Wolf G, Wenzel U, Stahl R A, Hüneke B
Medizinische Klinik, Abteilung Nephrologie und Osteologie, Universitätsklinikum Hamburg-Eppendorf.
Med Klin (Munich). 2001 Feb 15;96(2):78-86. doi: 10.1007/pl00002182.
Hypertensive complications contribute to maternal and fetal morbidity. Hypertensive diseases in pregnancy comprise various disorder from transient hypertension to the dangerous preeclampsia/eclampsia. Diagnosis of these diseases requires an understanding of the normal physiological adaptations during pregnancy.
The primary cause of preeclampsia/eclampsia is a disturbed growth of throphoblast cells, probably induced by an altered maternal immunotolerance. The consequence is a dysfunction of endothelial cells with a decrease in perfusion of the uterus and placenta. The normal balance between vasoconstrictors and vasodilators is changed in favor of vasoconstrictors. Complex changes in the renin-angiotensin system have been detected resulting in an increased angiotensin II-mediated vasoconstriction. The reduction in perfusion of the uterus and placenta eventually leads to preeclampsia/eclampsia and growth retardation of the fetus. Manifest preeclampsia/eclampsia is characterized by disturbed microcirculation of target organs such as brain, liver and kidney. An involvement of the liver causes the HELLP syndrome.
Various pharmacological approaches to prevent preeclampsia/eclampsia showed disappointing results, but patients with a risk for the eventual development of preeclampsia/eclampsia should be identified, closely monitored, and hypertension should be treated. A systolic blood pressure > 170 mm Hg and diastolic blood pressure > 100 mm Hg should be treated. Drugs such as alpha-methyldopa and dihydralazine that are well-characterized in their fetal effects are the primary choice for the treatment of hypertension in pregnancy. ACE-inhibitors and angiotensin II receptor antagonists are absolutely, diuretics are relatively contraindicated. The causal therapy for preeclampsia/eclampsia is delivery. Gravida before the 33th week of pregnancy should be admitted, hypertension should be treated, and the fetus should be monitored by duplex ultrasound and cardiotocography. New data suggest that early treatment with glucocorticoids may prevent the manifestation of HELLP syndrome. Hypertensive pregnant patients should be treated in tertiary centers with an interdisciplinary approach involving obstetricians, neonatologists, and nephrologists.
高血压并发症会导致孕产妇和胎儿发病。妊娠期高血压疾病包括从短暂性高血压到危险的先兆子痫/子痫等多种病症。这些疾病的诊断需要了解孕期正常的生理适应性变化。
先兆子痫/子痫的主要病因是滋养层细胞生长紊乱，可能是由母体免疫耐受性改变所致。其后果是内皮细胞功能障碍，子宫和胎盘灌注减少。血管收缩剂和血管舒张剂之间的正常平衡发生改变，有利于血管收缩剂。已检测到肾素-血管紧张素系统发生复杂变化，导致血管紧张素II介导的血管收缩增加。子宫和胎盘灌注减少最终导致先兆子痫/子痫和胎儿生长迟缓。典型的先兆子痫/子痫的特征是脑、肝和肾等靶器官的微循环紊乱。肝脏受累会导致HELLP综合征。
各种预防先兆子痫/子痫的药物治疗方法效果不佳，但应识别有最终发展为先兆子痫/子痫风险的患者，密切监测，并治疗高血压。收缩压>170mmHg和舒张压>100mmHg应进行治疗。在胎儿影响方面特征明确的药物，如α-甲基多巴和肼屈嗪，是妊娠期高血压治疗的首选药物。绝对禁用ACE抑制剂和血管紧张素II受体拮抗剂，相对禁用利尿剂。先兆子痫/子痫的病因治疗是分娩。妊娠33周前的孕妇应入院，治疗高血压，并用双功超声和胎心监护仪监测胎儿。新数据表明，早期使用糖皮质激素治疗可能预防HELLP综合征的发生。高血压孕妇应在三级中心接受由产科医生、新生儿科医生和肾病科医生参与的多学科治疗。
