Johns Hopkins Center for Fetal Therapy, Baltimore, Maryland.
Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
Am J Perinatol. 2024 Jul;41(10):1298-1310. doi: 10.1055/a-2051-2127. Epub 2023 Mar 9.
Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..
妊娠高血压疾病仍然是不良围产期结局和孕产妇死亡的重要原因，并且会对母婴终生心血管健康产生影响，其严重程度和妊娠并发症的频率成正比。胎盘是母体和胎儿之间的界面，它未能与母体心血管在第一 trimester 末同步进行血管成熟，这导致了妊娠高血压疾病和胎儿生长受限。虽然滋养细胞侵入失败伴不完全的母体螺旋动脉重塑被认为是子痫前期发病机制的核心，但与异常的第一 trimester 母体血压和心血管适应相关的心血管危险因素会产生相同的胎盘病理，导致妊娠高血压疾病。在妊娠之外，确定血压治疗阈值的目的是预防严重高血压（>160/100mmHg）的即时风险和源自血压升高（低至 120/80mmHg）的长期健康影响。直到最近，在妊娠期间采取不那么积极的血压管理趋势是由于担心在没有明确临床获益的情况下引起胎盘灌注不良。然而，在第一 trimester 期间，胎盘灌注并不依赖于母体灌注压，适当风险的血压正常化可能有机会保护胎盘发育不良，从而预防妊娠高血压疾病。最近的随机试验为更积极的适当风险的血压管理奠定了基础，这可能为预防妊娠高血压疾病提供更大的潜力。要点：· 为预防子痫前期及其风险而优化母体血压管理尚未明确。· 绒毛间隙的早期妊娠血流流变学损伤易引发子痫前期和 FGR。· 第一 trimester 的血压管理可能需要以正常血压为目标，以预防子痫前期。
