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CDC & ACOG Convene Meeting on Maternal Mortality & Maternal Safety in Chicago

May 23rd, 2014 by avatar
creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

Earlier this week, I shared information on the Safety Action Series kickoff that all were invited to participate in, by the National Partnership for Maternal Safety – focused on reducing the maternal mortality ratio and morbidity ratio for mothers birthing in the U.S.  This partnership is part of the Council on Patient Safety in Women’s Health Care.  Last month Christine Morton, PhD and Robin Weiss, MPH attended a meeting as board members of Lamaze International.  Christine shares meeting notes and topics that were discussed and what maternity professionals, including childbirth educators,  can do to help. – Sharon Muza, Science & Sensibility Community Manager.

Disclosure:  Christine is a member of the Patient/Family Support Workgroup of the National Partnership for Maternal Safety, and a current board member of Lamaze International. 

Since 1986, the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) convened interested persons in public health, obstetrics and maternity care to discuss and share information about maternal mortality, including methodologies for pregnancy mortality surveillance at state and national levels, and opportunities to reduce preventable maternal deaths.   Recently, under leadership of Dr. Elliott Main, medical director of California Maternal Quality Care Collaborative (CMQCC), and drawing from the recent experience of California in maternal quality improvement and work by other organizations and collaboratives, the focus of the interest group has shifted from surveillance to quality improvement.  The meeting has evolved from the early years when 12-20 persons sat around tables to discuss the issue, to this year’s meeting which had over 180 persons registered.  Clearly the time has come for a coalition around improving maternity outcomes in the U.S.

The National Partnership for Maternal Safety was proposed in 2013 in New Orleans, and the goal of the April 27, 2014 meeting in Chicago was to formally launch the initiative and report on the progress of each work group. The goal of the National Partnership for Maternal Safety is for every birthing facility in the United States to have the three designated core Patient Safety Bundles (Hemorrhage; Venous Thromboembolus Prevention; and Preeclampsia) implemented within their facility within three years. The bundles will be rolled out consecutively, beginning with obstetric hemorrhage and advancing to the other areas. To support this national effort, publications are underway in peer-reviewed journals. The first article, as an editorial call to action, appears in the October 2013 issue of Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists.

Highlights from this year’s meeting included two presentations from CDC researchers William Callaghan, MD, MPH and Andreea Creanga, MD, PhD, on work being done to better identify cases of severe maternal morbidity (SMM) and drivers of racial/ethnic disparities.  One of the goals of creating a working definition of SMM is to help facilities track and review cases in order to identify systems issues and address them through quality improvement efforts.

Next, representatives from selected work groups (Hemorrhage; Venous Thromboembolus Prevention; Patient/Family Support) shared their updates.    It has become very clear from ongoing work within large hospital systems, state-based quality collaboratives and other countries such as the UK, that standardized protocols for recognition and response to preventable causes of mortality and morbidity are effective.  Unfortunately, there is no national requirement for all birthing facilities (hospitals and birth centers) to have updated policies and protocols on these preventable causes of maternal complications.

The good news is that there is a groundswell of support for a coordinated effort to realize the goals of the Initiative.  From state quality collaboratives in California, New York, Ohio and Florida to Hospital Engagement Networks, there are many hospitals already implementing some maternal quality improvement toolkits.  The Joint Commission plays a key role in helping hospitals work on patient safety issues and identified maternal mortality as a sentinel event in 2010 and is now proposing that any intrapartum (related to the birth process) maternal death or severe maternal morbidity should be reviewed.  As the nation’s largest accreditation body for hospitals, the Joint Commission is in a position to provide oversight as well as guidance to hospitals as they develop system-level reviews of these outcomes.

More states are being supported by federal and nonprofit agencies to develop and conduct maternal mortality reviews, and the role of Title V, the only federal program that focuses solely on improving the health of mothers and children, is critical.  Title V is administered by each state to support programs enhancing the well being of mothers and their children.

The last topics of the day were how to address the most common cause of maternal mortality – cardiovascular disease in pregnancy – but not as preventable as the three causes featured in the Initiative.

Suggested topics for future meetings including looking at maternal mortalities due to suicide, helping states with small populations aggregate their data, and addressing the issue of prescription (and other) drug abuse among pregnant women.  Eleni Tsigas from the Preeclampsia Foundation stressed the importance of including women’s perspectives and the emotional, social and ongoing physical sequelae of living after a severely complicated childbirth experience.

How is this information relevant for childbirth educators, doulas and other maternity professionals?  First, the rising rates of maternal mortality and morbidity are in the news.  While deaths are rare, severe complications are more common.  CBEs and doulas can reassure pregnant women in their classes that the likelihood of a severe morbidity is low, and can provide resources to share with women and help them learn which hospitals in their communities have begun the work of maternal quality improvement.  CBEs can share this information with key nursing and medical leaders at hospitals where they teach, and offer to help with the Quality Improvment (QI) efforts.

Childbirth educators and others can help ensure the focus not become too one sided – while it is important for every hospital to be ready for typical obstetric emergencies, it is also important for every hospital to be prepared to support women through normal physiologic birth by trained staff and supportive physicians. AWHONN launched its campaign, “Go the full 40” in January 2012 to help everyone remember that while we don’t want to ELECTIVELY deliver babies prior to 39 completed weeks gestation, we also want to support labor starting on its own.  And most recently, ACNM unveiled its BirthTOOLs site, which includes resources, tools and improvement stories on supporting physiologic, vaginal births.  CBEs and doulas can be strong advocates in supporting facility and maternity clinician preparedness for the ‘worst case’ and ‘best case’ scenarios in childbirth.

For more info about National Partnership for Maternal Safety or the CDC/ACOG Maternal Mortality Interest Group, please contact:  Jeanne Mahoney, jmahoney@acog.org

Past and future webinars about the initiative are available to the public here: http://www.safehealthcareforeverywoman.org/safety-action-series.html

Archived presentations from past CDC/ACOG maternal mortality interest group meetings

2014:  http://bit.ly/1sXkaGw

2012: http://bit.ly/1pfay9S

 

Childbirth Education, Guest Posts, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Pregnancy Complications, Uncategorized , , , , ,

2014 Preeclampsia Awareness Survey Highlights Need for Education- Educators Play a Key Role

May 13th, 2014 by avatar

May is Preeclampsia Awareness Month and childbirth educators play a key role in informing families about the symptoms of this disease of pregnancy (or postpartum.) Eleni Tsigas, the Executive Director of The Preeclampsia Foundation shares the results of a recent survey quizzing women on their awareness of this potentially deadly disease.  CBEs and others have a responsibility to share information in a calm, factual way duing class so that women are informed but not scared, should this disease present itself during their childbearing year. – Sharon Muza, Community Manager, Science & Sensibility

Preeclampsia_Pledge

As Executive Director of the Preeclampsia Foundation®, the nation’s only patient advocacy organization for preeclampsia and related hypertensive disorders of pregnancy, I’m excited to announce the results of a recent nationwide Preeclampsia Awareness Survey of more than 1,500 expectant and new mothers. These survey findings are driving the Foundation’s strategies associated with National Preeclampsia Awareness Month this month.

The survey, which was conducted by BabyCenter®, shows a high overall awareness of preeclampsia and that it is serious and associated with high blood pressure. There was also near universal knowledge to call a healthcare provider if experiencing symptoms of preeclampsia.

We’re very encouraged by the awareness that’s been raised in recent years, in sharp contrast to our last study six years ago that found very low overall awareness of preeclampsia. But there’s more to do, because this year’s survey also shows low awareness when respondents were asked about specific symptoms associated with preeclampsia.

The more a pregnant woman knows about preeclampsia, the more likely she is to recognize and report symptoms to her doctor or midwife. That improves time to diagnosis and medical evaluation, which saves lives – for both mothers and babies. And that’s why we’re so focused on improving awareness of preeclampsia.

Preeclampsia and other hypertensive disorders of pregnancy remain a leading cause of maternal and infant illness and death. Globally, by conservative estimates, these disorders are responsible for 76,000 maternal and 500,000 infant deaths every year. In the United States, preeclampsia affects one in every 12 pregnancies, and its incidence has increased by 25 percent during the past two decades.

Key Survey Findings

The recent survey of 1,591 women shows high overall awareness of preeclampsia, its severity and link to high blood pressure, and to immediately report symptoms to their healthcare providers:

  • 83% of respondents had heard of preeclampsia and of those women, 99% knew that it is extremely serious, even life-threatening for mother and baby, very serious, or somewhat serious
  •  88% knew that high blood pressure is a sign of preeclampsia
  • 96% would call their doctor or midwife if they experienced symptoms

Results also show areas that the healthcare community needs to address:

  • Raise awareness of the specific symptoms associated with preeclampsia
    • 78% incorrectly linked preeclampsia to swelling of the feet
    • Only 70% correctly linked preeclampsia to headache and vision changes
    • 3 out of 5 women were not sure about several other symptoms
  • Educate women on when preeclampsia can occur and its long-term impact
    • 44% didn’t know that preeclampsia can occur even after the baby is delivered, up to six weeks postpartum
    • 46% didn’t know that women with preeclampsia are at risk for future health problems
  • Improve access to information, regardless of education or income level
    • Compared to the 83% of respondents in general who had heard of preeclampsia,
      • 51% with some high school education had heard of preeclampsia
      • 37% who earned under $25k a year had heard of preeclampsia

Download the Preeclampsia Infographic

Survey Findings Drive Education Campaign

Released in conjunction with Preeclampsia Awareness Month, the survey findings provided the basis of the Foundation’s education campaign launched this month. Its theme – Take the Preeclampsia Pledge: Know the Symptoms. Spread the Word – highlights the importance of early recognition and reporting of symptoms. The campaign features Promise Walks for Preeclampsia™ across the country, social media events, and an easy-to-understand and share video called Preeclampsia: 7 Symptoms Every Pregnant Woman Should Know. (Spanish version)


 Know the Symptoms. Spread the Word.

Early recognition and reporting of symptoms is the key to timely detection and management of preeclampsia. Women who are pregnant or recently delivered should contact their doctor or midwife right away if they experience any of the symptoms listed below, and healthcare providers should be appropriately responsive. While these symptoms don’t necessarily indicate preeclampsia, they are cause for concern and require immediate medical evaluation.

  • Swelling of the hands and face, especially around the eyes (swelling of the feet is more common in late pregnancy and probably not a sign of preeclampsia)
  • Weight gain of more than five pounds in a week
  • Headache that won’t go away, even after taking medication for pain relief
  • Changes in vision like seeing spots or flashing lights; partial or total loss of eyesight
  • Nausea or throwing up, especially suddenly, after mid pregnancy (not the morning sickness that many women experience in early pregnancy)
  • Upper right belly pain, sometimes mistaken for indigestion or the flu
  • Difficulty breathing, gasping, or panting
  • “I just don’t feel right”

It’s also important to know that some women with preeclampsia have NO symptoms. Healthcare providers can only diagnose preeclampsia by monitoring blood pressure and protein in the urine, which is routinely done at prenatal appointments, so keeping all appointments is vital throughout pregnancy and immediately after delivery.

About the Preeclampsia Awareness Survey

The survey was conducted among visitors to the BabyCenter® website from January 17 to January 20, 2014. A total of 1,591 respondents completed the survey; qualified respondents are defined as female U.S. residents, 18 years or older, who are pregnant or have at least one child three years of age or younger.

About the Preeclampsia Foundation

A U.S.-based 501(c)(3) non-profit organization established in 2000, the Preeclampsia Foundation is dedicated to providing patient support and education, raising public awareness, catalyzing research and improving health care practices, envisioning a world where preeclampsia and related hypertensive disorders of pregnancy no longer threaten the lives of mothers and babies. More information can be found at www.preeclampsia.org or by calling toll-free 800.665.9341.

How do you talk about preeclampsia in your childbirth classes?  When do you discuss it?  Are you also sharing that postpartum women can also develop this disease?  Would you consider showing the brief video above highlighting the seven key symptoms.  Let us know how you are discussing this topic in the comments section below. – SM

About Eleni Z. Tsigas 

eleni tsigas head shotEleni Z. Tsigas is the Executive Director of the Preeclampsia Foundation. Prior to this position, she served in a variety of volunteer capacities for the organization, including six years on the Board of Directors, two as its chairman. Working with dedicated volunteers, board members and professional staff, Eleni has helped lead the Foundation to its current position as a sustainable, mission-driven, results-oriented organization.

Eleni is married, and had has two of her three pregnancies seriously impacted by preeclampsia. As a preeclampsia survivor, she is a relentless champion for the improvement of patient and provider education and practices, for the catalytic role that patients can have to advance the science and status of maternal-infant health, and for the progress that can be realized by building global partnerships to improve patient outcomes.

Eleni has served as a technical advisor to the World Health Organization (WHO), is a member of the PRE-EMPT Technical Advisory Group and Knowledge Translation Committee (funded by the Gates Foundation), and participates in the Hypertension in Pregnancy Task Force created by the American College of Obstetricians and Gynecologists (ACOG), as well as a similar task force for the California Maternal Quality Care Collaborative (CMQCC). Eleni is frequently engaged as an expert representing the consumer perspective on preeclampsia at national and international meetings, and as a spokesperson in various public speaking venues. She was honored to deliver The Jim & Midge Breeden Lecture as part of ACOG’s 2012 Annual Clinical Meeting President’s Program.

Childbirth Education, Guest Posts, Maternal Mortality, Maternity Care, News about Pregnancy, Pre-eclampsia, Pregnancy Complications , , , ,

Now I Lay Me Down To Sleep Photography; Honoring the Babies Whose Stay Was Too Short

October 15th, 2013 by avatar

© Vicki Zoller

October 15 is National Pregnancy and Infant Loss Remembrance Day. If you are a professional who works with expecting families, you no doubt will at some point have a family who suffers a loss during their pregnancy, a stillbirth or the death of their newborn in the days and weeks after birth.  I wanted to share with Science & Sensibility readers a wonderful organization dedicated to honoring the loss or short life of a baby. Now I Lay Me Down To Sleep is a non-profit organization of photographers dedicated to capturing the images of a beautiful baby taken too  soon from the families who loved them.  I had the opportunity to interview a longtime photographer, Vicki Zoller with the program for today’s post in honor of this special day.  On Thursday, we will meet a family who lost a child and had their story documented by Vicki through the NILMDTS program.

_______________________

Sharon Muza:  How did you become involved in NILMDTS?

Vicki Zoller: 
I heard about the organization through another photographer. I haven’t experienced a loss but felt the draw of this work as a photographer. Being able to capture that moment in time, that private, painful moment in time and hold it captured forever for the family was the draw for me.  I have been involved in NILMDTS since 2008.

 SM:  What kind of photographer makes a great NILMDTS photographer?

VZ:  I think that a photographer that appreciates what a gift they possess and can share in such a meaningful way is what makes a great NILMDTS photographer. Having a skill, a unique skill that allows you to come into that room and forever record this moment is something that you either ‘get’ as a photographer or you don’t. The photographers that I have worked with, trained and become friends with in this organization have a passion for this. There is chord that resonates in us that tells us, ‘how can I NOT do this’. How often in life do we really get to make this kind of difference? How often do we really get the chance to make something a bit better out of something so horrible. It’s a chance to not just stand on the sidelines and say, ‘Oh how sad’ or to feel powerless. It’s that opportunity to know that you truly are making a difference.

SM: If there is a photographer interested in joining NILMDTS, what are the first steps that they should take?

VZ: They need to go to the main website at Now I Lay Me Down To Sleep and apply to become an affiliate photographer. During the application process an applicant will be asked to submit samples of their professional level work, demonstrating use of natural and auxiliary lighting. If they want to find out more about the organization before they apply they can, at the same website, click on the ‘find a photographer’ link and find someone in their area that might be willing to answer some questions for them.

SM:  Is there special training that a NILMDTS photographer receives before beginning this work.

VZ: NILMDTS photographers are given a training manual after they are accepted. Many larger areas, like here in the Greater Seattle Area, offer training on a fairly regular basis. We also have our new photographers go on a session with a more experienced photographer just to get a feel of where to go, what to say, how to handle the session, etc. But there are many of us, especially those that came into the organization early on, that never had that opportunity to ‘train’ or ‘shadow’ with a photographer. We just went when the hospital called and did what we knew how to do as photographers . . . capture beautifully lit and composed images that the family would have as keepsakes. Not really all that different than what we would try to do for a regular ‘paying’ client. We want to give our NILMDTS families the same quality as we would want to give to anyone.

SM:  How do you record the beauty of these little ones when their bodies may be scarred, or changed due to illness, medical equipment, etc. Do you “celebrate” these things or do you use your skills to portray the babies in a different light?

© Vicki Zoller

VZ: We never change anything that the baby was born with. These are special aspects of a beautiful new baby. So things like cleft lips or special features are kept as is and are indeed celebrated as part of this child. We do retouch images. We retouch blood, mucus, tears in skin, perhaps close the eyes if needed and generally try to create a gently retouched but authentic image of the baby. We may remove tape that held in medical equipment and try to give the family an image that doesn’t have “hospital’ written all over it. We try to pose the babies in gentle and sensitive ways with the parents and without. We tend to keep it simple and clean and truthful in the emotion of the day. We photograph many details, the little feet and hands, the profile, the ears, the swirl of hair on the top of the head. We want the family to have all these details to remember with. Especially when the detail may be a family trait of some kind such as a crocked finger or toes that splay wide . . . just little special things.
All our images are converted to Black and White or Sepia to provide a gentler viewing for the family.

SM: How do you not let the sadness and grief come into your life, when your work taking and processing the pictures is done?

VZ: The beauty of having a camera in front of your face is that is becomes a filter to the events and emotions in the room. That isn’t saying that we don’t feel things while we are there but when you have a job to do, a task to complete, that is where your mind tends to go and that camera is a filter. You are looking at the world through a bit of space that holds only a piece of the room at a time or a piece of the baby at a time. That makes a HUGE difference. We tend to go in to ‘photographer mode’ and that is where we stay during the session. Sometimes processing the images is the harder part. Now you have these images, large and real, on your computer screen and you are looking at them closely to see what you can do to improve them. It tends to come home emotionally for many photographers once they have the images on the computer. 

SM: Can you share a very challenging moment or situation in your work with NILMDTS?

VZ: That’s a tough one but generally the hardest tend to be the full term babies with NO VISIBLE signs of WHY they passed. I’ve been at sessions where mom was fine, baby was fine, all through labor but then at delivery things went south. On one occasion, it was a full term baby boy that came out screaming and crying but once the cord was cut he passed . . . instantly everything changed. I think that for me those kinds of sessions are the toughest. To be so CLOSE to the finish line, to almost have that baby all warm and pink and crying and then to have nothing . . . 
When you see a baby with obvious things wrong or they came too early or the parents have had to make that terribly hard choice to end the pregnancy due to health issues you can almost accept it better. Sort of like, ‘Ah ha! That’s the reason, there it is’. It gives you something to wrap your brain around. 
Not as easy to do with full term losses .  

SM: What would you like birth professionals to share with ALL parents about the NILMDTS program.

VZ: We are free. That is really important for them to know. I think they see our brochures and wonder how much it will cost them.
We are professional. We come in, we act professional, we capture professional quality images, we respect the environment we are in and we respect our families’ privacy and their pain. 

SM: Are there brochures available for placement in childbirth classes, health care provider offices, etc?

VZ: Yes, brochures are available either from our headquarters in Denver or you can get some from your local Area Coordinators or photographers.

 SM:  How does NILMDTS get the word out to birth professionals about the services that are offered to parents?

 

© Vicki Zoller

VZ: Our photographers and our Area Coordinators generally are the ones that get the information out there. I contacted the nursing managers at all our local hospitals when I first started. I built relationships and over time, as they saw the work we did, saw how we interacted with their patients, saw the benefits of what we can give, they began calling us more and more often. It’s a good feeling to be a part of the bereavement groups at the hospitals, to be something that the nurses can offer these families in such a horrible time. There is so little consolation that can be given but the prospect of having some beautiful and thoughtful images of your baby can be of great help in that horrible time.

SM: Who can use the services of NILMDTS?

VZ: All hospitals and birth centers. Also social workers for fetal medicine. Funeral homes as well. Any one that wants to contact us for any reason that might involve this special kind of photography is welcome to call. 

SM: Do you take pictures just of babies or do you also record older children?

VZ: Generally just babies. But if asked we would, if a photographer is ok with it, offer our service for older children. Soulumination (in the Puget Sound, WA area) is another photographer organization that often provides ‘life portraits’ for families of older kids facing a grim prognosis or for children under 18 whose parents are facing a terminal illness. 

SM: How are you received by the staff of the facilities you take pictures in?

VZ: At first it was a bit sketchy. Some nurses thought it was weird, grim, maybe not appropriate. But generally once they see the quality of our work and how it helps the family they become very accepting. We are now very well received at all the major hospitals in the greater Seattle Area.   

SM: What do you tell parents when they are unsure if they want pictures?

VZ: Generally it isn’t us that contacts the parents about our services. The nurses or the social worker will offer the service to the parents. We only come if the parents want us to come. We don’t come just because a nurse wants the photos taken. It is only at the request of the parents. 
Once there, parents might be feeling ambivalent about having images done. It is so surreal isn’t it? Here you are with a baby that has passed and in comes a professional photographer to take portraits!! 
If they tell me they don’t want any photos with the baby I gently remind them that today is raw and painful but there will come a time when the pain has lessened and I don’t want them to have any regrets about not having at least one image of their baby’s hand in their hand. Once I mention that it is just their hands they are more receptive and then sometimes it progresses from hands to a complete family portrait. But we don’t push too hard. As long as they have some photos of their baby, then they will find some peace in that.

 SM: Do you stay connected with families after you have completed your phot session?

VZ: On occasion. It isn’t something that I pursue. If it happens organically, then it’s wonderful. I have been able to see some of my families go on to have other babies, healthy, wonderful babies and I love that!!

SM: Is there anything you would like readers of Science & Sensibility to know?

VZ: If you or anyone you know has ever experienced a loss, please know that there are others out there just like you that are recovering and it’s important to not feel alone, find groups out there that have families going through loss as well. Stay connected to those that will understand what you are feeling.
 NILMDTS is an amazing organization that is always looking for new photographers and community volunteers. If anyone wants more information please contact me or NILMDTS headquarters.

Healthcare professionals are awesome and anyone working in the labor and delivery field knows how fragile the delivery process can be. There is always that moment when you can almost see mom and baby on that razor thin edge between life and death. Having a healthy baby is hard work and those that care for moms during pregnancy and birth are special people! We want to be a part of your bereavement kit but we hate it when you have to make that call. But when you do, please know we will be creating some meaningful images for your families and that we will do that with love and compassion.

Have you had experience with NILMDTS on a personal or professional level?  Do you share this resource with your students, clients and patients so that they are aware of this wonderful organization?   Are you also a photographer who captures these sweet babies? How do you help families experiencing pregnancy and infant loss?  What are your favorite resources.  Please share your thoughts with our readers in the comment section.  And if you know a NILMDTS photographer, thank them on this day, for the heart work that they do.

 

Babies, Childbirth Education, Newborns, Pre-term Birth, Pregnancy Complications, Trauma work, Uncategorized , , , , , , , ,

Seeking Real Life Stories from Women Who Have Experienced Pregnancy & Birth Complications

May 28th, 2013 by avatar

© http://flic.kr/p/3mcESR

Both expectant families and childbirth professionals alike would like nothing more than pregnancy and birth to remain uncomplicated and proceed normally. We can celebrate when that happens but we have a responsibility to also teach and share about some of the variations from normal that may come up during pregnancy and birth.

Cara Terreri, the Community Manager for Lamaze International’s parent blog, Giving Birth with Confidence, is looking for women’s input on pregnancy complications for a new series that she will be running in the coming months.

If you have had personal experience with one or more of the following (or know students, clients or patients who do) and would like to participate, please contact the blog manager, Cara Terreri at cterreri@lamaze.org

  • Preeclampsia/eclampsia & HELLP
  • Placental abruption/hemorrhage 
  • Placenta previa/accreta
  • Intrauterine growth restriction (IUGR)
  • Incompetent/weakened cervix
  • Hyperemis Gravidarum
  • Preterm labor
I look forward to reading this upcoming series and sharing the stories with my students and clients.  Thank you for any help you might provide.

Giving Birth with Confidence, Lamaze International, News about Pregnancy, Patient Advocacy, Pre-eclampsia, Pregnancy Complications , , , , ,

Preeclampsia: Research Roundup and Information for Professionals and Consumers

May 23rd, 2013 by avatar

by Caryn Rogers

May is National Preeclampsia Awareness Month and the Preeclampsia Foundation has been holding Promise Walks all around the country to raise awareness of this disease and generate funds for research.  Caryn Rogers, Senior Science Writer for the Preeclampsia Foundation has provided a research update and information about the etiology of the disease.  The Preeclampsia Foundation is rich in resources for birth professionals and women, including an active forum for mothers dealing with this complication of pregnancy (or postpartum). Lamaze International is a proud web content sponsor of the Promise Walk.- Sharon Muza, Science & Sensibility Community Manager

The Preeclampsia Foundation would like to thank Lamaze International and Science & Sensibility for this opportunity to present a research overview during National Preeclampsia Awareness MonthPreeclampsia, which means “before the lightning” in Greek, is a leading cause of maternal and neonatal mortality and morbidity worldwide. The syndrome probably got the name from its tendency to strike suddenly, out of nowhere. One in ten women develops gestational hypertension during her first pregnancy, while about one in twenty develops preeclampsia. The latter condition has historically been poorly understood, but new research has led to a deeper understanding of preeclampsia. Some of the new research has been supported with Preeclampsia Foundation Vision Grants over the last ten years.

What is Preeclampsia

Preeclampsia is a multifactorial, heterogeneous pregnancy syndrome diagnosed after the appearance of both hypertension and proteinuria (protein in the urine) any time after mid-pregnancy. Its cause is still unknown. Though called the “disease of theories,” research is closing in on triggers of the disorder, which will help to design specific treatments. Certain women have predisposing factors such as the presence of other diseases that make preeclampsia more likely. There may be specific genetic factors. While the disease’s primary symptoms are hypertension and proteinuria, many other organ systems may be involved, especially the liver, brain, and platelets. Symptom presentation is unpredictable, with some cases appearing to fulminate within hours and other cases remaining mild for weeks. Finally, some preeclamptics progress to a convulsive phase – the disease known as eclampsia.

How is Preeclampsia diagnosed

Two blood pressure readings, taken at least six hours apart, of 140/90 mm Hg or greater, and the excretion of 300 mg or more of proteinuria in a 24-hour urine sample are the primary diagnostic requirements. Currently, many clinics are measuring the ratio of protein to creatinine in a single urine sample, using a value that predicts the total will be 300 mg or more in a day. In some instances, the disease is diagnosed without proteinuria when preeclampsia-specific signs and symptoms of other organ system involvement occur.

Signs and Symptoms of Preeclampsia

No Symptoms
Hypertension
Proteinuria
Edema (Swelling)
Sudden Weight Gain
Nausea or Vomiting
Abdominal (stomach area) and/or Shoulder Pain
Lower back pain
Headache
Changes in Vision
Hyperreflexia

Racing pulse, mental confusion, heightened sense of anxiety, shortness of breath or chest pain, sense of impending doom

 adapted from Preeclampsia Foundation

What are the risk factors for Preeclampsia

Risk factors for preeclampsia include: first pregnancy, previous history of preeclampsia, multiple gestation, preexisting hypertension, diabetes, kidney disease, or organ transplant, obesity, age over 40 or under 18 years, maternal family history of preeclampsia.  Polycystic Ovary Syndrome (PCOS); Antiphospholipid Antibody Syndrome (APS), lupus or other autoimmune disorders; and use of any Assisted Reproductive Therapy (ART).

Much of what is included in standard prenatal care was developed primarily to detect preeclampsia. This is why blood pressure and urine protein are checked at every visit and why visits come more closely together as the end of pregnancy approaches. The careful attention of care providers to these potentially invisible symptoms, and their communication of worrisome signs and symptoms to patients, has saved countless lives. Women who have been educated to know the signs and symptoms are able to practice the Preeclampsia Foundation’s motto, “Know The Symptoms. Trust Yourself.” 75% of those who knew the risks were able to take life-saving action when symptoms developed, versus 6% of those who did not know the signs and symptoms.

Pathophysiology

Placentas from preeclamptic pregnancies are characteristically shallowly implanted. During differentiation, the blastocyst will divide into an internal set of cells (the embryoblast), and an outer layer that will become the placenta (the trophoblast). When the blastocyst embeds into the decidua, the trophoblast remodels the uterine spiral arteries that supply blood to the endometrium. This remodeling activity persists into the second trimester of pregnancy. In normal pregnancies, this remodeling produces arteries that deliver appropriate blood flow to the placenta; in preeclamptic pregnancies the remodeling process is flawed.

Trophoblastic cells enter the spiral arteries and induce apoptosis, which is the initiation of cell death in the endothelial cells lining the walls of the arteries. Once the cells have died, the trophoblastic cells convert into an endothelial form and adhere to the walls of the vessels. These cells ignore maternal signaling to contract the vessel, which is why, in a normal pregnancy, these arteries are relaxed at all times, bathing the placenta in oxygen and nutrients. In preeclamptic placentas, the remodeling does not extend as far as normal, impeding appropriate nutrition and oxygenation.

One theory is that shallowly implanted placentas may not be able to transfer the total of oxygen and nutrients the fetus requires to develop ideally. The flow of blood through the spiral arteries is affected by their smaller size. Several genetic mechanisms that can cause shallow implantation have been identified with more likely to be discovered as investigation into trophoblastic cells continues. (Colucci, 2011; van Dijk, 2010)

Once fetal growth accelerates in the later trimesters of pregnancy,  the fetal demand for more oxygen than the placenta is capable of ferrying eventually leads to placental hypoxia. Hypoxia triggers the placental release of a protein called soluble fms-like tyrosine kinase (sFlt-1.) SFlt-1 binds to vascular endothelial growth factor (VEGF) and a placentally derived factor that mimics it, placental growth factor (PlGF), rendering both unavailable to the receptors they usually target. SFlt-1 levels are measurably elevated in pregnant women who go on to develop preeclampsia. (Levine 2006; Maynard 2003)

In the vasculature, VEGF shepherds repair molecules along the walls of the blood vessels, plugging the holes that appear with normal wear and tear. When free VEGF is bound by sFlt-1, it cannot do this repair work.  Because the rate at which the repair slows depends on the amount of sFlt-1 that the placenta is producing and also on the amount of VEGF a woman’s body naturally produces, the symptoms that follow this damage vary widely. The effect of reduced levels of free VEGF and PlGF is that the vasculature is unable to achieve normal vasodilation and resists signals to contract or dilate appropriately.

Another circulating antiangiogenic factor is soluble endoglin, or sEng, which binds to and disrupts the normal functioning of TGF-beta, a protein that controls proliferation, cell differentiation and other functions in most cells.. Thus sEng, too, has also been identified as a culprit in preeclampsia. Although its mechanisms are not as clearly understood as those of sFlt-1, it’s been empirically confirmed that women who develop preeclampsia at term have increasing serum levels of sEng beginning as early as gestational week 25. There are also suggestions that women are more likely to develop the dangerous variant of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) if their levels of sEng are highly elevated relative to their sFlt-1 levels, and that they are more likely to develop severe preeclampsia when sFlt-1 levels are high relative to sEng. (Baumwell, 2007)

Depending on individual underlying susceptibilities and the ratios of antiangiogenic factors, a pregnant woman can develop the following symptoms at any rate and in any order, combination, and degree of severity, starting after midgestation and continuing for up to six weeks postpartum: hypertension, proteinuria, sudden weight gain and swelling, nausea, vomiting, upper right quadrant abdominal pain, shoulder pain that feels like a pinched nerve along the bra strap (referred from the liver), lower back pain, headache, visual disturbances, hyperreflexia, racing pulse, mental confusion, heightened sense of anxiety, shortness of breath or chest pain, sense of impending doom, abruption, IUGR, fetal distress, thrombocytopenia, either very low or conversely a large increase in urine output, seizure, pulmonary edema, liver rupture, abruption, and death.

The multi-organ nature of the syndrome means that a woman can feel fine, have hypertension and proteinuria that becomes apparent after testing, and then be admitted to the hospital with failing kidneys, liver and other organs. Or she can have a headache and begin seizing with comparatively low blood pressure and only mild proteinuria. The various presentations of preeclampsia make it challenging to consistently diagnose and manage appropriately.

The blood pressure increase indicates vascular damage that compromises the mother’s health and damages the spiral arteries which connect the placenta to the woman’s body. Women with preeclampsia also have a dysregulated metabolic response to pregnancy. (von Versen-Hoeynck, 2007)  Gestational diabetes is a risk factor for preeclampsia, and women with PE are more likely to have elevated cholesterol readings and alterations in many serum biomarkers. Placental debris from an enhanced inflammatory immune response is thought to sweep into the maternal bloodstream and trigger these metabolic responses. (Redman, 2012) Researchers are newly aware of this signaling mechanism and further research is in progress.

Treatment and Prevention

As of May 2013, the only definitive treatment for preeclampsia is delivery of the placenta. These pregnancies, whether or not they are initially low-risk, are medically complicated and are generally managed by OB-GYNS, sometimes in consult with maternal-fetal medicine specialists. Timing of delivery is one of the only tools available to manage and balance the competing interests of worsening maternal disease, a failing placenta, and a potentially premature baby. Patients are managed with close monitoring, anti-hypertensives as necessary, and sometimes steroid shots to accelerate fetal lung maturation, depending on gestational age. In severe cases, this monitoring occurs while the woman is hospitalized in a tertiary care center. Magnesium sulfate may be given to reduce the risk of seizure. In severe disease, delivery sometimes must take place regardless of gestational age to best protect both lives (even a very preterm baby can be better out than in when the placenta is failing and the mother’s liver is threatened) and is seriously considered in cases of severe preeclampsia for any worsening of symptoms after 34 weeks.

The HYPITAT trial has led to a new ACOG recommendation, to be released later this year, that any gestational hypertension (readings above 140/90 mm Hg) be induced at 37 weeks gestation. (Koopmans, 2009) The data show equally good outcomes for the neonate in either arm of the trial, and substantially reduced maternal risk of severe hypertension. 

Calcium supplementation to prevent preeclampsia has been evaluated in large randomized controlled trials (RCTs) and found to have no benefit except perhaps in populations with very low dietary intake. Antioxidant supplementation – specifically vitamins C and E, also evaluated in large RCTs, has shown no benefit. Supplemental baby aspirin showed no benefit or harm in two large RCTs, but meta-analysis showed a potential benefit to an as-yet-unidentified high-risk population when begun in the first trimester. The older therapies of dietary salt restriction, diuretics, and bed rest have not been shown to have benefits and may cause harm so are not recommended.

Risk of Cardiovascular Disease

In addition to being at higher risk of preeclampsia in any subsequent pregnancies, women with a history of preeclampsia are at roughly double the risk of developing heart disease or stroke over the five to fifteen years following delivery. Many women develop chronic hypertension postpartum. There are risk factors common to both preeclampsia and heart disease, and there is also evidence that preeclampsia can cause damage to the heart. 

Lifestyle changes are known to lower risk of heart disease, so women with a history are recommended to stop smoking (or never start), eat a heart-healthy diet, get regular exercise, and maintain a normal BMI. Because preeclampsia unmasks a higher risk, proactively consulting her physician and preferentially a general internist or cardiologist to discuss heart health postpartum can also help to monitor for the chance that heart disease will develop.

Lowering the Risk

Although there are no known therapies at this point, there are ways to reduce the risk of preeclampsia to mother and baby. Pre-conception or inter-conception care is gaining increasing value as women can be assessed and counseled to begin a pregnancy in the best possible health. Regular prenatal care, with close monitoring of symptoms, will detect the onset of hypertension in many women. For those whose disease progresses rapidly between appointments, knowledge of the signs and symptoms of the condition is the best protection. To this end, the Preeclampsia Foundation provides evidence-based patient education materials to care providers and encourages women to contact their care providers to report any headache, nausea, elevation in hypertension, changes in swelling or urine output, visual disturbances (like sparkles and flashing lights,) and pain in the upper right of the abdomen or along the bra strap. Being informed and closely monitored saves lives.

References and Recommended Reading

Baumwell, S., & Karumanchi, S. A. (2007). Pre-eclampsia: clinical manifestations and molecular mechanismsNephron Clinical Practice106(2), c72-c81.

Colucci, F., Boulenouar, S., Kieckbusch, J., & Moffett, A. (2011). How does variability of immune system genes affect placentation?. Placenta32(8), 539-545.

Garovic, V. D., Bailey, K. R., Boerwinkle, E., Hunt, S. C., Weder, A. B., Curb, D., … & Turner, S. T. (2010). Hypertension in pregnancy as a risk factor for cardiovascular disease later in lifeJournal of hypertension28(4), 826.

Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, van den Berg PP, de Boer K, Burggraaff JM, Bloemenkamp KW, Drogtrop AP, Franx A, de Groot CJ, Huisjes AJ, Kwee A, van Loon AJ, Lub A, Papatsonis DN, van der Post JA, Roumen FJ, Scheepers HC, Willekes C, Mol BW, van Pampus MG; HYPITAT study group. (2009) Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trialLancet. 374(9694):979-88

Levine, R. J., Lam, C., Qian, C., Yu, K. F., Maynard, S. E., Sachs, B. P., … & Karumanchi, S. A. (2006). Soluble endoglin and other circulating antiangiogenic factors in preeclampsiaNew England Journal of Medicine355(10), 992-1005.

Maynard, S. E., Min, J. Y., Merchan, J., Lim, K. H., Li, J., Mondal, S., … & Karumanchi, S. A. (2003). Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsiaJournal of Clinical Investigation111(5), 649-658.

Powers RW, Jeyabalan A, Clifton RG, Van Dorsten P, Hauth JC, et al. (2010) Soluble fms-Like Tyrosine Kinase 1 (sFlt1), Endoglin and Placental Growth Factor (PlGF) in Preeclampsia among High Risk Pregnancies. PLoS ONE 5(10): e13263. doi:10.1371/journal.pone.0013263

Redman, C. W. G., Tannetta, D. S., Dragovic, R. A., Gardiner, C., Southcombe, J. H., Collett, G. P., & Sargent, I. L. (2012). Review: Does size matter? Placental debris and the pathophysiology of pre-eclampsiaPlacenta,33, S48-S54.

Turner, J. A. (2010). Diagnosis and management of pre-eclampsia: an update.International journal of women’s health2, 327.

van Dijk, M., & Oudejans, C. (2010). Stox1: key player in trophoblast dysfunction underlying early onset preeclampsia with growth retardation.Journal of pregnancy2011.

von Versen-Hoeynck, F. M., & Powers, R. W. (2007). Maternal-fetal metabolism in normal pregnancy and preeclampsiaFront Biosci12, 2457-2470. 

Warning, J. C., McCracken, S. A., & Morris, J. M. (2011). A balancing act: mechanisms by which the fetus avoids rejection by the maternal immune systemReproduction141(6), 715-724.

World Health Organization. (2011). WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneve: WHO.

About Caryn Rogers

A native of Tempe, Arizona, Ms. Rogers is a graduate of Arizona State University. A freelance science writer and editor for medical nonprofits, she has been the senior science writer for the Preeclampsia Foundation since 2006. She lives with her family in Mt. Lebanon, PA, where she also plays the violin. Ms. Rogers can be contacted through the Preeclampsia Foundation or via email

 

 

 

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