P 14 Deficiency of regulatory profile in pregnant women with early-onset preeclampsia

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Abstracts / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 9 (2017) 36–63

P 12 Treatment of very preterm preeclampsia by heparinmediated extracorporeal LDL-Precipitation (H.E.L.P) apheresis results in favorable fetal outcome and weight gain without lowering soluble FMS-like Tyrosine Kinase-1 (sFlt-1) – The Freiburg preeclampsia HELP-Apheresis study Karl Winkler a, Christiane Contini a, Bärbel König a, Bärbel Krumrey a, Gerhard Pütz a, Stefan Zschiedrich b, Ulrich Pecks c, Dimitra Stavropoulou d, Heinrich Prömpeler e, Mirjam Kunze e, Filiz Markfeld-Erol e (a University of Freiburg, Institute of Clinical Chemistry and Laboratory Medicine, Freiburg, Germany, b University Hospital Freiburg, Renal Division, Department of Medicine, Freiburg, Germany, c University Hospital SchleswigHolstein Campus Kiel, Department of Gynecology and Obstetrics, Kiel, Germany, d University of Freiburg, Children’s Hospital, Department of Neonatology, Freiburg, Germany, e University Medical Center Freiburg, Department of Gynecology and Obstetrics, Freiburg, Germany) Background: Preeclampsia (PE) is a life-threatening complication of pregnancy. To date the only therapy of severe PE consists in timely delivery of the fetus. In PE a deranged lipoprotein metabolism considered to impair endothelial function is observed. Heparinmediated extracorporeal LDL-precipitation (H.E.L.P.)-apheresis is an established method for lipoprotein removal and has already been successfully applied in PE. Recently, angiogenetic and antiangiogenetic factors like placenta growth factor (PlGF) and soluble Fms-like tyrosine kinase-1 (sFlt-1) are discussed as risk factors and removal of sFlt-1 by dextran sulfate column (DCS) apheresis is suggested as specific cure for PE. By contrast, H.E.L.P.-apheresis does not remove sFlt-1. The present clinical trial revaluates the clinical efficacy of H.E.L.P.-apheresis in PE with focus on sFlt-1 and PlGF. Methods: Open pilot study assessing the prolongation by H.E.L.P.-apheresis in 6 women (30–41 years) with very preterm PE (24 + 4 to 27 + 0 gestational weeks (GW)) (NCT01967355) compared to a historic untreated PE-group matching treated patients by GW at admission (<28 GW; n = 6). Clinical outcome of mothers and babies, pre- and post H.E.L.P.-apheresis levels of sFlt-1, PlGF, as well as lipoprotein levels were monitored. Results: Women with PE received apheresis 2–6 times. In treated patients the average time from admission to birth was 15.0 days compared to 6.3 days in controls (p = 0.027). In treated patients the prolongation of gestation by apheresis converted to a mean fetal weight gain of 101 grams (p = 0.029). Lung maturation could be induced in all treated cases and all children could be dismissed in healthy condition. Apheresis significantly reduced levels of total cholesterol ( 33%), triglycerides ( 43%), and LDL-cholesterol ( 44%). However, sFlt-1 was not reduced but levels significantly increased initially by H.E.L.P.-apheresis and dropped to almost preapheresis levels before next apheresis, with sFlt-1/PLGF ratio remaining unaffected. Conclusions: H.E.L.P.-apheresis proved again to be a safe therapeutic option to prolong pregnancies in PE and results in significant fetal weight gain. However, H.E.L.P.-apheresis does not reduce circulating sFlt-1 levels. Thus, reducing lipids and other pro-inflammatory factors may be more relevant than reducing circulating sFlt-1 to improve outcome in PE. doi:10.1016/j.preghy.2017.07.090

P 13 Inflammasome downregulation by silibinin and vitamin D in monocytes from pregnant women with preeclampsia Mariana Leticia Matias a,b, Mariana Romao-Veiga b, Vanessa Rocha Ribeiro a, Priscila Rezeck Nunes a, Vera Therezinha Medeiros Borges a, Jose Carlos Peracoli a, Maria Terezinha Serrao Peracoli b

(a Botucatu Sao Paulo State University (UNESP), Gynecology and Obstetrics, Botucatu, Brazil, b Institute/Company Department City Country Botucatu Sao Paulo State University (UNESP), Microbiology and Immunology, Botucatu, Brazil) Introduction: Preeclampsia (PE) is characterized by a state of abnormal activation of the innate immune system. This pathology is associated with activation of inflammasome, a multi-protein structure which is important for processing and release of inflammatory cytokines such as interleukin-1 beta (IL-1b) and IL-18. The imbalance between pro- and anti-inflammatory cytokines in PE seems to be dependent on the deficiency of regulatory factors capable of modulating inflammatory response. This imbalance could be improved by administration of substances with antiinflammatory and modulatory properties such as silibinin (SB) and vitamin D (VD). Objective: The aim of this study was to evaluate the modulatory effect of silibinin and vitamin D on NLRP1 and NLRP3 inflammasomes in monocytes from pregnant women with PE. MethodsMonocytes obtained from peripheral blood of 20 pregnant women with PE and 20 normotensive (NT) pregnant women were cultured in the presence or absence of silibinin or vitamin D and the expression of NLRP1, NLRP3, CASP1, TLR4, MYD88, NFKB1, IL1B, IL18, TNF and IL10 were assayed by qPCR and the concentrations of cytokines were determined by ELISA. Results were analyzed by non-parametric tests at 5% significance level. Results: The basal expression of inflammation-related genes was significantly higher while IL-10 gene expression was lower in monocytes from preeclamptic group than in NT group. These cells treatment with SB and VD led to decrease in the expression of the inflammatory genes and to an increase in mRNA IL-10 in PE group. Basal levels of TNF-a and IL-1b were elevated in monocytes cultures from preeclamptic women and decreased after SB and VD treatment. Conclusion: The basal up-regulation of NLRP1, NLRP3, caspase-1, TLR4, MyD88, NF-jB, IL-1b, IL-18 and TNF-a mRNA expression in monocytes from PE group confirms the inflammatory profile activation of these cells. SB and VD treatment decreased the expression of inflammation-related genes and inflammatory cytokines production by monocytes from pregnant women with PE, suggesting that these modulators may contribute to inflammasome downregulation in preeclampsia. doi:10.1016/j.preghy.2017.07.091

P 14 Deficiency of regulatory profile in pregnant women with early-onset preeclampsia Vanessa Rocha Ribeiro a, Mariana Romao-Veiga b, Mariana Leticia Matias a, Priscila Rezeck Nunes a, Jose Carlos Peracoli a, Vera Therezinha Medeiros Borges a, Maria Terezinha Serrao Peracoli b (a Botucatu Sao Paulo State University (UNESP), Gynecology and Obstetrics, Botucatu, Brazil, b Botucatu Sao Paulo State University (UNESP), Microbiology and Immunology, Botucatu, Brazil) Introduction: Preeclampsia (PE) is a pregnancy specific syndrome characterized by a systemic inflammatory response. An imbalance between Th17 and regulatory T cell detected in this pathology seems to be dependent on the deficiency of regulatory factors capable of modulating this inflammation. Vitamin D generates an immune tolerogenic status through its regulatory activities on the inflammatory response. Objectives: The present study aimed to evaluate the plasma levels of vitamin D, cytokines and to analyze the profile of CD4+ T cells subsets as well as the expression of vitamin D receptor (VDR) in peripheral blood mononuclear cells from pregnant women with PE.

Abstracts / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 9 (2017) 36–63

Methods: Twenty women with early-onset PE, 20 women with late-onset PE and 20 normotensive (NT) pregnant women were studied. Plasma concentrations of vitamin D was evaluated by chemiluminescence and the levels of IL-10, IL-17 and TNF-a were determined by ELISA. Gene expression of VDR, transcription factors RORc (Th17) and FoxP3 (Treg) were evaluated by qPCR. Results were analyzed by non-parametric tests at 5% significance level. Results: Plasma concentration of vitamin D was significantly lower in early-onset PE group compared to late-onset PE and NT groups, while the levels of TNF-a and IL-17 were significantly higher in early-onset PE group. On the other hand, IL-10 levels were significantly lower in both PE groups than in NT group. Gene expression of VDR was significantly decreased in early-onset PE group compared to NT group, while higher expression of mRNA RORc and lower expression of mRNA FoxP3 were observed in preeclamptic women. Positive correlation between vitamin D vs VDR and VDR vs FoxP3 was observed in PE (r = 0.44, p < 0.05; r = 0.31, p < 0.05) and in NT group (r = 0.60, p < 0.05; r = 0.59, p < 0.05). A negative correlation between VDR vs RORc was detected in PE (r = 0.46, p < 0.05) and in NT group (r = 0.45, p < 0.05). Conclusion: In preeclamptic women there is a decrease in regulatory status, suggesting a deficient immunomodulatory role of vitamin D that result in higher inflammatory profile, more evident in the early-onset PE. This imbalance in maternal tolerance indicate that vitamin D may participate in the pathogenesis of the disease. doi:10.1016/j.preghy.2017.07.092

P 15 PARROT Ireland – Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity – A stepped wedge cluster randomised control trial Deirdre Hayes Ryan a,b, Declan Devane a,c, Deirdre Murphy d, Fergus McCarthy e,f, Amanda Cotter g, Fionnuala McAuliffe h, Fionnuala Breathnach i, John Morrisson c, Brendan McElroy b, Aileen Murphy b, Ali Khashan a,b, Karla Hemming j, Alyson Hunter k, Louise Kenny a,b,k (a Irish Centre for Foetal and Neonatal Translational Research, Cork, Ireland, b University

Figure 1:

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College Cork, Cork, Ireland, c National University of Ireland Galway, Galway, Ireland, d Trinity College Dublin, Dublin, Ireland, e St Thomas’s Hospital, London, UK, f Division of Women’s Health KCL, London, UK, g University of Limerick, Limerick, Ireland, h University College Dublin, Dublin, Ireland, i Royal College of Surgeons in Ireland, Dublin, Ireland, j University of Birmingham, Birmingham, UK, k Queens University Belfast, Belfast, Ireland) Introduction: Pre-eclampsia complicates 2–8% of pregnancies and is associated with significant maternal and neonatal morbidity and mortality. Previous studies suggest that Placental Growth Factor (PlGF) testing presents a realistic and innovative adjunct to the management of women with suspected pre term pre-eclampsia. NICE has recently advised that further research is completed prior to integration of PlGF testing to routine clinical care. Objectives: Our primary aim is to establish the effectiveness of plasma PlGF measurement in reducing maternal morbidity, without increasing neonatal morbidity, in women presenting with suspected pre-eclampsia prior to 37 weeks’ gestation. The long term aim is to demonstrate that knowledge of PlGF measurement enables appropriate stratification of antenatal management of women presenting with suspected pre-eclampsia. Methods: A prospective multi-centre, stepped wedge cluster randomised controlled trial of women presenting with suspected preeclampsia from 20 to 36 + 6 weeks” gestation inclusive. It will be conducted in the seven largest maternity hospitals in Ireland and will run from April 2017 until Dec 2018. See Figures 1 & 2. Results: The study will have 2 co-primary outcomes; maternal morbidity & neonatal morbidity assessed using composite scores as both outcomes are equally important. Secondary outcomes will include a Health Economic impact assessment which will be an important component of the trial. Conclusion: If this trail shows benefit for PlGF testing it will influence international guidance and change the way we currently assess women with suspected pre-eclampsia. doi:10.1016/j.preghy.2017.07.093