妊娠高血壓疾病PPT課件介紹

1、婦產(chǎn)科學(第3版)普通高等教育“十二五”國家級規(guī)劃教材衛(wèi)生部“十二五”規(guī)劃教材全國高等醫(yī)藥教材建設研究會 全國高等學校教材供基礎、臨床、預防、口腔醫(yī)學類專業(yè)用妊娠高血壓疾病 hypertension disorders complicating pregnancyYING ZHANGDepartment of Obstetrics and GynecologyThe first Affiliated HospitalSun Yat-sen UniversityPregnancy-Related Mortality United States (1998-2005)Preeclampsia (1

2、2.3%)Other medical conditions (13.2%)Embolism (18%) PE (10%) AFE (8%)Cardiomyopathy (11.5%)CVAcerebrovascular accident (6%)Anesthesia (1%)Unknown (2.1%)Hemorrhage (12.5%)Obstet Gynecol 2010Cardiovascular disease (12.4%)Infection (11 %)Common: 5% 12% of pregnanciesMorbidity: fetus: 12% of preterm del

3、iveries mother: stroke, CHF, renal injuryMortality: 12-13% of maternal mortalityCategoriesGestational Hypertension Preeclampsia and eclampsiaChronic HypertensionPreeclampsia superimposed on Chronic HypertensionClassification1. Chronic hypertensionGestational hypertension3. Preeclampsia- without seve

4、re features- with severe features (severe preeclampsia)4. Chronic hypertension with superimposed preeclampsia- without severe features- with severe features Hypertension in Pregnancy ACOG Task Force (Nov 2013)Risk FactorsFACTORRISK RATIORenal disease20:1Chronic hypertension10:1Antiphospholipid syndr

5、ome10:1Family history of PIH5:1Twin gestation4:1Nulliparity3:1Age 403:1Diabetes mellitus2:1African American1.5:1Immune mechanism (rejection phenomenon, insufficient blocking Ab)Injury of vascular endothelium-disruption of the equilibrium between vasoconstriction and vasodilatation, imbalance between

6、 PGI and TXACompromised placenta profusionGenetic factorDietary factors: nutrition deficiencyInsulin resistanceIncrease CNS irritabilityEtiologyUNCLEAR Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredD

7、ICComplicationsEtiologyVasospasm predominant findingEndothelialinjury Nitric oxide microthrombi developmentProstanoid balanceLipid peroxide, free radicals and antioxidantsIschaemiaPathophysiologyPathophysiologyNeurologic effectsRenal effectsHematologic effects Cardiovascular effectsBlood & coagulati

8、on Fetal effectsPathophysiologyNeurologic effects Raised BP disrupt autoregulationmicroinfarcts, and petechial hemorrhage, Cerebral edemaHeadache, Seizures, Serous retinal detachment ,Cortical blindnessradiologic imagingRenal effectsHematologic effects Cardiovascular effectsBlood & coagulation Fetal

9、 effectsPathophysiologyNeurologic effectsRenal effectsDecreased glomerular filtration rateGlomerular endotheliosisProteinuria, Increase of plasma uric acid, creatinineOliguriaAcute tubular necrosisHematologic effects Cardiovascular effectsBlood & coagulation Fetal effectsPathophysiologyNeurologic ef

10、fectsRenal effectsHematologic effects Subclinical involvementliver dysfunctionRupture of the liver or hepatic infarctionHELLP syndrome: hemolysis, elevated liver enzymes and low plateletsCardiovascular effectsBlood & coagulation Fetal effectsPathophysiologyNeurologic effectsRenal effectsHematologic

11、effects Cardiovascular effectsVasoconstriction, low-output, high-resistance stateSignificantly volume-depletedCapillary leakCardiac ischemia, hemorrhage, infarction, heart failureIncreased sensitivity to vasoconstrictor effects of angiotensinBlood & coagulation Fetal effectsPathophysiologyNeurologic

12、 effectsRenal effectsHematologic effects Cardiovascular effectsBlood & coagulation Hypovolemia,elevated hematocrit,third spacing of fluid, low oncotic pressurehypercoagulable state ThrombocytopeniaMicroangiopathic hemolytic anemia, DIC (5%)Fetal effectsPathophysiologyNeurologic effectsRenal effectsH

13、ematologic effects Cardiovascular effectsBlood & coagulation Fetal effectsatherosis of spiral arteries, vessel obliteration- placental abruptionfetal growth restriction,oligohydramnios,fetal distressPlacenta abruptionIncreased perinatal morbidity and mortalityClassification Clinical manifestationsHy

14、pertension (either):SBP 140DBP 90Severe hypertension (either):SBP 160DBP 110BP 4 hours apart (although on occasion, when faced with severe hypertension, the diagnosis can be confirmed within a short interval (even minutes) to facilitate timely antihypertensive therapy)Classification Clinical manifes

15、tationsAssessing BP (ideal):- seated, legs uncrossed, relaxed, quiet- back and arm supported- middle of cuff at level of right atrium- wait 5 minutes before first readingImproper assessment:- left lateral using upper arm- gives falsely low valuesClassification Clinical manifestationsDefinition Prote

16、inuria: - 24 hour* 300 mg - timed (i.e. 12hr) 300 mg (extrapolated) - P/C ratio 0.3 - urine dipstick* 1+* 24 urine is preferred method* urine dipstick used only if no other availableGestational HypertensionFormerly called PIH (Pregnancy Induced HTN)HTN without proteinuria occurring after 20 weeks ge

17、station and returning to normal within 12 weeks after delivery50% of women diagnosed with gestational hypertension between 24 and 35 weeks develop preeclampsiaClassification Clinical manifestationsChronic HypertensionBP measurement of 140/90 mm Hg or more on two occasions- Present prior to pregnancy

18、 or before 20 weeks of gestation- Persisting beyond 12 weeks postpartumDiagnosis dilemmas:- women with little care before pregnancy- women presenting after 20 weeksClassification Clinical manifestationsClassification Clinical manifestationsPreeclampsia【mild 】SBP of 140 mm Hg or more or a DBP of 90 m

19、m Hg or more on two occasions at least six hours apart after 20 weeks of gestation ANDProteinuria 300 mg in a 24-hour urine specimen or 1+ or greater on urine dipstick testing of two random urine samples collected at least four hours apart.Classification Clinical manifestationsPreeclampsia【 severe 】

20、BP 160 systolic or 110 diastolicMarked proteinuria (5.0 g/24-hr urine collection or 3+ or more) New onset cerebral or visual disturbancessevere RUQ pain or epigastric pain or both;Impaired liver function (LFTs 2X normal)Oliguria or serum creatinine in the absence of renal disease ; Progressive renal

21、 insufficiency (serum creatinine 1.1 mg/dL or 2X Thrombocytopenia 100,000,DIC, jaundice ,LDH Pulmonary edema, heart failureFGR or oligohydramnios early onset preeclampsia (EOSP)Classification Clinical manifestationsEclampsiaMeets the criteria of preeclampsiaPresence of rigidity. Convulsions.somnolence & coma, not attributable to other neurological disease, Occurrence: 0.5 -4 %, with 25% occurring in the 48 hs postpartumClassification Clinical manifestationsChronic hypertension with superimposed preeclampsia or eclamptiaHypertension predates the pregn