妊娠高血压疾病课件

Hypertension Disorders Complicating Pregnancy妊娠期高血压疾病妊娠期高血压疾病.Hypertension Disorders ComplicHypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related DiseasesHypertensiveGestational HypertCharacteristicsSystemic small arteries spasm Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension;Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic HypertensionCharacteristicsSystemic small Hypertension disorders complicating pregnancynPathophysiologynCategory and clinical 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Hypertension disorders complicEpidemiologynIncidence：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 death(20%)nCause of premature delivery（10%）nUnknown originEpidemiologyIncidence：6-9%Pathophysiology nBasic pathological changesnSpasm of systemic small arteries nVascular endothelial cell injuryPathophysiology Basic pathologPathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMultiple organs dysfunctionIschemiaEdemamalfunctionPathophysiologyfluidproteinHypSystemic DiseaseSystemic DiseaseBrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：VasospasmpermeabilityBrainHydrocephalusheadacheHypokidney renal vasospasmrenal blood flow glomerular filtration rate pathology：Glomerular expansion swollen vascular endothelial cellcellulose depositionrenocortical necrosisrenal irreversible damageclinical manifestation：albuminuriahypoproteinemiarenal dysfunction creatinine urea nitrogen uric acid oliguria renal failure kidney renal vasospasmrenal blliverhepatic vasospasm;hepatic ischemia;hepatic edema liver enlargement;hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed severe：Periportal necrosishepatic subcapsularhematomahepatorrhexis HELLP symdrome:Elevated hepatic enzymesDecreased blood plateletliverhepatic vasospasm;liver eCardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertension Pulmonary EdemaOliguriawater-sodium retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor abilityCardiovascular System Blood Prblood system nRelative hypovolemianAnemianDecreased blood plateletnHypercoagulability nblood clotting factorblood system Relative hypovoleplacenta-fetusnplacenta nPlacental hypoperfusionnSpiral arteries sclerosis nPlacental InfarctionnPlacental AbruptionnPlacental function decreasesofetus nIUGRnfetal distressnoligohydramniosnfetal death placenta-fetusplacenta fetPathophysiologynBrainnHeadache;visual blurred;coma;hernianKidneynRenal function compromised;proteinuria;renal failurenLivernPersistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;ruptureSystematic diseasePathophysiologyBrainSystematicPathophysiologynCardiovascular systemnLow output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failurenBloodnLow volume;hypercoagulability;DICPathophysiologyCardiovascular PathophysiologynUterus and PlacentanLow perfusion;placental atherosclerosisnPlacental infarction;placental abruption;fetal growth retardation;fetal deathPathophysiologyUterus and PlacHigh risk factorsnPrimiparan40ynMultiple pregnancynHypertensionnChronic nephritisnMalnutritionnPoor social statusnDiabetesnAnti-phospholipid syndromenAngiotensin gene T235(+)High risk factorsPrimiparaAntiEtiologynGenetic susceptibility hypothesisnImmune maladaptation hypothesisnPlacental ischemia hypothesisnOxidative stress hypothesisEtiologyGenetic susceptibility Immune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplications Genetic susceptibilityImmune Genetic susceptibility hypothesisHypertensionGenetic susceptibility hypotheImmune maladaptation hypothesisnMultiple gestationnAbortion and blood transfusionnOvum and sperm donationImmune maladaptation hypothesiPlacental ischemia hypothesisn40%total spiral artery area compared to normal pregnancynEndothelial cell injuryPlacental ischemia hypothesis4Oxidative stress hypothesisOxidative stress reactionEndothelial cell injuryOxidative stress hypothesisOxiCategory and clinical manifestationnGestational hypertension nPreeclampsianEclampsia nChronic hypertensionnPreeclampsia superimposed on chronic hypertensionCategory and clinical manifestclinical features ntypical:nhypertension、albuminuria、edemanuntypical：nasymptomatic nsevere：nnausea、vomitnheadache、dazzlenconvulsion、comanchest distress、palpitation clinical features typical:Gestational Hypertension nDefinition nHypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumnSBP=140mmHgnDBP=90mmHgnDiagnosed only after deliveryGestational Hypertension DefinPreeclampsianHypertention occurs 20 weeks after gestation nBP=140/90mmHgnProteinuria nProteinuria 300mg/24h nUrine protein（+）nOther symptomsnHeadache,visual blurringnUpper abdominal painPreeclampsiaHypertention occurSevere 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/24hnPulmonary edema nCerebrovascular accidentnIntravascular hemolysis:anemia,jaundicenCoagulation dysfunctionnFetal growth restriction/oligohydramniosSevere preeclampsiaAt least onSevere preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia:20.5mol/LnElevated serum level of Liver enzymesnAST70u/L,or 3SDnLDH600u/LnLow PlateletsnPLC100*109/LHELLP syndromeHemolysisElevateHELLPnSevere preeclampsia：nOne abnormalities 6%nTwo abnormalities 12%nThree abnormalities 10%n20 gw seldom occurn1/3 occur after deliveryn80%diagnosed prenatallyHELLPSevere preeclampsia：HELLPclinical diagnosis nMight be asymptomatic npain in the right upper abdomen80%n weight gain or severe edema 50-60%n20%cases 140/90 mmHgn6%cases without proteinuriaHELLPclinical diagnosis MighnSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsiaSome investigatiors regard HELClassification of HELLPnBy degree of thrombocytopenia：n100,000/mm3nNot widely acceptedClassification of HELLPBy degrPathogenesis and epidemic characteristics of HELLP ncore mechanismnendothelial injuryintravascular coagulation dysfunctionnpredisposing factorsnthe whitenmultipara nelder pregnant womenPathogenesis and epidemic charHELLP-mortalitynMaternal 0-24%nhepatorrhexisnDICnAcute renal failurenthrombosisncerebrovascular accidentsnPerinatal 7.7-60%nPremature deliverynIUGRnplacental abruption HELLP-mortalityMaternal 0-2Eclampsianprocess：ntonusnconvulsionnsleepinessncoma nOccurrencenprenatalnintrapartumnpostpartum Eclampsiaprocess：OccurrenceChronic Hypertension during PregnancynHypertension before pregnancy or nHypertension before 20 weeks gestationalnUnrelieved 12 weeks postpartumnPoor fetal outcomenPerinatal mortality 3 times nPlacental abruption 2 times nFGR,preterm birth Chronic Hypertension during Prpreeclampsia superimposed upon chronic hypertensionnChronic Hypertension nBefore 20 gestational weeksnPersist 12 weeks postpartumnProteinurianBefore 20wnAfter 20w;with higher BP;thrombocytopeniapreeclampsia superimposed uponDifferential diagnosisnChronic nephritis complicating pregnancynRenal dysfunctionnSeizure caused by other reasonsDifferential diagnosisChronic ManagementnPrinciplenSedationnAnti-spasmnAnti-hypertensionnDiuresisnTerminate pregnancy timelyManagementPrincipleManagementnCommon treatmentnRestnMonitoringnOxygen inhalationnDiet:salt restriction only for anasarca patientsManagementCommon treatmentManagementnSedationnDiazepamnHibernation drugsnPethidinenChlorpromazinenPromethazineManagementSedationManagementnAnti-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.ManagementAnti-spasmManagementnMgSO4nTreatment concentration 1.7-3mmol/LnToxic 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 dysfunctionManagementMgSO4ManagementnAntihypertensionnIndication 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 pregnancyManagementAntihypertensionManagementnVolumetric dilatancy-only for severe Hypoproteinemia and anemianDiuretic agent-only for severe edemaManagementVolumetric dilatancyManagementnTerminate 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 dysfunctionManagementChronic hypertensionPreventionnA well organized health care systemnA well monitored pregnant periodnAppropriate diet and restPreventionA well organized hea