title: OS032. Pharmacotherapy for pre-eclampsia in low and middle income countries: An analysis of essential medicines lists (EMLS).
abstract: Pre-eclampsia is the second leading cause of maternal mortality in low and middle income countries (LMIC). Pharmacological management of pre-eclampsia has five major components including antihypertensive therapy for severe and non-severe hypertension, magnesium sulphate for prevention or treatment of eclampsia, treatment of pre-eclampsia-related end-organ complications, antenatal corticosteroids for acceleration of fetal pulmonary maturity given iatrogenic preterm delivery for maternal and/or fetal indications, and labour induction for such indicated deliveries. Essential medicines are defined by the World Health Organization (WHO) as "drugs that satisfy the health care needs of the majority of the population". Essential Medicines Lists (EMLs) detail these essential medicines within an individual country and support the argument that the medication should be routinely available.
  
  
  
  To determine how many drugs required for comprehensive pre-eclampsia management are listed in national EMLs of LMIC.
  
  
  
  We conducted a descriptive analysis of relevant drug prevalence on identified EMLs. We searched for the national EMLs of the 144 LMIC identified by the World Bank. EMLs were collected by broad based internet searches and in collaboration with the WHO. The EMLs were surveyed for therapies for the different aspects of pre-eclampsia management: hypertension (non-severe and severe with oral or parenteral agents), eclampsia, pre-eclampsia complications (e.g., pulmonary oedema, thrombosis), preterm birth, and labour induction.
  
  
  
  EMLs were located and reviewed for 58(40.3%) of LMIC. One or more parenteral antihypertensive agents were listed in 51(87.9%) EMLs. The most common agents were: hydralazine (67.2%), verapamil (58.6%), propranolol (39.7%) and sodium nitroprusside (37.9%); parenteral labetalol was listed by only 19.0% of EMLs. The most prevalent oral antihypertensive therapies listed were: nifedipine (96.6%, usually 10 or 20mg intermediate-acting tablets), methyldopa (94.8%), propranolol (89.7%), and atenolol (87.9%). Captopril, enalapril, hydrochlorothiazide and spironolactone were commonly listed. Magnesium sulphate for prevention and management of eclampsia was present in 86.2% of EMLs (and its antidote, calcium gluconate in 82.8%). To manage complications of pre-eclampsia, oral frusemide was listed in 94.8% of EMLs and parenteral heparin in 91.4%. Most EMLs listed parenteral dexamethasone (91.4%) for acceleration of fetal pulmonary maturity and oxytocin (98.3%) or a prostanoid (usually misoprostol, 39.7%) for labour induction.
  
  
  
  EMLs of LMIC provide comprehensive coverage of all aspects of recommended pre-eclampsia pharmacotherapy. These EMLs may be used as advocacy tools to ensure the availability of these therapies within each country.
authors.affiliation: Faculty of Medicine.
authors.forename: S
authors.initials: S
authors.lastname: Lalani
authors.affiliation: Faculty of Medicine.
authors.forename: T
authors.initials: T
authors.lastname: Firoz
authors.affiliation: Clinical Professor of Medicine; Child and Family Research Institute; Obstetric Medicine, Children's and Women's Hospital and Health Centre, Vancouver, Canada.
authors.forename: L A
authors.initials: LA
authors.lastname: Magee
authors.affiliation: Maternal and Child Health Integrated Program, Washington, D.C., United States.
authors.forename: R
authors.initials: R
authors.lastname: Lowe
authors.affiliation: Child and Family Research Institute; Obstetrics and Gynaecology, University of British Columbia.
authors.forename: D
authors.initials: D
authors.lastname: Sawchuck
authors.affiliation: Obstetrics and Gynaecology, University of British Columbia.
authors.forename: B
authors.initials: B
authors.lastname: Payne
authors.affiliation: Obstetrics and Gynaecology, University of British Columbia.
authors.forename: R
authors.initials: R
authors.lastname: Gordon
authors.affiliation: Obstetrics and Gynaecology, University of British Columbia.
authors.forename: M
authors.initials: M
authors.lastname: Vidler
authors.affiliation: Obstetrics and Gynaecology, University of British Columbia; Maternal Fetal Medicine-Obstetrics and Gynaecology, Children's and Women's Health Centre of BC, Vancouver, Canada.
authors.forename: P
authors.initials: P
authors.lastname: von Dadelszen