《海洋与辛巴德的船（交响组曲《舍赫拉查德》选段）课件》初中音乐苏少2011课标版八年级下册课件_2

人工流產的臨床考量,何師竹 台中榮民醫院婦產部,人工流產的母體合併症 （官方手術說明書）,感染：極少數感染會造成子宮內膜炎、輸卵管炎、骨盆腔炎症或流產後敗血症，甚至會因而感染造成休克死亡。 不完全流產：容易發炎或造成大量出血。 出血：嚴重失血以致造成肺栓塞、腦部受損、心臟停止甚至死亡。 組織傷害：極少數，但情況嚴重時甚至須緊急施以腹腔鏡或剖腹手術探查： 1. 子宮頸裂傷：可能造成日後受孕困難、子宮頸閉鎖不全甚至早產。 2. 子宮內膜受損：少數會因子宮內膜腔沾黏造成阿休曼式症候群，術後子宮腔積血、經血量少、甚至無月經；或日後造成不孕症及復發性流產。,人工流產的母體合併症 （官方手術說明書）,3. 子宮穿孔：造成腸道損傷併發腹膜炎、腹腔膿瘍或併發腹內出血，嚴重可至休克死亡。 4. 子宮破裂 5. 神經損傷 嚴重出血時需要輸血，伴隨輸血的危險包括： 1. 感染 2. 溶血性輸血反應 3. 血量負荷過大、鬱血性心衰竭、肺水腫、輸血性抗宿主反應等合併症。 與麻醉有關之併發症：藥物過敏反應、神經作用、心跳過緩或停止，休克。,人工流產對長期身心健康上的後果 Long-Term Physical and Psychological Health Consequences of Induced Abortion:Review of the Evidence OBSTETRICAL AND GYNCOLOGICAL SURVEY 2007 V58:67,One can presume that abortion is most often chosen as a response to a crisis or unintended pregnancy. The high prevalence of history of induced abortion means that even small positive or negative effects on long-term health could influence the lives of many women and their families.,Abortion rate 1996 U.S.A. 23/1000 Women Age 15 to 44 26% all recognized pregnancy 1995 Canada 16/1000 England 15/1000 Sweden 18/1000 Netherland 6/1000,Obstetric Ethics：(the fetus as a patient)胎兒也是產科醫師的病人, The pregnant women has beneficence-based obligations to the fetus because she is its moral fiduciary. She is expected to protect and promote the best interests of her fetus. 孕婦是胎兒的法定代理人，有嘉惠胎兒的義務，被預期會保護及促進胎兒的權益。,Obstetric Ethics：(the fetus as a patient)胎兒也是產科醫師的病人,The physician also has beneficence-based obligation to the fetus, to protect and promote its interests. 醫師也有嘉惠胎兒的義務，會保護及促進胎兒的權益。 The beneficence model: prevention of premature death, disease, handicapping conditions, and unnecessary pain and suffering. 嘉惠原則：預防其提早死亡、疾病、殘障及不必要的受苦。,優生保健法 第三章 人工流產及結紮手術 第九條 懷孕婦女經診斷或證明有左列情事之一者，得依其自願， 施行人工流產。,一、本人或其配偶患有礙優生之遺傳性、傳染性疾病或精神病者 二、本人或其配偶之四等親以內之血親患有礙優生之遺傳性病者 三、有醫學上理由，足以認定懷孕或分娩有招致生命危險或有害 身體或精神健康者。 四、有醫學上理由，足以認定胎兒有畸型發育之虞者 五、因被強姦、誘姦或與依法不得結婚相姦而受孕者 六、因懷孕或生產，將影響其心理健康或家庭生活者 本項佔台灣 95%的人工流產 有配偶者，依前項第六款規定，施行人工流產應得配偶之同意,Prenatal diagnosis 產前診斷 Genetic counseling 遺傳諮詢 Screening 篩檢,為優生施行的流產涉及：,非引導性的遺傳諮詢與同意書 Informed consent and Nondirective genetic counseling,Disclosure by the physician to the patient of adequate information 醫生提供足夠資訊 2. Understanding of that information by the patient 病患對資訊充分了解 3. A voluntary decision by the patient to authorize or refuse clinical managemant 病患自主決定授權或拒絕處置,Ethical and legal considerations in screening, detection, and management of fetal anomalies,to provide emotional support to the stressed pregnant woman in circumstances of； 在下列情況提供孕婦情緒支持 Screening 篩檢 confirmatory testing 確定檢查結果 giving bad news 給壞消息 making abortion decisions 作流產的決定 making management decisions after viability 留存胎兒的處置決定 to help the pregnant woman make informed management decisions based on her values and goals. 以幫助孕婦根據她的價值觀與目標，做出正式的處置決定,產科醫師的責任 Duty of the obstetrician,產前診斷及發現異常之諮商的兩難情況（一） Dilemma in Prenatal Diagnosis and Counselling After Disclosure（I）,Small Neural tube defect? 小的神經管缺陷 MSAFPNormal level II ultrasound, normal karyotype AFAFP , AF Acetylcholinesterase Grand multiple pregnancy 超高胎數的懷孕 Third Trimester prenatal diagnosis 妊娠後期診斷 Preference of discolosure of the sex of fetus 是否告知胎兒性別,無腦兒 全水腦（空腦症） 嚴重複雜性心臟疾病合併心臟衰竭 致死性遺傳性胎兒多囊性腎臟 雙側性腎臟發育缺失 致死性骨骼發育異常 甲型致死性地中海型貧血 其他致死性遺傳或代謝疾病,妊娠24週以後合法中止懷孕適應症,內發現，宜於足月產後矯治 Detectable in Utero but Best Corrected After Delivery at Term,Esophageal, duodenal, jejunoileal, and anorectal atresias. Meconium peritonitis（ localized lesion without fetal ascites）. Small intact omphalocele. Uncomplicated gastroschistis. Unilateral multicystic dysplastic kidney Small intact myelomeningocele spina bifida Small sacrococcygeal teratoma. Ovarian cysts.,唇腭裂的產前照護 Obstetrical ManagementAntepartum for Cleft Lip and Palate,Careful survey by Ultrasonography 詳細超音波 Karyotyping：controversial 染色體 Follow up once a month 每月追蹤 Polyhydramnios 羊水量 Missed additional defect 是否遺漏其他異常 Standand obstetrical care if no other anomalies 標準產科照護 Delivery at a tertiary center 醫學中心生產 Respiratory Feeding problems 處置呼吸及餵食問題,需提前娩出子宮外作矯治 May Require Induced Preterm Delivery for Early Correction Ex Utero,Obstructive hydronephrosis. Obstructive hydrocephalus. Amniotic band malformation complex. Complicated gastroschisis or ruptured omphalocele.,產前診斷及發現異常之諮商的兩難情況（二） Dilemma in Prenatal Diagnosis and Counselling after Disclosure（II）,45,X；47,XYY；47,XXY、XX-male 性染色體異常 Androgen insensitivity 雄性素不敏感（無反應器） Trisomy Mosacism 鑲嵌性染色體 Inherited balanced translocation 遺傳性染色體平衡轉位,篩檢唐氏症的代價太高？ The Cost of Choice: A Price Too High in the Triple Screen for Down Syndrome. Elkins,et al. Clinical Obs/Gynecology, V36:532-540,Some fetal anomalies clearly bring greatly diminished life expectancy (ancephaly and trisomy 13 or 18). Other fetal conditions (Tay-Sachs disease or AIDS) lead to extreme infant suffering. These are vastly different from Downs syndrome, the discovery of Genetic traits, rather than disorders, would not be seen as important enough to warrant such extensive screening.,篩檢唐氏症的代價太高？The Cost of Choice: A Price Too High in the Triple Screen for Down Syndrome.,We argued against attaching a price tag to persons with Downs syndrome. Determining cost effectiveness is franght with difficulties. 唐氏症並非預期生命短（無腦兒、第、對染色體倍等），亦非嬰兒嚴重受苦（代謝異常、愛滋病等），所以可視為遺傳上的變異而非疾病。我們反對將生命加以標價。,產前診斷及中止懷孕所引發的倫理議題 Ethical problems raised by prenatal diagnosis and TOP,難下終止懷孕的決定 minor anomaliy 誰知孩子的未來？ 滑坡理論 擔心異常兒童在優生社會的處境。 允許醫師決定生死，使醫師的角色不合理。 女性懷孕過程充滿壓力，將造成心理上的後遺症，破壞孕期及出生後的親子關係。 部分醫事人員承認終止懷孕比兒童虐待好。,國人有更多的兩難 More dilemma in our practice,The tradition of sexual discrimation is still strong 性別偏見仍強 No consensus about the beginning of human life對生命起源無共識 The legal