Transcript PE/E Advocacy Presentation (English)

Preventing Maternal Deaths due to
Pre-Eclampsia/Eclampsia (PE/E)
Objectives
 Present PE/E as a public health priority
 Define interventions available for PE/E
prevention, detection and management
 Share country experiences and expected results
PE/E: Pregnancy-Induced Hypertension
 18% of all maternal
deaths worldwide
 Highest in Latin America
 Estimated in 2002:
 4,152,000 PE/E cases
30%
26%
25%
20%
15%
10%
 63,000 deaths
5%
 …and the lives of many
0%
babies
9%
9%
Africa
Asia
Latin America &
the Caribbean
Sources: Countdown to 2015 Decade Report (2000–2010) WHO and UNICEF 2010;
Balancing the Scales, Engender Health, 2007; Khan et al., 2006
Pre-Eclampsia/Eclampsia (PE/E)

Second to hemorrhage as
a specific direct cause of
maternal mortality
As MMR declines in Indonesia, a higher
proportion of maternal deaths are now due to
eclampsia.
 ↓MMR, ↑ % eclampsia

7–15% pregnant women
will develop PE
 1–3% progress to
eclampsia
 Increases risk of perinatal
mortality
Sources: Khan et al., 2006; WHO 1994; Lain, K et al 2002; Dolea, C., and AbouZahr, C. 2003;
Indonesia Maternal Health Assessment, 2010
Bearing the Burden
A woman in a developing country is
7 times more likely to develop PE,
3 times more likely to progress to
eclampsia, and
14 times more likely to die of eclampsia.
Source: Balancing the Scales, Engender Health, 2007
Photo credit: Stephjanie Suhowatsky
Why Do Women Die from PE/E?




Infrequent ANC means infrequent screening
Poor detection during ANC of high BP, proteinuria
<50% of women deliver with a SBA
Reluctance to treat:

Concern over the management of severe PE cases
 Reluctance to give the loading dose of MgSO4 before referral/transfer

Limited access to emergency obstetric and newborn care
(EmONC)
Source: Countdown to 2015 Decade Report (2000–2010) WHO and UNICEF 2010
Hypertension in Pregnancy
Source: Wagner, LK. First Choice Community Healthcare. American Family
Physician;70(12):2317-2324. 15 December 2004.
What is PE/E?
Probable Diagnosis
Mild PE
Severe PE
Eclampsia
Typical Signs and Symptoms
 Two readings of diastolic BP 90 mm Hg or more but below
110 mm Hg 4 hours apart
 Proteinuria up to 2+
 Diastolic BP 110 mm Hg or more
 Proteinuria 3+ or more
 Hyperreflexes (patellar or bicep)
 Headache (↑ frequency, unrelieved by regular analgesics)
 Blurred vision
 Oliguria (<400 mL urine in 24 hours)
 Upper abdominal pain (epigastric pain; pain in right upper quadrant)
 Pulmonary edema





Convulsions and coma (unconscious)
Diastolic blood pressure 90 mm Hg or more
Proteinuria 2+ or more
Coma (unconscious)
Other symptoms and signs of severe PE
Source: Prevention and management of pre-eclampsia and eclampsia Reference Manual for
Healthcare Providers, MCHIP, 2011
Who is at Risk for PE?





All pregnant women are potentially at risk.
All need prevention and early detection of PE.
Photo credit: Sheena Currie

A family history of PE or prior PE/E
Pre-existing condition: obesity,
chronic hypertension and diabetes
Age: Adolescents, women >35 years
Primigravida
Poor outcome of previous pregnancy
(IUGR, abruptio placentae, fetal
death)
First pregnancy with a new partner
What Can Be Done?
Seeking simple, inexpensive and effective solutions
that reach all pregnant women.
Prevention
Detection
Photo credit: Anita Khemka
Photo credit: Sheena Currie
Photo credit: Stephanie Suhowatsky
Management
Prevention
Almost 100 interventions tested in randomized trials
x
x
x
Primary Prevention
Intervention
Pregnancy outcome
Recommended?
Prevention of IUGR
Theoretically contributes to primary prevention of PE (and
IUGR) in the next generation
Yes
Family planning
Potential to reduce pregnancies at risk for PE
Yes
Pre-conceptual prevention and/or
treatment of obesity
Potential to reduce PE
Yes
Calcium supplementation
Reduces PE in those at high risk and with low baseline
dietary calcium intake; No effect on perinatal outcome
High risk of gestational
hypertension; low dietary
calcium intake
Low-dose aspirin
Reduces PE; Reduces fetal or neonatal deaths
Magnesium or zinc supplementation
No PE reduction
Insufficient evidence to
recommend*
Fish oil supplementation and other
sources of fatty acids
No effect on low- or high-risk populations
s/a*
Heparin or low-molecular weight
heparin
Reduces PE in women with renal disease and thrombophilia
s/a*
Anti-oxidant vitamins (C, E)
Reduced PE in one trial
s/a*
Protein or salt restriction
No effect
No
Source: Prevention and management of pre-eclampsia and eclampsia reference manual, MCHIP,
2011
Populations at increased risk
Potential Impact of Calcium
 Calcium reduces PE by
50%
 High-risk women
 Low calcium intake
 Universal calcium
supplementation could:
 Prevent 21,500 maternal
deaths
 Reduce DALYs by
620,000
Source: Bhutta et al., Lancet, 2008
Daily Calcium Intake
1500
Minimum daily calcium intake, Pregnant Women (1300−1500 mg/day)
Minimum daily calcium intake, Adult WRA (1000−1200 mg/day)
1000
500
860
499
472
346
363
Developing
countries
Africa
498
352
0
World
Developed
Countries
Latin
America
Source: Calcium and Prevention of Pre-eclampsia: Summary of Current Evidence,
Monitoring, Evaluation and Research Task Force of the PE/E working group 2010
Near East
Far East
Potential Impact of Aspirin

17% reduction in the risk of PE



>75 mg of aspirin per day
14% reduction in the risk of fetal, neonatal and infant deaths
Daily low-dose aspirin before 16 weeks of gestation among
women at risk for PE = significant decrease in:
 PE
 Severe PE
 IUGR
 Preterm birth
Source: Bujold et al., 2010; Knight M, Duley L, Henderson-Smart DJ, King JF. (Cochrane Review) 2007
Benefits of PE Prevention
Infants of women with PE
are 5 times
more likely to die
than those born to
mothers without PE
Photo credit: Geeta Sharma
Detecting PE/E: ANC Coverage
100
92
88
94
92
92
85
79
80
92
78
73
60
60
58
49
36
40
28
20
16
0
Afghanistan
Indonesia
Rwanda
Bangladesh
Kenya
South Africa
ANC coverage
Burkina Faso
Malawi
Tanzania
(at least 1 visit)
Ethiopia
Mozambique
Uganda
Source: Mandel B, Evidence Base for PE/E Strategy, 2009
Haiti
Nigeria
Zambia
India
Pakistan
93
Detecting PE: High BP, Proteinuria

Measuring BP:
 Significant training needed
 Robust, maintained equipment
• Not all who attend have BP
taken

Measuring urine protein:

Tests not available in lowresource settings
 Boiling not feasible in high
volume sites
Source: Mandel B, Evidence Base for PE/E Strategy, 2009
Photo credit: Daniel Antonaccio
 Only 50% women receive ANC
ANC in Africa: BP Measurement and
Urine Analysis
100
96
96
98
83 81
80
93
78 81
80
71
62
85
83
79
66
60
81
64
53
50 50
42
40
27
23
21
20
12
8
0
Blood pressure measured
Burkina Faso-2003
Malawi 2004
Uganda 2006
Ethiopia 2005
Nigeria 2003
Zambia 2007
Urine sample taken
Ghana 2003
Rwanda 2005
Egypt 2005
Source: DHS (as noted on the slide)
Kenya 2003
Senegal 2005
Liberia 2007
Tanzania 2004
Detecting PE: Point of Care Diagnostics
Protein Test
Photo credit: Daniel Antonaccio
This is an example of point of care diagnostic test:
 Low cost
 Easy to use: ANC, community level
 Immediate results
Jhpiego—JHU-BME: Patent Pending
Managing PE/E and Preventing
Eclampsia
 Severe PE and eclampsia management:
 Anti-convulsants: Magnesium sulfate can reduce
the occurrence of eclamptic seizures by more than
50% and maternal deaths by 46%.
 Anti-hypertensives: Indicated for maternal benefit
and may prolong pregnancy/improve fetal maturity.
 Induction of labor: In severe PE, within 24 hours
of the onset of symptoms; eclampsia within 12
hours of the onset of convulsions/fits.
Source: L, Gulmezoglu A, Henderson-Smart D. 2006. The Cochrane Library. Magpie
Trial Collaborative Group: Lancet 2002.
Magnesium Sulfate: Evidence

Treat severe PE

Magpie Trial, 2002, 10,000 women, 33 countries
 Reduced the occurrence of eclampsia by 58%
 Reduced maternal deaths by 46%

Treat eclampsia

Collaborative Eclampsia Trial (1995) compared 3 most popular
treatments (magnesium sulfate, diazepam, and phenytoin)
 Magnesium sulfate had a 52% and 67% lower recurrence of
convulsions than diazepam and phenytoin, respectively
Sources: Duley L, Gulmezoglu A, Henderson-Smart D. 2006; Duley L, Henderson-Smart D. 2003; Beguma R et al., 2001
Magnesium Sulfate and the Neonate
 Better outcomes than diazepam or phenytoin
 Fewer neonatal deaths
 Greater vigor of babies (5 minutes after birth)
 Decreased need for care:
• Lower chances of long hospital stay in intensive care unit;
• Shorter duration of stay in neonatal care unit; and
• Fewer neonatal admissions to a special care unit.
Source: Duley et al., 2003a
Preventing Eclampsia
1 case of eclampsia
can be prevented
by treating approximately
7women with severe PE
Source: Sibai, 2005
Photo credit: Geeta Sharma
Immediate Treatment: Magnesium
Sulfate

Seizure to Treatment Interval
# maternal deaths
% mortality
100%

80%
150
77%
60%
100
40%
50
% mortality
# maternal deaths
200
20%
18%
0
5%
< 6 hours
Source: Rashida et al., 2004
0%
6- 12 hours
Severe PE/E patients who
received a loading dose
before referral have:
> 12 hours

Reduced number of
convulsions
 Controlled convulsions
 Shortened time to full
consciousness
 Reduced maternal mortality
and stillbirths
Loading dose useful at
home births and peripheral
facilities
Magnesium Sulfate: Challenges



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
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Not uniformly recommended in national service delivery guidelines
Limited availability: Only included in half of the world’s national essential
drugs list
Perceived need for close monitoring
Requires updated, empowered and skilled providers to administer
Because eclampsia is rare experience with use of MgSO4 is minimal
Inexpensive: Little incentive for companies to commercialize
Inconvenient in packs of 500–1000 mL (need 250 mL)
Source: Reducing eclampsia-related deaths—a call to action, the Lancet, 2008
Benefits of Magnesium Sulfate Use
A 50% increase in the use of
magnesium sulfate would
prevent 10—15 maternal
deaths per 100,000 live
births
Source: Fernando Althabe presentation at CIHR, WHO and NIH Workshop Ottawa,
September 24—25, 2009
Photo credit:Daniel Antonaccio
Expected Results
 Reduced PE incidence among calcium-deficient
populations
 Increased detection of PE
 Improved severe PE case management
 Increased awareness about danger signs
 Decreased eclampsia cases
 Reduced maternal and perinatal mortality
0%
Valley N sg Home
Dhulikhel Hospital
NMC
*Abhiyan Hospital
Baseline %
WRH
Phewa City Hospital
Asha Hospital
Dumkauli PHC
Bharatpur Hospital
Facilities
JH
KZH
Saptakoshi NH
IDH
BPKIHS
UCMS
AMDA
LZH
BZH
MWRH
Malakheti PHC
Chaumala PHC
SZH
Score
Results: Improved Management of
Severe PE/E in Nepal, 2009
22 facilities: Average score on 3 standards
increased from 22%–60%
100%
80%
First %
60%
40%
20%
Results: Reduced Case Fatality Rate
from PE/E
Magnesium Sulfate Use in Purulia, West Bengal, India, 2002–2006
% MgSO 4 use
80%
Case fatality rate
25%
20%
19%
15%
60%
40%
11%
8%
8%
10%
8%
20%
5%
0%
0%
2002
2003
2004
2005
2006
Case fatality rate
% of Magnesium Sulfate Used
100%
On the Horizon: 2003…2011?
“The technologies identified 5 years ago
continue to be the key issues”
 Nutritional supplements to prevent PE/E
 Antiplatelets to prevent PE/E
 Methods for early detection of PE/E or elevated
risk for PE/E
 Scaling up use of magnesium sulfate for both
prevention and treatment of eclampsia
Source: Tsu and Coffey, BJOG, 2009
Conclusion

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
Eclampsia is a major contributor to maternal and neonatal
mortality.
Calcium and aspirin can reduce PE risk among some groups
of pregnant women.
Improved PE detection is needed: during ANC and to reach
those not using ANC.
Eclampsia can be prevented through early diagnosis and
prompt PE treatment.
Magnesium sulfate is effective and needs to be scaled up.