常见妊娠高血压疾病(专家解读)课件

1、Hypertension Disorders Complicating Pregnancy妊娠期高血压疾病第1页，共53页。HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases第2页，共53页。CharacteristicsSystemic small arteries spa

2、sm Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension; Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension第3页，共53页。Hypertension disorders complicating pregnancyPathophysi

3、ologyCategory and clinical manifestationDiagnosis and differential diagnosisManagement and prevention病理生理临床表现诊断治疗第4页，共53页。EpidemiologyIncidence： 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 d

4、eath (20%)Cause of premature delivery（10%）Unknown origin第5页，共53页。Pathophysiology Basic pathological changesSpasm of systemic small arteries Vascular endothelial cell injury第6页，共53页。PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMult

5、iple organs dysfunctionIschemiaEdemamalfunction第7页，共53页。Systemic Disease第8页，共53页。BrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：Vasos

6、pasmpermeability第9页，共53页。kidney renal vasospasmrenal blood flow glomerular filtration rate pathology ：Glomerular expansion swollen vascular endothelial cellcellulose depositionrenocortical necrosisrenal irreversible damageclinical manifestation ：albuminuriahypoproteinemiarenal dysfunction creatinine

7、 urea nitrogen uric acid oliguria renal failure 第10页，共53页。liverhepatic vasospasm;hepatic ischemia;hepatic edema liver enlargement; hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed severe：Periportal necrosishepatic subcapsularhematomahepatorrhexis HELLP s

8、ymdrome:Elevated hepatic enzymesDecreased blood platelet第11页，共53页。Cardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertension Pulmonary EdemaOliguriawater-sodiu

9、m retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor ability第12页，共53页。blood system Relative hypovolemiaAnemiaDecreased blood plateletHypercoagulability blood clotting factor第13页，共53页。placenta-fetusplacenta Placental hypoperfusionSpiral arteries sclerosis Placental Inf

10、arctionPlacental AbruptionPlacental function decreasesfetus IUGRfetal distressoligohydramniosfetal death 第14页，共53页。PathophysiologyBrainHeadache; visual blurred; coma; herniaKidneyRenal function compromised; proteinuria; renal failureLiverPersistent upper right abdominal pain; Elevated enzyme; jaundi

11、ce; hematoma; ruptureSystematic disease第15页，共53页。PathophysiologyCardiovascular systemLow output- high resistance; myocardial ischemia; pulmonary hypertension; edema; heart failureBloodLow volume; hypercoagulability; DIC第16页，共53页。PathophysiologyUterus and PlacentaLow perfusion; placental atherosclero

12、sisPlacental infarction; placental abruption; fetal growth retardation; fetal death第17页，共53页。High risk factorsPrimipara40yMultiple pregnancyHypertensionChronic nephritisMalnutritionPoor social statusDiabetesAnti-phospholipid syndromeAngiotensin gene T235 (+)第18页，共53页。EtiologyGenetic susceptibility h

13、ypothesisImmune maladaptation hypothesisPlacental ischemia hypothesisOxidative stress hypothesis第19页，共53页。 Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplications第20页，共53页。Genetic susceptibili

14、ty hypothesisHypertension第21页，共53页。Immune maladaptation hypothesisMultiple gestationAbortion and blood transfusionOvum and sperm donation第22页，共53页。Placental ischemia hypothesis40% total spiral artery area compared to normal pregnancyEndothelial cell injury第23页，共53页。Oxidative stress hypothesisOxidati

15、ve stress reactionEndothelial cell injury第24页，共53页。Category and clinical manifestationGestational hypertension PreeclampsiaEclampsia Chronic hypertensionPreeclampsia superimposed on chronic hypertension第25页，共53页。clinical features typical : hypertension、albuminuria、edemauntypical ：asymptomatic severe

16、：nausea、vomitheadache、dazzleconvulsion 、comachest distress 、palpitation 第26页，共53页。Gestational Hypertension Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumSBP=140mmHgDBP =90mmHgDiagnosed only after delivery第27页，共53页。PreeclampsiaHypertention occurs 20 weeks aft

17、er gestation BP=140/90mmHgProteinuria Proteinuria 300mg/24h Urine protein （+）Other symptomsHeadache, visual blurringUpper abdominal pain第28页，共53页。Severe preeclampsiaAt least one of the following features：Central nervous system abnormalities Hepatic subcapsular hematoma / hepatorrhexisHepatocyte inju

18、ry :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第29页，共53页。Severe pree

19、clampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia : 20.5mol/LElevated serum level of Liver enzymesAST70u/L, or 3SDLDH600u/LLow PlateletsPLC100*109/L第31页，共53页。HELLPSevere preeclampsia ：One abnormalities 6%Two abnormalities 12%Three abnormalities10%20 gw seldom occur1/3 occur

20、after delivery80% diagnosed prenatally第32页，共53页。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第33页，共53页。Some investigatiors regard HELLP syndrome as an entirely distinct disease enti

21、ty from preeclampsia第34页，共53页。Classification of HELLPBy degree of thrombocytopenia：100,000/mm3Not widely accepted第35页，共53页。Pathogenesis and epidemic characteristics of HELLP core mechanismendothelial injuryintravascular coagulation dysfunctionpredisposing factorsthe whitemultipara elder pregnant wom

22、en第36页，共53页。HELLP-mortalityMaternal 0-24%hepatorrhexisDICAcute renal failurethrombosiscerebrovascular accidentsPerinatal 7.7-60%Premature deliveryIUGRplacental abruption 第37页，共53页。Eclampsiaprocess：tonusconvulsionsleepinesscoma Occurrenceprenatalintrapartumpostpartum 第38页，共53页。Chronic Hypertension du

23、ring PregnancyHypertension before pregnancy or Hypertension before 20 weeks gestationalUnrelieved 12 weeks postpartumPoor fetal outcomePerinatal mortality 3 times Placental abruption 2 times FGR, preterm birth 第39页，共53页。preeclampsia superimposed upon chronic hypertensionChronic Hypertension Before 2

24、0 gestational weeksPersist 12 weeks postpartumProteinuriaBefore 20wAfter 20w; with higher BP; thrombocytopenia第40页，共53页。Differential diagnosisChronic nephritis complicating pregnancyRenal dysfunctionSeizure caused by other reasons第41页，共53页。ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiures

25、isTerminate pregnancy timely第42页，共53页。ManagementCommon treatmentRestMonitoringOxygen inhalationDiet: salt restriction only for anasarca patients第43页，共53页。ManagementSedationDiazepamHibernation drugsPethidineChlorpromazinePromethazine第44页，共53页。ManagementAnti-spasmFirst line treatment for pre-eclampsia

26、 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. 第45页，共53页。ManagementMgSO4Treatment 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 detoxi