Activated protein C in normal human pregnancy and pregnancies complicated by severe preeclampsia: a therapeutic opportunity?
OBJECTIVE
Given the efficacy and safety of recombinant human activated protein C (rhAPC) in the systemic inflammatory response syndrome, this study was designed to review the evidence for a role for APC in the pathogenesis of preeclampsia. Preeclampsia is a proinflammatory and procoagulant state, and it is a pregnancy-specific condition that mimics the systemic inflammatory response syndrome. rhAPC reduces mortality in patients with systemic inflammatory response syndrome and could potentially have a role as disease-modifying therapy in preeclampsia. To determine which patients would be offered rhAPC, the literature pertaining to fetal/neonatal outcomes for preeclampsia remote from term, transplacental transport of protein C, and pregnancy experience with the compound were reviewed.


METHODS
MEDLINE, review papers, hand searches of relevant nonindexed journals, and the bibliographies of relevant textbooks and articles reviewed.


METHODS
Randomized controlled trials were considered to provide the best quality of clinical data. Case-control series were considered over uncontrolled data. Some data were not available in the published literature (e.g., neonatal outcomes at various gestational ages and birthweights after a hypertensive pregnancy; and transplacental transfer of protein C), and these data were determined by us.


METHODS
Data were extracted by systematic review onto data collection sheets. Because of the quality of the data, this review is primarily qualitative.


RESULTS
APC levels fall during normal gestation, returning to normal values by 6 wks postpartum. Limited data suggest that early onset preeclampsia is a state of further, and inappropriate, reduction in APC. Preeclampsia resembles systemic inflammatory response syndrome in this regard. After hypertensive pregnancies, neonates have a 50% chance of intact survival if delivered after 27 + 0 wks of gestation with a birthweight of >600 g. It would seem ethical to offer women with preeclampsia with <50% chance of intact perinatal survival novel and potentially disease-modifying therapy such as rhAPC, especially as there is no transplacental transfer of protein C. Limited evidence would support the use of rhAPC in women with severe postpartum preeclampsia.


CONCLUSIONS
Sufficient data exist to support the use of rhAPC in phase II clinical studies for women with either early onset preeclampsia or severe or deteriorating postpartum disease.
von Dadelszen
Peter
P
Department of Obstetrics and Gynaecology,Division of Maternal-Fetal Medicine, University of British Columbia, Vancouver, British Columbia, Canada. pvd@cw.bc.ca
Magee
Laura A
LA
Lee
Shoo K
SK
Stewart
Shawn D
SD
Simone
Carmine
C
Koren
Gideon
G
Walley
Keith R
KR
Russell
James A
JA
D016022:Case-Control Studies; D017322:Clinical Trials, Phase II as Topic; D005260:Female; D006801:Humans; D016239:MEDLINE; D011225:Pre-Eclampsia / Q000097:blood* / Q000188:drug therapy*; D011247:Pregnancy / Q000097:blood*; D011248:Pregnancy Complications / Q000097:blood* / Q000188:drug therapy*; D011486:Protein C / Q000378:metabolism* / Q000627:therapeutic use*; D012720:Severity of Illness Index; D016387:Women's Health
D011486:Protein C