With much of the medical world focusing on the COVID-19 crisis, two new studies on preeclampsia — a pregnancy complication characterized by high blood pressure that can quickly progress to organ damage and even death — drew relatively little attention. But those studies contain critically important findings relevant to women at all stages of pregnancy and for the clinicians who care for them.
The first study, published in JAMA Psychiatry, found that full-term infants whose mothers had pregnancy-induced preeclampsia were more likely to develop a range of neurologic diseases, including autism spectrum disorder (ASD), epilepsy and intellectual disability. The study’s findings suggest that preeclampsia at term may have lasting effects on neurodevelopment of a child.
A second study, published in the Journal of Women’s Health, found that first-time preeclamptic women are at a significantly higher risk for adverse cardiovascular outcomes, including myocardial infarction, stroke, cardiovascular death and even all-cause death. The authors noted, "Because of the significantly increased cardiovascular outcomes of preeclamptic cases in this cohort, there may be indications that medical follow-up and intervention should be routinely recommended in these women after birth."
Together, the findings add to a growing body of evidence that preeclampsia presents a serious risk at all stages of pregnancy, both for women and their infants. While the world deals with the immediate threat of COVID-19, obstetricians must remain highly attuned to the risk of preeclampsia in their patients. Health system executives and policymakers should consider three crucial actions to address preeclampsia and eclampsia, and improve maternal and infant outcomes in both the short and long term.
Provide greater access to prenatal care, especially for at-risk individuals
In prenatal visits, obstetricians, nurse practitioners and certified nurse midwives regularly check for preeclampsia through blood pressure readings and test urine for signs of protein. But even though medical guidelines recommend 13 to 14 prenatal visits with an obstetrician or a midwife starting between weeks eight and ten of pregnancy, research shows that nearly one-quarter of American women start prenatal care late, or receive fewer than the recommended visits. Women without access to prenatal care are not assessed by providers for symptoms at all.
Congressional adoption of the nine bills that comprise the Black Maternal Health Momnibus Act will advance better screening for and monitoring of preeclampsia for all women, including at-risk populations, through innovative approaches such as group prenatal and postpartum care programs, state-based perinatal quality collaboratives and the Alliance for Maternal Health Innovation and improved access to care for women in rural areas.
Maintain 24/7 OB/CNMs at hospitals
According to a 2019 report by the Centers for Disease Control and Prevention (CDC), three in five pregnancy-related deaths are preventable. The CDC report lists “lack of appropriate personnel or services” as a contributing factor to the deaths that occurred between 2011-2015.
That’s absolutely not because private practice OBs are inappropriately qualified — it’s simply because they cannot be two places at once. Under the traditional model of maternal care, community OBs are called to the hospital when it is time to deliver the baby. This requires them to drop everything they are doing and rush to the hospital, which takes time even in the best of situations.
Unfortunately, preeclampsia can turn into an emergency very quickly. Women with eclampsia can present with multi-organ failures, including respiratory distress and cardiovascular hemorrhage, within minutes. Delays of any length can mean the difference between life and death.
OB hospitalist programs overcome delays by providing coverage and support to women until community OBs can arrive at the hospital or when the woman has no obstetrician, and staff hospitals on a 24/7 basis, including nights and weekends. Hospital administrators should consider adoption of hospitalist programs to ensure that such urgent health concerns and emergencies are quickly addressed by an OB/GYN with specialized training in those situations.
Expand Medicaid coverage for postpartum care
Postpartum eclampsia usually presents within 48 hours after the baby is delivered, but can present up to six weeks after delivery. Notably, postpartum eclampsia can occur regardless of whether a woman had high blood pressure or preeclampsia during pregnancy. Nearly half of postpartum eclampsia cases occur more than 48 hours after the birth.
What will be most impactful in keeping postpartum women with eclampsia safe? Clinical vigilance and the insurance coverage to facilitate it.
Although Medicaid covers four in 10 births in the United States, federal law only mandates Medicaid eligibility for pregnancy-related care for women through 60 days postpartum. The American College of Obstetricians and Gynecologists, the American Medical Association’s House of Delegates, and many other medical professionals recommend extending this period to one year postpartum.
In 2019, a handful of states expanded Medicaid coverage for pregnant women beyond 60 days postpartum, and Maternal Mortality Review Committees (MMRCs) in others have recommended such action. Policymakers in every state in the U.S. should follow suit. As noted by researchers from the Urban Institute, “This coverage would be temporary, but it could increase access to care during a critical period following delivery when pregnancy-related health complications often occur.”
Clinicians in OB hospitalist programs ensure that all patients presenting with pregnancy-related emergencies in the first weeks of the postpartum period are seen by an OB, either in the main emergency department or in the obstetrics emergency department. They also help to implement postpartum protocols and educate ED providers about signs and risks of postpartum health concerns.
The month of May is Preeclampsia Awareness Month. Now is the time for health executives and policy makers to step up, partner with clinicians and make these actions real. With diligence and purpose, we can improve care for the most vulnerable among us.
Rakhi Dimino, MD, is a Houston-based obstetrician and medical director of operations for Ob Hospitalist Group, the nation’s largest provider of OB hospitalist services, and on the Preeclampsia Foundation’s Board of Directors.