Preeclampsia and eclampsia

How does this happen?

Preeclampsia starts with the placenta. Early in pregnancy, the blood vessels supplying the placenta are remodeled so they can carry a large, low-pressure flow. In preeclampsia that remodeling is incomplete, so the placenta is under-perfused. ¹

The under-perfused placenta releases substances into the mother's circulation that damage the lining of her blood vessels throughout the body. That is why preeclampsia is a whole-body condition rather than just a blood pressure problem.

The consequences follow the organs affected.

• Blood vessels: high blood pressure, and leaking that causes swelling.
• Kidneys: protein leaks into the urine.
• Liver: pain in the upper right abdomen, raised liver enzymes.
• Blood: platelets fall, red cells break down. Together with the liver changes, that combination is HELLP syndrome.
• Brain: headache, visual disturbance, and in eclampsia, seizures.
• Lungs: fluid accumulating, causing breathlessness.
• The placenta itself: poor blood flow, so the baby may grow poorly, and a higher risk of abruption.

Because the underlying problem is the placenta, delivering the baby and the placenta is the only cure. Everything else is management while the pregnancy continues. ¹

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• A first pregnancy, which carries higher risk.
• A new partner, or a long gap since the last pregnancy.
• Twins or higher-order multiples.
• Pre-existing high blood pressure, kidney disease, diabetes or autoimmune disease. ³
• Preeclampsia in a previous pregnancy, or a family history.
• Age, obesity, and assisted conception, all of which are associated with higher risk.
• No identifiable risk factor at all, which is common. ¹

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Blood pressure not measured at visits, or high readings not repeated and acted on. ¹
• Symptoms dismissed. New severe headache, visual changes, upper abdominal pain, sudden swelling and breathlessness in pregnancy are warning signs, not normal pregnancy complaints.
• Low-dose aspirin not offered to someone at high risk, where guidance addresses preventive use. ¹
• Severely high blood pressure not treated urgently. Acute severe hypertension in pregnancy is treated as an emergency with a defined time frame. ¹
• Magnesium sulphate not given for seizure prevention where there were severe features. ¹
• Delivery not planned appropriately for the gestational age and severity. ¹
• Fetal growth and wellbeing not monitored, where the placenta is affected. ⁴
• Postpartum blood pressure follow-up not arranged, when the risk continues after birth and postpartum care is meant to be an ongoing process. ²

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

Warning signs during pregnancy and after birth

• A new headache that is severe or does not go away with usual pain relief.
• Visual changes: flashing lights, blurred vision, seeing spots, or temporary loss of vision.
• Pain under the ribs on the right side, or in the upper abdomen, sometimes mistaken for heartburn.
• Sudden swelling of the face, hands or feet.
• Breathlessness.
• Nausea and vomiting that starts in the second half of pregnancy.
• Reduced urine output.
• Feeling generally and unusually unwell.

The first week

• Blood pressure that stays high or rises after birth. This is common and it is often the point at which people have gone home.
• Headache and visual symptoms.
• Seizures, which is eclampsia and which can occur after delivery.
• Heavy bleeding, since low platelets affect clotting. ⁵

Around 3 months

• Blood pressure returning to normal in most people, though it can take weeks.
• Ongoing need for blood pressure medication in some.
• Post-traumatic stress after a frightening illness. ⁶

Around 6 months

• Most have normal blood pressure by now.
• Persisting high blood pressure needs proper investigation rather than being attributed to pregnancy. ²

Around 12 months

• Cardiovascular follow-up, given the recognized long-term association. ²

Toddler years

• For the baby, effects follow from prematurity or growth restriction if either was present. ⁷

School age

• For the baby, effects follow prematurity rather than the preeclampsia itself.

How is it diagnosed?

Blood pressure, measured properly, with repeat readings.

Urine testing for protein.

Blood tests: platelet count, liver enzymes, kidney function, and where indicated tests for red cell breakdown. These are what identify severe features and HELLP syndrome. ¹

Assessment of the baby: growth scans, nonstress testing, biophysical profile and Doppler study studies of blood flow, because the placenta is the origin of the problem. ⁴

Diagnosis without protein. Preeclampsia can be diagnosed in the absence of protein in the urine when there are severe features affecting other organs. This matters, because people are sometimes reassured by a negative urine test. ¹

After birth, blood pressure should be checked on a defined schedule, and postpartum care is meant to be an ongoing process rather than a single six-week visit. Ask what your follow-up plan is before you leave hospital. ²

What is the treatment?

Blood pressure treatment. Severely high blood pressure in pregnancy is treated urgently with specific medicines, because the immediate risk is stroke. ¹

Magnesium sulphate to prevent seizures where there are severe features. It makes people feel hot, flushed and heavy, which is expected. It is not a blood pressure treatment. ¹

Antenatal corticosteroids if preterm delivery is anticipated, to help the baby's lungs. ^{8 9}

Magnesium for the baby's brain if delivery before 32 weeks is expected, which is a separate indication from seizure prevention. ¹⁰

Timing of delivery, which is the central decision and is balanced between the risk to the mother of continuing and the risk to the baby of being born early. ¹

After delivery, continued monitoring, continued magnesium for a period, and blood pressure treatment which may be needed for weeks.

Prevention next time. Low-dose aspirin from early in a subsequent pregnancy is recommended for people at high risk. This is one of the most useful things to take from an episode of preeclampsia into a future pregnancy. ¹

What is the long-term outlook?

Most people recover fully. Blood pressure usually returns to normal over days to weeks, and sometimes takes longer. ¹

The postpartum period carries real risk, and the most preventable bad outcomes happen after discharge. Know the warning signs and act on them. ²

Long term, a history of preeclampsia is associated with higher cardiovascular risk later in life. That is a reason for lifelong attention to blood pressure and heart health, and it should be part of your medical history from now on. ²

For the baby, the effects come mainly from prematurity and from growth restriction where the placenta was significantly affected. ⁷

For a future pregnancy, the risk of recurrence is higher, and low-dose aspirin and closer monitoring are the response. ¹

What does daily life look like?

Blood pressure checks at home for weeks after birth in many cases. Ask for a monitor and be shown how to use it.

Medication, sometimes for weeks or months.

Fatigue, which is real and is compounded if there was also blood loss.

Many people describe preeclampsia as frightening in retrospect rather than at the time, because everything happened fast. Intrusive memories and anxiety afterward are common and treatable. ^{6 11}

Make sure preeclampsia is written into your permanent medical history, not just your maternity notes. It is relevant to your care for the rest of your life.

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for preeclampsia, and this site does not invent one.

Immediate costs are hospital care and, where the baby is born early, neonatal care. Long-term costs relate to cardiovascular follow-up.

See paying for care.

What can you do this week?

1. Learn the warning signs and take them seriously for six weeks after birth: severe headache, visual changes, upper abdominal pain, sudden swelling, breathlessness.
2. Ask for a home blood pressure monitor and a written follow-up schedule.
3. Ask what your blood pressure and blood results were, and when they should be rechecked.
4. Ask whether you should be on low-dose aspirin in a future pregnancy.
5. Get preeclampsia added to your permanent medical history.
6. Ask your primary care doctor for a cardiovascular risk review at the appropriate point.
7. If the baby was born early, ask what follow-up they need. ¹²

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the obstetrician

• Did I have severe features, and which ones?
• Was I given magnesium, and for how long?
• Why was the timing of delivery chosen?
• What is my blood pressure follow-up plan?
• Should I take low-dose aspirin in a future pregnancy?

For your primary care doctor

• When should my blood pressure be rechecked?
• What long-term cardiovascular follow-up do I need?
• Is preeclampsia recorded in my permanent record?

For the neonatal team, if your baby was born early

• Were antenatal steroids given?
• Was magnesium given for the baby's brain?
• What follow-up does my baby need?

You can also build a printable list with the question generator.