Mismanaged Preeclampsia During Pregnancy

If preeclampsia is untreated, the condition can progress into eclampsia, which is the development of maternal grand mal seizures.

Women who have  severe preeclampsia can experience fluid in the lungs, heart attack, stroke, liver and kidney failure, blood clots in the body’s small blood vessels, and injury to the retina, central nervous system disorders. The unborn baby may also be affected by potential problems like placental abruption, lack of blood flow to the placenta and premature delivery, which can result in serious birth injuries and complications such as:

• Hypoxic-ischemic encephalopathy (HIE)
• Intrauterine (fetal) growth restriction (IUGR/FGR)
• Cerebral palsy
• Seizures
• Developmental disabilities
• Breathing difficulties
• Hearing and vision impairments

Mothers with preeclampsia often do not show symptoms until the condition is severe and becomes life-threatening, which is why it is crucial for physicians to diagnose and treat preeclampsia early in pregnancy. It is recommended that a woman with severe preeclampsia deliver at 34 weeks gestation to avoid injury to the baby.

A mother who has preeclampsia experiences high blood pressure, which can change the rate of blood flow to the developing fetus. The mother’s high blood pressure increases resistance in blood vessels which can result in decreased blood flow across the placenta, depriving the baby of oxygen and nutrients. When babies don’t receive adequate nutrients, they grow and develop more slowly than normal. This condition is called intrauterine (fetal) growth restriction, abbreviated IUGR or FGR. A baby with decreased oxygen or IUGR can experience birth asphyxia and a form of brain damage known as hypoxic-ischemic encephalopathy (HIE) during contractions or labor and delivery. This can lead to further complications in the baby such as cerebral palsy if preeclampsia is not managed correctly.

Preeclampsia and high blood pressure are correlated with a higher risk of placental abruption, a condition in which the placenta separates from the uterus too soon. This can cause heavy bleeding in the space where the placenta was previously attached, and can also result in a drop in blood flow to the baby. An emergency C-section is the safest and quickest way to delivery the baby in cases of placental abruption. Delays in performing one can result in birth asphyxia, cerebral palsy, and developmental disabilities

Preeclampsia may cause the following injuries and conditions in the mother:

• Stroke
• Acute renal failure
• Blood clotting disorders
• Possible blindness
• Diabetes
• Seizures
• HELLP syndrome: HELLP stands for Hemolysis (the destruction of red blood cells), Elevated Liver enzymes and Low Platelet count. Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because it can occur before signs or symptoms of preeclampsia appear.
• Eclampsia: When preeclampsia isn’t controlled, eclampsia — which is essentially preeclampsia plus seizures — can develop. Eclampsia can permanently damage the mother’s vital organs, including the brain, liver, and kidneys. If mismanaged, it can cause coma in the mother and hypoxic-ischemic encephalopathy (HIE), brain damage, and cerebral palsy in the baby.
• Cardiovascular disease: Having preeclampsia may increase the risk of future cardiovascular disease, heart attack, and stroke in the mother.

Some experts believe that preeclampsia is caused by insufficient blood supply to the uterus and placenta, causing the development of high blood pressure in the mother. This rise in blood pressure is a compensatory response to improve the baby’s condition.  The following conditions are also thought to be possible causes:

• Damage to the blood vessels
• Immune system irregularities
• Poor diet or maternal obesity
• Genetic predisposition

The following may increase the risk of developing preeclampsia:

• Personal or family history of preeclampsia: If you’ve had the disorder before, the odds are 25% to 50% that you’ll develop it in a future pregnancy.
• Women aged over 35 years of age (“advanced maternal age”)
• Multiple gestations (twins, triplets, etc.).
• Having high blood pressure, kidney disease, migraines, diabetes, rheumatoid arthritis, or lupus prior to pregnancy.
• Women who are obese or have a BMI of 30+.
• Prolonged interval between pregnancies (over 10 years between pregnancies)

Preeclampsia is normally diagnosed during routine blood pressure checks and urine tests at prenatal appointments. A blood pressure reading higher than 140/90 mm Hg is abnormal in pregnancy. However, a single high blood pressure reading doesn’t necessarily indicate preeclampsia. Medical staff should do a second blood pressure check four hours after the first. If it is also abnormal, it may confirm preeclampsia. Medical staff often do additional blood pressure readings and urinary protein measurements for further confirmation.

If doctors suspect pregnancy-induced hypertension, it is the standard of care to order additional tests:

• Blood tests to determine how well the liver and kidneys are functioning
• Prolonged urine collection tests to determine how much protein is being lost in the urine (an indication of the severity of preeclampsia)
• Fetal ultrasound, nonstress tests, and biophysical profiles to make sure the baby is getting enough oxygen and nourishment.

In addition to protein in the urine and high blood pressure, preeclampsia symptoms can include:

• Edema (swelling) especially in the hands and face
• Rapid weight gain over 1-2 days caused by a significant increase in bodily fluid
• Abdominal pain, especially in the right side
• Severe headaches
• Change in reflexes
• Reduced urine or no urine output
• Dizziness
• Excessive vomiting and nausea
• Blurry vision, flashing lights, and floaters in the peripheral vision

Preeclampsia can occur in some women without any identifiable symptoms.. It is important for the prenatal provider to closely monitor the mother’s blood pressure and urine levels at each appointment throughout her pregnancy.

Unfortunately, pregnancy-induced hypertension is not a disease that can be simply treated and cured. The preeclampsia will continue until the baby is delivered. Generally, delivery will be induced or the baby will be delivered via C-section if more than 34 weeks gestation. Prolonging the pregnancy may be detrimental to the mother and baby.

If the preeclampsia is mild and the baby is not near full term, medical professionals will likely do the following (6):

• Check the mother’s blood pressure twice daily
• Increase prenatal checkups for observation of the baby, including fetal heart rate monitoring along with frequent ultrasounds, blood tests, blood pressure monitoring, and urine checks.
• Doctors should also talk to the mother about how to manage her pregnancy health. They will likely recommend the following:
  • • Rest, lying on the left side in order to take the weight of the baby off major blood vessels.
    • Consume less salt
    • Drink at least 8 glasses of water a day
    • Change diet to include more protein

With severe preeclampsia, the doctor may try blood pressure medication until the pregnancy is far enough along to deliver safely. This is usually done in conjunction with home or hospital bed rest, dietary changes, supplements, and corticosteroids for women less than 34 weeks gestation to help the baby’s lungs develop more quickly.

One of the key ways to prevent or reduce the risk of complications developing from preeclampsia is early screening of pregnant women for high blood pressure. While different organizations may have different recommendations about screening criteria, the US Preventive Services Task Force (USPSTF) recommends that all pregnant women be screened by having their blood pressure taken at each prenatal care visit to their doctor.

In addition to screening at prenatal care appointments, recent recommendations also include the use of low-dose aspirin (60 to 150 mg/day) as preventive medication after 12 weeks of gestation for women who are at high risk for preeclampsia, a recommendation consistent with the AHA’s guidelines for preventing stroke in women.

One of the critical things that medical professionals can do to help reduce the risk of birth injuries due to preeclampsia and high blood pressure is properly monitoring the mother and child throughout pregnancy. This means that doctors should be frequently checking up on the mother and baby’s health, especially during the third trimester. They can use a variety of tests, including non-stress tests (NSTs), biophysical profiles (BPPs), amniotic fluid index (AFIs), and Doppler flow monitoring. Proper monitoring allows medical staff to identify and address risk factors before they become severe and cause birth injury. If the medical staff isn’t monitoring the mother and baby’s healthcare properly, and either the mother or baby are injured, the medical staff has committed negligence.

In preeclampsia and hypertension (as well as in diabetes), one of the key problems that can occur is oligohydramnios (low amniotic fluid levels), which is why AFI testing is so critical – it allows for medical practitioners to confirm what the baby’s amniotic fluid levels are. To read more about antenatal testing, please see our FAQ page: What tests should my doctors give me during prenatal care?

In many cases, early delivery is recommended for the safety of both the mother and baby. There are different recommendations depending on individual mothers and babies’ health situations, but the following chart summarizes a few of these recommendations. Note that chronic hypertension is high blood pressure that occurred before the pregnancy began, while preeclampsia is high blood pressure diagnosed for the first time during pregnancy.

Source: Spong, Catherine et al. Timing of Indicated Late-Preterm and Early-Term Birth. Obstet Gynecol 2011;118:323-33.