常見妊娠高血壓疾病專家解讀

HypertensionDisordersComplicatingPregnancy妊娠期高血壓疾病常見妊娠高血壓疾病專家解讀第1頁HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseases常見妊娠高血壓疾病專家解讀第2頁CharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertension常見妊娠高血壓疾病專家解讀第3頁HypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理臨床表現(xiàn)診療治療常見妊娠高血壓疾病專家解讀第4頁EpidemiologyIncidence：6-9%Preeclampsia-eclampsia： 70%ChronicHypertension： 30%Eclampsia 0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）Unknownorigin常見妊娠高血壓疾病專家解讀第5頁P(yáng)athophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcell

injury常見妊娠高血壓疾病專家解讀第6頁P(yáng)athophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunction常見妊娠高血壓疾病專家解讀第7頁SystemicDisease常見妊娠高血壓疾病專家解讀第8頁BrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑常見妊娠高血壓疾病專家解讀第9頁kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis——renalirreversibledamageclinicalmanifestation：albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailure常見妊娠高血壓疾病專家解讀第10頁liverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplatelet常見妊娠高血壓疾病專家解讀第11頁CardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorability常見妊娠高血壓疾病專家解讀第12頁bloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓常見妊娠高血壓疾病專家解讀第13頁placenta-fetusplacenta

PlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetus

IUGRfetaldistressoligohydramniosfetaldeath常見妊娠高血壓疾病專家解讀第14頁P(yáng)athophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdisease常見妊娠高血壓疾病專家解讀第15頁P(yáng)athophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DIC常見妊娠高血壓疾病專家解讀第16頁P(yáng)athophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeath常見妊娠高血壓疾病專家解讀第17頁HighriskfactorsPrimipara<18yor>40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)常見妊娠高血壓疾病專家解讀第18頁EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesis常見妊娠高血壓疾病專家解讀第19頁

GeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplications常見妊娠高血壓疾病專家解讀第20頁GeneticsusceptibilityhypothesisHypertension常見妊娠高血壓疾病專家解讀第21頁ImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonation常見妊娠高血壓疾病專家解讀第22頁P(yáng)lacentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjury常見妊娠高血壓疾病專家解讀第23頁OxidativestresshypothesisOxidativestressreactionEndothelialcellinjury常見妊娠高血壓疾病專家解讀第24頁CategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertension常見妊娠高血壓疾病專家解讀第25頁clinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitation常見妊娠高血壓疾病專家解讀第26頁GestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP>=140mmHgDBP>=90mmHgDiagnosedonlyafterdelivery常見妊娠高血壓疾病專家解讀第27頁P(yáng)reeclampsiaHypertentionoccurs20weeksaftergestationBP>=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpain常見妊娠高血壓疾病專家解讀第28頁SeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:<100109/LProteinuria:≥5g/24hor(+++)4hoursapart

Oliguria:<500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramnios常見妊娠高血壓疾病專家解讀第29頁

SeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:<34wHELLPsyndrome常見妊娠高血壓疾病專家解讀第30頁HELLPsyndromeHemolysisbloodsmearsshowRBCdebrisHb60-90g/LTB>20.5μmol/LElevatedserumlevelofLiverenzymesAST>70u/L,or>3SDLDH>600u/LLowPlateletsPLC<100*109/L常見妊娠高血壓疾病專家解讀第31頁HELLPSeverepreeclampsia：Oneabnormalities 6%Twoabnormalities 12%Threeabnormalities 10%20gw seldomoccur1/3 occurafterdelivery80% diagnosedprenatally常見妊娠高血壓疾病專家解讀第32頁HELLP——clinicaldiagnosisMightbeasymptomaticpainintherightupperabdomen 80%weightgainorsevereedema 50-60%20%cases<140/90mmHg6%caseswithoutproteinuria常見妊娠高血壓疾病專家解讀第33頁SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsia常見妊娠高血壓疾病專家解讀第34頁ClassificationofHELLPBydegreeofthrombocytopenia：<50,000/mm350,000–100,000/mm3>100,000/mm3Notwidelyaccepted常見妊娠高血壓疾病專家解讀第35頁P(yáng)athogenesisandepidemiccharacteristicsofHELLP

coremechanismendothelialinjury——intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomen常見妊娠高血壓疾病專家解讀第36頁HELLP--mortalityMaternal0-24%hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidentsPerinatal7.7-60%PrematuredeliveryIUGRplacentalabruption常見妊娠高血壓疾病專家解讀第37頁Eclampsiaprocess：tonusconvulsionsleepinesscomaOccurrenceprenatalintrapartumpostpartum常見妊娠高血壓疾病專家解讀第38頁ChronicHypertensionduringPregnancyHypertensionbeforepregnancyorHypertensionbefore20weeks’gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3timesPlacentalabruption2timesFGR,pretermbirth常見妊娠高血壓疾病專家解讀第39頁preeclampsiasuperimposeduponchronichypertensionChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w;withhigherBP;thrombocytopenia常見妊娠高血壓疾病專家解讀第40頁DifferentialdiagnosisChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasons常見妊娠高血壓疾病專家解讀第41頁ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminatepregnancytimely常見妊娠高血壓疾病專家解讀第42頁ManagementCommontreatmentRestMonitoringOxygeninhalationDiet:saltrestrictiononlyforanasarcapatients常見妊娠高血壓疾病專家解讀第43頁ManagementSedationDiazepamHibernationdrugsPethidineChlorpromazinePromethazine常見妊娠高血壓疾病專家解讀第44頁ManagementAnti-spasmFirstlinetreatmentforpre-eclampsiaandeclampsiaMgSO4MechanismRegimen≥25-30g/dLoadingdose:25%MgSO410ml+10%GS20mliv5-10min25%MgSO460ml+5%GS500mlivgtt1-2g/h25%MgSO420ml+2%lidocaine2mlim.常見妊娠高血壓疾病專家解讀第45頁ManagementMgSO4Treatmentconcentration1.7-3mmol/LToxicconcentration>3mmol/LToxicityMuscularparalysisPreventionandtreatmentBeforetreatmentKneereflex(+);R≥16bpm;urine≥5ml/hor600ml/24hMgconcentrationmonitoring

Ifsomethinghappens…10%calciumgluconate10mlivfordetoxificationLowerdoseorstopusewhenrenaldysfunction

常見妊娠高血壓疾病專家解讀第46頁ManagementAntihypertensionIndicationSBP≥160mmHg,DBP≥110mmHg,MBP≥140mmHgPrincipleNoferaltoxicity;nolowerrenalanduterineperfusionHydralazine—firstlineLabetalol;calciumchannelblocker;methyldopaSodiumnitroprusside----onlywhenunmanageableBPACEI----contraindicatedduringpregnancy常見妊娠高血壓疾病專家解讀