What doctors wish patients knew about preeclampsia

Preeclampsia happens in 5% to 8% of all U.S. births. The potentially dangerous disorder can lead to serious and even fatal complications for mother and baby if left untreated. That is why early detection and intervention are key to turning the tide on maternal health and well-being.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what patients need to know about preeclampsia. They are:

• Kara Hoppe, DO, PhD, an ob-gyn and maternal-fetal medicine physician at UW Health in Madison, Wisconsin, and a leading physician researcher on hypertensive disorders of pregnancy.
• Katie Peterson, MD, an ob-gyn at Confluence Health in Wenatchee, Washington. Confluence Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Preeclampsia is “a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby,” Dr. Hoppe said, noting it “is characterized by high blood pressure and usually the presence of protein in the urine.”

“Hypertensive disorders of pregnancy is an all-encompassing term that indicates a woman had high blood pressure, meeting criteria for one or more hypertension conditions as it relates to pregnancy,” she said. Hypertensive disorders have been increasing and are “the most common medical complications of pregnancy and occur in up to 12–17% of pregnant women nationwide.”

Catch up on the seven keys to improving U.S. maternal health now.

Preeclampsia “often presents as high blood pressure and protein in the urine, but symptoms can also include headaches, blurry vision, severe abdominal pain, seizures and swelling,” Dr. Peterson said. “Unfortunately, we still don’t understand the exact trigger within the body that causes preeclampsia. But since preeclampsia affects small blood vessels in the body, it can lead to kidney, liver, brain and placenta dysfunction.”

There are also times when a person has no symptoms. Other times, symptoms can include swelling or sudden weight gain, nausea or vomiting, shortness of breath, anxious feelings and chest pain, Dr. Hoppe said.

Learn about four essentials to better management of hypertension in pregnancy.

“We don’t exactly know what causes preeclampsia. It’s likely a result of multiple, interacting things,” Dr. Hoppe said. “We think there’s a large component of the placenta or abnormal placentation and then other underlying risk factors such as mental health, genetics, immune response and lifestyle.

“But how all that interacts to create preeclampsia in one human—we just don’t know,” she added.

Explore the AMA’s advocacy to improve maternal health.

“Because of the changes that occur during pregnancy, it is sometimes the first time that women learn that they are at risk for chronic medical conditions such as diabetes or high blood pressure,” said Dr. Peterson. “For women with preeclampsia, there is a two times greater lifetime risk of cardiovascular disease—stroke, heart attack—or blood clot.” 

“To have preeclampsia, one must have elevated blood pressures—greater than or equal to 140/90 mm Hg—with either protein in the urine or, in the absence of protein in the urine, lab abnormalities such as low platelet counts, abnormal kidney function, abnormal liver function or other concerning clinical exam findings,” said Dr. Hoppe.

Those may include “pulmonary edema—fluid in the lungs—or headache and vision changes,” she added.

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That is why “preeclampsia can be a complicated diagnosis,” Dr. Peterson said, reiterating that diagnosis “involves paying close attention to vital signs [mainly BP], lab values … and patient symptoms.”

The American College of Obstetrics and Gynecologists “recommends that women with severe high blood pressure—BP of 160/110—during birth are evaluated again within 72 hours postpartum,” Dr. Peterson said. “For those with any hypertensive disorder during pregnancy, evaluation within seven to 10 days is recommended.

“There are not clear guidelines on the treatment of mild elevations in blood pressure postpartum, but any blood pressure over 160 systolic or 110 diastolic bears close monitoring and workup,” she added.

While it is unclear why some women develop preeclampsia, there are some factors that may put you in the high-risk category.

“These include previous history of preeclampsia, chronic hypertension, kidney disease, diabetes, multifetal gestation [twins, triplets or more] and autoimmune disease,” said Dr. Peterson.

There are also factors that may put you in the moderate-risk category and those include “nulliparity [first time being pregnant], being 35 or older, family history of preeclampsia, obesity, sleep apnea, pregnancy by assisted reproductive technology, among others,” she said.

“The treatment for preeclampsia is delivery, and the timing and route of delivery is based on the severity of disease and other obstetric factors,” Dr. Peterson said.

“I try to refer to preeclampsia more as a high hypertension disorder of pregnancy spectrum and that really starts with gestational hypertension, which is elevated blood pressure without spillage of protein or any of the other end organ symptoms,” Dr. Hoppe said. “A lot of those folks will be managed outpatient until they reach 37 weeks. If they don’t have underlying chronic hypertension, they would be delivered at that point for that condition.”

But patients with chronic hypertension “are at risk of evolving into preeclampsia,” she said. “Now, if one has preeclampsia, it’s managed pretty much the same as long as it’s mild blood pressure ranges, which is less than 140/90 mm Hg. We don’t treat anyone’s blood pressure until they become more severe.”

“That mild gestational hypertension or preeclampsia requires an increase in surveillance, frequent clinic visits – ideally in combination with home blood-pressure monitoring as long as the person does not have any symptoms of worsening of the hypertension disorder.  Patients will need an increase in their care, if they develop symptoms or achieve severe range blood pressures,” Dr. Hoppe said. “If people have a severe spectrum disorder—those higher ranges of blood pressures or symptoms that would be concerning—they are in the hospital when diagnosis happens and they’re delivered by 34 weeks, which is preterm, which is a big deal.

“We don’t typically go past 34 weeks gestation, but we also are trying to allow the baby to develop. It’s a balance of risk,” she added, noting that “before 34 weeks we’ll treat the blood pressure, try to keep them in a mild range, try to keep the mom and baby safe, and if we can do that, we’ll stay pregnant until 34 weeks and then proceed with delivery.”

“A lot of people think that they’re cured after they have their baby,” Dr. Hoppe said. “Once the person delivers, they typically do get better and they will look better for the first few days, but … three to four days after birth they can have recurrent spikes in their blood pressures.”

“Where we see a lot of the postpartum morbidity and mortality is that people are falsely assured that they’re recovered and that they’re fine, not realizing that these blood pressures can bounce back and become high again,” she explained. “Having close surveillance for those first couple weeks postpartum is really important.”

“Women who’ve had a hypertension related diagnosis in a prior pregnancy are at risk of developing hypertension during a subsequent pregnancy,” Dr. Hoppe said. “The earlier, more severe the hypertension disorder was increases that risk.

“So, some things to think about would be if you had preterm severe preeclampsia, the likelihood of recurrence is probably higher than somebody who had mild disease,” she added. “However, those risk factors are hard to predict. It’s not 100% that if you had it before, you’re going to have it again.”

“You could have preeclampsia in one pregnancy and gestational hypertension in another. Then there is a chance you may not have a hypertensive disorder of pregnancy in your next pregnancy,” Dr. Hoppe said. “We try to optimize health to achieve the best chances of the next pregnancy. You can’t eliminate the risk, but you can also have healthy pregnancy with good outcomes after a pregnancy with a hypertensive disorder of pregnancy.”

“I would suggest that prenatal care is set up to try to detect preeclampsia and other complications in pregnancy,” Dr. Hoppe said. “Preeclampsia is very rare before 20 to 24 weeks of the pregnancy and entry to prenatal care is typically between eight and 12 weeks of pregnancy.

“Then prenatal care visits are about every month thereafter, but as you get into the late second trimester and third trimester, people are seen more frequently,” she added. “At 32 weeks, we typically see people every two weeks and then at 36 weeks, every week.”

“But someone who is at higher risk, for example, may be seen twice a week starting at 32 weeks for frequent assessments and evaluations,” Dr. Hoppe said. “Preeclampsia is most commonly first asymptomatic, so we may see elevated blood pressure in a clinic setting that then leads to further workup and then labs that diagnose preeclampsia.”

“The next best thing would be in that second and third trimester that people who are at high risk can start doing earlier surveillance at home,” she said. “For example, check their blood pressure every day or multiple times a day at home. Then they’re going to be able to detect it sooner than typical prenatal care. But prenatal care being more frequent towards the end is designed to pick that up.”

“Once pregnant, we think aspirin can help lower one’s risk of getting preeclampsia,” said Dr. Hoppe. “Usually, we initiate aspirin by 12 to 14 weeks of the pregnancy.”

“Low dose aspirin therapy during pregnancy can reduce the chance of developing preeclampsia in patients who are at risk for the disease,” Dr. Peterson said.

Another preventive measure Dr. Hoppe suggests is “optimizing your health before you get pregnant.”

That means addressing “many of the factors that people have that could lead to preeclampsia,” she said. “For example, for people with obesity achieving a healthy weight and/or losing weight before pregnancy is important.”

It is also important to manage “chronic medical conditions. For example, controlling your blood pressure before getting pregnant,” Dr. Hoppe said. “But there’s really no preventative treatment that can eliminate all risks of developing preeclampsia during pregnancy.”

“There are risk factors for cardiovascular that first appear during pregnancy,” Dr. Peterson said. Those include “preterm delivery, gestational diabetes, high blood pressure in pregnancy, preeclampsia and eclampsia.

“Even when these conditions resolve after pregnancy, women who had them during pregnancy remain at increased risk of developing cardiovascular disease,” she added.  But there are some “important ways to improve heart health postpartum.”

To start, “follow up with your maternal care physician to verify resolution of conditions such as diabetes and high blood pressure,” Dr. Peterson said. “Establish or follow up with your primary care physician and make sure they know about your pregnancy complications.”

Healthy eating, physical activity and quitting smoking are also important for heart health during pregnancy and postpartum, she said.