婦產科筆記

2012 於國泰醫院婦產科

曾被考過兩次以上之題目: TOA, ovary cancer, breech, endometrial cancer, ovarian tumor良惡判斷, GBS, cancer分期, tumor marker, prolong labor.

	Site	別名	內含物	備註
Board ligament	子宮附近片狀		其實就是前後peritoneum
Round ligament	子宮到大陰唇	Ligamentum teres	Sampson’s artery在其內	TAH要打斷此ligament
Cardinal ligament (主韌帶)	子宮下(uterine cercix vagina)往pelvic wall	Transverse ligament	uterine artery 通過, broke造成Uterocele	最重要支持子宮的ligament
Infundibular pelvic ligament	輸卵管往上吊	Suspensory ligament	Contain ovarian artery	Salpingo oophorectomy打斷
Ovarian ligament	子宮到卵巢	Proper ligament		ATH+BSO切
Vesicouterine ligament	子宮到膀胱			支持子宮重要的ligament
Uterosacral ligament:	子宮到sacrum		Uterocele broke之ligment	在cervix與cardinal ligament相連
Vesicouterine pouch	子宮與膀胱間
Rectouterine pouch	Uterus和rectum間	Cul-de-sac of Douglas

T11&12 root傳導uterus pain sensation。

Secondeary amenorrhea是指6個月無月經，primary指16歲仍未有初經。

黃體退化是因為沒有HCG，HCG由synthetical trophoblast分泌。HCG約在10週達到最高（10000），此時也正好是vomiting最嚴重的時候，之後E2和黃體素改由胎盤分泌，12周後黃體會退化。

LH surge後12小時排卵，LH surge刺激第一次減數分裂且刺激granulosa, theca interna cell的LH receptor使黃體形成。

IVF在受精後第三天放入，正常胚胎受精後5或6天著床。

精子生成一般要70天左右。

Primary dysmenorrhea原因：prostaglandin上升會使子宮過度收縮，故可吃NSIAD. Prevelecnce: 60%.

 

PID Clinical Criteria (Novak 14)

Symptoms—-None necessary(下腹痛最常見，但也可能會完全沒症狀)

Pathogen:大多是重菌種。N gonorrhoeae. C trachomatis。但endocervical culture不一定符合intra-abdominal culture，可能也會有厭氧菌或腸內菌。

Signs⒈Pelvic organ tenderness(內診cervical有motion tenderness(lifting pain)或adnexal tenderness)⒉Leukorrhea and/or mucopurulent endocervicitis

Additional criteria to increase the specificity of the diagnosis

Endometrial biopsy showing endometritis

Elevated C-reactive protein or erythrocyte sedimentation rate

Temperature higher than 38°C

Leukocytosis

Positive test for gonorrhea or chlamydia

Elaborate criteria

Ultrasound documenting tubo-ovarian abscess

Laparoscopy visually confirming salpingitis

治療依據CDC guidline—–Outpatient Treatment

Regimen A Cefoxitin, 2 g IM, plus probenecid, 1 g oral concurrently, or Ceftriaxone, 250 mg IM, or Equivalent cephalosporin

Plus: Doxycycline, 100 mg oral BID for 14 daysa

With or without: Metronidazole, 500 mg oral BID for 14 days

Regimen B Ofloxacin, 400 mg oral BID14 days, or Levofloxacin, 500 mg oral QD14 days

With or without: Metronidazole, 500 mg orally BID for 14 daysa

Inpatient Treatment

Regimen A Cefoxitin, 2 g IV every 6 hours, or Cefotetan, 2 g IV every 12 hours,

Plus: Doxycycline, 100 mg orally or IV every 12 hours

Regimen B Clindamycin, 900 mg intravenously every 8 hours

Plus: Gentamicin, loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours

住院的indication：①diagnosis is uncertain ②pelvic abscess is suspected

③clinical disease is severe

TOA必須注院打抗生素，75%可以靠抗生素治好，治療無效時必須開刀引流。現在大多由放射科做echo或CT guide aspiration即可處理。

Fitz-Hugh-Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) It involves liver capsule inflammation. The symptoms are an acute onset, upper right-quadrant abdominal pain and tenderness. Laparoscopy may reveal “violin string” adhesions of parietal peritoneum to liver.

Dysfunction uterine bleeding

大多是anovulation造成的unopposed estrogen。量通常時大時小，但不會停。

Premarin (conjugated estrogens, CEE最早是從母馬中提鍊) 0.625mg。等價於estradiol valerate 2mg。Treatment: Premarin 4# q4h + Ponstan or Scanol (減少PGE1)+- Transamin (only 專家意見)。止血後Pemarin 1# QID吃三天或七天(內膜較薄時吃七天，較厚時只要吃三天)。最後Premarin 1# BID + Provera 5mg 1# BID吃14-21天。停藥後等一次月經來之後再吃一個週期的OCP(28days)調整經期。

OCP (簡稱Pill)

大多是levonorgestrel + ethinyl estradiol (EE)。優點：減少子宮內膜癌及卵巢癌機率，可能減低大腸癌機率。調整月經。

Side effects: estrogen: headache, nausea, mastalgia, melasma, hypertension.

Progestin: mood changes, fatigue, weight gain, libido decrease, acne, cholestasis.

Mini pill (只含preogesterol的效果)優點：哺乳時可用(estradiol會抵抗prolectin的泌乳效果)缺點：容易有break through breeding. 台灣目前買不到。

break through breeding: estrogen太低會使內膜變薄變脆反而會出血，量較正常月經少很多，但滴滴答答不會停。

新一代OCP: Diane-35: Progestin使用Cyproterone，它是一種antiandrogen，故不會有acne，反而能治療acne(仿單上的適應症之一)，weight gain效果較小。

Yasmin, Yaz(較低劑量): progestin使用Drospirenone, 它是spironolactone衍生物，除了anti-aldosterone的效果外也有antiandrogen的效果。因為有利尿效果，weight gain更低，目前市占率最高之OCP(超過50%)

Contraindications to estrogen-containing hormonal contraception (Johns Hopkins 4)

Smoking >15 cigarettes per day and age >35

Moderate or severe uncontrolled HTN

History of CVA or MI

Multiple risk factor for CAD: age, smoking, HTN, DM

History of or current DVT/PE

Symptomatic gallbladder disease

Migraines without aura and age >35

Migraines with aura or focal neurologic symptoms

Active hepatoma or liver cirrhosis or unexplained elevation of liver enzymes

Known or suspected breast cancer

Breast-feeding <6wk postpartum (theoretic risk of growth restriction)

Non-breast-feeding <3wk postpartum

Diabetic neuropathy, retinopathy, neuropathy, or other vascular disease

Valvular heart disease, complicated (SBE, pulmonary HTN, or AF)

Known thrombogenic mutation

Myoma:

Submucosal:最常見

Subserosal:可能torsion

Submucosal:造成不孕 or prolonged heavy bleeding.

Surgery 的indication?

• Myoma造成之anemia, abdominal pain (peritoneum distension), menorrhagia
• Size超過妊娠12wks, 擔心因此導致卵巢摸不到而延宕診斷卵巢病變
• 長的速度太快
• 產生壓迫的症狀mass effect，hydronephrosis
• 妨礙受孕
• 在low segment處怕會induce早產
• 肌瘤有torsion的現象
• Growth after menopause

	Adenomyosis	Myoma	Endometrial polyp
Symptom	Dysmenorrhea, menorrhagia, compression	Compression, dysmenorrhea	PMB若在更年期後的婦女，一般無症狀
Sono finding	Uterus脹大，hyper-echo, 無明顯之界線, 後壁亮	Hypo-echo, pseudocapsule	Hyperecho lesion, 有空泡狀
Specific	Honeycomb appearance, swiss cheese appearance	有時可見calcification，多為良性	像海綿的表現
Others	CA125↑	Menopause後會縮小	要與myoma D/D

Endometian cancer 停經後正常厚度<3mm，一般以5mm(Novak)或6mm(國衛院手冊)當cut off point。未停經正常可到15甚至18mm。多為serous or clear cell type(較惡性)。停經後出血最常見的原因是atrophy,非hyperplasia。

diagnosis: endometrial biopsy(類似用吸管去吸內膜，美國較常用) or D&C(sensitivity較高，需麻醉)or子宮鏡直接切片(用在高度懷疑但d&c無法確診時)，Pap smear檢出率低，不可以用於內膜癌篩檢或診斷。

Risk factor: PCOS, unopposed estrogen, obesity, DM, Tamoxifen use, nulliparity.初經早.

Hereditary nonpolyposis colonrectal caner(HNPCC)syndrome有50%的lifetime risk發生內膜癌，12%發生ovarian cancer。

Type I, 75% to 85% of cases, younger, perimenopausal women with a history of exposure to unopposed estrogen, either endogenous or exogenous. Mutations in the PTEN tumor suppressive gene and K-ras oncogene and microsatellite instability。

Type II, Estrogen independence.亞州&黑人較多。Arise in atrophic endometrium. p53 mutations.

子宮內膜癌的Histopathologic degree of differentiation:

Grade 1 <5% nonsquamous or nonmorular growth pattern (即<5% solid growth).

Grade 2  6%-50% nonsquamous or nonmorular growth pattern.

Grade 3 >50% nonsquamous or nonmorular growth pattern (>50% solid part)

Surgical staging. 新版!Ia:未超過一半myometrian; Ib:超過一半; Ic已取消; II: 侵犯cervical stroma未超出uterus(endocervical glandular involvement現在已歸到stageI)

Stage IIIa: 侵犯serosa或adnexae; IIIb; 侵犯vaginal或parametrial; IIIc1, positive pelvic  nodes; IIIc2: positive para-aortic nodes; stage VIa:侵犯bladder or bowl mucosa. VIb: diatant meta, include intraabdominal meta or inguinal lymph nodes.

治療原則(國衛院手冊): TAH+BSO, 拿pelvic and para-aortic nodes, washing cytology(但positive不影響stage), clear or serous type加做omentectomy及隨機腹膜取樣。做不做放療或化療無一致意見。

子宮內膜增生分類：

Simple hyperplasia (cystic without atypia): dilated or cystic glands with round to slightly irregular shapes, an increased glandular-to-stromal ratio without glandular crowding. Cancer change 1%.

Complex hyperplasia (adenomatous without atypia): architecturally complex (budding and infolding), crowded glands with less stroma without atypia. Cancer change 3%.

Atypical hyperplasia: cytologic atypia be categorized as simple or complex (8% and 29% cancer change)

Uterine Sarcoma staging不同於edometrium cancer，常見有Mixed Mullerian mesodermal tumor(MMMT，最惡性，與放射線照射有關)，Leiomyocarcoma(最常見)，Endometrial stromal sarcomas(ESS相較預後較好些)。總共約只占uterine cancers的2-5%。

Cervical cancer:  陰道鏡是各種pap smear病變大多可採用的選擇，包括ASC-H(high-grade squamous intraepithelial lesion), LSIC(low-grade squamous intraepithelial lesion),HSIC,SCC。ASC-US(atypical squamous cell of undetermined significance)另外可考慮3-6月後repeat pap smear或做HPV test(陽性要再做陰道鏡，陰性之後仍要每年檢查)。醋酸可使病變組織裡不正常蛋白質變性；懷疑是惡性的變化：acetowhite epithelium, mosaicism, punctuations, atypical vessels(最糟)。也可以用iodine染，染不上代表有問題。pap semar若打Adenocarcinoma可能來自endometrial (uterus), endocervical (cervix), extrauterine (origin from outside uterus and cervix), or the site。

	Regression to normal (%)	Persistent dysplasia (%)	Progression to CIN 2/CIN 3 (%)	Progression to invasive cancer (%)
CIN 1	57	30	11	0.3
CIN 2	43	35	–	14-22
CIN 3	32	48-56	–	22

CIN1可做LEEP或再follow，但CIN2及3一定要做LEEP或直接進一步手術。

High-risk HPV types (16, 18,最常見) 31, 33, 35, 45, (52, and 58臺灣較多)。6,11常見於菜花。

最常見的症狀：vaginal bleeding.尤其poscoital bleeding。

唯一用clinical staged的婦癌。治療原則early stage(IIa以前)傳統上以手術切除為主，IA1做extrafasia hysterectomy(純粹將子宮頸與子宮摘除)，IA2做modified或type 2 radical hysterectomy(拿掉parametrial and paracervical tissue到ureter附近及切除陰道上部)，並拿pelvics and paraarotic node，IB以上要做Radical Hysterectomy (Type 3:清到pelvic wall; ureter, rectum, bladder附近都要清)。Ib-IIa用骨盆放療或近接治療效果一樣。晚期多以放療為主，可加做化療效果較好(cisplatin最常用)。

Stage I: confined to the cervix (extension to the corpus would be disregarded). Stage Ia1: 顯微鏡下看到侵犯，深度不超過3mm, largest extension不超過7mm. Ia2: 深度不超過5mm. Ib不超出cervix: Ib1:肉眼下不超過4cm，Ib2：肉眼下超過4cm。Stage II:超出cervix: IIa:無parametrial invasion, IIa1: 肉眼下不超過4cm, IIa2: 肉眼下超過4cm. IIb:明顯parametrial侵犯。

Stage IIIa:侵犯下三之一vagina, IIIb: 侵犯pelvic wall and/or hydronephrosis or non-functions kidney. IVa: systemic meta IVb:侵犯臨近器官

Ovarian cancer以serous type最多,約佔七成，病理下會有psammoma body。

Tumor marker: CA125<35 IU/ml CA199<37 IU/ml   CEA<5ng/ml 無吸煙者<2.5

epithelian tumor cell type: Serous, Mucinous (類似endocervical的cell), endometrioid cell, clear cell(最惡性，組織學一定是grade3,類Mullerian cell ), malignant Brenner cell(transitional cell)。Peak incidence: 56-60 years。

High grade Serous tumor現在認為原發部位是在輸卵管而不是卵巢，可能是輸卵管去抓卵巢時將tumor cell掉到卵巢上，組織學上也類似fallopain tube的cell。

目前有研究對BRCA1/2突變者做預防性卵巢輸卵管切除可減少上皮癌的風險。

Hereditary nonpolyposis colonrectal caner(HNPCC)syndrome有50%的lifetime risk發生內膜癌，12%發生ovarian cancer。

Krukenberg’s tumor: May affect both ovaries; contains signet-ring cells. hematogenous metastatic caner常見來源: gastric, breast, colon.

Meigs’ syndrome: ovarian tumor, ascites, right hydrothorax.

Histology –Germ cell tumor: 15% to 20% of ovarian tumors	AFP	hCG
Dysgerminoma(LDH會高) related to Turner’s syndrome	–	±
Yolk sac tumor  (most common ovarian cancer in girls <4 years old)	+	–
Immature teratoma. (Struma ovarii type has functioning thyroid tissue)	±	–
Choriocarcinoma	–	+
Embryonal carcinoma	+	+
Mixed germ cell tumor(LDH會高)	±	±

Yolk sac tumor(endodermal sinus)–Schiller-Duval: glomerulus-like central blood vessel.

Granulose-theca cell tumor會分泌estrogen, Low-grade malignant tumor但All granulosa cell tumors are potentially malignant。Tumor marker為inhibin。Recurrence可能發生在5-30年後。—-Call-Exner bodies, small distinctive, like immature follicale。

Sertoli-Leydig tumors: <40 years。produces androgens。

Risk factor（國衛院手冊）：未曾生產、家族史(上皮癌5-10%有家族遺傳性)、第一胎晚於35歲，連續使用排卵藥超過一年。25歲前懷孕及哺餵母乳可減低風險。

Surgical staging(國衛院手冊): 必須開腹不可用腹腔鏡手術。TAH+BSO(salpingo-oophorectomy), omentectomy, 拿pelvic and paraaortic lymph nodes，若無明顯腹部轉移要做blind biopsy包括subdiaphragm, cul de sac等處，peritoneal washing and cytology, serous type應拿闌尾

Grade III & IV要做debulky surgery，切越乾淨越好並做化療，optimal resection是指殘存腫瘤的最大直徑小於1公分。

stage IA or IB, grade 1不用打化療, grade 3一定要打化療。

Chemo一線：carboplatin(或cisplatin) and paclitaxel。二線無明確首選藥物，下列可用： topotecan, gemcitabine, etoposide, doxorubicin等。

FIGO stage: I: 局限於卵巢內(單或雙側) Ia:單側，capsule intact, 卵巢表面無tumor, ascites or peritoneal washing無malignant cell。Ib:雙側，其餘同Ia。

Ic: tumor on surface, rupture or ascites peritoneal washings with malignant cells.

Stage II: pelvic implants or extension. IIa: extension or implants on uterus or tube. No malignant cells in ascites or peritoneal washings. IIb: extension or implants on other pelvis tissues. No malignant cells in ascites or peritoneal washings. IIc:等同IIa and IIb但有malignant cells in ascites or peritoneal washings.

Stage III: microscopicall peritoneal confirmed metastasis outside the pelvis.

IIIa: micropic peritoneal metastasis IIIb: macroscopic peritoneal metastasis beyond pelvis, mass<2cm. IIIc(最常見): >2cm peritoneal meta or regional lymph node meta.

Note: live capsule meta: T3/stageIII, live parenchymal meta: T4/stage VI, pleural effusion positive cytology: T4/stage VI.

超音波下分辦卵巢腫瘤：(ovary正常size: 初經前<1cm, 孕齡2-4cm)

	Benign	Malignant
RI (resistance index)	>0.4	<0.4
PI (pulsatility index)	>1	<1
Septum	薄、regular	Irregular、厚
Solid part (echo complex)	Non	Often
Papillary projection	Non	Often
Size	小	大
Site	通常單側	通常雙側
Appearance	Regular	irregular
Ascites*	Non	Often
Growth	Slow	rapid
可不可動	Moveable	fixed

*：有ascites要送cytology。

除此之外要考慮age，menopause與否，有無weight loss, general malaise,  fever, dyspnea。檢查Chest-ray。

 

 

產科：評估胎兒肺部成熟：phosphatidylglycerol。

安胎藥：Ritodrine=Yutopar=beta agonist, side effect: palpitation, tachycardia, headaches, anxiety, dyspnea, pulmonary edema。劑型:50mg/5ml/amp。FEMH dose: 150mg in D5-500ml run 20ml/h。

人工墮胎：Mifepristone=RU486，progesterone antagonist，用於早期懷孕-<49days。常會配合使用Misoprostol=PGE1=prostaglandin=Cytotec(用於引產時；FEMH dose 1/8顆塞陰道)。

MTX=Methotrexate：主要用於ectopic pregnancy，也可用於早期墮胎。造成abortion時間較久，約兩周。但abdominal cramping and hemorrhage等side effect較RU486少。

Suction curettage(D&C)：用於早期。

Dilation & evacuation(D&E):用於較晚期。

Induction of labor：用於較晚期。主要有三種方式：Oxytocin, 羊水內注射(hypertonic saline, PGF2a, hyperosmolar urea)。目前常用Cytotec塞vigina，但目前cytotec用於引產還是off label use。Cytotec原本是用來保護胃部 (吃NSAID時併用Cytotec當作胃藥)

Amniocentesis indication：15-18週(William23) 抽20ml羊水

• AMA高齡產婦>34歲(媽媽手冊) Serum screening risk >1/270(媽媽)
• 生過染色體異常or NTD的胎兒 父母或家族染色體異常
• 超音波篩檢異常(媽媽手冊) 父母為隱性帶原者
• (媽媽手冊)生過先天異常小孩，父母或家族有遺傳疾病

Vaginal spotting or amnionic fluid leakage in 2-3%. Fetal loss <0.5%.

Chorionic Villus Sampling (CVS) 10-13w (William23)

First trimester aminocentesis 11-14w: Higher rates of pregnancy loss, 2.5%.

	Strategy		Analytes				Detection Rate %
	First-trimester screen		NT, PAPP-A, hCG or free hCG				79–87(11-14weeks)
	NT (First trimester)		NT				64–70
	Triple test		MSAFP, hCG or free hCG, uE3				60–69(16-18weeks)
	Quadruple (Quad) test		MSAFP, hCG or free hCG, uE3, inh				67–81
		Beta-hCG		AFP	E3 (estriol)	Inhibin-A		PAPP-A
Down syndrome$		↑		↓	↓	↑		↑
NTD$				↑
Trisomy 18$		↓		↓	↓

	Trisomy 13	Trisomy 18	Trisomy 21
Name	Patau syndrome	Edward syndrome	Down syndrome
Incidence	1/10000	1/6000	1/800-1000 次胎Recurrence rate 1%
	Male=female	F > M (4:1)
致病機轉	1.      Trisomy 13(75%) 2.      Translocation (20%) 3.      Mosaicism (5%)	1.      Trisomy 18(90%) 2.      Mosaicism(10%)	1.      Trisomy 21 (95%) 2.      Unbalanced translocation (3-4%) 3.      Mosaicism (1-2%)
特徵	Holoprocencephaly前腦發育異常, coloboma貓眼(iris或其他眼睛結構有洞), microphthalmia, cleft lip or palate, polydactyly, Congenital heart disease	Microcephaly with prominent occiput凸枕骨, choroids plexus cyst , omphalocele, spinal bifida, overlapping clenched fingers手指交疊, rocker-bottom feet搖椅腳	沒有nasal bone, Low set ear, CHD, nuchal translucency↑, excess skin on neck, ear tag耳前凸一粒, simian crease斷掌, 眼距寬, epicanthic folds

Choroids plexus cyst並不算少見，大多會隨懷孕週數自行消失，寶寶大多也沒特別異常。若為雙側或伴有其他異常才要懷疑trisomy 18.

Percutaneous Umbilical Cord Blood Sampling；PUBS於妊娠20週或以上時，經皮採取臍帶血來進行細胞培養(約3天)，再做染色體分析。

Turner’s syndrome：Chromosome 45XO, webbed neck, heart defeats, cystic hygroma, kidney abnormalities，short status但智力正常，99%不孕。

產檢(媽媽手冊)：28週前4週1次，29-36週2週1次，37後每週1次

12週前驗：血液常規WBC, RBC, PLT, Hct, MCV, Hb。血型, Rh factor, VDRL, Rubella IgG(陰性宜在產後注射疫苗), HIV, urine routine。可以在11週一起做first trimester唐氏症篩檢，若second trimester做要多抽一次血。

MCV<80可能是地中海貧血帶原者，必須請爸爸來抽血，若爸爸MCV>80則生下重症地中海貧血寶寶機率低，若爸爸也MCV<80必須檢查ferritin、HbA2及基因分析。

大約6-8週可由超音波看到心跳。胎動大約18-20週出現，第二胎可能會更早。

32週驗：HbsAg, HbeAg,(兩個都陽性健保幾付IVIG), 第二次VDRL。

24-28週可驗GDM screening test- 50g glucose(不需空腹，非一定要做但臺灣醫院幾乎都會做)

35-37週可加驗GBS或發生ROM或有早產可能時提早做。

GBS (william23): Swabs for culture should be obtained from both the lower vagina (vaginal introitus) and rectum (insert swab through the anal sphincter).

Neonatal sepsis usually develops within 6 to 12 hours of birth—these include respiratory distress, apnea, and hypotension. Early onset disease: less than 7 days after birth, rate 2-3/1000 per live births, mortality had declined to 4%, and preterm newborns are affected disparately. Baby的Meningitis會發生在1 week to 3 months after birth. (媽媽手冊)死亡率最高可達50%.

Also cause preterm labor, prematurely ruptured membranes, chorioamnionitis.

抗生素用PenicillinG或ampicillin，但只能預防early onset disease。

In FEMH使用Cefazolin 2g st IV PUSH之後1g q8h。

GDM：gestational DM懷孕24w後出現，生產後恢復正常。Pregestational(overt) DM是指產前就有DM。PDM比較會致畸胎，因teratogen影響大多是在6-10w時。

Carbohydrate Metabolism：mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia. Insulin resistence上升。原因仍不明，可能與estrogen, progesterone間接或直接影響有關。Plasma levels of placental lactogen increase with gestation, and this protein hormone is characterized by growth hormone–like action that may result in increased lipolysis with liberation of free fatty acids. The increased concentration of circulating free fatty acids also may aid increased tissue resistance to insulin.

Complication: obstetric: polydramnios, preecalmpsia, miscarriage, preterm delivery. Fetus: macrosomia(>4500g):→shoulder dystocia or C/S; still birth(原因未明的胎兒死亡，尤其是在>36w後出現。) malformation: caudal regression syndrome（像美人魚）, neural tube defects, situs inversus, cardiovascular. Newborn: hypoglycemia, hypocalcemia, RDS.

DM not associated with increased risk for fetal chromosomal abnormalities

PC sugar對預後影響較AC大。

懷孕24~28wks時安排一個例行的screening test(國外只用在high risk孕婦, ex家族有DM)，喝50g的糖水1hr後抽血若<140就算正常，現在有少部份會用較嚴格的135或130當標準。若>140mg/dl，則再做一次OGTT 100g的test，但確診方式仍無一致見解(Wil23)美國常用標準：空腹<95；1h<180；2h<155；3h<140，四次中有兩次高即確診。歐洲會用75g的OGTT來當標準。

Gestational Hypertension(William): Systolic BP >=140 or diastolic BP >=90 mmHg for first time during pregnancy. May have other signs or symptoms of preeclampsia, for example, epigastric discomfort or thrombocytopenia

• No proteinuria
• BP returns to normal before 12 weeks postpartum
• Final diagnosis made only postpartum

Preeclampsia: Minimum criteria: BP >=140/90 mm Hg after 20 weeks’ gestation

and proteinuria >=300 mg/24 hours or 1+ dipstick.

Severe preeclampsia(William目前沒一致定義):只要有任一項即符合：

SBP>160 || DBP>110 || Proteinuria >=3+ || headache || Visual disturbances || upper abd pain || oliguria || elevated creatinine || Thrombocytopenia || Fetal-growth restriction || liver enzyme elevation || lung edema

Superimposed Preeclampsia On Chronic Hypertension:

• New-onset proteinuria >=300 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/uL in women with hypertension and proteinuria before 20 weeks’ gestation

Chronic Hypertension:

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

HELLP syndrome(William: no universally accepted definition)

Hemolysis: LDH elevation。 Elevated liver enzymes: >2 normal limit(林主任)。Low  platelet: <10000。

Risk Factors: Nulliparous;多胞胎; obesity; chronic hypertension, autoimmune disease, DM, renal disease，家族或本人曾得過(pre/)ecalmpsia, molar pregnancy.

Evidence(考科藍)指出High or moderate risk的人吃aspirin可預防preecalmpsia。Calcium於very high risk病人有幫助。

終止懷孕是唯一能完全治療的方法(<23週考慮termination)。

Mild preecalmpsia >37w且況狀允許就delivery，週數小且症狀不嚴重可以保守治療並多休息，觀察媽媽與胎兒狀況(NST, Biophysical profile)。

Severe preecalmpsia必須每24小時監測媽媽與胎兒狀況，打MgSO4，收縮壓大於160或舒張壓大於110時打降壓藥。降壓藥可打hydralazine, labetalol, methyldopa。大於34週時Maternal distress, non-reassuring fetal status, labor, ROM就delivery，小於34週看狀況打steroid and delivery。

MgSO4(2g/20ml/amp): FEMH dose: loading dose: 40ml in bag. Maintain dose: 200ml in D5-300ml run 25ml/h(等同1g/hr，但目前書上建議打到2g/hr)

安全範圍: serum測<7 mEq/L。toxic: >8時DTR下降(打MgSO4每天都需要測)。>12時會cons. Change, respiratory depression。也可能發生EKG變化甚至cardiac arrest。

• Conservative Management of Severe Pre-eclampsia.:
  • Bed rest
  • Seizure prophylaxis for the first 24 hours of hospitalization
  • BP measurement every 4 hours. Daily examination to assess weight, review systems, check for edema, and check deep tendon reflexes
  • Daily monitoring of 24-hr fluid status, CBC with platelet count; and measurement of AST, LDH, and bilirubin levels
  • Daily 24-hour urine protein
  • Daily fetal surveillance including fetal movement counts and NST or biophysical profile

Fluid Management frequently hypovolemic. IV fluids should be restricted to 84 to 125 mL/hr. Diuretics may be used to treat pulmonary edema but should not be used otherwise in pre-eclamptic patients.

• Hydralazine hydrochloride, administered IV, is the drug of choice for acute BP control because it controls the BP without sacrificing uteroplacental blood flow.
  • The onset of action is 10 to 20 minutes, with a peak effect in 60 minutes and a duration of effect of 4 to 6 hours.
  • Intermittent bolus infusion should be used rather than continuous infusion.
  • Dosing should begin with a 5-mg bolus, and, if BP is not in the range of 150 to 140 mm Hg systolic and 100 to 90 mm Hg diastolic at 20 minutes, the bolus should be repeated at a dose of 5 to 10 mg. Boluses may be repeated every 20 minutes and doses increased to a maximum of 20 mg if no response occurs.
  • A decrease in urine output may occur 2 to 3 hours after a bolus when diastolic BP is below 90 mm
• Labetalol hydrochloride, administered IV, is an alternative therapy to IV hydralazine for women who cannot be given or have not responded to hydralazine.

 

Non-stress test (NST)：觀察20min，>2次fetal movement、fetal heart rate accelerations >15下above baseline(120-160 bpm)，duration＞15sec，為reactive。

Tachycardia Baseline FHR > 160：maternal fever最常見, hypoxia, maternal hyperthyroidism, fetal arrhythmia (SVT), maternal using beta-mimetics(Tocolysis)

Bradycardia Baseline FHR < 110 (Willi23): hypoxia, fetal arrhythmia(heart block), maternal using beta blockers。

Beat to beat variability：每分鐘心跳的次數是有變異(上上下下)代表著胎兒是處於較好的狀態，原因是fetus sympathetic and parasympathetic nerve system 兩者之間的拮抗造成。diminished or absent variability顯示可能有(1)hypoxia, or compromised fetus (2)tachycardia, (3) fetal sleep, (4)maternal drugs (analgesics and sedatives)。

— Absent—amplitude range undetectable

— Minimal—amplitude range detectable but <=5 bpm

— Moderate (normal)—amplitude range 6–25 bpm

— Marked—amplitude range > 25 bpm

如何於產前定義Abnormal (Wili23)

(1) Baseline oscillation of less than 5 bpm, (2) absent accelerations, and (3) late decelerations with spontaneous uterine contractions.

Variable decelerations, if non-repetitive and brief—less than 30 seconds—do not indicate fetal compromise or the need for obstetrical intervention.

Decelerations lasting 1 minute or longer: even worse prognosis.

Deceleration較常見於intrapartem，包括以下：

	Early deceleration	Late deceleration	Variable deceleration
Fetal monitor	尖尖對尖尖 (V-shape)	HR↓在宮縮期末期，有delay (U shape)	HR↓與宮縮無關，快速下降(開始掉至最低點<30sec) duration<2min
Cause	胎頭受到壓迫，因為刺激vagus n.→影響傳導→HR↓	Uteroplacental insufficiency (UPI) 引起acidosis造成fetal distress #	Umbilical cord compression Cord around neck Cord prolapse
Management	Wait and see*	改左側臥，用facial mask給予O2氧氣，IVF輸液，立刻C/S	Wait and see*，但若到severe (HR<60bpm, or HR>60bpm但duration >60sec) 則馬上C/S

Prolonged deceleration (William23): Deceleration is >15 bpm, lasting >2 min but < 10 min from onset to return to baseline.

Early deceleration	In association with a uterine contraction, a visually apparent, usually symmetrical, gradual—onset to nadir >=30 sec—decrease in FHR with return to baseline Nadir of the deceleration occurs at the same time as the peak of the contraction
Late deceleration	In association with a uterine contraction, a visually apparent, gradual—onset to nadir >=30 sec decrease in FHR with return to baseline Onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively
Variable deceleration	An abrupt onset to nadir < 30 sec, visually apparent decrease in the FHR below the baseline The decrease in FHR is >= bpm, with a duration of >= sec but < 2 min

sinusoidal fetal heart rate pattern: 像正弦波.etiology包括fetal anemia, hypoxia, chorioamnionitis, maternal nacrotics，處理的方式同late deceleration

• Biophysical profile (胎兒生理活動評估，over 30mins duration)

是用來評估胎兒狀況最具體的方式，也是最耗時最耗金錢的antepartum assessment tests。

變數	0分	2分
NST	Non-reactive	Reactive
Fetal movement胎動	<2次/30mins	>3次/30mins
Fetal breathing胎兒呼吸	absent	1 次持續30sec/30mins
Fetal tone胎兒張力	半伸展或伸展後無回復	彎曲→伸展→彎曲至少1次
AFI or amniotic fluid volume羊水容積	兩個垂直面上最大羊水袋<2cm or AFI < 5cm	兩個垂直面上最大羊水袋>2cm or AFI > 5cm

• fetal breathing看diaphragm的移動來判斷。

8~10分都視為正常，隔3~7天repeat一次，6分則為equivocal，隔24hrs再recheck一次，4分以下表示胎兒有缺氧、窘迫的現象，是indication of delivery。

AFI羊水量：Amino fluid index用來評估羊水量，將母親肚子依umbilicus分四個象限，分別去量羊水加起來即是。若AFI<8(normal 8~24cm)為oligohydramnios，>25或單一象限>10cm，則為polyhydramnios。

胎重：在台灣28wks大概1000g，36wks約2500g。

 

Labor

Caput succedaneum: scalp and periosteum之間。生產時出現，數天後消失。

Cephalo-hematoma: periosteum and skull bone間。產後數小時出現，數週消失。

Perineal laceration: grade1: vaginal mucosa. Grade 2: submucosa tissue. Grade 3: anal spincter or perineal body. Grade 4: rectal mucosa.

胎盤剝離：gush of blood→elongation of cord→elevation of fundus→glubular shape of uterus。

PROM premature rupture of membranes(有s是因為包括羊膜和絨毛膜)

定義為沒有產痛即破水。PPROM是指小於37週+PROM。橘紅色羊水棒Amnicato放入cervix posterior fornix 30秒，若便成黑色就表示破水，或用石蕊試紙(Nitrazine Test)，黃色 (陰道分泌物為酸性) 變成藍綠色 (羊水為鹼性pH7-7.5) 就表示破水。Risk factor是有intrauterine infection，complication也是感染—-chorioamnionitis。34週以上況狀允許即可生產。小於34週做sterile speculum examination評估狀況並做cultrue，同時臥床休息、打抗生素(ampicilin and erythromycin，FEMH dose: Keflex 1# q6h)及steroid。若有chorioamnionitis即須dlivery不可以安胎。小於22週可考慮termination。

產程First stage：Onset of labor and ends with full cervical dilation, divided into latent and active phases.

Latent phase: <20 hours in a nulliparous; <14 hours in a multiparous

Active phase: cervical dilation 3 to 5 cm. 擴張速度>1.2 cm/hr for nulliparous and 1.5 cm/hr for multiparous。>2hrs子宮頸口沒有進展稱secondary arrest of dilation。>1hr胎頭沒有下降稱arrest of descent。

Second stage: between full cervical dilation and delivery of the infant.

<2 Hr in nulliparous or 1 Hr in parous.有做epidura麻醉可多1Hr。

Third stage: between delivery of the infant and delivery of the placenta. <30min

急產定義：產痛後三小時內完成分娩，或擴張速度nulliparous>5cm, multiparous >10cm per hr。

頭位分娩：旋下屈內伸外娩：1.engagement 2.descent 3.flexion 4.internal rotation 5.extention 6.external rotation 2.expulsion

Cephalopelvic disproportion: 生產三個P: power, pelvis, passenger

由pelvimetry檢查，可用x ray或CT, MRI，觀察以下項目：

Sacral promontory  and the inner pubic arch  is termed obstetrical conjugate

Midpelvis: laterally by the inferior margins of the ischial spines. (as station 0)

Pelvic outlet: lateral-ischial tuberosities.前後-pubic symphysis, tip of the sacrum.

Forceps Delivery: Simpson forceps(湯匙跟夾子)

Indication: No indication is absolute. Indications include prolonged second stage of labor, maternal exhaustion, inadequate maternal expulsive effort……

Complications:

• Uterine, cervical, or vaginal lacerations, extension of the episiotomy, bladder or urethral injuries, and hematomas.
• Cephalohematoma, bruising, lacerations, facial nerve injury, and, rarely, skull fracture and intracranial hemorrhage.

Prerequisite Criteria: 至少station +2, cervix must be fully dilated, exact position and station of the fetal head should be known, bladder should be empty……

Vacuum delivery:使用時機類似forceps(看醫師習慣)，complication類似forceps. Avoided less than 36 w or with known thrombocytopenia (John Hopkins3)

Malpresentations胎位不正:

Face presentation: 必須把下巴轉到前面才生得出來

Brow presentation: 除非胎兒小&骨盆大或轉成face, vertex不然很難生出來。

Coumpound presentation: 手能自己縮回去就不用處理，但要注意其他問題ex: cord prolapse。

• Breech– Major congenital anomalies occur in 6.3% of term breech presentation infants compared to 2.4% of vertex presentation infants.
  • Breech presentation occurs in 25% of pregnancies at less than 28 weeks’ gestation, 7% of pregnancies at 32 weeks’ gestation, and 3% to 4% of term pregnancies in labor.
  • Frank breech (A)(48% to 73%) occurs when both hips are flexed and both knees are extended.
  • Complete breech (B)(5% to 12%) occurs when the fetus is flexed at the hips and flexed at the knees.
  • Incomplete, or footling breech (C)(12% to 38%), occurs when the fetus has one or both hips extended.
• Risks
  • head entrapment–胎兒通常頭大身體小。正常頭位產時頭先出來會把洞撐大，breech時洞還沒完全打開身體就先過，頭容易卡在裡面.
  • The risk of cord prolapse is 15% in footling breech, 5% in complete breech, and 0.5% in frank breech.
  • Frank, complete可以嘗試自然產，frank成功率較高。CS會增加媽媽morbidity and mortality但Vaginal breech delivery仍會增加以下risk:
    • Mortality (three to five times greater mortality rate if the fetus is heavier than 2,500 g and does not have a lethal anomaly)
    • Asphyxia (3.8 times greater risk)
    • Cord prolapse (5 to 20 times greater risk)
    • Birth trauma (13 times greater risk)
    • Spinal cord injuries (in hyperextention head)

Breech score system：

小於3必須CS。 大於5 vaginal delivery機會較高。 Breech index scoring system
Points assigned	0	1	2
Parity	Primagravida	Multigravida
Gestational age	39wks or more	37~38wks	36~37wks
Estimated fetal weight	Over 8 lbs	7~8 lbs	5~7 lbs
Dilation	2cm	3cm	4cm or more
Station	-3	-2	-1 or lower
Previous Breech	None	One	2 or more

Vaginal delivery assistant method: (重點:小孩出得來就不要硬拉)

↑↑Mauriceau maneuver頭出不來時 (劉V: 摳小孩嘴巴，摳maxilla會抓不住)

Prague maneuver(劉V說這招沒用，小孩臉一定要朝下才出得來)↑↑

←Pinard maneuver (frank時把腳往外拉，讓knee flexion。劉V：frank比較好生, 這招把frank變complete是反效果)

• Lovsett’s maneuver(劉V：william圖錯，是要把手往下撥，往上撥會骨折)

Piper forceps may be used to assist in delivery of the head.

C/S indication.  (*)is absolute indication (J-Hopkins3):

• • Fetal indications include
    • Nonreassuring fetal heart tracing
    • Nonvertex or breech presentation
    • *Conjoined twins
    • Fetal anomalies, such as hydrocephalus, that would make successful vaginal delivery unlikely
  • Maternal indications include
    • Obstruction of the lower genital tract (e.g., large condyloma)
    • *Abdominal cerclage
    • Active maternal herpes simplex virus infection
    • Previous cesarean section (if not an appropriate candidate for VBAC or VBAC is declined by the patient)
    • Previous uterine surgery involving the contractile portion of the uterus (classical cesarean, myomectomy)
  • Maternal and fetal indications include
    • *Placenta previa or known vasa previa
    • Abruptio placentae
    • Labor dystocia or cephalopelvic disproportion

VBAC(vaginal birth after cesarean section)

Contraindication: previous classical, inverted T- or J-shaped incision. Inability to perform emergency C/S. normal contraindication to vaginal delivery. Transfundal uterine surgery.

Complication: Uterine rupture (low segment transverse C/S: 0.2-1%. T-incision及classic C/S等切到active segment of uterus時機率達4-9%故為VBAC禁忌症). Diagnosis: severe abd pain, FHB消失 or bradycardia, shock.

Pospartum hemorrhage

Definition: >=500ml for vaginal delivery, >=1000ml for C/S. Acute PPH: <24hr. Late PPH: 24hr to 6~12 weeks

Etiology: (1)uterine atony: first step is bimanual massage, remove clot from the lower uterine segment to allow the uterus to contract adequately. Uterine contractile agensts: oxytocin, methlergonovine misoprostol. 最後招式call radiologist for embolization. (2)laceration: vulvar and vaginal hematomas associated with episiotomies. Retroperitoneal hematoma.(3)retained of conception(POCs) (4)placenta accreta包括三種類型:placenta acrreta (attach to myometirum), placenta increta, placenta percreata(穿透myometrium and serosa). (5)uterine rupture (6) uterine inversion: 及早發現時可用手復位，等太久子宮收縮太久就必須手術。(7)coagulopathy

Antepartum hemorrhage

1.Placenta previa(William) 70-80%有無痛性出血. Bright red, acute onset.

Usually first episode is around 34w. 但1/3發生在30週之前。1/3發生在36週後。10%一直到term都沒出血。

Number of bleeding episodes is unrelated to the degree of placenta previa or the prognosis for fetal survival.

Placenta previa is associated with doubleing of the rate of congenital malformation.

Total placenta previa—the internal os is covered completely by placenta

Partial placenta previa—the internal os is partially covered by placenta

Marginal placenta previa—the edge of the placenta is at the margin of the internal os

Low-lying placenta—the placenta is implanted in the lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it.

2. Abruptio placentae(john-Hopkins)疼痛性出血
   • The amount of external bleeding varies from none to massive hemorrhage. The amount of bleeding, however, does not correlate well with the severity of the abruption
   • The presence of blood in the basalis stimulates uterine contractions, which results in abdominal pain.
   • Fetal and maternal mortality rates vary, depending on the location and size of the hemorrhage.

3. Vasa previa (VP) (john-Hopkins) can occur when the umbilical cord inserts into the membrane of the placenta instead of the central region of the placenta. When one of these vessels is located near the internal os, it is at risk of rupturing and causing fetal hemorrhage. VP can also occur when vessels that lead to an accessory lobe or a velamentous cord insertion cover the internal os. Velamentous cord insertion is much more common in multiple gestations.