Pre-eclampsia or Toxemia

Toxemia is a big problem.

Toxemia strikes about one in twenty pregnant women. It is usually mild, but sometimes is severe. Occasionally it will become life threatening. When it gets really bad, it develops into eclampsia (instead of pre-eclampsia). When it is super bad, it leads to a failure of the blood systems, then we call it HELLP syndrome. HELLP is an acronym for "Hemolysis, Elevated Liver Functions, and Low Platelets". About one out of 75,000 pregnant women will get toxemia so bad that they die of it. 

The professors of Ob all call this pre-eclampsia. The old folks will likely call it toxemia. Personally, I like to call it toxemia. I think the name toxemia better reflects an understanding of what the disease process is. The old latin name of pre-eclampsia just doesn't create any useful meaning to me. In any case, all physicians know both meanings. 

To put the mortality rate into perspective, there are about 5000 hospitals in the USA. This means that about 1 in 15 hospitals can be expected to lose a patient to toxemia in one year. And about one in 20 Obstetricians will lose one patient in his or her's entire career. This is assuming an Ob career involves about 5000 babies. Personally, I have already delivered more than 5000 babies, but I believe I have more experience than most. 

Some hospitals have more high risk cases. Those high risk hospitals will obviously have a much higher count of the risky cases. 

My hospital, The Valley Hospital in Ridgewood NJ, attracts these extremely high risk cases. We have one of the best Neonatal Intensive Care Units in existence. Our chief neonatologist is Dr Frank Manginello. He is a noted author of one of the best NICU reference books in existence. His best selling book is called Your Premature Baby. The book is available on Amazon. Here is the Amazon link: http://amzn.com/0471239968 . 

We also have a superb IVF program, and a wonderful Maternal Fetal Medicine team, not to mention a medical staff in the thousands, most of which were trained in New York City. Many of them maintain privileges at University hospitals. 

For instance, my favorite fetal cardiologist is Dr Zvi Maran. He has privileges at both Valley and at Columbia University. Columbia is about 20 minutes away just over the George Washington Bridge. Dr. Maran took care of my daughter when she had a very frightening cardiac arrhythmia. He and his excellent partners got her through this and eventually her heart healed itself. 

So, hospitals with a higher risk population is going to see a lot more of the riskier cases, and their experience is going to be higher than just the numbers will show. 

What is Toxemia? 

Nobody really knows for sure. But, even though we aren't sure what it is, we do know an awful lot about what it does. The body of the pregnant women is behaving as if there were a really bad toxin in the blood stream. No toxin has ever been found. But all of the organs start to fail. First, the blood pressure starts going up. This is due to the arteries feeding these organs squeezing down on the blood flow, leading to less flow to these organs. Early on, the kidneys start to malfunction. The kidneys start making less urine. This leads to fluid retention and severe swelling, and usually 10 pounds or more of fluid is retained all throughout the body.  The kidneys start to "spill" protein into the urine. There is usually no protein in urine because the kidneys are good at making clear urine and keeping the valuable protein in the body. In toxemia the protein spills out. 

So a lot of prenatal care is designed to check for these things. In a prenatal visit, the blood pressure will be checked, the patient will be weighed to see if there is this sudden severe fluid retention, and the urine will be checked for protein. All of these checks are to test for the signs of toxemia. 

Officially, the diagnosis of toxemia requires an elevated blood pressure, and some protein in the urine. 

The brain will eventually be affected. Some of the signs of toxemia affecting the brain are: a bad headache, visual changes including dark spots, sparkles, blurry vision, loss of vision, or more rarely, personality changes. 

The liver will be affected some times. This will lead to an elevation of the "liver enzymes" on a comprehensive panel of blood tests. If the liver gets too swollen, it can cause pain in the liver area of the abdomen. This is considered the right upper quadrant of the abdomen, just under the lower edge of lowest rib. A very swollen liver can actually rupture. If this happens, the patient may die from the blood loss into her abdominal cavity. I have never seen a liver rupture, but I have seen many many painful tender livers, with elevations of the liver blood tests. This is all quite common if toxemia gets to the HELLP stage. 

In the blood, the red cells can rupture. This can lead to severe anemia, and elevations of bilirubin in the blood on tests, and bilirubin in the urine as well. Also, in the blood, the platelets can get used up by the toxemia, leaving the platelet count perilously low. These women may need platelet transfusions.  Platelet transfusions are easy to order from the blood bank, and can be lifesaving If the platelet count gets too low, a life threatening hemorhage becomes likely, especially at the time of delivery. At delivery a woman needs all the platelets she has to shut off the blood flow to the placenta. Without that, there will be a hemorrhage. 

The blood flow to the heart muscle can be compromised, leading to heart failure, or a heart attack. 

All of the organs can be compromised. 

None of the toxemia directly affects the baby. Only to the extent that toxemia affects the mom or the placenta. 

If the blood flow to the placenta is compromised, then the baby may become short on oxygen, or may be short on nutrition. The baby may stop growing. The babies blood pressure may become very low. 

The placenta might even disconnect from the mother. If this disconnection is more than a mild case, then the baby will be distressed or even die. We call these placental disconnections Abruptions. Placental abruptions are much more common with hypertension, than will normal blood pressure. Abruptions can also happen from some kind of trauma to the pregnant uterus. Car accidents, falling over on ice or on the stairs, or physical assault on the fetus, can all cause the placenta to abrupt. A complete abruption when a woman is far away from the hospital will almost certainly end the babies life, and will very much risk the mothers as well. Sometime the blood just pours out of the vagina like a hose. If this happens there are only a few minutes, perhaps 10 but maybe up to 30 minutes, to try to save the baby and the mom. I have seen many abruptions. If it happens in the hospital it is almost certain that we can save the mom and the bay. If the private obstetrician is not there with the patient, then we have the on call ob. The "doc in box". In my years doing the on call, I have saved maybe 4 or 5 or more from a placental abruption. Mostly by doing a really fast C-Section. 

After the baby is delivered the nurses will sometimes come up to me and say, "thank you for coming right away when I called you. You saved this baby". My answer to that is, "no, you saved the baby by being there, recognizing the problem, and calling me without delay. You saved the baby, I was just doing my job". In the end, doing our jobs requires a lot of teamwork. Everyone becomes a link in this chain of human events. And when it all works out, we can all be really proud of what we do. 

But not all abruptions are complete. Many are partial. It is easier to save those babies. 

How to diagnose it? 

If the blood pressure is elevated, then we know there is a problem. It might be "gestational hypertension", which used to be called PIH, or pregnancy induced hypertension. Or, it might be toxemia. We will look for protein in the urine, either on a urine dip strip or on a 24 hour urine collection. We will order blood tests to look for hemolysis, low platelets, and liver function tests. We will likely need to do these tests in the hospital. The patient may be formally admitted, or she may be kept as an outpatient for up to 24 hours. 

We will ask her if she has a headache, or visual changes, or sudden fluid retention and swelling, We will ask her about nausea, and pain in the liver area. 

We will weigh her, examine her lungs, heart, liver, and uterus. We will check the reflexes. If they are elevated, that is a sign of toxemia. 

If the blood pressure is below 160/100, and there is no hemolysis and the platelets are normal, and there is no liver involvement, and no brain involvement, then we call it mild toxemia. Mild toxemia remote from full term can be observed, usually in the hospital, but sometimes at home. Mild toxemia at term should be delivered without delay. 

Delivery cures toxemia 100 percent of the time. If the women has permanent damage to her kidneys, or heart, or anything else, as result of a terrible toxemia, then those problems can last forever. But the toxemia itself will be gone. usually it fades away from hours or days after delivery, and is completely gone in 6 weeks time after delivery of the baby. 

A patient with severe toxemia will need to be delivered regardless of the gestational age. Even if it means losing the baby. We have to deliver the woman, even at 22 weeks, and sometimes deliver a non-viable baby. If we do not deliver the baby, then the mother may die or be permanently damaged from the multiple pathways of pathology I described above. We do not want to have a maternal mortality. 

Even having said all of that, ACOG (American College of Ob/Gyn) has written a recommendation that some milder cases of severe preeclampsia, if they are remote from term, may be allowed to stay pregnant a little bit longer if it means the difference between life and death for the fetus. ACOG will only allow this protocol under certain circumstances. Among them are an experienced facility with very experienced Obstetricians, perhaps with Maternal Fetal Medicine specialists available. Our facility fulfills all of those criteria. Therefore I am comfortable managing a "moderately" preeclamptic patient without immediate delivery. But in most cases, immediate delivery is necessary. 

Who is at risk? 

Some women are much more likely than others to get toxemia. Hypertensive patients, diabetics, older pregnant women, over stressed women, women who have had it before, women who use drugs like cocaine, women without prenatal care, women who suffer from poverty or who don't have a family or husband to help, women with anxiety disorder. 

But even so, it can happen to anybody at any time. 

Prevention? 

Many things have been tried to prevent toxemia. Nothing has worked. We can certainly prevent some of the risk factors, though. We can provide proper prenatal care, proper nutrition, prevention of diabetes, lower lifestyle stress issues, prevent drug abuse, and engage the family into a social support group. 

Aspirin has been tried and it doesn't work. 

Calcium, magnesium, vitamins, none of them work. 

We usually advise some moderate bedrest to lower the blood pressure, but most Obs don't believe that bedrest will actually prevent it. And bedrest itself has a number of severe risks, especially including lethal embolisms from DVTs, but also including severe decondioning, which may require physical therapy to overcome. 

Someday, someone may actually find the toxin of toxemia. If they do, there will surely be a Nobel prize to that individual. 

Thanks for reading. 

John Marcus MD Ob/Gyn 

89 North Maple Ave 

Ridgewood NJ  07450 

201-447-0077 

blog at doctorjohnmarcus.blogspot.com