Why is the search for pre-eclampsia prevention so elusive?

Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity globally. A recent World Health Organization analysis estimated that hypertensive disorders of pregnancy account for 14% of maternal deaths worldwide.1 These stark facts drive the search for effective, safe, and affordable treatment to prevent pre-eclampsia. Although low dose aspirin reduces the risk of pre-eclampsia by 17%,2 the remaining burden of disease is considerable and additional prophylactic treatments are still needed.

In a linked paper, Wen and colleagues (doi:10.1136/bmj.k3478) report the results of FACT, a double blinded, multinational randomised controlled trial that aimed to determine whether daily supplementation with 4 mg folic acid from the first trimester reduced pre-eclampsia in women with risk factors for the condition.3 Pre-eclampsia occurred in a similar proportion in the placebo and intervention groups and the authors concluded that high dose folic acid does not prevent pre-eclampsia in high risk women. All secondary outcomes (including proportions of small for gestational …