Predicció de complicacions maternes i fetals en pacients amb Pre-eclàmpsia

Abstract

PE is classified as the third cause of global maternal deaths and it is also associated with increased perinatal morbidity and mortality,

For all these conditions, an accurate identification of those patients at highest risk of complications remains a goal for modern obstetrics in developed countries. This would lead to a more appropriate management of these high-risk patients with a more intensive strategy and the possibility of home monitoring for those patients with a low-risk of complications.

Third-trimester abnormal uterine artery Doppler has been related to worse perinatal outcomes among patients both with and without pregnancy complications. Furthermore, in PE clinical severity has been directly related to the extension of placental ischemia: the larger the ischemia, the more severe the clinical manifestations and the poorer the perinatal outcome. However, the role of uterine artery Doppler evaluation in the identification of pregnancy at risk of maternal or foetal morbidity with early-onset PE has not been investigated. In that context, our first article evaluated the performance of Uterine Doppler in the prognostic assessment of adverse outcomes. Our second article further explored the performance of Uterine Doppler in early-PE.

Moreover, the excess in anti-angiogenic factors produced by the placenta may cause damage to the vasculature and distal orga. Karumanchi et al. showed that excess sFlt-1 would mediate the multiple symptoms of PE. Parallel, circulating PlGF levels are much lower in those patients who would develop PE than in normal pregnancies. The concentration of circulating PlGF begins to decrease 9 to 11 weeks before the onset of pre-eclampsia, with substantial reductions during the 5 weeks before the onset of hypertension or proteinuria. In that context, placental growth factor (PlGF) has emerged as a potential tool to be included in diagnostic and prognostic algorithms. This pro-angiogenic marker seems to be a more sensitive and precise predictor of PE than any other single biomarker, as it reflects placental function. Low concentrations of PlGF may reflect poor placentation and thus a response to oxidative stress in the placenta, which are mainly present in early PE.

However, this excellent profile of PlGF as a marker of early PE may limit its clinical applicability for prognostic assessment if a high number of women already have

very low levels at the onset of PE. The median of PlGF was of 12 pg/mL in women with either early onset or preterm PE.

According to our results:

1- Uterine Doppler was the best predictive parameter for perinatal outcomes in pregnancies with PE and it was even more effective than classical clinical parameters

2- Uterine Doppler should be incorporated in the management strategy of PE at the clinical onset of the disease

3- Early-onset preeclamptic patients with impaired uterine Doppler are at higher risk of maternal and neonatal complications.

4- Uterine Doppler may help in the prognostic evaluation of early-PE and should be incorporated in the management strategy at its clinical onset

5- Very low PlGF is a highly prevalent finding in early onset PE leading to its low specificity and low positive predictive value

6- The predictive role of a low PlGF level in predicting maternal complications in very early PE is limited