So pre-eclampsia is not rare. About 7% of all pregnancies are affected by pre-eclampsia. Sometimes it just needs to be monitored, sometimes it can rapidly deteriorate and the treatment for you and your baby becomes a decision about whether your baby is better off ‘out than in’.
In this episode we cover:
What is high blood pressure
What are the signs and symptoms of pre-eclampsia
Who is at risk of developing pre-eclampsia
What you can do to help with high blood pressure
How we treat pre-eclampsia
Brigid [00:00:36] Well, welcome, everyone, to Episode 23. Twenty three point twenty three part test. And today we're talking about hypertension and pre-eclampsia. Serious topic. A serious topic. Yes. And we sort of wanted to lead on from our last one, which was all the symptoms in late pregnancy. Yeah. And there's just some that we need to flesh out. So this is one of them. Yeah. A couple others that I think are important enough to have as a topic for their own podcast.
Patrick [00:01:02] Absolutely. So there are some things that that are not trivial, that the symptoms are serious and when and they can indicate significant underlying problems. And we want people to know a little bit about those. Yes.
[00:01:11] But before we get serious, I want to read out something that somebody sent us a direct message, which is very funny. We laughed a lot when we heard this. All right. So this is from Isabelle. I always liked the name Isabelle. My husband and I are at the beginning of our journey with all this stuff. And a friend got us onto your podcast. My husband has taken this all very seriously and has listened to episode three and now wants to be tested for fragile eggs, fragile eggs .
Patrick [00:02:27] Okay. Okay.
Brigid [00:02:28] Obviously he's only ever heard about it on our podcast and has never seen it written as Fragile X. So he thought it made perfect sense because the eggs may have had a thin shell or a crack on them. That is best.
Brigid [00:02:42] It is a whole new world. I know. And he said any of this stuff before they started. That's it.
Brigid [00:02:48] So I'm glad if we're helping everybody to sort of be more prepared and more knowledgeable as they either start their pregnancy or throughout their pregnancy, then that is our job done. Brilliant. We're very excited by that. All right. So on with today's episode. And it happens all the time. Every time you see an obstetrician or a healthcare provider. They put the blood pressure cuff on every single tiime every time. Why? Why are we having that done?
Patrick [00:03:14] Well, I guess it's because high blood pressure, whether you're pregnant or not, doesn't really have any reliable symptoms. Sometimes people say, I feel a bit sick. Could be my blood pressure. Well, yes, it could be. But the problem is you have your blood pressure can be very high. I feel totally fine. So in the absence of reliable symptoms, we just have to check everybody all the time. Yes. So checking your blood pressure is an essential part of antenatal appointment. And what we're looking for is blood pressure that's consistently high. We shouldn't be getting carried away about a single high measurement. If someone comes in to see me, they've got to send a very high blood pressure. They might be running late.
Patrick [00:03:53] They might actually he's anxious. They might have it sit in my waiting room while I'm running late. Yes.
Brigid [00:03:57] That would cause anyone's high blood pressure to take off.
Patrick [00:03:59] Right. So the first thing we do is take it again.
Patrick [00:04:01] Still high than first thing I do is would take her next door into the treatment room, the lie down deep breathing, and then get my nurse to come in and out and take half a dozen blood pressures over the next sort of 40 minutes and see whether we've got a real persistent problem or just a single elevated reading. So it's very important in pregnancy, sustained high blood pressure can cause all sorts of problems. And we want to we want to pick the people up who've got it and treat the ones who need treatment.
Brigid [00:04:28] And we'll go into why it's a problem. But firstly, what is a high blood pressure rating? What am I concerned with?
Patrick [00:04:35] Yeah, I think systolic blood pressures. So the top number consistently in in excess of 130 to 135. And then the the bottom number consistently in excess of 85, certainly 90. Then we really sit up and take notice of those numbers.
Brigid [00:04:55] And I know that this isn't it may not be a problem, but I always had low blood pressure. Like I was always sort of 90 on 60.
Patrick [00:05:01] Yes. So that's a normal blood pressure for a healthy young person. And so most of our pregnant patients are young and healthy. So it's perfectly normal to have a blood pressure of, you know, 80 or 90 systolic, 40 or 50. You know, certainly 50 or 60 diastolic. And that if that person is upright and conscious and smiling, then that's normal. Yeah.
Brigid [00:05:21] So is anyone at greater risk for developing high blood pressure?
Patrick [00:05:25] Well, in general, like in the in the general population, yes. And that's often related to family history. But in pregnant women, where we wouldn't expect if you had a parent on high blood pressure. You are 30 years old, we wouldn't expect you to have developed yet, but a family history of significant high blood pressure. You might be more likely to get that in pregnancy. But I guess the main risk factor is high blood pressure in previous pregnancies. All right. So if it's your first go, we don't know about that. But if in the first pregnancy you were treated for high blood pressure and eventually developed preeclampsia, then yes, you're at significantly higher risk than the rest of the community the next time around.
Brigid [00:06:03] Yeah. And so if if I do come back with a high blood pressure reading, what do I do now? What's the treatment?
Patrick [00:06:10] Well, it depends what what you know. Let's say we've established through a couple of visits that it's the real thing. It's consistently high and it's high despite, you know, taking a reading in a restful environment and what we call serial blood pressure, several in a row. So then we might get to the point where treatment is necessary. And it's a bit different to the treatment of high blood pressure in, say, a 50 year old man who is diagnosed with some high blood pressure from his local doc. But they might say, well, let's not reach for the pills straight away. Let's see what three months does of stopping smoking, weight reduction and stress management. Do we have three months in someone in pregnancy? Not really. Okay. So if someone's otherwise healthy person, we can't see a major contribution from anything else, then we tend to reach for the treatment pretty fast because high blood pressure in early pregnancy can affect the way the placenta forms and it can affect the stiffness of the blood vessels within the placenta. And that will have consequences for the baby in this pregnancy, not just the risk of big ticket things like preeclampsia, but even how big the baby is going to get.
Brigid [00:07:21] And they get too big or too little?
Patrick [00:07:24] Too little growth restricted if the placenta is not working properly. The origins of the placenta not working properly might date right back to the woman's blood pressure being too high at the time the placenta was forming.
Brigid [00:07:34] Right. And a growth restricted baby. We often see this on the internet. IUGR isn't it?
Patrick [00:07:41] IUGR. That's intrauterine growth restriction. And there are a lot of causes of that. But maternal hypertension is one of them.
Brigid [00:07:49] So if I've been diagnosed with high blood pressure and then you've started some medication. Is there anything that I could be doing also to help mitigate that?
Patrick [00:07:57] Yes, absolutely, so then you also do the other things that we know to help. So managing body weight, quit smoking and managing getting exercise and managing emotional stress. Yeah. Yeah. So all of those things will also make a contribution. And even if you might have already been started on tablets, it's not like those things were a waste of time. Yeah, you'll get away with less needing less medication if you addressing the other causes at the same time.
Brigid [00:08:23] Yeah. Okay. And so does that sort of keep everybody's high blood pressure under control or what happens now.
Patrick [00:08:30] It works most of the time.
Patrick [00:08:31] Yes. So we've got several medications that are safe to use and plenty of dose adjustments that can be made. And it's normal. It's pretty common for a single medication to do the trick, although we have to juggle the dose a little bit. And sometimes we'll have people on two medications, to really treat a hard case. And this is usually done by obstetricians themselves and occasionally in conjunction with, you know, blood pressure doctors, you have general physicians, cardiologists, whatever, who might help us out with a difficult case.
Brigid [00:09:06] And is there likely week for this to be happening?
Patrick [00:09:10] Well, it can start at the start, which is why we're checking the blood pressure at the start. But, you know, visit schedule at the start is only about every four weeks. So even if you were picking up a little bit of blood pressure and a couple of weeks away from an appointment, it would be picked up. But yeah, it can start in the first trimester. Yeah.
Brigid [00:09:29] And you mentioned preeclampsia, which I don't know. What is that?
Patrick [00:09:34] Well, preeclampsia is a common and serious complication of pregnancy, and it's a combination of high blood pressure plus other organ dysfunction within the month. And so typically, the woman will have high blood pressure, protein urea, which is protein leaking from the kidneys.
Brigid [00:09:56] And does that just get picked up from like a dipstick test? Yeah.
Patrick [00:09:59] And then extra an oedema, which is swelling. So more swollen ankles.
Brigid [00:10:03] And we covered that in the last episode.
Patrick [00:10:06] It's not not not always normal. Not always normal. Yeah. So typically works like this. You come in to have your blood pressure taken and if it's perfectly normal, then you don't have preeclampsia and we carry on. If it's abnormal, then we start saying, is this just pregnancy induced hypertension, which is high blood pressure pregnancy and we need to be three out of 10 worried? Or is this pre-eclampsia? We need to be eight out of 10 worried. And so we would then go and check the urine and have a careful look at the ankles and look for swelling and and build a case from there, could this be is this ordinary high blood pressure or preeclampsia? The significance of it being pre-eclampsia is one of the organs that preeclampsia affects acutely is the placenta. So suddenly we've got a dysfuncting placenta and a baby that's in trouble.
Brigid [00:10:54] And in trouble because it's not getting its nutrients and oxygen.
Patrick [00:10:57] As efficiently as it needs to.
Brigid [00:10:59] So would you also get a reduction in foetal movements?
Patrick [00:11:03] Well, you might if you were very sick. Yeah. Yeah, right.
Brigid [00:11:06] And you said it's common, but how common is preeclampsia? Yeah, it might affect up to seven percent of pregnancies, which is an awful lot. Yes, a lot.
Patrick [00:11:15] Now, it doesn't cause really serious disease in all of those, but it can and it can be unpredictable so that if someone's got a little bit of pre-eclampsia, they've got some mildly elevated blood pressure, a little bit of swelling and a little bit of urinary protein. Do we freak out and deliver? No. We observe and make a management plan. And the management plan will include a lot of surveillance in case it's about to suddenly turn more serious. And the that would mean more visits, watching more closely, taking more blood pressures and scanning the baby to make sure the baby's coping. All right. Yeah. Now, it might stay like that for weeks. Give you time for the baby to get bigger, growing and growing, get more more gestational weeks under its belt and certainly enough time to give those antenatal steroids. So maybe you've got someone at 33 weeks, develops pre-eclampsia, but it's mild. And we think, well, right now, baby is better off in the out. Let's give the steroids in case we need to deliver early. That helps baby get better lungs. Three or four days later, it all gets worse. Suddenly the baby's better off out than in. Well, bingo. We've given the steroids. And even though we're delivering 34 weeks, baby comes out with lungs like a 36 week and everybody's happy.
Brigid [00:12:39] Yeah. Wow. So is it all just dependent on age and stage, gestational stage? What happens, for example, if the baby is 30 weeks and it just has to be delivered? That's just a premmie situation?
Patrick [00:12:53] That's the way it is.
Patrick [00:12:53] So a certain number of very premature babies are that way because we've we've made them come. They know that they haven't all come by themselves. The only true treatment for pre-eclampsia is delivery, and that's the way it is. So if we've got a mother in danger, we have to get the baby. And we would try and prepare for that as best we can. But, you know, at any given time, you know, in a special care nursery, there'll be some prem babies who we made them be prem to treat the mother.
Brigid [00:13:25] So it's not just a risk to the baby. Preeclampsia can have a risk to the mother, too?
Patrick [00:13:29] Absolutely. So untreated it will it'll progress sometimes rapidly. There seems to be almost two types. There's a there's a slowly grumbling type where you can buy more time and there's a rapidly progressive type where the woman's fine one day and not the next. But we talked about the way pre-eclampsia causes organs within the mother's body to play up, kidney start leaking protein. The liver can become inflamed. But when the preeclampsia affects the woman's brain, she'll have a fit, a seizure. Okay. So in the developing world, seizures from pre-eclampsia are and the difficult management of that is responsible for quite a lot of the poor data of women not surviving pregnancy, would be under managed preeclampsia. And thankfully in the developed world, we picked this up before that happens. But if someone's in danger of that, if they're looking like they're showing a set of signs and symptoms, that they're getting rapidly sicker, then we bring that woman into the hospital and we start an infusion of some stuff called magnesium and magnesium given to them will change the seizure threshold so she won't have a fit. And then we buy ourselves some time to get the baby out and make sure the mum is safe.
Brigid [00:14:47] So what are the main signs of that Rapidly deteriorating pre-eclampsia?
Patrick [00:14:52] So it'll often be that the woman has not just the high blood pressure or the swollen ankles or the protein in the urine, but she's starting to get symptoms. So a severe headache is one of them. And that's the pre-eclampsia starting to affect the brain. Epigastric pain right in the middle, just below the sternum. That's the preeclampsia starting to affect the liver and hyperreflexia. So you examine woman and her reflexes are really increased. You only just touched below the knee and you only will kick right up. And that's a sign of an irritated central nervous system as part of the preeclampsia. Yeah, right. So we put all that picture together and say hang on this isn't just high blood pressure. This isn't just a mild grumbling case of mild preeclampsia. This is the real thing. Yeah. Into the hospital. Magnesium to avoid a fit and deliver.
Brigid [00:15:42] And how does that work? Well, I'm guessing you're gonna say it depends on the severity, but how does a woman with pre-eclampsia deliver?
Patrick [00:15:49] Depending on the severity. So we might we might easily have time to go for a vaginal birth. Best case scenario, that woman's had some babies before and she's near term. Yes. So we do a vaginal examination. Cervix is two centimetres favourable. I say that a lot. Favourable, favourable. So two centimetres. The cervix is nice and soft. It's not dilated in that she's already in labour. It's something called a multi os, which is that's just as close as the cervix gets. Yeah. When you've had some babies before. So it's just sitting there two centimetres easily allows us to break the waters, put up a drip to get the labour started and go for it even though she's got high blood.
Brigid [00:16:29] Well hypertension. Can she still sort of withstand this syntocin?
Patrick [00:16:35] And often it seems like women with severe preeclampsia, their body almost needs, almost knows the baby needs to get out because they often labour very well and it needs expert observation. One of the things that can happen with very severe pre-eclampsia is that it can affect your body's blood clotting systems. So if you lose your body's blood clotting, then having her vaginal birth or a caesarean section might be more dangerous. Right. So we've got to keep watching and make sure the body's clotting normally. And if it's not, we can give stuff from donor blood products to make it to restore its clotability until the baby's out in the preeclampsia passes. Wow. So it's funny. Preeclampsia is serious in an emergency, but it's also an everyday phenomenon,.
Brigid [00:17:20] Well especially at 7 percent. Like that's quite high.
Patrick [00:17:22] Yes. So it's an everyday phenomenon on Obstetric units is the management of preeclampsia. And in fact, you know, we talk about the big gains that we got in safety for women and babies in the 20th century and the proper management of preeclampsia would be right up there. Yeah. Safe caesarean sections and the proper management of pre-eclampsia probably are to thank for most of those safety gains. Yeah, right. Yeah.
Brigid [00:17:44] And so if a woman's had pre-eclampsia once, what's the risk for her in any future pregnancies?
Patrick [00:17:50] Yeah, it's interesting. I mean it's definitely higher than some random and a randomly selected person from the woman from the rest of the community. But the woman's actual risk, it depends a little bit. And one of the one of the interesting things is it depends on if she keeps the same partner.
Brigid [00:18:05] Oh, really? So, yeah.
Patrick [00:18:07] So if she has another baby with the same partner, the risk is less and that might have something to do.
Brigid [00:18:15] I'm so puzzled.
Patrick [00:18:15] We don't know. We know that that's a thing. But nobody knows exactly why it's a thing. But it does seem this is still a subject of research. We know how to fix preeclampsia. We still don't know exactly what it is or exactly what causes it to be. Good if we did. But to a certain degree, it might partially have an immune basis. And it might have something to do with the maternal response to paternally derived genes within the foetus.
Brigid [00:18:45] Oh, my God.
Patrick [00:18:46] So that might explain if you have another baby or the same person that you don't have such a strong reaction. You know, we're talking about possibilities here. We don't know this for sure. Getting you partner, you're preeclampsia risk goes back up again.
Brigid [00:19:02] It's like a new roll of the dice?
Patrick [00:19:02] Yes, a new roll of the dice. And so it's one of the many reasons why you should hang on to your existing partner. All things being equal,.
Brigid [00:19:12] You say that to me. Lucky I didn't have pre-eclampsia. Exactly. Yeah. Yeah. So what happens in future pregnancies then?
Patrick [00:19:21] Well, we might just watch that woman a little more closely. We watch everyone closely, but we might just watch that woman a little more closely and as the weeks go by. And in particular, when she approaches the weeks that she was when the preeclampsia kicked in last time. So if she had preeclampsia 35 weeks last time, then maybe 33, 34, 35 weeks this time, we might be bringing her to clinic more often, making sure she seems that sees a senior experienced obstetric person.
Patrick [00:19:50] Yeah. And taking any deviation from the normal course very seriously. Yeah. So someone else, if their blood pressure was a bit high, we might say that might be having a bad day. Yeah. But for that woman with that history we say its probably preeclampsia again. Let's let's admit observe do some more tests, take it seriously.
Brigid [00:20:10] Is that when you say admit is that somebody that gets told to have bed rest or bed rest doesn't help bed rest itself doesn't help?
Patrick [00:20:18] When I say I admit we're just we might admit that person for surveillance. Yeah. Yeah. So. So it's hard outside the hospital to do a blood pressure every half an hour for hours at a time. Couple of tests a day. Couple of CTG tests a day to make sure the baby's okay. Get an ultrasound. Sometimes the most efficient way to get all that done in one day is as an inpatient. And some people turn out to be fine and go home and other people deteriorate and the best place to deteriorate is in the hospital where we can move on quickly. Especially because as a disease, it's prone to getting rapidly worse.
Brigid [00:20:52] How often do you see preeclampsia? 7 percent of all your pregnancies?
Patrick [00:20:58] It's a weekly thing to consider.
Patrick [00:21:02] And, you know, and most weeks I'm in the public, all the private system, I'm treating it in one form or another.
Brigid [00:21:08] Yeah. I didn't. That's surprised me. I didn't realize it was so common.
Patrick [00:21:12] Yeah. Yeah, it is. So. So it's one of the many reasons why it used to be dangerous to have a baby.
Brigid [00:21:18] Yeah. Yeah. Well a big take for modern obstetrics. All right. Well I think we've covered everything we had on our list for hypertension and preeclampsia?
Patrick [00:21:28] Yeah. It's one of those things that I think it's not rare and we should know something about it.
Brigid [00:21:33] Yes. Yes and not avoid. Yeah. Yeah. Not.
Patrick [00:21:36] Not so that we hope it happens to you, of course we don't! But it is because head in the sand doesn't work.
Patrick [00:21:42] Yeah. This is something you may well and may well happen.
Brigid [00:21:45] Yep, when you know better you go better. That's definitely the ethos that we try to do everything from. Yeah.
Patrick [00:21:51] It's a bit like birth by caesarean section. It's not rare. So whilst you might not want it and you might not be planning for, it seems to me sensible to know something about it. Yeah, that's right. In case it winds up happening to you. Yeah. And that's not struck by lightning bolts.
Brigid [00:22:09] Yes, that's right. There were 33 percent of something. Something like that. Yes. Australian stats the other day. So worth worth knowing something about.
Patrick [00:22:16] Yeah. And by all means keep your attitude that you don't want it to happen and keep your attitude that you'll be, you know, really hopeful and planning and staying in good nick, watch your body weight and all those things that can help you avoid it. Yeah, but knowing a little something about it is what we're all about. Yeah, exactly our podcast, our Insta, our pregnancy program and preeclampsia in there.
Brigid [00:22:39] Yes, definitely. So if you've got any little comments that you want to make, please do so. We'd love to hear from you either as a DM on our Instagram which is @grow_my_baby or even leaving a review on our podcast. We listened and we read all of them short. We love them. And until next time, keep well and keep safe. Thanks for listening, everybody.