常见妊娠高血压疾病专家解读培训课件.ppt

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1、常见妊娠高血压疾病专家解读,常见妊娠高血压疾病专家解读,HypertensiveDisorders complicating Pregnancy,Gestational Hypertension,Preeclampsia,Preeclampsia Superimposed on Chronic Hypertension,Chronic Hypertension,Eclampsia,A Group of Related Diseases,2,常见妊娠高血压疾病专家解读,HypertensiveGestational Hypert,Characteristics,Systemic small ar

2、teries spasm,Endothelial cell injury,Hypertension,Proteinuria,Multiple organs dysfunction,Convulsion,Maternal mortality,Fetal mortality,Gestational Hypertension; Chronic hypertension,Eclampsia,Preeclampsia;Preeclampsia Superimposed on Chronic Hypertension,3,常见妊娠高血压疾病专家解读,CharacteristicsSystemic smal

3、l,Hypertension disorders complicating pregnancy,PathophysiologyCategory and clinical manifestationDiagnosis and differential diagnosisManagement and prevention,病理生理,临床表现,诊断,治疗,4,常见妊娠高血压疾病专家解读,Hypertension disorders complic,Epidemiology,Incidence： 6-9%Preeclampsia-eclampsia：70%Chronic Hypertension ：

4、30%Eclampsia0.5% - 1%China 1.0%Overseas 0.5%Reflection of medical level The second cause of maternal death (20%)Cause of premature delivery（10%）Unknown origin,5,常见妊娠高血压疾病专家解读,EpidemiologyIncidence： 6-9%5常见,Pathophysiology,Basic pathological changesSpasm of systemic small arteries Vascular endothelia

5、l cell injury,6,常见妊娠高血压疾病专家解读,Pathophysiology Basic patholog,Pathophysiology,fluid,protein,HypertensionEdemaProteinuriaHemoconcentration,Small arterial spasm,Endothelial cell injury,Multiple organs dysfunction,IschemiaEdemamalfunction,7,常见妊娠高血压疾病专家解读,PathophysiologyfluidproteinHyp,Systemic Disease,8

6、,常见妊娠高血压疾病专家解读,Systemic Disease8常见妊娠高血压疾病专家解读,Brain,HydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral hernia,headachedazzlenauseavomit,Hypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking,Eclampsiaconvulsion coma,brain：Vasospasmpermeability,9,常见妊娠高血压疾病专家解

7、读,BrainHydrocephalusheadacheHypo,kidney,renal vasospasm,renal blood flow ,glomerular filtration rate ,pathology ：Glomerular expansion swollen vascular endothelial cellcellulose depositionrenocortical necrosisrenal irreversible damage,clinical manifestation ：albuminuriahypoproteinemiarenal dysfunctio

8、n creatinine urea nitrogen uric acid oliguria renal failure,10,常见妊娠高血压疾病专家解读,kidney renal vasospasmrenal bl,liver,hepatic vasospasm;hepatic ischemia;hepatic edema,liver enlargement; hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed,severe：Periportal necro

9、sishepatic subcapsularhematomahepatorrhexis,HELLP symdrome:Elevated hepatic enzymesDecreased blood platelet,11,常见妊娠高血压疾病专家解读,liverhepatic vasospasm;liver e,Cardiovascular System,Blood Pressure ,Vasospasm,Vascular Resistance ,Cardiac Load ,heart failure,vasospasm,Myocardial IschemiaInterstitial Edema

10、Spotty Necrosis,pulmonary vasospasm,Pulmonary Hypertension,Pulmonary Edema,Oliguria,water-sodium retention,Relative Blood Volume Excess,Iatrogenic Blood Volume Excess,High burden,Poor ability,12,常见妊娠高血压疾病专家解读,Cardiovascular System Blood Pr,blood system,Relative hypovolemiaAnemiaDecreased blood plate

11、letHypercoagulability blood clotting factor,13,常见妊娠高血压疾病专家解读,blood system Relative hypovole,placenta-fetus,placenta Placental hypoperfusionSpiral arteries sclerosis Placental InfarctionPlacental AbruptionPlacental function decreases,fetus IUGRfetal distressoligohydramniosfetal death,14,常见妊娠高血压疾病专家解读

12、,placenta-fetusplacenta fet,Pathophysiology,BrainHeadache; visual blurred; coma; herniaKidneyRenal function compromised; proteinuria; renal failureLiverPersistent upper right abdominal pain; Elevated enzyme; jaundice; hematoma; rupture,Systematic disease,15,常见妊娠高血压疾病专家解读,PathophysiologyBrainSystemat

13、ic,Pathophysiology,Cardiovascular systemLow output- high resistance; myocardial ischemia; pulmonary hypertension; edema; heart failureBloodLow volume; hypercoagulability; DIC,16,常见妊娠高血压疾病专家解读,PathophysiologyCardiovascular,Pathophysiology,Uterus and PlacentaLow perfusion; placental atherosclerosisPla

14、cental infarction; placental abruption; fetal growth retardation; fetal death,17,常见妊娠高血压疾病专家解读,PathophysiologyUterus and Plac,High risk factors,Primipara40yMultiple pregnancyHypertensionChronic nephritisMalnutritionPoor social statusDiabetes,Anti-phospholipid syndromeAngiotensin gene T235 (+),18,常见妊

15、娠高血压疾病专家解读,High risk factorsPrimiparaAnti,Etiology,Genetic susceptibility hypothesisImmune maladaptation hypothesisPlacental ischemia hypothesisOxidative stress hypothesis,19,常见妊娠高血压疾病专家解读,EtiologyGenetic susceptibility,Genetic susceptibility,Immune maladaptation,Placental ischemia,Oxidativestress,A

16、bnormal placental,The change of cytokine,PE,development,Endothelium injured,DIC,Complications,20,常见妊娠高血压疾病专家解读,Genetic susceptibilityImmune,Genetic susceptibility hypothesis,Hypertension,21,常见妊娠高血压疾病专家解读,Genetic susceptibility hypothe,Immune maladaptation hypothesis,Multiple gestationAbortion and bl

17、ood transfusionOvum and sperm donation,22,常见妊娠高血压疾病专家解读,Immune maladaptation hypothesi,Placental ischemia hypothesis,40% total spiral artery area compared to normal pregnancyEndothelial cell injury,23,常见妊娠高血压疾病专家解读,Placental ischemia hypothesis4,Oxidative stress hypothesis,Oxidative stress reaction,

18、Endothelial cell injury,24,常见妊娠高血压疾病专家解读,Oxidative stress hypothesisOxi,Category and clinical manifestation,Gestational hypertension PreeclampsiaEclampsia Chronic hypertensionPreeclampsia superimposed on chronic hypertension,25,常见妊娠高血压疾病专家解读,Category and clinical manifest,clinical features,typical :

19、 hypertension、albuminuria、edemauntypical ：asymptomatic severe：nausea、vomitheadache、dazzleconvulsion 、comachest distress 、palpitation,26,常见妊娠高血压疾病专家解读,clinical features typical :,Gestational Hypertension,Definition Hypertension occurs 20 weeks after gestation and recovers 12 weeks postpartumSBP=140mm

20、HgDBP =90mmHgDiagnosed only after delivery,27,常见妊娠高血压疾病专家解读,Gestational Hypertension Defin,Preeclampsia,Hypertention occurs 20 weeks after gestation BP=140/90mmHgProteinuria Proteinuria 300mg/24h Urine protein （+）Other symptomsHeadache, visual blurringUpper abdominal pain,28,常见妊娠高血压疾病专家解读,Preeclamps

21、iaHypertention occur,Severe preeclampsia,At least one of the following features：Central nervous system abnormalities Hepatic subcapsular hematoma / hepatorrhexisHepatocyte injury :GPTBlood pressure：SBP160mmHg，or DBP110mmHgThrombocytopenia: 100109/LProteinuria: 5g/24h or (+) 4 hours apart Oliguria: 5

22、00ml/24hPulmonary edema Cerebrovascular accidentIntravascular hemolysis : anemia, jaundiceCoagulation dysfunctionFetal growth restriction / oligohydramnios,29,常见妊娠高血压疾病专家解读,Severe preeclampsiaAt least on,Severe preeclampsia complications,Hepatic subcapsularhematoma Early-onset preeclampsia : 34w HEL

23、LP syndrome,30,常见妊娠高血压疾病专家解读,Severe preeclampsia complic,HELLP syndrome,Hemolysisblood smears show RBC debrisHb 60-90g/LTB20.5mol/L,Elevated serum level of Liver enzymesAST70u/L, or 3SDLDH600u/LLow PlateletsPLC100*109/L,31,常见妊娠高血压疾病专家解读,HELLP syndromeHemolysisElevate,HELLP,Severe preeclampsia ：One a

24、bnormalities 6%Two abnormalities 12%Three abnormalities10%20 gw seldom occur1/3 occur after delivery80% diagnosed prenatally,32,常见妊娠高血压疾病专家解读,HELLPSevere preeclampsia ：32常见,HELLPclinical diagnosis,Might be asymptomatic pain in the right upper abdomen80% weight gain or severe edema 50-60%20% cases 14

25、0/90 mmHg6% cases without proteinuria,33,常见妊娠高血压疾病专家解读,HELLPclinical diagnosis Migh,Some investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia,34,常见妊娠高血压疾病专家解读,Some investigatiors regard HEL,Classification of HELLP,By degree of thrombocytopenia：100,000/mm3Not

26、widely accepted,35,常见妊娠高血压疾病专家解读,Classification of HELLPBy degr,Pathogenesis and epidemic characteristics of HELLP,core mechanismendothelial injuryintravascular coagulation dysfunctionpredisposing factorsthe whitemultipara elder pregnant women,36,常见妊娠高血压疾病专家解读,Pathogenesis and epidemic char,HELLP-mo

27、rtality,Maternal 0-24%hepatorrhexisDICAcute renal failurethrombosiscerebrovascular accidents,Perinatal 7.7-60%Premature deliveryIUGRplacental abruption,37,常见妊娠高血压疾病专家解读,HELLP-mortalityMaternal 0-2,Eclampsia,process：tonusconvulsionsleepinesscoma,Occurrenceprenatalintrapartumpostpartum,38,常见妊娠高血压疾病专家解

28、读,Eclampsiaprocess：Occurrence38常,常见妊娠高血压疾病专家解读培训课件,preeclampsia superimposed upon chronic hypertension,Chronic Hypertension Before 20 gestational weeksPersist 12 weeks postpartumProteinuriaBefore 20wAfter 20w; with higher BP; thrombocytopenia,40,常见妊娠高血压疾病专家解读,preeclampsia superimposed upon,Different

29、ial diagnosis,Chronic nephritis complicating pregnancyRenal dysfunctionSeizure caused by other reasons,41,常见妊娠高血压疾病专家解读,Differential diagnosisChronic,Management,PrincipleSedationAnti-spasmAnti-hypertensionDiuresisTerminate pregnancy timely,42,常见妊娠高血压疾病专家解读,ManagementPrinciple42常见妊娠高血压疾病,Management,C

30、ommon treatmentRestMonitoringOxygen inhalationDiet: salt restriction only for anasarca patients,43,常见妊娠高血压疾病专家解读,ManagementCommon treatment43常见,Management,SedationDiazepamHibernation drugsPethidineChlorpromazinePromethazine,44,常见妊娠高血压疾病专家解读,ManagementSedation44常见妊娠高血压疾病专,Management,Anti-spasmFirst l

31、ine treatment for pre-eclampsia and eclampsiaMgSO4 MechanismRegimen 25-30g/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,常见妊娠高血压疾病专家解读,ManagementAnti-spasm45常见妊娠高血压疾,Management,MgSO4Treatment concentration 1.7-3mmol/

32、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 renal dysfunction,46,常见妊娠高血压疾病专家解读

33、,ManagementMgSO446常见妊娠高血压疾病专家解读,Management,AntihypertensionIndication SBP160mmHg, DBP 110mmHg, MBP 140mmHgPrincipleNo feral toxicity; no lower renal and uterine perfusionHydralazine first lineLabetalol; calcium channel blocker; methyldopaSodium nitroprusside-only when unmanageable BP ACEI-contraindi

34、cated during pregnancy,47,常见妊娠高血压疾病专家解读,ManagementAntihypertension47常见,Management,Volumetric dilatancy-only for severe Hypoproteinemia and anemiaDiuretic agent-only for severe edema,48,常见妊娠高血压疾病专家解读,ManagementVolumetric dilatancy,Management,Terminate pregnancySevere pre-eclampsia unrelieved after ac

35、tive treatment for 24-48 hoursSevere pre-eclampsia, 34 wSevere pre-eclampsia, 34 w with matured fetus and placental dysfunctionSevere pre-eclampsia, 34 w with unmatured fetus and placental dysfunction, terminate after dexamethasone delivery 2h after controlling eclampsia,49,常见妊娠高血压疾病专家解读,ManagementT

36、erminate pregnancy4,Management,Terminate pregnancyInduced laborC-SPrevent postpartum eclampsia,50,常见妊娠高血压疾病专家解读,ManagementTerminate pregnancy5,Management,EclampsiaControl seizure by MgSO4 and 20% mannitol Anti-hypertensionCorrect acidosis and hypoxiaTerminate pregnancy 2 hours after controlling seiz

37、ureNursing,51,常见妊娠高血压疾病专家解读,ManagementEclampsia51常见妊娠高血压疾病,Management,Chronic hypertensionIndication SBP150-180mmHg; DBP100mmHg; hypertension related organ dysfunction,52,常见妊娠高血压疾病专家解读,ManagementChronic hypertension,Prevention,A well organized health care systemA well monitored pregnant periodAppropriate diet and rest,53,常见妊娠高血压疾病专家解读,PreventionA well organized hea,