News
Congratulations to our Founder - Dr Joyce Cowan
King's Honour List - Officer of the New Zealand Order of Merit - ONZM
For services to midwifery
Dr Joyce Cowan has contributed to the midwifery profession as a leader and educator for more than 50 years.
Dr Cowan registered as a midwife in the 1970s and has since provided community and hospital-based care to pregnant women and babies throughout South Auckland. She is a leading New Zealand midwifery expert in pre-eclampsia, a pregnancy condition that threatens the health and life of both mothers and babies. She co-founded the charity, New Zealand Action on Pre-eclampsia (NZ APEC) in 1994, which raises awareness and provides education for health professionals about pre-eclampsia and supports women with pre-eclampsia and their families. The programme has contributed to the low perinatal mortality now associated with pre-eclampsia in New Zealand. She introduced and currently leads the Growth Assessment Programme (GAP) in New Zealand, an education programme which has resulted in improved detection of smaller babies during pregnancy and a reduction in neonatal deaths. ACC has provided funding for the roll out of GAP nationally. While a Senior Lecturer at the Auckland University of Technology Midwifery Department, she published her doctoral thesis in 2020 on the effect of implementation of GAP in Counties Manukau on maternal and neonatal outcomes. Dr Cowan has presented her research findings on GAP education and pre-eclampsia at several national and international conferences.
Guidelines
Guidelines for the Diagnosis & Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand
The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice
Research & Article Reviews
Aspirin use during pregnancy and the risk of bleeding complications
Hastie, R., Tong, S., Wikström, AK., Sandström, A, Hesselman, S, & Bergman, L. (2020). Aspirin use during pregnancy and the risk of bleeding complications: A Swedish population-based cohort study. American Journal of Obstetrics and Gynecology. Doi:https://doi.org/10.1016/j.ajog.2020.07.023
Summary of study findings:
•Population based study using Swedish pregnancy registry data of 313 624 women of whom 4088 (1.3%) used aspirin in pregnancy.
•Analyses attempted to account for confounding factors, but confounding cannot be completely excluded.
•Unknown what dose or duration of aspirin was used although national guidance was 75mg from 12 until 36 weeks.
•Aspirin was not associated with increased risk of bleeding in pregnancy
•Aspirin was associated with an increased risk of PPH and postpartum haematoma in women who had a vaginal birth but not a caesarean section birth.
•Aspirin was associated an increased risk of neonatal intracranial haemorrhage in women who had a vaginal birth but not a caesarean section birth but the overall numbers of this complication were very low (total of 13 events in more than 313 000 pregnancies). This finding was not significant when women with preeclampsia were excluded from the aspirin users
NOTE: In data from the latest Cochrane Review comprising 20 randomised controlled trials and including 32,224 babies there were 147 events of intraventricular haemorrhage. Aspirin was not associated with any increased risk of intraventricular haemorrhage (RR 0.97, 95%CI 0.7-1.34). NB this is from the most recent Cochrane Review published last year Duley L, Meher S, Hunter KE, Seidler AL, Askie LM. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD004659. DOI: 10.1002/14651858.CD004659.pub3. The Hastie, et al., study referenced the 2007 version. This updated Cochrane review also found a small increase in PPH - 23,769 women, 19 trials; RR 1.06, 95% CI 1.00 to 1.12
What do these findings mean for us?
The current New Zealand recommendation for pregnancies at major risk of preeclampsia and SGA is for women to take 100mg LDA per day, taken at night from 12-16 weeks until 36 weeks gestation.
We do not believe that the findings of this study by Hastie et al., (2020) should change our advice to women who meet the NZ eligibility criteria for prophylactic treatment. Treatment should be discontinued at 36 weeks’ gestation or sooner if earlier delivery is planned. This is in keeping with the authors of the study who state “We do not interpret our findings to suggest that aspirin should no longer be used to prevent preeclampsia. In fact, we would strongly advise that women considered at high risk for developing preeclampsia…should still be offered aspirin” p.18.
In addition, we suggest that use of aspirin in pregnancy should be taken into consideration when assessing risk factors for PPH and planning best place of birth and additional precautions that may be required in labour and after birth.
NZAPEC would like to thank our medical advisors Professor Lesley McCowan & Associate Professor Dr Katie Groom for reviewing this study and giving our readers the above advice that the findings do not change our current best practice in New Zealand for prophylactic use of aspirin.
Could broccoli sprout extract be a future treatment for preeclampsia by protecting against oxidative and inflammatory stress?
Update on related publication:
SULFORAPHANE IMPROVES IN VITRO ENDOTHELIAL AND TROPHOBLAST FUNCTION: A POTENTIAL NEW ADJUVANT THERAPY FOR PREECLAMPSIA (2018) Cox AG, Gurusinghe S, Rahman R, Leaw, Chan ST, Mockler JC, Murthi P, Lim R, Wallace EM
NZAPEC has been very interested in this research after hearing Annie Langston-Cox speak at PSANZ in 2018. Annie’s clinical trial assessing broccoli sprout extract (sulforaphane) as an adjuvant therapy for women diagnosed with pre-eclampsia after her laboratory findings found evidence supporting sulforaphane’s ability to act as an antioxidant and improve cellular resilience to oxidative and inflammatory stress. Annie stated, “I hope to improve maternal vascular health, thereby allowing for safe prolongation of pregnancy to enable fetal maturation”.
Update: Prolong trial clinical trial protocol has been put forward (trial has not yet commenced) to carry out an RCT, which is pleasing to see this research moving forward – NZAPEC will continue to follow the outcome of this research.
Langston-Cox, A.G. et al., (2019). Prolong: a double-blind randomised placebo-controlled trial of broccoli sprout extract in women with early onset preeclampsia. A clinical trial protocol BMJ Open 2019 Oct 17;9(10):e027493. doi: 10.1136/bmjopen-2018-027493.
Introduction: Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality. There is a need for adjuvant, targeted therapies to improve outcomes. Broccoli sprout extract, rich in the antioxidant sulforaphane, reduces oxidative stress and placental secretion of the antiangiogenic factors that contribute to vascular dysfunction in preeclampsia. We propose a phase III trial investigating broccoli sprout extract. We will assess broccoli sprout extract in women with early onset (<34 weeks) preeclampsia, investigating (1) the interval between enrolment and delivery (days), (2) biomarkers of placental and endothelial function and (3) maternal and fetal outcomes.
Methods:
A double-blind, placebo-controlled randomised trial will be conducted at Monash Health, Melbourne, Australia. One hundred and eighty women (45 each arm of each stratum) with early onset preeclampsia (defined as per Society for Obstetric Medicine of Australia and New Zealand guidelines) will be recruited. Consenting women will be randomised to receive an oral dose of either broccoli sprout extract (24 mg of activated sulforaphane) or identical placebo, twice daily until delivery. Maternal blood will be collected antenatally for measurement of biomarkers of preeclampsia, including soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF), soluble endoglin (sEng) and activin A, as well as circulating sulforaphane metabolites. Maternal and perinatal outcomes will be monitored throughout. All clinical care decisions, including the timing of delivery, will be made by the treating team, blinded to treatment allocation. Participation in this trial will not affect routine care. At delivery, maternal and cord blood and placentae will be collected to measure sulforaphane metabolites and sFlt-1, PlGF, sEng and activin A.