At the Forefront Live: Understanding Preeclampsia
May 22, 2019
Preeclampsia is a common condition during pregnancy characterized by high blood pressure. Without treatment, it can lead to serious, even fatal complications for both mother and baby. Today on "At the Forefront Live," you can have your questions answered by our experts. That's coming up now on "At the Forefront Live."
And today on "At the Forefront Live," we have Dr. Sarosh Rana and Nurse Macaria Solache joining us. Welcome. Thank
Thank you very much.
Quick reminder, everyone. The show is not designed to take the place of a visit with your health care professional. But please ask lots of questions, and you could type them in the comments section right below the picture there. And we'll get to as many as we can over the next half hour. Let's start off with the basics, though. And Doctor, if you can kind of start us off and just tell us what is preeclampsia?
So thank you, Tim, so much for having us here. So preeclampsia is a common condition of pregnancy, like Tim mentioned. It is essentially characterized by high blood pressures. And you can sometimes have protein in your urine. So that's kind of the basic definition of preeclampsia. Many patients, though with preeclampsia and have other associated symptoms, such as they can have seizures. Sometimes, the patients can have liver dysfunction, even kidney dysfunction, and small sized babies.
So what actually causes preeclampsia?
So the question, I think, if you ask me in one sentence, the cause of preeclampsia is not really known. But it's a placental disease. So essentially, what happens is somehow-- and people have looked at it-- there are certain auto antibodies, genetic factors, even environmental factors that can affect your placenta, which can essentially then let, people believe, release some of these factors, which can cause preeclampsia.
And one of the things that surprised me, and I mentioned in the intro, that actually, it's more common than people might think.
Yeah, so the prevalence of how common it is varies by country to country. And also, different races. So preeclampsia in general, is about 7% to 8%. So in certain populations, definitely at the University of Chicago, it's even more common. So about 17% of our patients have some sort of high blood pressures in pregnancy. So yes so you can see one in 10 women will suffer from it.
And Macaria, let's bring you into the conversation a little bit. And just tell us a little bit about what you do here at UChicago Medicine to start, please.
OK. Thank you, Tim. So I've been a labor and delivery nurse here for about 14 years. And I've seen a lot of success stories on us treating our preeclamptic patients. But the ones that stick close to home are the ones that got late care or didn't come in for care. And that made me ask myself what I could do more.
And so what would happened then?
Our patients were coming back after having birth and seizing, coming into our ER. The ER didn't know necessarily how to treat these moms or didn't realize that this was preeclampsia. So I joined Dr. Rana's team to come up with ways to help prevent this in our institution.
And that's why we're here today. This is World Preeclampsia Day as well. So we want to get the word out to people exactly what preeclampsia is, the fact that it is more common than people oftentimes think. And preventative measures, what to take, what to be aware of as well. I think that's very important.
So let's talk a little bit about the folks that are at risk. And can you kind of go through that for us?
Yeah, so there are certain identified risk factors for somebody to develop preeclampsia. Obviously, and I joke about it, the risk factor is that you are pregnant. So men can't get it. But if you're nulliparous-- so if this is your first pregnancy-- if you have high blood pressures, African-American patients are at high risk not only to develop preeclampsia, but more importantly to develop complications related to preeclampsia. Obesity is a risk factor-- even IVF pregnancy, patients who have kidney transplants, or renal dysfunction diabetes. So there are a whole host of risk factors for the disease.
So Macaria, from your standpoint, that was very important to you to really get the word out to women so that they knew what to be aware of, and what to look for. And that's always been kind of a calling for you, is that correct?
That's correct. So my call to action was when I realized that only 30% of our patients were coming back for postpartum care. And that was very scary.
Can we talk a little bit about postpartum care and how critical that is for people, not only for the mom, but for the baby as well?
Right. So I think everything starts with educating our patients. We've had a lot of our patients say that they thought preeclampsia ended with delivery. And that is not the case. And through education, we stress that it can go on up to six weeks, that preeclampsia problems, if not longer.
One of the things that I thought was interesting. There was an interview that you'd done with a patient, and we're going to play a little clip from that interview. And it talks about some of the things that she was told to be aware of. And John, if we go ahead and roll that, and we'll talk a little bit about that afterwards.
My doctor said to me, there was something I wanted to look for. If you see a color wheel go across your eyes, I want you to go directly to the emergency room. And I asked, what does that mean? And he said, because your blood pressure has been a little elevated these past couple of appointments. That was the only instructions that I received.
I remember it was a Sunday morning. I was getting ready for church. I took a shower. And got off the shower. And the color wheel went across my vision. I said, this is so pretty. And then I remembered this is something that I need to call my doctor about.
When I was getting ready to tell my daughter's father that we need to call the doctor, after that, I don't have the memory.
So she's talking about a color wheel going across her vision. What is she referring to?
So sometimes, when you have preeclampsia-- our patient here that we just showed, she actually ended up having an eclamptic seizure. So that's something that when you have severe preeclampsia, you can actually have a seizure. And the majority of patients will have a seizure or complain of headache sometimes, and also, just kind of flashing lights and spots in front of your eyes. And then just from edema in the brain. So there's obviously a very, very severe symptom, and she ended up having a seizure, and ended up delivering early actually, because of that.
And Macaria, when you see patients come in and they're going through this situation, what what's done from your standpoint?
The first thing we do is we educate the patient of what is happening, because it is very stressful and scary. So let them know that they're in the best care. And what the treatment is.
Yeah, I imagine that would be a very scary experience if you don't know that this is happening or don't know what's happening, and this comes on all of a sudden. In her case, it sounds like it was completely out of the blue. She didn't anticipate this at all.
I would agree. And I think that's a major problem in terms of-- and that's why we're big into education. So there's not only systematic lack of knowledge, I want to say, in terms of patients don't know what they have. But also, if they are even at risk for it. But also, the providers.
So a couple of years ago, I did a study in Boston, and it was very clear that people who are seeing these patients in postpartum center-- for, example I did it in between cardiologists-- they don't even know that association for example, between preeclampsia and cardiovascular disease. So what we have created here is a part of our initiative is we have a video that we created for all our patients, which is a snippet we just showed. Which everybody who has preeclampsia actually watches that video, and if they have hypertension, to educate the patients. At least start there with patient education for her to know exactly what she is suffering from and what her risks.
Well, it's great that they can hear from other patients, and really hear that in lay people's terms. I think that's important. So we've got a question from one of our viewers that I want to throw out at you for an answer. And it says, I was diagnosed with preeclampsia, and that same evening I had a blood pressure of 248. Went to the ER, had my baby the same day. What could I have done to prevent it? It's been 22 days now, my blood pressure is normal, and I'm on the highest dosages of three different blood pressure medications. My headaches are awful without the meds and Tylenol and Advil. What can I do to get better?
So thank you for sharing this question. Yeah, so postpartum hypertension is a common problem, actually. About 50% of the patients-- so one in two people who have preeclampsia will have post-partum hypertension. And I know you had preeclampsia then had hypertension, but just what everybody's knowledge, you can have new onset hypertension just after having the baby, so we're actually giving instructions to anybody who delivers is at risk for postpartum hypertension.
I think for you specifically, I would suggest seems like you aren't taking your medications, a large majority of patients, your blood pressure should normalize. And sometimes, it takes time. And like Macaria was saying, even sometimes, I've seen patients who need medications for even like a year or even two out. So I would just keep your care with the cardiologist, with the medicine doctor that you are seeing, and continue to take their medications.
And of course, if you're experiencing anything that you think is out of the ordinary or significant. Make sure contact your physician.
Call your doctors, yes.
So one of the questions that we had was, are certain women, such as African-American women, at higher risk of developing complications? And if so, why?
So the second question is a difficult one. But yes, definitely, women who are African-American are at higher risk to develop complications related to pregnancy in general. And there is lots of data that the maternal mortality-- so just, frankly mothers dying in pregnancy-- is about three to four, and in some literature, about six times higher in women who are African-American. And it's so unfortunate that this has been continued for six decades. So for the past 60 years, more African-American women are dying from pregnancy related complications.
Now if you ask me why, I think it's a combination of physician lack of awareness for preventable causes that we can work with hospital levels, for lack of access to care. And I personally believe there is some systematic bias against women and the care that they receive.
And central to what you do, and your belief is education-- you're trying to get the word out and an awareness. I think that's also very important.
Yes. And hospital level interventions such as we have. We participated in the ILPQC, which was management of hypertension. We have AIM bundles, which are bundles that hospitals adopt. And so yeah, I think hospital level interventions for every patient every time, correct management.
Now the patient we just saw a moment ago, I think we have one more soundbite. And let's go ahead and hear from her again, and we'll chat about that a minute.
The next memory I have is waking up at the University of Chicago actually in labor. I had already been moved from the emergency department to a room. I found out that I had an eclamptic seizure.
I was 35 weeks when I had my daughter. And we stayed in hospital for a few days. She was in the neonatal intensive care unit. About a little over a year later I was diagnosed with chronic hypertension. After going to see my primary care physician, he did a lot of tests. We did my family history. And then he asked me about my delivery.
When he saw the records that I had, the eclamptic episode, he wanted to start putting together if there was a connection between the preeclampsia and my chronic hypertension.
So she mentions hypertension, as you mentioned just a few moments ago. It seems like that's an interesting connection. And how many women have you found-- is it very common for them to suffer from hypertension and then preeclampsia?
Yeah, so previously a few years ago, people would believe that perhaps it's the long term. It takes 10 years, 12 years. But there's recent data that women who have preeclampsia are about 25 times higher chance to have hypertension at one year-- within a year of their delivery-- compared to women who had a normal chance of delivery.
And then in terms of cardiovascular risks such as history of MI, you can have MI cardio- and cerebrovascular accidents, such as a stroke. There is about a two-fold increase. So that increases as much as if you're smoking. So history of preeclampsia puts a woman at higher risk to have cardiovascular disease as much as for example, somebody who's smoking. So pretty significant risk.
So Macaria, when you work with women that come in, and you educate them, and teach them about preeclampsia, what do you find are some of the most common misconceptions?
The most common and one of the most dangerous one is when they believe that once the baby is out, that they're cured. That the preeclampsia is gone.
And you mentioned up to six weeks after delivery?
Yes, if not longer.
So that's pretty significant. I do think that's something that probably a lot of people don't realize.
That is actually correct.
So we're getting more questions from our viewers. The next one is since I've had preeclampsia, I've started experiencing migraines. Is that normal?
I don't think there's a direct link between preeclampsia and migraines. There is a connection between preeclampsia and Alzheimer's many years later. But I think your migraines are probably unrelated to your preeclampsia postpartum, definitely. I would just see a neurologist to make sure it's not something that's significant and more than the migraine.
So that's a fascinating point. There is a connection between preeclampsia and Alzheimer's later in life. Wow. That's very interesting and kind of alarming, as well.
Yes. Very few studies done on that.
More questions from our viewers. We're getting quite a few. Keep them coming. We love them. Is there any connection between maternal malnutrition or being underweight prior to pregnancy at conception, and the development of preeclampsia? So I guess nutrition is what they're talking about.
Good question. Actually, epidemiologically, people have looked at it. People who are underweight are also at significantly higher risk to develop preeclampsia. I'm exactly not sure, and I don't think this literature as to why, like there's a particular nutrient. But certainly being underweight also puts you at risk to have preeclampsia.
It's interesting because we get so many physicians and scientists on the program. And they talk about how critically important nutrition is just in general. And here's another example. Very, very important. So again, from an education standpoint, if you are pregnant, you need to see your provider and talk to somebody like Macaria as well to get information about proper nutrition and how to be healthy throughout their pregnancy. That makes a big difference, right?
And I want to put a plug in that the last question is about-- and even in general, about recurrence of preeclampsia. I don't know if you have a question about that. But if you had preeclampsia in your prior pregnancy, you should certainly seek some sort of a high risk care. So definitely have your obstetrician be aware. And aspirin. Taking aspirin every day from about 20 weeks onwards to 36 weeks is the only preventative strategy that we have to prevent preeclampsia. So make sure that you talk to your physician about aspirin.
So if you've experienced preeclampsia before, you're more likely?
Yes. Or if you have risk factors. So the risk factors that are enumerated in the beginning, they are good guidelines about who these patients should be. So essentially, if you're obese and you're African-American, you pretty much should be getting aspirin throughout your pregnancy. And I would like to put the plug in to kind of remind your physicians and also, for other physicians to see if your patient will benefit from aspirin therapy.
Which is very much in line with this question we just received from a viewer. And she had severe preeclampsia starting at 19 weeks, delivered at 23 weeks. She's pregnant again. She's worried about getting it again. And so you just answered that.
So aspirin, yes, would be something that you should do. And then in my clinic, I see a lot of hypertensives. I do have a hypertension clinic for pregnancy. I give all my patients blood pressure cuffs, so you should ask your doctor whether home blood pressure monitoring is something that they would recommend you to do. Know your signs and symptoms of preeclampsia, and we can integrate them. So headache, low vision, swelling of your face, severe pain in your abdomen. And then kind of keep going over those signs and make sure that you are in touch with your health care provider to tell them that obviously you had this severe preeclampsia so early in your pregnancy.
And you mentioned blood pressure monitoring at home. Is that something that you would do on a daily basis?
So kind of depends on who you are, but you can do once a day blood pressure monitoring. Sometimes, if my patients are not on antihypertensives, I say maybe two times a week. And they can record those blood pressures. Then you can bring them to your physician's office.
There is actually data that blood pressures at home can be higher about a week before your doctors will catch it. And then I teach them about what are for example, severe blood pressure, such as 160 over 100, 110. That's when you can call your doctor. So if you have symptoms, you can check your blood pressure. And if it's really high, you can call your physician. So just kind of empowering my patients and empowering yourself to take care of your health.
Another question from a viewer, is nicotine a risk factor? So if you're a smoker.
So that's a good question.
You shouldn't smoke anyway if you're pregnant.
No, you should not smoke. But I don't even want to say this, but smoking is the only risk factor that reduces your prevalence for preeclampsia. But smoking increases so many other complications, such as you are at risk for preterm delivery. I would not recommend that. But scientifically, yes, there's been epidemiological studies showing that.
Interesting. I would have never have guessed that one.
More questions, I was diagnosed with gestational hypertension in my first pregnancy three years ago. I was on watch for preeclampsia, but did not get the diagnosis. Took a low dose of aspirin, just as you said, with my second pregnancy. I developed preeclampsia my 34th week and had to deliver baby in 34 weeks, five days this April. Is there anything else that could have been done to prevent preeclampsia? Are my chances of developing preeclampsia even higher in future pregnancies? It's a long one, but it's a good one.
So not really. So for the first part, aspirin is really just the only recommended thing that's been proven in large studies to prevent preeclampsia.
Yeah, not died. I tell all my patients to do some moderate degree of exercise, because I kind of believe that you kind of need to be a little bit more holistic. But no, nothing else that you could have done.
I would say that since you had preeclampsia first time or gestational hypertension first time, and then had early preeclampsia less than 34 weeks or around 34 weeks, I think you all have significant risk of developing preeclampsia if you get pregnant again. So I would just kind of watch through the things that I just talked about.
Now the question, is caffeine a risk factor?
No. That's an easy one.
Yeah. No, I don't you want to go into detail, but no. The short answer is no.
Great. So if you're African-American and obese-- this is another question-- should you take aspirin throughout your pregnancy even before a preeclampsia diagnosis?
Yes, so very good point. I think I didn't make it clear. So aspirin is a prevention for preeclampsia. So if you're at high risk, so if you have high blood pressure, or like you said, you're African-American and obese, yes. So you start your aspirin at 12 weeks to 16 weeks, somewhere there. So after your first trimester. And then I continue my patients all the way through delivery.
So it's to prevent preeclampsia, not once you have preeclampsia.
So Macaria, talk to us a little bit about just the education process both pre- and post-delivery. What kind of things do you tell moms? What do they need to know?
So after the provider talks about their diagnosis, we go through it again, make sure that they understand what was said to them. We talk about how the delivery is going to look like. If the baby might have a little bit of distress afterwords, if they're on magnesium. We talked to them about their medications, what that means for them. How they're restricted with that.
And then postpartum, we standardize the care so that we're all teaching them the same thing. And we're running through every single detail of what they need to know when they're at home. And we give them numbers to call when they have a question.
We also have been giving them blood pressure cuffs to take their blood pressure at home. And we talk about how to take their blood pressure, how not to take their blood pressure at home. And we give them also, a medical alert band that says preeclampsia and postpartum on the back, so that if they were to go to an emergency room, that they can communicate that they are a postpartum preeclamptic patient.
That sounds perfect. And I imagine it's a little overwhelming if you are being treated, if you're in the hospital, sometimes, the information comes at you pretty fast. So it's great that you're taking the time to really kind of walk through the steps and what needs to be done with moms and families. I think that's great.
A question here that I neglected to ask earlier, but it's a good one, does preeclampsia impact the child, my baby?
I was just going to say that. We've been talking for almost 20 minutes now about the moms. Yes, so obviously, preeclampsia affects the baby. Preeclampsia is actually the most common indication for a preterm delivery. So almost about 42%. So about 50% of the babies are born preterm iatrogenically. So somebody is delivering them because of preeclampsia.
And yeah, preeclampsia still is killing moms and still is killing babies. It's a common cause for growth restriction, for preterm delivery, for days in the ICU. And also, fetal deaths.
Question from a viewer, and this one is-- this is the big question. So should you not get pregnant if you've had multiple pregnancies with preeclampsia? And I imagine that kind of depends on the individual, obviously.
You know, I don't know. I do take care of a lot of patients who are very high risk. I never tell a patient don't get pregnant. If that's what she wants to do, we're here to help. We describe the risks.
I think the absolute risk is to not-- I never tell any patient your risk to have preeclampsia is 100%. I think if you have other underlying conditions, if you have lupus, if you have antiphospholipid antibody syndrome, if there's something else systematically, I think those patients are at significant risk for having recurrent preeclampsia.
I think it's such an individual discussion that has to be held between what the patient's values are, rather than kind of a global statement, I would say.
And again, it's about awareness and education. When you have a great team like Dr. Rana and Macaria to help you through the process, if you are a high risk, that obviously makes a difference. And we appreciate you doing that.
So if somebody actually does have preeclampsia-- we've touched on this a little bit-- but what are the treatment methods?
So big picture, the treatment-- there is no treatment for preeclampsia. The treatment for preeclampsia is-- and I don't want to say this in this virtual sense-- but it is essentially for some of the maternal syndrome, is delivery. So once you deliver, the patient, a large majority of the symptoms that she is having and blood pressure is usually resolved, barring the fact that you can obviously develop and continue to have postpartum blood pressures.
But if you're preterm, we do try to do something called expectant management. So we keep them in the hospital. The management includes controlling blood pressures. For patients who have severe disease, we give them magnesium, which is an IV medication that helps prevent seizures. And then we give betamethasone, for example. It's a drug that we give to mature babies' lungs. And then we obviously keep them in the hospital, review their labs, review their blood pressures, and time delivery to optimize the fetal growth.
Are there any new developments in the management of preeclampsia?
Research wise, yes. So actually, at the University of Chicago, we are doing an FDA study. We're going to start that. I've been studying biomarkers to predict adverse outcomes of preeclampsia for almost about 15 years. And some of these biomarkers are actually now being hopefully, put in front of the FDA to be approved for perhaps, prompt diagnosis, or even management decisions for patients with preeclampsia.
So if you will, talk to us a little bit more about long term effects. You mentioned Alzheimer's as one. Are there other long term effects?
Yes, so cardiovascular disease is the number one. So it's your risk to have an MI. It's risk to have your cerebral vascular disease, such as stroke, severe hypertension. And then very long term is Alzheimer's. But cardiovascular disease would be and hypertension would be the most common long term effect of preeclampsia.
Because you mentioned seeing a cardiologist earlier. So is this something that commonly happens?
So unfortunately, no. And I think very recently-- I think it was in 2015 when they actually put preeclampsia as one of the risk factors for cardiovascular disease. In our institution here-- so one thing that Macaria was saying is that we actually created a post-partum hypertension clinic, where all these patients are coming back. And once we see these patients, immediately we at postpartum, 7, 10 days out, we actually have collaboration with our cardiologist. And we send them to a cardiologist for long term follow up.
And Macaria I, would imagine that the postpartum hypertension clinic, that's a fairly unusual thing, I would guess, right?
Not many people are doing it?
It's new to our institution. And it's an important part of our program.
And what happens there?
So I mentioned earlier we give the moms their blood pressure cuff. So they have to do something with that information. So they come to our clinic, and they give us their log. A provider reviews the log, and sees if treatment needs to be done, or treatment needs to be adjusted. And go from there.
So we are just about out of time. If you would want to leave the moms watching or families watching with a parting thought, what would it be?
So I would say just be your own advocate. Like I said, be aware of your symptoms. It's a real thing. It's a very common complication that can happen to you or to your family member. I would also say that ask a lot of questions. And obviously, there are lots of websites. There's a very good patient driven website such as preeclampsia.org. You can empower yourself with knowledge. And I would say, ask your physicians and push them to make sure that they're diagnosing it correctly, and treating it correctly, too. As I would just say be your own advocate in terms of pushing and improving your care.
Macaria, any final thoughts for our viewers?
I would like to say that in order to take care of your baby, you need to take care of yourself. And you need to think about that. Coming back to your clinic and making sure that you're healthy for your baby.
Perfect. Well, that's all the time we have for the program. You guys were fantastic.
Thanks for being on. And thank you for all of the wonderful questions that you gave for our experts. If you want any more information, please contact the maternal fetal medicine physician team at 773-702-6118. Or you can visit the online site at uchicagomedicine.org/high-risk-ob. Thanks for watching, and have a great week.
Preeclampsia is a common condition during pregnancy characterized by high blood pressures. It can lead to serious complications for both mother and baby. Physician Sarosh Rana, MD, MPH, and nurse Macaria Solache, RN, joined us to discuss.