Welcome back, reader!! I know it’s been a while, so let’s not waste another minute. Let’s talk about hypertensive disorders of pregnancy (HDP).
Hypertension, or high blood pressure, in pregnancy is one of the most common medical complications in pregnancy and a third of adults don’t know they have it. In fact, most pregnant women with hypertension will demonstrate normal or below-normal blood pressures during pregnancy, thus appearing to be women without hypertension. So knowledge of your baseline blood pressures can make all the difference for the outcomes of your pregnancy. Diagnosis of hypertension can be made before the pregnancy is established, after 20 weeks of pregnancy, or with persistently high blood pressures after the 12th postpartum week.
Some women who have no known hypertension before pregnancy will develop higher blood pressures during the pregnancy. We call that “gestational hypertension” and it is usually the milder of the hypertensive disorders of pregnancy. Blood pressures are typically elevated above 140/90 but definitely less than 160/110; furthermore, there are no other signs or symptoms of worsening hypertension like headaches, blurry vision, low platelet levels in the blood, or evidence of protein spilling into the urine. Now don’t get it twisted: having this mild form of HDP doesn’t mean you are free of risk. In fact, almost half of women with gestational hypertension will progress to developing those signs and symptoms, which puts these women into a new category of HDP called pre-eclampsia.
Pre-eclampsia consumes much of the time and energy of the obstetrician when working with pregnant women like the boogeyman absorbs a child at night before sleep. The condition is marked by elevated blood pressures above a pregnant woman’s baseline levels, usually above 140/90, combined with signs like low platelets in the blood or protein spillage into the urine or symptoms like persistent headache, blurry vision, and abdominal pain under the breastbone and ribs. It has a foreboding presence because women can develop seizures (called eclampsia), strokes from severely elevated blood pressures above 160/110, premature separation of the placenta from the maternal circulation (called placental abruption) with death of the infant, and last–but certainly not least–death of the mother. Pre-eclampsia is the top killer of pregnant women in Haiti and other developing countries with African descent; it is the number two killer of pregnant women worldwide. Needless to say, pre-eclampsia is one of our primary focuses in our global clinical activities. The following story will elucidate the point for you.
Meet Marie Ange, a 17-year-old woman pregnant for the first time:
A young woman from Camp Perrin, Marie Ange has followed in our clinic for several months since the first trimester. Her baseline blood pressures have all been in the 90s/60s with little variation, as established by the meticulous vital sign recordings of our Mimsi community volunteers. However, during her last visit, Marie Ange reports feeling like her head is heavy and she is seeing “koukouyi” or fireflies in her vision. The community volunteer notes that she is 31 weeks and 6 days by her last menstrual period and first trimester ultrasound; the volunteer also discovers that Marie Ange has a blood pressure of 230/140, which she calls me over to double-check because she can’t believe her ears. I verify the blood pressure is indeed that high: 228/144. I ask the volunteer what she thinks Marie Ange has; she responds “pre-eklanpsi” correctly. Then I ask her what we should do, and the community nurse interrupts saying, “We need to stop quizzing the volunteer and get this woman to a hospital.” During the preparation for transfer, we discover another woman with a similar history and a similar presentation who needs transfer as well for pre-eclampsia.
Well, Mimsi takes on the responsibility for Marie Ange’s hospitalization and suspects they will do a C-section because of how high her blood pressures are and how remote she is to delivery. In the United States, we would have attempted to induce labor and deliver; however, in these remote areas without proper monitoring, I have come to appreciate the other options available. But in Marie Ange’s case, she stays on the ward for seven days as the obstetrical nurses in the hospital give this woman alpha-methyldopa (AMD), a commonly used antihypertensive which takes several days to work, to lower Marie Ange’s blood pressure. Her blood pressures elevate: 266/154; 242/144; 250/134.
Eventually on hospital day 8, the nurses and doctors are frustrated with Marie Ange’s case and discharge her home, saying that she needs to go to Port-au-Prince for further treatment. They do the same to the other woman with pre-eclampsia we admitted the same day as Marie Ange. No magnesium sulfate has been started; no effective antihypertensive medications are given to lower her blood pressures; no emergency vehicle is offered to make the 3.5 hour drive to Port-au-Prince.
We find them in the street in front of the hospital looking for cars to take them home. Luckily there is a hospital St Boniface Haiti in Fond-des-Blancs, Haiti that can take care of preterm pregnancies. So we refer Marie Ange and the other patient there for magnesium sulfate and IV antihypertensive therapy; Marie Ange is at 33 weeks and 1 day gestation. She delivers her baby vaginally at 33 weeks and 3 days gestation. Both she and the baby are doing really well at the special hospital St Boniface Haiti; her blood pressures are normalized and her symptoms have disappeared. However, the other patient undergoes a C-section at 33 weeks and 5 days for uncontrollable vaginal bleeding, likely a placental abruption; she loses the baby. We are grateful to St Boniface Haiti Foundation for their care of our patients.
Mimsi’s community-driven mobile prenatal clinic demonstrates how the community can be the solution to its own problems. Our community volunteers are showing proficiency in diagnosing pregnant women with pre-eclampsia and transferring them to hospitals for higher levels of care. The protocols under which the community volunteers operate guide them to make great choices for patient care and allow the community volunteers access to rapid response for critically ill patients. I wonder what would be possible if Mimsi International successfully replicated this community-driven mobile prenatal clinic in other areas of Haiti and the developing world. I speculate that we could effectively root out more complicated cases in pregnancy and save more lives, especially with collaborations in the field. Only time will tell. But the community volunteers of Mimsi are committed to continuing the great work it’s doing in Haiti, and I for one am grateful.