Randomized, placebo controlled, double blind trial evaluating early pregnancy phytonutrient supplementation in the prevention of preeclampsia.

OBJECTIVE: Daily provision of pregnant patients with dietary supplements containing antioxidants and phytonutrients, if initiated in the first trimester of pregnancy and continued throughout the gestation, may significantly decrease the incidence of preeclampsia. STUDY DESIGN: We conducted a single center, randomized, placebo-controlled investigation in which women were randomized by their risk status and assigned to daily ingestion of a supplement consisting primarily of a blended fruit and vegetable juice powder concentrate or placebo. RESULT: Of the 684 patients randomized to the trial, 267 (39.0%) completed it. The final analysis is based on those participants who completed the study. For the primary outcome of preeclampsia, there was no difference observed between the phytonutrient supplement group and the placebo group: 15.9% vs 16.3%, respectively, (R.R. 0.97 (0.56-1.69)). Non-significant trends toward lower placenta-related obstetrical complications were observed in the supplement group compared with the placebo cohort (8.3% vs 15.5%, respectively, (R.R. 0.57 (0.29-1.14). Those infants born to mothers taking the supplement in the high-risk stratified group demonstrated non-significant trends toward lower rates of respiratory distress syndrome (RDS); 5.3% in the supplement group vs 15.4% in the placebo group: R.R. 0.34 (0.12-1.01). CONCLUSION: Initiation of antioxidant/phytonutrient supplementation in the first trimester did not decrease rates of preeclampsia. Non-significant trends toward lower incidences of placental derived morbidity in those mothers taking the supplement in addition to decreased rates of RDS in infants born to supplemented mothers considered to be high-risk for preeclampsia, warrant further investigation.

OS011. Management of late preterm pregnancy complicated by mildpreeclampsia: A prospective randomized trial.

INTRODUCTION: In the absence of properly undertaken prospective randomized clinical trials, the optimal management of late preterm mild preeclampsia for best maternal and perinatal outcomes remains unclear for obstetricians worldwide. OBJECTIVES: We desired to determine if immediate or expectant management of the late preterm mother presenting with mild preeclampsia was more beneficial to her without compromise to her newborn. METHODS: This prospective randomized clinical trial of immediate versus expectant delivery for patients presenting with mild preeclampsia between the late preterm period of 34-0/7 to 36-6/7weeks gestation was undertaken using CONSORT guidelines. Patients were randomized to immediate delivery via induction of labor or cesarean delivery or inpatient expectant management with delivery at 37-0/7weeks gestation or earlier at onset of labor or progression to severe preeclampsia. The primary outcome was progression to severe preeclampsia; secondary outcomes were neonatal morbidity and mortality. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if p<0.05. RESULTS: One hundred and sixty nine patients during 2002-2008 satisfied and sustained protocol criteria in the immediate delivery (n=94) or inpatient expectant management (n=75) arms of the study. A third (33%) of expectantly managed patients developed severe preeclampsia during significantly longer hospitalization versus 3% in the immediately delivered patients (p=0.001). Cesarean delivery rates were similar. No significant neonatal morbidity differences were observed between groups; there were no maternal or neonatal deaths. The study was stopped in 2008 at 74% of the enrollment target when hospital policy changed to discourage inpatient hospitalization for uncomplicated mild preterm preeclampsia and in view of growing national concern for increased late preterm/early term neonatal morbidity and cost of care. CONCLUSION: Proceeding to delivery of the late preterm (⩾34weeks gestation) patient with mild preeclampsia lessens maternal risk without significantly increasing neonatal risk.

PP039. The importance of intentionally considering class 1 HELLP syndrome outcomes versus all other categories of HELLP syndrome or severe preeclampsia.

INTRODUCTION: Combining HELLP syndrome patient groups in publications and presentations may obfuscate any potential differences among patient groups with regard to maternal-perinatal outcomes and rendered therapies. OBJECTIVES: We explored the prevalence of major maternal morbidity (MMM) for patients with severe preeclampsia (SPRE) and each defined group of HELLP syndrome. METHODS: Retrospective cohort study 2000-2007 of patients categorized either as class 1 HELLP syndrome (HELLP1, platelets⩽50,000, AST⩽70,LDH⩽600), class 2 (HELLP2, platelets>50,000 to ⩽100,000), class 3 (HELLP3, platelets>100,000 to ⩽150,000), or partial/incomplete (HELLP4) with only 2 of 3 diagnostic parameters present. All SPRE patients (no HELLP) of 2005-2007 were also evaluated. Total MMM for each group was determined. MMM included cardiopulmonary [cardiogenic or noncardiogenic pulmonary edema, pleural or pericardial effusion, pulmonary embolus, indicated intubation, myocardial infarction or arrest], hematologic/coagulation [DIC, transfused blood products], central nervous system/visual [stroke, cerebral edema, hypertensive encephalopathy, vision loss], hepatic [subcapsular hematoma or rupture] or renal complications [acute tubular necrosis or renal failure]. All HELLP1 and HELLP2 patients received corticosteroids, magnesium sulfate and anti-hypertensives. Comparison among groups was done using Chi-square or Fisher exact test at 95% CI. RESULTS: Four hundred and twenty patients had a form of HELLP syndrome 2000-2007; 688 patients had SPRE 2005-2007.The prevalence of MMM for each patient group was determined: HELLP1=41.5%; HELLP2=10.3%; HELLP3=20.0%; HELLP4=21.0%; and SPRE=17.7%. MMM in HELLP1 was significantly increased over all other groups (P<0.001). Combining MMM for HELLP1+HELLP2 produced a prevalence of 22.1% MMM, insignificantly different from all others including HELLP3, HELLP4 and SPRE (p=0.19), thereby obscuring the significantly elevated MMM of HELLP1 patients. CONCLUSION: Only patients with HELLP1 have significantly increased MMM compared to other HELLP groups or SPRE. Failing to separately evaluate patients with HELLP1 in studies of HELLP syndrome could lead to mistaken conclusions about the effectiveness of a treatment to reduce MMM. All publications reviewing HELLP syndrome management should address how well it functions to reduce patient development of HELLP1 and thus minimize MMM.

PP137. Posterior reversible encephalopathy syndrome (PRES) is a constant component of eclampsia.

INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) has been reported to occur in patients with eclampsia. In both conditions there is evidence to suggest disordered cerebral autoregulation. OBJECTIVES: We sought to investigate the concurrence of PRES with eclampsia and to describe the associated obstetric, radiologic and critical care correlates. METHODS: Single center 2001-2010 retrospective cohort study of all patients with eclampsia who underwent neuroimaging via magnetic resonance imaging (MRI) or computerized tomography (CT) with or without contrast. The medical records of all patients with eclampsia during the study interval were identified, evaluated and extracted for pertinent data; a diagnosis of PRES was made by radiologists using standard criteria. RESULTS: Forty-six of forty-seven (97.9%) patients with eclampsia revealed PRES on neuroimaging using one or more modalities: MRI without contrast=41 (87.2%), MRI with contrast=27 (57.4%), CT without contrast=16 (34%), CT with contrast=7 (14.8%) and/or MRA/MRV=2 (4.3%). PRES was identified within the parietal (36, 78.3%), occipital (35, 76.1%), frontal (29, 63%), temporal (13, 28.3%) and basal ganglia/ brainstem/cerebellum (12, 26.1%). Eclampsia occurred antepartum in 23 patients, postpartum in 24 patients with 22 vaginal/25 cesarean deliveries at a mean maternal age of 21.8 years (range 15-39) and a mean gestational age of 33.9 weeks (range 22.4-41.7 weeks). Ethnicity was African-American in 38 patients. Headache was the most common presenting symptom (87.2%) followed by altered mental status (51.1%), visual disturbances (34%) and nausea/vomiting (19.1%). Severe systolic hypertension was present in 22 (47%) of patients.Use of antihypertensives (87%), magnesium sulfate (100%), diuretics (66%) and corticosteroids (50%) facilitated maternal recovery in all cases with usually a brief hospitalization (mean 3.9 days, range 1-20 days). CONCLUSION: The common finding of PRES in patients with eclampsia suggests that PRES may be part of the pathogenesis of eclampsia. We speculate that therapy targeted at prevention or reversal of PRES pathogenesis will prevent or facilitate recovery from eclampsia.

Antepartum eclampsia <34 weeks case series: advisable to postpone delivery to administer corticosteroids for fetal pulmonary benefit?

OBJECTIVE: To determine if postponement of delivery to administer fetal lung maturation corticosteroids (PDACs) in mothers with antepartum eclampsia <34 weeks gestation benefits the fetus without compromising the mother. STUDY DESIGN: A case series of 37 maternal-perinatal pairs over a 9-year period with antepartum eclampsia between 24 and 34 weeks gestation from a single tertiary center were reviewed retrospectively. Duration of PDAC, clinical course and maternal-fetal outcomes, including impact of duration of PDAC on neonatal pulmonary function, were recorded for each case. Group assignment was based on length of corticosteroid treatment course before delivery: Group A, 0 to ≤ 24 h, n=28; B, 24 to <48 h, n=5; C, ≥ 48 h, n=4. Data were collected and analyzed by one-way analysis of variance (ANOVA), ANOVA on ranks, χ(2)-test and Fisher's exact tests where appropriate; statistical significance was determined by a P-value <0.05. RESULT: Overall, 37 of 68 eclampsia patients in 1999 to 2007 met inclusion criteria. No adverse maternal or fetal event occurred while delivery was postponed. Immediate neonatal intubation or continuous positive airway pressure was required for 23/28 in A, 4/5 in B and 2/4 in C; room air was sufficient at birth for 5/28 in A, 1/5 in B and 2/4 in C. No newborn >33 weeks gestation required INI. Prolonged (that is, >1 day) mechanical ventilation was not required for any infant with a gestational age ≥ 32 weeks or PDAC ≥ 48 h. Two of three neonatal deaths in group A were attributed to pulmonary insufficiency. CONCLUSION: PDAC for antepartum preterm eclampsia, especially ≤ 32 weeks gestation, appears to offer notable fetal pulmonary benefit without significantly increasing maternal or fetal risk.