妊娠高血压疾病专业知识培训专家讲座.pptx

Hypertension Disorders Complicating Pregnancy妊娠期高血压疾病妊娠期高血压疾病妊娠高血压疾病专业知识培训第1页HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases妊娠高血压疾病专业知识培训第2页CharacteristicsSystemic small arteries spasm Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension;Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension妊娠高血压疾病专业知识培训第3页Hypertension 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疗诊疗治疗治疗妊娠高血压疾病专业知识培训第4页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 origin妊娠高血压疾病专业知识培训第5页Pathophysiology nBasic pathological changesnSpasm of systemic small arteries nVascular endothelial cell injury妊娠高血压疾病专业知识培训第6页PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMultiple organs dysfunctionIschemiaEdemamalfunction妊娠高血压疾病专业知识培训第7页Systemic Disease妊娠高血压疾病专业知识培训第8页BrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：Vasospasmpermeability妊娠高血压疾病专业知识培训第9页kidney 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 妊娠高血压疾病专业知识培训第10页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 platelet妊娠高血压疾病专业知识培训第11页Cardiovascular 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 ability妊娠高血压疾病专业知识培训第12页blood system nRelative hypovolemianAnemianDecreased blood plateletnHypercoagulability nblood clotting factor妊娠高血压疾病专业知识培训第13页placenta-fetusnplacenta nPlacental hypoperfusionnSpiral arteries sclerosis nPlacental InfarctionnPlacental AbruptionnPlacental function decreasesofetus nIUGRnfetal distressnoligohydramniosnfetal death 妊娠高血压疾病专业知识培训第14页PathophysiologynBrainnHeadache;visual blurred;coma;hernianKidneynRenal function compromised;proteinuria;renal failurenLivernPersistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;ruptureSystematic disease妊娠高血压疾病专业知识培训第15页PathophysiologynCardiovascular systemnLow output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failurenBloodnLow volume;hypercoagulability;DIC妊娠高血压疾病专业知识培训第16页PathophysiologynUterus and PlacentanLow perfusion;placental atherosclerosisnPlacental infarction;placental abruption;fetal growth retardation;fetal death妊娠高血压疾病专业知识培训第17页High risk factorsnPrimiparan40ynMultiple pregnancynHypertensionnChronic nephritisnMalnutritionnPoor social statusnDiabetesnAnti-phospholipid syndromenAngiotensin gene T235(+)妊娠高血压疾病专业知识培训第18页EtiologynGenetic susceptibility hypothesisnImmune maladaptation hypothesisnPlacental ischemia hypothesisnOxidative stress hypothesis妊娠高血压疾病专业知识培训第19页 Immune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplications妊娠高血压疾病专业知识培训第20页Genetic susceptibility hypothesisHypertension妊娠高血压疾病专业知识培训第21页Immune maladaptation hypothesisnMultiple gestationnAbortion and blood transfusionnOvum and sperm donation妊娠高血压疾病专业知识培训第22页Placental ischemia hypothesisn40%total spiral artery area compared to normal pregnancynEndothelial cell injury妊娠高血压疾病专业知识培训第23页Oxidative stress hypothesisOxidative stress reactionEndothelial cell injury妊娠高血压疾病专业知识培训第24页Category and clinical manifestationnGestational hypertension nPreeclampsianEclampsia nChronic hypertensionnPreeclampsia superimposed on chronic hypertension妊娠高血压疾病专业知识培训第25页clinical features ntypical:nhypertension、albuminuria、edemanuntypical：nasymptomatic nsevere：nnausea、vomitnheadache、dazzlenconvulsion、comanchest distress、palpitation 妊娠高血压疾病专业知识培训第26页Gestational Hypertension nDefinition nHypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumnSBP=140mmHgnDBP=90mmHgnDiagnosed only after delivery妊娠高血压疾病专业知识培训第27页PreeclampsianHypertention occurs 20 weeks after gestation nBP=140/90mmHgnProteinuria nProteinuria 300mg/24h nUrine protein（+）nOther symptomsnHeadache,visual blurringnUpper abdominal pain妊娠高血压疾病专业知识培训第28页Severe 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/oligohydramnios妊娠高血压疾病专业知识培训第29页Severe preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia:20.5mol/LnElevated serum level of Liver enzymesnAST70u/L,or 3SDnLDH600u/LnLow PlateletsnPLC100*109/L妊娠高血压疾病专业知识培训第31页HELLPnSevere preeclampsia：nOne abnormalities 6%nTwo abnormalities 12%nThree abnormalities 10%n20 gw seldom occurn1/3 occur after deliveryn80%diagnosed prenatally妊娠高血压疾病专业知识培训第32页HELLPclinical 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 proteinuria妊娠高血压疾病专业知识培训第33页nSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia妊娠高血压疾病专业知识培训第34页Classification of HELLPnBy degree of thrombocytopenia：n100,000/mm3nNot widely accepted妊娠高血压疾病专业知识培训第35页Pathogenesis and epidemic characteristics of HELLP ncore mechanismnendothelial injuryintravascular coagulation dysfunctionnpredisposing factorsnthe whitenmultipara nelder pregnant women妊娠高血压疾病专业知识培训第36页HELLP-mortalitynMaternal 0-24%nhepatorrhexisnDICnAcute renal failurenthrombosisncerebrovascular accidentsnPerinatal 7.7-60%nPremature deliverynIUGRnplacental abruption 妊娠高血压疾病专业知识培训第37页Eclampsianprocess：ntonusnconvulsionnsleepinessncoma nOccurrencenprenatalnintrapartumnpostpartum 妊娠高血压疾病专业知识培训第38页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 妊娠高血压疾病专业知识培训第39页preeclampsia superimposed upon chronic hypertensionnChronic Hypertension nBefore 20 gestational weeksnPersist 12 weeks postpartumnProteinurianBefore 20wnAfter 20w;with higher BP;thrombocytopenia妊娠高血压疾病专业知识培训第40页Differential diagnosisnChronic nephritis complicating pregnancynRenal dysfunctionnSeizure caused by other reasons妊娠高血压疾病专业知识培训第41页ManagementnPrinciplenSedationnAnti-spasmnAnti-hypertensionnDiuresisnTerminate pregnancy timely妊娠高血压疾病专业知识培训第42页ManagementnCommon treatmentnRestnMonitoringnOxygen inhalationnDiet:salt restriction only for anasarca patients妊娠高血压疾病专业知识培训第43页ManagementnSedationnDiazepamnHibernation drugsnPethidinenChlorpromazinenPromethazine妊娠高血压疾病专业知识培训第44页ManagementnAnti-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.妊娠高血压疾病专业知识培训第45页ManagementnMgSO4nTreatment concentration 1.7-3mmol/LnToxic concentration 3mmol/LnToxicitynMuscular paralysisnPrevention and treatmentIBefore treatmentKnee reflex(+);R16bpm;urine5ml/h or 600ml/24hMg concentration monitoring nIf something happensn10%calcium gluconate 10ml iv for detoxificationnLower dose or stop use when renal dysfunction妊娠高血压疾病专业知识培训第46页ManagementnAntihypertensionnIndication 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 pregnancy妊娠高血压疾病专业知识培训第47页ManagementnVolumetric dilatancy-only for severe Hypoproteinemia and anemianDiuretic agent-only for severe edema妊娠高血压疾病专业知识培训第48页ManagementnTerminate 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 dysfunction妊娠高血压疾病专业知识培训第52页PreventionnA well organized health care systemnA well monitored pregnant periodnAppropriate diet and rest妊娠高血压疾病专业知识培训第53页