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Hyperbaric index in the primary prevention of hypertensive complications in high-risk pregnancy
Índice hiperbárico en la prevención primaria de las complicaciones hipertensivas del embarazo de alto riesgo
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Uribe Moya, Ivan Gilberto Arenas Moncaleano, María Paz Borrajo Prol, María Jesús García García, Luis López Sánchez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Alfonso Otero" "apellidos" => "González" "email" => array:1 [ 0 => "alfonso.otero.gonzalez@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Silvia Uribe" "apellidos" => "Moya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Ivan Gilberto" "apellidos" => "Arenas Moncaleano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "María Paz" "apellidos" => "Borrajo Prol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "María Jesús" "apellidos" => "García García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Luis" "apellidos" => "López Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Centro Hospitalario Universitario de Ourense, Ourense, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Documentación Clínica, Centro Hospitalario Universitario de Ourense, Ourense, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Índice hiperbárico en la prevención primaria de las complicaciones hipertensivas del embarazo de alto riesgo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4167 "Ancho" => 1903 "Tamanyo" => 757674 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Normal ABPM. Excess area (red circle) less than 12. (B) Pathological ABPM. Excess area (red circle) greater than 12; the arrow points to the “excess area”: HBI is above a normal blood pressure threshold for pregnant woman.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">High blood pressure (HTN) is the most common clinical complication during pregnancy, and preeclampsia (PE) is a major cause of fetal morbi-mortality (low-birth weight or premature birth), and maternal complications including acute renal failure, HELLP syndrome, liver failure and even brain edema, seizures and death.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> In the Western world, PE affects a 2–7% of all pregnancies, and the basic pathogenic phenomenon is endothelial dysfunction caused by an imbalance of angiogenic factors producing placental abnormalities with ischemia. Endothelial dysfunction is not a limited process that is resolved at birth, but may persist and pose a future cardiovascular risk.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Therefore, even though PE should be diagnosed early, angiogenic factors are not sensitive or specific enough to be used in clinical practice<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3,4</span></a>; neither is hyperuricemia, although it is often correlated with the degree of severity early initiation of PE; according to two recent systematic reviews, evidence supporting a correlation between hyperuricemia and PE is limited.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> In addition, these reviews have shown that uric acid is a poor predictor of maternal-fetal complications.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> In our experience, based on the use of the hyperbaric index (HBI) as the gold standard, risk factors including primiparous pregnancies in advance age, use of oral contraceptive drugs, or a family history of HTN are predictive of PE.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For instrumental methods, experts do not recommend the use of the uterine artery Doppler<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a>; however, the HBI or the area of blood pressure (BP) excess above the upper limit of the tolerance range has a 99% sensitivity and specificity for the early screening of pregnant patients at risk of PE<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a>; only the identification serpina1 by the proteomic profiling of urine<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> or the evidence of podocyturia have a 100% sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> Once the risk is detected, PE is significantly reduced by the early administration of ASA<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> and vitamin D<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> at night.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore, the diagnosis is made with an HBI greater than 12, in addition to conventional risk factors, and prevention includes a high-dose of ASA, 100–300<span class="elsevierStyleHsp" style=""></span>mg at night, resulting in a significantly reduced risk of hypertensive complications resulting from pregnancy before week 17.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of the present work is to assess the use of the HBI for the primary prevention of PE in our health sector.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was a retrospective study in pregnant women followed in our area between 2007 and 2012 (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11,784). We reviewed the incidence of PE in pregnant women with high risk (HR) consultations and consultations “without HR” from three local hospitals (University Hospital Complex of Ourense [<span class="elsevierStyleItalic">Complejo Hospitalario Universitario de Ourense</span>, CHUOU]), the regional hospital ([<span class="elsevierStyleItalic">Hospital Comarcal</span>, HC] of Verín and Valdeorras) and in HR pregnant women referred to Nephrology Consultation (NC) services. In pregnant women referred to NC (before the 17th week of pregnancy), BP was monitored for 48<span class="elsevierStyleHsp" style=""></span>hs as an outpatients using Spacelab 92007. An HBI of greater than 12 was considered a marker of PE risk (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and pregnant women with a pathologic HBI were treated with 100<span class="elsevierStyleHsp" style=""></span>mg of AAS and vitamin D supplements at night provided that they had vitamin D deficiency. These pregnant women were monitored throughout pregnancy in the nephrology outpatient clinics.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">HR pregnant women were defined as women who met any of the following criteria: elderly pregnant woman, morbid obesity, previous history of PE, diabetes mellitus, HTN, systemic disease (DLE, antiphospholipid syndrome), cardiopathy, family history of cardiovascular disease, smoking, twin pregnancy, or use of oral contraceptives.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The total number of deliveries between 2005 and 2012 was 11,784 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), of which 85.20% took place in the CHUOU, 7.82% in the HC of Valdeorras, and 6.91% in the HC of Verín, and the mean age of these pregnant women attended in these different centers ranged from 30 to 31.63 years old (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Referral from Obstetrics to HR clinics in regional centers was exceptional: 0.4% in the HC of Valdeorras and 1.70% in the HC of Verín, whereas in the CHUOU, the percent of referrals was of 14.28%. Only 34.93% of these pregnant women were referred to NC, 61.8% of them had a HBI greater than 12, while 32.8% of them showed a normal HBI.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The incidence of PE was 4<span class="elsevierStyleHsp" style=""></span>episodes/year in the HC of Valdeorras and 2.3<span class="elsevierStyleHsp" style=""></span>episodes/year in the HC of Verín. In the CHUOU, the incidence of PE among pregnant women who were not referred to NC was 20<span class="elsevierStyleHsp" style=""></span>episodes/year, whereas 0.8<span class="elsevierStyleHsp" style=""></span>episodes/year were reported among patients attending NCs including four pregnant women, two of whom had DLE, the third had intolerance to ASA, and the fourth had HELLP syndrome.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">PE is a syndrome characterized by HTN and proteinuria after the 20th week of pregnancy in women with no previous history of HTN or proteinuria. In the Western world it affects between 2% and 7% of all pregnancies, although it may threefold greater in other geographical regions.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> Mortality is 10–15%, with nearly 50,000 deaths every year. Therefore, early detection is crucial and may alter its clinical course.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The basic mechanism is a defect in placental implantation. In a normal pregnancy the cytotrophoblast overregulates metalloproteinase expression causing the conversion of epithelium to endothelium, a process mediated by the vascular endothelium growth factor (VEGF), the placental growth factor (PIGF), and angiopoietin.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In PE, there is an increase in placental and serum levels of the antiangiogenic circulating factor, sFlt-1, which binds to PIGF and VEGF and inhibits the interaction with its endothelial receptors (FIt1); as a result, NOSe is also activated, resulting in oxidative stress and placental ischemia. In PE, these factors are elevated levels at weeks 9 and 11, together with a concurrent decrease in PGF before the onset of PE.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition to angiopoietin,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> other factors involved in the development of PE are low oxygen rates, resistance to insulin,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> and vitamin D deficiency. VEGF is regulated by vitamin D,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> and vitamin D deficiency-insufficiency in PE women leads to endothelial dysfunction and HTN. Finally, among other problems, placental abnormalities in the mother give rise to increased peripheral resistances due to the activity of AT1 agonistic antibodies<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> and increased endoglin levels, a co-receptor of TGF B1 and TGF B3, which acts as a potent anti-angiogenic protein, “kidnapping” PGF and VEGF.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Paradoxically, none of these factors have the sensitivity-specificity and availability required for clinical use<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> in the early diagnosis of PE, neither are conventional vascular risk factors<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5,6</span></a> or instrumental methods,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> except for BP. In early pregnancy, BP was classically considered to be useful for PE screening, and although accuracy was higher when mean BP was above 90<span class="elsevierStyleHsp" style=""></span>mmHg, its predictive value was low.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> These poor outcomes of the static measurement of BP resulted from the use of the threshold for the definition of essential HTN. The pattern of BP in women with PE or HTN is known to be different and predictable; this way, differences in BP between a normotensive pregnant woman and a pregnant woman with complications (PE or gestational HTN) are detected from the first trimester with significant differences in the circadian MESOR of systolic (12<span class="elsevierStyleHsp" style=""></span>mmHg) and diastolic (7<span class="elsevierStyleHsp" style=""></span>mmHg) BP. As a result, the “quantification” of the “excess” in the threshold of BP or HBI, with a 99% sensitivity-specificity, allows for the screening of pregnant women at risk of PE.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our series, HBI was pathological in 61.9% of pregnant women referred from HR visits, but it was normal in 38.2%, thereby showing that HBI allows for a more accurate differentiation than conventional AR criteria.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> Pregnant women at high risk of PE were identified “early”, and treatment decreased its incidence from 26.3 to 0.8<span class="elsevierStyleHsp" style=""></span>episodes/year, mainly in the CHUOU, which accounts for the 34% of HR pregnant women we received. No HR pregnant women came from the 2 HC, and the rate of PE remained similar to that of areas where primary care is not available.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> Protocols are common and this situation may have resulted from “clinical inertia”.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Activated platelets and coagulation system, leading to an imbalance between the synthesis of prostacyclins and thromboxane A2, result from the ischemic placental damage in PE. Therefore, several studies to assess the use of antiaggregants in the primary prevention of PE were conducted, but the initial results were discouraging,<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21–23</span></a> although a review report<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> reveals how the risk of PE is reduced by 17% by the use of antiplatelets. All these studies have a methodologic problem: the dose of ASA and the dosing schedule. Several studies have shown that 100–150<span class="elsevierStyleHsp" style=""></span>mg/dl of ASA is effective compared to lower dosing (50–80<span class="elsevierStyleHsp" style=""></span>mg/dl)<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> and that it should be administered before week 17 and at night,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> considering that inhibition of the thromboxane A2 synthesis by ASA is dose-dependent and that the dose is administered at night. Consequently, all pregnant women referred to NC (34.92%) and with a HBI greater than 12 (61.8%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) were treated with 100<span class="elsevierStyleHsp" style=""></span>mg of ASA at night during the entire pregnancy, and the incidence of PE episodes was decreased 96.94%.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, the use of NC for the primary prevention of HTN complications during pregnancy and the use of the HBI as a diagnostic method is highly effective, and this is why routine healthcare exams should be conducted between HR consultations and Nephrology consultations during pregnancy.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres818376" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815405" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818377" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815406" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-23" "fechaAceptado" => "2015-04-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815405" "palabras" => array:3 [ 0 => "Pregnancy" 1 => "Hyperbaric index" 2 => "Hypertension" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec815406" "palabras" => array:3 [ 0 => "Embarazo" 1 => "Índice hiperbárico" 2 => "Hipertensión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Preeclampsia (PE) is a major cause of fetal morbidity and mortality. In the Western World, PE affects 2–7% of pregnancies and is responsible for 50,000 deaths annually. Early detection is a priority as it can change the clinical course, but there are no biomarkers or instrumental methods with high sensitivity and specificity. Only the hyperbaric index has a sensitivity and specificity of 99% for early identification of pregnant women at risk of developing PE, but its use is not widespread.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the usefulness of the hyperbaric index in the primary prevention of hypertensive pregnancy complications in a public healthcare area.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study of pregnancies that occurred in our area during the period 2007–2012 (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11,784). The diagnosis was established by the hyperbaric index and pregnant women at risk were treated with ASA at night.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In pregnant patients referred to the nephrology clinic (38.2%), diagnosed as high-risk for PE, and treated with 100<span class="elsevierStyleHsp" style=""></span>mg ASA/night (from week 17), the incidence of PE episodes was reduced by 96.94%.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Introducción La preeclampsia (PE) es una importante causa de morbimortalidad fetal, que en el mundo occidental afecta al 2–7% de los embarazos y es responsable de 50.000 muertes anuales. La detección precoz es prioritaria, ya que puede cambiar su curso clínico, pero no se dispone de biomarcadores ni métodos instrumentales de alta sensibilidad y especificidad, solamente el índice hiperbárico tiene una sensibilidad y una especificidad del 99% para la identificación precoz de las gestantes en riesgo de desarrollo de PE, pero está escasamente difundido.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Valorar la utilidad del índice hiperbárico en la prevención primaria de las complicaciones hipertensivas del embarazo en un área sanitaria.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo realizado entre los embarazos habidos en nuestra área durante el periodo 2007–2012 (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11.784). El diagnóstico se estableció mediante el índice hiperbárico y las gestantes en riesgo fueron tratadas con AAS nocturno.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En las gestantes remitidas a consulta de Nefrología (38,2%), diagnosticadas de alto riesgo de PE y tratadas con AAS 100<span class="elsevierStyleHsp" style=""></span>mg nocturno (desde la semana 17) se redujo la incidencia de episodios de PE un 96,94%.</p></span>" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González AO, Moya SU, Arenas Moncaleano IG, Borrajo Prol MP, García García MJ, López Sánchez L. Índice hiperbárico en la prevención primaria de las complicaciones hipertensivas del embarazo de alto riesgo. Nefrologia. 2015;35:572–577.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4167 "Ancho" => 1903 "Tamanyo" => 757674 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Normal ABPM. Excess area (red circle) less than 12. (B) Pathological ABPM. Excess area (red circle) greater than 12; the arrow points to the “excess area”: HBI is above a normal blood pressure threshold for pregnant woman.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2143 "Ancho" => 2912 "Tamanyo" => 257211 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Total number of deliveries between 2005 and 2012.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Summary of the NHLBI Working Group on Research on Hypertension During Pregnancy" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "NHLBI Working Group on Research on Hypertension During Pregnancy" "etal" => false "autores" => array:4 [ 0 => "J.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 13 | 24 |
| 2024 October | 70 | 61 | 131 |
| 2024 September | 46 | 39 | 85 |
| 2024 August | 67 | 66 | 133 |
| 2024 July | 40 | 27 | 67 |
| 2024 June | 44 | 40 | 84 |
| 2024 May | 54 | 34 | 88 |
| 2024 April | 49 | 34 | 83 |
| 2024 March | 56 | 30 | 86 |
| 2024 February | 46 | 36 | 82 |
| 2024 January | 40 | 28 | 68 |
| 2023 December | 24 | 20 | 44 |
| 2023 November | 49 | 28 | 77 |
| 2023 October | 44 | 20 | 64 |
| 2023 September | 31 | 24 | 55 |
| 2023 August | 40 | 31 | 71 |
| 2023 July | 29 | 31 | 60 |
| 2023 June | 65 | 18 | 83 |
| 2023 May | 88 | 27 | 115 |
| 2023 April | 74 | 19 | 93 |
| 2023 March | 108 | 17 | 125 |
| 2023 February | 77 | 20 | 97 |
| 2023 January | 56 | 22 | 78 |
| 2022 December | 71 | 30 | 101 |
| 2022 November | 68 | 18 | 86 |
| 2022 October | 46 | 39 | 85 |
| 2022 September | 33 | 31 | 64 |
| 2022 August | 42 | 43 | 85 |
| 2022 July | 37 | 52 | 89 |
| 2022 June | 41 | 33 | 74 |
| 2022 May | 41 | 36 | 77 |
| 2022 April | 34 | 42 | 76 |
| 2022 March | 38 | 47 | 85 |
| 2022 February | 42 | 38 | 80 |
| 2022 January | 40 | 26 | 66 |
| 2021 December | 45 | 43 | 88 |
| 2021 November | 35 | 46 | 81 |
| 2021 October | 27 | 49 | 76 |
| 2021 September | 37 | 34 | 71 |
| 2021 August | 26 | 37 | 63 |
| 2021 July | 37 | 40 | 77 |
| 2021 June | 19 | 31 | 50 |
| 2021 May | 40 | 43 | 83 |
| 2021 April | 96 | 40 | 136 |
| 2021 March | 52 | 47 | 99 |
| 2021 February | 40 | 23 | 63 |
| 2021 January | 41 | 21 | 62 |
| 2020 December | 34 | 26 | 60 |
| 2020 November | 32 | 17 | 49 |
| 2020 October | 40 | 23 | 63 |
| 2020 September | 37 | 28 | 65 |
| 2020 August | 41 | 11 | 52 |
| 2020 July | 32 | 13 | 45 |
| 2020 June | 33 | 13 | 46 |
| 2020 May | 62 | 14 | 76 |
| 2020 April | 32 | 23 | 55 |
| 2020 March | 48 | 8 | 56 |
| 2020 February | 41 | 23 | 64 |
| 2020 January | 47 | 12 | 59 |
| 2019 December | 60 | 20 | 80 |
| 2019 November | 70 | 26 | 96 |
| 2019 October | 34 | 15 | 49 |
| 2019 September | 37 | 12 | 49 |
| 2019 August | 38 | 21 | 59 |
| 2019 July | 43 | 27 | 70 |
| 2019 June | 34 | 22 | 56 |
| 2019 May | 32 | 18 | 50 |
| 2019 April | 79 | 26 | 105 |
| 2019 March | 50 | 25 | 75 |
| 2019 February | 26 | 19 | 45 |
| 2019 January | 32 | 18 | 50 |
| 2018 December | 207 | 47 | 254 |
| 2018 November | 429 | 14 | 443 |
| 2018 October | 419 | 20 | 439 |
| 2018 September | 134 | 12 | 146 |
| 2018 August | 54 | 15 | 69 |
| 2018 July | 68 | 11 | 79 |
| 2018 June | 48 | 15 | 63 |
| 2018 May | 52 | 14 | 66 |
| 2018 April | 65 | 7 | 72 |
| 2018 March | 85 | 14 | 99 |
| 2018 February | 40 | 9 | 49 |
| 2018 January | 29 | 7 | 36 |
| 2017 December | 47 | 9 | 56 |
| 2017 November | 36 | 6 | 42 |
| 2017 October | 34 | 7 | 41 |
| 2017 September | 45 | 13 | 58 |
| 2017 August | 52 | 5 | 57 |
| 2017 July | 51 | 11 | 62 |
| 2017 June | 56 | 6 | 62 |
| 2017 May | 51 | 11 | 62 |
| 2017 April | 55 | 10 | 65 |
| 2017 March | 43 | 6 | 49 |
| 2017 February | 102 | 11 | 113 |
| 2017 January | 34 | 6 | 40 |
| 2016 December | 32 | 1 | 33 |
| 2016 November | 71 | 19 | 90 |
| 2016 October | 118 | 6 | 124 |
| 2016 September | 156 | 7 | 163 |
| 2016 August | 151 | 3 | 154 |
| 2016 July | 146 | 6 | 152 |
| 2016 June | 119 | 0 | 119 |
| 2016 May | 129 | 0 | 129 |
| 2016 April | 128 | 0 | 128 |
| 2016 March | 105 | 0 | 105 |
| 2016 February | 117 | 0 | 117 |
| 2016 January | 29 | 0 | 29 |
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