Maternal death: a century of getting it wrong | Basky Thilaganathan | TEDxWandsworth

Maternal death: a century of getting it wrong | Basky Thilaganathan | TEDxWandsworth

Translator: Denise RQ
Reviewer: Lena Clemente In a few days time, we’ll be commemorating Armistice Day In remembrance of the millions
of lives lost 100 years ago, in the First World War. This year, over 300,000 women
will die in childbirth. That is more maternal deaths than allied soldiers lost
during the First World War each year. The majority of maternal death is due to infection or bleeding
at the time of childbirth, and the cost of preventing these deaths is that of training expert birth care attendants
and organizing health care. Thankfully, the World Health Organization and other partner institutions
have worked relentlessly, and maternal death has decreased
by over 40% in the last 20 years to the levels that it is now. Today, I’d like to talk to you
about pre-eclampsia, a condition responsible
for one in five maternal deaths. That’s a maternal death every 12 minutes
somewhere in the world. Pre-eclampsia is
a complication of pregnancy that results in very high blood pressure. As a trainee obstetrician, your first encounter with pre-eclampsia
can be quite traumatic. A perfectly healthy mother
comes to our maternity unit accompanied by elated relatives,
expecting and primed for a happy event. The midwife puts on
a blood pressure cuff as routine. But within minutes, you can see from her expression
that things are not right. Her blood pressure is sky high and despite our best attempts
to control it, she becomes severely ill, and both her and her baby
are admitted to our intensive care unit. In many countries in the world,
they would both have died. It’s left to me to explain why this catastrophe has occurred. All I have, by way of explanation, is the same story that doctors
have been repeating for 100 years, and that story suggests that something abnormal
in the development of the placenta caused her high blood pressure to occur. It’s that story that I’d like
to explore with you today. Pre-eclampsia was
first described in 500BC, and the medical features of the condition
clearly documented about 100 years ago. That documentation firmly believes the placenta is central to the causation because you have to have a placenta
to develop pre-eclampsia. The finding of tiny cellular lesions
in the placenta, down a microscope, and the fact that the baby
grows poorly in pre-eclampsia, support the placental hypothesis. Presumably, the placenta
can’t feed the baby as well. Also, the fact that delivery
of the placenta cures pre-eclampsia is taken as irrefutable evidence
that the placenta causes pre-eclampsia. I’ve been an obstetrician
for over 25 years, with a research interest in pre-eclampsia, research that is embedded in the belief
– or at least, it was initially – that the placenta causes pre-eclampsia; something that I have begun
to regard with a different perspective; a perspective that challenges the prevailing medical opinion
and beliefs. We first realized things were different
when we started to look at how the mother responds in pregnancy. We found that most women
did not have anything wrong with their placenta, and in fact, their babies were normal
in size or even larger than average. Those don’t fit
with the placenta working poorly, but what we could not take away was the fact that you have to have
a placenta to develop pre-eclampsia, and that delivery of the placenta
cured pre-eclampsia. That seemed to be irrefutable
until our research on the long term health of our women, and that showed some interesting findings. Women who develop pre-eclampsia
are five times more likely to develop heart disease or stroke
in the subsequent 20 to 30 years. In fact, two out of three women
who develop pre-eclampsia will die from heart disease. Here’s a thought: how does the placenta
that we disposed of 20 years ago, have such a profound and serious effect
on the mother’s heart? The problem with pre-eclampsia is that we really didn’t know
how to analyze this effect, and it seemed a conundrum. Taking the placenta away
cured the disease, but yet, predisposed
to long term problems. That seemed difficult and confusing until I started to see parallels
with another disorder in pregnancy, the disorder called gestational diabetes, where a mother develops diabetes
as a consequence of the pregnancy. The mother’s pancreas is unable to deal
with the sugar load of pregnancy and can’t produce enough insulin
– the sugar-controlling hormone – and therefore, diabetes occurs. Interestingly, diabetes in pregnancy is cured by the delivery of the baby. What’s more, women
who develop pregnancy diabetes have a 50% risk of developing
diabetes themselves in the 10 years following pregnancy. I don’t know about you, but it seemed logical to me
to consider the possibility that pre-eclampsia had
nothing to do with the placenta but that pre-eclampsia
represented a condition where the mother’s heart was unable to
deal with the vascular load of pregnancy. St. Georges University of London,
where I work, has a renown sports cardiology center. A multi-disciplinary team
headed by professor Sanjay Sharma monitor and help our elite cyclists,
rugby players, Olympians achieve their best performances, and they have all the best
medical technologies available to them. They’re particularly interested
in the performance of the heart. For example, did you know that a young elite athlete
who is setting out on a training program will increase the weight of her heart
by 25% over a two-year period? Picture a pregnant mother. By nine months of pregnancy,
her heart mass has increased by 40%. Look at the little grooves in the heart,
those grooves are called trabeculations. The number and the depth of these grooves are related to the amount
of exercise you undertake. Here is a graph showing
the prevalence of trabeculations in various elite sportsmen. And where do you think
pregnancy comes there? Take a guess.
Off the scale. So yet again, pregnancy out-performs
our best and most elite sportsmen. To understand this, you need to realize that an Olympian may exercise for
10 hours a day, five days a week but rest. A pregnant mother is working,
24 hours a day, 7 days a week, for 9 months and increasingly so,
as time goes on with no rest, even when she’s sleeping. And therefore, you’ve got to acknowledge
that this is a truly Olympian achievement, and pregnant women
are mothers, are partners also deserve our respect for this. We are not all Olympians, and therefore, it should come as no surprise to you that about 10 to 15% of women struggle to cope with
the vascular load of pregnancy; their heart comes
under considerable strain. Evidence for this comes from reviewing the symptoms of pregnancy. Those of you who’ve been pregnant
will recognize some of these symptoms: shortness of breath, swollen ankles, etc. I’m not getting much acknowledgment
for the last one on the list, perhaps I should ask your partners. Is it just a coincidence that the symptoms of heart failure
are exactly the same? When we look at the heart function
in women who have pre-eclampsia, we find that it’s quite deranged in the same way
that pancreatic function is deranged in women who develop
diabetes in pregnancy. In fact, in most severely ill
pre-eclamptic women, the heart function is similar
to that of a 70-year-old woman. We followed these women up
for one to two years to chart their recovery, and were quite surprised to find
little if any recovery over those 2 years. And that was shocking. So the question remained, what is the effect of pre-eclampsia
on the mother’s health? In order to tackle this, we developed
a collaboration with Doctor Heather Boyd in the Statens Serum Institut in Denmark, and we followed up the postpartum health
of a million Danish women. What we found was that 20-year-old women
who developed pre-eclampsia had the same risk
of developing high blood pressure as a 40-year-old woman
who had a normal pregnancy. Pre-eclampsia appeared to advance your age-related risk
for heart disease by 20 years. It now seems totally absurd to me
that I went around for 20 years saying that age, and obesity, and ethnicity
were all risk factors for poor placental development, and then pre-eclampsia, when it is obvious to us all these are all risk factors
for heart disease. If it’s so obvious to us all,
why did we miss it? In order to understand that,
you need to understand the relationship between the heart
and the placenta is very similar to the relationship
of a pump and a radiator. For the radiator to work,
it needs hot water pumped through it; and for the placenta to work properly, it needs the heart to pump oxygen
and nutrients through it. And if the heart is not working properly, the placenta, which is
a very oxygen rich organ, will send out signals that makes the heart work harder
and increase the blood pressure. The problem has been for us that when we looked into and wanted
to investigate pre-eclampsia, we were left looking at the radiator, at the placenta, and guess what? The pump had gone home with the mother. So what conclusion could we come to other than pre-eclampsia
is a placental disorder? Because we simply failed
to look at the pump. I hope you’d agree that the evidence
for the heart being involved and the cardiac origins of pre-eclampsia
are quite over-whelming. Yet, we need to try and understand why the scientific community are finding it difficult
to grasp this ideology. There I must admit
to being culpable, as well. For many years, I was a believer
in the placental origins and suffered from something
called confirmation bias, that is a tendency to search for
and interpret evidence to support my prior beliefs. After all, we’re asking
them to throw away what they have believed
is the unshakeable truth for 20 years and accept a new paradigm. It’s even worse when you challenge
a researcher or colleague and say that they have misinterpreted
the evidence for 10 to 20 years. That insights anger and rejection. It’s far easier for me
to collude with them and say that actually
we haven’t got much evidence, and that’s why
we haven’t made any progress. And most important of all,
research funding drives our research and funding applications for money
are reviewed by pre-eclampsia experts who believe in the placental origins and are less tolerant of other hypotheses. For example, a US institution
recently awarded over 50 million dollars looking at placental health in disease; good luck with that. Where do we go from here? Understanding a disease is vital whether it’s pre-eclampsia,
or anything else, to help us cure and help. In pre-eclampsia,
a diagnostic test is blood pressure – technology that is 150 years old. I’ve seen a woman come to clinic in the morning
with a normal blood pressure and be admitted later on that day
with seizures from pre-eclampsia. It’s this inability to diagnose
pre-eclampsia in a timely fashion that leads to women
dying in a rural setting because they haven’t got time
to access healthcare. And only by understanding the disease
can we begin to work on appropriate diagnostic tests
that give us time. Our treatment for pre-eclampsia
is scheduling birth. Pre-term birth, being born early, is the leading cause of death
under the age of five – a million deaths a year. It’s not until we understand and accept
the cardiac origins of pre-eclampsia that we will begin
to even scrape the surface of a treatment or prevention
for the disease. Every women has the right
to safe childbirth. I fear that until the scientific community
understands and accepts the cardiac origins of pre-eclampsia
that we will make no progress in reducing death and disease
due to pre-eclampsia. What I hope is that we,
doctors and scientists, could be a little bit more open minded and see
things from a different perspective, as you have done today. Thank you. (Applause)

9 Replies to “Maternal death: a century of getting it wrong | Basky Thilaganathan | TEDxWandsworth”

  1. Very interesting. Yet I can't fully connect seizures, low platelet count and other preeclampsia related alterations merely to heart congestive failure.

  2. Well spoken Basky…Good luck with more funding to continue your research work. It is outrageous data on maternal deaths. Something needs to be done globally.

  3. A great talk, and a very interesting new perspective!

    How does this hypothesis explain the fact that the same mother in two or more different pregnancies does not develop preeclampsia or even high blood pressure in every pregnancy?

  4. Discussions around cardiovascular origins or preeclampsia are hotting up. Debates in BCOG, DIP, WCMFM, FMF, ISSHP and COGI congresses – all in one year. Please share!

  5. Maternal death or maternal mortality is defined by the World Health Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."

    There are two performance indicators that are sometimes used interchangeably: maternal mortality ratio and maternal mortality rate, which (confusingly) are both abbreviated "MMR".

    By 2017, the world maternal mortality rate had declined 44% since 1990, but still, every day 830 women die from pregnancy or childbirth related causes.

    According to the United Nations Population Fund (UNFPA) 2017 report, this is equivalent to "about one woman every two minutes and for every woman who dies, 20 or 30 encounter complications with serious or long-lasting consequences.

    Most of these deaths and injuries are entirely preventable."

    UNFPA estimated that 289,000 women died of pregnancy or childbirth related causes in 2013.

    These causes range from severe bleeding to obstructed labour, all of which have highly effective interventions.

    As women have gained access to family planning and skilled birth attendance with backup emergency obstetric care, the global maternal mortality ratio has fallen from 380 maternal deaths per 100,000 live births in 1990 to 210 deaths per 100,000 live births in 2013, and many countries halved their maternal death rates in the last 10 years.

    High rates of maternal mortality still exist in certain places, particularly in impoverished communities, with over 85% living in Africa and Southern Asia.

    The effect of a mother's death results in vulnerable families and their infants, if they survive childbirth, are more likely to die before reaching their second birthday.

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