PODCAST Preeclampsia Myths with Dr. Antonette T. Dulay

Season 6 | Episode 4

 

 

Merck Manuals Medical Myths Podcast –  What is Preeclampsia?

 

Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths podcast. On this show, we set the record straight on today's most talked about medical topics and questions.

Pregnancy is an exciting time, but it can also come with health risks and concerns. While the baby's health is a top priority, the health of the mother before, during, and after birth is just as important. It's essential for mothers and their families to recognize the signs and symptoms of many health conditions that can arise during pregnancy.

Today, we'll be focusing on one of them, preeclampsia. I'm your host, Joe McIntyre, and I'm joined today by Dr. Antonette T. Dulay. Dr. Dulay is the Maternal-Fetal Medicine Division Chief in the department of OBGYN at Mainline Health System located in the Philadelphia suburbs. She's also a senior physician with Axia Women's Health. She's board-certified in both maternal-fetal medicine and general obstetrics and gynecology. She was also recognized as a “Top Doc” by Philadelphia Magazine in 2024. Dr. Dulay is here to help answer some of the most common questions and dispel some of the myths surrounding preeclampsia. Dr. Dulay, welcome to the podcast.

Antonette T. Dulay, MD: Thank you, Joe, for having me here today.

Host: Well, it's great to have you. Let's first set our audience up with maybe a simple question, what is preeclampsia?

Antonette T. Dulay, MD: Preeclampsia is a common term that women who are pregnant will often hear. When they read books like, What to Expect When You are Expecting?, they can bet money that this term is going to show up. Preeclampsia, by definition, is experiencing new high blood pressure in pregnancy that develops after 20 weeks of gestational age. High blood pressure is defined as having that top number, or systolic reading, of 140 millimeters of mercury or higher and/or that bottom number, or diastolic reading, 90 millimeters of mercury or more on two or more separate occasions, at least four hours apart. So that's the high blood pressure part, but to have preeclampsia, you have to have that plus a specific amount of protein in your urine. Together, these factors make up the classic definition of preeclampsia.

Host: Got it. So, can you tell our audience what the difference is between a mother just having general high blood pressure and also having preeclampsia? What's the difference there and what's the risk factors of each?

Antonette T. Dulay, MD: First off, you have to differentiate high blood pressure, which is actually a similar definition, whether in or out of pregnancy. However, there are different types. There's chronic high blood pressure, hypertension, and that occurs before pregnancy or is found before 20 weeks of pregnancy. Then there's gestational hypertension, or gestational high blood pressure, that occurs after 20 weeks. Preeclampsia is in that mix - It's like a spectrum of disease, essentially. Preeclampsia, as I mentioned, happens after 20 weeks, but the difference is that you now have a certain amount of protein found in your urine. So why are they important? Well, first, just find out if you have high blood pressure or hypertension is crucial because it means that you're entering pregnancy with specific risks. For the mother, there can be risks like worsening hypertension.

We call that hypertensive emergency or urgency. Then those problems increase one's risk of things like strokes or even heart attacks. If we just look at what this means for what we call hypertensive diagnoses of pregnancy because remember chronic hypertension happens. It's a diagnosis you have coming in, but high blood pressure in pregnancy is when it's occurring after 20 weeks. And the two most common in there are preeclampsia and gestational hypertension.

So, while we're talking about preeclampsia, just if we take apart hypertension, which is the basis of all of it, so hypertension in pregnancy will actually bring to the mom the same risks that I just mentioned for those who have it coming in. So, you see it's like a whole spectrum of disease and complications. But to reiterate, a mom with a high blood pressure problem in pregnancy, be it preeclampsia or not, will have an increased risk of stroke, heart attack, and all their downstream effects and long-term impact of that too. 

For the developing baby or fetus, what are those risks? Well, there is a risk of the baby being too small, something we call growth restriction. There will be risk of placenta dysfunction, which can manifest as poor growth or low fluid, something we call oligohydramnios. Unfortunately, there's also going to be that scary risk of stillbirth or fetal demise. So those are your big risks. Then, if we look at the bigger picture and zoom out, the mom's long-term health can be impacted. This includes the impact of cardiovascular disease, not to mention in pregnancy her own morbidity and mortality is at risk if these disorders are not really diagnosed timely and treated effectively.

In the longer term, having preeclampsia means a mom will have a lifelong increased cardiovascular risk or any diagnoses in that category not just high blood pressure, but things like atherosclerosis, cholesterol problems and lipid disorders. So, it shows you that these diagnoses are important because pregnancy serves as a window into any woman's future health. It's important to note to your doctors later on when you present for your routine annual health checkups that this was my pregnancy history too.

Host: Are there any signs or symptoms that either the mother, the birthing parent or the family should be on the lookout for, besides just getting your blood pressure tested? If you're just at home, are there any signs or symptoms that you should be thinking about?

Antonette T. Dulay, MD: At home, we tell women to look out for headaches that don't go away or are dulled by extra-strength Tylenol. We tell them pointedly, when you're taking that Tylenol, do not take more than the maximum daily dose. So read the bottle. Look out for blurry vision. It's like a veil is waved in front of your eyes and the person with whom you're speaking to, suddenly there's two of them standing there. You can have punched-out holes of bright light in front of your eyes called scotomata. When you read about it, that's the term you hear. You can also have blackened fields of vision, rarely so, which indicates also maybe some kind of vascular issue happening. But the most common would-be headaches that don't go away or are dulled by Tylenol, blurry vision, bright patches of light in front of your eyes.

Some women have even described it as like a nuclear cloud in front of their eyes. You often hear about swelling, but the problem is there's general swelling of pregnancy, so it's hard to differentiate between the two. However, the swelling associated with preeclampsia, which is a tip-off that work needs to be done, involves your whole body or non-dependent areas like your face, neck, fingers, or wrists. Swelling is a finding you must tell your doctor about. It's not something that says you have preeclampsia, but all these things I mentioned are things with which you have to tell your doctors.

Some other big findings would be pain over your liver or midsection. I don't just mean baby movement and discomfort because as things grow, the geography and space can get a little bit tight, but you shouldn't have pain. If you're having, right upper quadrant or epigastric pain you absolutely must call your doctor right away.

Host: How common is preeclampsia and are there any demographics or groups of women who may be more susceptible to it than others?

Antonette T. Dulay, MD: I wouldn't say preeclampsia is common. It's still considered a rare disorder of pregnancies because, overall, most pregnancies will progress very well and be generally low risk. However, preeclampsia can affect basically any pregnant woman. Who is at most risk first are those who are at the most risk are young women who are experiencing their first pregnancy. Then, there are women on the older side of the spectrum, which the technical term, it's called “advanced maternal age.” It is an unfortunate term, but it is women who are age 35 years or older at the time of delivery. Women who have other existing medical conditions are also at risk. For example, we talked about chronic hypertension or chronic high blood pressure. In those cases, we call it superimposed preeclampsia because your blood pressure is not new, it's just worsening. That's another category of women to look out for. Women with chronic hypertension, women with rheumatologic disorder, disorders like lupus for example, that's important to keep an eye out for. Women with kidney disease coming in, they're really at high risk for developing preeclampsia. Women with multi-fatal gestations twins, triplets, they have an increased risk. For women with a history of any hypertensive disorder during pregnancy, have an increase in this in another pregnancy, too.

Host: Now, let's spend a few minutes here getting into some of the myths and maybe questions that mothers and their families may have about preeclampsia. Is it true that someone diagnosed with preeclampsia can only have a C-section or does that not really affect things? What is the reality there?

Antonette T. Dulay, MD: No, when you're diagnosed with preeclampsia, your mode of delivery, meaning C-section or attempted vaginal delivery, is governed by what we call the usual obstetrical indications. By that, I mean something wrong with the mother or the fetus where the act of labor is pretty much dangerous or futile. For example, there are some women who have what's called a non-reassuring fetal heart tracing, meaning on the heart rate monitor, when you're in labor trying to have a normal delivery, the heart rate tracing is problematic and the baby's not tolerating or liking the labor process. That's an example of an indication to have a C-section. Or maybe the mom's labor has stalled and stopped. So, having preeclampsia does not mean one must have a C-section. It does, however, increase the risk, just epidemiologically. But it does not mean you absolutely are committed to a C-section unless that's your desire with regard to mode of delivery.

Sometimes, it depends how far along you are when you're diagnosed with preeclampsia, because there are some women where there early, they're preterm and while preeclampsia, there are cases you can, and you do observe to get to term. There are some cases of preeclampsia that are so severe that delivery becomes indicated. It becomes unsafe to keep pushing a pregnancy forward day by day, week by week. In those cases where delivery indications are met, then a woman could be offered an induction of labor to try for a normal delivery.

Sometimes the situation of the mother can be so dangerous or can be very problematic that the doctor may be worried her health condition could take a turn for the worse. Induction of labor also, especially in a preterm patient, can take a long time. So, it becomes this risk-benefit balance. We know vaginal delivery would be fantastic and is easier to recover from and means avoiding surgery. But at the same time, you have to balance the maternal side of the equation. Sometimes with preeclampsia cases, a mom's lab values for example, can really be problematic. And you're then balancing the risk of one's, let's say, liver function worsening and platelet count may be dropping in the time you're trying to do an induction. So, it becomes that risk-benefit balance, and it's a discussion between patient and doctor about what risk you are willing to take to achieve a certain outcome.

Host: You mentioned a few of the risk factors earlier. Does the weight of the mother play a factor or how much of a factor may it play in a preeclampsia diagnosis? If it does, is it something that a mother who is a little bit overweight should consider addressing before pregnancy? What are the factors there?

Antonette T. Dulay, MD: When we talked about risk factors, that is by no means an exhaustive list; there is a whole slew of things and characteristics of a patient that can predispose to increased risk. Yes, body mass index, one's height and weight combination really does play a role. When you hit a body mass index of 30 or more, the literature really does show you have incurred an increased risk of hypertension and problems of pregnancy, of which preeclampsia is one of them. So, BMI does count as a risk factor. Now the risk then gets stratified by how high that BMI is. When you hit a BMI of 35 or higher, and especially 40 or higher, that risk is really magnified. So, to your point of losing weight, it's all about preconception.

Ideally, a woman would have a discussion with her OBGYN before becoming pregnant, or even her primary care doctor about her overall health This is important because when you enter pregnancy healthy and optimized, you minimize the risks that come just by being pregnant and improve your outcome. One aspect of preconception care is to take a look at your body mass index and see if you need to bring it down a little bit, thereby improving your risks in any future pregnancy So, when you ask, does one have to lose weight? No, the answer is a personal choice. However, if we talk about ways to reduce risk in pregnancy, certainly your cardiovascular health, that heart-healthy diet, heart-healthy lifestyle, which goes lockstep with maintaining a normal body mass index, will go a long way for anybody's pregnancy no matter what. That said, in pregnancy, we do not recommend actively trying to lose weight.

Host: You mentioned that preeclampsia, there's a higher risk with the first child. Should mothers who experience preeclampsia with their first child expect that they will have it with future pregnancies?

Antonette T. Dulay, MD: That's a great question because history is important. History is the biggest predictor of recurrence risk. So, by having a history of preeclampsia, be it preterm or term, there is a recurrence risk there no matter what your baseline health history is. So even in the healthy mom, if she had preeclampsia in that first pregnancy, the next time around, she would have a recurrence risk based on her history. That recurrence risk can be anywhere from about 30 to 40% range depending on who you read. The point is that it's there and it's a very significant risk. Which then begs the question, how can we reduce risk? One is having a pre-pregnancy preconception discussion with your OB or with a maternal-fetal medicine specialist like me to go over your history.

If you have a history of preeclampsia, there's something called low-dose aspirin that, in several large randomized controlled trials, has really been shown to be a great risk reducer of preeclampsia occurrence in a given pregnancy. In the United States, we use the dose of 81 milligrams daily. The trials showed starting this as early as 12 weeks but no later than 16 weeks. So somewhere in that four-week sweet spot to start, then you continue daily until you deliver, can help give you at least a 30% risk reduction in preeclampsia. Perhaps the risk reduction is wider for some, but at minimum that is significant in the grand scheme of prevention. I bring up the 81-milligram dose because as patients Google and read, they are going to come across the European dose, which is higher, but in this country, we don’t have the formulation of low-dose aspirin. There are some women whose doctors will say I need you to take two 81 milligram pills but before a woman does that, she should talk to her doctors to see if she qualifies for that out-of-the-box and alternate and yet accepted mode of management. One pill 81 milligrams daily is something we really teach our OBGYN trainees not to miss offering during a pregnancy.

Host: Now, some women can have a number of strong cravings for certain foods during pregnancy. Can diet impact your risk for preeclampsia at all?

Antonette T. Dulay, MD: So not necessarily. One of the myths was if you have a low-salt diet in pregnancy, you can and will prevent preeclampsia. Well, that's not true. However, in general, a heart-healthy diet, a heart-healthy lifestyle, which encompasses low salt, and avoiding a high-sugar diet will go a long way in the prevention of pregnancy problems in general because it will increase your own cardiovascular health. But unfortunately, there is no diet shown to truly, truly prevent or vitamin supplement truly prevent preeclampsia.

Host: Let's say a woman has preeclampsia during pregnancy and then successfully delivers her child. Can a woman still experience preeclampsia at post-delivery or does that change the calculation?

Antonette T. Dulay, MD: The pregnancy time period actually extends to six weeks post-delivery or postpartum, so women should still be on the lookout for the symptoms even post-delivery. Again, swelling. That can be a problematic thing, but really, you've got to pay attention to your body

Host: Are there any treatments for preeclampsia available for women these days?

Antonette T. Dulay, MD: So really, delivery is the cure. Why? Because the pathology behind preeclampsia is thought to be part of the placenta. Honestly, we still do not know exactly why, but there seems to be something with regard to faulty placentation and the development of preeclampsia. Technically speaking, delivery is the cure, but obviously there are cases where you don't just want to deliver. There are cases where you really have to balance the mother and the developing fetus and all the risks that we mentioned, especially field demise, poor growth, and low fluid. So, while yes, delivery is the cure, this is where specialties like mine are important as we can work with the general OBGYN, and talk about who are candidates for what we call expectant management.

And that's the key, making sure there's no clear contraindications that basically would spell delivery. Again, you're balancing mother and fetus at the same time. It's important too, because one of the things I don't think I mentioned yet is what people know as eclampsia. Because you hear preeclampsia, well, pre means before, right? Well, what's eclampsia? So, eclampsia is actually seizures. And so that's one of the biggest dreaded complications for the mother. So, you want to prevent seizures in all this as well as part of that bigger risk package. But deliveries are the cure, but we are careful when someone is preterm; therefore, before 37 weeks as to delivery term and beyond, 37 weeks, zero days and beyond delivery is done no matter what. That's a very clear American Congress of OBGYN and Society for Maternal-Fetal Medicine. Their guidelines are clear when you have preeclampsia and your term delivery is recommended.

In the preterm setting, there's a lot of factors that we weigh in to see is it safe to keep someone pregnant? There are some women you should really have in the hospital, but that's something that's good to have a consultation with a maternal-fetal medicine specialist to see where you fall in that way. The other thing to consider, which we didn't talk about, is the severity of preeclampsia. OP, right? There's something called severe feature preeclampsia. OP is what we call it now. It used to be called just severe preeclampsia. The point is that there are certain features of the diagnosis that, if you hit them, you get labeled as having severe feature preeclampsia. For example, having blood pressure top number one 60 or higher, and or bottom number one, 10 or higher lab abnormalities of a certain extent. And certain symptoms, the ones that I've been mentioning over and over again in women who meet the definition of severe feature preeclampsia, then these women are delivered as early as 34 weeks or on diagnosis thereafter because we're balancing mother and fetus. Studies show that in this situation, delivery at 34 weeks balanced well the maternal and fetal risks going forward.

Host: Dr. Dulay, is there anything, you wish more women, and their families understood about preeclampsia?

Antonette T. Dulay, MD Well that it can happen to anyone. What I wish is that women knew more about the signs and symptoms for which to look out and just being their own advocates in that space. It's also important to know how low-dose aspirin can really help prevent preeclampsia and whether they are a candidate for using it.

Host: Final question for you, Dr. Dulay, are there any other myths that you find yourself dispelling for your patients regarding preeclampsia or any other high-risk pregnancies that you come across?

Antonette T. Dulay, MD: One is just regarding high blood pressure. I wish women would understand that doctors need to take every finding seriously as they are good data points. When it keeps happening again and again, we have to pay attention and follow suit because of these risks that I previously mentioned. At the end of the day, we want healthy moms and healthy babies, and if we are really cognizant of the risks and take things seriously, we hopefully will improve maternal and fetal and newborn morbidity and mortality, not just in this country, in this world. Preeclampsia is a phenomenon worldwide in incidents rising because the landscape in patient profile of who's becoming pregnant is also changing.

Host: Dr. Dulay. This has been an incredible conversation so far. Do you have any parting words for our listeners or if our listeners are looking for more information about preeclampsia, where should they go?

Antonette T. Dulay, MD: The Merck Medical Manual online and in-print is an excellent source of vetted information that would be great for any woman who's pregnant or contemplating pregnancy to take a look at. Then of course, there's the resources published by pregnancy societies: The American Congress of OBGYN, and Society for Maternal Fetal Medicine. Always go to trusted sources. For example, March of Dimes.

Host: Any parting words for our listeners who just heard us talk about preeclampsia for a while and anything you have to say to them?

Antonette T. Dulay, MD: This is an important diagnosis. It can be a common diagnosis of pregnancy, but by no means is it common. Our discussion today is by no means exhaustive. There's a lot that goes hand in hand with preeclampsia, but these are just some of the basic things to look out for. At the end of the day, women should be aware of how they're feeling and always have that open communication with their OBGYN. As long as you have good communication with your doctors, you get ahead of the scary risks that we spoke of so as that way your doctor can do a proper evaluation sooner rather than later.

Host: Excellent. Dr. Dulay, thank you so much for joining us on the Merck Manuals Medical Myths Podcast. As you said, if anybody has any questions or wants more information about preeclampsia, we encourage everybody to please visit merckmanuals.com. As we close out, I'll let you, Dr. Dulay, leave our listeners with the final word.

Antonette T. Dulay, MD: Medical knowledge is power. Pass it on.