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腹膜透析婦女懷孕生產營養照護個案報告

Nutritional Care for Women Receiving Peritoneal Dialysis During Pregnancy-A Case Report

摘要


在腎衰竭的病患中,懷孕為很罕見的情況,腎衰竭會導致下視丘-腦垂體-卵巢的內分泌障礙,常常使病人合併排卵障礙或無月經症狀而導致不孕症。初期接受良好透析治療的育齡病人,受孕率會增加至1.5%。整體接受透析治療的病患來看,大約只有每年0.5%的受孕機會。個案是一位36歲女性,因A型免疫球蛋白腎炎2017年3月開始腹膜透析,每月常規透析門診追蹤,結婚數年一直想懷孕,於2017年3月懷孕未成功,再次於同年懷孕,最後一次月經週期為2017年11月17日,平日透析液使用「Dianeal low Ca 1.5%」2 L、2.5% 2 L各二袋及「Nutrineal PD4 1.1%」2 L一袋,藥物使用Folic acid、B-complex calcium carbonate。懷孕20週後,於2018年4月改以血液透析(使用permcath雙迴路導管)每週透析6次,也接受常規產檢,因懷孕28週,2018年6月因發燒由急診入院,原因為導管感染,抗生素治療後重新裝雙迴路導管出院,在院期間持續監測胎兒狀況,超音波胎兒生長狀況與胎心均在標準值。原預計懷孕36週剖腹生產,但在34週出現子癲前症症狀,緊急入院剖腹產下一名出生體重為2115 g的女嬰,出生狀況良好無呼吸窘迫(懷孕期已施打肺泡成熟劑)。而個案在懷孕初期(14~17週)營養問題為,食物與營養相關知識不足,因不瞭解透析懷孕期間飲食注意相關事項,營養師藉由門診諮詢與line通訊軟體詢問及協助個案瞭解孕期飲食注意事項。而懷孕20週開始每天透析6次,與一週3次透析病人的營養支持,在蛋白質與電解質鈉、磷、鉀、鈣需求不同,而此時營養問題為蛋白質攝取不足,藉由營養衛教後,個案蛋白質攝取量明顯增加。此個案所產下34週的女嬰體位也無文獻所呈現低體重現象,此個案順利產下胎兒正是醫院中各科團隊共同努力的結果。

關鍵字

懷孕 腹膜透析 營養

並列摘要


The renal failure in pregnant patients is rare and likely leads to the hypothalamus-pituitary-ovary endocrine disorders or menstrual symptoms which often result in infertility. The conception rate increases to 1.5% for childbearing women on good initial dialysis and is only about 0.5% annually in those on general dialysis. This 36-year-old woman started peritoneal dialysis (PD) in March 2006 due to immunoglobulin A (IgA) nephritis. She who was followed by a monthly dialysis clinic had been anticipating to be pregnant for several years since March 2017 in what year she had been pregnant after curettage. The last menstrual cycle was on November 17, 2017. The weekday dialysis was by: two bags of Dianeal low Ca 1.5% 2 L and 2.5% 2 L, respectively; one bag of Nutrineal PD4 1.1% 2 L. The medication was by folic acid, b-complex, calcium carbonate. Over 20-week pregnancy in April 2018, the Permcath double lumen catheter hemodialysis 6 times weekly began, and check-ups were routine. At 28-week pregnancy in June 2018, she visited emergency room, due to fever and was admitted attributed to catheter infection; the catheter was re-installed after antibiotics treatment. The fetal condition was continuously monitored during the hospitalization, with the fetal growth and fetal heart rate in the standard value. The caesarean delivery was to be at 36-week pregnancy and was at 34-week pregnancy after the emergency admission pertinent to the pre-epileptic symptoms. As for pregnancy, the alveolar maturation agent was plied. The baby girl, 2115 grams, came in good condition without respiratory distress. During the early pregnancy (14-17 weeks), the nutrition problem was lack of knowledge for pregnant woman receiving dialysis, intervention was to provide of nutrition counseling of outpatient visits or on-line consultation using Line messaging App. At the 20 week of pregnancy, frequencies of dialysis was prescribed as daily dialysis rather than 3 times per week. Nutrition requirement of protein, sodium, phosphate, potassium and calcium were differed between both types of dialysis. At this time, major nutrition problem was inadequate protein intake, provision of optimal level of protein through foods and oral nutrition supplements to increase protein intake was recommended by dietician. The 34-week baby girl was born without low birth weight problem, which has been the result of the efforts of multidisciplinary team in hospital.

並列關鍵字

pregnancy peritoneal dialysis nutrition

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