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Pregnancy: Preeclampsia

Preeclampsia, a complication of pregnancy, is characterized by high blood pressure (hypertension), and is one of the leading causes of maternal and infant death in the United States. (Preeclampsia Foundation, 2018). Preeclampsia usually begins after 20 weeks pregnancy in women whose blood pressure was previously normal, although in rare cases it can occur earlier or even postpartum (Mayo Clinic, 2018). It affects approximately 5-8% of all pregnancies, but the incidence has increased approximately 25% over the past two decades and continues to rise (Shih, et al., 2016).

Symptoms and Risks

Symptoms include swelling, sudden weight gain, headaches, and vision changes. However, some women do not have any warning symptoms until their blood pressure spikes dangerously, which can have fatal consequences for both mother and baby (Preeclampsia Foundation, 2019).

Who is at Risk?

Women who have a history of preeclampsia in a previous pregnancy are at higher risk, as are those with pre-existing chronic hypertension and/or secondary causes of hypertension, such as underlying renal disease. (Preeclampsia Foundation, 2018).

Conventional Care

For women with a history of preeclampsia, the standard of care, set by the American College of Obstetricians and Gynecologists is a recommendation of low dose aspirin (LDA, 81 mg) daily, starting between weeks 12-16 of subsequent pregnancies and continuing until delivery. This goal is to prevent or delay the onset of hypertension and preeclampsia (American College of Obstetricians and Gynecologists, 2018).

Low dose aspirin. Although daily LDA is considered safe during pregnancy and is not associated with serious maternal or fetal complications, the efficacy rate is not very impressive. A review of approximately 30,000 randomized subjects found only a 2-5% reduction in the rate of preeclampsia (Preeclampsia Foundation, 2016). A prospective1 longitudinal study conducted on 394 women who were considered high-risk for preeclampsia and given daily LDA showed no improvement in chronic hypertension in pregnancy with LDA. This study did show a significant effect on a biomarker warning of pending preeclampsia. A reduction of Soluble FMS-like Tyrosine Kinase 1 (sFlt1) and placental growth factor (PlGF), reported to be highly predictive several weeks before the onset of preeclampsia, strongly supported prophylactic use of LDA in high risk pregnant women (Mayer-Pickel, et al., 2019).

The low effectiveness of LDA in the prevention of preeclampsia has been the focus of many studies. One overview notes that numerous studies have tried to determine the effect of low dose aspirin on the incidence of preeclampsia, with very controversial results. For example, to avoid one case of preterm preeclampsia, 1,228 patients must be screened and nearly 10% of the population must be treated with aspirin (Atallah, et al., 2017).

High dose aspirin. A 2019 study looked at the mechanisms of LDA on preeclampsia and concluded that high dose aspirin may be superior to LDA for the prevention and treatment of preeclampsia (Mirabito Colafella, Neuman, Visser, Danser, & Versmissen, 2019).

Acupuncture

A pilot prospective1 cohort2 study that focused on the effects of acupuncture on preeclampsia was conducted in China in 2015. Pregnant women with a diagnosis of preeclampsia were offered acupuncture and divided into two groups, one group who received acupuncture for 10 sessions over a two-week period and one group who declined acupuncture. Participants were matched by age and gestational week at diagnosis. Blood pressure was recorded at the start of the study, at the end of acupuncture treatment, immediately before delivery, and postpartum (within 24 hours) (Zeng, et al., 2016). Although the study was small, the results were impressive. The acupuncture group had significantly lower blood pressure readings than the control group at time of delivery, and the change between readings at baseline and end of treatment was also significant. There were no major differences in perinatal outcomes between the groups, and no adverse effects were reported (Zeng, et al., 2016).

Other studies have looked at the effectiveness of acupuncture for general hypertension. One randomized controlled trial looked at 428 patients with hypertension and found that acupuncture was successful in reducing blood pressure readings in patients with mild hypertension (Zheng, et al., 2019).

Several other studies confirm that acupuncture reduces hypertension and is more effective than both a non-acupuncture control and a sham acupuncture control, leading the researchers to conclude that acupuncture has a stable antihypertensive effect (HealthCMI, 2014). However, the research on acupuncture for pregnancy hypertension and preeclampsia is limited. Two observational studies of acupuncture for treatment of hypertension in pregnancy have been conducted, but both lacked a control group with which to draw comparisons (Zeng, et al., 2016). The previously mentioned pilot prospective cohort study, Effects of acupuncture on preeclampsia in Chinese women, did show promising results, with patients in the control group having significantly lower blood pressure at time of delivery and greater reduction in blood pressure overall between baseline and end of treatment (Zeng, et al., 2016).

A single case study published in December, 2019 reported a 35-year old woman who "developed preeclampsia with severe features and HELLP3 at 27 weeks and 6 days of gestation," was admitted to a high-risk care facility, and was treated with acupuncture and acupressure for five weeks. Her blood pressure was temporarily reduced, uterine blood flow increased, and protection provided for her hepato-renal system and she was able to deliver a healthy baby. (Kocher, 2019).

Research Gap

A gap in research that needs to be investigated is to examine how the addition of acupuncture to the LDA standard of care in women with a history of preeclampsia affects the rates of recurrent preeclampsia. This could then be further expanded to explore the effectiveness of acupuncture in women with no history of preeclampsia to see if preeclampsia rates overall could be reduced, regardless of risk factors.

Conclusion

With the incidence of preeclampsia on the rise, and the serious complications and fatalities that can result from it, effective treatment is important. The standard of care LDA is not successful enough in reducing recurrence of preeclampsia. As previously mentioned, it may only reduce the rate of preeclampsia by as little as 2-5%, although other studies indicate a rate of 10- 20% (Preeclampsia Foundation, 2016). Even the higher estimate, however, leaves up to 80% of women at risk. In addition, some studies show 81 mg is a minimum dose for effectiveness, and that higher doses, up to 150 mg, may be more effective (Lockwood & Abbott, 2019). There is obviously a need for more successful intervention. Future research needs to show whether the addition of acupuncture to the standard of care further reduces the recurrence of preeclampsia. This would have not only a positive benefit for women at risk but could help reduce medical costs resulting from complications. In a 2017 report published by the American Journal of Obstetrics & Gynecology, researchers documented the short-term medical costs associated with preeclampsia. The aggregated incremental cost was $2.18 billion to the U.S. healthcare system for the first 12 months after delivery – $1.03 billion in maternal healthcare costs and $1.15 billion for infants born to mothers with preeclampsia (Preeclampsia Foundation, 2016).

About the Author

Dr. Cynthia Ignatovsky, DACM, LAc. has been involved with Chinese Medicine since 1997. She graduated from Five Branches Institute in Santa Cruz, CA, in 2002, where she earned her Masters of Science in Traditional Chinese Medicine. Currently a licensed acupuncturist and herbalist in California, she is pursuing her Doctorate in Acupuncture and Chinese Medicine at Pacific College of Oriental Medicine. Her post-graduate work includes on-going advanced training in the areas of gynecology, obstetrics, and reproductive medicine, which is the focus of her private practice in Campbell, CA.

References

American College of Obstetricians and Gynecologists. (2018, June 25). Low Dose Aspirin Use During Pregnancy. Retrieved November 1, 2019, from https://www.acog.org/ClinicalGuidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/LowDose-Aspirin-Use-During-Pregnancy

Atallah, A., Lecarpentier, E., Goffinet, F., Doret-Dion, M., Gaucherand, P., & Tsatsaris, V. (2017). Aspirin for Prevention of Preeclampsia. Drugs, 77(17), 1819–1831.

HealthCMI. (2014, February 18). Acupuncture Lowers Hypertension Finding. Retrieved November 1, 2019, from https://www.healthcmi.com/Acupuncture-ContinuingEducation-News/1255-acupuncture-lowers-hypertension-new-finding.

Lockwood, C. J., & Abbott, J. F. (2019, January 18). The value of low-dose aspirin for prevention of preeclampsia. Retrieved November 1, 2019, from https://www.mdedge.com/obgyn/article/172972/obstetrics/value-low-dose-aspirinprevention-preeclampsia.

Mayer-Pickel, K., Kolovetsiou-Kreiner, V., Stern, C., Münzker, J., Eberhard, K., Trajanoski, S., et al. (2019, September 10). Effect of Low-Dose Aspirin on Soluble FMS-Like Tyrosine Kinase 1/Placental Growth Factor (sFlt-1/PlGF Ratio) in Pregnancies at High Risk for the Development of Preeclampsia. Journal of Clinical Medicine, 8(9), 1429.

ACUPUNCTURE PLUS LDA FOR PREECLAMPSIA 13 Mayo Clinic. (2018, November 16). Preeclampsia. Retrieved November 1, 2019, from https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc20355745.

Mirabito Colafella, K. M., Neuman, R. I., Visser, W., Danser, A. H. J., & Versmissen, J. (2019, August 16). Aspirin for the prevention and treatment of pre-eclampsia: A matter of COX1 and/or COX-2 inhibition? Basic & Clinical Pharmacology & Toxicology. Retrieved November 1, 2019.

National Institute of Health. (2017, January 31). What are the risks of preeclampsia & eclampsia to the fetus? Retrieved November 1, 2019, from http://www.nichd.nih.gov/health/topics/preeclampsia/conditioninfo/risk-fetus.

Preeclampsia Foundation. (2016, August 1). Should you consider low-dose aspirin to reduce your preeclampsia risk? Retrieved November 1, 2019, from https://www.preeclampsia.org/the-news/145-patient-support/635-should-you-considerlow-dose-aspirin-to-reduce-preeclampsia-risk.

Preeclampsia Foundation. (2017, July 12). New study reports costs of preeclampsia to the U.S. healthcare system at .18 billion in first year. Retrieved November 1, 2019, from https://www.preeclampsia.org/the-news/138-latest-news/662-new-study-reports-costs-ofpreeclampsia-to-the-u-s-healthcare-system-at-$2-18-billion-in-first-year.

Preeclampsia Foundation. (2019, January 3). About Preeclampsia. Retrieved November 1, 2019, from https://www.preeclampsia.org/health-information/about-preeclampsia.

ACUPUNCTURE PLUS LDA FOR PREECLAMPSIA 14 Shih, T., Peneva, D., Xu, X., Sutton, A., Triche, E., Ehrenkranz, R. A., et al. (2016, March). The Rising Burden of Preeclampsia in the United States Impacts Both Maternal and Child Health. American Journal of Perinatology, 33(04), 329-338.

Zeng, Y., Liu, B., Luo, T., Chen, Y., Chen, G., & Chen, D. (2016, April). Effects of acupuncture on preeclampsia in Chinese women: a pilot prospective cohort study. Sage Journals, 34(2), 144-148.

Zheng, H., Li, J., Li, Y., Zhao, L., Wu, X., Chen, J., et al. (2019, March 21). Acupuncture for patients with mild hypertension: A randomized controlled trial. Journal of Clinical Hypertension, 21(3), 412-420.

Kocher Z, Hobbs V. (2019). Integrating Acupuncture for Preeclampsia with Severe Features and HELLP Syndrome in a High-Risk Antepartum Care Setting. Med Acupunct. Dec 1;31(6):407-415.

Footnotes

1. Prospective study: this means that the study looks at outcomes in the future, rather than retrospective outcomes from the past. In theory it has a smaller chance of bias and other inaccuracies than retrospective studies.
2. Cohort study: cohort studies are longitudinal and look at a group of people with similar characteristics.
3. Hemolysis, Elevated liver enzymes, Low Platelet count syndrome

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