妊娠高血壓hypertensive disorders in pregnancy課件

HYPERTENSIVEDISORDERSINPREGNANCY DR SALWANEYAZIASSISSTANTPROFKSU CONSULTANTOBGYNPEDIATRIC ADOLESCENTGYNECOLOGIST DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN TYPESOFHYPERTENSIVEDISEASEINPREGNANCY 1 Gestationalhypertension2 PET3 Eclampsia4 Chronichypertension5 PETsuperimposedonchronichypertension DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 1 Gestationalhypertension BP 140 90mmHgforthefirsttimeduringpregnancyNoproteinuriaBPreturnstoN 12WkpostpartumFinalDxmadeonlypostpartumMayhaveothersignsofPETeg Headache epigastricdiscomfortorthrombocytopenia DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN PET MinimumcriteriaBP 140 90mmHgafter20WkgestationProteinuria 300mg 24hrsor 1 dipstickIncreasedcertaintyofPETBP 160 110mmHgProteinuria 2gm 24hrsor 2 dipstickSerumcreatinine 1 2mg dlunlessknowntobepreviouslyelevatedPlatelets 100000 mm DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN IncreasedcertaintyofPETMicroangiopathichemolysis increasedLDH ElevatedALTorASTPersistantheadacheorothercerebral visualdisturbancePersistantepigastricpainECLAMPSIASeizuresthatcannotbeattributedtoothercausesinawomanwithPET 1 ofPtwithPETdevelopEC DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN CHRONICHYPERTENSIONBP 140 90mmHgbeforepregnancyorDxbefore20WkgestationHPTfirstDxafter20Wkgestation persistantafter12WkpostpartumPETSUPERIMPOSEDONCHRONICHYPERTENSIONNewonsetproteinuria 300mg 24hrsinhypertensivewomenbutnoproteinuriabefore20WkgestationAsuddenincreaseinproteinuriaorBPorPltcount 100000 mm inwomenwithHPT proteinuriabefore20Wkgestation DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN INCIDENCE RISKFACTORS PEToccursin6 8 ofalllivebirthRISKFACTORSExtremesofreproductiveage1535YNulliparityBlackraceHxofPETina1stdegreefemalerelativeHxofPETinpriorpregnancyDMChronicrenaldiseaseChHPT Multiplepregnancy twins13vs6 HydatidiformmoleNonimmunehydropsfetalisObesity 4 3 BMI 19 8kg m 13 3 BMI 35kg m Smoking riskofHPT DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN PATHOGENESIS Endothelialcellinjury prostacyclin thromboxaneA2Rejectionphenomenon inadequatematenalAbresponse CompromisedplacentalperfusionAlteredvascularreactivity sensitivitytovaspressinEPN NEPN angiotensin GFRwithretentionofsalt water intravascularvolume CNSirritabilityDICUterinemusclestretch ischemiaDietaryfactorsGeneticfactors DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN PATHOGENESIS Summaryofcurrenthypothesis Immunologicaldisturbance abnormalplacentalimplantation placentalperfusion productionofsubstancesthatactivateorinjureendothelialcellsofthebloodvessels multipleorgansysteminvolvement PATHOPHYSIOLOGY MULTIPLEORGANSYSTEMINVOLVMENT DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 1 CNS SimilartohypertensiveencephalopathyPetechialHgGrosshemorrhagesduetorupturedarteriesThrombosisofthearteriolesMicroinfarctsFibrinoidnecrosisinthewallsofbloodvesselsCerebraledema confusion blurredvision comaBrainstemherniationisaseriouscomplicationofcerebraledema deathMECHANISM cerebralhyperperfusion vasospasm forceddilation DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 1 CNS CTScan ofthept focalhypodensitiesinthewhitematter posthalfofthecerebralhemisphere occasionallyinthegreymatter mayrepresentpetechialHgSeverecases IVHgorsubarachnoidHgMRI Abnormalitiesinthecortical subcorticalwhitematteroftheoccipital parietalareasEEG nonspecificchanges DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 2 PULMONARYSYSTEM PulmonaryedemaMayoccurwithseverPETORECUsuallypostpartumMaybeduetoexcessivefluidadministrationwithcrystalloids plasmacolloidpressureduetoproteinuria inPtwithchHPT hypertensivecardiacdiseaseAspirationofgastriccontentwithEC DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 3 CVS Plasmavolumeisreduced thecauseisunknown theories 1 Generalizedvasoconstrictionwith vascularpermeability Advocatetheuseofvasodilators2 1ryhypovolemia hypoperfusionoftheuterus releaseofpressorsubstances HPT Advocatetheuseofvolumeexpanders avoidanceofdiuretics DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 3 CVS Highsystemicvascularresistance hyperdynamicventricularfunction avoidaggressivefluidadminstrationLossofthenormalrefractorinesstoangiotensinII DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 4 BLOOD HemoconcentrationThrombocytopenia600U L Tbilirubin 1 2mg dl AST 70U L Plt 100000 mm Foundin10 ofthePtwithseverePET DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 5 KIDNEYCharacteristiclesionglomeruloendotheliosis swellingofthegromelularcapillaryendothelium GFR creatinineclearance plasmacreatinine uricacidProteinuriaRenaltubularnecrosis renalfailure6 EyesVisualdisturbances duetoretinalarteryvasospasmRetinaldetachmentCorticalblindness occipitallobeischemiainfarctionoredemalastinghrs upto8days DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 7 Liver MinimalinvolvementwithfibrindepositionPeriportalhemorrhagicnecrosis serumliverenzymesBleedingfromtheselesions Subcapsularhematoma hepaticruptureHepaticinfarctionHEELPSYNDROME DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 8 Endocrine metabolicchanges plasmarenin angiotensinII aldosteronetothenormalprepregnancyvaluesVasopressinlevelsareNAtrialnatriureticpeptide VolumeexpansioninPET ANP COP periephalvascularresistanceExpansionoftheextracellularfluidvolume edema Proteinuria plasmaoncoticpressure displacementofintravascularfluidtointerstitium DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN 9 Uteroplacentalperfusion Vasospasm compromisedplacentalperfusion perinatalmorbidity mortalityDopplervelocimetry systolic diastolicvelocityratioofumbilical uterinearteries 20 N 15 NUmbilical Abnormaluterine 40 BothAbnormalHistologicalchangesinplacentalbedDefectivetrophoblasticinvasionofspiralarteries decidualvesselsbutnotmyometrialvesselsareinvadedbytrophoblastCharecteristiclipidrichlesionsintheuteroplacentalarteries DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN PREVENTION Calciumsupplementation Fishoil ineffectiveLowdoseaspirin selectivesupressionofthroboxanesynthesisbytheplt sparingendothelialprostacyclinproduction NoteffectiveinpreventingPETAntioxidants VitC Esupplementation significantreductioninPET DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN SYMPTOMS SIGNS BPProteinuriaEdemaoftheface hands butithasbeendroppedofthedefinitionduetopoorpredictivevalue HeadacheVisualdisturbanceEpigastricpainExaggeratedreflexes DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Fetal maternalrisks FetalIUGROligohydramniosPlacentalinfarctsPlacentalabruptionPrematurityUteroplacentalinsufficiencyPerinataldeath MaternalCNS seizures strokeDIC CSRenalfailureHepaticfailureorruptureDeath DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN CLASSIFICATIONOFPET SEVEREPETSystolicBP 160mmHgordiastolic 110mmHgontwooccasionsatleast6hrsapartProteinuria 5g 24hrsOliguria 500cc 24hrsCerebralorvisualsymptomsEpigastricorRtupperquadrantpainPulmonaryedemaorcyanosisLowPLt liverenzymesIUGRMILDPET anyPETthatisnotconsideredsevere MANEGEMENTOFPET EC DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Manegement OBJECTIVESTerminatonofpregnancywiththeleastpossibletraumatothemother fetusBirthofaninfantwhosubsequentlythrivesCompleterestorationofhealthtothemother1 HospitalizationWomenwithnewonsetBP 140 90WorseningBPDevelopmentofproteinuriainadditiontoexistingBP DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN INITIALHOSPITALMANAGEMENT Observeforheadache visualdisturbance epigastricpain rapidwtgainWtdailyAnalysisforproteinuriaevery2days dailyBPinsittingpositionevery4hrsexceptduringsleepBloodinvestigations Hct Plt Screatinine liverenzymesFrequentevaluationoffetalsize AFReducedphysicalactivitybutnotabsolutebedrestNdiet fluidintake DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN FURTHERMANAGEMENT Dependson SeverityofPETDurationofgestationConditionoftheCxCompleteresolutionofthesigns symptomsdoesnotoccurtillafterdeliveryLinesofmanagementTerminationofpregnancyAntihypertensivetherapyAnticonvulsanttherapyHomehealthcare ifBPimprovedwithinfewdaysPtcanbemanagedasoutpatient HomeBP urineproteinmonitoring Instructiontocometohospitalifshehaswaningsymptoms Restathome DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Terminationofpregnancy IndicationsTermpregnancywithmildorseverePETSeverePETregardlessofthegestationalageWarningsigns headache visualdisturbance epigastricpain oliguriaEclampsia Ptmustbestabilized deliveredimmediatelyPretermwithmildPET AssessfetalwellbeingbyNST BPP DopplerMethodsofterminationIOLwithprostaglandinestoripentheCxfollowedbyIVoxytocinElectiveCS SeverePETwithunfavorableCx DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Antihypertensivetherapy MildPETThereisnobenefitofantihypertensivetherapyReductioninthematernalBPwithlabetalolornifedipine IUGRACI contraindicated IUGR boneymalformations limbcontracture PDA pulmonaryhypoplasia RDS hypotension deathSeverePETAntihypertensivetherapyisusedtocontrolBPuntillthePtdeliversorinpretermfor48hrstoallowtimeforglucocorticoidadministrationforfetallungmaturitythendelivery DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN AntihypertensivetherapyforseverePET EC Hydralazine IVinfusionorIV5 10mgbolusat15 20mininterval whendiastolicBP 100 110mmHgorsystolicBP 160mmHgNifedipine10mgporepeatedin30minLabetalol10mgIV 20mgafter10min 40mgafter10min 80mg nottoexceed220mg Nitroprusside usedonlyinPTnotrespondingtootherdrugsDiureticsnotrecommendedbecauseintravascularvolumedepletionalreadyexistsinPET DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Fluidtherapy Hyperosmoticagentsnotrecommendedbecause intravascularinfluxoffluid subsequentescapeoffluidtovitalorgans pulmonaryedema cerebraledemaLR60 120ml hrExcessivefluidadministration pulmonaryedema cerebraledema DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN PREVENTION CONTROLOFCONVULSIONS MagnesiumsulfateIVinfusion 4gmloadingdosein100mlofIVfluidover20min 2gm hrmaintenanceMeasureserumMGlevelat4 6hrsmaintainat4 7mEq LD C24hrsafterdelivery 25 ofseizoccurpostpartumAvoidtoxicityby monitoringpatellarreflexes respiratoryrate urineoutputAntidote calciumgluconate1gmIVMgS myometrialcontractilityComparedtophenytoinordiazepam 50 inmaternalmortality 67 inconvulsionsInfantswerelesslikelytobeadmittedtoNICU intubation DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN Prognosis Maternaldeathrare duetocerebralHg aspirationpneumonia hypoxicencephalopathy thromboembolism hepaticrupture renalfailure ansthesiaRecurrence 25 33 primipara 70 multiparaPG PETbefore30wk 40 HEELP 5 CHRONICHYPERTENSIONinpregnancy DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN CHRONICHYPERTENSION IncidenceofchHPT0 5 4 80 essentialHPT20 duetorenaldiseaseSymptoms signs riskin Age 30 obese multipara DM renaldisease blackrace familyHxDifficulttodeffirentiateHPTwithsuperimposedPETfromHPTwithrenaldisease bothhaveproteinuria DRSALWANEYAZIASS PROF KSUCONSULTANTOBGYN INVESTIGATIONSChestxray cardiomegalyECG Ltventhypertrophy serumcreatinine creatinineclearance proteinuria 5 10 MATERNALCOMPLICATIONSSuperim