Toxemia – Pre-eclampsia and Hypertension in Pregnancy

For generations, the “toxemias of pregnancy” have perplexed physicans. The problem still does. We now know a lot more about the disease process than we did a 100 years ago…..but still have little clue of what causes it or how to prevent it. As recently as the early 1980’s, a reputable journal of obstetrics was reporting that a small, blood-borne worm was the cause. When injected into beagle dogs, the “worm” appeared to cause toxemia. Two years later, the “worm” was shown to be blood particles wrapped around talcum powder particles which had fallen from the gloves of the researchers. Fortunately, scientists are becoming much more enlightened with regards to the disease process of toxemia, but have yet to offer an explanation of the cause. It seems probable that the disease process arises where mother and baby meet…….in the cells of the placenta and uterine lining.

Approximately 6-7% of first-time pregnant women will develop toxemia. Less than 1% of women who have had a baby before will develop this problem. If not treated, this problem can lead to convulsions, blood clotting abnormalities, stillbirth, placental abruption, swelling and rupture of the liver, and even the death of mothers and babies. Fortunately, most cases are detected and treated before complications become serious. Screening women for this problem is a major component of prenatal care in the second half of pregnancy.

The old obstetric textbooks refer to this disease process as the “toxemias of pregnancy”. The suffix, “-emia”, means blood. “Tox-” refers to toxins, or poisons. The old-fashion idea of toxins in the blood of women with pre-eclampsia has all but died (but not entirely). The terms “toxemia” and “pre-eclampsia” are often used interchangably. But other terms may be used to refer to the same or similar problems……… “pregnancy-induced hypertension” or “PIH” is another term commonly used when discussing this problem. “Eclampsia” is the name given to the convulsions that can occur if “pre-eclampsia” is not treated. Since one of the components of this problem is high blood pressure (hypertension), some women will experience only blood pressure elevations without the other components of toxemia/pre-eclampsia. Together, all these names are used to describe the different manifestations of “the hypertensive diseases of pregnancy”. They may OR may not be components of the same disease…..no one is absolutely certain.

What we do know is that if a pregnant women develops significant hypertension (high blood pressure) and is losing protein through her kidneys (and into the urine), she probably has, or is developing, toxemia/pre-eclampsia. The classic triad of hypertension, proteinuria, and edema is the hallmark of the disease. The disease itself is characterized by spasms of the tiny blood vessels of the body. When these blood vessels spasm, less blood is delivered to the parts of the body they serve. Blood vessel spasm is the probable cause of the hypertension. The tiny blood vessels in the placenta may also be affected. This may explain some of the problems seen in the babies when the disease is severe or goes undetected…..growth retardation, fetal distress, and even death.

Some, if not most, of the women with toxemia/pre-eclampsia will experience an abnormal type of swelling. Swelling, or “edema”, is often a normal finding in a normal pregnancy. In fact, some studies have shown that healthy woman with healthy pregnancies who swell have healthier outcomes than women who do not swell. Swelling may be the body’s way of storing extra fluid for the demands of the pregnancy and to counteract the blood loss associated with delivery. In any event, swelling in women who do not have hypertension or proteinuria, is normal……especially, swelling in the hands and feet. The swelling often seen with toxemia/pre-eclampsia is generalized, that is, over the entire body….even the face and eyelids. But swelling is a “soft” sign of toxemia/pre-eclampsia, and not always obvious, and often confused with normal swelling.

There are some classic symptoms associated with the severe forms of toxemia/pre-eclampsia………headaches, epigastric pain, and visual disturbances. However, headaches are very common in pregnancy. Headaches, alone, are not indications of toxemia. Most pregnant women will experience headaches at some time in pregnancy. Usually these headaches occur late in the day and disappear with rest and fluids. It is generally alright to take an occasional acetominophen (like Tylenol) to make these disappear. They are probably the result of the stresses of the day. The word most often used with the headaches associated with toxemia/pre-eclampsia is “persistent”. These headaches are usually severe and persistent. Generally speaking, they will not go away with the usual methods. The epigastric pain associated with severe toxemia/pre-eclampsia is often in the upper middle of the abdomen just below the breastbone, or off to the right side. It is believed that this is due to a swollen liver. Visual disturbances, though common in normal pregnancy, are sometimes associated with severe toxemia/pre-eclampsia.

The progression of the disease is highly variable. Some women get very ill very quickly. Other women may exhibit signs of the disease in the last weeks of pregnancy and not show obvious progression. A particularly bad combination is the rapid progression of the disease before a baby is mature enough to be born……these women are often hospitalized, monitored closely, and delivered as soon as the baby’s lungs are mature enough.

One of the severe forms of toxemia/pre-eclampsia is called the HELLP syndrome. HELLP is an acronym for Hemolysis, Elevated liver enzymes, and Low Platelets. Hemolysis is the rupture of blood cells inside the blood stream. Liver enzymes are released when the liver is damaged or diseased. And platelets are one of the three cellular components of the blood….they help in the clotting of blood. HELLP syndrome is a very serious complication. If the baby is not delivered, the disease may progress very rapidly. The mother is at serious risk for liver rupture and blood clotting disorders. Often a woman with HELLP presents with a persistent pain in the upper abdomen (probably the stretching liver capsule). Since it is generally considered that the source of the problem is the reaction of the mother to chemicals produced in the placenta, delivery of the baby is the only cure. Often, the difficulty in treating the mother is the issue of prematurity of the baby. However, the baby’s life is in jeopardy, also.

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