Management of hypertensive disorders in pregnancy

doi:10.3877/cma.j.issn.2095-3216.2015.04.006

Abstract

Abstract:

Hypertensive disorders in pregnancy (HDP) is a common and serious clinical syndrome, characterized by hypertension, renal injury, and neurological symptoms in pregnancy, and is a major cause for maternal death. According to 2013 ACOG (American College of Obstetricians and Gynecologists) guideline, HDP is categorized as gestational hypertension, preeclamsia-eclamsia, chronic hypertension, and chronic hypertension complicated with preeclamsia. Patients with blood pressure of ≥160/110 mmHg need antihypertensive therapy of which the first-line drugs are calcium channel blockers and adrenoceptor blocking agents. Renin and angiotensin receptor blockers are contraindicated in the first trimester of pregnancy due to their potential teratogenicity. Patients with mild preeclampsia are suggested to receive expectant management, including antihypertensive medication, symptomatic treatment, and nutritional supportive treatment. HDP has a tendency to spontaneous remission within 12 weeks after delivery. Diagnosis of chronic hypertension is considered if hypertension persists. Renal biopsy should be advised to investigate the underlying chronic kidney disease if proteinuria persists more than six months after delivery.

Key words: Pregnancy, Hypertention, Proteinuria, Treatment

Yani He, Jiarui Liu. Management of hypertensive disorders in pregnancy[J]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2015, 04(04): 192-195.

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References 22

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分类	诊断标准
妊娠期高血压	妊娠20周后首次出现血压≥140/90 mmHg，并于产后12周内恢复正常。尿蛋白(－)。
子痫前期-子痫	妊娠20周后首次出现血压≥140/90 mmHg，或血压≥160/110 mmHg(重度子痫前期)。尿蛋白≥0.3 g/24 h或尿蛋白/肌酐≥0.3 mg/g·cr，无蛋白尿时伴有以下任一表现：血小板<100×10⁹/L、肝功能损害、肾功能损害、肺水肿、脑功能或视觉障碍。患者出现抽搐时即可诊断子痫。
慢性高血压	妊娠前或妊娠20周前检查发现血压升高，但妊娠期无明显加重；或妊娠20周后首次诊断高血压病并持续到产后12周以后。
慢性高血压并发子痫前期	慢性高血压孕妇妊娠前无蛋白尿，妊娠后出现蛋白尿≥0.3 g/24 h或妊娠前有蛋白尿，妊娠后尿蛋白明显增加或血压进一步升高并出现血小板<100×10⁹/L、肝肾功能损伤等子痫前期的症状和体征。

分类	诊断标准
妊娠期高血压	妊娠20周后首次出现血压≥140/90 mmHg，并于产后12周内恢复正常。尿蛋白(－)。
子痫前期-子痫	妊娠20周后首次出现血压≥140/90 mmHg，或血压≥160/110 mmHg(重度子痫前期)。尿蛋白≥0.3 g/24 h或尿蛋白/肌酐≥0.3 mg/g·cr，无蛋白尿时伴有以下任一表现：血小板<100×10⁹/L、肝功能损害、肾功能损害、肺水肿、脑功能或视觉障碍。患者出现抽搐时即可诊断子痫。
慢性高血压	妊娠前或妊娠20周前检查发现血压升高，但妊娠期无明显加重；或妊娠20周后首次诊断高血压病并持续到产后12周以后。
慢性高血压并发子痫前期	慢性高血压孕妇妊娠前无蛋白尿，妊娠后出现蛋白尿≥0.3 g/24 h或妊娠前有蛋白尿，妊娠后尿蛋白明显增加或血压进一步升高并出现血小板<100×10⁹/L、肝肾功能损伤等子痫前期的症状和体征。

药物	用法	特点	不良反应
硝苯地平	5～20 mg每8 h 1次口服缓释剂10～20 mg每12 h 1次口服	快速降低外周血管阻力，扩张冠状动脉，缓解冠状动脉痉挛，降低心肌耗氧量	头痛、颜面潮红、下肢水肿，与硫酸镁合用可致母体低血压、胎儿缺氧
甲基多巴	200～500 mg/d分3次口服	不影响心率、心输出量增加肾血流安全性高	抑郁、嗜睡、体位性低血压
拉贝洛尔	50～200 mg每12 h 1次口服	作用强、显效快不影响冠状动脉、肾血流量	支气管痉挛
酚妥拉明	10～20 mg/min静脉注射	改善微循环、降低心肌后负荷	动脉血压过低、反射性心动过速
硝酸甘油	起始量5～10 μg/min静脉注射，维持量20～50 μg/min静脉注射	用于合并心力衰竭和急性冠脉综合征的高血压急症	心动过缓、产程延长

药物	用法	特点	不良反应
硝苯地平	5～20 mg每8 h 1次口服缓释剂10～20 mg每12 h 1次口服	快速降低外周血管阻力，扩张冠状动脉，缓解冠状动脉痉挛，降低心肌耗氧量	头痛、颜面潮红、下肢水肿，与硫酸镁合用可致母体低血压、胎儿缺氧
甲基多巴	200～500 mg/d分3次口服	不影响心率、心输出量增加肾血流安全性高	抑郁、嗜睡、体位性低血压
拉贝洛尔	50～200 mg每12 h 1次口服	作用强、显效快不影响冠状动脉、肾血流量	支气管痉挛
酚妥拉明	10～20 mg/min静脉注射	改善微循环、降低心肌后负荷	动脉血压过低、反射性心动过速
硝酸甘油	起始量5～10 μg/min静脉注射，维持量20～50 μg/min静脉注射	用于合并心力衰竭和急性冠脉综合征的高血压急症	心动过缓、产程延长

治疗原则	治疗方案
妊娠期高血压疾病治疗	一般治疗为基础，联合降压、解痉、镇静、利尿等(如前所述)
肾脏支持治疗	减少肾损伤：避免使用肾毒性药物，如非甾体类消炎药、氨基糖苷类抗生素
	恢复或维持肾灌注：合理扩容(胶体液为主)，监测血液动力学指标以预防肺水肿，维持电解质和酸碱平衡
	透析治疗：采用每日短时间透析(或20 h/周)，透析参数可调整为碳酸氢盐25 mmol/L、钠135 mmol/L。干体重评估时要注意孕期体重每周增加0.3～0.5 kg。抗凝剂肝素及低分子肝素不通过胎盘屏障可安全使用
终止妊娠	出现脏器功能急剧恶化、血小板进一步减少、神经系统功能障碍、高血压难以控制以及胎儿发育异常等严重表现时应及时终止妊娠

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