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The bench is the bedside – the role of transthoracic echocardiography in translating pregnancy research into clinical practice

The World Health Organization’s Millennium Development Goal 5 has two objectives. The first aims to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The second aims to achieve, by 2015, universal access to reproductive health [1]. Whilst some significant progress has been made in these areas, the rate of progress is slow and it is unlikely that these goals will be achieved within the timeframe proposed. Concurrently, it has been proposed that in order to reduce mortality, access to high-quality reproductive care is needed, as well as the implementation of effective interventions. In countries where maternal mortality is already low and where women have access to reproductive healthcare, significant maternal morbidity remains high. It is estimated that short-term severe maternal morbidity, defined as ‘a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy’ occurs in approximately 1 in 200 pregnant women [2–4]. Long-term morbidity is more difficult to estimate; however, population-based work, especially examining the effect of severe pre-eclampsia on long-term maternal health, suggests that longterm adverse maternal cardiovascular health outcomes may be significant [5]. Despite access to high-quality maternity care in many countries, pregnant women still suffer significant pregnancy-related morbidity. Two reasons may help to explain why this is the case. The first is that the recognition and diagnosis of some of the most common and significant diseases of pregnancy still remain suboptimal [6]. Obstetric critical illnesses such as cardiac failure, severe complications of preeclampsia, obstetric haemorrhage and sepsis are sometimes poorly recognised, leading to morbidity and mortality [7, 8]. In many situations, there appears to be a failure to appreciate and/or observe abnormal clinical symptoms and signs, as well as a failure to translate the known physiological and pathophysiological processes underlying these critical illnesses into the clinical management at the bedside. The second reason relates to the choice of effective treatment interventions. Informed decision-making regarding interventions is often difficult since randomised controlled trials of pharmacological interventions may not have been performed to address the clinical question. Effective treatment is further impacted upon by the more fundamental problem of poor understanding of the basic pathophysiology of some significant diseases of pregnancy, such as pre-eclampsia. Rational therapeutic choices are sometimes based on very limited research or extrapolated from non-pregnant populations. The most recent H1N1 pandemic informed us that such assumptions may lead to poorer outcomes for pregnant women, as the pharmacology of specific therapeutic agents may not have been studied in this group. This pandemic and its effect on pregnant women provided an impetus for change in this area, and raised awareness of the need to include pregnant women in appropriate research studies both on scientific and ethical grounds [9]. A step towards effective solutions to clinical problems and reducing the global burden of pregnancy-related diseases is to be able to translate the pregnancy research that is done into changes in clinical practice. One of the significant problems regarding research is that it may not be translatable to clinical practice. Specifically in the area of pregnancy research, the scientific questions posed by researchers need