Preeclampsia

Screening for Preeclampsia

The diagnosis of preeclampsia has traditionally relied on the presence of raised blood pressure (hypertension) and excess protein in urine (proteinuria). In certain settings, the equipment to diagnose these indicators can be unreliable or there is a lack of trained personnel to use the standard diagnostics. Research has shown that women with severe forms of preeclampsia excrete in their urine unfolded or misfolded proteins, which bind to Congo Red dye (“congophilia”). The affinity of misfolded proteins for Congo Red led a hospital in the US to develop the Congo Red Dot (CRD) Test, a simple paper-based urine diagnostic test that can be used at the bedside or in outpatient settings.

With the CRD developers and hospitals in Mexico and Bangladesh, Gynuity evaluated the clinical utility and usability of the CRD test for the diagnosis and prediction of preeclampsia during pregnancy and in the postpartum period. Results from this prospective, case-control study suggest that urine congophilia can be rapidly identified and that a point-of-care diagnostic for detection of urine congophilia has the potential to improve the triage and diagnosis of patients with preeclampsia. Consult related resource here (2020).

Improving Management of Hypertension in Pregnancy

Treatment of elevated blood pressure—one of the primary signs of preeclampsia—reduces the risk for maternal complications. Historically, regimens for the acute treatment of high blood pressure used medications administered intravenously, which require venous access and monitoring of the fetus. Oral anti-hypertensive medications are easy to use, widely available and inexpensive, and can be used in a wider range of settings.

Together with the University of British Columbia, the University of Washington, Government Medical College (GMC) and Daga Memorial Women’s Hospital in Nagpur, India, Gynuity conducted a randomized trial to compare the efficacy of three oral anti-hypertensive drugs: labetalol, nifedipine and methyldopa. The study found that oral anti-hypertensives are effective in controlling severe hypertension in pregnancy without serious maternal or fetal complications. Use of oral anti-hypertensive drugs for treatment of severe hypertension in pregnancy represents an innovative approach with the potential to increase access to life-saving care at the lowest levels of the health system. Consult related resource published in The Lancet here (2019).

With funding from the Innovation Fund of the Reproductive Health Supplies Coalition, Gynuity conducted a landscape assessment of access to essential supplies for treatment of hypertensive disorders of pregnancy in Uganda, Mexico and India. In all three countries, challenges were identified on both the supply and demand sides in relation to the availability of good quality blood pressure devices and antihypertensive medications, which were the key supplies assessed in this analysis.

Improving Care at Delivery for Women with Preeclampsia

Prompt delivery, preferably by vaginal route, is a critical intervention for women with preeclampsia in order to prevent morbidity to the mother and baby. Together with the University of Liverpool and GMC Nagpur (India), Gynuity studied the relative risks and benefits of low-cost methods for labor induction (misoprostol and Foley catheterization) and augmentation (misoprostol and oxytocin) in women with preeclampsia.

The findings from the first study showed that oral misoprostol is more effective than transcervical Foley catheterization for the induction of labor. Enrollment was completed for a second study performed at three hospitals in India to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets. In many lower-income countries, electronic infusion pumps are not available and oxytocin has to be administered through a gravity pump. These infusions have potential for human error and require constant supervision from experienced staff. It is essential to understand how maternity care can be improved and offered more efficiently.

Increasing Access to Magnesium Sulfate

Magnesium sulfate is an inexpensive medication used to reduce the risk of seizures in women with preeclampsia, but it is used sub-optimally in many settings. In general, a loading dose of magnesium sulfate is administered intravenously and intramuscularly, followed by continuous intravenous (IV) infusion or regular intramuscular (IM) injections. Although the IV regimen is effective, it requires the use of an infusion pump for safe delivery and, when administered manually, has a greater potential for inadvertent overdose and missed or delayed administration. The IM dosing regimen, while potentially safer, requires painful injections.

The Springfusor® is a simple, mechanically flow-controlled pump that offers an alternative to IM magnesium sulfate where electronic pumps for IV administration are not available. A study by Gynuity and partners comparing the use of the Springfusor® for the delivery of magnesium sulfate with the standard of care found that the Springfusor® pump was superior in terms of accurate delivery of treatment, ease of use, demands on staff time, reduction of pain and side effects, and increased acceptability to patients.

A more recent study implemented in two hospitals in Egypt concluded that serial IV boluses achieve serum magnesium concentrations that are significantly higher but clinically comparable to those achieved with a continuous infusion and offer a third option for the administration of magnesium sulfate.