常见妊娠高血压疾病(专家解读)---陈晓军

HypertensionDisordersComplicatingPregnancy妊娠期高血压疾病HypertensiveDisorderscomplicatingPregnancyGestationalHypertensionPreeclampsiaPreeclampsiaSuperimposedonChronicHypertensionChronicHypertensionEclampsiaAGroupofRelatedDiseasesCharacteristicsSystemicsmallarteriesspasmEndothelialcellinjuryHypertensionProteinuriaMultipleorgansdysfunctionConvulsionMaternalmortalityFetalmortalityGestationalHypertension;ChronichypertensionEclampsiaPreeclampsia;PreeclampsiaSuperimposedonChronicHypertensionHypertensiondisorderscomplicatingpregnancyPathophysiologyCategoryandclinicalmanifestationDiagnosisanddifferentialdiagnosisManagementandprevention病理生理临床表现诊断治疗EpidemiologyIncidence：6-9%Preeclampsia-eclampsia：70%ChronicHypertension：30%Eclampsia0.5%-1%China1.0%Overseas0.5%ReflectionofmedicallevelThesecondcauseofmaternaldeath(20%)Causeofprematuredelivery（10%）UnknownoriginPathophysiologyBasicpathologicalchangesSpasmofsystemicsmallarteriesVascularendothelialcellinjuryPathophysiologyfluidproteinHypertensionEdemaProteinuriaHemoconcentrationSmallarterialspasmEndothelialcellinjuryMultipleorgansdysfunctionIschemiaEdemamalfunctionSystemicDiseaseBrainHydrocephalusHyperemia/ischemiaThrombosiscerebralhemorrhagecerebralherniaheadachedazzlenauseavomitHypopsiaretinaldetachmentCorticalblindnessDysesthesiaConfusionofthinkingEclampsiaconvulsioncomabrain：Vasospasmpermeability↑kidneyrenalvasospasmrenalbloodflow↓glomerularfiltrationrate↓pathology：•Glomerularexpansion•swollenvascularendothelialcell•cellulosedeposition•renocorticalnecrosis——renalirreversibledamageclinicalmanifestation：•albuminuria•hypoproteinemia•renaldysfunction•creatinine•ureanitrogen•uricacid•oliguria•renalfailureliverhepaticvasospasm;hepaticischemia;hepaticedemaliverenlargement;hepaticdysfunctionelevatedliverenzymejaundicehypoproteinemiacoagulationfunctionchangedsevere：PeriportalnecrosishepaticsubcapsularhematomahepatorrhexisHELLPsymdrome:ElevatedhepaticenzymesDecreasedbloodplateletCardiovascularSystemBloodPressure↑VasospasmVascularResistance↑CardiacLoad↑heartfailurevasospasmMyocardialIschemiaInterstitialEdemaSpottyNecrosispulmonaryvasospasmPulmonaryHypertensionPulmonaryEdemaOliguriawater-sodiumretentionRelativeBloodVolumeExcessIatrogenicBloodVolumeExcessHighburdenPoorabilitybloodsystemRelativehypovolemiaAnemiaDecreasedbloodplateletHypercoagulabilitybloodclottingfactor↓placenta-fetusplacentaPlacentalhypoperfusionSpiralarteriessclerosisPlacentalInfarctionPlacentalAbruptionPlacentalfunctiondecreasesfetusIUGRfetaldistressoligohydramniosfetaldeathPathophysiologyBrainHeadache;visualblurred;coma;herniaKidneyRenalfunctioncompromised;proteinuria;renalfailureLiverPersistentupperrightabdominalpain;Elevatedenzyme;jaundice;hematoma;ruptureSystematicdiseasePathophysiologyCardiovascularsystemLowoutput-highresistance;myocardialischemia;pulmonaryhypertension;edema;heartfailureBloodLowvolume;hypercoagulability;DICPathophysiologyUterusandPlacentaLowperfusion;placentalatherosclerosisPlacentalinfarction;placentalabruption;fetalgrowthretardation;fetaldeathHighriskfactorsPrimipara18yor40yMultiplepregnancyHypertensionChronicnephritisMalnutritionPoorsocialstatusDiabetesAnti-phospholipidsyndromeAngiotensingeneT235(+)EtiologyGeneticsusceptibilityhypothesisImmunemaladaptationhypothesisPlacentalischemiahypothesisOxidativestresshypothesisGeneticsusceptibilityImmunemaladaptationPlacentalischemiaOxidativestressAbnormalplacentalThechangeofcytokinePEdevelopmentEndotheliuminjuredDICComplicationsGeneticsusceptibilityhypothesisHypertensionImmunemaladaptationhypothesisMultiplegestationAbortionandbloodtransfusionOvumandspermdonationPlacentalischemiahypothesis40%totalspiralarteryareacomparedtonormalpregnancyEndothelialcellinjuryOxidativestresshypothesisOxidativestressreactionEndothelialcellinjuryCategoryandclinicalmanifestationGestationalhypertensionPreeclampsiaEclampsiaChronichypertensionPreeclampsiasuperimposedonchronichypertensionclinicalfeaturestypical:hypertension、albuminuria、edemauntypical：asymptomaticsevere：nausea、vomitheadache、dazzleconvulsion、comachestdistress、palpitationGestationalHypertensionDefinitionHypertensionoccurs20weeksaftergestationandrecovers12weekspostpartumSBP=140mmHgDBP=90mmHgDiagnosedonlyafterdeliveryPreeclampsiaHypertentionoccurs20weeksaftergestationBP=140/90mmHgProteinuriaProteinuria≥300mg/24hUrineprotein（+）OthersymptomsHeadache,visualblurringUpperabdominalpainSeverepreeclampsiaAtleastoneofthefollowingfeatures：CentralnervoussystemabnormalitiesHepaticsubcapsularhematoma/hepatorrhexisHepatocyteinjury:GPTBloodpressure：SBP≥160mmHg，orDBP≥110mmHgThrombocytopenia:100109/LProteinuria:≥5g/24hor(+++)4hoursapartOliguria:500ml/24hPulmonaryedemaCerebrovascularaccidentIntravascularhemolysis:anemia,jaundiceCoagulationdysfunctionFetalgrowthrestriction/oligohydramniosSeverepreeclampsiacomplicationsHepaticsubcapsularhematomaEarly-onsetpreeclampsia:34wHELLPsyndromeHELLPsyndromeHemolysisbloodsmearsshowRBCd