Update from Dawn – NZAPEC Consumer

RepresentativeI was honoured to be given the opportunity to speak at the NZAPEC pre-eclampsia and fetal growth restriction study day in November. As I quoted in my talk on the day from Steven Pressfeld, ‘The more important an activity is to your soul’s evolution, the more resistance you will feel to it’ after all, who was I to speak amongst such an exceptional group of presenters? I couldn’t offer anything revelatory in terms of research or progress with regards to pre-eclampsia.I had been apprehensive about bringing my vulnerability, my emotional self and my story that is anything but easy to speak or hear and being able to trust that it would be received in the right way by the right people. However, I needn’t have any concerns. I was overwhelmed by the number of people that connected with me after I spoke and asked if they could just give me a hug or share their thoughts or thank me or talk about infertility and their experiences or just to tell me they had a good cry or had changed their perspective. Being able to touch hearts, and inspire any action, makes a difference to those who have been in my situation and will be in my situation going forward.Most of all though I had underestimated the power of being heard, of being able to share my story, and that having the courage to share my story could inspire and influence has been so incredibly healing for me in bringing some level of peace, and which honours my daughter Imogen and my family’s story. What a great privilege that not all women who have experienced loss are given, and so for that reason I would ask that we never underestimate the importance of personal touch and connection that you can provide. Emotion in all its forms is what makes us human and reminds us that those caring for us are human too. And also, as was in my case, we cannot underestimate the way the pre-eclampsia can present itself, sometimes not all of the common signs are there or are obvious.

- Dawn

Newsletter Number 70

1 Monument Road, Clevedon,Auckland, New Zealand.

Phone: 0274 849 874

“Great to have Dawn’s story – thank you this was so important “

“Extremely high quality of speakers and information, an awesome day”

“Extremely relevant to my area of work, high risk maternity”“Excellent speakers who could present on both research

outcomes and practical applications”“5 years since I last attended an NZAPEC study

day. Fabulous to update on current research and advancements in detection of SGA babies and pre-eclampsia diagnosis. Thanks you for a great day”

Study Day Feedback

Joyce, Catherine & Lou on the welcome desk

Great to catch up.

Around 100 attendees enjoyed the day

STUDY DAYEDITIONSummer/Autumn 2020

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Update from the study day from our co-director Rachel Taylor Our annual study day held in Nelson in November 2019 was an enormous success thanks to a stellar line-up of internationally-acclaimed experts in the field of pre-eclampsia research. We were privileged to have our day commence with the heartfelt and harrowing journey of Dawn Mark, one of our consumer advisers whose story of her experience with pre-eclampsia was also shared with you in previous newsletters. Dawn’s story reminds us exactly why NZ

APEC was established in the first instance, primarily to support women and whānau afflicted by pre-eclampsia and provide educational opportunities for women and health practitioners alike. Associate Professor Katie Groom presented an introduction of the need-to-knows regarding the prevention, identification and management of pre-eclampsia, including an overview of the latest New Zealand Hypertension in Pregnancy Guidelines. Hypertension in pregnancy is defined as: ▪ Hypertension

Systolic BP 140 mmHg or diastolic BP 90 mmHg measured on two or more occasions at least four hours apart

▪ Gestational Hypertension New onset hypertension >20 weeks with no maternal or fetal features of pre-eclampsia, followed by return of BP to normal within 3 months postpartum

▪ Chronic Hypertension Hypertension pre-pregnancy or <20 weeks or on hypertension medications. This includes both essential hypertension and secondary hypertension (including consideration for chronic renal disease, renal artery stenosis, diabetes, endocrine disorders and coarctation of the aorta)

▪ Mild/moderate hypertension is defined as a systolic blood pressure of 140-159 mmHg or a diastolic blood pressure of 90-109 mmHg

▪ Severe hypertension is defined as a systolic blood pressure of >160 mmHg or a diastolic blood pressure of >110 mmHg

For confirmation of preeclampsia, the following diagnostic criteria are required:

▪ New onset hypertension >20 weeks AND one or more of the following:

a) Renal involvement:

✓ Proteinuria (PCR ≥ 30mg/mmol OR ≥ 2+ protein on dipstick then confirmed by PCR)

✓ Creatinine > 90μmol/L *

✓ Oliguria < 80mL over a four-hour time frame

b) Haematological involvement:

✓ Platelets < 100 x 10₉/L * ✓ Evidence of red cell destruction or

disseminated intravascular coagulation (DIC)

c) Liver involvement:

✓ Elevated liver transaminases (ALT ≥ 30u/L and/or AST ≥ 50u/L)

✓ Severe epigastric or right upper quadrant pain or pain between the shoulder blades

d) Neurological involvement:

✓ Convulsions / seizures (eclampsia) * ✓ Altered mental state, including

confusion or impending sense of danger

✓ Stroke ✓ Blindness ✓ Hyperreflexia with sustained

clonus ✓ Severe headache that doesn’t

resolve with analgesia or persistent visual disturbances

e) Evidence of fetal growth anomalies:

✓ Either fetal growth restriction or SGA +/- abnormal Doppler waveforms or evidence of placental dysfunction.

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Additional risks include placental abruption, infarction, antepartum haemorrhage, postpartum haemorrhage, hysterectomy, pre-term birth, neonatal hypoxia and stillbirth. * considered evidence of severe preeclampsia, along with a systolic BP ≥

160 or diastolic BP ≥ 110 or HELLP syndrome

(SOMANZ, 2014) Take home messages for both women and practitioners alike were:

There is insufficient evidence that folic acid or iodine reduce risk for preeclampsia, nor is there robust evidence that multivitamins or other supplements reduce preeclampsia. Some vitamins may cause harm including Vitamin C and E (antioxidants) and salt restriction has not been found to be of any benefit. Bed rest and restriction of activity is also NOT recommended.

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__________________________________________________ Dr Jane MacDonald from the Centre for Women’s Research at Victoria University of Wellington presented a series of nationally reviewed case-studies as part of her analytical research examining the incidence and impact of severe maternal morbidity resulting from both preeclampsia and eclampsia. Preeclampsia, HELLP syndrome, eclampsia and severe gestational hypertension have been identified as: ▪ Major causes of maternal and infant mortality

and morbidity

▪ WHO attributes approximately 14% of maternal mortality to hypertensive disease

▪ Largely preventable with early diagnosis and appropriate treatment

▪ Cause for serious long-term health impacts and consequences for both women and their babies alike

(Say et al., 2014) The primary goal of the centre’s research aim is to successfully identify preventable factors associated with increased progression on the continuum of maternal morbidity to ensure that women do not become sicker than they need to be. De-identified cases are reviewed by a multi-disciplinary panel of experts including obstetricians, midwives, anaesthetists and other specialists as required with a consensus on best practice interventions and treatment pathways identified. Moving forward, Jane has placed an application for funding from the Health Research Council that will enable a nationwide preeclampsia education package to be developed and launched. The team at NZ APEC extends Jane our support and very best wishes with this exciting research and education opportunity! _________________________________________

_________ Tarra McNally, PhD candidate from the US presented her research to date examining the challenges and opportunities in dissemination and implementation of best-practice national clinical practice guidelines on hypertension and preeclampsia in pregnancy. Tarra’s aim is to improve clinical and patient education (as well as improve access to resources and information) by implementing a standardised approach to care for women presenting with

hypertensive disorders in pregnancy that is cost-effective, evidence-based, and reduces the need for each region to “reinvent their own wheel” time and time again. We await the findings from Tara’s research and hope to be able to report back to you in the not-too-distant future. _________________________________________

_________ We were then privileged to have NZ APEC’s very own Joyce Cowan and Professor Lesley McCowan invite discussion on ways in which both health practitioners and women can become better aware and progressively involved with improving detection and prevention of small-for-gestation (SGA) and growth-restriction amongst New Zealand babies. Joyce Cowan presented her findings and results from her soon-to-be-published doctoral thesis on the successful implementation of the Growth Assessment Programme (GAP) at Counties Manukau Health (CMH); a screening tool designed to improve detection of small-for-gestation babies and thereby reduce risk and incidence of neonatal morbidity. Joyce’s research collaboration with Dr Chris McKinley (CMH neonatologist) and Professor Lesley McCowan (University of Auckland) has afforded conclusive evidence that GAP training with multi-disciplinary support and input have indeed been successful, with quantifiable clinical evidence of :

▪ increased detection of SGA, ▪ reduced risk for neonatal encephalopathy

(NE) (as a result of hypoglycaemia and other known confounders),

▪ reduced rate of stillbirth.

The programme is funded and supported by ACC as part of their strategy to reduce national rates of NE; each case costing the tax payer approximately $55 million, not to mention the ongoing impact for whānau and their afflicted babies. What GAP involves:

▪ Multidisciplinary education including standardized fundal height measurement

▪ Emphasis on risk assessment for SGA at booking

▪ Use of customised gestational-related optimal weight (GROW) charts

▪ Guidelines for ongoing management and surveillance

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▪ Baseline audits of SGA detection, ongoing reports of suspected and detected SGA and auditing of missed cases.

To date, 14 DHBs in New Zealand have implemented the programme, 10 clinical ‘champions’ or leads have been appointed, and nation-wide training workshops for health practitioners are being run throughout the country. The GAP programme in Counties Manukau involved an ethnically diverse cohort of pregnant women, including a high percentage of Māori, Pacific, Indian and Asian women, many of whom have increased odds for fetal growth restriction due to confounding risk factors including smoking, obesity, premature labour and birth, socio-economic deprivation and poverty and other barriers to maternity care and services. Women under the care of self-employed midwives were excluded from the study as access to their clinical notes could have been potentially problematic. Other exclusion criteria included:

▪ Women booked after 20 weeks ( an early pregnancy weight is necessary for generating an accurate GROW chart)

▪ Instances where no BMI was recorded at the time of booking

▪ Known fetal congenital anomalies

▪ Multiple pregnancy

▪ Premature birth prior to 24 weeks’ gestation

The primary hypothesis that GAP would increase detection of SGA was confirmed with analysis of the study’s results. Detection of SGA (based on ultrasound report) was 57.9% post-GAP

implementation compared to only 22.9% previously. Even more exciting was confirmation of an even greater impact of GAP on detection of SGA in Māori and Pacific women when compared to women of other ethnicities. This is particularly significant when we consider these women carry a far higher burden of adverse pregnancies outcomes than any other group in Aotearoa/New Zealand. Finally, while detection of SGA increased post-GAP over all maternal characteristics, antenatal detection of SGA for morbidly obese women was also particularly high at 66.7%. While rates of induction and caesarean section rose for both SGA and non-SGA pregnancies, there was no evidence that this increase differed significantly by SGA identification status. Furthermore, increased antenatal detection of SGA was found to impact positively on risk for both neonatal morbidity and prolonged newborn unit admission (>48 hours). Key ‘Take-Home’ Messages:

▪ Introduction of GAP at CMH has resulted in an almost five-fold increased likelihood for successful detection of SGA.

▪ While there was an increase in interventions (i.e. induction of labour and Caesarean section) between the audit periods, the effect was not more pronounced in the SGA pregnancies.

▪ Amongst identified SGA babies there was a reduction in both composite morbidity and prolonged newborn unit admission compared with those pregnancies where SGA had not been previously detected.

▪ GAP is a safe tool for increasing detection of SGA and is suitable for an ethnically diverse population

__________________________________________________ Dr Ngaire Anderson then presented on how optimal management of pregnancies afflicted with sub-optimal fetal growth may best be achieved, including consideration for the best use of obstetric ultrasound scanning and timing of delivery versus expectant management. Research into the field of SGA and IUGR (alongside standardized fundal height measurements and implementation of the GAP programme) clearly illustrates that antenatal detection of at-risk small babies reduces the risk of stillbirth and other adverse perinatal outcomes. Considering that 85% of SGA and preeclampsia occurs within term pregnancies, it is vital that women and practitioners remain vigilant for optimal fetal movements and growth velocity right up to birth. Key Take-Home Messages: (Note the below SGA Algorithm is available on our website www.nzapec.com

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I myself also had the enormous privilege of being invited to present my preliminary findings from a systematic review querying the merit of oral calcium supplementation for the prevention of preeclampsia amongst a cohort of pregnant women exposed to environmental lead. In New Zealand, 3 - 7% of pregnancies will be affected by preeclampsia. Preeclampsia and eclampsia are associated with pathological and epigenetic changes which engender severe maternal & neonatal morbidity. Lead exposure has recently been implicated as potentially causative of the primary diagnostic criteria for preeclampsia, redefined most recently in 2015 by published research from the Society of Obstetric Medicine of Australia and New Zealand (Lowe et al.). In 2018, researchers led by Dr Arthur Poropot from Griffith University in Queensland, Australia conducted a systemic review and meta-analysis to summarise information linking preeclampsia with lead toxicity (Poropot et al.). Ongoing investigation confirms that lead exposure during pregnancy is an independent risk factor for preeclampsia and that oral calcium supplementation may be protective.

Fetal growth places high demands on maternal calcium status, whereby insufficient dietary or supplementary oral intake of the mineral during pregnancy creates risk for gestational hypertension and preeclampsia, fetal growth restriction, low birth-weight, and premature delivery and birth (Williamse et al., 2019). While diet is the main source of total daily calcium, a World Health Organisation systematic review found it to be largely inadequate (<1000mg calcium per day) in primiparous women in both developing and first-world countries (Merialdi et al., 2005, as cited in Williamse et al.). While supplements are frequently used by pregnant women in developed nations, most contain neither sufficient nor suitably bioavailable amounts of calcium required to correct any deficiency. The research supporting calcium as a proven preventative measure to counteract risk for preeclampsia is indisputable. In 2014, meta-analysis of 13 randomised controlled trials comprising 15,730 pregnant women found that daily oral calcium supplementation of >1000mg during the second half of pregnancy until birth demonstrated a 55% risk reduction for preeclampsia when compared with women

I myself also had the enormous privilege of being invited to present my preliminary findings from a systematic review querying the merit of oral calcium supplementation for the prevention of preeclampsia amongst a cohort of pregnant women exposed to environmental lead. In New Zealand, 3 - 7% of pregnancies will be affected by preeclampsia. Preeclampsia and eclampsia are associated with pathological and epigenetic changes which engender severe maternal & neonatal morbidity. Lead exposure has recently been implicated as potentially causative of the primary diagnostic criteria for preeclampsia, redefined most recently in 2015 by published research from the Society of Obstetric Medicine of Australia and New Zealand (Lowe et al.). In 2018, researchers led by Dr Arthur Poropot from Griffith University in Queensland, Australia conducted a systemic review and meta-analysis to summarise information linking preeclampsia with lead toxicity (Poropot et al.). Ongoing investigation confirms that lead exposure during pregnancy is an independent risk factor for preeclampsia and that oral calcium supplementation may be protective.

Fetal growth places high demands on maternal calcium status, whereby insufficient dietary or supplementary oral intake of the mineral during pregnancy creates risk for gestational hypertension and preeclampsia, fetal growth restriction, low birth-weight, and premature delivery and birth (Williamse et al., 2019). While diet is the main source of total daily calcium, a World Health Organisation systematic review found it to be largely inadequate (<1000mg calcium per day) in primiparous women in both developing and first-world countries (Merialdi et al., 2005, as cited in Williamse et al.). While supplements are frequently used by pregnant women in developed nations, most contain neither sufficient nor suitably bioavailable amounts of calcium required to correct any deficiency. The research supporting calcium as a proven preventative measure to counteract risk for preeclampsia is indisputable. In 2014, meta-analysis of 13 randomised controlled trials comprising 15,730 pregnant women found that daily oral calcium supplementation of >1000mg during the second half of pregnancy until birth demonstrated a 55% risk reduction for preeclampsia when compared with women

I myself also had the enormous privilege of being invited to present my preliminary findings from a systematic review querying the merit of oral calcium supplementation for the prevention of preeclampsia amongst a cohort of pregnant women exposed to environmental lead. In New Zealand, 3 - 7% of pregnancies will be affected by preeclampsia. Preeclampsia and eclampsia are associated with pathological and epigenetic changes which engender severe maternal & neonatal morbidity. Lead exposure has recently been implicated as potentially causative of the primary diagnostic criteria for preeclampsia, redefined most recently in 2015 by published research from the Society of Obstetric Medicine of Australia and New Zealand (Lowe et al.). In 2018, researchers led by Dr Arthur Poropot from Griffith University in Queensland, Australia conducted a systemic review and meta-analysis to summarise information linking preeclampsia with lead toxicity (Poropot et al.). Ongoing investigation confirms that lead exposure during pregnancy is an independent risk factor for preeclampsia and that oral calcium supplementation may be protective.

Fetal growth places high demands on maternal calcium status, whereby insufficient dietary or supplementary oral intake of the mineral during pregnancy creates risk for gestational hypertension and preeclampsia, fetal growth restriction, low birth-weight, and premature delivery and birth (Williamse et al., 2019). While diet is the main source of total daily calcium, a World Health Organisation systematic review found it to be largely inadequate (<1000mg calcium per day) in primiparous women in both developing and first-world countries (Merialdi et al., 2005, as cited in Williamse et al.). While supplements are frequently used by pregnant women in developed nations, most contain neither sufficient nor suitably bioavailable amounts of calcium required to correct any deficiency. The research supporting calcium as a proven preventative measure to counteract risk for preeclampsia is indisputable. In 2014, meta-analysis of 13 randomised controlled trials comprising 15,730 pregnant women found that daily oral calcium supplementation of >1000mg during the second half of pregnancy until birth demonstrated a 55% risk reduction for preeclampsia when compared with women

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If you would like to share your story of pre-eclampsia,

please let us know, we would love to hear from you

Email: info@nzapec.com

receiving placebo (Hofmeyr, Lawrie, Atallah, Duley, & Torloni, 2014; Meertens, Scheepers, Willemse, Spaanderman, & Smits, 2016). Risk reduction for preeclampsia was even more significant amongst women with increased risk for hypertensive disorders and/or those with low dietary calcium intake. This opportunity has since led to an invitation to pitch a trial concept to a panel of experts at the Liggins Institute in Auckland, as part of the ON

TRACK network which embraces and affords opportunity for multi-disciplinary research that has a focus on public health improvement and Māori research responsiveness. It is fantastic to have such incredible support from this network of research specialists and academics and NZ APEC looks forward to sharing all ongoing findings and emergent best-practice indicators in future newsletters.

__________________________________________________ Finally, we closed our day with case-studies examining best-practice for the management of SGA, presented by Professor Lesley McCowan and Dr Ngaire Anderson. The audience was then invited to present any questions they had from the day to the entire panel of principal speakers. Feedback received from the day was overwhelmingly positive and we look forward to shortly announcing our 2020 dates for this year’s NZ APEC Study Day, to be held in Auckland –

details to be shortly released so you can save the date and ensure you don’t miss out on this exciting educational opportunity!!! Guest speakers’ presentation slides are all available to view via our website www.nzapec.org.nz Nga mihi, Rachel Taylor

For more information, see NZ Action on pre-eclampsia - www.nzapec.com

baby moving

less

Headaches

blurRy visionor seeing

flashing lights

hands or face

Swelling

upper abdominal

pain

1. Upper abdominal pain

2. Headaches3. Feeling unwell,

nauseous or throwing up

If you are past 20 weeks and start having even one of these warning signs, call your doctor or midwife as soon as possible.

Pre-eclampsia is a really serious complication that affects 3-7% of women in the second half of pregnancy. In extreme cases, babies and mothers have died from pre-eclampsia.If it’s discovered early, most mothers with pre-eclampsia can still have a healthy baby. If you get it, you’ll need extra care from a specialist, usually in hospital to ensure everything goes as smoothly as possible. These are the 6 warning signs to look for:

Feeling Generally

unwell

4. Blurry vision or seeing flashing lights

5. Swollen hands & face6. Reduced baby

movements

warning signs of Pre-eclampsia?

the

6Do you know

Major