What is the prevalence of Pre-eclampsia across the world? Are there any trends that you find?
The incidence of pre-eclampsia is about 5-8 % worldwide. And from my experience in Singapore it has been constant. Although the management of the disease does vary, it depends on the complications. If you manage the disease better, you will have lower complications rate. And one of the important complications related to pre-eclampsia is eclampsia, which is the onset of convulsions in women who have pre-eclampsia and hypertension. This is a very dangerous disease, a complication that is life threatening.
In Singapore we saw that there is a dramatic reduction of this complication from over 300 per 100, 000 women who are pregnant right down to 16 per 100,000 women. So this is a very dramatic drop and it is because of the better management we have instituted over the past 20 years.
How is pre-eclampsia currently diagnosed worldwide?
Pre-eclampsia is diagnosed by having the onset of hypertension above a certain value, 140/90 with protein in the urine will cause Proteinuria. So once this has been detected it is considered as pre-eclampsia.
Who is most at risk of developing it?
Pre-eclampsia affects pregnant women, pregnant women who are elderly, pregnant women who have a history of before. Also in first time mothers the risk of pre-eclampsia is higher. Certain ethnic groups may also have higher risk of pre-eclampsia. For example, in Singapore, our Malay ethnic group tends to have a higher incidence of pre-eclampsia.
Are there genetic factors involved?
Yes, of course. Genetic factors are very important. Sometimes in some families they have sisters who are pregnant who have pre-eclampsia. So, genetic factors are involved in this disease. We actually look at certain possible, as I mentioned before, our Malay ethnic group in Singapore have a higher incidence. So we target closer surveillance on this group. Especially when they are pregnant, we look out for the pre-eclampsia group. If certain areas have a higher risk then I think there should be more attention paid to that particular region or the particular group.
Globally, it is very important for me to look at the regions all over the world. We have America, Africa, Europe and Asia. In certain parts of Africa the risk of eclampsia is very high because the pre-eclampsia is not managed well. Most of the times, the complication is because there is not so good or poor management of the pre-eclampsia. So, for example in Africa the incidence of eclampsia, which is the leading to pre-eclampsia is as high as above 500 per 100,000 women who actually have the eclampsia.
How does this affect the economy?
Well. eclampsia is definitely a very important disease. Pre-eclampsia as you know affects 5-8 % of the population. The disease itself requires monitoring, so it has a cost involved. There was a study that estimated that pre-eclampsia when developed in the pregnancy increased the cost by 8000 British pounds per pregnancy itself. And in terms of the economy itself it goes up to millions of dollars spent trying to manage the disease of pre-eclampsia. So it is a very significant disease not only for the obstetrician but everybody must be concerned about.
What are the other challenges you find?
Very importantly there should be awareness both by the patients as well as the healthcare providers itself, in terms of trying to detect/screen, looking at blood pressure and if they have high blood pressure, there is need to monitor, admit them so that we can treat them with anti hypertensive and to deliver them if the disease has become serious. If we don't do that the patient may have an eclamptic fit or some serious organ failure at home and the life of the mother and the baby may be threatened. It's estimated that in the whole world, up to 80,000 of mothers death is due to pre-eclampsia. That itself is more than 40 % of the total maternal death of the whole world this year. More than half a million babies and foetus die because of pre-eclampsia every year. So it is a very serious disease globally.
Tell us about the diagnostic tools available?
In terms of diagnostics tools is measuring the blood pressure at each visits and that's why the women have to come quite regularly for visits. That ways we can detect the blood pressure rise and check the urine for any protein. If there is evidence of protein in urine and blood pressure rise then it is considered as pre-eclampsia. So this is the way we diagnose pre-eclampsia currently.
What are the technical advancements?
Recently there have been a lot interests in bio markers and the ability of these new bio markers to be able to predict the occurrence of pre-eclampsia accurately. One of them is PGF (placental growth factor), this biomarker itself reduces when there is pre-eclampsia, if pre-eclampsia is going to occur. So, it is a precursor of the pre-eclampsia developing. If you can detect that the level is low then we can be able to predict that pre-eclampsia is likely to come. More appropriate attention and more management can be given to the patient.
The other biomarker is the sFlt-1 itself, the sFlt-1 is the indications of the damage to the vessels inside the mother itself. So this will be used before pre-eclampsia. So, we use the ratio of the sFlt-1 divided by PIGF give us a very accurate predictor for pre-eclampsia. And this is the new advancement relating to the diagnosis of pre-eclampsia.
Your message for the clinicians
I think the management of pre-eclampsia has advanced a fair bit especially with the use of better biomarkers. These biomarkers very accurately are able to predict whether eclampsia works or not and the level of the biomarker also gives us an idea on how to manage this pregnant woman. If it is very low we can let them be back home, if little bit high we would want them to come back but if it is very high, then we have to do intense surveillance.