What is Preeclampsia?
Preeclampsia is a disease of pregnancy that affects the lining of the mother's
blood vessels causing high blood pressure, leaking of fluid from the blood
vessels, and damage to multiple organs. Preeclampsia is believed to be caused
by an abnormal placenta releasing higher than normal amounts of substances that
control the growth of blood vessels and the placenta [1-4]
Preeclampsia tends to be milder when it
occurs late in pregnancy, but can progress very quickly at anytime to a severe
form with the development of very high blood pressure and seizures (eclampsia).
Severe preeclampsia can also cause fetal growth restriction, placental
abruption (detachment of the placenta), stroke, pulmonary edema (fluid in the
bleeding disorders, kidney failure, and liver swelling.
Who gets Preeclampsia?
About 5% to 7% of all pregnancies are affected by preeclampsia Women are
more likely to develop preeclampsia during their first pregnancy, if they are
over the age of 40, have diabetes, a multiple gestation (twins), a
family history of preeclampsia, had preeclampsia in a previous pregnancy, or
they have had in
vitro fertilization. Women with antiphospholipid syndrome, chronic
hypertension, and chronic renal disease are ten times more likely to
develop preeclampsia than women without these conditions [5-7}.
Signs and Symptoms of Preeclampsia
Most women with early preeclampsia do not have symptoms. When symptoms
occur they usually occur in the second half of pregnancy and may include
- Persistent headache not relieved by mild pain killers
- Visual disturbance such as double vision, sensitivity
to light, blurred vision,
dimmed vision., loss of vision, or flashing lights (fireworks)
- Pain in right upper or middle upper abdomen
- Nausea or vomiting
- Difficulty breathing, new onset shortness of breath,
cough, or rapid breathing
- Dark colored urine, blood in urine, or decreased amount of
- Decreased fetal movement
- Sudden weight gain
Women should be advised to seek immediate medical advice
if they experience any of the above symptoms
How is Preeclampsia Diagnosed?[9,10]
The American College of Obstetricians and Gynecologists (ACOG) recommends
that preeclampsia should be diagnosed if the following conditions are met:
High blood pressure
occurring for the first time after 20 weeks
A systolic blood
pressure (SBP) greater than or equal to 140 mm Hg OR
a diastolic blood pressure (DBP) greater than or equal to 90 mm Hg on at
least two occasions at least 4 hours apart
A systolic blood
pressure (SBP) greater than or equal to 160 mm Hg OR
a diastolic blood pressure (DBP) greater than or equal to 110 mm Hg
measured on more than one occasion several minutes apart
Protein is in the urine (proteinuria). 300 mg or more in a 24 hour urine
timed collection or
a protein/creatinie ratio of at least 0.3 (each measured as mg/dL)
1+ on dipstick may be used only if the above methods are unavailable
ANY OF THE FOLLOWING SEVERE FEATURES
- Cerebral or visual disturbances (as above noted under
Pulmonary edema (fluid in the lungs)
Low platelet count (less than 100,000 /microliter)
Elevated liver enzymes ( transaminases ) to twice the normal concentration,
severe persistent pain in the right upper or middle upper abdomen that does not
respond to medication and is not explained by another condition or both.
Normal Ranges for Transaminases In Pregnancy
|Alanine aminotransferase ,
||2 - 33 U/L
||3- 33 U/L
- Renal insufficiency (serum creatinine greater than1.1 mg/dL)
,or a doubling of serum creatinine in the absence of other renal disease
Women who develop high blood pressure for the first time
after 20 weeks, but do not have protein in their
urine or severe features of preeclampsia are diagnosed with gestational
A woman who has chronic hypertension (high blood pressure
before 20 weeks) is likely to also have preeclampsia (superimposed) if :
- She develops protein in her urine for the first
time after 20 weeks,
- The amount of protein in her urine increases
dramatically if she had protein in her urine before 20 weeks
- Her blood pressure suddenly increases and becomes
difficult to control
- She develops any of the severe features of
How is Preeclampsia Treated?[9,10]
- Blood pressure medications are given to reduce the
chance of strokes, heart failure, and kidney injury in women with severe
greater than or equal to 160 mm Hg or DBP greater than or equal to 110
mm Hg )
- Magnesium sulfate is given to treat eclampsia (new
onset grand mal seizures), or to prevent eclampsia
during labor ,during cesarean section, and after delivery in women with SBP greater than or equal to 160
mm Hg , DBP greater than or equal to 110 mm Hg , OR with severe
features of preeclampsia, HELLP syndrome, or hyperactive reflexes (clonus).
- Magnesium sulphate more than halves the risk of
eclampsia, and reduces the risk of placental abruption 
- Medication (corticosteroid) to help the fetal lungs
mature and reduce other complications of being born prematurely are given
to women with a viable fetus who must be delivered before 34 weeks' .
Delivery is the only cure for preeclampsia.
However, the timing of delivery will depend on the severity of the disease and
gestational age. The mode of delivery (vaginal or cesarean) is determined by
the age of the fetus, presentation, cervical status, and maternal or fetal conditions.
ACOG recommends [8-10]
- Preeclampsia with severe features or HELLP
(hemolysis, elevated liver enzymes and low platelet count) syndrome before viability or at 34 weeks gestational age or after should be delivered
when the mother's condition is stable.
Gestational hypertension or preeclampsia without severe features at 37 weeks
gestational age or after should be delivered
- Preeclampsia with severe features after viability
and before 34 weeks should be hospitalized at a facility with
maternal and neonatal intensive care resources.
Women with uncontrolled high blood pressure, eclampsia,
pulmonary edema, placental abruption, disseminated intravascular coagulation (DIC)
, nonreassuring fetal status , or fetal demise should be delivered
after their condition has become stable.
- Gestational hypertension (GHTN) or preeclampsia without
severe features before 37 weeks should have
- Monitoring for symptoms,
- Instruction on daily kick counts,
- Twice weekly blood pressure measurement,
- Assessment of platelet count, liver enzymes (AST,
ALT) , and serum creatinine at least every week .
- Fetal growth should be checked every three weeks
- Umbilical artery doppler velocimetry if growth
restriction is suspected.
- Amniotic fluid level should be checked at least once
- Patients with GHTN should also have their blood
pressure taken, urine checked for protein, and nonstress tests
(NSTs) once weekly.
- Patients with preeclampsia without severe features
should have NSTs twice weekly.
- Strict bedrest or a low sodium diet are not
- Patients should be hospitalized if they develop
severe hypertension, severe features of preeclampsia, or fetal growth
Postpartum (after delivery) ACOG Recommends
- Blood pressure should be monitored for at least 72
hours after delivery and at 7 to 10 days after delivery or sooner in women
with symptoms. Signs and symptoms of preeclampsia should be reviewed with
mother before discharge to home.
- Medication to control blood pressure is suggested in women
with persistent SBP 150 mm Hg or higher or DBP of 100 mm Hg or higher on two
occasions 4 to 6 hours apart.
Avoid the use of nonsteroidal antiinflammatory agents (e.g. ibuprofen) in
women with hypertension that persists for more than one day after delivery.
- Advise women who have had preeclampsia that they have an increased
lifetime risk of cardiovascular disease later in life
Women with a history of recurrent preeclampsia or delivery before 37 weeks
for preeclampsia should consider yearly assessment of their lipids, fasting blood glucose and
body mass index (BMI )
- Preeclampsia and eclampsia can develop up to 4 to 6 weeks postpartum
- If a woman presents postpartum with new onset
high blood pressure with headache, or other symptoms such as
changes in her vision she should receive parenteral magnesium .
What are the chances that preeclampsia will occur again in a future
Women who had GHTN with their current pregnancy have a 16 to
47 % chance of having GHTN and a 2 to 7% chance of having
preeclampsia in future pregnancies
Overall, women who had preeclampsia with their current
pregnancy have a 13 to 53 % chance of having GHTN and a 16 % chance of
having preeclampsia in future pregnancies
Women who required delivery before 34 weeks for
severe preeclampsia, HELLP syndrome, or eclampsia have a 25% percent
chance of recurrence
in future pregnancies. The risk of recurrence is as high as 55 % if they required delivery before
28 weeks 
Low dose "baby aspirin"
ACOG recommends aspirin 80 mg daily in women with
chronic hypertension and history of early
onset preeclampsia at less than 34 weeks or preeclampsia in more than one prior
The National Institute for Health and Clinical Excellence (NICE) recommends
women at high risk of pre-eclampsia should take 75 mg of aspirin daily from
12 weeks until the birth of the baby [13,14] .
Women at high risk include: hypertensive disease during a previous pregnancy
,chronic kidney disease ,autoimmune disease such as systemic lupus
erythematosis or antiphospholipid syndrome , type 1 or type 2 diabetes and
chronic hypertension .
In addition NICE recommends women with more than one moderate risk factor for
pre-eclampsia should to take 75 mg of aspirin daily from 12 weeks until the
birth of the baby. Moderate risk factors are: first pregnancy , age 40 years
or older, pregnancy interval of more than 10 years , body mass index (BMI) of
35 kg/m2 or more at first visit , family history of pre-eclampsia multiple
Reviewed by Mark Curran, M.D. FACOG
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3 McMahon K, et. al., Does soluble fms-like tyrosine kinase-1 regulate placental invasion? Insight from the
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eclampsia. Number 33, January 2002. Obstet Gynecol. 2002
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Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet
Hypertension in pregnancy: executive summary. Obstet Gynecol. 2013
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Pregnancy. Hypertension, Pregnancy Induced --Practice Guideline wq244 2013
11. Hypertension in pregnancy. The management of hypertensive
disorders during pregnancy.National Institute for Health and Clinical Excellence
(NICE) clinical guideline 107 Issued: August 2010 last modified: January 2011
12. Duley L, et al., Magnesium sulphate and other
anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010
Nov 10;(11):CD000025. PMID: 21069663
13. Hypertension in pregnancy:the management of hypertensive disorders during
August 2010 (revised reprint January 2011)
http://www.nice.org.uk/nicemedia/live/13098/50475/50475.pdf .Accessed 7/12/2012
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hypertensive disorders during pregnancy
Available at :http://www.nice.org.uk/nicemedia/live/13098/50418/50418.pdf