1、 本科本科母婴护理学母婴护理学 要点提示要点提示妊娠期高血压疾病的临床分型、各型的临床表现及处妊娠期高血压疾病的临床分型、各型的临床表现及处理原则。理原则。The clinical classification, manifestation,and The clinical classification, manifestation,and the treatment principles of different hypertension states the treatment principles of different hypertension states of pregnancy
2、.of pregnancy.硫酸镁治疗妊娠期高血压疾病的用药方法及观察要点。硫酸镁治疗妊娠期高血压疾病的用药方法及观察要点。The usage and observation of the magnesium sulfate. The usage and observation of the magnesium sulfate. http:/www.health.am/pregnancy/hypertensive-states-of-pregnancy/http:/www.health.am/pregnancy/hypertensive-states-of-pregnancy/http:/ww
3、w.aafp.org/afp/2008/0701/p93.htmlhttp:/www.aafp.org/afp/2008/0701/p93.html第四节 妊娠期高血压疾病Hypertensive States of Pregnancy妊娠期高血压疾病(hypertensive states of pregnancy)包括：妊娠期高血压(gestational hypertension)子痫前期(preeclampsia)子痫(eclampsia)慢性高血压并发子痫前期( chronic hypertension with superimposed preeclampsia)妊娠合并慢性高血压
4、(chronic hypertension complicating pregnancy) 本病以高血压、蛋白尿、水肿为主要症状，可伴有全身多器官功能损害或衰竭，重者可出现抽搐、昏迷甚至死亡，严重危害母婴健康，是孕产妇及围生儿死亡的主要原因。hypertensive states of pregnancy：The main symptoms are hypertension, proteinuria, edema, accompanied by multiple organ disfunction or failure, seriously to be possible to have twi
5、tches, the stupor even maternal infant to die.http:/www.health.am/pregnancy/hypertensive-states-of-pregnancy/【高危因素高危因素 Risk factors 】精神过度紧张；寒冷季节或气压升高时；年轻初产妇18岁或高龄初产妇40岁；有慢性高血压、肾炎、糖尿病等病史的孕妇；营养不良者或者体形较胖者；低社会经济状况；子宫张力过高者，如双胎、羊水过多；家族中有高血压病史；the spiritual hypertension；in the cold reasons or increased bar
6、ometric pressure；nulliparity，maternal age below 20 or over 35；Past history of D.M, Hypertension and Renal diseases；malnutrition；Obesity；low socioeconomic statusMultiple gestation, polyhydramnios；Family history of hypertension；【病因pathogenesispathogenesis】可能与异常滋养细胞侵入子宫肌层、免疫机制、血管内皮细胞受损、遗传因素、营养缺乏、胰岛素抵抗等
7、有关。pathogenesis: pathogenesis: Some theories include (1) endothelial cell injury, (2) rejection phenomenon (insufficient production of blocking antibodies), (3) compromised placental perfusion, (4) altered vascular reactivity, (5) imbalance between prostacyclin and thromboxane, (6) decreased glomeru
8、lar filtration rate with retention of salt and water, (7) decreased intravascular volume, (8) increased central nervous system irritability, (9) disseminated intravascular coagulation, (10) uterine muscle stretch (ischemia), (11) dietary factors, and (12) genetic factors. 【病理生理病理生理】 全身小动脉痉挛全身小动脉痉挛管腔
9、狭窄，管腔狭窄，外周阻力增加外周阻力增加肾小动脉痉挛，血流量减少肾小动脉痉挛，血流量减少,肾缺血缺氧肾缺血缺氧肾小球通透性增加肾小球通透性增加血浆蛋白漏出血浆蛋白漏出肾小球滤过率降低肾小球滤过率降低血浆胶体血浆胶体渗透压降低渗透压降低激活激活RAA系统系统胎盘胎盘脑脑心脏心脏肝脏肝脏激活激活RAS系统系统【pathophysiologypathophysiology】 angiostenosis，Increased peripheral resistancerenal arteriole ，decreased glomerular perfusion, hypoxia-ischemiaincr
10、eased permeability of glomerular,plasma protein leakagedecreased glomerular filtration ratedecreased plasma colloid osmoticpressureactivation of renin angiotensin aldosterone system placentabraincardiovascularliverrenin-angiotensin system【临床表现及分类】【临床表现及分类】manifestation and calssificationmanifestatio
11、n and calssification (1)(1)妊娠期高血压妊娠期高血压 BP140/90mmHgBP140/90mmHg妊娠期首次出现，并于产后妊娠期首次出现，并于产后1212周恢复周恢复正常；尿蛋白（）；可伴有上腹部不适或血小板正常；尿蛋白（）；可伴有上腹部不适或血小板减少，产后方可确诊。减少，产后方可确诊。Gestational hypertension or pregnancy-induced hypertension (PIH) Gestational hypertension or pregnancy-induced hypertension (PIH) is defined
12、 as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation without the presence of protein in the urine. Gestational hypertension is further divided into transienttransient hypertension of pregnancy if preeclampsia is present at the time of delivery and the blood p
13、ressure is normal by 12 weeks postpartum, and chronic hypertension if the elevation in blood pressure persists beyond 12 weeks postpartum. 轻度轻度：BP140/90mmHgBP140/90mmHg，孕，孕2020周以后出现；尿蛋白周以后出现；尿蛋白300mg/24h300mg/24h或（或（+ +）。可伴有上腹不适、头痛、视力）。可伴有上腹不适、头痛、视力模糊等症状。模糊等症状。 Preeclampsia is hypertension associate
14、d with proteinuria and edema, occurring primarily in nulliparas nulliparas after the 20th gestational week and most frequently near term. There are 2 categories of preeclampsia, mild and severe. mild preeclampsia is defined as the following: (1) HTN (BP140/90mmHgBP140/90mmHg); (2) proteinuria exceed
15、ing 0.3 g in a 24-hour period or 1-2+ on dipstick testing;(3) Edema (hands or/and face) without other signs/symptoms(2)子痫前期 preeclampsia 重度重度：BP160/110mmHgBP160/110mmHg；尿蛋白；尿蛋白2.0g/24h2.0g/24h或（或（+）（）（+） ；血肌酐；血肌酐106mol/L106mol/L；血小板；血小板10010010109 9 /L /L；微血管病性溶血（血；微血管病性溶血（血LDHLDH升高）；血清升高）；血清ALTALT或
16、或ASTAST升高；持续性头痛或其它脑神经或视觉障碍升高；持续性头痛或其它脑神经或视觉障碍；持续性上腹不适。；持续性上腹不适。Severe preeclampsia is defined as the following: (1) blood pressure greater than 160 mm Hg systolic or 110 mm Hg diastolic on 2 occasions 6 hours apart; (2) proteinuria exceeding 2 g in a 24-hour period or 2-4+ on dipstick testing; (3) i
17、ncreased serum creatinine ( 1.2 mg/dL unless known to be elevated previously); (4) oliguria 500 mL/24 h; (5) cerebral or visual disturbances; (6) epigastric pain; (7) elevated liver enzymes; (8) thrombocytopenia (platelet count 100,000/mm3); (9) retinal hemorrhages, exudates, or papilledemapapillede
18、ma; and (10) pulmonary edema.(2)子痫前期 子痫子痫: :子痫前期患者发生抽搐不能用其它原因解释子痫前期患者发生抽搐不能用其它原因解释 子痫分产前子痫、产时子痫、产后子痫，以产前子痫子痫分产前子痫、产时子痫、产后子痫，以产前子痫多见。多见。 Eclampsia is the occurrence of seizures that cannot be attributed Eclampsia is the occurrence of seizures that cannot be attributed to other causes in a preeclampti
19、c patient. to other causes in a preeclamptic patient. prenatal eclampsia, intrapartum eclampsia, postpartum eclampsia prenatal eclampsia, intrapartum eclampsia, postpartum eclampsia clinical findingsclinical findings：seizureseizure，UnconsciousnessUnconsciousness，apneicapneic phase, hyperventilateshy
20、perventilates after the tonic-clonic seizure tonic-clonic seizure ，Seizure-induced complications may include tongue biting, broken bones, head tongue biting, broken bones, head trauma, or aspirationtrauma, or aspiration. Pulmonary edema and retinal detachment.Pulmonary edema and retinal detachment.(
21、3)子痫 EclampsiaEclampsia子痫发作表现子痫发作表现 抽搐发展迅速，前驱症状短暂，表现为抽搐、面部抽搐发展迅速，前驱症状短暂，表现为抽搐、面部充血、口吐白沫、深昏迷；随之深部肌肉僵硬、继而充血、口吐白沫、深昏迷；随之深部肌肉僵硬、继而发展为典型的全身高张阵挛惊厥、有节律的肌肉收缩发展为典型的全身高张阵挛惊厥、有节律的肌肉收缩和紧张，持续约和紧张，持续约1 11.5min1.5min，期间无呼吸；，期间无呼吸；然后抽搐停止，然后抽搐停止，呼吸恢复，但患者呼吸恢复，但患者仍仍昏迷。昏迷。最后意识最后意识恢复，但困惑、易恢复，但困惑、易激惹、烦躁。激惹、烦躁。(4)(4)慢性高血压
22、并发子痫前期慢性高血压并发子痫前期 高血压孕妇妊娠高血压孕妇妊娠2020周周前无尿蛋白，而妊娠前无尿蛋白，而妊娠2020周周后出现尿蛋白后出现尿蛋白300mg/24h300mg/24h；高血压孕妇妊娠；高血压孕妇妊娠2020周周后后突然出现尿蛋白增加或血压进一步升高或血小板突然出现尿蛋白增加或血压进一步升高或血小板10010010109 9 /L /L。Chronic hypertension is defined as hypertension that is present before conception or before 20 weeks gestation or persiste
23、nce of hypertension after the puerperium (6 weeks).Chronic hypertension with superimposed preeclampsiaChronic hypertension with superimposed preeclampsia:(1) no proteinuria before conception, but proteinuria exceeding 0.3 g in a 24-hour period after conception; (2)proteinuria increased or blood pres
24、sure greater or thrombocyte100109 /L (5)(5)妊娠合并慢性高血压妊娠合并慢性高血压妊娠前或妊娠妊娠前或妊娠2020周前血压周前血压140/90mmHg140/90mmHg，妊娠，妊娠期无明显加重；或妊娠期无明显加重；或妊娠2020周后首次诊断高血压周后首次诊断高血压，并持续至产后，并持续至产后1212周以后。周以后。defined as blood pressure equal to or greater than 140/90 mm Hg before conception or before 20 weeks gestation, and the h
25、ypertension is not increased significantly, or hypertension is firstly diagnosed after 20 weeks gestation and persists beyond 12 weeks postpartum. 并发症 脑出血、心力衰竭、肺水肿、急性肾功能衰竭、胎盘早剥、DIC、胎儿窘迫等。Complications: cerebral hemorrhage, Heart Failure, pulmonary edema, acute renal failure, placental abruption,diss
26、eminated intravascular coagulation, fetal distress子痫惊厥后咬伤造成舌血肿子痫惊厥后咬伤造成舌血肿子痫患者头部子痫患者头部CTCT箭头处箭头处可见低密度阴影可见低密度阴影 处理原则处理原则： 妊娠期高血压的处理原则为休息、镇静、间断吸氧、密切监妊娠期高血压的处理原则为休息、镇静、间断吸氧、密切监护母儿状态；护母儿状态； 子痫前期的处理原则为休息、镇静、解痉、降压、合理扩容子痫前期的处理原则为休息、镇静、解痉、降压、合理扩容和必要时利尿，密切监测母儿状态，适时终止妊娠；和必要时利尿，密切监测母儿状态，适时终止妊娠； 子痫的处理原则为控制抽搐，纠正
27、缺氧和酸中毒，及时终止子痫的处理原则为控制抽搐，纠正缺氧和酸中毒，及时终止妊娠。妊娠。 Rest, Sedation,Rest, Sedation,Intermittent inhalation of oxygen, Intermittent inhalation of oxygen, Close Close monitoring, spasmolysis, Control of hypertension, expand blood monitoring, spasmolysis, Control of hypertension, expand blood volume and diureti
28、c therapy,termination of pregnancy,Control volume and diuretic therapy,termination of pregnancy,Control of seizures.of seizures.【处理原则 Treatment】1 1有受伤的危险有受伤的危险 与发生抽搐及意识丧失有关。与发生抽搐及意识丧失有关。2 2潜在并发症潜在并发症 胎盘早剥、肾衰竭。胎盘早剥、肾衰竭。3 3焦虑焦虑 与担心自身及胎儿安危有关。与担心自身及胎儿安危有关。High risk for injuryHigh risk for injury，related
29、 to seizure or unconsciousnessrelated to seizure or unconsciousness。Potential for complications, related to renal failure, placental Potential for complications, related to renal failure, placental abruptionabruptionAnxiety: related to worrying about the safety of herself and the Anxiety: related to
30、 worrying about the safety of herself and the fetus .fetus .【护理诊断【护理诊断 nursing diagnosisnursing diagnosis】【护理措施】【护理措施】（一）妊娠期高血压患者的护理（一）妊娠期高血压患者的护理（二）子痫前期患者的护理（二）子痫前期患者的护理（三）子痫患者的护理（三）子痫患者的护理（四）产时及产后护理（四）产时及产后护理（五）心理护理（五）心理护理（六）健康指导（六）健康指导（一）妊娠期高血压患者的护理（一）妊娠期高血压患者的护理1 1休息与睡眠休息与睡眠 可在家治疗，充足的睡眠（可在家治疗，充足
31、的睡眠（1010小时小时/ /日日）；以左侧卧位为宜。）；以左侧卧位为宜。2 2间断吸氧间断吸氧 3 3饮食指导饮食指导 蛋白质（蛋白质（100100克克/ /日）、蔬菜，补充维生素日）、蔬菜，补充维生素、铁和钙剂；、铁和钙剂； 水肿不明显者不必严格限制食盐。水肿不明显者不必严格限制食盐。 4 4密切监测母儿状况密切监测母儿状况 监测患者体重、血压，询问患者监测患者体重、血压，询问患者有无头痛、视力改变、上腹不适等症状；协助患者进行有无头痛、视力改变、上腹不适等症状；协助患者进行尿蛋白测定、血液检查、胎儿发育状况和胎盘功能检查尿蛋白测定、血液检查、胎儿发育状况和胎盘功能检查 Be at hom
32、e, get enough sleep:left lateral position.Be at home, get enough sleep:left lateral position. Intermittent inhalation of oxygen.Intermittent inhalation of oxygen. Dietary Guidelines:Dietary Guidelines: Get close monitoring of the states of the mother and the babyGet close monitoring of the states of
33、 the mother and the baby（二）子痫前期患者的护理（二）子痫前期患者的护理1 1一般护理一般护理 住院治疗，卧床休息，左侧卧位。床旁住院治疗，卧床休息，左侧卧位。床旁准备开口器、吸氧装置、吸引器、产包等抢救物资及硫准备开口器、吸氧装置、吸引器、产包等抢救物资及硫酸镁、葡萄糖酸钙等药品。酸镁、葡萄糖酸钙等药品。2 2密切监测母儿状况密切监测母儿状况 3 3硫酸镁用药护理硫酸镁用药护理 硫酸镁是目前治疗妊娠期高血压疾硫酸镁是目前治疗妊娠期高血压疾病的首选解痉药物。病的首选解痉药物。General nursing: Be hospitalized,stay in bed:lef
34、t lateral position. Make General nursing: Be hospitalized,stay in bed:left lateral position. Make good preparation for rescuing.good preparation for rescuing.Close monitoring.Close monitoring.Medication care of magnesium sulfate:Medication care of magnesium sulfate:（三）子痫患者的护理（三）子痫患者的护理1 1协助医师控制抽搐协助医
35、师控制抽搐 Control of seizures Control of seizures 一旦发生抽搐，一旦发生抽搐，应尽快控制。硫酸镁为应尽快控制。硫酸镁为首选药物首选药物，必要时可加用强有力的镇静，必要时可加用强有力的镇静剂。剂。2 2防止受伤防止受伤 Prevent injuries.Prevent injuries.3 3避免再次抽搐避免再次抽搐 avoid the second seizure avoid the second seizure 单间，保持环境单间，保持环境安静，光线暗淡；治疗和护理操作应轻柔且相对集中。安静，光线暗淡；治疗和护理操作应轻柔且相对集中。4 4严密监护病
36、情严密监护病情 close monitoring and observation close monitoring and observation 密切观密切观察患者生命体征、神志、尿量等的变化，及早发现脑出血、肺察患者生命体征、神志、尿量等的变化，及早发现脑出血、肺水肿、急性肾衰竭、胎盘早剥等并发症。水肿、急性肾衰竭、胎盘早剥等并发症。5 5做好终止妊娠的准备做好终止妊娠的准备 Prepare for the termination of Prepare for the termination of pregnancy pregnancy 子痫发作者往往在发作后自然临产，应及时发现子痫发作者
37、往往在发作后自然临产，应及时发现产兆，并做好母子抢救准备。产兆，并做好母子抢救准备。3 3硫酸镁用药护理硫酸镁用药护理medication nursingmedication nursing（1 1）用药方法）用药方法 可采用肌内注射或静脉用药。可采用肌内注射或静脉用药。深部肌内注射：深部肌内注射：intramuscular injectionintramuscular injection作用时间长，但局部刺激性强，注射部位疼痛明显；注作用时间长，但局部刺激性强，注射部位疼痛明显；注射时可加利多卡因于硫酸镁溶液中，以缓解疼痛，注射时可加利多卡因于硫酸镁溶液中，以缓解疼痛，注射后用无菌棉球覆盖针
38、孔，防止注射部位感染。射后用无菌棉球覆盖针孔，防止注射部位感染。静脉用药静脉用药intravenous administration intravenous administration 可行静脉滴可行静脉滴注或推注。注或推注。（2 2）毒性反应）毒性反应膝腱反射消失膝腱反射消失 loss of deep tendon reflexes全身肌张力减退全身肌张力减退 muscle hypotonia呼吸抑制呼吸抑制 respiratory paralysis发生心脏停搏发生心脏停搏 cardiac arrest（3 3）注意事项）注意事项应监测患者血压，同时应注意以下事项：应监测患者血压，同时应
39、注意以下事项：膝腱反射必须存在；膝腱反射必须存在；呼吸不少于呼吸不少于1616次次/ /分；分；尿量尿量17ml/h17ml/h或或4400ml/24h00ml/24h。出现中毒反应，出现中毒反应，立即静脉注射立即静脉注射10%10%葡萄糖酸钙葡萄糖酸钙10ml(5-10min)10ml(5-10min)。existence of existence of deep tendon reflexes；breath no less than 16 per minutebreath no less than 16 per minute；urine volume no less thanurine v
40、olume no less than17ml/h or 17ml/h or 4 400ml/24h00ml/24h。if toxic reaction appearsif toxic reaction appears，10% calcium gluconate solution 10ml(5-10% calcium gluconate solution 10ml(5-10min) iv10min) iv。（四）产时及产后护理（四）产时及产后护理 1 1产时护理产时护理 经阴道分娩者，经阴道分娩者，第一产程第一产程应密切监测产妇的血压、脉搏、尿量、应密切监测产妇的血压、脉搏、尿量、胎心及子宫收缩
41、情况，并注意有无头痛、呕吐等自觉症状；胎心及子宫收缩情况，并注意有无头痛、呕吐等自觉症状； 第二产程第二产程期间避免产妇用力，尽量缩短产程，初产妇可行会阴侧期间避免产妇用力，尽量缩短产程，初产妇可行会阴侧切，并可采用产钳助产或胎头吸引器助产；切，并可采用产钳助产或胎头吸引器助产； 第三产程第三产程主主要是预防产后出血，在胎儿娩出前肩后立即静脉注射要是预防产后出血，在胎儿娩出前肩后立即静脉注射缩宫素，但禁用麦角新碱，及时娩出胎盘并按摩宫底。缩宫素，但禁用麦角新碱，及时娩出胎盘并按摩宫底。2 2产后护理产后护理 仍需严密监测血压变化，重视患者主诉，防止发生仍需严密监测血压变化，重视患者主诉，防止发
42、生产后子痫。产后子痫。（五）心理护理（五）心理护理 告知患者愉快心情对预防疾病发展的重告知患者愉快心情对预防疾病发展的重要性，并协助患者合理安排工作与生活，要性，并协助患者合理安排工作与生活，使不感到紧张劳累，又不单调乏味，保持使不感到紧张劳累，又不单调乏味，保持心情愉快、精神放松，积极配合治疗护理心情愉快、精神放松，积极配合治疗护理措施。措施。（六）健康指导（六）健康指导1 1预防预防 加强孕期健康教育，使孕妇了解疾病相关知识，认识到加强孕期健康教育，使孕妇了解疾病相关知识，认识到定期接受产前检查的重要性，并坚持检查，以便及早定期接受产前检查的重要性，并坚持检查，以便及早发现异常，及时处理；
43、发现异常，及时处理；指导孕妇合理饮食，增加蛋白质、维生素以及富含铁、指导孕妇合理饮食，增加蛋白质、维生素以及富含铁、钙、锌的食物，减少脂肪和过量盐的摄入，尤其对于钙、锌的食物，减少脂肪和过量盐的摄入，尤其对于有妊娠期高血压疾病高危因素者，应及早补钙；有妊娠期高血压疾病高危因素者，应及早补钙；保持足够的休息和愉快心情，并坚持左侧卧位。保持足够的休息和愉快心情，并坚持左侧卧位。2 2监护监护 对于妊娠期高血压疾病患者，根据病情需要增加产前对于妊娠期高血压疾病患者，根据病情需要增加产前检查的次数，加强母儿监护；检查的次数，加强母儿监护；为患者及家属讲解疾病相关知识，并指导自数胎动，为患者及家属讲解疾病相关知识，并指导自数胎动，监测体重，以便患者及时汇报病情变化，并取得家属的监测体重，以便患者及时汇报病情变化，并取得家属的理解与支持。理解与支持。
