Maternalmortality is of major concern for both international and national organizationsalike; 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 830of women die every day as a result of pregnancy and childbirth relatedcomplications of preventable causes, the large majority of these deaths unfortunatelyoccur in developing countries (WHO, 2016). In Jordan, maternal mortality rate in2015 was 58 per 100,000 live births (WHO, 2015). Maternal mortality is definedas “the death of a woman during pregnancy or within one year of the end ofpregnancy from a pregnancycomplication” (CDC, 2017), some of the most common maternalcomplications 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 increasedlevels of protein in the urine (proteinuria) and multisystem involvement(brain, cardiovascular, kidney and liver) (Ricci, 2016). Between 2002 – 2010, Preeclampsiaincidence 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, preeclampsiaincidence is 1.3%, which was found to be associated with an increased risk for bothmaternal and neonatal complications, including assisted vaginal delivery,cesarean section, low birth weight, prematurity and birth asphyxia (Khader,Batieha, Al-Njadat, & Hijazi, 2017).Once preeclampsia is diagnosed; the woman is managedaccording to the severity of her condition and its effect on the fetus, it isimportant to note that there is no “cure” for preeclampsia but the delivery ofplacenta in case the mother’s condition is worsening, which supports theoriesregarding the influence of placenta and the development of preeclampsia (Ricci,2016).
Advantages High risk women should be screened; in order to be monitoredregularly for preeclampsia during their pregnancy (Blood Pressure, Proteinuriaand frequent evaluation of fetal growth and Amniotic Fluid Index byultrasound). High risk factors for preeclampsia include: women with firstpregnancy, twin pregnancies, presence of chromosomal abnormalities orcongenital anomalies, diagnosis of preeclampsia in a previous pregnancy, familyhistory of preeclampsia (mother or sister), use of fertility and/or ovulationdrugs, low socioeconomic status or educational level, history or currentdiagnosis of DM, hypertension or renal disease, women < 20 years or > 35years and obese women (Ricci, 2016). Early screening of high risk women for preeclampsia willallow health care providers to detect complications as early as possible, thusclients will be managed effectively and further deterioration and worsening ofcondition will be prevented, preconception care, counseling, client education,early antenatal care and continuous monitoring of maternal and fetal health andwell-being are essential for accurate baseline information regarding onset ofdisease process (elevated blood pressure and proteinuria); allowing for timelyand effective prevention and /or management methods (e.
g. use of low doseaspirin and Ca supplements for women with low Ca intake) (SOGC, 2014). Disadvantages Preeclampsia is a serious condition thatnegatively affects both maternal and neonatal outcomes; Women with preeclampsia have ahigher incidence of:1.
Recurrence of preeclampsia in later pregnancies, inaddition to a higherrisk to develop other forms of hypertensive disorders later in life incomparison 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 11years after delivery (Alsnes, Janszky, Forman, Vatten, , 2014).
5. Low mental quality of life particularly inwomen with severe form of preeclampsia (Stern, et al., 2013) and mild cognitiveimpairment (Fields, et al., 2017).Neonatesof mothers with preeclamsia have a higher incidence of:1. Preterm delivery and retinopathyof prematurity (Shulman, Weng, Wilkes, Greene, & Hartnett, 2017). 2. Perinatal mortality, smallfor gestational age (SGA), NICU admission, respiratory distress syndrome (RDS),transient tachypnea of the newborn, apnea and birth asphyxia (Mendola, et al.
, 2015).Significance ofthe ProblemAs mentioned earlier, preeclampsia is aserious multisystem disorder with increased risk for adverse maternal and neonatalmorbidity and mortality, predictive factors of preeclampsia in Jordan include bothobesity and high blood pressure (Khader, Batieha, Al-Njadat, & Hijazi,2017). In a national Jordanian study conducted in 2009, prevalence of overweight and obesity among Jordanianwomen 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, familyhistory of preeclampsia (mother or sister), DM, high Body Mass Index (BMI),first pregnancy, history of preeclampsia in previous pregnancy and loweducational level were identified as risk factors for the development ofhypertensive disorders during pregnancy among Jordanian women(Suleiman, 2013). Furthermore,The risk to develop preeclampsiaamong Jordanian women during pregnancy is 2.3 times higher in the firstpregnancy compared with subsequent pregnancies (Khader, Batieha,Al-Njadat, & Hijazi, 2017).
Thus,though the overall preeclampsia incidence in Jordan is low (about 1.3% from anational survey of 21,928 women), theprevalence of risk factors for preeclampsia in comparison are high.Also, in regardto the overall cost and financial burden of preeclampsia; in the United States, the incident of preeclampsia in 2010 was3.8%. Yet, the total estimation of preeclampsia cost in the 12 months after delivery in2012; was 2.18 billion US dollars (1.3 billion dollars for mothers and 1.
15billion dollars for infants respectively) (Stevens,et al., 2017). These findings illustrate the significant impact of preeclampsiaon maternal and neonatal health on both the short and long-term after the initialdiagnosis, as well as the increase in preeclampsia risk factors within theJordanian population; which in return will result in an increase inpreeclampsia prevalence in the future. And finally, the significant financialburden of both preeclampsia and itssubsequent complications on the health care system. All these factors indicatea need to propose a national plan to prevent preeclampsia development amongJordanian women during pregnancy and also to recommend an effective method thatwill allow for the early detection and screening of high risk women for thepurpose of effective management.Problem StatementAccording to the US Preventive Services Task Force (USPSTF) there is no definitive screening tool and/orprevention regimen for preeclampsia, existing research is promising but moreresearch evidence is needed to make recommendations, current screening methods are merely routine practices.Yet, it is certain that screening for preeclampsia constitute a substantialbenefit for high risk pregnant women, The USPSTFrecommends the use of blood pressure as screening method for preeclampsia inpregnant women during the pregnancy period. furthermore, there is also limitedevidence on different urine protein screening tests regarding theirperformance, 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 preeclampsiaon maternal and neonatal well-being and health, its lifelong effects andcomplications and the limited research evidence on the effectiveness of differentscreening methods and tools; I have chosen to write my paper on this subject,as I will attempt to analyze and interpret current research evidence regardingthe early screening and prevention of preeclampsia as first line management; withthe intention to make recommendations for the public health care sector here inJordan. Literature ReviewThe Use of Uterine Artery Doppler for the Screening ofPreeclampsiaA prospective quantitative experimental studywas conducted in south Africa in 2016; to tested the effectiveness of uterineartery Doppler as a screening tool for the identification of clients who are atrisk for developing preeclampsia.
A total of 144 clients between 11 and 14weeks gestation were recruited, all participants have attended the antenatalclinic where the study was conducted between the period of 2008 and 2010, thefinal analysis was conducted on 121 participants after 23 of the participantshad to be excluded due to incomplete data, exclusion criteria also included;women will multiple gestation, fetal anomalies and women with hypertensivetreatment, after the initial assessment Doppler evaluation was repeatedbetween 22–24 week gestation and againbetween 28 and 32 weeks gestation. The research study found that 5.8% (7 participants)developed preeclampsia, the presence of uterine artery notching in the secondtrimester was found to be significantly associated with predicting the developmentof preeclampsia during pregnancy, which indicates a promising use of uterine arteryDoppler as a screening method for preeclampsia. However, in order to generalizeresearch findings, the use of large sample size is advised. Furthermore, themajority of research participants were black which is considered an independentpredisposing factor for preeclampsia by itself which may have resulted in bias,thus future studies need to focus on recruiting study participants fromdifferent educational level, socioeconomic status, cultural and ethnicbackgrounds (Casmod, Dyk, & Nicolaou, 2016).A meta-analysis by Velauthar et al in 2014 wasdone on 18 research studies (a total of 55,974 women), regarding theeffectiveness of uterine artery Doppler on predicting preeclampsia in firsttrimester of pregnancy, the sensitivity of (UAD) for the prediction ofearly-onset preeclampsia was (47.8%) and its specificity was (92.
1%), (UAD) sensitivityin 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), thesensitivity was (26.4%) and the specificity was (93.4%). In comparison, thesensitivity for (IUGR) prediction was (15.4%) and the specificity was(93.
3%). As a result, the number ofwomen needed to be treated with aspirin as a prophylactic was downsized, thusproviding justification for the restriction of antiplatelets’ use as apreventive measure of preeclampsia for high risk women only, which correspondsto international recommendations and guideline of preeclampsia management byNICE in 2011, ACOG in 2012 and SOGC in 2014. The use of uterine artery Dopplerin the meta-analysis was found to be useful in the prediction of preeclampsiaand fetal growth restriction (an adverse effect of preeclampsia). The body ofevidence regarding the use of uterine artery Doppler as a screening tool forpreeclampsia is promising, Jordanian pregnant women with high risk forpreeclampsia could be advised to undergo this procedure in order to effectivelyprevent and manage their conditions accordingly.The Efficacy of Dipstick Protein Test Screening An observational correlation clinical studybyPallavee & Nischintha in 2015 in India, was conducted to assess theeffectiveness of dipstick proteinuria test in the prediction of preeclampsia inhigh risk pregnant women in comparison with 24 hour urine collection test andprotein: creatinine ratio, proteinuria was measured in 72 clients using thethree tests mentioned above and a calculation of the degree of correlation wasmade between the dipstick test and the other tests (24 hour urine collectiontest and protein: creatinine ratio), there was a significant correlationbetween the dipstick proteinuria test and the 24 hour urine collection test, incomparison to the correlation between the dipstick test and protein: creatinineratio.
It is important to note that dipstick protein testing have sensitivitylimitations; it is highly sensitive with the presence of nitrite, leukocytesand 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, tomake recommendations on the re-evaluation of proteinuria with urinaryprotein-to-creatinine ratio after a dipstick test for confirmation purposes,2212 urine sample were collected from 1033 pregnant women with a hypertensivedisorder; to test for proteinuria presenceusing both tests (dipstick and protein to creatinine ratio).
Research resultsfound that the dipstick test was more susceptible to show a false positive resultin comparison to protein to creatinine ratio, thus the authors recommended thatwomen who have hypertension and have had ? 1+ on a dipstick test, as wellas women with no hypertension but with ? 2+ on dipstick test are to bere-evaluated using protein-creatinine ratio for confirmation (Baba, et al., 2015). There wereseveral types of products of dipsticks used in the study, also there was nodiscussion of the technique used to test urine samples with the dipstick test,or whether any of the participants had urinary tract infection which might havecaused bias and inaccurate findings in the research results. A urine sample shouldbe obtained after cleaning the external female genitalia and a mid-stream,clean catch technique is advised as to minimize inaccurate results andcontamination (Roberts, 2007). Jordanian women with high risk pregnancy, could be providedwith urine protein dipstick test for home monitoring of preeclampsia, this canbe beneficial for high risk women who do not attend antenatal checkupsregularly, as well as for women who live in rural areas, the dipstick proteintest is considered inexpensive and affordable, and if done correctly; candetect proteinuria early in pregnancy for proper management to be done byhealthcare providers. Women’s Knowledge of Preeclampsia An online survey on 754women who visited a website on preeclampsia called ” Preeclampsia Foundation”, found that 24% ofwomen recalled specific information regarding preeclampsia with only half ofthose understood the material.
However, 75% of the women who understood theinformation provided on preeclampsia by the website actually acted on them, thewomen were able to identify symptoms of preeclampsia as well as seeking andcomplying 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 thepreeclampsia foundation in the US in 2014, found that increased awareness wasassociated with pregnancy progression, increased educational level and economicstatus, the results showed high awareness level among the women. However, some symptomsspecific 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 capableof searching for information while answering the survey in the comfort andprivacy of their homes. Thus, surveys with high awareness level findings amongwomen are not to be considered representative of the actual awareness and knowledgeof preeclampsia in the population. The results of both surveysmentioned above illustrated the need for an effective educational program forJordanian women, as well as the use of media on a national level(advertisements, awareness campaigns, use of social media, billboards andonline surveys) to increase awareness and educate women on common pregnancycomplications like preeclampsia, women with high awareness will seek treatmentand monitor self for symptoms of preeclampsia which will benefit the timelymanagement of the condition.Health Care ProvidersKnowledge of PreeclampsiaA quasi-experimental (pretest-posttest)design was used to conduct a research study for the purpose of assessing theeffects of an educational program on preeclampsia knowledge among nurses in2017 in Egypt, 60 nurses were recruited for the study, a structured 5 pointlikert scale questionnaire was used to collect study data, the questionnaireconsisted of two parts, the first part was for nurses’ demographical data, andthe second part was used to assess nurses’ knowledge of preeclampsia regarding;definition, sign and symptoms, complications and treatment. Face and contentvalidity were performed by a panel of five experts, with a pilot study done toassess the accuracy of the obtained information, research findings demonstrateda beneficial effect of the educational program on nurses knowledge which can beof great significance in positively affecting their practice (Ahmed, Helmy,& Mohamed, 2017). However, the studyparticipants were all conveniently selected nurses with varying degrees innursing (institutional graduates, diploma and bachelor degrees), with themajority of them working in departments and not in antenatal, postnatal ordelivery rooms, midwives were not included in the study, these researchfindings (though cannot be generalized on midwives), show that an effectiveeducational program is of great benefit for maternity nurses and midwives whichcan have a positive effect in their clinical practice. A quantitativedescriptive correlation study was conducted in south Africa in 2016, to evaluatemidwives knowledge about hypertensive disorders during pregnancy, a randomsample of 43 clinics with a total of 101 midwives completed a self administeredquestionnaire, a panel of experts and a pilot study was conducted to evaluatethe validity and reliability of the tool.
Research results showed a deficiencyin midwives’ knowledge regarding the clinical manifestations (43.6%) andfactors affecting hypertension during pregnancy (31.7%), while (27.7%) showedno 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 wheredoctors did not visit as much, also midwives knowledge on preeclampsia wassignificantly associated with experience (Stellenberg & Ngwekazi, 2016). Conducting aresearch 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 andweaknesses and to establish educational programs to strengthen their knowledgeas to benefit high risk women during pregnancy with their clinical practice andmanagement of their conditions.
Aspirin, Heparin and CalciumSupplements use for the Prevention of PreeclampsiaThe use oflow-dose aspirin (75 to 162 mg/dl) and heparin are recommended for theprevention 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 ofpreeclampsia during pregnancy. Whereas, no research evidence is available onthe effectiveness of antioxidants, micronutrients (e.g.
zinc and selenium)and/or multivitamins (e.g. vitamin D, E, C, etc.) on the prevention ofpreeclampsia, thus they are not recommended for usage during pregnancy for thesole purpose of preeclampsia prevention (NICE, 2011; ACOG, 2012; SOGC, 2014). Method We searched PubMed,Medline, ScienceDirect and CINAHL databases for research articles onpreeclampsia screening and prevention for the period between 2012 and 2017, atotal of 32 articles were found from the search, inclusion criteria were: fullarticles within the last 5 years, in English language and on the subject ofpreeclampsia, 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 descriptivecorrelation studies were selected for discussion.
Keywords: preeclampsia, hypertension during pregnancy, highrisk pregnancy, preeclampsia screening, preeclampsia prevention.Summary and Conclusion In conclusion, preeclampsia is a serious condition withdevastating effects and complications, and since a “cure” is not available; thebest option for treatment and/or management is prevention, that is why moreefforts should be placed for the screening of high risk women in order to effectivelymonitor maternal and neonatal well-being, as well as to prevent chroniccomplications. Emerging research evidence in regard to new screening methodsfor preeclampsia are promising, some of these researches have demonstratedbeneficial outcomes through the use of uterine artery Doppler as a screeningtool for preeclampsia. However, more research is needed to recommend its use,screening is the optimal method for the management of preeclampsia, high riskwomen should be advised to monitor their condition at home the same as in theantenatal clinic, for the early detection of elevated blood pressure,proteinuria, fetal growth and amniotic fluid volume, obstetricians should betrained to use ultrasonography in the screening for preeclampsia, midwives andmaternity nurse’ knowledge on preeclampsia should be evaluated, updated andenhanced regularly, awareness on the subject of preeclampsia should be providedto all Jordanian women using various media outlets, which will encourage themto seek and comply to treatment.ImplicationsFuture recommendations and implications should be focused onthe following:1.
Conducting well-controlled research studies toassess the effectiveness of preeclampsia screening using uterine arteryDoppler. 2. Early screening and monitoring of high riskwomen during pregnancy of preeclampsia for timely and effective management(based on risk factors, obstetric, blood pressure, proteinuria and ultrasoundevaluation of fetal growth and amniotic fluid volume).3.
Establishing effective educational programs forJordanian healthcare providers, including midwives and maternity nurses; in order to enhance their knowledge andclinical practice.4. Increase awareness among women on the subject ofpreeclampsia and its lifelong complications on maternal and neonatal well-beingduring preconception and antenatal care visits.5.
Train high risk women on the use of bloodpressure devices, as well as providing them with protein dipstick test forself-assessment and home monitoring.6. Restrict the use of anticoagulants (e.g.heparin) and antiplatelets (e.g.
aspirin) for the prevention of preeclampsia onhigh risk women only.7. Provide hospitals with equipments and budgets toconduct uterine artery Doppler examinations on high risk women during pregnancy.Monitor high risk women andtheir infants in the postpartum period and beyond for the development ofadverse effects of preeclampsia, particularly cardiovascular and visionscreening.