Episode 202 - Pre-eclampsia management: the balance between protection and prematurity
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to the Great Birth Rebellion podcast. Our last episode was about preeclampsia. It was part one of a preeclampsia series. And we talked about the diagnosis, possible ways to prevent it, possible ways to predict it, what preeclampsia is. Today, this episode is more focused on if you've actually been diagnosed with preeclampsia. That's not to say that you shouldn't listen to this episode, because if you are diagnosed with preeclampsia, it can progress pretty quickly and there's not a lot of time for decision making. And so this is a great episode to just have some mental preparation. If it happens to you, then you've got a little bit of information to help you on your journey.
[1:09] You may be listening to this for a loved one or a client. It will be equally as helpful.
[1:15] Hello, Rebels. If you'll just give me 40 seconds of your time, I would like to personally thank the sponsor of this podcast because that means
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[2:20] Let's get started on today's episode. So last episode, we started our discussion about preeclampsia and we learned that preeclampsia actually starts right at the beginning of your pregnancy with the altered implantation of the placenta, which later leaves you predisposed to developing preeclampsia.
[2:40] As a result of that poor implantation. And there's a cascade of events that occur that are inflammatory, immunological, chemical in nature. And they start to involve multiple maternal organs in the pathology of preeclampsia.
[2:58] And we learnt that preeclampsia can progress quickly or slowly. And because of that care providers try to act quickly to get a diagnosis and monitor your condition because we need to work out are we or are you in a circumstance where preeclampsia is progressing quickly or slowly do we have time.
[3:21] Or do we need to act now? In that last episode, we also talked about how preeclampsia is a collection of symptoms that point to the fact that you are heading for preeclampsia. So preeclampsia are a collection of recognizable, diagnosable symptoms that point us in the direction where you're heading for a more serious condition of eclampsia or HELP syndrome.
[3:45] So if you are coming to this episode in a hurry because maybe you've got preeclampsia this is part two but for full context and full understanding of the condition the previous episode is a must listen before getting into this one this episode is just a continuation of the groundwork that we laid in the last episode so settle in for an hour and a half or so listen to both episodes wherever you are in your pregnancy journey because those two go together and I do want to say if you're coming to this with preeclampsia the shock and emotion of it might still feel really raw and new and that's okay and very normal because a diagnosis of preeclampsia can really change a lot of plans so some big deep breaths while you listen to this episode take your time and help process all of the feelings that are going to come up if you're sitting here with preeclampsia so to pick up where we left off in the last episode. We know that preeclampsia is diagnosed by a series of tests. When we consider them together, we can put together a picture that point to the diagnosis of preeclampsia. But there are some symptoms that you can feel as a woman and the things include potential puffiness in your face and your hands and feet, a frontal headache behind your eyes and over your forehead, visual disturbance.
[5:13] And as things progress, it can move to abdominal pain, so in your gut, up under your ribs. But also, remember, top tip is that the headache that's felt from preeclampsia, usually it can't be remedied by over-the-counter pain medication. So if you've got a headache in pregnancy and it seems like none of the over-counter medications are helping, that is a red flag to consider that this could be developing preeclampsia. So then if you feel those symptoms and then your care provider checks on you and they find a collection of other measurable symptoms, including an increase in your blood pressure, protein in your urine, an increase in the protein-creatinine ratio in your urine, they'll know how to check for that. They'll check your blood and they'll see that there's potential altered liver function, an altered kidney function from a liver and kidney function test. And they will also have a look at your at a full blood count and see what your platelet count is because that can start to drop in the later phases of preeclampsia as well so when all of these things are put together and considered your care team is left to decide is this preeclampsia is it developing slowly or quickly how often should we keep monitoring this scenario is this serious? Do we have to act now? And are these tests we are even doing to diagnose preeclampsia even appropriate and accurate?
[6:41] So preeclampsia diagnosis is not black and white. It takes thought and finesse and a dialed in and attentive care provider to monitor and manage your circumstances because preeclampsia is not the same for everyone and each woman needs a different management strategy. This is not a one size fits all scenario and in fact, there is controversy and varying levels of research about the exact criteria for preeclampsia which varies depending on your care provider and facility. Knowledge about preeclampsia is evolving so just know that we are very far from being very good at diagnosing and managing preeclampsia but at this stage we're doing the best with what we've got. My suggestion though is that if you feel like you've been misdiagnosed as either having or not having preeclampsia, do your very best to bundle up all of those test results that you've been given from all the tests that you've been getting and see if you can seek out a second opinion from a trusted care provider who maybe can have another look at all your test results and give a second opinion about a diagnosis.
[7:51] So for those thinking, and you know, you're listening and you're thinking, well, preeclampsia diagnosis research is watertight, and maybe I've got it all wrong. I would encourage you to read the articles in the resource folder. So the resource folder is something that is made available to anybody who's on the podcast mailing list. You get an email every Monday with a link to the podcast resource folder. And in there are all the papers and all the research that I use to create every single podcast episode. Now, when you have that link, you can access the research from all previous episodes as well, but we send that out to our mailing list. So if you want to get access to the resources, just scroll to the show notes of this podcast down below, click the link, and you'll be able to join the mailing list to get access to the resources.
[8:41] So go ahead, have a look there if you feel like you need to look deeper. But there is a great paper in there it's called the evolution of the diagnostic criteria of pre-eclampsia and eclampsia and it gives a great overview of the progress and controversies around pre-eclampsia diagnosis and there are lots of other papers in there to show the gap between current pre-eclampsia research and current professional guidelines.
[9:09] Some of the guidelines that are being used are not in line with current evidence, which should be no surprise to you if you've been listening to this podcast for any length of time. You'll know that there is often a gap between the research and clinical practice and clinical guidelines. So this podcast tries to aim for research evidence-based information, and you'll see all of that in the resource folder. So in the last episode, we spoke about the tests that you'll be offered if your clinician thinks you might have preeclampsia. So now let's talk about the diagnostic criteria, which means, you know, how do we properly diagnose it based on the tests that you've had? So many clinicians will still believe and tell you that preeclampsia is increasing blood pressure. so a blood pressure over 140 or 90, paired with protein in your urine. Even if there's an absence of all other symptoms and your blood pathology is normal, there are still a lot of clinicians and facilities that will diagnose you with preeclampsia with just those two things. You may not even have any symptoms.
[10:19] So first know that there is a collection of clinicians and a collection of facilities in institutions, hospitals, who will have a very low threshold for diagnosis. In fact, there's lots of hospital policies that state that you could be diagnosed with preeclampsia with just two symptoms, an increased blood pressure and protein in your urine. That might be okay because it means you're going to get lots of extra monitoring. But one of the other issues is that some facilities, based on those two things will offer you an induction or recommended induction. So from what I know of preeclampsia clinically, but also as I researched for this podcast episode, that this approach, it's called a narrow diagnostic criteria for preeclampsia. And in fact, the research suggests that we should approach diagnosis differently. And the research advocates for what they call a broad approach to diagnosis. And I'll explain what that is. But for now, just know that you'll likely be diagnosed based on the policy of the facility that you're at. And I'm generalizing here, there might be some clinicians within that facility who get to make their own clinical decisions and they don't have to follow the diagnostic criteria set out by a hospital policy.
[11:43] But if you're wondering what the criteria is within your facility, you can just ask them. They'll have that all on a policy document. And again, this will be different if you have a private care provider like a private obstetrician or a private midwife. They will be able to consider lots of different things. They'll have their own strategy for diagnosing preeclampsia. But many will lean into the hospital policy to define a diagnosis rather than taking the time to consider your personal circumstances and your symptoms. And also, some might not even take the time to track the progression of your preeclampsia. and they'll be very quick to recommend birth of the baby, either by induction or cesarean section. So I wanted to mention that because it's something that you might encounter if you've been diagnosed with preeclampsia, is it may feel a little bit like the clinician has given you a diagnosis, given you a treatment strategy, which could include birth of the baby if you're a full term. And if it all just feels a little bit like you haven't been given individual attention, consider those elements I just mentioned.
[12:54] So I did have a look at a few local hospital policies around where I am and a few around in other Australian states and territories. And if you're tuning in from overseas, you can do a search for the preeclampsia policies in the facilities near you or ask your care provider to print off the preeclampsia policy or the hypertension policy next time you're at an appointment. And then you'll properly understand the diagnostic criteria that's accepted in that facility. So it may not be an accurate one, but at least you know what you're working with. So let's have a look at what the research and the academic literature suggests about preeclampsia diagnosis. And there's a great paper in the resource folder. And it's a paper that looks at lots of different practice guidelines and just sees how well they align to research evidence. And this paper found that most guidelines defined preeclampsia as occurring after 20 weeks in association with at least one other target organ manifestation. So that means is there kidney malfunction? Is there liver malfunction? Is there neurological malfunction? And how is the placenta functioning? So if your blood pressure is going up and they check one of those other organ manifestations, symptoms, and one of those is also deranged, then they're lining you up for a preeclampsia diagnosis.
[14:23] The paper suggests that some guidelines still provide a traditional, what they call traditional preeclampsia definition, which is narrow, and that regards proteinuria, so protein in your urine, as a mandatory symptom that's combined with hypertension. So your blood pressure is 140 over 90. They're saying we can only diagnose you with preeclampsia if you also have protein and some other symptoms. But a lot of other guidelines defined preeclampsia more broadly, and they don't make protein urea mandatory as a symptom. So if your blood pressure is going up, there's no protein in your urine, but you do have those symptoms that you can feel, the headache, visual disturbance, puffiness, you might have tummy pain, nausea, and then your blood work is deranged.
[15:20] Then they will still diagnose you with preeclampsia even in the absence of protein in your urine. So they also considered the other organ manifestations because it impacts your liver and your kidneys and your placenta, as I said. Now, fortunately, in this paper, they explained that a lot of the laboratory tests and pathology tests that they'll do to check for preeclampsia are pretty routine and across the board. So pretty much wherever you go, if you're trying to diagnose preeclampsia, They'll do blood pressure, urine testing, blood testing. Quite likely, you'll also get some fetal monitoring and potentially an ultrasound. So what I'm trying to say here is that if your care provider has told you that you have preeclampsia because your blood pressure is elevated and you have protein in urine, and that they're suggesting it's time to get your baby out due to just these two things, Consider that the research suggests that we use a more broad and thorough definition and it's okay to be requesting a more thorough diagnosis where the clinician will actually go to the effort to check all those other diagnostic markers before making a diagnosis.
[16:35] So preeclampsia is too important not to miss, but if the diagnostic criteria is too narrow or the care provider is too quick to give a diagnosis without all the information, it's possible that women are being labelled as preeclampsic and induced unnecessarily because the care provider is working off a less thorough diagnostic criteria.
[17:00] Or they also maybe don't have the personal or professional capacity to track the progression. You know, do we have time? Do we have to have the induction now? Or can we have some monitoring or a plan on what to do next that maybe doesn't have to involve birth? There could be other reasons that your blood pressure has gone up, including hypertension, gestational hypertension, which is just high blood pressure in pregnancy. In the absence of other pathology, no other symptoms.
[17:34] Or we do recognize now medically something that's called white coat hypertension. So actually your blood pressure only goes up in the presence of a healthcare provider and that when women check their blood pressure themselves or with a trusted care provider, their blood pressure is very, very different. So both of those things don't require immediate induction and they aren't pre-eclampsia. And they're managed differently to preeclampsia. So diagnostic efforts should be focused on getting a full symptom picture to ensure that we aren't over-diagnosing preeclampsia either.
[18:11] So the NICE guidelines, NICE, NICE, whatever you want to call it, these have been long considered to be very thorough and I have included their full research process and reference list as they created their guidelines, which is in the resource folder. And so the NICE guidelines, basically, what they do is they select some things. So in this particular guideline, it was about blood pressure in pregnancy, so hypertension, hypertensive conditions, including preeclampsia. And they will offer their recommendations of what tests to do.
[18:51] You know, treatment plan, management plans. And the great thing about the NICE guidelines is that they're heavily researched. So they actually better align with current research than a lot of other guidelines. And they provide their reference list and it's quite thorough. So I've included all that in the resource folder. And I'm going to talk from that for a minute. And the NICE guidelines state that a clinician should interpret proteinuria measurements, so proteinuria urine for pregnant women in the context of a full clinical review of symptoms, signs, and other investigations for preeclampsia. So in that one sentence, they said what I've pretty much been saying for the last half of the podcast. And that's important because a diagnosis of preeclampsia puts a time limit on your pregnancy. The only definitive treatment that your medical provider can offer you is a plan to give birth to your baby either by induction if you're well enough and if your baby's well enough for an induction and if there's enough time or a cesarean section will be recommended if your condition's more serious.
[19:59] So getting the right diagnosis is pretty high stakes because the treatment is to give birth to your baby. So the first step is to get an accurate diagnosis. And then if you do have preeclampsia, your care provider will have an interest in managing your blood pressure and the symptoms as well. And then they want to track the progress of preeclampsia. So preeclampsia, The progress is an important thing to know. Is this getting worse quickly or slowly?
[20:30] And so the very first thing that you'll be offered is medication to control your blood pressure and there's a variety of options and clinicians are encouraged to choose the most suitable one for each woman and potentially try a number of them in order to get blood pressure under control as an initial step in pre-eclampsia management. So here we are, we're just managing preeclampsia. We can't cure it. The only cure is to no longer be pregnant and then wait out the few weeks after pregnancy while the symptoms alleviate. And I've experienced the full spectrum of this amongst my own clients. I've had clients who were admitted to hospital for weeks and weeks for preeclampsia for monitoring and management while they were still pregnant. Because if a woman is diagnosed with preeclampsia early in her pregnancy, the intention is to keep their baby in as long as possible while they closely monitor the preeclampsia.
[21:28] But then there's others whose condition has deteriorated within a day or two and the window for a safe induction is closed and it becomes obvious that as preeclampsia causes more and more issues, quickly for them a cesarean section is offered. So I personally, in my own work as a midwife, have seen the full spectrum of what preeclampsia can do. So each scenario is different. So while you can't control preeclampsia, if you have a dialed in and attentive care team, they can help tailor a plan that's most suited to your personal circumstances. And it's all about management, managing the symptoms and monitoring so that we know the optimal time for you to have your baby.
[22:14] And expedite that if it seems like things are progressing and you're getting more and more unwell. I know some of you might be here looking for exact numbers and values for all the tests that you might have and you might be sitting there with your own blood tests wanting me to tell you what the clinical cutoffs and levels are for preeclampsia so that you can check them and see if your circumstance is accurate but I'm not going to do that here live on the podcast but in the resource folder you'll find a number of clinical guidelines including the NICE guidelines and the Queensland Health guidelines are also pretty good. They give a specific diagnostic criteria as well as the actual number of values and results that they're looking for on the blood tests. So they might be of assistance for you if you want to compare your own blood test results and your own testing results to those that are listed out in the guidelines. So you've been diagnosed with preeclampsia.
[23:12] Just know that of course you will be offered medicine and a planned birth, by way of managing preeclampsia in the system but there are other complementary options that you could combine with your care if you want to take things into your own hands and you can do this in conjunction with the care that the hospital is already offering you. There are some complications in pregnancy that I do believe don't need medical attention, but preeclampsia is not one of them. By all means, you can use complementary therapies that feel right to you, but I would strongly suggest that you don't use them instead of medical treatment. For those of you who've been listening to the podcast for a while, you know that that sounds counterintuitive to what I normally talk about, but this is a different scenario altogether. So some complementary options for treatment and management are acupuncture and acupressure. And these two things have some research behind them with regards to prolonging the gestational period that you can stay pregnant and helping to stabilize a woman's condition so they can stay pregnant longer. So it doesn't cure preeclampsia completely, but it helps manage the symptoms to delay its progression obviously alongside the supportive care that you'll get from your hospital and from your care provider that you know that hopefully you're receiving through a medical facility.
[24:41] Are you getting ready to have a baby and if you are what are you going to do about the pain of contractions? There are lots of things you can do in fact I'm going to tell you about them because I've been watching women give birth without pain relief for over 18 years. I'm Dr Melanie Jackson and I'm a home birth midwife. I had my own babies at home without pain relief and I've been helping other women do the same for my entire career. If you want the top tips and tricks that I recommend to help women give birth without pain medication, it's all here in the link below in my guide to giving birth without pain relief. You can do it. Give it a go. Why not just prepare?
[25:23] So here's where it becomes tricky, that you're pregnant and you've been diagnosed with preeclampsia and depending on how many weeks you are, there will be a number of possible courses of action. So if you are less than 37 weeks pregnant, the focus will be on trying to control your blood pressure and prevent complications for as long as possible so they can keep you pregnant for as long as possible to try and prevent the complications of giving birth to a premature baby. But of course, where the risks of preeclampsia have become higher than the risks of preterm birth, then you and your care team are confronted with a decision of potentially planning an early birth because the other option could be severe preeclampsia and the sometimes irreversible consequences of that if it progresses to eclampsia or HELP syndrome. So to track the progression, the rest of your pregnancy, you'll now spend monitoring your blood pressure, any of the symptoms that you're already feeling, checking your urine and blood at various intervals, possibly every second day. If you're still out in your home, sometimes with milder versions of preeclampsia, they might send you home and give you a plan to have care set out in the community, or they may admit you to hospital for monitoring.
[26:52] But basically now, and I'm really sorry to say it, because if you have preeclampsia, this is sort of the time to make decisions about stopping your current life plans. So if you are still working, it's time to take leave. If you are caring for other children, your other children, it's time to seek full-time help with that. And whatever your circumstances, this now, this diagnosis of preeclampsia is going to require putting the brakes on normal life, gathering your help around you so that you can be responsive to the symptoms that you're feeling, so that you can go and get the tests and checks that are required and you're ready to plan your birth if your condition deteriorates.
[27:42] So you are now experiencing acute and sudden illness and it needs your attention. It's not your fault, but it is your responsibility. And I would love to water this down for you. And I know that preeclampsia often creeps up on women and there is this confusing time where you're trying to come to terms with this news, especially if it significantly affects your birth plans or the birth location. If you were planning a home birth or if you're an MGP or something that means it really changes things for you, then this is a huge adjustment and surprise.
[28:21] I'm really sorry if you're in this circumstance. It's a really emotional time. So take some time to adjust to this new reality. You can have a huge big cry. do whatever you need to do to come to a place of some acceptance that this is happening so that you can think clearly about the next steps. You are unwell and now it's time to make decisions about which interventions to accept and when they're best timed. It's a balancing act between prematurity for the baby and worsening preeclampsia. So you want the baby to be as old as possible, as many weeks pregnant as possible but you also need the baby to be born before it starts to get compromised by preeclampsia and before your body progresses into a state of eclampsia or help syndrome so.
[29:14] Some of the consequences of preeclampsia can't be reversed. If things go too far, there can actually be organ damage and body damage to you or your baby, and there is a risk of placental abruption and stillbirth. So the timing of these decisions is paramount. We don't want to jump straight into induction or cesarean section. If there's time, you might have a whole week or two where you are simply being monitored, and that could be suitable because your condition is stable or you might need something today. So the next stages are just uncertain and things and recommendations can change quickly. So that's why I say stop what you're doing, focus on this thing that's happening so that you can be responsive and flexible to the changing situation. Gathering people around you is going to be the key in this and this is going to relieve you of your usual responsibilities so that you can care for yourself and that's the important part here.
[30:17] This will actually also be important to have gathered and rallied people because preeclampsia doesn't just stop after you have the baby. So the current treatment plan for preeclampsia is as soon as you are full term that the baby would be born. So having the baby is the only sort of solution or cure, but it can take up to two weeks, sometimes longer, to reestablish control of the woman's blood pressure and for your body systems to return to a normal function. So postnatally, women are still at risk of seizures and eclampsia, and many require ongoing medication
[30:57] in the early weeks and months to stabilize their blood pressure. So recovery takes time. There are some things that can be solved, you know, gestational diabetes. Once the placenta is born, you no longer have gestational diabetes. It's not the same with preeclampsia. The risk exists still postnatally so close monitoring will still be offered to you. So activating your support network also means that they are hopefully around and alert for.
[31:29] Complicated postpartum period too. So women with preeclampsia will often be cared for for longer in hospital and then receive regular at-home care and checks to keep monitoring your condition. This might be taken over by your regular GP so the hospital might send you home and recommend follow-up with your GP or they may have their own specific plan. So it doesn't just all end once the baby and the placenta are born so let your people know that not only is there going to be this all-consuming run-up to the birth which is dynamic and things can change quickly.
[32:07] And it it might not be the birth that you were planning or anticipating which is a whole other thing to come to terms with when you've been diagnosed with preeclampsia but also realizing that there's a journey on the other side and it compounds the parenting journey that you're about to go on and it can also be complicated by having a preterm baby.
[32:30] So my final words are that when you have preeclampsia, you are not only on this new unexpected physical journey where all of your end of pregnancy plans change, your birth plans change and your early postpartum
[32:46] will look different, but it's this huge emotional journey. So you may encounter some very tender and conscious care providers who acknowledge this, but my experience would tell me that most of your care providers are going to be fixated on your physical experience and they will forget how emotionally taxing and burdensome this is for you pre-eclampsia hijacks your pregnancy birth and postpartum so while your physical health is important just also be conscious to make purposeful steps to nurture your emotional mental and social health and the most practical way to do that is to bring people around you that fill you with comfort.
[33:33] Do small and frequent things for yourself that are nurturing and nourishing and call on the practical help for usual life things like cleaning, shopping, food prep, home responsibilities, caring for your children. I'm so sorry if this is happening for you and I wish upon you a journey where you are cared for, where you're allowed the time to consider your options and where your care providers are kind and gentle and where you have all the support that you need to carry you through this.
[34:06] You've got this. That has been today's episode of The Great Birth Rebellion and we will see you in the next episode. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com, And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at TheGreatBirthRebellion.com. Follow me, Mel, @MelanieTheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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