4-妊娠高血压疾病-陈晓军

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,Eclampsia,Preeclampsia; Preeclampsia Superimposed on Chronic Hypertension,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,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,Pathophysiology,Basic pathological changes Spasm of systemic small arteries 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,Relative hypovolemia Anemia Decreased blood platelet Hypercoagulability blood clotting factor,placenta-fetus,placenta Placental hypoperfusion Spiral arteries sclerosis Placental Infarction Placental Abruption Placental function decreases,fetus IUGR fetal distress oligohydramnios fetal death,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,Pathophysiology,Cardiovascular system Low output- high resistance; myocardial ischemia; pulmonary hypertension; edema; heart failure Blood Low volume; hypercoagulability; DIC,Pathophysiology,Uterus and Placenta Low perfusion; placental atherosclerosis 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,Genetic susceptibility hypothesis Immune maladaptation hypothesis Placental ischemia hypothesis 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,Multiple gestation Abortion and blood transfusion Ovum and sperm donation,Placental ischemia hypothesis,40% total spiral artery area compared to normal pregnancy Endothelial cell injury,Oxidative stress hypothesis,Oxidative stress reaction,Endothelial cell injury,Category and clinical manifestation,Gestational hypertension Preeclampsia Eclampsia Chronic hypertension Preeclampsia superimposed on chronic hypertension,clinical features,typical : hypertension、albuminuria、edema untypical ： asymptomatic severe： nausea、vomit headache、dazzle convulsion 、coma chest distress 、palpitation,Gestational Hypertension,Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartum SBP=140mmHg DBP =90mmHg Diagnosed only after delivery,Preeclampsia,Hypertention occurs 20 weeks after gestation BP=140/90mmHg Proteinuria Proteinuria 300mg/24h Urine protein （+） Other symptoms Headache, visual blurring Upper abdominal pain,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: 100109/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,Severe preeclampsia complications,Hepatic subcapsularhematoma Early-onset preeclampsia : 34w HELLP syndrome,HELLP syndrome,Hemolysis blood smears show RBC debris Hb 60-90g/L TB20.5mol/L,Elevated serum level of Liver enzymes AST70u/L, or 3SD LDH600u/L Low Platelets PLC100*109/L,HELLP,Severe preeclampsia ： One abnormalities 6% Two abnormalities 12% Three abnormalities 10% 20 gw seldom occur 1/3 occur after delivery 80% diagnosed prenatally,HELLPclinical 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,Some investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia,Classification of HELLP,By degree of thrombocytopenia： 100,000/mm3 Not widely accepted,Pathogenesis and epidemic characteristics of HELLP,core mechanism endothelial injuryintravascular coagulation dysfunction predisposing factors the white multipara elder pregnant women,HELLP-mortality,Maternal 0-24% hepatorrhexis DIC Acute renal failure thrombosis cerebrovascular accidents,Perinatal 7.7-60% Premature delivery IUGR placental abruption,Eclampsia,process： tonus convulsion sleepiness coma,Occurrence prenatal intrapartum postpartum,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 ,preeclampsia superimposed upon chronic hypertension,Chronic Hypertension Before 20 gestational weeks Persist 12 weeks postpartum Proteinuria Before 20w After 20w; with higher BP; thrombocytopenia,Differential diagnosis,Chronic nephritis complicating pregnancy Renal dysfunction Seizure caused by other reasons,Management,Principle Sedation Anti-spasm Anti-hypertension Diuresis Terminate pregnancy timely,Management,Common treatment Rest Monitoring Oxygen inhalation Diet: salt restriction only for anasarca patients,Management,Sedation Diazepam Hibernation drugs Pethidine Chlorpromazine Promethazine,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.,Management,MgSO4 Treatment concentration 1.7-3mmol/L Toxic concentration 3mmol/L Toxicity Muscular paralysis Prevention and treatment Before treatment Knee reflex (+); R16bpm; 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,Management,Antihypertension Indication SBP160mmHg, 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,Manag