妊娠高血壓疾病陳曉軍

妊娠高血壓疾病陳曉軍第1頁(yè)/共54頁(yè)HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseases第2頁(yè)/共54頁(yè)CharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertension第3頁(yè)/共54頁(yè)HypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理臨床表現(xiàn)診斷治療第4頁(yè)/共54頁(yè)EpidemiologyIncidence：6-9%Preeclampsia-eclampsia：

70%ChronicHypertension：

30%Eclampsia 0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）Unknownorigin第5頁(yè)/共54頁(yè)P(yáng)athophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcell

injury第6頁(yè)/共54頁(yè)P(yáng)athophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunction第7頁(yè)/共54頁(yè)SystemicDisease第8頁(yè)/共54頁(yè)BrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑第9頁(yè)/共54頁(yè)kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：Glomerularexpansionswollenvascularendothelialcellcellulosedepositionrenocorticalnecrosis——renalirreversibledamageclinicalmanifestation：albuminuriahypoproteinemiarenaldysfunctioncreatinineureanitrogenuricacidoliguriarenalfailure第10頁(yè)/共54頁(yè)liverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplatelet第11頁(yè)/共54頁(yè)CardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorability第12頁(yè)/共54頁(yè)bloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓第13頁(yè)/共54頁(yè)placenta-fetusplacenta

PlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetus

IUGRfetaldistressoligohydramniosfetaldeath第14頁(yè)/共54頁(yè)P(yáng)athophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdisease第15頁(yè)/共54頁(yè)P(yáng)athophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DIC第16頁(yè)/共54頁(yè)P(yáng)athophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeath第17頁(yè)/共54頁(yè)HighriskfactorsPrimipara<18yor>40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)第18頁(yè)/共54頁(yè)EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesis第19頁(yè)/共54頁(yè)

GeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplications第20頁(yè)/共54頁(yè)GeneticsusceptibilityhypothesisHypertension第21頁(yè)/共54頁(yè)ImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonation第22頁(yè)/共54頁(yè)P(yáng)lacentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjury第23頁(yè)/共54頁(yè)OxidativestresshypothesisOxidativestressreactionEndothelialcellinjury第24頁(yè)/共54頁(yè)CategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertension第25頁(yè)/共54頁(yè)clinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitation第26頁(yè)/共54頁(yè)GestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP>=140mmHgDBP>=90mmHgDiagnosedonlyafterdelivery第27頁(yè)/共54頁(yè)P(yáng)reeclampsiaHypertentionoccurs20weeksaftergestationBP>=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpain第28頁(yè)/共54頁(yè)SeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:<100109/LProteinuria:≥5g/24hor(+++)4hoursapart

Oliguria:<500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramnios第29頁(yè)/共54頁(yè)

SeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:<34wHELLPsyndrome第30頁(yè)/共54頁(yè)HELLPsyndromeHemolysisbloodsmearsshowRBCdebrisHb60-90g/LTB>20.5μmol/LElevatedserumlevelofLiverenzymesAST>70u/L,or>3SDLDH>600u/LLowPlateletsPLC<100*109/L第31頁(yè)/共54頁(yè)HELLPSeverepreeclampsia：Oneabnormalities 6%Twoabnormalities 12%Threeabnormalities 10%20gw seldomoccur1/3 occurafterdelivery80% diagnosedprenatally第32頁(yè)/共54頁(yè)HELLP——clinicaldiagnosisMightbeasymptomaticpainintherightupperabdomen 80%weightgainorsevereedema 50-60%20%cases<140/90mmHg6%caseswithoutproteinuria第33頁(yè)/共54頁(yè)SomeinvestigatiorsregardHELLPsyndromeasanentirelydistinctdiseaseentityfrompreeclampsia第34頁(yè)/共54頁(yè)ClassificationofHELLPBydegreeofthrombocytopenia：<50,000/mm350,000–100,000/mm3>100,000/mm3Notwidelyaccepted第35頁(yè)/共54頁(yè)P(yáng)athogenesisandepidemiccharacteristicsofHELLP

coremechanismendothelialinjury——intravascularcoagulationdysfunctionpredisposingfactorsthewhitemultiparaelderpregnantwomen第36頁(yè)/共54頁(yè)HELLP--mortalityMaternal0-24%hepatorrhexisDICAcuterenalfailurethrombosiscerebrovascularaccidentsPerinatal7.7-60%PrematuredeliveryIUGRplacentalabruption第37頁(yè)/共54頁(yè)Eclampsiaprocess：tonusconvulsionsleepinesscomaOccurrenceprenatalintrapartumpostpartum第38頁(yè)/共54頁(yè)ChronicHypertensionduringPregnancyHypertensionbeforepregnancyorHypertensionbefore20weeks’gestationalUnrelieved12weekspostpartumPoorfetaloutcomePerinatalmortality3timesPlacentalabruption2timesFGR,pretermbirth第39頁(yè)/共54頁(yè)preeclampsiasuperimposeduponchronichypertensionChronicHypertensionBefore20gestationalweeksPersist12weekspostpartumProteinuriaBefore20wAfter20w;withhigherBP;thrombocytopenia第40頁(yè)/共54頁(yè)DifferentialdiagnosisChronicnephritiscomplicatingpregnancyRenaldysfunctionSeizurecausedbyotherreasons第41頁(yè)/共54頁(yè)ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminatepregnancytimely第42頁(yè)/共54頁(yè)ManagementCommontreatmentRestMonitoringOxygeninhalationDiet:saltrestrictiononlyforanasarcapatients第43頁(yè)/共54頁(yè)ManagementSedationDiazepamHibernationdrugsPethidineChlorpromazinePromethazine第44頁(yè)/共54頁(yè)ManagementAnti-spasmFirstlinetreatmentforpre-eclampsiaandeclampsiaMgSO4MechanismRegimen≥25-30g/dLoadingdose:25%MgSO410ml+10%GS20mliv5-10min25%MgSO460ml+5%GS500mlivgtt1-2g/h25%MgSO420ml+2%lidocaine2mlim.第45頁(yè)/共54頁(yè)ManagementMgSO4Treatmentconcentration1.7-3mmol/LToxicconcentration>3mmol/LToxicityMuscularparalysisPreventionandtreatmentBeforetreatmentKneereflex(+);R≥16bpm;urine≥5ml/hor600ml/24hMgconcentrationmonitoring

Ifsomethinghappens…10%calciumgluconate10mlivfordetoxificationLowerdoseorstopusewhenrenaldysfunction

第46頁(yè)/共54頁(yè)ManagementAntihypertensionIndicationSBP≥160mmHg,DBP≥110mmHg,MBP≥140mmHgPrincipleNoferaltoxicity;nolowerrenalanduterineperfusionHydralazine—firstlineLabetalol;calciumchannelblocker;methyldopaSodiumnitroprusside----onlywhenunmanageableBPACEI----contraindicatedduringpregnancy第47頁(yè)/共54頁(yè)ManagementVo