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Sun 25 Jan 2009 04:00 AM

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Giving birth safely: Dealing with pre-eclampsia

Sister Martha Clayton, nursing manager and midwife at City Hospital, has dealt with many pre-eclampsia and eclampsia patients during her time as a nurse in the UAE.

Sister Martha Clayton, nursing manager and midwife at City Hospital, has dealt with many pre-eclampsia and eclampsia patients during her time as a nurse in the UAE.

In her own first pregnancy Martha was a pre-eclampsia patient and in her second pregnancy developed severe eclampsia. From 24 weeks she received anti-hypertension medication and at 29 weeks she received steroids to help her unborn baby's lungs develop. At 34 weeks she was hospitalised for bed rest and close monitoring. Overnight, major swelling developed all over her body.

Her blood pressure rose, she was 8cm dilated and her baby was delivered before she could reach the operating room. During labour she experienced severe epigastric pain and vomiting. She was hospitalised for 12 days after the birth because her kidneys had failed. Despite all of this her son was born small, but healthy.

What is pre-eclampsia?

It is a hypertensive disorder of pregnancy that occurs most commonly - and causes most problems for mother and foetus - after 20 weeks of gestation.

Is it a danger to mother and baby?

Yes, if untreated it may lead to brain damage, organ damage, convulsions (eclampsia), blood thinning and death. Premature delivery, slow growth of foetus in the uterus and foetal distress.

Who is at risk?

• Women during their first pregnancy;

• Women younger than 20 and older than 35;

• Women with a previous history of pre-eclampsia;

• Women with chronic diseases such as diabetes, hypertension, lupus and kidney disease;

• Women with a family history of hypertension;

• Women who have had multiple pregnancies.

What are the symptoms?

The development of pre-eclampsia can be detected by routine screening tests carried out at antenatal visits.

There is no diagnostic test for pre-eclampsia, but a previously healthy woman who develops high blood pressure and proteinuria (protein in urine) after 20 weeks of gestation may be diagnosed with pre-eclampsia. Excessive swelling, which also involves the face, may occur in pre-eclampsia.

In severe pre-eclampsia the following symptoms may appear and should not be ignored: severe headaches, visual disturbances (such as flashing lights), upper abdominal pain (over liver area), nausea, vomiting and confusion.

What is the cause?

The precise cause is unknown. There is evidence that the placenta is centrally involved in the development of pre-eclampsia. It seems that the placenta does not receive enough maternal blood for its requirements, which results in a malfunction within the placental tissue.

The mother's blood vessels sustain damage due to certain factors produced by this malfunction, which causes increased blood pressure.

What are the complications?

Kidney function is disturbed and protein leaks from the mother's circulation, through the kidneys, into the urine. Due to the progressive nature of pre-eclampsia, organs affected are the liver, lungs, brain, heart and blood clotting system. Dangerous complications such as eclampsia, pulmonary oedema (fluid in the lungs from heart failure), kidney failure, liver damage and thinning of the blood may occur in serious cases.

What is HELLP syndrome?

This is a serious complication of pre-eclampsia involving a combination of liver and blood disorders. HELLP syndrome can be diagnosed with blood tests that examine liver enzymes, red blood cells and platelets. It can be linked to bleeding tendencies, in which case a blood transfusion may be essential before undertaking any surgery such as a caesarean section.

What is the treatment?

Once a woman with pre-eclampsia has developed persistent hypertension and significant proteinuria, hospitalisation is required to monitor maternal and foetal welfare, stabilise various complications and prepare for delivery.

Even though some features of pre-eclampsia can be temporarily improved by treatment, the disease itself gets worse until delivery. Blood pressure lowering and anticonvulsant drugs may be required to prevent or treat convulsions (eclampsia).

Bed rest is advised and, in some cases, hospitalisation to ensure this is required. If you're at high risk for pre-eclampsia, try to rest at home and have more frequent antenatal visits with your obstetrician.

Your doctor should advise you on practical ways to reduce the risk of injury if you have high blood pressure. For example:

• If you don't feel well, then don't drive alone;

• Don't lock the door if you go to the bathroom, in case you feel dizzy and people need to come and assist you;

• When you've been lying down or sitting still for long periods, you'll need to stand up slowly and breathe deeply. You might start to feel dizzy due to the effect of the pregnancy on your body;

• Keep the phone number of your obstetrician and friends close by, in case you need assistance;

• If unsure of anything, call the maternity ward and ask for advice. Or visit the maternity ward so that they can check your blood pressure, test your urine and listen to your baby's heart.

Be aware of the warning signs of pre-eclampsia and eclampsia: visual disturbances (stars in front of eyes), headache, epigastric pain in the liver area, swelling of the body and face, and vomit.

Remember that once you're admitted to hospital your blood pressure will be taken frequently. Depending on the severity of your symptoms, your urine will be checked regularly, and you'll be cared for on a one-to-one ratio in severe cases. Medication will be started according to your doctor's orders and will include anti-hypertensive drugs. Your baby's heart will be regularly monitored and you'll be guided to monitor foetal kicking, to gauge his or her wellbeing.

Successful treatment entails having medical staff who are emotionally supportive of you and your family members, giving you information regularly, so that you can make an informed choice. If you're diagnosed with hypertension in pregnancy, visit your chosen hospital's maternity ward and NICU and ask questions so that you're comfortable making decisions before delivery.

Nutritional advice

Pre-eclampsia has been linked to low levels of vitamin C, D and omega-3 fatty acids, as well as low antioxidant status.

A restricted salt intake is highly beneficial as it reduces water retention. Cookies, candy and potato chips often contain high amounts of sugar, salt and/or fat but little, if any nutritional value.

You may also find that eating smaller meals more frequently is more comfortable than eating three large meals a day and also helps reduce nausea.

Consulting a dietician may also help, as good nutrition is crucial during pregnancy.

Can it be cured?

Delivery of the baby and placenta is the answer to pre-eclampsia. But if pre-eclampsia occurs early in the second half of the pregnancy, delivery can solve the mother's problem but place the baby at risk, due to complications of extreme prematurity.

Are there any long-term effects?

Unfortunately, occasionally some kidney damage remains. Women may develop high blood pressure later in life, but this is thought to be a genetic tendency rather than one caused by previous pre-eclampsia.

Unless babies have suffered severe nutrient or oxygen deprivation in the uterus, or other complications due to prematurity, it's currently believed that they don't develop long-term health problems.

Summary

Pre-eclampsia is a progressive disease that can be detected early in pregnancy, through regular antenatal visits to the obstetrician. if left untreated, it can lead to severe complications such as eclampsia, HELLP syndrome, or maternal death. In severe cases, hospitalisation is required, treatment commenced and delivery planned. Pre-eclampsia may persist after delivery for a few days and in some cases leaves long-term kidney damage.

Follow-up visits with your doctor after delivery are important as hypertension may occur later on in life, due to genetic disorders. Always report any signs and/or symptoms to your doctor during pregnancy. There may be no need to worry, but you need to have blood pressure, urine and blood tests to be certain.

Learn to recognise the warning signs of this disease. The sad reality is that daily, women are still dying of untreated pre-eclampsia.

Sister Martha Clayton, nursing manager, City Hospital, Dubai Healthcare City RN, B Cur (ad et ed hon), Specialist in Midwifery, General, Community and Psychiatric nursing

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