MATERNA
TABLE OF
contents 1
Foreword Message - Prof. Jean Calleja Agius
2
Foreword Message - Michaela Zammit
3
Editors' Message
4
Postnatal Care and Postpartum Depression
8
Antenatal Screening
10
Designed by Owen Cachia
The importance of monitoring for pre-eclampsia in antenatal care
Foreword Message Prof. Jean Calleja Agius 6th March 2021. This day marks the 1st anniversary since the very first case of COVID-19 was identified by the Superintendency of Public Health in Malta. Like every other country in the world, the swift initial response to the COVID-19 pandemic was based on the basic principles of infection control, intended to protect all citizens. However, many countries were unprepared for a global pandemic of this magnitude and, in particular, for the multifactorial consequences on national healthcare systems. Maternity care bore the brunt. While grappling with the rapidly changing public health crisis, many institutions imposed significant restrictions on key aspects of provision of maternity service. This included prohibiting access of the birth partner as a companion in labour, reducing the level of contact between a mother and her baby and placing limitations on breastfeeding . While these interventions were introduced to keep women, babies, and healthcare staff safe from transmission of COVID-19, questions are now being raised across Europe about the appropriate balance between optimal maternity care and infection control. This is of particular concern in terms of the longer term clinical and psychosocial consequences for the mother, her baby, and the family. Stories are beginning to emerge where, women are reporting that they have been traumatised by both reduced access to professional care. These stories have fuelled fear for some women, especially in the absence of good quality information from official sources, and in the context of alarming social media comments. As a consequence, there are reports that substantial minorities of women across Europe around the world have not been accessing publicly provided maternity services, either because they are no longer on offer, or for fear of infection, or because they do not want to be isolated and separated from their accompanying partner. In some cases, this has resulted in an increase in private consultations, if they could afford them, thus widening the gap in health inequality.
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Many antenatal clinics and preparation for birth classes were replaced with virtual support. Most services required women having ultrasound screening to come alone, facing the possible diagnosis of a fetal anomaly, or even of intrauterine death, without the presence and support of their partner or significant other. Serious limitations were placed on community services, such as support for breastfeeding. In the case of medical students and future medical doctors, SCORA has an important role to play in raising awareness about the importance of professional maternity care, especially in this time of global crisis. Access to antenatal, intrpartum and postnatal care is a basic human right, irrespective of circumstances. In birth, and likewise, in death, the first to be stifled has been the human basic rights towards the entrance and the exit to our own humanity, with persons being born and dying ALONE. Healthsystems must strive so that despite this particular pandemic, maternity care and birth becomes more humane. SCORA, which I am proud to have been the one to set it up way back in 1997 in my third year of the MD course, is very well-placed to empower medical students to be the voice of the vulnerable, and are compassionate to those who are rendered voiceless.
PROF. JEAN CALLEJA AGIUS M.D.(MELIT.),PH.D.(LOND.),F.R.C.O.G.(LOND.), F.R.C.P.I.(DUBLIN),M.SC.(CLINICAL EMBRYOLOGY)(LEEDS)
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Foreword Message Michaela Zammit For another year the Sexual and Reproductive Health Team in the Malta Medical Students’ Associations brings to you the MATERNA journal! The idea for this journal formulated 1 year ago, we were hit with a pandemic and didn’t want to scrap any work we put towards our maternal health campaign. A year later, still living through a pandemic, we have introduced the MATERNA journal once more.
To all our readers, I hope you enjoy reading through this journal and find some comfort in it as expectant mothers and their family members.
As you read through this online journal, you will find different articles and pieces written by medical students and MMSA members. The articles will give you a better idea of what maternal health is and different aspects of it, including mental health in the form of postpartum depression, antenatal care and more! We also aim to delve into how COVID-19 affected mothers, not only as an infection but also how the normal process of giving birth at our hospitals have changed drastically throughout the pandemic. Maternal health is an important aspect of our reproductive health that one must not overlook. The focus our organisation has taken on this year is mental health, and here I would like to emphasise the essentiality of prioritising your mental health, before, during and after pregnancy. It is important also to avoid stigmatising mothers who may suffer with their mental health, providing support instead. I would like to take the opportunity to thank all the student writers for such a wonderful job in taking part in our journal, as this would not be possible without your contribution! I would like to express my gratitude to Professor Jean Calleja Agius for supporting our journal once again and providing us with a great insight into the world of maternal health and expectant mothers in these times. I would also like to thank my team, my MAMA campaign coordinators Daniela Chatlani and Jennifer Xuereb, and my assistant Francesca Karlsson for their dedication and perseverance throughout this project. Last but not least, a big thank you to the MMSA Board of Directors who supported this project, and to Owen Cachia for bringing the journal to life with his wonderful design!
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MICHAELA ZAMMIT (MD3) SCORA OFFICER 2020/2021
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Editors' Message DANIELA CHATLANI & JENNY XUEREB
Dear Reader,
We are very eager and grateful to have been given the opportunity to present this year’s MAMA Campaign journal! Our aim as SCORA is to raise awareness on the importance of sexual and reproductive health, which also encompasses that of maternal health. We took the initiative to coordinate this campaign due to having both a great interest in the topic and also a common wish to challenge misinformation regarding pregnancy and the health of the mother; before, during and after pregnancy. A common misconception is that maternal health is only limited to a certain group of people in society. While it does affect pregnant women the most, maternal health affects all of us and good maternal health, physical and mental, is a key indicator of where society stands. We are very proud to live in a country which has only had 2 maternal deaths in a decade (2006-2016). Malta also has one of the lowest rates in Europe for post-partum complications. We hope this journal will contribute in some way into keeping these statistics the way they are. Within this journal, one may find articles regarding antenatal care and its importance in mothers with preeclampsia. This is a crucial topic to cover, as good care reduces the risks of stillbirths and allows the mother to be more educated as she receives appropriate and timely advice regarding her pregnancy. Postnatal care is also important and is sometimes neglected. In fact, mothers or newborns may have health implications which are detrimental to their health and wellbeing such as postpartum depression, which is a very common yet overlooked disorder, that will be further discussed within this journal. We would like to especially thank Prof. Calleja Agius for kindly accepting to write our foreword message which helps to raise awareness on the link between COVID-19 and pregnancy. Furthermore, we would also like to thank our SCORA Officer Mick Zammit who continually guided and supported us throughout the campaign.
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Lastly, we would like to show our appreciation towards each contributing author who took the time and dedication to write their articles.
DANIELA CHATLANI (MD3)
JENNY XUEREB (MD2)
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Postnatal Care and Postpartum Depression KELSEY MARKHAM (MD4) & MARK MIRUZZI (MD4)
The postnatal period includes all aspects that involve the mother and the baby. It commences immediately, and extends up to 42 days (6 weeks) after birth. However, it may be extended further if there are associated complications (Mathai, Xylander & Zupan, 2010). Postnatal care describes the individualized care given to the mother and the baby in this postnatal period (National Institute for Health and Care Excellence (NICE, 2013)). This stagemarks a new phase of life for the mother, as well as the beginning of life for the neonate. The postnatal period consists of the immediate, the early and the late periods. The immediate postnatal period spans the first 24 hours after the birth. This encompasses close supervision by a trained attendant as it is the most crucial timeframe for the neonate. It is said that the first 48 hours after birth are when the neonate is at greatest risk of dying ("Postnatal care Healthy Newborn Network", 2021). The early postnatal period starts from day 2 till day 7 and the late postnatal period starts from day 8 until day 42 (Mathai, Xylander & Zupan, 2010). Postnatal care is essential and should identify any alterations from expected recovery after birth (NICE, 2013). During the immediate postnatal period, a full clinical examination has to be carried out around an hour after birth, just after the baby’s first breastfeed. The baby should be examined again before being discharged home. It is vital that healthy mothers and their new-born are kept for observation for at least 24 hours after birth. This is to ensure that the mother’s bleeding is controlled, if any, that there are no signs of infections or other diseases in the mother as well as in the baby, and that the baby is breastfeeding without difficulty.
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The mother and the baby need to be followed up after discharge, and must have at least four postnatal check-ups in the first 6 weeks, including the initial full examination occurring in the first 24 hours. The other follow ups include day 3 (48-72 hours), between days 7 and 14, and 6 weeks after birth. These checkups can be made at home or in a health facility, depending on the situation and the provider. Home visits by midwives or other skilled workers in the field can also be considered during the first week (WHO, 2013), in order to ascertain that the mother and the baby are coping well. The postpartum period can have certain detrimental effects too. Some mothers might experience a mental health disorder associated with childbirth. Three main psychiatric conditions affect women in this period: third-day blues, postpartum depression, and postpartum psychosis. Post-traumatic stress disorder can occur in mothers who suffer from particularly traumatic events during childbirth. Third-day blues are by far the commonest, affecting 50 to 70% of mothers. Clinical factors that help to differentiate from postpartum depression are the onset of symptoms between the third and fifth days after the birth of the baby, and the transient nature of the emotional lability. The mother commonly feels irritable, depressed, and tearful (M'baïlara et al., 2005). This state typically lasts less than a week. Good antenatal care involves providing reassurance that this is a common transient state, providing social support and giving practical advice to new mothers regarding how to take proper care of their baby.
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Postnatal Care and Postpartum Depression KELSEY MARKHAM (MD4) & MARK MIRUZZI (MD4)
The next commonest condition is postpartum depression, affecting 8 to 20% of mothers within a year following childbirth. In order to be able to diagnose PPD, the onset of major depressive episodes must be within the first 4 weeks after giving birth. The same criteria for major depressive disorder can be applied to PPD, and five or more of nine signs or symptoms must be present for at least 2 weeks, with at least one being an essential diagnostic feature. Essential diagnostic features: 1. Persistent low mood 2. Persistent anhedonia Additional diagnostic signs and symptoms: 3. Changes in appetite or body weight (increase or decrease) 4. Persisting insomnia or hypersomnia 5. Changes in psychomotor activity (agitated or slowed) 6. Persisting fatigue or energy loss 7. Feelings of worthlessness or excessive guilt 8. Persisting problems concentrating or making decisions 9. Recurring thoughts of death or suicide (Bobo & Yawn, 2014)
One must consider the variety of risk factors for postpartum depression. Maternal age of less than 16, depression during pregnancy, family history of depression, lack of support from husband or family, restricted access to medical antenatal care, medical complications during pregnancy are all associated with increased risk of development of postpartum depression. When several risk factors are present, there will be a cumulatively high risk and the clinician must screen for symptoms and institute appropriate management early. As discussed by
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Slomian et al. in 2019, maternal depression can have important negative consequences on the mother-child bond and the baby’s ability to maximise neurodevelopmental, behavioural, and emotional achievement. The Edinburgh Postnatal Depression Scale is a useful screening tool (Cox et al., 1987, see figure): a total score of 13 or more is the benchmark highlighting the need for follow up. Management of postpartum depression is biopsychosocial: it is a patientcentred approach that utilises the expertise of several healthcare professionals. Initial management is support and encouragement, with pharmacotherapy (SSRIs: selective serotonin reuptake inhibitors) used if such measures are not enough. If breastfeeding, care must be taken when giving an antidepressant medication. Sertraline is the drug of choice in breastfeeding mothers as it is considered relatively safe due to its low translactal passage (Bobo & Yawn, 2014). The physician should listen empathically and provide assistance in solving psychological and pragmatic issues related to becoming a mother. Psychotherapy has been proven to be effective (Perlstein et al., 2009), and includes cognitive behavioural therapy and couple therapy. Postnatal psychotic depression affects 1-3 per 1000 women: in this condition, the features of mood disorder that are present in postpartum depression are accompanied by delusions or hallucinations or both. The content of the delusions can be related to the death of the baby. It starts in the first 3 weeks after childbirth. Postnatal care should not be taken lightly and mothers and their partners should be informed and educated about what happens normally during
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Postnatal Care and Postpartum Depression KELSEY MARKHAM (MD4) & MARK MIRUZZI (MD4)
this period. Any dangers have to be ruled out in regard to the mother’s health, as well as the baby’s health, and this should not be compromised in any way. If any abnormalities are noticed and detected in the postnatal period check-ups, the mother and the baby must be referred for further investigations and treatment, if deemed necessary ("OLCreate: HEAT_PNC_ET_1.0 Postnatal Care Module: 2. The Normal Puerperium: 2.3 In conclusion", 2021).
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Postnatal Care and Postpartum Depression KELSEY MARKHAM (MD4) & MARK MIRUZZI (MD4) References: Bobo, W., & Yawn, B. (2014). Concise Review for Physicians and Other Clinicians: Postpartum Depression. Mayo Clinic Proceedings, 89(6), 835-844. doi: 10.1016/j.mayocp.2014.01.027 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 Jun;150:782-6. doi: 10.1192/bjp.150.6.782. PMID: 3651732. Impey, L., & Child, T. (2017). Obstetrics & gynaecology. Katona, C., Cooper, C., & Robertson, M. (2016). Psychiatry at a Glance (6th ed.). Chichester: WileyBlackwell. Mathai, M., Xylander, S., & Zupan, J. (2010). WHO technical consultation on postpartum and postnatal care. M'baïlara K, Swendsen J, Glatigny-Dallay E, Dallay D, Roux D, Sutter AL, Demotes-Mainard J, Henry C. Le baby blues: caractérisation clinique et influence de variables psycho-sociales [Baby blues: characterization and influence of psycho-social factors]. Encephale. 2005 May-Jun;31(3):331-6. French. doi: 10.1016/s0013-7006(05)82398-x. PMID: 16142048.
KELSEY MARKHAM (MD4)
National Institute for Health and Care Excellence. (2013). Postnatal care. https://www.nice.org.uk/guidance/qs37/resources/post natal-care-pdf-2098611282373 Oats, J., Llewellyn-Jones, D., Abraham, S., LlewellynJones, D., & Elsevier (Amsterdam). (2017). LlewellynJones fundamentals of obstetrics and gynaecology. Edinburgh [etc.: Elsevier. OLCreate: HEAT_PNC_ET_1.0 Postnatal Care Module: 2. The Normal Puerperium: 2.3 In conclusion. (2021). Retrieved 27 February 2021, from https://www.open.edu/openlearncreate/mod/ouconten t/view.php?id=336&section=20.5 Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009 Apr;200(4):357-64. doi: 10.1016/j.ajog.2008.11.033. PMID: 19318144; PMCID: PMC3918890. Postnatal care - Healthy Newborn Network. (2021). Retrieved 26 February 2021, from https://www.healthynewbornnetwork.org/issue/postna tal-care/ Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes [published correction appears in Womens Health (Lond). 2019 Jan-Dec;15:1745506519854864]. Womens Health (Lond). 2019;15:1745506519844044. doi:10.1177/1745506519844044 WHO. (2013). WHO recommendations care of the mother and newborn.
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on
KELSEY MARKHAM (MD4)
Postnatal
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Antenatal Screening GABRIELLE GRIXTI (MD3)
Antenatal screening aims to identify people at high risk of giving birth to babies with genetic disorders such as Down’s syndrome, Sickle cell disease (SCD), and Thalassaemia; or structural disorders such as Spina Bifida, kidney, brain, or limb defects. This can help pregnant women make informed decisions regarding further diagnostic tests.
which causes Down’s syndrome, and there are also cases of live births with trisomy 18 which causes Edwards’ syndrome, and trisomy 13 which causes Patau’s syndrome. However, trisomy 18 and 13 babies are commonly spontaneously aborted. With increasing maternal age, there is an increased likelihood of these aneuploidies (Loane et al., 2013).
Ultrasound (US) scans & Pregnancy
Screening is mainly done via US measurements, including the nuchal translucency scan, maternal serum analysis, and maternal age to determine whether there is a high risk score (Harraway, 2017). A positive nuchal translucency scan showing a larger amount of fluid in the nuchal area than expected, or a high risk result, is suggestive of Down’s syndrome, however it is not diagnostic. For diagnosis of Down’s syndrome further tests need to be carried out, such as amniocentesis or chorionic villus sampling, where foetal cells are obtained and then analysed. Being invasive procedures, there are risks of complications both for the mother and the foetus, including a slight risk of miscarriage (Kazal et al., 2018).
US scans are vital to monitor foetal growth and to check for physical abnormalities. Generally pregnant women have at least 2 US scans throughout their pregnancy, and such scans are painless and safe for both the mother and the baby (Abramowicz, 2013). The first scan is the dating scan which is usually done at around 12 weeks, and this scan aims to determine the baby’s due date and assess for multiple pregnancies. The second scan is done at around 20 weeks, and is called the anomaly or morphology scan to identify any foetal structural abnormalities. This scan can assess for Spina Bifida, heart defects, kidney problems, certain brain developmental abnormalities, as well as limb defects. A third scan can be done, which is called the nuchal translucency scan and screens for Down’s syndrome. This scan is done before week 13, and can be done in conjunction with the dating scan. Aneuploidy screening
Chromosomal abnormalities involving entire chromosome deletions are termed aneuploidies (Wapner et al., 2012). The most common aneuploidies which survive to birth are namely trisomy 21
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Haemoglobinopathy screening
Haemoglobinopathies (haemoglobin disorders) are highly prevalent in 71% of the world’s 229 countries, namely in those where consanguineous marriages are common (Chakravorty &; Dick, 2019). The main haemoglobinopathies that are screened for are Sickle Cell Disease, and Thalassaemia, which is carried out through a combination of blood tests and from adetailed family history. The aim of such screening is to start treatment as early as possible, hence reducing the morbidity and mortality in infancy (Bain, 2009).
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Antenatal Screening GABRIELLE GRIXTI (MD3)
Conclusion
Antenatal screening can be done to identify aneuploidy disorders such as Down’s syndrome, Edwards’ syndrome and Patau’s syndrome. Haemoglobinopathies such as Sickle Cell Disease and thalassaemia can also be screened for. Screening is carried out via blood tests, or US scans, which are carried out during week 12 and 20 of one’s pregnancy. References: Abramowicz JS. Benefits and risks of ultrasound in pregnancy. Semin Perinatol. 2013 Oct;37(5):295-300. doi: 10.1053/j.semperi.2013.06.004. PMID: 24176149. Bain, B J. "Neonatal/newborn Haemoglobinopathy Screening in Europe and Africa." Journal of Clinical Pathology 62.1 (2009): 53-56. Web. Chakravorty S, Dick MC. Antenatal screening for haemoglobinopathies: current status, barriers and ethics. Br J Haematol. 2019 Nov;187(4):431-440. doi: 10.1111/bjh.16188. Epub 2019 Sep 11. PMID: 31509241. Harraway J. Non-invasive prenatal testing. Aust Fam Physician. 2017 Oct;46(10):735-739. PMID: 29036772. Kazal RK, Chowdhury SA, Mirza TT, Pervin HH, Noor F, Chakma B, Aalpona FZ. Feasibility and Safety of Chorionic Villus Sampling (CVS) for Prenatal Diagnosis of Thalassemia in Bangladesh. Mymensingh Med J. 2018 Jul;27(3):578-584. PMID: 30141449. Loane M, Morris JK, Addor MC, et al. Twenty-year trends in the prevalence of Down syndrome and other trisomies in Europe: Impact of maternal age and prenatal screening. Eur J Hum Genet 2013;21(1):27–33 Wald NJ, Kennard A, Hackshaw A, McGuire A. Antenatal screening for Down's syndrome. Health Technol Assess. 1998;2(1):i-iv, 1-112. PMID: 9561893. Wapner RJ, Martin CL, Levy B, et al. Chromosomal microarray versus karyotyping for prenatal diagnosis. N Engl J Med 2012;367(23):2175–84
GABRIELLE GRIXTI (MD3)
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The importance of monitoring for pre-eclampsia in antenatal care LORNA MUSCAT BARON (MD1)
Pre-eclampsia is a pregnancy related disorder which has a very wide range of incidence, found from 2-8% of all pregnancies (Ghulmiyyah & Sibai, 2012; Young, Levine, & Karumanchi, 2010). It is characterised by the development of hypertension and proteinuria during pregnancy, which end once the placenta is removed after delivery (Espinoza, Vidaeff, Pettker, & Simhan, 2019). There are several complications associated with the development of pre-eclampsia in pregnancy due to dangerously high blood pressure levels such as liver and kidney failure, placental abruption, the development of HELLP syndrome ( haemolysis, elevated liver enzymes, low platelet levels, fetal growth restriction, low birthweights, and even fetal and maternal mortality (Kongwattanakul, Saksiriwuttho, Chaiyarach, & Thepsuthammarat, 2018). Pre-eclampsia may evade diagnosis to the extent that it is usually diagnosed late in pregnancy at 20 weeks gestation, due its heterogenous presentation, and lack of a specific test or treatment. It is only confirmed once multiple clinical tests have been run and all criteria met. Its diagnosis requires a high blood pressure of at least 140/90, and the presence of proteinuria (Young et al., 2010). However, some patients do not show proteinuria, and instead present with other gestational complications such as thrombocytopenia, renal insufficiency or impaired liver function (Espinoza et al., 2019). The only known cure for pre-eclampsia is delivery of the baby, however whilst this may end the immediate maternal risks, there are several long-term effects after having developed pre-eclampsia. Women who have had pre-eclampsia are at high risk of developing atherosclerosis and future hypertension, with a two-fold increase in future risk of developing
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wcardiovascular and cerebrovascular disease (Hod, Cerdeira, & Karumanchi, 2015). Women who developed preeclampsia, as well as their children, have had higher inflammatory and antiangiogenic maternal markers with reduced endothelial function, indicating a possible inherited risk of developing cardiovascular disease (Kvehaugen et al., 2011). Proper antenatal care can prevent the development of pre-eclampsia and severe pre-eclampsia, decreasing hospitalisation, mortality rates and serious future medical complications (Hod et al., 2015). To ensure proper antenatal care, pregnant women must be characterised as high risk for developing preeclampsia from the first antenatal visit. There are many high risk factors for preeclampsia, such as being primigravida, multiple gestation, having a Body Mass Index over 30kg/m2, maternal age being over 35, the mother being a diabetic, having a previous pregnancy with preeclampsia or high blood pressure and the use of assisted reproductive technology. All these characteristics increase the risk of a woman developing pre-eclampsia whilst pregnant (Espinoza et al., 2019). A noted drug with preventative and protective effects on the placenta against the development of preeclampsia is aspirin. Aspirin is commonly taken as a painkiller, due to its effects on inhibition of cyclooxygenases, preventing the production of prostaglandin, which cause inflammation, fever and pain (Flower, 2003). Aspirin is sometimes given in low doses (75mg) to pregnant women, who are at high risk of developing pre-eclampsia. Aspirin in the placenta is known to have various biochemical effects, not all of which
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The importance of monitoring for pre-eclampsia in antenatal care LORNA MUSCAT BARON (MD1)
have been elucidated. It is known to increase total cellular RNA, increasing its cytoprotective effects, inducing trophoblast migration and invasion into the endometrium, as well as inhibiting sFLT1, which would otherwise decrease trophoblastic invasion and increase endothelial dysfunction (Lin, Li, Zhang, Wang, & Yang, 2019; Su et al., 2019). When women are prescribed aspirin due to high-risk factors being identified early, an 18% in risk reduction of developing pre-eclampsia is noted, besides the protection conferred to the fetus. An 8% decrease in preterm births has been noted, and an overall, 14% fetal and neonatal mortality reduction has also been noted (Duley, Meher, Hunter, Seidler, & Askie, 2019). The American College of Obstetricians and Gynaecologists (ACOG) in the ‘Hypertension in Pregnancy Task Force Report’, recommended to women identified as high risk for developing preeclampsia, a prescription of low dose aspirin from 12 weeks gestation to 38 weeks gestation (American College of Obstetricians and Gynecologists, 2013). There is also evidence to suggest that placentation can be improved by starting aspirin as early as possible in pregnancy before 16 weeks can have even greater positive effects (Loussert et al., 2020). Management also includes repeated monitoring of the maternal blood pressure, which should be routine during every antenatal appointment, especially for those identified as high-risk patients for the development of pre-eclampsia. These women should also be seen more frequently, with regular urine checks, and growth assessments for fetal growth restriction (English, Kenny, & McCarthy, 2015).
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Once a woman develops pre-eclampsia, there is limited management options other than delivery. However, if the woman develops pre-eclampsia exceedingly early in pregnancy and is forced to have a preterm birth, this mode of management is associated with dire clinical neonatal complications related with prematurity. High blood pressure can be managed to a certain extent by alpha beta-blockers and vasodilators such as labetalol and hydralazine, calcium channel blockers such as nifedipine can also be considered in acute hypertensive emergency. If the hypertensive emergency results in maternal seizures, magnesium sulfate can be administered intravenously. However, these will not prevent the progression of preeclampsia, nor will they completely protect the woman from more severe pre-eclampsia developing (Amaral, Wallace, Owens, & LaMarca, 2017). Since there is limited action possible once pre-eclampsia is diagnosed, the ideal would be to identify high-risk women on their first antenatal visit and prescribe aspirin early in pregnancy, as well as monitor these high-risk women closely. However, since nulliparity is one of the risk factors, many women who later go on to develop pre-eclampsia previously had no identifiable comorbidities, as pre-eclampsia has no known cause (English et al., 2015). Use of maternal history – if there is any, and comorbidities only are able to identify 45% of women who later develop preeclampsia, and this assessment does not include determination of how severe the pre-eclampsia will be (Christina et al., 2005). There are potential screening tests
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The importance of monitoring for pre-eclampsia in antenatal care LORNA MUSCAT BARON (MD1)
which are being studied, to implement the use of early pregnancy biomarkers in pregnancy for the detection of preeclampsia before it begins clincially. Biomarkers such as sFLT1 have been identified as significantly higher in women who later develop pre-eclampsia, as early as the first trimester (Bian, Shixia, & Duan, 2015). Other studies have shown that sFLT1 can also predict the severity of the pre-eclampsia to develop (Maynard et al., 2003). Other biomarkers are also being considered, with women who would later develop pre-eclampsia having significantly lower levels of PlGF and even lower levels when they are to develop severe pre-eclampsia (Kim, Lee, Jeong, Sung, & Kim, 2009; Levine et al., 2004; Thadhani et al., 2004). However, until now, no early in pregnancy biomarker test has been approved for clinical use. New treatments have also been attempted, such as the use of apheresis to enable the extracorporeal removal of sFLT1, resulting in the stabilisation of blood pressure and proteinuria with even just one treatment. Consequently, extending gestational age, as well as enabling fetal weight gain (Thadhani et al., 2011; Thadhani et al., 2016). Other novel treatment studies include the use of metformin, and the introduction of VEGF infusion to reduce hypertension (Brownfoot et al., 2016; Gilbert et al., 2010). Pre-eclampsia is a severe pregnancy complication with many associated clinical complications. There is no definitive test for its detection, and when develops, clinical management is limited. Awareness on the implications of substandard management when a patient has significant comorbidities can increase the uptake of use of aspirin, which decreases the risk of developing this severe pregnancy complication.
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Along with current treatment protocols, early pregnancy detection testing, and pre-eclampsia treatments are needed to ensure optimal clinical care.
References Amaral, L. M., Wallace, K., Owens, M., & LaMarca, B. (2017). Pathophysiology and current clinical management of preeclampsia. Current Hypertension Reports, 19(8), 1-6. American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. report of the american college of obstetricians and gynecologists’ task force on hypertension in pregnancy. Obstetrics and Gynecology, 122(5), 11221131. Bian, Z., Shixia, C., & Duan, T. (2015). First-trimester maternal serum levels of sFLT1, PGF and ADMA predict preeclampsia. PloS One, 10(4), e0124684. Brownfoot, F. C., Hastie, R., Hannan, N. J., Cannon, P., Tuohey, L., Parry, L. J., . . . Tong, S. (2016). Metformin as a prevention and treatment for preeclampsia: Effects on soluble fms-like tyrosine kinase 1 and soluble endoglin secretion and endothelial dysfunction. American Journal of Obstetrics and Gynecology, 214(3), 356. e1-356. e15.
Christina, K., Smith, G. C., Papageorghiou, A. T., Cacho, A. M., Nicolaides, K. H., & Fetal Medicine Foundation Second Trimester Screening Group. (2005). An integrated model for the prediction of preeclampsia using maternal factors and uterine artery doppler velocimetry in unselected low-risk women. American Journal of Obstetrics and Gynecology, 193(2), 429-436. Duley, L., Meher, S., Hunter, K. E., Seidler, A. L., & Askie, L. M. (2019). Antiplatelet agents for preventing pre‐eclampsia and its complications. Cochrane Database of Systematic Reviews, (10) English, F. A., Kenny, L. C., & McCarthy, F. P. (2015). Risk factors and effective management of preeclampsia. Integrated Blood Pressure Control, 8, 7-12.doi:10.2147/IBPC.S50641 [doi] Espinoza, J., Vidaeff, A., Pettker, C. M., & Simhan, H. (2019). Gestational hypertension and preeclampsia. Obstetrics and Gynecology, 133(1), E1-E25. Flower, R. (2003). What are all the things that aspirin does? BMJ (Clinical Research Ed.), 327(7415), 572-573.
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