The Global Impact of Pre-eclampsia and Eclampsia

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Over half a million women die each year from pregnancy related causes, 99% in low and middle income countries. In many low income countries, complications of pregnancy and childbirth are the leading cause of death amongst women of reproductive years. The Millennium Development Goals have placed maternal health at the core of the struggle against poverty and inequality, as a matter of human rights. Ten percent of women have high blood pressure during pregnancy, and preeclampsia complicates 2% to 8% of pregnancies. Preeclampsia can lead to problems in the liver, kidneys, brain and the clotting system. Risks for the baby include poor growth and prematurity. Although outcome is often good, preeclampsia can be devastating and life threatening. Overall, 10% to 15% of direct maternal deaths are associated with preeclampsia and eclampsia. Where maternal mortality is high, most of deaths are attributable to eclampsia, rather than preeclampsia. Perinatal mortality is high following preeclampsia, and even higher following eclampsia. In low and middle income countries many public hospitals have limited access to neonatal intensive care, and so the mortality and morbidity is likely to be considerably higher than in settings where such facilities are available. The only interventions shown to prevent preeclampsia are antiplatelet agents, primarily low dose aspirin, and calcium supplementation. Treatment is largely symptomatic. Antihypertensive drugs are mandatory for very high blood pressure. Plasma volume expansion, corticosteroids and antioxidant agents have been suggested for severe preeclampsia, but trials to date have not shown benefit. Optimal timing for delivery of women with severe preeclampsia before 32 to 34 weeks' gestation remains a dilemma. Magnesium sulfate can prevent and control eclamptic seizures. For preeclampsia, it more than halves the risk of eclampsia (number needed to treat 100, 95% confidence interval 50 to 100) and probably reduces the risk of maternal death. A quarter of women have side effects, primarily flushing. With clinical monitoring serious adverse effects are rare. Magnesium sulfate is the anticonvulsant of choice for treating eclampsia; more effective than diazepam, phenytoin, or lytic cocktail. Although it is a low cost effective treatment, magnesium sulfate is not available in all low and middle income countries; scaling up its use for eclampsia and severe preeclampsia will contribute to achieving the Millennium Development Goals.

Section snippets

Maternal Health is a Human Right

More than 30 years ago, the high maternal mortality in low- and middle-income countries was highlighted as a “neglected tragedy.”3 Although the risk of maternal death has reduced in some of these countries over the intervening years, little has improved for many with the highest mortality. Nevertheless, most maternal deaths are potentially avoidable. Most could be prevented by access to appropriate maternity services and to emergency obstetric care, and many of the root causes are related to

Pre-eclampsia and Eclampsia

Hypertension is common during pregnancy. Approximately 10% of women will have their blood pressure recorded as above normal at some point before delivery. Pre-eclampsia, defined as hypertension accompanied by proteinuria,9 usually occurs during the second half of pregnancy and complicates 2%-8% of pregnancies.10 For women who have mild to moderate hypertension alone, pregnancy outcome is similar to that for women with normal blood pressure. Once proteinuria develops, or blood pressure becomes

Mortality and Morbidity for Women

Eclampsia is rare in Europe, with 2 to 3 cases reported per 10,000 births.11, 12 In developing countries, eclampsia is more common, with the incidence estimated as 16-69 cases per 10,000 births.13 Although rare, eclampsia accounts for more than 50,000 maternal deaths each year.14 Overall, 10%-15% of direct maternal deaths are associated with pre-eclampsia and eclampsia in low- and middle-income countries.14, 15 Ninety-nine percent of maternal deaths occur in low- and middle-income countries.1

Mortality and Morbidity for Infants

Pre-eclampsia can affect blood supply to the placenta, leading to poor intrauterine growth, and can precipitate preterm birth. Therefore, risks for the infant are also increased. Pre-eclampsia is an antecedent for up to 12% of infants born small for gestational age35 and one-fifth of those born preterm.36 Perinatal mortality is high after pre-eclampsia,18, 37 and even higher after eclampsia.13, 27, 38 One-quarter of stillbirths and neonatal deaths in developing countries are associated with

Long-term Sequelae for Women and Children

Whether pre-eclampsia and eclampsia have long-term implications for the health and well-being of the women remains uncertain. Nevertheless, there is growing evidence that women who have had gestational hypertension or pre-eclampsia are at increased risk later in life for hypertension, stroke, and ischemic heart disease.46, 47, 48 What is less clear is whether this reflects a common pathway, or whether having pre-eclampsia increases this risk.49

There are also long-term consequences for the

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