Preventing Eclampsia
Bill Gates has said that for the year of 2024, artificial intelligence (AI) will revolutionize many parts of our economy, including medical care. Of course, he is not the only one delusional enough to think that AI can somehow manage to cure the physician shortage. You can replace physicians with AI, nurse practitioners, or physician assistants, but none of these substitutes can perform with the expertise of physicians. Why? For anything to be counted in AI, it has to be put into some form that can be turned into data. As Hubert Dreyfus tells us, expertise does not arise from rules. In other words, the real art of medicine often never appears in words to be collected and massaged. Hence, much of the real expertise of physicians is never captured by AI.
Case in point: the management of preeclampsia. To avoid eclampsia, seizures, strokes, permanent injury, and death require a series of complicated judgment calls. The most important factor for managing preeclampsia is one single blood pressure elevation. To be a critical factor in preeclampsia, the patient’s blood pressure doesn’t even need to be greatly elevated. For example, if the normal blood pressure is 110/70, a pressure of 120/80 is often all the more that is needed to begin a necessary complex change in medical care.
Preeclampsia and eclampsia (eclampsia plus seizure) are sometimes said to be surprising and mysterious. I’ve found them to be neither. In four decades of delivering about 6000 babies, I’ve never had a patient with eclampsia; although, I had several hundred patients with preeclampsia. In my experience with my patients, there were no strokes, no permanent injury, and no death associated with elevated blood pressure.
In the early 50s, when television arrived on the scene, we often heard the phrase “better living through chemistry.” This was a DuPont commercial originating in 1936 which originally said, “better things for a better living through chemistry.” Today we could echo the notion with “better living through Big Pharma.” Same idea. Mr. Gates knows very well that there’s a lot of money in Big Pharma. He has invested several million dollars in a blood test called Mirvie which is touted as a miracle test for predicting preeclampsia.
News flash! We already have a tool for predicting preeclampsia. It’s called a blood pressure cuff.
The biggest problem with the blood pressure cuff is not that it is inaccurate. It is rather that we have all been trained to recheck that one elevated blood pressure until it returns to normal. If the patient has been lying on the left side long enough and blood pressures are checked often enough, a lower blood pressure can be found and recorded. The problem with this approach is that when the patient returns in a week or so for a recheck, the blood pressure is going to be a lot higher. With this kind of delay, the opportunity for prevention, early treatment, and effective management of preeclampsia has passed. By then, the patient may have progressed to sustained hypertension and preeclampsia, with a greater risk for seizures, strokes, permanent injury, and death.
In reality, what matters most is not that the blood pressure will come down if the patients are tested often enough and long enough. Rather that first elevated blood pressure is likely to be the canary in the coal mine. So, we don’t need Mirvie. We don’t need to spend millions of dollars on expensive and unneeded tests, but we do need to be trained to use the tools at our disposal to manage and avoid serious injury and death.
Mirvie isn’t going to provide any useful information if we ignore the test. So, whether we use the new test, Mirvie, or our old test, the blood pressure cuff, we still must pay attention to the values that we recover from the test.
So, how can one single elevated blood pressure help to avoid the complications of preeclampsia? First, I always recommended my patients have a blood pressure cuff at home and check their blood pressure twice a day. Blood pressures rarely go up suddenly. Usually the pressure slowly elevates. During that time, activity can be modified. For example, if you have a patient who works three 12-hour days, begin treatment by recommending five- or six-hour days. Years ago bedrest was often recommended, but bedrest is no longer considered safe or effective. Simply reducing activity is a place to start.
We need to carefully consider the phrase, “Better living through Big Pharma.” No matter what test we use, Mirvie or a blood pressure cuff, we need to use our judgment to proactively manage the complications of preeclampsia and high blood pressure during pregnancy.
There are a lot of mistaken notions in medical care such as postpartum depression cannot be prevented as well as the complications of preeclampsia. Promoting Big Pharma’s continued development of unneeded tests and medications simply drives up the cost of healthcare and often, sadly, deprives us of cheap, safe, and effective healthcare alternatives.