Preeclampsia involves the development of hypertension accompanied by protein in the urine and edema in women, and occurs between the 20th week of pregnancy and the first week after delivery. Early-stage preeclampsia produces few clinical signs, but symptoms progressively appear. Left untreated, it can develop into eclampsia, a potentially fatal ailment that produces seizures, bleeding, or liver or kidney problems in the woman and threatens the life of her unborn child. Preeclampsia develops in about 5% of pregnant women. That proportion has fallen in recent years, presumably because of improved prenatal care. The mothers of 26 in every 1,000 live-born infants will have had the condition, which may develop into the second leading cause of maternal mortality. The condition, sometimes called toxemia, is more common in first pregnancies and in women who already have hypertension or vascular disease. Babies of women with preeclampsia may weigh less than those born to women without preeclampsia, and are four to five times more likely than others to experience problems soon after birth. About one woman in 200 with preeclampsia develops eclampsia.

Eclampsia also may be associated with a bleeding problem called disseminated intravascular coagulation, in which the body's blood clotting products are depleted. A group of symptoms called HELLP (hemolysis, elevated liver function tests, and low platelets) may also occur.

The cause for preeclampsia or eclampsia is unknown. Despite the nickname toxemia, no one has isolated any toxic substance in pregnant women's blood that can cause the symptoms. Potential causes include genetic, dietary, vascular, and neurological factors.

• First pregnancy
• Teenage pregnancy
• Pregnancy over the age of 40
• Multiple pregnancies, multiple fetuses
• Preeclampsia in prior pregnancy
• History of hypertension
• History of diabetes
• History of kidney disease
• African-American patient
• Strenuous jobs that require a hectic pace or heavy lifting

Preeclampsia:

• Blood pressure of more than 140/90 mm of Hg
• Increase of 30 mm Hg systolic or 15 mm Hg diastolic, when blood pressure is under 140/90
• Excessive weight gain of more than five pounds per week
• Very sudden weight gain over one or two days
• Edema, particularly of the hands and face on arising
• Protein in the urine
• Reduction of amount of urine

Eclampsia:

• Pain in the upper right side of the abdomen
• Disturbances to vision, such as seeing flashing lights

• Chronic hypertension
• Pregnancy-induced hypertension
• Pregnancy-worsened hypertension
• Kidney disease
• Lupus or autoimmune diseases

Measure blood pressure. Look for edema in the hands and face, particularly around the eyes, caused by fluid retention. Pitting edema in lower extremities. Check reflexes for hyperreflexia.

• A 24-hour urine indicates the level of protein and amount of urine.
• Obtain routine laboratory tests, including CBC with platelets, urinalysis, electrolyte levels, uric acid concentration, prothrombin time, and partial thromboplastin time.
• Obtain levels of BUN and creatinine, to rule out unsuspected kidney disease.
• Obtain liver function tests to rule out liver involvement.

Fibrin in kidneys and liver.

A 24-hour urine test to measure protein. Assess lab results for differentiating diagnosis.

The type of treatment depends on the severity of preeclampsia. Patients with a blood pressure of 150/110 mm, with marked edema, or high levels of protein in the urine have severe preeclampsia, and require hospitalization and vigorous therapy. The initial goal of treatment is to prevent development of eclampsia or the HELLP syndrome, which poses great risk of maternal or fetal/neonatal morbidity and mortality.

Having stabilized the hospitalized patient, the provider should aim to deliver the fetus as soon as possible. Delivery may represent the best form of treatment for severe preeclampsia, yet a balanced treatment plan should consider the severity of preeclampsia, the gestational age of the fetus, and the assessment of maternal and fetal well-being. For patients near term, the provider can induce labor or perform a cesarean section.

In pregnancies that are less than 28 weeks, in which the fetus has low chances of surviving delivery, many providers try to forestall labor. However, prolonging such pregnancies with worsening symptoms causes maternal complications and death of the fetus in 87% of cases. Providers often recommend induction of labor in pregnancies less than 24 weeks with severe preeclampsia, despite the minimal likelihood of a viable fetus. For pregnancies of 24 to 28 weeks, conservative management with constant monitoring of mother and fetus is generally the therapy of choice.

In cases of mild preeclampsia, prescribe bed rest and advise the patient to lie on her left side, to increase her output of urine and lessen intravascular dehydration. She should also drink more water than usual. Check blood pressure and urinary protein every two days. Ensuring fetal well-being includes fetal heart tones and a nonstress test. Fetal growth should be monitored by ultrasound every few weeks. If the mother's condition does not improve, she should be hospitalized, stabilized, and prepared for delivery. If possible, close monitoring should continue after delivery, as one in four cases of eclampsia occurs at this stage—normally within two to four days of delivery. Examine patients every two weeks for the first two months after delivery.

For hospitalized patients with mild preeclampsia, fluids and intravenous magnesium sulfate usually reduce blood pressure to normal levels. Loading dose of 4 g IV in 200 ml saline over 20 to 30 minutes, maintenance dose then 1 to 2 g/hour IV. Toxicity therapy for above is calcium gluconate, 1 g over two to three minutes. If intravenous magnesium sulfate does not reduce blood pressure within four to six hours, use an intravenous infusion of hydralazine.

Avoid driving the blood pressure below 130/80 in cases of severe preeclampsia, which would decrease perfusions of the uterus so severely as to endanger the fetus. If the patient's urine output does not increase, a solution of furosemide, given intravenously, produces diuresis.

Preeclampsia can appear and progress rapidly. It is imperative that the patient be under qualified medical care. Alternative therapies can be used preventively or concurrently with medical treatment.

• Omega-3 oils (1,000 mg tid) are highly beneficial in pregnancy, and help reduce inflammation.
• Increasing protein intake may help minimize preeclampsia.
• Magnesium 200 mg bid to tid, has mild vasodilatory effects and helps reduce high blood pressure.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20 minutes and drink 2 to 4 cups/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 tid to qid.

May be helpful in lowering blood pressure and generally improving circulation.

Hospitalized patients require ongoing assessment after delivery. Examine patient at least every two weeks for the first two months after delivery. Blood pressure may remain high for up to eight weeks after delivery.

Patients should remove rings as soon as fingers begin to swell.

Eclampsia remains a threat after delivery, usually within four days.

Preeclampsia is a condition to be aggressively and continually managed. Patients hospitalized should be closely followed, depending on the severity of the preeclampsia and the absence or presence of any complications.

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