《妊娠期高血压疾病》由会员分享，可在线阅读，更多相关《妊娠期高血压疾病（49页珍藏版）》请在金锄头文库上搜索。
1、Hypertensive Disorders in PregnancyTengTeng YinChengYinChengShanghai Shanghai JiaotongJiaotong University Affiliated Sixth Peoples University Affiliated Sixth Peoples Hospital, Dept of Hospital, Dept of ObsObs & & GynGynContentsIncidence and Risk FactorsIncidenceIncidence Commonly about 5 percentCom
2、monly about 5 percent Markedly influenced by parityMarkedly influenced by parity Related to race and ethnicityA genetic predispositionRelated to race and ethnicityA genetic predispositionMain Risk FactorsMain Risk Factors NulliparousNulliparous ( (初初产妇产妇) ) Multiple pregnancyMultiple pregnancy Histo
3、ry of chronic hypertensionHistory of chronic hypertension Maternal age over 35 yearsMaternal age over 35 years ObesityObesity Lower socioeconomic status Lower socioeconomic status Your company sloganYour company sloganRoberts, J. M. et al. Hypertension 2005;46:1243-1249Used with permissionTwo-stage
4、model of the pathophysiology of preeclampsiaStage 2 develops in some, but not all women with stage 1Etiology and PathogenesisEtiology and PathogenesisNormal: vessel remodeling (血管重铸血管重铸) of the decidua and myometriumtransforming into large-capacitance, low-resistance vesselsPreeclampsia: incomplete
5、remodelinglimited to the superficial deciduamyometrial segments remain narrowYour company sloganYour company sloganYour company sloganYour company sloganEtiology and PathogenesisOxidative distress Oxidative distress （氧化应激）（氧化应激）（氧化应激）（氧化应激）Incomplete vessel remodeling Reduced placental perfusion pla
6、centa ischemia（缺血）（缺血） and hypoxemia（缺氧）（缺氧） Oxidative distress Endothelia dysfunction affected production of Nitric Oxide/ Prostaglandins（前列腺素）（前列腺素）Other factorsOther factors Immune system dysfunction Genetic predisposition MalnutritionPathogenesis of preeclampsiaPhysiopathology - sgage II Physiop
7、athologyClinical manifestationHypertensionEdemaProteinuriaSevere casesHeadacheblurred visionnausea, vomitright upper quadrant pain seizure (抽搐) Your company sloganYour company sloganWHAT LINKS STAGE 1 & 2?Theory exploration: Genetics/Abnormal lipid metabolismGenetics/Abnormal lipid metabolismEndocri
8、ne dysfunctionEndocrine dysfunctionInflammationInflammationYour company sloganYour company sloganNot all women with reduced placental perfusion develop preeclampsia What links stages 1 and 2?Reduced placental perfusion must interact with maternal factors to result in preeclampsia.Stage 1?Stage 2Robe
9、rts, J.M., Gammill H.S. (2005)Your company sloganYour company sloganDiverse manifestations are possible: maternal and fetal/placental factors may vary in proportion. In a woman with many predisposing factors, even a minor reduction in placental perfusion is sufficient for stage 2 to develop.In a wom
10、an with few predisposing factors, a profound reduction in placental perfusion may be required for preeclampsia to develop. Roberts, J.M., Gammill H.S. (2005)Predisposing factorsReduced placental perfusionMicrosoft Office 2000Microsoft Office 2000Your company sloganYour company sloganCould maternal g
11、enetics play a role in the link between stage 1 & 2?Stage 1Stage 2GeneticsYour company sloganYour company sloganWhat do we know? We know that abnormalities in lipid metabolism have a genetic basis.We have learned that preeclampsia is characterized by profound lipid abnormalities such as hypertriglyc
12、eridemiaGratacos, E. (2000)Microsoft Office 2000Microsoft Office 2000Your company sloganYour company sloganCould abnormal lipid metabolism be a genetic factor linking the stages of preeclampsia?Stage 1Stage 2Abnormal lipid metabolismYour company sloganYour company sloganPreeclampsia is characterized
13、 by metabolic abnormalities similar to those present in atherosclerosis:HypertriglyceridemiaReduced HDL cholesterolPredominance of small-dense LDL cholesterol which have an increased potential to cause endothelial cell damage as compared to larger, more buoyant LDLs.Gratacos E., 2000.Your company sl
14、oganYour company sloganStage 1 Abnormal lipid metabolism Stage 2In the presence of oxidative stress and inflammation, susceptible small-dense lipoproteins may be more easily oxidized, triggering Stage 2, maternal disease.+ Oxidative Stress+ InflammationGratacos E., 2000 Your company sloganYour compa
15、ny sloganMost of the suggested linkages could contribute to or be stimulated by oxidative stress.Oxidative stress is proposed as relevant to many diseases.Evidence supports the presence of oxidative stress in preeclampsia:Protein products of oxidative stress present in maternal and fetal tissuesAnti
16、bodies to oxidatively modified LDLs present in maternal and fetal tissuesConcentrations of certain antioxidants reduced in preeclamptic women. Roberts, J.M., Gammill H.S. (2005)Your company sloganYour company sloganIn summary:Hypertriglyceridemia and predominance of small-dense LDLs prior to pregnan
17、cy could be one predisposing factor for developing preeclampsia.Oxidative stress and inflammation may trigger the maternal disease. Gratacos E., (2000)Microsoft Office 2000Microsoft Office 2000Your company sloganYour company sloganCould endocrine dysfunction be a factor linking Stage 1 and Stage 2?S
18、tage 1Stage 2Endocrine dysfunctionYour company sloganYour company sloganThere is growing evidence suggesting that preeclampsia may be an early manifestation of the “metabolic syndrome”:elevated triglyceride levelshyperinsulinemia insulin resistance relative glucose intolerance elevated blood pressur
19、e These factors have been linked to the development of preeclampsia.Innes, K., Weitzel, L., Laudenslager, M. (2005)Your company sloganYour company sloganStudies have repeatedly demonstrated that metabolic abnormalities precede the clinical signs of preeclampsia:Insulin resistance and associated hype
20、rinsulinemiaGlucose intoleranceHypertriglyceridemiaThis suggests that insulin resistance and dyslipidemia may be factors involved in the development of preeclampsia.Innes, et al. (2005)Your company sloganYour company sloganSimilarities between the risk factors for preeclampsia and cardiovascular dis
21、ease include:Insulin resistanceDyslipidemia- decreased HDL levels and elevated triglyceride levelsThese risk factors are thought to play a causal role in the development of endothelial dysfunction, a characteristic feature of preeclampsia and cardiovascular disease.Innes, et al. (2005)Your company s
22、loganYour company sloganFuture implications:Studies have demonstrated that women with a history of preeclampsia are at increased risk of developing cardiovascular disorders later in life.Women with preeclampsia who deliver preterm or with recurrent preeclampsia are at greatest risk.Women with preecl
23、ampsia have an approximate doubling of risk death from cardiovascular disease.These findings suggest that pregnancy may constitute a metabolic and vascular stress test which reveals a womans health in later life.Identification of maternal factors provides specific targets for prevention of preeclamp
24、sia in “at-risk” women.Innes, et al. (2005)Roberts, J.M., Gammill H.S. (2005)Your company sloganYour company sloganCould inflammation be a factor linking Stage 1 and Stage 2?InflammationStage 1Stage 2Your company sloganYour company slogan“Preeclampsia is associated with an excessive inflammatory res
25、ponse compared with normal pregnancy.”In a study done by Braekke, et.al (2005) inflammatory markers (calprotectin, CRP) were evaluated in maternal and fetal serum and amniotic fluid. BraekkeBraekke, K., , K., HoltheHolthe, Ml, , Ml, HarsemHarsem, N., , N., FagerholFagerhol, M., Staff, A., 2005, M.,
26、Staff, A., 2005Your company sloganYour company sloganInflammatory Markers:Calprotectin:Is a protein released by activated neutrophilsC-reactive protein (CRP):Is a protein produced by the liverProduction is stimulated by inflammatory cytokinesBraekkeBraekke, K. et. al. (2005), K. et. al. (2005)Micros
27、oft Office 2000Microsoft Office 2000Your company sloganYour company sloganCalprotectin and C-reactive protein (CRP), markers of inflammation, are elevated in preeclampsia.The concentration of calprotectin in the maternal plasma of preeclamptic women was higher than in the control group (normal pregn
28、ant women).No statistically significant difference in calprotectin levels was noted between women with mild and severe preeclampsiaBraekkeBraekke, K. et al. (2005), K. et al. (2005)Your company sloganYour company sloganC-reactive protein:Has been used to evaluate low-grade inflammation as a cardiova
29、scular risk factorBraekke et al. 2005Microsoft Office 2000Microsoft Office 2000Your company sloganYour company sloganCRP levels in the maternal plasma of pregnant women:Correspond to a low-grade inflammation in preeclampsia and in normal pregnancy. Braekke et al. 2005Microsoft Office 2000Microsoft O
30、ffice 2000Your company sloganYour company sloganConcentrations of calprotectin in both arterial and venous umbilical plasma, and amniotic fluid were much lower than in maternal plasmaCRP levels in fetal circulation were 1/100 of maternal CRP levels.No inflammatory response was noted in the fetal cir
31、culation.Braekke et al. 2005Your company sloganYour company sloganTheoretically,“Calprotectin concentrations could play a role in the pathophysiology of preeclampsia through augmented placental cell death or reduced trophoblast invasion (stage 1)”Braekke et al. 2005Your company sloganYour company sl
32、oganWhat stimulates the inflammatory response (activates the neutrophils) in preeclampsia?Researchers have been unable to determine why or exactly where the neutrophils become activated.Maternal or placenta factors triggering maternal inflammation do not appear to be transferred into the fetal circu
33、lation. Braekke et al. 2005Your company sloganYour company sloganFuture implications:Further research is needed to evaluate the role of calprotectin in pregnancy or pregnancy complications.Will calprotectin concentrations be usedto predict preeclampsia before the onset of clinical symptoms or as a m
34、arker of the clinically established disease? Braekke et al. 2005ClassificationGestational HypertensionGestational HypertensionBP 140/90 mmHg for first time during pregnancyNo proteinuriaBP return to normal 12 weeks postpartum Final diagnosis made only postpartum（产后）后）PreeclampsiaPreeclampsia BP 140/
35、90 mmHg after 20 weeks gestationProteinuria 300 mg/24 hours or 1+ dipstick EclampsiaEclampsiaSeizures that cannot be attributed to other causes in a woman with preeclampsiaClassificationPreeclampsia Superimposed on Preeclampsia Superimposed on Chronic HypertensionChronic HypertensionNew-onset protei
36、nuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks gestationA sudden increase in proteinuria or blood pressure or platelet count 100109/LChronic Hypertension in PregnancyChronic Hypertension in PregnancyBP 140/90 mmHg before pregnancy or diagnosed before 20 weeks gestatio
37、n Or Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartumDiagnosis HistoryHypertensionProteinuriaEdemaAssistant examinationDiagnosis of severe preeclampsiaCentral nervous system: headache, visual changes, coma Subcapsular hematoma or hepatic rupture: epigast
38、ric discomfort or persist right upper quadrant pain Hepatic impairment: elevated hepatic enzymesSystolic pressure 160 mmHg, or dystolic pressure 110 mmHgThrombocytopenia: 100 109/LProteinuria: 5 g/24 hoursOliguria: 3 mmol/LNotes: knee reflex, respiratory rates, urine flowManagementAntihypertension T
39、o prevent maternal cerebrovascular complicationsLabetalol: 拉贝洛尔 , -adrenaline receptor blockerNifedipine: 硝苯地平 calcium channel blockerHydrelazine: 肼屈嗪ACE (angiotensin-converting enzyme inhibitors): 血管紧张素转换酶抑制剂， contraindicated (禁用)ManagementDiuresis (利尿利尿)IndicationGeneralized edemaAcute heart failu
40、rePulmonary edemaPlasma volume expansion (扩容治疗扩容治疗)Indication Severe hypoproteinemiaAnemiaManagementDelivery an ultimate treatmentTiming maternal safety fetal safety (premature)IndicationsDelivery methodsVaginal delivery: induced laborCesarean section (剖剖宫产)Management of eclampsia General careControl seizure: MgSO4, Diazepam (安定), mannitol (甘露醇)Supply of oxygen Anti-acidosis (纠正酸中毒纠正酸中毒)Anti-hypertensionDelivery: 2 hours after seizure controlled Thank you!
