常见妊娠高血压疾病专家解读.pptx

Hypertension Disorders Complicating Pregnancy妊娠期高血压疾病妊娠期高血压疾病HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related DiseasesCharacteristicsSystemic small arteries spasm Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension;Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic HypertensionHypertension disorders complicating pregnancynPathophysiologynCategory and clinical manifestationnDiagnosis and differential diagnosisnManagement and prevention病理生理病理生理临床表现临床表现诊断诊断治疗治疗EpidemiologynIncidence：6-9%nPreeclampsia-eclampsia：70%nChronic Hypertension：30%nEclampsia0.5%-1%nChina 1.0%nOverseas 0.5%nReflection of medical level nThe second cause of maternal death(20%)nCause of premature delivery（10%）nUnknown originPathophysiology nBasic pathological changesnSpasm of systemic small arteries nVascular endothelial cell injuryPathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMultiple organs dysfunctionIschemiaEdemamalfunctionSystemic DiseaseBrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：Vasospasmpermeabilitykidney renal vasospasmrenal blood flow glomerular filtration rate pathology：Glomerular expansion swollen vascular endothelial cellcellulose depositionrenocortical necrosisrenal irreversible damageclinical manifestation：albuminuriahypoproteinemiarenal dysfunction creatinine urea nitrogen uric acid oliguria renal failure liverhepatic 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 plateletCardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertension Pulmonary EdemaOliguriawater-sodium retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor abilityblood system nRelative hypovolemianAnemianDecreased blood plateletnHypercoagulability nblood clotting factorplacenta-fetusnplacenta nPlacental hypoperfusionnSpiral arteries sclerosis nPlacental InfarctionnPlacental AbruptionnPlacental function decreasesofetus nIUGRnfetal distressnoligohydramniosnfetal death PathophysiologynBrainnHeadache;visual blurred;coma;hernianKidneynRenal function compromised;proteinuria;renal failurenLivernPersistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;ruptureSystematic diseasePathophysiologynCardiovascular systemnLow output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failurenBloodnLow volume;hypercoagulability;DICPathophysiologynUterus and PlacentanLow perfusion;placental atherosclerosisnPlacental infarction;placental abruption;fetal growth retardation;fetal deathHigh risk factorsnPrimiparan40ynMultiple pregnancynHypertensionnChronic nephritisnMalnutritionnPoor social statusnDiabetesnAnti-phospholipid syndromenAngiotensin gene T235(+)EtiologynGenetic susceptibility hypothesisnImmune maladaptation hypothesisnPlacental ischemia hypothesisnOxidative stress hypothesis Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplicationsGenetic susceptibility hypothesisHypertensionImmune maladaptation hypothesisnMultiple gestationnAbortion and blood transfusionnOvum and sperm donationPlacental ischemia hypothesisn40%total spiral artery area compared to normal pregnancynEndothelial cell injuryOxidative stress hypothesisOxidative stress reactionEndothelial cell injuryCategory and clinical manifestationnGestational hypertension nPreeclampsianEclampsia nChronic hypertensionnPreeclampsia superimposed on chronic hypertensionclinical features ntypical:nhypertension、albuminuria、edemanuntypical：nasymptomatic nsevere：nnausea、vomitnheadache、dazzlenconvulsion、comanchest distress、palpitation Gestational Hypertension nDefinition nHypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumnSBP=140mmHgnDBP=90mmHgnDiagnosed only after deliveryPreeclampsianHypertention occurs 20 weeks after gestation nBP=140/90mmHgnProteinuria nProteinuria 300mg/24h nUrine protein（+）nOther symptomsnHeadache,visual blurringnUpper abdominal painSevere preeclampsianAt least one of the following features：nCentral nervous system abnormalities nHepatic subcapsular hematoma/hepatorrhexisnHepatocyte injury:GPTnBlood pressure：SBP160mmHg，or DBP110mmHgnThrombocytopenia:100109/LnProteinuria:5g/24h or(+)4 hours apart nOliguria:500ml/24hnPulmonary edema nCerebrovascular accidentnIntravascular hemolysis:anemia,jaundicenCoagulation dysfunctionnFetal growth restriction/oligohydramniosSevere preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia:20.5mol/LnElevated serum level of Liver enzymesnAST70u/L,or 3SDnLDH600u/LnLow PlateletsnPLC100*109/LHELLPnSevere preeclampsia：nOne abnormalities 6%nTwo abnormalities 12%nThree abnormalities 10%n20 gw seldom occurn1/3 occur after deliveryn80%diagnosed prenatallyHELLPclinical diagnosis nMight be asymptomatic npain in the right upper abdomen80%n weight gain or severe edema 50-60%n20%cases 140/90 mmHgn6%cases without proteinurianSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsiaClassification of HELLPnBy degree of thrombocytopenia：n100,000/mm3nNot widely acceptedPathogenesis and epidemic characteristics of HELLP ncore mechanismnendothelial injuryintravascular coagulation dysfunctionnpredisposing factorsnthe whitenmultipara nelder pregnant womenHELLP-mortalitynMaternal 0-24%nhepatorrhexisnDICnAcute renal failurenthrombosisncerebrovascular accidentsnPerinatal 7.7-60%nPremature deliverynIUGRnplacental abruption Eclampsianprocess：ntonusnconvulsionnsleepinessncoma nOccurrencenprenatalnintrapartumnpostpartum Chronic Hypertension during PregnancynHypertension before pregnancy or nHypertension before 20 weeks gestationalnUnrelieved 12 weeks postpartumnPoor fetal outcomenPerinatal mortality 3 times nPlacental abruption 2 times nFGR,preterm birth preeclampsia superimposed upon chronic hypertensionnChronic Hypertension nBefore 20 gestational weeksnPersist 12 weeks postpartumnProteinurianBefore 20wnAfter 20w;with higher BP;thrombocytopeniaDifferential diagnosisnChronic nephritis complicating pregnancynRenal dysfunctionnSeizure caused by other reasonsManagementnPrinciplenSedationnAnti-spasmnAnti-hypertensionnDiuresisnTerminate pregnancy timelyManagementnCommon treatmentnRestnMonitoringnOxygen inhalationnDiet:salt restriction only for anasarca patientsManagementnSedationnDiazepamnHibernation drugsnPethidinenChlorpromazinenPromethazineManagementnAnti-spasmnFirst line treatment for pre-eclampsia and eclampsianMgSO4 nMechanismnRegimen 25-30g/dnLoading dose:25%MgSO4 10ml+10%GS 20ml iv 5-10minn25%MgSO4 60ml+5%GS 500ml ivgtt 1-2g/hn25%MgSO4 20ml+2%lidocaine 2ml im.ManagementnMgSO4nTreatment concentration 1.7-3mmol/LnToxic concentration 3mmol/LnToxicitynMuscular paralysisnPrevention and treatmentIBefore treatmentnKnee reflex(+);R16bpm;urine5ml/h or 600ml/24hnMg concentration monitoring LIf something happensn10%calcium gluconate 10ml iv for detoxificationnLower dose or stop use when renal dysfunctionManagementnAntihypertensionnIndication nSBP160mmHg,DBP 110mmHg,MBP 140mmHgnPrinciplenNo feral toxicity;no lower renal and uterine perfusionnHydralazine first linenLabetalol;calcium channel blocker;methyldopanSodium nitroprusside-only when unmanageable BP nACEI-contraindicated during pregnancyManagementnVolumetric dilatancy-only for severe Hypoproteinemia and anemianDiuretic agent-only for severe edemaManagementnTerminate pregnancynSevere pre-eclampsia unrelieved after active treatment for 24-48 hoursnSevere pre-eclampsia,34 wnSevere pre-eclampsia,34 w with matured fetus and placental dysfunctionnSevere pre-eclampsia,150-180mmHg;DBP100mmHg;hypertension related organ dysfunctionPreventionnA well organized health care systemnA well monitored pregnant periodnAppropriate diet and rest