妊娠期期高血壓疾病中英

1、,要點(diǎn)提示妊娠期高血壓疾病的臨床分型、各型的臨床表現(xiàn)及處理原則。The clinical classification, manifestation,and the treatment principles of different hypertension states of pregnancy.硫酸鎂治療妊娠期高血壓疾病的用藥方法及觀察要點(diǎn)。The usage and observation of the magnesium

2、sulfate.,http://www.health.am/pregnancy/hypertensive-states-of-pregnancy/http://www.aafp.org/afp/2008/0701/p93.html,第四節(jié) 妊娠期高血壓疾病Hypertensive States of Pregnancy,妊娠期高血壓疾病(hypertensive states of pregnancy)包括：妊娠期高血壓(gest

3、ational hypertension)子癇前期(preeclampsia)子癇(eclampsia)慢性高血壓并發(fā)子癇前期( chronic hypertension with superimposed preeclampsia)妊娠合并慢性高血壓(chronic hypertension complicating pregnancy),本病以高血壓、蛋白尿、水腫為主要癥狀，可伴有全身多器官功能損害或衰竭，重者可出現(xiàn)抽搐、昏

4、迷甚至死亡，嚴(yán)重危害母嬰健康，是孕產(chǎn)婦及圍生兒死亡的主要原因。hypertensive states of pregnancy：The main symptoms are hypertension, proteinuria, edema, accompanied by multiple organ disfunction or failure, seriously to be possible to have twitches, th

5、e stupor even maternal infant to die.http://www.health.am/pregnancy/hypertensive-states-of-pregnancy/,【高危因素 Risk factors 】,①精神過度緊張；②寒冷季節(jié)或氣壓升高時(shí)；③年輕初產(chǎn)婦＜18歲或高齡初產(chǎn)婦＞40歲；④有慢性高血壓、腎炎、糖尿病等病史的孕婦；⑤營(yíng)養(yǎng)不良者或者體形較胖者；⑥低社會(huì)經(jīng)濟(jì)狀況；⑦子宮張力

6、過高者，如雙胎、羊水過多；⑧家族中有高血壓病史；,①the spiritual hypertension；②in the cold reasons or increased barometric pressure；③nulliparity，maternal age below 20 or over 35；④Past history of D.M, Hypertension and Renal diseases；⑤malnutr

7、ition；Obesity；⑥low socioeconomic status⑦M(jìn)ultiple gestation, polyhydramnios；⑧Family history of hypertension；,【病因pathogenesis】,可能與異常滋養(yǎng)細(xì)胞侵入子宮肌層、免疫機(jī)制、血管內(nèi)皮細(xì)胞受損、遺傳因素、營(yíng)養(yǎng)缺乏、胰島素抵抗等有關(guān)。pathogenesis: Some theories include (1) en

8、dothelial cell injury, (2) rejection phenomenon (insufficient production of blocking antibodies), (3) compromised placental perfusion, (4) altered vascular reactivity, (5) imbalance between prostacyclin and thromboxane,

9、(6) decreased glomerular filtration rate with retention of salt and water, (7) decreased intravascular volume, (8) increased central nervous system irritability, (9) disseminated intravascular coagulation, (10) uterine m

10、uscle stretch (ischemia), (11) dietary factors, and (12) genetic factors.,,,【病理生理】 全身小動(dòng)脈痙攣,全身小動(dòng)脈痙攣,管腔狹窄，外周阻力增加,血壓升高,腎小動(dòng)脈痙攣，血流量減少,腎缺血缺氧,腎小球通透性增加血漿蛋白漏出,,,,,蛋白尿,腎小球?yàn)V過率降低,,水腫,血漿膠體滲透壓降低,,激活RAA系統(tǒng),,,,,胎盤,,腦,,心臟,,肝臟,激活RAS系統(tǒng)

11、,,,,【pathophysiology】 systemic arteriole spasm,systemic arteriole spasm,angiostenosis，Increased peripheral resistance,hypertension,renal arteriole spasm，decreased glomerular perfusion, hypoxia-ischemia,increased per

12、meability of glomerular,plasma protein leakage,,,,,proteinuria,decreased glomerular filtration rate,,edema,decreased plasma colloid osmoticpressure,,activation of renin angiotensin aldosterone system,,,,,placenta

13、,,brain,,cardiovascular,,liver,renin-angiotensin system,,,,【臨床表現(xiàn)及分類】manifestation and calssification,(1)妊娠期高血壓 BP≥140/90mmHg妊娠期首次出現(xiàn)，并于產(chǎn)后12周恢復(fù)正常；尿蛋白（－）；可伴有上腹部不適或血小板減少，產(chǎn)后方可確診。Gestational hypertension or pregnancy-indu

14、ced hypertension (PIH) is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation without the presence of protein in the urine. Gestational hypertension is further divided int

15、o transient hypertension of pregnancy if preeclampsia is present at the time of delivery and the blood pressure is normal by 12 weeks postpartum, and chronic hypertension if the elevation in blood pressure persists beyon

16、d 12 weeks postpartum.,,輕度：BP≥140/90mmHg，孕20周以后出現(xiàn)；尿蛋白≥300mg/24h或（+）?？砂橛猩细共贿m、頭痛、視力模糊等癥狀。Preeclampsia is hypertension associated with proteinuria and edema, occurring primarily in nulliparas after the 20th gestational wee

17、k and most frequently near term. There are 2 categories of preeclampsia, mild and severe. mild preeclampsia is defined as the following: (1) HTN (BP≥140/90mmHg); (2) proteinuria exceeding 0.3 g in a 24-hour period or 1-

18、2+ on dipstick testing;(3) Edema (hands or/and face) without other signs/symptoms,(2)子癇前期 preeclampsia,,重度：BP≥160/110mmHg；尿蛋白≥2.0g/24h或（++）～（++++） ；血肌酐＞106μmol/L；血小板＜100×109 /L；微血管病性溶血（血LDH升高）；血清ALT或AST升高；持續(xù)性頭痛或其它腦神

19、經(jīng)或視覺障礙；持續(xù)性上腹不適。Severe preeclampsia is defined as the following: (1) blood pressure greater than 160 mm Hg systolic or 110 mm Hg diastolic on 2 occasions 6 hours apart; (2) proteinuria exceeding 2 g in a 24-hour period o

20、r 2-4+ on dipstick testing; (3) increased serum creatinine (> 1.2 mg/dL unless known to be elevated previously); (4) oliguria ≤500 mL/24 h; (5) cerebral or visual disturbances; (6) epigastric pain; (7) elevated liver

21、enzymes; (8) thrombocytopenia (platelet count < 100,000/mm3); (9) retinal hemorrhages, exudates, or papilledema; and (10) pulmonary edema.,(2)子癇前期,,子癇:子癇前期患者發(fā)生抽搐不能用其它原因解釋子癇分產(chǎn)前子癇、產(chǎn)時(shí)子癇、產(chǎn)后子癇，以產(chǎn)前子癇多見。Eclampsia is the oc

22、currence of seizures that cannot be attributed to other causes in a preeclamptic patient. prenatal eclampsia, intrapartum eclampsia, postpartum eclampsia clinical findings：seizure，Unconsciousness，apneic phase, hyperven

23、tilates after the tonic-clonic seizure ，Seizure-induced complications may include tongue biting, broken bones, head trauma, or aspiration. Pulmonary edema and retinal detachment.,(3)子癇 Eclampsia,,子癇發(fā)作表現(xiàn) 抽搐發(fā)展迅速，前驅(qū)癥狀短暫

24、，表現(xiàn)為抽搐、面部充血、口吐白沫、深昏迷；隨之深部肌肉僵硬、繼而發(fā)展為典型的全身高張陣攣驚厥、有節(jié)律的肌肉收縮和緊張，持續(xù)約1～1.5min，期間無呼吸；然后抽搐停止，呼吸恢復(fù)，但患者仍昏迷。最后意識(shí)恢復(fù)，但困惑、易激惹、煩躁。,(4)慢性高血壓并發(fā)子癇前期 高血壓孕婦妊娠20周前無尿蛋白，而妊娠20周后出現(xiàn)尿蛋白≥300mg/24h；高血壓孕婦妊娠20周后突然出現(xiàn)尿蛋白增加或血壓進(jìn)一步升高或血小板＜100×

25、;109 /L。Chronic hypertension is defined as hypertension that is present before conception or before 20 weeks' gestation or persistence of hypertension after the puerperium (6 weeks).Chronic hypertension with superi

26、mposed preeclampsia:(1) no proteinuria before conception, but proteinuria exceeding 0.3 g in a 24-hour period after conception; (2)proteinuria increased or blood pressure greater or thrombocyte＜100×109 /L,(5)妊娠合并慢性高

27、血壓妊娠前或妊娠20周前血壓≥140/90mmHg，妊娠期無明顯加重；或妊娠20周后首次診斷高血壓，并持續(xù)至產(chǎn)后12周以后。defined as blood pressure equal to or greater than 140/90 mm Hg before conception or before 20 weeks gestation, and the hypertension is not increased sign

28、ificantly, or hypertension is firstly diagnosed after 20 weeks gestation and persists beyond 12 weeks postpartum.,并發(fā)癥 腦出血、心力衰竭、肺水腫、急性腎功能衰竭、胎盤早剝、DIC、胎兒窘迫等。Complications: cerebral hemorrhage, Heart Failure, pulmonary ed

29、ema, acute renal failure, placental abruption,disseminated intravascular coagulation, fetal distress,子癇驚厥后咬傷造成舌血腫,子癇患者頭部CT箭頭處可見低密度陰影,處理原則：妊娠期高血壓的處理原則為休息、鎮(zhèn)靜、間斷吸氧、密切監(jiān)護(hù)母兒狀態(tài)；子癇前期的處理原則為休息、鎮(zhèn)靜、解痙、降壓、合理擴(kuò)容和必要時(shí)利尿，密切監(jiān)測(cè)母兒狀態(tài)，適時(shí)終止妊

30、娠；子癇的處理原則為控制抽搐，糾正缺氧和酸中毒，及時(shí)終止妊娠。 Rest, Sedation,Intermittent inhalation of oxygen, Close monitoring, spasmolysis, Control of hypertension, expand blood volume and diuretic therapy,termination of pregnancy,Control of se

31、izures.,【處理原則 Treatment】,,1．有受傷的危險(xiǎn) 與發(fā)生抽搐及意識(shí)喪失有關(guān)。2．潛在并發(fā)癥 胎盤早剝、腎衰竭。3．焦慮 與擔(dān)心自身及胎兒安危有關(guān)。High risk for injury，related to seizure or unconsciousness。Potential for complications, related to renal failure, placental abrupt

32、ionAnxiety: related to worrying about the safety of herself and the fetus .,【護(hù)理診斷 nursing diagnosis】,【護(hù)理措施】,（一）妊娠期高血壓患者的護(hù)理（二）子癇前期患者的護(hù)理（三）子癇患者的護(hù)理（四）產(chǎn)時(shí)及產(chǎn)后護(hù)理（五）心理護(hù)理（六）健康指導(dǎo),（一）妊娠期高血壓患者的護(hù)理,1．休息與睡眠 可在家治療，充足的睡眠（≥10小時(shí)/日）

33、；以左側(cè)臥位為宜。2．間斷吸氧 3．飲食指導(dǎo) 蛋白質(zhì)（＞100克/日）、蔬菜，補(bǔ)充維生素、鐵和鈣劑； 水腫不明顯者不必嚴(yán)格限制食鹽。 4．密切監(jiān)測(cè)母兒狀況 監(jiān)測(cè)患者體重、血壓，詢問患者有無頭痛、視力改變、上腹不適等癥狀；協(xié)助患者進(jìn)行尿蛋白測(cè)定、血液檢查、胎兒發(fā)育狀況和胎盤功能檢查Be at home, get enough sleep:left lateral position.Intermittent inhalati

34、on of oxygen.Dietary Guidelines:Get close monitoring of the states of the mother and the baby,（二）子癇前期患者的護(hù)理,1．一般護(hù)理 住院治療，臥床休息，左側(cè)臥位。床旁準(zhǔn)備開口器、吸氧裝置、吸引器、產(chǎn)包等搶救物資及硫酸鎂、葡萄糖酸鈣等藥品。2．密切監(jiān)測(cè)母兒狀況 3．硫酸鎂用藥護(hù)理 硫酸鎂是目前治療妊娠期高血壓疾病的首選解痙藥物

35、。General nursing: Be hospitalized,stay in bed:left lateral position. Make good preparation for rescuing.Close monitoring.Medication care of magnesium sulfate:,（三）子癇患者的護(hù)理,1．協(xié)助醫(yī)師控制抽搐 Control of seizures 一旦發(fā)生抽搐，應(yīng)盡快控制。硫酸

36、鎂為首選藥物，必要時(shí)可加用強(qiáng)有力的鎮(zhèn)靜劑。2．防止受傷 Prevent injuries.3．避免再次抽搐 avoid the second seizure 單間，保持環(huán)境安靜，光線暗淡；治療和護(hù)理操作應(yīng)輕柔且相對(duì)集中。4．嚴(yán)密監(jiān)護(hù)病情 close monitoring and observation 密切觀察患者生命體征、神志、尿量等的變化，及早發(fā)現(xiàn)腦出血、肺水腫、急性腎衰竭、胎盤早剝等并發(fā)癥。5．做好終止妊娠的準(zhǔn)備 P

37、repare for the termination of pregnancy 子癇發(fā)作者往往在發(fā)作后自然臨產(chǎn)，應(yīng)及時(shí)發(fā)現(xiàn)產(chǎn)兆，并做好母子搶救準(zhǔn)備。,3．硫酸鎂用藥護(hù)理medication nursing,（1）用藥方法 可采用肌內(nèi)注射或靜脈用藥。①深部肌內(nèi)注射：intramuscular injection作用時(shí)間長(zhǎng)，但局部刺激性強(qiáng)，注射部位疼痛明顯；注射時(shí)可加利多卡因于硫酸鎂溶液中，以緩解疼痛，注射后用無菌棉球覆蓋針孔，防止

38、注射部位感染。②靜脈用藥intravenous administration 可行靜脈滴注或推注。,（2）毒性反應(yīng),膝腱反射消失 loss of deep tendon reflexes全身肌張力減退 muscle hypotonia呼吸抑制 respiratory paralysis發(fā)生心臟停搏 cardiac arrest,（3）注意事項(xiàng),應(yīng)監(jiān)測(cè)患者血壓，同時(shí)應(yīng)注意以下事項(xiàng)：①膝腱反射必須存在；②呼吸不少于16次/分；

39、③尿量≥17ml/h或≥400ml/24h。④出現(xiàn)中毒反應(yīng)，立即靜脈注射10%葡萄糖酸鈣10ml(5-10min)。①existence of deep tendon reflexes；②breath no less than 16 per minute；③urine volume no less than≥17ml/h or 400ml/24h。④if toxic reaction appears，10% calcium

40、gluconate solution 10ml(5-10min) iv。,（四）產(chǎn)時(shí)及產(chǎn)后護(hù)理,1．產(chǎn)時(shí)護(hù)理 經(jīng)陰道分娩者，第一產(chǎn)程應(yīng)密切監(jiān)測(cè)產(chǎn)婦的血壓、脈搏、尿量、胎心及子宮收縮情況，并注意有無頭痛、嘔吐等自覺癥狀； 第二產(chǎn)程期間避免產(chǎn)婦用力，盡量縮短產(chǎn)程，初產(chǎn)婦可行會(huì)陰側(cè)切，并可采用產(chǎn)鉗助產(chǎn)或胎頭吸引器助產(chǎn)； 第三產(chǎn)程主要是預(yù)防產(chǎn)后出血，在胎兒娩出前肩后立即靜脈注射縮宮素，但禁用麥角新堿，及時(shí)娩出胎盤并按摩宮底。2