Prognostic value of ambulatory blood pressure monitoring in pregnancy.
Prognostic value of ambulatory blood pressure monitoring in pregnancy.
复制标题
妊娠期动态血压监测的预后价值。
DOI：
10.1097/hjh.0b013e328338a966
复制
发表时间：
2010
影响因子：
4.9
通讯作者：
D. Ayala
中科院分区：
文献类型：
--
作者：
R. Hermida;D. Ayala
在最近的一篇论文中，Vollebregt等人报道了动态血压（BP）监测（ABPM）在预测妊娠高血压方面的有限准确性。他们的方法是在妊娠前三个月使用（高度可重复性的）ABPM谱作为妊娠后期临床血压升高（高度可变和低可重复性）的预测因子。这种方法，远非新颖，在过去已经被许多其他产科医生使用，并在其他地方进行了广泛的审查。正如人们所预料的那样，这些报告显示ABPM在预测妊娠后期收缩压/舒张压至少140/90 mmHg的临床血压方面只有有限的效用，这导致了“ABPM不应该在妊娠期间使用”的可疑结论。因此，国际妊娠期高血压研究学会（ISSHP）仅依靠妊娠20周后至少140/90 mmHg的临床血压来确定妊娠期高血压的诊断，这并不奇怪，顺便说一下，这与诊断无并发症情况下原发性高血压的阈值相同。过时的ISSHP指南甚至没有提到ABPM，尽管欧洲高血压和心脏病学会的一致建议，已经表明“24小时血压在预测蛋白尿、早产风险、婴儿出生体重和妊娠一般结果方面优于传统测量”b[6]， ISSHP没有意识到或不重视这一说法。我们认为Vollebregt等人使用的方法（即在妊娠早期进行单一ABPM来预测妊娠后期根据临床血压定义的高血压）由于许多原因是无效的。当临床和ABP都可用时，ABPM，而不是临床血压，用于诊断。这是因为，通过比较临床和ABP，人们能够区分血压正常、持续性高血压、孤立性临床（白大褂）高血压和隐匿性高血压患者。我们之前已经证明，在高危妊娠中，隐匿性妊娠高血压（ABPM升高，临床血压“正常”）的患病率为15.2%，而持续妊娠高血压（临床和ABP升高，无蛋白尿）的患病率为16.1%。最重要的是，从围产期结局的角度来看，这两组完全具有可比性，这是怀孕中真正重要的问题，但两组的特点都是早产、宫内生长迟缓和剖宫产的发生率明显高于真正血压正常的孕妇和妊娠期白大褂高血压的孕妇。
In a recent manuscript, Vollebregt et al.[1] reported on the limited accuracy of ambulatory blood pressure (BP) monitoring (ABPM) in predicting hypertension in pregnancy. Their approach was to use an (highly reproducible [2]) ABPM profile in the first trimester of gestation as predictor of an elevated (highly variable and poorly reproducible) clinic BP later in pregnancy. This approach, far from novel, has been used in the past by many other obstetricians, as extensively reviewed elsewhere [3]. As one could expect, these reports showed that ABPM was only of limited utility in predicting clinic BP of at least 140/90 mmHg for SBP/DBP later in pregnancy, which led to the questionable conclusion that ‘ABPM should not be used in pregnancy’[4]. Thus, it is not surprising that the International Society for the Study of Hypertension in Pregnancy (ISSHP) relies only on a clinic BP of at least 140/90 mmHg after 20 weeks of gestation to establish the diagnosis of gestational hypertension [5], which, by the way, is the same threshold used for the diagnosis of essential hypertension in uncomplicated situations [6]. The obsolete ISSHP guidelines do not even make mention of ABPM, in spite of the consensus recommendations of the European Societies of Hypertension and Cardiology, which have stated that ‘24-h BP has been shown to be superior to conventional measurements in predicting proteinuria, risk of preterm delivery, infant weight at birth, and in general outcome of pregnancy’[6], statement that either the ISSHP is unaware of or does not value.We feel that the approach used by Vollebregt et al.[1](ie, conduct of a single ABPM early in pregnancy to predict, later in pregnancy, hypertension that is defined on the unique basis of clinic BP) is invalid for many reasons. When both clinic and ABP are available, ABPM, and not clinic BP, prevails for diagnosis. This is so because, by comparing clinic and ABP, one is able to distinguish groups of patients with normotension, sustained hypertension, isolated clinic (white-coat) hypertension, and masked hypertension [6]. We have previously demonstrated a comparable prevalence in high-risk pregnancies of 15.2% for masked gestational hypertension (elevated ABPM with ‘normal’clinic BP) and of 16.1% for sustained gestational hypertension (elevated clinic and ABP, without proteinuria)[7]. Most important, those two groups are fully comparable from the point of view of perinatal outcome, the issue that really matters in pregnancy, but both groups are characterized by an incidence of preterm delivery, intrauterine growth retardation, and delivery by cesarean section that is markedly greater than that of true normotensive pregnant women and of white-coat gestational hypertension [7].