妊娠高血壓疾病陳曉軍英文教學(xué)課件

HypertensionDisordersComplicatingPregnancy妊娠期高血壓疾病HypertensionDisordersComplic1HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseasesHypertensiveGestationalHypert2CharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertensionCharacteristicsSystemicsmall3HypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理臨床表現(xiàn)診斷治療Hypertensiondisorderscomplic4EpidemiologyIncidence：6-9%Preeclampsia-eclampsia： 70%ChronicHypertension： 30%Eclampsia 0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）UnknownoriginEpidemiologyIncidence：6-9%5PathophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcell

injuryPathophysiologyBasicpatholog6PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunctionPathophysiologyfluidproteinHyp7SystemicDiseaseSystemicDisease8BrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑BrainHydrocephalusheadacheHypo9kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis——renalirreversibledamageclinicalmanifestation：albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailurekidneyrenalvasospasmrenalbl10liverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplateletliverhepaticvasospasm;livere11CardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorabilityCardiovascularSystemBloodPr12bloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓bloodsystemRelativehypovole13placenta-fetusplacenta

PlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetus

IUGRfetaldistressoligohydramniosfetaldeathplacenta-fetusplacentafet14PathophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdiseasePathophysiologyBrainSystematic15PathophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DICPathophysiologyCardiovascular16PathophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeathPathophysiologyUterusandPlac17HighriskfactorsPrimipara<18yor>40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)HighriskfactorsPrimiparaAnti18EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesisEtiologyGeneticsusceptibility19

GeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplicationsGeneticsusceptibilityImmune20GeneticsusceptibilityhypothesisHypertensionGeneticsusceptibilityhypothe21ImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonationImmunemaladaptationhypothesi22Placentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjuryPlacentalischemiahypothesis423OxidativestresshypothesisOxidativestressreactionEndothelialcellinjuryOxidativestresshypothesisOxi24CategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertensionCategoryandclinicalmanifest25clinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitationclinicalfeaturestypical:26GestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP>=140mmHgDBP>=90mmHgDiagnosedonlyafterdeliveryGestationalHypertensionDefin27PreeclampsiaHypertentionoccurs20weeksaftergestationBP>=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpainPreeclampsiaHypertentionoccur28SeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:<100109/LProteinuria:≥5g/24hor(+++)4hoursapart

Oliguria:<500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramniosSeverepreeclampsiaAtleaston29

SeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:<34wHELLPsyndrome

Severepreeclampsiacomplic30HELLPsyndromeHemolysisbloodsmearsshowRBCdebrisHb60-90g/LTB>20.5μmol/LElevatedserumlevelofLiverenzymesAST>70u/L,or>3SDLDH>600u/LLowPlateletsPLC<100*109/LHELLPsyndromeHemolysisElevate31HELLPSeverepreeclampsia：Oneabnormalities 6%Twoabnormalities 12%Threeabnormalities 10%20gw seldomoccur1/3 occurafterdelivery80% diagnosedprenatallyHELLPSeverepreeclampsia：32HELLP——clinicaldiagnosisMightbeasymptomaticpainintherightupperabdomen 80%weightgainorsevereedema 50-60%20%cases<140/90mmHg6%caseswithoutproteinuriaHELLP——clinicaldiagnosisMigh33SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsiaSomeinvestigatiorsregardHEL34ClassificationofHELLPBydegreeofthrombocytopenia：<50,000/mm350,000–100,000/mm3>100,000/mm3NotwidelyacceptedClassificationofHELLPBydegr35PathogenesisandepidemiccharacteristicsofHELLP

coremechanismendothelialinjury——intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomenPathogenesisandepidemicchar36HELLP--mortalityMaternal0-24%hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidentsPerinatal7.7-60%PrematuredeliveryIUGRplacentalabruptionHELLP--mortalityMaternal0-237Eclampsiaprocess：tonusconvulsionsleepinesscomaOccurrenceprenatalintrapartumpostpartumEclampsiaprocess：Occurrence38ChronicHypertensionduringPregnancyHypertensionbeforepregnancyorHypertensionbefore20weeks’gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3timesPlacentalabruption2timesFGR,pretermbirthChronicHypertensionduringPr39preeclampsiasuperimposeduponchronichypertensionChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w;withhigherBP;thrombocytopeniapreeclampsiasuperimposedupon40DifferentialdiagnosisChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasonsDifferentialdiagnosisChronic41ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminatepregnancytimelyManagementPrinciple42ManagementCommontreatmentRestMonitoringOxygeninhalationDiet:saltrestrictiononlyforanasarcapatientsManagementCommontreatment43ManagementSedationDiazepamHibernationdrugsPethidineChlorpromazinePromethazineManagementSedation44ManagementAnti-spasmFirstlinetreatmentforpre-eclampsiaandeclampsiaMgSO4MechanismRegimen≥25-30g/dLoadingdose:25%MgSO410ml+10%GS20mliv5-10min25%MgSO460ml+5%GS500mlivgtt1-2g/h25%MgSO420ml+2%lidocaine2mlim.ManagementAnti-spasm45ManagementMgSO4Treatmentconcentration1.7-3mmol/LToxicconcentration>3mmol/LToxicityMuscularparalysisPreventionandtreatmentBeforetreatmentKneereflex(+);R≥16bpm;urine≥5ml/hor600ml/24hMgconcentrationmonitoring

Ifsomethinghappens…10%calciumgluconate10mlivfordetoxificationLowerdoseorstopusewhenrenaldysfunction

ManagementMgSO446ManagementAntihypertensionIndicationSBP≥160mmHg,DBP≥110mmHg,MBP≥140mmHgPrincipleNoferaltoxicity;nolowerrenalanduterineperfusionHydralazine—firstlineLabetalol;calciumchannelblocker;methyldopaSodiumnitroprusside----onlywhenunmanageableBPACEI----contraindicatedduringpregnancyManagementAntihypertension47ManagementVolumetricdilatancy----onlyforsevereHypoproteinemiaandanemiaDiureticagent----onlyforsevereedemaManagementVolumetricdilatancy48ManagementTerminatepregnancySeverepre-eclampsiaunrelievedafteractivetreatmentfor24-48hoursSeverepre-eclampsia,>34wSeverepre-eclampsia,<34wwithmaturedfetusandplacentaldysfunctionSeverepre-eclampsia,<34wwithunmaturedfetusandplacentaldysfunction,terminateafterdexamethasonedelivery2haftercontrollingeclampsiaManagementTerminatepregnancy49ManagementTerminatepregnancyInducedlaborC-SPreventpostpartumeclampsiaManagementTerminatepregnancy50ManagementEclampsiaControlseizurebyMgSO4and20%mannitolAnti-hypertensionCorrectacidosisandhypoxiaTerminatepregnancy2hoursaftercontrollingseizureNursingManagementEclampsia51ManagementChronichypertensionIndicationSBP>150-180mmHg;DBP>100mmHg;hypertensionrelatedorgandysfunctionManagementChronichypertension52PreventionAwellorganizedhealthcaresystemAwellmonitoredpregnantperiodAppropriatedietandrestPreventionAwellorganizedhea53HypertensionDisordersComplicatingPregnancy妊娠期高血壓疾病HypertensionDisordersComplic54HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseasesHypertensiveGestationalHypert55CharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertensionCharacteristicsSystemicsmall56HypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理臨床表現(xiàn)診斷治療Hypertensiondisorderscomplic57EpidemiologyIncidence：6-9%Preeclampsia-eclampsia： 70%ChronicHypertension： 30%Eclampsia 0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）UnknownoriginEpidemiologyIncidence：6-9%58PathophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcell

injuryPathophysiologyBasicpatholog59PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunctionPathophysiologyfluidproteinHyp60SystemicDiseaseSystemicDisease61BrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑BrainHydrocephalusheadacheHypo62kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis——renalirreversibledamageclinicalmanifestation：albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailurekidneyrenalvasospasmrenalbl63liverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplateletliverhepaticvasospasm;livere64CardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorabilityCardiovascularSystemBloodPr65bloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓bloodsystemRelativehypovole66placenta-fetusplacenta

PlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetus

IUGRfetaldistressoligohydramniosfetaldeathplacenta-fetusplacentafet67PathophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdiseasePathophysiologyBrainSystematic68PathophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DICPathophysiologyCardiovascular69PathophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeathPathophysiologyUterusandPlac70HighriskfactorsPrimipara<18yor>40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)HighriskfactorsPrimiparaAnti71EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesisEtiologyGeneticsusceptibility72

GeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplicationsGeneticsusceptibilityImmune73GeneticsusceptibilityhypothesisHypertensionGeneticsusceptibilityhypothe74ImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonationImmunemaladaptationhypothesi75Placentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjuryPlacentalischemiahypothesis476OxidativestresshypothesisOxidativestressreactionEndothelialcellinjuryOxidativestresshypothesisOxi77CategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertensionCategoryandclinicalmanifest78clinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitationclinicalfeaturestypical:79GestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP>=140mmHgDBP>=90mmHgDiagnosedonlyafterdeliveryGestationalHypertensionDefin80PreeclampsiaHypertentionoccurs20weeksaftergestationBP>=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpainPreeclampsiaHypertentionoccur81SeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:<100109/LProteinuria:≥5g/24hor(+++)4hoursapart

Oliguria:<500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramniosSeverepreeclampsiaAtleaston82

SeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:<34wHELLPsyndrome

Severepreeclampsiacomplic83HELLPsyndromeHemolysisbloodsmearsshowRBCdebrisHb60-90g/LTB>20.5μmol/LElevatedserumlevelofLiverenzymesAST>70u/L,or>3SDLDH>600u/LLowPlateletsPLC<100*109/LHELLPsyndromeHemolysisElevate84HELLPSeverepreeclampsia：Oneabnormalities 6%Twoabnormalities 12%Threeabnormalities 10%20gw seldomoccur1/3 occurafterdelivery80% diagnosedprenatallyHELLPSeverepreeclampsia：85HELLP——clinicaldiagnosisMightbeasymptomaticpainintherightupperabdomen 80%weightgainorsevereedema 50-60%20%cases<140/90mmHg6%caseswithoutproteinuriaHELLP——clinicaldiagnosisMigh86SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsiaSomeinvestigatiorsregardHEL87ClassificationofHELLPBydegreeofthrombocytopenia：<50,000/mm350,000–100,000/mm3>100,000/mm3NotwidelyacceptedClassificationofHELLPBydegr88PathogenesisandepidemiccharacteristicsofHELLP

coremechanismendothelialinjury——intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomenPathogenesisandepidemicchar89HELLP--mortalityMaternal0-24%hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidentsPerinatal7.7-60%PrematuredeliveryIUGRplacentalabruptionHELLP--mortalityMaternal0-290Eclampsiaprocess：tonusconvulsionsleepinesscomaOccurrenceprenatalintrapartumpostpartumEclampsiaprocess：Occurrence91ChronicHypertensionduringPregnancyHypertensionbeforepregnancyorHypertensionbefore20weeks’gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3timesPlacentalabruption2timesFGR,pretermbirthChronicHypertensionduringPr92preeclampsiasuperimposeduponchronichypertensionChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w;withhigherBP;thrombocytopeniapreeclampsiasuperimposedupon93DifferentialdiagnosisChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasonsDifferentialdiagnosisChronic94ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminatepregnancytimelyManagementPrinciple95ManagementCommontreatmentRestMonitoringOxygeninhalationDiet:saltrestrictiononlyforanasarcapatie