Preeclampsia/eclampsia is one of the most common complications of pregnancy that affects approximately 5-10% of pregnant women and causes approximately 14% of maternal death worldwide. Available data from Nigeria points to preeclampsia/eclampsia affecting approximately 163/10000 deliveries, and causing several maternal deaths in the process (Danmusa, Coeytaux, Potts, & Wells, 2016). Preeclampsia/eclampsia treatment and management has evolved over the years, however more people need to be aware of this condition and seek appropriate care when suspected. This paper explains preeclampsia and its complications including eclampsia.
Preeclampsia
Preeclampsia describes a condition where a woman’s blood pressure becomes abnormally high after 20 weeks of pregnancy. With this condition, a woman who was previously normotensive (normal blood pressures) is diagnosed with hypertension and her urine when tested also shows the presence of excess protein (proteinuria). The condition can develop without any symptoms and is detected during routine pre-natal checkup. However, depending on the severity of the condition, a woman may present with symptoms including severe headaches, visual changes such as blurry vision and increased light sensitivity, excess protein in urine, low urine output, abdominal pain particularly near the ribcage and towards the right side, liver dysfunction on lab test, nausea and vomiting, shortness of breath, and sudden swelling/weight gain (edema) most noticeable in face and hands (Salam, Das, Ali, Bhaumik, & Lassi, 2015).
Diagnostic Criteria for Preeclampsia
Preeclampsia
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Severe Preeclampsia
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The cause of preeclampsia is unknown. However, studies have shown that pregnancy causes growth of new blood vessels with placental development and implantation. These blood vessels are supposed to supply the placenta. In women with preeclampsia, these vessels are not well developed or functional, leading to impairment in placental blood flow and blood vessel spasms (vasopasm), which interferes with blood supply to multiple organs including the kidneys (Wagner, 2004). The sequela of this condition is intra-uterine growth restriction and severe hypertension for the mother. Some women who were diagnosed with hypertension before pregnancy can also have worsening hypertension and new protein in urine indicating the development of preeclampsia superimposed on prior hypertension. It is important to note that there are other types of hypertension during pregnancy that are different from preeclampsia, and these include Gestational Hypertension which describes high blood pressure first diagnosed during pregnancy without protein in urine, and Chronic Hypertension which classifies those patients who were already diagnosed with hypertension before pregnancy. There are many risk factors for preeclampsia, and they include:
- History of hypertension
- Family history of preeclampsia
- First pregnancy (primigravity)
- Teenage pregnancies or women > 35 years
- Obesity
- Multifetal pregnancies (pregnancy with multiples: twins, triplets etc)
- In-vitro fertilization
- Renal disease
- Thrombophilia
- Gestational diabetes
- Systemic lupus erythematous
Complications of Preeclampsia
Preeclampsia causes several complications including intra-uterine growth restriction and low birth weight, preterm birth, placental infarcts and abruption, HELLP syndrome, and Eclampsia etc.
Intra-uterine Growth Restriction: Preeclampsia affects arteries that supply oxygenated blood to the placenta. Therefore, a decrease in oxygenated blood flow throw the placenta decreases blood supply to the baby resulting in slower growth, small for gestational age, and possible preterm birth.
Preterm Birth: Depending on the severity of preeclampsia, the baby may need to be delivered early to decrease the risk of intrauterine death or possible death of the mother. Unfortunately, premature delivery has its own problems as the baby’s lungs may be immature, resulting in respiratory distress and other complications after delivery.
Placental Abruption: As mentioned earlier, preeclampsia affects the blood vessels supplying oxygenated blood to the placenta. A decrease in oxygen supply to the placenta can cause placental infarcts and separation from the wall of the uterus. Placental separation is usually indicated by bleeding, and the degree of separation determines the severity of bleeding. However, placental separation requires immediate medical attention as the life of the baby and mother are at stake.
HELLP Syndrome (Hemolysis (destruction of red blood cells), Elevated Liver Enzymes, Low Platelets): This condition is one of the most severe end-organ complications of preeclampsia. It describes a set of clinical signs signaling a dire situation that is potentially fatal if not identified early and properly managed. HELLP syndrome is diagnosed with laboratory results which would point to red blood cell hemolysis, abnormal liver enzymes, and low platelets which result from platelet destruction. Immediate medical attention is needed to avoid fatal outcomes. Symptoms of HELLP syndrome include nausea and vomiting, headaches, and right upper abdominal pain (likely related to liver dysfunction).
Eclampsia: This describes the presence of grand-mal seizures or coma in a pregnant woman with no prior neurologic history or post-partum woman with preeclampsia. Eclampsia is one of the most dangerous complications of preeclampsia and necessitates emergent delivery of the baby to avoid death of both mother and child, as well as complex treatment and management to prevent further seizures in the immediate postpartum period. In some parts of Nigeria particularly northern Nigeria, Eclampsia contributed to approximately 33% of maternal deaths (Esike et al., 2017). Approximately 80% of cases of eclampsia occur in the 3rd trimester, during labor, or within 48 hours after delivery. There has been a few reports of cases occurring even up to 23 days post-partum but these are extremely rare (Ross & Ramus, 2017).
Treatment and Management of Preeclampsia
Preeclampsia has no direct cure except delivery of the baby. Depending on gestational age of the fetus, the mother may be managed primarily with anti-hypertensives (medications to control blood pressure) to allow time for adequate fetal development. Arising complications including liver dysfunction are also monitored closely, and she is followed up more frequently by the obstetrician to assess need for emergent delivery. Apart from anti-hypertensives such as Labetalol and Hydralazine used to control blood pressure throughout pregnancy, Magnesium Sulfate has become a must in the management of women with preeclampsia. The medication is primarily used during labor and in the post-partum period to reduce the risk of seizures in women with preeclampsia, and to treat seizures in those who have already developed eclampsia. The use of magnesium sulfate has been shown to reduce the risk of eclampsia by 58% and mortality by up to 45%. The value of magnesium sulfate cannot be understated, and in 2007 the MacArthur Foundation began to fund programs to improve availability of Magnesium sulfate in Nigerian healthcare centers, as part of an initiative to reduce maternal mortality (Danmusa et al., 2016).
As stated earlier, the only cure for preeclampsia is delivery of the baby. However, several factors influence the timing at which the baby is delivered, and the gestational age and maternal/fetal well-being are primary considerations. Most healthcare providers will focus on blood pressure control and symptom management to allow time for fetal development, and carry out emergent delivery if the fetal or maternal well-being is severely compromised. Factors influencing timing of emergent delivery include severe intrauterine growth restriction, non-assuring fetal vital signs, deficiency in amniotic fluid (Oligohydramnios), platelet counts < 100,000, worsening liver function, suspected placental abruption, and eclampsia etc. Once the baby is delivered, the woman must be monitored closely with proper treatment to ensure recovery from the complications that developed over the course of pregnancy.
Till date, there is no available information on ways to prevent preeclampsia. Therefore, it is imperative for healthcare providers to educate pregnant women and carryout timely assessments and tests once they present with symptoms suspicious for preeclampsia. In addition, there is need for more public education on this condition, as public awareness can possibly improve health seeking behaviors and encourage pregnant women in places like Nigeria to obtain pre-natal healthcare from skilled healthcare providers, learn to monitor themselves for signs of complications, and report immediately to their obstetricians if any of these arises. With such concerted efforts, we stand a chance of reducing the rates of maternal and perinatal mortality in Nigeria.
Written by Dr. Idongesit Udoh Bassey