Examining long-term health outcomes for mothers post birth

Associate Professor Greg Davis, Senior Staff Specialist and Dr Lynne Roberts, Clinical Midwifery Consultant (Research), Conjoint Senior Lecturer (UNSW) have worked with each other in the Department of Women’s Health at St George Hospital for 20 years conducting research studies, and before that, in a clinical setting. Their friendly banter reveals a long working relationship and friendship.

Associate Professor Greg Davis and Dr Lynne Roberts who lead the P4Study, evaluating mothers after birth

A/Prof Davis, Dr Roberts and the P4 Study

A/Prof Davis and Dr Roberts work together on the P4 Study – a study of women and their babies after normal pregnancy and those with high blood pressure in pregnancy. Women and their babies are seen when the child is six months, two and five years of age.  The women’s physical and psychological health, and the development and health of their babies are assessed, to establish what is normal or otherwise in these areas. Rather than focus on high blood pressure during pregnancy, the study looks at the long-term health outcomes, especially for the mothers, which are not well understood.

The study began recruiting in 2013 and will run until the end of 2023. The Study has recruited 300 women with normal blood pressure in pregnancy and 90 who experienced preeclampsia during their pregnancy.

Preeclampsia is a complication of pregnancy where the mother has high blood pressure in the second half of pregnancy and problems with other organs, most commonly the kidneys. Other body systems such as the liver, blood clotting, and nervous system or problems with blood flow through the placenta causing slowing of the baby’s growth can occur. It is one of the leading causes of preterm birth requiring admission of the baby to the nursery. It is a common serious medical complication of pregnancy, affecting around 5 per cent of all pregnancies in Australia. The causes of this condition are not fully understood, but genetic factors and the placenta seem to play significant roles. The woman’s blood pressure usually returns to normal after the baby is born and the placenta is delivered.

Women are often unaware of having preeclampsia as they usually feel well in the early stages. This highlights the importance of attending antenatal care regularly for blood pressure checks, urine testing and general health check-ups.  Management of preeclampsia aims to avoid serious complications to both the woman and her unborn baby. Rarely, preeclampsia develops into eclampsia, where the woman has seizures, and, even more rarely, can be fatal to both the woman and her baby.

“We control their blood pressure. All you can do is control their blood pressure and keep them going as long as you think it’s safe. And then the only real treatment is to deliver the baby, so these babies will tend to be delivered earlier. We aim to get them to 37 weeks, but sometimes, they have to be delivered earlier than that if the baby is having problems or the mother is not under control as well,” answered A/Prof Davis.

In addition to publishing seven research papers on their findings, the P4 study has “provided an important vehicle for projects for medical students coming through UNSW.” To complete their fourth-year projects, 15 UNSW medical students have done research in some aspect of P4. “Not only do we have papers, but we have 25-30 presentations at academic meetings that both students and also Lynne and [I] and others have presented at,” shared A/Prof Davis.

The collaborative approach has been hugely productive. As well as the core research team, three PhD candidates been undertaken in the project including Dr Roberts, who investigated the psychological aspects of the study for her PhD thesis.

And there is more research to come. The P4 Study has led to the BP2 Study (Blood Pressure Postpartum Study), for which Dr Roberts is also research co-ordinator. This is “a big randomised controlled trial looking at what is the best method of giving these women, after they’ve had high blood pressure, information to try and look after themselves after they’ve had a baby and educate them in that. So that’s an ongoing study which has been spawned by P4, really. It’s a baby of P4,” shared A/Prof Davis.

The P4 Study has had two big outcomes. Firstly, it has raised awareness that women who have had preeclampsia are at four to five times the risk of developing cardiovascular disease – hypertension, strokes, heart disease and kidney failure – later in life. Secondly, “we’ve redefined a new level for the blood pressure which we consider normal after pregnancy,” said A/Prof Davis. “People used to consider 140/90 the upper limit of normal, but we’ve shown that, in our normal population, the upper limit of normal is 120/80.”

“Our big problem now is actually getting that information out there to both the women and also to GPs and people that look after women postpartum.” said A/Prof Davis. This is one of the drivers for the BP2 study.

Dr Roberts’ personal experience inspired her to be involved in this project and others like it. “I experienced preeclampsia myself 28 years ago. I was a midwife at the time, and I found the whole experience quite traumatic. My son was born 10 weeks early here at St George, and he was transferred out because he needed to be on a ventilator, which we don’t do here at St George. He spent the first seven-and-a-half weeks of his life in hospital…I spent three days in the intensive care unit here at St George, and then a few more days back down in the maternity ward when I was well enough for that. I didn’t see him for a few days till I was well enough to go [to Randwick].”

“So, it can be a really traumatic experience for some women, separation from their baby, just having something that’s life-threatening to yourself, having a preterm baby. It can be pretty awful, and I took quite a long time to come to terms with what had happened,” shared Dr Roberts.

After returning to work as a midwife, one of the women in labour that Dr Roberts was caring for asked “Do you have children?” Upon answering yes, the woman replied saying “Oh, you must know what I’m going through then.” Dr Roberts thought to herself “Well, actually, no, I don’t… that was my lightbulb moment that working in the birth centre was not the place to be. I left the birth centre and moved to the RAP team, which was risk-associated pregnancy.”

“I was looking after women who had complicated pregnancies, particularly hypertension and preeclampsia. We looked after them through their pregnancy, through their labour, any admission in hospital afterwards, and I loved it. It had to be the most rewarding area of maternity I’d worked in, and I felt that I did really good work with the women because I really understood a lot of what they were going through with preeclampsia.”

Dr Roberts successfully applied for a six-month secondment on a research project examining the recurrence of high blood pressure in pregnancies. “I wanted to learn everything I could about hypertension in pregnancy. It fascinated me and wanted to know what I could do about it.”

The P4 Study evolved from the Obstetric Medicine Research Group, a multidisciplinary collaboration of obstetricians, midwives and renal physicians, as well as a psychiatrist, a dietitian, a paediatrician and an endocrinologist. Dr Roberts reflected on how the group is “such a collection of great minds and skillsets, and everybody trusts everyone else and respects everyone else, and they’re friendly, and they’re just a great group to work with.”

“I often think that the work I’m doing now may actually benefit me in the future now that we’ve moved on and we’re looking a bit more at long-term health after preeclampsia,” shared Dr Roberts. “I do love the work and the team I work with, and preeclampsia is such an interesting topic to be researching as well. And knowing that we’re doing great work with women’s health is really rewarding as well.”

A/Prof Davis believes that research plays an important role in being a doctor, and in his career. Research “improves your skills and keeps you thinking about things and keeps you up to date with the literature. I’ve always believed that research was important, so I’ve always been involved with research all the way through my medical career.”

One of the first people A/Prof Davis met at St George Hospital was Professor Mark Brown, who has played a pivotal role in the P4 project. “He’s just such a lovely human being and a fabulous doctor and so committed to research … our collaboration started from then. At that time, we also had a very forward-thinking midwifery group… it was very collaborative right from the start. But initially, it was just really the renal physicians – or Mark Brown, really, me, and the midwives involved initially, and then as Lynne has said, it’s grown over the time.”

“Mark’s the ideas person … he’s come up with the ideas, and then we’ve sort of implemented the studies to actually answer all those ideas.”

“I’m an obstetrician. I work in high-risk pregnancy. Mark is a renal physician, works in preeclampsia and hypertension side of medical problems in pregnancy,” explained A/Prof Davis. “Most of my research has been working with Mark and then the larger team on hypertension and pregnancy.”

“A lot of the earlier work was on measuring protein in urine, [and] how you measure blood pressure. As Lynne said, does it recur in subsequent pregnancies? What’s the best way for measuring blood pressure in pregnancy?”

“When I started training, everyone said preeclampsia had disappeared by three months after the birth. That was the standard belief, and it’s really only become apparent over the last 15 years that that is not true. And these women are at high risk, and we’re not really doing anything about it.” Over the past 10 year the group has focussed on postpartum research. “A lot of the intrapartum stuff has been sorted out, the diagnosis and management, and when you deliver people, when you make that decision, what drugs you use in pregnancy. All that stuff has been sorted out to a large extent.”

“We still don’t know how to prevent [preeclampsia], but once women actually have it, we know how to diagnose it. We know how to manage it. So that’s why we’ve moved on to trying to actually improve women’s health after they’ve had preeclampsia and do something about it – try and intervene so that they don’t have these high risks afterwards,” A/Prof Davis explained.

Achieving a balanced life

When asked about his life outside of work, A/Prof Davis stated “I have a very balanced life. So we have a private practice as well. I’m an obstetrician on call, so I’m on call Monday to Friday and one weekend in four. And the rest of the time, I exercise.”

Currently, with my daughter, I’m doing a big jigsaw. I’m sort of into jigsaw puzzles. And what else am I doing? I read a lot, actually. I don’t read serious stuff. I read crime novels. And I think in our job – you deal with a lot of human pain and emotion, and I find most of what they describe as great literature is about human pain and emotion, and I think we deal with that on a daily basis. And I don’t really need to read about it any more to know that it’s not very nice, so I tend to read crime and murder – seems much less traumatic somehow.”

Dr Roberts shares A/Prof Davis’ love of jigsaws. Outside of work Ms Roberts likes to “go out walking with my dog. She’s crazy and needs to burn off energy. And like Greg, I love doing jigsaw puzzles. I just finished a 2,000-piece puzzle on the weekend, which I was pretty chuffed about. I find them a great thing to do just for a bit of quiet downtime, but very hard to tear myself away from them. It’s very addictive… Sometimes, I set myself a timer, otherwise, I could just be there till the early hours of the morning without realising it… I also love to cook. I do like to cook sweet things. I’m a very good scone maker, so I like to host high teas at my place. I love to get out all the fine bone china and put on a show with it all with the scones with my homemade jam, as well. But yeah, I do like to cook lots of different things.”

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