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New Research: Majority of Preeclampsia-Related Maternal Deaths Deemed Preventable

May 12th, 2015 by avatar

By Eleni Z. Tsigas

Preeclampsia Awareness Month 2015May is Preeclampsia Awareness Month and the journal Obstetrics and Gynecology highlighted some new research published by doctors and researchers at the California Maternal Quality Care Collaborative that demonstrated that the majority of preeclampsia-related deaths could have been prevented.  This is significant because preeclampsia is one of the top perinatal causes of death. Today on Science & Sensibility, Preeclampsia Foundation Executive Director Eleni Z. Tsigas provides an update on this new research and important facts that birth professionals should know.  As childbirth educators, along with teaching families about normal labor and birth, we have an obligation to share information about warning signs and potential complications.  While not as much “fun” as teaching how to cope with a contraction, it is equally important.  Have you checked out the information available at the Preeclampsia Foundation‘s website?  There is a great short video, class tear sheets and even information en español.  How do you teach about preeclampsia to the families that you work with?  Let us know in the comments section. – Sharon Muza, Science & Sensibility Community Manager

Research published in the April 2015 issue of Obstetrics & Gynecology shows that 60 percent of preeclampsia-related maternal deaths were deemed preventable. This large study – Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities – analyzed U.S. pregnancy-related mortality administrative reports and medical records for each maternal death to identify the causes and contributing factors, and improve public health and clinical practices.

Over the last 20 years, a previous decline in maternal deaths has reversed and is cause for concern. The 2009 U.S. pregnancy-related mortality rate was 17.8 deaths per 100,000 live births, up from 7.7 per 100,000 in 1997 and above that of other high-resource countries.

One of every eight U.S. births occurs in California, resulting in more than 500,000 annual deliveries with extensive racial and ethnic diversity. With California’s large population-based sample, this study provides a unique opportunity to compare major causes of pregnancy-related mortality and identify improvement opportunities.

Preeclampsia-related maternal death deemed most preventable

Among the 207 pregnancy-related deaths from 2002 to 2005 studied in California, preeclampsia or eclampsia were identified as one of the five leading causes. The others were cardiovascular disease, hemorrhage, venous thromboembolism, and amniotic fluid embolism.

Of the five leading causes of death, preeclampsia was deemed one of the most preventable – preeclampsia-related deaths had a good-to-strong chance of preventability, estimated at 60%.

Healthcare provider factors were the most common type of contributor, especially delayed response to clinical warning signs followed by ineffective care.

Patients play important role in preventing preeclampsia-related deaths 

The leading patient factors among preeclampsia deaths were delays in seeking care (42%), presumed lack of knowledge regarding the severity of a symptom or condition (39%), and underlying medical condition (39%).

Preeclampsia deaths were most common among foreign-born Hispanic and African American women and associated with early gestational age, consistent with studies demonstrating the increased severity of early-onset preeclampsia.

These findings illustrate the need for public health interventions aimed at helping all women understand and recognize their risks and attain optimal pre-pregnancy health and weight.

It’s worth noting that since the study period, patient awareness has improved, led by several Preeclampsia Foundation education initiatives – currently preeclampsia awareness among pregnant women is 83%, according to a survey conducted last year by BabyCenter®.

The findings also underscore the need for focused approaches to improve care such as hospital-based safety bundles as well as comprehensive programs for patient education, communication, and teamwork development. Read the full report here.

Maternal health improvement initiatives underway 

As these Pregnancy-Related Mortality research findings are announced, several states have already moved forward with maternal health improvement initiatives. Recently the California Maternal Quality Care Collaborative (CMQCC), Hospital Corporation of America, and the American College of Obstetricians and Gynecologists released guidelines and quality improvement toolkits with standardized approaches to recognize and treat severe hypertension, and to increase awareness of atypical clinical presentations and patient education.

CMQCC’s Preeclampsia Toolkit incorporated the Preeclampsia Foundation’s Illustrated Symptoms Tear Pad that effectively informs women who are pregnant or recently gave birth about preeclampsia, which can strike up to six weeks after delivery. Developed by the Preeclampsia Foundation and researchers at Northwestern University Feinberg School of Medicine, the tear pad uses illustrations to describe the symptoms of preeclampsia so they are easily understandable, especially for those with poor health literacy. This toolkit is freely available online and has been downloaded by over 5,100 persons in the United States and more than 60 other countries. It is also being implemented in more than 150 California hospitals as part of the California Partnership for Maternal Safety.

In the year since implementing a Severe Maternal Morbidity Pre- and Post-Toolkit, CMQCC has noted a 34% reduction in maternal adverse outcomes. After implementing Pre- and Post-Hypertension Bundles, the rate of eclampsia has decreased by 31%.

New York joins California in distributing the tear pad throughout the state – as part of a statewide Maternal Preeclampsia Initiative, the New York State Perinatal Quality Collaborative, an initiative of the New York State Department of Health and the New York State Partnership for Patients – has adopted this patient education tool, making it available to all New York birthing facilities.

The Preeclampsia Foundation is proud to play a role in reversing the rate of maternal mortality and severe morbidity; it’s a team effort that requires the combined efforts of public health, clinical and hospital leaders and their institutions, and professional and consumer organizations.

References

Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., & Lawton, E. S. (2015). Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstetrics & Gynecology, 125(4), 938-947.

About Eleni Z. Tsigas

G8FK7644Eleni 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.

As a preeclampsia survivor herself, Eleni 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.

She has served as a technical advisor to the World Health Organization (WHO) and participated in the Hypertension in Pregnancy Task Force created by the American College of Obstetricians and Gynecologists to develop the national guidelines introduced in 2013, as well as a similar task force for the California Maternal Quality Care Collaborative (CMQCC). Eleni also serves on the National Partnership for Maternal Safety initiative, the Patient Advisory Board of IMPROvED (IMproved PRegnancy Outcomes via Early Detection), Ireland, and the Technical Advisory Group and Knowledge Translation Committee for PRE-EMPT (funded by the Bill & Melinda Gates Foundation). Eleni is frequently engaged as an expert representing the consumer perspective on preeclampsia at national and international meetings, and has been honored to deliver keynote addresses for several professional healthcare providers’ societies.

Eleni has collaborated in numerous research studies, has authored invited chapters and papers in peer-reviewed journals, and is the Principal Investigator for The Preeclampsia Registry.

A veteran of public relations, she has secured media coverage about preeclampsia in national consumer magazines, as well as newspapers, radio and online. Eleni previously spent 8 years executing and managing strategic communications and public relations for technology and biotech companies with Waggener Edstrom Worldwide and for 6 years prior in the television industry.

She is married, and has had two of her three pregnancies seriously impacted by preeclampsia. 

 

Childbirth Education, Guest Posts, Maternal Quality Improvement, Maternity Care, Pre-eclampsia, Research , , , ,

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 , , , ,

Why the California Toolkit: “Improving Health Care Response to Preeclampsia” Was Created

February 6th, 2014 by avatar

by Christine H. Morton, PhD

Researcher and Lamaze International Board Member Christine H. Morton, Phd shares information about a just released Toolkit on educating professionals about preeclampsia and it’s potentially very serious consequences.  Dr. Morton discusses how you can get a copy, take a webinar introducing the features and help reduce the number of women impacted by this serious pregnancy illness. – Sharon Muza, Community Manager.

Screen Shot 2014-02-05 at 10.25.11 PMWhen my academic partner and I observed childbirth classes several years ago as part of our Lamaze International-funded research (Morton 2009, Morton et al, 2007), we noted that many childbirth educators included a list of signs and symptoms to watch out for during their initial class meeting with expectant couples.  Some of these signs and symptoms were signals of early labor (mucous plug, leaking amniotic sac, contractions) while others might portend a more serious complication such as placental abruption (bright red bleeding), or preeclampsia (blurred vision, extreme swelling, headache), or worse case scenario, fetal demise (reduced to no fetal movement).  At the time, we wondered about the seeming contradiction of classes ostensibly designed to promote confidence in women’s bodies to give birth while from the outset telling women about things to watch out for, or “warning signs.”  Some instructors advised students to post the list on the fridge or on the bathroom mirror.

Now, after five years working at the California Maternal Quality Care Collaborative, and reviewing hundreds of cases of maternal death, I understand the importance of sharing information with pregnant women (and their partners) so they can understand when a symptom or condition goes beyond normal.  I understand why it is so important for women to know their own bodies, including their normal blood pressure, so they (or their partners) can be effective patient advocates if they sense something doesn’t feel right.

It’s an important balance for educators and other birth professionals to discuss the normality of physiological birth alongside the reality that about 8-12% of women will have medically complicated births. (Creanga, 2014), (Fridman, 2013) I remember hearing from partners who wanted to know what to look out for, so they could fulfill their roles as “protectors” as well as “co-creators of sacred space,” as one educator referred to them. Screen Shot 2014-02-05 at 10.25.45 PM

Preeclampsia is the second leading cause of pregnancy-related death in California, accounting for 17% of all deaths. (Druzin et al, 2014.) Preeclampsia is a severe obstetric condition characterized by high blood pressure, which left untreated, can lead to stroke, prematurity and death of women and babies.  As part of the California Pregnancy-Associated Review (CA-PAMR), an expert committee analyzed the medical records of 25 women who died of preeclampsia.  The committee identified contributing factors, and opportunities to improve care. All of the California deaths due to preeclampsia had some chance of preventability, with nearly half having a good-to-strong chance to alter the outcome.  For every woman who dies, at least 40-50 experience severe complications requiring ICU admission and another 400-500 experience moderate-to-severe complications from preeclampsia or other hypertensive disorders.   One important factor in the deaths was delayed recognition and response to signs and symptoms of severe hypertension.

Screen Shot 2014-02-05 at 10.26.04 PMThe lessons we learned from reviewing those cases were used to inform the development of the California Toolkit: Improving Health Care Response to Preeclampsia.  CMQCC and the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division collaborated to develop and disseminate this toolkit using Title V MCH funds provided by CDPH-MCAH. The goal of this toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and organized, swift response to preeclampsia and to implement successful quality improvement programs for preeclampsia that will decrease short- and long-term preeclampsia-related morbidity in women who give birth in California. (Druzin et al 2014).

Experts from obstetrics, perinatology, midwifery, nursing, anesthesia, emergency medicine and patient advocacy relied on best evidence, expert opinion and the Toolkit includes:

  • Compendium of Best Practices: eighteen articles on multiple topics around hypertensive disorders
  • Appendices: Collection of all Care Guidelines including tables, charts and forms that are highlighted in Article Sample forms for policy and procedure
  • Slide set for Professional Education: slides that summarize the problem of and the best practices for preeclampsia to be used for local education and training

Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge for women who were diagnosed with severe hypertension during childbirth.  The Preeclampsia Foundation was a partner on the Task Force, and has created educational material for pregnant women and their families, in English and Spanish.  Hospitals, clinics and childbirth educators can order these materials at no cost (shipping and handling only) from the Foundation.  There is a free webinar available on February 25th introducing the toolkit to professionals.preeclampsia

Thinking back to my childbirth education observations, I am struck that the educators never mentioned preeclampsia or defined it.  Not one suggested women should know their normal blood pressure.  The Preeclampsia Foundation commissioned a report in 2012 which reviewed the top pregnancy and childbirth advice books and found that many either failed to mention the condition or contained misleading or incorrect information about preeclampsia, HELLP or eclampsia.  With hypertensive disorders of pregnancy on the rise (as well as other maternal morbidities) (Fridman et al 2013; Creanga et al 2014) it’s important for childbirth educators and birth professionals to help women understand signs and symptoms and to know what those signs and symptoms might mean.

Even as we know most women are healthy and are highly unlikely to experience a severe complication in pregnancy and childbirth, we must also acknowledge that some women do, and by leaving them out of the classes and books, we silence their reality.  As one woman noted in a research study on experiences of severe pregnancy complications said:

There’s a lot of information out there or bad information that can make you feel like you did this to yourself. But there’s every kind of woman that has gone through some sort of thing. You don’t see red flag kind of behaviors in the population of women who get preeclampsia or a lot of the other kinds of issues that can cause childbirth injury and the bad childbirth experiences. I understand the way the books put it is that they want to reassure you that it’s not going to happen to you, but the kind of flipside of that is to say that when it does happen to you, where are you then? You know? I think they set you up for PTSD, for postpartum depression. They kind of make it seem, like, “Oh hey! You’re fine. Everything’s going to be great. It’s not going to happen to you” so what are you left when it does happen? (Lisa, in Morton et al 2103).

We owe it to pregnant women to give them the information they need to understand the fullness of their pregnancy and childbirth experiences, whether normal or complicated.  The Preeclampsia Toolkit will hopefully help those clinicians who care for childbearing women better manage and reduce the severity of complications when they arise.  Since its release last month, the Toolkit has been downloaded over 1376 times in all 50 states states (plus District of Columbia and Puerto Rico) along with 5 countries; Australia, Canada, Wales, Mexico and Malaysia.  The response to this Toolkit has been incredible and it is clear that there is a need for practical tools that hospitals and clinicians can use to improve their response to hypertensive disorders of pregnancy. 

Do you share information about preeclampsia in your classes and with your clients?  How do you discuss it?  What are your favorite learning tools?  Let us know in the comments. – SM

References

Creanga, MD, PhD, Andreea A. ; Cynthia J. Berg, MD, MPH, Jean Y. Ko, PhD, Sherry L. Farr, PhD, Van T. Tong, MPH, F. Carol Bruce, RN, MPH, and William M. Callaghan, MD, MPH, Maternal Mortality and Morbidity in the United States: Where Are We Now? JOURNAL OF WOMEN’S HEALTH, Volume 23, Number 1, 2014, DOI: 10.1089/jwh.2013.4617

Druzin, MD Maurice; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, January 2014.

Fridman, PhD, Moshe; Lisa M. Korst, MD, PhD, Jessica Chow, MPH, Elizabeth Lawton, MHS, Connie Mitchell, MD, MPH, and Kimberly D. Gregory, MD, MPH, Trends in Maternal Morbidity Before and During Pregnancy in California, Am J Public Health. Published online ahead of print December 19, 2013: e1–e9. doi:10.2105/AJPH.2013.301583)

Morton, C. H. (2009). A fine line: Ethical issues facing childbirth educators negotiating evidence, beliefs, and experience. The Journal of perinatal education, 18(1), 25.

Morton, C.H., A. Nack, and J. Banker, Traumatic Childbirth Experiences: Narratives of Women, Partners, and Health Care Providers. Unpublished manuscript. 2013.

Morton, C. H., & Hsu, C. (2007). Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. The Journal of perinatal education, 16(4), 25. Chicago

 

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

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

 

 

 

Childbirth Education, Evidence Based Medicine, Maternity Care, New Research, News about Pregnancy, Pregnancy Complications, Research, Uncategorized , , , , , , , ,

The Unexpected Project: Pre-eclampsia Researched, Revealed and Reviewed. Part II of an interview with Jennifer Carney

February 7th, 2013 by avatar

By: Walker Karraa

Regular contributor Walker Karraa wraps up her interview with Jennifer Carney, who became active with The Preeclampsia Foundation and the Unexpected Project after suffering from eclampsia while pregnant with her second child.  Have you had to answer any questions in your classes or with your clients and patients after the recent episode of Downton Abbey, where one of the characters developed eclampsia?  What have you shared with your pregnant families? Part one of Walker’s interview with Jennifer Carney can be found here. – Sharon Muza, Community Manager.  

Walker: What do you see are the common myths regarding pre-eclampsia?

JC: Common myths? Oh, there are so many. A lot of people seem to think they know what causes preeclampsia and how to cure it. There’s a whole faction of advocates who buy into the work of Dr. Tom Brewer, who in the 1960’s, devised a very high protein diet for mothers based on the idea that preeclampsia is caused by malnutrition. This isn’t supported by the current research, but it gets repeated all the time. Other people argue that preeclampsia is a so-called “lifestyle” disease – caused by obesity and poor prenatal care. Obesity is a risk factor, but it is only one of many and poor prenatal care can cause the disease to go undetected, but it will not cause it to happen in the first place. There are also a lot of people who think that the delivery of the baby will end the risk to the mother – and while it’s true that the removal of the placenta is essential, preeclampsia or eclampsia can still happen up to 6 weeks after delivery. There are other myths, but it strikes me that so many of these myths are rooted in a desire to control pregnancy. If we can blame preeclampsia on one central cause or on the women who develop it themselves, then we can reassure ourselves that we won’t develop it, too. There are risk factors that can increase a woman’s chances of developing the disease, but women without any known risk factors have developed it, too.

It’s not comforting to think that no one is safe, but with knowledge of the signs and symptoms – a woman can react to it promptly and receive the care that she needs. But this will only happen if women get the information and understand that it CAN happen to them. I am blown away by the ways in which preeclampsia and other serious complications are downplayed and dismissed in pregnancy books, online and even by some medical practitioners. Preeclampsia CAN happen to you – but you can deal with it IF you know the signs and the symptoms.

Walker: Can you share with our readers what you are doing with Anne Garrett Addison at The Unexpected Project?

JC: The Unexpected Project is a documentary, website, and book project that will examine the rate of maternal deaths and near-misses in the United States. Anne Garrett Addison, who founded the Preeclampsia Foundation, and I are both classified as near-misses due to preeclampsia. With Unexpected, we want to take a look at all maternal deaths regardless of the cause – preeclampsia, amniotic fluid embolism, hemorrhage, placenta previa, placental abruption, infection, suicide, and any other causes. We also want to look at the women who survived these complications because the line between surviving and dying is in these cases, often quite thin. Every case is different and there is no one factor to blame for the maternal death rate in the US. We will look at interventions and cesarean sections, but we will also look at the lack of information available to women and the tendency of some birth activists to minimize the dangers of serious birth complications.

Current Preeclampsia/Eclampsia StatisticsMaternal mortality and morbidity are, unfortunately, a part of the pregnancy and childbirth experience for women and their families in the US and the world.  While most (99%) of maternal mortalities occur in the developing world, the 1% that occur in developed countries like the US are still of concern to maternity care providers and advocates.  Indeed, U.S. still ranks 50th in the world for its maternal mortality rate (1).

More common than a maternal death, are severe short- or long-term morbidities due to obstetric complications (2).  Some estimate that unexpected complications occur in up to 15% of women who are otherwise healthy at term (2).  

In particular, hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies worldwide each year. (3)  Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension.  

In the U.S., upwards of 8 percent or 300,000 pregnant or postpartum women develop preeclampsia or the related condition, HELLP syndrome each year. This number is growing as more women enter pregnancy already hypertensive (cite).  Preeclampsia is still a leading cause of pregnancy-related death in the US and one of the most preventable.  Annually, approximately 300 women die and another 75,000 women experience “near misses” – severe complications and injury such as organ failure, massive blood loss, permanent disability, and premature birth or death of their babies.  Usually, the disease resolves with the birth of the baby and placenta. But, it can occur postpartum–indeed, most maternal deaths occur after delivery.

Recent statistics from Christine Morton, PhD.

The trend toward “normal” or “natural” birth does not seem to allow a lot of space for our stories to be heard or to be told. This has the effect of making survivors feel marginalized – as though their experience is somehow too far outside “normal” to be a part of the overall conversation. The one constant of all of our stories is that none of us expected to become statistics. Our birth plans did not include emergency cesarean sections, seizures, ICUs, blood transfusions, strokes, hysterectomies, CPR, prematurity, PTSD, depression, or death. No one was more surprised than us. This isn’t about assigning blame – this is about finding answers, improving birth for ALL moms to come, and learning to live with the unexpected.

Walker: How did you get involved with researching for the Preeclampsia Foundation?

JC: I started out volunteering with the March of Dimes in the spring following my son’s birth. I started a walk team and raised money, hoping that I would be able to meet other moms who had been through something similar. I felt very alone in the months following his birth. I was dealing with postpartum depression (PPD) and post-traumatic stress disorder (PTSD) symptoms and struggling to feel normal again. I had a premature infant – which meant sleeping through the night was a problem for a long time. When I returned to work, I was greeted by a coworker who declared that she now no longer wanted to have children because of what I had gone through. This weighed heavily on me – and I felt like I was the cautionary tale, the one bad pregnancy story that everyone knows. I know I had never heard a story as bad as mine – so I felt deflated, flattened by the whole thing.

With the March of Dimes, I found moms to help me deal with the preemie part of it. As he matured and grew out of the preemie issues, I found that I still had a lot of issues to deal with regarding my own health – both physically and mentally. I decided to volunteer with the Preeclampsia Foundation after they merged with the HELLP Syndrome Society.  The Preeclampsia Foundation is much smaller than the March of Dimes, which allowed me to be much more active as a volunteer. I was able to use my writing and editing skills to work on the newsletter – and when I suggested that someone do a review of the available pregnancy literature based on how well they cover preeclampsia, I was given the opportunity to conduct that research and write the report myself. This was something I had been doing informally in bookstores for a while anyway, so it felt good to be able to look at the literature and confirm that the information really is severely lacking if not downright misleading in a large number of so-called comprehensive books. It really isn’t my fault that I missed the symptoms.

This year, I am coordinating the Orange County, California Promise Walk in Irvine as part of the foundation’s main fundraising campaign on May 18. I am hoping to bring a mental health expert from the California Maternal Mental Health Collaborative out to the walk to talk to the moms about dealing with the emotional impact of their birth experiences.  Many of these moms lost babies, delivered preemies, or suffered severe health issues of their own. Our community as a whole is at a very high risk for mental health issues, myself included.

It wasn’t until this year – 6 years after the birth of my son – that I finally sought professional help dealing with the PTSD from the very difficult birth experience. I feel that the volunteer work helped fill that spot for the past 6 years and brought me to the point where I can now process the trauma in a healthy way. I am not happy that I had eclampsia, but I am beyond grateful for all of the great people that it has indirectly brought into my life.

Closing Thoughts

To have to wait 6 years to receive the vital treatment for PTSD is a travesty. We are so thankful that Jennifer survived both the initial trauma, but endured its legacy of traumatic stress that lingers today. Unfortunately, PTSD subsequent to traumatic childbirth is growing in prevalence, and under-recognized by the majority of women’s health and maternity care providers.  I have learned a great deal from Jennifer and look forward to the work she and her colleagues will continue to do for the benefit of all women.

References

1.  WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf. Last accessed:January 3, 2011.

2. Guise, J-M.  Anticipating and responding to obstetric emergencies.  Best Practice and Research Clinical Obstetrics and Gynaecology. 2007; 21 (4): 625-638

3. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167. 

 

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