Beyond Blood Pressure: Knowing the Complexities of Preeclampsia
Pregnancy can be a wonderful and exciting time, but there can also be serious health problems, such as preeclampsia. Preeclampsia is considered a multi-system disorder that develops after 20 weeks of gestation in women who had normal blood pressure until that point. It occurs in 5-8% of all pregnancies in the world, and it is a leading cause of maternal and perinatal morbidity and mortality across the globe. For example, in India, where there is a very limited availability of uninterrupted prenatal checkups, the importance of early identification and treatment of preeclampsia is paramount. If preeclampsia goes untreated, it may lead to extremely serious complications such as seizures, strokes, organ failure, premature birth, and/or restricted fetal growth. It is imperative for expectant mothers, their families, and healthcare providers to understand preeclampsia to have the best opportunity for safe outcomes.
What is Preeclampsia?
Preeclampsia is a serious medical condition that can occur about midway through pregnancy (after 20 weeks). People with preeclampsia experience high blood pressure, protein in their pee, swelling, headaches, and blurred vision. Preeclampsia is characterized by maternal endothelial dysfunction that occurs during pregnancy or postpartum. It is caused by complications with the development and function of the placenta. Preeclampsia results in constricted, less compliant blood vessels, leading to inadequate blood flow to the placenta. This inadequately perfused placenta initiates inflammation, resulting in injury to the endothelial lining of blood vessels. This chain reaction causes systemic vascular constriction, increased vascular permeability, dysregulation of coagulation, and eventual organ injury. Preeclampsia may impact the function of multiple organ systems, including the kidneys, liver, brain, and lungs. It is important to distinguish preeclampsia from gestational hypertension, which is high blood pressure in pregnancy without protein in urine or other injury to involved organs. Gestational hypertension can transition into preeclampsia in certain cases, but they are distinct phenomena.
Understanding the Progression & Severe Types
Preeclampsia can occur with varying severity and onset; the following are some of the common types and stages of preeclampsia:
- Gestational Hypertension: Hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg) developing after 20 weeks of pregnancy in an individual whose blood pressure had previously been normal, without protein in the urine or end-organ dysfunction. Some will resolve, and others will develop into preeclampsia.
- Preeclampsia (without severe features): Hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg) developing after 20 weeks of gestation with proteinuria (protein in urine) or other forms of end-organ dysfunction (e.g., impaired renal function, hepatic) (e.g., pulmonary edema, new-onset headache that is not relieved by medications, visual disturbances, low platelets).
- Preeclampsia with Severe Features: Significantly elevated blood pressure (systolic ≥160 mmHg or diastolic ≥110 mmHg) on two readings at least four hours apart OR lower-level hypertension with signs of severe organ dysfunction (e.g., severe proteinuria, significantly impaired hepatic function, severe headache/persistent headache with visual disturbance, pulmonary edema, low platelets, elevated creatinine). There is a greater need for intervention in this situation.
- Eclampsia: The most serious complication recognized as the occurrence of new grand mal seizures in a person who had preeclampsia, provided they had no prior neurologic disease. Eclampsia is a medical emergency and can result in coma, brain damage, and maternal/fetal death.
- HELLP Syndrome: A severe form of preeclampsia, sometimes regarded as a medical emergency. HELP is an acronym for
- Hemolysis (the breakdown of red blood cells)
- Elevated liver enzymes (indicates liver damage)
- Low platelet counts (affecting blood clotting) and HELLP can occur with or without elevated blood pressure and proteinuria and have a significant risk of morbidity and mortality for both mother and child.
- Postpartum Preeclampsia: Preeclampsia can also develop after delivery. It occurs typically between 48 hours and 6 weeks after delivery. Symptoms and risks are similar to preeclampsia and need appropriate management.
Preeclampsia Symptoms
Preeclampsia can be insidious because its earliest signs and symptoms can often be benign or clinically indistinguishable from normal pregnancy aches, pains, and discomforts. This is why it is imperative to have regular prenatal visits, which include blood pressure measurement and urinalysis. Some of the common warning signs and symptoms of preeclampsia (particularly after 20 weeks of gestation) are as follows:
- New-Onset Hypertension: This is the hallmark sign. A blood pressure reading of ≥ 140/90 mmHg on two occasions, at least four hours apart, in a previously normotensive female is supportive of the diagnosis.
- Proteinuria (Protein in Urine): Usually confirmed most easily via dipstick during your prenatal visit.
- Severe Headaches: A new, persistent headache that does not resolve with over-the-counter pain relievers. Sometimes patients describe a “thunderclap” headache or a dull, throbbing headache.
- Visual Disturbances: May include blurring of vision, flashes of light, spots or auras, temporary blindness, or photophobia.
- Sudden Swelling (Edema): While swelling of the feet and ankles may be expected at this point in your pregnancy, sudden swelling of the hands or face (swollen eyelids) may be more concerning.
- Upper Abdominal Symptoms: Pain in the upper right abdomen (under the ribs) or in the mid-epigastrium (just below the breastbone) indicates liver involvement and could be mistaken for heartburn or indigestion.
- Nausea and Vomiting: New or worsening nausea and/or vomiting, particularly in the third trimester.
- Shortness of Breath (Dyspnea): This could be a sign of fluid overload in the lungs (pulmonary edema) and could signify serious complications.
- Decreased Urine Output: A significant decrease in urine output may suggest decreased kidney function.
- Weight Gain: Sudden and excessive weight gain due to fluid overload.
- Altered Mental Status: In severe cases, confusion, disorientation, or seizures (eclampsia).
It is of the utmost importance for all pregnant women to check for the above symptoms and to consult their physician for further evaluation at the first thought of any symptom.
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What Causes Preeclampsia? Identifying Risk Factors
While any woman experiencing a pregnancy can be affected by preeclampsia, several factors can increase the likelihood that a woman will have preeclampsia:
- First Pregnancy: Risk is higher for a woman who is having her first pregnancy.
- Prior History of Preeclampsia: Women who had preeclampsia in a prior pregnancy have a much higher recurrence risk (40-70%).
- Family History: For a woman who has a mother and/or sister with preeclampsia, risk increases.
- Chronic Hypertension: Women with chronic hypertension (and high blood pressure) prior to the pregnancy.
- Chronic Kidney Disease: For women who have chronic kidney conditions, risks may increase.
- Diabetes: Women who have either pre-existing or gestational diabetes.
- Obesity: A woman with a higher BMI prior to the pregnancy.
- Multiple Pregnancy: Women who are experiencing a multiple pregnancy, such as twins or more.
- Age: Women who are under 20 years of age or over the age of 35 (especially over 40 years old) have a higher risk.
- Assisted Reproductive Technology (ART): Women experiencing a pregnancy as a result of IVF may have a slightly increased risk of having preeclampsia.
- New Paternity: Some studies suggest women with new partners may be at higher risk of developing preeclampsia. It is theorized that this may be due to the mother’s immune system response to different paternal antigens.
- Autoimmune Conditions: Some autoimmune conditions, such as lupus or antiphospholipid syndrome.
- Sleep Apnea: Untreated sleep apnea might result in preeclampsia.
Having one or more of the above risk factors does not definitively mean she will have preeclampsia; as well, many women who do not have any of the above risk factors may also develop preeclampsia.
Preeclampsia Complications: Is Preeclampsia Serious?
Untreated or rapidly advancing preeclampsia can result in serious and potentially fatal complications for both mother and baby, including
Maternal Complications:
- Eclampsia: This is defined as a seizure episode that takes place in a pregnant woman and can cause significant brain injury, coma, or death.
- Stroke: Very high blood pressure in pregnancy can lead to bleeding in the brain and can result in a stroke.
- HELLP Syndrome: This syndrome causes destruction of red blood cells, damage to the liver, and a serious drop in platelet count; it is life-threatening.
- Placental Abruption: This occurs when the placenta separates from the uterine wall and causes excessive bleeding in the mother and fetal distress.
- Pulmonary Edema: This occurs when fluid collects in the lungs, causing extreme difficulty breathing and severe shortness of breath.
- Acute Kidney Injury: This involves a very sudden and very serious injury to the kidneys and can be temporary or, in some cases, permanent.
- Liver Failure: This is a serious condition of failure of the liver to function properly.
- Disseminated Intravascular Coagulation (DIC): A severe syndrome that causes blood to clot within the body’s small blood vessels, using up remaining clotting factors and causing uncontrollable bleeding.
- Increased Risk of Future Cardiovascular Disease: Women who have had preeclampsia are more likely to develop hypertension, heart disease, stroke, and diabetes long after having their baby.
Fetal/Neonatal Outcomes:
- Early Delivery: The baby must be delivered early to save the mother and/or when fetal distress is present. Premature birth carries its own risks, including, but not limited to, respiratory distress syndrome, intraventricular hemorrhage, cerebral palsy, and developmental delays.
- Intrauterine Growth Restriction (IUGR): The fetus may not grow as expected due to decreased blood flow and nutrient supply from the placenta.
- Fetal Distress: The fetal baby may not tolerate labor and, in particular, early labor due to placental insufficiency.
- Stillbirth or Neonatal Death: In severe cases of preeclampsia that are not controlled, the ultimate result is stillbirth or neonatal death.
Note: The above-discussed complications do not occur in everyone and may only occur in some severe cases.
Preeclampsia Diagnosis
The diagnosis of preeclampsia consists of clinical evaluations and laboratory studies:
- Monitoring Blood Pressure: Monitoring blood pressure regularly is crucial. Diagnosis of hypertension = Blood pressure ≥ 140/90 mmHg on two occasions at least four hours apart (after gestational age of 20 weeks)
- Dipstick Urine Test (for proteinuria): Usually available at prenatal visits and the easiest way to check for protein in the urine.
- 24-hour Urine Collection: The 24-hour urine collection is usually done if the dipstick test is positive for protein in the urine. A 24-hour urine collection tells the quantity of protein (which is a more helpful measure because it measures true proteinuria). Proteinuria is usually defined as ≥ 300mg in a 24-hour urine collection.
- Blood Tests:
- CBC (complete blood count) : These are done to check platelet count (note: low platelets is a marker for either severe preeclampsia or HELLP syndrome).
- LFTs (liver function tests) : These are taken to assess liver enzymes (note: elevations in the liver enzymes indicate liver damage).
- Kidney Function Tests : This measures creatinine and blood urea nitrogen (BUN) to assess kidney function.
- Uric Acid : These levels are often elevated in preeclampsia.
- Lactate Dehydrogenase (LDH) : The elevation can indicate hemolysis (breakdown of red blood cells) in HELLP syndrome.
- Fetal Monitoring:
- Ultrasound: This is suggested in order to assess for fetal growth (most notably intrauterine growth restriction—IUGR), amniotic fluid levels, and estimated fetal weight.
- Non-Stress Test (NST) and Biophysical Profile (BPP): Suggested to monitor fetal well-being.
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Management of Preeclampsia
Although the only definitive “cure” for preeclampsia is to deliver the baby and placenta, if preeclampsia develops prior to term, the healthcare team’s goal is to manage it in a manner that keeps both the mom and baby safe as long as possible by allowing the baby to continue to grow and develop. Preeclampsia treatment will vary widely depending on how severe the preeclampsia is, how far along the baby is in gestation, and the mother’s health.
A. Mild Preeclampsia (without severe features): Pregnancy Monitoring Protocols
- Close monitoring: Monitoring blood pressure regularly and urine protein levels along with kidney/liver function.
- Fetal monitoring: Ultrasounds, NSTs, and BPPs on a regular basis to monitor growth and well-being, looking for any signs of deterioration.
- Rest: Reduction in activity and stress is helpful.
- Hydration: Staying well hydrated is key.
- Admission to the hospital: If needed, referred for closer monitoring to the hospital.
- Time of delivery: Inducing labor is fine for babies nearing term, but the aim is to prolong if the mother and baby are stable.
B. For Preeclampsia with Severe Features or Near-Term/Term Pregnancy
- Hospitalization: This occurs so that the mother and the baby can be monitored continuously.
- Blood Pressure Medications: High blood pressure can be treated with antihypertensive medications (e.g., labetalol, nifedipine, hydralazine) to bring dangerously high blood pressure down and prevent stroke.
- Magnesium Sulfate: Magnesium sulfate is an IV medication and is the most important medication during this entire process, as it is given in order to prevent seizures (eclampsia). It will be administered during labor and for at least 24 hours postpartum. Again, while magnesium sulfate can lower blood pressure slightly, magnesium is administered primarily as seizure prophylaxis.
- Corticosteroids: If the baby is preterm (usually before 34 weeks), the mother may be given corticosteroids to help the baby’s lungs mature in the event of an early delivery.
- Delivery:
- Induction of Labor : If both the mother and baby are stable enough, then labor may be induced.
- Cesarean Section : If labor cannot be induced, or if the mother is not stable enough, or if fetal distress occurs, then a cesarean section may be performed.
The timing of delivery is a balancing act between the maternal risks and continued fetal development. In general, with severe preeclampsia, labor and delivery at any gestational age are generally recommended, especially if there is preterm labor, because the risks of continuing to stay pregnant outweigh the benefits in terms of maternal and neonatal outcomes.
C. Postpartum Management
Preeclampsia symptoms can persist or develop in the postpartum period, and blood pressure and symptoms should continue to be monitored. Magnesium sulfate may be continued for 24 hours postpartum for seizure prophylaxis. Oral antihypertensives may also be prescribed for blood pressure control. All women experiencing preeclampsia should be counseled about their increased risk for cardiovascular disease and to discuss changes in lifestyle habits to lower their risk.
Note: Preeclampsia treatment might not be the same for all; based on the patient’s condition, severity, and the diagnostic findings, the treatment plan will be customized.
When to Seek Doctor’s Support?
Here are a few important reminders of when to talk to the doctor for preeclampsia:
- Severe Headache : A headache that doesn’t go away with your normal pain relief.
- Vision Changes : blurred vision, seeing lights or things that aren’t really there, or temporary loss of vision.
- Upper Abdomen Pain : Severe pain below your ribs (usually the right side).
- Shortness of Breath : Difficulty breathing related to fluid in your lungs.
- Sudden Swelling : Unusual and sudden swelling in your face, hands, and/or feet that’s more than your normal pregnancy swelling.
- Sudden Weight Gain : Sudden weight gain (for example, 2-5 pounds in one week) is related to fluid retention.
- Nausea or Vomiting : New or worsening nausea and vomiting, particularly if it’s severe.
If you are experiencing these symptoms during your pregnancy, see your gynecologist or visit your nearest emergency room.
Conclusion
Preeclampsia poses a serious maternal health risk and requires diligent prenatal care, regular blood pressure checks, and identification of symptoms early by the mother and family. Recently developed approaches to medical management for preeclampsia have greatly improved maternal and infant outcomes. Use your voice if you are experiencing new or unusual symptoms, listen to your instinct, share openly with the gynecologists, and remember that early recognition and intervention are the most effective strategies for dealing with preeclampsia to ensure safe pregnancy and motherhood!
Yashoda Hospitals, one of the healthcare providers in Hyderabad, is equipped to manage complex obstetric conditions like preeclampsia. Our multidisciplinary team includes experienced obstetricians, gynecologists, neonatologists, and critical care specialists. We use advanced diagnostic tools for accurate assessment of the mother’s and baby’s health, including blood pressure monitoring, urine protein checks, liver and kidney function tests, and fetal monitoring. Treatment strategies range from close outpatient surveillance for mild cases to hospitalization for severe preeclampsia. We are prepared for timely delivery, ensuring maternal and fetal well-being in a state-of-the-art labor and delivery unit supported by neonatal intensive care services.
Have any questions or concerns about your health? We’re here to help! Call us at +918929967127 for expert advice and support.
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