Strategies to prevent and treat preeclampsia: evidence from randomized controlled trials (original) (raw)
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Se ha dirigido una gran cantidad de esfuerzos a la identificación de factores demográficos, analitos bioquímicos o hallazgos biofísicos, solos o en combinación, para predecir al comienzo del embarazo el desarrollo posterior de la preeclampsia. La evidencia relacionada con la confiabilidad de las pruebas de predicción para la preeclampsia se revisa de la siguiente manera. Definición de una prueba predictiva ideal La utilidad de una prueba predictiva dependerá de la prevalencia general de la enfermedad (1). Aunque la sensibilidad y la especificidad se han utilizado para evaluar qué tan bien una prueba puede identificar a los pacientes con una enfermedad, no se centran en el significado de un único resultado de la prueba. En este sentido, la mejor manera de evaluar el valor de un resultado de prueba específico es mediante el uso de razones de verosimilitud (2). La probabilidad La razón de campana (LR) de un resultado de prueba en particular es la proporción de participantes con la condición objetivo que tienen un resultado de prueba positivo en relación con la proporción sin la condición objetivo que tienen el mismo resultado de la prueba. Debido a que la incidencia de preeclampsia es relativamente baja, las pruebas de detección con resultados de prueba positivos requieren altas LR para predecir adecuadamente la probabilidad de la enfermedad, y las pruebas con resultados negativos requieren bajas LR para excluir con confianza el trastorno. Por lo tanto, la predicción útil para la preeclampsia requeriría una LR alta (superior a 10) para una prueba positiva, así como una baja LR para un resultado negativo (menor de 0,2). Incluso la prueba de predicción más confiable solo tendrá utilidad clínica si existen enfoques preventivos efectivos e intervenciones terapéuticas disponibles o si el seguimiento cercano después de la predicción demuestra mejores resultados maternos o fetales. Epidemiología y factores de riesgo para la preeclampsia Varias circunstancias clínicas, resumidas en el cuadro 3-1, aumentan el riesgo de preeclampsia (3). El riesgo de preeclampsia se incrementa de dos a cuatro veces si un paciente tiene un familiar de primer grado con un historial médico del trastorno y se multiplica por siete si la preeclampsia complicó un embarazo anterior (3, 4). La gestación múltiple es un factor de riesgo adicional; tripletgestation es un riesgo mayor que la gestación gemela. Los factores de riesgo cardiovascular clásicos también se asocian con una mayor probabilidad de preeclampsia, como la edad materna mayor de 40 años, la diabetes, la obesidad y la hipertensión preexistente. La mayor prevalencia de hipertensión crónica y otras enfermedades médicas comórbidas en mujeres mayores de 35 años puede explicar el aumento de la frecuencia de preeclampsia entre las mujeres mayores. Las diferencias raciales en la incidencia y severidad de la preeclampsia han sido difíciles de evaluar debido a la confusión por factores socioeconómicos y culturales. No obstante, es importante recordar que la mayoría de los casos de preeclampsia ocurren en mujeres nulíparas sanas sin otros riesgos obvios. Los intentos de predecir la preeclampsia durante el embarazo temprano utilizando factores de riesgo clínicos han revelado valores predictivos modestos, con la detección del 37% de aquellos que desarrollaron preeclampsia de inicio temprano y 29% que desarrollaron preeclampsia de inicio tardío, con tasas de falsos positivos del 5% (5) Un estudio que utilizó un algoritmo que incluía factores de riesgo conocidos para la preeclampsia en mujeres nulíparas detectó un 37% de mujeres que desarrollaron preeclampsia con una tasa de falsos positivos del 10% (LR positivo = 3.6) (6).
Journal of Pregnancy, 2012
Preeclampsia (PE) affects around 2-5% of pregnant women. It is a major cause of maternal and perinatal morbidity and mortality. In an attempt to prevent preeclampsia, many strategies based on antenatal care, change in lifestyle, nutritional supplementation, and drugs have been studied. The aim of this paper is to review recent evidence about primary and secondary prevention of preeclampsia.
Primary, secondary, and tertiary prevention of pre-eclampsia
Lancet, 2001
Pre-eclampsia remains one of the major obstetrical problems in less-developed countries. The causes of this condition are still unknown, thus effective primary prevention is not possible at this stage. Research in the past decade has identified some major risk factors for pre-eclampsia, and manipulation of these factors might result in a decrease in its frequency. In the early 1990s aspirin was thought to be the wonder drug in secondary prevention of pre-eclampsia. Results of large trials have shown that this is not the case: if there is an indication for using aspirin it is in the patient at a very high risk of developing severe early-onset disease. The calcium story followed a more or less similar pattern, with the difference that existing evidence shows that women with a low dietary calcium intake are likely to benefit from calcium supplementation. Proper antenatal care and timed delivery are of utmost importance in tertiary prevention of pre-eclampsia. There is evidence to sugge...
Chinese Medical Journal, 2018
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2014
Preeclampsia remains a major problem worldwide for mothers and babies. It is estimated that yearly 50 000 women die in developing countries from preeclampsia. Careful maternal observation for the signs of preeclampsia and delivery of women with increasingly severe preeclampsia is the cornerstone of management (as it has been for the past 100 years). Maternal mortality is, therefore, much less in developed countries with the capacity for careful perinatal observation, but morbidity is considerable and remains the leading cause of admissions to intensive care for pregnant women. Also, the appropriate delivery of women who develop increasingly severe preeclampsia early in gestation accounts for 8% of all preterm births.
Preeclampsia: Narrative Review for Clinical Use
SSRN Electronic Journal
Preeclampsia is a very complex multisystem disorder characterized by mild to severe hypertension. Methods: PubMed and the Cochrane Library were searched from January 1, 2002 to March 31, 2022, with the search terms "pre-eclampsia" and "hypertensive disorders in pregnancy". We also look for guidelines from international societies and clinical specialty colleges and we focused on publications made after 2015. Results: The primary issue associated with this physiopathology is a reduction in utero-placental perfusion and ischemia. Preeclampsia has a multifactorial genesis, its focus in prevention consists of the identification of high and moderate-risk clinical factors. The clinical manifestations of preeclampsia vary from asymptomatic to fatal complications for both the fetus and the mother. In severe cases, the mother may present renal, neurological, hepatic, or vascular disease. The main prevention strategy is the use of aspirin at low doses, started from the beginning to the end of the second trimester and maintained until the end of pregnancy. Conclusion: Preeclampsia is a multisystem disorder; we do not know how to predict it accurately. Acetylsalicylic acid at low doses to prevent a low percentage, especially in patients with far from term preeclampsia. There is evidence that exercising for at least 140 min per week reduces gestational hypertension and preeclampsia. Currently, the safest approach is the termination of pregnancy. It is necessary to improve the prediction and prevention of preeclampsia, in addition, better research is needed in the long-term postpartum follow-up.
Evidence-Based Prevention of Preeclampsia: Commonly Asked Questions in Clinical Practice
Journal of Pregnancy, 2019
In this review, we discuss the recent literature regarding the prevention of preeclampsia and aim to answer common questions that arise in the routine antenatal care of pregnant women. Prescription of low-dose aspirin for high-risk patients has been shown to reduce the risk of preeclampsia (PE). A daily dose between 100 and 150 mg taken in the evening should be initiated prior to 16 weeks of gestation and can be continued until delivery. Calcium supplementation seems to be advantageous but currently it is only considered for patients with poor dietary intake and high risk for PE. Recent data about heparin are still conflicting, and therefore, heparin can currently not be recommended in the prevention of PE.