cardiac output ? 30-50
  • Almost half of the total increase has occurred
    by 8 wks.
  • Maximum at midpregnancy (20-24 wks)
  • Decrease vascular resistance
  • Diminished blood pressure
  • Increased resting pulse in late pregnancy

89
Effect of pregnancy
to heart disease
  • Problem on diagnosis
  • Increase severity of heart disease
  • Recurrence of rheumatic fever
  • Cardiomyopathy

90
Effect of heart disease
to pregnancy
  • Spontaneous abortion, preterm
  • Increased rate of DFIU
  • Increased IUGR
  • Increased rate of congenital heart disease in
    child
  • Increased rate of therapeutic abortion

91
Diagnosis of heart disease
  • Diagnostic studies
  • Clinical classification

92
Diagnostic studies
(Cardiovascular disease. Williams obstetrics 21st
Ed, 2001 441183 )
93
Diagnostic studies
  • Electrocardiography
  • Normal preg. ? 30? left-axis deviation, mild ST
    changes, atrial or ventricular premature beat,
    bigeminy
  • Chest radiograph
  • Echocardiography
  • Normal changes Tricuspid regurgitation and
    significantly increased left-atrial size and
    left-ventricular outflow cross-sectional area

94
Clinical Classification
  • New York Heart Association (1979)
  • Class1 Uncompromised ??????????????????????????
    ????????
  • Class2 Slightly compromised ????????????????????
    ?????????????????????????
  • Class3 Markedly compromised ????????????????????
    ??????????????????????????
  • Class4 Severely compromised ??????????????????
    ???
  • ?????????????????????

95
???????????????????????????????
???????????????
  • Preconceptional counseling
  • General management

96
Preconceptional counseling
  • Counseling before the decision to become
    pregnant.
  • Maternal mortality generally varies directly
    with functional classification at pregnancy
    onset.
  • ??????????????????????????????????? ?

97
(Cardiovascular disease. Williams obstetrics 21st
Ed, 2001 441185 )
98
Preconceptional counseling
  • ????????????????????? Class I,II and no Hx of
    heart failure
  • ???????????????????????
  • Class II and Hx of heart failure
  • Class III and IV

99
General management
  • ????????????????????????
  • Class I, II ????????????????? ?????
  • ?????????????? ??????????????????? functional
    class
  • ????????? 28-32 ???????
  • ???????? 1-2 ???????
  • Class III, IV ???? ??????????????? ??????????????
    ????????????????????????????????
    ????????????????

100
General management
  • ?????????????????????
  • ?????????????????????????????????????????????????
    ?????
  • Diminished stress conditions of preg. effect to
    heart e.g. anemia, infection
  • ???????????????????????????????????????????
    ??????????????????????????????????????????????????
    ???????????
  • ????????????????? ??????????? ???????????????????
    ???
  • ???????? (???????????) ??????? ?????????????

101
General management
  • ?????????????????????
  • ??? Rheumatic prophylaxis ?????????????????? 25
    ??
  • ?????? ?????? ?????????? (???? cocaine,
    amphetamine)
  • ?????????????????????? 10 ???????????????????
    ??????????????????????????????
  • ANC
  • 28 ??????????????????? 2 ???????
  • ??????????????????? ????????????????????????????
    ???

102
General management
  • ?????????????????????
  • ???????????????????????????????
  • ??????????????????????????????????????
  • ??????????????? ????? atrial fibrillation
  • ???????????? thromboembolism

103
??????????????????????????????????
  • u/s ?????????????????????????? heart anomalies
    ???? IUGR ???????
  • ???????????????????? IUGR ????????????????????????
    ?????? oligohydraminos ???????????????
  • NST ????? moniyor ????????????????????????????????
    ??????

104
General management
  • ?????????????????????????????????????
    ??????????????????????????????????????????????????
    ????????????????
  • ??????????????????????????????????????????????????
    ?????????? ???????????????????????????????????????
    ????????? ?????????????????
    streptococci ????
  • ????????????????????????????????????? ????????
    ???????????????????????????? ????????????
    ????????? ????????? ????
  • ???????????????????????????????????????

105
General management
  • Digitalis ??????????????????????
    ????????????????????????????????????
    ????????????????????????????????????????????
    ??????????????????????????????? ??????
  • 1. ???????? Class III, IV
  • 2. ???????????????????????????????
  • 3. ???????
  • 4. Atrial fibirillation

106
General management
  • ?????????????????
  • ?????????????????? (?????????????????????????????
    )
  • ??????? v/s ??? 30 ???? ????????? 1
    ?????????? ??? 10 ???? ????????? 2
    ??????????
  • ????????????? (semirecumbent position)
  • ?????????? I/O
  • 5 D/W 500 ml ??????????????????????? KVO
  • ???? EKG

107
General management
  • ?????????????????
  • Electronic fetal monitoring
  • ????????????? ???? pethidine (IM) ?? active
    phase ???? Continous epidural anesthesia
  • ??? antibiotic ??????? ???? infective
    endocarditis

108
General management
  • ?????????????????
  • ????????????? (prosthetic heart valves, previous
    endocarditis, complex congenital cyanotic heart
    disease, surgically constructed systemic
    pulmonary shunts)
  • ???????? 30 ???? Ampicillin 2 gm IV/IM
    Gentamicin 1.5 mg/Kg (??????? 120 mg) IV/IM
  • ??????????? 6 ??????? ??? ampicillin 1 gm IV/IM
    (???? Amoxicillin 1 gm oral)
  • ???? ??? ampicillin ??? Vancomycin 1gm IV 1-2 hr
    (?????????????? 30 ????) ??? ampicillin

109
General management
  • ?????????????????
  • ????????????????? (most other congenital
    malformation not in high or low risk categories,
    acquired valvar dysfunction, hypertrophic
    cardiomyopathy, mitral-valve prolapse with valvar
    regurgitation and/or thickened leaflets)
  • ???????? 1 ??????? ??? amoxicillin 2 gm oral ????
    ???????? 30 ???? ??? ampicillin 2 gm IV/IM

110
General management
  • ?????????????????
  • ????????????? (ASD, surgically corrected lesions
    without prosthesis (ASD, VSD, PDA), coronary
    artery disease with previous bypass surgery,
    mitral-valve prolapse without regurgitation,
    physiological murmurs, previous rheumatic fever
    without valvar dysfunction, pacemakers)
  • ?????? antibiotic prophylaxis

111
General management
  • ?????????????????
  • ???????????????????? active phase
    ????????????????????????
  • ???????????????????????????
  • ??? morphine 2-4 mg ??????????????????
  • ?????????????? mask with bag 10 ????/????
  • Furosemide 20-50 mg ??????????????????
  • ????????????????????????
  • ???????????????????? digitalis ???????????????????
    ? 1/4 - 1/2

112
General management
  • ?????????????????
  • ?????????????? ??????????????????????????
  • ???????? Forcept ???? first choice
  • ?????? forcept ?????? ??????????? vaccum
  • ???????????????????????????????? oxytocin IV
    (??????? methergin)

113
General management
  • ?????????????????????
  • ??????????????????????????????? 24
    ?????????????????????????????????????????????
  • ???????????????? ???????????????
    (?????????????????? 24 ???????)
  • ?????????????????????????? 5-7 ??????????????
    (??????????????????????????)

114
General management
  • ?????????????????????
  • ??????????????????????? ?? class III, IV
    ??????????????????????????
  • ?????????????? ?????????????????????? 5 ???
  • ????????????????? ?????????????????????????

115
General management
  • ??????????????????????
  • Hx of heart failure ????????????????????
  • Heart disease group 3
  • Heart disease class III, IV
  • ?? carditis ??? rheumatic fever

116
???????????????????????????????????? class I,II
  • ???????????
  • ????? heart failure ????????????????????????????
  • ????????????????
  • ??????????????????
  • ?????????????????????????????? 2
    ???????????????forceps, vacuum

117
???????????????????????????????????? class III
  • ????? Therapeutic abortion????????????
    ?????????????????
  • ?????????????? ?????????????????.???????????????
    ?
  • ??????????????????

118
???????????????????????????????????? class IV
  • ????????????????????
  • ???????????????????????

119
????????????
  • ??????????? Cardiac output ???????????
  • ????????????? laparoscope
  • ????????????????????????
  • ???????????????????????????????????????
    bacterial endocarditis

120
???????????????????????????????
  • FDA ????????????????????????????????????????????
    ??? ??????? 5 ????? ??????
  • Category A ?????????????????????????????
    ?????????????????????
  • Category B ??????????????????????
    ?????????????????????????

121
???????????????????????????????
  • Category C ???????????????????????????????????
    ???????????? ????????????????????????????????????
  • Category D ???????????????????????????????????
    ?? ???????????????????????????????????
  • Category X ???????????????????????????????????
    ?? ??????????????????????????????????????????????

122
???????????????????????????????????? ??? Category
  • Category B low MW heparin,Urokinase B
  • Category C ACEinhibitor,Digoxin,Methydopa,
  • Furosemide,Quinidine,Heparin,
  • streptokinase,Cacium antagonist,
  • beta-blocker
  • Category D Coumarins,amiodarone,Thiazides

123
Prognosis
  • Severity
  • Complication
  • Quality of management
  • ?????????????????????????
  • ?????????
  • ??????????? 30 ??
  • ??????????

124
References
  • ?????? ???????.???????????????????????????. ??
    ??????? ??????????, ?????? ???????????????,
    ?????? ???????, ????? ????????????, ????????
    ???????????, ??????????.??????????. ?????????????
    3. ???????? ??.??? ???????????????,2548445-453.
  • ???? ?????????????.??????????????????????????. ??
    ??????? ??????????, ?????? ???????????????,
    ?????? ???????, ????? ????????????, ????????
    ???????????, ??????????.??????????. ?????????????
    3. ???????? ??.??? ???????????????,2548455-467.
  • ???????? ??????????.???????????????????????. ??
    ??????? ??????????, ?????? ???????????????,
    ?????? ???????, ????? ????????????, ????????
    ???????????, ??????????.??????????. ?????????????
    3. ???????? ??.??? ???????????????,2548469-478.
  • ???? ?????????????, ?????? ????????????.??????????
    ????????????. ?? ??????? ??????????, ??????
    ???????????????, ?????? ???????, ?????
    ????????????, ???????? ???????????,
    ??????????.??????????. ????????????? 3. ????????
    ??.??? ???????????????,2548479-494.

125
References
  • ???? ?????,??????? ??????????, ??????????.????????
    ??. ????????????? 4. ?????????? ?? ?? ?????
    ??????,2541.
  • Cunningham FG, Gant NF, Lenovo KJ,Gilstrap III
    LC, Hauth JC,Wenstrom KD, eds. William
    obstertrics. 22nd ed. New York McGraw-Hill,
    Inc.,2005.

126
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