Preeclapmsia- How silent a killer is it!

Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. 

Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Any type of high blood pressure occuring during pregnancy is a type of "gestational hypertension". Preeclampsia is severe high blood pressure during pregnancy, and eclampsia is very severe pregnancy gestational hypertension leading to seizures.

Preeclampsia is a condition that typically starts after the 20th week of pregnancy (in the late 2nd or 3rd trimesters or middle to late pregnancy), though it can occur earlier. Proper prenatal care is essential to diagnose and manage preeclampsia. Preeclampsia, Pregnancy Induced Hypertension (PIH) and toxemia are closely related conditions.

HELLP Syndrome and eclampsia are other manifestations of the same syndrome. It is important to note that research shows that more women die from preeclampsia than eclampsia and one is not necessarily more serious than the other. and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the condition is known as eclampsia--the second leading cause of maternal death in the world. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death. By conservative estimates, these disorders are responsible for 76,000 deaths each year.

Risk for preeclampsia

Preeclampsia is more common in a woman's first pregnancy and in women whose mothers or sisters had preeclampsia. The risk of preeclampsia is higher in women carrying multiple babies, in teenage mothers and in women older than age 40. Other women at risk include those who had high blood pressure or kidney disease before they became pregnant. The cause of preeclampsia isn't known.

Does high blood pressure mean preeclampsia?

Not necessarily. If your doctor sees that your blood pressure is high, he or she will watch you closely for changes that could mean you have preeclampsia. In addition to high blood pressure, women who have preeclampsia also have excessive swelling. They may also have protein in their urine. Many women with high blood pressure during pregnancy don't have protein in their urine or extreme swelling, and don't get preeclampsia.

Does swelling mean preeclampsia?

Swelling alone doesn't necessarily mean you have preeclampsia. Some swelling is normal during pregnancy. For example, your rings or shoes might become too tight. Swelling is more serious if it doesn't go away after resting, if it's very obvious in your face and hands, or if it's a rapid weight gain of more than 5 pounds in a week.

What tests can show if there is preeclampsia?

No one test diagnoses preeclampsia. Your blood pressure will be checked during each doctor's visit. A big rise in your blood pressure can be an early sign that you might have preeclampsia. A urine test can tell if there is protein in your urine. Your doctor may order certain blood tests, which may show if you have preeclampsia. If you have signs of preeclampsia, your doctor may want to see you at least once a week and possibly every day.

 Signs and tests   

• Documented weight gain
• Swelling in the upper body
• Elevated blood pressure
• Proteinuria (protein noted in urine)
• Thrombocytopenia (platelet count less than 100,000)
• Elevated liver function tests

Preeclampsia may also alter the results of some laboratory tests

What are the risks of preeclampsia to the baby and mother?

Preeclampsia can prevent the placenta (which gives air and food to your baby) from getting enough blood. If the placenta doesn't get enough blood, your baby gets less air and food. This can cause low birth weight and other problems for the baby. Most women with preeclampsia still deliver healthy babies. A few develop a condition called eclampsia (seizures caused by toxemia), which is very serious for the mother and baby, or other serious problems. Fortunately, preeclampsia is usually detected early in women who get regular prenatal care, and most problems can be prevented.

What is the treatment for preeclampsia?

Currently, the only way to cure preeclampsia is to deliver the baby. However, if that delivery would be very premature, the disease may be managed by bed rest, close monitoring, and delivery as soon as the fetus has a good chance of surviving outside the womb.

Patients are usually hospitalized, but occasionally they may be managed on an outpatient basis with careful monitoring of blood pressure, urine checks for protein, and weight. Optimally, attempts are made to manage the condition until a delivery after 36 weeks of pregnancy can be achieved. In cases of severe preeclampsia when the pregnancy is between 32 and 34 weeks, delivery is the treatment of choice. For pregnancies less than 24 weeks, the induction of labor is recommended, although the likelihood that the fetus will survive is very small.

Prolonging pregnancies has been shown to result in maternal complications, as well as infant death in approximately 87% of cases. Pregnancies between 24 and 34 weeks gestation present a "gray zone," and the medical team and the parents may decide to attempt to delay delivery in order to allow the fetus to mature. During this time, the mother is treated with steroid injections which help speed the maturity of some fetal organs including the lungs. The mother and baby are closely monitored for complications.

During induction of labor and delivery, medications are given to prevent seizures and to keep blood pressure under good control. The decision for vaginal delivery versus Cesarean section is based on how well the fetus is able to tolerate labor.

Expectations (prognosis)  

The risk of recurrent preeclampsia in subsequent pregnancies is approximately 33%. Preeclampsia does not appear to lead to chronic high blood pressure. One way to control high blood pressure when you're not pregnant is to cut the amount of salt you eat. This isn't a good idea if you have high blood pressure during pregnancy. Your body needs salt to keep up the flow of fluid in your body, so you need a normal intake of salt. Your doctor will tell you how much salt to eat each day and how much water you should drink each day.Your doctor might tell you to take aspirin or extra calcium to prevent preeclampsia. Your doctor might also tell you to lie on your left side while you are resting. This will improve blood flow and take weight off your large blood vessels. Many doctors give magnesium sulfate to their patients during labor and for a few days afterward to help prevent eclampsia.

Knowing what can go wrong is to be safer than sorry.

Resources:

BOOKS

• Mabie, William C., and Baha M. Sibai. "Hypertensive States of Pregnancy." In Current Obstetric and Gynecologic Diagnosis and Treatment, edited by Alan H. DeCherney and Martin L. Pernoll. Norwalk, CT: Appleton & Lange, 1994.

PERIODICALS

• Roberts, James M. "Prevention or Early Treatment of Preeclampsia." The New England Journal of Medicine 337, no. 2 (July 10, 1997): 124+.

REFERENCES

• DeVoe SF, O'Shaughnessy RW. Clinical manifestations and diagnosis of pregnancy-induced hypertension. Clin Obstet Gynecol 1984;27:836-853.
• Chesley LC. History and epidemiology of preeclampsia-eclampsia. Clin Obstet Gynecol 1984;27: 801-820.
• Redman CWG, Roberts JM. Management of pre-eclampsia. Lancet 1993;341:1451- 1454.
• Atrash HK, Koonin LM, Lawson HW, et al. Maternal mortality in the United States, 1979-1986. Obstet Gynecol 1990;76:1055-1060.
• Roberts JM, Redman CWG. Pre-eclampsia: more than pregnancy-induced hypertension. Lancet 1993;341: 1447-1451.
• Cunningham FG, Lindheimer MD. Hypertension in pregnancy. N Engl J Med 1992;326:927-932.
• Cunningham FG, MacDonald PC, Gant NF, et al. Hypertensive disorders of pregnancy. In: Williams obstetrics. 19th ed. Norwalk, CT: Appleton & Lange, 1993:763-817.

Supporting Research

• Berkow R, ed. Merck Manual of Diagnosis and Therapy. 16th edition. Rahway, NJ: The Merck Publishing Group; 1992.
• Berkow R, Beers MH, Fletcher AJ, eds. Merck Manual, Home Edition. Rahway, NJ: Merck & Co; 1997.