常见妊娠高血压疾病(专家解读)---陈晓军.ppt

HypertensionDisordersComplicatingPregnancy 妊娠期高血压疾病 HypertensiveDisorderscomplicatingPregnancy GestationalHypertension Preeclampsia PreeclampsiaSuperimposedonChronicHypertension ChronicHypertension Eclampsia AGroupofRelatedDiseases Characteristics Systemicsmallarteriesspasm Endothelialcellinjury Hypertension Proteinuria Multipleorgansdysfunction Convulsion Maternalmortality Fetalmortality GestationalHypertension Chronichypertension Eclampsia Preeclampsia PreeclampsiaSuperimposedonChronicHypertension Hypertensiondisorderscomplicatingpregnancy PathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention 病理生理 临床表现 诊断 治疗 Epidemiology Incidence 6 9 Preeclampsia eclampsia 70 ChronicHypertension 30 Eclampsia0 5 1 China1 0 Overseas0 5 ReflectionofmedicallevelThesecondcauseofmaternaldeath 20 Causeofprematuredelivery 10 Unknownorigin Pathophysiology BasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcellinjury Pathophysiology fluid protein HypertensionEdemaProteinuriaHemoconcentration Smallarterialspasm Endothelialcellinjury Multipleorgansdysfunction IschemiaEdemamalfunction SystemicDisease Brain HydrocephalusHyperemia ischemiaThrombosiscerebralhemorrhagecerebralhernia headachedazzlenauseavomit HypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinking Eclampsiaconvulsioncoma brain Vasospasmpermeability kidney renalvasospasm renalbloodflow glomerularfiltrationrate pathology Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis renalirreversibledamage clinicalmanifestation albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailure liver hepaticvasospasm hepaticischemia hepaticedema liverenlargement hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchanged severe Periportalnecrosishepaticsubcapsularhematomahepatorrhexis HELLPsymdrome ElevatedhepaticenzymesDecreasedbloodplatelet CardiovascularSystem BloodPressure Vasospasm VascularResistance CardiacLoad heartfailure vasospasm MyocardialIschemiaInterstitialEdemaSpottyNecrosis pulmonaryvasospasm PulmonaryHypertension PulmonaryEdema Oliguria water sodiumretention RelativeBloodVolumeExcess IatrogenicBloodVolumeExcess Highburden Poorability bloodsystem RelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor placenta fetus placentaPlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreases fetusIUGRfetaldistressoligohydramniosfetaldeath Pathophysiology BrainHeadache visualblurred coma herniaKidneyRenalfunctioncompromised proteinuria renalfailureLiverPersistentupperrightabdominalpain Elevatedenzyme jaundice hematoma rupture Systematicdisease Pathophysiology CardiovascularsystemLowoutput highresistance myocardialischemia pulmonaryhypertension edema heartfailureBloodLowvolume hypercoagulability DIC Pathophysiology UterusandPlacentaLowperfusion placentalatherosclerosisPlacentalinfarction placentalabruption fetalgrowthretardation fetaldeath Highriskfactors Primipara40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetes Anti phospholipidsyndromeAngiotensingeneT235 Etiology GeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesis Geneticsusceptibility Immunemaladaptation Placentalischemia Oxidativestress Abnormalplacental Thechangeofcytokine PE development Endotheliuminjured DIC Complications Geneticsusceptibilityhypothesis Hypertension Immunemaladaptationhypothesis MultiplegestationAbortionandbloodtransfusionOvumandspermdonation Placentalischemiahypothesis 40 totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjury Oxidativestresshypothesis Oxidativestressreaction Endothelialcellinjury Categoryandclinicalmanifestation GestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertension clinicalfeatures typical hypertension albuminuria edemauntypical asymptomaticsevere nausea vomitheadache dazzleconvulsion comachestdistress palpitation GestationalHypertension DefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP 140mmHgDBP 90mmHgDiagnosedonlyafterdelivery Preeclampsia Hypertentionoccurs20weeksaftergestationBP 140 90mmHgProteinuriaProteinuria 300mg 24hUrineprotein OthersymptomsHeadache visualblurringUpperabdominalpain Severepreeclampsia Atleastoneofthefollowingfeatures CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma hepatorrhexisHepatocyteinjury GPT Bloodpressure SBP 160mmHg orDBP 110mmHgThrombocytopenia 100 109 LProteinuria 5g 24hor 4hoursapartOliguria 500ml 24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis anemia jaundiceCoagulationdysfunctionFetalgrowthrestriction oligohydramnios Severepreeclampsiacomplications HepaticsubcapsularhematomaEarly onsetpreeclampsia 34wHELLPsyndrome HELLPsyndrome HemolysisbloodsmearsshowRBCdebrisHb60 90g LTB 20 5 mol L ElevatedserumlevelofLiverenzymesAST 70u L or 3SDLDH 600u LLowPlateletsPLC 100 109 L HELLP Severepreeclampsia Oneabnormalities6 Twoabnormalities12 Threeabnormalities10 20gwseldomoccur1 3occurafterdelivery80 diagnosedprenatally HELLP clinicaldiagnosis Mightbeasymptomaticpainintherightupperabdomen80 weightgainorsevereedema50 60 20 cases 140 90mmHg6 caseswithoutproteinuria SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsia ClassificationofHELLP Bydegreeofthrombocytopenia 100 000 mm3Notwidelyaccepted PathogenesisandepidemiccharacteristicsofHELLP coremechanismendothelialinjury intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomen HELLP mortality Maternal0 24 hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidents Perinatal7 7 60 PrematuredeliveryIUGRplacentalabruption Eclampsia process tonusconvulsionsleepinesscoma Occurrenceprenatalintrapartumpostpartum ChronicHypertensionduringPregnancy HypertensionbeforepregnancyorHypertensionbefore20weeks gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3times Placentalabruption2times FGR pretermbirth preeclampsiasuperimposeduponchronichypertension ChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w withhigherBP thrombocytopenia Differentialdiagnosis ChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasons Management PrincipleSedationAnti spasmAnti hypertensionDiuresisTerminatepregnancytimely Management CommontreatmentRestMonitoringOxygeninhalationDiet saltrestrictiononlyforanasarcapatients Management SedationDiazepamHibernationdrugsPethidineChlorpromazinePromethazine Management Anti spasmFirstlinetreatmentforpre eclampsiaandeclampsiaMgSO4MechanismRegimen 25 30g dLoadingdose 25 MgSO410ml 10 GS20mliv5 10min25 MgSO460ml 5 GS500mlivgtt1 2g h25 MgSO420ml 2 lidocaine2mlim Management MgSO4Treatmentconcentration1 7 3mmol LToxicconcentration 3mmol LToxicityMuscularparalysisPreventionandtreatmentBeforetreatmentKneereflex R 16bpm urine 5ml hor600ml 24hMgconcentrationmonitoringIfsomethinghappens 10 calciumgluconate10mlivfordetoxificationLowerdoseorstopusewhenrenaldysfunction Management AntihypertensionIndicationSBP 160mmHg DBP 110mmHg MBP 140mmHgPrincipleNoferaltoxicity nolowerrenalanduterineperfusionHydralazine firstlineLabetalol calciumchannelblocker methyldopaSodiumnitroprusside onlywhenunmanageableBPACEI contraindicatedduringpreg