摘要
子痫前期是一种严重的妊娠特有疾病,是引起孕妇和围生儿死亡的主要原因之一。目前关于子痫前期的病因仍不明,与多器官血管痉挛、血管病理性损害和凝血系统激活相关。正常妊娠时存在着生理性的高凝状态,各种凝血因子及纤维蛋白原也较非孕妇女增加,使正常孕妇机体止血功能保持动态平衡状态。子痫前期时,血管内皮细胞受损,凝血因子及血小板激活,使机体凝血与抗凝血平衡失调呈明显的血栓倾向。迄今为止,建立了许多动物模型,但尚没有一个动物模型能较全面反映人类子痫前期的特点。2005年,Omatsu等建立了一种新的子痫前期动物模型,将能够提供凝血因子酶促反应表面的磷脂酰丝氨酸注射入妊娠ICR小鼠体内,最终引起了孕鼠高血压、蛋白尿,血浆抗凝血酶活性降低,胎盘绒毛间隙广泛纤维蛋白沉积,胎仔生长受限,而孕鼠其他器官如肺、肾、肝则未未能发现明显的纤维蛋白沉积,提示胎盘高凝状态血栓形成能引起孕鼠子痫前期样改变。模型的建立为从止血功能角度探讨子痫前期病机,以及纠正止血功能紊乱防治子痫前期提供例理论依据。已有报道,临床应用肝素、小分子肝素、阿司匹林抗凝,预防、治疗子痫前期,特别是发病早、病情重或多次复发者,可使部分患者获益。但是但其结论尚存在争议,且母胎安全性评价不足,应用时机和剂量选择尚无证据,使其临床使用带来了障碍。
丹参为唇形科植物丹参(Salvia miltiorrhiza Bunge)的干燥根,是化学成分研究进行比较深入的一种中草药。以丹参水溶性组分丹参素(Danshensu)为主丹参注射液在临床产科应用的安全性良好,且丹参素抗血栓形成作用已得到体内外试验证实。近年来,我国学者对丹参素的药理作用进行了许多研究,证明其具有保护心肌缺血、降血脂及抗动脉粥样硬化、抗炎及增强机体免疫、保肝、抗肿瘤等多种药理活性。祖国医学认为子痫前期为本虚标实症,其病机以“血瘀”为中心,这使利用丹参素的抗血栓效应预防、治疗止血功能障碍为发病机制的子痫前期成为可能。
在本研究第一部分中,我们成功重复了Omatsu等建立的以胎盘广泛性纤维蛋白沉积和微血栓形成为特征的子痫前期动物模型。清洁级ICR小鼠按雌雄1:1夜间合笼,次日晨见到阴道栓定为妊娠第0.5天。将能够提供凝血因子酶促反应表面的磷脂酰丝氨酸(PS)在胎盘形成早期(妊娠第5.5天)连续从尾静脉注射到妊娠小鼠体内至妊娠第16.5天。分别测定孕鼠血压(无创鼠尾血压测定法)、尿蛋白(12小时尿蛋白浓度测定)、血小板计数、血浆ATⅢ含量(免疫比浊法)、血浆D-D含量(免疫沉淀夹心法)、凝血酶时间;仔鼠体重、鼻臀长、体重指数(PI)和胎盘重量;胎盘纤维蛋白PTAH染色、血栓调节素(TM)免疫组化染色;胎盘、肝、肾、尾HE染色。模型孕鼠表现出高血压、蛋白尿、FGR、死胎、血小板含量降低、血浆ATⅢ含量降低、D-D含量升高、胎盘绒毛间隙广泛纤维蛋白沉积及微血栓形成,而孕鼠其它器官如肝肾则未能发现明显的器质性改变,类似人类子痫前期的表现。本试验中子痫前期孕鼠的血浆ATⅢ含量降低、血小板计数降低及TT缩短,提示体内血小板活化,凝血系统激活:而D-D含量升高,提示血管内血栓的形成和继发性纤溶激活,与人类重度子痫前期表现相似。胎盘组织广泛纤维蛋白沉积和微血栓形成,以及TM强阳性表达证实局部凝血及抗凝激活状态,而其他脏器如肝肾未出现器质性改变,其表明妊娠早期胎盘循环中增强的高凝状态血栓形成倾向可能是子痫前期和FGR的发病机理之一和重要病理生理学过程。
第二部分我们在第一部分建立的动物模型基础上,排除体内多因素影响前提下,探讨了肝素和阿司匹林在抗凝治疗的有效性,并对比了中药丹参水溶液中的重要组分丹参素在抗凝治疗中的作用。66只孕鼠随机分为对照组(Control group,C组)15只,模型组(Pre-eclampsia group,PE组)12只,肝素组(Heparin groupH组)9只,阿司匹林组(Aspirin group,A组)10只,低剂量丹参素组(Low-dosage Danshensugroup,L-D组)10只,高剂量丹参素组(High-dosage Danshensu group,H-D组)10只。自妊娠第5.5天始,对照组雌鼠尾静脉给予生理盐水,而其余实验组雌鼠尾静脉给予PS/PC微团液,每日一次,每次注射量为100μl,持续至妊娠第16.5天(共计给液12天)。自妊娠第6.5天始,H组、A组、L-D组和H-D组每日同时予普通肝素1IU,赖氨匹林20μg/g,低剂量丹参素(10μg/g)和高剂量丹参素(30μg/g)加入上述药液中,静脉给药,每日一次,持续至妊娠第16.5天(共计给药11天)。结果发现肝素对于子痫前期母体综合征—高血压和蛋白尿效果明显。不同剂量丹参素具有一定疗效,高剂量丹参素和阿司匹林对降低孕鼠血压较低剂量丹参素有效,药物干预后血压更接近正常孕期水平;高剂量丹参素对减少孕鼠尿蛋白较阿司匹林和低剂量丹参素有效,药物干预后尿蛋白更接近正常孕期水平。可见高剂量丹参素较低剂量丹参素对于母体临床综合征的改善更为显著,但总体较肝素作用为弱。进一步分析各剂量丹参素对于血浆止血功能的作用,发现高、低剂量丹参素均可显著提高血浆ATⅢ含量,作用强度同阿司匹林,弱于肝素;高剂量丹参素较低剂量丹参素对于血小板计数增加作用更为显著,强于阿司匹林;低剂量丹参素对于降低D-D作用明显,相当于肝素治疗水平,强于高剂量丹参素和阿司匹林;高、低剂量丹参素均能明显缩短TT至正常孕期水平,相当于肝素治疗水平;不同抗凝药物对于胎盘组织中纤维蛋白沉积均有显著改善作用,但高剂量丹参素和肝素干预后胎盘迷路层中血管TM表达较低剂量丹参素和阿司匹林降低;高剂量丹参素的总体抗凝效果仍不如肝素作用全面。本研究中发现,尽管肝素和阿司匹林均为小剂量,但长期使用可增加出血的风险,表现出各组一例胎盘早剥及肝素组肠管出血的风险。丹参素使用并未观察到明显副作用。
第三部分我们继续在第一、二部分建立的动物模型及试验分组基础上,进一步丹参素对于子痫前期者仔代发育(胎儿综合征)影响。每组测量孕鼠体重增长;仔鼠体重、鼻臀长、体重指数(PI)和胎盘重量;每窝随机选取2只胎仔取脑称量,并行HE染色和尼氏(Nissle)染色。研究结果发现孕鼠体重增长下降;低妊娠率(仔鼠数减少),高死胎、吸收胎率;胎盘重量减少、仔鼠体重下降、唇臀长减少、体重指数不变;仔鼠脑重下降,大脑神经元细胞数减少,Nissle小体数减少。仔鼠总体表现为匀称性FGR,脑发育障碍。本部分继续对比研究了肝素、阿司匹林和不同剂量丹参素对于模型仔鼠FGR的疗效。结果发现各治疗组对于FGR者体重和身长的增长均有良好的改善作用;肝素对于FGR者各方面指标的改善作用均明显;高剂量丹参素对于FGR者母体体重增加、仔鼠鼻臀长、仔鼠脑重等指标的改善优势相对明显,总体作用接近肝素疗效;低剂量丹参素对于FGR者存活仔鼠数这一指标作用显著,其他方面的改善效果不如高剂量丹参素组;高低剂量丹参素对于仔鼠脑发育改善作用明显,明显优于阿司匹林组。
我们认为该动物模型能较全面的模拟了子痫前期,特别是重度子痫前期的临床症候群(母体综合征和胎儿综合征),且应证了止血功能失调的病机学假说,同时为该疾病的临床诊治提供了新的研究思路。高、低剂量丹参素对子痫前期模型小鼠的母体综合征(高血压、蛋白尿、止血功能异常)有显著改善作用,但作用弱于肝素,高剂量丹参素作用强于低剂量丹参素,低剂量丹参素作用与阿司匹林作用相当。高、低剂量丹参素对子痫前期模型小鼠的胎儿综合征(FGR、死胎、吸收胎)有显著改善作用,高剂量丹参素作用与肝素作用相当,低剂量丹参素作用相对较弱,而阿司匹林作用不显著。丹参素治疗子痫前期的优势还在于对于仔鼠脑发育障碍具有很好的改善作用,且临床使用具有较高的安全性和有效性。尽管由于用药时间短,样本量相对较小,试验结果有一定的局限性,但本试验为探索丹参素治疗子痫前期提供了一定的理论依据。
Preeclampsia(PE) is a serious pregnancy-specific syndrome of unknown etiology associated with vasospasms and pathologic vascular lesion in multiple organs as well as activation of the coagulation system,being one of the leading causes of maternal death and a major contributor of maternal and prenatal morbidity.There is a physiological hypercoagulable state during normal pregnancy,with the activity of "fibrinolysis system" increasing correspondingly and but maintaining dynamic balance of hemostatic functional. Preeclampsia occurs followed by vessel endothelium lesion,coagulation factor and platelet activation,and further tendency to disequilibrium of coagulation and anticoagulation.So far, none of established preeclampsia-like animal models can show overall feature of preeclampsia.Recently,Omatsu established a new preeclampsia-like model in mice.They injected phosphatidylserine/phosphatidylcholine(PS/PC) microvesicles to Institute of Cancer Research(ICR) mice,and induced preeclampsia-like changes,such as hypertension, proteinuria,FGR,diffuse fibrin depositions and microthrombosis in the labyrinth layer of placentas.But no obvious sign of fibrin depositions in the lung,kidney and liver,which indicate that preeclampsia-like changes can be induced by hypercoagulable state in the placenta.The model supports the theoretic evidences of hemostatic functional disorder as pathogenesis and treatment.It has been reported that treatment with the heparin, low-molecular-weight heparin(LMWH),or aspirin has made some desired benefits for partial patients,especially during the early stage of the disease or in severe an recurrent cases.But their clinical applications are difficult because of the controversy of antithrombotic therapy,the insufficient safety evaluation and no evidences to application opportunity and dose.
Danshen Root,the dried root from Salvia miltiorrhiza Bunge of Labiate,is one herb clearly studied on the chemical composition.Danshen Injection,Danshensu as the major component,is safely applied to Obstetrics disorders.Danshensu's antithrombotic effects in vitro and in vivo have been confirmed.Recently,Danshensu's multiple pharmacologic actions have been studied and testified,such as protecting from myocardial ischemia, lowering hyperlipemia,inhibiting atherosclerosis,anti-inflammatory,strengthening immunity,protecting liver and anticancer.Traditional medicine considers preeclampsia as disease of asthenia in origin and asthenia in superficiality,and presumes blood stagnation to be pivotal pathogenesis.They provide the probabilities of using Danshensu as prevention and treatment for preeclampsia.
In the first part of the article,we successfully duplicated the preeclampsia-like animal model with the features of diffuse fibrin depositions and microthrombogenesis priorly established by Omatsu.The ICR mice were mated at 1:1 female/male ratio in the evenings and presence of a coital plug was taken as an indication of probable pregnancy(day 0.5). PS/PC microvesicles suspension,which can provide catalytic surfaces to coagulation factor and accelerate the coagulation process,were injected into tail veins every day from days 5.5 to 16.5 of pregnancy.Blood pressure(by Non-invasive Blood Pressure controller instrument),urine protein(by 12-hours urine protein quality),platelet counts,plasma antithrombin activity(by immunoturbidimetry),D-D concentration(by immunoprecipitate sandwich method),thrombin time were tested,body weight,nose-breech length,ponderal index(PI) of fetal mice and placental weight were measured,placental fibrin depositions(by PTAH staining) and thrombomodulin(by IHC staining),pathologies of placentas,livers, kidneys and tails were detected on day 17.5.Mice in model group show features,similarly shown by human PE syndrome,as hypertension,proteinuria,FGR,fetal death,decreasing platelet counts and plasma ATⅢactivity,increasing plasma D-D levels,and diffuse fibrin depositions and microthrombogenesis in placentas,but no obvious changes in other organs such as liver and kidney.Reduced plasma ATⅢactivity,platelet counts and thrombin time suggested activation of platelet and coagulation system,while increasing plasma D-D levels indicated thrombogenesis in vessel and activation of secondary fibrolysis.All of these changes look like those occurred in human serious preeclampsia.Placental diffuse fibrin depositions and microthrombogenesis,accompanied by powerful positive expression on thrombomodulin indicate regional activation of coagulation and anticoagulation,but no obvious changes in other organs,which suggest augmented hypercoagulable state in placental circulation in early trimester of pregnancy may be one of pathogenesis and the important process of pathophysiology of preeclampsia and FGR.
In the second part of the article,we investigated the availability of anticoagulant therapy by heparin and aspirin,and further compared the that of Danshensu on the condition of animal model established in first part of the article and excluding multiple factors impacts in corpore.Sixty-six pregnant mice were randomly divided into control group(15 animals),preeclampsia group(12 animals),heparin group(9 animals),aspirin group(10 animals),low-dose Danshenau group(10 animals) and high-dose Danshensu group(10 animals).PS/PC microvesicles suspension and saline as control were injected into tail veins every day from days 5.5 to 16.5 of pregnancy.In addition to the injections,1U of common heparin,20μg/g of Aspisol,10μg/g of Danshensu,or 30μg/g of Danshensu was respectively injected into mice simultaneously every day from days 6.5 to 16.5 of pregnancy.The results suggest heparin presents significant effects on maternal syndrome of preeclampsia such as hypertension and proteinuria,and different dose Danshensu also presents the certain effects.High-dose Danshensu and aspirin all process better effects than low-dose Danshensu on decreasing blood pressure to normal level,while high-dose Danshensu process better effects than aspirin and low-dose Danshensu on decreasing proteinuria to normal level.In conlusion,the effects of high-dose Danhsneuon improving maternal syndrome is superior to low-dose Danshensu,but inferior to heparin in all.As to Danshensu's effects on hemostatic function,high- and low-dose Danshensu's marked effects on increasing the plasma ATⅢactivity are same to aspirin and inferior to heparin. High-dose Danshensu's better effect on elevating the platelet counts is superior to low-dose Danshensu and aspirin.Low-dose Danshensu's obvious effect on decreasing D-D levels is close to heparin and superior to high-dose Danshensu and aspirin.High- and low-dose Danshensu's significant effects on reduced thrombin time to normal level are same to heparin.Different anticoagulant all have the improvement roles on placental fibrin depositions,but heparin and high-dose Danshensu's roles on lowering thrombomodulin expression in placentas are superior to low-dose Danshensu and aspirin.But anticoagulant function of high-dose Danshensu is still inferior to heparin.We found long-term use of heparin and aspirin,in spite of low dose administration,can raise the risk of bleeding such as placental abruption and intestinal hemorrhage,but no side effects ware observed in our study.
In the second part of the article,we continued to investigate the effects of Danshensu on growth of fetal mice(fetal syndrome).Mice in every group mentioned above were measured on the indices as maternal body weight increasing,body weight,nose-breech length and PI of fetal mice,placental weight,as well as weight of fetal brains and their pathological staining of HE and Nissle's.The results showed reduced maternal body weight, lower pregnancy rate,higher rate of fetal death and absorbed fetal,decreasing placental weight,as well as body weight and nose-breech length of fetal mice,but invariably fetal PI in PE group.Lost fetal brain weight,with reduced cerebral nerves and Nissle's body,was also observed.Features mentioned above showed off symmetric FGR and cerebral dysgenesis.The research in this part further observed and compared the curative effects between heparin,aspirin and different dose Danshensu on FGR,and found following changes:increasing fetal body weight and length in every group,obvious overall improvement in heparin group,greater amelioration equaling to that in heparin group on maternal body weight,fetal nose-breech length and fetal brain weight in high-dose Danshensu group,better changes on survival fetal number in low-dose group than in other groups,and more corrected brain development in high-dose Danshensu group than in aspirin group.
We presume the animal model can completely mimic the syndrome of preeclampsia, especially serious preeclampsia,manifesting as either maternal syndrome or fetal syndrome. The model not only corresponds to the hypothesis on hemostatic functional disorder as the pathogenesis of preeclampsia,but also provides the brand-new way to studying clinical diagnosis and treatment.High- and low-dose Danshensu can significantly improve maternal syndrome(hypertension,proteinuria and hemostatic function disorder) in PE mice model, but inferior to heparin.The roles of high-dose Danshensu are superior to low-dose Danshensu and aspirin.Simultaneously,high- and low-dose Danshensu can also obviously improve maternal syndrome(FGR,fetal death and absorbed fetal),and the roles of high-dose Danshensu are equal to those of heparin and but superior to those of low-dose Danshensu,with no similar roles in aspirin.Danshensu process the predominance on better curative effect of cerebral dysgenesis,as well as safety and effectivity in clinical use. Although the trial results is limited because of the short-term administration and small sample size,the experimental exploration provide the theoretic foundation for Danshensu applying to treatment of preeclampsia.
引文
[1]Redmanc WG,Sargent IL.Latest advances in understanding pre-eclampsia[J].Science,2005,308(5728):1592-1594.
[2]Sibai B,Dekker G,Kupferminc M.Pre-eclampsia[J].Lancet,2005,365(9461):785-799.
[3]Sibai BM.Diagnosis and management of gestational hypertension and preeclampsia[J].Lancet,2003,102(1):181-192.
[4]Brown MA,Lindheimer MD,de Swiet M,et al.The classification and diagnosis of the hypertensive disorders of pregnancy:a statement from the International Society for the Study of Hypertension in Pregnancy(ISSHP)[J].Hypertens Pregnancy,2OO1,20:Ⅳ-ⅩⅣ.
[5]Haelow FH,Brown MA.The diversity of diagnosis of preeclampsia[J].Hypertens Pregnancy,2001,20(2):57-67.
[6]沈杨,蒋小青.妊娠高血压疾病孕前高危因素研究进展[J].国外医学·妇幼保健分册,2005,16(2):76-78.
[7]Duckitt K,Harrington D.Risk factors for preeclampsia at antenatal booking:systemic review of controlled studies[J].BrNedJ,2005;330(7491):565-572.
[8]曹桂荣,曹树军,等.胎儿宫内发育迟缓与重度妊高征的关系[J].华中医学杂志,2000,24(5):277-278.
[9]张建平,刘玉昆,等.胎儿宫内发育迟缓患者的胎盘免疫病理学观察[J].中华妇产科杂志,2001,36(4):202-205.
[10]王志坚,余艳红.妊娠高血压综合征合并胎儿生长受限胎盘组织血管细胞黏附分子1的表达[J].中华围产医学杂志,2003,6(2):75-77.
[11]Santoso DI,Rogers P,Wallace EM,et al.Localization of indoleamine2,3-dioxygenase and 4-hydroxynonenal in normal and pre-eclamptic placenta[J].Placenta,2002;23(5):373-379.
[12]Darmochwal-Kolarz D,Leszczynska-Gorzela K,Rolinski J,et al.The expression and concentrations of Fas/APO-1(CD95)antigen in patients with severe pre-eclampsia[J].J Repro Immunol,2001,49(2):153-164.
[13]胡娅莉,王杰.血浆纤维蛋白预测妊高症的探讨[J].江苏医药,1994,20(11):605-606.
[14]Leviner J,Maynard S,Qian C,et al.Circulating angiogenic factors and risk of preeclampsia[J].New Engl J Med,2004,350(7):672- 683.
[15]Mckeeman GC,Ardill JE,Caldwell CM,et al.Solubie vascular endothelial growth factor receptor-Ⅰ(sFlt-1) is increased throughout gestation in patients who have preeclampsia develop[J].Am J Obstet Gynecol,2004,191(4):1240-1246.
[16]Kupferminc MJ,Fair G,Many A,et al.Severe preeclampsia and high frequency of genetic thrombophilic mutations[J].Obstet Gynecol,2000,96(1):45-49.
[17]Driul L,Damante G,D'Elia A,et al.Genetic thrombophilias and uterine artery Doppler velocimetry and preeclampsia[J].Int J Gynaecol Obstet,2005,88(3):265-270.
[18]Lin J,August P.Genetic thrombophilias and preeclampsia:a meta analysis[J].Obstet Gynecol,2005,105(1):182-192.
[19]Anteby EY,Musalam B,Milwidsky A,et al.Fetal inherited thrombophilias influence the severity of preeclampsia,IUGR and placental abruption[J].Obstet EurJ Gynecol ReprodBiol,2004,113(1):31-35.
[20]Vefring H,Lie RT,O'Degard R,et al.Maternal and fetal variants of genetic thrombophilias and the risk of preeclampsia[J].Epidemiol,2004,15(3):317-322.
[21]Kujovich,JL.Thrombophilia and pregnancy complications.American Journal of Obstetrics and Gynecology 2004,191(2),412-424.
[22]Lee RM,Brown MA,Branch DW,et al.Anticardiolipin and anti-B2 glycoprotein-Ⅰantibodies in preeclampsia[J].Obstet Gynecol,2003,102(2):294-300.
[23]Holthe MR,Staff AC,Berge LN,et al.Different levels of plate let activation in preeclamptic,normotensive pregnant,and nonpregnant women[J].Am J Obstet Gynecol,2004,190(4):1128-1134.
[24]张奕.重度妊高征患者血小板计数和红细胞压积与母婴预后的关系.中国优生与遗传杂志,2002,10(4):73-74.
[25]Osmanagaoglul MA,Topcuoglu K,Ozeren M,et al.Coagulation inhibitors in preeclamptic pregnant women[J].Arch Gynecol Obstet,2005,271(3):227-230.
[26]Di Paolo S,Volpe P,Grandaliano G,et al.Increased placental expression of tissue factor is associated with abnormal uterine and umbilical Doppler wave forms in severe preeclampsia with fetal growth restriction[J].J Nephrol,2003,16(5):650-657.
[27]Paternoster DM,Stella A,Simioni P,et al.Activated protein C resistance in normal and pre-eclamptic pregnancies[J].Gynecol Obstet Invest,2002,54(3):145-149.
[28]Kenneth J.Assessment of red blood cell and coagulation laboratory data[J].AACN Clin Issues,2004,15(6):622-637.
[29]胡娅莉.妊高症止血功能变化的初步观察[J].中华妇产科杂志,1986,21(5):268-271.
[30]郑媛媛,翟桂荣.子痫前期的凝血功能变化[J].北京医学,2007,29(4):238-240。
[31]Redman CWG,Sargent IL.Latest advances in understanding preeclampsia[J].Science,2005,308(5728):1592-1594.
[32]Merviel P,Carbillon L,Challier JC,et al.Pathophysiology of preeclampsia:links with implantation disorders[3].European J Obstet Gynecol Reprod Biol,2004,115(2):134-147.
[33]Hiby SE,Walker JJ,O'Shaughnessy KM,et al.Combination of maternal KIR fetal HLA-C genes influence the risk of preeclampsia and reproductive success[J].J Exp Med,2004,200(8):957-965.
[34]Sargent IL,Borzychowski AM,Redman CW.NK cells and pre-eclampsia[J].J Reprod Immunol,2007,Epub ahead of print.
[35]Sedlmayr P.Indoleamine 2,3-dioxygenase in materno-fetal interaction[J].Curr Drug Metab,2007,8(3):205-208.
[36]Darmochwal-Kolarz D,Leszczynska-Gorzela K,Rolinski J,et al.The expression and concentrations of Fas/APO-1(CD95)antigen in patients with severe pre-eclampsia[J].J Repro Immunol,2001,49(2):153-164.
[37]Dong MY,He J,Wang ZP,et al.Placental imbalance of Th1- and Th2-type cytokines in preeclampsia[J].Acta Obstet Gynecol Scand,2005,84(8):788-793.
[38]Redman CWG,Sargent IL.Pre-eclamspia,the placenta,and the maternal systemic inflammatory response-a review[J].Placenta,2003,24(SupplA):S21-S27.
[39]Robillard PY.Interest in pre-eclampsia for researchers in reproduction[J].J Reprod Immun,2002;53(1-2):279-287.
[40]Salonen RH,Lichtenstein P.Genetic effects on the liability of developing pre-eclampsia and gestational hypertension[J].Am J Med Genet,2000,91(6):256-260.
[41]Kane S,Kisiel J,Shih L,et al.HLA disparity determines disease activity through pregnancy in woman with inflammatory bowel disease[J].Am J Gastroenterol,2004,99(8):1523-1526.
[42]Saftlas AF,Beydoun H,Triche E.Immunogenetic determinants of preeclampsia and related pregnancy disorders:a systematic review[J].Obstet Gynecol,2005,106(1):162-172.
[43]董生伟,沈进,朱明.妊娠并发脑静脉窦血栓形成一例分析[J].中华妇产科杂志,2003,38(7):426.
[44]SaistoT,Tiitinen A,Ulander VM,et al.Clinical cure of severe,early onset preeclampsia with low molecular weight heparin therapy in primigravida with hyperreactio luteinalis and thrombophilia[J].Hum Reprod,2004,19(3):725-728.
[45]Vormittag R,Pabinger I.Thrombophilia and pregnancy complications[J].Hamostaseologie,2006;26(1):59-62.
[46]Duley L,Henderson-Smart D,Knight M,et al.Anti-platelet drugs for prevention of pre-eclampsia and its consequences.BMJ,2001,322(7282):329-333.
[47]Coomarasamy A,Honest H,Papaioannou S,et al.Aspirin for prevention of preeclampsia in women with historical risk factors:a systematic review[J].Obstet Gynecol,2003,101(6):1319-1332.
[48]Rotchell YE,Cruickshank JK,Gay MP,et al.Barbados Low Dose Aspirin Study in Pregnancy(BLASP):a randomised trial for the prevention of pre-eclampsia and its complications[J].Br J Obstet Gynaecol,1998,105(3):286-292.
[49]Subtil D,Goeusse P,Puech F,et al.Aspirin(100mg) used for prevention of pre eclampsia in nulliparous women:the Essai Regional Aspirine Mere Enfantstudy(Part1)[J].BJOG,2003,110(5):475-484.
[50]段涛,孔北华,杨孜,等.妊娠期高血压疾病的热点问题讨论[J].现代妇产科进展,2004,13(6):401-405.
[51]Ruano R,Fontes RS,Zugaib M.Prevention of preeclampsia with Low-dose aspirin-A systematic review and meta-analysis of the main randomized controlled trials.Clinics,2005,60(5):407-414.
[52]Yamada H,Kato EH,Kobashi G,et al.Recurrent pregnancy loss:etiology of thrombophilia[J].Semin Thromb Hemost,2001,27(2):121 129.
[53]Kobayashi T.Antithrombin abnormalities and perinatal management[J].Curr Drug Targets,2005,6(5):559-566.
[54]Kobayashi T,Terao T,Ikenoue T,et al.Treatment of severe preeclampsia with antithrombin concentrate:results of a prospective feasibility study[J].Semin Thromb Hemost,2003,29(6):645-652.
[55]vonDadelszen P,Magee LA,Lee SK,et al.Activated protein C in normal human pregnancy and pregnancies complicated by severe preeclampsia:a therapeutic opportunity[J]? Crit Care Med,2002,30(8):1883-1892.
[56]Antovic JP,Rafik HR,Antovic A,et al.Does thrombin activatable fibrinolysis inhibitor(TAFI) contribute to impairment of fibrinolysis in patients with preeclampsia and/or intrauterine fetal growth retardation[J]? Thromb Haemost,2002,88(4):644-647.
[57]Harnett MJ,Datta S,Bhavani SK.The effect of magnesium on coagulation in parturients with preeclampsia[J].Anesth Analg,2001,92(5):1257-1260.
[58]Zhou L,Zuo Z,Chow MS.Danshen:an overview of its chemistry,pharmacology,pharmacokinetics,and clinical use[J].J Clin Pharmacol,2005,,45(12):1345-1359.
[59]Chen LN,Zhu XX.Advances in study of the pharmacological effects of danshen on phemorheology(in Chinese)[J].Zhongguo Zhong Yao Za Zhi,2005,30(8):630-633,640.
[60]袁恒杰.丹参素药理作用研究新进展[J].中国医院药学杂志,2006,26(5):604-606.
[61]肖刚峰,张怀勤,季亢挺,等.丹参素对体外培养内皮祖细胞数量和功能的影响[J].华西药学杂志,2006,21(3):232 234.
[62]王若光,尤昭玲,刘小丽,等.黄芪丹参复方成分对一氧化氮合成阻滞孕鼠胎盘超微结构的影响[J].中国中医药科技,2005,12(5):303-304.
[63]Wang RG,You Zh,Liu XL.Effect of ingredients of Astragalus-Salvia compound on vascular endothelial cell in placenta and vascular endothelial growth factor mRNA expression in trophocyte in pregnant rats with inhibited nitric oxide synthesis(in Chinese)[J].Zhongguo Zhong Xi Yi Jie He Za Zhi,2005,25(6):516-519.
[64]Wang XF,Zhao MQ.Ligustrazine and Salvia miltiorrhiza injection solution in complementary therapy of pregnancy-induced hypertension:clinical analysis of 60cases(in Chinese)[J].Di Yi Jun Yi Da Xue Xue Bao,2003,23(9):969-971.
[65]熊钰,李笑天,马端.子痫前期和子痫出凝血功能改变的特点及其防治[J].中国实用妇科与产科杂志,2006,22(3):224-226.
[66]Omatsu K,Kobayashi T,Murakami Y,et al.Phosphatidylserine/phosphatidylcholine microvesicles can induce preeclampsia-like changes in pregnant mice[J].Semin Thromb Hemost,2005,31(3):314-320.
[1]Sibai B,Dekker G,Kupferminc M.Pre-eclampsia[J].Lancet,2005,365(9461):785-799.
[2]Sibai BM.Diagnosis and management of gestational hypertension and preeclampsia[J].Lancet,2003,102(1):181-192.
[3]Omatsu K,Kobayashi T,Murakami Y,et al.Phosphatidylserine/phosphatidylcholine microvesicles can induce preeclampsia-like changes in pregnant mice[J].Semin Thromb Hemost,2005,31(3):314-320.
[4]Zhang P,Schmidt M,Cook L.Maternal vasculopathy and histologic diagnosis of preeclampsia:poor correlation of histologic changes and clinical manifestation[J].Am J Obstet Gynecol,2006,194(4):1050-1056.
[5]Sugimura M,Kobayashi T,Shu F,et al.Annexin V inhibits phosphatidylserine-induced intrauterine growth restriction in mice[J].Placenta,1999,20(7):555-560.
[6]Bretelle F,Sabatier F,Desprez D,et al.Circulating microparticles:a marker of procoagulant state in normal pregnancy and pregnancy complicated by preeclampsia or IUGR[J].Thromb Haemost,2003,89(4):486-492.
[7]Said J,Dekker G.Pre-eclampsia and thrombophilia[J].Best Pract Res Clin Obstet Gynaecol,2003,17(3):441-458.
[8]Meroni PL,di Simone N,Testoni C.Antiphospholipid antibodies as cause of pregnancy loss[J].Lupus,2004,13(9)649-652.
[9]胡娅莉.妊高症止血功能变化的初步观察[J].中华妇产科杂志,1986,21(5):268-271.
[10]Olson GL,Saade GR,Buhimschil,et al.The effect of an endothelin antagonist on blood pressure in a rat model of preeclampsia[J].Am J Obstet Gynecol,1999,181(3):638-641.
[11]李东至,林其德.妊娠高血压综合征动物模型研究进展[J].国外医学妇幼保健分册,2001,12(3):118-120.
[12]Karalis I,Nadar SK,Al Yemeni E,et al.Platelet activation in pregnancy-induced hypertension[J].Thromb Res,2005,116(5):377-383.
[13]Howarth S,Marshall,LR,Barr,AL,et al.Platelet indices during normal pregnancy and pre-eclampsia[J].Br J Biomed Sci,1999,56(1):20-22.
[14]BeloL,SantosSA,RumleyA,etal.Elevated tissue plasminogen activator as a potential marker of endothelial dysfunction in pre-eclampsia:correlation with proteinuria[J].BJOG,2002,109(11):1250-1255.
[15]Heilmann L,Rath W,Pollow K.Hemostatic abnormalities in patients with severe preeclampsia[J].Clin Appl Thromb Hemost,2007,13(3):285-291.
[16]Osmanagaoglu MA,Topcuoglu K,Ozeren M,et al.Coagulation inhibitors in preeclamptic pregnant women[J].Arch Gynecol Obstet,2005,271(3):227-230.
[17]Kobayashi T,Sumimoto K,Tokunaga N,et al.Coagulation index to distinguish severe preeclampsia from normal pregnancy[J].Semin Thromb Hemost,2002,28(6):495-500.
[18]Lopez-Ramirez Y,Carvajal Z,Arocha-Pinango CL.Hemostatic system parameters of placental extracts in normal pregnancy and severe preeclampsia[J].Invest Clin,2006,47(3):233-240.
[19]Freyssinet JM,Gauchy J,Cazenave JP.The effect of phospholipids on the activation of protein C by the human thrombin-thrombomodulin complex[J].Biochem J.1986,238(1):151-157.
[20]李春梅,王若光,尤昭玲,等.黄芪丹参复方成分对一氧化氮合成阻滞孕鼠胎盘超微形态影响研究[J].中华现代中西医杂志,2005,3(2):97-99.
[1]Vormittag R,Pabinger I.Thrombophilia and pregnancy complications[J].Hamostaseologie,2006;26(1):59-62.
[2]SaistoT,Tiitinen A,Ulander VM,et al.Clinical cure of severe,early onset preeclampsia with low molecular weight heparin therapy in primigravida with hyperreactio luteinalis and thrombophilia[J].Hum Reprod,2004,19(3):725-728.
[3]Duley L,Henderson-Smart D,Knight M,et al.Anti-platelet drugs for prevention of pre-eclampsia and its consequences.BM J,2001,322:329-333.
[4]Zhou L,Zuo Z,Chow MS.Danshen:an overview of its chemistry,pharmacology,harmacokinetics,and clinical use[J].J Clin Pharmacol,2005,,45(12):1345-1359.
[5]梁娟,李维敏,王艳萍,等.1996-2000年全国孕产妇死亡率变化趋势[J].中华妇产科杂志,2003,38(5):257-260.
[6]Redmanc WG,Sargent L.Latest advances in understanding preeclampsia[J].Science,2005,308(5728):1529-260.
[7]Sibai B,Dekker G,Kupherminc M.Preeclampsia[J].Lancet,2005,365(9461):785-799.
[8]Duckitt K,Harringion D.Risk factors for preeclampsia at antenatal booking:systemic review of controlled studies[J].Br Med J,2005,330(7491):565-572.
[9]中国中西医结合妇产科专业委员会第三届学术会议.子宫内膜异位症妊娠高血压综合征及女性不孕症的中西医结合诊疗标准[J].中国中西医结合杂志,1991,11(6):376-379.
[10]刘亚滨.复方丹参注射液治疗妊高症的临床观察[J].辽宁医学志.1993,7(1)26.
[11]郝翠芳.复方丹参对妊高征孕妇微循环的影响[J].实用妇产科杂志,1998,14(4):203-204.
[12]刘惠萍.中西医结合治疗妊娠高血压综合征[J].陕西中医学院学报,2003,26(2):31-33.
[13]金季玲.中医治疗妊娠高血压综合征研究进展[J].辽宁中医杂志,1996,23(10):45-47.
[14]Said J,Dekker G.Pre-eclampsia and thrombophilia[J].Best Pract Res Clin Obstet Gynaecol,2003,17(3):441-458.
[15]SaistoT,Tiitinen A,Ulander VM,et al.Clinical cure of severe,early onset preeclampsia with low molecular weight heparin therapy in primigravida with hyperreactio luteinalis and thrombophilia[J].Hum Reprod,2004,19(3):725-728.
[16]Vormittag R,Pabinger I.Thrombophilia and pregnancy complications[J].Hamostaseologie,2006;26(1):59-62.
[17]Duley L,Henderson-Smart D,Knight M,et al.Anti-platelet drugs for prevention of pre-eclampsia and its consequences.BM J,2001,322:329-333.
[18]Ruano R,Fontes RS,Zugaib M.Prevention of preeclampsia with Low-dose aspirin-A systematic review and meta-analysis of the main randomized controlled trials.Clinics,2005,60(5):407-414.
[19]Rotchell YE,Cruickshank JK,Gay MP,et al.Barbados Low Dose Aspirin Study in Pregnancy(BLASP):a randomised trial for the prevention of pre-eclampsia and its complications[J].Br J Obstet Gynaecol,1998,105(3):286-292.
[20]Subtil D,Goeusse P,Puech F,et al.Aspirin(100mg) used for prevention of pre eclampsia in nulliparous women:the Essai Regional Aspirine Mere Enfantstudy(Part1)[J].BJOG,2003,110(5):475-484.
[21]段涛,孔北华,杨孜,等.妊娠期高血压疾病的热点问题讨论[J].现代妇产科进展,2004,13(6):401-405.
[22]Wang XF,Zhao MQ.Ligustrazine and Salvia miltiorrhiza injection solution in complementary therapy of pregnancy-induced hypertension:clinical analysis of 60cases(in Chinese)[J].Di Yi Jun Yi Da Xue Xue Bao,2003,23(9):969-971.
[23]Roberts JM,Lain KY.Recent insights into the pathogenesis of Preeclampsia[J].Placenta,2002,23(5):359-372.
[24]尚涛,乔宠.肝素在重度妊高征治疗中的价值[J].中国实用妇科与产科杂 志,1997,13(4):229.
[25]白涛,尚涛.肝素治疗产科子痫11例分析[J].辽宁药物与临床,1998,1(3):112-113.
[26]SaistoT,Tiitinen A,Ulander VM,et al.Clinical cure of severe,early onset preeclampsia with low molecular weight heparin therapy in primigravida with hyperreactio luteinalis and thrombophilia[J].Hum Reprod,2004,19(3):725-728.
[27]Vormittag R,Pabinger I.Thrombophilia and pregnancy complications[J].Hamostaseologie,2006;26(1):59-62.
[28]Ioannis K,Sunil K,Eman A.Platelet activation in pregnancy-induced hypertension[J].Thromb Res,2005,116(1):377-383.
[29]Duley L,Henderson-Smart D,Knight M,et al.Anti-platelet drugs for prevention of pre-eclampsia and its consequences.BM J,2001,322:329-333.
[30]Ruano R,Fontes RS,Zugaib M.Prevention of preeclampsia with Low-dose aspirin-A systematic review and meta-analysis of the main randomized controlled trials.Clinics,2005,60(5):407-414.
[31]Askie LM,Duley L,Henderson-Smart DJ,et al(PARIS Collaborative Group).Antiplatelet agents for prevention of pre-eclampsia:a meta-analysis of individual patient data[J].Lancet,2007,369(9575):1791-1798.
[32]段涛,孔北华,杨孜,等.妊娠期高血压疾病的热点问题讨论[J].现代妇产科进展,2004,13(6):401-405.
[33]Zhou L,Zuo Z,Chow MS.Danshen:an overview of its chemistry,pharmacology,pharmacokinetics,and clinical use[J].J Clin Pharmacol,2005,,45(12):1345-1359.
[34]Chen LN,Zhu XX.Advances in study of the pharmacological effects of danshen on hemorheology(in Chinese)[J].Zhongguo Zhong Yao Za Zhi,2005,30(8):630-633,640.
[35]王绍娟,韦少云.丹参注射液对妊娠高血压综合征患者肾功能的保护作用.中山大学学报:医学科学版,2004,25(6):136-138.
[36]王雪峰,赵苗青.川芎嗪及复方丹参注射液辅助治疗妊娠高血压综合征60例临床分析[J].第一军医大学学报,2003,23(9):269-271.
[37]袁恒杰.丹参素药理作用研究新进展[J].中国医院药学杂志,2006,26(5):604-606.
[38]肖刚峰,张怀勤,季亢挺,等.丹参素对体外培养内皮祖细胞数量和功能的影响[J].华西药学杂,2006,21(3):232-234.
[1]Redmanc WG,Sargent L.Latest advances in understanding preeclampsia[J].Science,2005,308(5728):1529-260.
[2]Sibai B,Dekker G,Kupherminc M.Preeclampsia[J].Lancet,2005,365(9461):785-799.
[3]龚志锦,詹镕洲.病理组织制片和染色技术.上海科技大学出版社,1994,第一版:99.
[4]National Institute for Clinical Excellence,Scottish Executive Health Department,Department of Health,et al.Why mothers die 2000-2002.The sixth report of the confidential enquiries in to maternal deaths in the United Kingdom[M].London:RCOG Press,2004.
[5]Grisaru-Granovsky S,Halevy T,Eidelman A,et al.Hypertensive disorders of pregnancy and the small for gestational age neonate:not a simple relationship[J].Am J Obstet Gynecol,2007,196(4):335.e1-5.
[6]Koler A,Sun D,Huang A,et al.Corelease of nitric oxide and prostaglandins mediates flow dependent dilation of rat gracilis muscle arterioles[J].Am J Physiol,1994,267(36):326-332.
[7]Jonathan G,Poston L.Nitric oxide is involved in flow-induced dilation of isolated human small fetoplacental arteries[J].Am J Obstet Gynecol,1996,174(2):583-588.
[8]Gagnon R.Placental insufficiency and its consequences[J].Eur J Obst Gynecol Reprod Biol,2003,110(1S):99-104.
[9]Kassanos D,Siristatidis C,Vitoratos N,et al.The clinical significance of Doppler findings in fetal middle cerebral artery during labor[J].Eur J Obstet Gynecol Reprod Biol,2003,109(I):45-48.
[10]尤昭玲,王若光.妊娠高血压综合征中医药研究思路[J].中国中西医结合杂志,2002,22(7):545-546.
[11]陈敦全,余琳.抗凝剂在妊娠及分娩并发中的应用[J].中国实用妇科与产科杂志,2006,22(3):170-172.
[12]余勤,罗依,鄂艳,等.丹参素定向诱导骨髓间质干细胞分化为神经元样细胞的研究[J].中国中西医结合杂志,2005,25(1):49-53.
[13]Guo GQ,Shen WZ,Zhong SZ.Induction effect of danshensu and salvianolic acid on the migration of neural stem cells from mouse embryo[J].Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu,2007,11(7):1225-1228(China).
[14]Tanjung MT,Siddik HD,Hariman H,et al.Coagulation and fibrinolysis in preeclampsia and neonates[J].Clin Appl Thromb Hemost,2005,11(4):467-473.