Pre-eclampsia is a medical condition that affects pregnant women and women who have just had their baby.  In women who have pre-eclampsia, blood pressure rises and protein is present in the urine (proteinuria). Pre-eclampsia can develop anytime after 20 weeks of pregnancy but it is more common in the last third of pregnancy (the third trimester).

Pre-eclampsia usually resolves soon after the birth. Severe pre-eclampsia is less common and women with this condition need to be monitored in hospital and have treatment. Pre-eclampsia can also have effects on the unborn baby, which may result in early delivery and a small baby.  Mild pre-eclampsia affects up to 10 percent of pregnant women and severe pre eclampsia can affect 2 percent.

In some cases pre-eclampsia can lead to severe complications, this is rare in the UK, but it is important for women and their families to be aware of the symptoms and seek advice. 

Complications for the mother:

The eclampsia part of pre-eclampsia means seizures in the mother. These seizures can be life threatening to both mother and baby. They can happen in pregnancy, or shortly after the birth.

HELLP is a complication of pre-eclampsia and can affect women during pregnancy and even after delivery. It involves changes in the blood, particularly the clotting particles (platelets) and some liver functions.  It can be life threatening if not monitored closely but usually resolves following delivery of the baby and placenta.

Other problems. There is a risk of blood clotting problems, problems with the lungs, liver and kidney failure and stroke (cerebral haemorrhage).

Complications for the baby:

Premature delivery. Birth of the baby will stop pre-eclampsia and pre-emptive delivery before 37 weeks may be necessary if the pre-eclampsia can no longer be controlled and serious complications develop. The medical team may decide this if the mother or baby is at risk if the pregnancy continues.

Growth restriction. Pre-eclampsia can damage the placenta and reduce the transfer of nutrients to the baby, resulting in the baby being born smaller than usual. Again this can be monitored if it is detected and more research is needed to understand growth restriction.

Causes and risk factors

The exact cause of pre-eclampsia is unknown, but it is believed that it may develop from problems with the implantation of the placenta as well as other factors. Problems with the placenta can affect the blood supply between mother and baby and the way the mother’s blood vessels work.

Any pregnant woman can develop pre-eclampsia but there are certain risk factors that increase the likelihood:

• First pregnancy.
• Having a sister or mother that has been affected.
• Any pregnancy with a new partner.
• Women aged 40 or over.
• Women who have had pre-eclampsia in a previous pregnancy.
• Being overweight with a raised body mass index (BMI) of over 30.
• Multiple pregnancies- twins, triplets etc.
• Pre-existing medical problems such as high blood pressure, kidney problems and diabetes.

Symptoms

Pre-eclampsia can develop anytime after 20 weeks of pregnancy but it is more common in the last third of pregnancy (the third trimester).

Pre-eclampsia in the early stages usually starts with raised blood pressure and protein in the urine, so it is important that all pregnant women attend their routine antenatal appointments to have blood pressure and urine tested.  

Symptoms include:

• Headache.
• Excessive swelling to the hands, feet and sometimes the face. It is normal in pregnancy to develop mild swelling of the hands and feet but excessive swelling may develop with pre-eclampsia.
• Abdominal pain up under the ribs.
• Visual blurring or flashing lights.
• Generally feeling unwell.

If you are unsure and have any of these symptoms it is important to speak to a midwife or doctor immediately. Do not wait for your next routine appointment. 

Diagnosis

Pre-eclampsia is usually diagnosed when raised blood pressure and protein in the urine is found at a routine appointment. However, if any symptoms are noticed in between appointments it is important to get advice immediately. 

Monitoring blood pressure, blood results and urine tests are used to assess the severity of the condition. Depending on the severity of pre-eclampsia it can be managed in the community or in hospital. If the pre-eclampsia is mild then the doctor or midwife will give advice about symptoms to monitor and arrange regular appointments for follow up. A scan will usually be arranged to check the growth of the baby and blood tests will be taken from the mother.

If blood pressure is significantly raised or symptoms are severe then admission to hospital will be needed for further treatment and assessment.

Treatment

Pre-eclampsia is treated by the birth of the baby. In mild pre-eclampsia the aim is to closely monitor and manage the condition whilst allowing the pregnancy to continue for as long as it’s safe to do so. However, if severe pre-eclampsia develops the mother or baby may become at risk from the condition and delivery may need to be sooner.

Treatments may involve:

• Admission to hospital.
• Monitoring the mother’s symptoms.
• Regular monitoring of blood pressure, blood results and urine tests.
• Monitoring the baby’s heartbeat
• Monitoring the baby’s wellbeing with ultrasound scans.
• Medication to treat the raised blood pressure.
• Administration of steroids to help mature the baby’s lungs if premature delivery is needed.
• Delivery of the baby by starting labour or by caesarean section (operation).
• Administration of drugs to the mother to help prevent further complications.

Treatment after birth

Most women do not require ongoing treatment after their baby is born, but occasionally blood pressure medication may be required for up to 6 weeks.

If premature delivery was needed, the baby will most likely need treatment on a special care baby unit for a period of time before going home. Please see our premature birth information page for more information.

It is important to remember that although this condition can be serious, with monitoring and treatment pre-eclampsia can be managed and complications are rare. However, if any symptoms are noticed they should be reported immediately and any family history or pre-disposing factors should be discussed with the midwife at the beginning of pregnancy.

 Pre-eclampsia: Text Version

 Welcome to our podcast.

 Today, I am speaking to Professor James Walker. Jimmy is Professor of Obstetrics and Gynaecology at the University of Leeds and Consultant Obstetrician and Gynaecologist at St James’s University Hospital Leeds. He is also Senior Vice President and Global Health Officer at the Royal College of Obstetricians and Gynaecologists. Today we will be speaking about pre-eclampsia.

 Sadly in the developing world complications from severe pre-eclampsia and eclampsia are common and many women and babies die as a result. In the UK this is much less common, but it can still happen. Increased awareness of the symptoms and the risk factors is needed and continued research is key, as there are still aspects of the condition that are unknown. Wellbeing of Women is currently funding the Baby Bio Bank which is a collection of samples that will help researchers investigate the four main complications of pregnancy- one of which is pre-eclampsia.

Hi Jimmy.

 Hi. Good morning.

 Thank you for joining us today.

 Pre-eclampsia can be complicated for many people to understand so it’s great to have your expert opinion to help us understand more about it.

 First of all could you tell us a little bit more about pre-eclampsia and how many women are affected by it?

 Pre-eclampsia is a specific problem of pregnancy which presents as high blood pressure and the presence of protein in the urine. It occurs in the second half of pregnancy and goes away once the baby has delivered. Up to about 10 percent of women can be affected to some degree with problems of high blood pressure, although the severe condition only affects about 1-2 percent. Women often don’t feel anything and that’s why antenatal care is so important because the purpose of attending clinics is to check blood pressure and to check the urine for protein; because as you say, many women won’t feel unwell when the condition is developing. Some women can have symptoms and the most common ones are headache and abdominal pain, they also can feel like they have got flu and other general feelings of un-wellness.

 There are different degrees of severity with this condition. Could you explain the difference between pre-eclampsia and eclampsia?

 Yes. Pre-eclampsia can present in many many different ways. It is often said it’s a condition that can mimic virtually any other condition in pregnancy. So there are classic presentations and that is people presenting with severe headache and high blood pressure, but there are also other facets of the disease. Eclampsia is when convulsions or fits arise in pregnancy in association with the high blood pressure and proteinuria. It was the fits which were the first thing really discovered and labelled as eclampsia in pregnancy, and it wasn’t until blood pressure could be measured in the early 1900s that  the condition of pre-eclampsia was then coined. Other conditions can present with pre-eclampsia and they relate to pulmonary odema or heart failure and also conditions of stroke. They can get problems of liver, bleeding, and particularly problems with the baby- of small growth because of poor placental function.

 We are very lucky these days with modern health care and often these complications can be picked up. But it’s important for early recognition would you say, to be able to manage these? So that’s why awareness of the symptoms is so important and having regular antenatal checks even if those symptoms don’t present?

 Yes. The early diagnosis of the problem is very important because it then can be controlled in many cases and certainly for the mother and baby, the symptoms not only can be controlled, but delivery can be planned on the best day in the best way to the benefit of both mother and baby. So it’s the purpose, as I have said already, of antenatal care to measure blood pressure and test for proteinuria and about 50 percent (at least) of women who present with severe disease can be picked up that way. But the other 50 percent pick up because of presentation of symptoms; particularly headache and abdominal pain which are the two most common presenting symptoms that the women may feel. So they then go to their doctor or midwife who can test their blood pressure and test their urine. But if there are concerns for these symptoms and particularly if it’s associated with women getting more puffy or oedematous, then they should contact their midwife quickly to be assessed.

 Wellbeing of Women supported your research in the 90s into genetic predisposition for pre-eclampsia and this is now well known as a pre-disposing factor. What are the other risk factors for the condition?

 A lot of work has been done looking at methods of prediction of this condition and looking at people who are at risk and certainly we know from work that I and others did that there is a family predisposition to it. So in other words, if someone’s mother had pre-eclampsia they probably have a 1 in 4 chance of developing the condition themselves. Similarly if their sister had pre-eclampsia they probably have 1 in 3 chance of developing it themselves, so these are important risk factors. But other things such as women with underlying high blood pressure problems, or underlying kidney problems and some other conditions such as lupus can also predispose to this condition. But women who are overweight with a BMI (body mass index) of over 30 have an increased risk and as they get heavier the risk increases further than that. There are other factors relating to information not only in family history but information of other medical conditions that can also help to select people who are at greater risk. But at the moment we still don’t know why the majority of women even with these risk factors actually get the disease; which is why the work on genetics and other work relating to the bio bank is so important to try and discover markers of this condition, so we can select people early who are at risk who can then benefit from interventions.

 And we were just talking about how it can be difficult to know the exact cause. There is still investigation into it and is it possible that one of the processes is to do with how the placenta works and the implantation of this and the blood vessels involved in that?

 Yes. For the majority of women with pre-eclampsia, probably the condition starts with abnormal placentation (embedding of the placenta) occurring within the first few weeks and months of pregnancy. This limits the amount of function that the after birth can actually produce through the pregnancy, which can then cause the baby to start outgrowing its nutrition and oxygen supply. Meaning, it begins to grow more slowly and also becomes relatively hypoxic. This appears to be the drive towards the mother developing the condition which may be partly a pathophysiological response to try and overcome this problem; or it maybe due to other factors relating to placental function which then produces the systemic disease which is almost certainly due to inflammation. There are other people who do develop pre-eclampsa for other reasons and it’s got to be remembered that this is a syndrome of conditions put together into forming pre-eclampsia, so it’s not a specific disease. So women who have problems with infections in the womb such as parvovirus and women who have some congenital abnormalities in the baby can also present with pre-eclampsia and we don’t really understand fully why they do this.

 If women are informed that they have pre-eclampsia what forms of treatment might they expect? Because, as I understand, there are different levels, so you could have quite mild pre-eclampsia and this be monitored and not need any treatment for that, or it could go on progressively.

 Pre-eclampsia is generally a progressive disease but takes time to go from mild, to moderate, to severe and some women will present with severe disease at the time that they are admitted. The important thing about pre-eclampsia is that it is something which affects different women in different ways. So there may be a situation where a woman herself may not be particularly sick but had pre-eclampsia and her baby is poorly grown, or there may be a situation that she is particularly sick but her baby is well. The sickness the woman has will depend on levels of blood pressure and the effect of other organs such as the liver and the lungs etc. Now, when people present, probably the most important factor for both mother and baby, is how many weeks they are in the pregnancy, because in later pregnancy the woman can be stabilised and delivered; because delivery is the ultimate cure. Once you deliver the baby and the placenta then the mother starts getting better, although may take a few days to fully recover. The main problem is when people present very early in pregnancy,  let’s say 26 or 28 weeks when delivery of the baby could be detrimental because of prematurity. An attempt then is to control the condition and to try and prolong the pregnancy. Now we can do this in various ways, the most important thing is lowering blood pressure because that is the immediate risk to the mother. So if the mother presents with high blood pressure we give them drugs, either a drug like labetalol or methyldopa which are tablets which lower blood pressure to try and protect the mother from having a stroke. Now these tablets do not harm the baby, but take the risk away from the mother and it means that the pregnancy can be prolonged, often for up to 2 weeks after presentation.  The other main treatment would be to give steroids to mature the baby’s lungs, if we think that delivery is going to occur before 34 weeks, but other than that there is not a lot of treatments we can give to help to control the condition. So if her blood pressure is not well controlled or if her bloods show that there are destruction of the cells within the blood, particularly the platelets, then delivery may have to be carried out for maternal safety. Similarly, if the baby is affected and becomes unwell within the womb with evidence of fetal distress, it is possible that we have to deliver the baby even though the mother is stable. So we can lower blood pressure, we can take away a lot of the risks but we cannot solve all the underlying problems of the condition and delivery is the ultimate cure for the problem.

 As you say delivery resolves the problem, but there might be a treatment period after birth is that right?

 Yes. From the baby’s point of view delivery takes the baby out of that hostile environment, but if it’s premature it can then be put into a relatively hostile environment of being in a premature baby unit and having to survive the problems of being delivered too early. So the baby may need treatment actually in hospital for a number of weeks, or months even, to get them to the maturity you want. From the mother’s point of view the mother should recover relatively quickly, but can get worse within the first 24 hours and still be quite sick at 48 and 72 hours before she then starts recovering herself. So controlling blood pressure, controlling convulsions if they have occurred and particularly watching fluid balance in the mother are very important things to be done in the first 24- 48 hours. The main difference is that after delivery it’s the balance of fluid which could lead to pulmonary odema, or fluid in the lungs, which is the mother’s greatest risk apart from the blood pressure problems. So she may require fairly intensive care for the first 24-48 hours then hopefully will then start recovering normally and within a week may be completely normal.

 Thank you.

 This is obviously a complex condition and we need to know more about it. You mentioned areas for further research earlier on, are there any specific areas that you feel really need that extra research?

 I have been researching this area for 30 years and what is important is that one, we have moved along way in understanding how this condition presents and how to manage it and therefore from the point of women in the UK, we have improved the outcome for mother and baby very greatly. But the more work we do, the more things we realise we don’t know and the most important thing is to look at the markers of the development of this condition and to try and select women who are at risk so we can then start looking at prevention. Now this will help women in this country and there are still women who die every year from this condition as well as their babies, but more importantly simple interventions that could help reduce deaths would be very beneficial worldwide, where at the moment there are several tens of thousands of women dying every year worldwide because of pre-eclampsia. So there is an awful lot of work to be done to try and simplify how we investigate this condition and simplify how we treat it and more importantly, how we prevent it.

 Thank you. Is there anything else you wanted to add?

 I think that it is important to emphasise if women are diagnosed with having this problem, not to worry too much about it. The vast majority can be managed very simply and easily and it may mean that they need to be induced early or delivered early and they may need to take some tablets to control blood pressure. There are some who it severely affects, the importance is to seek medical advice and go to the midwife or doctor quickly if they have symptoms like headache and abdominal pain so they can be seen and quickly managed. One more important thing is that if they have had pre-eclampsia in their first pregnancy, they are at an increased risk of having the condition in the next pregnancy, but it’s not an absolute. So the importance is to talk to people after, no matter how sick you were, so you can find out what the risks would be for you and your future baby for any future pregnancy and hopefully reassured that having a further pregnancy is a good and safe thing to do.

 Thank you. It’s great to have access to your expert opinion.

Thanks for joining us.

 Ok. Thank you very much.

Discover the truth behind the myths and understand more about pre-eclampsia.
 

Pre-eclampsia only happens in the first pregnancy.

No. This is not true. Any pregnant women can develop pre-eclampsia. Pre-eclampsia is more common in first pregnancies, but it can also affect women who have had babies before and/or are pregnant with a new partner.

Pre-eclampsia only happens in late pregnancy.

Pre-eclampsia can develop anytime after 20 weeks of pregnancy but it is more common in the last third of pregnancy (the third trimester).

You can prevent pre-eclampsia by resting and minimizing stress.

Although these are good choices in pregnancy overall, there is no evidence that stress is related to pre-eclampsia at all.  

If I am developing pre-eclampsia I will get some symptoms and warning signs.

Women often do not notice or feel that they have symptoms of the condition. That is why it is so important to attend routine checkups where blood pressure and urine can be checked. The most common symptoms to watch out for are: headache, abdominal pain or a general feeling of being ‘un-well’.

Pre-eclampsia only affects the mother.

Pre-eclampsia can damage the placenta and reduce the transfer of nutrients to the baby, resulting in the baby possibly being born smaller, or earlier than usual. Again this can be monitored if it is detected. Scans and regular appointments can monitor the growth and wellbeing of the baby.

To find out about our research follow these links:
 

• Baby Bio Bank
   
• Mechanisns of the systemic inflammatory response in pre-eclampsia and HELLP syndrome

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx