Pregnancy conditions explained: Pre-eclampsia 

What is pre-eclampsia?

Whilst the exact cause of pre-eclampsia isn’t known, scientists believe it occurs when the placenta’s blood vessels don’t develop properly, causing it not to function as it should. 

As a result of the placenta not working correctly, several issues can arise. The baby may not receive enough nutrients, and the mum can develop pregnancy-induced hypertension (high blood pressure) and proteinuria. Proteinuria is when the kidneys don’t function properly, and protein leaks from the bloodstream into the urine. 

Generally, it develops during the second half of pregnancy, typically after 24 to 26 weeks gestation or even after the birth of your baby. 

Known risk factors

During your booking appointment, your midwife will ask questions about your medical history, lifestyle and family history to identify any risk factors that might increase your likelihood of developing pre-eclampsia. 

If you have two or more of the following risk factors, you may be slightly more likely to develop pre-eclampsia:  

• First pregnancy or first pregnancy with a new partner.
• A gap of more than 10 yrs since you last gave birth.
• Aged 40 yrs or older.
• A family history of pre-eclampsia (mother or sister).
• Multiple pregnancy – twins, triplets or more.
• Obesity (BMI of 35 or higher).

If you have more than one of these risk factors, your midwife (or doctor) will advise you to take 75-150mg of aspirin daily until your baby is born. Doing this can reduce the likelihood of developing pre-eclampsia. 

Studies show several factors associated with a much higher likelihood of developing pre-eclampsia. These include:

• A history of hypertension.
• High blood pressure in a previous pregnancy.
• Type 1 or 2 Diabetes.
• A history of chronic kidney disease.
• An autoimmune disease, e.g. Lupus or antiphospholipid syndrome (also known as Hughes syndrome).

If you have any of these risk factors, your midwife (or doctor) will advise you to take 75-150mg of aspirin daily until your baby is born.  

They will also offer additional antenatal appointments to monitor your baby’s growth. It is essential not to miss any antenatal appointments during pregnancy and to take anti-hypertensive medications your doctor prescribes – even if you are feeling well. Not doing so can lead to serious complications for you and your baby.

Signs and symptoms of pre-eclampsia

Pre-eclampsia affects approximately 8 in 100 pregnant women, most cases are mild, but 1 in 200 women will experience it more severely. The early signs of pre-eclampsia include:

• Unusually high blood pressure.
• Too much protein in the urine.

You will not be able to recognise these symptoms yourself, so your midwife takes your blood pressure at each antenatal appointment and takes a urine sample to test for protein; it is one of the reasons it’s so important to attend your routine antenatal appointments. If not treated quickly, it may lead to severe complications for both mother and baby.

If your midwife is concerned that you may have pre-eclampsia, they may recommend a blood test to rule it out. The sample will test the level of protein growth factor in your bloodstream. Low levels may indicate pre-eclampsia, and your maternity team will refer you to the hospital for further tests. 

Other symptoms of pre-eclampsia can develop later in pregnancy and indicate a more severe case include: 

• Severe headaches that do not get better with painkillers.
• Visual disturbances – blurred vision; flashing lights; spots before the eyes.
• Sudden swelling in your hands, feet, ankles and face (known as oedema, caused by fluid retention). 
• Severe heartburn that is not relieved by antacids.
• Intense pain under the ribs (often on the right-hand side).
• Nausea and vomiting.
• Feeling very unwell.

If you notice any combination of these symptoms, contact your midwife immediately, day or night. Without quick treatment, pre-eclampsia can lead to more serious complications for you and your baby.

Medical support for pre-eclampsia

Treatment for pre-eclampsia will depend on its severity and relies on anti-hypertensive medications to reduce blood pressure and, if needed, intravenous magnesium sulphate. These treatments do not cure pre-eclampsia but aim to stop it from developing into full-blown eclampsia and reduce the likelihood of other complications. 

Your maternity team may include the following people if you are diagnosed with pre-eclampsia:

• Midwife and senior midwife.
• Senior obstetrician.
• Anaesthetist.
• Neonatal doctors and nurses.

Your doctor may ask to admit you to the antenatal ward for regular observations if you develop pre-eclampsia, especially if your symptoms are severe. If your case is mild, they may be happy to see you as an outpatient. These observations will include: 

• Stability of your blood pressure.
• Urine samples to test for protein levels.
• Blood tests, including checking your kidney and liver function.
• Baby’s heart rate and wellbeing, by CTG.
• Baby’s growth and volume of amniotic fluid, by ultrasound scan.
• Placenta function, by ultrasound scan.

Because pre-eclampsia usually resolves within 48 hours post birth, the decision to deliver the baby is often the best treatment. The doctors monitoring you will base this decision on:

• The severity of your condition.
• Gestation (weeks of pregnancy).
• Your health.
• The baby’s health. 

They will always consider whether the risks of pre-eclampsia to you and your baby’s health outweigh the risks associated with premature birth. 

Your maternity team will discuss the best course of action for your situation. The B.R.A.I.N. decision-making tool can be helpful to use in these discussions. 

Complications if undiagnosed or untreated

If pre-eclampsia is not diagnosed or left untreated, it can cause several severe complications for mum and baby: 

Mum: 

• Eclampsia
• HELLP syndrome
• Stroke
• Blood-clotting disorder
• Organ failure
• About 2 women die from pre-eclampsia in the UK each year. 

Baby:

• Growth restriction (known as intrauterine growth restriction (IUGR))
• Small baby (known as small for gestational age (SGA))
• Premature birth
• Stillbirth or early neonatal death

Let’s explore these in more detail now.

Eclampsia

Eclampsia is the fit or convulsion women with severe pre-eclampsia may experience. Fits can last about a minute, cause jerky movements throughout the body, and possibly a loss of consciousness. Whilst most women fully recover from eclampsia, some may be brain damaged or have permanent disabilities if the fit is severe. 

Hopefully, it’s reassuring to know that eclamptic fits are rare; they occur in approximately 1 in 4,000 pregnancies. Magnesium sulphate is routinely used in UK maternity services to prevent and treat eclampsia. 

HELLP syndrome

HELLP syndrome is a combined liver and blood clotting disorder. It occurs in 1 in 200 to 2 in 220 of all pregnancies and more commonly if women have severe pre-eclampsia. 

The letters in the name spell out each aspect of the condition:

• H – Haemolysis: this is where the red blood cells in the body’s circulatory system break down
• EL – Elevated liver enzymes: a high level of enzymes in the liver is a sign of liver damage
• LP – Low platelet count: platelets are substances in the blood supply needed for the blood to clot.

The only treatment for HELLP syndrome is to deliver your baby, which may involve an induction or caesarean section. Sometimes it may be necessary to have the baby before your pregnancy reaches term (37 weeks). If this is the case, you will be offered corticosteroid medicine before birth to help your baby’s lungs develop.

A Stroke

High blood pressure can negatively affect the blood supply to the brain, therefore impacting the supply of nutrients and oxygen. The reduced blood supply can cause a stroke, as the brain cells die. If not caught quickly, this can result in brain damage, disability and death. 

A stroke due to pre-eclampsia is rare. Your doctor will prescribe medicine to bring down your blood pressure if you have pre-eclampsia, reducing the likelihood of this. 

FAST is the acronym that may help you remember the key symptoms of a stroke: 

• F – Face: Face droops, usually on one side.
• A – Arms: Numbness or weakness in the arms, inability to lift both arms and keep them up.
• S – Speech: You may not understand what the person is trying to say, or they may not be able to speak.
• T – Time: Call 999 immediately. Time is of the essence with a stroke.

Impairment of normal organ function

Undiagnosed pre-eclampsia or diagnosed pre-eclampsia that is left untreated or not closely monitored can lead to more severe health issues due to the impairment of the normal function of major organs, including:  

• Pulmonary oedema: A fluid build-up in and around the lungs blocks oxygen absorption, leading to breathing difficulties.
• Liver failure:  the liver is essential in digesting the body’s proteins and fats, producing bile to break them down and excreting toxins. When these functions are upset, it can lead to serious health issues and even death.
• Kidney failure – the kidneys filter waste products and toxins from our bloodstream and excrete them from the body in our urine. Kidney failure causes toxins and fluids to build up in the body, severely damaging our health and wellbeing.

Disseminated intravascular coagulation (DIC)

It’s a complicated term that describes problems with the body’s blood clotting function. DIC can result in either

• Too much bleeding because there aren’t enough proteins in the blood to help it clot effectively.
• Overactive proteins cause blood clots throughout the body, which block blood vessels, causing organ damage due to the impact on normal blood flow to these organs.

The effects of pre-eclampsia on the baby

Pre-eclampsia also affects the health and wellbeing of the unborn baby, especially if the condition develops in early pregnancy.

Growth restriction resulting in small babies

The placenta is your baby’s lifeline. It delivers oxygen and nutrients to support their development throughout your pregnancy. Because pre-eclampsia negatively impacts the normal function of the placenta, it can affect their healthy growth and development. 

Babies who experience growth restriction are at a higher likelihood of stillbirth and health complications after birth. It is why your maternity team will recommend you take aspirin daily and want to monitor your baby’s growth closely with growth scans; also monitoring their wellbeing by monitoring their heart rate on a CTG.

Learning to recognise your baby’s typical pattern of movements is the best way for you to monitor their health and wellbeing. Never use a home dopplers, as it is easy to mistake your heartbeat for your baby’s. Find out more: Baby’s movements in pregnancy.

Premature birth

As the only way to cure pre-eclampsia is to give birth to your baby and placenta, your maternity will generally advise you to have your baby between 38-39 weeks – as per the NICE guidelines. However, it may be safest to deliver your baby before 37 weeks if you have severe pre-eclampsia, especially if there are any concerns for your or your baby’s health if the pregnancy continues. In this case, your baby would be premature. A premature baby may need specialist care in a neonatal unit, including help with their breathing and temperature control.

Early neonatal death or stillbirth

Sadly, despite substantial scientific advances in obstetrics and neonatal care, around 1,000 babies die due to the condition. The majority are either stillborn or die due to complications from premature birth.

Giving birth with pre-eclampsia

Your maternity team may advise you to have your baby early via induction or a caesarean section. If your case is mild, this will be at around 37 weeks. 

When you are in labour, your team will want to monitor your baby’s wellbeing with a cardiotocograph (CTG). They may also advise you to have a low-dose epidural or combined spinal-epidural for pain relief during labour, which also helps lower the blood pressure.

The goal of induction is for you to have a vaginal birth. However, your doctor may recommend a caesarean section earlier than 37 weeks if:

• They are unable to control your blood pressure.
• Your baby is showing signs of distress.
• Your health is at risk, including poor kidney and liver function or blood clotting results.

Post birth

As previously mentioned, pre-eclampsia usually disappears soon after childbirth. However, you will need close monitoring for signs of eclampsia or other complications in the early postnatal period, meaning a slightly longer stay in hospital. Your baby will also need additional monitoring, especially if they are premature or small for their gestational age. 

Your doctor may advise you to continue taking the blood pressure medication for several weeks. Call your maternity team immediately if you experience any symptoms of pre-eclampsia in the early postnatal period, such as pain below your ribs or severe headaches. 

Six to eight weeks after you are discharged, you will have a follow-up appointment with your GP to complete a final blood pressure and urine test. They will tell you if you can stop taking your medication or not. 

Birth debrief

With any complicated pregnancy or birth experience, it can be helpful to book a birth debrief. Often this will be with the obstetrician who looked after you, or it may be via your hospital debrief service. It is an excellent opportunity to discuss your experience and ask any lingering questions you have.

The likelihood of recurrence

As already mentioned, having pre-eclampsia once makes it more likely you will get it again in a future pregnancy; this happens to 1 in 6 women.

If you suffer from a severe form of pre-eclampsia, the likelihood of recurrence can be higher: 

• 1 in 2 women will get pre-eclampsia again if their baby is born before 28 weeks.
• 1 in 4 women will get pre-eclampsia again if their baby was born before 34 weeks.  

The risk of recurrence can understandably influence whether or not you choose to have another baby. Your midwife and doctor can discuss this with you in more detail and offer you and your partner specialist counselling. They will explain the closer monitoring that is recommended for future pregnancies. It is important to remember that many women who experience pre-eclampsia in their first pregnancy will have straightforward pregnancies in the future.

Final thoughts

Discussing pregnancy complications, such as pre-eclampsia can be worrying. However, it is essential to remember that only a relatively small number of women develop pre-eclampsia and an even smaller number of women go on to develop eclampsia.

We hope that understanding the condition makes you feel empowered to make informed choices about your care during pregnancy and birth. Studies show that where pre-eclampsia is detected early and treated quickly, the outlook for both mother and baby is much better.

Content Disclaimer

The information contained above is provided for information purposes only. The contents of this article are not intended to amount to advice, and you should not rely on any of the contents of this article. Professional advice should be obtained before taking or refraining from taking any action as a result of the contents of this article. New Life Classes disclaims all liability and responsibility arising from any reliance placed on any of the contents of this article.

References

Action on pre-eclampsia: HELLP Syndrome 

Burwick RM, et al. (2018) Evaluation of Hemolysis as a severe feature of pre-eclampsia. Hypertension Aug 2018 vol 72, issue 2 (460-465). 

Knight M et al (2021) MBRRACE-UK Report: Saving lives, improving mother’s care. 

NHS (2021). Pre-eclampsia 

NICE guideline [NG133]. Hypertension in pregnancy: diagnosis and treatment. Published June 2019. 

NICE Diagnostics guidance [DG23] . PIGF-based testing to help diagnose suspected pre-eclampsia. Published May 2016 

Paudyal P, Shrestha P, Bajracharya S, et al. HELLP Syndrome among Pregnant Women Delivering at a Tertiary Care Hospital in Kathmandu: A Descriptive Cross-sectional Study. J South Asian Feder Obst Gynae 2022;14(2):132–135. 

Royal College of Obstetricians and Gynaecologists. Pre-eclampsia patient information leaflet 

Royal College of Obstetricians and Gynaecologists (2014). Greentop guideline No. 31: Small for gestational age fetus investigation and management 

Tommy’s (2020).Fetal growth restriction (intrauterine growth restriction)