ZWANGERSCHAP 2
ZWANGERSCHAP 2
Inhoud
PATHOLOGISCHE ZWANGERSCHAP – E. FAES........................................................................................ 11
H1. Bloedverlies .......................................................................................................................................... 11
Vaginaal bloedverlies ............................................................................................................................ 11
Bloedverlies < 20 weken → 1ste trimester bloedverlies ............................................................................ 11
Vaginaal bloedverlies bij > 20w ZS → Tweede en derde trimester ............................................................ 18
H2. Hypertensieve aandoeningen ................................................................................................................. 24
Definities ................................................................................................................................................. 24
Hypertensie ......................................................................................................................................... 24
Chronische hypertensie ........................................................................................................................ 24
Witte jas hypertensie ............................................................................................................................ 24
Zwangerschapshypertensie= gestational hypertension .......................................................................... 24
Pre-eclampsie ...................................................................................................................................... 24
Eclampsie ............................................................................................................................................ 25
HELLP-syndroom.................................................................................................................................. 26
Pre-eclampsie ......................................................................................................................................... 26
H3. Stoornissen in de foetale groei ............................................................................................................... 32
1. Foetale groeirestrictie (FGR) ............................................................................................................. 33
Oorzaken: ............................................................................................................................................ 34
Opvolging ............................................................................................................................................. 35
Diagnostiek .......................................................................................................................................... 35
Therapie ............................................................................................................................................... 38
Wijze van bevalling ............................................................................................................................... 38
Gevolgen na geboorte en op lange termijn ............................................................................................. 38
Constitutionele SGA: ............................................................................................................................ 39
FGR: .................................................................................................................................................... 39
2. Intra-uteriene vruchtdood – mors in utero (MIU) ................................................................................ 40
3. Macrosomie..................................................................................................................................... 40
4. Oligohydramnion ............................................................................................................................. 42
5. Polyhydramnion ............................................................................................................................... 43
H4. Zwangerschapsduur .............................................................................................................................. 44
1. Preterme arbeid ............................................................................................................................... 44
Fibronectine test .................................................................................................................................. 44
Cervixmeting transvaginaal ................................................................................................................... 45
Etiologie vroeggeboorte: ....................................................................................................................... 45
Beleid bij dreigende vroeggeboorte : ...................................................................................................... 46
1
, ZWANGERSCHAP 2
Preterme contracties: opname .............................................................................................................. 46
Voorbereiding van de foetus op een vroeggeboorte ................................................................................ 47
Gevolgen van prematuriteit voor de neonaat .......................................................................................... 48
Tocolyse ............................................................................................................................................... 48
Preventie van vroeggeboorte volgende zwangerschap ............................................................................ 49
2. Cervixinsufficiëntie .......................................................................................................................... 50
3. PPROM ............................................................................................................................................ 51
4. Serotiniteit ....................................................................................................................................... 53
5. Inductie ........................................................................................................................................... 53
H5. Tweeling/ meerlingen ............................................................................................................................. 55
1. Definities ............................................................................................................................................. 55
2. Verwikkelingen van een meerlingzwangerschap ................................................................................ 59
Twin to twin transfusie syndroom (TTTS) ................................................................................................ 60
Twin anaemie polycythemies sequentie (TAPS) ...................................................................................... 61
Twin reversed arterial perfusion (TRAP) .................................................................................................. 61
MCMA twins: modus partus = sectio ..................................................................................................... 62
Tijdens de zwangerschap voor de moeder ............................................................................................. 62
3. Follow up ......................................................................................................................................... 63
4. Bevalling .......................................................................................................................................... 63
5. Beleid .............................................................................................................................................. 63
6. Hogere ................................................................................................................................................. 63
H6. Hematologie ......................................................................................................................................... 65
1. Iso-immunisatie............................................................................................................................... 65
Bloedgroepen ....................................................................................................................................... 65
Immunisatie ......................................................................................................................................... 66
Spectrum resusziekte ........................................................................................................................... 69
2. Maternele anemie ............................................................................................................................ 70
Definitie ............................................................................................................................................... 71
Incidentie ............................................................................................................................................. 71
Kliniek .................................................................................................................................................. 71
Screenen ............................................................................................................................................. 71
Ijzergebrekanemie ................................................................................................................................ 72
Foliumzuurtekort .................................................................................................................................. 73
Hemoglobinpathie ................................................................................................................................ 74
3. Trombocytopenie ............................................................................................................................. 76
Trombocytopenie bij de zwangere ......................................................................................................... 76
Trombocytopenie bij de foetus .............................................................................................................. 76
2
, ZWANGERSCHAP 2
4. Trombo-embolie, trombose en trombofilie ........................................................................................ 77
Diep veneuze trombose ........................................................................................................................ 77
Longembolie ........................................................................................................................................ 77
Trombofilie ........................................................................................................................................... 77
H7. Infectieziekten ....................................................................................................................................... 78
Trichomonas ............................................................................................................................................ 78
Candida................................................................................................................................................... 78
Bacteriele vaginose .................................................................................................................................. 78
Gonorroe ................................................................................................................................................. 78
Chlamydia ............................................................................................................................................... 79
Syphilis.................................................................................................................................................... 79
Herpes vaginalis ...................................................................................................................................... 80
Neonatale groep B – streptokokkenziekte .................................................................................................. 80
Listeria .................................................................................................................................................... 80
Cytomegalovirus ...................................................................................................................................... 80
Congenitale toxoplasmose ....................................................................................................................... 81
HIV .......................................................................................................................................................... 81
Rubella-infectie ....................................................................................................................................... 81
Parvovirusinfectie .................................................................................................................................... 81
Vaccinatie en zwangerschap .................................................................................................................... 82
Tetanus ................................................................................................................................................ 82
Influenza .............................................................................................................................................. 82
RSV vaccinatie ..................................................................................................................................... 82
H8. Urologische ziekten ............................................................................................................................... 83
1. Urolithiasis = niersteen ........................................................................................................................ 83
2. Urineweginfecties ................................................................................................................................ 83
3. Urineretentie ........................................................................................................................................ 85
H9. Neurologische aandoeningen ................................................................................................................ 86
1. Epilepsie .............................................................................................................................................. 86
2. Migraine ............................................................................................................................................... 86
3. Cerebrovasculaire accidenten (= hersenbloedingen) ............................................................................. 87
4. Carpaltunnelsyndroom ......................................................................................................................... 87
H10. Hartziekten ......................................................................................................................................... 88
Hartziekten .............................................................................................................................................. 88
H11. Longziekten ......................................................................................................................................... 89
1. Astma.............................................................................................................................................. 89
2. Mucoviscidose of cystische fibrose of CF .......................................................................................... 90
3
, ZWANGERSCHAP 2
3. Hooikoorts ....................................................................................................................................... 90
H12. Trauma ................................................................................................................................................ 91
H13. Bekkeninstabiliteit en bekkenpijn ......................................................................................................... 93
Bekkeninstabiliteit ................................................................................................................................... 93
H14. Gastro-intestinale aandoeningen ......................................................................................................... 95
1. Hyperemesis gravidarum ...................................................................................................................... 95
2. Appendicitis ......................................................................................................................................... 95
4. Zwangerschapscholestase ............................................................................................................... 95
4. Acute vetlever (fatty liver of pregnancy) ................................................................................................. 97
5. Cholecystitis /cholelithiase .............................................................................................................. 98
6. Inflammotoire darmziekten ................................................................................................................... 98
Verloskundig echografisch onderzoek .......................................................................................................... 99
Indicaties voor vroedvrouwen ................................................................................................................... 99
Deel 1: Algemene begrippen ..................................................................................................................... 99
1.1 Inleiding ................................................................................................................................... 99
1.2 Fysica en basisbegrippen ....................................................................................................... 100
1.3 Prenatale diagnostiek ............................................................................................................. 102
Deel 2: Echo anatomie ........................................................................................................................... 105
2.1 Vroege zwangerschapsecho ................................................................................................... 105
2.2 Eerste trimester echografie ..................................................................................................... 106
2.3 Tweede trimester echografie (SEO).......................................................................................... 110
2.4 Derde trimester echografie ..................................................................................................... 117
2.5 Doppler onderzoek........................................................................................................................ 117
Deel 3: Echoscopisch zichtbare afwijkingen ............................................................................................ 120
3.1 Inleiding........................................................................................................................................ 120
Centraal zenuwstelsel ........................................................................................................................ 120
Gelaat ................................................................................................................................................ 123
Thorax ................................................................................................................................................ 124
Hart ................................................................................................................................................... 125
Abdomen ........................................................................................................................................... 125
Extrimiteiten ....................................................................................................................................... 127
Conclusie .......................................................................................................................................... 128
Serologie tijdens prenatale raadpleging ...................................................................................................... 130
Doel prenatale zorg ................................................................................................................................ 130
Vaststellen ZS ........................................................................................................................................ 130
Prenatale controles ~ risicoselectie/ klinisch redeneren .......................................................................... 130
1e prenatale controle .............................................................................................................................. 131
4
ZWANGERSCHAP 2
Inhoud
PATHOLOGISCHE ZWANGERSCHAP – E. FAES........................................................................................ 11
H1. Bloedverlies .......................................................................................................................................... 11
Vaginaal bloedverlies ............................................................................................................................ 11
Bloedverlies < 20 weken → 1ste trimester bloedverlies ............................................................................ 11
Vaginaal bloedverlies bij > 20w ZS → Tweede en derde trimester ............................................................ 18
H2. Hypertensieve aandoeningen ................................................................................................................. 24
Definities ................................................................................................................................................. 24
Hypertensie ......................................................................................................................................... 24
Chronische hypertensie ........................................................................................................................ 24
Witte jas hypertensie ............................................................................................................................ 24
Zwangerschapshypertensie= gestational hypertension .......................................................................... 24
Pre-eclampsie ...................................................................................................................................... 24
Eclampsie ............................................................................................................................................ 25
HELLP-syndroom.................................................................................................................................. 26
Pre-eclampsie ......................................................................................................................................... 26
H3. Stoornissen in de foetale groei ............................................................................................................... 32
1. Foetale groeirestrictie (FGR) ............................................................................................................. 33
Oorzaken: ............................................................................................................................................ 34
Opvolging ............................................................................................................................................. 35
Diagnostiek .......................................................................................................................................... 35
Therapie ............................................................................................................................................... 38
Wijze van bevalling ............................................................................................................................... 38
Gevolgen na geboorte en op lange termijn ............................................................................................. 38
Constitutionele SGA: ............................................................................................................................ 39
FGR: .................................................................................................................................................... 39
2. Intra-uteriene vruchtdood – mors in utero (MIU) ................................................................................ 40
3. Macrosomie..................................................................................................................................... 40
4. Oligohydramnion ............................................................................................................................. 42
5. Polyhydramnion ............................................................................................................................... 43
H4. Zwangerschapsduur .............................................................................................................................. 44
1. Preterme arbeid ............................................................................................................................... 44
Fibronectine test .................................................................................................................................. 44
Cervixmeting transvaginaal ................................................................................................................... 45
Etiologie vroeggeboorte: ....................................................................................................................... 45
Beleid bij dreigende vroeggeboorte : ...................................................................................................... 46
1
, ZWANGERSCHAP 2
Preterme contracties: opname .............................................................................................................. 46
Voorbereiding van de foetus op een vroeggeboorte ................................................................................ 47
Gevolgen van prematuriteit voor de neonaat .......................................................................................... 48
Tocolyse ............................................................................................................................................... 48
Preventie van vroeggeboorte volgende zwangerschap ............................................................................ 49
2. Cervixinsufficiëntie .......................................................................................................................... 50
3. PPROM ............................................................................................................................................ 51
4. Serotiniteit ....................................................................................................................................... 53
5. Inductie ........................................................................................................................................... 53
H5. Tweeling/ meerlingen ............................................................................................................................. 55
1. Definities ............................................................................................................................................. 55
2. Verwikkelingen van een meerlingzwangerschap ................................................................................ 59
Twin to twin transfusie syndroom (TTTS) ................................................................................................ 60
Twin anaemie polycythemies sequentie (TAPS) ...................................................................................... 61
Twin reversed arterial perfusion (TRAP) .................................................................................................. 61
MCMA twins: modus partus = sectio ..................................................................................................... 62
Tijdens de zwangerschap voor de moeder ............................................................................................. 62
3. Follow up ......................................................................................................................................... 63
4. Bevalling .......................................................................................................................................... 63
5. Beleid .............................................................................................................................................. 63
6. Hogere ................................................................................................................................................. 63
H6. Hematologie ......................................................................................................................................... 65
1. Iso-immunisatie............................................................................................................................... 65
Bloedgroepen ....................................................................................................................................... 65
Immunisatie ......................................................................................................................................... 66
Spectrum resusziekte ........................................................................................................................... 69
2. Maternele anemie ............................................................................................................................ 70
Definitie ............................................................................................................................................... 71
Incidentie ............................................................................................................................................. 71
Kliniek .................................................................................................................................................. 71
Screenen ............................................................................................................................................. 71
Ijzergebrekanemie ................................................................................................................................ 72
Foliumzuurtekort .................................................................................................................................. 73
Hemoglobinpathie ................................................................................................................................ 74
3. Trombocytopenie ............................................................................................................................. 76
Trombocytopenie bij de zwangere ......................................................................................................... 76
Trombocytopenie bij de foetus .............................................................................................................. 76
2
, ZWANGERSCHAP 2
4. Trombo-embolie, trombose en trombofilie ........................................................................................ 77
Diep veneuze trombose ........................................................................................................................ 77
Longembolie ........................................................................................................................................ 77
Trombofilie ........................................................................................................................................... 77
H7. Infectieziekten ....................................................................................................................................... 78
Trichomonas ............................................................................................................................................ 78
Candida................................................................................................................................................... 78
Bacteriele vaginose .................................................................................................................................. 78
Gonorroe ................................................................................................................................................. 78
Chlamydia ............................................................................................................................................... 79
Syphilis.................................................................................................................................................... 79
Herpes vaginalis ...................................................................................................................................... 80
Neonatale groep B – streptokokkenziekte .................................................................................................. 80
Listeria .................................................................................................................................................... 80
Cytomegalovirus ...................................................................................................................................... 80
Congenitale toxoplasmose ....................................................................................................................... 81
HIV .......................................................................................................................................................... 81
Rubella-infectie ....................................................................................................................................... 81
Parvovirusinfectie .................................................................................................................................... 81
Vaccinatie en zwangerschap .................................................................................................................... 82
Tetanus ................................................................................................................................................ 82
Influenza .............................................................................................................................................. 82
RSV vaccinatie ..................................................................................................................................... 82
H8. Urologische ziekten ............................................................................................................................... 83
1. Urolithiasis = niersteen ........................................................................................................................ 83
2. Urineweginfecties ................................................................................................................................ 83
3. Urineretentie ........................................................................................................................................ 85
H9. Neurologische aandoeningen ................................................................................................................ 86
1. Epilepsie .............................................................................................................................................. 86
2. Migraine ............................................................................................................................................... 86
3. Cerebrovasculaire accidenten (= hersenbloedingen) ............................................................................. 87
4. Carpaltunnelsyndroom ......................................................................................................................... 87
H10. Hartziekten ......................................................................................................................................... 88
Hartziekten .............................................................................................................................................. 88
H11. Longziekten ......................................................................................................................................... 89
1. Astma.............................................................................................................................................. 89
2. Mucoviscidose of cystische fibrose of CF .......................................................................................... 90
3
, ZWANGERSCHAP 2
3. Hooikoorts ....................................................................................................................................... 90
H12. Trauma ................................................................................................................................................ 91
H13. Bekkeninstabiliteit en bekkenpijn ......................................................................................................... 93
Bekkeninstabiliteit ................................................................................................................................... 93
H14. Gastro-intestinale aandoeningen ......................................................................................................... 95
1. Hyperemesis gravidarum ...................................................................................................................... 95
2. Appendicitis ......................................................................................................................................... 95
4. Zwangerschapscholestase ............................................................................................................... 95
4. Acute vetlever (fatty liver of pregnancy) ................................................................................................. 97
5. Cholecystitis /cholelithiase .............................................................................................................. 98
6. Inflammotoire darmziekten ................................................................................................................... 98
Verloskundig echografisch onderzoek .......................................................................................................... 99
Indicaties voor vroedvrouwen ................................................................................................................... 99
Deel 1: Algemene begrippen ..................................................................................................................... 99
1.1 Inleiding ................................................................................................................................... 99
1.2 Fysica en basisbegrippen ....................................................................................................... 100
1.3 Prenatale diagnostiek ............................................................................................................. 102
Deel 2: Echo anatomie ........................................................................................................................... 105
2.1 Vroege zwangerschapsecho ................................................................................................... 105
2.2 Eerste trimester echografie ..................................................................................................... 106
2.3 Tweede trimester echografie (SEO).......................................................................................... 110
2.4 Derde trimester echografie ..................................................................................................... 117
2.5 Doppler onderzoek........................................................................................................................ 117
Deel 3: Echoscopisch zichtbare afwijkingen ............................................................................................ 120
3.1 Inleiding........................................................................................................................................ 120
Centraal zenuwstelsel ........................................................................................................................ 120
Gelaat ................................................................................................................................................ 123
Thorax ................................................................................................................................................ 124
Hart ................................................................................................................................................... 125
Abdomen ........................................................................................................................................... 125
Extrimiteiten ....................................................................................................................................... 127
Conclusie .......................................................................................................................................... 128
Serologie tijdens prenatale raadpleging ...................................................................................................... 130
Doel prenatale zorg ................................................................................................................................ 130
Vaststellen ZS ........................................................................................................................................ 130
Prenatale controles ~ risicoselectie/ klinisch redeneren .......................................................................... 130
1e prenatale controle .............................................................................................................................. 131
4
