Preeclampsia in Pregnancy: Warning Signs, Symptoms, and When to Call
Preeclampsia is a serious disorder of pregnancy that occurs after 20 weeks. It is a disease related to the placenta that causes mom’s blood pressure to become dangerously high and can cause issues with many of mom’s other organ systems. It can occur to anyone, but is more common in women who are over 35, have never had a baby, or in women with a history of preeclampsia in a previous pregnancy. Complications related to Preeclampsia (PreE) can be life threatening, especially if not recognized and managed appropriately, and it is one of the biggest causes of maternal morbidity and mortality nation-wide.
At Calhoun Women’s Center we want patients to know a couple things:
If you are feeling unwell, you should always feel welcome to call and check in.
Most symptoms of pregnancy (headaches, swelling, etc) are not preeclampsia and are completely benign, but sometimes they are not, and it never hurts to ask.
Preeclampsia is a complex diagnosis and if you are ever concerned, you should call and check in.
What is preeclampsia?
Preeclampsia is a pregnancy-related hypertensive disorder that develops after 20 weeks of pregnancy. It is defined by new-onset high blood pressure with either high levels of protein in the urine or other signs that organs such as the kidneys, liver, lungs, blood, or brain are being affected. Importantly, some women have preeclampsia without proteinuria, which is why the diagnosis depends on the full clinical picture rather than one finding alone.
Who is at higher risk?
Preeclampsia can happen to anyone. However, some women are significantly higher risk of developing the condition. Risks are higher with:
First pregnancy
Twins or multiple gestation
History of preeclampsia
Chronic hypertension
Diabetes prior to or during pregnancy
Lupus
Antiphospholipid antibody syndrome
Obesity
Maternal age over 35
Kidney disease
Assisted reproductive technology
Obstructive sleep apnea.
Even without risk factors many cases still occur in otherwise healthy patients with no obvious risk factors.
Common warning signs
Please call us if you develop any of the following, especially in the second half of pregnancy:
Headache that does not go away
Blurred vision, spots, flashing lights, or other visual changes
Pain in the upper abdomen, especially on the right side, or significant epigastric pain
Shortness of breath
Nausea or vomiting that feels unusual later in pregnancy
Sudden swelling, especially of the face or hands
Elevated blood pressure readings at home
A sense that something just does not feel right
A practical note: headache can be nonspecific, so it is not by itself a perfect diagnostic marker. The bulletin specifically says a careful diagnostic approach is needed when corroborating findings are absent.
A note about swelling
Swelling is usually normal in pregnancy. When it is accompanied by New high blood pressure it can be concerning for preeclampsia. Swelling without high blood pressure is usually fine and nothing to be worried about.
How is preeclampsia diagnosed?
Preeclampsia is diagnosed using a combination of blood pressure and lab work along with your clinical findings.
Blood pressure criteria
140/90 or higher on two occasions at least 4 hours apart after 20 weeks in a patient with previously normal blood pressure (some patients have high blood pressure outside of pregnancy and this is more complicated to diagnose in those situations).
Anything 160 or higher for the top number or 110 or higher for the bottom number may be confirmed within a shorter interval to allow timely treatment. This is typically a more severe form of preeclampsia. Again this is assuming patients don’t have high blood pressure outside of pregnancy (which makes things more difficult to diagnose).
Proteinuria criteria
300 mg or more in a 24-hour urine collection
Protein/creatinine ratio of 0.3 or more
This is NOT REQUIRED to make the diagnosis
Some patients have protein in their urine at baseline, so this can be more complicated than simply getting a single measurement
Preeclampsia can also come with other significant lab findings that indicate a severe version of the condition:
Platelets below 100,000
Creatinine (labs that measure kidney function) greater than 1.1 mg/dL or doubling of baseline
Liver enzymes elevated to twice the normal range
There are also clinical findings that can indicate a more severe version of Preeclampsia:
Fluid in the lungs
New-onset headache unresponsive to medication
Visual symptoms
What are “severe features”?
When doctors and midwives talk about preeclampsia we talk about whether it is severe or not. The reason for this is because patients who have “severe features” have a significantly higher likelihood of developing seizures (AKA Eclampsia). These seizures can be dangerous for patients and in order to reduce that risk we put these patients on a medication called “Magnesium Sulfate”. Preeclampsia with severe features includes any of the following:
Severe-range blood pressure: systolic (top number) 160 or higher or diastolic (bottom number) 110 or higher
Platelets below 100,000
Liver enzymes more than double normal ranges
Severe pain in the middle and upper part of the belly not explained by something else
Creatinine (kidney function) more than 1.1 mg/dL or doubling of baseline
Fluid in the lungs
New-onset headache unresponsive to medication
Certain vision changes
Why is Preeclampsia important
Preeclampsia can affect both mother and baby. It can be associated with serious maternal complications including fluid in the lungs, heart attack, stroke, difficulty breathing, difficulty stopping bleeding, kidney failure, and eye injury. Some effects on the baby can include Small size (likely because the placenta is not working well), low fluid around the baby, placental abruption (placenta separating from the uterus), and preterm delivery.
Ultimately, preeclampsia can progress to seizures (eclampsia) or even a complex condition involving failure of the liver (HELLP syndrome) and many other rare complications.
It is also important to know that preeclampsia does not always progress in a neat, predictable sequence. Ultimately, it is important to get regular care with an OBGYN/CNM who can help identify issues early.
When to call Calhoun Women’s Center
Please call us the same day if you have:
a persistent headache that doesn’t respond to acetaminophen
new changes in vision
pain just under the right ribcage that doesn’t resolve with antacids
shortness of breath
elevated blood pressure at home
a strong sense that something is off
We would always rather hear from you and help sort it out than have you sit at home worrying or miss something important.
When to go to Labor & Delivery or the ER right away
Please seek urgent evaluation immediately for:
severe headache
major visual changes
severe pain under the ribcage
trouble breathing
very high blood pressure
seizure
symptoms that are rapidly worsening
Can preeclampsia happen after delivery?
Yes. Preeclampsia and other severe conditions (such as HELLP syndrome and eclampsia) can first appear or worsen postpartum. A significant portion of patients don’t get sick until after delivery. This is one of the reasons why we don’t recommend going straight home after a delivery.
How is it evaluated?
If preeclampsia is suspected, evaluation commonly includes:
blood pressure monitoring
urine testing for protein
blood work to evaluate your liver function, kidney function, and blood counts
fetal assessment with ultrasound for growth and amniotic fluid and antepartum testing when indicated
In many patients this is an ongoing work up over the course of days to weeks as some people develop preeclampsia over a longer period of time. This can often look like having multiple appointments a week and include several ultrasounds and repeated lab work. This all depends heavily on what is going on with an individual patient.
What treatment may involve
Treatment depends on how far along you are in the pregnancy, the severity of your condition, and overall how you and your baby are doing.
For preeclampsia without severe features, expectant management with close surveillance is appropriate in selected patients until 37 0/7 weeks, and delivery is recommended at or beyond that point.
For preeclampsia with severe features at or beyond 34 0/7 weeks, delivery is generally recommended after stabilization.
For selected stable patients with severe features before 34 0/7 weeks, expectant management may be considered in an appropriate setting with close maternal and fetal surveillance. This tends to require prolonged stays in the hospital.
Ultimately, treatment can be complex and recommendations can range widely for individual circumstances. It is important to be under close care of your doctor and CNM team.
Common misconceptions
“If I don’t have protein in my urine, I can’t have preeclampsia.”
Not true. This was a change that was recognized over a decade ago that not all preeclampsia causes protein in the urine.
“If I’m swollen, I definitely have preeclampsia.”
Not necessarily. Swelling alone is not diagnostic. And, as discussed above, is typically very normal in pregnancy assuming all else is well.
“If I feel okay, I’m definitely fine.”
Not always. Many patients with preeclampsia are completely without symptoms
“This only matters before delivery.”
False. Preeclampsia, HELLP, and eclampsia can occur postpartum.
Our approach at CWC
At Calhoun Women’s Center, we take symptoms seriously without creating unnecessary panic. Our goal is to help patients understand what is common, what is concerning, and when they need to be seen right away. You should never feel silly for calling.
Professional references
American College of Obstetricians and Gynecologists.Gestational Hypertension and Preeclampsia. Practice Bulletin No. 222. Obstet Gynecol. 2020;135(6):e237-e260. Source bulletin uploaded by you.
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183:S1-S22. Listed in the bulletin references.
Bernstein PS, Martin JN Jr, Barton JR, et al. National Partnership for Maternal Safety: consensus bundle on severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017;130:347-357. Listed in the bulletin references.
von Dadelszen P, Payne B, Li J, et al. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet. 2011;377:219-227. Listed in the bulletin references.
Balogun OA, Sibai BM. Counseling, management, and outcome in women with severe preeclampsia at 23 to 28 weeks’ gestation. Clin Obstet Gynecol. 2017;60:183-189. Cited by the bulletin in Box 4.
