What is Pre-eclampsia ?
Pre-eclampsia is the most common of the serious complications of pregnancy. It is caused by a defect in the placenta, which joins mother and baby and supplies the baby with nutrients and oxygen from the mother’s blood. Pre-eclampsia is symptom-less in the early stages and is detectable only by regular antenatal checks on the mother’s blood pressure and urine.
In its widest forms, pre-eclampsia affects about one in 10 pregnancies overall and one in 50 pregnancies severely. Pre-eclampsia can be very serious and is still responsible for the deaths of between three and five women a year as well as between 500 and 600 babies.
It is potentially life-threatening to mother and baby if allowed to develop and progress undetected.
Pre-eclampsia is curable only by delivery, which puts some babies at risk of death from prematurity. Pre-eclampsia cannot be predicted, reliably prevented or treated to allow the pregnancy to continue. Although first identified more than 150 years ago, its prime cause remains unknown.
Who is most at risk?
Most at risk are first-time mothers; the over-40s; those with a BMI over 35; women with a family history of pre-eclampsia; where it is ten years or more since a last baby; those suffering from high blood pressure, diabetes or kidney disease; those carrying more than one baby and those who have had it before.
What are the signs?
High blood pressure, protein in the urine and in some cases severe swelling (oedema) in the mother and, sometimes, poor growth in the baby – all of which should be detected by routine ante-natal checks.
The size of the global problem.
Pre-eclampsia is a massive problem throughout the globe. Every year pre-eclampsia is developed by between 1.5 and 8 million women. Of these women, approximately 150,000 have eclamptic convulsions. It is believed that, conservatively, between 40,000 and 60,000 women die each year and approximately 12% of their babies die within the first month. Globally, pre-eclampsia is associated with approximately 4,000,000 growth restricted babies.
What is HELLP Syndrome?
HELLP is the medical term for one of the most serious complications of pre-eclampsia, in which there is a combined liver and blood clotting disorder.
H stands for Haemolysis (rupture of the red blood cells);
EL stands for Elevated Liver enzymes in the blood (reflecting liver damage);
LP stands for Low blood levels of Platelets (specialised cells which are vital for normal clotting).
HELLP is as dangerous as eclampsia (convulsions) and probably more common, although it is less easy to diagnose.
Some specialists believe that HELLP may be on the increase for reasons which are not known.
What are the signs and symptoms?
HELLP syndrome may be preceded by clear signs of pre-eclampsia – most typically high blood pressure, protein in the urine and swelling of hands, feet or face. But, like eclampsia, it can also arise out of the blue without any of the classic warning signs. The typical presenting symptom is pain just below the ribs (‘epigastric pain’), sometimes accompanied by vomiting and headaches. This pain is sometimes confused with the discomfort of heartburn, a very common problem during pregnancy. But, unlike heartburn, the pain of HELLP syndrome is not burning, does not spread upwards towards the throat and is not relieved by antacid. The pain is often very severe and is associated with tenderness over the liver. It is not uncommon for women with this pain to be diagnosed as suffering from some other acute abdominal condition, typically inflammation of the gall bladder (cholecystitis).
When does it occur?
As with eclampsia, HELLP syndrome is most likely to occur immediately after delivery – sometimes developing with devastating speed. However, it can arise at any stage during the second half of pregnancy – and some rare cases have been recorded even earlier.
What are the risks?
HELLP syndrome may be associated with one or more of the following problems:
severely disturbed blood clotting function, leading to heavy, uncontrollable bleeding, particularly after surgery;
severe liver damage, which can lead to failure or even rupture of this vital organ;
severe kidney problems, including kidney failure;
breathing difficulties, which may be severe enough for the mother to need artificial ventilation.
stroke (cerebral haemorrhage) with or without eclampsia (convulsions).
How is it treated?
The diagnosis of HELLP syndrome can only be confirmed in hospital, and emergency admission is essential for all suspected cases. Once the syndrome is diagnosed the baby should be delivered as soon as the mother’s condition is stable, regardless of the maturity of the baby, since delivery is the only cure for this life-threatening condition. If the blood clotting system is severely disturbed it may be necessary to give transfusions of the platelets essential to clotting before delivery can take place. It is not uncommon for the symptoms to become worse – or to develop for the first time – in the 48 hours following delivery, and treatment in an intensive care unit may be necessary.
All treatment is aimed at supporting the mother’s systems which have failed (liver, kidney, lungs, clotting) until such time as they have recovered enough to cope on their own. Providing no permanent damage has occurred, the mother should enjoy a full recovery. This may take as little as a few days or as long as two to three months (not all of it spent in hospital) depending on the severity of the mother’s problems.
How is the baby affected?
HELLP is a maternal problem which has no specific effects on the unborn baby. However, as with all cases of severe pre-eclampsia, the baby may suffer growth retardation and even distress as a result of the underlying cause – a shortage of maternal blood flow to the placenta. But in most cases of HELLP delivery is for the mother’s benefit, sometimes with tragic results for babies who are too premature to survive outside the womb.
What happens in the next pregnancy?
About one sufferer in every 20 will suffer a recurrence of HELLP in her next pregnancy. However, there is no way of predicting who is most likely to suffer a recurrence and no specific means of prevention, although treatment with low-dose aspirin may be recommended in cases where the syndrome developed relatively early in pregnancy – ie before 32 weeks (1).
For optimum safety, any woman who has suffered HELLP in one pregnancy should be considered ‘at risk’ in the next pregnancy and monitored carefully throughout with a view to detecting signs of recurrence at the earliest possible stage. Former sufferers may like to consider preconception counselling with an expert to devise an appropriate antenatal care programme for the next pregnancy (2).
1. Low-dose Aspirin for High-risk Pregnancy.
2. Consult An Expert Via APEC: list of consultants who are considered expert in the management of all aspects of pre-eclampsia and are willing to accept referrals from GPs