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Bleeding Disorders and Pregnancy

Bleeding disorders, also known as coagulopathy, are conditions that affect your body’s ability to
clot normally at the site of an injury, resulting in bleeding that can range from mild to severe.
The bleeding can be inside or outside the body.

During pregnancy, bleeding disorders can pose serious risks to the mother and baby.

Most bleeding disorders are inherited. Others are acquired, meaning they may develop at any
time, in some cases as a result of pregnancy.

Complications of Bleeding Disorders in Pregnancy


Women with bleeding disorders or a history of bleeding are at greater risk of pregnancy
complications that include:

 Bleeding during pregnancy


 Severe postpartum hemorrhage that may require transfusion or hysterectomy
 Anesthesia risks during delivery
 Delivery risks to babies with inherited bleeding disorders

Causes of Bleeding Disorders


Causes of bleeding disorders include:

 Von Willebrand disease


 Hemophilia
 Other clotting factor deficiencies
 Platelet disorders
 Disorders caused by anticoagulants (blood thinners)
 Obstetric complications associated with coagulopathy (such as placental
abruption, preeclampsia or acute fatty liver of pregnancy)

Bleeding disorders may be diagnosed through blood tests or by clinical symptoms and signs.

Treatment of Bleeding Disorders during Pregnancy


 Treatment depends on the woman’s bleeding disorder, her overall health and her pregnancy. In
general, treatment may include:
 Specialized care from a maternal-fetal medicine physician, an OB/GYN who specializes in high-
risk pregnancies
 Frequent prenatal visits for close monitoring
 A carefully planned delivery, including anesthesia and delivery options that minimize the risk of
bleeding
 Genetic counseling to evaluate the baby’s risk of an inherited bleeding disorder
 A multidisciplinary health care team, including a hematologist (a specialist in treating blood
disorders), an anesthesiologist experienced in pregnancies with bleeding disorders, and a
pediatric hematologist, pharmacy and blood bank, as needed
 Delivery at a state-of-the-art facility with the resources required to address serious bleeding
problems

Eclampsia
Medical Author:

Melissa Conrad Stöppler, MD, Chief Medical Editor


Medical Editor:

Charles Patrick Davis, MD, PhD

Facts and definition of Eclampsia

 Eclampsia, a life-threatening complication of pregnancy.


 Eclampsia is a condition that causes a pregnant woman, usually previously
diagnosed with preeclampsia (high blood pressure and protein in the urine), to
develop seizures or coma. In some cases, seizures or coma may be the first
recognizable sign that a pregnant woman has had preeclampsia.
 Key warning signs and symptoms for the development of eclampsia in a
woman previously diagnosed with preeclampsia include
o severe headaches,
o blurred or double vision,
o seeing spots, or
o abdominal pain.
 There has never been any evidence to suggest an orderly evolution of disease
beginning with mild preeclampsia with progression to severe preeclampsia and
ultimately to eclampsia. The disease process can be recognized in its mildest
form and remain so throughout pregnancy, or it can present as full-blown
eclampsia.
 Less than one in 100 women with preeclampsia will develop eclampsia
(characterized by seizures and/or coma).
 Up to 20% of all pregnancies are complicated by high blood pressure.
Complications resulting from high blood pressure, preeclampsia, and eclampsia
may account for up to 20% of all maternal deaths.
 Toxemia of pregnancy is a common name formerly used to describe
preeclampsia and/or eclampsia.

What causes eclampsia?

 No one knows what exactly causes preeclampsia or eclampsia, although


abnormalities in the endothelium (the inner layer of blood vessel walls) have
been considered as a potential cause.
 Since the exact cause of preeclampsia or eclampsia is poorly understood, it is
not possible to effectively predict when preeclampsia or eclampsia will occur,
or to enact any preventative measures that might prevent these problems from
developing.
 Preeclampsia usually occurs during an initial (first) pregnancy.
What are the risk factors for eclampsia?

 Preeclampsia also occurs more frequently in women with multiple gestations,


who are older than 35 years, who had high blood pressure prior to pregnancy,
are diabetic, and have other medical problems (such as connective tissue and
kidney diseases).
 Obese women have a higher risk of preeclampsia and eclampsia than women of
normal weight.
 For unknown reasons, African American women are more likely to develop
preeclampsia and/or eclampsia than white women.
 Preeclampsia occurs more frequently within families, although a genetic basis
for this has not been determined.
 Preeclampsia is associated with disorders of the placenta, such as excess or
diminished placental mass or an abnormal position of the placenta on the wall
of the uterus.
 Preeclampsia is associated with hydatidiform molar pregnancies, in which
normal placental or fetal tissue may be absent.
 Nothing can be done pre-emptively to prevent the development of preeclampsia
or eclampsia.
 Other risk factors for eclampsia include lower socioeconomic status, teen
pregnancy, and poor outcomes during previous pregnancies (including fetal
death or intrauterine growth restriction).
What are the warning signs and symptoms of
eclampsia?
The most common symptom of eclampsia is seizures, or convulsions. Similar to
preeclampsia, other changes and symptoms may be present and vary according to the
organ system or systems that are involved. These changes can affect the mother, the
baby, or more commonly both mother and baby together. Some of these following
symptoms may be perceived by the pregnant woman, but, more commonly, she is
unaware that she has this disease:

 The most common sign of preeclampsia is elevated blood pressure and is also
found in eclampsia. Again, the patient may be unaware that she is hypertensive.
 Blood pressure may be only minimally elevated, or it can be dangerously high.
The degree of blood pressure elevation varies from woman to woman, and also
varies during the progression and resolution of the disease process. Some
women never have significant blood pressure elevation (including
approximately 20% of women with eclampsia).
 A common belief is that the risk of eclampsia rises as blood pressure increases
above 160/110 mm Hg.
 The kidneys may be unable to filter the blood efficiently. There may also be an
abnormal excretion of protein in the urine. The first sign of excess urinary
protein is usually determined on a urine specimen obtained at the time of a
routine prenatal visit. It is unusual for a patient to experience symptoms related
to excess urinary protein loss. In rare cases there may be excretion of a large
amount of urinary protein.
 Nervous system changes can include blurred vision, seeing spots,
severe headaches, convulsions, and, occasionally, blindness. Any of these
symptoms require immediate medical attention, preferably at a hospital which
provides obstetrical care, as the emergent delivery of the infant may be
required.
 Changes that affect the liver can cause pain in the upper abdomen. This pain
may be confused with the pain of indigestion or gall bladder disease. Other
more subtle changes that affect the liver can alter platelet function, thus
compromising the ability of the blood to clot. Excess bruising may be a sign of
impaired platelet activity.
 The hypertension that is characteristic of preeclampsia can diminish placental
blood flow, thus impairing fetal development. As a result, the baby may not
grow properly and may be smaller than anticipated. In severe cases, fetal
movements may be lessened as a result of impaired oxygenation of the fetus. A
patient should call her physician immediately if she notices a marked decrease
in fetal movement.

Pre-eclampsia Signs and Symptoms During Pregnancy


The various changes and symptoms that occur with preeclampsia vary according to the organ
system or systems that are affected. These changes can affect the mother only, baby only, or
more commonly affect both mother and baby. Some of these symptoms give the woman warning
signs, but most do not. When they do the woman may experience:
 Swelling in the legs or the face
 Rapid weight gain
 Headaches
 Pain in the upper abdomen (liver pain)
 High blood pressure
When to seek medical care for eclampsia

 If a pregnant woman has questions regarding her health or that of her baby.
 If a pregnant woman has severe or persistent headaches or any visual
disturbance, such as double vision or seeing spots (This may be a harbinger of
impending eclampsia).
 If, during pregnancy, the blood pressure rises above 160/110 mm Hg.
 If a pregnant woman has severe pain in the middle of their abdomen or on the
right side of the abdomen under the rib cage. (This may indicate swelling and
possible rupture of the liver).
 If there is any unusual bruising or bleeding during pregnancy.
 If there is excessive swelling or weight gain during pregnancy.
 If there has been a marked decrease in fetal activity.
 If increasing vaginal bleeding or severe abdominal cramping is noted during
pregnancy.

Is there a test to diagnose eclampsia?


If any of the previously mentioned symptoms are experienced, a health-care
professional should be notified immediately. If home blood pressure monitoring is
being performed, the readings, if elevated, should be reported to the doctor. It is
likely that a visit to the doctor's office or the hospital may be necessary.

 All signs, symptoms, and concerns should be reported to the health-care


professional. Blood pressure, weight, and urine protein will be determined at
every prenatal visit.
 If a health-care professional suspects the possibility of preeclampsia, they will
order blood tests to check a platelet count, as well as liver and kidney function.
The health-care professional may order a 24-hour urine collection to check for
total protein in the voided specimen. The results of the blood tests should be
available within 24 hours (if sent to an outside laboratory), or within several
hours if performed at a hospital.
 The well-being of your baby should be checked by monitoring the rate and
rhythm of the fetal heart.
 Further evaluations of fetal well-being may include non-stress testing, a
biophysical profile (ultrasound), and an ultrasound to measure the growth of the
baby (if it has not been done within the previous 2-3 weeks).
 Ancillary studies may include ultrasound, CT scan, or MRI scan of the
maternal head to rule out a stroke.

What medications treat eclampsia?


Once eclampsia develops, the only treatment is delivery of the baby (if eclampsia
occurs prior to delivery). Eclampsia can develop following delivery, typically within
the first 24 hours postpartum. Rarely, the onset of post-partum eclampsia can be
delayed and occur up to one week following delivery. There is no cure for eclampsia
other than the delivery of the infant.

Seizure treatment

 Intravenous magnesium sulfate is the pharmacologic treatment of choice once

aseizure occurs. This medication diminishes the chance of recurrent seizures.


Magnesium treatment is continued for a total of 24 to 48 hours following the
last recorded seizure. Patients may receive magnesium in an intensive care or
high risk labor and delivery unit. Close observation of the patient is mandatory
while she is receiving magnesium sulfate. During infusion of magnesium
sulfate, the patient will be given supplemental intravenous fluids. They will
also require an in-dwelling urinary catheter in order to monitor urinary output.
 Occasionally, seizures recur despite the utilization of intravenous magnesium
sulfate. In such cases, treatment with a short-acting barbiturate such as sodium
amobarbital may be necessary to "break" or stop the seizure. Other
medications including diazepam (Valium) or phenytoin (Dilantin) may also be
used.

Once the mother's condition is stabilized following a seizure, the physician will
prepare for emergent delivery of the infant. This can occur by either cesarean section
or induction of labor and vaginal delivery. If the patient is already in labor, labor can
be allowed to progress provided there is no evidence that the baby has become
"distressed " or compromised by the seizure.

High blood pressure medication

 Patients may require medication to treat high blood pressure during labor
and/or after delivery. Hydralazine
(Apersoline), labetalol (Normodyne, Trandate), and nifedipine are commonly
used products to reduce blood pressure to systolic levels below 160 mm Hg. It
is unusual to require medication for high blood pressure beyond six weeks post-
partum unless the patient has a problem with hypertension that is unrelated to
the pregnancy.
Medication to deliver the baby

The closer the patient is to her due date, the more likely her cervix will be favorable
for delivery, and that induction of labor will be successful. Sometimes medications,
such as oxytocin (Pitocin), are given to induce or shorten labor.

 If the pregnancy is less than 34 weeks of gestational age, it is less likely that
induction of labor will be successful (although induction is still possible). More
commonly a Cesarean section will be necessary to forestall a bad outcome.
 If the baby shows signs of compromise, such as decreased fetal heart rate, an
immediate cesarean delivery should be performed.
 Some patients may be given intramuscular steroids to mature the fetal lungsif
the fetal gestational age is less than 32 weeks.

What is the prognosis for a woman with eclampsia?


Most women will have good outcomes for their pregnancies, even when complicated
by preeclampsia or eclampsia. Some women will continue to have problems with their
blood pressure and will need to be followed closely after delivery. About 25% of
women who have had eclampsia will have elevated blood pressure in a subsequent
pregnancy, and about 2% will develop eclampsia.

Most babies do well. Babies born prematurely will usually stay in the hospital longer.
A rule of thumb is to expect the baby to stay in the hospital until their due date.

Unfortunately, a few women and babies experience life-threatening complications


from preeclampsia or eclampsia. Complications in babies are generally related to
prematurity, and outcomes for both mothers and babies are significantly worse in
developing countries. The maternal mortality (death) rate from eclampsia in
developed counties ranges from 0% to 1.8% of cases. Most of the cases of maternal
death are complicated by a condition known as HELLP syndrome, which is
characterized by hypertension, hemolytic anemia, elevated liver function tests (LFTs),
and a low platelet count.

Just as there were no tests to predict or prevent eclampsia, there are no tests to predict
whether preeclampsia or eclampsia will recur in a subsequent pregnancy.
Unfortunately, in a small number of women, preeclampsia and/or eclampsia will
recur. This chance seems to increase if the preeclampsia or eclampsia was particularly
severe in the previous pregnancy, occurred very early in that pregnancy (late second
trimester or early third trimester), or there is a new father for the subsequent
pregnancy. Because there are no tests to predict recurrent preeclampsia/eclampsia, a
previously affected patient should be followed more closely during a subsequent
pregnancy.

Source:

https://women.texaschildrens.org/program/high-risk-pregnancy-care/conditions/bleeding-disorders-and-
pregnancy

https://www.emedicinehealth.com/eclampsia/article_em.htm#what_is_the_prognosis_for_a_woman_with
_eclampsia

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