妊娠高血压疾病.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,.,*,Hypertension Disorders Complicating Pregnancy,妊娠期高血压疾病,1,.,Hypertensive,Disorders complicating Pregnancy,Gestational Hypertension,Preeclampsia,Preeclampsia Superimposed on Chronic Hypertension,Chronic Hypertension,Eclampsia,A Group of Related Diseases,2,Characteristics,Systemic small arteries spasm,Endothelial cell injury,Hypertension,Proteinuria,Multiple organs dysfunction,Convulsion,Maternal mortality,Fetal mortality,G,estational Hypertension,;,C,hronic hypertension,E,clampsia,P,reeclampsia,;,P,reeclampsia Superimposed on Chronic Hypertension,3,Hypertension disorders complicating pregnancy,Pathophysiology,Category and clinical manifestation,Diagnosis and differential diagnosis,Management and prevention,病理生理,临床表现,诊断,治疗,4,Epidemiology,Incidence,：,6-9%,Preeclampsia,-,eclampsia,：,70%,Chronic Hypertension,：,30%,Eclampsia,0.5%-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,5,Pathophysiology,Basic pathological changes,Spasm of systemic small arteries,Vascular endothelial cell,injury,6,Pathophysiology,fluid,protein,Hypertension,Edema,Proteinuria,Hemoconcentration,Small arterial spasm,Endothelial cell injury,Multiple organs dysfunction,Ischemia,Edema,malfunction,7,Systemic Disease,8,Brain,Hydrocephalus,Hyperemia/ischemia,Thrombosis,cerebral hemorrhage,cerebral hernia,headache,dazzle,nausea,vomit,Hypopsia,retinal detachment Cortical blindness,Dysesthesia,Confusion of thinking,Eclampsia,convulsion,coma,brain,：,Vasospasm,permeability,9,kidney,renal vasospasm,renal blood flow,glomerular filtration rate,pathology,：,Glomerular expansion,swollen vascular endothelial cell,cellulose deposition,renocortical necrosisrenal irreversible damage,clinical manifestation,：,albuminuria,hypoproteinemia,renal dysfunction,creatinine,urea nitrogen,uric acid,oliguria,renal failure,10,liver,hepatic vasospasm;,hepatic ischemia;,hepatic edema,liver enlargement;,hepatic dysfunction,elevated liver enzyme,jaundice,hypoproteinemia,coagulation function changed,severe,：,Periportal necrosis,hepatic subcapsularhematoma,hepatorrhexis,HELLP symdrome:,Elevated hepatic enzymes,Decreased blood platelet,11,Cardiovascular System,Blood Pressure,Vasospasm,Vascular Resistance,Cardiac Load,heart,failure,vasospasm,Myocardial Ischemia,Interstitial Edema,Spotty Necrosis,pulmonary vasospasm,Pulmonary Hypertension,Pulmonary Edema,Oliguria,water-sodium retention,Relative Blood Volume Excess,Iatrogenic Blood Volume Excess,High burden,Poor ability,12,blood system,Relative hypovolemia,Anemia,Decreased blood platelet,Hypercoagulability,blood clotting factor,13,placenta-fetus,placenta,Placental hypoperfusion,Spiral arteries sclerosis,Placental Infarction,Placental Abruption,Placental function decreases,fetus,IUGR,fetal distress,oligohydramnios,fetal death,14,Pathophysiology,Brain,Headache;visual blurred;coma;hernia,Kidney,Renal function compromised;proteinuria;renal failure,Liver,Persistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;rupture,Systematic disease,15,Pathophysiology,Cardiovascular system,Low output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failure,Blood,Low volume;hypercoagulability;DIC,16,Pathophysiology,Uterus and Placenta,Low perfusion;placental atherosclerosis,Placental infarction;placental abruption;fetal growth retardation;fetal death,17,High risk factors,Primipara,40y,Multiple pregnancy,Hypertension,Chronic nephritis,Malnutrition,Poor social status,Diabetes,Anti-phospholipid syndrome,Angiotensin gene T235(+),18,Etiology,Genetic susceptibility hypothesis,Immune maladaptation hypothesis,Placental ischemia hypothesis,Oxidative stress hypothesis,19,Genetic susceptibility,Immune,maladaptation,Placental,ischemia,Oxidative,stress,Abnormal placental,The change of cytokine,PE,development,Endothelium injured,DIC,Complications,20,Genetic susceptibility hypothesis,Hypertension,21,Immune maladaptation hypothesis,Multiple gestation,Abortion and blood transfusion,Ovum and sperm donation,22,Placental ischemia hypothesis,40%total spiral artery area compared to normal pregnancy,Endothelial cell injury,23,Oxidative stress hypothesis,Oxidative stress reaction,Endothelial cell injury,24,Category and clinical manifestation,Gestational hypertension,Preeclampsia,Eclampsia,Chronic hypertension,Preeclampsia superimposed on chronic hypertension,25,clinical features,typical:,hypertension,、,albuminuria,、,edema,untypical,：,asymptomatic,severe,：,nausea,、,vomit,headache,、,dazzle,convulsion,、,coma,chest distress,、,palpitation,26,Gestational Hypertension,Definition,Hypertension occurs 20 weeks after gestation and recovers 12 weeks,postpartum,SBP=140mmHg,DBP=90mmHg,Diagnosed only after delivery,27,Preeclampsia,Hypertention occurs 20 weeks after gestation,BP=140/90mmHg,Proteinuria,Proteinuria,300mg/24h,Urine protein,（,+,）,Other symptoms,Headache,visual blurring,Upper abdominal pain,28,Severe preeclampsia,At least one of the following features,：,Central nervous system abnormalities,Hepatic subcapsular hematoma/hepatorrhexis,Hepatocyte injury:,GPT,Blood pressure,：,SBP160mmHg,，,or DBP110mmHg,Thrombocytopenia:,100,10,9,/L,Proteinuria:,5g/24h or(+)4 hours apart,Oliguria:,500ml/24h,Pulmonary edema,Cerebrovascular accident,Intravascular hemolysis:,anemia,jaundice,Coagulation dysfunction,Fetal growth restriction/oligohydramnios,29,Severe preeclampsia complications,Hepatic subcapsularhematoma,Early-onset preeclampsia:,20.5,mol/L,E,levated serum level of,L,iver enzymes,AST70u/L,or 3SD,LDH,600u/L,L,ow,P,latelets,PLC,100*10,9,/L,31,HELLP,Severe preeclampsia,：,One abnormalities 6%,Two abnormalities 12%,Three abnormalities10%,20 gw seldom occur,1/3 occur after delivery,80%diagnosed prenatally,32,HELLP,clinical diagnosis,Might be asymptomatic,pain in the right upper abdomen,80%,weight gain or severe edema 50-60%,20%cases 140/90 mmHg,6%cases without proteinuria,33,Some investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia,34,Classification of HELLP,By degree of thrombocytopenia,：,100,000/mm,3,Not widely accepted,35,Pathogenesis and epidemic characteristics of HELLP,core mechanism,endothelial injury,intravascular coagulation dysfunction,predisposing factors,the white,multipara,elder pregnant women,36,HELLP-mortality,Maternal 0-24%,hepatorrhexis,DIC,Acute renal failure,thrombosis,cerebrovascular accidents,Perinatal 7.7-60%,Premature delivery,IUGR,placental abruption,37,Eclampsia,process,：,tonus,convulsion,sleepiness,coma,Occurrence,prenatal,intrapartum,postpartum,38,Chronic Hypertension during Pregnancy,Hypertension before pregnancy or,Hypertension before 20 weeks,gestational,Unrelieved 12 weeks postpartum,Poor fetal outcome,Perinatal mortality 3 times,Placental abruption 2,times,FGR,preterm birth,39,preeclampsia superimposed upon chronic hypertension,Chronic Hypertension,Before 20 gestational weeks,Persist 12 weeks postpartum,Proteinuria,Before 20w,After 20w;with higher BP;thrombocytopenia,40,Differential diagnosis,Chronic nephritis complicating pregnancy,Renal dysfunction,Seizure caused by other reasons,41,Management,Principle,Sedation,Anti-spasm,Anti-hypertension,Diuresis,Terminate pregnancy timely,42,Management,Common treatment,Rest,Monitoring,Oxygen inhalation,Diet:salt restriction only for anasarca patients,43,Management,Sedation,Diazepam,Hibernation drugs,Pethidine,Chlorpromazine,Promethazine,44,Management,Anti-spasm,First line treatment for pre-eclampsia and eclampsia,MgSO4,Mechanism,Regimen,25-30g/d,Loading dose:25%MgSO4 10ml+10%GS 20ml iv 5-10min,25%MgSO4 60ml+5%GS 500ml ivgtt 1-2g/h,25%MgSO4 20ml+2%lidocaine 2ml im.,45,Management,MgSO4,Treatment concentration 1.7-3mmol/L,Toxic concentration 3mmol/L,Toxicity,Muscular paralysis,Prevention and treatment,Before treatment,Knee reflex(+);R,16bpm;urine5ml/h or 600ml/24h,Mg concentration monitoring,If something happens,10%,calcium gluconate 10ml iv for detoxification,Lower dose or stop use when renal dysfunction,46,Management,Antihypertension,Indication,SBP,160mmHg,DBP 110mmHg,MBP 140mmHg,Principle,No feral toxicity;no lower renal and uterine perfusion,Hydralazine first line,Labetalol;calcium channel blocker;methyldopa,Sodium nitroprusside-only when unmanageable BP,ACEI-contraindicated during pregnancy,47,Management,Volumetric dilatancy-only for severe Hypoproteinemia and anemia,Diuretic agent-only for severe edema,48,Management,Terminate pregnancy,Severe pre-eclampsia unrelieved after active treatment for 24-48 hours,Severe pre-eclampsia,34 w,Severe pre-eclampsia,34 w with matured fetus and placental dysfunction,Severe pre-eclampsia,150-180mmHg;DBP100mmHg;hypertension related organ dysfunction,52,Prevention,A well organized health care system,A well monitored pregnant period,Appropriate diet and rest,53,