子痫前期和子痫PBLD课件.pptx

1、子痫前期和子痫PBLD讨论目的1.讨论妊娠期高血压疾病的鉴别诊断2.了解抗高血压药物在妊娠期高血压疾病治疗中的作用3.讨论硫酸镁在子痫前期病人治疗中的作用4.讨论重度子痫前期病人的麻醉方案为什么还要讨论“子痫前期”n高血压位居“产科大出血”之后，是母亲死亡的第二大原因n目前临床使用的推荐意见主要来自于“专家意见”和小样本量的研究n发病机制和病理生理机制仍然不明确n麻醉科医师 围术期医学的“领航者”熟悉子痫前期的病理生理识别疾病的严重性提供麻醉、心脏监护和重症监测病 例n女性，18 岁，G1P0，孕 33 周n主诉：剧烈头痛n体格检查：血压：210/130 mmHg，血小板 98000/mm3，

2、尿蛋白 4+n治疗抗高血压预防抽搐问 题1.Classify the hypertensive disorders of pregnancy.2.What are the incidence and risk factors of preeclampsia?3.Explain the etiology and pathophysiology of preeclampsia.4.Outline the obstetric management of the patient with preeclampsia.5.What medications are used to treat elevate

3、d blood pressure in preeclampsia?Prevent seizures?妊娠期高血压疾病应当如何分类？1.The term hypertension in pregnancy is commonly used to describe a wide spectrum of patients who may have only mild elevations in blood pressure(BP)or severe hypertension with various organ dysfunctions2.妊娠期高血压疾病尽管临床表现相仿（高血压、蛋白尿），然而原因

4、却各不相同。高血压可能是慢性高血压、肾功能不全或单纯的子痫前期传统 经典的分类法更新的分类nChronic hypertensionnGestational hypertensionnPre-eclampsia de novo（新发的）or superimposed on chronic hypertensionnWhite coat hypertension子痫前期的定义n传统的定义妊娠20周后出现n高血压n蛋白尿n水肿n最新定义妊娠20周后出现高血压，并伴以下一种或多种新发的问题1.蛋白尿2.其它母亲器官功能障碍3.子宫-胎盘功能障碍 一旦确诊后，“轻症”的子痫前期病人极有可能在短时间内进

5、展到严重的器官功能障碍！子痫前期-新发高血压伴有新发的1.Fetal growth restriction and severe proteinuria(5 g in 24 hours)are no longer considered features of severe preeclampsia.2.Blood pressures should be measured on two occasions at least 4 hours apart while the patient is on bed rest.3.Indicated by elevated blood concentrat

6、ions of liver enzymes(more than twice normal)and severe persistent right upper quadrant,or epigastric pain.如何鉴别诊断？n慢性高血压n妊娠期高血压n子痫前期不伴有严重症状的子痫前期重症子痫前期子痫n慢性高血压病并发子痫前期如何鉴别诊断？排除“白大褂高血压”子痫前期的发病机制：学说众多1.胎盘发育异常2.免疫学因素3.遗传学因素4.对血管紧张素的敏感性增加5.环境因素：钙摄入和体重指数6.全身性内皮功能障碍7.炎症/感染子痫前期的发病机制Angiogenic Factors as Medi

7、ators of theMaternal Syndrome子痫前期的发病机制子痫前期的发病机制主要临床表现临床表现：小结子痫前期的主要病理生理改变n心血管系统n神经系统n呼吸系统n泌尿系统n消化系统n血液系统n子宫 胎盘子痫前期的主要病理生理改变发病率和危险因素n美国的发病率 3%-4%n全世界报道 1.8%-16.7%，子痫 0.2%-0.7%n中国报道上海 5.57%北京 1.66%我国除北京地区外，其他地区的发病率差异并不大危险因素（1）Or 18 years危险因素（2）危险因素（3）*Teenage mother,primipaternity,assisted reproductiv

8、e technique.在孕妇妊娠初期是否可以预测1.病史第一！通过病史寻找子痫前期的高危因素2.以下辅助检查可供参考Combination screening using clinical risk factors,multiple serum biomarkers and uterine artery velocimetry has the highest sensitivity and specificity for the prediction of preeclampsia,and is likely the future of early detection子痫前期可以预防吗？残酷

9、的事实是：这些方法都被证明无效或收效甚微子痫前期的并发症（母亲）n脑出血n肺水肿n心衰、心肌缺血n肝破裂n胎盘早剥n肾功能衰竭nDICnHELLP综合征子痫前期的并发症（胎儿）n严重的胎儿宫内生长迟缓n低氧血症n酸中毒n早产n胎儿死亡预测子痫前期是否会出现并发症nfullPIERS modelearly gestational agechest pain or dyspneaoxygen saturationplatelet countCreatinineaspartate aminotransferase concentrations 子痫前期的评估：新的进展n酸碱平衡碱剩余的离散度增加。高

10、氯性酸中毒和低白蛋白血症的碱中毒相互抵消。低白蛋白血症性碱中毒可预测胎儿的风险，决定分娩的时机nfocused cardiac ultrasound（foCUS）：TTEnlung ultrasoundnBNPn神经系统标志物视神经鞘直径（ONSD）脑氧饱和度（rcSO2）问 题1.Classify the hypertensive disorders of pregnancy.2.What are the incidence and risk factors of preeclampsia?3.Explain the etiology and pathophysiology of preec

11、lampsia.4.Outline the obstetric management of the patient with preeclampsia.5.What medications are used to treat elevated blood pressure in preeclampsia?Prevent seizures?具体措施n妊娠晚期应住院治疗卧床，子宫左倾n系列检查，确定孕妇的血压、体重、肾功能、凝血功能和中枢神经系统功能n胎儿监测n确定分娩的时机子痫前期病人产科治疗目标？1.控制血压2.预防“子痫”（抽搐）的发生3.恢复血管内容量4.确定分娩的时机和方式 45岁的孕妇

12、缓释制剂：血压稳定后的口服制剂主要副作用：心动过速和头痛n可以安全的和硫酸镁联合应用尼卡地平nNicardipine is a calcium entryblocking agent that can be administered by intravenous infusion and has been shown to achieve rapid decreases in systolic and diastolic blood pressures in pregnant women.It is an excellent option for treating severe hyperte

13、nsion that is not responsive to labetalol or hydralazine硝普钠nNitroprusside,a potent arterial vasodilator,is often used when immediate control of blood pressure is required.It is administered by infusion making it easy to titrate to effect.However,nitroprusside crosses the placenta,and cyanide toxicit

14、y has been described in the neonate after prolonged infusion in the mother硝酸甘油nNitroglycerin,a venous dilator,is useful when tight control of blood pressure is required for prolonged periods.Nitroglycerin is not as potent as nitroprusside,but it is easy to titrate and has minimal effect on the fetus

15、子痫前期病人常用抗高血压药物硫酸镁（magnesium sulfate）nThe routine use of magnesium sulfate for seizure prophylaxis in women with severe preeclampsia is an established obstetric practice in the United States and has gained popularity throughout the world 硫酸镁的作用，请记住哦！nCentral nervous system depressantnAnticonvulsant（N

16、MDA受体）nMyoneural junctionInhibits release of acetylcholineDecreases acetylcholine sensitivity of motor end plateDecreases excitability of muscle membranenMild vasodilatornDecreases uterine hyperactivitynCrosses placentanToxicity treated with calcium administration硫酸镁的用法nParenteral magnesium sulfate

17、is the treatment of choice in the United States to prevent eclampsia.Intravenous loading dose is 4 grams over 20 minutes and is followed by a continuous infusion of 1-2 grams/hour硫酸镁的副作用nSide effects include chest pain and tightness,palpitations,nausea,blurred vision,sedation,transient hypotension,a

18、nd,rarely,pulmonary edema硫酸镁的血药浓度和临床效应由于Mg离子是两价，所以换算成mmol/L要除以2哦，不要忘记了毒性作用的监测n膝反射：是否存在，是否减弱n呼吸频率：12 bpm or or 25 ml/hour继续，继续，继续nThe obstetricians decide to induce labor and they request labor analgesian问题1.How will you evaluate and manage her fluid?Will you place a central monitor?If yes,would you

19、place a CVP or PAC?2.What additional laboratory data will you request?3.What anesthetic would you utilize for labor?Spinal,epidural,or combined spinal-epidural?4.What medication will you utilize?子痫前期病人的麻醉前评估n麻醉前评估的主要内容airway examinationmaternal hemodynamiccoagulation statusfluid balance如何评估产妇的容量状况n病

20、史重点关注尿量，产妇是否存在少尿或无尿如果病人有少尿，应进行补液试验n辅助检查优先选择有创动脉压监测：CO,SPV,SVV较少监测CVP或放置Swan Ganz导管TTE用于子痫前期病人是近年来的新进展有创动脉压监测的指征1.poorly controlled maternal blood pressure2.need for frequent arterial blood gas measurements3.planned use of a rapid-acting vasodilator4.use of dynamic hemodynamics to estimate intravascu

21、lar volume status(LiDCO)5.need for continuous blood pressure monitoring during the induction of and emergence from general anesthesia in hypertensive women with severe preeclampsia其他需要关注的实验室检查n肾功能Crn肝功能n血小板计数，尤其是系列血小板计数更有临床意义n凝血功能：PT,aPTT,纤维蛋白原说明：如果没有血小板减少，则不必检查凝血功能子痫前期剖宫产的麻醉选择n最近25年最大的进展就是确立了方法首选区域

22、麻醉明确了区域麻醉的禁忌证n不同的产科要求分娩镇痛：硬膜外 or 腰硬联合剖宫产术n腰麻n硬膜外阻滞 or 腰硬联合阻滞n全身麻醉子痫前期产妇实施分娩镇痛n子痫前期病人早期实施分娩镇痛的理由1.避免紧急剖宫产时全身麻醉及其可能存在的“气道问题”和插管时的高血压2.硬膜外导管放置的时间正好避开可能会发生的血小板减少3.椎管内阻滞改善子宫-胎盘的血液灌注硬膜外或腰硬联合镇痛：优点n优点最佳的镇痛效果：缓解疼痛导致的高血压降低血液中儿茶酚胺和其他应激激素水平可能改善绒毛间血流n腰硬联合的潜在缺点腰麻首先起效，因此无法测试硬膜外导管的位置是否理想子痫前期病人实施分娩镇痛1.assessment of

23、coagulation status2.intravenous hydration before the epidural administration of a local anesthetic3.treatment of hypotension4.use of epinephrine-containing local anesthetic solutions.n方法：给予30名健康产妇腰麻前750ml晶体液预扩容，监测“血流动力学”，检测“血管内皮多糖-蛋白质复合物”的相关指标n结论：预扩容破坏了“血管内皮多糖-蛋白质复合物”；预扩容没有获得预期的“血流动力学”效应International Journal of Obstetric Anesthesia(2014)23,330334揭示：子痫前期的病人由于mRNA转录减少，导致“血管内皮-多糖蛋白质”结构变化提示：这种变化可能发生在肺血管，导致肺毛细血管通透性增加感谢关注，欢迎批评