周產學工作規範

產前檢查時間表及項目 

健保建議產檢時間表：

一般產前檢查通則：

n           懷孕28週以前：每四週一次。

n           懷孕29 ~ 35週：每兩週一次。

n           懷孕36週以後：每一週一次。

一般產檢項目：

 驗血：

初次產檢：CBC; Blood type; Rh type; VDRL

32週前後：HBs Ag; HBe Ag; Rubella Ab

14 ~ 18週：唐氏症篩檢（ABBA）

（a fetoprotein; free b–hCG; Body weight; gestational age & maternal age）

24 ~ 28週：糖尿病篩檢（DM screen: 50 gm glucose; PC 1 hr blood sugar）

DM screen positive者（sugar>140），需進一步做OGTT。

（OGTT: 需NPO overnight，測blood sugar AC，PC 1 hr，2 hr & 3 hr）

 超音波：

健保給付一次：約在20 ~ 24週

32 ~ 37週時：胎兒生長超音波評估

妊娠初期超音波：用於脅迫性流產、確定子宮內妊娠、胎數、確定妊娠週數等。

高層次超音波（Level II sonography & fetal echocardiography）

n           懷孕期危險之徵象

出現下列危險徵象應立即就醫：

1.    陰道出血，無論量多或量少。

2.    面部及手指，小腿浮腫。

3.    嚴重而連續性之頭痛。

4.    視力模糊。

5.    腹部疼痛。

6.    很厲害之嘔吐而且持久。

7.    突然發燒及畏寒。

8.    陰道突然有液體流出。

9.    尿量減少。

10.體重增加太快。

11.胎動明顯減少或消失。

產房規則

產房住院標準

DR admission criteria: (in labor or tocolysis)

ð Cx Os ³ 3cm

ð ROM & PROM (premature rupture of membrane)

ð Induction (overterm, high risk pregnancy, others)

ð Previous C/S or malpresentation in labor

ð Other conditions need emergent C/S

ð PTL (preterm labor) & PPROM (preterm PROM)

ð APH (antepartum hemorrhage)

ð Others (ex: PIH for controlling BP)

產兆包括：

1.    見紅（bloody show）：帶血之紅色黏液分泌物。需跟產前出血（antepartum hemorrhage, APH）做區分，如前置胎盤（Placenta previa），胎盤早期剝離（Abruptio placenta）。

2.    破水（ROM or PROM）：不自主之陰道液體流出，可用石蕊試紙測試（Nitrazine test顏色由粉紅色變藍色）或Fern test確認，有破水即住院。

3.    規則陣痛（Labor pain）：需跟假性陣痛區分，若孕婦表現出非常疼痛之表情，需小心是否為胎盤早期剝離或子宮破裂（Uterine rupture）。

Table Characteristics of True Labor and False Labor

Factors                                    True Labor                     False Labor

Contractions                                         Regular intervals                       Irregular intervals

Interval between contractions                      Gradually shortens                    Remains long

Intensity of contractions                    Gradually increases                   Remains same

Location of pain                                   In back and abdomen               Mostly in lower abdomen

Effect of analgesia                               Not terminated by sedation     Frequently abolished by sedation

Cervical change                                    Progressive effacement and    No change

                                                                dilatation

產科住院常規

1.    病史詢問：包括胎數(G)、產數(P)、產檢情形、有否併發症？並需詳閱舊病例察各項檢查結果，記錄產痛或破水時間。

2.    檢查項目：

ð 胎位（Presentation）？

ð 胎心音（Fetal heart beat）？

ð 胎頭是否已固定（Engagement）？

ð 是否破水（ROM or PROM）？

ð 是否為真產痛（True labor pain）？

n           檢查後對暫時無須住院者應囑以注意事項或做NST並做記錄，告知孕婦及家屬在何種情況下需再來醫院檢查。

檢查步驟：

ò 孕婦先行排空膀胱，平躺採Lithotomy姿勢，使用Doppler測得胎心音後，經陰道做內診（子宮頸開啟之情形、胎頭位置及先露部位），檢查時須注意無菌觀念（Aseptic procedure）。

ò 記錄體溫、脈博、血壓，並做血液（CBC/DC）及尿液檢查（U/A）。

ò 測量孕婦肚子大小（FSD & AC）。

ò 予以Skin prepare及Fleet enema，避免生產時傷口感染。

一般住院待產醫囑：

ò Admitted to the service of Dr.              。

ò Check vital sign as DR routine。

ò NPO since Cx Os ³ 3 cm。

ò Set IV with D5W run 100 ml/hr。

ò Skin prepare and Fleet enema。

ò Check CBC/DC, U/A。(CRP if ROM or PROM)

ò On fetal monitor and check fetal heart beat every 30 min。

內診

PV：（切記：內診時間不宜過長，且不宜在產婦面前討論，並需注意無菌觀念）

ò 先用Cetavlex oint抹在一手之食指及中指

ò 用拇指及第四指將labia majora及minora撐開

ò 再將食指及中指伸入vagina內，用兩隻指頭感覺下列各項：

n         Os dilatation：Close, FT (finger tip), 1 ~ 9 cm, NF (near full), Full。

（以食指及中指撐開子宮頸之寬度或子宮頸兩邊剩下之寬度判斷之，全開為10公分）

n         Effacement：Poor（似鼻尖硬度），Moderate（似耳垂厚度及硬度），Good（軟而薄）。

n         Station：floating, Dipping, engaged (+/- 0), +1 ~ +3 (以ischia spine以下1 ~ 3公分為準)。

（變通方法：若食指及中指伸入陰道頂到胎頭，尚能露出一指節為+1，兩指節為+2，三指節為+3）

n         Fetal presentation：Vertex or breech, ant/post fontanel, ROA/LOA, ROP/LOP。

Bishop score：用以評估子宮頸之狀況，分數愈高愈易引產。

Bishop scores:

催生（Induction）

引產病人之選擇：

適應項目：

懷孕引起之高血壓（Pregnancy induced hypertention）

早期破水（Premature rupture of membranes）

絨毛羊膜炎（Chorioamnionitis）

經由生化或生理評估，懷疑胎兒有危險者

 （例如胎兒生長遲滯、過期妊娠、同種免疫isoimmunization）

母體內科問題（例如糖尿病、腎臟病、慢性阻塞性肺部疾病）

胎兒死亡

地域問題（離醫院太遠，擔心急產）

過期妊娠

禁忌項目：

胎盤或血管前置（Placenta or vasa previa）

胎位不正

臍帶先露（Cord presentation）

先前做過縱向子宮切開（Classical incision）

生殖器官感染活性期庖疹

骨盆腔不正常結構

侵犯性子宮頸癌

Bishop scores：（評估子宮頸之狀況）

常用方式：

Prostaglandin E2

PG E2 (0.5 mg/tab) P.O. 1# q1h ´ dose/day。

Prostin E2 (3 mg/vaginal tablet), by a further 3 mg after 6 ~ 8 hrs if necessary, a total dose £ 6 mg。

PGE2不僅可促使子宮頸成熟，也可成功地引產，降低產程延長之機會，增加子宮收縮及降低子宮收縮素之要求。對於初產婦且有未成熟之子宮頸，PGE2效用大於人工破水及子宮收縮素。

Oxytocin (Piton-S): 10 unit/ml/amp

Medical induction or augmentation of labor。促進子宮收縮，預防產後出血等。

Piton-S 5U in D5W 500 ml run 6 mgtt/min (30 min later)

 ò Piton-S run 12 mgtt/min      （30 min later）

 ò Piton-S run 20 mgtt/min      （30 min later）

 ò Piton-S run 30 mgtt/min      （30 min later）

 ò Piton-S run 40 mgtt/min      （30 min later）

 ò Piton-S run 50 mgtt/min      （30 min later）

 ò Piton-S run 60 mgtt/min      （30 min later必要時換成大滴，但須注意最大劑量及I/O）

 ò Piton-S run 20gtt/min  （30 min later）

 ò Piton-S run 30 gtt/min （30 min later）

 ò Piton-S run 40 gtt/min （30 min later）

 ò Piton-S run 50 gtt/min （30 min later）

 ò Piton-S run 60 gtt/min （Maximal）（60 mgtt =1 ml; 1gtt = 4 mgtt）

調整子宮收縮素之劑量直到每10分鐘約有3 ~ 4次之宮縮即可。

Amniotomy

人工破水可安全且有效地引產或促進產程，人工破水之所以會引起宮縮，是由於產生了前列腺素，而內因性的子宮收縮素可能沒有此項作用。

產婦有不錯之子宮頸（Bishop score大於等於9分），人工破水會引發成功之生產，此種產婦偶而需要子宮收縮素來加強。人工破水對於引產也有助益，擁護積極處理產程者認為人工破水是一關鍵因素，而他們的主張也由於有關子宮頸擴張大於3公分後使用人工破水而縮短產程之研究得到印證。

在人工破水之前需先確定胎頭已經在好的子宮頸位置，人工破水之後應立即記錄胎心音，產程通常會很快開始，此時可給予適當劑量之子宮收縮素。

待產過程

 Labor course:

影響生產之3P：Power (uterine contraction), Passage (birth canal), Passenger (fetus). (若加上Presentation則為4P)

& Arrest disorder:

Type of delivery:

 I.  Vaginal delivery: NSD (including Vacuum & forceps delivery):

Stage of labor:

H 1^st stage：從產痛開始到子宮頸口全開。

H 2^nd stage：從子宮頸口全開至胎兒娩出。

H 3^rd stage：從胎兒娩出至胎盤產出。

H 4^th stage：從胎盤產出至產後1 ~ 2小時。 

n           Episiotomy: 

·  Local anesthesia with xylocaine

·  Median vs medial lateral

n           Perineal laceration:

1^st degree:  injury to vaginal mucosa

2^nd degree:  injury to perineal body

3^rd degree:  injury to anal sphincter

4^th degree:  injury to rectal mucosa

è Repair with 3-0 vicryl or 2-0 chromic catgut suture.

Patient prepare:

ò 協助病人移至待產台並放好腳架（Lithotomy position）

ò 以無菌方式戴上手套並抽取2% Xylocaine 10 ml（需先打入一些空氣才容易抽出）

ò 將產械放置妥當（大毛巾、小彎盆及其內物品放至warmer處）

ò 穿上無菌手術衣

ò 手拿羊水收集器（DeLee trap）準備吸出嬰兒口鼻內之羊水，尤其有meconium時。（需注意放入嬰兒嘴內時要先折住DeLee，以免壓力過大傷到mucosa）

ò 若有機會隨時準備delivery。Delivery procedure：參見下圖。

ò 協助會陰縫合。（縫合方式見附圖）

ò 術後協助搬運病人，並完成接生記錄單及藥單。

II. Cesarean section: 

常見之indications:

Previous C/S                                            Acute fetal distress

Malpresentation                                        Chorioamnionitis

Multiple Pregnancy                                   CPD

Previous myomectomy                              Placenta previa

2^nd arrest of Cx dilatation                  Others

Arrest of descent

Patient prepare:

ê 協助病人移至手術台上。

ê 麻醉前及麻醉後用Doppler聽胎心音。（聽胎兒之背部，large part）

ê 通常會讓病人左側躺，以避免子宮壓到inferior vena cava，減少venous reture。

ê 用soap清洗手術部位，然後用無菌單擦拭乾淨。

ê 刷手上刀。

ê 手術步驟：（實際操作及講解）

ê 術後協助搬運病人，並完成接生記錄單、藥單及檢驗單。

C/S types: 

H Intraperitoneal low segment transverse (LST) C/S

H Extraperitoneal low segment transverse C/S

H Others:

Classical C/S, lower segment vertical incision, invert T incision, Porro’s (cesarean) hysterectomy, combined with myomectomy, cystectomy or oophorectomy, ATS

Cesarean section operative Procedures:

 The woman was brought to the operating room. After oSpinal oEpidural oGeneral anesthesia, the patient was put in supine position. The abdomen was prepared with soap and better iodine and draped as usual. A o pfannestial incision o median longitudinal incision was made. The abdominal wall was opened layer by layer.

o After the peritoneum was opened, two pads were put into the peritoneal cavity to push the intestine upward. A third blade was put in the caudal aspect to expose the lower segment of the uterus.----------------------------(Intraperitoneal type)

o By dissecting through the space of Retzius and then along one side and beneath the bladder to reach the lower uterine segment.----------(Extraperitoneal type)

A transverse incision of the lower segment of the uterus was made. A baby was delivered smoothly. The placenta was removed manually. Then the uterus was closed by two layers sutures with 1-0 o vicryl / o catgut. The serosa was approximated.

The abdomen wall was closed layer by layer. The skin was approximated with o 3-0 Dexon suture material.

唐氏症母血篩檢

& 經由母血內一些因懷孕而產生之物質（AFP, b-hCG, free b-hCG etc），配合妊娠週數、母親年齡及體重，而計算出唐氏症之危險機率。

篩檢週數：14 ~ 18週 

目前長庚醫院使用之檢驗方式為：ABBA

（a-fetoprotein, free b–hCG, maternal body weight, gestational age & maternal age） 

產前母體血清篩檢報告：

結果

free b–hCG (游離型貝他人類絨毛膜性腺激素): ----MoM (中位值倍數) (----ng/ml)

AFP      (甲型胎兒蛋白)                : ----MoM (中位值倍數) (----ng/ml) 

本胎兒患有唐氏症之危險機率為：                                   

本胎兒患有神經管缺損之危險機率為：                             

說明：

1.      35歲高齡孕婦在妊娠中期胎兒患有唐氏症之機率為1/270。若本篩檢唐氏症危險機率 ³ 1/270，則應考慮做羊膜穿刺術檢查。

2.      母血篩檢可找出65% ~ 75%的唐氏症胎兒，仍有3至4成無法偵測出來。

3.      此種抽血檢驗是一種篩檢方法，並非最後確定診斷方法。

4.      中國人患有神經管缺損之危險機率為1/1000，若本篩檢神經管缺損之危險機率 ³ 1/1000，則應考慮做高層次超音波或羊膜穿刺。 

P.S. 除看危險機率外，仍須看APF及free b–hCG之MoM值，決定是否進一步檢查。 

胎兒監視（Fetal monitoring）

 Fetal monitoring:

  Fetal heart rate, variability, uterine contraction strength, duration & interval.

  Running rate: 1 cm/min

   FHR deceleration:

n           Early deceleration: fetal head compression.

n           Variable deceleration: cord compression

n           Late decelearation: placenta dysfunction

n           Acute fetal distress 

Nonstress test (NST):

Determination of fetal heart rate (FHR) accelerations in response to fetal movement in a defined period of time.

Reactive:    two or more FHR accelerations of at least 15 beats per minutes for at least 15 s duration in a 20-min period.

Nonreactive: no acceptable FHR accelerations over a 40-min period.

Oxytocin challenge test (OCT), contraction stress test (CST):

  Three completed contractions of at least 40 to 60 s duration in a 10-min interval.

ð Negative:  no late decelerations

ð Positive:   late decelerations following > 50% of the contractions. 

è Suspicious: intermittent late or variable decelerations with < 50% of the contractions.

Hyperstimulation: FHR decelerations associated with excessive uterine activity. (frequency > every 2 minutes or duration > 90 s)

è Unsatisfactory: fewer than 3 contractions in 10-min or a poor-quality FHR tracing.

安胎（Tocolysis）

 新生兒死亡中仍以早產者佔大多數，因此應讓胎兒儘量留在子宮內至足月。 

需安胎之情況：

1.    早期宮縮（Preterm labor, PTL）。

2.    早期破水（Premature rupture of membrane, PROM）。

3.    子宮異常。

4.    子宮過度漲大，如羊水過多（Polyhydramnios），多胞妊娠。

5.    產前出血（Antepartum hemorrhage, APH），如胎盤早期剝離，前置胎盤。

6.    母親疾患，如妊娠高血壓（PIH），妊娠糖尿病（GDM）等。

一般住院安胎醫囑：

ò Admitted to the service of Dr.                     

ò Check vital sign as DR/Ward routine

ò On diet

ò Check CBC/DC, U/A, CRP

ò Set IV with D5W run 100 ml/hr

ò Bed rest (with hip elevated when PROM)

ò On fetal monitor & check FHB q30 min.（若週數較小，則適時聽胎心音即可）

ò Ultrasonography

安胎第一線藥物為Ritodrine，但須注意其禁忌症，其用法為：

ò Ritodrine 3 Amp in D5W 500 ml run 20 mgtt/min

ò Ritodrine á30 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á40 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á50 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á60 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á70 mgtt/min 

若仍有規則宮縮則考慮加上第二線藥物MgSO4

ò MgSO4 2 amp IV slowly push ( > 15 min) as loading dose

ò MgSO4 10 amp in D5W 300 ml run 1 gm/hr（調整至無宮縮）

ò MgSO4 10 amp in D5W 300 ml run 1.5 gm/hr（調整至無宮縮）

ò MgSO4 10 amp in D5W 300 ml run 2 gm/hr（調整至無宮縮）

ò Check DTR, RR & I/O q4h, if DTR ê, RR< 12/min & urine output < 100 ml/4hr, notify Dr. soon

ò Prepare Ca gluconat 1 amp at bedside.-----------必要時拮抗MgSO4之作用。 

其他安胎常用之方法尚有：

1.  Hydration

2.  Indomethacin (Inteban) 1# supp (大於32週者禁用，以避免ductus arteriosus提早關閉)

3.  Nifedipine 

& 為促進胎兒肺部成熟，於28週以後可給予steroid (Dexan 12.5 mg ´ 3 dose qwk)，必要時可做羊膜穿刺術測胎兒肺部成熟（PG, L/S, Lamellar body）

 & Ritodrine (b-mimetic): 50 mg/5 ml/amp; 10 mg/tab.

MgSO4: 10%, 20 ml/amp.

Inteban: 50 mg/supp.

 Ritodrine由IV form改成口服方法：

ò Ritodrine run 10 mgtt/min combined with Ritodrine 1# P.O. q2h ´ 12 hr

ò DC IV form Ritodrine & keep Ritodrine 1# P.O. q2h ´ 12 hr

ò Ritodrine change to 1# P.O. q4h ´ 1 day

ò Ritodrine change to 1# P.O. q6h

Contraindications of tocolytic agents:

ð Ritodrine: Heart disease, Hyperthyroidism, Hypertension, DM.

ð MgSO4: Heart block, Myasthenia gravis, Myocardial damage, Impairment renal function.

Can not be used with Barbiturate, Narcotics, Hypnotic drugs.

Can not be used when Resp rate < 12/min, Urine output < 30 ml/hr

ð Nifedipine: Hypersensativity

Steroid administration:

  Dexan 12.5 mg iv q12h ´ 3 doses qwk

Contractions for the steroid administration

1.  PROM

2.  Multiple gestation

3. Less than 28 wks GA

羊膜外引產（Extraovular (Extra-amniotic) induction）

 Indication:

妊娠12週以上，因?胎死腹中?胎兒畸形?基於優生保健考量，需引產者。

作法：

ò 病人排空膀胱後，採lithotomy姿勢，外陰部予以清潔消毒，並鋪無菌罩單。

ò 用鴨嘴（speculum）撐開陰道並予以Aq. B-I徹底消毒。

ò 將20 ~24 近Foley伸入子宮腔內，並打入40 ~ 60蒸餾水，Foley末端以臍夾夾住。

ò 將1 ml之Prostamon (PG F2a)加入3 ml之N/S稀釋，從Foley先打入1 ml入子宮腔做test。若無不適，15min之後再將剩餘3 ml打入

ò 拉緊Foley並以布膠固定於大腿內側。

ò 之後每1 ~ 2小時打入4 ml之混液，直到Foley掉出或滿12 doses。

ò 之後用3 amp之Piton-S加入500 ml之IV中，調整子宮收縮程度（按照一般待產程序）。

ò 胎兒掉出後視出血情況進產房清胎盤（一般在一小時後），必要時需超音波指引。

ò 整個待產過程可給予抗生素、Demeral、Novamine。

羊膜穿刺  （Amniocentesis） 

Indication:

Chromosome study

Fetal lung maturity

R/O chorioamnionitis (culture & gram stain)

Releasing polyhydramnios

Procedure:

ê 先以超音波找出最適宜下針處（羊水最多，並避開胎盤）。

ê 將Jelly擦掉，用Alc B-I及75% Alc消毒皮膚並鋪無菌罩單。

ê 將超音波探頭裝入消毒過之塑膠袋內。（不一定要用adaptor）

ê Sona guide下，以22#之羊水針抽出羊水。

（Chromosome study 20 ml; lung maturity & Gram stain/culture 10 ~ 15 ml）

附錄：

產前遺傳診斷適應症（衛生署）

1.    高齡產婦。

2.    本胎次有生育先天缺陷兒之可能者：?神經管缺陷?染色體異常（超音波或母血篩檢）?代謝異常?地中海型貧血。

3.    曾生育過先天缺陷兒者：?神經管缺陷?染色體異常?代謝異常?地中海型貧血或水胎。

4.    本人或配偶有遺傳疾病者：?性聯遺傳?染色體異常?代謝異常?地中海型貧血帶因

5.    家族中有遺傳疾病者：?性聯遺傳?染色體異常?代謝異常

6.    重複性流產。

7.    其他。

新生兒急救(Neonatal Resuscitation)

Apgar Score:

 Initial stabililzation:

 1.  Enviroment:          Warm & Dry

2.  Positioning:           Sniffing Position

3.  Suction:                60~80mm Hg pressure; mouth first,then nose.

4.  Tactile stimulation

Resuscitation:

Oxygen administration-5L/min

Ventilation-40~60/min; pressuure 20~70 cmH₂O initially,then 20~30 cmH₂O.

Endotracheal Tube Size and Depth Of Insertion:

Neonatal Resuscitation Supplies and Equipment

1.  Suction equipment

Bulb syringe

Suction catheter 5,8, 10 Fr

Wall suction set at low continuous suction (60 to 80 mmHg)

8-Fr feeding tube and 20-ml syringe

Meconium aspirator if available or 10-Fr suction Catheter

2.  Bag and Mask equipment

250 ml premature infant resuscitation bag capable of delivering 90% to 100% oxygen

450ml term infant resuscitation bag, capable of delivering 90% to 100%oxygen

Face masks: premature and newborn size(cushioned rims)

Oxygen with flow meter and tubing

Oral airways: newborn and premature sizes

3.  Intubation Equipment

Laryngoscope with straight blades: No 0 (premature)& No.1 (newborn)

Extra bulbs and batteries for laryngoscope

Endotracheal tubes:2.5,3.0,3.5,4.0 mm

Stylet

4.  Medications

Epinephrine 1:10,000

Naloxone 1 mg/ml

Volume expanders (one or more of these)

Normal saline

Ringer’s lactate

Albumin 5% solution

O-negative blood

Sodium bicarbonate 8.4% solution (1 mEq/ml) to be diluted 1:1 with sterile water (0.5 mEq/ml)

Detrose 10% or Detrose 25% (to be diluted 1:1 with sterile water)

Sterile water

5.  Miscellaneous

Radiant warmer

Adhesive tape

Syringes: 1, 3, 5, 10, 20, 50 ml

Needles: 25, 21, 18 g

Intravenous catheters: 24, 22 g

Alcohol and betadine sponges

Benzoline spray

Umbillical tape

Umbillical catheters: 3.5, 5.0 Fr

3-way stopcock

5 Fr feeding tube

Warm blankets and towels

Cord clamps

早期破水 （Premature rupture of membrane）

Admission routine:

ò Endocervical swab for group B streptococcus, aerobic and anaerobic culture.

ò Tocolysis as preterm labor protocol, if indicated.

ò Transvaginal sonography for exclusion of forelying cord and measurement on diameter of cervical canal. (without contact with exocervix)

ò Sonography fetal assessment

Amniotic fluid index (adequate AFI ³ 8 cm)

Routine fetal biometry, estimated fetal weight, fetal monography, fetal biophysical activity

Umbilical cord Doppler wave form study. (S/D ratio, PI, RI)

ò Ultrasound guided amniocentesis

Amniotic fluid for Gram staining and culture

L/S ratio, PG, Lamellar body. ( > 32 wks GA)

ò Expectant management

Confined to bed rest

CRP st and qwk

CBC/DC st & qW2, W5

Weekly ultrasound for amniotic fluid index

Ultrasound fetal assessment every 2 weeks

NST bid

ò Repeated amniocentesis indicated when

increased white count over 50% of baseline data

significant increased CRP

maternal fever, tender lower abdomen, foul discharge.

Persistent fetal tachycardia.

妊娠與高血壓（Hypertensive Disorder of Pregnancy）

 定義及分類：

Pre-eclampsia (pregnancy induced hypertension; toxemia): 大於20週

Triad: proteinuria, edema, hypertension

Hypertension:      Diastolic pressure > 90 mmHg; or a rise of diastolic pressure of 15 mmHg at least

Systolic pressure > 140 mmHg; or a rise in systolic pressure of 30 mmHg血壓測量至少兩次（間隔6小時以上）

Proteinuria:          24小時尿中protein > 300 mg/L; or任意兩次尿液檢查（間隔6小時以上）之protein濃度> 1g/L.

Edema:                general accumulation of fluid.休息12小時之後仍有1+以上之pitting edema或一週間體重增加大於51b.

Table: Criteria for severe pre-eclampsia

收縮血壓 > 180 mmHg或舒張血壓 > 110mmHg;

（休息後測量，至少兩次間隔6小時以上）

Protein uria > 5 gm/24 hr urine; (3+ ~ 4+)

少尿 (Oligouria < 400 ml/24 hr)

Cerebral or visual disturbance

上腹痛 (epigastric pain)

肺水腫或Cyanosis

不明原因肝功能受損 (impaired liver function)

血小板減少 (thrombocytopenia)

Eclampsia:

Pre-eclampsia plus the development of generalized tonic-clonic seizure not caused by neurological disorders.

Chronic hypertension:

Persistent hypertension of at least 140/90 mmHg or greater before 20 wks GA.

Persistent hypertension beyond 6 weeks postpartum.

Superimposed pre-eclampsia or eclampsia:

Development of pre-eclampsia or eclampsia in woman with chronic hypertensive vascular or renal disease.

Transient hypertension:

Development of isolated hypertension later in pregnancy or early in the puerperium.

Management:

F Lab assessment:

CBC/DC Platelet qwk, Mg, Ca, Na, K, C1 qwk

Renal function: BUN, Cr, CCr qwk

Liver function: GOT, GPT, Alk-P qwk

Coagulation profile: PT, APTT qwk

DIC profile if abnormal PT, APTT or platelet

U/A, 24 hr urine protein

Anticonvulsant medication:

Magnesium sulfate (MgSO4 2 gm/amp): used > 60 years (美國)；治療濃度4 ~ 7meq/1.

Regimen: 4 gm (2 amp) slowly IV push as loading dose.

10 gm (5 amp) in D5W 400 ml run 1 ~ 2 Gm/hr with IV pump as maintain dose.

*20 gm (10 amp) in D5W 300 ml run 1 ~ 2 gm/hr with IV pump可減少輸液量

急救盤：Calcium gluconate; tongue depressor; Valium. (Oxygen and endo-tracheal tube)

注意項目：DTR q4h; Resp rate ( > 12 min); I/O ( > 100 ml/4hr)

Table: Magnesium toxicity

       癥        狀                        鎂濃度(mg/dl)

loss of patellar reflex                                8 ~ 12

feelinf of warmth, flushing                 9 ~ 12

somnolence                                             10 ~ 12

slurred speech                                         10 ~ 12

muscular paralysis                                    15 ~ 17

respiratory difficulty                         15 ~ 17

cardiac arrest                                           30 ~ 35

 其他anticonvulsant medication (歐洲)：dilantin; phenobarbital

*使用sedative (Valium and chlormethiazole) or antihypertensives無特別預防痙攣之作用。

Antihypertensive therapy:

Hydralazine hydrochloride (Apresoline): vasodilator; 10 mg/tab; 50 mg/tab; 20 mg/amp

Methyldopa (Aldomet): central a-agonist; 250 mg/tab

Labetalol (Trandate): a/b blocker; 200 mg/tab; 25 mg/amp

Management flow chart:

Nifedipine (Adalat): Ca blocker, 10 mg/cap

        150/100 mmHg < BP < 170/110

       BP > 170/110 mmHg

胎兒監視

· Non-stress test (NST):

· Biophysical profile:

Score < 6: Suspected chronic asphyxia

· Umbillical artery Doppler flow study: S/D ratio, RI, PI

· Amniocentesis for lung maturity: PG, L/S ratio, lamellar body

糖尿病與妊娠（Diabetes and Pregnancy）

※糖尿病母親胎兒之先天異常

心臟血管系統                                                Transposition of great vessels

（Cardiovascular）                                  Ventricular septal defect

                                                                Atrial septal defect

                                                                Hypoplastic left ventricle

                                                                Situs inversus

                                                                Anomalies of aorta

中樞神經系統                                                Anencephaly

（Central nervous system）                      Encephalocele

                                                                Menigomyelocele

                                                                Holoprosencephaly

                                                                Microcephaly

骨骼系統                                                        Caudal regression syndrome

（Skeletal）                                             Spinal bifida

泌尿生殖系                                            Abscent kidney (Potter syndrome)

（Genitourinary）                                    Polycystic kidneys

                                                                Double ureter

腸胃系統                                                        Tracheoesophageal fistula

（Gastrointestinal）                                  Bowel atresia

                                                                Imperforate anus

Classification of diabetes during pregnancy

Type of maternal diabetes

        Type I                                      Ketoacidosis

        Type II                                     obesity; hypertension

Metabolic control and timing

        Early pregnancy                        birth defects & spontaneous abortion

        Late pregnancy                         hyperinsulinemia, overgrowth, stillbirth,

                                                        Polyththemia, RDS

Maternal vascular complications

        Retinopathy                               worsening during pregnancy

        Nephropathy                             edema, hypertension, IUGR

        Atherosclerosis                         maternal death

Gestational Diabetes

        Fetal risk                                   hyperinsulinemia and macrosomia

                                                        ? stillbirth

        Maternal risk                             hypertensive disorder of pregnancy

                                                        Diabetes following pregnancy

Metabolic control

        Fasting glucose < 105 mg/dl (class A1)

        Fasting glucose > 105 mg/dl (class A2)      

妊娠與糖尿病-1 (From American Colledge of Obstetricians and Gynecologist)

A             Any                  Any                          None                                        A-1, diet only

B              Over 20            < 10                          None                                        Insulin

C              10 to 19            or 10 to 19                        None                                        Insulin

D             Before 10         or > 20                      Benign retinopathy             Insulin

F              Any                  Any                          Nephropathy                     Insulin

R              Any                  Any                          Proliferative retinopathy     Insulin

H             Any                  Any                          Heart disease                    Insulin

 妊娠與糖尿病-2

Class                Fasting Plasma Glucose                                     Postprandial Plasma Glucose

A-1          < 105 mg/dL                             and                   < 120 mg/dL

A-2          > 105 mg/dL                       and / or                 > 120 mg/dL

 DM Screen:

週數：24 ~ 28 weeks GA.

對象：肥胖者、有糖尿病（家族）史者、產檢有尿糖者等。（理論上應每位孕婦皆做）。

作法：不用禁食、服用50 gm葡萄糖水，一小時後測血糖（sensitivity 80%; specificity 90%）。若sugar ³ 140 mg/dL，則需做100 gm葡萄糖水之OGTT (oral glucose tolerance test)。

＊100 gm glucose tolerance test：需空腹至少8小時，先測空腹血糖值，然後喝下100 gm之葡萄糖水，之後隔1, 2, 3小時抽血，若四個數值中有任二數值異常則稱為妊娠糖尿病。

NDDG*           100 gm     105                  190          165          145          Plasma

Carpenter         100 gm     95                    180          155          140          Plasma

O’Sullivan        100 gm     90                    165          145          125          Whole blood

WHO               75 gm       £ 140                               £ 200                       Plasma
　

妊娠期間血糖控制目標（Rigid Control）

早餐前                                                            69 ~ 90

午餐、晚餐、睡前點心前                            60 ~ 105

飯後                                                                £ 120

凌晨2:00 ~ 6:00                                              > 60

 Insulin regimens for diabetic women during pregnancy

Regimen 1 * short + intermediate                           short + intermediate                  -

Regimen 2  short + intermediate      short            short + intermediate                  -

Regimen 3                short                  short            short + intermediate                  -

                                                                                                or long

Regimen 4                short                  short                       short                       Intermediate

                                                                                                                                  or long

Regimen 5                                   Constant infusion pump         

胰島素劑量從妊娠早期每公斤理想體重0.6單位，逐漸增加至足月之每公斤體重1單位左右。給法通常以短效型（regular insulin）搭配中長效型（NPH），分成早餐前及晚餐前二次給藥（餐前15 ~ 30分鐘）。

早餐前RI: NPH = 1:2

晚餐前RI: NPH = 1:1 (劑量約為早餐前之1/3)

Work-up and management during hospitalization for pregnant diabetes:

1.  SMA 12, HbA1c

2.  EKG

3.  U/A & U/C; 24 hr urine for CCr

4.  Consultation for Ophthalmologist, Dietian, social worker and diabetologist.

5.  DM diet 1800 kcal/day

6.  Blood sugar monitoring: AC & PC 1 hr tid. Plasma or Glucometer

7.  Adjust insulin requirement

Fetal well-being surveillance

1.  Baseline ultrasound examination

2.  Daily fetal movement (DFMR) since 32 wks GA

3.  NST

4.  Biophysical profile

5.  Doppler ultrasound examination

Tocolytic agents for pregnant diabetics

1.  Magnesium sulfate

2.  Prostaglandin synthase inhibitor

3.  b-mimetic (last resort)

4.  if ritodrine used, add KC1 40 meq in 500 ml fluid

Management for pregnant diabetics admitted in labor floor

ò Assessment of fetal lung maturity

        Ultrasound evaluation for good control diabetics

        Amniocentesis: lung maturity profile (PG, L/S ratio)

ò On continuous fetal monitoring

ò May on diet prior to active labor

ò Monitor blood sugar q2 ~ 4h

ò Prepare IV fluid: N/S 500 c.c. + RI 50 u (discard initial 50 c.c.)

ò NPO when in active labor

ò If blood sugar > 110 mg%: N/S run 100 c.c./hr

ò IV fluid: N/S 500 c.c. + RI 50 run 0.5 u/hr (5 mgtt/min)

  increase RI at 0.5 u increment per hour according to sugar level

ò If blood sugar ranging between 60 ~ 110 mg%

  switch IV fluid to D5S 500 c.c. run 100 ml/hr

ò If blood sugar < 60 mg%

  switch IV fluid D5S 500 c.c.

        165 ml/hr when BW 50 ~ 59.9 kg

        180 ml/hr when BW 60 ~ 64.9 kg

        195 ml/hr when BW 65 kg and over

ò When in active phase of labor (cervical dilatation over 4 cm)

  switch IV fluid to D5S

        165 ml/hr when BW 50 ~ 59.9 kg

        180 ml/hr when BW 60 ~ 64.9 kg

        195 ml/hr when BW 65 kg and over