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Recent Advances in Pre-Eclampsia and Eclampsia

It is estimated that one woman dies every 30 seconds from a complication of pregnancy. Pre-eclampsia and eclampsia contribute to at least 40 000 to 60 000 of these deaths worldwide each year with significant additional maternal morbidity from complications such as intracerebral haemorrhage, pulmonary oedema and liver involvement. There are equally serious consequences for the fetus, particularly as delivery remains the mainstay of treatment, and may be required in order to save the life of the mother. So what lessons have we learned from recent developments in pre-eclampsia that are applicable in lowresource settings? The ideal situation would entail identification of women at risk and prevention with a single cheap agent. However, this can be a complicated task as pre-eclampsia is a complex syndrome in which a number of different pathways can lead to the characteristic clinical signs which include hypertension and proteinuria. Abnormal implantation of the placenta and activation of the maternal systemic endothelium may both be important features, but the precise pathophysiological mechanisms are still not fully understood. What is currently available? The good news is that those treatments which have been shown to work are generally cheap. The first of these is aspirin. There have been nearly two decades of trials involving aspirin, or similar anti-platelet agents, in the prevention of preeclampsia. This is based on the premise that aspirin will inhibit the cyclo-oxygenase enzyme, with a preferential effect on platelet-derived thromboxane, thus attenuating vasoconstriction and platelet aggregation. A recent metaanalysis of aspirin in this setting has shown a significant 15% reduction in pre-eclampsia, together with a 14% reduction in fetal and neonatal deaths'. This translates into 89 women requiring treatment to prevent one case of pre-eclampsia, raising the possibility that more targeted treatment may decrease the number to be treated. However, at present, aspirin remains the only prophylactic treatment in which there is good evidence of significant benefit for both mother and baby with no ill effects. There is also potential promise for antioxidant vitamins C and E, with a single randomized trial demonstrating a significant reduction in the occurrence of pre-eclampsia in high-risk wornen/. Use of these drugs is based on the extensive evidence for oxidative stress in pre-eclampsia, showing increased markers of free radical induced damage and inadequate antioxidant capacity in the disease. Current multicentre trials are now underway in high-risk women in the UK, low-risk women in the USA, and are being set up by the World Health Organization elsewhere. It is essential that the results of these trials are awaited so that the results from the single trial can be confirmed and fetal and neonatal safety established before these antioxidant vitamins are introduced into clinical practice. Once a woman has developed pre-eclampsia, treatment then turns to preventing complications and optimizing the outcome for the mother and baby. This may require a