常见妊娠高血压疾病专家解读培训课件.ppt

1、常见妊娠高血压疾病专常见妊娠高血压疾病专家解读家解读HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases2常见妊娠高血压疾病专家解读CharacteristicsSystemic small arteries spasm Endothelial cell injuryHyper

2、tensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension;Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension3常见妊娠高血压疾病专家解读Hypertension disorders complicating pregnancynPathophysiologynCategory and clinica

3、l manifestationnDiagnosis and differential diagnosisnManagement and prevention病理生理病理生理临床表现临床表现诊断诊断治疗治疗4常见妊娠高血压疾病专家解读EpidemiologynIncidence：6-9%nPreeclampsia-eclampsia：70%nChronic Hypertension：30%nEclampsia0.5%-1%nChina 1.0%nOverseas 0.5%nReflection of medical level nThe second cause of maternal deat

4、h(20%)nCause of premature delivery（10%）nUnknown origin5常见妊娠高血压疾病专家解读Pathophysiology nBasic pathological changesnSpasm of systemic small arteries nVascular endothelial cell injury6常见妊娠高血压疾病专家解读PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell

5、 injuryMultiple organs dysfunctionIschemiaEdemamalfunction7常见妊娠高血压疾病专家解读Systemic Disease8常见妊娠高血压疾病专家解读BrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvu

6、lsion comabrain：Vasospasmpermeability9常见妊娠高血压疾病专家解读kidney renal vasospasmrenal blood flow glomerular filtration rate pathology：Glomerular expansion swollen vascular endothelial cell cellulose deposition renocortical necrosisrenal irreversible damageclinical manifestation：albuminuria hypoproteinemia

7、renal dysfunction creatinine urea nitrogen uric acid oliguria renal failure 10常见妊娠高血压疾病专家解读liverhepatic vasospasm;hepatic ischemia;hepatic edema liver enlargement;hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed severe：Periportal necrosishepatic subcapsu

8、larhematomahepatorrhexis HELLP symdrome:Elevated hepatic enzymesDecreased blood platelet11常见妊娠高血压疾病专家解读Cardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertensi

9、on Pulmonary EdemaOliguriawater-sodium retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor ability12常见妊娠高血压疾病专家解读blood system nRelative hypovolemianAnemianDecreased blood plateletnHypercoagulability nblood clotting factor13常见妊娠高血压疾病专家解读placenta-fetusnplacenta nPlacenta

10、l hypoperfusionnSpiral arteries sclerosis nPlacental InfarctionnPlacental AbruptionnPlacental function decreaseso fetus nIUGRnfetal distressnoligohydramniosnfetal death 14常见妊娠高血压疾病专家解读PathophysiologynBrainnHeadache;visual blurred;coma;hernianKidneynRenal function compromised;proteinuria;renal failur

11、enLivernPersistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;ruptureSystematic disease15常见妊娠高血压疾病专家解读PathophysiologynCardiovascular systemnLow output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failurenBloodnLow volume;hypercoagulability;DIC16常见妊娠高血压疾病专家

12、解读PathophysiologynUterus and PlacentanLow perfusion;placental atherosclerosisnPlacental infarction;placental abruption;fetal growth retardation;fetal death17常见妊娠高血压疾病专家解读High risk factorsnPrimiparan40ynMultiple pregnancynHypertensionnChronic nephritisnMalnutritionnPoor social statusnDiabetesnAnti-ph

13、ospholipid syndromenAngiotensin gene T235(+)18常见妊娠高血压疾病专家解读EtiologynGenetic susceptibility hypothesisnImmune maladaptation hypothesisnPlacental ischemia hypothesisnOxidative stress hypothesis19常见妊娠高血压疾病专家解读 Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placental

14、The change of cytokinePEdevelopmentEndothelium injuredDICComplications20常见妊娠高血压疾病专家解读Genetic susceptibility hypothesisHypertension21常见妊娠高血压疾病专家解读Immune maladaptation hypothesisnMultiple gestationnAbortion and blood transfusionnOvum and sperm donation22常见妊娠高血压疾病专家解读Placental ischemia hypothesisn40%to

15、tal spiral artery area compared to normal pregnancynEndothelial cell injury23常见妊娠高血压疾病专家解读Oxidative stress hypothesisOxidative stress reactionEndothelial cell injury24常见妊娠高血压疾病专家解读Category and clinical manifestationnGestational hypertension nPreeclampsianEclampsia nChronic hypertensionnPreeclampsia

16、superimposed on chronic hypertension25常见妊娠高血压疾病专家解读clinical features ntypical:nhypertension、albuminuria、edemanuntypical：nasymptomatic nsevere：nnausea、vomitnheadache、dazzlenconvulsion、comanchest distress、palpitation 26常见妊娠高血压疾病专家解读Gestational Hypertension nDefinition nHypertension occurs 20 weeks aft

17、er gestation and recovers 12 weeks postpartumnSBP=140mmHgnDBP=90mmHgnDiagnosed only after delivery27常见妊娠高血压疾病专家解读PreeclampsianHypertention occurs 20 weeks after gestation nBP=140/90mmHgnProteinuria nProteinuria 300mg/24h nUrine protein（+）nOther symptomsnHeadache,visual blurringnUpper abdominal pain2

18、8常见妊娠高血压疾病专家解读Severe preeclampsianAt least one of the following features：nCentral nervous system abnormalities nHepatic subcapsular hematoma/hepatorrhexisnHepatocyte injury:GPTnBlood pressure：SBP160mmHg，or DBP110mmHgnThrombocytopenia:100109/LnProteinuria:5g/24h or(+)4 hours apart nOliguria:500ml/24h

19、nPulmonary edema nCerebrovascular accidentnIntravascular hemolysis:anemia,jaundicenCoagulation dysfunctionnFetal growth restriction/oligohydramnios29常见妊娠高血压疾病专家解读Severe preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia:20.5mol/LnElevated serum level of Liver enzymesnAST7

20、0u/L,or 3SDnLDH600u/LnLow PlateletsnPLC100*109/L31常见妊娠高血压疾病专家解读HELLPnSevere preeclampsia：nOne abnormalities 6%nTwo abnormalities 12%nThree abnormalities 10%n20 gw seldom occurn1/3 occur after deliveryn80%diagnosed prenatally32常见妊娠高血压疾病专家解读HELLPclinical diagnosis nMight be asymptomatic npain in the r

21、ight upper abdomen80%n weight gain or severe edema 50-60%n20%cases 140/90 mmHgn6%cases without proteinuria33常见妊娠高血压疾病专家解读nSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia34常见妊娠高血压疾病专家解读Classification of HELLPnBy degree of thrombocytopenia：n100,000/mm

22、3nNot widely accepted35常见妊娠高血压疾病专家解读Pathogenesis and epidemic characteristics of HELLP ncore mechanismnendothelial injuryintravascular coagulation dysfunctionnpredisposing factorsnthe whitenmultipara nelder pregnant women36常见妊娠高血压疾病专家解读HELLP-mortalitynMaternal 0-24%nhepatorrhexisnDICnAcute renal fai

23、lurenthrombosisncerebrovascular accidentsnPerinatal 7.7-60%nPremature deliverynIUGRnplacental abruption 37常见妊娠高血压疾病专家解读Eclampsianprocess：ntonusnconvulsionnsleepinessncoma nOccurrencenprenatalnintrapartumnpostpartum 38常见妊娠高血压疾病专家解读preeclampsia superimposed upon chronic hypertensionnChronic Hypertensi

24、on nBefore 20 gestational weeksnPersist 12 weeks postpartumnProteinurianBefore 20wnAfter 20w;with higher BP;thrombocytopenia40常见妊娠高血压疾病专家解读Differential diagnosisnChronic nephritis complicating pregnancynRenal dysfunctionnSeizure caused by other reasons41常见妊娠高血压疾病专家解读ManagementnPrinciplenSedationnAnt

25、i-spasmnAnti-hypertensionnDiuresisnTerminate pregnancy timely42常见妊娠高血压疾病专家解读ManagementnCommon treatmentnRestnMonitoringnOxygen inhalationnDiet:salt restriction only for anasarca patients43常见妊娠高血压疾病专家解读ManagementnSedationnDiazepamnHibernation drugsnPethidinenChlorpromazinenPromethazine44常见妊娠高血压疾病专家解读

26、ManagementnAnti-spasmnFirst line treatment for pre-eclampsia and eclampsianMgSO4 nMechanismnRegimen 25-30g/dnLoading dose:25%MgSO4 10ml+10%GS 20ml iv 5-10minn25%MgSO4 60ml+5%GS 500ml ivgtt 1-2g/hn25%MgSO4 20ml+2%lidocaine 2ml im.45常见妊娠高血压疾病专家解读ManagementnMgSO4nTreatment concentration 1.7-3mmol/LnTox

27、ic concentration 3mmol/LnToxicitynMuscular paralysisnPrevention and treatmentIBefore treatmentKnee reflex(+);R16bpm;urine5ml/h or 600ml/24hMg concentration monitoring nIf something happensn10%calcium gluconate 10ml iv for detoxificationnLower dose or stop use when renal dysfunction46常见妊娠高血压疾病专家解读Man

28、agementnAntihypertensionnIndication nSBP160mmHg,DBP 110mmHg,MBP 140mmHgnPrinciplenNo feral toxicity;no lower renal and uterine perfusionnHydralazine first linenLabetalol;calcium channel blocker;methyldopanSodium nitroprusside-only when unmanageable BP nACEI-contraindicated during pregnancy47常见妊娠高血压疾

29、病专家解读ManagementnVolumetric dilatancy-only for severe Hypoproteinemia and anemianDiuretic agent-only for severe edema48常见妊娠高血压疾病专家解读ManagementnTerminate pregnancynSevere pre-eclampsia unrelieved after active treatment for 24-48 hoursnSevere pre-eclampsia,34 wnSevere pre-eclampsia,34 w with matured fetus and placental dysfunctionnSevere pre-eclampsia,150-180mmHg;DBP100mmHg;hypertension related organ dysfunction52常见妊娠高血压疾病专家解读PreventionnA well organized health care systemnA well monitored pregnant periodnAppropriate diet and rest53常见妊娠高血压疾病专家解读