Sunday, January 27, 2013

What Happened to Lady Sybil on Downton Abbey?

(WARNING: This entire post is a spoiler if you are not watching Downton as it airs in the US)


On tonight's Downton Abbey, Lady Sybil died of toxemia of pregnancy. What does this mean?

Toxemia is the older name for a disease now known as preeclampsia/ eclampsia. Sybil felt unwell, and complained of headaches and swollen ankles. Sometimes this happens in normal pregnancies, so it can be hard to differentiate between disease and normal. She also looked pale and uncomfortable, which had me nervous from the beginning of the episode.

At one point in the episode, Dr. Clarkson can be seen checking her blood pressure. The illness usually first starts with elevating blood pressure. A normal blood pressure in pregnancy generally ranges around 100-120/60-80, and can be as low as 90/50. When it gets above 140/90, that is when disease is present. It can get even higher, above 160/110, and the higher it gets, the more the danger. It's not clear whether the blood pressure connection was known in the era of Downton, as none of the doctors mention it.

Dr. Clarkson also mentions that Sybil's baby seems small. In toxemia, or preeclampsia, there is an abnormal placental attachment - the arteries of the placenta and uterus don't adapt in a normal way to pregnancy, and there is increased resistance to blood flow. When this happens, the baby doesn't get quite enough nutrition and oxygen, and might be growth restricted. It would be born small, even at full term (9 months).

During Sybil's labor, Dr. Clarkson insists on checking Sybil's urine for albumin, or protein. The phenomenon of preeclampsia is now known to manifest first in elevated blood pressure plus protein in the urine. This combination makes the diagnosis, and often predicts the poor outcomes associated. Women with preeclampsia are at risk of seizure, stroke, fetal death, and maternal death.
Dr. Clarkson insists on bringing Sybil to the hospital for a cesarean because the only known cure for toxemia (preeclampsia) is delivery. That remains true today - delivery is the only cure. However, we have another tool in our arsenal these days, which is the administration of a high dose of magnesium sulfate, an electrolyte. It's not know why, but magnesium is extremely effective at preventing the seizures associated with preeclampsia. It doesn't cure the problem, nor prevent the other outcomes like stroke or fetal death, but it makes a huge difference in preventing seizure. It can also be rapidly administered at the time of an eclamptic seizure to stop the seizure and save the woman.

Sadly, it seems that the benefits of magnesium sulfate were not known during the era of Downton, because once Sybil begins to seize, Dr. Clarkson says that there is nothing he can do. When seizing starts, the disease is called eclampsia - the combination of elevated blood pressure, proteinuria, and seizure. Sybil seizes to death in a matter of minutes. The scene was devastatingly accurate, and horrifying.

In the United States, we still see a lot of preeclampsia, but very little eclampsia. That's because we are able to detect the warning signs - elevated blood pressure and proteinuria - and give magnesium and induce labor before the dangerous outcomes occur. Intervening in preeclampsia is one of the most important developments of modern obstetrics.

In developing countries, preeclampsia/eclampsia is one of the most common causes of death. As was noted by the downstairs Downton staff, many women before Sybil have died in childbirth. We still haven't eliminated this problem. I was gratified to see it portrayed in such a popular show. Although it meant losing one of my favorite characters, it is important to highlight this tragically common problem.