妊娠期高血压指南.doc

妊娠期高血压疾病执行摘要Hypertension in Pregnancy: Executive Summary（ACOG 2013）The American College of Obstetricians and Gynecologists (the College) convened a task force of experts in the management of hypertension in pregnancy to review available data and publish evidence-based recommendations for clinical practice. The Task Force on Hypertension in Pregnancy comprised 17 clinician-scientists from the fields of obstetrics, maternal-fetal medicine, hypertension, internal medicine, nephrology, anesthesiology, physiology, and patient advocacy. This executive summary includes a synopsis of the content and task force recommendations of each chapter in the report and is intended to complement, not substitute, the report.美国妇产科学会组织专家通过回顾现有的研究数据及基于证据的建议颁布了妊娠期高血压疾病的临床指南。妊高病专家组成员由的17位专家组成，他们来自临床专家，产科学、母胎医学、高血压疾病、内科学、肾脏学、麻醉学、生理学和患方维权者。这个执行摘要包括内容概要和每章节的专家组推荐。它不是替代而是补充说明该报告。Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the United States. Preeclampsia, either alone or superimposed on preexisting (chronic) hypertension, presents the major risk. Although appropriate prenatal care, with observation of women for signs of preeclampsia and then delivery to terminate the disorder, has reduced the number and extent of poor outcomes, serious maternal-fetal morbidity and mortality still occur. Some of these adverse outcomes are avoidable, whereas others can be ameliorated. Also, although some of the problems that face neonates are related directly to preeclampsia, a large proportion are secondary to prematurity that results from the appropriate induced delivery of the fetuses of women who are ill. Optimal management requires close observation for signs and premonitory findings and, after establishing the diagnosis, delivery at the optimal time for both maternal and fetal well-being. More recent clinical evidence to guide this timing is now available. Chronic hypertension is associated with fetal morbidity in the form of growth restriction and maternal morbidity manifested as severely increased blood pressure (BP). However, maternal and fetal morbidity increase dramatically with the superimposition of preeclampsia. One of the major challenges in the care of women with chronic hypertension is deciphering whether chronic hypertension has worsened or whether preeclampsia has developed. In this report, the task force provides suggestions for the recognition and management of this challenging condition.在美国、妊高病是一种严重威胁母胎健康的疾病。子痫前期或慢性高血压并发子痫前期是主要危险因素。尽管通过恰当的产前管理、子痫前期的监测以及适时终止妊娠来减少发病率以及不利的结局，但是严重的母胎发病率及死亡率依然存在。一些不良结局是可以避免的、还有一些是可以改善的。尽管一些新生儿面临的问题与子痫前期直接相关、但是大部分继发于因母体疾病导致的医源性早产。优化管理需要严密监测疾病征兆、建立诊断、以及分娩时机的选择（考虑母胎因素）。最新的临床证据提供了研究的可能。慢性高血压对胎儿的影响主要是胎儿生长受限、对母体的影响主要是严重的高血压。慢性高血压面临的问题之一是鉴别疾病是否加重或是否并发子痫前期。在这个报告中、专家组提供了建议及管理办法。In the past 10 years, there have been substantial advances in the understanding of preeclampsia as well as increased efforts to obtain evidence to guide therapy. Nonetheless, there remain areas on which evidence is scant. The evidence is now clear that preeclampsia is associated with later-life cardiovascular (CV) disease; however, further research is needed to determine how best to use this information to help patients. The task force also has identified issues in the management of preeclampsia that warrant special attention. First, is the failure by health care providers to appreciate the multisystemic nature of preeclampsia. This is in part due to attempts at rigid diagnosis, which is addressed in the report. Second, preeclampsia is a dynamic process, and a diagnosis such as “mild preeclampsia” (which is discouraged) applies only at the moment the diagnosis is established because preeclampsia by nature is progressive, although at different rates. Appropriate management mandates frequent reevaluation for severe features that indicate the actions outlined in the recommendations (which are listed after the chapter summaries). It has been known for many years that preeclampsia can worsen or present for the first time after delivery, which can be a major scenario for adverse maternal events. In this report, the task force provides guidelines to attempt to reduce maternal morbidity and mortality in the postpartum period.过去十年、大量研究加深了对子痫前期的理解同时提供证据指导治疗。然而、这一领域的研究证据依然缺乏。目前研究显示，子痫前期与随后的心血管疾病相关。但是、进一步的研究需要充分利用这一信息为病人提供指导帮助。同样、专家组在子痫前期管理上提供了特别关注点。首先、医疗工作者没有理解子痫前期发病的多系统性。这部分是由严格的诊断标准造成的、这个标准将在这个报告中阐述。其次、子痫前期是一种动态的过程、轻度子痫前期的诊断只适用在诊断建立时、因为子痫前期具有渐进性、尽管进展速度不一。合适的管理需要对子痫前期重症进行反复评估、子痫前期重症将在随后的章节中阐述。众所周知、子痫前期可以在产后加重或首次出现、它是母体不良事件的主要节点。在这个报告中，专家组提供指南减少产后子痫前期的发病率和死亡率。The Approach方法The task force used the evidence assessment and recommendation strategy developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group (available at /index.htm). Because of its utility, this strategy has been adapted worldwide by a large number of organizations. With the GRADE Working Group approach, the function of expert task forces and working groups is to evaluate the available evidence regarding a clinical decision that, because of limited time and resources, would be difficult for the average health care provider to accomplish. The expert group then makes recommendations based on the evidence that are consistent with typical patient values and preferences. The task force evaluated the evidence for each recommendation, the implications, and the confidence in estimates of effect. With this combination, the available information was evaluated and recommendations were made. In this report, the confidence in estimates of effect (quality) of the available evidence is judged as very low, low, moderate, or high.专家组采用发展和评估工作组的分级建议评估系统对证据及建议分级管理。由于它的实用性、这一方法已被全球多个组织采用。利用分级建议评估系统、专家组的任务是根据临床决策对现有证据进行评估。由于时间及资源有限，临床决策很难由一般的医疗工作者来完成。然后，专家组根据与典型病人相符的证据提出建议。专家组对每一建议、实用性以及可行度进行证据评估。利用这个方法、对现有信息评估和提出建议。在这报告中、对现有证据可信度分级为：很低、低、中等和高。Recommendations are practices agreed to by the task force as the most appropriate course of action; they are graded as strong or qualified. A strong recommendation is one that is so well supported that it would be the approach appropriate for virtually all patients. It could be the basis for health care policy. A qualified recommendation is also one that would be judged as appropriate for most patients, but it might not be the optimal recommendation for some patients (whose values and preferences differ, or who have different attitudes toward uncertainty in estimates of effect). When the task force has made a qualified recommendation, the health care provider and patient are encouraged to work together to arrive at a decision based on the values and judgment and underlying health condition of a particular patient in a particular situation.专家组推荐的是最合适的实践过程。他们是分级的或合格的。强烈推荐是适合所有的患者，它可以作为健康政策的基础。一个合格的建议同样适合大多数患者、但对一部分患者可能不是最适合的。对于合格的建议，医疗工作者需要依据个体化原则和患者沟通已达成共识。Classification of Hypertensive Disorders of Pregnancy妊娠期高血压疾病分类The task force chose to continue using the classification schema first introduced in 1972 by the College and modified in the 1990 and 2000 reports of the Working Group of the National High Blood Pressure Education Program. Similar classifications can be found in the American Society of Hypertension guidelines, as well as College Practice Bulletins. Although the task force has modified some of the components of the classification, this basic, precise, and practical classification was used, which considers hypertension during pregnancy in only four categories: 1) pre-eclampsia-eclampsia, 2) chronic hypertension (of any cause), 3) chronic hypertension with superimposed preeclampsia, and 4) gestational hypertension. Importantly, the following components were modified. In recognition of the syndromic nature of preeclampsia, the task force has eliminated the dependence of the diagnosis on proteinuria. In the absence of proteinuria, preeclampsia is diagnosed as hypertension in association with thrombocytopenia (platelet count less than 100,000/microliter), impaired liver function (elevated blood levels of liver transaminases to twice the normal concentration), the new development of renal insufficiency (elevated serum creatinine greater than 1.1 mg/dL or a doubling of serum creatinine in the absence of other renal disease), pulmonary edema, or new-onset cerebral or visual disturbances (see Box El). Gestational hypertension is BP elevation after 20 weeks of gestation in the absence of proteinuria or the aforementioned systemic findings; chronic hypertension is hypertension that predates pregnancy; and superimposed preeclampsia is chronic hypertension in association with preeclampsia.工作组继续采用现有的分类方案，该方案在1972年首次提出，并在1990年至2000年由全国高血压教育工作组进行修订。类似的分类方案出现在美国高血压协会指南和学院实践公布里。工作组对分类方案进行部分修改，妊高病分为4类：1）子痫前期-子痫 2）慢性高血压（任何原因）3）慢性高血压并发子痫前期 4）妊娠期高血压。特别注意，以下部分进行了修改。基于对子痫前期的综合征特点的认识，工作组取消了对蛋白尿的依赖。在缺乏蛋白尿时，子痫前期可以诊断：高血压伴有血小板减少（100x109/L）、肝功能异常（血肝酶升高至2倍）、肾功能不全（血肌酐 1.1 mg/dL或血肌酐翻倍、在排除其他肾脏疾病情况下）、肺水肿、中枢神经系统异常或视力障碍（新出现的）（BOX E-1）。妊娠期高血压是指妊娠20周后出现高血压、但缺乏蛋白尿或上述系统发现。慢性高血压指妊娠前出现高血压；慢性高血压并发子痫前期指慢性高血压同时伴有子痫前期。BOX E-1 Severe Features of Preeclampsia (Any of these findings)* Systolic blood pressure of 160 mm Hg or higher, ordiastolic blood pressure of 110 mm Hg or higher on two occasions at least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy is initiated before this time)* Thrombocytopenia (platelet count less than 100,000/microliter)* Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unrespon sive to medication and not accounted for by alternative diagnoses, or both* Progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)* Pulmonary edema* New-onset cerebral or visual disturbances子痫前期重症诊断标准（以下任何一项发现）血压 收缩压160mmHg或舒张压110mmHg（需两次测量、间隔4小时、患者已卧床休息）血小板减少 1.1 mg/dL(97.24umol/L)或血肌酐翻倍、在排除其他肾脏疾病情况下肺水肿 中枢神经系统异常表现或视力障碍Establishing the Diagnosis of Preeclampsia or EclampsiaThe BP criteria are maintained from prior recommendations. Proteinuria is defined as the excretion of 300 mg or more of protein in a 24-hour urine collection. Alternatively, a timed excretion that is extrapolated to this 24-hour urine value or a protein/creatinine ratio of at least 0.3 (each measured as mg/dL) is used. Because of the variability of qualitative determinations (dipstick test), this method is discouraged for diagnostic use unless other approaches are not readily available. If this approach must be used, a determination of 1+ is considered as the cutoff for the diagnosis of proteinuria. In view of recent studies that indicate a minimal relationship between the quantity of urinary protein and pregnancy outcome in preeclampsia, massive proteinuria (greater than 5 g) has been eliminated from the consideration of preeclampsia as severe. Also, because fetal growth restriction is managed similarly in pregnant women with and without preeclampsia, it has been removed as a finding indicative of severe preeclampsia (Table E-l). 子痫前期-子痫诊断标准血压 妊娠20周后首次出现收缩压140mmHg或舒张压90mmHg(需测2次，至少间隔4小时) 收缩压160mmHg或舒张压110mmHg（数分钟内确定，立即用药）和蛋白尿 24小时尿蛋白0.3g 尿蛋白/尿肌酐0.3 尿蛋白（+）(仅不能提供定量检测时) 或者缺乏蛋白尿，但出现新发高血压伴以下新出现的情况血小板减少 1.1 mg/dL(97.24umol/L)或血肌酐翻倍、在排除其他肾脏疾病情况下肺水肿 中枢神经系统异常表现或视力障碍Prediction of PreeclampsiaA great deal of effort has been directed at the identification of demographic factors, biochemical analytes, or biophysical findings, alone or in combination, to predict early in pregnancy the later development of preeclampsia. Although there are some encouraging findings, these tests are not yet ready for clinical use.子痫前期的预测目前大量的研究工作集中在流行病学调查、生化化学以及生物物理研究，单独或联合使用来预测子痫前期。尽管取得了很大的进展，但是这些检测方法还不能用于临床。TASK FORCE RECOMMENDATION专家组建议* Screening to predict preeclampsia beyond obtaining an appropriate medical history to evaluate for risk factors is not recommended.Quality of evidence: ModerateStrength of recommendation: Strong不推荐排除适当病史的筛查方法来预测子痫前期质量中等强烈推荐Prevention of Preeclampsia It is clear that the antioxidants vitamin C and vitamin E are not effective interventions to prevent preeclampsia or adverse outcomes from preeclampsia in unselected women at high risk or low risk of preeclampsia. Calcium may be useful to reduce the severity of preeclampsia in populations with low calcium intake, but this finding is not relevant to a population with adequate calcium intake, such as in the United States. The administration of low-dose aspirin (60-80 mg) to prevent preeclampsia has been examined in meta-analyses of more than 30,000 women, and it appears that there is a slight effect to reduce preeclampsia and adverse perinatal outcomes. These findings are not clinically relevant to low-risk women but may be relevant to populations at very high risk in whom the number to treat to achieve the desired outcome will be substantially less. There is no evidence that bed rest or salt restriction reduces preeclampsia risk.子痫前期预防很明显，未经筛选的低危/高危女性使用抗氧化剂维生素C和维生素E不能预防子痫前期的发生以及子痫前期导致的不良结局。钙剂使用能降低钙摄入量低的孕妇子痫前期发病的严重程度、但对钙摄入正常的人群无效，如美国人。一项基于3万多孕妇的meta-分析显示，低剂量阿司匹林（60-80 mg/天）能预防子痫前期的发生、同时能轻微的降低子痫前期的严重程度及不良的围产结局。这一结论适用于子痫前期高危孕妇，对低危孕妇无临床相关性。卧床休息或低盐饮食不能降低或治疗子痫前期。* For women with a medical history of early-onset preec lampsia and preterm delivery at less than 34 0/7 weeks of gestation or preeclampsia in more than one prior pregnancy, initiating the administration of daily low-dose (60-80 mg) aspirin beginning in the late first trimester is suggested.*Quality of evidence: ModerateStrength of recommendation: Qualified有早发型子痫前期病史或子痫前期反复发作、或有孕周34周早产孕妇，建议在早孕期末期口服小剂量阿司匹林（60-80mg/天）质量：中等中等推荐* The administration of vitamin C or vitamin E to prevent preeclampsia is not recommended.Quality of evidence: HighStrength of recommendation: Strong不推荐口服维生素C或维生素E来预防子痫前期质量：高强烈推荐* It is suggested that dietary salt not be restricted dur ing pregnancy for the prevention of preeclampsia.Quality of evidence: LowStrength of recommendation: Qualified不推荐限盐饮食来预防子痫前期质量：低中等推荐* It is suggested that bed rest or the restriction of other physical activity not be used for the primary prevention of preeclampsia and its complications.Quality of evidence: LowStrength of recommendation: Qualified不推荐卧床休息或限制活动来预防或治疗子痫前期质量：低中等推荐Management of Preeclampsia and HELLP SyndromeClinical trials have provided an evidence base to guide management of several aspects of preeclampsia. Nonetheless, several important questions remain unanswered. Reviews of maternal mortality data reveal that deaths could be avoided if health care providers remain alert to the likelihood that preeclampsia will progress. The same reviews indicate that intervention in acutely ill women with multiple organ dysfunction is sometimes delayed because of the absence of proteinuria. Furthermore, accumulating information indicates that the amount of proteinuria does not predict maternal or fetal outcome. It is for these reasons that the task force has recommended that alternative systemic findings with new-onset hypertension can fulfill the diagnosis of preeclampsia even in the absence of proteinuria.Perhaps the biggest changes in preeclampsia management relate to the timing of delivery in women with preeclampsia without severe features, which based on evidence is suggested at 37 0/7 weeks of gestation, and an increasing awareness of the importance of preeclampsia in the postpartum period. Health care providers are reminded of the contribution of nonsteroidal antiinflammatory agents to increased BP. It is suggested that these commonly used postpartum pain relief agents be replaced by other analgesics in women with hypertension that persists for more than 1 day postpartum.子痫前期和HELLP综合征的管理临床试验提供证据来管理子痫前期的几个方面。然而、有些重要的问题仍然没有解决。回顾分析母体死亡率数据显示如果医疗工作者能够对子痫前期的进展保持警惕，死亡是能够避免的。同样，由于缺乏蛋白尿、对于合并多器官功能障碍的病重孕妇的治疗有时是延迟的。并且，越来越多的研究显示，蛋白量不能预测母胎的结局。因此，工作组推荐新发的高血压伴任何一项系统异常发现可以诊断子痫前期，即使缺乏蛋白尿。在不伴有重症的子痫前期的处理中，最大的变化可能是终止娠的时机以及重视产后子痫前期。基于证据的研究推荐在37周分娩。医疗工作者提醒非甾体抗炎药能升高血压。他们建议妊娠期高血压患者产后常用止痛药应该被其他类别的药物替代至少1天。TASK FORCE RECOMMENDATIONS专家建议* The close monitoring of women with gestational hyper tension or preeclampsia without severe features, with serial assessment of maternal symptoms and fetal move ment (daily by the woman), serial measurements of BP (twice weekly), and assessment of platelet counts and liver enzymes (weekly) is suggested.Quality of evidence: ModerateStrength of recommendation: Qualified密切监护妊娠期高血压或未合并子痫前期重症患者的病情发展，应不断监测母体病情及胎动情况（由孕妇每日自行观察），测量血压（每 周 次），血小板计数和肝酶检测（每周 次）质量：中等中等推荐* For women with gestational hypertension, monitoring BP at least once weekly with proteinuria assessment in the office and with an additional weekly measurement of BP at home or in the office is suggested.Quality of evidence: ModerateStrength of recommendation: Qualified建议妊娠期高血压患者至少每周在院内测量 次血压，并进行尿蛋白检测。每周可在家或医院多测量一次血压。质量：中等中等推荐* For women with mild gestational hypertension or preec lampsia with a persistent BP of less than 160 mm Hg systolic or 110 mm Hg diastolic, it is suggested that anti- hypertensive medications not be administered.Quality of evidence: ModerateStrength of recommendation: Qualified妊娠期高血压或未合并子痫前期重症患者，收缩压 或舒张压 时，不应用降压药物治疗。质量：中等中等推荐* For women with gestational hypertension or preeclampsia without severe features, it is suggested that strict bed rest not be prescribed.*Quality of evidence: LowStrength of recommendation: Qualified妊娠期高血压或未合并子痫前期重症患者不建议绝对卧床休息。质量：中等中等推荐* For women