妊娠高血压疾病专业知识培训培训课件.ppt

1、妊娠高血压疾病专业妊娠高血压疾病专业知识培训知识培训HypertensiveDisorders complicating PregnancyGestational Hypertension PreeclampsiaPreeclampsia Superimposed on Chronic HypertensionChronic HypertensionEclampsia A Group of Related Diseases2妊娠高血压疾病专业知识培训CharacteristicsSystemic small arteries spasm Endothelial cell injuryHyper

2、tensionProteinuriaMultiple organs dysfunctionConvulsionMaternal mortalityFetal mortalityGestational Hypertension;Chronic hypertensionEclampsiaPreeclampsia;Preeclampsia Superimposed on Chronic Hypertension3妊娠高血压疾病专业知识培训Hypertension disorders complicating pregnancynPathophysiologynCategory and clinica

3、l manifestationnDiagnosis and differential diagnosisnManagement and prevention病理生理病理生理临床表现临床表现诊断诊断治疗治疗4妊娠高血压疾病专业知识培训EpidemiologynIncidence：6-9%nPreeclampsia-eclampsia：70%nChronic Hypertension：30%nEclampsia0.5%-1%nChina 1.0%nOverseas 0.5%nReflection of medical level nThe second cause of maternal deat

4、h(20%)nCause of premature delivery（10%）nUnknown origin5妊娠高血压疾病专业知识培训Pathophysiology nBasic pathological changesnSpasm of systemic small arteries nVascular endothelial cell injury6妊娠高血压疾病专业知识培训PathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmall arterial spasmEndothelial cell

5、 injuryMultiple organs dysfunctionIschemiaEdemamalfunction7妊娠高血压疾病专业知识培训Systemic Disease8妊娠高血压疾病专业知识培训BrainHydrocephalusHyperemia/ischemia Thrombosiscerebral hemorrhagecerebral herniaheadachedazzlenauseavomitHypopsiaretinal detachment Cortical blindnessDysesthesiaConfusion of thinking Eclampsiaconvu

6、lsion comabrain：Vasospasmpermeability9妊娠高血压疾病专业知识培训kidney renal vasospasmrenal blood flow glomerular filtration rate pathology：Glomerular expansion swollen vascular endothelial cell cellulose deposition renocortical necrosisrenal irreversible damageclinical manifestation：albuminuria hypoproteinemia

7、renal dysfunction creatinine urea nitrogen uric acid oliguria renal failure 10妊娠高血压疾病专业知识培训liverhepatic vasospasm;hepatic ischemia;hepatic edema liver enlargement;hepatic dysfunction elevated liver enzymejaundice hypoproteinemia coagulation function changed severe：Periportal necrosishepatic subcapsu

8、larhematomahepatorrhexis HELLP symdrome:Elevated hepatic enzymesDecreased blood platelet11妊娠高血压疾病专业知识培训Cardiovascular System Blood Pressure Vasospasm Vascular Resistance Cardiac Load heart failure vasospasm Myocardial IschemiaInterstitial EdemaSpotty Necrosis pulmonary vasospasm Pulmonary Hypertensi

9、on Pulmonary EdemaOliguriawater-sodium retentionRelative Blood Volume ExcessIatrogenic Blood Volume ExcessHigh burdenPoor ability12妊娠高血压疾病专业知识培训blood system nRelative hypovolemianAnemianDecreased blood plateletnHypercoagulability nblood clotting factor13妊娠高血压疾病专业知识培训placenta-fetusnplacenta nPlacenta

10、l hypoperfusionnSpiral arteries sclerosis nPlacental InfarctionnPlacental AbruptionnPlacental function decreaseso fetus nIUGRnfetal distressnoligohydramniosnfetal death 14妊娠高血压疾病专业知识培训PathophysiologynBrainnHeadache;visual blurred;coma;hernianKidneynRenal function compromised;proteinuria;renal failur

11、enLivernPersistent upper right abdominal pain;Elevated enzyme;jaundice;hematoma;ruptureSystematic disease15妊娠高血压疾病专业知识培训PathophysiologynCardiovascular systemnLow output-high resistance;myocardial ischemia;pulmonary hypertension;edema;heart failurenBloodnLow volume;hypercoagulability;DIC16妊娠高血压疾病专业知识

12、培训PathophysiologynUterus and PlacentanLow perfusion;placental atherosclerosisnPlacental infarction;placental abruption;fetal growth retardation;fetal death17妊娠高血压疾病专业知识培训High risk factorsnPrimiparan40ynMultiple pregnancynHypertensionnChronic nephritisnMalnutritionnPoor social statusnDiabetesnAnti-ph

13、ospholipid syndromenAngiotensin gene T235(+)18妊娠高血压疾病专业知识培训EtiologynGenetic susceptibility hypothesisnImmune maladaptation hypothesisnPlacental ischemia hypothesisnOxidative stress hypothesis19妊娠高血压疾病专业知识培训 Genetic susceptibilityImmune maladaptationPlacental ischemiaOxidativestressAbnormal placental

14、The change of cytokinePEdevelopmentEndothelium injuredDICComplications20妊娠高血压疾病专业知识培训Genetic susceptibility hypothesisHypertension21妊娠高血压疾病专业知识培训Immune maladaptation hypothesisnMultiple gestationnAbortion and blood transfusionnOvum and sperm donation22妊娠高血压疾病专业知识培训Placental ischemia hypothesisn40%to

15、tal spiral artery area compared to normal pregnancynEndothelial cell injury23妊娠高血压疾病专业知识培训Oxidative stress hypothesisOxidative stress reactionEndothelial cell injury24妊娠高血压疾病专业知识培训Category and clinical manifestationnGestational hypertension nPreeclampsianEclampsia nChronic hypertensionnPreeclampsia

16、superimposed on chronic hypertension25妊娠高血压疾病专业知识培训clinical features ntypical:nhypertension、albuminuria、edemanuntypical：nasymptomatic nsevere：nnausea、vomitnheadache、dazzlenconvulsion、comanchest distress、palpitation 26妊娠高血压疾病专业知识培训Gestational Hypertension nDefinition nHypertension occurs 20 weeks aft

17、er gestation and recovers 12 weeks postpartumnSBP=140mmHgnDBP=90mmHgnDiagnosed only after delivery27妊娠高血压疾病专业知识培训PreeclampsianHypertention occurs 20 weeks after gestation nBP=140/90mmHgnProteinuria nProteinuria 300mg/24h nUrine protein（+）nOther symptomsnHeadache,visual blurringnUpper abdominal pain2

18、8妊娠高血压疾病专业知识培训Severe preeclampsianAt least one of the following features：nCentral nervous system abnormalities nHepatic subcapsular hematoma/hepatorrhexisnHepatocyte injury:GPTnBlood pressure：SBP160mmHg，or DBP110mmHgnThrombocytopenia:100109/LnProteinuria:5g/24h or(+)4 hours apart nOliguria:500ml/24h

19、nPulmonary edema nCerebrovascular accidentnIntravascular hemolysis:anemia,jaundicenCoagulation dysfunctionnFetal growth restriction/oligohydramnios29妊娠高血压疾病专业知识培训Severe preeclampsia complicationsHepatic subcapsularhematoma Early-onset preeclampsia:20.5mol/LnElevated serum level of Liver enzymesnAST7

20、0u/L,or 3SDnLDH600u/LnLow PlateletsnPLC100*109/L31妊娠高血压疾病专业知识培训HELLPnSevere preeclampsia：nOne abnormalities 6%nTwo abnormalities 12%nThree abnormalities 10%n20 gw seldom occurn1/3 occur after deliveryn80%diagnosed prenatally32妊娠高血压疾病专业知识培训HELLPclinical diagnosis nMight be asymptomatic npain in the r

21、ight upper abdomen80%n weight gain or severe edema 50-60%n20%cases 140/90 mmHgn6%cases without proteinuria33妊娠高血压疾病专业知识培训nSome investigatiors regard HELLP syndrome as an entirely distinct disease entity from preeclampsia34妊娠高血压疾病专业知识培训Classification of HELLPnBy degree of thrombocytopenia：n100,000/mm

22、3nNot widely accepted35妊娠高血压疾病专业知识培训Pathogenesis and epidemic characteristics of HELLP ncore mechanismnendothelial injuryintravascular coagulation dysfunctionnpredisposing factorsnthe whitenmultipara nelder pregnant women36妊娠高血压疾病专业知识培训HELLP-mortalitynMaternal 0-24%nhepatorrhexisnDICnAcute renal fai

23、lurenthrombosisncerebrovascular accidentsnPerinatal 7.7-60%nPremature deliverynIUGRnplacental abruption 37妊娠高血压疾病专业知识培训Eclampsianprocess：ntonusnconvulsionnsleepinessncoma nOccurrencenprenatalnintrapartumnpostpartum 38妊娠高血压疾病专业知识培训preeclampsia superimposed upon chronic hypertensionnChronic Hypertensi

24、on nBefore 20 gestational weeksnPersist 12 weeks postpartumnProteinurianBefore 20wnAfter 20w;with higher BP;thrombocytopenia40妊娠高血压疾病专业知识培训Differential diagnosisnChronic nephritis complicating pregnancynRenal dysfunctionnSeizure caused by other reasons41妊娠高血压疾病专业知识培训ManagementnPrinciplenSedationnAnt

25、i-spasmnAnti-hypertensionnDiuresisnTerminate pregnancy timely42妊娠高血压疾病专业知识培训ManagementnCommon treatmentnRestnMonitoringnOxygen inhalationnDiet:salt restriction only for anasarca patients43妊娠高血压疾病专业知识培训ManagementnSedationnDiazepamnHibernation drugsnPethidinenChlorpromazinenPromethazine44妊娠高血压疾病专业知识培训

26、ManagementnAnti-spasmnFirst line treatment for pre-eclampsia and eclampsianMgSO4 nMechanismnRegimen 25-30g/dnLoading dose:25%MgSO4 10ml+10%GS 20ml iv 5-10minn25%MgSO4 60ml+5%GS 500ml ivgtt 1-2g/hn25%MgSO4 20ml+2%lidocaine 2ml im.45妊娠高血压疾病专业知识培训ManagementnMgSO4nTreatment concentration 1.7-3mmol/LnTox

27、ic concentration 3mmol/LnToxicitynMuscular paralysisnPrevention and treatmentIBefore treatmentKnee reflex(+);R16bpm;urine5ml/h or 600ml/24hMg concentration monitoring nIf something happensn10%calcium gluconate 10ml iv for detoxificationnLower dose or stop use when renal dysfunction46妊娠高血压疾病专业知识培训Man

28、agementnAntihypertensionnIndication nSBP160mmHg,DBP 110mmHg,MBP 140mmHgnPrinciplenNo feral toxicity;no lower renal and uterine perfusionnHydralazine first linenLabetalol;calcium channel blocker;methyldopanSodium nitroprusside-only when unmanageable BP nACEI-contraindicated during pregnancy47妊娠高血压疾病专

29、业知识培训ManagementnVolumetric dilatancy-only for severe Hypoproteinemia and anemianDiuretic agent-only for severe edema48妊娠高血压疾病专业知识培训ManagementnTerminate pregnancynSevere pre-eclampsia unrelieved after active treatment for 24-48 hoursnSevere pre-eclampsia,34 wnSevere pre-eclampsia,34 w with matured fetus and placental dysfunctionnSevere pre-eclampsia,150-180mmHg;DBP100mmHg;hypertension related organ dysfunction52妊娠高血压疾病专业知识培训PreventionnA well organized health care systemnA well monitored pregnant periodnAppropriate diet and rest53妊娠高血压疾病专业知识培训