429. Preeclampsia Treatment Strategies: Subtraction vs. Addition

Abstract

Preeclampsia can be complicated by end-organ damage, including severe hypertension, cerebral edema, and kidney and liver failure. Impending end-organ damage necessitates immediate delivery, often at the expense of the fetus in cases of preterm preeclampsia. Methods to prolong pregnancy may benefit the fetus, if of course maternal signs and symptoms can be tempered. Towards that end, we have developed a novel method to remove circulating sFlt-1 from maternal circulation in hopes to prolong pregnancy in women presenting with severe preterm preeclampsia. Such a strategy is novel for preeclampsia, but not entirely new in general Obstetrics, since historically and even today pregnant women undergo chronic hemodialysis, and plasma pheresis, during pregnancy for a variety of indications. Implementing such a strategy was stepwise, with a gradual increase in the duration and frequency of apheresis. Care was taken to avoid changes in blood pressure during the treatments, and management of flow rates and anticoagulation had to be modified appropriately. Nevertheless, we have shown that such a strategy has the potential to safely prolong pregnancy, potentially by weeks, in the setting of severe preterm disease. We have also followed women and their offspring now for 3–8 years following treatments, and no adverse events related to the intra-partum interventions were noted. Clinical trials are now underway to examine the utility of both selective and semi-selective removal strategies, and in the coming years we believe such a strategy will be available for women with this devastating condition.