妊娠高血压疾病陈晓军

妊娠高血压疾病陈晓军第1页/共54页HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseases第2页/共54页CharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertension第3页/共54页HypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理临床表现诊断治疗第4页/共54页EpidemiologyIncidence：6-9%Preeclampsia-eclampsia：

70%ChronicHypertension：

30%Eclampsia 0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）Unknownorigin第5页/共54页PathophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcell

injury第6页/共54页PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunction第7页/共54页SystemicDisease第8页/共54页BrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑第9页/共54页kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis——renalirreversibledamageclinicalmanifestation：albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailure第10页/共54页liverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplatelet第11页/共54页CardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorability第12页/共54页bloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓第13页/共54页placenta-fetusplacenta

PlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetus

IUGRfetaldistressoligohydramniosfetaldeath第14页/共54页PathophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdisease第15页/共54页PathophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DIC第16页/共54页PathophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeath第17页/共54页HighriskfactorsPrimipara<18yor>40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)第18页/共54页EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesis第19页/共54页

GeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplications第20页/共54页GeneticsusceptibilityhypothesisHypertension第21页/共54页ImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonation第22页/共54页Placentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjury第23页/共54页OxidativestresshypothesisOxidativestressreactionEndothelialcellinjury第24页/共54页CategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertension第25页/共54页clinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitation第26页/共54页GestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP>=140mmHgDBP>=90mmHgDiagnosedonlyafterdelivery第27页/共54页PreeclampsiaHypertentionoccurs20weeksaftergestationBP>=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpain第28页/共54页SeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:<100109/LProteinuria:≥5g/24hor(+++)4hoursapart

Oliguria:<500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramnios第29页/共54页

SeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:<34wHELLPsyndrome第30页/共54页HELLPsyndromeHemolysisbloodsmearsshowRBCdebrisHb60-90g/LTB>20.5μmol/LElevatedserumlevelofLiverenzymesAST>70u/L,or>3SDLDH>600u/LLowPlateletsPLC<100*109/L第31页/共54页HELLPSeverepreeclampsia：Oneabnormalities 6%Twoabnormalities 12%Threeabnormalities 10%20gw seldomoccur1/3 occurafterdelivery80% diagnosedprenatally第32页/共54页HELLP——clinicaldiagnosisMightbeasymptomaticpainintherightupperabdomen 80%weightgainorsevereedema 50-60%20%cases<140/90mmHg6%caseswithoutproteinuria第33页/共54页SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsia第34页/共54页ClassificationofHELLPBydegreeofthrombocytopenia：<50,000/mm350,000–100,000/mm3>100,000/mm3Notwidelyaccepted第35页/共54页PathogenesisandepidemiccharacteristicsofHELLP

coremechanismendothelialinjury——intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomen第36页/共54页HELLP--mortalityMaternal0-24%hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidentsPerinatal7.7-60%PrematuredeliveryIUGRplacentalabruption第37页/共54页Eclampsiaprocess：tonusconvulsionsleepinesscomaOccurrenceprenatalintrapartumpostpartum第38页/共54页ChronicHypertensionduringPregnancyHypertensionbeforepregnancyorHypertensionbefore20weeks’gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3timesPlacentalabruption2timesFGR,pretermbirth第39页/共54页preeclampsiasuperimposeduponchronichypertensionChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w;withhigherBP;thrombocytopenia第40页/共54页DifferentialdiagnosisChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasons第41页/共54页ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminatepregnancytimely第42页/共54页ManagementCommontreatmentRestMonitoringOxygeninhalationDiet:saltrestrictiononlyforanasarcapatients第43页/共54页ManagementSedationDiazepamHibernationdrugsPethidineChlorpromazinePromethazine第44页/共54页ManagementAnti-spasmFirstlinetreatmentforpre-eclampsiaandeclampsiaMgSO4MechanismRegimen≥25-30g/dLoadingdose:25%MgSO410ml+10%GS20mliv5-10min25%MgSO460ml+5%GS500mlivgtt1-2g/h25%MgSO420ml+2%lidocaine2mlim.第45页/共54页ManagementMgSO4Treatmentconcentration1.7-3mmol/LToxicconcentration>3mmol/LToxicityMuscularparalysisPreventionandtreatmentBeforetreatmentKneereflex(+);R≥16bpm;urine≥5ml/hor600ml/24hMgconcentrationmonitoring

Ifsomethinghappens…10%calciumgluconate10mlivfordetoxificationLowerdoseorstopusewhenrenaldysfunction

第46页/共54页ManagementAntihypertensionIndicationSBP≥160mmHg,DBP≥110mmHg,MBP≥140mmHgPrincipleNoferaltoxicity;nolowerrenalanduterineperfusionHydralazine—firstlineLabetalol;calciumchannelblocker;methyldopaSodiumnitroprusside----onlywhenunmanageableBPACEI----contraindicatedduringpregnancy第47页/共54页ManagementVo