The Public Health Implications of the Thing That Happened on Downton Abbey

Spoiler Alert! You have been alerted! I am not messing around. I am about to spoil the crap out of Downton Abbey, namely Season 3 Episode 5. I am only half kidding when I say I revived this blog in order to avoid spoiling this episode for my Facebook friends, so if you haven’t seen it, please do me a solid and find something else to read. May I recommend a poem by Margaret Atwood to pass the time? As for the rest of you, let’s find out what Maggie Smith and Penelope Wilton had to say about filming their graphic love scene.

Or we could contemplate something a lot less wonderful and a lot more tragic, namely, poor Sybil. Three months or so have passed since she died on American TV, but I’m going to guess you’re still not over it. Who would have thought that the line, “My head!” could be so haunting?

http://pensieve.typepad.com/.a/6a00d8341c61d153ef017c366c47bf970b-450wi

Image via Pensieve

From a public health perspective, Sybil’s fictional death from eclampsia was a fascinating creative choice. Often Downton Abbey reminds us of just how much the world has changed in the past century–think of Mrs. Hughes’ electric toaster, or pretty much anything the dowager countess has to say. Yet Downton creator Julian Fellowes and his collaborators chose a death for Sybil that reminds us of some ways in which very little has changed at all. Fellowes has shared that Sybil had to be written off because Jessica Brown Findlay was leaving the show, but there were a lot of ways Sybil could have died. Even within the realm of death in childbirth there were more obvious choices. In 1920, death by so-called puerperal fever was relatively common. Now it is understood as sepsis, and preventable with antibiotics–for developed countries at least, one of the clearest public health victories in history. Not so for eclampsia.

So, what is this eclampsia business? The terminology is a little confusing for historical reasons. Today eclampsia is considered to be the most severe end of the essential disease, which is preeclampsia. As soon as Sybil mentioned having swollen ankles, I immediately shouted, “Preeclampsia! She’s got preeclampsia!” Since swollen hands or feet are usually the cardinal symptom, my diagnosis was about as clever as figuring out who the murderer is on Law & Order, but I still acted smug all evening. The hallmark of preeclampsia is high blood pressure in pregnancy, with protein in the urine. And feeling truly awful.

via Cartoon Guide to Becoming a Doctor

Preeclampsia is a disorder of the placenta, but no one has been able to demonstrate much about the disease mechanism, or what causes it (but I’m going to go ahead and facepalm over the phrase “trophoblast deportation” anyway). Groups of women at higher risk, for unknown reasons, include women with a personal or family history of preeclampsia, women with no previous pregnancies, African-American women, heavier women, and women at extremes of age pregnancy-wise. Weirdly, smokers seem to have lower risk (you knew if you were patient you had to get thrown ONE bone, right?). Preeclampsia is one of the leading causes of maternal mortality in developed countries; along with other so-called disorders of hypertension it is currently ranked second in the UK.

Most striking to me in watching this episode was that the options for managing preeclampsia are basically the same now as they were in 1920. If it’s caught early and both mother and fetus are doing ok, the usual recommendation is bed rest, on the theory that moving around raises your blood pressure. But there’s no evidence that bed rest actually improves pregnancy outcomes (that paper is from 1994 but its findings are current, and there still has not been a randomized trial of bed rest). The only definitive treatment for preeclampsia is to hasten delivery, either by inducing labor or by c-section, just as Dr. Clarkson recommended for Sybil.

Ninety-three years.

By the way, if you were wondering, preeclampsia is not the leading cause of death for pregnant women in the US. The #1 cause of death is homicide.

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