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Hypertension in pregnancy mind map
This is a mind map about hypertension in pregnancy, including high-risk factors, pathogenesis, pathophysiology, diagnosis, auxiliary examinations, etc. Hope this helps!
Edited at 2023-11-05 21:21:37
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Hypertension in pregnancy mind map
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Hypertensive disorders of pregnancy
include
Hypertension during pregnancy
Systolic blood pressure ≥140mmhg and diastolic blood pressure ≥90mmhg first appear after 20 weeks of pregnancy and return to normal within 12 weeks postpartum
Urinary protein (-)
Systolic blood pressure ≥160mmhg and diastolic blood pressure ≥110mmhg are severe gestational hypertension.
Preeclampsia
After 20 weeks of pregnancy, systolic blood pressure ≥140mmhg and diastolic blood pressure ≥90mmhg are found, accompanied by: urine protein ≥0.3g/24h; urine protein/creatinine ratio ≥0.3; random urine protein ≥ ( )
After 20 weeks of pregnancy, systolic blood pressure ≥140mmhg and diastolic blood pressure ≥90mmhg are found, accompanied by: urine protein ≥0.3g/24h; urine protein/creatinine ratio ≥0.3; random urine protein ≥ ( )
No proteinuria but accompanied by involvement of any of the following organs or systems: heart, lungs, liver, kidneys and other important organs, blood system, digestive system, abnormal changes in the nervous system, placenta-fetal involvement and
Severe
Blood pressure continues to rise, systolic blood pressure ≥160mmhg and diastolic blood pressure ≥110mmhg
Persistent headache, visual disturbance, or other central nervous system abnormalities
Persistent upper abdominal pain and subcapsular liver hematoma or liver rupture
Abnormal liver enzymes: elevated blood alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels
Impaired kidney function: urine protein ≥2.0g/24h or ( ); oliguria (24h urine output <400ml or hourly urine output <17ml); serum creatinine >06μmol/L
Hematological abnormalities; platelets <100×10⁹/L; intramicrovascular hemolysis, anemia, jaundice or elevated blood LDH
Hypoalbuminemia with peritoneal effusion, pleural effusion, or pericardial effusion
heart failure
Pulmonary Edema
Fetal growth restriction or oligohydramnios, intrauterine fetal death, placental abruption
Pregnant women with preeclampsia experience convulsions
Eclamptic convulsions progress rapidly, and the prodromal symptoms are short-lived, manifesting as convulsions, facial congestion, foaming at the mouth, and deep coma.
Muscle rigidity develops throughout the body and limbs in a few seconds, with hands clenched and arms flexed, strong twitching occurs rapidly, and the intensity weakens after about 1 minute.
During the convulsion, the patient has no breathing movements. When the convulsion stops, the patient resumes breathing but remains comatose. Finally, consciousness recovers but he feels sleepy, irritable, and restless.
Eclampsia (mostly occurs in late pregnancy and before delivery, called prepartum eclampsia, accounting for 71%; a few occur during delivery, called intrapartum eclampsia; it may also occur within 48 hours after delivery, called postpartum eclampsia)
deal with
General emergency treatment: Keep the respiratory tract open, maintain respiratory and circulatory functions, and closely observe vital signs and urine output. Avoid sound and light stimulation, lip and tongue bites and injuries from falling to the ground
Control tics
control blood pressure
Correct hypoxia and acidosis: Intermittent oxygen inhalation by mask or air bag, and appropriate intravenous administration of sodium bicarbonate as appropriate to correct acidosis.
Terminate pregnancy
Chronic hypertension complicated by preeclampsia
Pregnant women with chronic hypertension have no proteinuria before 20 weeks of pregnancy, but then develop proteinuria ≥0.3g/24h; women with hypertension and proteinuria have proteinuria after 20 weeks of pregnancy (urinary protein ≥0.3g/24h or urine protein ≥ ( ) is defined as a significant increase in proteinuria or a progressive increase in blood pressure or any of the severe preeclampsia
Pregnancy complicated by chronic hypertension
Systolic blood pressure ≥140mmhg and diastolic blood pressure ≥90mmhg before pregnancy or before 20 weeks of pregnancy, with no obvious aggravation during pregnancy
Hypertension is first diagnosed after 20 weeks of pregnancy and persists beyond 12 weeks postpartum
Mortality accounts for 10%-16% of total pregnancy-related deaths
high risk factors
The first pregnancy is separated by more than 10 years
Pregnant women aged 40 and above
Have a history and family history of preeclampsia
Chronic hypertension, chronic nephritis, antisquamous antibody syndrome, diabetes mellitus
Obesity and malnutrition
Early pregnancy systolic blood pressure ≥130mmhg or diastolic blood pressure ≥80mmhg
Pathogenesis
Immune mechanism: excessive activation of maternal immunity and reduced immune tolerance to the embryo, leading to preeclampsia
Shallow placental implantation: In patients with gestational hypertension, trophoblast infiltration is too shallow and uterine spiral arterioles are insufficiently recast, resulting in insufficient placental blood volume and preeclampsia.
Damage to vascular endothelial cells: pathological changes in preeclampsia. Toxic substances and inflammatory mediators such as oxygen free radicals, tumor necrosis factor, interleukin-6, very low-density lipoprotein, etc. can promote oxidative stress, cause vascular endothelial damage, and interfere with the balance of the prostate. Prostacyclin (PG|2 ) secretion decreases, and the production of thromboxane A2 (TXA2), a vascular endothelial contraction factor secreted by platelets, increases, resulting in an imbalance in the ratio of contraction factors and relaxation factors and an increase in blood pressure. Vascular endothelial injury can activate platelets and coagulation factors, aggravating the hypercoagulable state of preeclampsia.
Genetic factors: Study pinpoints more than a dozen chromosomal susceptibility regions for preeclampsia
Nutritional deficiencies: Lack of various nutrients such as calcium, magnesium, zinc, and selenium are related to the occurrence and development of preeclampsia. In patients with pregnancy-induced hypertension, intracellular calcium ions increase and serum calcium decreases, causing vascular smooth muscle cells to contract and blood pressure to increase. (Selenium can prevent the body from being damaged by lipid peroxides, improve the body's immune function, and avoid damage to blood vessel walls)
Pathophysiology
brain
Cerebral vasospasm and increased permeability can cause brain tissue hypoxia, edema, ischemia, intramicrovascular thrombosis, hemorrhage, or softening of local brain parenchymal tissue, resulting in dizziness, headache, nausea, vomiting, blurred vision, etc., and even convulsions, coma
Extensive cerebral edema can lead to increased intracranial pressure and even brain herniation.
kidney
Glomerular capillary spasm and hypoxia, glomerular dilation, endothelial cell swelling, and cellulose deposition in endothelial cells
Leakage of plasma proteins from the glomerulus causing proteinuria
Vasospasm leads to a decrease in renal blood flow, a decrease in glomerular filtration rate, an increase in plasma uric acid concentration, and an increase in plasma creatinine to twice that of normal pregnancy. Oligouria, edema, proteinuria, and casts may occur. In severe cases, renal failure may occur.
cardiovascular
Vasospasm, peripheral resistance increases, blood pressure rises, cardiac output significantly decreases, and the cardiovascular system shows low discharge and high resistance.
Activation of endothelial cells increases vascular permeability, intravascular fluid enters the interstitium, and interstitial water and sodium retention leads to myocardial ischemia, interstitial edema, myocardial punctate hemorrhage and necrosis, and pulmonary edema.
Increased blood viscosity increases the burden on the heart, and in severe cases, heart failure may occur.
blood
Spasm of small arteries throughout the body, increased permeability of blood vessel walls, blood concentration, and increased hematocrit
Preeclampsia is often accompanied by a hypercoagulable state caused by a certain amount of activation or mutation of coagulation factors.
Severe patients may develop microangiopathic hemolysis, manifested as thrombocytopenia, elevated liver enzymes, and hemolysis.
liver
Abnormal liver function, elevated transaminase levels, and elevated plasma alkaline phosphatase may occur in preeclampsia.
Periportal hemorrhage and necrosis around the liver lobules are characteristic injuries of the liver
Bleeding caused by injury can cause subcapsular hematoma formation and even liver rupture.
fundus
Spasm of retinal arterioles, tissue ischemia and edema, may cause visual impairment, blurred vision, and in severe cases, retinal detachment and sudden blindness.
uteroplacenta
Spasm of small uterine blood vessels, insufficient recasting of uterine spiral arterioles, and the average diameter of spiral arteries is only half of that of normal pregnant women, resulting in insufficient blood supply to the placenta and decreased placental function, resulting in oligohydramnios, fetal growth restriction, fetal distress, and even fetal death.
Placental abruption caused by rupture of retroplacental blood vessels
diagnosis
Edema
Pregnant women whose weight increases ≥0.9Kg per week or 2.7kg every 4 weeks may develop invisible edema
It usually starts from the ankle and gradually extends to the ankle, which is pitting edema that does not subside after resting.
Edema limited to the ankles and calves is represented by , extending to the thighs is represented by , extending to the vulva and abdominal wall is represented by , generalized edema or accompanied by abdominal effusion is represented by .
Auxiliary inspection
Blood tests: Can detect acidosis early
Urine test: can alert to the seriousness of hypertension during pregnancy
Liver and kidney function test: Understand the damage to liver and kidney function
Fundus examination: reflects the spasm of small blood vessels throughout the body
Others: electrocardiogram and echocardiogram to understand cardiac function; CT or MR examination for suspected cerebral hemorrhage; fetal and placental function examination, fetal intrauterine safety status and fetal maturity examination
deal with
General treatment
rest, food
Get enough sleep and sleep on your left side; get enough protein and calories
Patients with generalized edema: appropriately limit salt intake
For those who are stressed and have poor sleep at night: Diazepam 2.5-5 mg orally, 3 times a day or 5 mg taken before going to bed
Closely monitor the condition of mother and child
If the condition worsens, you should be hospitalized
Antihypertensive treatment
Hypertensive patients with systolic blood pressure ≥140mmhg and diastolic blood pressure ≥90mmhg should use antihypertensive drugs
Pregnant women without organ damage control systolic blood pressure 130-155mmhg diastolic blood pressure 80-105mmhg
Control organ damage in pregnant women: systolic blood pressure 130-139mmhg, diastolic blood pressure 80-89mmhg (not lower than 130/80mmhg, to ensure uterine-placental blood perfusion, and blood pressure reduction should not fluctuate greatly)
labelore
αβ receptor antagonist, lowers blood pressure without affecting renal and placental blood flow. It can inhibit platelet aggregation and promote fetal lung maturation
Add 50-100mg to 250-500ml of 5% glucose solution for intravenous infusion/when blood pressure is stable, take 50-100mg 3-4 times a day.
nifedipine
Calcium channel blockers inhibit smooth muscle contraction, dilate systemic blood vessels and reduce blood pressure
Take 5-10mg orally, 3-4/d, and the total amount in 24 hours shall not exceed 60g. In an emergency, take 10 mg sublingually. Sustained-release tablet 20 mg taken 1-2 times/d
nimodipine
Calcium channel blockers, which can selectively dilate cerebral blood vessels
20-60mg taken 2-3 times/d. Intravenous infusion: 20-40mg added to 250ml of 5% glucose solution, the total daily dose should not exceed 360mg
Nicardipine
calcium channel blockers
The initial dose is 20-40 mg orally, 3 times/d. Intravenous infusion of 1 mg/h is the starting point, and the dosage is adjusted every 10 minutes if blood pressure changes.
Phentolamine
alpha adrenergic receptor antagonist
Dissolve 10-20mg in 100-200ml of 5% glucose solution, start intravenous infusion at a rate of 10/min, and adjust the drops according to the antihypertensive effect.
Nitroglycerin
Acts on nitrous oxide synthase, which can simultaneously dilate the veins and arteries and reduce the preload and postload of the heart.
Mainly used for antihypertensive treatment of hypertensive emergencies combined with acute heart failure and acute coronary syndrome.
The initial dose is 5-10 μg/min intravenously, and the infusion rate is increased every 5-10 minutes to a maintenance dose of 20-50 μg/min.
sodium nitroprusside
A potent vasodilator
50mg, add 500ml of 5% glucose solution, and infuse slowly at 0.5-0.8μg/(kg.min)
Pregnant women with hypertensive crisis who are ineffective with other antihypertensive drugs. Prenatal application should not exceed 4 hours
Magnesium sulfate prevents and treats eclampsia
First-line drugs for treating eclampsia and preventing seizures
Function control
Magnesium ions inhibit the release of acetylcholine from motor nerve terminals, block neuromuscular transmission, and relax skeletal muscles.
Magnesium ions stimulate the vascular endothelium to synthesize prostaglandins, reduce the body's response to angiotensin II, and relieve vasospasm.
Magnesium ions can increase the affinity of pregnant women and fetal hemoglobin and improve oxygen metabolism
Magnesium ions block glutamate channels, prevent the influx of calcium ions, and relieve vasospasm
usage
Control convulsions: intravenous loading dose of 4-6g, dissolved in 20ml of 10% glucose solution, intravenous infusion (15-20mg), or 100% rapid intravenous infusion of 5% glucose solution, followed by 1-2g/h intravenous infusion maintenance. Or stop intravenous administration at night before going to bed and switch to intramuscular injection. Usage: 25% magnesium sulfate 20ml, 2% lidocaine 2ml intramuscularly in the arm, total magnesium sulfate 25-30g in 24 hours
Prevention of seizures: Suitable for severe preeclampsia and post-eclampsia seizures, the loading dose is 2.5-5g, and the maintenance dose is the same as for controlling eclamptic convulsions. Generally, intravenous infusion is given for 6-12 hours every day, and the total amount in 24 hours should not exceed 25g. Magnesium sulfate can be used continuously during labor induction and during delivery, and for 24h-48h after delivery.
Application for newly discovered high blood pressure combined with headache or blurred vision after childbirth
Regarding the effects of long-term use on fetal calcium levels and bone quality, magnesium sulfate should be discontinued after 5-7 days of use in patients whose condition is stable. In the expectant management of severe preeclampsia, use intermittently when necessary
toxicity
The effective concentration for treatment is 1.8-3.0mmol/L. Poisoning symptoms will occur if it exceeds 3.5mmol/L.
The knee reflex weakens or disappears. As the blood magnesium concentration increases, systemic hypotonia and dyspnea may occur, diplopia, and slurred speech. In severe cases, respiratory muscle paralysis may occur, and even respiratory arrest and cardiac arrest may occur, which is life-threatening.
calm
It can eliminate patients' anxiety and tension, prevent and control eclampsia attacks
Diazepam: 2.5-5.0 mg orally, 2-3 times/d, or before going to bed. 10 mg intramuscularly or intravenously if necessary
Phenobarbital: The oral dose during sedation is 30 mg, 3 times/d. Intramuscular injection of 0.1g to control eclampsia
Hibernation mixture: composed of chlorpromazine (50mg), pethidine (100mg) and promethazine (50mg), usually 1/3-1/2 of the amount is intramuscularly injected, or half the amount is added to 250ml of 5% glucose solution for intravenous infusion. Since chlorpromazine can sharply drop blood pressure, reduce renal and placental blood flow, and cause certain damage to the liver of pregnant women and fetuses, and can also inhibit fetal breathing, it should only be used in cases where magnesium sulfate is ineffective in controlling convulsions.
diuretic
It is generally not recommended that patients with generalized edema, acute heart failure, pulmonary edema, or cerebral edema may use rapid diuretics such as furosemide as appropriate.
Promote fetal lung maturation
Pregnant women with preeclampsia whose gestational age is <34 weeks and expected to give birth within 1 week should receive glucocorticoid treatment to promote fetal lung maturation.
Can reduce the incidence of neonatal respiratory distress syndrome
Dexamethasone 6 mg intramuscularly, once every 12 hours, a total of 4 times. Or betamethasone 12 mg intravenously, once every 12 hours, a total of 2 times.
If after the initial fetal lung stimulation, conservative treatment has been performed for a period of time (about 2 weeks), and the gestational age is still <34 weeks, the same dose of fetal lung maturity stimulation treatment can be given again.
Terminate pregnancy
Hypertension during pregnancy, if the condition does not reach severe preeclampsia, can be expected after 37 weeks of pregnancy
If the treatment of severe preeclampsia is not effective, it is recommended to terminate it.
Termination of pregnancy may be considered after eclampsia is controlled
Consider natural birth first, and no longer consider relaxing the indications for cesarean section
prevention
People with low calcium intake (<600mg/d) should take calcium by mouth, with a supplement of at least 1g/d to prevent preeclampsia.
People with high risk factors for preeclampsia should start taking low-dose aspirin (50-100 mg) in early pregnancy (12-16 weeks of pregnancy) and continue until 28 weeks of pregnancy.