扬州大学：《妇产科学》课程教学课件（PPT讲稿）09 妊娠期肝内胆汁淤积症 ICP during Pregnancy

Intrahepatic cholestasis(ICP)ofpregnancy妊娠肝内胆汁郁积症Pruritus occurring in pregnancyin the absence ofdermatologic abnormalities,is usually due to ICP Symptoms(pruritus)usually commence between 28and34weeksIncidence:1-2/1000 pregnancies

Intrahepatic cholestasis of pregnancy （ICP） 妊娠肝内胆汁郁积症 ❖ Pruritus occurring in pregnancy ,in the absence of dermatologic abnormalities,is usually due to ICP ❖ Symptoms(pruritus)usually commence between 28 and 34 weeks Incidence: 1-2/1000 pregnancies

DiagnosisICP should be suspected when widespread pruritus occursin the third trimester.without skin rash.Highlevels of bileacids(5-100 times normal)Bilirubin appears in the urine.(in most ),alkaline phosphatase and bilirubin be elevated.transaminases is elevated (in many)fordifferential diagnosis,hepatitis serology,hepatobiliarytract ultrasonoguaphy and autoantibodies screan should beperformed in all cases.(ultrasonography is very important toexclude abstruction of the biliary tree.)

ICP should be suspected when widespread pruritus occurs in the third trimester. without skin rash. High levels of bile acids(5-100 times normal) Bilirubin appears in the urine. (in most ),alkaline phosphatase and bilirubin be elevated. transaminases is elevated (in many) for differential diagnosis ,hepatitis serology ,hepatobiliary tract ultrasonoguaphy and autoantibodies screan should be performed in all cases.(ultrasonography is very important to exclude abstruction of the biliary tree.) Diagnosis

Maternal/FetalRisksFor the motherit carries a 10-22% risk ofobstetric Hemorrhage,and preterm labor.For the fetal prognosis,stillbirth(up to 15%),Preterm delivery (up to 30%),fetal distress(up to 25%),and meconium staining of the amniotic fluid(30-40%),The mechanism of fetal compromise is uncertain

❖ For the mother,it carries a 10-22% risk of obstetric Hemorrhage,and preterm labor. ❖ For the fetal prognosis,stillbirth(up to 15%), Preterm delivery (up to 30%), fetal distress(up to 25%), and meconium staining of the amniotic fluid (30-40%), The mechanism of fetal compromise is uncertain. Maternal/Fetal Risks

ManagementPrenatal monitoring of fetal well being;timing of delivary;maternal symptom control;vitamin K supplementation.intramuscular Vit.K 10mg weekly should be given from 36 weeksIntrapartumVitaminK 1Omg is given to mother;The newborn body should receive VitaminK(there is evidence of a bleeding tendency)Postnatal Biliary tract ultrasonography (for stones),(if pruritus does not disapear>7-10 days after delivery.)In occasional case where abnormalities do not resolveafter delivery liver biopsy may need consideration

Prenatal monitoring of fetal well being; timing of delivary; maternal symptom control; vitamin K supplementation. intramuscular Vit.K 10mg weekly should be given from 36 weeks. Intrapartum Vitamin K 10mg is given to mother; The newborn body should receive Vitamin K (there is evidence of a bleeding tendency). Postnatal Biliary tract ultrasonography (for stones), (if pruritus does not disapear >7-10 days after delivery.) In occasional case where abnormalities do not resolve after delivery ,liver biopsy may need consideration. Management

Medical and SurgicalComplications duringPregnancyChronic Glomerulonephritis慢性肾小球肾炎AndPyelonephritis

Medical and Surgical Complications during Pregnancy Chronic Glomerulonephritis慢性 肾小球肾炎 And Pyelonephritis

Urinary Tract Changes during Pregnancy. Urinary tract dilation(It involves dilatation of the renalcalyces and pelves,as well as the ureters)These changesare more promiment on the right side.The size ofkidney increases lcm.The glomerularfiltrationrate increases about50%..The renal plasmaflowincreases about35%.These changes create urinary stasis,and may lead to seriousupperurinaryinfections

• Urinary tract dilation(It involves dilatation of the renal calyces and pelves,as well as the ureters)These changes are more promiment on the right side. • The size of kidney increases 1cm. • The glomerular filtration rate increases about 50%. • The renal plasma flow increases about 35%. These changes create urinary stasis,and may lead to serious upper urinary infections. Urinary Tract Changes during Pregnancy

Assessment ofRenalDisease DuringPreglancy.Urinalysisisessential.·Most degree that proteinuria must exceed 500mg/day to beconsidered abnormalforpregnancy..Ifthe serum creatininepersistentlyexceeds 0.9mg/dl(75umol/L),then intrinsic renal disease should be suspected.Ultrasonogaphy provides imaging of renal size and relativeconsistency,as well as elements of obstructionIf necessary,cystoscop,intravenous pyelography,orrenalbiopsymaybeconsidered

• Urinalysis is essential. • Most degree that proteinuria must exceed 500mg/day to be considered abnormal for pregnancy. • If the serum creatinine persistently exceeds 0.9mg/dl (75umol/L), then intrinsic renal disease should be suspected. • Ultrasonogaphy provides imaging of renal size and relative consistency,as well as elements of obstruction. • If necessary,cystoscop, intravenous pyelography, or renal biopsy may be considered. Assessment of Renal Disease During Preg1ancy

AcutePyelonephritis>Incidence·About1-2%ofpregnancies.V Acute Pyelonephritis is the most common seriousmedical complication of pregnancyPyelonephritisis more common aftermidpregnancy.Itisunilateral and right-sided in more than half of cases,andbilateralin onefourth.In most women, renal parenchymal infection is caused bybacteria that ascend from the lower tract

➢ Incidence • About 1-2% of pregnancies. ✓ Acute Pyelonephritis is the most common serious medical complication of pregnancy. • Pyelonephritis is more common after midpregnancy.It is unilateral and right-sided in more than half of cases,and bilateral in one fourth. • In most women, renal parenchymal infection is caused by bacteria that ascend from the lower tract. Acute Pyelonephritis

>Effecton pregnancy.The high fever can creates abortion, preterm labor.In the firsttrimester,malformations areincrease.(such as spinal defects)Toxic shock.(bybacteriatoxin)>Clinical findingsGeneral symptoms:o The onset of pyelonephritis is usually rather abruptoHighfever (as well as 40degreeC),Shaking chills.(thermoregulatory instability)o Nausea and vomitingoHeadache

➢ Effect on pregnancy • The high fever can creates abortion, preterm labor. • In the first trimester, malformations are increase. (such as spinal defects) • Toxic shock.(by bacteria toxin) ➢ Clinical findings • General symptoms: o The onset of pyelonephritis is usually rather abrupt. o High fever (as well as 40degree C), Shaking chills.(thermoregulatory instability) o Nausea and vomiting o Headache

>Clinical findings(con't): Urinary systemic symptoms:o Aching pain in one or both lumbar regions.o Tenderness in one or both costovertebral angles(by percussion)o Dysuria,urgency,and frequency·Asymptomatic bacteriuriaThe reported prevalence of asymptomatic bacteriaduring pregnancy varies from 2-7%.·About 15% of women with acute pyelonephritis alsohavebacteremia

➢ Clinical findings(con’t) • Urinary systemic symptoms: o Aching pain in one or both lumbar regions. o Tenderness in one or both costovertebral angles (by percussion) o Dysuria,urgency,and frequency. • Asymptomatic bacteriuria The reported prevalence of asymptomatic bacteria during pregnancy varies from 2-7%. • About 15% of women with acute pyelonephritis also have bacteremia