Maternal
mortality is of major concern for both international and national organizations
alike; as a result, the United Nations have declared “Improve Maternal Health”
the fifth goal on their list of the eight Millennium Development Goals (MDGs)
in 2015 (WHO, 2015). It comes to no surprise; as it is approximated that about 830
of women die every day as a result of pregnancy and childbirth related
complications of preventable causes, the large majority of these deaths unfortunately
occur in developing countries (WHO, 2016). In Jordan, maternal mortality rate in
2015 was 58 per 100,000 live births (WHO, 2015). Maternal mortality is defined
as “the death of a woman during pregnancy or within one year of the end of
pregnancy from a pregnancy
complication” (CDC, 2017), some of the most common maternal
complications experienced by women during pregnancy that cause mortality include;
anemia, gestational DM, hypertensive disorders (e.g. preeclampsia/eclampsia)
and infections (CDC, 2016).

Pre-eclampsia  is a hypertensive disorder of pregnancy,
usually occurs after 20 weeks gestation and is characterized by increased
levels of protein in the urine (proteinuria) and multisystem involvement
(brain, cardiovascular, kidney and liver) (Ricci, 2016). Between 2002 – 2010, Preeclampsia
incidence was 4.6% internationally and 1.0% in the Eastern Mediterranean region,
including Afghanistan, Iran, Kuwait, Morocco, Pakistan, Saudi Arabia and Syria (Abalos,
Cuesta, Grosso, Chou, & Say, 2013). In Jordan however, preeclampsia
incidence is 1.3%, which was found to be associated with an increased risk for both
maternal and neonatal complications, including assisted vaginal delivery,
cesarean section, low birth weight, prematurity and birth asphyxia (Khader,
Batieha, Al-Njadat, & Hijazi, 2017).

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Once preeclampsia is diagnosed; the woman is managed
according to the severity of her condition and its effect on the fetus, it is
important to note that there is no “cure” for preeclampsia but the delivery of
placenta in case the mother’s condition is worsening, which supports theories
regarding the influence of placenta and the development of preeclampsia (Ricci,
2016).

Advantages

High risk women should be screened; in order to be monitored
regularly for preeclampsia during their pregnancy (Blood Pressure, Proteinuria
and frequent evaluation of fetal growth and Amniotic Fluid Index by
ultrasound). High risk factors for preeclampsia include: women with first
pregnancy, twin pregnancies, presence of chromosomal abnormalities or
congenital anomalies, diagnosis of preeclampsia in a previous pregnancy, family
history of preeclampsia (mother or sister), use of fertility and/or ovulation
drugs, low socioeconomic status or educational level, history or current
diagnosis of DM, hypertension or renal disease, women 35
years and obese women (Ricci, 2016).

Early screening of high risk women for preeclampsia will
allow health care providers to detect complications as early as possible, thus
clients will be managed effectively and further deterioration and worsening of
condition will be prevented, preconception care, counseling, client education,
early antenatal care and continuous monitoring of maternal and fetal health and
well-being are essential for accurate baseline information regarding onset of
disease process (elevated blood pressure and proteinuria); allowing for timely
and effective prevention and /or management methods (e.g. use of low dose
aspirin and Ca supplements for women with low Ca intake) (SOGC, 2014).

 

 

 

 

Disadvantages

Preeclampsia is a serious condition that
negatively affects both maternal and neonatal outcomes; Women with preeclampsia have a
higher incidence of:

1.     
Recurrence of preeclampsia in later pregnancies, in
addition to a higher
risk to develop other forms of hypertensive disorders later in life in
comparison to women with no prior preeclampsia diagnosis ( Takahashi, Ohkuchi,
Kobayashi, Matsubara, & Suzuki, 2014).

2.     
Cesarean section and maternal mortality
(Amorim,
et al., 2014).

3.     
Maternal ophthalmic complications, including;
diabetic retinopathy and retinal detachment (Beharier, et al., 2016).

4.     
Increased risk of adverse metabolic and cardiovascular disorders up to 11
years after delivery (Alsnes, Janszky, Forman, Vatten, &
Økland, 2014).

5.     
Low mental quality of life particularly in
women with severe form of preeclampsia (Stern, et al., 2013) and mild cognitive
impairment (Fields, et al., 2017).

Neonates
of mothers with preeclamsia have a higher incidence of:

1.     
Preterm delivery and retinopathy
of prematurity (Shulman, Weng, Wilkes, Greene, & Hartnett, 2017).

2.     
Perinatal mortality, small
for gestational age (SGA), NICU admission, respiratory distress syndrome (RDS),
transient tachypnea of the newborn, apnea and birth asphyxia (Mendola, et al., 2015).

Significance of
the Problem

As mentioned earlier, preeclampsia is a
serious multisystem disorder with increased risk for adverse maternal and neonatal
morbidity and mortality, predictive factors of preeclampsia in Jordan include both
obesity and high blood pressure (Khader, Batieha, Al-Njadat, & Hijazi,
2017). In a national Jordanian study conducted in 2009, prevalence of overweight and obesity among Jordanian
women aged between 15 and 49 years were 30% and 38.8% respectively (Al Nsour,
Al Kayyali, & Naffa, 2013). In another study, chronic and gestational hypertension, family
history of preeclampsia (mother or sister), DM, high Body Mass Index (BMI),
first pregnancy, history of preeclampsia in previous pregnancy and low
educational level were identified as risk factors for the development of
hypertensive disorders during pregnancy among Jordanian women
(Suleiman, 2013). Furthermore,
The risk to develop preeclampsia
among Jordanian women during pregnancy is 2.3 times higher in the first
pregnancy compared with subsequent pregnancies (Khader, Batieha,
Al-Njadat, & Hijazi, 2017). Thus,
though the overall preeclampsia incidence in Jordan is low (about 1.3% from a
national survey of 21,928 women), the
prevalence of risk factors for preeclampsia in comparison are high.

Also, in regard
to the overall cost and financial burden of preeclampsia; in the United States,
 the incident of preeclampsia in 2010 was
3.8%. Yet, the total estimation of preeclampsia
 cost in the 12 months after delivery in
2012; was 2.18 billion US dollars (1.3 billion dollars for mothers and 1.15
billion dollars for infants respectively) (Stevens,
et al., 2017). These findings illustrate the significant impact of preeclampsia
on maternal and neonatal health on both the short and long-term after the initial
diagnosis, as well as the increase in preeclampsia risk factors within the
Jordanian population; which in return will result in an increase in
preeclampsia prevalence in the future. And finally, the significant financial
burden of both  preeclampsia and its
subsequent complications on the health care system. All these factors indicate
a need to propose a national plan to prevent preeclampsia development among
Jordanian women during pregnancy and also to recommend an effective method that
will allow for the early detection and screening of high risk women for the
purpose of effective management.

Problem Statement

According to the US Preventive Services Task Force (USPSTF) there is no definitive screening tool and/or
prevention regimen for preeclampsia, existing research is promising but more
research evidence is needed to make recommendations, current screening methods are merely routine practices.
Yet, it is certain that screening for preeclampsia constitute a substantial
benefit for high risk pregnant women, The USPSTF
recommends the use of blood pressure as screening method for preeclampsia in
pregnant women during the pregnancy period. furthermore, there is also limited
evidence on different urine protein screening tests regarding their
performance, benefits and/or risk prediction (Henderson, et al., 2017).

Why am I interested in this topic?

Due to the severity of the adverse effects of preeclampsia
on maternal and neonatal well-being and health, its lifelong effects and
complications and the limited research evidence on the effectiveness of different
screening methods and tools; I have chosen to write my paper on this subject,
as I will attempt to analyze and interpret current research evidence regarding
the early screening and prevention of preeclampsia as first line management; with
the intention to make recommendations for the public health care sector here in
Jordan.

 

 

 

 

 

 

 

Literature Review

The Use of Uterine Artery Doppler for the Screening of
Preeclampsia

A prospective quantitative experimental study
was conducted in south Africa in 2016; to tested the effectiveness of uterine
artery Doppler as a screening tool for the identification of clients who are at
risk for developing preeclampsia. A total of 144 clients between 11 and 14
weeks gestation were recruited, all participants have attended the antenatal
clinic where the study was conducted between the period of 2008 and 2010, the
final analysis was conducted on 121 participants after 23 of the participants
had to be excluded due to incomplete data, exclusion criteria also included;
women will multiple gestation, fetal anomalies and women with hypertensive
treatment, after the initial assessment Doppler evaluation was repeated
between  22–24 week gestation and again
between 28 and 32 weeks gestation. The research study found that 5.8% (7 participants)
developed preeclampsia, the presence of uterine artery notching in the second
trimester was found to be significantly associated with predicting the development
of preeclampsia during pregnancy, which indicates a promising use of uterine artery
Doppler as a screening method for preeclampsia. However, in order to generalize
research findings, the use of large sample size is advised. Furthermore, the
majority of research participants were black which is considered an independent
predisposing factor for preeclampsia by itself which may have resulted in bias,
thus future studies need to focus on recruiting study participants from
different educational level, socioeconomic status, cultural and ethnic
backgrounds (Casmod, Dyk, & Nicolaou, 2016).

A meta-analysis by Velauthar et al in 2014 was
done on 18 research studies (a total of 55,974 women), regarding the
effectiveness of uterine artery Doppler on predicting preeclampsia in first
trimester of pregnancy, the sensitivity of (UAD) for the prediction of
early-onset preeclampsia was (47.8%) and its specificity was (92.1%), (UAD) sensitivity
in the prediction of early-onset (IUGR) was (39.2%) and its specificity was
(93.1%). In regard to predicting any preeclampsia (early or late-onset), the
sensitivity was (26.4%) and the specificity was (93.4%). In comparison, the
sensitivity for (IUGR) prediction was (15.4%) and the specificity was
(93.3%).  As a result, the number of
women needed to be treated with aspirin as a prophylactic was downsized, thus
providing justification for the restriction of antiplatelets’ use as a
preventive measure of preeclampsia for high risk women only, which corresponds
to international recommendations and guideline of preeclampsia management by
NICE in 2011, ACOG in 2012 and SOGC in 2014. The use of uterine artery Doppler
in the meta-analysis was found to be useful in the prediction of preeclampsia
and fetal growth restriction (an adverse effect of preeclampsia). The body of
evidence regarding the use of uterine artery Doppler as a screening tool for
preeclampsia is promising, Jordanian pregnant women with high risk for
preeclampsia could be advised to undergo this procedure in order to effectively
prevent and manage their conditions accordingly.

The Efficacy of Dipstick Protein Test Screening

An observational correlation clinical study
by
Pallavee & Nischintha in 2015 in India, was conducted to assess the
effectiveness of dipstick proteinuria test in the prediction of preeclampsia in
high risk pregnant women in comparison with 24 hour urine collection test and
protein: creatinine ratio, proteinuria was measured in 72 clients using the
three tests mentioned above and a calculation of the degree of correlation was
made between the dipstick test and the other tests (24 hour urine collection
test and protein: creatinine ratio), there was a significant correlation
between the dipstick proteinuria test and the 24 hour urine collection test, in
comparison to the correlation between the dipstick test and protein: creatinine
ratio. It is important to note that dipstick protein testing have sensitivity
limitations; it is highly sensitive with the presence of nitrite, leukocytes
and blood as in the case of (UTI) (Mambatta, et al., 2015),
which can contribute to a false positive result of preeclampsia.

A prospective observational study was conducted in Japan in 2015, to
make recommendations on the re-evaluation of proteinuria with urinary
protein-to-creatinine ratio after a dipstick test for confirmation purposes,
2212 urine sample were collected from 1033 pregnant women with a hypertensive
disorder;  to test for proteinuria presence
using both tests (dipstick and protein to creatinine ratio). Research results
found that the dipstick test was more susceptible to show a false positive result
in comparison to protein to creatinine ratio, thus the authors recommended that
women who have hypertension and have had 
? 1+  on a dipstick test, as well
as women with no hypertension but with ? 2+ on dipstick test are to be
re-evaluated using protein-creatinine ratio for confirmation (Baba, et al., 2015). There were
several types of products of dipsticks used in the study, also there was no
discussion of the technique used to test urine samples with the dipstick test,
or whether any of the participants had urinary tract infection which might have
caused bias and inaccurate findings in the research results.

A  urine sample should
be obtained after cleaning the external female genitalia and a mid-stream,
clean catch technique is advised as to minimize inaccurate results and
contamination (Roberts, 2007).

Jordanian women with high risk pregnancy, could be provided
with urine protein dipstick test for home monitoring of preeclampsia, this can
be beneficial for high risk women who do not attend antenatal checkups
regularly, as well as for women who live in rural areas, the dipstick protein
test is considered inexpensive and affordable, and if done correctly; can
detect proteinuria early in pregnancy for proper management to be done by
healthcare providers.

Women’s Knowledge of Preeclampsia

An online survey on 754
women who visited a website on preeclampsia called ” Preeclampsia Foundation”, found that 24% of
women recalled specific information regarding preeclampsia with only half of
those understood the material. However, 75% of the women who understood the
information provided on preeclampsia by the website actually acted on them, the
women were able to identify symptoms of preeclampsia as well as seeking and
complying with the treatment (Wallis, Tsigas, Saftlas, & Sibai, 2013).

An online preeclampsia awareness survey,
which was conducted on a total of 1591 women by Baby Center website and the
preeclampsia foundation in the US in 2014, found that increased awareness was
associated with pregnancy progression, increased educational level and economic
status, the results showed high awareness level among the women. However, some symptoms
specific to preeclampsia were not identified, e.g. edema in face and feet,
headache and visual disturbances (Baby Center, 2014).

Online surveys are subjected to bias; as women are capable
of searching for information while answering the survey in the comfort and
privacy of their homes. Thus, surveys with high awareness level findings among
women are not to be considered representative of the actual awareness and knowledge
of preeclampsia in the population. 

The results of both surveys
mentioned above illustrated the need for an effective educational program for
Jordanian women, as well as the use of media on a national level
(advertisements, awareness campaigns, use of social media, billboards and
online surveys) to increase awareness and educate women on common pregnancy
complications like preeclampsia, women with high awareness will seek treatment
and monitor self for symptoms of preeclampsia which will benefit the timely
management of the condition.

Health Care Providers
Knowledge of Preeclampsia

A quasi-experimental (pretest-posttest)
design was used to conduct a research study for the purpose of assessing the
effects of an educational program on preeclampsia knowledge among nurses in
2017 in Egypt, 60 nurses were recruited for the study, a structured 5 point
likert scale questionnaire was used to collect study data, the questionnaire
consisted of two parts, the first part was for nurses’ demographical data, and
the second part was used to assess nurses’ knowledge of preeclampsia regarding;
definition, sign and symptoms, complications and treatment. Face and content
validity were performed by a panel of five experts, with a pilot study done to
assess the accuracy of the obtained information, research findings demonstrated
a beneficial effect of the educational program on nurses knowledge which can be
of great significance in positively affecting their practice (Ahmed, Helmy,
& Mohamed, 2017).

However, the study
participants were all conveniently selected nurses with varying degrees in
nursing (institutional graduates, diploma and bachelor degrees), with the
majority of them working in departments and not in antenatal, postnatal or
delivery rooms, midwives were not included in the study, these research
findings (though cannot be generalized on midwives), show that an effective
educational program is of great benefit for maternity nurses and midwives which
can have a positive effect in their clinical practice.

A quantitative
descriptive correlation study was conducted in south Africa in 2016, to evaluate
midwives knowledge about hypertensive disorders during pregnancy, a random
sample of 43 clinics with a total of 101 midwives completed a self administered
questionnaire, a panel of experts and a pilot study was conducted to evaluate
the validity and reliability of the tool. Research results showed a deficiency
in midwives’ knowledge regarding the clinical manifestations (43.6%) and
factors affecting hypertension during pregnancy (31.7%), while (27.7%) showed
no knowledge of preeclampsia. What is interesting in these research findings,
is that midwives working in clinics where doctors were present regularly,
showed significant knowledge in comparison to midwives working in clinics where
doctors did not visit as much, also midwives knowledge on preeclampsia was
significantly associated with experience (Stellenberg & Ngwekazi, 2016).

Conducting a
research study on midwives’ knowledge regarding preeclampsia is of great importance,
yet future research should test the knowledge of midwives working in antenatal,
postnatal and delivery rooms, it is important to estimate their strength and
weaknesses and to establish educational programs to strengthen their knowledge
as to benefit high risk women during pregnancy with their clinical practice and
management of their conditions.

Aspirin, Heparin and Calcium
Supplements use for the Prevention of Preeclampsia

The use of
low-dose aspirin (75 to 162 mg/dl) and heparin are recommended for the
prevention of preeclampsia in high risk women, also calcium supplements ( ?
1 g/d) are recommended for women with low calcium intake who are at high risk of
preeclampsia during pregnancy. Whereas, no research evidence is available on
the effectiveness of antioxidants, micronutrients (e.g. zinc and selenium)
and/or multivitamins (e.g. vitamin D, E, C, etc.) on the prevention of
preeclampsia, thus they are not recommended for usage during pregnancy for the
sole purpose of preeclampsia prevention (NICE, 2011; ACOG, 2012; SOGC, 2014).

 

Method

We searched PubMed,
Medline, ScienceDirect and CINAHL databases for research articles on
preeclampsia screening and prevention for the period between 2012 and 2017, a
total of 32 articles were found from the search, inclusion criteria were: full
articles within the last 5 years, in English language and on the subject of
preeclampsia, incidence, complications, risk factors, screening and prevention.
Six articles, two surveys and three international guidelines on preeclampsia
(regarding prevention recommendations), were included in the literature review,
a prospective quantitative experimental study, a meta-analysis, an observational correlation, a prospective observational, a quasi-experimental (pretest-posttest) and a quantitative descriptive
correlation studies were selected for discussion.

Keywords:  preeclampsia, hypertension during pregnancy, high
risk pregnancy, preeclampsia screening, preeclampsia prevention.

Summary and Conclusion

In conclusion, preeclampsia is a serious condition with
devastating effects and complications, and since a “cure” is not available; the
best option for treatment and/or management is prevention, that is why more
efforts should be placed for the screening of  high risk women in order to effectively
monitor maternal and neonatal well-being, as well as to prevent chronic
complications. Emerging research evidence in regard to new screening methods
for preeclampsia are promising, some of these researches have demonstrated
beneficial outcomes through the use of uterine artery Doppler as a screening
tool for preeclampsia. However, more research is needed to recommend its use,
screening is the optimal method for the management of preeclampsia, high risk
women should be advised to monitor their condition at home the same as in the
antenatal clinic, for the early detection of elevated blood pressure,
proteinuria, fetal growth and amniotic fluid volume, obstetricians should be
trained to use ultrasonography in the screening for preeclampsia, midwives and
maternity nurse’ knowledge on preeclampsia should be evaluated, updated and
enhanced regularly, awareness on the subject of preeclampsia should be provided
to all Jordanian women using various media outlets, which will encourage them
to seek and comply to treatment.

Implications

Future recommendations and implications should be focused on
the following:

1.     
Conducting well-controlled research studies to
assess the effectiveness of preeclampsia screening using uterine artery
Doppler.

2.     
Early screening and monitoring of high risk
women during pregnancy of preeclampsia for timely and effective management
(based on risk factors, obstetric, blood pressure, proteinuria and ultrasound
evaluation of fetal growth and amniotic fluid volume).

3.     
Establishing effective educational programs for
Jordanian healthcare providers, including 
midwives and maternity nurses; in order to enhance their knowledge and
clinical practice.

4.     
Increase awareness among women on the subject of
preeclampsia and its lifelong complications on maternal and neonatal well-being
during preconception and antenatal care visits.

5.     
Train high risk women on the use of blood
pressure devices, as well as providing them with protein dipstick test for
self-assessment and home monitoring.

6.     
Restrict the use of anticoagulants (e.g.
heparin) and antiplatelets (e.g. aspirin) for the prevention of preeclampsia on
high risk women only.

7.     
Provide hospitals with equipments and budgets to
conduct uterine artery Doppler examinations on high risk women during pregnancy.

Monitor high risk women and
their infants in the postpartum period and beyond for the development of
adverse effects of preeclampsia, particularly cardiovascular and vision
screening.

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