Analysis Of The Clinical Characteristics And The Expression Of Th17/Treg Cells Of Patients With Severe Preeclampsia And Eclampsia In Intensive Care Unit

The research backgroundHypertensive disorders in pregnancy(HDIP),that is,pregnancy induced hypertension(PIH)which occurres 20 weeks later after gestation,has the clinical performance of high blood pressure,proteinuria,edema,even organ dysfunction,convulsion,coma,and the death of maternal and infant.It's a unique disease in pregnancy,the incidence is about 9.4%-10.4%in china.PIH can be divided into five types:gestational hypertension,mild preeclampsia(MPE),severe preeclampsia(SPE),eclampsia,preeclampsia superimposed upon chronic hypertension and chronic hypertension complicating pregnancy.Among them severe preeclampsia and eclampsia cause the most serious consequences.The cesarean section rate is relatively high in patients with severe preeclampsia and eclampsia,and often because of the complexity conditions,organ damage,Stubborn hypertension and seizures,these patients need monitoring and treatment in the intensive care unit(ICU).The clinical study on these patients during late pregnancy and in ICU are relatively scarce,and often the two kinds of diseases are mixed together in the research,the deterioration of diseases in the late pregnancy leads to poor prognosis,therefore in order to improve the success rate of rescuing,it is necessary for us to reknowing the similarities and differences of clinical characteristics between the two kinds of patients from the perspective of intensive medical.Furthermore,the clinical features of severe preeclampsia and eclampsia in patients with late pregnancy and postpartum have great differences,but the underlying pathophysiological mechanisms of the difference are not clear,the associated basic research is rare.At present,research of the immune mechanism in PIH become a hotspot,in particular,the role of Th17(T help 17 cell)cells and Treg(CD4CD25 regulation T cell)cells take more and more attention.Both Th 17 and Treg cells belong to the T CD4 cell subsets,they have pro-inflammatory and anti-inflammatory effects Separately,the imbalance of Th17/Treg will lead to the occurrence of a variety of diseases.A growing number of studies have proved that disorder of Th17/Treg play an important role in the occurrence and development of PIH.Most of the research focused on prenatal.There are variety complications in the late pregnancy of severe preeclampsia and eclampsia such as cerebral edema,cerebrovascular disease,pulmonary edema,cardiac insufficiency,renal damage and liver damage.Often there is high rate of systemic inflammatory response syndrome(SIRS)after operation.The chronic inflammatory of vascular endothelial and the spasm of small blood vessels is the pathophysiological basis of the organ function damage,At present,it has been recognized that the abnormal expression of Th17 and Treg cells is closely related to vascular endothelial injury and the happeness of SIRS.Therefore,we hypothesized that Th17 and Treg cells play a role in the postoperative in:flammatory immune response and later pregnancy in patients with PIH,but there are few studies in this area.Patients with PIH are mainly distributed in relatively backward rural areas,our hospital is a first class hospital which serving the surrounding rural and urban residents,severe preeclampsia and eclampsia are often admitted to ICU,so the patients source for study is adequate.In addition,we have made a systematic study on the expression of Th17 and Treg cells in the peripheral blood of patients with sepsis.Therefore,we conducted clinical and basic research of patients with severe preeclampsia and eclampsia.The research is divided into two parts,the first part is the retrospective study,patients with severe preeclampsia and eclampsia in the ICU of our hospital were as the research object,we analyzed the clinical characteristics and the difference between the two groups in prenatal and postnatal period of ICU.The second part is a prospective controlled study.According to the different clinical characteristics such as the occurrence of placenta or not,the time of occurrence of eclampsia,and the occurrence of SIRS or not,all the patients were divided into several groups,we compared the peripheral expression of Th17 and Treg cells of different groups.The purpose of the study was to summarize the clinical features and differences of patients with severe preeclampsia and eclampsia in ICU,and to explore the underlying pathophysiological mechanisms,to improve the level of prevention and treatment of disease.Part ? THE CLINICAL CHARACTERISTICS OF PATIENTS WITH SEVERE PREECLAMPSIA AND ECLAMPSIA IN ICUObjective1.To analyse the clinical characteristics,complication,rescue process and health situation of maternal and infant of patients with severe preeclampsiaand eclampsia in ICU and summary the differences between the two kinds of disease.2.To observe the effect of different anesthesia methods on early warning of the severity of patients with severe preeclampsiaand eclampsia.3.To Summary reasonable treatment process for patients with eclampsia.Methods1.182 cases of patients with severe preeclampsia and 86 cases of patients with eclampsia admitted to the ICU of our hospital between January 1,2008 to December 30,2015 were included in our research,they served as SPE and E group separately,a retrospective analysis of general information,admission conditions,complications,APACHE? score,duration of mechanical ventilation,time in ICU,maternal and child health postpartum was conducted,also we summed up the characteristics and differences of the two groups.2.According to the different methods of anesthesia the patients were divided into general anesthesia(GA)-SPE group(n=70),(Nerve block anesthesia;NBA)-SPE group(n=98),GA-E group(n=39)and NBA-E group(n=33).The rate of placental abruption,rate of blood transfusion,APAGHE? score of different groups were compared to observethe warning effect of different anesthesia methods on the severity of the illness.3.According to the first admitted department,eclampsia patients were divided into A,B,C group,A group(n=49)for the patients admitted to department of obstetrics firstly;group B(n=22)for the patients admitted ICU firstly;C group(n=15)for the patients admitted to department of obstetrics firstly,then transferred to ICU because of inadequat eseizure controlling.Gestational age,convulsions controlling,average arterial blood pressure,cerebral vascular disease of the three groups of patients were compared to sum up a more reasonable rescue program of patients with eclampsia.Results1.Clinical characteristics of patients with severe preeclampsia and eclampsia and their differencesThe patients with severe preeclampsia and eclampsia accounted for 24.0%and 11.4%of patients with pathological obstetrics respectively,the vast majority of patients of the two groups were farmers,and most of them had no regular prenatal care during pregnancy.The age and gestational age of patients with severe preeclampsia were higher than that of patients with eclampsia(all P<0.05).The overall health situation of infants of patients with severe preeclampsia were better than that of patients with eclampsia.The fetal mortality of the two groups had no obvious difference.Patients with eclampsia develops stillbirth in gestational age<32 weeks.Patents with severe preeclampsia have two fetal death peaks,one in gestational age<32weeks,the other in gestational age around 32?34 weeks,the latter was considered associated with placental abruption.The propotion of liver and kidney damage,pulmonary edema,postpartum hemorrhage and infection were higher in SPE group than that in E group(P<0.05).Superior sagittal sinus thrombosis and the incidence of cerebral infarction were higher in E group than that in the SPE group(P<0.01).2.Differences in severity of illness among patients with different anesthesia methodsThe rate of fetal mortality,placental abruption,blood transfusion and the APACHEII scores were higher in GA-SPE group than those in NBA-SPE group(all P<0.05).Fetal mortality and APACHEII scores were higher in GA-E group than those in NBA-E group(all P<0.05).3.Summary of the reasonable treatment process of patients with eclampsiaThe gestational age in B group and C group was less than that of A group(P<0.05),the mean arterial pressure and incidence rate of cerebral infarction disease were higher than that of group A(both P<0.05);there was no significant difference between the B and C groups.23.4%of the patients in group A were transferred to ICU because of unsatisfactory seizure controlling and even other more serious complications,while all the patients of the B group had ideal seizure controlling,and then had termination of pregnancy.Conclusion1.The pathogenic condition of severe preeclampsia is relatively moderate,the age and gestational age of patients with severe preeclampsia are higher than that of patients with eclampsia,also there are high rate of multiple organ dysfunction,many of them had placental abruption which resulted in the second stillbirth peak of infants.There is high rate of brain infarction in patients with eclampsia which characteristed by sudden convulsions.2.Patients with severe preeclampsia and eclampsia are always with high rate of cesarean section,the choice of general anesthesia methods tends to suggest that the patient's condition is relatively severe,in some extent the adoption of general anesthesia plays a warning role.3.The rational treatment process is very important for patients with eclampsia,we summarized a more rational rescue program:Emergency ?Controling convulsions in ICU? End the pregnancy by obstetric ? ICU monitoring after postpartum.SignificanceThis research summarized the characteristics and clinical difference of patients with severe preeclampsia and eclampsia during late pregnancy and in ICU,the early warning function of general anesthesia and reasonable treatment process of eclampsia,so as to achieve better clinical effects.Part ? THE LEVEL OF TH17 AND TREG IN PERIPHERAL BLOOD OF PATIENTS WITH SEVERE PREECLAMPSIA AND ECLAMPSIA PRO AND AFTER CESAREAN SECTIONObjective1.To compare the expression of Th17 and Treg cells(percentage of CD4T cells)in peripheral blood and the balance of Th17/Treg of patients with severe preeclampsia and eclampsia before surgery.2.To compare the expression of Th17 and Treg cells in peripheral blood and the equilibrium state of Thl7/Treg of severe preeclampsic patients with and without placental abruption.3.To compare the expression of Th17 and Treg cells in peripheral blood and the equilibrium state of Th17/Treg of eclampsic patients with gestational age<34W and>34W4.To compare the expression of CD4 T and Th17 cell in peripheral blood of severe preeclampsic and eclampsic patients with or without SIRS after surgery.Methods53 patients with severe preeclampsia and 26 patients with eclampsia admitted to ICU after cesarean delivery operation between Jan 01,2013 and December 30,2014 were enrolled in this study.20 normal late pregnant(NLP)women were as control group.Cesarean delivery operation were conducted in nerve block anesthesia(NBA)in normal late pregnancy pantients.1.Detecte the proportion of Thl7 and Treg in peripheral blood and the ratio of Thl7/Treg of SPE group(n=53),E group(n=26)and control group(n=20).2.According to the presence of placental abruption(PA),patients with SPE were divided into.two groups,PA-SPE group(n=19)and Non-PA-SPE group(n=34),observe the Proportion of Th17 and Treg(Percentage in CD4 Tcells)irn peripheral blood and the ratio of Th17/Treg of two groups.3.According to gestational age,patients with eclampsia were divided into two groups,<34W-E group(n=14)and(?)34W-E group(n=12);observe the proportion of Th17 and Treg in peripheral blood and the ratio of Th17/Treg of two groups.4.According to the hapenness of SIRS in 24 hours postoperative,the patients were divided into four groups:SIRS-SPE group(n=30);Non-SIRS-SPE group(n=23);SIRS-E group(n=12);Non-SIRS-E group(n=14),observed proportion of Th17 and Treg in peripheral blood of the four groups on the first day postoperative.Results1.The percentage of Th17,Treg and the ratio of Th17/Treg in SPE group,E group and NLP group.The percentage of Th17 and the ratio of Th17/Treg were higher in E group than those in the SPE group,(all P<0.0 1).The percentage of Treg was lower in E group than that in the SPE group,(P<0.01).The percentage of Th17 and the ratio of Th17/Treg in SPE group and E group were significantly higher than those in the NLP control group(both P<0.01),the percentage of Treg in the two groups was significantly lower than that in the NLP control group(both P<0.01).2.The percentage of Th17,Treg and the ratio of Th17/Treg in PA-SPE group and Non-PA-SPE groupThe percentage of Th17,Treg and the ratio of Thl7/Treg in the PA-SPE group were higher than those in Non-PA-SPE group(all P<0.05).3.The percentage of Th17,Treg and the ratio of Th17/Treg in<34W-E group and(?)34W-E groupThe percentage of Th17 and ratio of Th17/Treg were significantly higher in<34W-E group than.those in(?)34W-E group(both P<0.05);There was no obvious difference of the expression of Treg between the two groups.4.The percentage of Th17 and Treg in SIRS-SPE group;Non-SIRS-SPE group;SIRS-E group;Non-SIRS-E groupThe percentage of Th17 in SIRS-SPE-group and SIRS-E-group were higher than those of groups without SIRS(all P<0.05),The percentage of Treg in different group had no obvious difference.Conclusion1.There are abnormal expression of Th17,Treg and imbalance of Thl7/Treg in patients wtih severe preeclampsia and eclampsia,but the degree of imbalance of Th17/Treg in eclampsia is more significantly than that in severe preeclampsia.2.The imbalance of Th17/Treg takes part in the pathogenesis of placental abruption of severe preeclampsia and the incidence of early eclampsia.3.In the early stage postoperative,there is still intense inflammatory response in patients,the high expression of Th17 is involved in the occurrence of SIRS in patients with severe preeclampsia and eclampsia.SignificanceThrough the research we found that the abnormal expression of Th17,Treg and Th17/Treg imbalance play a role in placental abruption,early eclampsia and the occurrence of SIRS after surgery in patients with severe preeclampsia and eclampsia,thus we have further understanding of the immune mechanism of severe preeclampsia and eclampsia.