Preeclampsia, an Introduction

Karin Harmer

Pathophysiology ALH 2220

Joseph Gregory Dudash

Sinclair College

July 27, 2018

 Harmer 2

Preeclampsia, an Introduction

During pregnancy, a woman’s body must adjust to the conditions of sustaining the child, or

children, that she is carrying. Some of the changes will include stretching of the round ligament

connected to the uterus, growth of the breast tissue in preparation for breastfeeding, and

increased blood supply to support both the mother and fetus. The increase blood supply is a

contributing factor to higher blood pressure in women, and approximately one in twenty women

will develop a disorder called preeclampsia. Care providers are constantly monitoring

pregnancies for indicators of preeclampsia, and will perform various tests to verify the presence

of the disease, which is indicated by repeated elevated blood pressures, swelling of the hands and

feet, and the presence of protein in the urine. This disease typically develops in the second half

of pregnancy, and is an indicator to induce labor prior to 40 weeks gestation. It is vital that once

diagnosed, patients get proper treatment to protect the mother, prolong the gestation of the fetus,

and reduce complications during delivery. Without proper medical management, preeclampsia

can be fatal for the mother and child.

Pathophysiology

The cause of preeclampsia is not fully understood; however, it is believed that poorly developed

vasculature of the placenta is the predominant factor. The placenta is an organ that develops

inside of the uterus during pregnancy and, in the case of preeclampsia, the vessels cannot

properly adjust to the blood supply from the mother, increasing resistance resulting in elevated

blood pressure. There are several possible reasons that the vessels cannot accommodate the

maternal blood supply, chromosomal or immunologic abnormalities, or damage to the cell

membranes from free radicals (Dulay).

 Harmer 3

Hypertension can lead to ischemia and even infarction in multiple organ systems, and the

placenta is no different. Ischemic injury may also be contributing to preeclampsia in ways other

than poor oxygenation. When placental tissue reperfuses after an ischemic injury or an infarction

event, oxidative stress may occur. The oxidative stress is a result of free radicals, the unpaired

electrons of oxygen molecules, stealing electron from other molecules creating a destabilization

of molecules within the affected tissue (Mandal). Oxidative stress is also more common during

pregnancy, without the occurrence of ischemic injury, due to the increase of oxygen as a result of

increased blood supply. The occurrence of free radicals stealing electrons from lipids, resulting

in lipid peroxidation, can cause damage to tissue cells. This specific form of cell damage due to

oxidative stress is considered as another potential cause of preeclampsia (Gupta).

In the development of the placenta the growth of the arteries and arterioles may be inhibited,

causing increased arteriole pressure and decreased blood flow to the placenta and uterus. The

limited development may be due to an inadequate response to hormones. Improper development

of the placenta, as is seen in pregnancies where the fetus has trisomy 13, correlate with an

increased incidence of preeclampsia (Chen). There is also evidence of increased probability of

preeclampsia in Down syndrome pregnancies, which has lead to the belief that aneuploidy,

chromosomal abnormality, is a contributing factor of preeclampsia in applicable pregnancies

(Bianco). Immunologic reactions may also cause preeclampsia. During a pregnancy the body is

host to paternal antigens and the DNA of the fetus, the autoimmune response of the mother may

lead to hormonal and chemical responses that causes decreased lumen size of blood vessels,

leading to preeclampsia (Verlohren).

The presence of preeclampsia can result in ischemia, and even placental infarction leading to

diminished fetal growth due to the lack of nutrients and oxygen, or fetal death. In the mother,
 Harmer 4

complications may include decreased liver function, decreased kidney function, vision

impairment, pulmonary edema, and thrombocytopenia (Lim). Preeclampsia can develop into

eclampsia, which causes the mother to start experiencing seizures, or HELLP syndrome, which is

the breakdown of red blood cells resulting in elevated liver enzymes and decreased platelet

counts (HELLP). Without proper medical management preeclampsia can lead to death of the

mother, the fetus, or both.

Clinical Manifestation

Preeclampsia presents after the 20th week of gestation, although it is possible to develop

preeclampsia up to six weeks postpartum. Swelling of the hands, feet and face, blood pressure

with a systolic greater than 140 mm Hg, a diastolic greater than 90 mmHg, individually or in

combination, and unexplained protein in the urine of greater than 300mg/24 hours are primary

signs of preeclampsia. Severe cases may present with headaches, dyspnea, blurred vision or

blindness, abdominal pain, nausea/vomiting, and dysuria (Dulay). Contributing risk factors

include family history of preeclampsia, history of preeclampsia during previous pregnancies,

maternal age, pregnancy of more than one fetus, prior history of high blood pressure, obesity,

diabetes, and other disorders representative of poor vasculature. Preeclampsia has a occurs more

frequently in primigravida pregnancies, and in women that were diagnosed with preeclampsia in

a previous pregnancy. Different paternity in subsequent pregnancies increases the chance of

preeclampsia (Nordqvist). Pregnant women under 18 years old and women that are considered to

be of advanced maternal age, 35 years or older, are more likely to suffer from preeclampsia, as

are women that are carrying multiple fetuses. Prior to pregnancy, women that are obese,

hypertensive, diabetic, individually, and particularly in combination, have a higher chance of

 Harmer 5

developing preeclampsia. It is important to note that hypertension prior to pregnancy, and during

pregnancy is not an absolute indicator of preeclampsia.

During antenatal appointments women will provide a urine sample which will be tested for

protein, if a dipstick indicates elevated proteinuria, a 12 or 24 hour urine collection will be

ordered. Absence of protein in the urine does not eliminate the possibility of preeclampsia

(Dulay). If during the exam blood pressure is elevated, another reading will be done at the end of

the exam. If the pressure remains elevated blood tests will be performed and continuous blood

pressure monitoring will be prescribed; more than two elevated blood pressure readings taken

four hours apart represents hypertension and blood work will be ordered prior to a diagnosis of

preeclampsia. During a physical exam, a nurse or physician will check the hands and feet for

signs of edema. While edema is common during pregnancy, it typically is minimal in the

morning and gradually worsens during the day. However, in the context of preeclampsia, the

onset of edema is sudden and the swelling is more severe. Weight gain of more than two pounds

per week may be caused by excessive fluid retention, indicating preeclampsia. During an exam a

care provider may begin to suspect the presence of preeclampsia if the mother complains of

headaches, vision impairment, back and abdominal pain that exceed the typical discomforts of a

healthy pregnancy, or a decrease in urination (Nordqvist).

Upon suspicion of preeclampsia the blood tests ordered will include renal and liver function tests

as well as testing for thrombocytopenia, or decreased blood platelets (Dulay). Decreased lumen

size in blood vessels is one of the potential causes of preeclampsia, and it is important to

understand that happens across all of the organ systems. Decreased blood flow to the kidneys and

liver leads to reduced function which is why liver and renal function testing can help to diagnose

preeclampsia.
 Harmer 6

Medical Management

The best and ultimate treatment for preeclampsia is delivery of the fetus, however there are times

when the gestational age of the fetus is not conducive with birth. When delivery is not an

immediate option, or absolutely necessary, rest is the first line of treatment. Depending on the

degree of preeclampsia, reduced physical activity may be all that is advised. However, in some

instances complete bed rest is required, and severe cases may result in hospitalization for

continuous monitoring. Non-stress tests will become more frequent, with the purpose of

monitoring heart rates of the mother and fetus, as well as fetal movement. Preeclampsia causes a

decrease in the nutrients and oxygen supplied to the fetus, which may result in intrauterine

growth restriction (IGUR) where the fetal growth becomes inhibited. Fetal ultrasound is used to

monitor the physical growth of the fetus.

In some cases hypertensive drug therapy is prescribed. In general terms, hypertensive

medications are not recommended during pregnancy. Angiotensin-converting enzyme (ACE)

inhibitors should not be used as a treatment in preeclampsia, as there are known risks to the fetus

including, but not limited to, decreased amniotic fluid volume, renal failure, limb deformities,

intrauterine growth restriction, respiratory distress syndrome, and death. In some situations

Hydralazine and Labetalol, an adrenergic receptor blocker, may be able to decrease blood

pressure due to their vasodilating capabilities. However, Labetalol should not be used by women

that have asthma or congestive heart failure (Wagner). During delivery magnesium sulfate will

administered to prevent against seizures.

Conclusion

Preeclampsia is a disease of pregnancy and, unfortunately, is in the top three leading causes of

maternal mortality in the world. It is a disease where many signs are easily observable, and
 Harmer 7

diagnostic confirmation testing is relatively inexpensive, particularly in developed

countries. With medical supervision and appropriate treatment favorable outcomes can become

the norm, but it is imperative that pregnant women receive regular prenatal care with qualified

providers.
 Harmer 8

References

HELLP Syndrome: Symptoms, Treatment and Prevention. (2016, March 29). Retrieved July 6,

2018, from http://americanpregnancy.org/pregnancy-complications/hellp-syndrome/

Preeclampsia: Symptoms, Risks, Treatment and Prevention. (2017, April 04). Retrieved July 6,

2018, from http://americanpregnancy.org/pregnancy-complications/preeclampsia/

Bianco, K., Cheng, Y., Fisher, S., Mcmaster, M., Garza, J. D., & Caughey, A. (2008). 613:

Chromosomal abnormalities and the risk for preeclampsia/eclampsia. American Journal

of Obstetrics and Gynecology, 199(6). doi:10.1016/j.ajog.2008.09.643

Chen, C. (2009). Placental Abnormalities and Preeclampsia in Trisomy 13 Pregnancies.

Taiwanese Journal of Obstetrics and Gynecology, 48(1), 3-8. doi:10.1016/s1028-

4559(09)60028-0

Dulay, A. T. (2017, October). Preeclampsia and Eclampsia - Gynecology and Obstetrics.

Retrieved July 6, 2018, from https://www.merckmanuals.com/professional/gynecology-

and-obstetrics/abnormalities-of-pregnancy/preeclampsia-and-eclampsia

Gupta, S., Agarwal, A., & Sharma, R. K. (2005). The Role of Placental Oxidative Stress and

Lipid Peroxidation in Preeclampsia. Obstetrical & Gynecological Survey, 60(12), 807-

816. doi:10.1097/01.ogx.0000193879.79268.59

Lim, K. (2018, February 16). Preeclampsia: Practice Essentials, Overview, Pathophysiology.

Retrieved July 6, 2018, from https://emedicine.medscape.com/article/1476919-overview

Mandal, A. (2017, August 03). What is Oxidative Stress? Retrieved July 27, 2018,

fromhttps://www.news-medical.net/health/What-is-Oxidative-Stress.aspx

Nordqvist, C. (2017, December 22). Preeclampsia: Causes, symptoms, and treatments. Retrieved

July 6, 2018, from https://www.medicalnewstoday.com/articles/252025.php

 Harmer 9

Wagner, L. K. (2004, December 15). Diagnosis and Management of Preeclampsia. Retrieved

July 20, 2018, from https://www.aafp.org/afp/2004/1215/p2317.html