Preventing Maternal Deaths due to Pre-Eclampsia/Eclampsia (PE/E)

1. Preventing Maternal Deaths due to Pre-Eclampsia/Eclampsia (PE/E)

2. 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

3. PE/E: Pregnancy-Induced Hypertension • 18% of all maternal deaths worldwide • Highest in Latin America • Estimated in 2002: • 4,152,000 PE/E cases • 63,000 deaths • …and the lives of many babies Sources: Countdown to 2015 Decade Report (2000–2010) WHO and UNICEF 2010; Balancing the Scales, Engender Health, 2007; Khan et al., 2006

4. Pre-Eclampsia/Eclampsia (PE/E) As MMR declines in Indonesia, a higher proportion of maternal deaths are now due to eclampsia. • Second to hemorrhage as a specific direct cause of maternal mortality • ↓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

5. Bearing the Burden A woman in a developing country is 7 times more likely to develop PE, 3 times more likely to progress toeclampsia, and 14 times more likely to die of eclampsia. Photo credit: StephjanieSuhowatsky Source: Balancing the Scales, Engender Health, 2007

6. 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

7. Hypertension in Pregnancy Source: Wagner, LK. First Choice Community Healthcare. American Family Physician;70(12):2317-2324. 15 December 2004.

8. What is PE/E? Source: Prevention and management of pre-eclampsia and eclampsia Reference Manual for Healthcare Providers, MCHIP, 2011

9. Who is at Risk for PE? • 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 Photo credit: Sheena Currie All pregnant women are potentially at risk. All need prevention and early detection of PE.

10. Prevention Management What Can Be Done? Seeking simple, inexpensive and effective solutions that reach all pregnant women. Detection Photo credit: Stephanie Suhowatsky Photo credit: Sheena Currie Photo credit: Anita Khemka

11. Prevention Almost 100 interventions tested in randomized trials x x x

12. Primary Prevention Source: Prevention and management of pre-eclampsia and eclampsia reference manual, MCHIP, 2011

13. 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

14. Minimum daily calcium intake, Pregnant Women (1300−1500 mg/day) Minimum daily calcium intake, Adult WRA (1000−1200 mg/day) Daily Calcium Intake Source: Calcium and Prevention of Pre-eclampsia: Summary of Current Evidence, Monitoring, Evaluation and Research Task Force of the PE/E working group 2010

15. 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

16. 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

17. Detecting PE/E: ANC Coverage Source: Mandel B, Evidence Base for PE/E Strategy, 2009

18. Detecting PE: High BP, Proteinuria • Measuring BP: • Significant training needed • Robust, maintained equipment • Only 50% women receive ANC • Not all who attend have BP taken • Measuring urine protein: • Tests not available in low-resource settings • Boiling not feasible in high volume sites Photo credit: Daniel Antonaccio Source: Mandel B, Evidence Base for PE/E Strategy, 2009

19. ANC in Africa: BP Measurement and Urine Analysis Source: DHS (as noted on the slide)

20. Jhpiego—JHU-BME: Patent Pending Detecting PE: Point of Care Diagnostics Protein Test • This is an example of point of care diagnostic test: • Low cost • Easy to use: ANC, community level • Immediate results Photo credit: Daniel Antonaccio

21. 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.

22. 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

23. 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

24. Preventing Eclampsia 1case of eclampsia can be prevented by treating approximately 7women with severe PE Photo credit: Geeta Sharma Source: Sibai, 2005

25. Immediate Treatment: Magnesium Sulfate • Severe PE/E patients who received a loading dose before referral have: • 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 Seizure to Treatment Interval Source: Rashida et al., 2004

26. Magnesium Sulfate: Challenges • 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

27. 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:DanielAntonaccio

28. 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

29. Results: Improved Management of Severe PE/E in Nepal, 2009 22 facilities: Average score on 3 standards increased from 22%–60%

30. Results: Reduced Case Fatality Rate from PE/E Magnesium Sulfate Use in Purulia, West Bengal, India, 2002–2006

31. “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 On the Horizon: 2003…2011? Source: Tsu and Coffey, BJOG, 2009

32. Conclusion • 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.