Prevalence des differents phenotypes d'hypertension arterielle apres une pre-eclampsie

La pré-éclampsie (PE) est un trouble hypertensif gravidique qui touche 3-5% des grossesses. Elle s'associe à un risque d'hypertension artérielle (HTA) 4 fois supérieur à la population générale. L'objectif de cette étude prospective contrôlée est d'évaluer la prévalence des différents phénotypes d'hypertension par la mesure de la pression artérielle de 24 heures (MAPA) dans le post-partum. Des MAPA sur 24 heures ont été effectuées 6-12 semaines après l'accouchement, chez 115 femmes ayant fait une PE et 41 femmes ayant eu une grossesse normale. Les valeurs de MAPA diurne et nocturne étaient significativement plus élevées après une PE. Cinquante % des patientes avec PE présentaient une HTA persistante, 17.9% une HTA de la blouse blanche, 11.6% une HTA masquée et 62.3% étaient non-dippers. La MAPA après une PE permet l'identification des patientes à risque cardiovasculaire élevé et l'implémentation précoce de mesures préventives.Preeclampsia is associated with increased cardiovascular and renal risk. The aim of this prospective cohort study was to characterize the early postpartum blood pressure (BP) profile after preeclampsia. We enrolled 115 women with preeclampsia and 41 women with a normal pregnancy in a prospective cohort study. At 6 to 12 week postpartum, we assessed the prevalence of different hypertensive phenotypes using 24-hour ambulatory BP monitoring (ABPM), as well as the risk of salt sensitivity and the variability of BP derived from ABPM parameters. Among patients with preeclampsia, 57.4% were still hypertensive at the office. Daytime ABP was significantly higher in the preeclampsia group (118.9±15.0/83.2±10.4 mm Hg) than in controls (104.8±7.9/71.6±5.3 mm Hg; P<0.01). Differences between groups were similar for nocturnal BP values. Fifty percent of preeclampsia women remained hypertensive on ABPM in the postpartum, of whom 24.3% were still under antihypertensive treatment; 17.9% displayed a white-coat hypertension and 11.6% had masked hypertension. In controls, 2.8% had white-coat hypertension; none had masked hypertension or needed hypertensive treatment. The prevalence of nondippers was similar 59.8% in the preeclampsia group versus 51.4% in controls. High-risk class of salt sensitivity of BP was increased in preeclampsia women (48.6%) compared with controls (17.1%); P<0.01. In conclusion, ABPM 6 to 12 weeks after delivery reveals a high rate of sustained ambulatory, nocturnal, and masked hypertension after preeclampsia. This finding may help identify women who should be included in a postpartum cardiovascular risk management program

La pré-éclampsie du post-partum : hypothèses physiopathologiques

Contexte : La pré-éclampsie (PE) est une pathologie ischémique placentaire se manifestant par un syndrome materno-fœtal pendant la grossesse, et dont seul l’accouchement peut interrompre la progression. La PE peut survenir dans le post-partum et cette forme atypique de PE n’est pas expliquée par notre compréhension actuelle de la maladie. L’objectif de ce travail est de formuler des hypothèses physiopathologiques et de les explorer par l’étude des facteurs de risques, des potentiels facteurs déclencheur et de les corréler à l’étude de l’histopathologie des placentas. Méthode : Il s’agit d’une étude cas-témoins, comparant les caractéristiques démographiques et obstétricales des cas de PE du post-partum (n=50), à celles des cas de PE ante-partum précoce (n=100) et tardive (n=100), et à des grossesses normotensives (n=100). Pour l’étude de l’histopathologie placentaire, 30 placentas par groupe ont été étudiés. Les patientes ont été recrutées sur la base de registres de patientes avec troubles hypertensifs, tenus par les centres participants et sur la base des codes diagnostiques issus de la classification internationale des maladies (CIM). Résultats : Aucune différence statistiquement significative n’a été observée entre les groupes en terme d’âge, d’indice de masse corporelle, de primiparité, de recours aux techniques de procréation médicalement assistée et de décès néonataux. La PE du post-partum est associée à l’ethnie afro-caribéenne (OR 3.0, IC 95% 1.3-6.7 ; p <0.01), l’hypertension artérielle (HTA) pré-gestationnelle (OR 46.3, IC 95% 7.4-∞; p <0.01), la gémellité (OR 7.7, IC 95% 1.4-78.7) ; p<0.01), un état infectieux péri-partum (OR 6.5, IC 95% 1.8-29.7 ; p<0.01), la provocation du travail (OR 6.0, IC 95% 1.8-21.4 ; p <0.01), et des valeurs de tension artérielle (TA) avant la sortie de la maternité normales-hautes, tant pour la valeur systolique (OR 10.2, IC 95% 4.3-25.4 ; p<0.01) que pour la valeur diastolique (OR 30.2, IC 95% 8.3-168.3 ; p<0.01). Au niveau placentaire, 40% des placentas des cas de PE post-partum présentaient une déciduite aiguë (PE précoce: 5.7% (2), p<0.01; PE tardive: 16.7% (5), p=0.046; normotendues: 3.2% (1), p<0.01), 39.4% (13) démontraient une anomalie de la maturité villositaire (PE précoce: 77.2% (27), p<0.01; PE tardive: 26.7% (8), p=0.3; normotendues: 3.2% (1), p<0.01), 18.2% (6) montraient une vasculopathie déciduale (PE précoce: 34.3% (12), p=0.13; PE tardive: 10% (3), p=0.35; normotendues: 9.7% (3), p=0.33) et 9.1% (3) présentaient des signes d’ischémie et d’infarctus (PE précoce: 51.4% (18), p<0.01; PE tardive: 13.3% (4), p=0.6; normotendues: 16.1% (5), p=0.4). Conclusions : Les résultats de nos travaux suggèrent que les patientes présentant une PE dans le post-partum ont un profil de risque similaire à celui de la PE typique de l’ante partum, en particulier des PE tardives survenant au delà de 34 SA. La modification de la date de l’accouchement par l’intervention médicale et la provocation du travail pourrait agir comme facteur déclencheur de la PE dans le post-partum, de même qu’une infection aiguë. Les premiers signes de PE post-partum peuvent être détectés par la mesure de la TA avant la sortie de la maternité. Aucune différence significative n’a été observée au niveau placentaire, en terme de vasculopathie déciduale et de signes d’ischémie placentaire. Le taux de déciduite aiguë était plus important dans la PE du post-partum. Au total, la PE du post-partum semble être une pathologie maternelle, survenant dans un contexte d’état inflammatoire accru, possiblement déclenchée par une infection aiguë, où la maladie ischémique placentaire joue peu ou aucun rôle.Background: Pre-eclampsia (PE) is an ischemic placental disease that is clinically expressed by a maternal-fetal syndrome. Only delivery can stop the progression of the disease. PE can occur after delivery and this atypical from of PE is not explained by our current understanding of the physiopathology. The objective of this work was to formulate physiopathological hypotheses for post-partum PE, to explore them by identifying the risk factors, potential triggers and to correlate them to a histological study of the placenta of women who would later present with post-partum pre-eclampsia. Methods: This is a case-control study, comparing the demographic and obstetrical characteristics of cases of post-partum PE (n=50) with cases of early-onset PE (n=100), late-onset PE (n=100) and normotensive pregnancies (n=100). For the pathological study, 30 placentas per group were included. Patients were identified on a registry of hypertensive disorders of pregnancy and through the codification of the International Classification of Diseases (ICD). Results: There was no difference in term of age, body mass index, primiparity, use of reproductive technology and neonatal death between groups. Post-partum PE was associated with Afro-Caribbean ethnicity (OR 3.0, CI 95% 1.3-6.7; p <0.01), pre-gestationnal hypertension (OR 46.3, CI 95% 7.4-∞; p <0.01), twin pregnancies (OR 7.7, CI 95% 1.4-78.7); p<0.01), peri-partum infectious diseases (OR 6.5, IC 95% 1.8-29.7; p<0.01), induction of labor (OR 6.0, IC 95% 1.8-21.4; p <0.01), and normal-high blood pressure value before discharge of the maternity ward, for the systolic value (OR 10.2, IC 95% 4.3-25.4; p<0.01) as well as for the diastolic value (OR 30.2, IC 95% 8.3-168.3 ; p<0.01). Forty percent of placenta of post-partum PE had acute deciduitis (early PE: 5.7% (2), p<0.01; late PE: 16.7% (5), p=0.046; normal: 3.2% (1), p<0.01), 39.4% (13) had abnormal maturation of the villi (early PE: 77.2%(27), p<0.01; late PE: 26.7%(8), p=0.3; normal: 3.2 %(1), p<0.01), 18.2% (6) had decidual arteriolopathy (early PE: 34.3% (12), p=0.13; late PE: 10% (3), p=0.35; normal: 9.7% (3), p=0.33) and 9.1% (3) had villous ischemia and infarction (early PE: 51.4% (18), p<0.01; late PE: 13.3% (4), p=0.6; normal: 16.1% (5), p=0.4). Conclusions: Our work suggests that patients presenting with post-partum PE have similar risk profile than the typical antepartum PE, in particular with late-onset PE (after 34 weeks of gestation). Modification of the delivery date by medical intervention and induction of labor, might act as a trigger, as well as an acute infection. First signs of post-partum PE can be detected through measurement of blood pressure before discharge of the maternity. There were no significant differences in the placentas in terms of decidual arteriolopathy and villi ischemic changes between post-partum PE, late onset PE and the controls. There was a higher level of acute deciduitis in the placenta of post-partum PE. Altogether, our results suggests that post-partum preeclampsia is more of a maternal disease, characterized by an increased inflammatory state, potentially triggered by infection, and in which placental ischemic disease has little or no role to play

Gynécologie-obstétrique. Médecine interne obstétricale : le succès d'une approche transdisciplinaire de la santé maternelle

Obstetric medicine is a specialty that addresses maternal health and medical complications during pregnancy. This emerging specialty responds to the increasing need for specialized intervention in cases of high risk pregnancies, at a time when pregnancies can occur at more advanced ages and where advances in therapeutics now allow to consider pregnancy in mothers with chronic illness. Furthermore, medical conditions specific to pregnancy, such as hypertensive disorders of pregnancy or gestational diabetes, are now recognized as emerging risk factors for cardiovascular, metabolic and renal diseases, for which longitudinal care beyond the maternity ward is of critical importance

Nutritional approach to preeclampsia prevention

International audienc

Hypertensions gravidiques : considérations pratiques

Hypertension is the most frequent medical disorder of pregnancy. Whether in the form of a chronic hypertension or a pregnancy induced-hypertension, or preeclampsia, it is associated with major maternal and neonatal morbidity and mortality. Improvement of prenatal care allowed a reduction in the number of poor outcomes. However, our partial understanding of the origin of gestational hypertension and preeclampsia limits the establishment of robust prediction models and efficient preventive interventions. This review discusses actual considerations on the clinical approach to hypertension in pregnancy

Diabète prégestationnel : une entité de plus en plus fréquente

Pre-gestational diabetes, which is defined by the presence of diabetes prior to pregnancy, is an ever-increasing entity. Its management includes an optimization of the glycemic control before the beginning of pregnancy, but also a constant adaptation of the treatment during pregnancy. Good monitoring and adequate glycemic control throughout pregnancy are of course necessary to minimize complications for both the fetus and the mother

Les présentations cliniques atypiques de la prééclampsie

Preeclampsia is a pregnancy-related syndrome, which still represents one of the major causes of maternal-fetal mortality and morbidity. Diagnosis can be made difficult due to the complexity of the disorder and its wide spectrum of clinical manifestations. In order to provide an efficient diagnostic tool to the clinician, medical societies regularly rethink the definition criteria. However, there are still clinical presentations of preeclampsia that escape the frame of the definition. The present review will address atypical forms of preeclampsia, such as preeclampsia without proteinuria, normotensive preeclampsia, preeclampsia before 20 weeks of gestation and post-partum preeclampsia

Pronostic réno-vasculaire de la prééclampsie chez la mère et l'enfant

Preeclampsia is a pregnancy-related disease that affects 2 to 8% of pregnancy worldwide. It is now a well-established risk factor for cardiovascular and renal diseases. Preeclampsia is a well-recognized risk factor for future cardiovascular, renal and neurological disorders for the mother. It predetermines the risk profile of the future child's health. A long-term follow-up aimed on prevention and screening should be offered. Further studies are needed to determine the modality of that follow-up as well as the prevention strategies specific for that population. This article proposes a non-exhaustive review of the cardiovascular, renal and neurological consequences of the disease on the mother and child's health

Biological rhythms and preeclampsia

The impact of impaired circadian rhythm on health has been widely studied in shift workers and trans-meridian travelers. A part from its correlation with sleep and mood disorders, biological rhythm impairment is a recognized risk factor for cardiovascular diseases and breast cancer. Preeclampsia is a major public health issue, associated with a significant maternal and fetal morbidity and mortality worldwide. While the risks factors for this condition such as obesity, diabetes, pre-existing hypertension have been identified, the underlying mechanism of this multi-factorial disease is yet not fully understood. The disruption of the light/dark cycle in pregnancy has been associated with adverse outcomes. Slightly increased risk for "small for gestational age" babies, "low birth weight" babies, and preterm deliveries has been reported in shift working women. Whether altered circadian cycle represents a risk factor for preeclampsia or preeclampsia is itself linked with an abnormal circadian cycle is less clear. There are only few reports available, showing conflicting results. In this review, we will discuss recent observations concerning circadian pattern of blood pressure in normotensive and hypertensive pregnancies. We explore the hypothesis that circadian misalignments may represent a risk factor for preeclampsia. Unraveling potential link between circadian clock gene and preeclampsia could offer a novel approach to our understanding of this multi-system disease specific to pregnancy

Le placenta : nouvel organe cible de l'hypertension artérielle ?

The placenta has generated many beliefs over centuries and in all ethnicities. Considered in our society as a surgical waste, it is elsewhere contemplated for its mysterious protective powers, viewed as the seat of the soul, disposed of, burnt or even buried. However, once time is taken for its examination, the placenta tells a story. Of interest is the similarity observed between placental vascular disease in hypertensive pregnancy and atherosclerosis in coronary artery disease for example. Hypertension in pregnancy is frequent and associated with increased adverse obstetrical outcomes, and long-term risk of cardiovascular and kidney disease. This article will discuss the role of placental histopathology in hypertensive pregnancies, its indicative value for long-term cardiovascular risk in mothers and for subsequent pregnancy