Songstress Beyoncé revealed in the September issue of Vogue that she suffered from toxemia, also known as preeclampsia, while she was pregnant with her twins. The 36-year-old star shared that she was “swollen from toxemia” and had an emergency C-section because her health and her babies’ health was in danger.
According to James T. Christmas, MD, national medical director for women’s and obstetric services for HCA Healthcare, preeclampsia occurs in approximately four or five percent of pregnancies worldwide. That’s 1 out of 20 to 25 pregnancies.
“Preeclampsia is a progressive, multi-system disorder unique to pregnancy,” Dr. Christmas said. “It’s characterized by high blood pressure occurring during the second half of pregnancy (after 20 weeks gestation). And it’s a condition that we see on a daily basis,” he added.
Because it’s common and dangerous, Dr. Christmas says, HCA pioneered the implementation of standardized protocols for the management of sudden and severe high blood pressure for pregnant women. Those protocols are now used in hospitals worldwide to decrease the likelihood of complications from severe high blood pressure associated with the condition.
“Introduced in 2007, the practice consists of a rapid and graduated response to patients presenting in labor and delivery with severely elevated blood pressure,” Dr. Christmas explained. “We looked back at 1.2 million deliveries in 2014 within our hospitals and virtually eliminated severe high blood pressure as a cause of maternal death.”
Dr. Christmas says that a choice of three medications are available to caregivers who administer a dose of medication if a patient’s blood pressure is persistently above, for example, 160/110. If the blood pressure is elevated 20 minutes later, a larger dose of medication will be administered to the patient. If it’s still elevated 20 minutes later, a larger dose is given. If it persists, caregivers switch to a different medication as a way to ensure prompt, effective rapid response to severely elevated blood pressure.
Dr. Christmas discusses what else you should know about this prenatal condition.
When does preeclampsia occur in pregnancy?
It’s relatively common. When preeclampsia occurs during pregnancy, it always resolves after delivery. Also, we see it develop temporarily after delivery on rare occasions.
What are the symptoms?
For generations, the classic presentation for patients was high blood pressure, protein in the urine and edema, or swelling in the tissues such as the hands, feet or face.
Why is it dangerous?
Historically, back in the 1800s and early 1900s, preeclampsia was the leading cause of maternal death before there were medications and techniques facilitate early delivery.
Also, high blood pressure due to preeclampsia can lead to:
- fluid in the lungs (pulmonary edema), or
- premature separation of the placenta.
A small proportion of patients who have preeclampsia can develop:
- seizures, or
- abnormalities of the blood, or inability of the patient’s blood to clot, which can lead to excessive bleeding.
Who’s most at-risk?
There are lots of different risk factors.
- Patients in their first pregnancy carry more risk than subsequent pregnancies.
- Young patients’ first pregnancies and relatively older first pregnancies are at increased risk.
- Patients who have preeclampsia in a previous pregnancy can be as high as 20 to 40 percent at risk.
- Patients with pre-existing medical conditions like high blood pressure, diabetes, obesity, chronic kidney disease, and lupus, for example, are all at increased risk.
- Patients who have twins or triplets.
- Patients who have a family history of preeclampsia.
- African-American women are at a slightly increased risk.
- Pregnancies conceived using in vitro fertilization also have a slightly increased risk.
What causes it?
We don’t really know the exact cause. We’ve been studying it for decades. We know there is some interaction between the maternal immune system and the placental tissue and that leads to some damage in the lining cells of the small blood vessels, especially in the placenta. That results in the release of substances which can cause damage to blood vessels throughout the maternal circulation and leads to clinical signs and symptoms of preeclampsia. For example, damage in the kidneys leads to protein the urine; generalized damage to the blood vessels leads to collection of fluids under the skin (edema); and damage of the blood vessels in the brain can lead to headaches.
How is it detected?
It’s most commonly diagnosed by serial blood pressure and urine tests that are performed during every prenatal visit. Certainly there are times when we perform lab work to quantify how much protein is in the urine or how much kidney damage is occurring. Those tests are performed to access the severity.
Patients also may present with symptoms like worsening of swelling that doesn’t wane at night; or headaches or upper abdominal pain. Again, typically the screenings that are performed include the blood pressure and urine checks that every pregnant gets during prenatal visits.
How is it treated?
The only curative treatment is delivery. The immediate goal when we see someone with preeclampsia is to make sure we are controlling the severe high blood pressure. Once we have that under control, we balance the risks of premature delivery against how severe the condition is to determine whether it’s safer to deliver or try to continue the pregnancy.
If the blood pressure can easily be controlled and the fetus appears to be healthy, we may give medications to accelerate fetal lung maturity so that if the patient has to deliver early, the baby will do better.
In mild cases, we may be able to manage the patient as an outpatient with frequent follow-up in the office, checking blood pressure and performing lab work.
Some patients will require prolonged hospitalization and, ultimately, make decisions regarding delivery if:
- we cannot control the patient’s blood pressure,
- the patient develops worsening symptoms,
- the patient develops evidence of progressive liver or kidney or other organ damage, or
- if the fetus isn’t growing well or there is evidence that the fetus isn’t tolerating pregnancy.
When we know patients are at elevated risk for developing preeclampsia, there’s evidence that taking baby aspirin daily will decrease the likelihood or severity of preeclampsia.
Does preeclampsia affect the baby?
It can cause damage in the blood vessels of the uterine wall and placenta that could lead to poor fetal growth. Sometimes, before signs or symptoms of preeclampsia, severely elevated blood pressure can lead to premature separation of the placenta, causing stillbirth, and is severe enough to cause heavy maternal bleeding. Because the only effective cure is delivery, it’s a common cause of preterm delivery and obviously that effects the baby with some complications for prematurity.
What should pregnant women pay attention to?
Signs or symptoms that should immediately prompt a call to a provider include:
- rapid accumulation of swelling in the feet, and especially in the hands and face, that doesn’t diminish;
- headaches that don’t go away or headaches associated with visual symptoms;
- upper abdominal pain that doesn’t fit any pattern and is resembles a bad heartburn that doesn’t subside.
If a pregnant woman should experience any of those symptoms, please contact a health professional.
James T. Christmas, MD, serves as national medical director for women’s and obstetric services for HCA Healthcare. He is also director of maternal-fetal medicine for HCA Virginia.