Patient information: Preeclampsia

INTRODUCTION

There are four major types of high blood pressure that may occur during pregnancy:

• Preeclampsia
• Chronic hypertension
• Preeclampsia superimposed upon chronic hypertension
• Gestational hypertension (also called transient hypertension)

This topic will review high blood pressure related to preeclampsia, the treatment of preeclampsia, and the possible complications of preeclampsia.

WHAT IS PREECLAMPSIA?

Women with preeclampsia gradually develop high blood pressure (hypertension) and excess protein in the urine (proteinuria) (table 1). Signs of preeclampsia can appear anytime during the last half of pregnancy (after 20 weeks of pregnancy) or in the first few days postpartum, and typically resolve within a few days after delivery.

Preeclampsia is sometimes called by other names, including toxemia, pregnancy-induced hypertension, and preeclamptic toxemia. It is mild in most cases. One severe form of preeclampsia is called HELLP syndrome (H = hemolysis, EL = elevated liver enzymes, LP = low platelets). A woman is said to have eclampsia if she has one or more seizures and has no other conditions that could have caused the seizure.

In the United States, preeclampsia occurs in 5 to 8 percent of pregnancies. Most cases occur at or near term (after 37 weeks of pregnancy), although 10 percent of cases occur before 34 weeks of pregnancy.

Chronic hypertension — Chronic hypertension is defined as a blood pressure ≥140/90 mmHg diagnosed before pregnancy, before the 20th week of pregnancy, or that persists more than 12 weeks after delivery.

Chronic hypertension with superimposed preeclampsia — This refers to a woman with chronic hypertension who develops signs of preeclampsia after the 20th week of pregnancy.

Gestational hypertension — Women with gestational hypertension have all of the following:

• Blood pressure ≥140/90 mmHg
• No protein in the urine (proteinuria)
• Are ≥20 weeks pregnant
• No previous history of high blood pressure.

Over time, some pregnant women with gestational hypertension will develop proteinuria and be considered preeclamptic, while others will be diagnosed with chronic hypertension because of persistently high blood pressure after delivery.

WOMEN AT RISK FOR PREECLAMPSIA

Women with preeclampsia have abnormal blood vessels feeding the placenta, although the exact cause of this abnormality is not know. There are no tests that can reliably predict who will get preeclampsia, and there is no way to prevent it. Women with one or more of the following characteristics have an increased risk of developing preeclampsia:

• First pregnancy (excluding miscarriages)
• High blood pressure, kidney disease, lupus, or diabetes prior to pregnancy
• Gestational diabetes
• Multiple gestation (eg, twins or triplets)
• A family history of preeclampsia in a sister or mother
• A previous history of preeclampsia
• Age under 20 years and possibly age over 35 to 40 years
• Obesity

Conversely, women who do not develop preeclampsia in their first pregnancy are at low risk of developing it in a subsequent pregnancy.

PREECLAMPSIA SIGNS AND SYMPTOMS

The signs and symptoms of preeclampsia occur, in part, due to increased pressure inside small arteries, which decreases blood flow to major organs such as the kidney, placenta, brain, and liver.

Maternal — Most women with preeclampsia never experience anything more than mild high blood pressure and a small amount of excess protein in the urine. These changes do not cause symptoms; therefore, prenatal visits to check blood pressure and measure urinary protein are scheduled frequently in the last half of pregnancy.

Swelling (edema) was once considered to be a sign of preeclampsia, especially when it occurred in the face or hands. However, since many women who do not have preeclampsia also develop swelling, it is no longer considered a reliable sign of the disease.

Signs of severe preeclampsia — Mild preeclampsia can worsen and become severe. This usually occurs over several days to weeks, but may occur more quickly. Severe preeclampsia may be characterized by one or more of the following signs or symptoms. However, the signs of both mild and severe preeclampsia may be subtle, and patients should not hesitate to mention any concerns about possible signs of preeclampsia to their provider:

• Blood pressure ≥160/110 mmHg. Women with blood pressures in this range have an increased risk of stroke
• Persistent severe headache
• Visual problems (blurred or double vision, blind spots, flashes of light or squiggly lines, loss of vision)
• Abnormal kidney tests or decreased urination (urinating less than 500 mL in 24 hours)
• Fluid in the lungs, which may cause new shortness of breath
• Low platelet count; platelets help the blood to clot, which may cause easy bruising or bleeding
• Liver abnormalities (detected by blood tests); symptoms may include nausea, vomiting, or pain in the mid- or right upper abdomen (similar to heartburn)
• Destruction of red blood cells (hemolysis, which is detected by blood tests).
• Partial or complete separation of the placenta from the uterus (called abruption); symptoms include vaginal bleeding, uterine pain, and/or decreased fetal activity

Fetal — Blood flow to the placenta carries oxygen and nutrients from mother to baby. Preeclampsia can reduce blood flow to the placenta, which can the following effects on the baby:

• Abnormal nonstress test or biophysical profile score (see 'Fetal monitoring' below)

• Slowed growth of the baby, based upon an ultrasound
• Decreased amount of amniotic fluid around the baby, noted on ultrasound
• Decreased blood flow through the umbilical cord, noted on Doppler tests (performed during ultrasound).

PREECLAMPSIA MANAGEMENT

The only cure for preeclampsia is delivery of the baby and placenta. Although bedrest and taking high blood pressure medication can lower blood pressure and reduce the risk of stroke, these treatments do not improve abnormalities in the mother's blood vessels.

At term — The most effective treatment for preeclampsia at or near term (before 37 weeks of pregnancy) is to deliver the baby. This helps to minimize the risk of harm to the woman or her baby from worsening preeclampsia. Babies at or near term are not at high risk of complications from prematurity and usually will not need to spend time in a special care nursery.

Before term — If severe preeclampsia occurs before term, delivery is often necessary to prevent complications in the woman or her baby. If mild preeclampsia occurs before term, it may be possible delay delivery to allow the baby more time to grow and mature, while monitoring the woman and baby closely.

The method of delivery (vaginal or cesarean birth) depends upon a number of factor, such as the position of the baby, the dilatation and effacement (thinning) of the cervix, and the baby's condition. In most situations, vaginal delivery is possible.

Steroids — Babies delivered prematurely are at risk for breathing problems because their lungs may not be fully developed. Women who are likely to require preterm delivery (at or before 34 weeks of pregnancy) are usually given two steroid injections (eg, betamethasone) to speed fetal lung development. The steroids also decrease other potential complications of preterm birth, such as intraventricular hemorrhage (bleeding into the brain). The two injections must be given 24 hours apart, and the full benefit of the treatment occurs 48 hours after the first injection.

Maternal monitoring — When delivery is delayed, the mother and baby will be monitored. The woman may be admitted to the hospital or may be allowed to stay at home and have frequent office visits. Women who are at home should call their healthcare provider immediately if any of the signs or symptoms of severe preeclampsia develop (see 'Maternal' above.

Maternal monitoring usually includes blood pressure measurements and blood and urine tests to check liver and kidney function, and blood cell counts.

Fetal monitoring — Fetal monitoring includes a combination of nonstress tests and ultrasound examination (table 2).

Non-stress testing is performed to monitor the baby's condition. It is done by measuring the baby's heart rate with a small device that is placed on the mother's abdomen. The device uses sound waves (ultrasound) to measure the baby's heart rate over time, usually for 15 to 30 minutes. Normally, the baby's baseline heart rate should be between 120 and 160 beats per minute. Normally, an increased rate should occur periodically; the increase should be at least 15 beats per minute above the baseline heart rate for 15 seconds. The test is considered reassuring if two or more fetal heart rate increases are seen within a 20 minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes.

Ultrasound is used to monitor the baby's growth, assess its well-being, and evaluate blood flow through the umbilical cord (called a Doppler test). A biophysical profile assesses well-being by using ultrasound to evaluate the baby's movements, breathing activity, movement of the arms and legs, and amniotic fluid volume.

Induced labor — If the mother or baby's test results are concerning, the healthcare provider will usually recommend delivery. The most common reasons for delivery in women with preeclampsia are listed in table 3 (table 3):

If the cervix is still closed and long, medications may be applied directly to the cervix to help it open and thin. Most women will also require an intravenous medication, oxytocin (Pitocin), to stimulate the uterus to contract. If labor does not progress with these measures, or if complications develop that require the baby to be delivered quickly, a cesarean birth is usually performed. (See "Patient information: Cesarean delivery".)

Preventing seizures — Because women with preeclampsia can develop eclampsia (seizures), most patients are treated with an anticonvulsant medication. Intravenous (IV) magnesium sulfate is the drug most commonly used to prevent seizures. Dietary supplements that contain magnesium are not effective or recommended for prevention of seizures. IV magnesium is safe, although the mother and baby are monitored closely during treatment; high blood levels of magnesium can be harmful. Magnesium is given to the woman during labor and usually for 24 hours after delivery.

Severe hypertension is treated with one or more IV high blood pressure medications to lower the risk of a maternal stroke.

CARE AFTER DELIVERY

High blood pressure and protein in the urine resolve after delivery, usually within a few days. Severe hypertension should be treated, and some women will require a high blood pressure medication after being discharged from the hospital. This can be discontinued when the blood pressure returns to normal levels, usually within six weeks.

Blood pressure that continues to be elevated beyond 12 weeks after delivery is unlikely to be related to preeclampsia and may require long-term treatment. (See "Patient information: High blood pressure treatment in adults".)

OUTCOMES

Mildly elevated blood pressure over a few weeks or months is not usually harmful; it does not have the same long-term risks (stroke, heart attack) as chronic high blood pressure. Losing protein in the urine due to preeclampsia does not damage the kidneys. In women with mild preeclampsia near term, newborn outcomes are generally good.

Severe preeclampsia can cause temporary abnormalities in the woman's liver and kidney function and a low platelet count (thrombocytopenia, which can be associated with bleeding). In women with severe preeclampsia, especially when it occurs preterm, there is an increased risk of problems related to prematurity, such as low birth weight. (See "Short-term complications of the premature infant".)

Women who have severe preeclampsia that develops before term, recurrent preeclampsia, or gestational hypertension appear to be at increased risk of cardiovascular disease later in life, including during the premenopausal period.

RISK OF PREECLAMPSIA IN FUTURE PREGNANCIES

Most women who experience preeclampsia will not have it in a subsequent pregnancy. The risk of recurrent preeclampsia is between 5 and 70 percent

• Women who developed severe preeclampsia and were delivered before 30 weeks gestation having the highest risk of preeclampsia in future pregnancies.
• Women with mild preeclampsia near term have only a 5 percent chance of developing it again.

SUMMARY

• Women with preeclampsia develop high blood pressure (greater than 140/90) and protein in the urine. This can occur anytime during the last half of pregnancy (after 20 weeks of gestation) or in the first few days after delivery.
• Preeclampsia occurs in 5 to 8 percent of pregnancies in the United States. It is not known why some women develop preeclampsia while others do not. Currently, there are no tests that can reliably predict who will get the disease, and there is no way to prevent it.
• The majority of women with mild preeclampsia have no symptoms, although mild preeclampsia can worsen and become severe. Severe preeclampsia is characterized by the following maternal signs and symptoms (table 3).
• A woman should immediately call her healthcare provider if any of the signs or symptoms of severe preeclampsia develop, or if there is decreased fetal activity, vaginal bleeding, or frequent uterine contractions or pain.
• The only cure for preeclampsia is delivery of the baby and placenta. Bedrest and taking high blood pressure medication can lower the blood pressure but will not stop preeclampsia from worsening or reduce the risk of its complications.
• If the mother or baby's monitoring shows concerning results, the healthcare provider may recommend delivery. A vaginal delivery is often possible.
• Because women with preeclampsia can develop seizures, most women are treated with an anticonvulsant medication. Magnesium sulfate is the drug most commonly used to prevent seizures. It is safe for both mother and baby. It is given intravenously to the mother during labor and usually for 24 hours after delivery.
• High blood pressure and protein in the urine resolve after delivery, usually within a few. Some women will require high blood pressure medication after being discharged from the hospital.
• Most women who experience preeclampsia will not have it in a future pregnancy.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Cesarean delivery
Patient information: High blood pressure treatment in adults

Professional Level Information:
Abnormalities of coagulation and platelet function in preeclampsia
Acute kidney injury (acute renal failure) in pregnancy
Clinical features, diagnosis, and long-term prognosis of preeclampsia
Critical illness during pregnancy and peripartum
Eclampsia
Expectant management of severe preeclampsia
Gestational hypertension
Headache in pregnancy
HELLP syndrome
Management of hypertension in pregnancy
Management of preeclampsia
Pathogenesis of preeclampsia
Prediction of preeclampsia
Prevention of preeclampsia
Short-term complications of the premature infant

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The Mayo Clinic

      (www.mayoclinic.com)

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