I Could Have Died’: The Dangers of Postpartum Pre-eclampsia.

NY Times articlel.jpg

Five days after giving birth to her second child, Lauren Lowrey woke up feeling cheerful. By the standards of a woman recovering from childbirth while caring for a newborn and a toddler, she was feeling energetic, too.

“I was a little tired and sore, you know, but basically I felt really good,” said Lowrey, 34, a news anchor for a Nashville television station. She had enjoyed an easy, uncomplicated pregnancy and expected to bounce back quickly, just as she had after having her first baby three years earlier. But by the next morning, Lowrey’s confidence and sense of well-being had evaporated. “I just didn’t feel right,” she said. At first, her malaise was nonspecific: intense fatigue, an aching back and a headache that wouldn’t respond to ibuprofen. But as the day wore on, Lowrey’s head and back pain became excruciating, and she had trouble catching her breath.

In the late afternoon, when Lowrey lay down for a nap, she was alarmed to realize that her heartbeat seemed both irregular and unusually slow. “I was exhausted, but now I was afraid to close my eyes,” she said. “I remember thinking, ‘If I go to sleep, I might not wake up again.’”

Instead of napping, Lowrey called her obstetrician, who listened to her symptoms and told her to come to the hospital immediately. “She was very calm, but she made it clear to me that it was urgent,” Lowrey said, noting her doctor’s request that she arrive at the hospital in 30 minutes. “I got off the phone and I just cried, I was so scared.” That night, a C.T. scan helped to confirm that Lowrey had severe postpartum pre-eclampsia, a condition that’s generally characterized by perilously high blood pressure and, usually, excess protein in the urine. Had Lowrey ignored her instincts and gone to sleep, she could have suffered a fatal seizure or stroke.

A growing concern

For centuries, pre-eclampsia was understood to be a relatively rare condition that could only affect a woman during pregnancy. But according to the National Institutes of Health, cases — while still rare — have risen streadly in the past three decades.

While the prevailing wisdom among obstetricians long held that the only “cure” for pre-eclampsia was to deliver the baby, recent research suggests that for some, the condition might happen after delivery. And for reasons researchers don’t yet fully understand, an increasing number of women like Lauren Lowrey, who had healthy pregnancies and uncomplicated deliveries, are experiencing spikes in blood pressure and other symptoms for the first time days, or even weeks, after checking out of the maternity ward. Though the consensus on postpartum risk among pre-eclampsia researchers is changing fast, Eleni Tsigas, the C.E.O. of the Preeclampsia Foundation, a Florida-based nonprofit devoted to educating patients and supporting research on pre-eclampsia, said that an alarming number of medical practitioners still believe pre-eclampsia can’t develop after delivery.

Even seemingly authoritative organizations, such as WebMD, get it wrong. Google “pre-eclampsia,” for instance, and you are likely to land on the WebMD page for it, which makes no mention of the fact that pre-eclampsia symptoms may appear for the first time during the postpartum period.

Not only does this absence of information mislead women, according to Tsigas, “it impacts the entire health care team, from doctors to nurses to midwives.”

“They mentally relax after delivery,” Tsigas continued. “They lose sight of the surveillance and care that many women continue to require.”

‘We are missing a lot … ’

When pre-eclampsia develops during pregnancy, signs of it usually occur after the 20th week; pre-eclampsia affects more than 4 percent of all pregnancies in the United States, according to the N.I.H. Pre-eclampsia that presents during pregnancy has well-known treatment protocols and risk factors — including obesity, advanced maternal age, a history of high blood pressure and conception via I.V.F. Postpartum pre-eclampsia, by contrast, is far less common, and there are few studies, little reliable incidence data and no conclusively established risk factors.

Perhaps, in part, because it is still so poorly understood, postpartum pre-eclampsia is often more dangerous than pre-eclampsia during pregnancy. Though pregnant women with pre-eclampsia are usually asymptomatic and only learn of their condition through blood pressure testing at a prenatal medical visit, postpartum pre-eclampsia tends to develop suddenly. Its characteristic symptoms — fatigue, swelling, nausea, shortness of breath, headaches and pain in the back or shoulders — can be difficult to distinguish from more run-of-the-mill maternal complaints. Since the condition can appear up to six weeks after delivery — when most women are sleep-deprived, preoccupied with infant care and no longer closely monitored by their doctors — these symptoms are frequently overlooked.

Because postpartum pre-eclampsia is less well-understood, said Dr. Cynthia Gyamfi-Bannerman, M.D., a maternal-fetal medicine specialist at NewYork-Presbyterian/Columbia University Irving Medical Center, it’s harder to predict who will be affected by it after giving birth. “Women who had pre-eclampsia during their pregnancies are going to be more closely monitored,” said Dr. Gyamfi-Bannerman. “But it’s hard to determine who else may be at risk and, in the sadder scenarios, women aren’t seeking attention until their symptoms are already severe.”

Untreated, postpartum pre-eclampsia can progress rapidly, and can lead to life-threatening complications, including seizures, strokes, blood clots, excess fluid in the lungs and permanent damage to the brain, kidneys and liver. In the United States, most maternal deaths linked to pre-eclampsia occur after delivery. Dr. Leslie Moroz, M.D., director of the Mothers Center at NewYork-Presbyterian/Columbia University Irving Medical Center, said the conventional approach to postpartum care in the United States made this period riskier for some mothers. “In the traditional American model, the next check-in with her doctor is six weeks” after birth, Dr. Moroz said. In northern and western Europe, by contrast, even women with normal pregnancies receive home visits by medical professionalsduring the days and weeks after their deliveries.

“There are lots of women who might have been low-risk during their pregnancies, but something new arises during the postpartum period,” Dr. Moroz explained. “We are missing a lot due to the way the system is set up in this country. It’s definitely time to rethink how we do postpartum care in the United States.” Tsigas, of the Preeclampsia Foundation, concurred, but argued that patient education and a re-evaluation of postpartum care can only go so far. Given the increasing rates of postpartum pre-eclampsia in the United States and the apparently increasing severity of the condition, investment in pre-eclampsia research is urgently needed. “This is not just an awareness issue,” Tsigas said. “There are also real gaps in the research.”

In Lauren Lowrey’s case, prompt treatment with magnesium sulfate — an anticonvulsant drug that lowers blood pressure and reduces seizure risk — resolved her symptoms quickly, and she suffered no permanent organ damage. But she still recalls, with dismay, the hours she spent trying to brush aside her symptoms and the way she initially hesitated before calling her doctor. “We need to be encouraging women to listen to their bodies, and to seek help right away if something doesn’t feel right,” Lowrey said. “I just cannot overstate that enough. If I hadn’t listened to my body that day, I could have died.”

This article originally appeared on www.newyorktimes.com