Pre-eclampsia in low and middle-income settings: What are the barriers to improving perinatal outcomes and evidence-based recommendations?

OBJECTIVE: To discuss the points that still challenge low- and middle-income countries (LMICs) and strategies that have been studied to help them overcome these issues. METHODS: Narrative review addressing 20 years of articles concerning pre-eclampsia morbidity and mortality in LMICs. We summarized evidence-based strategies to overcome the challenges in order to reduce the pre-eclampsia impact on perinatal outcomes. RESULTS: Pre-eclampsia is the first or second leading cause in the ranking of avoidable causes of maternal death, and approximately 16% of all maternal deaths are attributable to eclampsia and pre-eclampsia. Considering the social and economic contexts, it represents a major public health concern, and prevention and early detection of pre-eclampsia seem to be a major challenge. Reducing maternal mortality related to hypertensive disturbances depends on public policies to manage these preventable conditions. Early and continuous recognition of signs of severity related to hypertensive disorders during pregnancy and childbirth, self-monitoring of symptoms and blood pressure, as well as preventive approaches such as aspirin and calcium, and magnesium sulfate, are lifesaving procedures that have not yet reached a universal scale. CONCLUSION: This review provides a vision of relevant points to support pregnant women in overcoming the constraints to healthcare access in LMICs, and strategies that can be applied in primary prenatal care units.

Eclampsia and posterior reversible encephalopathy syndrome in a parturient complicated by SARS COVID-19 pneumonia.

A primigravida at 32 weeks of gestation presented to us with eclampsia and Posterior Reversible Encephalopathy Syndrome (PRES) along with SARS COVID-19 pneumonia. Immediate termination of pregnancy was done under general anesthesia and patient was electively ventilated in view of increased oxygen requirements. Further therapy using magnesium sulphate, antihypertensives, steroids, and convalescent plasma was carried out. The condition of the patient steadily improved leading to her extubation on the 4th postoperative day and subsequent discharge on the 8th day of admission.

Acceptability and adoption of clinical practice guidelines and treatment protocols on preeclampsia/eclampsia in the Dominican Republic / Aceptabilidad y adopción de guías de práctica clínica y protocolos de atención sobre preeclampsia-eclampsia en la República Dominicana / Aceitabilidade e adoção de diretrizes de prática clínica e protocolos de atenção para pré-eclâmpsia e eclâmpsia na República Dominicana

ABSTRACT Objective. Estimate the acceptability and adoption by health care workers of clinical practice guidelines and treatment protocols for women with preeclampsia/eclampsia and identify the facilitating factors and barriers to their implementation. Methods. A qualitative study was conducted, using semi-structured interviews and focus groups in five maternity hospitals. Interviews were compiled for analysis, and barriers and facilitators were characterized. Results. Seventy health professionals (52 female and 18 male) participated, representing different levels of the health system. The majority of workers and managers were aware of the existence and content of clinical practice guidelines (CPGs) for preeclampsia/eclampsia, especially the participants with more time in the health service. With respect to facilitating factors, both medical and nursing staff were positive about continued development and implementation of high-quality CPGs. There was consensus that limitations exist, especially with respect to a lack of the necessary medicines, supplies, and equipment to meet and implement the established recommendations. Discussion. The results of the study show the need to strengthen strategies that help close the gap between research and public policy. Studies suggest that research should focus on users, policymakers, and decisionmakers in the health system. The actors in the Dominican health system recognize the GRADE methodology as an appropriate instrument for the development and implementation of CPGs. Implementation barriers require systemic and comprehensive approaches.

RESUMEN Objetivo. Estimar la aceptabilidad y adopción de las guías de prática clínica (GPC) y protocolos de atención a la mujer con preeclampsia-eclampsia por parte del personal prestador de los servicios de salud, e identificar los factores facilitadores y las barreras para su implementación. Métodos. Se desarrolló un estudio cualitativo por medio de entrevistas semiestructuradas y grupos focales en cinco maternidades. Se recopilaron las entrevistas para su análisis y se caracterizaron las barreras y facilitadores. Resultados. Participaron 70 profesionales de la salud (52 de sexo femenino y 18 de sexo masculino) que se desempeñan en distintos niveles del sistema de salud, participaron. La mayoría de los prestadores y gerentes conocen la existencia de las GPC de eclampsia-preeclampsia y su contenido, sobre todo los participantes con más tiempo en el servicio. Para los facilitadores, se estableció una valoración positiva entre el personal médico y de enfermería ante el proceso de continuar con la elaboración e implementación de GPC de alta calidad. Hubo consenso en cuanto a la existencia de limitaciones, sobre todo, por la falta de medicamentos, insumos y equipos requeridos, para cumplir y aplicar las recomendaciones formuladas. Discusión. Los resultados del estudio exponen la necesidad de fortalecer estrategias que ayuden a cerrar la brecha entre la investigación y la política pública. Estudios fundamentan la investigación en priorizar la atención a los usuarios, y los encargados de formular políticas y los tomadores de decisiones en el sistema de salud. Los actores del sistema de salud dominicano reconocen la metodología GRADE como un instrumento apropiado para la formulación e implementación de GPC. Las barreras de implementación requieren de abordajes sistémicos e integrales.

RESUMO Objetivo. Estimar a aceitabilidade e a adoção de diretrizes de prática clínica (DPCs) e protocolos de atenção para mulheres com pré-eclâmpsia e eclâmpsia por profissionais da saúde e identificar os fatores facilitadores e barreiras à sua implementação. Métodos. Desenvolvemos um estudo qualitativo baseado em entrevistas semiestruturadas e grupos focais em cinco maternidades. As entrevistas foram coletadas para análise, sendo caracterizadas as barreiras e fatores facilitadores. Resultados. O estudo contou com a participação de 70 profissionais da saúde (52 mulheres e 18 homens) que trabalham em diferentes níveis do sistema de saúde. Em sua maioria, os profissionais e administradores estão cientes da existência de DPCs para pré-eclâmpsia e eclâmpsia e conhecem seu conteúdo, especialmente os que têm mais tempo de experiência. Em relação aos fatores facilitadores, os profissionais médicos e de enfermagem consideraram positivo o processo de elaboração e implementação de DPCs de alta qualidade. Houve consenso sobre a existência de limitações, especialmente no que diz respeito à falta de medicamentos, insumos e equipamentos necessários para cumprir e implementar as recomendações. Discussão. Os resultados do estudo deixam clara a necessidade de reforçar as estratégias que ajudam a estabelecer vínculos entre a pesquisa e as políticas públicas. A pesquisa futura deve priorizar a atenção aos usuários e o apoio aos decisores e responsáveis pela elaboração de políticas no sistema de saúde. Os atores do sistema de saúde dominicano reconhecem a metodologia GRADE como um instrumento apropriado para a formulação e implementação de DPCs. As barreiras à implementação exigem abordagens sistêmicas e abrangentes.

Maternal and fetal outcome in women with hypertensive disorders of pregnancy: the impact of prenatal care.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are the most important cause of maternal and fetal death and pregnancy complications in Latin America and the Caribbean. OBJECTIVES: The objective of this study was to characterize the epidemiological profile of women with HDP admitted to a Brazilian tertiary reference hospital, and to evaluate maternal and fetal outcome in each HDP and the impact of prenatal care on the maternal and fetal outcome. METHODS: HDP in 1501 women were classified according to usual definitions as chronic hypertension (n = 564), pre-eclampsia (n = 579), eclampsia (n = 74) and pre-eclampsia/eclampsia superimposed on chronic hypertension (n = 284). Adverse maternal and fetal outcomes registered as maternal death and near miss and fetal outcomes documented as stillbirth, neonatal death and newborn respiratory complications were compiled. Prenatal care was classified as complete (⩾ 6 visits), incomplete (< 6 visits) or not done. RESULTS: Women with eclampsia were younger (15 years), 68% were on their first pregnancy, had higher blood pressure, higher mortality and greater number of near miss cases and their children had lower birth weight, higher intra-uterus and neonatal mortality, and more respiratory distress. Women with pre-eclampsia/eclampsia superimposed on chronic hypertension and their fetuses had intermediate outcome and those with chronic hypertension and pre-eclampsia the better outcome among those with HDP. Women who had incomplete prenatal care or prenatal not done had progressive higher mortality rates and greater frequency of near miss cases, and their children had higher mortality rates. CONCLUSION: In a tertiary reference hospital, eclampsia and chronic hypertension superimposed on pre-eclampsia are associated with a worst outcome for mothers and fetuses, whereas complete prenatal care is associated with a better maternal and fetal outcome in HDP.

Pre-eclampsia-eclampsia admitted to critical care unit.

OBJECTIVE: To evaluate women with hypertensive disorder admitted to critical care unit. METHODS: This study was carried out in Cartagena, Colombia, between January 2006 and December 2009. Patients were divided into 4 groups; severe pre-eclampsia, eclampsia, HELLP syndrome and HELLP with eclampsia (HEEH). RESULT: A total of 217 cases were admitted. The admitting diagnoses were severe pre-eclampsia without HELLP syndrome (39.2%), HELLP syndrome without eclampsia (33.6%), eclampsia without HELLP syndrome (20.3%) and Eclampsia with HELLP syndrome or HEEH (6.9%). Groups were similar with respect to parity (p = 0.25), gestational age (p = 0.11), cesarean section (p = 0.58), mechanical ventilation (p = 0.54), level of systolic (p = 0.48) and diastolic blood pressure (p = 0.15) and inotropic support (p = 0.32). Average total duration of hospitalization was significantly different among groups, more time in women with HEEH (p = 0.001). Multiple organ dysfunctions was diagnosed > 70% of all women admitted to intensive care, but was significantly more frequent in patients with HELLP syndrome and HEEH (p = 0.001). There were 5 maternal deaths (2.3%). Causes of maternal death were intracranial hemorrhage (3), intra-abdominal bleeding (1) and pulmonary complications (1). CONCLUSION: Women with HELLP syndrome with or without eclampsia are associated with major morbidity and mortality. Therefore, the maternal outcome in eclampsia is influenced for HELLP syndrome.

[Clinical guideline. Preeclampsia-eclampsia]. / Guía de práctica clínica. Preeclampsia-eclampsia.

Preeclampsia remains a major cause of worldwide pregnancy related maternal and neonatal mortality and morbidity, it accounts for more than 50,000 maternal deaths each year. The World Health Organization estimates that at least one woman dies every 7 minutes from a complication of preeclampsia. It is the main cause of maternal death in Mexico and Latin America. Standarized assessment and surveillance of women with preeclampsia is associated with reduced maternal risk. Standarized sequence was established to search for practice guidelines from the clinical questions raised on diagnosis and treatment of preeclampsia-eclampsia. The working group selected clinical practice guidelines found in the Cochrane Library, Medline and PubMed. The results were expressed as levels of evidences and grade of recommendation. Evidence suggests, that treatment of severe hypertension, seizures prophylaxis with magnesium sulfate, and management by experienced health-care professionals will improve maternal, fetal and neonatal outcomes. Treatment remains supportive with pregnancy termination being the only definitive cure.

Urgencias en obstetricia / Emergencies in obstetrics

Tradicionalmente, el embarazo es considerado un evento fisiológico. Sin embargo, cerca de un 20 por ciento de las embarazadas desarrolla patologías obstétricas que se asocian a mortalidad materna y perinatal. A nivel mundial, cada año medio millón de mujeres fallece durante el embarazo y parto debido a estas complicaciones. Desafortunadamente, un número significativo de las urgencias obstétricas ocurre en pacientes sin factores de riesgo, por lo que la prevención, identificación precoz e intervención a tiempo de estos eventos juegan un rol fundamental para contrarrestar un resultado perinatal adverso. En el presente capítulo hemos seleccionado las emergencias que concentran la mayor morbimortalidad de nuestra especialidad. Si bien algunas han quedado fuera, creemos que los temas aquí presentados representan las urgencias obstétricas más importantes que enfrentamos a diario, para las cuales debemos estar preparados con el fin de realizar un manejo óptimo del embarazo y parto para la obtención de un resultado perinatal favorable.

Traditionally, pregnancy is considered a physiologic condition. However, close to 20 percent of pregnant women develop obstetrical diseases that are associated to maternal and perinatal mortality. World wide, every year half a million of women die during pregnancy, labor and delivery due to these complications. Unfortunately, a significant number of obstetrical emergencies occur among patients without risk factors, so that prevention, early identification and timely intervention play a key role to overcome an adverse pregnancy outcome. In the present chapter, we have selected the emergencies that concentrate most of the morbidity and mortality of our field. Although some have not been included, we believe that the obstetrical emergencies presented here in represent the most important ones that we face daily, and for which we should be prepared in order to execute the best possible obstetrical care either during pregnancy or at the time of delivery to obtain a favourable perinatal outcome.

Eclâmpsia: diagnóstico e manejo / Eclampsia: diagnosis and treatment

Os autores realizaram uma revisão sobre epidemiologia e quadro clinico, enfatizando a importância dos diagnóstico precoce e do manejo correto da crise eclâmptica na emergência.

Timeliness of care for eclampsia and pre-eclampsia in Benin, Ecuador, and Jamaica.

OBJECTIVE: Cases meeting diagnostic criteria for severe pre-eclampsia or eclampsia were reviewed in three countries to determine timeliness and effectiveness of care. METHOD: Cases were retrospectively selected from 11 emergency obstetric care facilities and medical records reviewed by trained obstetricians. RESULT: Of 91 cases (Benin, 28; Ecuador, 25; Jamaica, 38), 74% were correctly treated with anticonvulsant and 77% with antihypertensive therapy. The median interval to treat eclampsia (anticonvulsant, 28 min; antihypertensive, 77 min) was shorter than for severe pre-eclampsia (anticonvulsant, 45 min; antihypertensive, 85 min). Two in three cases (65%) received anticonvulsant but only 41% received antihypertensive therapy within 60 min of diagnosis. While 74% of eclamptics had been delivered within 12 h, only 39% of severe pre-eclamptics were delivered within 24 h. CONCLUSION: Timeliness can be studied in developing countries. Its objective measurement is a first step towards improving this component of care.

[TOLUCA experience in preeclampsia-eclampsia]. / Experiencia TOLUCA en preeclampsia-eclampsia.

INTRODUCTION: Reducing morbidity and mortality due to preeclampsia-eclampsia represents a challenge in health care. Since 1997, in the city of Toluca, Estado de México, a research unit was implemented along with a national expert committee for the study of preeclampsia-eclampsia. This was followed by the development of an educational program and the establishment of a diagnosis and treatment protocol TOLUCA. MATERIAL AND METHODS: We reviewed the mortality registered in the obstetric ICU of our institute, before and after the implementation of the TOLUCA protocol and including a review of the impact of human resources obtained from our educational program, clinical research and the establishment of a research unit. RESULTS: During a period of 12 years, 1723 patients were treated, with 102 (5.9%) maternal deaths. Preeclampsia-eclampsia accounted for 49 (48%), obstetric hemorrhage 29 (28%), sepsis 9 (9%) and miscellaneous 15 (15%) of all deaths. Data were chronologically divided from 1992 to 1996 (group A) and from 1997 to 2003 (group B), before and after the implementation of the TOLUCA protocol. Group A included 289 admissions with 39 deceased representing a relative mortality of 13.4% (1 death per 7 admissions). Group B included 1434 admissions with 63 deaths, representing a relative mortality of 4.3% (1/23 admissions). Twenty obstetrician/gynecologists were graduates in clinical medicine, 25 research papers were published, four books on preeclampsia were published including preeclampsia, critical medicine, arterial hypertension and renal failure, six book chapters, and the physical implementation of a research unit with laboratory, physician's office and surgical facility. CONCLUSIONS: Results obtained using the TOLUCA protocol allow us to propose it as a prototype for application in obstetric-gynecology hospitals in order to improve medical care by establishing a high-level of care with on-going research.

Mediciones hemodinámicas de la preeclampsia severa/eclampsia: ¿Es determinante su aportación para aplicar maniobras terapéuticas? / Severe pre-eclampsia/eclampsia. Hemodynamic measuring: is its contribution a determinant to apply therapeutic maneuvers?

La preeclampsia severa/eclampsia presenta cambios en el gasto cardíaco y en la oxigenación sistémica. Estas pacientes pueden cursar con fase hipodinámica o hiperdinámica, por lo que es determinante conocer objetivamente cual de estas etapas está presente. Objetivo: Utilizando el principio de Fick, determinar el estado hemodinámico, las variables del gasto cardíaco y del equilibrio del oxígeno, y realizar la estabilización prealumbramiento. Materiales y métodos: Se realizó un estudio descriptivo, prospectivo y longitudinal en pacientes portadoras de preeclampsia severa/eclampsia. Se analizaron el gasto cardíaco (Qt), la disponibilidad de O2 (DO2), el consumo de oxígeno (VO2), la tasa de extracción de O2 (O2ER) y las resistencias periféricas totales (RPT), y los valores de la presión venosa central (PVC), TAS, TAD, PAM y FC durante las tres fases siguientes: basal, la estabilización prealumbramiento y final. La terapia de estabilización se efectuó con administración de soluciones cristaloides, coloides, vasodilatadoras y sulfato de magnesio. Estas variables se analizaron mediante la prueba de ANOVA con una p< 0.05. Resultados: todas las pacientes cursaron con fase hipodinámica. Durante la terapia de prealumbramiento se observó un incremento en el Qt, DO2, VO2 y PVC en la fase de estabilización, y una disminución de las RPT estadísticamente significativa. En las variables de TAS, TAD y PAMd existió disminución, siendo más acentuada en la fase final. Los volúmenes urinarios fueron mayores de 1 ml/ka/h en la fase final. Discusión y conclusiones: Las pacientes estudiadas cursaron con fase hipodinámica con una evolución satisfactoria. Concluimos que es indispensable el conocimiento de la oxigenación sistémica para definir una terapéutica dirigida y favorecer el pronóstico en el postoperatorio inmediato. (AU)

Mediciones hemodinámicas de la preeclampsia severa/eclampsia: ¿Es determinante su aportación para aplicar maniobras terapéuticas? / Severe pre-eclampsia/eclampsia. Hemodynamic measuring: is its contribution a determinant to apply therapeutic maneuvers?

La preeclampsia severa/eclampsia presenta cambios en el gasto cardíaco y en la oxigenación sistémica. Estas pacientes pueden cursar con fase hipodinámica o hiperdinámica, por lo que es determinante conocer objetivamente cual de estas etapas está presente. Objetivo: Utilizando el principio de Fick, determinar el estado hemodinámico, las variables del gasto cardíaco y del equilibrio del oxígeno, y realizar la estabilización prealumbramiento. Materiales y métodos: Se realizó un estudio descriptivo, prospectivo y longitudinal en pacientes portadoras de preeclampsia severa/eclampsia. Se analizaron el gasto cardíaco (Qt), la disponibilidad de O2 (DO2), el consumo de oxígeno (VO2), la tasa de extracción de O2 (O2ER) y las resistencias periféricas totales (RPT), y los valores de la presión venosa central (PVC), TAS, TAD, PAM y FC durante las tres fases siguientes: basal, la estabilización prealumbramiento y final. La terapia de estabilización se efectuó con administración de soluciones cristaloides, coloides, vasodilatadoras y sulfato de magnesio. Estas variables se analizaron mediante la prueba de ANOVA con una p< 0.05. Resultados: todas las pacientes cursaron con fase hipodinámica. Durante la terapia de prealumbramiento se observó un incremento en el Qt, DO2, VO2 y PVC en la fase de estabilización, y una disminución de las RPT estadísticamente significativa. En las variables de TAS, TAD y PAMd existió disminución, siendo más acentuada en la fase final. Los volúmenes urinarios fueron mayores de 1 ml/ka/h en la fase final. Discusión y conclusiones: Las pacientes estudiadas cursaron con fase hipodinámica con una evolución satisfactoria. Concluimos que es indispensable el conocimiento de la oxigenación sistémica para definir una terapéutica dirigida y favorecer el pronóstico en el postoperatorio inmediato.

[Perinatal result with conservative treatment in preeclampsia-eclampsia]. / Resultado perinatal con tratamiento conservador en la preeclampsia-eclampsia. Reporte preliminar.

INTRODUCTION: Conservative treatment in severe preeclampsia has been documented by several authors citing significant improvement in neonatal outcome lacking a significant increase in maternal complications. OBJECTIVE: Our objective was to inform of our preliminary results using protocolized conservative management in women with preeclampsia-eclampsia, favoring better neonate conditions. MATERIAL AND PATIENTS: We included 34 patients with average age of 28.2 years with documented severe preeclampsia-eclampsia complicating a 36-weeks or less pregnancy, admitted in the obstetric intensive care unit (OICU) between October 2001 and February 2002. Patients received protocolized management consisting of intravascular colume expansion, anti-hypertensive control, target organ protection, monitoring, and clinical observation. We considered conservative management as a 24 or more period offered to patients with satisfactory response to medical treatment and no evidence of binomial compromise. RESULTS: Of our group, 85% corresponded to severe preeclampsia, 9% to eclampsia, 3% to imminence of eclampsia, and 3% to HELLP syndrome. Average stay in OICU was 5.5 days with 3.5 days average management before pregnancy was interrupted. These patients presented mean gestational age of 32.8 weeks during which we observed anemia, low platelets, D dimmer increments, MAP average of 112.8, PCOc 18.6, and BI 0.15. We obtained 36 live newborns of whom 12% four died, two were extremely immatures (510 g and 600 g, respectively); one 980-g newborn presented intraventricular hemorrhage, and a 1,450-g newborn had multiple organ failure. Conservative treatment in patients with severe preeclampsia-eclampsia is a feasible alternative in hospitals with an ICU. Conservative management can improve neonatal survival and prognosis in preterm newborns.