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Preeclampsia, Eclampsia, & HELLP syndrome

Preeclampsia, Eclampsia and HELLP syndrome are all serious complications of pregnancy. Preeclampsia is characterized by hypertension, and Eclampsia is the worsening of Preeclampsia where the woman experiences

convulsions or goes into a coma. HELLP syndrome is a severe form of Preeclampsia, characterized high blood pressure as well. Both of these Eclampsia and HELLP syndrome can stem from Preeclampsia but they can also come about on their own with out ever having had Preeclampsia. There is no way to prevent any of these diseases; you can’t eat something or take a prescription, or anything. The only known cure for theses diseases is delivery of the baby. The treatments for these diseases are mainly to keep the mother pregnant for as long as possible. With all of these diseases death of the mother or baby is a serious complication. Studies have shown that if the mother goes to her health care provider on all of her prenatal visits there is a better chance that the baby and the mother will have little or no adverse effects.

Preeclampsia is a universal problem during pregnancy, affecting up to one in seven pregnant women around the world. This condition is defined by high blood pressure and extra protein in the urine after twenty weeks of pregnancy. It has other names such as toxemia, or pregnancy-induced hypertension. In the United States Preeclampsia is usually mild. But if not treated it can lead to serious complications and even death for the mother and the unborn baby. Globally, Preeclampsia and other high blood pressure disorders during pregnancy are a leading cause of maternal and infant death (Mayo Clinic, Sept. 2006).

Preeclampsia is a condition in pregnant women or immediately after pregnancy that is a form of toxemia of pregnancy characterized by hypertension; a ‘diastolic blood pressure of at least 90 mm Hg or a systolic blood pressure of at least 140 mm Hg, or a rise in the former of at least 15mm Hg or in the latter of at least 30mm Hg’ (Am J Obstetric Gynecology, 1998), fluid retention (when fluid isn’t removed from the body tissues), and albuminuria (albumin found in the urine) sometimes progressing to Eclampsia. The exact cause of Preeclampsia is still a mystery, there have been numerous studies but all the theories are still un-proven; some of the theories are: genetic, dietary, vascular, and autoimmune factors (Am J Obstetric Gynecology, 1998).

Preeclampsia is most common in women who are pregnant for the first time (nulliparity), pregnant teens, and women who are over 40 years of age. The biggest risk factor of Preeclampsia is merely to be pregnant. Other risk factors are history of high blood pressure before pregnancy, previous history of Preeclampsia, history of Preeclampsia in mother or sisters, black race, obesity before pregnancy, carrying more than one baby and history of diabetes, kidney disease, lupus or rheumatoid arthritis (The Cleveland Clinic Birthing Services, Department of Obstetrics and Gynecology, 2006).

Signs and symptoms of Preeclampsia can be asymptomatic, which is the scariest because women diagnoses with Preeclampsia do not usually fell sick. A lot of the times women with this disease think the signs of it are normal pregnancy symptoms. The more obvious symptoms are high blood pressure (hypertension) and the presence of extra protein in the urine after twenty weeks of pregnancy. Other signs of Preeclampsia are not always as obvious and include severe headaches, changes in vision; temporary loss of vision, blurred vision or light sensitivity, upper abdominal pain that usually occurs under the ribs on the right side, unexplained anxiety, nausea and vomiting, dizziness, decreased urine output, blood in the urine, rapid heartbeat, ringing in the ears, and fever. Sudden weight gain such as more than two pounds a week or six pounds in a month is a common sign as well. Preeclampsia can also happen gradually or very sudden. It may occur during the last half of the pregnancy, during delivery or even a few days after the baby is born (Mayo Clinic, Sept. 2006).

Preeclampsia is usually diagnosed on scheduled prenatal blood pressure checks and urine tests. If the mother has one reading of a high blood pressure she may be asked to come in more often to check her blood pressure so she can be monitored more closely (Mayo Clinic, Sept. 2006). The protein test for urine is important and if the test comes back even 1+ on the dipstick of a clean catch the doctor may order a twenty four hour urine collection to determine whether there is protein leaking from the kidneys (Sarah Henry, 2004).
Lab studies such as complete blood count (CBC), thrombocytopenia (disorder where there are not enough platelets), hemoconcentration (increased concentration of cells and solids in the blood), liver functions tests, serum cretonne (measures the amount of creatinine in the blood), uric acid (used to evaluate the blood) and elevated PT may be ran to see if the patient has Preeclampsia. The doctor may also order an ultrasonography for fetal assessment (Wagner, LK, Family Physician, 2004).

Most women with Preeclampsia give birth to healthy babies. Complications that may occur are lack of blood flow to the placenta and the problem with that is the baby may receive less oxygen and nutrients, which can lead to slow growth, low birth weight, preterm still birth and placental abruption. Placental abruption is when the placenta separates from the inner wall of the uterus before delivery. If it is severe abruption it can cause heavy bleeding (which can be deadly for the mother and baby), HELLP syndrome and Eclampsia (Mayo Clinic, 2007). Other complications of Preeclampsia are abruption placentae disseminated intravascular coagulopathy, renal insufficiency or failure, Hemolysis, ventricular arrhythmia, elevated liver enzymes, low platelet count, cerebral hemorrhage, fetal growth retardation, and death of the mother and/or baby (Dawn C. Jung, 2006).

Prevention of Preeclampsia is still not known, there are some things that may make it less likely to occur. The most important thing that can be done is to keep all prenatal appointments with the doctor, since the condition is usually most often detected during these visits. A good thing to do is for the mother to participate in her own care: fond out her usual blood pressure (before pregnancy) and then she should ask what her blood pressure is at each visit. Also she should ask if there is protein is her urine, if yes then how much (Sarah Henry, 2004)?

There are currently no known treatments other then delivery of the baby. If the mother is near the end of her pregnancy the doctor may decide to put her on bed rest to give the baby more time to grow and mature. The rules for bed rest depend on each individual’s case. If it is a mild case the mother may be able to stay at home and monitor her own blood pressure as well as going to see her doctor a couple of times a week. The doctor will tell her how much she is able to get up and what her activities should include. The patient should be very clear on what her restrictions are. She should prepare her resting room, if she chooses to rest in her bedroom or living room, etc. she should have everything set up around her within reach. The hours in the day will seem very long so the patient should try and organize her day, set a routine, have specific times for television, reading, and even telephone use. It might be a good idea to stay on the same times for meals and bedtime. The last thing she could is to take up a hobby such as scrap booking, knitting, painting, etc. (Mayo Clinic, 2006).

In more severe cases of Preeclampsia the mother may have to be on bed rest in the hospital. The patient may have to do stress tests or biophysical profiles to monitor the baby’s well being. If there is a low amount it is a sign that the blood supply to the baby is inadequate and the mother may have to deliver the baby. Most of the women who have Preeclampsia are closely monitored and their doctors will not let them go past their fortieth week of pregnancy because of the risks to the baby. The readiness of the cervix- whether it’s beginning to dilate, efface, or ripen may also be a determining factor on when the doctor will deliver the baby (Mayo Clinic, 2006).

The doctor may have to induce labor or perform a caesarean section is the Preeclampsia is severe enough. It all depends on the health of the mother and the unborn baby. In cases like these the benefits of delivering the baby early are better then the risks of waiting. During the delivery the mother may be given magnesium sulfate intravenously to boost uterine blood flow and avoid seizures (Mayo Clinic, 2006).

Corticosteroids may benefit the women with Preeclampsia. Powerful corticosteroid medications can temporarily improve liver and platelet functioning in women with severe Preeclampsia. These medications might be able to lengthen pregnancy in situations where the baby is to young for delivery in terms of gestational development. Corticosteroids may also be able to make the baby’s lungs more mature in as little as forty-eight hours (Mayo Clinic, 2006).

The impact on the baby when the mother has Preeclampsia depends on the degree of severity of the disease. The most common impact is the baby will be undernourished as a result of utero-placental vascular insufficiency, which leads to growth retardation. The baby’s health as well as weight is compromised, leading to various degrees of fetal morbidity, and possibly fetal death (Alicia M. Lapidus, OBGYN, 1999).

There have been long term follow up studies and the results are that the baby is more likely to develop hypertension, coronary artery disease, and diabetes when they become adults. Studies are still in progress on the impact of the fetus (Alicia M. Lapidus, OBGYN, 1999).

Eclampsia is a complication of Preeclampsia and it comes from the Greek word “ek” meaning “out” and the Greek word “lampein” meaning “to flash”, put the two words together and you get “to flash out” (Med Friendly). Eclampsia is a life threatening condition of pregnancy. In some cases comas or seizures may be the first signs that are acknowledged in a woman already diagnosed with Preeclampsia (eMedicine Health, 2006). Eclampsia is not as common as Preeclampsia it occurs in about one of every two thousand to three thousand pregnancies (Dominic Marchiano, MD, 2004).

Eclampsia like Preeclampsia is not well understood. It involves a multi-system complication of pregnancy that significantly contributes to maternal morbidity and mortality (BMJ, 2005). The systems included are the cardiovascular system (CVS), renal system, and the central nervous system (CNS) (Stephanie R. Fugate, DO, 2005).

The CVS derangements caused Eclampsia include generalized vasospasm, which is a sudden constriction of an artery leading to a decrease in its width and in the amount of blood it can deliver. Increased peripheral vascular resistance, increased left ventricular stroke work index, decreased central venous pressure, and decreased pulmonary wedge pressure. Renal system includes decreased glomeruler filtration tare, decreased renal plasma flow, and decreased uric acid clearance. The central nervous system includes problems with cerebral edema and cerebral hemorrhage (Stephanie R. Fugate, DO, 2005).

Signs of Eclampsia are seizures, severe agitation, and unconsciousness for an unpredictable period of time, possible musculoskeletal aches and pains after an event caused by trauma. Other signs are involuntary movements, the relaxation phase of deep-tendon reflexes may be longer, breathing may come to an end for brief periods, physical evidence of trauma may be eminent, and an eye examination may not retinal changes caused by hypertension. About twenty percent of women who have Eclampsia only have slight change in blood pressure, and that may be there only sign (Web MD, 2007).

The risk of Eclampsia is random and is not always physical signs so the doctor may give an anticonvulsant medication during labor to prevent seizures. Magnesium sulfate is a common choice of doctors to help control seizures. Medications might be used to lower blood pressure during pregnancy and the goal is to manage the condition of the mother until she is at least thirty-six weeks pregnant. The condition will be resolved when the baby is delivered or shortly after (Dominic Marchiano, MD, 2004).

There are no known treatments for Eclampsia. If possible the doctor wants to keep the mother pregnant for as long as possible, so he may decide to put her on bed rest. Delivery is the only known treatment for Eclampsia. Causes that the doctor may decide to induce the mother are; diastolic blood pressure is greater then 110mm Hg for a six hour period of time, persistent or severe headaches, stomach pain, abnormal liver function tests, rising serum creatinine, HELLP syndrome, fluid in the lungs (pulmonary edema), thrombocytopenia (an abnormal decrease in the number of platelets in the circulatory blood), abnormal fetal heart pattern, and failure of fetal growth that is obvious on the ultrasound (Dominic Marchiano, MD, 2004).

The complications of Eclampsia are as many as fifty six percent of patients may have brief deficits, including loss of sight due to organic lesions in the visual cortex. Most women do not develop long-term abnormal conditions from eclamptic seizures, but their cases should be followed closely by their doctors for resolution of symptoms (Rosen P., 1998). Serious complications include liver failure, kidney failure, lung failure, bleeding of the brain, a build up of fluid in the lungs, and pneumonia (inflammation of the lungs due to infection). Other complications are Hemolysis (a break down of red blood cells with discharge of hemoglobin), hypofibrinogenemia (an abnormal deficiency of fibrinogen in the blood that causes bleeding to stop), bleeding in the retina (a delicate, multilayered, light sensitive membrane lining the inner eyeball and connected to the optic nerve to the brain), temporary blindness, and abrupt placentae; a sac-shaped organ that attaches the embryo or fetus to the uterus, which is when the placenta separates in pregnancy of twenty weeks or more. The placenta is important to the fetus because it is the organ which links the blood supply to the fetus and by which the baby can release wastes (Med Friendly, 2007).

The most severe complication of Eclampsia is that the mother and/or baby die. About ten percent of the mothers die from this disease and thirty three to fifty percent of the babies die, typically because they are not getting enough oxygen. Characteristically, of these deaths about half take place before birth and the other half after birth (Med Friendly, 2007).
The most serious complication of Preeclampsia besides death is the HELLP syndrome. H stands for Hemolysis (rupture of red blood cells); EL stands for Elevated Liver enzymes in the blood (reflecting liver damages); LP stands for Low blood levels of Platelets (specialized cells which are vital for normal clotting), in which there is a combined liver and blood clotting disorder. This condition occurs in mid-second trimester of pregnancy, and up to eight percent of women it occurs in is after the baby is born. The HELLP syndrome can also occur on its own, with out ever having Preeclampsia. Women who have this syndrome may have problems with bleeding, high blood pressure or liver problems that can hurt both the mother and/or the baby (Internet Health Library, 2005).
Comparison of risk factors for the HELLP syndrome and Preeclampsia (Maureen O’Hara Padden LCDR, MC, USN, 1999):
HELLP Syndrome Preeclampsia
Multiparous Nulliparous
Maternal age greater than 25 years of age Maternal age less than 20 years or greater than45 years
White race Family history of Preeclampsia
History of poor pregnancy outcome Minimal prenatal care diabetes mellitusChronic hypertension Multiple gestation
Any pregnant woman can get the HELLP syndrome. Most of the women who get this illness have high blood pressure, but this is not always the case. The most common people who get this are women who are white and over the age of 25, if they have had children previously or if there was a problem in a past pregnancy such as Preeclampsia (Maureen O’Hara Padden, 1999).
‘Key abnormalities include vasoconstriction (constriction of a blood vessel), increased vascular tone, platelet aggregation (the attachment of platelets to one another) and an alteration of the thromboxane (any of several compounds, originally derived from prostaglandin precursors in platelets, that stimulate aggregation of platelets and constriction of blood) and prostacyclin (a prostaglandin produced in the walls of blood vessels that acts as a vasodilator and inhibits platelet aggregation) ratio. The changes can be partly explained by the activation of complement and the coagulation (process of clot formation) cascade causing multi-organ endothelial and micro vascular injury, and resulting in microangiopathic hemolytic anemia, elevated liver enzymes (periportal and hepatic necrosis) and thrombocytopenia.’ (Egerman RS, Sibai BM, 1999)
The most obvious signs of HELLP syndrome are nausea, epigastric pain (pain just below the ribs), or right upper quadrant pain (Sibai BM, 1993). Other symptoms include feeling tired and bad headaches. There may be swelling that occurs mostly in the face and hands, and on rare occasions bleeding from the gums and other places such as massive bleeding due to minor injuries (Maureen O’Hara Padden, 1999).
There are diagnostic tests that can be done to find out if the patient has the HELLP syndrome. The first is hematocrit; it may be decreased or normal and is the last of the three abnormalities to appear. If the finding of a serum haptoglobin level is decreased the mother will have to have continuing Hemolysis until the hematocrit is normal. The serum transaminase levels may be as high as four thousand U per L, but milder elevations are nothing out of the ordinary. The platelet counts can drop as sow as six thousand per mm3, but if there is any platelet count less then one hundred and fifty per mm3 to be watched by the doctor. The platelet count is the best way to recognize the HELLP syndrome. Laboratory abnormalities typically get worse after delivery of the baby and hit the highest point at twenty four to forty eight hours after the baby is born. The high levels of lactate dehydrogenase level signals the beginning changes for the better and successive normalization of the platelet count (Maureen O’Hara Padden, LCDR, MC, USN, 1999).
There are two classifications systems that are used to identify the HELLP syndrome. The first one is based on the number of abnormalities that are there. In this system this system the patients are classified as having partial HELLP syndrome, which is just one or two of the abnormalities. The class 2 HELLP syndromes are the full HELLP syndromes are at a greater risk of complications, which include DIC (disseminated intravascular coagulation), then the women with class one or partial HELLP syndrome. The patients with full HELLP syndrome should be considered for the delivery of the baby within forty-eight hours (Maureen O’Hara Padden, LCDR, MC, USN, 1999).
Typically in the past, the deliveries of patients with the HELLP syndrome were routinely proficient by a cesarean section (C-section). The patients that had the full HELLP syndrome superimposed DIC (disseminated intravascular coagulation), or a C-section then 32 weeks should deliver a gestation that is less. A trial labor is appropriate in patients that have mild to moderate HELLP syndrome and if they are stable, have an approving cervix and are at least 32 weeks pregnant (Maureen O’Hara Padden, LCDR, MC, USN, 1999).
The treatment of HELLP syndrome is determined by the physician and will be based on: your pregnancy and overall health and medical history, extent of the disease, the patients tolerance for specific medications, procedures and therapies, expectations for the course of the disease and the opinion of the patient. Treatments may include: bed rest, hospitalization because specialized personnel and equipment may be necessary, blood transfusions, magnesium sulfate, antihypertensive medications and fetal monitoring to check the health of the baby (UVa Health, 2006).
The doctor may decide to check the baby while the mother is still pregnant, and these may include fetal movement count- keeping track of the baby’s kicks and movements. A change in this number or regularity might mean the baby is under stress. A nonstress testing, which is a test that combines nonstress testing with ultrasound to observe the baby. A Doppler flow study is a type of ultrasound that uses sound waves to measure the flow of blood through a blood vessel (UVa Health, 2006).
The patients that are diagnosed with HELLP syndrome should be treated with corticosteroids regularly. The antenatal administration of dexamethasone (Decadron) in a high dosage of 10 mg through an IV every 12 hours has been shown to clearly make the laboratory abnormalities connected with the HELLP syndrome get better. The mothers treated with this drug show signs of longer time for delivery. Steroids that are sometimes given do not classically prevent the worsening of laboratory abnormalities after delivery; patients who get the steroids postpartum make the laboratory abnormalities resolve quicker. Patients should also be treated with magnesium sulfate to prevent one of the complications, which are seizures. If the patients blood pressure remains high (greater then 160/110 mm Hg) even after the magnesium sulfate is used they should use antihypertensive therapy. This will make the risk of maternal cerebral hemorrhage, placental abruption and seizures less likely to occur (Maureen O’Hara Padden, LCDR, MC, USN, 1999).
The complications of HELLP syndrome are seizures, which occur as a result of restricted blood flow to the organs caused by high blood pressure Anemia, which is caused by the breakdown of red blood cells, problems with blood clotting, including Disseminated Intravascular Coagulation that cause internal hemorrhaging, placental abruption, difficulty breathing which can be caused by fluid buildup in the lungs. Then there is liver damage or failure, kidney damage or failure and stroke (Pregnancy info, 2007).
Patients who have the HELLP syndrome are at a greater risk of danger then the babies. The compromised body functions can cause liver failure, heart failure or stroke. The baby’s health is threatened because the decline of blood flow can cause placental separation and lower birth weight, and because the baby ultimately will have to be delivered prematurely The greater part of baby’s born to mothers with this syndrome do very well (Christine Fisher Guy, 2005).
If the baby weighs more then a thousand grams when they are born the survival weight and the time they stay at the hospital are similar to baby’s born at about the same birth weight to mothers that do not have the HELLP syndrome, and there are not usually any long term effects on the baby. If the baby weighs less then a thousand grams at birth the news is not as good. The studies that have been conducted have shown that the baby will probably have to stay in the hospital longer and may even have to be on a ventilator. The studies show that these smaller babies have a decreased chance of living compared to babies of the same birth weight to mothers with Eclampsia. The same studies declare that the prenatal mortality from HELLP syndrome ranges from 7.7 percent to 60 percent. The most common cause of these deaths is recognized by abruption of the placenta prematurely separating, intrauterine asphyxia (when the baby does not get enough oxygen), and extreme prematurity (HELLP syndrome society, 2005).
Prevention of the HELLP syndrome is not known at this time. The only thing the patient can do is to know the warning signs and to be well informed on them. The patient should also keep regular check ups with their health care provider, and if they get the HELLP syndrome they can receive treatment and hopefully try to prevent this disease from getting worse (UVa Health, 2006).
The most common medical complication of pregnancy is hypertension. The women diagnosed with the HELLP syndrome, Eclampsia, and Preeclampsia presents a variety of management issues. Regardless of the diagnosis, severe Preeclampsia, the HELLP syndrome, or Eclampsia can intensely affect the woman and her unborn baby. The underlying pathophysiology must be evaluated and treated with both patients in mind at all times. The main goal for all of these diseases is to keep the mother pregnant for as long as possible. She may be given magnesium sulfate or an anticonvulsant to help her stay pregnant. Both the mother and baby will be closely monitored, and if the mother is close to the end of her pregnancy or if the baby is in distress the doctor may decide to induce labor or do a C-section. The most important thing is to make sure that both parties are doing well until the baby is delivered and they are both out of harms way.