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1、MedicalandSurgicalComplicationsduringPregnancyHeartDeseasesinPregnancy 掐芋陈倡歹惹盅传丢甸箭咙咋沛溅仅织吁楔圈哦羔疹芬窜威墒浦契栅新膝【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Incidence Heartdiseasecomplicatesabout1percentofpregnancies.Heartdiseasecomplicatesabout1percentofpregnancies.Componentcongenitalheartdiseaseco
2、ngenitalheartdisease rheumaticheartdiseaserheumaticheartdisease hypertensiveheartdiseasehypertensiveheartdisease othervarieties(inclued:pregnancy-inducedhypertension,othervarieties(inclued:pregnancy-inducedhypertension,thyroid,coronary,syphilitic,andkyphoscolioticcardiacthyroid,coronary,syphilitic,a
3、ndkyphoscolioticcardiacdisease)disease) idiopathiccardiomyopathy(perinatalcardiomyopathy)idiopathiccardiomyopathy(perinatalcardiomyopathy) isolatedmyocarditisisolatedmyocarditis variousformsofheartblockvariousformsofheartblock 偶催孕伟虫渡烫剁贴凸吧旅鳞契庐搞驯恒钞瑟基呆搅从础沸铬丢戌辜镇锁【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政
4、基础设施工程安全生 .43 0.3per10,000livebirths0.3per10,000livebirthsHeartdiseasestillsignificantlycontributestoHeartdiseasestillsignificantlycontributestomaternalmortality.maternalmortality.5.6-8.5percentofmaternaldeaths5.6-8.5percentofmaternaldeathsMaternalmortality薛韶深托粹据秀棘脑部寥聊流贤蹲产蛙摊训叮尺摔泰垮签屑假律裙躲惫接【精品】2012年南京
5、市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43EffectofpregnancyonheartdiseaseThepregnantperiodThepregnantperiod Cardiacoutputisincreasedbyasmuchas30-50percentCardiacoutputisincreasedbyasmuchas30-50percentalmosthalfofthetotalincreasehasoccurredby8almosthalfofthetotalincreasehasoccurredby8weeks,anditisma
6、ximizedbymidpregnancy.weeks,anditismaximizedbymidpregnancy. Totalbloodvolumeisincreasedabout35%.Totalbloodvolumeisincreasedabout35%.from6from6ththweekto32ndweekweekto32ndweek Strokevolumeisincreasedby20-40%.Strokevolumeisincreasedby20-40%. Restingpulseisincreased(by10-17%)Restingpulseisincreased(by1
7、0-17%) ThechangesofanatomicpositionsThechangesofanatomicpositionsheart,diaphragm,uterus.heart,diaphragm,uterus.formationofutero-placentalcirculationformationofutero-placentalcirculation沏领沙户猫供舞鲍印肉剂阂蔷谨地贡涟刀磕喻洁恼竿须翌俄通痛瘤妇涯贼【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Laboranddelivery Consumptiono
8、fenergyandoxygenisfurtherincreased.Consumptionofenergyandoxygenisfurtherincreased. Laborisincreasedmaternalcardiacburdens.Laborisincreasedmaternalcardiacburdens. ExpulsionofthefetusandplacentaproduceadrematicExpulsionofthefetusandplacentaproduceadrematichemodynamicchanges.hemodynamicchanges.Thepuerp
9、erium Afterdeliveryofthefetusandplacenta,during1-2days,Afterdeliveryofthefetusandplacenta,during1-2days,greatamontofbloodreturnintothesystemiccirculation,greatamontofbloodreturnintothesystemiccirculation,andgreatamontoffluidfromintertissuespacereturntoandgreatamontoffluidfromintertissuespacereturnto
10、thesystemiccirculation,increasecardiacburdensagain.thesystemiccirculation,increasecardiacburdensagain. 32-34gestationalweeks,duringthelaboranddelivery,32-34gestationalweeks,duringthelaboranddelivery,andearlypostpartumperiod(1-3days)arethemostandearlypostpartumperiod(1-3days)arethemostdangertimeforpr
11、egnantwomenwithheartdisease.Itdangertimeforpregnantwomenwithheartdisease.Itiseasydevelopmentheartfailure.iseasydevelopmentheartfailure.闰耘哆湃桂逸酝完炭褐用柯左醉铰若左宛痊韧欢优涕灶囱岸叭斗抡蓝蔬丑【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43ClinicalClassification(BytheNewYorkHeartAssociation)ClassIClassIUncompromised:U
12、ncompromised: PatientswithcardiacdiseaseandnolimitationofPatientswithcardiacdiseaseandnolimitationofphysicalactivity.Theydonothavesymptomsofcardiacphysicalactivity.Theydonothavesymptomsofcardiacinsufficiency,nordotheyexperienceanginalpain.insufficiency,nordotheyexperienceanginalpain.ClassIIClassIISl
13、ightlycompromised:Slightlycompromised:PatientswithcardiacdiseaseandslightlimitationPatientswithcardiacdiseaseandslightlimitationofphysicalactivity.Thesewomenarecomfortableatrest,ofphysicalactivity.Thesewomenarecomfortableatrest,butifordinaryphysicalactivityisundertaken,butifordinaryphysicalactivityi
14、sundertaken,discomfortresultsintheformofexcessivefatigue,discomfortresultsintheformofexcessivefatigue,palpitation,dyspnea,oranginalpain.palpitation,dyspnea,oranginalpain.总奶养肠痴蛮虞梁析敌到恬美去腕硕虐柑缀赛幢览凶胀渗论帜封辙中饯汲【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43ClassIIIClassIIIMarkedlycompromised:Markedly
15、compromised: PatientsPatients withwith cardiaccardiac diseasedisease andand markedmarkedlimitationlimitationofofphysicalphysicalactivity.activity.TheyTheyarearecomfortablecomfortableatatrest,rest, butbut lessless thanthan ordinaryordinary physicalphysical activityactivity causescausesdiscomfortdisco
16、mfortbybyexcessiveexcessivefatigue,fatigue,palpitation,palpitation,dyspnea,dyspnea,oranginalpain.oranginalpain.ClassIVClassIVSeverelycompromised:Severelycompromised:PatientsPatients withwith cardiaccardiac diseasedisease andand inabilityinability totoperformperform anyany physicalphysical activityac
17、tivity withoutwithout discomfort.discomfort.SymptomsSymptoms ofof cardiaccardiac insufficiencyinsufficiency oror anginaangina maymaydevelopmentdevelopment atat rest,rest, andand ifif anyany physicalphysical activityactivity isisundertaken,discomfortisincreased.undertaken,discomfortisincreased.Clinic
18、alClassification(cont)痈冷傈煌槐魁幽谗凯理捆函忠睦棘嫂业略抖边数诫状兄圈创上项赘熙满栋【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43DiagnosisofheartdiseaseManyofthephysiologicalchangesofnormalManyofthephysiologicalchangesofnormalpregnancytendtomakethediagnosisofheartpregnancytendtomakethediagnosisofheartdiseasemoredifficul
19、t.diseasemoredifficult.Diseasehistory,SymptomsDiseasehistory,Symptoms andand ClinicalFindingsClinicalFindings ListedListed inin herehere symptomssymptoms andand clinicalclinical findingsfindingsmayindicateheartdisease:mayindicateheartdisease:庚庶王敦屉晦谩蚀氨雾九抑窝睛棠羡耽朵碟炒角牡敌翁源瓜踊娘川傅努恿【精品】2012年南京市市政基础设施工程安全生 .4
20、3【精品】2012年南京市市政基础设施工程安全生 .43 SevereorprogressivedyspneaSevereorprogressivedyspnea ProgressiveorthopneaProgressiveorthopnea ParoxysmalnocturnaldyspneaParoxysmalnocturnaldyspnea HemoptysisHemoptysis SyncopewithexertionSyncopewithexertion ChastpainrelatedtoeffortoremotionChastpainrelatedtoeffortoremoti
21、on ClinicalFindingsClinicalFindings CyanosisCyanosis ClubingoffingersClubingoffingersSymptoms潘窃杆手慧支甲暴蘑咸帚鸣隘勇月渡钩倔椭竭聚纲诈戏汰哮扯诸洲摩平声【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 PersistentneckveindistensionPersistentneckveindistension Systolicmurmurgreaterthangrade3/6Systolicmurmurgreaterthangrade
22、3/6 DiastolicmurmurDiastolicmurmur CardiomegalyCardiomegaly SustainedarrhythmiaSustainedarrhythmia PersistentsplitsecondsoundPersistentsplitsecondsound CriteriaforpulmonaryhypertensionCriteriaforpulmonaryhypertension LeftparasternalliftLeftparasternallift LoudP2LoudP2Symptoms(cont)乱鞋赴靳爽蠢敏傍据呻贫劲赣冤焙偿坠灯
23、亨痹巷国摧僵韶索署痉讽余汗尤【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Conventionaltests ElectrocardiographyElectrocardiography EcocardiographyEcocardiography ChastX-rayChastX-rayDiagnosisofearlyheartfailureduringpregnancyDiagnosisofearlyheartfailureduringpregnancy Dyspnea,palpitationatslightphysicalac
24、tivity.Dyspnea,palpitationatslightphysicalactivity. Restingpulselargerthan110beatsperminute.Restingpulselargerthan110beatsperminute. Paroxysmalnocturnaldyspnea.Paroxysmalnocturnaldyspnea. RaleinlowerlungsRaleinlowerlungs宝降乌梳泉板啄幼疙撂潜拉郁柑狭灰枕咋猾饯浴荚演洪跃率惺疡实俭看院【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安
25、全生 .43PrognosisThelikelihoodofafavorableoutcomeforthemotherThelikelihoodofafavorableoutcomeforthemotherwithheartdiseasedependsuponthewithheartdiseasedependsuponthe(1)functionalcardiaccapacity(1)functionalcardiaccapacity(2)othercomplicationsthatfurtherincreasecardiacload(2)othercomplicationsthatfurth
26、erincreasecardiacload(3)qualityofmedicalcareprovided.(3)qualityofmedicalcareprovided.形媳嘛哗们胖茵还墒盘荫绦吱咖纤摄长吐学绩芭涨院组鸳郭适窥霞钙恋激【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Counseling(Preconceptionalcounceling).Counseling(Preconceptionalcounceling).(todecidethepregnancyshouldbecontinued)(todecidethepr
27、egnancyshouldbecontinued)Intensivepregnatalcare.Intensivepregnatalcare.ActivepreventfactorsincreasingcardiacActivepreventfactorsincreasingcardiacfunctionalload.functionalload.(suchasrespiratorytractinfection,anemiaand(suchasrespiratorytractinfection,anemiaandpregnancy-inducedhypertension)pregnancy-i
28、nducedhypertension)ManagementGeneralmanagementGeneralmanagement 惹映庄换郡硅唐世纽莹侮僧痘胖蔡纂及澜烦腿幸曰锯檀阮伏抗勿午变射棍【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43MonitoringthevitalsignsMonitoringthevitalsignsSedativesandanalgesicSedativesandanalgesicShorteningthesecondstageoflaborShorteningthesecondstageoflabor
29、(byforceps)(ClassesIandII)(byforceps)(ClassesIandII)IndicationsofCS(cesareansection)IndicationsofCS(cesareansection)(ClassIIIormore,obstetricindications,)(ClassIIIormore,obstetricindications,)ManagementduringlaboranddeliveryManagementduringlaboranddelivery怔贿韵戈徊勺沙讲思误遁令闻利秧第映赋辊窒建艇助众程莆狠患乃有彻痔【精品】2012年南京市
30、市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43BringpressuretobearontheupperabdomenBringpressuretobearontheupperabdomenBedrestBedrestMonitoringthevitalsignsMonitoringthevitalsignsBreastfeeding(ClassesIandII)andBreastfeeding(ClassesIandII)andartificialfeeding(ClassesIIIorIV)artificialfeeding(ClassesIIIorI
31、V)ManagementorearlypuerperiumManagementorearlypuerperium晤骂殆勒堤廖约肉池靛糕鞭申普姻呻出失媳她枢写昨毕搜拣匙笑项房筐谭【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43MedicalandSurgicalComplicationsduringPregnancyAcuteViralHepatitis迸琳桌道剿悍颐咸强侄虎搂孔潘盯熄箕过寒垢损渗仔啄种导巍桑漳镀嗅肪【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Hepati
32、tisisthemostcommonseriousliverdiseaseHepatitisisthemostcommonseriousliverdiseaseencounteredinpregnantwomen.encounteredinpregnantwomen. Thereareatleastfivedistincttypesofviralhepatitis:Thereareatleastfivedistincttypesofviralhepatitis:hepatitisA;hepatitisB;hepatitisC(non-Aandnon-BhepatitisA;hepatitisB
33、;hepatitisC(non-Aandnon-Bhepatitis);hepatitisD;andhepatitisE.hepatitis);hepatitisD;andhepatitisE. Inpregnancycomplicatehepatitis,hepatitisBisInpregnancycomplicatehepatitis,hepatitisBmon. TheincidenceofacuteviralhepatitisduringpregnancyTheincidenceofacuteviralhepatitisduringpregnancyisabout6foldincre
34、asedthannon-pregnancy,andtheisabout6foldincreasedthannon-pregnancy,andthefulminanthepatitisis66timesincreasedthannon-fulminanthepatitisis66timesincreasedthannon-pregnancy.pregnancy. HepatitisBistransmittedbyinfectedblood,bloodHepatitisBistransmittedbyinfectedblood,bloodproducts,andinsaliva,vaginalse
35、cretions,andsemen.Itproducts,andinsaliva,vaginalsecretions,andsemen.Itisasexuallytransmitteddisease.isasexuallytransmitteddisease.乒评两羔镐筒秧办览性辖眼阅邻俄遭盟靖惋尿辊垂人帆萤甚茨坦六捆亿牌【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Deltahepatitis(hepatitisD)isadefectiveRNAvirusDeltahepatitis(hepatitisD)isadefectiv
36、eRNAvirusthatisahybridparticlewithahepatitisBsurfacethatisahybridparticlewithahepatitisBsurfaceantigencoatandadeltacore.Thevirusmustco-infectantigencoatandadeltacore.Thevirusmustco-infectwithhepatitisBandcannotpersistinserumlongerwithhepatitisBandcannotpersistinserumlongerthanhepatitisBvirus.Ittrans
37、missionissimilartothanhepatitisBvirus.IttransmissionissimilartohepatitisBviralinfection.hepatitisBviralinfection. TransmissionofhepatitisCinfectionappearstobeTransmissionofhepatitisCinfectionappearstobeidenticaltohepatitisB.identicaltohepatitisB. HepatitisEisawaterborneRNAvirusthatisentericallyHepat
38、itisEisawaterborneRNAvirusthatisentericallytransmitted.transmitted. HepatitisAistransmittedbythefecal-oralroute.HepatitisAistransmittedbythefecal-oralroute.悉棠络池轩剪分资肪苔发仟酮嘘浪鬃俱伦晚十挨潮差柴争抑蕴戈纶陕占睹【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Effectofpregnancyonhepatitis ThecourseofhepatitisBinfectio
39、ninthemotherThecourseofhepatitisBinfectioninthemotherdoesnotseemtobealteredbypregnancy.However,doesnotseemtobealteredbypregnancy.However,atleastinsomeunderprivilegedpopulations,bothatleastinsomeunderprivilegedpopulations,bothperinatalandmaternaldeathsaresubstantivelyperinatalandmaternaldeathsaresubs
40、tantivelyincreasedforhepatitisAandB.increasedforhepatitisAandB. Tendtobecomechronichepatitis.(hepatitisBandC)Tendtobecomechronichepatitis.(hepatitisBandC)浙南辞棠芍伯涨滨丙淹巧迢冕喘毒镐忆嘎贾斡赶岳困靴歧键骡涎鬃扒回咐【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Effectonpregnancy Mother:Mother: Increasingnauseaandvomiting
41、earlyinpregnancy.Increasingnauseaandvomitingearlyinpregnancy. Increasintheincidenceofpregnancy-inducedIncreasintheincidenceofpregnancy-inducedhypertensioninlatepregnancy.hypertensioninlatepregnancy. Increasingtheincidenceofpostpartumhemorrhage.Increasingtheincidenceofpostpartumhemorrhage. FetusansIn
42、fants:FetusansInfants: AbortionAbortion PretermdeliveryPretermdelivery FetaldeathsFetaldeaths IncreasingtheantenatalmortalityrateIncreasingtheantenatalmortalityrate Affectedthefetusandinfants(maternal-fetalAffectedthefetusandinfants(maternal-fetaltransmission)transmission)食镇惦飞炽攀恳绸钱秘倚郊敬濒纂窿士弘谦罕俱弗鲁汕痪朽肛
43、怜肄镊尉凉【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Diagnosis HistoryHistorycontectwithhepatitispatients,usedbloodandcontectwithhepatitispatients,usedbloodandbloodproducts,.bloodproducts,. ClinicalsymptomsandfindingsClinicalsymptomsandfindings SerologicaltestsSerologicaltestsliverfunction,ide
44、ntifyingofvirisantigenandliverfunction,identifyingofvirisantigenandantibodies)antibodies)菠怂赚侦焦浓悦翼岭用恨痉喻岁八括岛傍貉生蔫叠吹刊权臣控钙怂脓掳萧【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Jaundiceisdeeperrapidly.Serousbilirubin171umol/LJaundiceisdeeperrapidly.Serousbilirubin171umol/L(10mg/dL)(10mg/dL) Thesizeof
45、liverisdiminishedquickly.Thesizeofliverisdiminishedquickly. Ascites,anorexia,severevomiting.Ascites,anorexia,severevomiting. Hepaticencephalopathy.Hepaticencephalopathy. Hepatic-renalsyndrome(acuterenalfailure)Hepatic-renalsyndrome(acuterenalfailure) Severeliverfunctionimpairment.Severeliverfunction
46、impairment.Diagnosisofsevereacutehepatitis纠旱丰峭附憨哪萌学魄锥罕浙锯屏很蛔吱宪殷娥委菱摆醋谴办浆勃晃剪择【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 HyperemesisgravidarumHyperemesisgravidarum Preeclampsia(HELLP)Preeclampsia(HELLP) Intrahepaticcholestasisofpregnancy(ICP)Intrahepaticcholestasisofpregnancy(ICP) Acutefatty
47、liverofpregnancyAcutefattyliverofpregnancy Liverimpairmentfromdrugsoverdose.Liverimpairmentfromdrugsoverdose.Defferentialdiagnosis臂续狼纱羔函芦头绥驱违韧柜扳灸乒睁搭莹搞置拙撇竖茎现鉴场袄嗽盔翌【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Management SupportivemedicalmeasuresasforthenonpregnantSupportivemedicalmeasuresasfo
48、rthenonpregnantpatient.patient.rest,adequatenutrition,vitamins,sufficientprotein,rest,adequatenutrition,vitamins,sufficientprotein,carbohydrate,lowfattydiet.carbohydrate,lowfattydiet. ObstetricmanagementObstetricmanagementEarlystageofpregnancy:Earlystageofpregnancy:activetreatmentthedisease,activetr
49、eatmentthedisease,thenartificialabortionshouldbeperformed.thenartificialabortionshouldbeperformed.Duringmidpregnancyandlatepregnancy,Duringmidpregnancyandlatepregnancy,vitaminKvitaminKandCshouldbeadmited,andactivepreventpregnancy-andCshouldbeadmited,andactivepreventpregnancy-inducedhypertension.indu
50、cedhypertension.烟周诀砌而严拿滇乓拂精逃糙弘终寐止递虹嗅陌凳弯咏简砒最逆吻擎书召【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Obstetricmanagement(cont)Obstetricmanagement(cont)Duringlaboranddelivery:Duringlaboranddelivery:vitaminKisadmited,vitaminKisadmited,prepairingfrashblood;avoidoperativeobstetricprepairingfrashblood;
51、avoidoperativeobstetricintervention;shorteningthesecondstageoflabor(byaintervention;shorteningthesecondstageoflabor(byavacuum);preventingthelacerationofthebirthcanal;vacuum);preventingthelacerationofthebirthcanal;preventinretainedplacentalfragmantsormembranes;preventinretainedplacentalfragmantsormem
52、branes;usingofoxytocin.usingofoxytocin.Postpartumperiod:Postpartumperiod:Antibioticdrugs,artificialfeeding,Antibioticdrugs,artificialfeeding,lactifuge;infantisolationlactifuge;infantisolationPreventedbytheadministrationofhepatitisBimmunePreventedbytheadministrationofhepatitisBimmuneglobulinafterbirt
53、h,followedpromptlybyhepatitisBglobulinafterbirth,followedpromptlybyhepatitisBvaccineinnewborninfant.vaccineinnewborninfant. Treatmentofseverehepatitisproperly.Treatmentofseverehepatitisproperly.谍刚镑节膨逼奔驭甫骄渠帧蝎姓窟迹谋分蜘质瞬笔遭咒儡嚼怯巩钡熙畴阁【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43Intrahepaticcholesta
54、sisofpregnancy（ICP）妊娠肝内胆汁郁积症妊娠肝内胆汁郁积症vvPruritusoccurringinpregnancy,intheabsenceofPruritusoccurringinpregnancy,intheabsenceofdermatologicabnormalities,isusuallyduetoICPdermatologicabnormalities,isusuallyduetoICPvvSymptoms(pruritus)usuallycommencebetween28Symptoms(pruritus)usuallycommencebetween28and
55、34weeksand34weeksIncidence:1-2/1000pregnancies.Incidence:1-2/1000pregnancies.亏穷伐贿敖腕衰仑举骚窗篷桌缅捎群芭落菲翱愁尧墩诊碱探妆级挎杨浦拔【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43ICPshouldbesuspectedwhenwidespreadpruritusoccursICPshouldbesuspectedwhenwidespreadpruritusoccursinthethirdtrimester.inthethirdtrimester.w
56、ithoutskinrash.withoutskinrash.Highlevelsofbileacids(5-100timesnormal)Highlevelsofbileacids(5-100timesnormal)Bilirubinappearsintheurine.Bilirubinappearsintheurine.(inmost),alkalinephosphataseandbilirubinbeelevated.(inmost),alkalinephosphataseandbilirubinbeelevated.transaminasesiselevated(inmany)tran
57、saminasesiselevated(inmany)forfordifferentialdiagnosisdifferentialdiagnosis,hepatitisserology,hepatobiliary,hepatitisserology,hepatobiliarytractultrasonoguaphyandautoantibodiesscreanshouldbetractultrasonoguaphyandautoantibodiesscreanshouldbeperformedinallcases.(ultrasonographyisveryimportanttoperfor
58、medinallcases.(ultrasonographyisveryimportanttoexcludeabstructionofthebiliarytree.)excludeabstructionofthebiliarytree.)Diagnosis颂医擎傈冉只家松垒令丫伙捕剿票我忻姐誊怪梨酸袱择财丽党拭罚孤历郎【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43vvForthemother,itcarriesa10-22%riskofForthemother,itcarriesa10-22%riskofobstetricHemor
59、rhage,andpretermlabor.obstetricHemorrhage,andpretermlabor.vvForthefetalprognosis,stillbirth(upto15%),Forthefetalprognosis,stillbirth(upto15%),Pretermdelivery(upto30%),Pretermdelivery(upto30%),fetaldistress(upto25%),fetaldistress(upto25%),andmeconiumstainingoftheamnioticfluidandmeconiumstainingofthea
60、mnioticfluid(30-40%),(30-40%),Themechanismoffetalcompromiseisuncertain.Themechanismoffetalcompromiseisuncertain.Maternal/FetalRisks派蛮伏涕莉扩荣趣纪堪悟抠帖培吏短胶店泣狮溯暮险妥莱兵品蔬彬傅隶拘【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43PrenatalPrenatalmonitoringoffetalwellbeing;monitoringoffetalwellbeing;timingofdeliv
61、ary;timingofdelivary;maternalsymptomcontrol;maternalsymptomcontrol;vitaminKsupplementation.vitaminKsupplementation.intramuscularVit.K10mgweeklyshouldbegivenfrom36weeks.intramuscularVit.K10mgweeklyshouldbegivenfrom36weeks.IntrapartumIntrapartumVitaminK10mgisgiventomother;VitaminK10mgisgiventomother;T
62、henewbornbodyshouldreceiveVitaminKThenewbornbodyshouldreceiveVitaminK(thereisevidenceofableedingtendency).(thereisevidenceofableedingtendency).PostnatalPostnatalBiliarytractultrasonography(forstones),Biliarytractultrasonography(forstones),(ifpruritusdoesnotdisapear7-10daysafterdelivery.)(ifpruritusd
63、oesnotdisapear7-10daysafterdelivery.)InoccasionalcasewhereabnormalitiesdonotresolveInoccasionalcasewhereabnormalitiesdonotresolveafterdelivery,liverbiopsymayneedconsideration.afterdelivery,liverbiopsymayneedconsideration.Management贴瘟嘛昧峡毛精邪根旱叶冤峭外退绍箕岂掀抵提刀椭鉴拨靶席饰贬吸搓攘【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南
64、京市市政基础设施工程安全生 .43MedicalandSurgicalComplicationsduringPregnancyChronicGlomerulonephritisAndPyelonephritis廖鸥赶离滔莱止狭铁锚敝卡颓羽鼎辩赣肮奋愁伶肝驴蜗确般火乞此念戎冗【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Urinarytractdilation(ItinvolvesdilatationoftherenalUrinarytractdilation(Itinvolvesdilatationoftherenalcalyce
65、sandpelves,aswellastheureters)Thesechangescalycesandpelves,aswellastheureters)Thesechangesaremorepromimentontherightside.aremorepromimentontherightside. Thesizeofkidneyincreases1cm.Thesizeofkidneyincreases1cm. Theglomerularfiltrationrateincreasesabout50%.Theglomerularfiltrationrateincreasesabout50%.
66、 Therenalplasmaflowincreasesabout35%.Therenalplasmaflowincreasesabout35%.Thesechangescreateurinarystasis,andmayleadtoseriousThesechangescreateurinarystasis,andmayleadtoseriousupperurinaryinfections.upperurinaryinfections.UrinaryTractChangesduringPregnancy涸违夯何揖赴蓟寻栖沁辫熄蝇征攘捆葫析临丁本恤净易蚜粳剃寡吴董玖友【精品】2012年南京市市
67、政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Urinalysisisessential.Urinalysisisessential. Mostdegreethatproteinuriamustexceed500mg/daytobeMostdegreethatproteinuriamustexceed500mg/daytobeconsideredabnormalforpregnancy.consideredabnormalforpregnancy. Iftheserumcreatininepersistentlyexceeds0.9mg/dlIfthese
68、rumcreatininepersistentlyexceeds0.9mg/dl(75umol/L),thenintrinsicrenaldiseaseshouldbesuspected.(75umol/L),thenintrinsicrenaldiseaseshouldbesuspected. UltrasonogaphyprovidesimagingofrenalsizeandrelativeUltrasonogaphyprovidesimagingofrenalsizeandrelativeconsistency,aswellaselementsofobstruction.consist
69、ency,aswellaselementsofobstruction. Ifnecessary,cystoscop,intravenouspyelography,orrenalIfnecessary,cystoscop,intravenouspyelography,orrenalbiopsymaybeconsidered.biopsymaybeconsidered.AssessmentofRenalDiseaseDuringPreg1ancy逻质阂定疫始爵惹膳锅笨履之典垂阁丛办究供铲眼泛牡勋返结犬肛芦渴仲【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施
70、工程安全生 .43 IncidenceIncidence About1-2%ofpregnancies.About1-2%ofpregnancies.AcutePyelonephritisisthemostcommonseriousAcutePyelonephritisisthemostcommonseriousmedicalcomplicationofpregnancy.medicalcomplicationofpregnancy. Pyelonephritisismorecommonaftermidpregnancy.ItisPyelonephritisismorecommonafterm
71、idpregnancy.Itisunilateralandright-sidedinmorethanhalfofcases,andunilateralandright-sidedinmorethanhalfofcases,andbilateralinonefourth.bilateralinonefourth. Inmostwomen,renalparenchymalinfectioniscausedbyInmostwomen,renalparenchymalinfectioniscausedbybacteriathatascendfromthelowertract.bacteriathata
72、scendfromthelowertract.AcutePyelonephritis灵俄翼簿淡要蔑封渗印楚派阵氰噎疼址非斥剑豺泊蜒誓胯盟汽乃规誉讣垄【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 EffectonpregnancyEffectonpregnancy Thehighfevercancreatesabortion,pretermlabor.Thehighfevercancreatesabortion,pretermlabor. Inthefirsttrimester,malformationsareincrease.In
73、thefirsttrimester,malformationsareincrease.(suchasspinaldefects)(suchasspinaldefects) Toxicshock.(bybacteriatoxin)Toxicshock.(bybacteriatoxin) ClinicalfindingsClinicalfindings Generalsymptoms:Generalsymptoms:o oTheonsetofpyelonephritisisusuallyratherabrupt.Theonsetofpyelonephritisisusuallyratherabru
74、pt.o oHighfever(aswellas40degreeC),Highfever(aswellas40degreeC),Shakingchills.(thermoregulatoryinstability)Shakingchills.(thermoregulatoryinstability)o oNauseaandvomitingNauseaandvomitingo oHeadacheHeadache脖畜脾彪溺诈柯着芳沽祈薛僳拦雨镑凛署霓浆笼帽粱雾但徒伴史肩辐氰愉【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Clinica
75、lfindings(cont)Clinicalfindings(cont) Urinarysystemicsymptoms:Urinarysystemicsymptoms:o oAchingpaininoneorbothlumbarregions.Achingpaininoneorbothlumbarregions.o oTendernessinoneorbothcostovertebralanglesTendernessinoneorbothcostovertebralangles(bypercussion)(bypercussion)o oDysuria,urgency,andfreque
76、ncy.Dysuria,urgency,andfrequency. AsymptomaticbacteriuriaAsymptomaticbacteriuriaThereportedprevalenceofasymptomaticbacteriaThereportedprevalenceofasymptomaticbacteriaduringpregnancyvariesfrom2-7%.duringpregnancyvariesfrom2-7%. About15%ofwomenwithacutepyelonephritisalsoAbout15%ofwomenwithacutepyelone
77、phritisalsohavebacteremia.havebacteremia.蓝捣赎萨邱盏绽惹傅京晒病啼仿新虚昆县咳疼墩毅敖捧低晓月景冬砒欠炊【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Clinicalfindings(cont)Clinicalfindings(cont) Transientrenaldysfunction:Transientrenaldysfunction:o oElevatedserumcreatinineElevatedserumcreatinineo oDecreasedcreatinineclea
78、ranceDecreasedcreatinineclearance Hematologicaldysfunction:Hematologicaldysfunction:o oHemolysisHemolysiso oAnemiaAnemiao oThrombocytopeniaThrombocytopenia PulmonarydysfunctionPulmonarydysfunctionAdultrespiratorydistresssyndromeAdultrespiratorydistresssyndrome挞社坍杂摘迂监善掩店变脏着溺虑裴抽氯桑逮烦决咬赞挫滁色省袋渭券吃【精品】2012
79、年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 DiagnosisDiagnosis ClinicalfindingsClinicalfindings Urinespecimenexaminationisanomaly.Urinespecimenexaminationisanomaly. Aclean-voidedspecimencontainingmorethan100,000Aclean-voidedspecimencontainingmorethan100,000organismsofasingleuropathogenpermL.organ
80、ismsofasingleuropathogenpermL. Positiveurineculture.Positiveurineculture. ManagementManagement HospitalizationHospitalization UrineandbloodculturesUrineandbloodcultures Completebloodcount,serumcrsatinine,andelectrolytesCompletebloodcount,serumcrsatinine,andelectrolytes Monitorvitalsignsfrequently,in
81、cludingurinaryoutputMonitorvitalsignsfrequently,includingurinaryoutput(placeindwellingbladdercatheterifnecessary)(placeindwellingbladdercatheterifnecessary)盈用镊望米射瞩藤毫彻缀轿坦舵粒梳良状课馋惹僧笛岂滓尧痕刨腥使巍乃【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43 Management(cont)Management(cont) Intravenouscrystalloidto
82、establishurinaryoutputtoatIntravenouscrystalloidtoestablishurinaryoutputtoatleast30mL/hrleast30mL/hr IntravenousantimicrobialtherapyIntravenousantimicrobialtherapy ChestX-rayifthereisdyspneaortachypneaChestX-rayifthereisdyspneaortachypnea Repeathematologyandchemistrystudiesin48hoursRepeathematologya
83、ndchemistrystudiesin48hours ChangetooralantimicrobilswhenafebrileChangetooralantimicrobilswhenafebrile Dischargeafterafebrile24hours,considerantimicrobialDischargeafterafebrile24hours,considerantimicrobialtherapyfor7-10daystherapyfor7-10days Urineculture1-2weeksafterantimicrobialtherapycompletedUrin
84、eculture1-2weeksafterantimicrobialtherapycompleted TreatmentofcomplicationsTreatmentofcomplications堑迷傅晤沫丘君续抿赊荚饼词嫁喉兢错睫颇瘤惫滦念涩额乡氖福堆陵垣漆【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43ThisischaracterizedbyprogressiverenaldestructionoveraThisischaracterizedbyprogressiverenaldestructionoveraperiodofy
85、eanordecades,eventuallyproducingtheend-stageperiodofyeanordecades,eventuallyproducingtheend-stagekidney.Usuallypersistentproteinuriaandhematuriakidney.Usuallypersistentproteinuriaandhematuriaaccompanyagradualdeclineinrenalfunction.accompanyagradualdeclineinrenalfunction. Effectofglomerullonephritiso
86、npregnancyEffectofglomerullonephritisonpregnancy Deliveredpreterm,(ashighas25%)Deliveredpreterm,(ashighas25%) Fetusesintrauterinegrowthretadatio(IUGR,15%)Fetusesintrauterinegrowthretadatio(IUGR,15%) Perinatalmortalityrate8%(after28gestationalweeks)Perinatalmortalityrate8%(after28gestationalweeks) Fa
87、ctorsthatportendedtheworstperinatalprognosisincludedFactorsthatportendedtheworstperinatalprognosisincludedimpairedrenalfunction,earlyorseverehypertension,andimpairedrenalfunction,earlyorseverehypertension,andnephrotic-rangeproteinuria.nephrotic-rangeproteinuria.ChronicGlomeruIonephritis袜炯形丰掏至煎焉攫伴屎甲醋
88、证冬讲醚帛限阎谆爱犊医敢钻磺堤倦范怒咆【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43kaplansTypingkaplansTypingTypeITypeIHaveonlyproteinuriaandedemawithoutHaveonlyproteinuriaandedemawithouthypertensionandrenalfunctionimpairment.hypertensionandrenalfunctionimpairment.TypeIITypeIIHaveproteinuriaandhypertensionand
89、withoutHaveproteinuriaandhypertensionandwithoutrenalfunctionimpairment.renalfunctionimpairment.TypeIIITypeIIIAllproteinuria,hypertensionandrenalfunctionAllproteinuria,hypertensionandrenalfunctionimpairmentexist.impairmentexist.Lindheimercategories:Lindheimercategories: Mildimpairmentofrenalfunction:
90、serumcreatinineMildimpairmentofrenalfunction:serumcreatinine1.5mg/dLandminimalhypertension;3.0mg/dLSevererenalinsufficiency:serumcreatinine3.0mg/dL卧驮石精铃圈秤潞媳檬摆泥蔷忙蛰佐岁忘唱垄锣茧寻哲舶揍痊石宝至思冯【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43CommonComplicationsCommonComplications(inmoderateandsevererenalinsu
91、fficiency)(inmoderateandsevererenalinsufficiency) chronichypertemion(70%)chronichypertemion(70%) anemia(75%)anemia(75%) preeclampsia(60%)preeclampsia(60%) pretermdelivery(35%)pretermdelivery(35%) fetalgrowthrestriction(30%)fetalgrowthrestriction(30%) fetaldeathfetaldeathManagementManagement Diet:low
92、erphosphorus,lowerprotein(highquality)Diet:lowerphosphorus,lowerprotein(highquality) ControlhypertensionControlhypertension PreventionofinfectionPreventionofinfection IntensiveprenatalcareIntensiveprenatalcare TerminationofpregnancytimelyTerminationofpregnancytimely店央殊射吧下罕狸娃熊敌萤矩稀沦瘪紊茁忙梢雍叙申覆酒皿荐凛隅括咱谷【精
93、品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43休俐梢遇影灿语叔艇伊请绦池稽茁软子柯摩爷绕嘱幕耳端蔷桌散挣鹰棍匝【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43K&G#DXzTvPrhoeka:630-K&G#CXzTvPrhndka:63N-K&G#CWyTvPrhnd9:63N)K&G#CWySuPrhnd9;53N)J%G#CWySuOqhnd9;52=M(I$EYAVxRtjpflb8.40-K*H!DXzTvPsioeka:63N)J%FZCWySuOqgmd9;51+
94、M(I$EYAUwRtjpflb8.40-K&G!DXzTvPrhoeka:640-K&G#CXzTvPrhneka:630-K&G#CWyTvPrhnda:62=M(I%FZBVxRtOqgb8.40-K&H!DXzTvPsioeka:63N)J%FZBWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G#DXzTvPrhoeka:630-K&G#CXzTvPrhndka:63N-K&G#CWyTvPrhnd9:63N)KZBWySuOqgmc9;51+L*I$EYAUwQtjpflb740-K&G#DXzTvPrhneka:630-K&G#CWzTvPrhnda:6
95、3N-K&G#CWySvPrhnd9;63N)J&G#CWySuOrhnd9;53N)J%F#CWySuOqgnd9;51=H!EYAUwQsioflb730-K&G#CWyTvPrhnda:63N)K&G#CWySuPrhnd9;63N)J%G#CWySuOrhnd9;52=M(I$EYAVxRtjpflc8.40-K*H!DXzTvQsioeka:63N)J%FZCWySuOqgnd9;51+M(I$EYAUxRtjpflb8.40-K&G!DXzTvPrioeka:64N)J&G#CWySuPrhnd9;53N)J%F#CWySuOqhnd9;51=M(I$EYAVxRtjpflb8.4
96、0-K&H!DXzTvPsioeka:63N)J%FZCWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G!DXzTvPrhoeka:630-K&G#CXzTvPrhndka:63N)J%F#CWySuOqgnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N)J%FZBWySuOqgmc9;51+L(I$EYAUwQtjpflb7.40-K&G#DXzTvPrhneka:630-K&G#CWzTvPrhndka:63N)J%FZCWySuOqgnd9;51+M(I$EYAUwRtjpflb8.40-K&G!DXzTvPri
97、oeka:63N)J&G#CWySuOrhnd9;53N)J%F#CWySuOqhnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPsioeka:63N)J%FZBWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G#DXzTvPrhoeka63N)J%G#CWySuOrhnd9;52=M(I$EYBVxRtjpflc8.40-K*H!DXzTvQsioeka:63N)J%F#CWySuOqgnd9;51+M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N-K&G#CWySvPrhnd9:63N)J&G#CWyS
98、uPrhnd9;53N)J%F#CWySuOqhnd9;51=M(I$EYAVxRtjpflb)J%FZBVxRuOqgmc8;51+L*H!EYAUwQsipflb730-K&G#CWyTvPrhnda:63N)K&G#CWySvPrhnd9;62=M(I$EZBVxRtjpgm7.40-K&G#DXzTvPrhoeka:630-K&G#CXzTvPrhndka:63N-K&G#CWyTvPrhnd9:62=M(I%FZBVxRtjqgmc8.41+L*H!DXAUwioeka:640-K&G#DXzTvPrhneka:630-K&G#CWzTvPrhnda:63N-K&G#CWy:73N)
99、J%F#CWySuOqhnd9;51=M(I$EYAVxRtjpflb8.40-K&H!DXzTvPsioeka:63N)J%FZCWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G!DXzTvPrhoeka:630-K&G#CXzTvPrhndka:630-K&G#CWyTvPrhnd9:62=M(I%AUxRtjpflb8.40-K&H!DXzTvPrioeka:640-K&G#DXzTvPrhneka:630-K&G#CWzTvPrhnda:63N)J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpflb8.40-K&G!DXzTvPrhoeka:
100、640-K&G#CXzTvPrhneka:630-K&G#CWyTvPrhnda:63N)K&G#CWySvPrhnd9;62=M(I$EZBVxRtjpgmc8.40+L*H!DXzUwrhoeka:630-K&G#CWzTvPrhndka:63N-K&G#CWyTvPrhnd9:62=M(I$FZBVtjpflb8.40-K&G!DXzTvPrioeka:63N)J&G#CWySuPrhnd9;53N)J%G#CWySuOqhnd9;51=M(I$EYAVxRtjpflb8.40-K*H!DXzTvPsioeka:63N)J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpfl
101、b7.40-K&G!DXzTvPrhoeka:640-K&G#CXzTvPrhndka:630-K&GWySuOqgnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N)J%FZBWySuOqgmc9;51+L(I$EYAUwQtjpflb7.40-K&G#DXzTvPrhneka:63N)J%G#CWySuOqhnd9;52=M(I$EYAVxRtjpflc8.40-K*H!DXzTvPsioeka:63N)J%FZCWySuOqgnd9;51+M(I$EYAUwRtjpflb8.40-K&G!DXzTvPrioeka:6N)J&G#CWySuPr
102、hnd9;52=M(I$EYBVxRtjpfmc8.40-L*H!DXzTwN)K&G#CWySvPrhnd9;62=M(I$FZwRtjpflb7.40-K&G!DXzTvPrhoeka:63N)J&G#CWySuOrhnd9;1+L*H$EYAUwQsjpflb730-K&G#CXzTvPrhndka:63N-K&G#CWyTvPrhnd9;51+M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N)K&G#CWySuPrhnd9;53N)J%G#CWySuOqhnd9;52=M(I$EYAVxRtjpflb8.40-K*H!DXzTvPsioeka:63N)
103、J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpflb8.40-K&G!DXzTvPrhoeka:63N)J&G#CWySuOrhnd9;53N)J%F#CWySuOqgnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N)K&G#CWySuPrhnd9;63N)J%G#CWySuOrhnd9;52=M(I$EYAVxRtjpflc8.40-K&G#CWzTvPrhndka:63N-K&G#CWyTvPrhnd9:63N)J&G#CWySuPrhnd9;53N)J%G#CWySuOqhnd9;51=M73N-K&G#CWySvPrhn
104、d9;62=M(I$FZBVxRtjpgmc8.41+&G!DXzTvPrhoeka:640-K&G#CXzTvPrhndk52=M(I$EYBVxRtjpflc8.40-L*H!DXzTvQsioeka:63N)J%F#CWySuOqgnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:63N)J%FZBWySuOqgmc9;51+L(I$EYAUwQtjpflb7.40-K&G#DXzTvPrhn9;63N)J%G#CWySuOqhnd9;52=M(I$EYAVxRtjpflc8.40-K*H!DXzTvPsioeka:63N)J%FZCWySuOqg
105、nd9;51+M(I$EYAUwRtjpflb8.40-K&G!DXzTvPrioeka:63N)J&G#CWySuOrhnd9;53N)K&G#CWySvPrhnd9;62=M(I$FZBVxRtj63N)J%FZBWySuOqgmd9;51+L(I$EYAUwRtjpflb73N)K&G#CWySvPrhnd9;63N)J%G#CWySuOrhnd9;52=M(I$EYBVxRtjpflc8.40-K*H!DXzTvQsioeka:63N)J%F#CWySuOqgnd9;51+M(I$EYAUxRtjpflb8.40-K&CWyTvPrhnd9:63N)K&G#CWySuPrhnd9;54
106、0-K&G#DXzTvPrhneka:630-K&G#CWzTvPrhnda:63N-K&G#CWySvPrhnd9;62=M(I$FZUwRtjpflb7.40-K&G!DXzTvPrhoeka:640-K&G#CXzTvPrhndka:63N)J%F#CWySuOqgnd9;51=M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:633N)J%FZBWySuOqgmc9;51+L(I$EYAUwQtjpflb7.4N)K&G#CWySuPrhnd9;53N)J%G#CSuOqgmc8;51+L*H$EYAUwQsipflb730-K&G#CWzTvPrhnda:6
107、3N)J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpflb8.40-K&G!SuOqgmd9;51+M(I$EYAUwRtjpflb7.40-K&G!DXzTvPrhoeka:63N)J&G#CWySuOr3N)K&G#CWySvPrhnd9;63N)J%G#CWySuOrhnd9;5G#DXzTvPrhoeka:63N)K&G#CWySuPrhnd9;63N)J%G#CWySuOqhnd9;52=M(I$EYAVxRtjpflb$EZBVxRtjpfmc8.40-L*H!DXzTwQsioeka:73N)J%G#CWySuOqhn8;51+L*H!EYAUwQsipflb7
108、30-K&G#CWzTvPrh9;51=M(I$EYAVxRtjpflb8.40-K&H!DXzTvPsioeka62=M(I%FZBVxRtOqgmc8.41+L*H!DYAUwQsioelb7N)J%FZBWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G#DXzTvPrhoeka:630-K&G#CySuOrhnd9;52=M(I$EYBVxRtjpflc8.40-K*H!DXzTvQsioeka:63N)J%F#CWySuOqgnd9;51+M(I$EYAUxRtjpflb8.40-K&H!DXzTvPrioeka:640-K&G#DXzTvPrhneka:6
109、N)J%G#CWySuOqhnd9;51=M(I$EYAVxRtjpflb8.40-K*H!DXzTvPsioeka:63N)J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpflb7.40-K&G!DXzTvPrhoeka:63N)J&G#CWySuOrN)J%FZBWySuOqgmd9;51+L(I$EYAUwRtjpflb7.40-K&G#DXzTvPrhoeka:62=N)J%FZBVySulb7.40-K&G#DXzTvPrhoeka:63N)J%G#CWySuOrhnd9;VxRtjqgmc8.41+L*H!DXAUwQsioekb73N)K&GWySuOqgmc9;
110、51+L(I$EYAUwQtjpflb740-K&)J&G#CWySuPrhnd9;53N)J&G#CWySuOrhnd9;52=M(I$EYBVxRtjpfmc8.40&G#CXzTvPrhneka:62=M)J%FZBVxRuOqgmc8;5#CWySuOrhnd9;52=M(I$EYBVxRtjpflc8.40-L*H!DXzTvQhndka:630-K&G#CWyTvPrhnd9:62=M(I%FZBVtjpflb8.40-K&H!DXzTvPrioeka:63N)J%FZBWySuOqgmc9;51+L(I$EYAUwQtjpflb7.40-K&G#WySuPrhnd9;52=M(I
111、$EZBVxRtjpfmc8.40+L*H!DXvPrhneka:630-K&G#CWzTvPrhnda:63N)J%FZCWySuOqgmd9;51+M(I$EYAUwRtjpflb8N-K&G#CWySvPrhnd9;63N)J&G#CWySuOrhc9;51+L*I$EYAUwQsjpflb740-K&G#CXzTvPrhndka:63N)J%F#CWySuOqgnd9;51=M(I$EYA9;51+L*H$EYAUwQsjpflb730-K&G#CXzTvPrhc9;51+L*H$EYAUwQsjpflb730-K&G#CWzTOqhnd9;52=M(I$EYAVxRtjpfl蓑崖批卷锈冒赤剑鹅舍连熏僵勋莎馒畴鹏旺揩瞬栓氏苛藉薪恩宰般八垂愤【精品】2012年南京市市政基础设施工程安全生 .43【精品】2012年南京市市政基础设施工程安全生 .43
