By Rebecca Britt, Preeclampsia Foundation

May is Preeclampsia Awareness Month and this year, The Preeclampsia Foundation has a campaign that focuses on postpartum preeclampsia, symptoms that remain or develop after delivery. Families need more support and guidance about things to look for. Preeclampsia does not go away after delivery in some cases. Childbirth educators and other birth professionals can play a key role in helping to spread this message and supporting families in being diligent after birth and once at home. There is an excellent resource, stillatrisk.org that offers more information that you can share with your families. Today, Rebecca Britt shares valuable information with us on this dangerous condition. - Sharon Muza, Science & Sensibility Community Manager.

When Todd Heiden's wife was diagnosed with preeclampsia and admitted to the hospital at 35 weeks, he, of course, was concerned for the health of his wife and unborn child. Unfortunately, he could never prepare himself for what transpired after her diagnosis. Here is Todd's story:

On July 14, my wife visited the high-risk OB and found that her blood pressure was 171/95. She was diagnosed as severe preeclampsic and immediately admitted to the hospital, being told that they might deliver the baby that evening though they would try to manage her blood pressure and give the baby more time to develop. He was 35 weeks and 4 days at that time. Her BP never improved below 154/90 and our baby boy was delivered successfully via c-section without complications on July 16.

All along we were told that the cure for preeclampsia was delivery.

48-hours later on July 18, my wife was cleared to go home. As she had had her prerequisite bowel movement that morning and her vitals checked out for the most part (BP now at ~140/85), she was discharged with the usual spiel on caring for the c-section wound site and taking care of the child. No mention was made about the threat of eclampsia. She was told to schedule an appointment with her OB for that Friday with no additional follow-up scheduled in between.

We returned home to find our daughter had a cold. On Monday afternoon, my wife began to complain of shortness of breath - not being able to get a full breath. We passed it off as normal for someone who had just had a c-section and swollen breasts from breastfeeding. On Tuesday I returned to work for a team exercise while my wife made a visit to the pediatrician with her brother. She was again experiencing shortness of breath and was finding every step to be a struggle.

That evening we went to bed at around 11:15 pm. About an hour later I was awoken by her and was told that she "needed my help." Quite groggy, I took a moment to get my bearings and then accompanied her into our kitchen. When I asked her what was wrong, she said she couldn't breathe and quickly devolved into what appeared to be hyperventilation accompanied by extreme anxiety and fear.

I tried to calm her but it just increased to a point that I called 911, having determined that it was beyond my scope of understanding. I stayed on the phone with the dispatcher for seven painful minutes while my wife went from a seated-on-the-chair position to a seated-on-the-ground position to a laying-on-the-ground position. At the same moment that the paramedics arrived, my wife stopped breathing and began to turn blue. Though the paramedics tried in vain to get a pulse and start her breathing again, they ultimately left the house performing CPR on her, heading to the hospital only 5 minutes from our house.

I was told upon arriving at the hospital that they had managed to regain a pulse after 25 minutes but that my wife had most likely suffered severe brain damage from the lack of oxygen. Their prognosis for recovery was grim, with little hope given for any meaningful recovery. For all intents and purposes, my wife had died in my arms on our kitchen floor, her final words being "I love you."

Joan stayed with us for 17 days. Her family - her mother, father, 7 sisters, 1 brother and numerous nieces, nephews, friends, and in-laws - were by her side constantly, providing a 24-hour vigil and soothing her as best they could with prayers, music, and conversation. She never regained consciousness and on August 6, three days after being removed from support, she passed into the arms of her loving Lord. The silence, since then, has been deafening and we all miss her more and more each day.

According to the coroner, her official cause of death was determined to be post-partum eclampsia, a disease that many doctors refuse to acknowledge as real.

For decades we have heard 'delivery is the cure for preeclampsia.' It is understandable that this comes from the fact that delivery is a necessary intervention. Removing the placenta is the only way to begin reversing the disease process, so when the pregnant person or baby are too unwell to continue the pregnancy, delivery is delivery is indicated. The nuance here is the definition of 'cure'.

The term 'cure' leaves postpartum persons thinking they are in the clear and no longer need to monitor their own health once delivered. This couldn't be farther from the truth. In fact, 97% of maternal deaths related to preeclampsia, happen in the postpartum period (Creanga, 2017). This is why it is necessary to make patients and medical health professionals aware that a person who has delivered is still at risk for preeclampsia and needs to stay alert for symptoms of preeclampsia and related comorbidities, for at least six weeks after delivery.

Most people with preeclampsia will deliver healthy babies and fully recover. However, some will experience complications, several of which may be life-threatening to the delivering person and/or the baby. A pregnant person's condition can progress to severe preeclampsia, eclampsia or HELLP syndrome quickly. Delivery, sometimes after a period of expectant management ('watchful waiting'), is a necessary intervention.

Any pregnant person can develop preeclampsia after their baby is born, whether they experienced high blood pressure during their pregnancy or not. Because the vast majority of deaths due to preeclampsia happen AFTER the baby is born, it is imperative that patients are advised after delivery and before they are sent home to continue monitoring their health. Here's what patients need to know.

What is postpartum preeclampsia?

Postpartum preeclampsia is a serious condition related to high blood pressure. It can happen to anyone who just had a baby. It has most of the same features of preeclampsia or other hypertensive disorders of pregnancy, without affecting the baby.

Risks to Postpartum Person:

• Seizures
• Stroke
• Organ Damage
• Death

Warning Signs:

• Stomach Pain (Epigastric upper right quadrant (URQ) pain)
• Feeling nauseous or throwing up
• Swelling of hands and face
• Severe headache
• Seeing spots (or other vision changes)
• Shortness of breath

What can patients do?

• Ask if a one-week follow-up appointment is necessary
• Keep all follow-up appointments
• Watch for warning signs and report any to their healthcare provider
• Trust their instincts
• If possible monitor their blood pressure

What can childbirth educators do?

Childbirth educators have the opportunity to educate pregnant people and their support on the symptoms of preeclampsia during pregnancy. If a childbirth educator knows a person has been diagnosed with preeclampsia, make sure they know to monitor their blood pressure, to trust their instincts when something doesn't "feel right," and report all concerns to their healthcare provider. Postpartum people may not be told that they are still at risk at discharge and therefore, it is important that they are informed, in a mindful manner, that they need to monitor their symptoms for preeclampsia for at least six weeks after delivery. Many providers are nervous about scaring their patients or putting too much undue stress on them while they are postpartum, but patients have reported that they would have rather been told and that they can handle the information.

Here is an example of how a childbirth educator could approach the topic.

Hey Cindy, I heard you are being monitored for preeclampsia. It is more common than you would think. Although I'm sure you will be one of the many people diagnosed with preeclampsia who deliver a healthy baby and have no adverse outcomes, it is very important that you not only monitor yourself for symptoms up until you deliver but also for at least six weeks postpartum.

This information can be delivered to patients easily, using this postpartum tear pad offered by the Preeclampsia Foundation

It is also important that hospital staff are aware of postpartum signs and symptoms so postpartum people showing up at the ER are triaged properly. Many states have developed quality improvement collaboratives that create toolkits for hospitals including tools that aid in diagnosis, evaluation, and treatment of postpartum preeclampsia. The California Maternal Quality Care Collaborative has extensive resources for healthcare systems looking to improve quality protocols.

ACOG has recently released new guidelines for optimizing postpartum care, recommending that all postpartum persons should have contact with their obstetric care providers within the first three weeks after delivery. (Science & Sensibility covered that here.)

This growing concern for postpartum persons is a step in the right direction for maternal health outcomes. Unfortunately, we understand that as many as 40% of all postpartum visits are not attended as planned (ACOG, 2018). One can expect this number not to improve with the new guidelines due to the many obstacles that a new parent faces with scheduling, transportation, fatigue and a primary focus on the newborn's health. This is why it is imperative that people who have delivered understand they are still at risk for poor outcomes, and to know the symptoms and how to respond appropriately.

References

ACOG. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved from The American College of Obstetricians and Gynecologists: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

California Maternal Quality Care Collaborative. (n.d.). Preeclampsia Toolkit. Retrieved from CMQCC: https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit

Creanga, A. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. The American College of Obstetricians and Gynecologists., 366-373.

Preeclampsia Foundation. (n.d.). Marketplace. Retrieved from Preeclampsia Foundation: www.preeclampsia.org/store

About Rebecca Britt

Rebecca Britt is the Community Education and Engagement Manager for the Preeclampsia Foundation. Her calling to advocate and support those who often don't have a voice led her to earn a Bachelor of Science in Social Work from the University of Vermont.

Rebecca has worked with varying populations including children in foster care, adults surviving with persistent mental illness, and women facing fertility challenges. She is passionate about reducing isolation for preeclampsia patients and survivors by building community connections and raising awareness. Her desire to demonstrate the impact of mission-focused initiatives, lead her to enroll Michigan State University where she is currently earning her Master's Degree in Program Evaluation.

Rebecca is a visionary and global thinker. She is enthusiastic about putting her passion and experience together to unite the preeclampsia community. Upholding the Preeclampsia Foundation's mission, Rebecca aims to provide the education and tools necessary to empower patients to advocate for systemic change to save lives.

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