Preeclampsia In Low-resource Setting Research Articles

Early Detection of Preeclampsia in Low-Resource Setting: Examining Risk Factors, Mean Arterial Blood Pressure (Map), Body Mass Index (Bmi), and Urine Protein at Public Primary Health Care

Early Detection of Preeclampsia in Low-Resource Setting: Examining Risk Factors, Mean Arterial Blood Pressure (Map), Body Mass Index (Bmi), and Urine Protein at Public Primary Health Care

Challenges to diagnosing and managing preeclampsia in a low-resource setting: A qualitative study of obstetric provider perspectives from Ghana.

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Developing shared understanding of pre-eclampsia in Haiti and Zimbabwe using Theory of Change.

Pre-eclampsia, a complex and multi-system disorder specific to pregnancy, is a leading cause of preventable maternal and perinatal deaths in low-resource settings. Early detection and appropriate intervention with management of hypertension, prevention of eclampsia and timely delivery are effective at reducing mortality and morbidity. Outcomes can be greatly improved with the provision and uptake of good quality care. Cultural contexts of maternal care, social practices and expectations around pregnancy and childbirth profoundly shape understanding and prioritisation when it comes to seeking out care. Few studies have addressed health education specifically targeting pre-eclampsia in low resource settings. The existing literature has limited descriptions of contextual barriers to care or of the intervention development processes employed. More engaging, holistic approaches to pre-eclampsia education for women and families that recognise the challenges they face and that support a shared understanding of the disorder, are needed. We describe our experience of developing a Theory of Change (ToC) as part of the co-production of educational resources for pre-eclampsia in Haiti and Zimbabwe.

Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial.

BackgroundCommunity-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women’s knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial.MethodsThe CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals.ResultsThere were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI) = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters.ConclusionsThe findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study.Trial registrationClinical Trials.gov – INCT01911494.

Development and validation of risk prediction models for adverse maternal and neonatal outcomes in severe preeclampsia in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe.

Hypertensive disorders of pregnancy are major causes of global maternal and neonatal morbidity and mortality. This study aimed to develop and validate models to predict composite adverse maternal and neonatal outcome in severe preeclampsia in low-resource settings. A retrospective cross-sectional study of women with severe preeclampsia giving birth in a tertiary referral centre in Zimbabwe between 01/01/2014-31/12/2018. Candidate variables identified from univariable logistic regression (p<0.2) were entered into stepwise backward elimination logistic regression models to predict composite adverse maternal and neonatal outcomes. Models' performance was assessed by the area under the curve of the receiver operator characteristic (AUC ROC). The models were validated internally using bootstrap-based methods and externally using the Preeclampsia Integrated Estimate of RiSk dataset. The co-primary outcomes were composite adverse maternal outcome and composite adverse neonatal outcome. 549 women had severe preeclampsia from whom 567 neonates were born. The predictive model for composite adverse maternal outcome included maternal age, gestational age on admission, epigastric pain, vaginal bleeding with abdominal pain, haemoglobin concentration and platelets; the AUC ROC was 0.796 (95% CI 0.758-0.833). External validation showed poor discrimination (AUC ROC 0.494, 95% CI 0.458-0.552). The model for composite adverse neonatal outcome included: gestational age, platelets, alanine transaminase and birth weight; the AUC ROC was 0.902 (95% CI 0.876-0.927). While the models accurately predicted composite adverse maternal and neonatal outcomes in the study population, they did not in another cohort. Understanding factors which affect model performance will help optimize prediction of adverse outcomes in severe preeclampsia.

Design and evaluation of a low-cost sphygmomanometer to monitor women with pre-eclampsia in low-resource settings

We developed and pilot tested a sphygmomanometer designed to monitor pregnant women in low-resource settings. Blood pressure was assessed in 138 subjects, including healthy adults (n=85), pregnant women (n=42), and women at-risk for pre-eclampsia (n=11) using the novel sphygmomanometer, manual auscultation, and the GE Dinamap Procare 400. Accuracy of the device was evaluated by comparing measurements of the test device and the Dinamap in healthy volunteers and pregnant women in Texas and in women at risk for pre-eclampsia in Malawi. Measurements from the test device in pregnant and healthy volunteer populations differed from those collected using the auscultatory method by 0.2 mmHg (95% CI: -18.8 to 19.2, systolic) and -2.8 mmHg (95% CI: -21.0 to 15.4, diastolic). In women at risk for pre-eclampsia, measurements with the test device differed from those of the Dinamap on average by 2.9 mmHg (95% CI: -29.3 to 35.1, systolic) and -5.4 mmHg (95% CI: -45.8 to 34.9, diastolic). Compared against the auscultatory method, measurements with the Dinamap differed on average by 0.0 mmHg (95% CI: -31.8 to 31.9, systolic) and -3.7 mmHg (95% CI: -28.6 to 21.3, diastolic). Accuracy was reduced when patients were moving or not seated during measurement. When testing the device against British Hypertension Society standards, the device achieved a grade of A/A in pregnant persons. This sphygmomanometer has the potential to provide low-resource hospitals with an affordable, accurate option for regular blood pressure monitoring. However, algorithm improvements are needed to reduce sensitivity to subject motion and posture.

HIGH PREVALENCE AND SEVERITY OF POSTPARTUM RETINOVASCULAR CHANGES FOLLOWING PRE- ECLAMPSIA WITH SEVERE FEATURES COMPARED TO NORMAL PREGNANCY.

Background: Hypertensive retinopathy complicates about 40-100% of pregnancies with hypertensive disorders and its severity worsens with progression of hypertension. Reactive retinal vessel changes demonstrably also mirror cardiovascular changes in the course of normal pregnancy. There is low utility of fundoscopy in assessing target organ damage and prognosis in pre-eclampsia in low resource setting. Objective: To compare postpartum maternal retinovascular (RV) findings between pregnancies complicated with preeclampsia with severe features (PES) and normal pregnancies at Kenyatta National Hospital (KNH). Methodology: Design: Comparative cross-sectional study conducted between May 2017 and March 2018. Setting: KNH, a regional Teaching and Referral hospital. Study population: Sixty-five women within 72 hours postpartum without preexisting ocular or medical co morbidities following normal pregnancy (n=35) or pregnancies complicated with PES (n=30). Data collection: Participants were interviewed on sociodemographic and reproductive health characteristics and clinical parameters obtained from medical records. Visual acuity assessment was done using a portable LogMAR chart and non-mydriatic fundus photography used for retinovascular evaluation. RV changes were graded using Keith Wagner grading. Data analysis: Postpartum retinovascular findings and severity grades were analyzed and presented as percentages and compared between the two groups using Chi square or Fisher’s exact test. Odds ratios (OR) of retinovascular changes following pre-eclampsia compared to normal pregnancy was estimated. A p value of &lt;0.05 and 95% confidence interval (CI) that doesn’t include the null value were considered significant. Results: Overall prevalence of hypertensive retinovascular change was 90.8% (83.3% in PES versus 97.1% in normal pregnancies). We found statistically significantly greater odds, OR 5.05 CI (0.93, 27.6) of severe retinovascular changes after pregnancies complicated with PES (p=0.045). Conclusion: There is high but comparable prevalence of maternal retinovascular changes within 72 hours postpartum after pregnancies complicated with PES or normal pregnancy. PES is associated with greater odds of postpartum retinovascular changes Compared to normal pregnancies.

Cost effectiveness of medical devices to diagnose pre-eclampsia in low-resource settings

BackgroundMaternal mortality remains a major health challenge facing developing countries, with pre-eclampsia accounting for up to 17% of maternal deaths. Diagnosis requires skilled health providers and devices that are appropriate for low-resource settings. This study presents the first cost-effectiveness analysis of multiple medical devices used to diagnose pre-eclampsia in low- and middle-income countries (LMICs). MethodsBlood pressure and proteinuria measurement devices, identified from compendia for LMICs, were included. We developed a decision tree framework to assess the cost-effectiveness of each device using parameter values that reflect the general standard of care based on a survey of relevant literature and expert opinion. We examined the sensitivity of our results using one-way and second-order probabilistic multivariate analyses. ResultsBecause the disability-adjusted life years (DALYs) averted for each device were very similar, the results were influenced by the per-use cost ranking. The most cost-effective device combination was a semi-automatic blood pressure measurement device and visually read urine strip test with the lowest combined per-use cost of $0.2004 and an incremental cost effectiveness ratio of $93.6 per DALY gained relative to a baseline with no access to diagnostic devices. When access to treatment is limited, it is more cost-effective to improve access to treatment than to increase testing rates or diagnostic device sensitivity. ConclusionsOur findings were not sensitive to changes in device sensitivity, however they were sensitive to changes in the testing rate and treatment rate. Furthermore, our results suggest that simple devices are more cost-effective than complex devices. The results underscore the desirability of two design features for LMICs: ease of use and accuracy without calibration. Our findings have important implications for policy makers, health economists, health care providers and engineers.

90 Petograph: Innovative and comprehensive monitoring tool for the integrated management of pre-eclampsia and eclampsia in low resource setting

Background Pre-eclampsia is a form of hypertensive disorder of pregnancy characterized by hypertension, proteinuria and oedema after 20 completed weeks of gestation.It is the second preventable cause of maternal mortality and morbidity. Aim To develop a universal monitoring tool, for the effective management of pre-eclampsia in low resource setting. Methodology/principle A. WHAT IS A PETOGRAPH? This is a new monitoring tool, invented to provide integrated graphical presentation of clinical condition of patients diagnosed of pre-eclampsia–eclampsia, in order to achieve prompt and effective intervention. It is an acronym meaning Pre- Eclamptic TOxaemia GRAPH (PETOGRAPH) B. WHY IS PETOGRAPH INVENTED i.To provide timely and effective care for pre-eclampsia. ii.To improve the quality of care and outcome of pregnant women who develop pre-eclampsia and eclampsia. iii.To provide evidence-based clinical practices in the management of women with pre-eclampsia and eclampsia. iv.To provide information that can effectively guide decision making for early intervention. v.To use the petograph as a data collection tool for Maternal Death Surveillance and Response (MDSR). C.WHERE DO WE USE THE PETOGRAPH 1.Health facility equipped with resources to manage pre-eclampsia–eclampsia 2.P.E.T (Pre-eclamptic Toxaemia) room 3.Labour room 4.Theatre 5.Antenatal care clinic D. WHO SHOULD USE THE PETOGRAPH 1.Doctors 2.Midwives 3.Clinical officers E. WHEN DO WE OPEN/FILL A PETOGRAPH Petograph is open after making a provisional diagnosis of pre-eclampsia–eclampsia Criteria for Diagnosis i.Gestational age (weeks of amenorrhea) at least 28 completed weeks (age of viability) ii.Persistent blood pressure of >160/110 mmHg iii.Proteinuria of at least0.3g/24 h iv. Oedema F. HOW DOES THE PETOGRAPH WORKS The petograph has eight (8) components 1. Biodata 2. Clinical history 3. Physical findings 4. Investigation results 5. Provisional diagnosis 6. Treatment plan 7. Graph 8. Particulars of the managing clinician Results Awaiting validation study results currently on going in five secondary and tertiary health centres in Uganda. Report on data collation and analysis to be available by 2nd week of July 2016. Conclusion To be concluded with validation results.

Towards biomarker-based tests that can facilitate decisions about prevention and management of preeclampsia in low-resource settings.

In recent years, an increasing amount of literature is emerging on candidate urine and blood-based biomarkers associated with incidence and severity of preeclampsia (PE) in pregnant women. While enthusiasm on the usefulness of several of these markers in predicting PE is evolving, essentially all work so far has focused on the needs of high-resource settings and high-income countries, resulting primarily in multi-parameter laboratory assays based on proteomic and metabolomics analysis techniques. These highly complex methods, however, require laboratory capabilities that are rarely available or affordable in low-resource settings (LRS). The importance of quantifying maternal and perinatal risks and identifying which pregnancies can be safely prolonged is also much greater in LRS, where intensive care facilities that can rapidly respond to PE-related health threats for women and infants are limited. For these reasons, simple, low cost, sensitive, and specific point-of-care (POC) tests are needed that can be performed by antenatal health care providers in LRS and that can facilitate decisions about detection and management of PE. Our study aims to provide a comprehensive systematic review of current and emerging blood and urine biomarkers for PE, not only on the basis of their clinical performance, but also of their suitability to be used in LRS-compatible test formats, such as lateral flow and other variants of POC rapid assays.

Treatment approaches for preeclampsia in low-resource settings: A randomized trial of the Springfusor pump for delivery of magnesium sulfate

Objective To test the safety, efficacy, and acceptability of a simple, mechanically flow-controlled pump (Springfusor®) for the delivery of magnesium sulfate for the treatment of preeclampsia. Design Eligible women ( n = 300) had blood pressure ⩾140/100 mm Hg, and proteinuria ⩾1+ (30 mgdL); the clinic team determined that they were likely to benefit from magnesium sulfate. Women were randomized to 24 h of magnesium sulfate by either IV administered by the Springfusor® pump ( n = 147) or standard hospital practice – IV loading dose administered manually followed by maintenance therapy using an IM route of administration ( n = 153). Main outcome measures Our primary outcome of interest was the safety and efficacy of the Springfusor pump including the side and adverse effects experienced during drug administration. Data on side effects, patient acceptability, delivery complications, and maternal and neonatal outcomes were collected. Results Fewer women stopped treatment due to side effects, toxicity, oliguria or renal failure, or women’s request in the Springfusor arm (4% or 6 of 147 women) compared to the Standard of Care arm (6.5% or 10 of 153 women). Women in the Springfusor arm reported significantly less nausea, headache, and pain than women in the Standard of Care arm. Almost all women (97%) in the Springfusor arm reported their pain level as ‘acceptable’ or ‘very acceptable’ compared to only 30% of women given the Standard of Care. Conclusion The Springfusor pump may offer an alternative to intramuscular administration of magnesium sulfate where electronic pumps are not available.

W11.1 The management of preeclampsia in low-resource settings

The optimal timing for surgery for patients with spinal cord injury without radiographic evidence of trauma (SCIWORET) remains unclear. This is especially true in the elderly, given that most studies are done with younger patients to avoid age-related comorbidities. We aimed to compare the efficacy of early (<24 hours postinjury) and late (>24 hours postinjury) surgery in patients with SCIWORET aged ≥65 years.We identified patients aged ≥65 years who underwent surgery for SCIWORET between January 1995 and February 2016. The primary outcome was a change in the Japanese Orthopaedic Association (JOA) score at discharge, with a recovery of >50% defined as a favorable neurologic outcome. Logistic regression analysis was performed, and model fit was assessed using the Hosmer–Lemeshow test.Eighty patients aged ≥65 years with SCIWORET underwent surgery were enrolled. Favorable neurologic outcomes were seen in 43.3% of those who underwent early surgery, but only in 18.0% of those who underwent late surgery. Logistic regression analysis, adjusted for age, sex, comorbidities (Charlson Comorbidity Index), and JOA score, revealed that early surgery independently predicted favorable outcomes (odds ratio, 4.06; 95% confidence interval, 1.25–13.20), with excellent calibration (Hosmer–Lemeshow, P = 0.857).The present study indicated that early surgery within 24 hours of injury for elderly patients with SCIWORET could lead to more favorable neurologic improvements. We believe that chronological age alone should not be considered sufficient justification to deny patients early surgical decompression for SCIWORET.

O645 Preeclampsia in low-resource settings: A randomized trial of IV MgSO4 via flow controlled pump

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S278-S278 Free communication (oral) presentations O645 Preeclampsia in low-resource settings: A randomized trial of IV MgSO4 via flow controlled pump S. Mundle, S. MundleSearch for more papers by this authorA. Regi, A. RegiSearch for more papers by this authorB. Biswas, B. BiswasSearch for more papers by this authorH. Bracken, H. BrackenSearch for more papers by this authorT. Easterling, T. EasterlingSearch for more papers by this authorB. Winikoff, B. WinikoffSearch for more papers by this author S. Mundle, S. MundleSearch for more papers by this authorA. Regi, A. RegiSearch for more papers by this authorB. Biswas, B. BiswasSearch for more papers by this authorH. Bracken, H. BrackenSearch for more papers by this authorT. Easterling, T. EasterlingSearch for more papers by this authorB. Winikoff, B. WinikoffSearch for more papers by this author First published: 06 October 2011 https://doi.org/10.1016/S0020-7292(09)61018-3Citations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S278-S278 RelatedInformation