目的:确定在妊娠35-37周时预测先兆子痫(PE)的最具歧视性的母体血管指数,并在妊娠35-37周时通过母体危险因素以及生物物理和生化标志物的组合来检查筛查PE的性能。
方法:这是一项前瞻性观察性的非干预性研究,对象是妊娠35+0~36+6周常规住院就诊的妇女。访视包括记录产妇的人口学特征和病史,通过非侵入性操作员独立设备获得的血管指数和血液动力学参数(脉搏波速度,增强指数,心输出量,每搏输出量,中心收缩压和舒张压,总外周阻力和胎儿心率)平均动脉压(MAP),子宫动脉搏动指数(UtA-PI),胎盘生长因子(PlGF)和可溶性fms样酪氨酸激酶-1(sFLT-1)的血清浓度。通过母体风险因素的组合和生物标志物的各种组合,确定在评估后的任何时间和<3周用PE进行递送的筛查性能。
结果:研究人群包括6,746名单胎妊娠妇女,包括随后发展PE的176人(2.6%)。有三个主要发现。首先,在发展体育的女性中,与那些没有的人相比,中心收缩压和舒张压较高,脉搏波速度(PWV),外周血管阻力和增强指数。第二,最具辨别性的指标是收缩压和舒张压以及PWV,与其他指数的预测差。然而,通过母亲危险因素加MAP的组合进行筛查的表现至少与母亲危险因素加中心收缩压和舒张压的组合一样高;因此,在筛查PE时,我们使用了PWV,MAP,UtA-PI,PlGF和sFLT-1。第三,在3周内筛查PE,并在评估后的任何时间筛查PE,由母体危险因素加上MAP组成的生物物理测试的假阳性率为10%时的检出率,UtA-PI和PWV(3周内PE:85.2%,95%CI75.6-92.1%;任何时候的PE:69.9%,95%CI62.5-76.6%)与使用竞争风险模型将母体风险因素与PlGF和sFLT-1相结合的生化测试没有显着差异(3周内的PE:80.2%,95CI69.9-88.3%;任何时候的PE:64.2%,95%CI56.6-71.3%),并且它们都优于低PlGF浓度的筛查(3周内PE:53.1%,95%CI41.7-64.3%;任何时候的PE:44.3,95%CI36.8-52.0%)或高sFLT-1/PlGF浓度比(3周内的PE:65.4%95%CI54.0-75.7%;任何时候的PE:53.4%,95%CI45.8-60.9%)。
结论:首先,母亲动脉僵硬度的增加先于PE的临床发作。第二,妊娠35-37周的孕妇PWV与MAP和UtA-PI联合使用,为PE的后续发展提供了有效的预测。
Epidemiological studies have shown that women with preeclampsia (PE) are at increased long term cardiovascular risk. This risk might be associated with accelerated vascular ageing process but data on vascular abnormalities in women with PE are scarce.
This study aimed to identify the most discriminatory maternal vascular index in the prediction of PE at 35 to 37 weeks\' gestation and to examine the performance of screening for PE by combinations of maternal risk factors and biophysical and biochemical markers at 35 to 37 weeks\' gestation.
This was a prospective observational nonintervention study in women attending a routine hospital visit at 35 0/7 to 36 6/7 weeks\' gestation. The visit included recording of maternal demographic characteristics and medical history, vascular indices, and hemodynamic parameters obtained by a noninvasive operator-independent device (pulse wave velocity, augmentation index, cardiac output, stroke volume, central systolic and diastolic blood pressures, total peripheral resistance, and fetal heart rate), mean arterial pressure, uterine artery pulsatility index, and serum concentration of placental growth factor and soluble fms-like tyrosine kinase-1. The performance of screening for delivery with PE at any time and at <3 weeks from assessment using a combination of maternal risk factors and various combinations of biomarkers was determined.
The study population consisted of 6746 women with singleton pregnancies, including 176 women (2.6%) who subsequently developed PE. There were 3 main findings. First, in women who developed PE, compared with those who did not, there were higher central systolic and diastolic blood pressures, pulse wave velocity, peripheral vascular resistance, and augmentation index. Second, the most discriminatory indices were systolic and diastolic blood pressures and pulse wave velocity, with poor prediction from the other indices. However, the performance of screening by a combination of maternal risk factors plus mean arterial pressure was at least as high as that of a combination of maternal risk factors plus central systolic and diastolic blood pressures; consequently, in screening for PE, pulse wave velocity, mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 were used. Third, in screening for both PE within 3 weeks and PE at any time from assessment, the detection rate at a false-positive rate of 10% of a biophysical test consisting of maternal risk factors plus mean arterial pressure, uterine artery pulsatility index, and pulse wave velocity (PE within 3 weeks: 85.2%; 95% confidence interval, 75.6%-92.1%; PE at any time: 69.9%; 95% confidence interval, 62.5%-76.6%) was not significantly different from a biochemical test using the competing risks model to combine maternal risk factors with placental growth factor and soluble fms-like tyrosine kinase-1 (PE within 3 weeks: 80.2%; 95% confidence interval, 69.9%-88.3%; PE at any time: 64.2%; 95% confidence interval, 56.6%-71.3%), and they were both superior to screening by low placental growth factor concentration (PE within 3 weeks: 53.1%; 95% confidence interval, 41.7%-64.3%; PE at any time: 44.3; 95% confidence interval, 36.8%-52.0%) or high soluble fms-like tyrosine kinase-1-to-placental growth factor concentration ratio (PE within 3 weeks: 65.4%; 95% confidence interval, 54.0%-75.7%; PE at any time: 53.4%; 95% confidence interval, 45.8%-60.9%).
First, increased maternal arterial stiffness preceded the clinical onset of PE. Second, maternal pulse wave velocity at 35 to 37 weeks\' gestation in combination with mean arterial pressure and uterine artery pulsatility index provided effective prediction of subsequent development of preeclampsia.