妊娠高血壓疾病專業(yè)知識培訓培訓課件

1、妊娠高血壓疾病專業(yè)知識培訓妊娠高血壓疾病專業(yè)知識培訓HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases2妊娠高血壓疾病專業(yè)知識培訓HypertensiveGestational HypertCharacteristicsSystemic small arteries spas

2、m Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension; Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension3妊娠高血壓疾病專業(yè)知識培訓CharacteristicsSystemic small Hypertension disorder

3、s complicating pregnancyPathophysiologyCategory and clinical manifestationDiagnosis and differential diagnosisManagement and prevention病理生理臨床表現(xiàn)診斷治療4妊娠高血壓疾病專業(yè)知識培訓Hypertension disorders complicEpidemiologyIncidence： 6-9%Preeclampsia-eclampsia：70%Chronic Hypertension ： 30%Eclampsia0.5% - 1%China 1.0%Ov

4、erseas 0.5%Reflection of medical level The second cause of maternal death (20%)Cause of premature delivery（10%）Unknown origin5妊娠高血壓疾病專業(yè)知識培訓EpidemiologyIncidence： 6-9%5妊娠Pathophysiology Basic pathological changesSpasm of systemic small arteries Vascular endothelial cell injury6妊娠高血壓疾病專業(yè)知識培訓Pathophysi

5、ology Basic pathologPathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMultiple organs dysfunctionIschemiaEdemamalfunction7妊娠高血壓疾病專業(yè)知識培訓PathophysiologyfluidproteinHypSystemic Disease8妊娠高血壓疾病專業(yè)知識培訓Systemic Disease8妊娠高血壓疾病專業(yè)知識培訓BrainHydro

6、cephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：Vasospasmpermeability9妊娠高血壓疾病專業(yè)知識培訓BrainHydrocephalusheadacheHypokidney renal vasospasmrenal blo

7、od 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 10妊娠高血壓疾

8、病專業(yè)知識培訓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 hepa

9、tic enzymesDecreased blood platelet11妊娠高血壓疾病專業(yè)知識培訓liverhepatic vasospasm;liver eCardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertension Pulmonary EdemaOligu

10、riawater-sodium retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor ability12妊娠高血壓疾病專業(yè)知識培訓Cardiovascular System Blood Prblood system Relative hypovolemiaAnemiaDecreased blood plateletHypercoagulability blood clotting factor13妊娠高血壓疾病專業(yè)知識培訓blood system Relative hypovolep

11、lacenta-fetusplacenta Placental hypoperfusionSpiral arteries sclerosis Placental InfarctionPlacental AbruptionPlacental function decreasesfetus IUGRfetal distressoligohydramniosfetal death 14妊娠高血壓疾病專業(yè)知識培訓placenta-fetusplacenta fetPathophysiologyBrainHeadache; visual blurred; coma; herniaKidneyRenal

12、function compromised; proteinuria; renal failureLiverPersistent upper right abdominal pain; Elevated enzyme; jaundice; hematoma; ruptureSystematic disease15妊娠高血壓疾病專業(yè)知識培訓PathophysiologyBrainSystematicPathophysiologyCardiovascular systemLow output- high resistance; myocardial ischemia; pulmonary hyper

13、tension; edema; heart failureBloodLow volume; hypercoagulability; DIC16妊娠高血壓疾病專業(yè)知識培訓PathophysiologyCardiovascular PathophysiologyUterus and PlacentaLow perfusion; placental atherosclerosisPlacental infarction; placental abruption; fetal growth retardation; fetal death17妊娠高血壓疾病專業(yè)知識培訓PathophysiologyUt

14、erus and PlacHigh risk factorsPrimipara40yMultiple pregnancyHypertensionChronic nephritisMalnutritionPoor social statusDiabetesAnti-phospholipid syndromeAngiotensin gene T235 (+)18妊娠高血壓疾病專業(yè)知識培訓High risk factorsPrimiparaAntiEtiologyGenetic susceptibility hypothesisImmune maladaptation hypothesisPlace

15、ntal ischemia hypothesisOxidative stress hypothesis19妊娠高血壓疾病專業(yè)知識培訓EtiologyGenetic susceptibility Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplications20妊娠高血壓疾病專業(yè)知識培訓 Genetic susceptibilityIm

16、mune Genetic susceptibility hypothesisHypertension21妊娠高血壓疾病專業(yè)知識培訓Genetic susceptibility hypotheImmune maladaptation hypothesisMultiple gestationAbortion and blood transfusionOvum and sperm donation22妊娠高血壓疾病專業(yè)知識培訓Immune maladaptation hypothesiPlacental ischemia hypothesis40% total spiral artery area

17、compared to normal pregnancyEndothelial cell injury23妊娠高血壓疾病專業(yè)知識培訓Placental ischemia hypothesis4Oxidative stress hypothesisOxidative stress reactionEndothelial cell injury24妊娠高血壓疾病專業(yè)知識培訓Oxidative stress hypothesisOxiCategory and clinical manifestationGestational hypertension PreeclampsiaEclampsia Ch

18、ronic hypertensionPreeclampsia superimposed on chronic hypertension25妊娠高血壓疾病專業(yè)知識培訓Category and clinical manifestclinical features typical : hypertension、albuminuria、edemauntypical ：asymptomatic severe：nausea、vomitheadache、dazzleconvulsion 、comachest distress 、palpitation 26妊娠高血壓疾病專業(yè)知識培訓clinical feat

19、ures typical : Gestational Hypertension Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumSBP=140mmHgDBP =90mmHgDiagnosed only after delivery27妊娠高血壓疾病專業(yè)知識培訓Gestational Hypertension DefinPreeclampsiaHypertention occurs 20 weeks after gestation BP=140/90mmHgProtei

20、nuria Proteinuria 300mg/24h Urine protein （+）Other symptomsHeadache, visual blurringUpper abdominal pain28妊娠高血壓疾病專業(yè)知識培訓PreeclampsiaHypertention occurSevere preeclampsiaAt least one of the following features：Central nervous system abnormalities Hepatic subcapsular hematoma / hepatorrhexisHepatocyte i

21、njury :GPTBlood pressure：SBP160mmHg，or DBP110mmHgThrombocytopenia: 100109/LProteinuria: 5g/24h or (+) 4 hours apart Oliguria: 500ml/24hPulmonary edema Cerebrovascular accidentIntravascular hemolysis : anemia, jaundiceCoagulation dysfunctionFetal growth restriction / oligohydramnios29妊娠高血壓疾病專業(yè)知識培訓Sev

22、ere preeclampsiaAt least onSevere preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia : 20.5mol/LElevated serum level of Liver enzymesAST70u/L, or 3SDLDH600u/LLow PlateletsPLC100*109/L31妊娠高血壓疾病專業(yè)知識培訓HELLP syndromeHemolysisElevateHELLPSevere preeclampsia ：One abnormalities

23、6%Two abnormalities 12%Three abnormalities10%20 gw seldom occur1/3 occur after delivery80% diagnosed prenatally32妊娠高血壓疾病專業(yè)知識培訓HELLPSevere preeclampsia ：32妊娠HELLPclinical diagnosis Might be asymptomatic pain in the right upper abdomen80% weight gain or severe edema 50-60%20% cases 140/90 mmHg6% cases

24、 without proteinuria33妊娠高血壓疾病專業(yè)知識培訓HELLPclinical diagnosis MighSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia34妊娠高血壓疾病專業(yè)知識培訓Some investigatiors regard HELClassification of HELLPBy degree of thrombocytopenia：100,000/mm3Not widely accepted35妊娠高血壓疾病專業(yè)

25、知識培訓Classification of HELLPBy degrPathogenesis and epidemic characteristics of HELLP core mechanismendothelial injuryintravascular coagulation dysfunctionpredisposing factorsthe whitemultipara elder pregnant women36妊娠高血壓疾病專業(yè)知識培訓Pathogenesis and epidemic charHELLP-mortalityMaternal 0-24%hepatorrhexis

26、DICAcute renal failurethrombosiscerebrovascular accidentsPerinatal 7.7-60%Premature deliveryIUGRplacental abruption 37妊娠高血壓疾病專業(yè)知識培訓HELLP-mortalityMaternal 0-2Eclampsiaprocess：tonusconvulsionsleepinesscoma Occurrenceprenatalintrapartumpostpartum 38妊娠高血壓疾病專業(yè)知識培訓Eclampsiaprocess：Occurrence38妊妊娠高血壓疾病專業(yè)知

27、識培訓培訓課件preeclampsia superimposed upon chronic hypertensionChronic Hypertension Before 20 gestational weeksPersist 12 weeks postpartumProteinuriaBefore 20wAfter 20w; with higher BP; thrombocytopenia40妊娠高血壓疾病專業(yè)知識培訓preeclampsia superimposed uponDifferential diagnosisChronic nephritis complicating pregn

28、ancyRenal dysfunctionSeizure caused by other reasons41妊娠高血壓疾病專業(yè)知識培訓Differential diagnosisChronic ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminate pregnancy timely42妊娠高血壓疾病專業(yè)知識培訓ManagementPrinciple42妊娠高血壓疾病專業(yè)ManagementCommon treatmentRestMonitoringOxygen inhalationDiet: salt re

29、striction only for anasarca patients43妊娠高血壓疾病專業(yè)知識培訓ManagementCommon treatment43妊娠ManagementSedationDiazepamHibernation drugsPethidineChlorpromazinePromethazine44妊娠高血壓疾病專業(yè)知識培訓ManagementSedation44妊娠高血壓疾病專業(yè)知ManagementAnti-spasmFirst line treatment for pre-eclampsia and eclampsiaMgSO4 MechanismRegimen 2

30、5-30g/dLoading dose: 25% MgSO4 10ml +10%GS 20ml iv 5-10min25% MgSO4 60ml +5%GS 500ml ivgtt 1-2g/h25% MgSO4 20ml +2%lidocaine 2ml im. 45妊娠高血壓疾病專業(yè)知識培訓ManagementAnti-spasm45妊娠高血壓疾病專ManagementMgSO4Treatment concentration 1.7-3mmol/LToxic concentration 3mmol/LToxicityMuscular paralysisPrevention and treatmentBefore treatmentKnee reflex (+); R16bpm; urine5ml/h or 600ml/24hMg concentration monitoring If something happens10% calcium gluconate 10ml iv for detoxificationLower dose or stop use when re