Hypertensive disorders
in pregnancy are a leading
cause of peripartum
morbidity and mortality. Preeclampsia is a heterogeneous
maternal syndrome. Large studies have
pointed out the
association of impaired
spiral artery remodeling
at the fetomaternal interphase in
preeclampsia, but how exactly is the fetomaternal dialogue mediated and what
are the biomarkers to detect the subclinical disease in various subsets of
high-risk pregnancies is still a
challenge. These biomarkers
can finally be
used to diagnose
renal function (Kallikrein-creatinine ratio), vascular
resistance (uterine artery Doppler), coagulation disorders (platelet volume,
fibronectin, prostacyclin, thromboxane,
oxidant stress (lipid
peroxidase, 8-isoprostane, antioxidants, anticardiolipin antibodies,
homocysteine, serum uric
acid), vascular adaptation
(Placental growth factor,
Vascular endothelial growth factor, s-flt, s-eng) and markers ofplacental
function and ischemia (placental
CRH, CRH bp,
activin, inhibin, hCG).Post partum
preeclampsia can be
predicted by identifying the
factors preventing the excretion of sodium, puerperal diuresis and shift of intravascular fluid into the
extra vascular compartment compartment(atrial natriuretic peptide in the first
week after delivery, natriuresis and
inhibition of aldosterone,
angiotensin II, vasopressin).
Preeclampsia is a heterogeneous disease.
The late onset
preeclampsia at or
near term has
low fetal and maternal morbidity. But the early onset
preeclampsia (1%) of all preeclampsia has significant risks. Prediction of risks
and identification of
subclinical disease is
mandatory. The majority
of at risk
groups in multigravida are
chronic hypertension, pregestational and
gestational diabetes, age
and multiple fetuses. Whereas, in
primi only 14% have these risks. This suggests that there are multiple
underlying etiologies of different
clinical presentations. A
clinical algorithm based
on clinical, biochemical
and ultrasound markers is outlined. Post partum eclampsia can be
predicted and monitored with central venous
pressure and pulmonary
capillary wedge pressure.
The maternal syndrome
(proteinuria, edema and hypertension)
also has differences
in time of onset,
severity and organ
system involvement as highlighted in several studies. These clinical subpopulations
need to be identified and preeclampsia predicted with rigorous definition of
different biomarkers of different clinical phenotypes. The future endeavors should
be to identify
subclinical disease in
various clinical phenotypes
with these potential biomarkers in prospective longidunal studies.
Author(s) Details
Dr. Jayavelan Ramkumar
Department of Cardiothoracic
Surgery, Sri Ramachandra Medical College and University, Chennai-600116, India.
Dr. Nidhi Sharma
Department of Obstetrics and
Gynaecology, Saveetha Medical College, Saveetha University, Chennai-602105,
India.
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