Critical barriers for preeclampsia diagnosis and treatment in low-resource settings: An example from Bolivia

Increased adherence to ACOG diagnostic guidelines for HDP following a workshop in Bolivia, a LMIC

OBJECTIVES

Hypertensive disorders of pregnancy (HDP) exert a heavy mortality burden in low- to middle-income countries (LMIC). ACOG revised HDP diagnostic guidelines to improve identifying pregnancies at greatest risk but whether they are used in LMIC is unknown.

STUDY DESIGN

We held a workshop to review ACOG guidelines in La Paz, Bolivia (BO) and then reviewed prenatal, labor and delivery records for all HDP diagnoses and twice as many controls at its three largest delivery sites during the year before and the nine months after a workshop (n = 1376 cases, 2851 controls during the two periods).

MAIN OUTCOME MEASURES

HDP diagnoses, maternal, and infant characteristics.

RESULTS

Bolivian and ACOG criteria identified similar frequencies of gestational hypertension (GH) or eclampsia, but preeclampsia with severe features (sPE) was under- and preeclampsia without severe features (PE) over-reported during both periods. Increases occurred after the workshop in testing for proteinuria and the detection of abnormal laboratory values and severe hypertension in HDP women. Any adverse maternal outcome occurred more frequently after the workshop in women with BO PE or sPE diagnoses who met ACOG sPE criteria.

CONCLUSIONS

Utilization of ACOG guidelines increased following the workshop and improved identification of PE or sPE pregnancies with adverse maternal outcomes. Continued use of a CLAP perinatal form recognizing HELLP as the only kind of sPE resulted in under-reporting of sPE.

FUNDING

NIH TW010797, HD088590, HL138181.

A socioecological description of the influencing factors to midwives' management of preeclampsia in a Ghanaian tertiary hospital

INTRODUCTION

In low-resource settings, midwives are the first contact for women with preeclampsia and lead the coordination of care. Unfavourable preeclampsia outcomes create a burden for women, families, and the health system. It is therefore important to understand the unique context of midwives' practice and the complex factors that influence the delivery of maternal healthcare.

AIM

This qualitative study explored the perspectives of key stakeholders in a tertiary hospital in Ghana regarding the facilitators and barriers influencing midwives' provision of preeclampsia care using a socioecological model.

METHODS

Semi-structured interviews were conducted with 42 participants comprising senior managers (n = 7) and hospital midwives (n = 35) in 2021. Thematic analysis used Braun and Clarke's six-step method, and the findings were organised within four levels of the socioecological model: individual, interpersonal, organisational, and public policy.

RESULTS

Two main themes were identified: 1) Facilitators of preeclampsia management, and 2) Barriers to preeclampsia management. Facilitators were identified at three levels (individual, interpersonal, and organisational) and included midwives' knowledge of preeclampsia; midwives' self-efficacy; midwives' skillset to enhance preeclampsia care; collaborative practice; and strategies for preeclampsia care quality improvement. At the individual level, the barriers were inadequate pre-service preparation, lack of evidence-based midwifery care, and colleagues' work attitudes. Hierarchical decision-making and staff views of women's risk perceptions were identified as barriers at the interpersonal level. At the organisational level, the barriers were: scarce resources and staff shortages, and a lack of midwifery-specific guidelines. Two barriers were identified within the public policy level: the high cost of preeclampsia care and issues with the referral system.

CONCLUSION

Multi-faceted factors play a significant role in midwives' management of preeclampsia. Hence context-specific multi-level interventions have the potential to improve the quality-of-care women in Ghana receive.

Altered placental ion channel gene expression in preeclamptic high-altitude pregnancies

High-altitude (>2,500 m) residence increases the risk of pregnancy vascular disorders such as fetal growth restriction and preeclampsia, each characterized by impaired placental function. Genetic attributes of highland ancestry confer relative protection against vascular disorders of pregnancy at high altitudes. Although ion channels have been implicated in placental function regulation, neither their expression in high-altitude placentas nor their relationship to high-altitude preeclampsia has been determined. Here, we measured the expression of 26 ion-channel genes in placentas from preeclampsia cases and normotensive controls in La Paz, Bolivia (3,850 m). In addition, we correlated gene transcription to maternal and infant ancestry proportions. Gene expression was assessed by PCR, genetic ancestry evaluated by ADMIXTURE, and ion channel proteins localized by immunofluorescence. In preeclamptic placentas, 11 genes were downregulated (ABCC9, ATP2A2, CACNA1C, KCNE1, KCNJ8, KCNK3, KCNMA1, KCNQ1, KCNQ4, PKD2, and TRPV6) and two were upregulated (KCNQ3 and SCNN1G). KCNE1 expression was positively correlated with high-altitude Amerindian ancestry and negatively correlated with non-high altitude. SCNN1G was negatively correlated with African ancestry, despite minimal African admixture. Most ion channels were localized in syncytiotrophoblasts (Cav1.2, TRPP2, TRPV6, and Kv7.1), whereas expression of Kv7.4 was primarily in microvillous membranes, Kir6.1 in chorionic plate and fetal vessels, and MinK in stromal cells. Our findings suggest a role for differential placental ion channel expression in the development of preeclampsia. Functional studies are needed to determine processes affected by these ion channels in the placenta and whether therapies directed at modulating their activity could influence the onset or severity of preeclampsia.

High-altitude residence alters blood-pressure course and increases hypertensive disorders of pregnancy

Objectives: To determine whether the full spectrum of hypertensive disorders of pregnancy (HDP) - comprising gestational hypertension; preeclampsia with or without severe features; eclampsia; and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) Syndrome - is increased at high (≥2500 m, 8250 ft) compared with lower altitudes in Colorado independent of maternal background characteristics, and if so their relationship to neonatal well-being.Methods: A retrospective cohort study was conducted using statewide birth-certificate data to compare the frequency of gestational hypertension, preeclampsia (with or without severe features), eclampsia, HELLP Syndrome, or all HDP combined in 617,958 Colorado women who lived at high vs. low altitude (<2500 m) and delivered during the 10-year period, 2007-2016. We also compared blood-pressure changes longitudinally during pregnancy and the frequency of HDP in 454 high (>2500 m)- vs. low (<1700 m)-altitude Colorado residents delivering in 2013 and 2014, and matched for maternal risk factors. Data were compared between altitudes using t-tests or chi-square, and by multiple or logistic regression analyses to adjust for risk factors and predict specific hypertensive or neonatal complications.Results: Statewide, high-altitude residence increased the frequency of each HDP disorder separately or all combined by 33%. High-altitude women studied longitudinally also had more HDP accompanied by higher blood pressures throughout pregnancy. The frequency of low birth weight infants (<2500 g), 5-min Apgar scores <7, and NICU admissions were also greater at high than low altitudes statewide, with the latter being accounted for by the increased incidence of HDP.Conclusions: Residence at high altitude constitutes a risk factor for HDP and recommends increased clinical surveillance. The increased incidence also makes high altitude a natural laboratory for evaluating the efficacy of predictive biomarkers or new therapies for HDP.