"Downton Abbey" Revisited: Modern Medicine's Approach to a Dangerous Complication of Pregnancy

For Release: February 21, 2013

PALO ALTO, Calif. - When "Downton Abbey" TV character Lady Sybil Crawley's life-threatening pregnancy complication went ignored in a recent episode of the show, real-life obstetrician Maurice Druzin, MD, turned from his television and said to his wife, "We're going to have a real tragedy here."

Druzin, the service chief of obstetrics and gynecology at Lucile Packard Children's Hospital Stanford, was correct. Lady Sybil did not receive the emergency cesarean section she needed. Shortly after delivering her baby, she developed seizures and died. Her condition, eclampsia – in which an expectant, laboring or newly-delivered mother's high blood pressure escalates into deadly seizures – was a tragically frequent cause of maternal death in the 1920s world that the popular TV show depicts.

The morning after the "Downton Abbey" episode aired, a woman in labor at Packard Children's suffered a sudden, unexpected eclamptic seizure. The team caring for her at the hospital's Johnson Center for Pregnancy and Newborn Services knew they had to take immediate action. Although full-blown eclampsia is much rarer now than in Lady Sybil's day, it can still kill. Speedy recognition and treatment of the problem are essential to saving moms' and babies' lives.

"Eclampsia and its precursor, pre-eclampsia, can arise out of nowhere," said Scott Oesterling, MD, the attending physician at this delivery. "It can be very scary for the patient and the providers." Fortunately, eclampsia treatment has advanced greatly since the 1920s, and Packard Children's high-risk obstetric team is at the forefront of those improvements. Druzin is himself among his field's leaders, having served recently on two expert committees that made recommendations for the American College of Obstetrics and Gynecology and also the California Department of Public Health on how to diagnose and treat the problem. The new recommendations will be published soon.

Thanks to regular prenatal care, it is now rare for pregnant women to develop full-blown eclampsia, Druzin noted; patients are usually caught at the stage of pre-eclampsia, when high blood pressure warns that something is going wrong. Six to 12 percent of women experience high blood pressure in the last few weeks of pregnancy, and a smaller number have the problem earlier along.

For the rare cases where eclampsia still occurs, the entire Packard Children's team has a concrete plan for taking quick action. Using the hospital's in-house simulation-based training program, in which full medical teams rehearse emergencies with realistic medical mannequins, they regularly practice and evaluate the steps needed to treat eclampsia successfully. Since Packard Children's sees only about three patients per year with full-blown eclampsia, the simulations are an essential part of maintaining the care team's skills, according to Druzin's colleague Kay Daniels, MD, who co-directs the simulation program. They have also assembled a "pre-eclampsia box," an idea Druzin adapted from a colleague who treats the condition in developing countries, where it is much more common. The box contains all the medications needed to treat a patient, so that no time is lost in tracking down the drugs when they're needed.

On Jan. 28, the preparations and practice paid off. Within a few minutes of patient Veronica De La Cruz's seizure, she had received medications to prevent further seizures and lower her blood pressure. "One of the things I love about working at Packard is that Packard works," Oesterling said. "The hospital's well-rehearsed team was ready for this rare but known complication of healthy labor." Soon afterward, De La Cruz got the most important medical intervention for eclampsia: Her baby was delivered. Although baby Aiden was born four weeks early, he was healthy at birth. Mom and baby are now home from the hospital and are doing well.

"I remember, during the c-section, my mom telling me not to go to sleep, not to fall asleep, and then hearing the baby cry," said De La Cruz, speaking through an interpreter. "That's when I woke up totally." De La Cruz was glad to be at Packard Children's. "The doctors know what they are doing, and they take very good care of you in the hospital," she said. Even with good prenatal care, such as De La Cruz had, a few patients still develop eclamptic seizures, though the problem is more common among women who don't get prenatal care, Druzin noted. "Pre-eclampsia can unpredictably progress into severe eclampsia, right in front of your eyes," he said, adding that seizures can occur before, during or after labor. In a 2011 report from the California Department of Public Health, 17 percent of the state's maternal deaths were linked to pre-eclampsia and eclampsia, and nearly half of those deaths were judged by experts to have been preventable, a number Druzin wants to reduce.

As part of that effort, he wants to educate pregnant women about warning signs of pre-eclampsia, which include high blood pressure, swelling in the lower limbs, headaches, blurred vision or light sensitivity, nausea, upper abdominal pain, and mental confusion or fogginess. If they experience such symptoms, pregnant women should alert their caregivers immediately. Druzin is also leading efforts to equip every California hospital for saving moms' and babies' lives when confronted with a case like De La Cruz's. He is co-chair of a state task force developing a practical guide for caregivers who diagnose and manage pre-eclampsia. "It was shaped by the latest thinking around the disease, and will be distributed to every hospital in the state that sees obstetric patients," Druzin said. "The good news is that with a modern treatment approach, most women and their babies can have safe, healthy outcomes."

Authors

Erin Digitale
(650) 724-9175
digitale@stanford.edu