本文選題：子癇前期 + 慢性高血壓并發(fā)子癇前期　； 參考：《山東大學》2014年博士論文

【摘要】：第一部分子癇前期與慢性高血壓并發(fā)子癇前期妊娠結局的回顧性研究 研究背景：子癇前期是一種妊娠期常見的、嚴重影響母嬰健康的妊娠特異性疾病。子癇前期,特別是重度子癇前期發(fā)生胎盤早剝、凝血功能障礙、肝腎功能損害等的風險明顯增加。在胎兒生長受限的病因中,子癇前期約占10%；約25%的新生兒死亡與子癇前期相關。慢性高血壓患者妊娠后,發(fā)生子癇前期的風險增加。在育齡期婦女中,慢性高血壓的發(fā)病率約為1%-5%。隨著妊娠年齡的推遲,以及肥胖患者數(shù)目的增加,慢性高血壓患者的數(shù)目逐年增加。既往的回顧性研究發(fā)現(xiàn),慢性高血壓患者妊娠后,發(fā)生子癇前期、胎盤早剝、早產(chǎn)、胎兒生長受限等的風險大大增加。但是這些研究,多集中在上個世紀90年代。探討慢性高血壓患者的妊娠結局,特別是對比分析子癇前期與慢性高血壓并發(fā)子癇前期患者的妊娠結局,可以更好的指導慢性高血壓患者的孕期保健工作,預防不良妊娠結局的發(fā)生。 研究目的：回顧性分析妊娠期高血壓疾病所導致的不良妊娠結局。特別是與子癇前期相比,慢性高血壓并發(fā)子癇前期,是否增加不良妊娠結局的發(fā)生。 研究方法：我們回顧性分析了2011年1月到2012年3月期間,在山東大學附屬省立醫(yī)院住院分娩的單胎妊娠孕婦,統(tǒng)計分析正常孕婦、子癇前期、妊娠合并慢性高血壓以及慢性高血壓并發(fā)子癇前期患者的下列臨床資料：孕婦年齡、妊娠分娩史、既往疾病史(包括糖尿病、高血壓病等)、本次分娩孕周、分娩方式、胎兒性別,以及胎兒生長受限、死胎、胎盤早剝,胎膜早破等的發(fā)生等。 研究結果：共有3691例孕婦納入到本研究中。其中正常孕婦2993例,子癇前期患者461例,妊娠合并慢性高血壓患者91例,慢性高血壓并發(fā)子癇前期患者146例。妊娠期高血壓疾病組患者的年齡較大(P0.01),分娩孕周較小(P0.01),糖尿病患者的比例(P0.01)以及胎膜早破的發(fā)生率(P0.01)較高。與正常孕婦相比,子癇前期患者發(fā)生胎兒生長受限(OR:4.88;95%CI:2.76-8.63)、死胎(OR;11.84;95%CI:6.75-20.75)、早產(chǎn)(OR;6.69;95%CI:5.30-8.46)、剖宮產(chǎn)(OR;2.32;95%CI:1.89-2.89)、胎盤早剝(OR;21.7;95%CI:7.04-66.79)的風險明顯增加。慢性高血壓并發(fā)子癇前期患者發(fā)生死胎(OR;30.71;95%CI:16.59-56.83)、早產(chǎn)(OR;21.28:95%CI:14.79-30.60)、剖宮產(chǎn)(OR;7.33:95%CI:4.55-11.82)、胎盤早剝(OR;10.38:95%CI:1.88-57.13)的風險明顯增加。妊娠合并慢性高血壓患者發(fā)生剖宮產(chǎn)(OR;2.76:95%CI:1.75-4.35)、胎盤早剝(OR;16.79;95%CI:3.04-92.88)的風險明顯增加。與子癇前期患者相比,慢性高血壓并發(fā)子癇前期患者,發(fā)生死胎(OR;2.59;95%CI:1.49-4.52)、早產(chǎn)(OR;3.18;95%CI:2.16-4.68)以及剖宮產(chǎn)(OR;3.16;95%CI:1.89-5.26)的風險明顯增加。 研究結論：妊娠期高血壓疾病,增加不良妊娠結局的發(fā)生。與子癇前期相比,慢性高血壓并發(fā)子癇前期增加死胎、早產(chǎn)以及剖宮產(chǎn)等不了妊娠結局的發(fā)生。 第二部分慢性高血壓易感基因(CDH13, ATP2B1, UMOD)多態(tài)性與子癇前期發(fā)病的相關性研究 研究背景：子癇前期,是一種以高血壓和蛋白尿為特點的妊娠期特異性疾病,具有明顯的家族聚集傾向,遺傳因素在其發(fā)病過程中發(fā)揮了重要作用。慢性高血壓患者妊娠后,發(fā)生子癇前期的風險明顯增加。子癇前期患者今后發(fā)生慢性高血壓的風險明顯高于正常孕婦。全基因組關聯(lián)分析(Genome wide association study, GWAS)是研究復雜疾病易感基因的一種有效手段。慢性高血壓的GWAS研究報道,CDH13基因、ATP2B1基因、UMOD基因為慢性高血壓的易感基因,并在隨后的許多研究中得到證實。 CDH13基因位于16q24.2,編碼鈣粘著蛋白-13(也稱為T鈣粘蛋白或H鈣粘蛋白),在心血管系統(tǒng)中廣泛表達。鈣粘著蛋白-13在血管生成、保護血管內皮細胞免受氧化應激損傷等方面發(fā)揮著重要作用。ATP2B1基因位于12q21.3,編碼質膜鈣ATP酶異構體1(plasma membrane Ca2+ATPase1,PMCA1),屬于P-型離子轉運ATP酶家族中的一員。PMCA1在維持細胞內鈣離子平衡方面發(fā)揮著重要作用。UMOD基因位于16p12.3,編碼尿調節(jié)蛋白,正常人尿液中含有豐富的尿調蛋白,24小時尿排量約為20-70mg。 研究目的：通過病例一對照關聯(lián)分析的研究方法,探討慢性高血壓易感基因多態(tài)性位點(CDH13基因SNP位點rs11646213;ATP2B1基因SNP位點rs2681472；UMOD基因SNP位點rs13333226)與子癇前期發(fā)病的關系。 研究方法：(1)選取在山東大學附屬省立醫(yī)院住院分娩的914名孕婦,其中正常孕婦460名,子癇前期患者454名。采用基因測序的方法,對CDH13基因SNP位點rs11646213進行基因分型。 (2)采用taqman-MGB探針的方法對ATP2B1基因SNP位點rs2681472進行基因分型研究。實驗分為兩個階段進行：第一階段為2009年12月至2011年11月,收集在山東大學附屬省立醫(yī)院住院分娩的1218名孕婦的外周血,其中正常孕婦503名,子癇前期患者715名。第二階段的研究對象為2011年12月至2013年3月,在山東大學附屬省立醫(yī)院住院分娩的344名孕婦,其中早發(fā)型子癇前期166例,正常孕婦178例。同時采用隨機抽樣的方法,抽取5%的標本進行直接測序,以驗證taqman-MGB探針的準確性。 (3)選取在山東大學附屬省立醫(yī)院住院分娩的1418名孕婦,其中正常孕婦716例,子癇前期患者702例。采用taqman-MGB探針的方法對UMOD基因SNP位點rs13333226進行基因分型研究。同時采用隨機抽樣的方法,抽取5%的標本進行直接測序,以驗證taqman-MGB探針的準確性。 統(tǒng)計學方法：計量資料采用均數(shù)±標準差的方式表示,計數(shù)資料以百分率的形式表示。采用Haploview軟件檢測連鎖不平衡(Broad Institute,Cambridge, Massachusetts,USA).等位基因頻率的比較采用卡方檢驗進行計算。非條件logistic回歸分析校正孕婦年齡、產(chǎn)次、孕前體重指數(shù)等危險因素。數(shù)據(jù)分析采用SPSS軟件進行分析(version17.O；SPSS Inc.,Chicago,IL,USA).檢驗水平取P0.05。 研究結果：(1)CDH13基因SNP位點rs11646213的最小等位基因頻率(minor allele frequency,MAF)在正常孕婦和子癇前期患者之間,存在統(tǒng)計學差異(P=0.017；OR:1.36；95%CI:1.06-1.76).按照疾病的嚴重程度,將子癇前期患者分為兩組：輕度子癇前期、重度子癇前期后發(fā)現(xiàn),重度子癇前期患者與正常孕婦之間的MAF存在統(tǒng)計學差異(P=0.002；OR:1.57；95%CI:1.16-2.13)；輕度子癇前期與正常孕婦之間的MAF不存在統(tǒng)計學差異(P=0.91；OR:1.02,95%CI:0.70-1.50)。按照疾病的發(fā)病時間,將子癇前期分為早發(fā)型子癇前期、晚發(fā)型子癇前期后發(fā)現(xiàn)：早發(fā)型子癇前期與正常孕婦之間的MAF存在統(tǒng)計學差異(P=0.004； OR:1.54；95%CI:1.17-2.03)；晚發(fā)型子癇前期與正常孕婦之間的MAF不存在統(tǒng)計學差異(P=O.27；OR:1.19,95%CI:0.87-1.62). (2)ATP2B1基因SNP位點rs2681472的基因分型在第一階段的研究結果為：MAF在正常孕婦和子癇前期患者之間不存在統(tǒng)計學差異(P=0.23；OR：1.11,95%CI：0.94-1.31)。按照發(fā)病時間將子癇前期患者分為早發(fā)型子癇前期、晚發(fā)型子癇前期后發(fā)現(xiàn),正常孕婦和早發(fā)型子癇前期患者之間的MAF存在統(tǒng)計學差異(P=0.02； OR:1.29,95%CI:1.04-1.59).在第二階段的驗證實驗中也發(fā)現(xiàn),ATP2B1基因SNP位點rs2681472的MAF在正常孕婦和早發(fā)型子癇前期患者之間存在統(tǒng)計學差異(P=0.011:OR:1.50,95%CI:1.10-2.06). (3)UMOD基因SNP位點rs13333226的MAF在正常孕婦和子癇前期患者之間不存在統(tǒng)計學差異(P=0.45; OR:1.13,95%CI:0.83-1.53),按照發(fā)病時間以及疾病的嚴重程度進行亞組分析,正常孕婦與疾病組之間的MAF不存在統(tǒng)計學差異(P0.05)。 研究結論：在中國漢族婦女中,CDH13基因的SNP位點rs11646213多態(tài)性與子癇前期的發(fā)病之間存在相關性。ATP2B1基因的SNP位點rs2681472多態(tài)性與早發(fā)型子癇前期的發(fā)病之間存在相關性。 第三部分CDH13基因在胎盤組織中的表達及甲基化水平的初步研究 研究背景：子癇前期是一種嚴重影響孕產(chǎn)婦健康的疾病,具體發(fā)病機制不明,早孕期胎盤絨毛滋養(yǎng)細胞侵襲力下降,子宮螺旋動脈重鑄障礙、胎盤灌注不足可能在其發(fā)病過程中發(fā)揮了關鍵作用。近年來,表觀遺傳學在子癇前期發(fā)病中的作用受到越來越多的關注,特別是DNA甲基化水平的研究。我們在前期的關聯(lián)性分析研究中發(fā)現(xiàn),CDH13基因為子癇前期的遺傳易感基因。CDH13基因在體內廣泛表達,與腫瘤細胞的侵襲、血管生成等密切相關。已有研究報道,在許多腫瘤組織中CDH13基因啟動子區(qū)域的甲基化水平存在異常改變,并對其表達產(chǎn)生顯著影響。但是,CDH13基因是否在胎盤組織中表達,在正常孕婦與子癇前期患者的胎盤組織中CDH13基因的表達水平以及啟動子區(qū)域的甲基化水平是否存在差異,尚不清楚。 研究目的：為進一步明確CDH13基因在子癇前期發(fā)病中的作用,對CDH13基因在胎盤組織中的表達水平、甲基化水平進行研究。比較分析子癇前期與正常孕婦的胎盤組織中,CDH13基因啟動子區(qū)域的甲基化水平以及mRNA的表達水平是否存在差異。 研究方法：選擇留取年齡、孕次、孕前體重指數(shù)相匹配的20例正常孕婦,20例子癇前期患者的胎盤組織：(1)將胎盤組織在4%的甲醛中侵泡24小時,石蠟包埋,進行冰凍切片,免疫組化的方法分析CDH13基因在胎盤組織中的表達情況。(2)采用[rizol法,從30g胎盤組織中提取RNA,采用熒光定量PCR的方法分析CDH13基因的mRNA在正常孕婦與子癇前期患者的胎盤組織中的表達水平。(3)提取胎盤組織的DNA,通過重亞硫酸鹽測序的方法,分析CDH13基因啟動子區(qū)域的甲基化水平在正常孕婦與子癇前期患者之間是否存在差異。 研究結果：(1)CDHl3基因在胎盤血管內皮細胞上表達豐富,也在合體滋養(yǎng)細胞上表達。(2)與正常孕婦相比,子癇前期患者組CDH13基因的mRNA表達水平較高,但兩組之間的差異無統(tǒng)計學意義(P0.05)。(3)CDH13基因在胎盤組織中呈現(xiàn)明顯的去甲基化狀態(tài),子癇前期組的甲基化率高于正常孕婦,但差異無統(tǒng)計學意義(P0.05)。 研究結論：CDH13基因在胎盤組織中表達；正常孕婦與子癇前期患者之間的胎盤組織中CDH13基因的表達水平不存在統(tǒng)計學差異；CDH13基因在正常孕婦與子癇前期患者的胎盤中呈現(xiàn)去甲基化狀態(tài)。
[Abstract]:A retrospective study on the outcome of pre - eclampsia and pregnancy outcome in patients with chronic hypertension

Background : Preeclampsia is a common pregnancy - specific disease which affects mother - to - child health seriously . In the early stage of eclampsia , especially in the early stage of severe pre - eclampsia , there is a significant increase in the risk of placental abruption , coagulation dysfunction , liver and kidney function damage , etc . In the cause of fetal growth restriction , the pre - eclampsia accounts for about 10 % ;
There is a significant increase in the number of patients with chronic hypertension after pregnancy . The incidence of chronic high blood pressure is about 1 % -5 % . In the period of childbearing age , the incidence of chronic hypertension increases . However , the study shows that the pregnancy outcome of patients with chronic hypertension , especially in the early 1990s , can guide the pregnancy outcome of patients with chronic hypertension and to guide the pregnancy health of patients with chronic hypertension , and to prevent the occurrence of adverse pregnancy outcomes .

Objective : To retrospectively analyze the outcome of adverse pregnancy caused by hypertensive disorder complicating pregnancy , especially in the early stage of chronic hypertension complicated with eclampsia , whether or not to increase the outcome of adverse pregnancy .

Methods : We analyzed retrospectively the following clinical data from January 2011 to March 2012 , including the age of pregnant women , the history of pregnancy , the history of previous diseases ( including diabetes , hypertension , etc . ) , the gestational weeks of pregnancy , the mode of delivery , the sex of the fetus , and the limitation of fetal growth , stillbirth , placental abruption , premature rupture of fetal membranes , etc .

Results : A total of 3691 pregnant women were included in the study . There were 2993 normal pregnant women , 461 cases of pre - eclampsia , 91 cases with chronic hypertension complicated with chronic hypertension , 146 cases of chronic hypertension complicated with pre - eclampsia ( OR ; 21.28 : 95 % CI : 1.89 - 2.89 ) , premature delivery ( OR ; 21.28 : 95 % CI : 14.79 - 30.60 ) , cesarean section ( OR ; 7.33 : 95 % CI : 4.55 - 11.82 ) , placental abruption ( OR ; 10.38 : The risk of cesarean section ( OR ; 2.76 : 95 % CI : 1.75 - 4.35 ) , placental abruption ( OR ; 16.79 ; 95 % CI : 3.04 - 92.88 ) increased significantly in pregnant women with chronic hypertension .

Conclusion : Hypertensive disorder complicating pregnancy can increase the outcome of adverse pregnancy . Compared with the pre - eclampsia , there is no pregnancy outcome in patients with chronic hypertension complicated with pre - eclampsia , such as stillbirth , premature delivery and cesarean section .

Study on the relationship between polymorphism of the second part of chronic high blood pressure susceptibility gene ( CD13 , ATP2B1 , UMOD ) and pre - eclampsia

Background : Preeclampsia is a kind of pregnancy - specific disease characterized by high blood pressure and proteinuria . It has obvious family aggregation tendency . The risk of chronic high blood pressure in patients with chronic hypertension is obviously higher than that of normal pregnant women . Genome wide association study ( GWAS ) is an effective way to study the susceptibility genes of complex diseases . The GWAS study of chronic high blood pressure has been reported that the gene of CD13 , ATP2B1 , UMOD is the susceptible gene of chronic high blood pressure , and has been confirmed in many subsequent studies .

Calcium binding protein - 13 plays an important role in maintaining calcium ion balance in cells . The gene of ATP2B1 is located at 12q21.3 and encodes the plasma membrane Ca2 + ATPase1 , PMCA1 , which is a member of P - type ion transport ATP enzyme family .

Objective : To investigate the SNP loci rs11646213 and rs2681472 of the SNP site of chronic high blood pressure susceptible gene ( SNP ) by a case - control correlation analysis .
The relationship between SNP locus rs13333226 of UMOD gene and pre - eclampsia .

Methods : ( 1 ) 914 pregnant women who had been hospitalized in the Affiliated Hospital of Shandong University were selected , including 460 normal pregnant women and 454 patients with pre - eclampsia . Using gene sequencing , rs11646213 was genotyped for SNP locus rs11646213 .

( 2 ) The SNP locus rs2681472 of ATP2B1 gene was genotyped by taqman - MGB probe . The experiment was divided into two stages : Phase I : From December 2009 to November 2011 , we collected the peripheral blood of 1218 pregnant women who had been hospitalized in the affiliated provincial hospital of Shandong University . The second phase consisted of 166 normal pregnant women and 178 normal pregnant women . At the same time , a random sampling method was used to extract 5 % of specimens for direct sequencing to verify the accuracy of taqman - MGB probe .

( 3 ) The gene typing of the SNP locus rs13333226 of UMOD gene was studied by using taqman - MGB probe , and 5 % of specimens were directly sequenced to verify the accuracy of taqman - MGB probe .

Statistical method : The measurement data is expressed by mean 鹵 standard deviation , and the count data is expressed as percentage . The chain imbalance is detected using Haploview software ( Broad Institute , Cambridge , Massachusetts , USA ) . The frequency of allele was calculated by means of Chi - square test . Non - conditional logistic regression analysis corrected the risk factors , such as age , birth rate and body mass index of pregnant women . The data analysis was carried out with SPSS software ( version 17.O ;
SPSS Inc.,Chicago,IL,USA). The level of test was P 0 . 05 .

Results : ( 1 ) The minimum allele frequency ( MAF ) of the SNP locus rs11646213 of CD13 gene was significantly different between normal pregnant women and pre - eclampsia ( P = 0 . 017 ) .
OR:1.36錛，

本文編號：1858011