What should I know about pre-eclampsia (toxemia)?

Preeclampsia is more common in first-time moms and very young or older moms. It is not certain what causes preeclampsia or why some women are more prone to get it, but it is thought that it starts very early in pregnancy with faulty attachment of the placenta to the inside of the uterus.  (Note the narrowing of the blood vessel as it passes from maternal circulation through the placenta in the diagram.)  The signs and symptoms do not usually occur until much later, however, during the last weeks or days of pregnancy, sometimes not developing until labor starts.

Preeclampsia may lead to serious complications including seizures, stroke, kidney damage, and damage to the baby. If the midwife notices that your blood pressure is rising, your weight has jumped up, or you have protein in your urine, she may order some blood tests and a “24-hour urine,” she will have you cut back on activities and increase your rest, and she will want to watch you very closely. Signs of preeclampsia to watch for and tell your midwife about if they occur are headaches that won’t go away, blurry vision or spots in front of your eyes that won’t go away, pain in your upper abdomen on the right side, sudden swelling in your face or hands, or just feeling lousy, like you’re coming down with the flu.

*Preeclampsia is a pregnancy-induced condition that affects about 5% of pregnant women.  The diagnosis is made when a woman develops high blood pressure and either protein in the urine (the main reason for all those urine specimens) and/or significant swelling, particularly in the face and hands.  Symptoms may be non-existent, or may include headaches, drowsiness, and a general malaise that feels like the flu.  Preeclampsia involves many organ systems, including the kidneys, the liver, and the brain.  Complications include eclampsia or seizures and changes in the blood clotting factors.   The risk of stillbirth to the baby is high if these complications occur.  Currently, the only “cure” for these conditions is delivery of the baby.  Preeclampsia remains one of the three main causes of maternal mortality in both the developed and the developing world, along with hemorrhage and infection.

More information for consumers and help for those who have experienced preeclampsia are available at the Preeclampsia Foundation website.  Risk factors as well as signs and symptoms are discussed.

NOTE: The American College of Obstetricians and Gynecologists has recently (November 2013) revised its definition of preeclampsia.

“According to the new ACOG guidelines, the diagnosis of preeclampsia no longer requires the detection of high levels of protein in the urine (proteinuria). Evidence shows organ problems with the kidneys and livers can occur without signs of protein, and that the amount of protein in the urine does not predict how severely the disease will progress. Prior to this time, most healthcare providers traditionally adhered to a rigid diagnosis of preeclampsia based on blood pressure and protein in the urine(proteinuria).

Preeclampsia is now to be diagnosed by persistent high blood pressure that develops during pregnancy or during the postpartum period that is associated with a lot of protein in the urine or the new development of decreased blood platelets, trouble with the kidney or liver, fluid in the lungs, or signs of brain trouble such as seizures and/or visual disturbances.”

NOTE: Severe preeclampsia is a dangerous medical condition that requires care from an export obstetric provider such as a perinatologist.  There is currently no “cure” for preeclampsia; it usually resolves spontaneously once the baby is delivered.  If you have symptoms as described on the Preeclampsia Foundation website of your midwife suspects that you have this condition, she should promptly refer you to a perinatologist for evaluation and ongoing assessment.

For a fascinating article in The New Yorker on one young researcher’s search for the etiology (cause) of preeclampsia, go to The Preeclampsia Puzzle – Making Sense of a Serious Pregnancy Disorder.

NOTE: Women in first-world countries who receive good prenatal care rarely develop eclampsia, a progression of preeclampsia characterized by seizures (tonic and clonic convulsions), coma, and possible death.  Eclampsia was more common in Europe and the U.S. before blood pressure measurement came into use in the early years of the 20th Century when stethoscopes and sphygnomanometers (blood pressure cuffs) became part of the physician’s equipment.  When high blood pressure in pregnant women was recognized and found to be associated with eclamptic seizures, obstetricians began to “treat” women with signs and symptoms of pre-eclampsia with bedrest and dietary changes, while frequently measuring their blood pressure and the protein in their urine.  If the woman’s condition worsened despite these treatments, induction of labor was attempted. As Williams said in the 5th Edition of his “Obstetrics” in 1923, “Induction of labor is the last resort, and should be regarded as a confession that our therapeutic resources have failed.”  Unfortunately, little has changed in the 90 years since those words were written.  However, close monitoring and a timely decision to deliver have almost eliminated the progress of this disease to the eclamptic stage.

In third-world countries where access to maternity care is limited or non-existent, eclampsia continues to occur with regularity and to be a major cause of maternal mortality.  In my many years of practice as a midwife in the U.S., I never saw a case of eclampsia and only heard of one in our medical center (OHSU), but in the past three years, working as a volunteer with nurses in a rural hospital in Nepal, I have seen three women brought to the center from outlying villages suffering from eclamptic seizures when they arrived.  Fortunately, the hospital has drugs (magnesium sulfate, diazepam) to control the condition, and these women survived, although in two cases their babies did not.  Until all pregnant women have access to prenatal and delivery care in pregnancy, or until research discovers an easy fix that can be used by remote village health workers, these deaths will continue.