Magee-Womens Research Institute, Department of Obstetrics Gynecology and Reproductive Sciences, Epidemiology and Clinical and Translational Research, University of Pittsburgh (J.M.R.).
Department of Epidemiology, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA (J.W.R.-E.).
Hypertension. 2021 May 5;77(5):1430-1441. doi: 10.1161/HYPERTENSIONAHA.120.14781. Epub 2021 Mar 29.
The concept that preeclampsia is a multisystemic syndrome is appreciated in both research and clinical care. Our understanding of pathophysiology recognizes the role of inflammation, oxidative and endoplasm reticulum stress, and angiogenic dysfunction. Yet, we have not progressed greatly toward clinically useful prediction nor had substantial success in prevention or treatment. One possibility is that the maternal syndrome may be reached through different pathophysiological pathways, that is, subtypes of preeclampsia, that in their specificity yield more clinical utility. For example, early and late onset preeclampsia are increasingly acknowledged as different pathophysiological processes leading to a common presentation. Other subtypes of preeclampsia are supported by disparate clinical outcomes, long-range prognosis, organ systems involved, and risk factors. These insights have been supplemented by discovery-driven methods, which cluster preeclampsia cases into groups indicating different pathophysiologies. In this presentation, we review likely subtypes based on current knowledge and suggest others. We present a consideration of the requirements for a clinically meaningful preeclampsia subtype. A useful subtype should (1) identify a specific pathophysiological pathway or (2) specifically indicate maternal or fetal outcome, (3) be recognizable in a clinically useful time frame, and (4) these results should be reproducible and generalizable (but at varying frequency) including in low resource settings. We recommend that the default consideration be that preeclampsia includes several subtypes rather than trying to force all cases into a single pathophysiological pathway. The recognition of subtypes and deciphering their different pathophysiologies will provide specific targets for prevention, prediction, and treatment directing personalized care.
子痫前期是一种多系统综合征的概念，在研究和临床护理中都得到了认可。我们对病理生理学的理解认识到炎症、氧化和内质网应激以及血管生成功能障碍的作用。然而，我们在临床有用的预测方面并没有取得很大进展，也没有在预防或治疗方面取得实质性成功。一种可能性是，母体综合征可能通过不同的病理生理途径达到，即子痫前期的亚型，其特异性提供了更多的临床实用性。例如，早发型和晚发型子痫前期越来越被认为是导致共同表现的不同病理生理过程。子痫前期的其他亚型则由不同的临床结局、长期预后、涉及的器官系统和危险因素支持。这些见解得到了基于发现的方法的补充，这些方法将子痫前期病例聚类为表明不同病理生理学的组。在本次演讲中，我们根据现有知识回顾了可能的亚型，并提出了其他亚型。我们考虑了子痫前期亚型具有临床意义的要求。一个有用的亚型应该（1）确定特定的病理生理途径，或（2）特别指示母体或胎儿的结局，（3）在临床上有用的时间框架内可识别，（4）这些结果应该是可重复和可推广的（但频率不同），包括在资源有限的环境中。我们建议默认考虑子痫前期包括几种亚型，而不是试图将所有病例归入单一的病理生理途径。对亚型的识别和对其不同病理生理学的解码将为预防、预测和治疗提供具体目标，指导个性化护理。
