妊娠与肾脏病预案.pptVIP

中山大学附一院肾内科陈崴 CASE A 32-year-old white woman is admitted with headache and hypertension at 22 weeks gestation. During the current pregnancy, her BP was 110/80 at 7 weeks gestation, but increased to 130/80 at 9 weeks and 140/90 at 19 weeks. Her past history is positive for two previous spontaneous abortions at 11 and 12 weeks gestation.Physical examination reveals BP of 150/110, both pulmonary congestion and peripheral edema, and hyperreflexia with 3 to 4 beat clonus. LABORATORY DATA BUN 3.23mmol/LCreatinine 88μ mol/L Hematocrit 28 % Hgb 9g/L Ret 2% Platelets 61,000 PT,APTT normalC3 0.6 (normal equals 0.83-1.77)ALT,AST,GGT increasedUric acid 321 μ mol/L ACL + Three days later, the patient had blurred vision and nausea; she had a grand mal seizure in the emergency room. At this time her BP is 205/130, retinal hemorrhages and papilledema are noted, and the patient is hyperreflexic. Her blood pressure is very difficult to control 诊断 The patient is diagnosed as having eclampsia with the HELLP syndrome and pregnancy is terminated. (HELLP = hemolysis, elevated liver enzymes and low platelets.)  诊断 Acute thrombotic angiopathy in a patient with anti-phospholipid antibody syndrome and habitual abortion. 妊娠时的解剖和生理功能的改变 先兆子痫和子痫 肾脏病患者的妊娠问题 SLE患者的妊娠问题 妊娠时心血管改变 妊娠期最显著的特点是血压下降 主要原因是周围血管阻力下降 Friedman 等统计了386365例孕妇，发现若舒张压84mmHg（妊娠中任何时期），胎儿的死亡率明显升高 妊娠期的舒张压的正常高限应定为75mmHg（妊娠中3个月）和85mmHg（妊娠后3个月） 妊娠时心血管改变 血容量 从妊娠期的前3个月开始，血容量将逐渐升高约50％ 细胞外液的增加导致水肿，可见于35％－83％的正常孕妇。单纯水肿多是良性的，同新生儿围产期死亡率无相关性。 妊娠期水肿常常局限于下肢，而累及面部及双手的血管神经源性的水肿则提示并警惕先兆子痫的发生。 妊娠时肾脏改变 肾脏体积和重量增加：由于肾脏血流增加、血管间质容量增加。显微镜下可见血管和间质容积增加、肾小球体积增大，肾脏的直径约增加1cm，产后6个月内恢复正常。 肾脏集合管系统：肾盏、肾盂和输尿管在入骨盆以上部位都明显扩张，从妊娠期的前3个月开始出现，产后3－4个月逐渐恢复。由于雌激素和孕激素的平滑肌松弛作用及晚期时增大的子宫压迫所致。 妊娠时肾脏改变 肾脏有效血流量（ERPF）和肾小球滤过率（GFR）显著升高：45－50％ 妊娠期的血肌酐、尿素氮、和尿酸的正常值应分别为70.7μmol/L、4.64m mol /L和 268μmol/L GFR显著升高，蛋白的滤出增加，正常孕妇的尿蛋白可达300－500mg /24小时。葡萄糖、氨基酸和水溶性维生素从肾脏排泄增加，导致妊娠期肾性糖尿和氨基酸尿 妊娠时肾脏改变 显著的ERPF、GFR增高，使肾小球处于高灌注和高滤过的状态，这种生理性改变对于已有的肾脏疾病和高血压的孕妇，会导致和加速肾小球的