1、,要点提示 妊娠期高血压疾病的临床分型、各型的临床表现及处理原则。The clinical classification, manifestation,and the treatment principles of different hypertension states of pregnancy. 硫酸镁治疗妊娠期高血压疾病的用药方法及观察要点。 The usage and observation of the magnesium sulfate.,http:/www.health.am/pregnancy/hypertensive-states-of-pregnancy/ http:/w
2、ww.aafp.org/afp/2008/0701/p93.html,第四节 妊娠期高血压疾病 Hypertensive States of Pregnancy,妊娠期高血压疾病(hypertensive states of pregnancy)包括： 妊娠期高血压(gestational hypertension) 子痫前期(preeclampsia) 子痫(eclampsia) 慢性高血压并发子痫前期( chronic hypertension with superimposed preeclampsia) 妊娠合并慢性高血压(chronic hypertension complicati
3、ng pregnancy),本病以高血压、蛋白尿、水肿为主要症状，可伴有全身多器官功能损害或衰竭，重者可出现抽搐、昏迷甚至死亡，严重危害母婴健康，是孕产妇及围生儿死亡的主要原因。 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, the stupor even maternal
4、 infant to die. http:/www.health.am/pregnancy/hypertensive-states-of-pregnancy/,【高危因素 Risk factors 】,精神过度紧张； 寒冷季节或气压升高时； 年轻初产妇18岁或高龄初产妇40岁； 有慢性高血压、肾炎、糖尿病等病史的孕妇； 营养不良者或者体形较胖者； 低社会经济状况； 子宫张力过高者，如双胎、羊水过多； 家族中有高血压病史；,the spiritual hypertension； in the cold reasons or increased barometric pressure； nulli
5、parity，maternal age below 20 or over 35； Past history of D.M, Hypertension and Renal diseases； malnutrition；Obesity； low socioeconomic status Multiple gestation, polyhydramnios； Family history of hypertension；,【病因pathogenesis】,可能与异常滋养细胞侵入子宫肌层、免疫机制、血管内皮细胞受损、遗传因素、营养缺乏、胰岛素抵抗等有关。 pathogenesis: Some theo
6、ries include (1) endothelial cell injury, (2) rejection phenomenon (insufficient production of blocking antibodies), (3) compromised placental perfusion, (4) altered vascular reactivity, (5) imbalance between prostacyclin and thromboxane, (6) decreased glomerular filtration rate with retention of sa
7、lt and water, (7) decreased intravascular volume, (8) increased central nervous system irritability, (9) disseminated intravascular coagulation, (10) uterine muscle stretch (ischemia), (11) dietary factors, and (12) genetic factors.,【病理生理】 全身小动脉痉挛,全身小动脉痉挛,管腔狭窄， 外周阻力增加,血压升高,肾小动脉痉挛，血流量减少,肾缺血缺氧,肾小球通透性增
8、加 血浆蛋白漏出,蛋白尿,肾小球滤过率降低,水肿,血浆胶体 渗透压降低,激活 RAA系统,胎盘,脑,心脏,肝脏,激活RAS系统,【pathophysiology】 systemic arteriole spasm,systemic arteriole spasm,angiostenosis， Increased peripheral resistance,hypertension,renal arteriole spasm， decreased glomerular perfusion, hypoxia-ischemia,increased permeability of glomerular
9、, plasma protein leakage,proteinuria,decreased glomerular filtration rate,edema,decreased plasma colloid osmotic pressure,activation of renin angiotensinaldosterone system,placenta,brain,cardiovascular,liver,renin-angiotensinsystem,【临床表现及分类】 manifestation and calssification,(1)妊娠期高血压 BP140/90mmHg妊娠期
10、首次出现，并于产后12周恢复正常；尿蛋白（）；可伴有上腹部不适或血小板减少，产后方可确诊。 Gestational hypertension or pregnancy-induced 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 div
11、ided into 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 beyond 12 weeks postpartum.,轻度：BP140/90mmHg，孕20周以后出现；尿蛋白300mg/24h或（+）。可伴有上腹不适
12、、头痛、视力模糊等症状。 Preeclampsia is hypertension associated with proteinuria and edema, occurring primarily in nulliparas after the 20th gestational week and most frequently near term. There are 2 categories of preeclampsia, mild and severe. mild preeclampsia is defined as the following: (1) HTN (BP140/90m
13、mHg); (2) proteinuria exceeding 0.3 g in a 24-hour period or 1-2+ on dipstick testing;(3) Edema (hands or/and face) without other signs/symptoms,(2)子痫前期 preeclampsia,重度：BP160/110mmHg；尿蛋白2.0g/24h或（+）（+） ；血肌酐106mol/L；血小板100109 /L；微血管病性溶血（血LDH升高）；血清ALT或AST升高；持续性头痛或其它脑神经或视觉障碍；持续性上腹不适。 Severe preeclampsi
14、a 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 or 2-4+ on dipstick testing; (3) increased serum creatinine ( 1.2 mg/dL unless known to be elevated previously); (4
15、) oliguria 500 mL/24 h; (5) cerebral or visual disturbances; (6) epigastric pain; (7) elevated liver enzymes; (8) thrombocytopenia (platelet count 100,000/mm3); (9) retinal hemorrhages, exudates, or papilledema; and (10) pulmonary edema.,(2)子痫前期,子痫:子痫前期患者发生抽搐不能用其它原因解释 子痫分产前子痫、产时子痫、产后子痫，以产前子痫多见。 Ecla
16、mpsia is the occurrence 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, hyperventilates after the tonic-clonic seizure ，Seizure-induced complicatio
17、ns may include tongue biting, broken bones, head trauma, or aspiration. Pulmonary edema and retinal detachment.,(3)子痫 Eclampsia,子痫发作表现 抽搐发展迅速，前驱症状短暂，表现为抽搐、面部充血、口吐白沫、深昏迷；随之深部肌肉僵硬、继而发展为典型的全身高张阵挛惊厥、有节律的肌肉收缩和紧张，持续约11.5min，期间无呼吸； 然后抽搐停止， 呼吸恢复，但患者 仍昏迷。最后意识 恢复，但困惑、易 激惹、烦躁。,(4)慢性高血压并发子痫前期高血压孕妇妊娠20周前无尿蛋白，而妊娠
18、20周后出现尿蛋白300mg/24h；高血压孕妇妊娠20周后突然出现尿蛋白增加或血压进一步升高或血小板100109 /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 superimposed preeclampsia:(1) no prote
19、inuria before conception, but proteinuria exceeding 0.3 g in a 24-hour period after conception; (2)proteinuria increased or blood pressure greater or thrombocyte100109 /L,(5)妊娠合并慢性高血压妊娠前或妊娠20周前血压140/90mmHg，妊娠期无明显加重；或妊娠20周后首次诊断高血压，并持续至产后12周以后。 defined as blood pressure equal to or greater than 140/90
20、 mm Hg before conception or before 20 weeks gestation, and the hypertension is not increased significantly, or hypertension is firstly diagnosed after 20 weeks gestation and persists beyond 12 weeks postpartum.,并发症 脑出血、心力衰竭、肺水肿、急性肾 功能衰竭、胎盘早剥、DIC、胎儿窘迫等。 Complications: cerebral hemorrhage, Heart Failu
21、re, pulmonary edema, acute renal failure, placental abruption,disseminated intravascular coagulation, fetal distress,子痫惊厥后咬伤造成舌血肿,子痫患者头部CT箭头处 可见低密度阴影,处理原则： 妊娠期高血压的处理原则为休息、镇静、间断吸氧、密切监护母儿状态； 子痫前期的处理原则为休息、镇静、解痉、降压、合理扩容和必要时利尿，密切监测母儿状态，适时终止妊娠； 子痫的处理原则为控制抽搐，纠正缺氧和酸中毒，及时终止妊娠。 Rest, Sedation,Intermittent inh
22、alation of oxygen, Close monitoring, spasmolysis, Control of hypertension, expand blood volume and diuretic therapy,termination of pregnancy,Control of seizures.,【处理原则 Treatment】,1有受伤的危险 与发生抽搐及意识丧失有关。 2潜在并发症 胎盘早剥、肾衰竭。 3焦虑 与担心自身及胎儿安危有关。 High risk for injury，related to seizure or unconsciousness。 Pote
23、ntial for complications, related to renal failure, placental abruption Anxiety: related to worrying about the safety of herself and the fetus .,【护理诊断 nursing diagnosis】,【护理措施】,（一）妊娠期高血压患者的护理 （二）子痫前期患者的护理 （三）子痫患者的护理 （四）产时及产后护理 （五）心理护理 （六）健康指导,（一）妊娠期高血压患者的护理,1休息与睡眠 可在家治疗，充足的睡眠（10小时/日）；以左侧卧位为宜。 2间断吸氧 3
24、饮食指导 蛋白质（100克/日）、蔬菜，补充维生素、铁和钙剂； 水肿不明显者不必严格限制食盐。 4密切监测母儿状况 监测患者体重、血压，询问患者有无头痛、视力改变、上腹不适等症状；协助患者进行尿蛋白测定、血液检查、胎儿发育状况和胎盘功能检查 Be at home, get enough sleep:left lateral position. Intermittent inhalation of oxygen. Dietary Guidelines: Get close monitoring of the states of the mother and the baby,（二）子痫前期患者的
25、护理,1一般护理 住院治疗，卧床休息，左侧卧位。床旁准备开口器、吸氧装置、吸引器、产包等抢救物资及硫酸镁、葡萄糖酸钙等药品。 2密切监测母儿状况 3硫酸镁用药护理 硫酸镁是目前治疗妊娠期高血压疾病的首选解痉药物。 General nursing: Be hospitalized,stay in bed:left lateral position. Make good preparation for rescuing. Close monitoring. Medication care of magnesium sulfate:,（三）子痫患者的护理,1协助医师控制抽搐 Control of s
26、eizures 一旦发生抽搐，应尽快控制。硫酸镁为首选药物，必要时可加用强有力的镇静剂。 2防止受伤 Prevent injuries. 3避免再次抽搐 avoid the second seizure 单间，保持环境安静，光线暗淡；治疗和护理操作应轻柔且相对集中。 4严密监护病情 close monitoring and observation 密切观察患者生命体征、神志、尿量等的变化，及早发现脑出血、肺水肿、急性肾衰竭、胎盘早剥等并发症。 5做好终止妊娠的准备 Prepare for the termination of pregnancy 子痫发作者往往在发作后自然临产，应及时发现产兆，
27、并做好母子抢救准备。,3硫酸镁用药护理 medication nursing,（1）用药方法 可采用肌内注射或静脉用药。 深部肌内注射：intramuscular injection 作用时间长，但局部刺激性强，注射部位疼痛明显；注射时可加利多卡因于硫酸镁溶液中，以缓解疼痛，注射后用无菌棉球覆盖针孔，防止注射部位感染。 静脉用药intravenous administration 可行静脉滴注或推注。,（2）毒性反应,膝腱反射消失 loss of deep tendon reflexes 全身肌张力减退 muscle hypotonia 呼吸抑制 respiratory paralysis 发
28、生心脏停搏 cardiac arrest,（3）注意事项,应监测患者血压，同时应注意以下事项： 膝腱反射必须存在； 呼吸不少于16次/分； 尿量17ml/h或400ml/24h。 出现中毒反应，立即静脉注射10%葡萄糖酸钙10ml(5-10min)。 existence of deep tendon reflexes； breath no less than 16 per minute； urine volume no less than17ml/h or 400ml/24h。 if toxic reaction appears，10% calcium gluconate solution 10ml(5-10min) iv。,（四）产时及产后护理,1产时护理 经阴道分娩者，第一产程应密切监测产妇的血压、脉搏、尿量、胎心及子宫收缩情况，并注意有无头痛、呕吐等自觉症状；第二产程期间避免产妇用力，尽量缩短产程，初产妇可行会阴侧切，并可采用产钳助产或胎头吸引器助产；第三产程主要是预防产后出血，在胎儿娩出前肩后立即静脉注射缩宫素，但禁用麦角新碱，及时娩出胎盘并按摩宫底。 2产后护理 仍需严密监测血压变化，重视患者主诉，防止发生产后子痫。,
