Pre-eclampsia

Symptoms

• Swelling (edema), particularly in hands, face, or eyes (though swelling can be common in normal pregnancy)
• Sudden weight gain (more than 2-5 pounds in a week)
• Headaches (often persistent and dull or throbbing)
• Nausea or vomiting (new onset in the second half of pregnancy)
• Severe headache that doesn't resolve with simple pain medication
• Visual disturbances: blurred vision, flashing lights, dark spots, or temporary loss of vision
• Severe pain in the upper right side of the abdomen or epigastric pain (often described as heartburn that doesn't go away)
• Shortness of breath, often due to fluid in the lungs
• Decreased urine output
• Altered mental status or confusion
• Pre-eclampsia can develop without any noticeable symptoms

Causes & Risk Factors

• The definitive cause of pre-eclampsia is the placenta.
• The condition resolves after the delivery of the placenta.
• It is believed to involve a two-stage process:
• Stage 1: Abnormal development of the placental blood vessels, leading to reduced blood flow and oxygen to the placenta.
• Stage 2: The affected placenta releases certain factors into the mother's bloodstream. These factors cause widespread damage to the mother's blood vessels, leading to high blood pressure, protein in the urine, and other symptoms of organ dysfunction.
• History of pre-eclampsia in a previous pregnancy (high-risk)
• Carrying multiple babies (multifetal gestation) (high-risk)
• Chronic high blood pressure before pregnancy (high-risk)
• Diabetes before pregnancy (Type 1 or 2) (high-risk)
• Kidney disease (high-risk)
• Autoimmune diseases (e.g., systemic lupus erythematosus, antiphospholipid syndrome) (high-risk)
• First pregnancy (nulliparity) (moderate-risk)
• Obesity (BMI >30 kg/m²) (moderate-risk)
• Family history of pre-eclampsia (mother or sister) (moderate-risk)
• Maternal age 35 years or older (moderate-risk)
• Previous adverse pregnancy outcomes (e.g., low birth weight) (moderate-risk)
• Pregnancy interval of more than 10 years (moderate-risk)
• In vitro fertilization (IVF) (moderate-risk)
• African-American race (moderate-risk)
• Modifiable risk factors include pre-pregnancy obesity and uncontrolled chronic hypertension or diabetes.
• Non-modifiable risk factors include previous history of pre-eclampsia, first pregnancy, maternal age, family history, multifetal gestation, race, and autoimmune conditions.

Diagnosis

• Review of your medical history, including any risk factors for pre-eclampsia.
• Inquiry about symptoms, especially severe headaches, visual changes, or upper right abdominal pain.
• Accurate measurement of blood pressure, typically on two occasions at least 4 hours apart.
• Assessment for swelling, particularly in the face or hands.
• Abdominal examination for tenderness in the upper right area.
• Neurological assessment for reflexes.
• Urine tests: Urine protein/creatinine ratio or a 24-hour urine collection to measure protein levels.
• Blood tests: Complete Blood Count (CBC) to check platelet levels, Liver Function Tests (LFTs) to assess liver health, and Renal Function Tests (serum creatinine, uric acid) to check kidney function.
• Fetal ultrasound: Used to assess the baby's growth, amniotic fluid volume, and blood flow through the umbilical artery. This helps monitor the baby's well-being and potential complications, but does not diagnose pre-eclampsia itself.
• Diagnosis is based on new onset hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) after 20 weeks of gestation, combined with either proteinuria (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3) OR new onset hypertension with any of the following severe features in the absence of proteinuria:
• Thrombocytopenia (platelet count <100,000/microliter)
• Renal insufficiency (serum creatinine >1.1 mg/dL or a doubling of serum creatinine)
• Impaired liver function (elevated liver transaminases to twice normal concentration) or severe persistent upper right abdominal/epigastric pain
• Pulmonary edema (fluid in the lungs)
• New-onset headache unresponsive to medication or visual disturbances.
• Emerging diagnostic tools include biomarkers like placental growth factor (PlGF) and sFlt-1/PlGF ratio, which can help rule out pre-eclampsia, especially between 20 and 35 weeks of gestation.

Treatment Options

• The only definitive cure for pre-eclampsia is the delivery of the placenta.
• Management depends on your gestational age, the severity of the condition, and the health of both you and your baby.
• Watchful Waiting (Expectant Management): For pre-eclampsia without severe features before 37 weeks of gestation, close monitoring is often recommended, usually in a hospital setting. This includes regular blood pressure checks, symptom review, and laboratory tests for the mother, and non-stress tests, biophysical profiles, and growth scans for the baby. If you are less than 34 weeks pregnant, corticosteroids (e.g., betamethasone) may be given to help your baby's lungs mature.
• Antihypertensive Therapy: Medications are used to control dangerously high blood pressures (systolic ≥160 mm Hg or diastolic ≥110 mm Hg) to prevent maternal complications like stroke. These medications do not treat the underlying cause of pre-eclampsia. Common first-line agents include Labetalol, Nifedipine, and Hydralazine. Certain blood pressure medications like ACE inhibitors and ARBs are not used during pregnancy.
• Seizure Prophylaxis: Magnesium sulfate is the medication of choice to prevent and treat seizures (eclampsia) in patients with pre-eclampsia, especially those with severe features. It is typically given intravenously and continued for 24 hours after delivery.
• Delivery: Delivery is indicated for any pre-eclampsia at 37 weeks of gestation or later. For pre-eclampsia with severe features, delivery is usually recommended at 34 weeks of gestation or later. Delivery may be necessary at any gestational age if there is maternal or fetal instability, such as uncontrollable severe hypertension, eclampsia, pulmonary edema, placental abruption, or non-reassuring fetal status. The mode of delivery (vaginal or cesarean section) is determined by standard obstetric considerations.
• Postpartum Management: Close monitoring of blood pressure is essential for at least 72 hours after delivery and again at 7-10 days postpartum. Pre-eclampsia can sometimes develop or worsen in the postpartum period. Antihypertensive medication may be needed after delivery.

Frequently Asked Questions