常见妊娠高血压疾病(专家解读) 陈晓军ppt课件.ppt

Hypertension Disorders Complicating Pregnancy,妊娠期高血压疾病,HypertensiveDisorders complicating Pregnancy,Gestational Hypertension,Preeclampsia,Preeclampsia Superimposed on Chronic Hypertension,Chronic Hypertension,Eclampsia,A Group of Related Diseases,Characteristics,Systemic small arteries spasm,Endothelial cell injury,Hypertension,Proteinuria,Multiple organs dysfunction,Convulsion,Maternal mortality,Fetal mortality,Gestational Hypertension; Chronic hypertension,Eclampsia,Preeclampsia;Preeclampsia Superimposed on Chronic Hypertension,Hypertension disorders complicating pregnancy,PathophysiologyCategory and clinical manifestationDiagnosis and differential diagnosisManagement and prevention,病理生理,临床表现,诊断,治疗,Epidemiology,Incidence： 6-9%Preeclampsia-eclampsia：70%Chronic Hypertension ： 30%Eclampsia0.5% - 1%China 1.0%Overseas 0.5%Reflection of medical level The second cause of maternal death (20%)Cause of premature delivery（10%）Unknown origin,Pathophysiology,Basic pathological changesSpasm of systemic small arteries Vascular endothelial cell injury,Pathophysiology,fluid,protein,HypertensionEdemaProteinuriaHemoconcentration,Small arterial spasm,Endothelial cell injury,Multiple organs dysfunction,IschemiaEdemamalfunction,Systemic Disease,Brain,HydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral hernia,headachedazzlenauseavomit,Hypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking,Eclampsiaconvulsion coma,brain：Vasospasmpermeability,kidney,renal vasospasm,renal blood flow ,glomerular filtration rate ,pathology ：Glomerular expansion swollen vascular endothelial cellcellulose depositionrenocortical necrosisrenal irreversible damage,clinical manifestation ：albuminuriahypoproteinemiarenal dysfunction creatinine urea nitrogen uric acid oliguria renal failure,liver,hepatic vasospasm;hepatic ischemia;hepatic edema,liver enlargement; hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed,severe：Periportal necrosishepatic subcapsularhematomahepatorrhexis,HELLP symdrome:Elevated hepatic enzymesDecreased blood platelet,Cardiovascular System,Blood Pressure ,Vasospasm,Vascular Resistance ,Cardiac Load ,heart failure,vasospasm,Myocardial IschemiaInterstitial EdemaSpotty Necrosis,pulmonary vasospasm,Pulmonary Hypertension,Pulmonary Edema,Oliguria,water-sodium retention,Relative Blood Volume Excess,Iatrogenic Blood Volume Excess,High burden,Poor ability,blood system,Relative hypovolemiaAnemiaDecreased blood plateletHypercoagulability blood clotting factor,placenta-fetus,placenta Placental hypoperfusionSpiral arteries sclerosis Placental InfarctionPlacental AbruptionPlacental function decreases,fetus IUGRfetal distressoligohydramniosfetal death,Pathophysiology,BrainHeadache; visual blurred; coma; herniaKidneyRenal function compromised; proteinuria; renal failureLiverPersistent upper right abdominal pain; Elevated enzyme; jaundice; hematoma; rupture,Systematic disease,Pathophysiology,Cardiovascular systemLow output- high resistance; myocardial ischemia; pulmonary hypertension; edema; heart failureBloodLow volume; hypercoagulability; DIC,Pathophysiology,Uterus and PlacentaLow perfusion; placental atherosclerosisPlacental infarction; placental abruption; fetal growth retardation; fetal death,High risk factors,Primipara40yMultiple pregnancyHypertensionChronic nephritisMalnutritionPoor social statusDiabetes,Anti-phospholipid syndromeAngiotensin gene T235 (+),Etiology,Genetic susceptibility hypothesisImmune maladaptation hypothesisPlacental ischemia hypothesisOxidative stress hypothesis,Genetic susceptibility,Immune maladaptation,Placental ischemia,Oxidativestress,Abnormal placental,The change of cytokine,PE,development,Endothelium injured,DIC,Complications,Genetic susceptibility hypothesis,Hypertension,Immune maladaptation hypothesis,Multiple gestationAbortion and blood transfusionOvum and sperm donation,Placental ischemia hypothesis,40% total spiral artery area compared to normal pregnancyEndothelial cell injury,Oxidative stress hypothesis,Oxidative stress reaction,Endothelial cell injury,Category and clinical manifestation,Gestational hypertension PreeclampsiaEclampsia Chronic hypertensionPreeclampsia superimposed on chronic hypertension,clinical features,typical : hypertension、albuminuria、edemauntypical ：asymptomatic severe：nausea、vomitheadache、dazzleconvulsion 、comachest distress 、palpitation,Gestational Hypertension,Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumSBP=140mmHgDBP =90mmHgDiagnosed only after delivery,Preeclampsia,Hypertention occurs 20 weeks after gestation BP=140/90mmHgProteinuria Proteinuria 300mg/24h Urine protein （+）Other symptomsHeadache, visual blurringUpper abdominal pain,Severe preeclampsia,At least one of the following features：Central nervous system abnormalities Hepatic subcapsular hematoma / hepatorrhexisHepatocyte injury :GPTBlood pressure：SBP160mmHg，or DBP110mmHgThrombocytopenia: 100109/LProteinuria: 5g/24h or (+) 4 hours apart Oliguria: 500ml/24hPulmonary edema Cerebrovascular accidentIntravascular hemolysis : anemia, jaundiceCoagulation dysfunctionFetal growth restriction / oligohydramnios,Severe preeclampsia complications,Hepatic subcapsularhematoma Early-onset preeclampsia : 34w HELLP syndrome,HELLP syndrome,Hemolysisblood smears show RBC debrisHb 60-90g/LTB20.5mol/L,Elevated serum level of Liver enzymesAST70u/L, or 3SDLDH600u/LLow PlateletsPLC100*109/L,HELLP,Severe preeclampsia ：One abnormalities 6%Two abnormalities 12%Three abnormalities10%20 gw seldom occur1/3 occur after delivery80% diagnosed prenatally,HELLPclinical diagnosis,Might be asymptomatic pain in the right upper abdomen80% weight gain or severe edema 50-60%20% cases 140/90 mmHg6% cases without proteinuria,Some investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia,Classification of HELLP,By degree of thrombocytopenia：100,000/mm3Not widely accepted,Pathogenesis and epidemic characteristics of HELLP,core mechanismendothelial injuryintravascular coagulation dysfunctionpredisposing factorsthe whitemultipara elder pregnant women,HELLP-mortality,Maternal 0-24%hepatorrhexisDICAcute renal failurethrombosiscerebrovascular accidents,Perinatal 7.7-60%Premature deliveryIUGRplacental abruption,Eclampsia,process：tonusconvulsionsleepinesscoma,Occurrenceprenatalintrapartumpostpartum,Chronic Hypertension during Pregnancy,Hypertension before pregnancy or Hypertension before 20 weeks gestationalUnrelieved 12 weeks postpartumPoor fetal outcomePerinatal mortality 3 times Placental abruption 2 times FGR, preterm birth ,preeclampsia superimposed upon chronic hypertension,Chronic Hypertension Before 20 gestational weeksPersist 12 weeks postpartumProteinuriaBefore 20wAfter 20w; with higher BP; thrombocytopenia,Differential diagnosis,Chronic nephritis complicating pregnancyRenal dysfunctionSeizure caused by other reasons,Management,PrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminate pregnancy timely,Management,Common treatmentRestMonitoringOxygen inhalationDiet: salt restriction only for anasarca patients,Management,SedationDiazepamHibernation drugsPethidineChlorpromazinePromethazine,Management,Anti-spasmFirst line treatment for pre-eclampsia and eclampsiaMgSO4 MechanismRegimen 25-30g/dLoading dose: 25% MgSO4 10ml +10%GS 20ml iv 5-10min25% MgSO4 60ml +5%GS 500ml ivgtt 1-2g/h25% MgSO4 20ml +2%lidocaine 2ml im.,Management,MgSO4Treatment concentration 1.7-3mmol/LToxic concentration 3mmol/LToxicityMuscular paralysisPrevention and treatmentBefore treatmentKnee reflex (+); R16bpm; urine5ml/h or 600ml/24hMg concentration monitoring If something happens10% calcium gluconate 10ml iv for detoxificationLower dose or stop use when renal dysfunction,Management,AntihypertensionIndication SBP160mmHg, DBP 110mmHg, MBP 140mmHgPrincipleNo feral toxicity; no lower renal and uterine perfusionHydralazine first lineLabetalol; calcium channel blocker; methyldopaSodium nitroprusside-only when unmanageable BP ACEI-contraindicated during pregnancy,Management,Volumetric dilatancy-only for severe Hypoproteinemia and anemiaDiuretic agent-only for severe edema,Management,Terminate pregnancySevere pre-eclampsia unrelieved after active treatment for 24-48 hoursSevere pre-eclampsia, 34 wSevere pre-eclampsia, 34 w with matured fetus and placental dysfunctionSevere pre-eclampsia, 34 w with unmatured fetus and placental dysfunction, terminate after dexamethasone delivery 2h after controlling eclampsia,Management,Terminate pregnancyInduced laborC-SPrevent postpartum eclampsia,Management,EclampsiaControl seizure by MgSO4 and 20% mannitol Anti-hypertensionCorrect acidosis and hypoxiaTerminate pregnancy 2 hours after controlling seizureNursing,Management,Chronic hypertensionIndication SBP150-180mmHg; DBP100mmHg; hypertension related organ dysfunction,Prevention,A well organized health care systemA well monitored pregnant periodAppropriate diet and rest,