A algorithm for prediction of exudative retinal detachment risk of patients with pregnancy-induced hypertension

INTRODUCTION

Pregnancy-induced hypertension (PIH) is one of the most common obstetric diseases, an unresolved and unpreventable problem in obstetrics, which remains the leading risk on the health life of mother and infant

. PIH causes a variety of pathological vascular changes, subsequently damages the function of most of all organs, such as liver, heart,renal, brain, and eye.

Statistical analysis was performed using SPSS 16.0. The data were described by mean±standard deviation and median (interquartile interval) [M (P25, P75)],and compared between groups by independent sample

-test and Mann-Whitney

nonparametric test. Binary Logistic regression Rorward: LR method were used to value and sieve the potential risk factors of ERD in PIH patients. Receiver operating characteristic (ROC) curve was used to test the prediction and diagnostic efficiency of the algorithm.

選擇“D”的小意粉可真是實誠啊！其實握手時間一般根據(jù)雙方熟悉程度而定，初次見面的話，握手時間控制在三秒鐘左右比較合適。

此外，將土地用途管制權(quán)概念的界定分為靜態(tài)和動態(tài)兩個層面來詮釋，亦與我國現(xiàn)行《土地管理法》體系和內(nèi)容的安排甚相契合。作為1998年《土地管理法》修訂所確立的土地用途管制法律制度乃土地管理制度的核心和根本。為實現(xiàn)土地用途管制的目標，在《土地管理法》第三章、第四章和第五章分別就土地利用總體規(guī)劃、耕地保護和建設(shè)用地進行了較為詳細的制度設(shè)計和規(guī)范展開，從這些條文的設(shè)計內(nèi)容來看，其實質(zhì)都是圍繞著我國土地用途管制權(quán)的基本內(nèi)容而展開的。

The common fundus changes include retinal artery spasm, high retinal artery reflection, arteriovenous cross indentation, retinal hemorrhage, optic disc edema, chorioretinitis

and exudative retinal detachment (ERD). Optical coherence tomography(OCT) manifestations retinal neuroepithelial detachment,retinal pigment epithelium (RPE) detachment and ellipsoid band change

.

Pregnancy can induce retinal diseases or aggravate the original retinal diseases

, a composite of severe maternal outcomes,including maternal near-miss defined by World Health Organization, cortical blindness, retinal detachment, temporary facial paralysis and maternal death, were adopted

.

ERD is the main cause of blurred vision in PIH patients,with the incidence of 0.1%-2% worldwide

. Fluorescence angiographic findings support the hypothesis that retinal detachment in pre-eclampsia is secondary to choroidal ischemia from intense arteriolar vasospasm

. The happening of the ERD could mean a higher risk of core outcomes:stillbirth, small gestational age at delivery, lower birthweight,cardiovascular disease, neonatal mortality, seizures, admission to neonatal unit required and respiratory support

. Although most patients with ERD have good visual prognosis, but some patients have sustained damage in RPE layer and ellipsoid zone, which can lead to permanent loss of visual function in severe cases

. Therefore, identifying and intervening the risk factors related to ERD in pregnancy with hypertension can effectively reduce the abnormal pregnancy rate.

However, there is little knowledge on the risk factors of ERD in PIH patients. Here we conducted a retrospective study on the risk factors in PIH patients and found a significant correlation between the accidence of ERD and blood pressure (BP) and total protein concentration. Then we formed an algorithm with BP and total protein concentration to predict the accidence of ERD, which may extent more time before ERD and other hidden troubles occurring in PIH patients.

在靠近斷層的中心位置，應(yīng)力較為集中，構(gòu)造作用較為明顯，因此這種作用有利于引導(dǎo)形成礦物質(zhì)的進一步遷移，進而是成礦的條件更好。

SUBJECTS AND METHODS

The exclusion criteria were as follows: 1) the fundus photography and OCT examination were not completed; 2)with previous retinal and choroidal diseases; 3) the patients suffered from other conditions which could damage the retina,such as high myopia, diabetes, uremia, thrombocytopenic purpura, syphilis, dengue fever, and infection

.

ROC curve analysis showed that the sensitivities of maximum systolic BP, total protein concentration and combined diagnosis were 0.717, 0.870, and 0.870, respectively; the specificities were 0.617, 0.837, and 0.908, respectively; the area under the curve (AUC) was 0.707 (95%CI: 0.622-0.792), 0.917 (95%CI:0.868-0.967), and 0.933 (95%CI: 0.890-0.975), respectively.The AUC of combined diagnosis was higher than that of single diagnosis (

<0. 01; Table 3, Figure 3).

From January 2017 to February 2020, 188 patients with PIH hospitaled in the Obstetrics Department of the Third Affiliated Hospital of Guangzhou Medical University, were enrolled and divided into two groups according to the results of fundus examination, namely, 46 ERD cases (ERD group) and 142 non-ERD ones (non-ERD group).

寧樂美術(shù)館藏2件3種敦煌寫本：其一是《八相變》，據(jù)說原為吳昌碩舊藏，尾部鈐有“木齋審定”印；其二是《太公家教》和《王梵志詩》，尾部鈐有“德化李氏凡將閣珍藏”印，背面首部亦鈐有“李盛鐸印”，可知出自李盛鐸舊藏。

Best corrected visual acuity (BCVA) of 188 patients ranged from 0.1 to 1.0, with an average of 0.59±0.18. The diagnostic criteria for ERD were retinal neurodermis detachment, which was detected by fundus photography, retinal prescopy, and OCT. At the same time, the retinal detachment caused by tear and pull factor was excluded. Patients with ERD in one eye or more were enrolled to the ERD group. ERD fundus photography and OCT were shown in Figures 1 and 2.

The study was conducted in accordance with the Declaration of Helsinki and all the patients signed the informed consent.

All patients were asked if there were blurred vision and dark shadow in front of their eyes. The common data of them,including age, gestational weeks, duration of hypertension, past medical history, pre-pregnancy body mass index (BMI) were recorded. And then, every case underwent 24-hour ambulatory BP monitor and the maximum systolic and diastolic BP were determined by measurement results. Visual acuity, fundus examination, fundus photography, and OCT examination were conducted by the senior ophthalmologist. Plasma total protein(PTP) concentration were also collected. The plasma colloid osmotic pressure

was calculated as following: plasma colloid osmotic pressure (PCOP, mm Hg)=2.1×PTP concentration(g/dL)+0.16×PTP concentration

(g/dL)+0.009×PTP concentration

(g/dL).

It is the only one vascularity of retina which could be directly seen in the whole body. The vascular pathological changes of retina caused by PIH are considered as the ominous signs to value the progress and prognosis of PIH.

RESULTS

There was no significant difference in age and pre-pregnancy BMI between ERD group and non-ERD group (

>0.05).Nevertheless, there were statistically significant differences in gestational weeks, duration of hypertension, maximum and minimum systolic and diastolic BP, and PTP concentration between two groups (

<0.05; Table 1).

The variables (gestational weeks, duration of hypertension,PTP concentration, maximum and minimum systolic and diastolic BP) which had statistical differences between two groups were analyzed by binary logistic regression analysis.The results showed that the maximum systolic BP and PTP concentration were statistically correlated with the occurrence of ERD (Table 2).

2.4 管理因素 果園管理精細、有機肥施用多的受凍輕，采取灌水、涂干、包干等防凍措施的凍害輕。氮肥使用過多、灌水量過大、樹體過旺，貪青徒長，不能正常落葉的樹受凍嚴重。

DISCUSSION

As is known to all, there are two kinds of blood retinal barrier in normal retina to keep retina dry and transparent,

, inner retinal barrier and outer retinal barrier. The inner retinal barrier is formed by the occlusive zone between the retinal capillary endothelial cells and the pericytes, the outer retinal barrier is composed of the RPE cell and its occlusive zone. When the RPE barrier is damaged, choroidal plasma leaks into the subneuroepithelial layer and accumulates in the neuroendothelial layers, then it forms a localized, well-defined, flat discoid retinal detachment, if the RPE barrier is extensively damaged,it may cause wide and highly uplifted ERD

. It is common in malignant hypertension

, Harada disease

, central serous chorioretinopathy

, choroidal tumor

, uveal effusion syndrome

, posterior scleritis

. PIH is associated with severe damage to choroidal circulation, which is generally believed to be caused by extensive destruction of the retinal barrier

.

ERD is a serious complication of PIH and characterizes by the accumulation of serous or haemorrhagic fluid in the subretinal space secondary to hydrostatic factors. The retina is separated from the RPE beneath it and vision is lost because photoreceptors require contact with the RPE and choroid for metabolic and vascular support. Although most ERD resolves by clinical management after delivery 2 to 12wk

, the symptoms caused by ERD, such as blurred vision, dark shadow in front of the eyes, and permanent visual loss may be left in a small number of PIH patients and seriously affected the their normal life. Arab

found that peripapillary retinal nerve fiber layer reduced in preeclamptic and eclamptic cases as well as in normotensive pregnant women at 2mo postpartum. This reduction was more in the severe forms of PIH. Meanwhile,offspring of mothers with hypertensive disorders during pregnancy have increased risk of cardiovascular disease

.Higher maternal BP during pregnancy is associated withpersistent microvasculature adaptations in their children.Children of mothers with gestational hypertensive disorders tended to have narrower retinal arteriolar caliber

. The destruction of micro-circulation in retina reflects the deterioration of micro-circulation in the other organs. The occurrence of ERD also means the requirement to terminate pregnancy in timely for preventing further damage of multiple organs. Thereby, early prediction of ERD is particularly important and may earn more time for preventing the further damage of the multiple organs before ERD and other hidden troubles occurring in PIH patients.

In the study, independent sample

test and Mann-Whitney

nonparametric test were used to compare gestational weeks,duration of hypertension, maximum and minimum systolic and diastolic BP, and PTP concentration between ERD group and non-ERD group. The results showed significant difference in maximum/minimum systolic and diastolic BP and PTP between the two groups, which suggested they would be involved in ERD. Then, logistic regression analysis was conducted to screen out the independent risk factors of ERD.It was found that BP and PTP concentration were independent predictors of ERD occurrence.

The effective filtration pressure is associated with intra capillary pressure, tissue colloid osmotic pressure, plasma colloid osmotic pressure, and tissue hydraulic pressure.However the level of plasma osmotic pressure depends on the protein content in plasma, some studies have shown that the decrease of PTP or albumin content led to the decrease of plasma colloid osmotic pressure, it weakened the strength of tissue fluid flowing back to capillaries, then choroidal plasma leaked through RPE and its small closure zone which led to ERD

, this was consistent with our results. In addition,we think that the increase of systolic BP lead to the rise of capillary internal pressure, which will promote the infiltration of tissue fluid into tissues, and cause damage of choroidal circulation, which will also lead to the occurrence of ERD.

ROC curve was used to analyze the diagnostic value of this algorithm: (maximum systolic pressure–plasma colloid osmotic pressure)/plasma colloid osmotic pressure. The AUC was as high as 0.933, and the cut-off value was 8.714 (Yoden index 0.778), with the corresponding sensitivity of 87.0%and specificity of 90.8%, respectively. Although it still needs a large number of samples to further verification, it seems feasible to predict and early sieve the high-risk PIH patients,its application may reduce stillbirth, small gestational age at delivery, lower birthweight, neonatal mortality, seizures, longterm coronary atherosclerotic heart disease and heart failure,which is great significant for early clinical intervention and improving the short-term and long-term prognosis of patients.

隨著經(jīng)濟社會的發(fā)展和科學(xué)技術(shù)的進步，企業(yè)內(nèi)外部環(huán)境發(fā)生了顯著變化，呈現(xiàn)出信息全球化、媒介現(xiàn)代化、文化開放化、價值多樣化、思想多元化等特點。面……