Pregnancy Concern: Preeclampsia

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Preeclampsia is one of the most serious health problems that affect pregnant women. It is a multisystem inflammatory syndrome that is often progressive but has an unclear causation. Worldwide, it is the second most common cause of maternal morbidity and mortality. Here in the U.S., it is a complication in about 4% of pregnancies. It also accounts for 6% of preterm births and 19% of medically indicated preterm births.

The primary risk factors for preeclampsia include preeclampsia in previous pregnancies, type 1 or 2 diabetes, and chronic hypertension. Other risk factors include multifetal gestation, conception using assisted reproductive technology (e.g., IVF), autoimmune disease, kidney disease, nulliparity (1st pregnancy), high maternal BMI (obesity), family history of preeclampsia, and higher maternal age (over 35). Preeclampsia is defined by hypertension (BP over 140/90 in the second half of the pregnancy [>20 weeks]) and proteinuria (protein in the urine). In the absence of proteinuria, preeclampsia is diagnosed as hypertension with any of the following: thrombocytopenia (low platelet count), impaired liver function, kidney insufficiency, pulmonary edema (fluid in the lungs), or brain or visual dysfunction.

Not only does preeclampsia increase the risk of maternal and/or fetal death, it also interferes with the growth of the infant in the womb, known as intrauterine growth restriction (IUGR), causing small-for-gestational-age (SGA) infants.

Interventions to manage preeclampsia include antihypertensive medications, early delivery, and magnesium sulfate treatment. The definitive treatment for preeclampsia is delivery of the placenta. Delivery alone, however, does not cure the manifestations of preeclampsia as they may last days to weeks following delivery, with some cases presenting in the postpartum period and requiring additional intervention.

The key to preeclampsia is preventing it from occurring, because once it occurs, the only cure is delivery of the infant. Preventative measures include blood pressure control, blood sugar control, and weight loss for obese women. In October 2020 the FDA released a safety drug communication warning that the use of anti-inflammatory drugs (i.e., Motrin, Aleve) around 20 weeks of gestation or later may cause rare but serious kidney problems in unborn infants, resulting in low levels of amniotic fluid. An exception to this warning is the use of low dose aspirin.

Aspirin has anti-inflammatory properties plus it prevents platelets from clumping together to form blood clots, making it useful in preventing heart attacks and strokes. Because of its anti-inflammatory properties, aspirin has been found to be very effective in preventing the development of preeclampsia in high-risk women. So much so that in 2014, the US Preventive Services Task Force (USPSTF) recommended the use of low-dose (81 mg) aspirin after 12 weeks gestation as a preventative medication in women at high-risk for preeclampsia, provided that they do not have any condition that increases the risk of bleeding. This year, the USPSTF reaffirmed that recommendation based on additional clinical trials. They concluded that there is a “substantial net benefit of low-dose aspirin use” to reduce the risk of preeclampsia, preterm birth, SGA, IUGR, and perinatal mortality in pregnant women at high risk for preeclampsia.

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By Peter Galvin, MG

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