妊娠性高血压(英文)

Hypertensivedisordersofpregnancy(HDP)

(Pregnancy-inducedHypertensionsyndrome，PIH)

ThehypertensivedisordersofpregnancyarealeadingcauseofmaternalandperinatalmortalityandmorbidityTherate:9.4%(7-12%)Reference:SOGCCLINICALPRACTICEGUIDELINE

Diagnosis,Evaluation,andManagementoftheHypertensiveDisordersofPregnancy23Etiology:

1.Utero-placentalischaemia:

Abnormaldevelopmentoftheplacentalbedvessels/shallowtrophoblastinvisioninspiralarteries/acutearterosis/

2.Endothelialcellactivation/dysfunction:

Cytotoxicfactors:oxygenfreeraicals/lipidperoxidation/verylowdensitylipoprotein(VLDL)/fibronection/plateletderivedgrowthfactor(PDGF)/tumornecrosisfactor-a(TNF-a)/interleukins-6(IL-6)/anti-vascularendothelialfactor/endothelialinhibitivefactor

3.Immunity;

(1)

failtoexpressHLA-GmRNAorprotein.

(2)

abnormalmaternalimmunesituationsuchasTs/ThdecreaseandTh1functiondominent.

4.Genetics:

generecessivetrait.

4

Pathophysiology:

Basicpathophysiologychanges:spasmofthearterioles---activation/damageofendothelium---reducedorganperfusion:Hypertension/

Proteinuria/

Edema

Pathology:hemorrhage/ischemia/necrosis/

1.

Placenta:

(1)

prematureagingofvilli

(2)

hemorrhage

(3)necrosis

5

2.

Kidney----glomerularchanges

(1)

swellingofendothelialcells

(2)

thedepositionofamorphousmaterialsincytoplasm

produceenlargement

(3)

swellingoftheglomerularcapillarities.

3.

Liver:periportalareas

4.Brain:cortical/subcorticalareas

5.Heart:increaseofcardiacafterload,preloadmayor.

6.Hematologicalchanges:hypercoagulationstatus,

HELLP(hemolysis,elevatedliverenzymes,lowcountplatelets)

6Clinicalfinding1.

HypertensionisthemostsignificantprimarysignofHDP.2.

Proteinuriaisaverycommonfindinginpreeclampsia3.

Edemaisacommonfirstsignofimpendingoractualpreeclampsia.

classifiedinto4degrees:

1:edemainvolvesinshanks

2:edemainvolveinthighs

3:edemainvolvesinvulvaandabdomen

4:edemainvolvesfaceandfingers4.

Headache5.

Visualdisturbances6.

Tightnessofchest7.

Convulsion(惊厥）

7DiagnosisofHDPTheclassificationisbasedonthetwomostcommonmanifestationsofpreeclampsia:hypertensionproteinuria8DIAGNOSISOFHYPERTENSION

1.Thediagnosisofhypertensionshouldbebasedonofficeorin-hospitalBPmeasurements.(II-2B)2.HypertensioninpregnancyshouldbedefinedasadiastolicBPof90mmHg,basedontheaverageofatleasttwomeasurements,takenusingthesamearm.(II-2B)3.WomenwithasystolicBPof140mmHgshouldbefollowedcloselyfordevelopmentofdiastolichypertension.(II-2B)4.SeverehypertensionshouldbedefinedasasystolicBPof160mmHgoradiastolicBPof110mmHg.(II-2B)5.Forseverehypertension,arepeatmeasurementshouldbetakenforconfirmationin15minutes.(III-B)9MEASUREMENTOFPROTEINURIA1.Allpregnantwomenshouldbeassessedforproteinuria.(II-2B)2.Urinarydipsticktestingmaybeusedforscreeningforproteinuriawhenthesuspicionofpreeclampsiaislow.(II-2B)3.Moredefinitivetestingforproteinuria(byurinaryprotein:creatinineratioor24-hoururinecollection)isencouragedwhenthereisasuspicionofpreeclampsia,includinginhypertensivepregnantwomenwithrisingDiagnosis,Evaluation,andManagementoftheHypertensiveDisordersofPregnancyS10MARCHJOGCMARS2008BPorinnormotensivepregnantwomenwithsymptomsorsignssuggestiveofpreeclampsia.(II-2A)10DIAGNOSISOFCLINICALLYSIGNIFICANTPROTEINURIA1.Proteinuriashouldbestronglysuspectedwhenurinarydipstickproteinuriais2+.(II-2A)2.Proteinuriashouldbedefinedas0.3g/dina24-hoururinecollectionor30mg/mmolurinarycreatinineinaspot(random)urinesample.(II-2B)3.Thereisinsufficientinformationtomakearecommendationabouttheaccuracyoftheurinaryalbumin:creatinineratio.(II-2I)11HELLPsyndromeisalife-threateningobstetriccomplicationusuallyconsideredtobeavariantofpre-eclampsia.Bothconditionsusuallyoccurduringthelaterstagesofpregnancy,orsometimesafterchildbirth.HELLPisanabbreviationofthemainfindings:Hstandsforhaemolysis(ruptureoftheredbloodcells).

ELstandsforelevatedliverenzymesintheblood(reflectingliverdamage).

LPstandsforlowbloodlevelsofplatelets(specialisedcellswhicharevitalfornormalclotting).12CLASSIFICATIONOFHDPpre-existinghypertensiongestationalhypertensionpreeclampsiaeclampsiaPreeclampsiawithpre-existinghypertension13分类和诊断中国版（五类）：妊娠期高血压子痫前期(轻度,重度)子痫慢性高血压并发子痫前期妊娠合并慢性高血压ACOG版分四类：子痫前期-子痫慢性高血压慢性高血压合并子痫前期妊娠期高血压14子痫前期诊断（中国版）轻度：妊娠20周后出现收缩压≥140mmHg和（或）舒张压≥90mmHg伴蛋白尿≥0.3g/24h重度：血压和尿蛋白持续升高，发生母体脏器功能不全或胎儿并发症。15重度子痫前期（中国版）子痫前期患者出现下述任一不良情况可诊断为重度子痫前期：①血压持续升高：收缩压≥160mmHg和（或）舒张压≥110mmHg；②蛋白尿≥2.0g/24小时或随机蛋白尿≥（++）；③持续性头痛或视觉障碍或其它脑神经症状；④持续性上腹部疼痛等肝包膜下血肿或肝破裂症状；⑤肝酶异常：血ALT或AST升高；⑥肾脏功能异常：少尿（24小时尿量<400ml或每小时尿量<17ml）或血肌酐>106μmol/L；⑦低蛋白血症伴腹水或胸水；⑧血液系统异常：血小板呈持续性下降并低于100×109/L；血管内溶血、贫血、黄疸或血LDH升高；⑨心力衰竭、肺水肿；⑩胎儿生长受限或羊水过少；（11）孕34周前发病(II-2B)。1.血压重度升高2.蛋白尿标准3.母儿二方面评判4.发病孕周16子痫前期诊断（ACOG，2013）如果没有蛋白尿，新出现的高血压伴下列任何一条也可诊断孕20W后BP≥140/90mmHg，间隔4h重复测定；BP≥160/110mmHg，间隔数分钟测定尿蛋白≥0.3g/24h；尿蛋白/肌酐≥0.3mg/dl；尿试纸（+）血小板减少肝肾功能减退（2倍以上）肺水肿视力或脑部症状17ACOG新版子痫前期严重性卧床休息，每4h间隔测定，有二次BP≥160/110mmHg；血小板减少；肝酶异常（2倍以上），右上腹疼痛；肾损害；肺水肿；新发脑部异常；不同点：没有尿蛋白；没有“早发型子痫前期”的概念；

胎儿和羊水问题不考虑

18CLASSIFICATIONOFHDP1.shouldbeclassifiedaspre-existingorgestationalhypertensiononthebasisofdifferentdiagnosticandtherapeuticfactors.(II-2B)2.Thepresenceorabsenceofpreeclampsiamustbeascertained,givenitsclearassociationwithmoreadversematernalandperinataloutcomes.(II-2B)3.Inwomenwithpre-existinghypertension,preeclampsiashouldbedefinedasresistanthypertension,neworworseningproteinuria,oroneormoreoftheotheradverseconditions.(II-2B)194.Inwomenwithgestationalhypertension,preeclampsiashouldbedefinedasnew-onsetproteinuriaoroneormoreoftheotheradverseconditions.(II-2B)5.Severepreeclampsiashouldbedefinedaspreeclampsiawithonsetbefore34weeks’gestation,withheavyproteinuriaorwithoneormoreadverseconditions.(II-2B)6.ThetermPIH(pregnancy-inducedhypertension)shouldbeabandoned,asitsmeaninginclinicalpracticeisunclear.(III-D)20Preeclampsia

Theterm,preeclampsiahasbeenre-introducedforitsbrevityandbecauseofitsinternationaluse.Itcorrespondstothefollowingpreviousterms•pre-existinghypertensionwithsuperimposedgestationalhypertension,proteinuriaand/oranadverseconditionorconditions•gestationalhypertensionwithproteinuria•gestationalhypertension(withoutproteinuria)withoneormoreoftheadverseconditions.21INVESTIGATIONSTOCLASSIFYHDP1.Forwomenwithpre-existinghypertension,serumcreatinine,serumpotassium,andurinalysisshouldbeperformedinearlypregnancyifnotpreviouslydocumented.(II-2B)2.Amongwomenwithpre-existinghypertension,additionalbaselinelaboratorytestingmaybebasedonotherconsiderationsdeemedimportantbyhealthcareproviders.(III-C)3.Womenwithsuspectedpreeclampsiashouldundergothematernallaboratory(II-2B)andfetal(II-1B)testing224.Ifinitialtestingisreassuring,maternalandfetaltestingshouldberepeatedifthereisongoingconcernaboutpreeclampsia(e.g.,changeinmaternaland/orfetalcondition).(III-C)5.UterinearteryDopplervelocimetrymaybeusefulamonghypertensivepregnantwomentosupportaplacentaloriginforhypertension,proteinuria,and/oradverseconditions.(II-2B)6.UmbilicalarteryDopplervelocimetrymaybeusefultosupportaplacentaloriginforintrauterinefetalgrowthrestriction.(II-2B)CommentsPre-23PREDICTINGPREECLAMPSIA

Thereisnosinglepredictorofpreeclampsiaamongwomenateitherloworincreasedriskofpreeclampsia.1.Atbookingforantenatalcare,womenwithmarkersofincreasedriskforpreeclampsiashouldbeofferedobstetricconsultation.(II-2B)2.Womenatincreasedriskofpreeclampsiashouldbeconsideredforriskstratificationinvolvingamultivariableclinicalandlaboratoryapproach.(II-2B)24PreventingPreeclampsiaanditsComplicationsinWomenatLowRisk1.Calciumsupplementation(ofatleast1g/d,orally)isrecommendedforwomenwithlowdietaryintakeofcalcium(<600mg/d).(I-A)2.Thefollowingarerecommendedforotherestablishedbeneficialeffectsinpregnancy:(1)abstentionfromalcoholforpreventionoffetalalcoholeffects,(II-2E)(2)exerciseformaintenanceoffitness,(I-A)(3)periconceptualuseofafolate-containingmultivitaminforpreventionofneuraltubedefects,(I-A)(4)smokingcessationforpreventionoflowbirthweightandpretermbirth.(I-E)3.Thefollowingmaybeuseful:periconceptualuseofafolate-containingmultivitamin,(I-B)orexercise.(II-2B)254.Thefollowingarenotrecommendedforpreeclampsiaprevention,butmaybeusefulforpreventionofotherpregnancycomplications:prostaglandinprecursors,(I-C)orsupplementationwithmagnesium,(I-C)orzinc.(I-C)5.Thefollowingarenotrecommended:dietarysaltrestrictionduringpregnancy,(I-D)calorierestrictionduringpregnancyforoverweightwomen,(I-D)low-doseaspirin,(I-E)vitaminsCandE(basedoncurrentevidence),(I-E)orthiazidediuretics.(I-E)6.Thereisinsufficientevidencetomakearecommendationaboutthefollowing:aheart-healthydiet,(II-2I)workloadorstressreduction,(II-2I)supplementationwithironwith/withoutfolate,(I-I)orpyridoxine.(I-I).26PreventingPreeclampsiaanditsComplicationsinWomenatIncreasedRisk1.Low-doseaspirin(I-A)andcalciumsupplementation(ofatleast1g/d)arerecommendedforwomenwithlowcalciumintake,(I-A)thefollowingarerecommendedforotherestablishedbeneficialeffectsinpregnancy(asdiscussedforwomenatlowriskofpreeclampsia):abstentionfromalcohol,(II-2E)periconceptualuseofafolate-containingmultivitamin,(I-A)smokingcessation.(I-E)272.Low-doseaspirin(75–100mg/d)(III-B)shouldbeadministeredatbedtime,(I-B)startingpre-pregnancyorfromdiagnosisofpregnancybutbefore16weeks’gestation,(III-B)andcontinuinguntildelivery.(I-A)3.Thefollowingmaybeuseful:

avoidanceofinterpregnancyweightgain,(II-2E)increasedrestathomeinthethirdtrimester,(I-C)reductionofworkloadorstress.(III-C)4.Thefollowingarenotrecommendedforpreeclampsiapreventionbutmaybeusefulforpreventionofotherpregnancycomplications:

prostaglandinprecursors(I-C)magnesiumsupplementation.(I-C)285.Thefollowingarenotrecommended:calorierestrictioninoverweightwomenduringpregnancy,(I-D)Weightmaintenanceinobesewomenduringpregnancy,(III-D)antihypertensivetherapyspecificallytopreventpreeclampsia,(I-D)vitaminsCandE.(I-E)6.Thereisinsufficientevidencetomakearecommendationabouttheusefulnessofthefollowing:theheart-healthydiet(III-I);exercise(I-I);heparin,evenamongwomenwiththrombophiliaand/orpreviouspreeclampsia(basedoncurrentevidence)(II-2I);selenium(I-I);garlic(I-I);zinc,pyridoxine,iron(withorwithoutfolate),Ormultivitaminswith/withoutmicronutrients.(allIII-I)29PROGNOSIS(MATERNALANDFETAL)INPREECLAMPSIA

1.Serialsurveillance（监测）ofmaternalwell-beingisrecommended,bothantenatallyandpostpartum.(II-3B)2.Thefrequencyofmaternalsurveillanceshouldbeatleastonceperweekantenatally,andatleastonceinthefirstthreedayspostpartum.(III-C)3.Serialsurveillanceoffetalwell-beingisrecommended.(II-2B)4.AntenatalfetalsurveillanceshouldincludeumbilicalarteryDopplervelocimetry.(I-A)5.Womenwhodevelopgestationalhypertensionwithneitherproteinurianoradverseconditionsbefore34weeksshouldbefollowedcloselyformaternalandperinatalcomplications.(II-2B)30TreatmentPrincipleofHDPRestDietaryChangesLifestyleChangesAntihypertensiveTherapyEclampsiaProphylaxisorTreatmentTherapiesforHELLPSyndromeFetalPulmonaryMaturityOtherTherapies31AntihypertensiveTherapyForSevereHypertension(BPof>160mmHgSystolicor110mmHgDiastolic)1.BPshouldbeloweredto<160mmHgsystolicand<110mmHgdiastolic.(II-2B)2.Initialantihypertensivetherapyshouldbewithlabetalol,(I-A)nifedipinecapsules,(I-A)nifedipinePAtablets,(I-B)orhydralazine.(I-A)3.MgSO4isnotrecommendedasanantihypertensiveagent.(I-E)4.ContinuousFHRmonitoringisadviseduntilBPisstable.(III-I)5.NifedipineandMgSO4canbeusedcontemporaneously.(II-2B)32ForNon-SevereHypertension(BPof140–159/90–109mmHg)1.Forwomenwithoutcomorbidconditions,antihypertensivedrugtherapyshouldbeusedtokeepsBPat130–155mmHganddBPat80–105mmHg.(III-C)2.Forwomenwithcomorbidconditions,antihypertensivedrugtherapyshouldbeusedtokeepsBPat130–139mmHganddBPat80–89mmHg.(III-C)3.InitialtherapycanbewithoneofavarietyofantihypertensiveagentsavailableinCanada:methyldopa,(I-A)labetalol,(I-A)otherbeta-blockers(acebutolol,metoprolol,pindolol,andpropranolol),(I-B)andcalciumchannelblockers(nifedipine).(I-A)4.Angiotensinconvertingenzyme(ACE)inhibitorsandangiotensinreceptorblockers(ARBs)shouldnotbeused.(II-2E)5.Atenololandprazosinarenotrecommended.(I-D)33MagnesiumSulphate(MgSO4)forEclampsia

ProphylaxisorTreatment

1.MgSO4isrecommendedforfirst-linetreatmentofeclampsia.(I-A)2.MgSO4isrecommendedasprophylaxisagainsteclampsiainwomenwithseverepreeclampsia.(I-A)3.MgSO4maybeconsideredforwomenwithnon-severereeclampsia.(I-C)4.Phenytoinandbenzodiazepinesshouldnotbeusedforeclampsiaprophylaxisortreatment,unlessthereisacontraindicationtoMgSO4oritisineffective.(I-E)34TherapiesforHELLPSyndrome

1.Prophylactictransfusionofplateletsisnotrecommended,evenpriortoCaesareansection,whenplateletcountis>50x109/Landthereisnoexcessivebleedingorplateletdysfunction.(II-2D)2.Considerationshouldbegiventoorderingbloodproducts,includingplatelets,whenplateletcountis<50109/L,plateletcountisfallingrapidly,and/orthereiscoagulopathy.(III-I)3.Platelettransfusionshouldbestronglyconsideredpriortovaginaldeliverywhenplateletcountis<20109/L.(III-B)4.PlatelettransfusionisrecommendedpriortoCaesareansection,whenplateletcountis<20109/L.(III-B)5.Corticosteriodsmaybeconsideredforwomenwithaplateletcount<50109/L.(III-I)6.Thereisinsufficientevidencetomakearecommendationregardingtheusefulnessofplasmaexchangeorplasmapheresis.(III-I)35CorticosteroidsforAccelerationofFetalPulmonaryMaturity

1.Antenatalcorticosteroidtherapyshouldbeconsideredforallwomenwhopresentwithpreeclampsiabefore34weeks’gestation.(I-A)2.Antenatalcorticosteroidtherapymaybeconsideredforwomenwhopresentat<34weeks’withgestationalhypertension(despitetheabsenceofproteinuriaor‘adverseconditions’)ifdeliveryiscontemplatedwithinthenext7days.(III-I)36OtherTherapiesforTreatmentofPreeclampsia1.Womenwithpreeclampsiabefore34weeks’gestationshouldreceiveantenatalcorticosteroidsforaccelerationoffetalpulmonarymaturity.(I-A)2.Thromboprophylaxismaybeconsideredwhenbedrestisprescribed.(II-2C)3.Low-doseaspirinisnotrecommendedfortreatmentofpreeclampsia.(I-E)4.Thereisinsufficientevidencetomakerecommendationsabouttheusefulnessoftreatmentwiththefollowing:activatedproteinC,(III-I)antithrombin,(I-I)heparin,(III-I)L-arginine,(I-I)long-termepiduralanaesthesia,(I-I)N-acetylcysteine,(I-I)probenecid,(I-I)orsildenafilnitrate.(III-I)37ModeofDelivery1.ForwomenwithanyHDP,vaginaldeliveryshouldbeconsideredunlessaCaesareansectionisrequiredfortheusualobstetricindications.(II-2B)2.Ifvaginaldeliveryisplannedandthecervixisunfavourable,thencervicalripeningshouldbeusedtoincreasethechanceofasuccessfulvaginaldelivery.(I-A)3.AntihypertensivetreatmentshouldbecontinuedthroughoutlabouranddeliverytomaintainsBPat<160mmHganddBPat<110mmHg.(II-2B)4.Thethirdstageoflabourshouldbeactivelymanagedwithoxytocin5unitsIVor10unitsIM,particularlyinthepresenceofthrombocytopeniaorcoagulopathy.(I-A)5.Ergometrineshouldnotbegiveninanyform.(II-3D)38TimingofDeliveryofWomen

WithPreeclampsiaManagementshouldbebasedontheunderstandingthatdeliveryistheonlycurefo