You, Preeclampsia, and Your Sprout

Blog Post 3.21.15 PreeclampsiaSince this is my first pregnancy post on Little Sproutings, I wanted to write about something relevant that I went through during mine. (You can skip ahead to the “So What’s Preeclampsia?” part if you don’t want to read about my experience.)

My “Pre”-Preeclampsia Experience

For the last month and a half of my pregnancy, I was on “pre-eclampsia watch.” It was hard for me to distinguish between pre-eclampsia symptoms and being stressed out at a busy job as an ICU nurse. My heart rate would go up, sure, but whose wouldn’t when one of your two patients is crashing? My feet were ridiculously swollen, but I was pregnant! And on my feet all day! Sick patients don’t take a break so a swollen busy nurse can elevate her feet! Sure, my charge nurses and manager had no problem (as far as I know) with my frequent trips to the bathroom, needing to sit down more often as I lugged around my planet-sized mid-section, or taking lots of mini-breaks to eat a snack. They were great in assigning me with patients that didn’t require super heavy lifting and avoided putting me with patients that were on contact/droplet/airborne isolation (and we had quite a few during my last trimester). The nurses I worked with were so sweet and helped grab supplies for me, would turn my patients for me so I didn’t have to strain; they really were the best nurses and coworkers I could ask for. 

However, about 7 weeks before our due date, I was nearing the end of my week’s shift at the ICU when I felt cramping. I was seeing spots, my heart was racing, and I was feeling cold and clammy (“diaphoretic” in our lingo). I sat down and waited for about 5 minutes, drank some water, and waited for my heart rate to slow down. It didn’t. So I grabbed a disposable blood pressure cuff from the supply room and sat in an empty ICU room and hooked myself up to the monitor. My systolic blood pressure (BP) was in the 180s. (To you non-healthcare readers, that’s high. Way high. Less than 120 mmHg – millimeters of mercury – is normal. Systolic BP is the top number of your blood pressure reading, and indicates the pressure in your arteries when blood is ejected from the heart when it contracts) I took my BP a few more times after waiting to calm down and it was still elevated. Soon after, the cramping subsided, but I was still clammy.

I called the on-call OB and she told me I could come right away or after my shift ended, whatever I was more comfortable with, considering my symptoms. Since by then it was 6:15 PM and my shift ended around 7 PM, I told her I’d be by after. (The beauty of working in your delivery hospital is swinging by for some blood draws, fetal monitoring, and donning that hospital gown – even if only momentarily.)

All was OK, Baby Jia was happy and moving and her heart rate was good. No protein in the urine, my blood panel checked out well. I was having more contractions than preferable and my swelling wasn’t great, but nothing a good pitcher of water and rest couldn’t help a bit.

I had a routine visit with our OB a couple of days later, where I was instructed to take my blood pressure 2-3 times a day and to call if any readings were sustained (a couple in a row) more than 150 mmHg and if the swelling in my feet worsened. I think I called in twice, but really I didn’t have another episode like that one shift. My BP ranged between 120-150s. I also started seeing a high-risk OB every week, in addition to my regular weekly OB appointments. Anyway, over the next two weeks, my swelling worsened and my blood pressures weren’t improving to where my OB was satisfied, so he took me out of work. (Nursing requires you to be on your feet for almost the entire 13 hours and they are long shifts in a high-stress environment. Patients crashing, hefty nurse:patient ratios, it’s a really hard job to “scale back” on job stress and elevating my feet on the unit wasn’t an option.) The upside: I get to relax and prepare for Jia’s arrival. The downside: my maternity leave started four weeks early. 

In the end we collectively decided to go through an induction, which meant inducing contractions to deliver Jia early. The premise was that inducing would reduce the risk of a failing placenta (due to high blood pressures and byproducts of pre-eclampsia) causing fetal distress and impaired oxygenation to her. In the end, my BP’s started to level off in the 120s and they said we could either wait for natural labor or induce. We’d already prepared ourselves mentally for an induction, so we scheduled it for Valentine’s Day. (You may recall from Jeff’s Dad’s Post from Valentine’s Day when he wrote about Jia’s arrival) All was good and I ended up having a semi-emergent C-Section (not due to the blood pressures). 

So What’s Preeclampsia? 

Preeclampsia is the leading cause of maternal and infant illness and death worldwide. It is a disorder that happens only during pregnancy characterized by high blood pressures and the presence of excess circulating proteins in the mother’s urine. It occurs in the late 2nd or 3rd trimester of pregnancy, after the 20th week. Around 5-8% of pregnancies result in preeclampsia and 17% of those will lead in death. It is a quickly deteriorating condition that is unique in that it affects both the baby and mom, requiring close medical intervention and careful attention. According to preeclampsia.org, nearly all preeclampsia-related deaths could have been prevented. 

Due to the glaring relationship between preeclampsia and a two-fold risk of stroke, The American Heart Association has recently issued a recommendation guideline for pregnant women to take low-dose aspirin and calcium supplementation to prevent preeclampsia, though research studies have seen benefits in countries where calcium deficiency is a problem (not the US). Additionally, due to the increased risk of stroke and heart disease with a history of preeclampsia, the American College of Obstetrics and Gynecology (ACOG) stated a 2013 recommendation to evaluate and treat of cardiac risk factors in postpartum women from 6 months postpartum to 1 year postpartum. 

The result of untreated (and even treated) preeclampsia can get so bad, that due to the extent of organ damage that occurs, seizures, liver rupture, stroke, and death are a considerable risk. This is referred to as HELLP Syndrome (Hemolysis – breaking down of red blood cells, Elevated Liver Enzymes, Low Platelet Count). Also, when blood pressure are sustained and elevated, the placenta can shrink from lack of oxygen and proper nutrients and can detach. Neither of these are good. 

Causes of Preeclampsia

There are many theories as to what causes preeclampsia. Preeclampsia.org lists the following:

  • Biological changes in the placenta that resulting in “placental debris” that enter the maternal blood circulation, wreaking havoc on the mother’s organs causing a systemic (whole-body) inflammatory response
  • Maternal circulation of various hormones and other proteins
  • Pregnancy related changes in immune factors and responses
  • Mom has a cardiac history (known or undiagnosed) that was unable to tolerate the physiologic changes of pregnancy
  • Insulin resistance and diabetes
  • Deficiencies in vitamins, minerals, and nutrients

One of the above theories that seems very likely (based on research studies) is the first one (biological changes in the placenta).

In pregnancy (and in other conditions that require an increase in blood circulation), collateral circulation (additional networks of veins) is created, so that the body can accommodate an increase in blood volume. In pregnancy, blood volume expands greatly, and this increase in volume is responsible for a significant amount of pregnancy weight-gain (besides the baby and placenta). So this increase in blood vessels is so important so that the necessary blood volume can be handled by the body and so baby gets adequate blood flow and oxygenation. 

With preeclampsia, this theory leads that the placenta produces proteins that actually prevent these important blood vessels from forming, leading to a dangerous increase in blood pressure (since the increase blood volume needs somewhere to go!) which in turn also damages the kidneys and liver. Remember, sustained high blood pressure also increases your risk of a stroke, where blood vessels in the brain become blocked or burst.

Who is At Risk?

According to MedLine Plus, those with a higher risk of developing preeclampsia include the following:

  • First pregnancy (that was me)
  • Multiples (twins, etc)
  • Obesity
  • Older than 35 years
  • History of diabetes, high blood pressure (and preeclampsia), kidney disease 

How is Preeclampsia Diagnosed?

It is so important to diagnose and detect preeclampsia early, because the progression can be very rapid. Mom will be watched for:

  • Urine tests for protein (proteinuria) – not required
  • High Blood Pressures (usually higher than 140/90, with the upper number as more important)
  • Fetal movement/distress/growth
  • Changes in Amniotic Fluid
  • Blood tests (elevated liver values, reduced coagulation factors)

Symptoms

  • Headache
  • Dizziness
  • Swelling
  • Sudden Weight Gain (2 pounds per week)
  • Changes in Vision
  • Nausea
  • Right-sided abdominal pain
  • Vomiting
  • No symptoms

Cases of preeclampsia, especially since it is such a rapidly progressing condition, are sometimes only diagnosed once it is problematic. This is also why some cases are found in women who do not experience any specific symptoms. 

Management of Preeclampsia

First things first: Prenatal care throughout your entire pregnancy is a key step in making sure that your pregnancy is a healthy one. Routine bloodwork, urine tests, blood pressures, and fetal doppler checks will ensure (as best as possible) that you and your little one are growing and progressing as on-track as possible. Recall from above that cases of preeclampsia are sometimes unaccompanied by obvious symptoms. This makes routine prenatal care very important. 

Additional Management of Preeclampsia < 37 weeks gestation:

  • More frequent prenatal visits to monitor mom
  • Daily low-dose aspirin (for high-risk women and those with a history of preeclampsia or preterm delivery)
  • Antihypertensive medications (blood pressure-lowering medications)
  • Intravenous (in the vein) Magnesium Sulfate (to prevent seizures) in the presence of seizures or seizure prevention or in those with moderate to severe preeclampsia. Magnesium Sulfate is thought to work by calming nerve impulses that result in seizure activity.
  • High-risk fetal monitoring of the baby, placenta, and amniotic sac 
  • Bedrest
  • Plenty of water and a low sodium diet (to prevent worsening in blood pressure)

According to ACOG, “the cure for preeclampsia starts with the delivery of the baby.” If the baby has been successfully carried to 37 weeks or later, the baby may have to be delivered in order to prevent preeclampsia from worsening.

If preeclampsia worsens and baby is < 37 weeks gestation (should not be delivered) hospital management is likely required. For more on hospitalization with preeclampsia, read here. 

A Big Whew!

Thankfully we didn’t experience worsening symptoms. Though it was really nice to be able to put my feet up and rest during my last month, had I been diagnosed with preeclampsia things would have been much more stressful. I’m so glad that my OB’s (and High-Risk OB) were conservative and on top of my symptoms, monitoring little Jia, and managing my “Pre-Preeclampsia.” 

Sources:

The Preeclampsia Foundation: http://www.multivu.com/mnr/61626-preeclampsia-foundation-illustrated-symptoms-tear-pad-for-pregnant-women

American College of Obstetrics and Gynecology’s Task Force on Hypertension in Pregnancy – http://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Ob-Gyns_Issue_Task_Force_Report_on_Hypertension_in_Pregnancy

Mayo Clinic: Preeclampsia http://www.mayoclinic.org/diseases-conditions/preeclampsia/basics/definition/con-20031644

National Library of Medicine Medline Plus Preeclampsia  http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm