PLASMA-EXCHANGE FOR PREECLAMPSIA .2. UNSUCCESSFUL ANTEPARTUM UTILIZATION FOR SEVERE PREECLAMPSIA WITH OR WITHOUT HELLP-SYNDROME

OBJECTIVE: To explore the efficacy of plasmapheresis/plasma exchange a s the primary therapy to arrest and reverse the progression of severe preeclampsia with or without HELLP syndrome in order to postpone deliv ery and improve perinatal outcome in very preterm pregnancies. STUDY D ESIGN: In this case series of patients managed over a 4-year period fr om 1984 to 1987, seven gravidas with severe preterm preclampsia underw ent 1-2 plasmaphereses/plasma exchange procedures using the IBM 2997 C ell Separator with continuous electronic fetal heart rate monitoring ( n = 7 patients) and central cardiovascular monitoring (n = 3 patients) . RESULTS: The seven patients (one with HELLP syndrome, six without HE LLP) presented between 24 and 30 weeks gestation and, despite plasmaph eresis/plasma exchange, the severity of each study subject's preeclamp sia persisted without clinically significant improvement. Maternal-fet al deterioration required cesarean delivery in all cases within 48 (in four patients within <36) hours of therapy. No clinically significant adverse effect of plasma exchange therapy was recorded during cardiov ascular and laboratory monitoring; two fetuses developed repetitive la te decelerations during exchange despite adequate maternal fluid prelo ad. The only patient with HELLP syndrome developed eclampsia as her th ird plasma exchange within 25 hours was being initiated. Significant p roblems with fluid retention and displacement (variable amounts of pul monary edema, pleural effusions, large volume ascites) were encountere d in all patients. Four neonates died (24-27 weeks/438-820 g) and thre e survived intact (740, 950, and 1,280 g). One mother (case 5) develop ed end-stage renal disease 21 months postpartum. CONCLUSIONS: The appl ication of plasmapheresis/plasma exchange therapy as described in orde r to prolong very preterm pregnancies in the undelivered patient with severe preeclampsia/eclampsia with or without HELLP syndrome did not p roduced encouraging results. Patients in general were exposed to addit ional medical and surgical risk without a corresponding improvement in perinatal outcome.