Preeclampsia a leading cause of pregnancy-related deaths

Elizabeth Barnett, who was diagnosed with severe preeclampsia during her first pregnancy, gave birth to Quinn two years later. Photo: Michael Short, The Chronicle

Elizabeth Barnett was five months pregnant when her feet swelled.

Her pregnancy with her first child, a boy, hadn't been going smoothly. Seventeen weeks in, the doctors had found an unexplained mass on the placenta and the baby's growth had slowed.

But when the swelling occurred in March 2011, the San Jose woman didn't connect the dots. She'd been running around all week on the job as an elementary schoolteacher, so she just figured her feet needed a break. And after all, didn't all expectant mothers get a little puffy?

The next morning, however, her hands and face were so swollen, and she could barely see. At a doctor's visit, her blood pressure was abnormally high and a lab test detected protein in her urine. She was told: Go to the hospital, now.

Barnett had a severe form of preeclampsia, a hypertensive disorder that occurs after the 20th week of pregnancy and can be fatal to the mother and fetus. The only cure is to deliver the baby, sometimes weeks before the due date.

Barnett had little choice but to induce. She and her husband were devastated when their son, Cooper, was stillborn.

"I wish I had known more about preeclampsia," the 33-year-old said. "Not that the outcome necessarily could have been that much different because of how severe I had it, but I definitely would have gone into the hospital earlier and would have been more on top of it."

Barnett hadn't known that preeclampsia affects 5 to 8 percent of all pregnancies. Or that it causes an estimated 76,000 maternal and 500,000 infant deaths worldwide each year, making it among the leading causes of pregnancy-related deaths in the world. In California, preeclampsia and its full-blown form, eclampsia, are together the second-most-common causes of death among pregnant women.

Trying to save lives

Those alarming figures prompted the California Maternal Quality Care Collaborative, a statewide team of women's health experts, to release a guidebook last month that draws on the latest research and advises clinicians how to promptly and accurately recognize and respond to the condition.

"Nobody realizes it's a problem. Preeclampsia is the most common medical complication of pregnancy essentially," said Dr. Maurice Druzin, an obstetrics and gynecology professor atStanford University School of Medicine and an attending physician at Lucile Packard Children's Hospital. Druzin helped lead the group of clinicians that wrote the guidebook.

From 2002 to 2004 in California, 25 women died of preeclampsia or eclampsia, making up 17 percent of all pregnancy-related deaths in the state during that time, according to an analysis of the most recent data. The number of maternal deaths in California, in general, is relatively small. The numbers had, in fact, been declining for years, but increased between 1999 and 2010 because of chronic conditions among pregnant women, variety in quality of pre- and postnatal care and other factors.

Most women with preeclampsia deliver healthy babies, especially if they are able to safely wait to deliver until near the end of their pregnancies, but the condition can have consequences if it festers for too long. It inhibits the arteries from carrying blood to the placenta, potentially reducing the amount of oxygen and nutrients the baby receives.

And if uncontrolled, preeclampsia can escalate into eclampsia, which consists of seizures. It can permanently damage the mother's vital organs and cause coma, brain damage and death. It was eclampsia that killed the fictional Lady Sybil Crawley on the popular PBS show "Downton Abbey" last year.

Risk factors

Clinicians aren't sure what causes preeclampsia. Risk factors include pregnancy before age 20 or after 40, first-time pregnancy, obesity and chronic high blood pressure. Although it was Barnett's first pregnancy, she said she exercised regularly, wasn't overweight and didn't have high blood pressure, although it runs in her family.

But as rates of hypertension and obesity have increased nationwide, and women are having children later in life, the risk for preeclampsia has grown simultaneously, experts say. In addition, for reasons unclear, African American women are likelier to be afflicted than any other racial or ethnic group.

In the guidebook, the authors draw attention to new knowledge about two of preeclampsia's main symptoms: high blood pressure and excess protein in urine, a condition known as proteinuria.

Symptoms of disease

Most patients with preeclampsia have high blood pressures of 140/90 or above. There are, however, some women whose blood pressures do not quite make the cutoff for a standard diagnosis of hypertension but may have it, the researchers said. The key, they said, is to monitor pregnant patients.

Traditionally, clinicians diagnose preeclampsia when a woman has both hypertension and proteinuria. But a woman with preeclampsia can have one or the other, on top of other telltale symptoms such as headaches, blurred vision, breathlessness and swelling of the hands or face.

"You don't have to have both to say she may have preeclampsia, and that simple fact makes all the difference in the world," Druzin said.

Because many of those symptoms are common side effects in a healthy pregnancy, clinicians and patients can miss the red flags if they don't know what to look for, saidAudrey Lyndon, an associate professor at UCSF's School of Nursing who also worked on the guidebook.

"It can seem as though everything is completely fine until fairly late in the pregnancy when it starts to manifest in signs we can actually detect," she said.

To be proactive, women should know their baseline blood pressure and follow up with their health care providers when it changes, Lyndon advises. They should also ask whether they have other risk factors for preeclampsia and discuss symptoms that should prompt a checkup.

"If people have new onsets of headaches, visual disturbances, abdominal pain and swelling, they need to see the doctor and the doctor needs to take them seriously," Druzin said.

Contrary to long-standing belief in the medical community, a woman is not automatically cured once she delivers, the guidebook's authors warn. Her symptoms can dramatically improve after the birth, but the disease can linger up to three days afterward. So doctors should closely monitor patients during that period.

'Listen to that feeling'

Barnett will probably never know why preeclampsia caused her to lose her son. But in March, she and her husband were thrilled to welcome a healthy baby girl, Quinn, after a preeclampsia-free pregnancy. Now Barnett is expecting yet another girl.

Women, she said, would do well to be informed and trust their instincts.

"You know when something's off and not right," she said. "You need to listen to that feeling."

About preeclampsia

For more about preeclampsia: https:// www.cmqcc.org/preeclampsia_toolkit and http://preeclampsia.org.