26 April 2019

Nigeria: Preeclampsia - a Pregnant Woman's Nightmare

For Toyin Ajibade (not real name), having a baby went from her happiest moment to her scariest.

Mrs Ajibade tried to conceive for six years and finally did through in-vitro fertilisation (IVF). But she never imagined the pregnancy would come with complications that almost took her life.

"I was looking forward to my pregnancy and having photo-shoots of my baby bumps. Unfortunately, I could not."

The complications started 28 weeks (in the third trimester) into her pregnancy.

Mrs Ajibade said aside from the normal morning sickness in the first trimester, she was doing well until week 28.

"I stopped sleeping and all the medication I was given were not working. I thought it was part of the normal complications of being pregnant. But when I began feeling dizziness in my head, my doctor gradually increased my sleeping medication until he could not any longer, in order not to harm the child. That was when we knew there was a problem," she recalled.

"Meanwhile, I was registered for ante-natal from the onset of the pregnancy because I got pregnant when I was around 34 years."

That step probably saved her life.

According to Mrs Ajibade, the doctors were at first perplexed until they noticed that her Blood Pressure (BP) kept rising. It was then they realised she had a pregnancy-related complication known as preeclampsia.

Preeclampsia is pregnancy-induced hypertension and protein in the urine which affects some pregnant women.

Five months into her pregnancy, she observed that her feet, hands, and face were swollen. She initially thought this was normal until her morning sickness started again in the sixth month of the pregnancy. She was vomiting until the 36th week when the doctors had to bring the baby out by surgery.

Her BP kept rising, peaking at 160/140 at week 36. She was having fainting spells when walking, dizziness and was always throwing up.

"Once you are pregnant, whether you are young, middle-aged or old, make sure you go to a good hospital and register.

"Whenever I walked I felt like there were puddles of water at my feet. I always told my husband that I felt as if fishes were swimming in my legs.

"I used to wear size 39-40 shoes. I went up to 42 and started wearing my husband's shoes. I could not wear any of my shoes. My feet were tired as they were so big and the headache was out of this world."

Mrs Ajibade said immediately the BP started rising, her doctor ruled out a normal delivery. The doctor said she had to go through Caesarean Section (CS).

Mrs Ajibade's case would have been further complicated if she had diabetes as patients usually do alongside preeclampsia.

During the surgery, she lost consciousness for three days and her BP kept rising.

"I did not see my baby until 72 hours after birth. Despite the emergency CS, my BP did not come down. Normally it should be falling gradually but mine kept rising. The doctors were worried, I was in the ICU for three days and was just drifting in and out of consciousness," she recalled.

Three years after, Mrs Ajibade still struggles with her BP. She was not hypertensive until her pregnancy, although she has a history of hypertension in her family.

"Up till now, I still struggle with my BP. If I get pregnant now, they will term it high-risk pregnancy," she said.

What is Preeclampsia?

Preeclampsia is a dangerous pregnancy complication, one of the leading causes of maternal and infant mortality and illness.

Unfortunately, preeclampsia has no cure, it is not easily detected and is often missed.

There are no accurate statistics for the incidence of preeclampsia. However, it is estimated that it occurs in three to 10 per cent of all pregnancies worldwide.

According to the World Health Organisation (WHO), the incidence of preeclampsia is seven times higher in developing countries (2.8 per cent of live births) than in developed countries (0.4 per cent).

Although there are no accurate statistics on preeclampsia in Nigeria, there are an estimated 100,000 cases per year.

Infant death is one of the most devastating consequences of preeclampsia. In the United States, approximately 10,500 babies die from preeclampsia each year and an estimated 500,000 worldwide.

Despite medical advances, the only known cure for preeclampsia remains assisted delivery of the baby and placenta.

Preeclampsia alters blood flow from the mother to the placenta, resulting in an insufficient supply of oxygen and nutrients to the baby inside the womb.

It usually reveals itself after 20 weeks of pregnancy and sometimes even in port partum phase (after delivery).

The disease is characterised by elevated blood pressure and a high level of protein in the urine. Women with the disease complain of sudden weight gain, severe headaches, visual disturbances, upper abdominal pain, excessive swelling in the face, feet and legs. But these are often misdiagnosed as side effects of pregnancy.

Medical expert explains

A consultant gynaecologist at the University College Hospital (UCH), Ibadan, Chris Aimahiku, said preeclampsia is a disease where some women develop high blood pressure in pregnancy. He said it affects the kidney, making the sufferer have protein in her urine.

"It is a disease of hypertension and proteinuria. It is a disease that a woman will not have usually since she is not hypertensive; she develops the disease around the 20th week of pregnancy," he said.

Mr Aimahiku said pregnancy is usually for 40 weeks or nine months. But, halfway into pregnancy, the woman may develop high blood pressure and this can also affect the kidney.

"That is where we have the proteinuria. This is a severe disease because it just happens and causes a lot of complications.

"You may want to ask why it happens. Unfortunately, it is a disease of theory because we do not know why people develop it. But one thing is certain; it is a disease that affects the placenta (Placenta is what separates the mother from the baby)."

Imran Morhason-Bello, an honourary consultant at the Department of Obstetrics and Gynaecology also at UCH, said a diagnosis of the diseases is based on new onset of hypertension and proteinuria.

This, he said, can also affect multiple organs in the body, especially the kidney and liver.

Mr Morhason-Bello said so many theories are associated with preeclampsia.

One is that preeclampsia is common among first-timers, more common among people in the extreme of the reproductive age group; that is pregnant adolescent young girls or women who for whatever reason delay child bearing till very late. Women above 35 years are most likely at the risk of developing pregnancy-induced hypertension.

He said there is also a story of new husband syndrome.

This he explained occurs when a woman who recently changed husband or sexual partner takes in and her body tends to react like that of a first timer. This makes them also prone to the disease.

"Preeclampsia is also common among women who have chronic hypertension; they may have what is termed chronic hypertension with super-imposed preeclampsia.

"It is also common among women who have had preeclampsia pregnancy, meaning they could have it in the next pregnancy. It is also common among women with multiple pregnancies and other medical complications like diabetes," Mr Morhason-Bello said.

He, however, said the real cause of the disease is not known. "But there are different theories such as genetics, vascular problem, and autoimmune problems among others."

Managing preeclampsia

Mr Morhason-Bello said the best way to manage the illness is early presentation at health facilities.

Pregnant women, irrespective of the number of births, should present early for ante-natal.

"That is why we tell every woman who is pregnant to register for ante-natal in the first trimester (first three months) so that they will know her blood pressure, take her urinalysis, and other necessary tests.

"This will help the health workers know those who do not have blood pressure and when it begins to rise.

"We also want to check when preeclampsia surfaces. By definition, it is any woman who has a blood pressure of 140/90ml of mercury and above with significant proteinuria. Such tend to have preeclampsia," he said.

Mrs Ajibade also advised pregnant women to attend ante-natal and not wait till delivery or when they start having complications.

Delay, she said, could lead to loss of mother or child or even both, as the health professionals may not know what to look for at such stage if they do not have the medical history of the woman.

On the management of the disease, Mr Morhason-Bello said preeclampsia is classified into mild and severe ones.

He said with severe preeclampsia, many patients would be bloated, have swollen faces, tummy, hand and feet, such that they may not be able to remove their wedding rings.

"This condition can also affect them that they will not be able to pass urine. So if nothing is done, such women can go into convulsion and have what is called eclampsia," he said.

He said eclampsia accounted for a significant proportion of the cases in the country.

For preeclampsia, some researches in Nigeria show that three to five per cent of pregnant women have the disease.

Because the blood vessels are affected, the baby may not grow well and sometimes it may die in the womb.

The category of the disease is either mild or severe preeclampsia.

If it is mild, the woman is advised to report frequently at the hospital for checkups. Usually, at 38 weeks, she would be induced for delivery.

Mr Morhason-Bello said in cases of severe preeclampsia, the principle of management is to prevent convulsion, control BP and deliver the baby in the fastest and safest way.

He said management of severe cases should be done in facilities that have good neonatal care, where they can control blood pressure and plan delivery.

"This is because the baby could be brought out premature and might need neonatal attention. However, in some severe cases, the baby might be brought out dead because they are not yet matured to live and the doctors need to save the mother's life.

"If the baby's gestational age is less than 34 weeks, the doctor might want to buy time for the baby to mature, but at 34 weeks the baby is matured," he said.

"The dilemma is when the baby is between 20 and 24 weeks. The doctor has to weigh the options and know if the woman can be managed till 34 weeks.

"In a case where such is of more risk to the woman's life, delivery is essential at this point, even if the baby is premature."

How to manage preeclampsia

1. Early ante-natal registration and attendance is advised for pregnant women

2. Constant checking of the blood pressure

3. Report to a good medical facility if blood pressure is high

4. Discuss extensively with a caregiver during ante-natal

5. Endeavour to carry out all medical test advised during pregnancy

6. Watch out for abnormal body changes such as swelling in the leg and feet, sometimes dizziness and gaining more than 4lb a week.

Risk factors

While more research is needed, medical experts agree upon the following risk factors:

1. Multiple pregnancies

2. Obesity and primigravidity

3. Medical history of chronic high blood pressure, diabetes or kidney disorder

4. Pre-existing hypertension, diabetes, connective tissue disease such as rheumatoid arthritis

5. Pregnancy in early teens or past age 40.

The bottom line is that a pregnant woman has to register in hospital early for ante-natal care. Early detention is vital in the management of preeclampsia.

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