醫智庫 婦產科
10-1. 妊娠高血壓與相關疾症
婦產科
周明明 醫師
學習目標
Hypertensive
disorders
of
pregnancy,
including
preeclampsia complicates up to 10% of pregnancies
worldwide, constituting one of the greatest causes of
maternal and perinatal mortality and morbidity, New best
practice recommendations are greatly needed to guide
clinicians in the care of women with all forms of
preeclampsia and hypertension that occur during
pregnancy, particularly women with acute severe
hypertension and superimposed preeclampsia.
學習大綱
1. 高血壓新定義
2. 妊娠高血壓發生率,分類
3. 妊娠高血壓篩檢,預防
4. 妊娠高血壓藥物治療
1. 高血壓新定義
New ACC/AHA High Blood Pressure
Guidelines Lower Definition of Hypertension
Nov 13, 2017
BP Category
SBP
DBP
Normal
<120 mm Hg
and
<80 mm Hg
Elevated
120–129 mm Hg
and
<80 mm Hg
Hypertension
Stage 1
130–139 mm Hg
or
80–89 mm Hg
Stage 2
≥140 mm Hg
or
≥90 mm Hg
*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2
occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.
Doing HBPM by the book to avoid the misleading white coat hypertension
Home Is Where the Real Blood Pressure Readings Are
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Prior to labeling a person with hypertension, it is important to use an
average BP based on ≥2 readings obtained on ≥2 occasions. Out-of-office
and self-monitoring of BP measurements are recommended to confirm the
diagnosis of hypertension
Take two BP measurements 1-2 minute apart during 6-9 a.m. Avergae
them
Take two BP measurements 1-2 minute apart during 6-9 p.m. Avergae
them.
Average the morning and evening measurements for an all-day average.
Average all of the other morning, evening, and all-day measurements for
the week. This final average is used to describe how to manage the
patient.
Home blood-pressure monitoring in a hypertensive pregnant population
Ultrasound Obstet Gynecol. 2018 Apr;51(4):524-530
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An automated Microlife© ‘WatchBP Home’ bloodpressure machine (Microlife Corporation, Taipei,
Taiwan), which has been validated for use in
pregnancy and PE
NICE recommendations for hospital admission for
systolic blood pressure of 160 mmHg or diastolic blood
pressure of 110 mmHg
Conclusion：HBPM in hypertensive pregnancies has
the potential to reduce the number of hospital visits
required by patients without compromising maternal
and pregnancy outcomes
數位血壓量測系統
全球產量排名第二名
懷孕期血壓變化
Blood Pressure Changes in Pregnancy
Blood Pressure (mm-Hg)
120
100
80
60
40
nonpregnant
8
12
16
20
24
28
32
Pregnancy Duration (weeks)
36
40
6 wks
postpartum
2. 妊娠高血壓發生率,分類
妊娠高血壓分類
Classification of hypertensive disorders complicating pregnancy
Gestational hypertension
妊娠高血壓
Gestational hypertension refers to elevated BP first detected after 20 weeks of
gestation in the absence of proteinuria or other diagnostic features of PE. Over
time, some patients with gestational hypertension will develop proteinuria or endorgan dysfunction characteristic of PE and be considered preeclamptic, while
others will be diagnosed with preexisting hypertension because of persistent BP
elevation postpartum.
Preeclampsia-eclampsia
(妊娠毒血症)子癎前症.
子癎症
PET refers to the syndrome of new onset of hypertension and proteinuria or new
onset of hypertension and end-organ dysfunction with or without proteinuria, most
often after 20 weeks of gestation in a previously normotensive woman. Eclampsia
is diagnosed when seizures have occurred.
Chronic (preexisting)
hypertension
慢性高血壓
Chronic hypertension is defined as hypertension that antedates pregnancy, is
present before the 20th week of pregnancy, or persists longer than 12 weeks
postpartum.
Preeclampsia-eclampsia
superimposed upon
chronic hypertension
子癎前症.子癎症加重原
本存在的慢性高血壓疾病
Preeclampsia-eclampsia superimposed upon chronic hypertension is diagnosed
when a woman with chronic hypertension develops worsening hypertension with
new onset proteinuria or other features of preeclampsia (eg, elevated liver
chemistries, low platelet count)
原發性酮荃固醇過多症
Primary aldosteronism
低血鉀引起肌肉病變及血壓高
Midpregnancy presented with severe hypertension and hypokalemia
腎上腺皮質腺瘤
Adrenocortical adenoma
妊娠高血壓發生率
UpToDate 2018
Commonly cited to be about 5-10%
( 6-17% of healthy nulliparous women and 2-4% of multiparous women)
(influenced by parity, racial, genetic, age and environmental factors).
Eclampsia
approx. 4-5/10,000 live births
(1.5-10 /10,000 deliveries in developed countries . In developing countries,
however, the incidence varies widely: from 6-157/10,000 deliveries).
HELLP syndrome
0.1 - 0.2 % of pregnancies overall and in 10-20% of women with severe
preeclampsia/eclampsia.
Who are at risk for preeclampsia?
Primiparity vs. multiparity
3-6X 第一胎
Family history of preeclampsia
3.5-7.0X 家族史
Overweight,
obesity > 40%
3X 肥胖
Essential hypertension
12X 本態性高血壓
Chronic renal disease
10X 慢性腎臟疾病
Diabetes
4X 糖尿病
Multiple pregnancy
4X 多胞胎懷孕
Hydatidiform mole
12X 葡萄胎
Fetal hydrops
12X 胎兒水腫
Susceptible genetic predisposition, the identification of groups
of women predisposed to preeclampsia
哪些人容易妊娠先兆子癇(子癇前症)?
 先兆子癇家族史(RR 2.90, 95% CI: 1.70 to 4.93)
In familial occurrence of the disease higher frequency of preeclampsia has been
observed in mothers, daughters and sisters.
 上一胎先兆子癇：relative risk 7.9, 95% confidence
interval 5.85 to 8.83
 免疫風濕抗心脂抗体 RR 9.72 95% CI 4.34 to 21.75)
病因學拼圖
Placental ischemia (failure of trophoblast invasion)
胎盤微小循環系統沒有成功建立起來產生低阻力的
子宮胎盤血流,可能會產生嚴重的母親細胞激素發炎
反應滋養層細胞浸潤能力下降
胎盤缺血
氧化應激
細胞凋亡、釋出微顆粒
、抗血管生長因子
血管重塑障礙
血管內皮損傷
免疫因素
最後導致全身小
動脈痙攣、血壓
增高
Hypertensive disorder complicating
pregnancy is a syndrome of T-helper 1 and
T-helper 2 (Th1 and Th2).Over-expression
of Th1 cells and imbalance of Th1/Th2
might lead to hypertensive disorder
complicating pregnancy.It is a form of
rejection of the paternal half of the fetal
genetic makeup.
隨病情發展可出現
一系列臟器損傷
Uterine
blood
vessels
3. 妊娠高血壓篩檢, 預防
Screening for PIH
History：primigravida,
woman with a new partner,
past and family history of
PIH
High body mass
index
Blood pressure measurement:
Mean BP > 90 mmHg and Uterine
artery Doppler velocimetry
waveforms: diastolic notch and
uterine artery pulsatility index (PI)
are increased
Biochemical tests ：
pregnancy associated
plasma protein-A (PAPP-A),
placental insulin growth
factor (PIGF) are decreased
at 11-13 weeks
Vascular pressor
angiotensin II
sensitivity test
Early screening for PIH by a
combination of maternal factor,
MAP, UA PI, and PAPP-A and
PIGF is particularly effective in
identifying severe early onset PIH
Fig. 8.1 Uteroplacental waveform from a normal pregnancy after 24 weeks’ gestation
Fig. 8.2 Uteroplacental waveform from a normal pregnancy complicated by pre-eclampsia.
Note the presence of the notch.
Biochemical prediction of preeclampsia
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Serum uric acid concentration .
Antithrombin III and platelet count
Thrombocytopenia may be the first indicator of disease, mild 100,000150,000/uL; moderate 50,000-100,000; severe <50,000
Microalbuminuria (20-200 mg/24 h)
Markers of endothelial dysfunction and TNF: Soluble vascular
endothelial growth factor (VEGF) receptor 1 (sFlt-1), soluble Endoglin
and placental growth factor, plasminogen activator inhibitor (PAI-1),
serum thrombomodulin, endothelin-1 (potent vasoconstrictor), free fatty
acids
Increased plasma free beta hCG during maternal serum Down
syndrome screening test.
First-Trimester Risk Assessment for
Early - Onset Preeclampsia
Recommendations
Taking a detailed medical history to evaluate for risk factors is currently the
best and only recommended screening approach for preeclampsia; it should
remain the method of screening for preeclampsia until studies show that
aspirin or other interventions reduce the incidence of preeclampsia for women
at high risk based on first-trimester predictive tests.
Current predictive tests for preeclampsia may harm more women than they benefit
because of their low positive predictive value (PPV). These tests require a large
number of women to be identified as high risk and to potentially undergo intensive
surveillance in order to detect one case of early-onset preeclampsia.
The American College of Obstetricians and Gynecologists does not
recommend screening to predict preeclampsia beyond obtaining an
appropriate medical history.
ACOG COMMITTEE OPINION (Number 638, September 2015, Reaffirmed 2017)
Box1. Clinical Risk
Factors for Preeclampsia
Primiparity
Previous
preeclamptic
pregnancy
Chronic
hypertension,
chronic renal
disease, or both
History of
thrombophilia
Multifetal
pregnancy
In vitro
fertilization
Family history of
preeclampsia
Type I diabetes
mellitus or
type II diabetes
mellitus
Obesity
BMI >35
Systemic lupus
erythematosus
and APS
Advanced maternal
age(older than 40 ears)
Reprinted from American College of Obstetricians and Gyne-cologists. Hypertension in
pregnancy. Washington, DC: Ameri-can College of Obstetricians and Gynecologists; 2013.
Implementation of the sFlt-1/PlGF ratio for prediction
and diagnosis of pre-eclampsia in singleton pregnancy:
implications for clinical practice
聲明1
Statement 1: sFlt-1/PlGF < 38
 sFlt-1/PlGF ratio < 38 rules out PE, irrespective of gestational age, for at least 1 week.
Further management is according to the clinician‘s discretion.
H Stepan et al. Ultrasound Obstet Gynecol. 2015 ; 45: 241–246
聲明2
比值>85為早發性子癲前症，比值>110為晚發性子癲前症
Statement 2: sFlt-1/PlGF ratio > 85 (early-onset PE) or > 110 (late-onset PE)
 Diagnosis of PE or placenta-related disorder is highly likely. Management according to
local guidelines.
 Severely elevated sFlt-1/PlGF ratios (> 655 at <34 + 0 weeks; > 201 at ≥ 34 + 0 weeks)
are associated closely with the need to deliver within 48 h. Close surveillance and (if
< 34 weeks) prompt initiation of antenatal corticoids to accelerate fetal lung maturation
are mandatory.(<34周>655及>34周>201比值嚴重升高，建議在48小時內生產
聲明3
比值>85為早發性子癲前症，比值>110為晚發性子癲前症，建議2-4天重
新再驗，看比值趨勢變化
Statement 3: sFlt-1/PlGF ratio > 85 (early-onset PE) or > 110 (late-onset PE),
repeat measurement
 Re-measure after 2–4 days to determine trend and follow up according to clinician's
discretion depending on severity.
 The test frequency can be adapted to the clinical situation and trend in sFlt-1/PlGF ratio
dynamics.
Prevention of preeclampsia
 Low-dose aspirin therapy (80-150 mg/day)
 Nutritional prevention: Vit C and E, Zinc, Magnesium,
Omega-3-fatty acids, Calcium supplementation do not
seem to be a definitive preventive strategy.
 Failure of diuretics and dietary sodium restriction.
Aspirin versus Placebo in Pregnancies at
High Risk for Preterm Preeclampsia
Background
Preterm preeclampsia is an important cause of maternal and perinatal death and complications.
It is uncertain whether the intake of low-dose aspirin during pregnancy reduces the risk of
preterm preeclampsia.
Methods
In this multicenter, double-blind, placebo-controlled trial, we randomly assigned 1776
women with singleton pregnancies who were at high risk for preterm preeclampsia to
receive aspirin, at a dose of 150 mg per day (at night), or placebo from 11 to 14
weeks of gestation until 36 weeks of gestation. The primary outcome was delivery
with preeclampsia before 37 weeks of gestation. The analysis was performed
according to the intention-to-treat principle.
Rolnik DL et al. N Engl J Med 2017; 377:613-622
Results
798 participants in the aspirin group and 822 in the placebo group. Preterm
preeclampsia occurred in 13 participants (1.6%) in the aspirin group, as compared
with 35 (4.3%) in the placebo group (odds ratio in the aspirin group, 0.38; 95%
confidence interval, 0.20 to 0.74; P=0.004, 62% drop ). ------Conclusions
Treatment with low-dose aspirin in women at high risk for preterm preeclampsia
resulted in a lower incidence of this diagnosis than placebo.
Rolnik DL et al. N Engl J Med 2017; 377:613-622
4. 妊娠高血壓藥物治療
Antihypertensive therapy-When to treat
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Treatment of severe hypertension (systolic BP ≥160 mmHg and/or
diastolic BP ≥110 mmHg) is always recommended because it is
believed to reduce the risk of maternal stroke and other serious
maternal complications.
The optimal blood pressure threshold for initiating therapy-systolic
pressures ≥150 mmHg or diastolic blood pressures ≥100 mmHg. We
may initiate treatment at even lower levels in women with signs of
cardiac decompensation or cerebral symptoms (e.g, headache, visual
disturbances, chest discomfort, shortness of breath, confusion) and in
younger women whose baseline blood pressures were low (less than
90/75 mmHg).
Antihypertensive therapy-When to treat
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In a 2015 trial (CHIPS, Control of Hypertension in Pregnancy Study) that
randomly assigned pregnant women with gestational or chronic hypertension to
diastolic blood pressure treatment targets of 85 mmHg (tight control) or 100
mmHg (less tight control), there were no differences in maternal, fetal, or
neonatal outcomes for the two blood pressure targets, although fewer women
in the tight group developed severe hypertension.
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An important finding of the CHIPS trial was that, in a post hoc analysis, severe
maternal hypertension was associated with lower infant birth weight, and more
preterm delivery, preeclampsia, and features of HELLP syndrome
In a 2017 meta-analysis of 15 trials of antihypertensive therapy versus placebo/no
treatment of pregnant women with chronic hypertension, antihypertensive
therapy reduced the incidence of severe hypertension (relative risk [RR]
0.33, 95% CI 0.19‐0.56), with no difference in birth weight, nor the incidence of
superimposed preeclampsia, stillbirth/neonatal death, or small for gestational age
Antihypertensive Medications
Our target blood pressures are 130 to 150 mmHg/ 80 to 100 mmHg
1
First-line in pregnancy: Methyldopa (500-3000 mg/day) —Methyldopa has been widely used in
pregnant women and its long-term safety for the fetus has been demonstrated, but it is only a
mild antihypertensive agent and has a slow onset of action (three to six hours).It remains useful
in this setting.
2
Labetalol (trandate) has both alpha- and beta-adrenergic blocking activity, and may preserve
uteroplacental blood flow than traditional beta-blockers. labetalol is effective and generally safe in
pregnancy, although data are limited. 200-400 mg bid; Beta-adrenergic blockers that lack alphablocking properties (eg, atenolol) have been associated with slightly lower placental and fetal weight at
delivery when used early in pregnancy, and are generally avoided
3
4
5
6
Calcium channel blockers-Data on the safety of calcium channel blockers during pregnancy are mixed.
amlodipine 1# qd-bid
Thiazide diuretics -Diuretics are not generally used in women with preeclampsia unless pulmonary
edema has developed
Clonidine — Clonidine has a similar mechanism of action as methyldopa and can be an effective drug
for treatment of mild hypertension in pregnancy.
Postpartum treatment: diuretics, tenormin, nifidipine, trandate and/or ACE inhibitor and ARB
(contraindicated during pregnancy), use either singly or in combination
Antihypertensive Medications
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Long-acting nifedipine (30 to 90 mg once daily as sustained release
tablet, increase at 7- to 14-day intervals, maximum dose 120 mg/day)
has been used without major problems.
We caution against the use of immediate release oral nifedipine,
although an American College of Obstetricians and Gynecologists
committee opinion endorsed its use as an option for emergent
treatment of acute, severe hypertension in pregnancy or postpartum
less than 2 percent of women treated with nifedipine developed
hypotension and short-acting nifedipine, parenteral hydralazine, and
labetalol were associated with similar rates of adverse maternal and
fetal outcomes
MANAGEMENT OF SEVERE PRE ECLAMPSIA
Control Hypertension
Treat Hypertension if systolic BP≥ 160mmHg or diastolic BP ≥110 mmHg or MAP
≥120mmHg.Aim to reduce BP to around 150/85-100mmHg
Labetalol: (Trandate)If BP still uncontrolled, 5-15 mg IV, then 20-80 mg IV q 10-20
min, titrated IV infusion 1-2 mg/min (oral 3:1 beta to alpha ratio, IV 7:1 ratio); or IV
infusion of 200 mg in 200 ml NS,starting at 40 mg/hour, increasing dose at 1/2 hourly
intervals as required to a maximum of 160 mg/hour
Calcium channel blockers or iv nicardipine infusion (initial iv infusion 3 mg/h, increase
by 2.5 mg/hour increments every 15 min to maximum 9 mg/h; nicardipine should be
diluted with NS or D5W to 0.1-0.2 mg/mL)
Hydralazine : (Apresoline) 10 mg IV slowly Repeat doses: 5 mg IV at 20 minute
intervals may be given if necessary (the effect of a single dose can last up to 6 hours)If
no lasting effect with boluses (assess over 20 minutes), consider an infusion at 2.0
mg/hour increasing by 0.5 mg/hour as required 2-20 mg/hour usually required.
避免使用
Nitroglycerine
Initial IV infusion of 5 mcg/min and titrate to desired
response by doubling the dose every 5 minutes.
避免使用強效血管擴張劑，容易造成腦部血流增加充血造成腦水腫
Magnesium sulphate MgSO4
 MgSO4 to control convulsions (mainly central blocking effect),
is not given to treat hypertension, however, significant fall in
BP have been observed.
 Dosage schedule: loading dose of 4-6 g i.v. followed by i.v.
infusion of 1-2 g/h continued for 24 -48 hr after delivery.
 Therapeutic levels 4-7 mEq/Ln ( 4.8-8.4 mg/dl), loss of
patellar reflex with 8-10 mEq/L, respiratory arrest >12 mEq/L
 Reduced dose in renal insufficiency or oliguria, plasma
magnesium levels must be checked periodically
 Antidote 1 g calcium gluconate 10ml of a 10% solution.
Magnesium sulfate tocolysis and pulmonary
edema: The drug or the vehicle?
 肺水腫發生危險因子靜脈點滴液輸入過多所致、硫酸鎂藥
物過度使用、多胞胎、發燒感染以及合併其他安胎藥物或
類固醇使用
 Risk factors for developing pulmonary edema include:
greater MgSO4 and intravenous fluid infusion rates, less
concentrated MgSO4, infection, multiple gestations,
concomitant tocolytics, large positive net fluid balances,
and maternal transport. The mean latency period to
diagnosis was 1.96 days. Six percent of patients had
recurrence if MgSO4 tocolysis was continued.
Pulmonary edema MgSO4
infusion only one day
Following Rinderon inj
Placenta previa
Preeclamptic woman is
waiting for pulmonary
edema to happen.
妊娠毒血症孕婦正等著肺
水腫隨時發生
The definitive treatment of preeclampsia is
delivery
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Fetal distress: biophysical profile < 4
AFI <2
IUGR
Reversed umbilical artery diastolic flow
Uncontrolled severe hypertension
Eclampsia
HELLP
Severe preeclampsia
Conservative management
 Biophysical profile > 6
 Controlled hypertension
 S&S of severe preeclampsia resolved
Timing of delivery
38+0 to 39+6 weeks of
gestation for women not
requiring medication
37+0 to 39+6 weeks for
women with hypertension
controlled with medication
36+0 to 37+6 weeks or
earlier for women with
severe hypertension
difficult to control
For women with superimposed preeclampsia or other pregnancy complications
(eg, fetal growth restriction, previous stillbirth, abruption in the current or past
pregnancy), the timing of delivery should be decided on a case-by-case basis
based on the type and severity of these complications.
Treatment of Eclampsia
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Control of convulsions with magnesium sulfate
Blood pressure control
Hypoxia and acidosis treatment
Platelets & FFP BT only if the platelets < 20,000 and
signs of clinically abnormal coagulation function.
 Delivery (vaginal delivery or C/S depending on the
presentation and condition of the fetus, status of the
cervix after control of convulsions
TREATMENT OF ECLAMPSIA
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ABC Turn the patient on her side. Suck out all secretions. Insert a
mouthgag, spatula or an airway. Give oxygen by mask if necessary
ZUSPAN REGIMEN
A loading dose of 4 g of MgSO4 i.v. slow push over no less
than 3 minutes is followed by a constant i.v. infusion of 1 g
MgSO4 per hour
Give an injection of 10 mg of Valium i.v. prn single use only
If patient is not already on effective antihypertensive treatment start
immediately an i.v. infusion with labetalol (trandate) , well sedated
and BP has come down to 150/100 or lower.
TREATMENT OF ECLAMPSIA
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If the urine output is less than 30 ml/hour, give lasix. Commence
patient on an adequate antibiotic.
The pulse rate, respiration, BP, color and restlessness must be
closely monitored.
Further management and mode of delivery has to be discussed
with the Specialist/Consultant.
The Specialist/Consultant may transfer the patient, in selected
patients, to the ICU after consultation with the Anaesthetist.
鑑別診斷
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TTP/HUS: Incredibly similar to one another, if not one and the same (HUS,
TTP and acute fatty liver of pregnancy may prove to be variants of the same
process, rather than distinct diseases).
TTP: The classic pentad: thrombocytopenia, microangiopathic hemolysis,
neurologic symptoms, renal impairment, and fever.
TTP/HUS: maternal mortality 16%, renal injury 24%, CNS injury 12%.
Antithrombin III: low in toxemia, normal in TTP/HUS; von Willebrand factor
molecules are found in TTP/HUS
First line Tx: plasma transfusions and exchanges
If toxemia is not improving one week after delivery, or a progressive
deterioration in renal or hematologic parameters is seen, consider the Dx of
TTP/HUS.
造成孕婦生產死亡的三大原因之一
嚴重性妊娠子癇症Severe Preeclampsia
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高血壓>160/110 mmHg
蛋白尿5g/24 hrs or 3+ to 4+ on dipstick
乏尿症 <500 ml/24hrs
頭痛,上腹痛,視力模糊等症狀
肺水腫或發紺
HELLP症候群H(溶血Hemolysis LDH>600 U/L)EL(肝功
能異常Elevatedliver enzymes:GPT>70 U/L)LP(血小板減
少low platelet count <100,000/ml);各種症候群組合型式
如EL,HEL,ELLP and LP.
Classification systems
of HELLP syndrome
Class 1 (severe)
platelet count < 50,000/uL, AST or ALT ≧70 IU/L,
LDH ≧ 600 IU/L
Class 2 (moderate)
50,000 ≧ platelet count ≦ 100,000, AST or ALT
≧ 70 IU/L, LDH ≧ 600 IU/L
Class 3 (mild)
100.000 ≦ platelet count ≦ 150,000, AST or ALT
≧ 40 IU/L, LDH ≧ 600 IU/L
Partial or incomplete HELLP
ELLP,EL,LP
Recognizing and managing HELLP syndrome
and its imitators
 Hemolysis: Abnormal peripheral blood smear (burr cells,
schistocytes), increased serum indirect bilirubin, LDH >
600 IU/L or decreased serum levels of haptoglobin
 Elevated Liver enzymes: GPT > 70 (>40 borderline
hepatic dysfunction) IU/L
 Low platelet count: platelet < 100,000/uL-ill advised,
suggest ed threshold <150,000
 Variations exist: complete HELLP or partial EL, HEL,
ELLP and LP.
 Require delivery from 1 to 10 days after admission
HELLP syndrome
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LDH > 1400, GPT >150, GOT >100, uric acid > 7.8 mg/dL, creatinine >1.0
mg/dL and 4+ proteinuria can be used to discriminate the patient at high risk
for significant maternal morbidity. Thrombocytopenia occurred first, elevated
liver enzymes second, and hemolysis third
SGOT > 2000 IU/L or LDH > 3000 IU/L mark patients at high risk for maternal
death (FFP or plasma exchange may be lifesaving in such cases)
The lowest platelet count and the peak SGOT and LDH values occurred within
72-96 hours after delivery.
The normal time course for resolution of lab abnormalities is about 4 days, and
delayed recovery need to be evaluated for additional causes.
Although HELLP syndrome takes an indolent course, in some patients, the
disease may progress with astonishing and frightening rapidity, and culminate
in maternal death.
HELLP syndrome-the “great masquerader or imitator”
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A challenge to diagnose because the signs and symptoms of preeclampsia
may appear late in its disease course or not at all and because the
patient‘s presentation can resemble other disorders
Absence of hypertension and proteinuria have been documented in HELLP
An accurate diagnosis is essential. Imitators of the HELLP syndrome
include acute fatty liver of pregnancy (AFLP), thrombotic thrombocytopenic
purpura (TTP), and hemolytic uremic syndrome (HUS)
Early recognization, close medical supervision, and timely delivery are the
keys to the succesful treatment of HELLP.
HELLP綜合徵（溶血，肝酶升高和低血小板）的一部分，嚴重先兆
子癇中的廣泛肝梗塞：CT結果的演變和血漿置換治療的成功治療
周明明醫師作者案例報告
一名38歲女性在懷孕28週時血壓升高至140-180 / 90-120 mmHg和3+
蛋白尿。 入院兩天后，病人突然抱怨上腹疼痛和頭痛。 她的血壓大幅
上升至195/120 mmHg。 一名980克女性由緊急剖宮產分娩。 分娩後，
患者的臨床狀況和實驗室檢查值惡化，進展性肝功能不全（AST峰值水
平= 4246 IU / L，ALT = 3685 IU / L，LDH = 6237 IU / L，血小板=
72,000 / mm3）。 在產後第3天和第4天進行了兩次連續的血漿交換
（PEX）。 產後8天進行的腹部造影增強CT表現為地形楔形低衰減區域，
右肝葉呈斑駁狀。 此後不久，患者康復，所有實驗室參數在分娩後3週
逐漸恢復正常。 對產後2個月肝臟的隨訪CT掃描顯示沒有梗死證據，完
全康復。
大量肝臟細胞梗塞壞死
結論
我們建議患有上腹疼痛的HELLP綜合徵的重症患者應進行肝臟CT影像學
檢查。 應考慮採用產後PEX治療HELLP綜合徵合併肝梗死，這與常規醫
療管理不相容，並且在分娩後72-96小時內未能減輕。
Taiwanese J Obstet Gynecol。 2012年9月; 51（3）：418-20
血漿置換術後，肝組織恢復正常
Maternal mortality associated with HELLP
syndrome
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Most maternal deaths occurred among women with class 1 HELLP
syndrome
Delay in diagnosis and management was associated with mortal
consequences
Cerebral hemorrhage (45%), cardiopulmonary arrest (40%), DIC
(39%), ARDS (28%), renal failure (28%), sepsis (23%), HIE (16%)
in a series of 54 maternal deaths due to HELLP.
總結
Preeclampsia: what we know and what we do not know.
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Preeclampsia has been recognized for at least 100 years.
Preeclampsia is not a single disease - “great obstetric syndromes” with many causes
Placenta is the root cause of preeclampsia in most cases.
In the last 20 years, These two-stage placental ischemia with endothelial dysfunction
insights would seem to provide a guide for the prediction of the disorder in early
pregnancy , along with 2nd-3rd trimester preeclampsia prediction by sFlt-1/PlGF ratio
targets for timely intervention.
However, this has not been the case. Predictive tests guided by this knowledge do not
predict very well and several interventions guided by the expanded understanding of
pathophysiology requires continued research and validation.
The optimal blood pressure threshold for initiating therapy-systolic pressures
≥150 mmHg or diastolic blood pressures ≥100 mmHg.
Target blood pressures are 130 to 150 mmHg/ 80 to 100 mmHg (varied by
different guidelines)
總結
Preeclampsia: what we know and what we do
not know.
 If we know so much about preeclampsia, why
haven't we cured the disease?
 Identification of patients with severe forms of
preeclampsia continue to challenge clinicians.
 Improved patient education and counseling
strategies are needed to convey more effectively
the dangers of preeclampsia.
閱讀建議
 Hypertension in pregnancy ACOG 2013
 Phyllis August. Management of hypertension in
pregnant and postpartum women. UpToDate Literature
review current through: Apr 2018. | This topic last
updated: May 22, 2018.
 Emergent Therapy for Acute-Onset, Severe
Hypertension During Pregnancy and the Postpartum
Period. ACOG Number 692, April 2017 (Replaces
Committee Opinion No. 623, February 2015)
醫智庫 婦產科
10-2. 妊娠糖尿病
婦產科
周明明 醫師
學習目標
妊娠合併糖尿病(diabetes in pregnancy)涵蓋孕前糖尿病(pre- gestational diabetes mellitus
，PGDM)和妊娠糖尿病(gestational diabetes mellitus，GDM)
PGDM可能在孕前即已被診斷或在妊娠期才被確立診斷；PGDM包括1型糖尿病(type 1
diabetes)及2型糖尿病(type 2 diabetes)。GDM則是一種婦女在懷孕期間發生並被檢測出來的
的葡萄糖耐受不良的狀態。
糖尿病的初段預防(Primary prevention) 是由社區基層醫療體系出發，對於糖尿病的高危險群
提供必要的定期篩檢。初段預防的目的是對於糖尿病感受性高的群體進行預防性介入，而來防
止糖尿病發生。次段預防(Secondary prevention)在於早期診斷糖尿病並積極有效的治療來獲
取最佳的控制，以期避免或減少糖尿病的病情持續進行。至於三段預防(Tertiary prevention)
的目標是防止糖尿病 晚期併發症的發生與持續惡化。
提供對於妊娠合併糖尿病診斷、監測、諮詢、衛教、治療，及產後追蹤之臨床實務指導。
學習大綱
1. Prevalence of GDM妊娠糖尿病盛行
2. GDM篩檢診斷
3. GDM糖尿病懷孕的管理
4. GDM的管理--藥物治療
5. 妊娠糖尿病懷孕分娩,產時血糖監測控制及
產後照顧
妊娠糖尿病母胎併發症挑戰
Up to 50% of GDM women will develop
DM 22-28 years after pregnancy
GDM usually does not
cause birth defects
妊娠發生DKA糖尿病酮症酸中毒危
及胎兒和母親 (MMR 4-15%; fetal
loss rate 9%).它通常發生在懷孕後
期階段，也見於新近篩檢出的1型糖
尿病患者。儘管它的發病率(1-3%)
和多年來診治成果有改善，它仍是
一個重大的臨床問題，因為它往往
比非懷孕的患者容易發生在較低的
血糖水平和更快速發病過程。造成
診治延誤
1. Prevalence of GDM
妊娠糖尿病
Prevalence of GDM妊娠糖尿病盛行率
China: from 5% to >16%; India: from 11% to 32%; Taiwan 2.6% to 13.4%
Sceptical take on the new criteria
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Different diagnostic criteria will identify different degrees of maternal hyperglycemia and
maternal-fetal risk, leading some experts to debate, and disagree on optimal strategies for the
diagnosis of GDM 不同診斷標準妊娠糖尿病盛行率不同, 差異性而導致GDM診斷爭議
Up to 6-7% (ACOG 2013); Approximately 7% of the 4 million women who give birth each year
in the US develop GDM
17.8% in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study (population
25505 women) N Engl J Med 2008; 358:1991-2002
8.4% (NDDG) and 18.9% (IADPSG) (25674 women) .
台灣妊娠糖尿病發生機率為 5.7% (2.6-13.4%).13.44% by IADPSG criteria; 2.59% by Carpeter
and Coustan criteria in Taiwan ( Wu ET J Diabetes Investig 2016;7:121-126)
7.9% ( 2 step 50 g OGTT, C&C criteria or NDDG) ( Chou CY, Taiwan, J Womens Health
2010 May;19:935-9.
18.4% 50g OGTT篩檢異常, GDM 確診3.1% (NDDG) (2561 women) 周明明等人 中華醫誌Chin
Med J (Taipei) 1992; 49; 277-82) 妊娠性糖尿病篩檢計畫及臨床經驗
2. GDM篩檢診斷
GDM篩檢診斷
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妊娠前即已確診為糖尿病的患者即為PGDM，建議自孕前至孕期進行血糖干預及管理。
妊娠前未確診為糖尿病的孕婦，存在糖尿病高危因素之一，包括肥胖症(obesity)－身體
質量指數BMI超過或等於30 , 一等親屬為2型糖尿病患者，曾生育超過4000公克巨嬰之既
往史，具妊娠糖尿病既往史，多囊性卵巢(Polycystic ovary syndrome)既往史，已知葡萄
糖代謝失調(impaired glucose metabolism)，建議於妊娠早期進行血糖篩檢。確認是否存
在PGDM (undiagnosed type 2 DM)或GDM 。若妊娠早期血糖篩檢顯示不存在PGDM
或GDM ，則建議糖尿病高危孕婦在妊娠24-28週重覆進行血糖篩檢。
所有尚未被診斷為PGDM或GDM，亦不存在糖尿病高危因素的孕婦，建議在妊娠24-28
週進行血糖篩檢。
Screen women with gestational diabetes mellitus for persistent diabetes at 6–12 weeks
postpartum分娩後6～12週，GDM孕婦應該接受2小時75公克的葡萄糖耐量試驗。再依據
試驗的結果重新分類為正常，葡萄糖耐量異常或是有糖尿病。
GDM篩檢診斷
 建議採取一階段方式(one-step approach)－75公克，2小
時口服葡萄糖耐量試驗進行血糖篩檢，確診孕婦是否存
在PGDM或GDM。
 75-g，2-hour OGTT檢驗方式：檢驗前需連續三天維持
正常飲食，即每日進食碳水化合物不少於150g，檢驗前
至少禁食8小時，檢驗期間維持靜坐、禁菸。檢驗時，先
抽取孕婦空腹的靜脈血後，孕婦在5分鐘內口服含75g的
葡萄糖液體300ml，接著再抽取孕婦口服葡萄糖液後1小
時及2小時的靜脈血(從開始飲用葡萄糖液計算時間)，抽
取之靜脈血放入含有氟化納的試管中，採用實驗室認證
合格葡萄糖氧化酶法測定血糖值。
孕婦正常標準值
75-g，2-hours OGTT標準值
空腹<92 mg/dL (5.1 mmol/L)
服糖後1小時<180 mg/dL (10.0 mmol/L)
服糖後2小時<153 mg/dL (8.5 mmol/L)
GDM的診斷
GDM& PGDM
的診斷
75-g，2-hours OGTT檢驗值中
空腹 ≥ 92 mg/dL (5.1 mmol/L)且<126mg/dL
服糖後1小時 ≥ 180 mg/dL (10.0 mmol/L)
服糖後2小時 ≥ 153 mg/dL (8.5 mmol/L)且 <200mg/dL
符合以上三項當中一項，或一項以上，即診斷為GDM
PGDM的診斷
75-g，2-hours OGTT檢驗值中
空腹 ≥ 126 mg/dL (7.0 mmol/L)
服糖後2小時 ≥ 200 mg/dL (11.1 mmol/L)
符合以上二項當中一項，或兩項，即診斷為PGDM
一階段妊娠性糖尿病篩檢與
兩階段妊娠性糖尿病篩檢法之比較
Table 2.1— Criteria for the diagnosis of diabetes
糖尿病診斷標準
肌餓血糠FPG ≥ 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for
at least 8 h.*
-------------------------------------------------OR--------------------------------------------------------餐後血糖2-h PG ≥ 200 mg/dL (11.1 mmol/L) during an 75 g OGTT. The test should
be performed as described by the WHO.
-------------------------------------------------OR--------------------------------------------------------A1C ≥ 6.5% (48 mmol/mol). The test should be performed in a laboratory using a
method that is NGSP certified and standardized to the DCCT assay.
-------------------------------------------------OR--------------------------------------------------------In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma glucose ≥ 200 mg/dL (11.1 mmol/L).
*In the absence of unequivocal hyperglycemia, results should be confirmed by
repeat testing.
(Diabetes Care January 2016)
GDM診斷採用新舊標準的爭辯-挑战
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美國糖尿病協會(American Diabetes Association， ADA)，依2008年HAPO study發表在NEJM之報告，在2011年
建議採用75g-2hr OGTT篩檢GDM，並放寬診斷標準。
但美國婦產科學會(ACOG)， 2018年仍支持原兩階段篩檢方法與標準(先50g-1hr OGTT篩檢，再100g-3hr OGTT
either Carperter and Coustan or NDDG criteria確診.因為目前還沒有足夠證據支持投入較多成本篩檢與治療後，
可以對孕產婦與胎兒帶來好處(2013 Eunice Kennedy Shriver National Institure of Child Health and Human
Development Consensus Development Conference on diagnosing GDM)。
1 step approach (75 g OGTT) on all women will increase the diagnosis of GDM but sufficient prospective studies
demonstrating improved outcomes still lacking. ACOG does acknowledge that some centers may opt for ‘1 step’
if warranted based on their population
One of the concerns about a 1-step approach is that it is anticipated to increase the frequency of diagnosis of
GDM 2- to 3-fold. 5-6% to 15-20% (Diabetes Care 2016)
No evidence exists that using 75g-2hr OGTT would lead to clinically significant improvements in maternal or
newborn outcomes, but would lead to a significant increase in interventions and health care costs .
Potential for increased “medicalization” of pregnancies previously categorized as normal.懷孕產檢過度醫療化
There remains strong consensus that establishing a uniform approach to diagnosing GDM will benefit patients,
caregivers, and policymakers. Longer-term outcome studies are currently under way對病人醫療照護者及衛生政
策主管製定者,最理想的篩檢診斷方法正仍在尋求強烈一致的共識中、
GDM的管理
孕前諮商
血糖監測
醫療營養治療
低衝擊的適當體能運動(moderate exercise
program)
 口服降血糖藥物或胰島素的使用(< 1/10 GDM孕
婦需要)
 非侵入性的母體及胎兒監測
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3. GDM糖尿病懷孕的管理
糖尿病懷孕的管理 - 孕前諮商
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接受孕前照顧的最佳時機為計畫受孕前3-6個月開始，有充足的時間來評估
母親的健康狀況及將血糖控制正常化或最佳化。
有關未計畫懷孕的潛在危險 :
(1)無證據顯示受孕力低於非糖尿病患
(2)控制良好者，流產率與非糖尿病患相同。流產機率隨A1C值增加而明顯的提高。
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A1C> 6.9%的胎兒畸形率增加,圍產期死亡率也會增加。 A1C > 10.4%,胎兒
畸形率高達16% 。
在停止避孕前，應徹底檢查血管合併症，視網膜，腎功能，微量白蛋白，心
電圖等.確定腎病變的分期並給予諮詢以免危及母親與胎兒的安全。
適當的停止口服藥物.評估自我血糖監測技能與正確性， 確認血糖機是準確
的。評估血糖控制狀況，確實避孕直到血糖達控制目標。病患在開始接受孕
前照顧時可能已停 止避孕，需再強調在達到正常或接近正常血糖控制前需
維持避孕的重要性。
血糖監測
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治療GDM及PGDM的主要目的在於控制妊娠期間的血糖值以降低巨嬰(macrosomia)(13)及肩難產
(shoulder dystocia)的發生風險。對於PGDM婦女，在孕前或妊娠早期控制血糖可減少胎兒畸形的風
險。治療GDM同時可降低妊娠期間發生子癇前症(preeclampsia)及妊娠期高血壓的風險。
自我監控血糖包括監測空腹(fasting)，餐前(preprandial)及餐後(postprandial)血糖值，可以作為指導
GDM及PGDM治療的重要參考。
對於GDM或PGDM孕婦，餐後一小時血糖的監測比空腹及餐前的血糖值監測能更有效預測巨嬰,血
糖控制及胎兒罹病風險。
Use of 1-h postprandial measurement for management of GDM was associated with better
glycemic control, lower incidence of LGA infants, and lower CS rates due to CPD (ACOG
2013)。
血糖監測方式：採用標準化之居家型血糖機自行測定毛細血管全血血糖值。妊娠前已確診之PGDM
，妊娠後新診斷之PGDM，妊娠期間血糖控制不良或不穩定者，以及妊娠期需要使用胰島素治療之
孕婦，應每日監測血糖7次，包括三餐前30分鐘，三餐後2小時(進食第一口食物開始計時後2小時)和
睡前血糖，根據血糖監測結果調整飲食、運動及胰島素劑量。
妊娠後新診斷之GDM孕婦，建議每日監測血糖4次，包括空腹血糖及三餐後2小時血糖，直至生產。
妊娠期間血糖控制目標
glycemic targets
GDM孕婦的妊娠期血糖應控制在
建議
ADA
ACOG
空腹
≤ 95mg/dL (5.3 mmol/L)
≤ 95mg/dL
一小時
≤140mg/dL (7.8 mmol/L)
≤140mg/dL
兩小時
≤120mg/dL (6.7 mmol/L)
≤120mg/dL
PGDM孕婦的妊娠期血糖應控制在
空腹、餐前、睡前及夜間血糖值為60-99mg/dL (3.3-5.5 mmol/L)
餐後2小時血糖值為100-129mg/dL (5.6-7.2 mmol/L)
糖化血色素(hemoglobin A1C，A1C)值的監測
不建議對GDM孕婦進行A1C的定期監測
對於PGDM孕婦，妊娠期間血糖控制不良、不穩定或需要使用胰島素治
療的GDM孕婦，建議每2個月檢測一次A1C值，理想的A1C值為<6.0%
糖尿病懷孕的管理－酮尿(ketonuria)監測
每日需測晨起第一次尿液的尿酮
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Production of ketone bodies is a normal response to a shortage of glucose, meant to provide an alternate source
of fuel from fatty acids. Urine ketones appear before there is any significant increase in blood ketones. the
acidosis causes acetoacetate to accept an H+ and become betahydroxybutyrate. Since the nitroprusside
reaction on dipstix detects acetoacetate but NOT betahydroxybutyrate, this can be deceptive in very acidotic
patients血糖匱乏能量轉化脂肪產生酮體, 尿酮出現早於血酮。試紙浸尿液15秒後檢測, 嚴重酸中毒會影響檢測判讀
, 須注意以免誤判。
酮尿有助於及時偵測出孕婦碳水化合物或能量獲取的不足，也可用作早期糖尿病酮酸中毒(diabetes mellitus
Ketoacidosis，DKA)的預測標誌。GDM或PGDM孕婦出現血糖值>200mg/dL (11.1 mmol/L)時，生病時,不明原因
噁心、嘔吐、乏力而無法進食時的任何時間等不適症狀時應及時監測酮尿。
正常或低血糖而出現酮體，表示其飲食量不足，血糖稍高，出現酮體，表示即將酮酸血症。懷孕期間血糖值正常
，也有酮酸血症的可能。
懷孕期間的酮酸血症合併有高週產期死亡率。使用Ritodrine或Terbutaline來治療早產，可能會造成血糖控制惡化
及酮酸血症。這些藥物不應為糖尿病孕婦的第一線用藥。如果使用，應小心的監測血糖。
醫學營養治療
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醫學營養治療(medical nutrition therapy，MNT)的目的在於透過合理的營養攝取、適
當的運動使糖尿病孕婦的血糖值及體重控制在正常範圍，減少母胎併發症的發生。一
旦確立GDM的診斷後應立即對孕婦進行MNT，運動指導並同時教育孕婦如何自我監
控血糖。在醫療資源足夠的條件下，GDM及PGDM孕婦應轉介至專業的營養師
(registered dietician)進行MNT諮詢及衛教。
妊娠期間透過MNT維持良好血糖狀況,應考慮到幾個重要因素，包括每日攝取總熱量
(caloric allotment;daily total caloric intake)，熱量組成(caloric contents)－特別是碳水
化合物carbohydrate intake limit to 33-40%)，每日餐次熱量的配置(daily caloric
distribution of meals)。
每日攝取總熱量：PGDM及GDM孕婦應根據妊娠前BMI進行整體熱量攝取規劃，並以
妊娠期間體重增加及每日血糖值進行熱量攝取的調整。糖尿病孕婦MNT每日攝取總熱
量，在妊娠早期不應低於1500kcal/d，在妊娠晚期不應低於1800kcal/d，以避免酮酸
血症DKA的發生。
醫學營養治療 - 熱量組成
碳水化合物
建議每日碳水化合物攝取量占總熱量的40%~50% (33-40%) 為
(carbohydrates) 宜，每日碳水化合物攝取量不低於120g對維持妊娠期穩定血糖更
為合適。除了考量碳水化合物的總量外，選擇低升糖指數
(glycemic index,，GI)或低升糖負荷(glycemic load，GL)的飲食
更有助於GDM孕婦的血糖控制。建議GDM及PGDM孕婦應儘量
避免食用蔗糖等精製糖；等量碳水化合物的食物選擇時，低GI或
低GL類食物應列入優先考慮。無論採用碳水化合物的計算法、食
品交換份法或經驗估算法，監測碳水化合物的攝取總量是血糖控
制成功與否的重要關鍵。
懷孕期間的估算熱量需求(estimated energy requirements， EER)，是以未懷孕時的
熱量需求，第二及第三孕期各增加300大卡。
醫學營養治療 - 熱量組成
蛋白質
(protein)
建議蛋白質攝取量占每日攝取總熱量的20%。蛋白質的合理攝取在於提供孕婦妊娠期間的生理調
節及胎兒生長發育所需。蛋白質來源中一半以上來自高生物價（High Biological Value, HBV）的
蛋白質，如：低脂奶類製品、豆漿、豆腐、豆干等黃豆製品、魚、肉、蛋。
脂肪(fat)
建議脂肪攝取量占每日攝取總熱量的30%~40%。妊娠期間應適度限制飽和脂肪酸(saturated
fatty acid)含量高的食物，如動物油脂、紅肉、椰奶等。GDM及PGDM孕婦每日飽和脂肪酸攝取
量不應超過每日攝取總熱量的7%；而單元不飽和脂肪酸(monounsaturated fatty acid)如橄欖油、
山茶油等應占每日脂肪攝取量的30%以上。糖尿病孕婦宜減少反式脂肪酸(trans fatty acids)攝取
量以降低密度脂蛋白膽固醇(LDL cholesterol)，增加高密度脂蛋白膽固醇(HDL cholesterol)。
纖維素
建議每日攝取25-30g的纖維素；目的在於控制餐後血糖上升程度，改善葡萄糖耐受度，降低血膽
固醇。
每日餐次熱量的配置：建議採取少量多餐，定時定量進餐的飲食原則；可採取2332的
熱量配置方式，亦即早、中、晚餐各占每日攝取總熱量的20%、30%和30%，另20%
則為2至3次加餐(snacks)的總熱量。加餐的目的在於分散主餐熱量，減少血糖劇升風
險，亦可避免進食主餐前之低血糖。孕前體重過重或肥胖婦女可不配置加餐，或減少
加餐的熱量配置。睡前點心可以預防夜間低血糖，並避免隔 夜飢餓造成酮尿或酮血症。
GDM的管理-醫學營養治療
聰明吃
和「糖」說不
含糖飲料、珍珠奶茶,榴蓮, 精緻澱粉這幾類不碰。糖與酒精同樣
具成癮可能性，且攝取糖會誘導許多慢性疾病的發生，並加速身
體老化。減糖從生活細節做起，攜帶環保水壺，避免喝含糖飲料
(珍珠奶茶)；拒絕隨餐贈送含糖飲料；以水果及適量無調味堅果
種子取代糕餅零食。
----------------------------------------------------------------------------------------------------------------
「挑」過再吃
挑白肉、挑瘦肉；挑蔬菜、挑水果；挑全穀、挑堅果；挑天然、
挑在地。建議民眾飲食要精挑細選，選擇天然食材避免加工品，
選擇少油烹調方式，並減量8分飽，另每天皆應攝取適量未精製
全穀雜糧、堅果種子及低脂乳品，並達天天五蔬果。
GDM的營養建議摘要
熱量
足以提供適當的體重增加及避免酮體的產生，過重或肥胖者可能需要中度熱量限制，最低為每天
1800大卡
醣類
根據對血糖值影響，以少量多餐方式分配於一天之中，以避免酮症的產生，懷孕期間的醣類
recommended daily allowance (RDA)為175公克。早餐後血糖最容易升高，建議醣類攝取量為
15～45公克，可參考餐後血糖值調整醣類份量與種類。中餐與晚餐為45～75公克，點心為15～
45公克
蔗糖及其他含熱量甜味劑 限量使用，考慮維持血糖值在目標範圍的能力、營養是否足夠、及對整體飲食計畫的影響
蛋白質
脂肪
鈉
纖維質
RDA為1.1 g/kg/day，或每天增加25公克，雙胞胎每天增加50公克，攝取量可能會因為醣類的減
少而需增加
通常會隨蛋白質的攝取而增加；限制飽和脂肪酸
不特別限制
懷孕期間足夠攝取量為每天28公克，增加攝取可能改善便秘
非營養性甜味劑
一般而言是安全的
維生素及礦物質
評估需要，從食物或補充品攝取葉酸總量為600µg （懷孕建議增加200µg），第3期時每天需額外
補充鐵30 mg；血漿鋅濃度過低或懷孕前體重過低婦女補充鋅
酒精
咖啡因
避免
限制在300 mg/day（約兩杯至兩杯半，一杯240 c.c.）
GDM的管理 - 運動
聰明吃、快樂動、天天量體重


2018 年美國婦產科學院出版孕婦安全運動指引：運動 30 分鐘，可幫助妊
娠糖尿病孕婦血糖維持目標範圍內，安全運動方式包括：快走、騎腳踏車和
游泳。
2018 年美國婦產科學院GDM孕婦運動指引：運動可降低妊娠期基礎胰島素
拮抗(insulin resistance)，為GDM的整體治療措施之一。若無禁忌，例如:懷
孕誘發的高血壓，過早破水，早產或早產病史，子宮頸閉鎖不全/施行子宮
頸環紮術，及在懷孕二、三期持續出血。建議孕婦選擇一種中等強度運動
(moderate-intensity aerobic exercise)的有氧運動，如步行、游泳。避免於
餐後30分內運動,開始先暖身10分鐘，接著進行30分鐘有氧耐力運動，再經
過10分鐘和緩動作即結束運動過程。運動過程中維持微喘、不渴、不熱為原
則；其中可穿插間歇休息。適宜的運動頻率為5次/周 (a minimum of 150
minutes per week) 。
表1、依妊娠前身體質量指數(BMI)建議孕婦每日熱量攝取值及妊娠期體重增加標準
妊娠前
BMI(kg/m2)
妊娠期體重
增加值(kg)
妊娠中晚期每周體重
增加值(kg)
<19.8
12.5~18
0.5
19.9~26.0
11.5~16
0.4
26.0~29.0
7~11.5
0.3
>29.0
≧7.0
雙胞胎
15.9~20.4
三胞胎
22.7
0.7
4. GDM的管理 -- 藥物治療
GDM的管理--藥物治療
GDM傳統胰島素治療方法


中效型NPH與短效型RI 2/3比1/3作搭配在早餐15到30分前給予皮下注射
(2/3 total dose) 。晚餐前的劑量，約略為早餐的三分之一量，再各以一半劑
量的中效NPH搭配短效胰島素RI。往後視空腹及飯後血糖值的偏高或偏低增
減各個區段的胰島素劑量
例如早餐空腹血糖值高於≥ 95 mg/dL (5.3 mmol/L) 或低於60 mg/dL (3.3
mmol/L)，即應增減晚餐前的中效型劑量。早餐後的血糖值偏高(一小時之
後高於140 mg/dL (7.8 mmol/L)，兩小時高於120 mg/dL (6.7 mmol/L)應
酌量增加早餐前短效型胰島素。午餐後的血糖偏高，應酌量增加早餐前中效
胰島素劑量。晚餐後的血糖偏高，應酌量增加晚餐前短效型胰島素。藉此動
機調整劑量，希望將血糖控制在空腹不超過95mg/dL n(5.3 mmol/L)，飯後
2小時血糖不超過120 mg/dL (6.7 mmol/L)的標準之內。
GDM的管理--藥物治療
GDM傳統胰島素治療方法
 然而，我們必須要特別注意的是胰島素藥效有很
大的個人藥物感受差異性。 尤其是在慢性type 1
糖尿病患者長期接受胰島素注射,已經有抗體產生
。在這些病人胰島素作用的發生時效忽快、忽慢
及持續療效非常不穩定，血糖因而上下波動變化
極大，特別強調的是許多病人並不會依據藥物動
力學(PK curve)理論上的胰島素藥物作用時效,波
動性很大,造成病人及醫師很大的困擾。
GDM的管理--藥物治療



PGDM孕婦在孕前即已接受糖尿病藥物治療，PGDM孕
婦有醫學適應症須接受糖尿病治療，或GDM孕婦經醫學
營養治療及運動治療後1至2星期，空腹或餐前血糖值
≥95mg/dL (5.3 mmol/L) ，或餐後2小時血糖值
≥120mg/dL (6.7 mmol/L) ，應啓動糖尿病的藥物治療
。妊娠期間的糖尿病藥物治療可選擇胰島素(insulin)或
口服降血糖藥物(oral hypoglycemic agents)。
胰島素治療：妊娠期間，對胰島素的需求劑量隨孕週逐
漸增加。 不同個案胰島素治療的差異性甚多，應有個別
化的考量、規劃、調整。
早孕期平均為 (0.7) 0.8 units/kg/day，中孕期 (0.8) 1.0
units/kg/day，晚孕期 (0.9) 1.2 units/kg/day。
(Obstet Gynecol 2003;102:857-68)
GDM的管理--藥物治療



單獨空腹高血糖：建議每日睡前注射中效胰島素NPH或長效胰島素Insulin
Detemir (long-acting insulin) (英文商品名LEVEMIR FLEXPEN) ，再漸序
調整劑量以達成空腹血糖值≤ 95mg/dL (5.3 mmol/L)的目標 。
餐後高血糖：建議每日1次(睡前)或每日2次(早餐前及睡前)注射長效胰島素
，配合三餐前注射短效胰島素(short-acting insulin)，漸序調整劑量以達到空
腹血糖值≤ 95mg/dL，餐後2小時血糖值≤ 120 mg/dL (6.7 mmol/L)的目標。
胰島素類似物(Insulin analogues )：Insulin lispro和Insulin aspart (諾和
瑞諾易筆NovoRapid FlexPen 100U/mL 3mL)等速效胰島素(rapid-acting
insulin)類似物配合三餐前注射，不通過胎盤亦可考慮在妊娠期間使用。這
類藥物啓動作用的時間比Regular insulin更快速，可以更便利、更有效的
控制餐後血糖 。
23
表2、常用胰島素製劑的作用評價
製劑
作用啟動
作用巔峰
(h)
作用效期
(h)
FDA妊娠
安全分類
Insulin lispro
1-15 minutes
1-2
4-5
B
Insulin aspart
1-15 minutes
1-2
4-5
B
30-60
minutes
2-4
6-8
B
Isophane insulin
suspension(NPH insulin)
1-3 hours
5-7
13-18
B
Insulin zine suspension
1-3 hours
4-8
13-20
Extended insulin zinc
suspension
2-4 hours
8-14
18-30
Insulin detemir
1-3 hours
6-8
20-24
Regular insulin
B
Modified from Gabbe SG, Graves CR. Management of DM complicating pregnancy
懷孕期間的胰島素治療


一天注射四次是最常用方式:早餐前速效胰島素類似物(recombinant insulin
analogues )：Insulin lispro和Insulin aspart (諾和瑞諾易筆NovoRapid )
，中餐前速效胰島素，晚餐前速效胰島素,注射後立即進食。睡前長效胰島素
Insulin Detemir (long-acting insulin) (英文商品名LEVEMIR FLEXPEN)。
但胰島素的適當劑量，仍應以孕婦的日常血糖記錄單所登錄的資料作調整劑
量的依據。
懷孕各期
胰島素需要量(units/kg)
第一期
0.7～0.8
第二期
0.8～1.0
第三期
0.9～1.2
肥胖，＞150% 理想體重
1.5～2.0
產後
＜0.6
速效胰島素Insulin Aspart Flexpen (NovoRapid FlexPen) 中文商品名諾和瑞諾易筆
速效胰島素Insulin Lispro KWIKPEN 優泌樂筆注射劑


藥動學Onset: 10-15 minutes;
Peak effect: 1-2 hours;
Duration: 3-5 hours.劑量和給
藥方法Usual initial dose: 0.5-1
unit/kg/day in divided doses;
SC within 5-10 min before a
meal.
Recombinant insulin lispro is a
rapid-acting human insulin速效
胰島素Onset of action: SubQ:
15-30 minutes; Peak effect:
0.5-1.5 hrs; Duration: ≦5 hrs;
速效胰島素藥物動力學吸收區線
Novorapid PK curve





From time bolus taken:
30 min - 10% used 90% Insulin On Board (IOB)
60 min - 30% used 70% IOB
90 min - 50% used 50% IOB
120 min - 65% used 35% IOB
150 min - 80% used 20% IOB
180 min - 90% used 10% IOB
210 min - 95% used 5% IOB
240 min - 100% used
The dose of recombinant insulin analogue must be individualized based on clinical
response.
Blood glucose monitoring is essential in all patients receiving insulin therapy.
The action will be some what different for different people.不同的人速效胰島素
藥物動力學吸收作用會有一些差異
book "Think Like a Pancreas" by Gary Scheiner on page 168
長效胰島素INSULIN DETEMIR INJ 300U/3ML
英文商品名long-acting LEVEMIR FLEXPEN長效瑞和密爾諾易筆


Onset: 3-4 hr; Duration: 6-23 hr (dose-dependent); at lower starting dosage 10 units (0.1-0.2 units/kg), the
mean duration is variable (5.7-12 hr); at 0.6 units/kg, mean duration: 19.9 hr; at high dosage (＞0.6
units/kg), the duration is longer and less variable. Time to peak: 6~8 hrs; Levemir is not recommended for
the treatment of DKA. Intravenous rapid-acting or short-acting insulin is the preferred treatment for DKA.
If converting from NPH insulin, the change can be done on a unit-to-unit basis. However, some patients with
type 2 diabetes may require more Levemir than NPH insulin, as observed in one trial .
口服降血糖藥物






GDM孕婦經由醫學營養治療、運動及生活方式的改善通常能維持正常的血糖；透過這些介入方式仍無
法達到正常血糖值的孕婦應優先採用胰島素治療。
相當多的臨床試驗顯示使用口服降血糖藥物二甲雙胍 metformin及格列本脲 glyburide對於GDM孕婦的
血糖控制療效和使用胰島素治療效果相當。同時，統合分析(meta-analysis)顯示，和使用胰島素治療比
較，使用metformin及glyburide並不增加立即或短期的母胎不良結果。目前台灣食品藥物管理署(Taiwan
Food and Drug Administration，TFDA)核可的metformin及glyburide仿單適應症仍未將GDM孕婦的治療
納入。對於胰島素用量較大或拒絕應用胰島素的GDM孕婦，考量應用這二類口服降血糖藥物的潛在風
險遠小於未控制血糖的妊娠期高血糖對胎兒的危害；經由完整的諮詢過程及知情同意程序，部分GDM
孕婦可審慎使用。
If a patient cannot take insulin or declines, metformin can be used
Counsel about metformin risks including placental cross over and no long term studies in offspring
available.Starting dose: 500 mg nightly for 1 week, increase to 500 twice daily,Maximal dose is 2,5003,000 mg per day, in two or three divided doses
Glyburide should not be used in place of insulin as studies show worse outcome, including
macrosomia and birth injury.Starting does is 2.5-20 mg per day in divided doses.Up to 30 mg may be
necessary to obtain glycemic control
Long term outcome studies also still lacking , although no short term adverse events have been noted
口服降血糖藥物 (not approved by FDA)
Metformin (Glucophage)二甲雙胍
分類
Glyburide (Glibenclamide) 格列本脲
Biguanide (雙胍類 )
Sulfonylureas (磺醯脲類)
降低胰島素阻抗
刺激週邊組織葡萄糖攝取
減少肝臟輸出葡萄糖
刺激胰島素分泌
胰島素SENSITIVITY
不易發生低血糖症狀
血糖控制效果較Metformin佳,效果與Insulin類同, 20-40%也
許須要合併使用Insulin達到較佳血糖目標
較高機率(1-5%)發生新生兒低血糖
胃腸副作用
Sulfa drug allergy
胃腸皮膚副作用
劑量
常用: 500 mg 一日分兩次或三次使用
每日最大劑量2500 mg
常用: 2.5-5mg早餐時使用
每日最大劑量 20mg
懷孕
藥物會通過胎盤
短期無生育缺陷報告長期預後結果有待研究
Human data suggest low risk
藥物會通過胎盤
短期無生育缺陷報告
Human data suggest low risk
哺乳
藥物少量(<0.5%)通過乳汁, 哺乳謹慎使用,目前無
胎兒副作用報告;breastfeeding compatible
藥物微量(<1.5% and <0.7%, 可忽略)通過乳汁
目前無資料報告limited human data-probably compatible
作用機轉
母体安全性
及治療效果
副作用及
禁忌症
5. 妊娠糖尿病懷孕分娩,
產時血糖監測控制及產後照顧
胎兒監測




建議PGDM孕婦應有完整的產前胎兒監測規劃。由於PGDM妊娠胎兒不良結局的風險
與血糖控制不良有關；可預期，GDM孕婦若血糖控制不良亦可能增加胎兒不良結局風
險。由此，對於血糖控制不良的GDM孕婦，完整的產前胎兒監測亦有助益。
胎動監測(fetal movement monitoring)：建議血糖控制良好的GDM孕婦自妊娠32~34
週開始進行胎動監測。對於血糖控制不良及需要藥物治療的GDM孕婦，和PGDM孕婦
除了胎動監測外，亦應適時進行更嚴格，但適當的胎兒監測，包括非壓力測試(non
stress test，NST)，收縮壓力測試(contraction stress test，CST)及生物物理評估
(biophysical profile)。
胎兒構造監測：建議HbA1c≥7%，或空腹血糖值>120mg/dL的PGDM或GDM孕婦適
時接受胎兒構造性超音波檢查，以評估胎兒先天性構造異常尤其是中樞神經系統和心
臟的發育狀況是否良好。
胎兒生長速度監測：對於血糖控制不良的PGDM或GDM孕婦適時安排超音波檢查進行
胎兒體重監測，尤其注意監測胎兒腹圍(abdominal circumference;AC)。以超音波進
行胎兒AC監測亦可用以輔助評估糖尿病孕婦血糖控制的成效。當超音波檢查胎兒AC
超過75個百分位。(75th percentile)應立即考慮是否啓動或調整胰島素治療劑量以減少
巨嬰症的風險。
分娩






GDM和PGDM孕婦可依是否藥物治療、血糖控制狀況，預估胎兒體重擬定其分娩時機及分娩方式。
採取MNT、運動、生活行為改善，且不需要藥物治療而血糖控制良好，胎兒體重亦在合理範圍的
GDM孕婦的分娩可以比照一般低危妊娠孕婦。
分娩時機(39-40 6/7 weeks):不需要胰島素及藥物治療，血糖控制良好且無母胎併發症的GDM孕婦
在嚴密監測下可等待至預產期；至40孕週可提供孕婦諮詢並討論引產的可能性；至41孕週仍未臨產
則建議孕婦引產。
PGDM及需要胰島素或藥物治療的GDM孕婦，血糖控制良好且無母胎併發症，在嚴密監測下建議孕
婦分娩時機39 0/7 to 39 6/7 weeks孕週。
血糖控制不理想，或出現其他母胎併發症的PGDM或GDM孕婦，可於39孕週之前依病情決定妊娠終
止及分娩時機。
分娩方式：PGDM或GDM並非剖腹產的適應症。糖尿病孕婦若合併嚴重微血管病變，或具備其他剖
腹產適應症可考慮計畫性剖腹生產。雖然應用超音波預測胎兒體重可能存在誤差及準確度的不足；
基於避免巨大胎兒導致的肩難產及生產創傷(birth trauma)的考量，對於產前超音波預估胎兒體重
>4000g (Taiwan)/>4500 g (USA)之PGDM及GDM孕婦，應提供計畫性分娩及可能剖腹產的諮詢及
建議。
決定陰道自然分娩的PGDM或GDM孕婦，應於足月前協助其製定分娩計畫；進入產程後，密切進行
母胎監測，應避免產程過長。
Intrapartum glycemic control
產時血糖監測控制





PGDM及需要胰島素或藥物治療的GDM孕婦於進入產程，剖腹產手術前後，產後非正
常飲食期間應停用所有皮下注射胰島素及口服降血糖藥物，改使用胰島素靜脈注射，
每小時以醫院病房血糖機監測血糖，維持血糖值<110mg/dL。
計畫剖腹產或引產前之睡前胰島素正常使用，停用空腹或餐前胰島素，開始給予
normal saline生理食鹽水靜脈點滴注射。
正式進入產程活躍期，或血糖<70mg/Dl (3.9 mmol/L)時，將輸液從生理食鹽水改為
5% dextrose葡萄糖輸液以100-150cc/h速度靜脈點滴注射, 以維持血糖值接近
100mg/dL (5.6 mmol/L)( 70-110 mg/dL)；再依血糖值調整胰島素及葡萄糖液的輸液
點滴速度。假如血糖值>100 mg/dL (or >110-120 mg/dL (6.1-6.7 mmol/L)則將短效胰
島素RI加入5%dextrose輸液以1.2u/h速度靜脈點滴注射。
1-2 h血糖監測隨時調整胰島素劑量
產後需注意病人血糖可能急速降低，通常邊緣性糖耐受性不良及飲食控制糖尿病人，
不需胰島素注射，原來糖尿病患者接受胰島素治療，劑量需調整降低。
糖尿病孕婦待產中
低劑量持續胰島素靜脈滴注法
Blood glucose
（mg/dl）
Insulin
（U/h）
Fluids
（125ml/h）
<100 (5.6 mmol/L)
0.5
D5/Ringer lactate
100-140 (5.6-7.8)
1.0
D5/Ringer lactate
141-180 (7.8-10)
1.5
Normal saline
•181-220(10-12.2)
2.0
Normal saline
>220 (12.2 mmol/L)
2.5
Normal saline
Table 52-9. Protocol Recommended by the American College of Obstetricians and Gynecologists
(2005) for Management of Diabetic Ketoacidosis during Pregnancy糖尿病酮酸中毒處置策略
Laboratory assessment
Obtain arterial blood gases to document degree of acidosis present; measure glucose, ketones, and electrolyte levels at 1- to 2-hour intervals
實驗室血液氣体分析,血糖,酮体,電解質1-2小時監測
Insulin胰島素劑量 Intravenous rapid-acting or short-acting insulin is the preferred treatment for DKA.
•
•
•
Low-dose, intravenous
Loading dose: 0.2–0.4 U/kg
Maintenance: 2–10 U/h
Fluids輸液
•
•
•
•
•
Isotonic sodium chloride
Total replacement in first 12 hours of 4–6 L
1 L in first hour
500–1000 mL/h for 2–4 hours
250 mL/h until 80 percent replaced
Glucose葡萄糖輸液
Begin 5-percent dextrose in normal saline when glucose plasma level reaches 250 mg/dL (14 mmol/L)
Potassium鉀離子補充及適時調整
If initially normal or reduced, an infusion rate up to 15–20 mEq/h may be required; if elevated, wait until levels decrease into the normal range,
then add to intravenous solution in a concentration of 20–30 mEq/L
Bicarbonate碳酸氫鈉
Add one ampule (44 mEq) to 1 L of 0.45 normal saline if pH is < 7.1
產後血糖管理



妊娠期間需要胰島素治療的PGDM或GDM孕婦，一旦恢復正常飲食
應同時恢復血糖監測，開始給予妊娠期間所需胰島素劑量的一半 (產
後的特點是立即降低胰島素的需求，非哺乳者的胰島素需求為
0.6U/kg，哺乳者為0.4U/kg偶爾在產後的 24〜48小時不需或只需少
量的胰島素)，再依血糖監測結果調整藥物劑量。
妊娠期間不需胰島素治療的GDM孕婦；產後可恢復正常飲食；但應
避免高糖,高脂飲食。
無論是否需要胰島素治療，應鼓勵所有的PGDM及GDM產婦母乳哺
餵，有助於減輕產後體重,以減少胰島素的使用量，降低子代發生糖
尿病的風險。
GDM
產後的追踪管理照顧
僅管GDM孕婦的碳水化合物耐受不良現象往往在分娩後自然恢復正常，
但其中仍有多達三分之一的孕婦在產後篩檢呈現糖尿病或血糖代謝異常狀
態，而往後大約15%-50%產婦會發生2型糖尿病。
建議所有GDM孕婦於產後6至12週進行葡萄糖耐受度篩檢，以評估是否
有糖尿病，空腹血糖異常(impaired fasting glucose)或葡萄糖耐受不良
(impaired glucose tolerance)等狀況。
GDM
產後的追踪管理照顧
篩檢方式
診斷標準
 採用75-g，2-h OGTT，檢
 正常：空腹血糖值≤99mg/dL
驗前至少禁食8小時；檢驗
(5.5 mmol/L)，且服糖後2小時
時，先抽取受檢者空腹的靜
血糖≤139mg/dL (7.7 mmol/L)。
脈血後，受檢者5分鐘內口
 糖尿病：空腹血糖值
服含75g的葡萄糖液體
≥126mg/dL (7 mmol/L)或(且)
300ml，間隔2小時再抽取
服糖後2小時血糖值
受檢者靜脈血，分析空腹血
≥200mg/dL (11.1 mmol/L)。
糖值及服糖後2小時血糖值。  空腹血糖異常：空腹血糖值
100-125 mg/dL (5.6-6.9
mmol/L)。
 葡萄糖耐受不良：服糖後2小時
血糖值140-199mg/dL (7.811.1 mmol/L)。
追踪管理
 診斷為糖尿病之個案應轉介至
新陳代謝專科進行治療。
 篩檢結果為正常者，建議每三
年定期評估血糖狀況，提供健
康促進諮詢，輔導體重控制及
運動。
 出現空腹血糖異常者，葡萄糖
耐受不良當中，一項或兩項異
常者，建議進行MNT，體重控
制及運動，並提供健康促進諮
詢；經追蹤複檢情況若未改善
應考慮藥物治療。
表4、分婉後血糖標準
3.4
正常
糖尿病
IFG
空腹
<100 mg/dL
且
≥126 mg/dL
或(且)
100-125 mg/dL
服糖後2小時
<140 mg/dL
≥200 mg/dL
IGT
140-199 mg/dL
IFG：空腹血糖異常；IGT ：葡萄糖耐受不宜
 正常：空腹血糖值≤99mg/dL (5.5 mmol/L)，且服糖後2小時血糖≤139mg/dL
(7.7 mmol/L)。
 糖尿病：空腹血糖值≥126mg/dL (7 mmol/L)或(且)服糖後2小時血糖值
≥200mg/dL (11.1 mmol/L)。
 空腹血糖異常：空腹血糖值100-125 mg/dL (5.6-6.9 mmol/L)。
 葡萄糖耐受不良：服糖後2小時血糖值140-199mg/dL (7.8-11.1 mmol/L)
GDM的管理 - 產後照顧
 避孕方法:與所有婦女相同。忌用含高劑量雌性素
及黃體素的口服避孕藥.子宮內避孕器，子宮帽，
保險套或結紮可提供做為避孕方法。單獨使用黃體
素製劑的口服避孕藥(“mini pill”)是安全的。
 產後可修正的危險因子:肥胖，將來體重增加情形,
其它生活型態的修正包括飲食習慣，運動，不吸菸
以及避免使用會對胰島素阻抗產生影響的藥物。
糖尿病懷孕的管理－哺乳




哺乳期的飲食計畫相當於妊娠第三
期， 可能需要點心與宵夜
若第 2 型糖尿病於哺乳期無法單獨
以營養治療來控制血糖，建議使用
胰島素
在產後前六個月哺乳，可使體重每
個月可降0.8kg，等於每天消耗
170Kcal
泌乳本身每天可消耗500Kcal，通常
滿六個月後，泌乳的熱量降為每天
400Kcal
總結


飲食習慣西化,少運動,肥胖,胰島素釋放不良及高齡化是造成妊娠糖尿
病患激增的主因。特別是近年糖尿病有年輕化趨勢。
GDM則是一種婦女在懷孕期間發生並被檢測出來的的葡萄糖耐受不
良的狀態。是糖尿病的初段預防(Primary prevention)醫療體系出發
，對於糖尿病的高危險群提供必要的定期篩檢。初段預防的目的是
對於糖尿病感受性高的群體進行預防性介入，而來防止糖尿病發生
。次段預防(Secondary prevention)在於早期診斷糖尿病並積極有效
的治療來獲取最佳的控制，以期避免或減少糖尿病的病情持續進行
。至於三段預防(Tertiary prevention)的目標是防止糖尿病 晚期併發
症的發生與持續惡化。
總結






Universal screening or risk factor based screening 全面篩檢或風險因子選擇性篩檢
One step or two step screening method and diagnostic criteria一階段或兩階段篩檢
Critics反方: Over diagnosis of GDM and unnecessary interventions過度診斷及不必
要介入
Optimism樂觀正方: IADPSG criteria is the only outcome based criteria, it has the
ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal
complications associated with GDM. This one step method has an advantage of
simplicity in execution, more patient friendly, accurate in diagnosis and close to
international consensus. IADPSG 75-g OGTT執行簡單,對孕婦較友善,及早診斷,減少
母胎併發症?
依據種族人口,食安文化,生活形態,孕婦意願及醫療資源等差異性,採用適合自己國情社
會篩檢及處置的策略
Where do you stand? Answer is in your heart你站在那方?答案在心中
閱讀建議
 ACOG Practice Bulletin No. 190: Gestational
Diabetes Mellitus. Obstet Gynecol. 2018
Feb;131(2):e49-e64.
 Hyperglycemia and Adverse Pregnancy
Outcomes. The HAPO Study Cooperative
Research Group N Engl J Med 2008; 358:19912002
醫智庫 婦產科
10-3. 產後大出血 (PPH and DIC)
婦產科
周明明 醫師
學習目標
產後大出血」（postpartum hemorrhage；簡稱PPH）是指出血量大於1000 mL以上
, 是產後嚴重的併發症，可能產後立即發生，多是由於子宮收縮不良,子宮破裂或產道
裂傷所導致。也可能產後一天至產後1、2個月內之後才發生，原因可能是因胎盤殘
留或子宮復原不良所引起。
根據產後大出血發生的原因不同，其危險性也大不相同。早發性出血的危險性比遲
發性還嚴重，需要立即處理。然而無論是什麼原因引起的出血，只要失血量達一定
程度，即有可能發生生命跡象不穩定、瀰漫性血管內凝血反應症DIC，甚至休克及死
亡。一直以來高居產後母親死亡原因的前三名(the leading cause of maternal
mortality worldwide) 。
若碰到產後大出血，必須在最短急救的黃金時間內,緊急轉送到大醫院跨科團隊照護
處理,所以千萬不可輕忽。
學習大綱
1. Definition of PPH
2. Primary prevention of hemorrhage
3. Early recognition and effective treatment of
hemorrhage
4. Preparation to manage hemorrhage
1. Definition of PPH
產後出血定義


Blood loss of > 1000 mL or more accompanied
by signs or symptoms of hypovolemia ( e.g.
tachycardia or hypotension) within 24 hours
after the birth (include intrapartum loss)
regardless of route of delivery.
傳統定義觀點不同:產後24小時內陰道分娩和剖
腹產出血量分別≧500ml和≧1000ml
2. Primary prevention of hemorrhage
Prevention 1- Identify high-risk women
Risk Factors for PPH - Prelabor
Previous retained
placenta or PPH
(recurrence rate 8-10%)
Previous CS associated
with previa, accreta
BMI > 35
Older women
APH from placental
abruption
Existing uterine
abnormalities-fibroids,
adenomyosis
Overdistension of uterusmultiple pregnancy,
polyhydramnios,
macrosomia
Preeclapsia
Anemia Hb < 9 g/dl
Grand multiparity
Risk Factors for PPH-Intrapartum
產中危險因子-產後出血
引產
產程過長
Induction of labor
Prolonged first,
second or third
stage of labor
產鉗及真空吸引
第二產程剖宮產
Operative vagina birth
CS particularly in the
second stage of
labor
催產素使用
胎盤殘留
急產
Oxytocin use in labor
Retained
placenta
Precipitate labor
胎盤剝離
產中感染發燒
Placental abruption
Pyrexia in labor
耶和華見證人拒
絕輸血病人
Women who decline
blood products
3. Early recognition and effective
treatment of hemorrhage
Early recognition

Remember：出血預估有時有其困難之處

Blood loss can be difficult to estimate
Bleeding can be concealed within the uterus, broad ligament or abdominal cavity

Vital to monitor heart rate, BP and RR

Act on signs and symptoms

Monitor fundal height postnatally
Conventional Temporal Classification of PPH
Class I
(Alert line, need close observation, replacement therapy if necessary) :blood loss
輕度出血 10-15% (500-1000 ml) normal BP, palpitations (PR/SBP < 1), dizziness,
tachycardia
Class II
(Action line, replacement therapy and oxytocics): blood loss 15-25% (1000-1500
中度出血 ml), slightly low BP, tachycardia, (PR/SBP 1-1.5), weakness, sweating.
Class III (Urgent active management):blood loss 25-35% blood loss (1500-2000 ml), PR
嚴重出血 120/min, systolic BP 70-80 mmHg (PR/SBP 1.5-2.0), restlessness, pallor, oliguria.
Class IV (Critical active management, high mortality 50%): blood loss35-45% ( 2000-3000
致命出血 ml), PR 140/min, BP 50-70 mmHg (PR/SBP > 2),collapse, air hunger, anuria.
(modified and adapted from Bonner J. Baillieres Best Pract Res Clin Obstet Gynecol 2000;14:1
依據孕產婦臨床徵狀處理而非依據目測失血量
Action is often taken following maternal S&S rather than on visual EBL
不要輕忽輕度出血，
有可能極短時間快速進展到危及生命的出血
Never ignore class 1 PPH, it can rapidly progress to point of no return with life
threatening class IV PPH unless appropriate interventional procedures be taken.
Estimated blood loss - Aide Memoire
Small swab：50ml
Kidney dish ：600ml
Medium swab：100ml
Bedpan：500ml
Large swab：350ml Sanitary towel：100ml Inco sheet：250ml
Vomit bowl：300ml
Floor spills
PPH
50x50cm (500ml)
75x75cm (1000ml)
100x100cm (1500ml)
On bed only(1000ml)
Spilling to floor(2000ml)
Rapid evaluation of maternal and fetal condition
Ascertain obstetric and clinical history
1.
2.
3.
4.
Gestational age
Previous uterine surgery/caesarean section
Position of placenta (refer to any antenatal scans)
Abdominal pain
Examination
1. Estimate blood loss Uterine palpation for tone and tenderness
2. Assess placental site using ultrasound scan
3. Once placenta praevia has been excluded, perform a PV to assess degree of
bleeding and possible local causes (trauma, polyps, ectropion); consider a vaginal
examination to ascertain degree of bleeding, possible local cuases(trauma,
polyp,s,ectropion) and stage of labour.
PPH may occur in women without identifiable
clinical or historical risk factors
休克指指數
Shock Index (pulse /systolic BP – normal is 0.5 to 0.7 – and > 0.9 indicates
onset of shock and further increase indicates increasing shock) or reduced
Rule of 30 (rise in pulse >30/min, drop in systolic BP > 30 mm Hg, reduced
urinary output <30 ml/min, absolute respiratory rate 30/min, drop in
hematocrit >30 %)
休克出血分類
Shock is proportionate to blood loss - mild 15%, moderate 25%, and severe
35% - but this need to be calculated based on the woman’s blood volume
that depends on her weight (approx Blood volume in Liters = 70 ml X wt in
Kg). A 14 or 16 gauge cannula and rapid infusion with a Hb of < 7 is a must
to avoid tissue hypoperfusion and hypoxia that may lead to lactic acidosis
and aggravate the situation.
四T原則Four Ts
Tone (uterine atony);Tissue (retained products) ;Trauma (cervical and genital
tract damage during delivery); Thrombin (coagulation disorder)
內科治療失敗需考慮
外科手術積極治療
Failure to arrest haemorrhage by medical therapy may require aggressive
surgical measures.
INITIAL ACTIONS
ONGOUNG MANAGEMENT
平躺
給予高流量
氧氣
建立二條大口徑16號
靜脈輸液管路,凝血功
能全套驗血及備血,至
少四單位
子宮按摩
雙手按壓子宮
快速輸液
2000 ml
crystalloid –
Hartmann’s or
0.9% saline
觀察生命徵象
呼吸脈搏血壓
血氧飽和度
評估出血四大原因
宮縮乏力
產道裂傷
胎盤病變
凝血病變
停止產後出血處置
Syntocinon 10 units/
Ergometrine 500
micrograms
40 units
syntocinon
IV infusion
IM or slow IV injection
尿管置放
評估每小時小
便量
Carboprost
250 micrograms given
IM every 15 minutes
up to 8 doses
Misoprostol
800 micrograms
given sublingual
Massage uterus and bimanual comression , pelvic arterial embolization and surgical treatment Repair perineal /
vaginal / cervical tears etc.
評估
監測
病歷完整記錄
準確評估出血量
輸液平衡
再次評估出血四大原因
宮縮乏力
產道裂傷
胎盤病變
凝血病變
輸血:依據輸大量輸血指引方針
緊急狀況可輸 O型陰性血
(考慮溫血裝置使用,產婦保溫)
凝血病變:新鮮冷凍血漿,血小板, cryoprecipitate, 第七重組凝血因子factor VIIa
重大產後出血ＰＰＨ立即處置標準流程圖
資深產科醫師
放射線介入療
法專科醫師
緊急呼救
護理人員
產後出血快速急救小組成員
血庫
麻醉醫師
AMTSL - Safe Motherhood
Modified or mixed management approach
目前的文獻支持主動管理的第三產程處理
來預防宮縮乏力引起的產後出血
預防性宮縮劑使用，嬰兒肩膀出
生後給予靜脈滴注催產素
胎盤娩出後2小時內，每15
分鐘評估子宮收縮情況，以
決定是否需要持續子宮按摩
以減少產後出血的發病率
胎兒臍帶動脈停止跳動
(約1-3分鐘)再剪斷臍帶
我們採行的措施
胎盤剝離後再使用controlled
cord traction方式分娩胎盤
第三產程主動處理，預防子宮收縮乏力及產後出血





催產素Oxytocin仍是首選藥物預防子宮收縮乏力。
Carbetocin (duratocin) 100mcg/1ml 單一的劑量與傳統催產素相比能夠增加子
宮收縮的頻率強度4-10倍，持續時間更久約相當於傳統催產素靜脈滴注8小時。
There is evidence to suggest that 100 µg of intravenous carbetocin is more
effective than oxytocin for preventing PPH in women undergoing caesarean
deliveries, but more studies are needed to validate this finding.
There is limited clinical data on the effectiveness of carbetocin used after
vaginal delivery.
10 IU oxytocin (intravenous or intramuscular) is preferable to 600 μg oral
misoprostol in the active management of the third stage of labor in hospital
settings where active management is the norm.
宮縮劑使用要點
藥物
劑量
副作用
Intravenous infusion of
oxytocin (20 to 40 IU in 1000
mL, 150 mL/hour)
10 U intramyometrial inj. (inject
oxytocin 10 u diluted in N/S 10
ml directly into the uterus)
水中毒：噁心.嘔吐
過敏
Ergonovine
2nd line
0.25mg im./
0.125mg iv.
Q15min; ≦5次
高血壓.噁心.嘔吐
心肺疾病.
高血壓.過敏
15-methyl
PGF2α 3rd line
0.25mg im.宮體注射
Q15min; ≦8次
通常使用2~3次
噁心.嘔吐.潮紅.
腹瀉.支氣管痙孿.
躁動.氧飽和度降低
心肺疾病.
過敏.氣喘
Pitocin 1st line
禁忌症
PPH, Panic Panic Hemorrhage--Avoidable- System-Based
Standardized Approach

Developing a better L&D rapid response team. Called for assistance or help

Temporal Classification of PPH- Measure blood loss, BP and PR, laboratory
exam such as CBC, PT and APTT exam. etc.
Rule 1 Insert large gauge IV lines for excellent venous access.
Rule 2 A ready accessibility of blood products becomes crucial for the survival of patient with PPH.
4-6 units un-cross-matched blood group O Rh positive RBCs is used for immediately life-threatening
hemorrhage.
Rule 3 Identification and management of the underlying cause(s) of PPH. Short differential diagnosis:
Act on findings.
Rule 4 Activate massive transfusion standard protocol incorporating surgical interventions.
Rule 5 Post hempstatic resuscitation intensive medical care-CAB rule:
Rule 6 PPH”Fire Drill”-Master of PPH
Rule 1
be ahead in the PPH game



Call for help
Place 2 large-bore (16-18-gauge) intravenous lines. There is no
use to have any of these protocols if you are unable to deliver the
blood products.
Fluids and blood products to prevent shock-A ready accessibility of
blood products with 4-6 units un-cross-matched blood group O Rh
positive RBCs is used for immediately life-threatening hemorrhage
until type-compatible or fully cross-matched blood is available.
Rule 2
know what is really available
麻醉醫師
手術房
做好準備
Getting or ready
(是否需要婦癌科醫師協助
Gyn Oncologist Assistance?)
放射科
血管介入
栓塞做好準備
Is invasive radiology
really an option at night?
加護病房
是否有床位
Can you get a ICU bed?
血庫做好準備
是否有第七凝
血因子
Heamatology
(Factor VII)
Rule 3
Treatment the causes對症治療
Drugs
Tamponade
Invasive radiology
Surgery
藥物
填塞壓迫止血
放射介入血管栓塞
手術
治療策略選擇
Treatment Options
Overdistended uterus
Large fetus
Multiple fetuses
Hydramnios
Uterine Atony
子宮收縮無力
Distention with clots
Anesthesia Halogenated agent
Prolonged labor with exhausted myometrium
Rapid labor
Oxytocin or prostaglandin hyperstimulation
Chorioamnionitis
Previous uterine atony
Genital Tract Lacerations





Bleeding while the uterus is firmly contracted is strong evidence of genital
tract laceration, retained placental fragments, or both
Perineal lacerations; Vaginal lacerations; Injuries to the cervix or lower
uterine segment; Injuries to Levator Ani
Puerperal hematomas; CS incisional wound hematoma, subfascial
hematoma, vaginal or vulvar hematomas etc.
Angiographic embolization has become popular for management of
intractable puerperal hematomas or where there is continuing expansion of
a supralevator hematoma without extension into the cervix, vagina fornix or
uterus. It can be used primarily or usually when hemostasis is not obtained
by surgical methods.
Laparotomy (TAH) is indicated where there is a supralevator/broad ligament
hematoma due to a ruptured uterus or where cervical tear have extended
up into the uterus.
Coagulation Defects-Intensify Other Causes
Severe
preeclampsia
and eclampsia
Tamponade
Placental
abrupiton
Sepsis with
endotoxemia
Massive
transfusions
填塞壓迫止血
Prolonged retention
of dead fetus
Congenital
coagulopathies
Amnionic fluid
embolism
Anticoagulant
treatment
Surgical approaches







Bimanual compression
Manual removal of retained placenta
(contraindicated in placenta
acceta/increta/percreta)
Repair of tears – vaginal, cervical, uterine etc.
B-Lynch suture for uterine atony
Sutures to placental bed
Uterine/internal iliac vessel ligation
Hysterectomy
單側子宮上段子宮
動脈上行枝結紮
1
進階式子宮動脈結紮術
( stepwise uterine devascularization)
單側子宮上段子宮
動脈上行枝結紮
1
2
雙側子宮動脈
上行枝結紮
進階式子宮動脈結紮術
( stepwise uterine devascularization)
雙側子宮下段子宮動脈下降
枝 (cervicovaginal branch)
結紮，前置胎盤及前置-植入
胎盤引起之出血往往須要結
紮子宮頸陰道 動脈分枝血管,
才能成功止住出血。
單側子宮上段子宮
動脈上行枝結紮
1
2
3
雙側子宮動脈
上行枝結紮
進階式子宮動脈結紮術
( stepwise uterine devascularization)
雙側子宮下段子宮動脈下降
枝 (cervicovaginal branch)
結紮，前置胎盤及前置-植入
胎盤引起之出血往往須要結
紮子宮頸陰道 動脈分枝血管,
才能成功止住出血。
單側子宮上段子宮
動脈上行枝結紮
1
2
雙側子宮動脈
上行枝結紮
4
3
單側卵巢血管結紮,原則上結
紮卵巢動脈，如不容易分離
卵巢靜脈，亦可同時結紮
進階式子宮動脈結紮術
( stepwise uterine devascularization)
雙側子宮下段子宮動脈下降
枝 (cervicovaginal branch)
結紮，前置胎盤及前置-植入
胎盤引起之出血往往須要結
紮子宮頸陰道 動脈分枝血管,
才能成功止住出血。
單側子宮上段子宮
動脈上行枝結紮
1
2
雙側子宮動脈
上行枝結紮
雙側卵巢
血管結紮
4
3
單側卵巢血管結紮,原則上結
紮卵巢動脈，如不容易分離
卵巢靜脈，亦可同時結紮
進階式子宮動脈結紮術
( stepwise uterine devascularization)
5
Figure 1. Interrupted circular suture for the anterior lower segment . B=bladder
Figure 2. Interrupted circular suture for the posterior lower segment .
Figure 5. The Haman uterine compression suture without opening the uterine cavity 11
Figure 2a-c. Summary of the application of the B-Lynch procedure
Figure 3. Bakri balloon
Tranarterial Embolization (TAE)






PPH
Uterine atony
Vulvar hematoma , vaginal hematoma, pelvic
hematoma etc.
Placenta previa accrete
Postpartum decidual sinus bleeding
Deep birth canal lacerations difficult for surgical
repair
4. Preparation to manage hemorrhage
We need to prevent PPH in the first place, then
to aggressively manage it with all what is
available in our armamentarium. Aim of
management should be to save every drop of
blood, because with every additional drop of
blood lost, the condition of the patient worsens
and enters a vicious cycle of hemorrhage,
coagulopathy, and hypothermia. Many a times,
patients are lost with a too little done, too late.
Fluid Resuscitation



Initial resuscitation with large volumes of normal saline
(NS) or Lactated Ringer’s solution (LRS)
Remember that the loss of 1 L of blood requires
replacement with 3-5 L of crystalloid
PPH of up to 1500 mL in a healthy pregnant woman can
usually be managed by crystalloid infusion alone if the
cause of bleeding is arrested. Blood loss in excess of
this usually requires the addition of a PRBC transfusion.
Massive obstetric transfusion protocol
– Hemostatic resuscitation






Compatible (fresh) whole blood is ideal for treatment of
hypovolemia from catastrophic acute hemorrhage-PPH patient is
losing whole blood.
Packed RBCs (one U increase Hb1-1.5g or 3-4 volume % Hct.)
FFP (5-10 ml FFP/Kg ;one U increase coagulation factors 2-3%)
Platelet concentrate- 1 unit of apheresis platelet from a single
donor=6-11 units of conventional whole blood derived random
donor platelets.
Earlier and more aggressive infusion of packed RBC:
conventional (not apheresis) unit of platelet: FFP in 1:1:1
ratio.
Cryoprecipitate- one U increase fibrinogen 5 mg/dl.
Massive obstetric transfusion protocol
– Hemostatic resuscitation


Prevention and treatment of hypothermia, acidosis and
hypocalemia
Recombinant activated factor VII rFVIIa (Novoseven) has been
effectively used “off label” on an empirical basis in the treatment of
massive PPH which did not respond to conventional methods in
acute uncontrolled bleeding conditions.
Massive obstetric transfusion protocol
– Hemostatic resuscitation



Hemoglobin levels should be preferably above 7 g/dl, international
normalized ratio <1.5, and platelet levels above 50 000/cumm.
Fibrinogen levels of a minimum of 100 mg/dl must be ensured
before administration of rFVIIa
Recombinant Factor VIIa 40-100 μg/Kg, repeat 3-4 times at 15-30
min interval. Early use instead of last resort therapy.
Decision to use rFVIIa should be taken in time during management
of PPH before metabolic complications develop and before the
symptoms of severe thrombocytopathies, hypoxia, and organ injury
appear.
Effect of early tranexamic acid administration on mortality, hysterectomy, and other
morbidities in women with post-partum haemorrhage (WOMAN): an international,
randomised, double-blind, placebo-controlled trial
In this randomised, double-blind, placebo-controlled trial from 193 hospitals in 21
countries. 1 g intravenous tranexamic acid. If bleeding continued after 30 min, or
stopped and restarted within 24 h of the first dose, a second dose of 1 g of
tranexamic acid could be given.
Interpretation Tranexamic acid reduces death due to bleeding in women with postpartum haemorrhage with no adverse effects. When used as a treatment for
postpartum haemorrhage, tranexamic acid should be given as soon as possible
after bleeding onset.
The Lancet Volume 389, Issue 10084, Pages 2105-2116 (May 2017) DOI: 10.1016/S0140-6736(17)30638-4
Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions
總結
: 正確早期快速診斷及處置產後出血







識別容易產後出血的高危險妊娠病人。
正確評估失血量，適時適量快速輸血。
及時有效治療因大量出血所造成的DIC凝血病變。
針對產後大出血4大原因鑑別診斷及適當內外科療法。
Stop the PPH medical errors- avoidable maternal deaths. The margin of
error is so small between living and dying. There is no time to lose. Every
minute is critical in the PPH fight to save women’s lives.
要預防這些狀況，醫師的教育最重要。所以轉診要即時，只要一感覺不易處
理，就要先做好基本急救處理：打好點滴、壓迫止血、立即上救護車、車上
立即輸血，不然好幾千mL的血一直流，會危及產婦的生命！
必須在最短急救的黃金時間內,緊急轉送到大醫院跨科團隊照護
閱讀建議



Ö zge Tunçalp, João Paulo Souza, Metin Gülmezoglu. New WHO
Recommendations on Prevention and Treatment of Postpartum
Hemorrhage. International Journal of Gynecology and Obstetrics
123 (2013) 254–256
ACOG Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet
Gynecol. 2017 Oct;130(4):e168-e186.
Michael A Belfort. Overview of postpartum hemorrhage. UpToDate
Literature review current through: Apr 17, 2018. |
醫智庫 婦產科
10-4. 懷孕出血-異常胎盤
婦產科
袁嘉駿 醫師
學習目標
產前出血是懷孕常見併發症的其中一項，甚至屬於產
科急症，因此熟悉產前出血的鑑別診斷是處置，在臨
床上是很重要的。
學習大綱
1. APH, Antepartum hemorrhage
2. Placenta previa
3. Placental abruption
1. APH, antepartum hemorrhage
產前出血
Definition
After GA 28 weeks, before delivery
Placenta
abnormality
Hematologic
disease
Cause
Urinary
tract disease
Cervical
disease
Vaginal
disease
Cervical disease
Small polyp
Small and large polyps
Laceration
Vaginal disease
Foreign body
Varicose vein
rupture
2. Placenta previa
前置胎盤
Definition
Placenta is located over or very near the internal os
Classification
Types of Placenta Previa
Etiology



Prior cesarean section
Prior uterine surgery
Uterine anomaly




Advancing maternal age
Multiparity
Multiple pregnancy
Smoking
Diagnosis
Painless vaginal bleeding
Transvaginal ultrasonography
Management
Cesarean delivery
3. Placenta abruptio
胎盤早期剝離
Definition
妊娠第20週後，生產第三產程前正常著床的胎盤
與基蛻膜 (decidua basalis) 分離的現象
Risks





Increased age and parity
Preeclampsia
Chronic hypertension
Preterm ruptured
membranes
Multifetal gestation






Polyhydramnios
Cigarette smoking
Thrombophilia
Cocaine use
Prior abruption
Uterine myoma
Classification
Diagnosis








Painful vaginal bleeding
Uterine tenderness or back pain
Fetal distress
Preterm labor
High-frequency contractions
Hypertonus
Dead fetus
Retro-placental hematoma


Management



Check vital sign
Laboratory examination
Ultrasonography
Speculum examination
Check FHR pattern
總結
Antepartum hemorrhage
Common cause of APH
Placenta previa
Definition, diagnosis, and management
Placenta abruption
Definition, diagnosis, and management
閱讀建議

Williams Obstetrics, 24th edition, chapter 44,
obstetrical hemorrhage
醫智庫 婦產科
10-5. 早產及早期破水
婦產科
袁嘉駿 醫師
學習目標
早產或早產早期破水是很常見的高危險妊娠疾病，
在臨床也很常會遇到。希望學習過後能對早產和早
產早期破水更加認識，在鑑別和病人處理上也能更
加熟練。
學習大綱
1. Preterm labor, PTL
2. Preterm premature rupture of membranes,
PPROM
1. Preterm labor
早產
Diagnosis
GA 20 ~ 36 6/7 weeks
Uterine contraction


> 4 times in 20 minutes
> 6 times in 1 hour
Cervical dilatation



Progress
> 2cm
> 80%
Classification
By GA (WHO)




<28：extremely preterm
28-32：very preterm
32-37：moderate to late preterm
34-36：late preterm
Incidence
Figure 42-2 Preterm and low-birthweight rate : United
States, final 1990 to 2010 and preliminary
2011.(Redrawn from Hamilton, 2012.)

Symptoms and signs



Abdominal tightness
Bloody show
Vaginal bleeding
Low back soreness
Etiology

Uterine distention



Maternal-fetal stress



Contraction-associated proteins (CAPs)
Stretch-induced potassium channel, TREK-1
Rise in estrogen levels may alter myometrial quiescence and
accelerate cervical ripening
Premature cervical change
Infection
Management




24 ~ 34 weeks:
corticosteroids
< 32 weeks: MgSO4
First line tocolytic
agent < 48 hours:
Low back soreness
Beta-agonist
CCB
NSAID
Oxytocin antagonist
2. PPROM
早產早期破水
Diagnosis
Preterm, < 37 weeks
ROMs





Pooling sign
Nitrazine test
Decreased AFI
Ferning test
羊水試紙 (ActimPROM, AmniSure)
Incidence
Occurs in up to 10% of pregnancies
Symptoms and signs
Vaginal watery discharge
Etiology
Weakened membranes
Associated with the presence of infection
Cervical incompetence.
Rupture because of poor support
Abnormally raised intrauterine pressure.
Due to polyhydramnios, distension of the uterus by multiple pregnancy
Management
總結
Preterm labor




Symptoms and signs
Diagnosis
Management
34 weeks
Preterm premature rupture of
membranes


Most similar to PTL
Antibiotics
閱讀建議



ACOG, practice bulletin, Management of Preterm
Labor
ACOG, practice bulletin, Preterm Premature
Rupture of Membranes
Williams Obstetrics, 34th edition, Chapter 44.
Preterm Labor
醫智庫 婦產科
10-6. 胎兒生長異常
婦產科
袁嘉駿 醫師
學習目標
例：胎兒的體重評估是每次產前檢查中都必須評估的
項目，許多疾病都會影響到體重變化。本單元將介紹
常見導致胎兒體重變化的疾病，希望學習本單元後，
在臨床上遇到類似的狀況，都能做出良好的鑑別診斷
和評估。
學習大綱
1. 胎兒較小(IUGR, intrauterine growth
restriction)
2. 胎兒較大(Fetal overgrowth)
1.胎兒較小
IUGR
IUGR
Definition/
Diagnosis
Etiology
Prognosis
Management
Definition / Diagnosis




10% of pregnancies
EBW < 10th percentile
Suboptimal uterineplacental perfusion
and fetal nutrition
Constitutional
Etiology / Classification








Maternal disorders
Substance use and abuse
Maternal nutrition
Multiple gestation
Teratogen exposure
Infectious disease
Genetic and structural
disorders
Placental disorders and
umbilical cord abnormalities
Etiology / Classification
Symmetric IUGR



Teratogen exposure
Infectious disease
Genetic and structural
disorders
Asymmetric IUGR

Brain sparing
Symmetric IUGR
Management




Karyotyping
Infection screen
Anatomic survey
Close follow up if no clear diagnosis
Management
Asymmetric IUGR



Karyotyping and infection screen if early onset
Test for thrombophilia disease
Increase fetal surveillance





Kick count
Doppler
AFI, amniotic fluid index
NST, non-stress test
BPP, biophysical profile
Management
IUGR with risks for
adverse outcome
Isolated IUGR

38 0/7 – 39 6/7

34 0/7 – 37 6/7
2.胎兒較大
fetal overgrowth
Fetal overgrowth
Definition/
Diagnosis
Etiology
Prognosis
Management
Definition / Diagnosis


Birth weight > 90 percentile
Macrosomnia > 4000g or 4500g

Etiology



Pre-gestational diabetes
Uncontrolled gestational diabetes
1/3 with idiopathic polyhydramnios
Constitutional
Associated risks
Maternal morbidity


Labor abnormalities, Cesarean
delivery
PPH, vaginal laceration
Fetal morbidity and mortality


Clavicle fracture, brachial plexus
injury
Depressed 5-minute Apgar scores

Management


Check GDM
Consider induction
Cesarean section
總結
IUGR
Common
cause of
IUGR
Fetal
overgrowth
Associated
risks of fetal
overgrowth
閱讀建議



Williams Obstetrics, 24th edition, chapter 44
ACOG practice bulletin, fetal growth restriction
ACOG practice bulletin, fetal macrosomnia
醫智庫 婦產科
10-7. 多胞胎妊娠
婦產科
陳怡燕 醫師
學習目標


認識多胞胎妊娠
多胞胎妊娠的風險及併發症
學習大綱
1.
2.
3.
4.
多胞胎的風險
Zygosity, chorionicity
TTTS
多胞胎的處置
1. 多胞胎的風險
Introduction
多胞胎妊娠比例增加


生育年紀上昇，較可能出現自然
受孕的多胞胎妊娠
使用人工生殖技術婦女增加
多胞胎併發症





早產(6X) →新生兒併發症及死亡率
自然流產比率較高
先天性異常比例較高
低出生體重
母體併發症
妊娠劇吐、妊娠糖尿病、高血壓、貧血、產後大出血、
剖腹產、產後憂鬱、死亡、周產期子宮切除
單胞胎
雙胞胎
三胞胎
高血壓
發生率
6.5%
12.7%
20%
2. Zygosity, chorionicity
zygosity
Dizygotic
twins
DCDA
Monozygotic
twins
DCDA
MCDA
MCMA
Chorionicity
Separate
placenta
Fused
placenta
Dichorionic
diamnionic
Monochorionic
diamnionic
Monochorionic
monoamnionic
DCDA
MCDA
MCMA
Chorionicity
Dichorionic
Twin peak sign
lambda sign
delta sign
Monochorionic
T sign
3. TTTS
Twin-twin transfusion syndrome
Criteria
DDx
 Monochorionicdiamniotic twin
gestation
 oligohydramnios in
one sac and
polyhydramnios in the
other sac.
 selective fetal growth
restriction,
fetal discordance for
structural,
genetic, or infectious
disorders.
Treatment
laser coagulation, amnioreduction
Quintero staging system
4. 多胞胎的處置
處置
生產時機
預測早產
減少風險
沒有併發症的
雙絨毛膜雙胞胎
子宮頸長度
＋
fibronectin
Selective reduction and
selective termination
建議在38週生產
沒有併發症的
單絨毛膜雙胞胎
安胎
建議在37週生產
沒有研究證實有效的方法
臥床
β-mimetics安胎藥
針劑或陰道黃體素
子宮頸環紮術
子宮托
總結





多胞胎的產檢目的在減少母親及胎兒的併發症
多胞胎的早產機率高、母體併發症比率高
早期判斷Zygosity與chorionicity是很重要的
TTTS的診斷與分期
多胞胎沒有有效的安胎處置
參考文獻


Williams 24th edition
ACOG practice bulletin: Multifetal gestations: twin, triplet, an higherorder multifetal pregnancies