A Message from Peter von Dadelszen, Principal Investigator of PRE-EMPT
This has been a year of prodigious achievement and great intellectual agility across all the PRE-EMPT objectives (Prevention, Monitoring, Treatment, the CoLaboratory and knowledge Translation), and I want to thank everyone involved globally for this success - what we are doing matters.
With additional investment by WHO RHR, Justus Hofmeyr and the Calcium And Pre-eclampsia RCT team have expanded their recruitment footprint to include three centres in Argentina, with a noticeable upswing in recruitment as a consequence of this investment. I am deeply grateful to the RHR for their active partnership with the CAP trial and involving us in the maternal morbidity working group. In addition, through creative dialogue within the CAP team in Africa, innovative strategies have been shared and implemented to improve recruitment success at the existing sites.
In terms of the Monitoring objective within PRE-EMPT, the main miniPIERS manuscript makes its way through the process of peer-review. The paper will be all the better for that process. In addition, we have put miniPIERS into Android and iPhone apps and have shown that the phone oximeter improves the stratification performance of the miniPIERS model. In terms of new endeavours, much of what we have learned about obstetric outcome prediction modelling is now being applied to critically ill pregnant and recently pregnant women, women at increased risk for adverse placental outcomes in pregnancy, and a probabilistic model of ill health and disease to support and guide antenatal care in all settings.
pre-eclampsia-related attitudes, beliefs, myths and practices
The findings of the CLIP Feasibility Studies in Nigeria, Pakistan and India, summaries of which are included in this report, provide new and important insights into the place of pre-eclampsia in the thoughts of women of reproductive age, their mothers and mothers-in-law, and the male decision makers with whom they interact (including their husbands in some settings), as well as those who have a duty of care towards these women as clinicians and health administrators. The Mozambique CLIP Feasibility Study has started, the findings of which will be summarized in next year’s Annual Report. We are not aware of any data sets that provide such rich contextual insights into pre-eclampsia-related attitudes, beliefs, myths and practices. These data are informing the design and implementation of the CLIP Trial in each country, tailoring the trial to each country’s needs, barriers and facilitators, and giving CLIP Nigeria, CLIP Pakistan and CLIP India (and, in 12 months, CLIP Mozambique) the stamp of individuality. The Feasibility Study data were not derived in the absence of a great deal of effort. This effort has been, and is being, expended by each national team and the Vancouver group. In particular, I want to acknowledge the contributions of Diane Sawchuck and Rahat Qureshi in designing the studies, the country lead investigators (Femi Oladapo, Khatia Munguambe, Rahat Qureshi, and Jaya Bellad), the focus discussion group leads, in-depth interviewers and data collection teams, and Marianne Vidler, who will be using her co-ordination of, and active participation in both the Feasibility Studies and the planned meta-synthesis, as the basis of her PhD.
The international CLIP collaboration of site investigators, co-ordinating centre in Vancouver and steering committee members have finalised the CLIP Trial protocol and data collection forms, sourced mobile phones, tablets, drugs and devices, successfully obtained ethics approvals and are poised to commence a landmark set of CLIP Trials. The concerted and always collegial effort required to get us all to this point has been astounding and all those involved should feel justifiably proud. The whole Vancouver PRE-EMPT team and our corridor neighbours in paediatric anaesthesia and computer engineering, with whom we share the PIERS on the Move project, have undertaken a substantial amount of work this year - with an ever strengthening sense of team and momentum.
Oral Options for Severe Hypertension
The Gynuity Health Projects Oral Antihypertensive Trial is beginning recruitment. Women will be randomised to a head-to-head comparison between three oral options for the management of severe pregnancy hypertension: methyldopa, nifedipine, or labetalol. These unique data will be important for practitioners in all settings.
CoLaboratory Continues Growth
The Global Pregnancy CoLaboratory has had another year of great success. The collaboration now includes more than 20 member centres globally, has data related to more than 300,000 pregnancies, and has produced “white papers” on important topics to guide and harmonise research: (i) harmonising research in general on the adverse pregnancy outcome, pre-eclampsia; (ii) genetic research in pre-eclampsia; and (iii) placental research. Each of these will be submitted for publication. We have developed new statistical methods for merging datasets related to parallel studies of angiogenic factors in pregnancy performed using different analytical platforms and will produce a series of definitive papers summarising the role of angiogenic imbalance in the origins and subclassification of pre-eclampsia, fetal growth restriction and other placental complications of pregnancy. In addition, a number of hypothesis-driven studies are underway and the CoLab is looking towards finding self-sustainability through leveraged funding built on this increasing body of success. I want to thank Jim Roberts, Chris Redman, Roberta Ness, and the indomitable Lee Rager for their leadership of CoLab. In addition, I am grateful to Jim for his ongoing support of me personally and the broader PRE-EMPT initiative in his role as special advisor.
Translating New Knowledge
In terms of knowledge translation, the PRE-EMPT team has been well-represented in activities ranging from Women Deliver and the WHO Commission on Life-Saving Commodities to continued expansion of the Preeclampsia Foundation’s impact on global women’s health. On my travels, I keep hearing how valuable the WHO pre-eclampsia recommendations are - and people seem to have read the document as they ask me to clarify my views around calcium and pre-eclampsia prevention! I am looking forward to the new relationship with the Global Library of Women’s Medicine as we look to convert international, evidence-based pregnancy hypertension guidelines into a textbook and online resources useful to colleagues in low, middle and high income countries.
Gates Foundation Funding Additions
This third year both began and ends with the announcement of additional funding to support PRE-EMPT. At last year’s Annual Meeting, France Donnay, Senior Program Officer at the Bill & Melinda Gates Foundation, announced the approval of an almost $17 million supplement to the initial $7.4 million PRE-EMPT award. This most impressive investment in the PRE-EMPT initiative has strengthened the Calcium And Pregnancy Trial, the CLIP Trial (enabling the transition from a single funded CLIP Pilot Trial to three pilot trials and four definitive trials), the Global Pregnancy CoLaboratory, and Preeclampsia Foundation outreach, as well as enabling the Gynuity Health projects Oral Antihypertensive Trial. To round out the year, I am delighted to be able to confirm that we have received an additional $1.5 million from the Gates Foundation to ensure that the CLIP Trial in Mozambique will be fully funded. We recognise that this supplement is a substantial award earnt through the combined effort of the global PRE-EMPT team. This places upon us all the obligation to keep performing at our current level - it can be all-consuming, it is intimidating, but it is never anything less than fully rewarding. This investment is supplemented by direct practical support and advice from the Foundation for which I am deeply thankful.
PRE-EMPT Team Updates
There have been a number of transitions in the PRE-EMPT team. In particular, I want to welcome and thank Sharla Drebit for her enthusiasm, calm, cheerfulness and effectiveness since taking the role of the PRE-EMPT Manager this June. Also, I would like to acknowledge the effort and commitment of Diane Sawchuck to PRE-EMPT during its first two-and-a-half years. Congratulations to Femi Oladapo in his new role at the WHO Headquarters In Geneva, and thank you for making CLIP Nigeria the success that it has been to date and for your ongoing commitment to the team.
Finally, I would like to talk of mentorship and inspiration. I did not anticipate being in this role three-and-a-half years ago, before the grantmaking process began, and felt (and often still feel) very under-prepared for this particular responsibility and task. However, if I am achieving some level of success it relates directly to the support and advice of important mentors and friends, particularly Zulfi Bhutta, Jim Roberts, Chris Redman, Lucilla Poston, Arul Arulkumaran, Mario Merialdi, Stuart MacLeod, more latterly, Richard Derman, and, most importantly, France Donnay. The country teams have taught me immeasurable amounts about their own countries and contexts - I am learning so much. In terms of inspiration, I have to acknowledge three major sources. First, the girls and women whom I have met and observed in Africa, South and East Asia, Latin America and Oceania to whom this work is dedicated. Second, thirty years after his death, my father, Richard, GP, maternity care provider and astounding polymath who taught me to think and to understand the social responsibility that comes with personal opportunity. Finally, as always, my family — Laura and all five of my children are my anchor and greatest inspiration, especially Laura, who is my soul mate and who carries a highly unequal burden of domestic and organisational responsibility, particularly related to PRE-EMPT absences, but seems to love, and, even, like me nevertheless.
Thank you all for your interest and support as we enter the fourth year of this great adventure.
Peter von Dadelszen