常見妊娠高血壓疾病專家解讀培訓(xùn)課件

1、常見妊娠高血壓疾病專家解讀常見妊娠高血壓疾病專家解讀HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases2常見妊娠高血壓疾病專家解讀HypertensiveGestational HypertCharacteristicsSystemic small arteries spas

2、m Endothelial cell injuryHypertensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension; Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension3常見妊娠高血壓疾病專家解讀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常見妊娠高血壓疾病專家解讀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常見妊娠高血壓疾病專家解讀EpidemiologyIncidence： 6-9%5常見Pathophysiology Basic pathological changesSpasm of systemic small arteries Vascular endothelial cell injury6常見妊娠高血壓疾病專家解讀Pathophysi

5、ology Basic pathologPathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell injuryMultiple organs dysfunctionIschemiaEdemamalfunction7常見妊娠高血壓疾病專家解讀PathophysiologyfluidproteinHypSystemic Disease8常見妊娠高血壓疾病專家解讀Systemic Disease8常見妊娠高血壓疾病專家解讀BrainHydro

6、cephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvulsion comabrain：Vasospasmpermeability9常見妊娠高血壓疾病專家解讀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常見妊娠高血

8、壓疾病專家解讀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常見妊娠高血壓疾病專家解讀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常見妊娠高血壓疾病專家解讀Cardiovascular System Blood Prblood system Relative hypovolemiaAnemiaDecreased blood plateletHypercoagulability blood clotting factor13常見妊娠高血壓疾病專家解讀blood system Relative hypovolep

11、lacenta-fetusplacenta Placental hypoperfusionSpiral arteries sclerosis Placental InfarctionPlacental AbruptionPlacental function decreasesfetus IUGRfetal distressoligohydramniosfetal death 14常見妊娠高血壓疾病專家解讀placenta-fetusplacenta fetPathophysiologyBrainHeadache; visual blurred; coma; herniaKidneyRenal

12、function compromised; proteinuria; renal failureLiverPersistent upper right abdominal pain; Elevated enzyme; jaundice; hematoma; ruptureSystematic disease15常見妊娠高血壓疾病專家解讀PathophysiologyBrainSystematicPathophysiologyCardiovascular systemLow output- high resistance; myocardial ischemia; pulmonary hyper

13、tension; edema; heart failureBloodLow volume; hypercoagulability; DIC16常見妊娠高血壓疾病專家解讀PathophysiologyCardiovascular PathophysiologyUterus and PlacentaLow perfusion; placental atherosclerosisPlacental infarction; placental abruption; fetal growth retardation; fetal death17常見妊娠高血壓疾病專家解讀PathophysiologyUt

14、erus and PlacHigh risk factorsPrimipara40yMultiple pregnancyHypertensionChronic nephritisMalnutritionPoor social statusDiabetesAnti-phospholipid syndromeAngiotensin gene T235 (+)18常見妊娠高血壓疾病專家解讀High risk factorsPrimiparaAntiEtiologyGenetic susceptibility hypothesisImmune maladaptation hypothesisPlace

15、ntal ischemia hypothesisOxidative stress hypothesis19常見妊娠高血壓疾病專家解讀EtiologyGenetic susceptibility Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placentalThe change of cytokinePEdevelopmentEndothelium injuredDICComplications20常見妊娠高血壓疾病專家解讀 Genetic susceptibilityIm

16、mune Genetic susceptibility hypothesisHypertension21常見妊娠高血壓疾病專家解讀Genetic susceptibility hypotheImmune maladaptation hypothesisMultiple gestationAbortion and blood transfusionOvum and sperm donation22常見妊娠高血壓疾病專家解讀Immune maladaptation hypothesiPlacental ischemia hypothesis40% total spiral artery area

17、compared to normal pregnancyEndothelial cell injury23常見妊娠高血壓疾病專家解讀Placental ischemia hypothesis4Oxidative stress hypothesisOxidative stress reactionEndothelial cell injury24常見妊娠高血壓疾病專家解讀Oxidative stress hypothesisOxiCategory and clinical manifestationGestational hypertension PreeclampsiaEclampsia Ch

18、ronic hypertensionPreeclampsia superimposed on chronic hypertension25常見妊娠高血壓疾病專家解讀Category and clinical manifestclinical features typical : hypertension、albuminuria、edemauntypical ：asymptomatic severe：nausea、vomitheadache、dazzleconvulsion 、comachest distress 、palpitation 26常見妊娠高血壓疾病專家解讀clinical feat

19、ures typical : Gestational Hypertension Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumSBP=140mmHgDBP =90mmHgDiagnosed only after delivery27常見妊娠高血壓疾病專家解讀Gestational Hypertension DefinPreeclampsiaHypertention occurs 20 weeks after gestation BP=140/90mmHgProtei

20、nuria Proteinuria 300mg/24h Urine protein （+）Other symptomsHeadache, visual blurringUpper abdominal pain28常見妊娠高血壓疾病專家解讀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常見妊娠高血壓疾病專家解讀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常見妊娠高血壓疾病專家解讀HELLP syndromeHemolysisElevateHELLPSevere preeclampsia ：One abnormalities

23、6%Two abnormalities 12%Three abnormalities10%20 gw seldom occur1/3 occur after delivery80% diagnosed prenatally32常見妊娠高血壓疾病專家解讀HELLPSevere preeclampsia ：32常見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常見妊娠高血壓疾病專家解讀HELLPclinical diagnosis MighSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia34常見妊娠高血壓疾病專家解讀Some investigatiors regard HELClassification of HELLPBy degree of thrombocytopenia：100,000/mm3Not widely accepted35常見妊娠高血壓疾病

25、專家解讀Classification of HELLPBy degrPathogenesis and epidemic characteristics of HELLP core mechanismendothelial injuryintravascular coagulation dysfunctionpredisposing factorsthe whitemultipara elder pregnant women36常見妊娠高血壓疾病專家解讀Pathogenesis and epidemic charHELLP-mortalityMaternal 0-24%hepatorrhexis

26、DICAcute renal failurethrombosiscerebrovascular accidentsPerinatal 7.7-60%Premature deliveryIUGRplacental abruption 37常見妊娠高血壓疾病專家解讀HELLP-mortalityMaternal 0-2Eclampsiaprocess：tonusconvulsionsleepinesscoma Occurrenceprenatalintrapartumpostpartum 38常見妊娠高血壓疾病專家解讀Eclampsiaprocess：Occurrence38常常見妊娠高血壓疾病專

27、家解讀培訓(xùn)課件preeclampsia superimposed upon chronic hypertensionChronic Hypertension Before 20 gestational weeksPersist 12 weeks postpartumProteinuriaBefore 20wAfter 20w; with higher BP; thrombocytopenia40常見妊娠高血壓疾病專家解讀preeclampsia superimposed uponDifferential diagnosisChronic nephritis complicating pregn

28、ancyRenal dysfunctionSeizure caused by other reasons41常見妊娠高血壓疾病專家解讀Differential diagnosisChronic ManagementPrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminate pregnancy timely42常見妊娠高血壓疾病專家解讀ManagementPrinciple42常見妊娠高血壓疾病ManagementCommon treatmentRestMonitoringOxygen inhalationDiet: salt re

29、striction only for anasarca patients43常見妊娠高血壓疾病專家解讀ManagementCommon treatment43常見ManagementSedationDiazepamHibernation drugsPethidineChlorpromazinePromethazine44常見妊娠高血壓疾病專家解讀ManagementSedation44常見妊娠高血壓疾病專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常見妊娠高血壓疾病專家解讀ManagementAnti-spasm45常見妊娠高血壓疾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