CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 48, Number 2, 416429

2005, Lippincott Williams & Wilkins

Prevention of
Preeclampsia With
Antioxidants:
Evidence From
Randomized Trials
JOSEPH A. SPINNATO, MD
and JEFFERY C. LIVINGSTON, MD
Department of Obstetrics and Gynecology,
University of Cincinnati College of Medicine, Cincinnati, Ohio

Introduction
From the beginnings of scientific research in
reproductive biology, the etiology of preeclampsia has been the subject of much investigation and speculation. Although it is
fair to note that a single unifying etiology
of preeclampsia has not been identified,
investigations performed during the last 2+
decades have substantially advanced our understanding of the pathophysiological pathways that produce this clinical syndrome.
Indeed, multiple etiologic pathways may exist and share a remarkably similar final common pathophysiology.

Correspondence: Joseph A. Spinnato, MD, Department of

Obstetrics and Gynecology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH
45202. E-mail: joe.spinnato@uc.edu
Supported, in part, by grant no. 1 U01 HD40565-01 and
cosponsored by the National Institute for Child Health
and Human Development and the Bill and Melinda Gates
Foundation.
CLINICAL OBSTETRICS AND GYNECOLOGY

416

The vast literature exploring the etiology(ies) of preeclampsia is beyond the scope
of this chapter and is addressed elsewhere in
this edition of Clinical Obstetrics and Gynecology. This chapter explores the evidence
that supports the role of oxidative stress in
the pathophysiology of preeclampsia and
the potential for antioxidant therapy to prevent its occurrence.

Pathophysiology of
Oxidative Stress
Reports in the literature regarding the role of
oxidative stress in the pathophysiology of
preeclampsia are confusing. Important methodological differences among studies, including technique, timing of sampling, studied analytes, presence or absence of clinical
disease, disease severity, and even disease
definition, have produced explainable and unexplainable differences in the results and conclusions of these investigations. Nonetheless,
VOLUME 48

NUMBER 2

JUNE 2005

Preeclampsia Prevention With Antioxidants

the bulk of the evidence strongly supports a
central role for oxidative stress in the production of disease. This evidence has been summarized in several recent publications.13
LIPID PEROXIDATION AND FREE
RADICAL FORMATION

As a result of an imbalance of oxidant and

antioxidant activity involving placental and
maternal lipid peroxidation, the multiorgan
endothelial dysfunction observed among
preeclamptic patients appears to be related
to damage caused by unregulated free radical
production. Free radical production during
lipid peroxidation is central to the induction
of disease. Free radicals are molecules that
contain 1 or more unpaired electrons, typified
by the oxygen-containing hydroxyl radical
(HO), superoxide anion radical (O2), and
nitric oxide (NO). Reactive oxygen species
(ROS) include free radicals, but also include
molecules that do not have unpaired electrons
such as hydrogen peroxide (H2O2), hypochlorous acid (HOCl), and peroxynitrite
anion (ONOO). The lipid hydroperoxides
are highly reactive products of lipid peroxidation formed by the action of free radicals
on fatty acids or cholesterol in endothelial
cell membranes, damaging it and producing
the resultant endothelial cell dysfunction. As
early as 1983, Saeed and Mitchell4 studied
the formation of lipoxygenase metabolites
by human uterine and intrauterine tissues.
Their early observations suggested that uterine and intrauterine tissues were potential
sources of lipoxygenase products during
pregnancy and parturition, and that aberrant
lipoxygenase activities may contribute to the
complications of preeclampsia.
ANTIOXIDANTS

Antioxidants are molecules, which scavenge

free radicals and block the chain reaction
of unregulated oxidation before damage
occurs. There are several enzyme systems
within the body that scavenge free radicals,
including superoxide dismutase (SOD),
catalase, glutathione peroxidase (GSHPx),

417

and glutathione reductase. The principle

micronutrient (vitamin) antioxidants are
vitamins C and E as well as carotenoids such
as beta-carotene. Additionally, selenium,
a trace metal and cofactor for glutathione
peroxidase behaves as an antioxidant and
peroxynitrite scavenger when incorporated
into selenoproteins. Zinc is an important
trace element implicated in scavenging free
radicals. Deficient zinc levels decrease cytosolic superoxide dismutase activity resulting
in depleted antioxidant potential.5 These are
essential micronutrients and they must be
supplied in the diet. Additionally, coenzyme
Q, melatonin, and nicotine are important
mitochondrial antioxidants.612 Together
these vitamins, enzymes, and cofactors provide protection from the potentially damaging consequences of reactive oxygen species
to endothelial cells.
NORMAL PREGNANCY

In normal pregnancy, some have observed

an increase in lipid peroxidation whereas
others have not.1317 Oxidative stress is kept
in check by an increase in maternal antioxidant capacity. Takehara et al14 investigated
the lipoperoxide concentration, antioxidant
activities, and in vitro lipoperoxide formation in placental tissue during normal pregnancy. The lipoperoxide concentration was
50% lower in placental tissue of 40 weeks
gestation than in tissue of 5 to 11 weeks
gestation. Catalase and superoxide dismutase activities in placental tissues increased
as gestation progressed, whereas glutathione
peroxidase activity and alpha-tocopherol
concentration did not change significantly
during the gestational period. The in vitro
formation of lipoperoxides in placental
tissue decreased as gestation progressed.
These findings suggest that, in normal pregnancy, placental tissue may suppress lipoperoxide formation in the late gestational
age, lowering the concentration of lipoperoxides in the blood and protecting mother
and fetus against oxygen toxicity. Supporting this argument, Burlingame et al15 noted
that total antioxidant capacity levels are

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Spinnato and Livingston

present in amniotic fluid at least as early as

the second trimester and increase with
advancing gestational age. Increased
antioxidant capacity in the third trimester
of normal pregnancy has been noted using
various techniques,16 whereas other studies
have suggested possible increased lipid peroxidation and decreased antioxidant capacity in the third trimester of normal pregnancy.17,18 Levels of vitamin E are increased
in normal pregnancy,16,19 whereas selenium
is consistently noted to be decreased.18,20,21
Total triglycerides, cholesterol, and lowdensity lipoprotein cholesterol are increased
in pregnancy and reached a maximum in the
third trimester of pregnancy.16

OBSERVATIONS WITH
PREECLAMPSIA

Among patients with preeclampsia, there is an

increase observed in the rate of lipid peroxidation,19,2225 increased lipid availability,26
and decreases of antioxidants such as alphatocopherol,22,23,2631 ascorbate,28,31,32 betacarotene,31 and selenium.33 Evidences of increased oxidative stress as measured by thiobarbituric acid reactive substances (TBARS),
peroxyl radical trapping capacity (TRAP), increased malonaldehyde, decreased total thiol,
or total antioxidant potential are consistently
reported among studies of preeclamptic versus
control patients.19,2326,34,35 Similar changes
have been noted with complete hydatidiform
molar pregnancy suggesting a limited, if
any, role for the fetus in the pathophysiology
of clinical preeclampsia.36 In a representative
study, Williams et al37 examined the relationship between maternal plasma lipoprotein and
antioxidant status to the risk of preeclampsia
among women delivering in Zimbabwe.
One hundred seventy-three pregnant women
with preeclampsia and 186 controls were
included in a casecontrol study. Maternal
plasma total cholesterol, high-density lipoprotein (HDL), and total triglycerides were
measured using enzymatic methods. Plasma
carotenoids (alpha-carotene, beta-carotene,
lycopene, lutein, beta-cryptoxanthin, zeaxan-

thin), retinol, and tocopherols were determined. Preeclampsia risk was noted to be increased with successively higher quartiles of
plasma triglyceride. They noted decreasing
rates of preeclampsia with increasing concentrations of alpha-carotene, beta-carotene, betacryptoxanthin, lutein, and zeaxanthin. Women
with beta-carotene concentrations in the highest quartile, as compared with those in the
lowest quartile, experienced a 50% decreased
risk of developing preeclampsia. Similarly,
Aksoy et al38 measured plasma antioxidant
potential (AOP) status, ceruloplasmin (Cp),
and transferrin (Trf) levels as antioxidants
and malondialdehyde (MDA) levels as an
indicator of lipid peroxidation among 21
patients with mild preeclampsia, 15 patients
with severe preeclampsia, and 19 normotensive pregnant women. The AOP and Trf levels of the severe and mild preeclampsia
groups were found to be reduced; the
MDA and Cp levels were increased compared with those of the normotensive pregnant group. There were statistically significant negative correlations between AOP
and MDA in all groups.
Reduced levels of SOD24,30,34 and glutathione peroxidase19,30 among preeclamptic
patients are particularly important to the
production of disease. Important in the
placenta and, in most maternal tissues, a deficiency of SOD results in decreased inactivation of superoxide radical, oxidative
stress, and lipid peroxidation. Additionally,
deficiencies of SOD impede the beneficial
effects of nitric oxide for blood pressure
regulation by allowing nitric oxide to react
with superoxide to form peroxynitrite to
increase oxidative stress.39 Antioxidants,
like N-acetylcysteine (NAC), remove these
reactive oxygen species, resulting in an improvement of endothelial function.40 Representative studies include Madazli et al,41
who investigated the plasma and placental
levels of malondialdehyde (a marker of oxidative stress), glutathione, and superoxide
dismutase in normotensive and preeclamptic
pregnancies. The mean plasma and placental
levels of malondialdehyde were significantly

Preeclampsia Prevention With Antioxidants

higher, and glutathione and superoxide dismutase levels were significantly lower in
preeclamptic compared with normotensive
patients. The plasma and placental levels
of malondialdehyde significantly increased;
glutathione and superoxide dismutase significantly decreased with the incremental
increases in diastolic blood pressure. Orhan
et al42 measured maternal plasma glutathione S-transferase, selenium-dependent glutathione peroxidase (Se-GPx), catalase
activity, and thiobarbituric acid reactivesubstances (TBARs) in the third trimester
and immediately after the delivery. Erythrocyte Se-GPx activity and levels of TBARs
suggestive of oxidative stress were increased
among preeclamptic patients. Serdar et al43
evaluated the lipid and protein oxidation and
antioxidant function in preeclampsia versus normotensive pregnant women. Lipid
peroxides in serum, placenta, and decidua
basalis and protein carbonyls in serum were
significantly increased, and vitamin E and
total carotene levels in serum were significantly decreased, especially in women with
severe preeclampsia compared with mild
preeclampsia and normotensive pregnant
controls.
Both serum4446 and leukocyte47 zinc
concentrations are reduced in women with
preeclampsia compared with normotensive
pregnant controls. Deficient concentrations
of zinc decrease cytosolic superoxide dismutase activity and hence deplete antioxidant potential.5
Vaughan and Walsh48 have postulated
that hyperlipidemia and increased iron levels in the maternal compartment in preeclampsia might be responsible for excess
placental production of lipid peroxides and
thromboxane. They exposed a trophoblastlike cell line to a combination of linoleic
acid and an oxidizing solution composed
of hypoxanthine, xanthine oxidase, and
ferrous sulfate. After 6 days, the activities
of superoxide dismutase and glutathione
peroxidase were significantly decreased as
compared with exposure to linoleic acid
alone (control). These effects were attenuated

419

by deferoxamine, an iron chelator, suggesting a role for Fe++ in the decreased activities.
Additionally, increased thromboxane secretion and lipid peroxidation were noted in
the treatment group. Deferoxamine inhibited the lipid peroxidation, but not the
increase in thromboxane. Their findings suggest that maternal hyperlipidemia and increased iron levels may be responsible for
placental oxidative stress and abnormalities
in antioxidants and thromboxane. These
postulates require confirmation. Whether
manipulations of lipid metabolism and/or
diet in pregnancy might influence preeclampsia is unknown.
Excess placental lipid peroxidation has
been linked to placental production of tumor
necrosis factor alpha (alpha-TNF), interleukin-1 (IL1), and interleukin-6 (IL6).4957
Overproduction of alpha-TNF by the placenta may stimulate lipid peroxidation and
cause increased plasma levels, activate neutrophils, and produce subsequent endothelial
dysfunction in preeclampsia. Postulated
mechanisms involve vascular cellular adhesion molecule (VCAM), cytokines, and other
vasoactive substances. The precise cause and
effect relationship of alpha-TNF and lipid
peroxidation is yet to be determined. Defective trophoblast invasion and spiral artery development may be the prime stimulants for
both lipid peroxidation and production of
alpha-TNF. The role of vascular endothelial growth factor and VCAM are discussed
elsewhere in this edition.

PARALLEL STUDIES IN
RENOVASCULAR DISEASES

Renal juxtaglomerular hyperplasia (Bartters

syndrome) shares striking similarities to normal pregnancy. Bartters syndrome is a rare
renal tubular disorder, involving juxtaglomerular cells hyperplasia, characterized by
normotensive hyperreninism and secondary
hyperaldosteronism. It is not a single disorder but rather a set of closely related disorders. At least 3 clinical phenotypes have been
distinguished: 1) classic Bartter syndrome;

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Spinnato and Livingston

2) the hypocalciurichypomagnesemic
Gitelman variant; and 3) the antenatal hypercalciuric variant (also termed hyperprostaglandin E syndrome). It differs from pregnancy by the associated marked renal loss
of potassium and profound hypokalemia.
In this condition, there are marked increases
of renin, angiotensin I, and angiotensin II.
Elevated levels of prostaglandin E2 are
a common feature of this syndrome.
Angiotensin II, through the type 1 (AT1)
receptor, stimulates oxidative stress. The
vasculature, interstitium, juxtaglomerular
apparatus and the distal nephron in the kidney express nicotinamide adenine dinucleotide phosphate (NADPH) oxidase that generates superoxide anion, which is an important component of angiotensin II-induced
oxidative stress. The angiotensinogen gene
is stimulated by NF-kappaB activation,
which is sensitive to the reduction/oxidation
ratio, providing positive feedback loop that
can upregulate angiotensin II production.
AT1 receptor antagonists can abrogate the
effects of angiotensin II on oxidative stress,
thus explaining the renal protective effects
of these agents in conditions associated with
angiotensin II excess.58 It is likely that
the resistance to angiotensin II-related hypertension in Bartters syndrome share mechanisms similar to that of normotensive
pregnancy.
Oxidative stress in blood vessels and the
kidney in hypertension can be induced by
diverse vasoconstrictor mechanisms, including blockade of nitric oxide synthase
and activation of angiotensin II type I
receptors and thromboxane receptors. It
can cause vasoconstriction through bioinactivation of nitric oxide and by nitric
oxide synthase-independent mechanisms
that include increased generation of endothelin-1 and the effects of superoxide
anion and hydrogen peroxide on vascular
smooth muscle cells. Oxidative stress
can accompany hypertension in many
models, including the spontaneously hypertensive rat, the angiotensin II-infused
rat, renovascular hypertension, the deoxy-

corticosterone acetate-salt model, and obesity-related hypertension. In the kidney,

NADPH oxidase-generating superoxide
anion is expressed in the vasculature, interstitium, juxtaglomerular apparatus, and
the distal nephron. Much progress has
been made in defining the pathways that
intervene between agonist stimulation
of blood vessels and reactive oxygen
species-mediated contractile and renal
functional responses in animal models in
hypertension.59
The mechanisms that produce disease in
Bartters syndrome parallel those involved in
the development of preeclampsia. Leung
et al60 demonstrated an upregulated expression of placental mRNA for AT(1) receptor
subtype in patients with preeclampsia when
compared with those in controls. In addition,
there was also a significant activation of placental expression of angiotensinogen mRNA
in patients with preeclampsia. The expression
of AT(1) receptor was also upregulated. Their
data suggests that upregulation of placental
reninangiotensin components, notably AT(1)
receptor in the syncytiotrophoblasts, could
play a pathophysiological role in patients
with preeclampsia in the same way as observed for Bartters syndrome. The initiating
event in preeclampsia has been postulated to
be reduced uteroplacental perfusion as a result of abnormal cytotrophoblast invasion of
spiral arterioles. Placental ischemia/hypoxia
is thought to lead to widespread dysfunction
of the maternal vascular endothelium, which
results in enhanced formation of endothelin,
thromboxane, and superoxide, increased
vascular sensitivity to angiotensin II, and decreased formation of vasodilators such as
nitric oxide and prostacyclin. Precisely in
what manner placental ischemia/hypoxia
produces maternal endothelial and vascular
abnormalities remains uncertain.
The antioxidant deficiency of preeclampsia may persist beyond pregnancy. Ozan
et al61 compared the total antioxidant status
(TAS) on menstrual days 1719 of 32 formerly preeclamptic, nongravid women with
that of 28 age-matched nongravida women

Preeclampsia Prevention With Antioxidants

who had never had preeclampsia. The TAS
value was subnormal in 72% of the
formerly preeclamptic group and in 35%
of the control group. They concluded that
decreased antioxidant potential in women
with a history of preeclampsia may have
an important role in its pathophysiology.
The pathophysiological changes that are
postulated to explain the final common
pathway of preeclampsia are summarized
in Figure 1. In is important to note that this
represents a pathophysiological pathway
that is suspected to result from multiple
causes of failed angiogenesis of the spiral
arteries. The proposed mechanisms involved
in this occurrence continue to be the subject
continued research and debate.

FIGURE 1.

421

CLINICAL TRIALS

In response to the mounting evidence for the

role of oxidative stress in the pathophysiology of the endothelial damage seen in preeclampsia, several clinical studies have been
reported that attempt to improve the antioxidant capability of women at risk for preeclampsia. Explorations of this type are in
their infancy, and it is probably premature
to judge the benefit of any scheme designed
to improve the balance between oxidation
and antioxidation in pregnancy.
Vitamin C and Vitamin E
The rationale for supplementation of these
vitamins suggested by the preliminary investigations gained strength when Pressman

Oxidative stress and preeclampsia: proposed mechanisms.

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Spinnato and Livingston

et al,62 in a randomized, double-blind study,

studied 20 women who received a daily
vitamin E, and amniotic fluid vitamin C levels
were determined. Maternal plasma vitamin E
levels increased in the supplemented women
but not in the control subjects. No changes
in maternal vitamin C levels were noted.
Maternal plasma vitamin C concentrations
at delivery correlated closely with amniotic
fluid vitamin C levels. Similarly, maternal
plasma vitamin E levels at delivery correlated
with the chorioamnion concentration of
vitamin E in the amniotic fluid and vitamin
E in the chorioamnion, respectively.
In perhaps the most provocative and important of the reported clinical trials, Chappell et al63 conducted a blind, randomized,
placebo-controlled trial of antioxidant vitamins aimed at preventing the development
of preeclampsia.3 The study design flow diagram is presented in Figure 2. Women with
a history of preeclampsia or with abnormal
uterine artery Doppler in the second trimes-

ter (1822 weeks of gestation) were identified as being at high risk for the development of preeclampsia. Those identified as
high risk were randomized to receive vitamin C (1000 mg per day) and vitamin E
(400 mIU per day) or placebo. Women initially identified as high risk by abnormal
second-trimester uterine artery Doppler
waveforms analysis had an additional uterine artery waveform analysis at 24 weeks.
Those who had a normal waveform were
no longer considered at high risk and stopped receiving study medication. Those with
persistently abnormal uterine artery waveforms continued study medication until delivery. Because of the study design, 123 of
283 (43%) women initially randomized
did not complete the trial. Preeclampsia
was defined as hypertension with new-onset
proteinuria.
Data analyzed by intention to treat demonstrated nearly a 60% reduction in the occurrence of preeclampsia (odds ratio [OR]

FIGURE 2. Vitamin C and E supplementation to at-risk patient. Study

designChappell et al63 (1999).

Preeclampsia Prevention With Antioxidants

0.39, 95% confidence interval [CI] 0.17
0.90) from 17% in those who received antioxidants to 8% in women who received placebo. When only data from those who continued the trial were analyzed, the protective
effects of antioxidants persisted (OR 0.24,
95% CI: 0.080.70), suggesting a 76% reduction in the rate of preeclampsia among
these at-risk patients. Women with preeclampsia who finished the trial demonstrated
a reduction in endothelial cell activation
compared with normotensive women who
finished the trial. Women who receive antioxidant supplementation demonstrated biochemical improvements in measures of oxidative stress. A trend toward earlier delivery
of lower birthweight infants among those
patients who developed preeclampsia and
were randomized to the supplementation
group requires further study.
Chappell et al, in a separate report describing the same high-risk cohort,64 noted
that women identified as high risk for developing preeclampsia who were assigned vitamins C and E supplementation demonstrated
a reduction in measures of oxidative stress.
Concentrations of 8-epi-isoprostaglandin
F(2 alpha), leptin, and ascorbic acid were
similar in antioxidant-supplemented women
at high risk compared with women who
were identified as being at low risk for developing preeclampsia who were not taking
supplements.
The remarkable reduction in the risk of
preeclampsia noted within this high-risk
population is very intriguing. If these results
can be confirmed, the potential benefit to
patients at high risk for preeclampsia will
be substantial. However, like in the case of
previous efforts to prevent preeclampsia
whose initial reports of success could not
be confirmed in subsequent studies, it is premature to endorse this therapy. Beazley et al65
reported a blind, placebo-controlled study
of 109 patients with chronic hypertension,
prior preeclampsia, insulin-requiring diabetes mellitus, or multiple gestation who were
randomized to the same therapy. They noted
no difference between treatment and control

423

groups in the rate of preeclampsia (17.3%

vs. 18.8%) or for the total antioxidant status
or 8-isoprostane levels among patients who
completed the trial. Although the authors
admit that the study is underpowered and
was prematurely discontinued, this study
calls into question the dramatic reductions
observed by Chappell and her associates,
and the authors suggest that randomized
trials with less than 1000 subjects ultimately
may be underpowered. Several large ongoing studies of similar design are in progress and should help to clarify the role of
vitamin E/C supplementation in both at-risk
and low-risk populations.
Antioxidant Treatment of Preeclampsia
Treating women who have already manifested clinical preeclampsia with vitamin E
appears to have little benefit. In a small nonrandomized, nonblind study, Stratta et al66
studied 36 preeclamptic patients to evaluate
the effect of vitamin E supplementation
(100300 mg/d) on fetal and maternal outcome. Fetal mortality was similar in 14
patients treated with conventional therapy plus
oral vitamin E supplementation (35%) and in
22 patients treated with conventional therapy
only (36%). They concluded that, with these
dosages and in case of an already established
disease, vitamin E does not improve fetal
outcome in severe preeclampsia. Similarly,
Gulmezoglu et al67 randomized 56 women
with early-onset severe preeclampsia managed expectantly to receive vitamin E or
placebo. There was no difference in gestational age gained by expectant management,
the rate of eclampsia (1 case of eclampsia
in each group), or measurements of lipid
peroxidation.

Other Antioxidants
LYCOPENE

Lycopene is a dietary carotenoid with antioxidant activity. Yamini et al68 demonstrated

that beta-carotene supplementation in pregnancy will increase its level in maternal
serum. Casecontrol studies have failed to

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Spinnato and Livingston

demonstrate a relationship between preeclampsia and lycopene.6971 However,

Sharma et al72 conducted a prospective clinical trial which randomized 251 primigravida women to receive oral lycopene (2 mg
twice daily beginning at 1620 wks) or
matched placebo. Women randomized to
lycopene were less likely to develop preeclampsia (8.6% vs. 17.7%, P , 0.05) than
those who received placebo.
ZINC

Two randomized placebo-controlled trial

evaluated supplementation with zinc to prevent preeclampsia. Mohomed et al73 (n =
492) and Jonsson et al74 (n = 1206) randomized low-risk women to receiving zinc (44 mg
per day) or placebo. There was no difference
in occurrence of preeclampsia in those who
received zinc compared with those who
received placebo in either study.
SELENIUM

Selenium is important in the role of glutathione peroxidase pathway to remove damaged

cellular peroxidases, hence antioxidant
activity. Serum selenium concentrations
are reduced in women with preeclampsia
compared with normotensive pregnant controls.33 Rayman et al75 measured concentrations of selenium in toenail clippings of
women who developed preeclampsia and
matched pregnant controls. Toenail clippings are a reliable measurement of selenium
status in the previous 3 to 12 months, suggesting that decreased selenium occurs before the onset of clinical disease in women
destined to develop preeclampsia. A group
from Beijing76 randomized 52 women at
high risk for developing preeclampsia to
receive 1000 mg per day of liquid selenium
or placebo for 6 to 8 weeks during late gestation. There was a decreased incidence
of pregnancy-induced hypertension from
22.7% to 7.7% in the treatment group. This
brief report did not define pregnancy-induced
hypertension and gave little information of its
methods and results.

MAGNESIUM

Magnesium sulfate is the primary therapy to

treat eclampsia. Magnesium has a protective
effect on endothelial cells. Although the
exact mechanism of this protection is not
clear, involvement of lipid peroxidation has
been implicated. There is level 1 evidence that
intravenous/intramuscular magnesium reduces eclampsia in women with severe
preeclampsia.77 However, 2 randomized,
placebo-controlled trials enrolling a total
of 968 women have examined antenatal oral
magnesium supplementation to prophylaxis
against the development of preeclampsia. In
both trials, the occurrence rate of preeclampsia was similar in those assigned magnesium
compared with placebo78,79
MITOCHONDRIAL ANTIOXIDANTS

Nicotine
A recent metaanalysis80 of observational trials demonstrated a strong protective effect
of cigarette smoking and the development
of preeclampsia.81 In this analysis of
833,794 pregnancies, the relative risk of preeclampsia was 0.68 (95% CI: 0.670.69).
Over 4000 chemicals comprise cigarettes.
Nicotine, which is responsible for the addictive aspect of smoking, has potent antioxidant activity by stimulating nitric oxide production and scavenging free radicals in
endothelial cells. No clinical trials using nicotine to prevent preeclampsia have been
published, and nicotines potential worsening of the risk of intrauterine growth restriction may prohibit such trials.
Coenzyme Q
Coenzyme Q is a potent mitochondrial antioxidant, which also exhibits an antihypertensive effect.82 Teran et al8 investigated
the concentration of coenzyme Q10 in
normal pregnancy and preeclampsia. Pregnant women (n = 18), women with preeclampsia (n = 12), and nonpregnant
normotensive women (n = 22) were included. Plasma coenzyme Q10 levels were
significantly higher in normal pregnant

Preeclampsia Prevention With Antioxidants

women (mean = 1.08, standard error of
mean [SEM] = 0.08 mmol/L; P , 0.005)
in comparison to nonpregnant women
(mean = 0.86, SEM = 0.16 mmol/L) and
women with preeclampsia (mean = 0.7,
SEM = 0.03 mmol/L; P , 0.0001). These
results demonstrated that during preeclampsia, there is a significant decrease
in plasma levels of coenzyme Q10 compared with normal pregnant women and
compared with those who are not pregnant.
No prospective, randomized trials of coenzyme Q supplementation in pregnant
women have been published.
Melatonin
Melatonin is a powerful scavenger of oxygenfree radicals and protects against oxidative
mitochondrial damage in the placenta by
inhibiting NADPH-dependent lipid peroxidation.83 Serum concentration of melatonin
is reduced in women with severe preeclampsia compared with normotensive pregnant
controls.84 When melatonin is administered
to placental homogenates from late human
gestation, there is a reduction in glutathione
peroxidase activity, suggesting that melatonin supplementation may have direct placental antioxidant activity.85 In vitro studies
suggest that melatonin protects against oxidative mitochondrial damage in a ischemia
reperfusion model of preeclampsia.86 No
prospective, randomized trials of melatonin
administration to prevent or treat preeclampsia have been published.

Summary
There is increasing evidence that oxidative
stress is an important contributing factor
to the pathogenesis of preeclampsia, in part,
as a result of an overabundance of reactive
oxygen substances. The consequence of an
overproduction of ROS can be observed as
increased levels of markers of oxidative
stress such as lipid peroxides. Pregnant
women affected by preeclampsia have abnormal ROS production, abnormal antioxidant defenses, and increased placental lipid

425

peroxidation that contribute to endothelial

dysfunction and the multisystemic pathology
of preeclampsia.
At this point in time, trials of antioxidant
therapy used before the onset of preeclampsia in an attempt to decrease its frequency must be considered to be in their infancy. The stunning success noted in the
Chappell et al63 trial must be viewed
cautiously. Historically, supplementation
studies have had initial reports of success
followed by more sober accounts. We await
the results of ongoing trials of vitamin E and
vitamin C supplementation with great anticipation. For now, it would seem imprudent
to implement these supplements as a public
health policy pending further study. If confirmed as a successful intervention, it may
be prudent to separately study vitamin E
and vitamin C. With regard to melatonin
and coenzyme Q, data is absent. Preliminary
reports using selenium and lycopene are intriguing but need confirmation. Although
nicotine may reduce the risk of preeclampsia, its therapeutic use for this condition
seems unlikely. Whether other combinations
of antioxidant therapies might be effective is
unknown.

References
1. Walker JJ. Antioxidants and inflammatory
cell response in preeclampsia. Semin Reprod
Endocrinol. 1998;16:4755.
2. Hubel CA. Oxidative stress in the pathogenesis of preeclampsia. Proc Soc Exp Biol Med.
1999;222:222235.
3. Walsh S. Maternalplacental interactions
of oxidative stress and antioxidants in preeclampsia. Semin Reprod Endocrincol. 1998;
16:93104.
4. Saeed SA, Mitchell MD. Conversion of
arachidonic acid to lipoxygenase products
by human fetal tissues. Biochem Med.
1983;30:322327.
5. Thakur S, Gupta N, Kakkar P. Serum copper
and zinc concentrations and their relation to
superoxide dismutase in severe malnutrition. Eur J Pediatr. 2004; (e-pub prior to
publication).

426

Spinnato and Livingston

6. Barua RS, Ambrose JA, Srivastava S, et al.

Reactive oxygen species are involved in
smoking-induced dysfunction of nitric oxide
biosynthesis and upregulation of endothelial
nitric oxide synthase: an in vitro demonstration in human coronary artery endothelial
cells. Circulation. 2003;107:23422347.
7. Burke BE, Neuenschwander R, Olson RD.
Randomized, double-blind, placebo-controlled trial of coenzyme Q10 in isolated
systolic hypertension. South Med J. 2001;
94:11121117.
8. Teran E, Racines-Orbe M, Vivero S, et al.
Preeclampsia is associated with a decrease
in plasma coenzyme Q10 levels. Free Radic
Biol Med. 2003;35:14531456.
9. Milczarek R, Klimek J, Zelewski L. Melatonin inhibits NADPH-dependent lipid peroxidation in human placental mitochondria.
Horm Metab Res. 2000;32:8485.
10. Nakamura Y, Tamura H, Kashida S, et al.
Changes of serum melatonin level and its relationship to feto-placental unit during pregnancy. J Pineal Res. 2001;30:2933.
11. Okatani Y, Wakatsuki A, Shinohara K, et al.
Melatonin stimulates glutathione peroxidase
activity in human chorion. J Pineal Res.
2001;30:199205.
12. Okatani Y, Wakatsuki A, Shinohara K, et al.
Melatonin protects against oxidative mitochondrial damage induced in rat placenta
by ischemia and reperfusion. J Pineal Res.
2001;31:173178.
13. Arikan S, Konukoglu D, Arikan C, et al.
Lipid peroxidation and antioxidant status
in maternal and cord blood. Gynecol Obstet
Invest. 2001;51:145149.
14. Takehara Y, Yoshioka T, Sasaki J. Changes in
the levels of lipoperoxide and antioxidant
factors in human placenta during gestation.
Acta Med Okayama. 1990;44:103111.
15. Burlingame JM, Esfandiari N, Sharma RK,
et al. Total antioxidant capacity and reactive
oxygen species in amniotic fluid. Obstet
Gynecol. 2003;101:756761.
16. De Vriese SR, Dhont M, Christophe AB.
Oxidative stability of low density lipoproteins and vitamin E levels increase in maternal blood during normal pregnancy. Lipids.
2001;36:361366.
17. Arikan S, Konukoglu D, Arikan C, et al.
Lipid peroxidation and antioxidant status

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.
29.

in maternal and cord blood. Gynecol Obstet

Invest. 2001;51:145149.
Mihailovic M, Cvetkovic M, Ljubic A, et al.
Selenium and malondialdehyde content and
glutathione peroxidase activity in maternal
and umbilical cord blood and amniotic fluid.
Biol Trace Elem Res. 2000;73:4754.
Morris JM, Gopaul NK, Endresen MJ, et al.
Circulating markers of oxidative stress are
raised in normal pregnancy and pre-eclampsia.
Br J Obstet Gynaecol. 1998;105:11951199.
Rayman MP, Abou-Shakra FR, Ward NI,
et al. Comparison of selenium levels in
pre-eclamptic and normal pregnancies. Biol
Trace Elem Res. 1996;55:920.
Zachara BA, Wardak C, Didkowski W, et al.
Changes in blood selenium and glutathione
concentrations and glutathione peroxidase
activity in human pregnancy. Gynecol Obstet
Invest. 1993;35:1217.
Gratacos E, Casals E, Deulofeu R, et al. Serum and placental lipid peroxides in chronic
hypertension during pregnancy with and
without superimposed preeclampsia. Hypertens Pregnancy. 1999;18:139146.
Yanik FF, Amanvermez R, Yanik A, et al.
Pre-eclampsia associated with increased
lipid peroxidation and decreased serum vitamin E levels. Int J Gynaecol Obstet. 1999;
64:2733.
Poranen AK, Ekblad U, Uotila P, et al. Lipid
peroxidation and antioxidants in normal and
pre-eclamptic pregnancies. Placenta. 1996;
17:401405.
Uotila JT, Tuimala RJ, Aarnio TM, et al.
Findings on lipid peroxidation and antioxidant function in hypertensive complications
of pregnancy. Br J Obstet Gynaecol. 1993;
100:270276.
Kharb S, Gulati N, Singh V, et al. Lipid
peroxidation and vitamin E levels in preeclampsia. Gynecol Obstet Invest. 1998;46:
238240.
Akyol D, Mungan T, Gorkemli H, et al.
Maternal levels of vitamin E in normal and
preeclamptic pregnancy. Arch Gynecol
Obstet. 2000;263:151155.
Kharb S. Vitamin E and C in preeclampsia.
Eur J Obstet Gynecol Reprod Biol. 2000;93:
3739.
Kharb S. Lipid peroxidation in pregnancy
with preeclampsia and diabetes. Gynecol
Obstet Invest. 2000;50:113116.

Preeclampsia Prevention With Antioxidants

30. Wang Y, Walsh SW. Antioxidant activities
and mRNA expression of superoxide dismutase, catalase, and glutathione peroxidase in
normal and preeclamptic placentas. J Soc
Gynecol Investig. 1996;3:179184.
31. Mikhail MS, Anyaegbunam A, Garfinkel D,
et al. Preeclampsia and antioxidant nutrients:
decreased plasma levels of reduced ascorbic
acid, alpha-tocopherol, and beta-carotene
in women with preeclampsia. Am J Obstet
Gynecol. 1994;171:150157.
32. Hubel CA, Kagan VE, Kisin ER, et al. Increased ascorbate radical formation and
ascorbate depletion in plasma from women
with preeclampsia: implications for oxidative stress. Free Radic Biol Med. 1997;23:
597609.
33. Rayman MP, Abou-Shakra FR, Ward NI,
et al. Comparison of selenium levels in
pre-eclamptic and normal pregnancies. Biol
Trace Elem Res. 1996;55:920.
34. Mutlu-Turkoglu U, Ademoglu E, Ibrahimoglu
L, et al. Imbalance between lipid peroxidation and antioxidant status in preeclampsia. Gynecol Obstet Invest. 1998;46:3740.
35. Shaarawy M, Aref A, Salem ME, et al.
Radical-scavenging antioxidants in preeclampsia and eclampsia. Int J Gynaecol
Obstet. 1998;60:123128.
36. Harma M, Harma M, Erel O. Increased oxidative stress in patients with hydatidiform mole. Swiss Med Wkly. 2003;133:
563566.
37. Williams MA, Woelk GB, King IB, et al.
Plasma carotenoids, retinol, tocopherols,
and lipoproteins in preeclamptic and normotensive pregnant Zimbabwean women. Am J
Hypertens. 2003;16:665672.
38. Aksoy H, Taysi S, Altinkaynak K, et al. Antioxidant potential and transferrin, ceruloplasmin, and lipid peroxidation levels in
women with preeclampsia. J Investig Med.
2003;51:284287.
39. Radi R, Beckman JS, Bush KM, et al. Peroxynitrite-induced membrane lipid peroxidation: The cytotoxic potential of superoxide
and nitric oxide. Arch Biochem Biophys.
1991;288:481487.
40. Bisseling TM, Maria Roes E, Raijmakers
MT, et al. N-acetylcysteine restores nitric
oxide-mediated effects in the fetoplacental
circulation of preeclamptic patients. Am
J Obstet Gynecol. 2004;191:328333.

427

41. Madazli R, Benian A, Aydin S, et al. The

plasma and placental levels of malondialdehyde, glutathione and superoxide dismutase
in pre-eclampsia. Obstet Gynaecol. 2002;22:
477480.
42. Orhan H, Onderoglu L, Yucel A, et al. Circulating biomarkers of oxidative stress in complicated pregnancies. Arch Gynecol Obstet.
2003;267:189195 [e-pub October 15,
2002].
43. Serdar Z, Gur E, Colakoethullary M, et al.
Lipid and protein oxidation and antioxidant
function in women with mild and severe preeclampsia. Arch Gynecol Obstet. 2003;268:
1925.
44. Ilhan N, Simsek M. The changes of trace elements, malondialdehyde levels and superoxide dismutase activities in pregnancy
with or without preeclampsia. Clin Biochem.
2002;35:393397.
45. Kumru S, Aydin S, Simsek M, et al. Comparison of serum copper, zinc, calcium, and magnesium levels in preeclamptic and healthy
pregnant women. Biol Trace Elem Res.
2003;94:105112.
46. Lazebnik N, Kuhnert BR, Kuhnert PM. Zinc,
cadmium, and hypertension in parturient
women. Am J Obstet Gynecol. 1989;161:
437440.
47. Mahomed K, Williams MA, Woelk GB, et al.
Leukocyte selenium, zinc, and copper concentrations in preeclamptic and normotensive pregnant women. Biol Trace Elem
Res. 2000;75:107118.
48. Vaughn JS, Walsh SW. Oxidative stress
reproduces placental abnormalities of preeclampsia. Hypertens Pregnancy. 2002;21:
205223.
49. Madazli R, Aydin S, Uludag S, et al. Maternal plasma levels of cytokines in normal and
preeclamptic pregnancies and their relationship with diastolic blood pressure and fibronectin levels. Acta Obstet Gynecol Scand.
2003;82:797802.
50. Anim-Nyame N, Gamble J, Sooranna SR,
et al. Microvascular permeability is related
to circulating levels of tumour necrosis
factor-alpha in pre-eclampsia. Cardiovasc
Res. 2003;58:162169.
51. Scalera F. Intracellular glutathione and lipid
peroxide availability and the secretion of
vasoactive substances by human umbilical
vein endothelial cells after incubation with

428

52.

53.

54.

55.

56.

57.

58.

59.
60.

61.

62.

Spinnato and Livingston

TNF-alpha. Eur J Clin Invest. 2003;33:
176182.
Visser W, Beckmann I, Knook MA, et al.
Soluble tumor necrosis factor receptor II
and soluble cell adhesion molecule 1 as
markers of tumor necrosis factor-alpha release in preeclampsia. Acta Obstet Gynecol
Scand. 2002;81:713719.
Munno I, Chiechi LM, Lacedra G, et al.
Spontaneous and induced release of prostaglandins, interleukin (IL)-1beta, IL-6, and
tumor necrosis factor-alpha by placental tissue
from normal and preeclamptic pregnancies.
Am J Reprod Immunol. 1999;42:369374.
Rinehart BK, Terrone DA, LagooDeenadayalan S, et al. Expression of the
placental cytokines tumor necrosis factor
alpha, interleukin 1beta, and interleukin 10
is increased in preeclampsia. Am J Obstet
Gynecol. 1999;181:915920.
Wang Y, Walsh SW. TNF alpha concentrations and mRNA expression are increased
in preeclamptic placentas. J Reprod Immunol. 1996;32:157169.
Vince GS, Starkey PM, Austgulen R, et al.
Interleukin-6, tumour necrosis factor and
soluble tumour necrosis factor receptors in
women with pre-eclampsia. Br J Obstet
Gynaecol. 1995;102:2025.
Greer IA, Lyall F, Perera T, et al. Increased
concentrations of cytokines interleukin-6
and interleukin-1 receptor antagonist in
plasma of women with preeclampsia:
a mechanism for endothelial dysfunction?
Obstet Gynecol. 1994;84:937940.
Agarwal R, Campbell RC, Warnock DG.
Oxidative stress in hypertension and chronic
kidney disease: role of angiotensin II. Semin
Nephrol. 2004;24:101114.
Wilcox CS. Reactive oxygen species: roles
in blood pressure and kidney function. Curr
Hypertens Rep. 2002;4:160166.
Leung PS, Tsai SJ, Wallukat G, et al. The
upregulation of angiotensin II receptor AT(1)
in human preeclamptic placenta. Mol Cell
Endocrinol. 2001;184:95102.
Ozan H, Ilcol Y, Kimya Y, et al. Plasma
anti-oxidant status and lipid profile in nongravida women with a history of preeclampsia.
J Obstet Gynaecol Res. 2002;28:274279.
Pressman EK, Cavanaugh JL, Mingione M,
et al. Effects of maternal antioxidant supplementation on maternal and fetal antioxidant

63.

64.

65.

66.
67.

68.

69.

70.

71.

72.

73.

levels: a randomized, double-blind study. Am

J Obstet Gynecol. 2003;189:17201725.
Chappell LC, Seed PT, Briley AL, et al.
Effect of antioxidants on the occurrence of
pre-eclampsia in women at increased risk:
a randomised trial. Lancet. 1999;354:810
816.
Chappell LC, Seed PT, Kelly FJ, et al. Vitamin C and E supplementation in women at
risk of preeclampsia is associated with
changes in indices of oxidative stress and
placental function. Am J Obstet Gynecol.
2002;187:777784.
Beazley D, Ahokas R, Livingston J, et al. Vitamin C and E supplementation in women at
high risk for preeclampsia: a double-blind,
placebo-controlled trial. Am J Obstet Gynecol. 2005;192:520521.
Stratta P, Canavese C, Porcu M, et al. Vitamin E supplementation in preeclampsia.
Gynecol Obstet Invest. 1994;37:246249.
Gulmezoglu AM, Hofmeyr GJ, Oosthuisen
MM. Antioxidants in the treatment of severe
pre-eclampsia: an explanatory randomised
controlled trial. Br J Obstet Gynaecol.
1997;104:689696.
Yamini S, West KP Jr, Wu L, et al. Circulating levels of retinol, tocopherol and carotenoid in Nepali pregnant and postpartum
women following long-term beta-carotene
and vitamin A supplementation. Eur J Clin
Nutr. 2001;55:252259.
Williams MA, Woelk GB, King IB, et al.
Plasma carotenoids, retinol, tocopherols,
and lipoproteins in preeclamptic and normotensive pregnant Zimbabwean women. Am J
Hypertens. 2003;16:665672.
Palan PR, Mikhail MS, Romney SL. Placental and serum levels of carotenoids in preeclampsia. Obstet Gynecol. 2001;98:459
462.
Zhang C, Williams MA, Sanchez SE, et al.
Plasma concentrations of carotenoids, retinol, and tocopherols in preeclamptic and
normotensive pregnant women. Am J Epidemiol. 2001;153:572580.
Sharma JB, Kumar A, Malhotra M, et al.
Effect of lycopene on pre-eclampsia and
intra-uterine growth retardation in primigravidas. Int J Gynaecol Obstet. 2003;81:
257262.
Mahomed K, Williams MA, Woelk GB, et al.
Leukocyte selenium, zinc, and copper con-

Preeclampsia Prevention With Antioxidants

74.

75.

76.

77.

78.

79.

80.

centrations in preeclamptic and normotensive pregnant women. Biol Trace Elem

Res. 2000;75:107118.
Jonsson B, Hauge B, Larsen MF, et al. Zinc
supplementation during pregnancy: a double
blind randomised controlled trial. Acta
Obstet Gynecol Scand. 1996;75:725729.
Rayman MP, Bode P, Redman CW. Low
selenium status is associated with the occurrence of the pregnancy disease preeclampsia
in women from the United Kingdom. Am J
Obstet Gynecol. 2003;189:13431349.
Han L, Zhou SM. Selenium supplement in
the prevention of pregnancy induced hypertension. Chin Med J (Engl). 1994;107:870
871.
Duley L, Gulmezoglu AM, HendersonSmart DJ. Magnesium sulphate and other
anticonvulsants for women with preeclampsia. Cochrane Database Syst Rev.
2003:CD000025.
Sibai BM, Villar MA, Bray E. Magnesium
supplementation during pregnancy: a
double-blind randomized controlled clinical
trial. Am J Obstet Gynecol. 1989;161:
115119.
Spatling L, Spatling G. Magnesium supplementation in pregnancy. A double-blind
study. Br J Obstet Gynaecol. 1988;95:
120125.
Barua RS, Ambrose JA, Srivastava S, et al.
Reactive oxygen species are involved in

81.

82.

83.

84.

85.

86.

429

smoking-induced dysfunction of nitric oxide

biosynthesis and upregulation of endothelial
nitric oxide synthase: an in vitro demonstration in human coronary artery endothelial
cells. Circulation. 2003;107:23422347.
Conde-Agudelo A, Althabe F, Belizan JM,
et al. Cigarette smoking during pregnancy
and risk of preeclampsia: a systematic review. Am J Obstet Gynecol. 1999;181:
10261035.
Burke BE, Neuenschwander R, Olson RD.
Randomized, double-blind, placebo-controlled
trial of coenzyme Q10 in isolated systolic hypertension. South Med J. 2001;94:11121117.
Milczarek R, Klimek J, Zelewski L. Melatonin inhibits NADPH-dependent lipid peroxidation in human placental mitochondria.
Horm Metab Res. 2000;32:8485.
Nakamura Y, Tamura H, Kashida S, et al.
Changes of serum melatonin level and its relationship to feto-placental unit during pregnancy. J Pineal Res. 2001;30:2933.
Okatani Y, Wakatsuki A, Shinohara K, et al.
Melatonin stimulates glutathione peroxidase
activity in human chorion. J Pineal Res.
2001;30:199205.
Okatani Y, Wakatsuki A, Shinohara K, et al.
Melatonin protects against oxidative mitochondrial damage induced in rat placenta
by ischemia and reperfusion. J Pineal Res.
2001;31:173178.