Cartas al editor
Treating patients with severe preeclampsia and eclampsia in Oaxaca, Mexico
To the editor: The Mexican state of Oaxaca continues to be marked by dramatic maternal mortality rates (MMR). In 2009, it had the second-highest MMR with 98.3 maternal deaths per 100 000 live births, compared to the national average of 62.2.1 Almost one-fourth of these deaths were due to hypertensive disorders during pregnancy.1 One such disorder, preeclampsia, is characterized by high blood pressure and excess protein in the urine, usually during the second half of gestation, and is 'severe' when manifested with extreme hypertension, heavy proteinuria or substantial maternal organ dysfunction. If not managed properly, severe preeclampsia can progress to eclampsia, triggering convulsions.2
The Mexican Ministry of Health (MOH)'s technical guidelines list magnesium sulfate (MS) as the drug of choice to prevent and treat convulsions; only when MS is unavailable do they recommend other antihypertensive drugs like phenytoin or phenobarbital. Furthermore, termination of the pregnancy or delivery of the fetus and placenta within six hours of diagnosis is strongly advised.3
Prior studies in Mexico have suggested, however, that providers often do not treat according to technical guidelines, using MS inconsistently or not at all.4,5 The purpose of this letter is to document the treatment of women with preeclampsia and eclampsia in MOH hospitals in Oaxaca, identify barriers to optimal treatment, and develop recommendations for improved practice through a series of studies.
We used a combination of quantitative and qualitative methods for our research. For our quantitative analyses, we reviewed medical records of women diagnosed with severe preeclampsia and eclampsia in 2008 across eight general MOH hospitals and one community-based facility. That year, there were 23 300 obstetric events archived,6 493 of which had complete records and were reported as cases with severe preeclampsia and eclampsia. To gauge usage of antihypertensive and anticonvulsant drugs for patients with severe preeclampsia and eclampsia, 84 obstetric physicians from 12 general MOH hospitals and one community-based facility self-administered anonymous surveys. We performed descriptive analyses of socio-demographic characteristics and analyzed the use of anticonvulsant drugs disaggregated per hospital.
For our complementary qualitative analyses, we reviewed 13 maternal mortality records that recorded hypertensive disorders as the main cause of death, and extracted relevant variables in an Excel spreadsheet. Additionally, we recruited 14 key stakeholders, including heads of Obstetrics and Gynecology departments and researchers in the maternal health field in Oaxaca, via snowball sampling to participate in an in-depth interview. Interviews explored types of drugs used to treat preeclampsia and eclampsia, adherence to MOH technical guidelines, and general implementation of evidence-based practices. Themes were then extracted from transcribed interviews.
Our medical record review found that in 33% of cases, pregnancy termination took longer than six hours. Only 5% of women were admitted to intensive care units (ICU), and 33% of hospitals lacked ICUs. For these cases, the use of anticonvulsant medication did not follow technical guidelines. Of women with severe preeclampsia, only 50% were treated with MS. Of these, almost one-quarter were administered MS in combination with other anticonvulsants; 38% were not provided anticonvulsant treatment at all. For women with eclampsia, MS was given in 82% of cases, of which three-quarters received MS in conjunction with other drugs.
Of the 13 women whose death certificates we reviewed, nine were referred from a smaller facility to a general hospital. Reasons included lack of an obstetrics and gynecology laboratory, or ICU. According to the records, only two of these women were given MS.
Of the 84 physicians surveyed, 96% reported being aware of their hospital's treatment guidelines for care of preeclampsia and eclampsia, and 92% stated that MS was always available in their facilities. Barriers to its usage included fear of side effects and lack of experience managing the drug. Stakeholder interviews further explored barriers to MS usage. These included erratic or incomplete administration of MS due to shift changes or unclear information from a referring facility; the amount of time it takes to prepare dosages of MS; lack of supervision over guideline implementation; and staff shortages and heavy patient-loads that make consistent, quality monitoring of patients difficult.
To improve alignment between knowledge of technical guidelines and practice, we recommend stocking facilities with pre-prepared dosages of MS; establishing incentives for staff to follow evidence-based practices; ensuring adequate coverage of shifts and supervision; and improved communication between referral facilities and providers regarding the order and timing of treatment. While these recommendations would require wide-sweeping health system changes, a comprehensive approach is vital to avert maternal mortality in Oaxaca and in other states of the country.
Marieke G Van Dijk, MD, MA,(1) Mónica García-Rojas, MD, MPH,(2) Xipatl Contreras, BA,(3) Abigail Krumholz, MPH,(3) Sandra G García, ScD,(3) Claudia Díaz-Olavarrieta, Phd.(4)
(1) Population Council, Mexico Office. Westerbork, The Netherlands.
(2) Ministry of Health of Oaxaca. Oaxaca, Mexico.
(3) Population Council, Mexico Office. Mexico City, Mexico.
(4) Research Center for Health Population, National Institute of Public Health. Mexico City, Mexico. email@example.com
1. Observatorio de Mortalidad Materna. Numeralia 2009. Mortalidad materna en México [internet document]. Mexico: OMM, 2010. [Retrieved 2012 September 19]. Aviable at: http://www.omm.org.mx/images/stories/documentos/NumeraliaMM2009.pdf
2. World Health Organization. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneva: WHO, 2011.
3. Centro Nacional de Equidad de Género y Salud Reproductiva. Prevención, diagnóstico y manejo de la preeclampsia/eclampsia. Lineamiento técnico. México, DF: Secretaría de Salud, 2007.
4. Van Dijk MG, Diaz-Olavarrieta C, Zuñiga PU, Gordillo RL, Gutiérrez MER, García SG. Use of magnesium sulfate for treatment of pre-eclampsia and eclampsia in Mexico. Int J Gynaecol Obstet 2013;121(2):110-114.
5. Lumbiganon P, Gülmezoglu AM, Piaggio G, Grimshaw J. Magnesium sulfate is not used for pre-eclampsia and eclampsia in Mexico and Thailand as much as it should be. Bull World Health Organ 2007;85(10):763-767.
6. Gómez J, Núñez RM. Data from SINERHIAS 2009, with data from SAEH 2008.