Preeclapmpsia - A Silent Killer!

Lakshmi Sivasubramaniam

Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby.

Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Any type of high blood pressure occuring during pregnancy is a type of "gestational hypertension". Preeclampsia is severe high blood pressure during pregnancy, and eclampsia is very severe pregnancy gestational hypertension leading to seizures.

Preeclampsia is a condition that typically starts after the 20th week of pregnancy (in the late 2nd or 3rd trimesters or middle to late pregnancy), though it can occur earlier. Proper prenatal care is essential to diagnose and manage preeclampsia. Preeclampsia, Pregnancy Induced Hypertension (PIH) and toxemia are closely related conditions.

HELLP Syndrome and eclampsia are other manifestations of the same syndrome. It is important to note that research shows that more women die from preeclampsia than eclampsia and one is not necessarily more serious than the other. and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the condition is known as eclampsia--the second leading cause of maternal death in the U.S. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death. By conservative estimates, these disorders are responsible for 76,000 deaths each year.

Swelling, sudden weight gain, headaches and changes in vision are important symptoms; however, some women with rapidly advancing disease report few symptoms.

Alternative names   

Toxemia; Pregnancy-induced hypertension

Risk for preeclampsia

Preeclampsia is more common in a woman's first pregnancy and in women whose mothers or sisters had preeclampsia. The risk of preeclampsia is higher in women carrying multiple babies, in teenage mothers and in women older than age 40. Other women at risk include those who had high blood pressure or kidney disease before they became pregnant. The cause of preeclampsia isn't known.

Does high blood pressure mean preeclampsia?

Not necessarily. If your doctor sees that your blood pressure is high, he or she will watch you closely for changes that could mean you have preeclampsia. In addition to high blood pressure, women who have preeclampsia also have excessive swelling. They may also have protein in their urine. Many women with high blood pressure during pregnancy don't have protein in their urine or extreme swelling, and don't get preeclampsia.

Does swelling mean preeclampsia?

Swelling alone doesn't necessarily mean you have preeclampsia. Some swelling is normal during pregnancy. For example, your rings or shoes might become too tight. Swelling is more serious if it doesn't go away after resting, if it's very obvious in your face and hands, or if it's a rapid weight gain of more than 5 pounds in a week.

Symptoms of Preeclampsia

What tests can show if there is preeclampsia?

No one test diagnoses preeclampsia. Your blood pressure will be checked during each doctor's visit. A big rise in your blood pressure can be an early sign that you might have preeclampsia. A urine test can tell if there is protein in your urine. Your doctor may order certain blood tests, which may show if you have preeclampsia. If you have signs of preeclampsia, your doctor may want to see you at least once a week and possibly every day.

 Signs and tests   

• Documented weight gain
• Swelling in the upper body
• Elevated blood pressure
• Proteinuria (protein noted in urine)
• Thrombocytopenia (platelet count less than 100,000)
• Elevated liver function tests

Preeclampsia may also alter the results of some laboratory tests

What are the risks of preeclampsia to the baby and mother?

Preeclampsia can prevent the placenta (which gives air and food to your baby) from getting enough blood. If the placenta doesn't get enough blood, your baby gets less air and food. This can cause low birth weight and other problems for the baby. Most women with preeclampsia still deliver healthy babies. A few develop a condition called eclampsia (seizures caused by toxemia), which is very serious for the mother and baby, or other serious problems. Fortunately, preeclampsia is usually detected early in women who get regular prenatal care, and most problems can be prevented.

What is the treatment for preeclampsia?

Currently, the only way to cure preeclampsia is to deliver the baby. However, if that delivery would be very premature, the disease may be managed by bed rest, close monitoring, and delivery as soon as the fetus has a good chance of surviving outside the womb.

Patients are usually hospitalized, but occasionally they may be managed on an outpatient basis with careful monitoring of blood pressure, urine checks for protein, and weight. Optimally, attempts are made to manage the condition until a delivery after 36 weeks of pregnancy can be achieved.

Labor may be induced if any of the following occur:

• Diastolic blood pressure greater than 100 mmHg consistently for a 24 hour period, or any confirmed reading over 110 mmHg
• Persistent or severe headache
• Abdominal pain
• Abnormal liver function tests
• Rising serum creatinine
• HELLP syndrome
• Pulmonary edema (fluid in lungs)
• Eclampsia
• Thrombocytopenia (low platelet count)
• Non-reassuring fetal monitoring tracings
• Failure of fetal growth noted by ultrasound
• Abnormal biophysical profile (a test to monitor the health of the fetus)

In cases of severe preeclampsia when the pregnancy is between 32 and 34 weeks, delivery is the treatment of choice. For pregnancies less than 24 weeks, the induction of labor is recommended, although the likelihood that the fetus will survive is very small.

Prolonging pregnancies has been shown to result in maternal complications, as well as infant death in approximately 87% of cases. Pregnancies between 24 and 34 weeks gestation present a "gray zone," and the medical team and the parents may decide to attempt to delay delivery in order to allow the fetus to mature.

During this time, the mother is treated with steroid injections which help speed the maturity of some fetal organs including the lungs. The mother and baby are closely monitored for complications.

During induction of labor and delivery, medications are given to prevent seizures and to keep blood pressure under good control. The decision for vaginal delivery versus Cesarean section is based on how well the fetus is able to tolerate labor.

Expectations (prognosis)   

Maternal deaths caused by preeclampsia are rare in the U.S. Fetal or perinatal deaths are high and generally decrease as the fetus matures. The risk of recurrent preeclampsia in subsequent pregnancies is approximately 33%. Preeclampsia does not appear to lead to chronic high blood pressure.

One way to control high blood pressure when you're not pregnant is to cut the amount of salt you eat. This isn't a good idea if you have high blood pressure during pregnancy. Your body needs salt to keep up the flow of fluid in your body, so you need a normal intake of salt. Your doctor will tell you how much salt to eat each day and how much water you should drink each day.

Your doctor might tell you to take aspirin or extra calcium to prevent preeclampsia. Your doctor might also tell you to lie on your left side while you are resting. This will improve blood flow and take weight off your large blood vessels. Many doctors give magnesium sulfate to their patients during labor and for a few days afterward to help prevent eclampsia. Talk to your doctor about these things.

If doctor decides to deliver the baby early, will it be a cesarean section?

This is up to your doctor and you. A cesarean section (an operation to deliver the baby) is more likely if your health or your baby's health is in danger. If things aren't this serious, your doctor may use medicine (such as oxytocin) to start your labor, and you can deliver your baby through a vaginal delivery.

Complications   

Preeclampsia may develop into eclampsia, the occurrence of seizures. Fetal complications may occur because of prematurity at time of delivery.

Prevention   

Although there are currently no known prevention methods, it is important for all pregnant women to obtain early and ongoing prenatal care. This allows for the early recognition and treatment of conditions such as preeclampsia.

Screening for Preeclampsia

Recommendation

Screening for preeclampsia with blood pressure measurement is recommended for all pregnant women at the first prenatal visit and periodically throughout the remainder of pregnancy.

Burden of Suffering

Hypertension is a common medical complication of pregnancy, occurring in about 6-8% of all pregnancies. It is seen in a group of disorders that include preeclampsia-eclampsia, latent or chronic essential hypertension, a variety of renal diseases, and transient (gestational) hypertension. The definitions used to distinguish these disorders are a matter of debate, leading to uncertainty about their exact prevalence, natural history, and response to treatment. Based on 1992 birth certificate data, pregnancy-associated hypertension was noted in 3% of all pregnancies, and eclampsia in 0.4%.

Preeclampsia and eclampsia, once called toxemias of pregnancy, are the most dangerous of these disorders. Although definitions differ, many describe preeclampsia as acute hypertension (blood pressure greater than 140 mm Hg systolic or 90 mm Hg diastolic; or a rise of 30 mm Hg or 15 mm Hg above the usual systolic and diastolic pressures, respectively) presenting after the 20th week of gestation, accompanied by abnormal edema, proteinuria (more than 0.3 g/24 hours), or both. Women with preeclampsia are at increased risk for such complications as abruptio placentae, acute renal failure, cerebral hemorrhage, disseminated intravascular coagulation, pulmonary edema, circulatory collapse, and eclampsia. The fetus may become hypoxic, increasing its risk of low birth weight, premature delivery, or perinatal death. Complications of pregnancy-induced hypertension, including eclampsia (the advanced stage of this disorder characterized by seizures), are major causes of maternal deaths in the U.S. Women with preeclampsia are not at increased risk of developing chronic hypertension. Individuals at increased risk of developing preeclampsia and eclampsia include primigravidas and women with multiple gestations, molar pregnancy or fetal hydrops, chronic hypertension or diabetes, or a personal or family history of eclampsia or preeclampsia.

Other causes of hypertension during pregnancy include transient and chronic hypertension. Transient (gestational) hypertension is defined as the acute onset of hypertension in pregnancy or the early puerperium without proteinuria or abnormal edema and resolving within 10 days after delivery. Chronic hypertension that had been latent prior to the pregnancy may also become evident during gestation. Pregnant women with latent chronic hypertension are also at increased risk for stillbirth, neonatal death, and other fetal complications, but the risk is much lower than that of women with preeclampsia or eclampsia. Women with transient or latent chronic hypertension are also more likely to develop chronic hypertension in later years.

Accuracy of Screening Tests

Screening tests for preeclampsia are difficult to evaluate due to the absence of a "gold standard" to confirm the diagnosis. Glomerular endotheliosis, the renal lesion characteristic of preeclampsia, is present in only about half of patients who meet the clinical criteria for the disease; diagnosis requires an invasive renal biopsy. In addition, the glomerular lesions of preeclampsia are not specific for preeclampsia, having been observed in association with other conditions, such as abruptio placentae and chronic renal disease. For practical reasons, most studies of potential screening tests for preeclampsia have relied on clinical criteria to confirm the diagnosis.

Many proposed screening tests have been found unsuitable for early detection of preeclampsia. The appearance of edema and proteinuria alone is unreliable. Edema is common in normal pregnancies and therefore lacks specificity. Measurable proteinuria usually occurs after hypertension is manifested and therefore is not useful for early detection. In a prospective study of women between 24 and 34 weeks of gestation, a urine albumin concentration equal to or greater than 11 mg/mL had a sensitivity of 50% in predicting subsequent preeclampsia. The conventional urine dipstick test is unreliable in detecting the moderate and highly variable elevations in albumin that occur early in the course of preeclampsia. The definitive test for proteinuria, the 24-hour urine collection, is not practical for screening. Because of these considerations, edema is no longer required to diagnose preeclampsia by some experts and the inclusion of proteinuria is being reconsidered as well. Other tests that have been suggested include the angiotensin II infusion test and the supine pressor "rollover" examination, but these have also been found to be unsuitable, as the former is impractical and the latter lacks adequate sensitivity, specificity, and positive predictive value.

The most promising screening test for preeclampsia is sphygmomanometry to detect elevated blood pressure, although there are several problems in relying on blood pressure readings as an accurate predictor. Common sources of measurement error associated with sphygmomanometry include instrument defects and examiner technique. In addition, maternal posture can significantly affect blood pressure in pregnant women; the results can be erroneous, for example, if blood pressure is measured with the woman in the supine position. Measurements should be taken in the sitting position, after the patient's arm has rested at heart level for 5 minutes. Most important, a single elevated blood pressure reading is neither diagnostic of nor a good predictor for preeclampsia. Diagnosis utilizing only a change from baseline also has limited sensitivity (21-52% and 7-23% for the diastolic and systolic criteria, respectively) in predicting preeclampsia. A combination of the blood pressure levels and the change from baseline may be more effective in identifying women at risk for preeclampsia, and the trend in blood pressure over time is more important than a single isolated measurement.

In the middle trimester of pregnancy, the normal decline in blood pressure is often dampened or absent in women who subsequently develop preeclampsia. Some experts therefore recommend using the middle trimester mean arterial pressure (MAP)_defined as (systolic pressure + [2 3 diastolic pressure])/3)_as a screening test.6 Studies indicate that a middle trimester MAP above 90 mm Hg has a sensitivity of 61-71% and a specificity of 62-74% in predicting preeclampsia, and even higher sensitivity and specificity have been reported by some researchers.23 Other studies report a much lower sensitivity of this test in detecting preeclampsia (22-35%) and suggest it is of little value in predicting eclampsia itself. One review concluded that, due to inconsistencies in the definition of "preeclampsia" used in most of these studies (e.g., failure to require proteinuria for the diagnosis), elevations in second trimester blood pressure may be a better predictor of transient or chronic hypertension than of true preeclampsia.

Effectiveness of Early Detection

The early detection of hypertension during pregnancy permits clinical monitoring and prompt therapeutic intervention for severe preeclampsia or eclampsia. The delivery of the fetus is considered to be the most definitive method to minimize preeclamptic complications, but other measures (e.g., bed rest and pharmacologic agents) have not been conclusively shown to improve outcome. A randomized controlled trial found that antihypertensive therapy and hospitalization, when compared with hospitalization alone, did not improve maternal or fetal outcome. There have been no clinical trials to determine whether hypertensive preeclamptic women treated early in pregnancy have a better prognosis than those who are not detected early.

Clinical experience, however, suggests that early detection and treatment of preeclampsia is beneficial to the patient and fetus. This view is based in part on inferences drawn from the apparent effectiveness of regular prenatal care in reducing the complications of preeclampsia-eclampsia. Studies conducted as early as the 1940s suggested an inverse relationship between the extent of prenatal care and the incidence of eclampsia, perhaps reflecting benefits of early detection. These findings do not provide direct evidence that better outcomes are due solely to blood pressure screening itself, rather than to other components of prenatal care or to the characteristics of women who receive regular prenatal care.

Society issues for Preeclampsia   

Hospitalization statistics for Preeclampsia: The following are statistics from various sources about hospitalizations and Preeclampsia:

• 0.013% (1,682 ) of hospital consultant episodes were for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 98% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 3% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2.2 days was the mean length of stay in hospitals for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1 days was the median length of stay in hospitals for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 32 was the mean age of patients hospitalised for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 3% of hospital consultant episodes for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.007% (3,455) of hospital bed days were for pre-existing hypertension complications complicating pregnancy, childbirth and puerperium in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.002% (242) of hospital consultant episodes were for pre-existing hypertension disorder with superimposed proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 98% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 5.4 days was the mean length of stay in hospitals for pre-existing hypertension disorder with superimposed proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 3 days was the median length of stay in hospitals for pre-existing hypertension disorder with superimposed proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 31 was the mean age of patients hospitalised for pre-existing hypertension disorder with superimposed proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1% of hospital consultant episodes for pre-existing hypertension disorder with superimposed proteinuria were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.002% (1,247) of hospital bed days were for pre-existing hypertension disorder with superimposed proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.13% (16,383) of hospital consultant episodes were for gestational hypertension without significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 98% of hospital consultant episodes for gestational hypertension without significant proteinuria required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for gestational hypertension without significant proteinuria were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2% of hospital consultant episodes for gestational hypertension without significant proteinuria required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2.1 days was the mean length of stay in hospitals for gestational hypertension without significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1 days was the median length of stay in hospitals for gestational hypertension without significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 29 was the mean age of patients hospitalised for gestational hypertension without significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for gestational hypertension without significant proteinuria occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for gestational hypertension without significant proteinuria occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1% of hospital consultant episodes for gestational hypertension without significant proteinuria were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.06% (32,479) of hospital bed days were for gestational hypertension without significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.094% (11,949) of hospital consultant episodes were for gestational hypertension with significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 96% of hospital consultant episodes for gestational hypertension with significant proteinuria required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for gestational hypertension with significant proteinuria were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2% of hospital consultant episodes for gestational hypertension with significant proteinuria required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 5 days was the mean length of stay in hospitals for gestational hypertension with significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 3 days was the median length of stay in hospitals for gestational hypertension with significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 29 was the mean age of patients hospitalised for gestational hypertension with significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for gestational hypertension with significant proteinuria occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for gestational hypertension with significant proteinuria occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 3% of hospital consultant episodes for gestational hypertension with significant proteinuria were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.105% (54,808) of hospital bed days were for gestational hypertension with significant proteinuria in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.002% (266) of hospital consultant episodes were for eclampsia in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 87% of hospital consultant episodes for eclampsia required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for eclampsia were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 6% of hospital consultant episodes for eclampsia required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 5.8 days was the mean length of stay in hospitals for eclampsia in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 5 days was the median length of stay in hospitals for eclampsia in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 28 was the mean age of patients hospitalised for eclampsia in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for eclampsia occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for eclampsia occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for eclampsia were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.003% (1,398) of hospital bed days were for eclampsia in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.206% (26,227) of hospital consultant episodes were for unspecified maternal hypertension in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 99% of hospital consultant episodes for unspecified maternal hypertension required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 100% of hospital consultant episodes for unspecified maternal hypertension were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2% of hospital consultant episodes for unspecified maternal hypertension required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1.3 days was the mean length of stay in hospitals for unspecified maternal hypertension in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0 days was the median length of stay in hospitals for unspecified maternal hypertension in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 30 was the mean age of patients hospitalised for unspecified maternal hypertension in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 10% of hospital consultant episodes for unspecified maternal hypertension occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0% of hospital consultant episodes for unspecified maternal hypertension occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 8% of hospital consultant episodes for unspecified maternal hypertension were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.06% (30,391) of hospital bed days were for unspecified maternal hypertension in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)

Causes of Preeclampsia

Cause details for Preeclampsia: Preeclampsia is a pregnancy-specific syndrome in which there is increased vascular responsiveness to vasoconstrictor stimuli and activation of the coagulation cascade. The initial insult appears to be reduced placental perfusion frequently due to abnormal implantation of the blastocyst and abnormal remodeling of the maternal vessels that supply the intervillous space. These phenomena lead to decreased perfusion of the placenta and are considered by some to represent stage one of a two-stage process. Stage two refers to development of the maternal and fetal syndrome of preeclampsia. At present, the link between stages is not clear. It is evident that reduced placental perfusion does not always result in the maternal syndrome, and that maternal factors also are required. Genetic polymorphisms, fetal signals, and increased hypoxia at the maternal fetal interface likely play a role in the interaction of reduced placental perfusion and the maternal constitution to generate the preeclampsia syndrome. Many of these predisposing maternal factors are also risk factors for cardiovascular disease in later life. For example, coagulation abnormalities, dyslipidemia, increased inflammatory markers, and evidence of oxidative stress and endothelial activation are associated with increased cardiovascular disease risk, and also are detectable in women who develop preeclampsia, occurring before the overt clinical symptoms appear.

Some women with preeclampsia also have autoimmune disorders. There are several promising animal models that suggest a role for inflammation in the pathogenesis of preeclampsia. There is evidence of activation of the inflammatory response in pregnancy that is further increased in preeclampsia. Researchers have thus been led to consider inflammatory markers both as important in the epidemiology of preeclampsia, and as a potential link between preeclampsia and future cardiovascular disease.

Many of the features of preeclampsia mimic the insulin resistance or metabolic syndrome, and insulin resistance is a prominent feature of preeclampsia. These findings provide evidence of a link between preeclampsia and future cardiovascular disease, although the direction of causation is unclear at present.

Preeclampsia as a complication: Other conditions that might have Preeclampsia as a complication might be potential underlying causes of Preeclampsia. The list of conditions listing Preeclampsia as a complication includes:

• Diabetes
• Type 1 diabetes
• Type 2 diabetes

Causes of Preeclampsia: medical news summaries: The following medical news items are relevant to causes of Preeclampsia:

• Obesity increases risk of complications during pregnancy

Researchers find that urine protein measurement can determine preeclampsia risk

{mospagebreak title=Risk factors for preeclampsia}

Risk Factors for Preeclampsia

Risk factor list: The list of risk factors mentioned for Preeclampsia in various sources includes:

• Maternal Age
• Multiple Births
• Hypertesion Before Pregnancy
• Blood vessel Disorders
• First Pregnancy
• Previous pregnancy gestational hypertension
• Previous pregnancy preeclampsia
• Obesity
• Mother under the age of 20
• Mother over the age of 40
• Diabetes
• Kidney disease
• Rheumatoid arthritis
• Lupus
• Scleroderma

Risk factors discussion: Who Is More Likely to Develop Preeclampsia?

• Women with chronic hypertension (high blood pressure before becoming pregnant).
• Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy.
• Women who are obese prior to pregnancy.
• Pregnant women under the age of 20 or over the age of 40.
• Women who are pregnant with more than one baby.
• Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma.

Preeclampsia occurs more frequently and is more severe in women with preexisting hypertension than in women who are normotensive prior to pregnancy. From a public health perspective, it is alarming that the rate of preeclampsia has increased by nearly one-third over the past decade, likely due to a rise in the number of older mothers and multiple births, scenarios that predispose to preeclampsia. Older maternal age during pregnancy also contributes to an increased frequency of chronic hypertension and thus preeclampsia complicating pregnancy.

Inheritance and Genetics of Preeclampsia

Inheritance of Preeclampsia refers to whether the condition is inherited from your parents or "runs" in families. The level of inheritance of a condition depends on how important genetics are to the disease. Strongly genetic diseases are usually inherited, partially genetic diseases are sometimes inherited, and non-genetic diseases are not inherited.

Genetics of Preeclampsia:

Differences in the frequency, timing, and severity of preeclampsia among populations, as well as evidence of heritability, suggest a role for genetic influence.

What can moms of multiples do to prevent complications from preeclampsia?

Frequent checkups with your physician or midwife are imperative. Your caretaker should carefully monitor your blood pressure, weight gain, and urine output. Let your doctor know if you have any history of preeclampsia in your family -- including your own past pregnancies. Women who already have hypertension, obesity, diabetes or kidney disease are at increased risk, as well.

Hopefully this new information about the cause of preeclampsia will provide the medical community with tools to limit the impact from the condition. Researchers say the finding could provide "an amazing breakthrough," which is good news for the mothers of multiples who are at high risk for this disorder during their pregnancy with twins, triplets or more.

Complementary and Alternative Therapies

Complementary and alternative therapies can be used with medical treatment. Some of the most common ones are described below.

Nutrition

• Omega-3 oils (1,000 mg three times a day) are highly beneficial in pregnancy, and help reduce swelling.
• Increasing protein intake may help minimize preeclampsia.
• Magnesium (200 mg two to three times per day) helps reduce high blood pressure

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to determine a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. Tinctures may be used singly or in combination as noted.

Herbs that can be used to treat mild hypertension in pregnancy include the following: Passionflower (Passiflora incarnata), hawthorn berries (Crataegus laevigata), cramp bark (Viburnum opulus), milk thistle (Silybum marianum), and Indian tobacco (Lobelia inflata). Use equal parts of each in a tincture, 20 drops three to four times a day.

Resources:

BOOKS

• Cunningham, F. Gary, et al. Williams Obstetrics, 20th Edition. Stamford, CT: Appleton & Lange, 1997.
• Mabie, William C., and Baha M. Sibai. "Hypertensive States of Pregnancy." In Current Obstetric and Gynecologic Diagnosis and Treatment, edited by Alan H. DeCherney and Martin L. Pernoll. Norwalk, CT: Appleton & Lange, 1994.

PERIODICALS

• Caritis, Steve, et al. "Low-Dose Aspirin to Prevent Preeclampsia in Women at High Risk." The New England Journal of Medicine 338, no. 11 (March 12, 1998): 701+.
• Roberts, James M. "Prevention or Early Treatment of Preeclampsia." The New England Journal of Medicine 337, no. 2 (July 10, 1997): 124+.

REFERENCES

• DeVoe SF, O'Shaughnessy RW. Clinical manifestations and diagnosis of pregnancy-induced hypertension. Clin Obstet Gynecol 1984;27:836-853.
• Chesley LC. History and epidemiology of preeclampsia-eclampsia. Clin Obstet Gynecol 1984;27: 801-820.
• World Health Organization. The hypertensive disorders of pregnancy: report of a WHO Study Group. Technical Report Series no. 758. Geneva: World Health Organization, 1987.
• Redman CWG, Roberts JM. Management of pre-eclampsia. Lancet 1993;341:1451- 1454.
• Atrash HK, Koonin LM, Lawson HW, et al. Maternal mortality in the United States, 1979-1986. Obstet Gynecol 1990;76:1055-1060.
• Roberts JM, Redman CWG. Pre-eclampsia: more than pregnancy-induced hypertension. Lancet 1993;341: 1447-1451.
• Cunningham FG, Lindheimer MD. Hypertension in pregnancy. N Engl J Med 1992;326:927-932.
• Cunningham FG, MacDonald PC, Gant NF, et al. Hypertensive disorders of pregnancy. In: Williams obstetrics. 19th ed. Norwalk, CT: Appleton & Lange, 1993:763-817.
• Vollman RF. Study design, population and data characteristics. In: Friedman EA, ed. Blood pressure, edema and proteinuria in pregnancy. New York: Alan R. Liss, 1976:99.
• Wallenburg HCS. Detecting hypertensive disorders of pregnancy. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:382-402. 
• Moutquin JM, Rainville C, Giroux L, et al. A prospective study of blood pressure in pregnancy: prediction of preeclampsia. Am J Obstet Gynecol 1985;151:191-196.
• National Institutes of Health. Caring for our future: the content of prenatal care. Washington, DC: Department of Health and Human Services, 1989. (Publication no. 90-3182.)

Supporting Research

· Berkow R, ed. Merck Manual of Diagnosis and Therapy. 16th edition. Rahway, NJ: The Merck Publishing Group; 1992.

· Berkow R, Beers MH, Fletcher AJ, eds. Merck Manual, Home Edition. Rahway, NJ: Merck & Co; 1997.

· Klonoff-Cohen HS, Cross JL, Pieper CF. Job stress and preeclampsia. Epidemiol. 1996;7:245-249.

· Larson DE, ed. Mayo Clinic Family Health Book. 2nd ed. New York, NY: William Morrow and Company; 1996.

· Murray M. Encyclopedia of Nutritional Supplements. Rocklin, Calif: Prima Health; 1996.

· Scalzo R. Naturopathic Handbook of Herbal Formulas. Durango, Colo: 2nd ed. Kivaki Press; 1994.

Madhumathi Seshadri^b, Neha Shah^c and Mrs. Lakshmi Sivasubramaniam ^a, *

^{* a} Lecturer, Department of Pharmaceutical Analysis, College of Pharmacy, SRM Institute of Science and Technology
^b  Department of Chemistry, Pharmaceutical Chemistry unit, Vellore Institute of Technology, Vellore-632 014, India
^c Bio medical Genetics, Department of Bio sciences, Vellore Institute of Technology, Vellore-632 014, India

Mrs. Lakshmi Sivasubramaniam

^{* a} Lecturer, Department of Pharmaceutical Analysis, College of Pharmacy, SRM Institute of Science and Technology, Deemed University, Katangulathur, Chennai, India.

*^,a Author for Correspondence: Lakshmi Sivasubramaniam, Lecturer, Department of Pharmaceutical Analysis, College of Pharmacy, SRM Institute of Science and Technology, Deemed University, Katangulathur, Chennai, India.E-mail: laxmisiva@rediffmail.com

Madhumathi Seshadri

^b  Department of Chemistry, Pharmaceutical Chemistry unit, Vellore Institute of Technology, Vellore-632 014, India