Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without hellp syndrome

Martin, James N.; Perry, Kenneth G.; Roberts, William S.; Norman, Patricia F.; Files, Joe C.; Blake, Pamela G.; Morrison, John C.; Wiser, Winfred L.

doi:10.1002/jca.2920090302

Cited by 35 publications

(27 citation statements)

References 27 publications

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“…In 1986 fourteen cases of PE with fresh frozen plasma for maternal indications in selected cases of preeclampsia and eclampsia were reviewed with promising results [114] . In contrast, PE did not prolong pregnancy in preterm preeclampsia in a report by Martin et al [115] . In another report, plasma exchange was commenced at 23, 26 and 29 wk of gestation in preeclamptic women and continued until delivery.…”

Section: Plasmapheresis/ Apheresismentioning

confidence: 78%

Preeclampsia from a renal point of view: Insides into disease models, biomarkers and therapy

Müller-Deile

Schiffer

2014

WJN

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Proteinuria is a frequently detected symptom, found in 20% of pregnancies. A common reason for proteinuria in pregnancy is preeclampsia. To diagnose preeclampsia clinically and to get new insights into the pathophysiology of the disease it is at first essential to be familiar with conditions in normal pregnancy. Animal models and biomarkers can help to learn more about disease conditions and to find new treatment strategies. In this article we review the changes in kidney function during normal pregnancy and the differential diagnosis of proteinuria in pregnancy. We summarize different pathophysiological theories of preeclampsia with a special focus on the renal facets of the disease. We describe the current animal models and give a broad overview of different biomarkers that were reported to predict preeclampsia or have a prognostic value in preeclampsia cases. We end with a summary of treatment options for preeclampsia related symptoms including the use of plasmapheresis as a rescue therapy for so far refractory preeclampsia. Most of these novel biomarkers for preeclampsia are not yet implemented in clinical use. Therefore, we recommend using proteinuria (measured by UPC ratio) as a screening parameter for preeclampsia. Delivery is the only curative treatment for preeclampsia. In early preeclampsia the primary therapy goal is to prolong pregnancy until a state were the child has an acceptable chance of survival after delivery.© 2014 Baishideng Publishing Group Inc. All rights reserved.Key words: Preeclampsia; Pregnancy; Proteinuria; Biomarkers; Treatment Core tip: This review summarises different pathophysiological theories of preeclampsia with a special focus on the renal facets of the disease. In this context current animal models are presented. The reader gets a broad overview about different biomarkers for preeclampsia. Furthermore, the article discusses treatment options for preeclampsia related symptoms including the use of plasmapheresis as a rescue therapy for so far refractory preeclampsia.Müller-Deile J, Schiffer M. Preeclampsia from a renal point of view: Insides into disease models, biomarkers and therapy. World

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Section: Plasmapheresis/ Apheresismentioning

confidence: 78%

Preeclampsia from a renal point of view: Insides into disease models, biomarkers and therapy

Müller-Deile

Schiffer

2014

WJN

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“…17 Similarly, plasmapheresis to remove circulating antibodies and immune complexes has not prolonged pregnancy in preterm preeclampsia. 18 Because circulating sFlt-1 represents Ͻ20% of the total body sFlt-1 burden, 19 we hypothesized that a selective adsorption column would create a concentration gradient and augment its removal. Herein we characterize the charge of sFlt-1, perform in vitro experiments to test commercially available devices that could adsorb circulating sFlt-1, and then describe our early experience in treating women with very preterm preeclampsia with the goal of prolonging pregnancy.…”

Section: Clinical Perspective On P 950mentioning

confidence: 99%

Pilot Study of Extracorporeal Removal of Soluble Fms-Like Tyrosine Kinase 1 in Preeclampsia

et al. 2011

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Background-Targeted therapies to stabilize the clinical manifestations and prolong pregnancy in preeclampsia do not exist. Soluble fms-like tyrosine kinase 1 (sFlt-1), an alternatively spliced variant of the vascular endothelial growth factor receptor 1, induces a preeclampsia-like phenotype in experimental models and circulates at elevated levels in human preeclampsia. Removing sFlt-1 may benefit women with very preterm (Ͻ32 weeks) preeclampsia. Methods and Results-We first show that negatively charged dextran sulfate cellulose columns adsorb sFlt-1 in vitro. In 5 women with very preterm preeclampsia and elevated circulating sFlt-1 levels, we next demonstrate that a single dextran sulfate cellulose apheresis treatment reduces circulating sFlt-1 levels in a dose-dependent fashion. Finally, we performed multiple apheresis treatments in 3 additional women with very preterm (gestational age at admission 28, 30, and 27ϩ4 weeks) preeclampsia and elevated circulating sFlt-1 levels. Dextran sulfate apheresis lowered circulating sFlt-1, reduced proteinuria, and stabilized blood pressure without apparent adverse events to mother and fetus. Pregnancy lasted for 15 and 19 days in women treated twice and 23 days in a woman treated 4 times. In each, there was evidence of fetal growth. Conclusions-This pilot study supports the hypothesis that extracorporeal apheresis can lower circulating sFlt-1 in very preterm preeclampsia. Further studies are warranted to determine whether this intervention safely and effectively prolongs pregnancy and improves maternal and fetal outcomes in this setting. (Circulation. 2011;124:940-950.)Key Words: angiogenic factor Ⅲ apheresis Ⅲ preeclampsia P reeclampsia is a devastating medical complication of pregnancy associated with significant maternal and fetal morbidity and mortality. 1 The risk is highest in very preterm (Ͻ32 weeks) preeclampsia when the infant mortality rate is 70 times higher than at term. 2,3 Delivery of the placenta remains the only effective means to treat preeclampsia. Randomized trials have tested nonspecific interventions including antihypertensive agents; however, the ability of these and other interventions to prevent or stabilize the clinical manifestations and prolong pregnancy in preterm preeclampsia is limited. 4 -6 The underlying pathogenesis of preeclampsia has remained elusive, hampering successful development of targeted interventions for the condition. Clinical Perspective on p 950The prevailing hypothesis suggests that preeclampsia involves a placental factor that circulates to distal organs and causes damage to the vasculature. 7 We and others have suggested that excess placental derived soluble fms-like tyrosine kinase 1 (sFlt-1) or the soluble vascular endothelial growth factor (VEGF) receptor 1, an alternatively spliced variant of VEGF receptor 1, mediates the signs and symptoms of preeclampsia, and elevated circulating levels are associated with clinical preeclampsia. 8 -11 Circulating sFlt-1 levels in very preterm preeclampsia are among the highest obs...

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“…The antepartum use of plasmapheresis or eculizumab is not a part of the usual management plan, though; both modalities were used by Eckford, yet, with limited benefits [13]. Similarly Martin et al also reported on the poor response of PE/HELLP syndrome to plasmapheresis in the antenatal period [14]. Here, the presence of neurologic or renal dysfunction or extremely abnormal laboratory tests (severe thrombocytopenia, severe anemia, very high LDH and increasing creatinine) are findings that point to TTP as the underlying pathology and plasmapheresis must be started even Ramadan et al J Hematol.…”

Section: Discussionmentioning

confidence: 99%

“…In addition there is a possible added-value of enhancement of platelet count as reported by Eckford et al [13], which might be needed when cesarean delivery is planned. If this trial-plasmapheresis could induce a dramatic improvement in the clinical and laboratory parameters within this short trial, which is unlikely with HELLP syndrome [13,14], then we might consider the working diagnosis as TTP, hence plasmapheresis should be continued as indicated with the possibility of adding steroids and rituximab if AD-AMTS-13 results showed acquired-TTP. On the other hand, if no improvement was elicited, then delivery must be done as scheduled (within 24 -48 h) [15].…”

Section: Discussionmentioning

confidence: 99%

HELLP Syndrome, Thrombotic Thrombocytopenic Purpura or Both: Appraising the Complex Association and Proposing a Stepwise Practical Plan for Differential Diagnosis

et al. 2018

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Both thrombocytopenia and microangiopathic hemolytic anemia (TMA) are seen in thrombotic thrombocytopenic purpura (TTP) and HELLP syndrome among other disorders during pregnancy. Although both share backgrounds of endothelial injury and microvascular thrombi and some clinical features, yet, they have different etiologies and courses. In late pregnancy, differentiating between these two pathologies can be extremely difficult due to the immense overlap in clinical and laboratory manifestations and this becomes only possible with the use of specific markers as ADAMTS-13, when available. Hereby, we describe three cases that may exemplify the complex association between PE/HELLP syndrome and TTP. The first case presented with PE/HELLP syndrome and deteriorated postpartum to improve on plasmapheresis. The second case was a known TTP patient who developed superimposed PE/HELLP at 27 weeks gestation which necessitated emergent delivery. The third was a case of preeclampsia that progressed to HELLP syndrome on day 2 postpartum but 3 days later was complicated by TTP. HELLP syndrome and TTP can co-exist, but can also complicate one another. In the absence of instantaneous results of ADAMTS-13 and when diagnosis with clinical judgement alone cannot be done with certainty, a short trial-plasmapheresis could be attempted with close observation of the immediate response. This stepwise approach might prove to be a valuable tool when integrated in the usual workup of clinical and laboratory evaluation both before and after delivery.

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Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without hellp syndrome

Cited by 35 publications

References 27 publications

Preeclampsia from a renal point of view: Insides into disease models, biomarkers and therapy

Preeclampsia from a renal point of view: Insides into disease models, biomarkers and therapy

Pilot Study of Extracorporeal Removal of Soluble Fms-Like Tyrosine Kinase 1 in Preeclampsia

HELLP Syndrome, Thrombotic Thrombocytopenic Purpura or Both: Appraising the Complex Association and Proposing a Stepwise Practical Plan for Differential Diagnosis

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