Abstract
Globally, preeclampsia-eclampsia (PE-E) is a major cause of puerperal intensive care unit admission, accounting for up to 10% of maternal deaths. PE-E primary prevention is possible. Antepartum low-dose aspirin prophylaxis, costing USD $10–24 can cut the incidence of PE-E in half. Antepartum low molecular weight heparin combined with low-dose aspirin prophylaxis can cut the incidence of early onset PE-E and fetuses that are small for their gestational age in half. Despite predictive antepartum models for PE-E prophylaxis, said prophylaxis is not routinely provided. Therefore, magnesium sulfate secondary prevention of eclampsia remains the globally recommended intervention. Implementation of a PE-E checklist is a continuous quality improvement (CQI) tool facilitating appropriate antepartum PE-E prophylaxis and maternal care from the first trimester through the postpartum fourth trimester inter-partum interval. A novel clinical PE-E checklist and implementation strategy are presented below. CQI PE-E checklist implementation and appropriate PE-E prophylaxis provides clinicians and healthcare systems an opportunity to achieve Millennium Development Goals 4 and 5, reducing child mortality and improving maternal health. While CQI checklist implementation may be a tedious ongoing process requiring healthcare team resiliency, improved healthcare outcomes are well worth the effort.
Highlights
Preeclampsia (PE), which globally affects up to 7.6% of pregnancies, including up to 21% of twin pregnancies, is new-onset hypertension from 20 weeks gestation with pulmonary edema, or fetal, renal, hematologic, hepatic, or neurological involvement [1,2,3]
Combined with body mass index (BMI), mean arterial blood pressure (MAP) 10 mm Hg higher than mean MAP, a history of PE, and African ancestry increase the accuracy of PE prediction (p < 0.001) [3]
Whereas previous algorithms and protocols focus on the inpatient PE-E care, this checklist begins first trimester antepartum care with risk assessment facilitating prophylaxis
Summary
Preeclampsia (PE), which globally affects up to 7.6% of pregnancies, including up to 21% of twin pregnancies, is new-onset hypertension from 20 weeks gestation with pulmonary edema, or fetal, renal, hematologic, hepatic, or neurological involvement [1,2,3]. In high-resource settings, the Fetal Medicine Foundation PE predictive algorithm, comprised of the maternal serum pregnancy-associated placental protein (PAPP-A), placental growth factor (PIGF), maternal uterine artery Doppler pulsatility index (UTPI), mean arterial blood pressure (MAP), and risk factors, is used to predict early and preterm PE [3]. Low molecular weight heparin (LMWH) combined with low-dose aspirin can reduce early-onset PE (relative risk (RR) 0.54, 95% confidence interval (CI) 0.31–0.92), and the incidence of small for gestational age (SGA) fetuses (RR 0.54, 95% CI 0.32–0.91) [14]. Combined with body mass index (BMI), MAP 10 mm Hg higher than mean MAP, a history of PE, and African ancestry increase the accuracy of PE prediction (p < 0.001) [3]. Other first trimester plasma PE tests under development include the glycosylated fibronectin immunochromatographic strip rapid detection test and the inositol phosphoglycan P-type immunoassay [15]
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