by Craig L. Bissinger, MD, FACOG
I am often asked about a very common condition associated with pregnancy called preeclampsia, once known as toxemia. Preeclampsia occurs when a woman's blood pressure rises, and it affects seven percent of all pregnancies worldwide. It most frequently strikes first-time mothers and women who are carrying twins, or multiple pregnancies.
The women most at risk for preeclampsia are women with:
- Family histories of preeclampsia
- Long-standing high blood pressure or kidney disease
- Pregnancy-induced diabetes
- Autoimmune diseases (systemic lupus and others)
Preeclampsia is a vexing problem for obstetricians. Many fine researchers have devoted their life's work to finding a cure for this condition because of the potential dangers it poses to both mother and baby. In countries like the United States, this condition is readily diagnosed and treated, whereas in third-world countries, it may go unrecognized until serious health damage has occurred.
When I talk to my patients about preeclampsia, I start by describing the most common finding in this condition: an elevation in blood pressure. In some cases, a blood pressure of 130/80 can represent preeclampsia, whereas others might not be diagnosed until their pressure reaches much higher numbers.
The reason for the variation is that every woman has her own unique blood pressure. Some women have blood pressures of 90/60. For them, a pressure of 130/80 represents a significant change. In contrast, if her early pregnancy blood pressure is 130/80, then we need to adjust our levels to make a diagnosis of preeclampsia. Simply put, if the top number goes up by 30 or the bottom number by 15, over her base blood pressure, we begin our evaluation for preeclampsia.
The following are a series of questions I often hear from my patients about pre-eclampsia.
When does preeclampsia occur?
In general, preeclampsia is a disease that manifests itself in the second half of pregnancy, generally in the last weeks of a woman's term. For the rare patient, especially those with risk factors (listed above), it may begin much earlier.
What are the symptoms?
Some of the symptoms of preeclampsia are:
- Blurry vision
- Swelling of the face or hands
- Rapid weight gain
- Right upper-abdominal pain
- Less frequent urination
Many of these symptoms are associated with normal pregnancies too. In order to make the correct diagnosis we have to look at the whole patient, not just a few symptoms.
Are there any lab tests to help determine a preeclampsia diagnosis?
If I suspect a patient may have preeclampsia, I order a series of blood tests including a complete blood count (including platelets) and liver and kidney tests. If the platelet (blood cells responsible for clotting) count is low or the other tests are abnormal, these results help to establish a diagnosis. In addition, I check the woman's urine for signs of protein. This is another rapid test to help diagnose the condition.
If I had preeclampsia during my first pregnancy, will I have it again?
Ten percent of women will have preeclampsia with a subsequent pregnancy. The likelihood of recurrent preeclampsia increases for women with high risk factors (listed in the introduction).
Is there any way I can prevent preeclampsia?
Not at the present time. Several years ago, doctors believed that baby aspirin could prevent an onset of preeclampsia. Unfortunately, it proved not to be effective and most doctors have stopped using it for this purpose.
Are there any long-term consequences of preeclampsia?
No. However, ten percent of my patients with preeclampsia have high blood pressure for some weeks following delivery and some of them require treatment with medication. Still, preeclampsia is not a predictor of high blood pressure later in life.
Preeclampsia, Different Degrees
I'd like to tell you how we go about making this important determination before I discuss the way we treat each condition.
Severe preeclampsia is characterized by at least one of the following findings:
- A blood pressure of 160/110
- Large quantities of protein in the urine
- Visual blurring and headaches
- Right upper abdominal pain
- Reduced urination
- Low-platelet count
- Elevated liver tests
(If a patient suffers from a seizure, then she is known to have eclampsia).
Mild Preeclampsia is characterized by:
- Blood pressure not to exceed 160/110
- Mild facial or hand edema (swelling)
- Brisk reflexes
- Mild to moderate amounts of protein in the urine
In reality, the distinction between the two types of preeclampsia is not so cut and dry. A woman may have a significant amount of protein in her urine and a marginally elevated blood pressure. There are many factors involved in a diagnosis, and it is a physician's job to sort through the signs and symptoms to determine what is happening to the mother and baby.
The following are some real case studies from my practice that will help to underscore the diagnosis and treatment options available for severe and mild preeclampsia.
Severe Preeclampsia Case Study
This was JC's first pregnancy. She was eight weeks from her due date when she came to the office for a visit. When I came into the room, I was immediately alarmed. She had gained eight pounds in one week, her blood pressure was 150/105 and she had a significant amount of protein in her urine. She told me she had been having headaches for the last couple days and was feeling lousy.
The diagnosis of eclampsia was apparent to me even though her blood pressure hadn't reached the magic 160/110. I admitted her to the hospital where lab tests confirmed my suspicion. Her platelets (which help prevent you from bleeding) were very low and her liver tests were moderately elevated.)
In this situation, there was no question what had to be done. Both mother and baby were in danger. JC could develop seizures. She could hemorrhage from her low platelet count. Meanwhile her baby was living in a hostile environment due to the elevated blood pressure. There was a reduced level of blood flowing to the baby, which meant that less oxygen and food were reaching the baby. This situation could be lethal to the baby if left untreated.
After doing a vaginal exam, I discovered that JC was not ready for labor and would take many hours to be successfully induced. Due to the risk of hemorrhage, a cesarean section was the safest, quickest way to treat the condition. I treated JC prior to delivery with a medication called magnesium sulfate to prevent seizures and performed a cesarean section.
JC's preeclampsia resolved over the next several days and her lab test reverted back to normal. The baby required several weeks of hospitalization before going home. Both mother and baby are doing well now.
This case represents a dramatic example of severe preeclampsia. Not all cases are this challenging nor do they all require cesarean sections. Let's take the same case and modify the findings ever so slightly.
JC has all the same findings except her platelet count is just marginally low. In this case, she still needs to be delivered but is not at high risk of hemorrhaging. She can undergo induction of labor with the drug pitocin and have a vaginal delivery. Her baby will still need the same extra hospital care and JC's preeclampsia will resolve the same way as with the cesarean section.
Mild Preeclampsia Case Study
In mild forms, we can be more conservative in our treatment depending on the situation. If the woman's blood pressure rises and she is close to her due date, we will opt to induce her. If she is many weeks from her due date, we will treat her with bed rest and careful monitoring. The following case illustrates this situation:
LM was seven weeks from her due date when her blood pressure was noted to be 145/95. She had a small amount of protein in her urine and had noted a five-pound weight gain over the past several weeks. She didn't have any other signs of preeclampsia. Her blood tests came back normal. We ordered an ultrasound to check on the baby's growth, and a fetal heart monitoring study to ensure the baby was getting enough oxygen. All the tests indicated that the baby was growing.
We put LM on bed rest and continued to watch her carefully over the ensuing weeks by repeating many of the tests. When she was four weeks from her due date, her blood pressure began to rise and we found more protein in her urine. It was time for LM to deliver. We gave her magnesium to prevent seizures and pitocin to initiate labor.
LM had a healthy six-pound daughter who was able to go home with her mom on the second post-delivery day.
This case illustrates the concept of conservative management. Careful observation is an acceptable management plan with mild preeclampsia. It is a poor plan if severe preeclampsia is present.
Preeclampsia is a very common medical condition during pregnancy. Properly identifying the disease enables your physician to make important decisions, which will affect the outcome of your pregnancy. If you have any worrisome symptoms during your pregnancy, pick up the phone and call your doctor.
Craig L. Bissinger, MD is a board certified Obstetrician/Gynecologist practicing in Parsippany, NJ. Dr. Bissinger is vice-chairman of the Department of OB/GYN at Morristown Memorial Hospital where is is also actively involved in teaching medical students and residents. Dr. Bissinger is a frequent speaker on a host of women's health topics and a member of the Eli Lilly Speakers Bureau.
Copyright © Craig L. Bissinger. Permission to republish granted to Pregnancy.org, LLC.