Артериальная гипертензия у беременных: диагностика, лечение, профилактика осложнений


О.А. Пустотина

Кафедра акушерства, гинекологии и репродуктивной медицины ФПК МР РУДН, Москва
У беременных женщин наличие артериальной гипертензии ассоциируется с такими серьезными осложнениями беременности, как преэклампсия, эклампсия, преждевременные роды, отслойка плаценты, антенатальная гибель плода, нарушение мозгового кровообращения и инсульт у матери. В обзоре представлена современная классификация гипертензии у беременных (хроническая гипертензия; гестационная гипертензия; преэклампсия, возникшая «de novo» или на фоне хронической гипертензии; гипертензия «белого халата»), рассмотрены принципы диагностики различных гипертензивных расстройств и их патогенез при беременности. Приведены международные и отечественные рекомендации по тактике ведения преэклампсии, ее профилактике и лечению (антигипертензивная терапия, аспирин, препараты кальция, витамин D). Подчеркивается, что результаты терапии гипертензивных расстройств у беременных женщин далеко не всегда успешны. Поэтому особое внимание необходимо уделять профилактике их развития на этапе подготовки и планирования беременности.

Литература


1. Duley L. The global impact of pre-eclampsia and eclampsia. Semin. Perinatol. 2009;33(3):130–37.

2. Steegers E.A., von Dadelszen P., Duvekot J.J., Pijnenborg R. Preeclampsia. Lancet. 2010; 376(9741):631–44.

3. WHO. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA. The World Bank and the United Nations Population Division, 2014.

4. Материнская смертность в Российской Федерации в 2014 г. (методическое письмо) / Под ред. Е.Н. Байбариной. МЗ РФ, 2015. 73 с.

5. Tranquilli A.L., Dekker G., Magee L., Roberts J., Sibai B.M., Steyn W., Zeeman G.G., Brown M.A. The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy Hypertens. 2014;4(2):97–104.

6. Brown M.A., Lindheimer M.D., de Swiet M., Van Assche A., Moutquin J.M. The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the international society for the study of hypertension in pregnancy (ISSHP). Hypertens. Pregnancy. 2001;20(1):IX–XIV.

7. Tranquilli A.L., Brown M.A., Zeeman G.G., Dekker G., Sibai B.M. The definition of severe and early-onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Pregnancy Hypertens. 2013;3(1):44–7.

8. Шехтман М.М. Руководство по экстрагенитальной патологии у беременных. М., 2011. 896 с.

9. Brown M.A., Mangos G., Davis G., Homer C. The natural history of white coat hypertension during pregnancy. BJOG. 2005;112(5):601–6.

10. Brown M.A. Is there a role for ambulatory blood pressure monitoring in pregnancy? Clin. Exp. Pharmacol. Physiol. 2014;41(1):16–21.

11. Ananth C.V., Keyes K.M., Wapner R.J. Pre-eclampsia rates in the United States, 1980–2010: age-period-cohort analysis. BMJ. 2013;347:f6564.

12. Гипертензивные расстройства во время беременности, в родах и послеродовом периоде. Преэклампсия. Эклампсия. Клинические рекомендации МЗ РФ (протокол лечения). М., 2016. 72 с.

13. Haram K., Svendsen E., Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy Childbirth. 2009;9:8.

14. Sibai B.M.. Eclampsia. Maternal-perinatal outcome in 254 consecutive cases. Am. J. Obstet. Gynecol. 1990;163(3):1049–54.

15. Cunningham F.G., Twickler D. Cerebral edema complicating eclampsia. Am. J. Obstet. Gynecol. 2000;182(1 Pt 1):94–100.

16. Qureshi A.I., Frankel M.R., Ottenlips J.R., Barney J. Cerebral Hemodynamics in Preeclampsia and Eclampsia. Arch. Neurol.1996;53:1226–31.

17. Шифман Е.М. Преэклампсия, эклампсия, HELLP-синдром. Петрозаводск, 2003. С. 202–6.

18. Wallace A.E., Whitley G.S., Thilaganathan B., Cartwright J.E. Decidual natural killer cell receptor expression is altered in pregnancies with impaired vascular remodeling and a higher risk of pre-eclampsia. J. Leukoc. Biol. 2015;97(1):79–86.

19. Brosens I., Pijnenborg R., Vercruysse L., Romero R. The «great Obstetrical Syndromes» are associated with disorders of deep placentation. Am. J. Obstet. Gynecol. 2011;204(3):193–201

20. Wu P., van den Berg K., Alfirevic Z., O’Brien S., Röthlisberger M., Baker P.N., Kenny L.C., Kublickiene K., Duvekot J.J. Early Pregnancy Biomarkers in Pre­Eclampsia: A Systematic Review and Meta­Analysis. Int. J. Mol. Sci. 2015;16(9):23035–56.

21. Navaratnam K., Alfirevic Z., Baker P.N., Gluud C., Grüttner B., Kublickiene K., Zeeman G., Kenny L.C. A multi­centre phase IIa clinical study of predictive testing for preeclampsia: improved pregnancy outcomes via early detection (IMPROvED). BMC Pregnancy Childbirth. 2013;13:226.

22. English F.A., Kenny L.C., McCarthy F.P. Risk factors and effective management of preeclampsia. Integr. Blood Press Control. 2015;8:7–12.

23. Duckitt K., Harrington D. Risk factors for pre­eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330(7491):565.

24. North R.A., McCowan L.M., Dekker G.A., Poston L., Chan E.H., Stewart A.W., Black M.A., Taylor R.S., Walker J.J., Baker P.N., Kenny L.C. Clinical risk prediction for pre-eclampsia in nulliparous women: development of model in international prospective cohort. BMJ. 2011;342:d1875.

25. Lie R.T., Rasmussen S., Brunborg H., Gjessing H.K., Lie-Nielsen E., Irgens L.M. Fetal and maternal contributions to risk of pre­eclampsia: population based study. BMJ. 1998;316(7141):1343–47.

26. Khong S.L., Kane S.C., Brennecke S.P., da Silva Costa F. First-Trimester Uterine Artery Doppler Analysis in the Prediction of Later Pregnancy Complications. Dis. Markers. 2015;2015:679730.

27. Lykke J.A., Bare L.A., Olsen J., Lagier R., Arellano A.R., Tong C., Paidas M.J., Langhoff-Roos J. Thrombophilias and adverse pregnancy outcomes: results from the Danish National Birth Cohort. J. Thromb. Haemost. 2012;10(7):1320–25.

28. Saftlas A.F., Levine R.J., Klebanoff M.A., Martz K.L., Ewell M.G., Morris C.D., Sibai B.M. Abortion, changed paternity, and risk of preeclampsia in nulliparous women. Am. J. Epidemiol. 2003;157(12):1108–14.

29. Kho E.M., McCowan L.M., North R.A., Roberts C.T., Chan E., Black M.A., Taylor R.S., Dekker G.A.; SCOPE Consortium. Duration of sexual relationship and its effect on preeclampsia and small for gestational age perinatal outcome. J. Reprod. Immunol. 2009;82(1):66–73.

30. Skjærven R., Wilcox A.J., Lie R.T. The interval between pregnancies and the risk of preeclampsia. N. Engl. J. Med. 2002;346(1):33–8.

31. Magee L.A., Dadelszen P., Singer J., Lee T., Rey E., Ross S., Asztalos E., Murphy K.E., Menzies J., Sanchez J., Gafni A., Gruslin A., Helewa M., Hutton E., Lee S.K., Logan A.G., Ganzevoort W., Welch R., Thornton J.G., Moutquin J.M. Can adverse maternal and perinatal outcomes be predicted when blood pressure becomes elevated? Secondary analyses from the CHIPS (Control of Hypertension In Pregnancy Study) randomized controlled trial. Acta Obstet. Gynecol. Scand. 2016;95(7):763–76.

32. Payne B., Hodgson S., Hutcheon J.A., Joseph K.S., Li J., Lee T., Magee L.A., Qu Z., von Dadelszen P.; PIERS Study Group. Performance of the full PIERS model in predicting adverse maternal outcomes in pre-eclampsia using patient data from the PIERS (Pre- eclampsia Integrated Estimate of RiSk) cohort, collected on admission. BJOG. 2013;120(1):113–18.

33. von Dadelszen P., Payne B., Li J., Ansermino J.M., Broughton Pipkin F., Côté A.M., Douglas M.J., Gruslin A., Hutcheon J.A., Joseph K.S., Kyle P.M., Lee T., Loughna P., Menzies J.M., Merialdi M., Millman A.L., Moore M.P., Moutquin J.M., Ouellet A.B., Smith G.N., Walker J.J., Walley K.R., Walters B.N., Widmer M., Lee S.K., Russell J.A., Magee L.A.; PIERS Study Group. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet. 2011;377(9761):219–27.

34. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. Geneva, Switzerland: World Health Organization, 2011.

35. Abalos E., Duley L., Steyn D.W., Henderson-Smart D.J. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst. Rev. 2007;1:CD002252.

36. Duley L., Henderson-Smart D., Meher S. Altered dietary salt for preventing pre-eclampsia, and its complications. Cochrane Database Syst. Rev. 2005;4:CD005548.

37. Virkus R.A., Løkkegaard E., Lidegaard Ø., Langhoff-Roos J., Nielsen A.K., Rothman K.J., Bergholt T. Risk factor for venous thromboembolism in 1,3 mln pregnancies: a nationwide prospective cohort. PLoS One. 2014;9(5):e96495.

38. Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated ACOG Recommendations, 2016.

39. Henderson J.T., Whitlock E.P., O’Connor E., Senger C.A., Thompson J.H., Rowland M.G. Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann. Intern. Med. 2014;160(10):695–703.

40. Roberge S., Giguere Y., Villa P., Nicolaides K., Vainio M., Forest J.C., von Dadelszen P., Vaiman D., Tapp S., Bujold E. Early administration of low-dose aspirin for the prevention of severe and mild preeclampsia: a systematic review and metaanalysis. Am. J. Perinatol. 2012;29(7):551–56.

41. Overview of calcium in book: Ross A.C., Taylor C.L., Yaktine A.L., et al. IOM (Institute of Medicine). Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC, 2011. P. 35–74.

42. Пигарова Е.А. Роль кальция в профилактике и лечении остеопороза. Эффективная фармакотерапия. 2015;46(2):2–6.

43. Мирная С.С., Пигарова Е.А., Беляева А.В., Мокрышева Н.Г., Тюльпаков А.Н., Рожинская Л.Я. Роль кальций-чувствительного рецептора в поддержании системы кальциевого гомеостаза. Остеопороз и остеопатии. 2010;3:32–6.

44. Sauberlich H.E. Laboratory tests for the assessment of nutritional status, 2nd ed. Boca Raton, 1999.

45. Hanson M.A., Bardsley A., De-Regil L.M., Moore S.E., Oken E., Poston L., Ma R.C., McAuliffe F.M., Maleta K., Purandare C.N., Yajnik C.S., Rushwan H., Morris J.L. The International Federation of Gynecology and Obstetrics (FIGO) Recommendations on Adolescent, Preconception, and Maternal Nutrition: «Think Nutrition First». Int. J. Gynecol. Obstet. 2015;131(Suppl 4):S213–53.

46. WHO Guideline: Calcium supplementation in pregnant women. Geneva, 2013.

47. Margolis K.L., Manson J.E. Calcium supplements and cardiovascular disease risk: what do clinicians and patients need to know? Ann. Intern. Med. 2016;165(12):884–85.

48. Yuasa S., Sumikura T., Yura T., Takahashi N., Shoji T., Uchida K., Fujioka H., Miki S., Matsuo H., Takamitsu Y. Effect of low dietary calcium intake on blood pressure and pressure natriuresis response in rats: a possible role of the renin-angiotensin system. Blood Press. 1996;5(2):121–27.

49. Buppasiri P., Lumbiganon P., Thinkhamrop J., Ngamjarus C., Laopaiboon M., Medley N. Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes. Cochrane Database Syst. Rev. 2015;2:CD007079.

50. Hofmeyr G.J., Lawrie T.A., Atallah A.N., Duley L., Torloni M.R. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst. Rev. 2014;6:CD001059.

51. Imdad A., Jabeen A., Bhutta Z.A. Role of calcium supplementation during pregnancy in reducing risk of developing gestational hypertensive disorders: a meta-analysis of studies from developing countries. BMC Public Health. 2011;11(Suppl. 3):S18.

52. Tang R., Tang I.C., Henry A., Welsh A. Limited evidence for calcium supplementation in preeclampsia prevention: a metа-analysis and systematic review. Hypertens. Pregnancy. 2015;34(2):181–203.

53. Ross A.C., Manson J.E., Abrams S.A., Aloia J.F., Brannon P.M., Clinton S.K., Durazo-Arvizu R.A., Gallagher J.C., Gallo R.L., Jones G., Kovacs C.S., Mayne S.T., Rosen C.J., Shapses S.A. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J. Сlin. Еndocrinol. Metab. 2011;96(1):53–8.

54. Prentice R.L., Pettinger M.B., Jackson R.D., Wactawski-Wende J., Lacroix A.Z., Anderson G.L., Chlebowski R.T., Manson J.E., Van Horn L., Vitolins M.Z., Datta M., LeBlanc E.S., Cauley J.A., Rossouw J.E. Health risks and benefits from calcium and vitamin D supplementation: Women’s Health Initiative clinical trial and cohort study. Osteoporos. Int. 2013;24:567–80.

55. Лиманова О.А., Торшин И.Ю., Сардарян И.С. и др. Обеспеченность микронутриентами и женское здоровье: интеллектуальный анализ клинико-эпидемиологических данных. Вопр. гинекологии, акушерства и перинатологии. 2014;2:5–15.

56. Sunyecz J.A. The use of calcium and vitamin D in management of osteoporosis. Ther. Clin. Risk Manag. 2008;4(4):827–36

57. Heaney R.P., Dowell M.S., Bierman J., Hale C.A., Bendich A. Absorbability and cost effectiveness in calcium supplementation. J. Am. Coll. Nutr. 2001;20(3):239–46.

58. Straub D.A. Calcium supplementation in clinical practice: a review of forms, doses, and indications. Nutr. Clin. Pract. 2007;22(3):286–96.

59. Management Sciences for Health. International drug price indicator guide 2011 edition. Arlington, Management Sciences for Health Inc, 2012 (http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2011_en.pdf

60. Aspray T.J., Bowring C., Fraser W., Gittoes N., Javaid M.K., Macdonald H., Patel S., Selby P., Tanna N., Francis R.M.; National Osteoporosis Society. National Osteoporosis Society Vitamin D Guideline Summary. Age Ageing. 2014;43(5):592–95.

61. Overview of vitamin D in book: Ross A.C., Taylor C.L., Yaktine A.L., et al. IOM (Institute of Medicine). Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC, 2011. P. 75–125.

62. Pludowski P., Holick M.F., Pilz S., Wagner C.L., Hollis B.W., Grant W.B., Shoenfeld Y., Lerchbaum E., Llewellyn D.J., Kienreich K., Soni M. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality-a review of recent evidence. Autoimmun. Rev. 2013;12(10):976–89.

63. Plank M.J., Wall D.J., David T. Atherosclerosis and calcium signalling in endothelial cells. Prog. Biophys. Mol. Biol. 2006;91(3):287–313.

64. WHO. Guideline: Vitamin D supplementation in pregnant women. Geneva, World Health Organization, 2012.

65. Дедов И.И., Мельниченко Г.А., Пигарова Е.А. и др. Клинические рекомендации РАЭ «Дефицит витамина D у взрослых: диагностика, лечение и профилактика», 2015, 68 с. www.endocrincentr.ru

66. Jafarzadeh L., Motamedi A., Behradmanesh M., Hashemi R. A comparison of serum levels of 25-hydroxy Vitamin D3 in pregnant women at risk for gestational diabetes mellitus and women without risk factors. Mater. Sociomed. 2015;27(5):318–22.

67. Ozturk C., Atamaz F.C., Akkurt H., Akkoc Y. Pregnancy-associated osteoporosis presenting severe vertebral fractures. J. Obstet. Gynaecol. Res. 2014;40(1):288–92.

68. Principi N., Bianchini S., Baggi E., Esposito S. Implications of maternal vitamin D deficiency for the fetus, the neonate and the young infant. Eur. J. Nutr. 2013;52(3):859–67.

69. Cardús A., Parisi E., Gallego C., Aldea M., Fernán-dez E., Valdivielso J.M. 1,25-Dihydroxyvitamin D3 stimulates vascular smooth muscle cell proliferation through a VEGF-mediated pathway. Kidney Int. 2006;69:1377–84.

70. Evans K.N., Nguyen L., Chan J., Innes B.A., Bulmer J.N., Kilby M.D., Hewison M. Effects of 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3 on cytokine production by human decidual cells. Biol. Reprod. 2006;75:816–22.

71. Perez-Lopez F.R., Pasupuleti V., Mezones-Holguin E., Benites-Zapata V.A., Thota P., Deshpande A., Hernandez A.V. Effect of vitamin D supplementation during pregnancy on maternal and neonatal outcomes: a systematic review and meta- analysis of randomized controlled trials. Fertil. Steril. 2015;103(5):1278–88.e4.

72. Roth D.E. Vitamin D supplementation during pregnancy: safety considerations in the design and interpretation of clinical trials. J. Perinatol. 2011;31(7):449–59.

73. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. Cochrane Database Syst. Rev. 2016;1:CD008873.

74. Радзинский В.Е., Пустотина О.А., Верижникова Е.В., Дикке Г.Б., Артымук Н.В. и др. Прегравидарная подготовка: клинический протокол. М., 2016. 80 с.

75. Narang N., Sharma J. Sublingval mucosa as a route for systemic drug delivery. Int. J. Pharm. Pharm. Sci. 2011;3(Suppl 2):18–22.


Об авторах / Для корреспонденции


Автор для связи: О.А. Пустотина – д.м.н., проф. кафедры акушерства, гинекологии и репродуктивной медицины ФПК МР РУДН, Москва; e-mail: pustotina@gmail.com


Похожие статьи


Бионика Медиа