By James M. Roberts.
The number of pregnant women who die yearly due to high blood pressure is very high and 99% of these deaths occur in low- and middle-income countries. Latin America remains one of the biggest contributors to this figure. Their killer is known as preeclampsia. Do you know what it is?
What is it and what can be done to bring preeclampsia numbers down
Preeclampsia occurs in women who regularly have normal pressure, but around the 20th week of pregnancy develop hypertension and an excess of protein in the urine.
The answer on how to reduce it is disturbing because the means to reduce mortality are already available. The WHO recently presented guidelines that if followed correctly would dramatically improve outcomes in preeclampsia.
We need now to determine through careful research how to effectively deliver this care and to increase awareness of potential unique factors in our region. For example, a major need is implementation research focused on studies that relate to successfully modify care delivery within the existing health care system. This requires imagination and knowledge of the current systems including their strengths and limitations. Based upon this knowledge, studies should be directed at testing what is appropriate in each specific setting.
For example, through the Bill and Melinda Gates Foundation I am engaged with a team of researchers, in a program in Pakistan that takes advantage of a well-organized system of “lady health care workers” to bring the initial emergent treatment of preeclampsia into a community setting. These providers also work with women, families, community and clergy to modify attitudes towards health care and autonomy of women to make decisions relevant to their health. The approach is relevant in this setting, but it is unlikely that could be generalized to Latin America. Specific approaches need to be tested in specific settings.
Understanding preeclampsia in low and middle income countries
Although the crucial approach to quickly save lives is implementation research, studies should also be directed at the risk factors that cause and develop preeclampsia in pregnant women in low and middle income countries. It is distressing that virtually all that we know about preeclampsia, knowledge that directs prediction and prevention, is based upon studies performed in high income countries. Almost no empirical research has taken place to understand preeclampsia in the setting where 99% of women die from the disorder. It is also quite likely that preeclampsia, has different routes to its abnormalities in different populations. Behavioral, dietary and other diseases undoubtedly result in factors of importance that differ from low to high income countries.
Brazil accounts for almost 20% of all preterm births with preeclampsia.
Together with Brazilian researchers, the Global Pregnancy CoLaboratory (where I work), is preparing a strategy that will combine implementation and empirical research. The first intervention will use conventional and innovative approaches to identify women at high risk for preeclampsia. These women will then be cared for as directed by WHO guidelines with the following two goals in mind: to demonstrate how practical and efficient the WHO guidelines are and to reduce the frequency of preeclampsia through preventive therapy with low dose aspirin and calcium accompanied by patient education.
The second intervention will be applied to women who risk preterm (less than 37 weeks gestation) or are suspected to have preterm preeclampsia. It will use two approaches that have proven to be effective:
- The full PIERS clinical assessment, which is a tool to rank or grade the risk of preeclampsia for adverse maternal outcomes within 48hrs of admission to a hospital
- The use of measurements to evaluate placental development and growth factors.
Interestingly, although the use of these tests is currently directed at identifying women at risk, we propose to use these to identify preeclamptic women who do not need to deliver. With this approach we can reduce unnecessary preterm delivery of preeclamptic women. Further, as part of the study, blood drawn in early pregnancy and at the time of diagnosis will be stored for rapid assessment of concepts especially relevant in Latin America that become evident through careful attention and assessment of women cared for in the study.
We know largely how to effectively care for women to prevent mortality and other complications from preeclampsia in Latin America. It is now time to figure through research how to implement what is the best way to deliver the service and the unique characteristics associated to preeclampsia that the Region may have.
Have you and some of your friends had preeclampsia? Teel us your story leaving a comment on this blog or in twitter @BIDgente.
Dr. James M. Roberts is a professor at the Department of Obstetrics, Gynecology & Reproductive Sciences and Epidemiology at the University of Pittsburgh. His research is interdisciplinary and involves fundamental, clinical, behavioral and epidemiological studies. He was protocol chair of a recent NIH trial (10,000 women) of vitamins C and E given to prevent preeclampsia.