妊娠高血压疾病陈晓军英文教学课件

Hypertension Disorders Complicating Pregnancy 妊娠期高血压疾病 Hypertensive Disorders complicating Pregnancy Gestational Hypertension Preeclampsia Preeclampsia Superimposed on Chronic Hypertension Chronic Hypertension Eclampsia A Group of Related Diseases Characteristics Systemic small arteries spasm Endothelial cell injury Hypertension Proteinuria Multiple organs dysfunction Convulsion Maternal mortality Fetal mortality Gestational Hypertension; Chronic hypertension EclampsiaPreeclampsia; Preeclampsia Superimposed on Chronic Hypertension Hypertension disorders complicating pregnancy n Pathophysiology n Category and clinical manifestation n Diagnosis and differential diagnosis n Management and prevention 病理生理 临床表现 诊断 治疗 Epidemiology n Incidence： 6-9% n Preeclampsia-eclampsia： 70% n Chronic Hypertension ： 30% n Eclampsia 0.5% - 1% n China 1.0% n Overseas 0.5% n Reflection of medical level n The second cause of maternal death (20%) n Cause of premature delivery（ 10%） n Unknown origin Pathophysiology n Basic pathological changes n Spasm of systemic small arteries n Vascular endothelial cell injury Pathophysiology fluid protein Hypertension Edema Proteinuria Hemoconcentration Small arterial spasm Endothelial cell injury Multiple organs dysfunction Ischemia Edema malfunction Systemic Disease 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 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 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 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 blood system n Relative hypovolemia n Anemia n Decreased blood platelet n Hypercoagulability n blood clotting factor placenta-fetus n placenta n Placental hypoperfusion n Spiral arteries sclerosis n Placental Infarction n Placental Abruption n Placental function decreases o fetus n IUGR n fetal distress n oligohydramnios n fetal death Pathophysiology n Brain n Headache; visual blurred; coma; hernia n Kidney n Renal function compromised; proteinuria; renal failure n Liver n Persistent upper right abdominal pain; Elevated enzyme; jaundice; hematoma; rupture Systematic disease Pathophysiology n Cardiovascular system n Low output- high resistance; myocardial ischemia; pulmonary hypertension; edema; heart failure n Blood n Low volume; hypercoagulability; DIC Pathophysiology n Uterus and Placenta n Low perfusion; placental atherosclerosis n Placental infarction; placental abruption; fetal growth retardation; fetal death High risk factors Primipara 40y Multiple pregnancy Hypertension Chronic nephritis Malnutrition Poor social status Diabetes Anti-phospholipid syndrome Angiotensin gene T235 (+) Etiology n Genetic susceptibility hypothesis n Immune maladaptation hypothesis n Placental ischemia hypothesis n Oxidative stress hypothesis Genetic susceptibility Immune maladaptation Placental ischemia Oxidative stress Abnormal placental The change of cytokine PE development Endothelium injured DIC Complications Genetic susceptibility hypothesis Hypertension Immune maladaptation hypothesis n Multiple gestation n Abortion and blood transfusion n Ovum and sperm donation Placental ischemia hypothesis n 40% total spiral artery area compared to normal pregnancy n Endothelial cell injury Oxidative stress hypothesis Oxidative stress reaction Endothelial cell injury Category and clinical manifestation n Gestational hypertension n Preeclampsia n Eclampsia n Chronic hypertension n Preeclampsia superimposed on chronic hypertension clinical features n typical : n hypertension、 albuminuria、 edema n untypical ： n asymptomatic n severe： n nausea、 vomit n headache、 dazzle n convulsion 、 coma n chest distress 、 palpitation Gestational Hypertension n Definition n Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartum n SBP=140mmHg n DBP =90mmHg n Diagnosed only after delivery Preeclampsia n Hypertention occurs 20 weeks after gestation n BP=140/90mmHg n Proteinuria n Proteinuria 300mg/24h n Urine protein （ +） n Other symptoms n Headache, visual blurring n Upper abdominal pain Severe preeclampsia n At least one of the following features： n Central nervous system abnormalities n Hepatic subcapsular hematoma / hepatorrhexis n Hepatocyte injury :GPT n Blood pressure： SBP160mmHg， or DBP110mmHg n Thrombocytopenia: 20.5mol/L n Elevated serum level of Liver enzymes n AST70u/L, or 3SD n LDH600u/L n Low Platelets n PLC100,000/mm3 n Not widely accepted Pathogenesis and epidemic characteristics of HELLP n core mechanism n endothelial injury intravascular coagulation dysfunction n predisposing factors n the white n multipara n elder pregnant women HELLP-mortality n Maternal 0-24% n hepatorrhexis n DIC n Acute renal failure n thrombosis n cerebrovascular accidents n Perinatal 7.7-60% n Premature delivery n IUGR n placental abruption Eclampsia n process： n tonus n convulsion n sleepiness n coma n Occurrence n prenatal n intrapartum n postpartum Chronic Hypertension during Pregnancy n Hypertension before pregnancy or n Hypertension before 20 weeks gestational n Unrelieved 12 weeks postpartum n Poor fetal outcome n Perinatal mortality 3 times n Placental abruption 2 times n FGR, preterm birth preeclampsia superimposed upon chronic hypertension n Chronic Hypertension n Before 20 gestational weeks n Persist 12 weeks postpartum n Proteinuria n Before 20w n After 20w; with higher BP; thrombocytopenia Differential diagnosis n Chronic nephritis complicating pregnancy n Renal dysfunction n Seizure caused by other reasons Management n Principle n Sedation n Anti-spasm n Anti-hypertension n Diuresis n Terminate pregnancy timely Management n Common treatment n Rest n Monitoring n Oxygen inhalation n Diet: salt restriction only for anasarca patients Management n Sedation n Diazepam n Hibernation drugs n Pethidine n Chlorpromazine n Promethazine Management n Anti-spasm n First line treatment for pre-eclampsia and eclampsia n MgSO4 n Mechanism n Regimen 25-30g/d n Loading dose: 25% MgSO4 10ml +10%GS 20ml iv 5-10min n 25% MgSO4 60ml +5%GS 500ml ivgtt 1-2g/h n 25% MgSO4 20ml +2%lidocaine 2ml im. Management n MgSO4 n Treatment concentration 1.7-3mmol/L n Toxic concentration 3mmol/L n Toxicity n Muscular paralysis n Prevention and treatmentI Before treatment n Knee reflex (+); R16bpm; urine5ml/h or 600ml/24h n Mg concentration monitoring L If something happens n 10% calcium gluconate 10ml iv for detoxific