Pre-eclampsia and high blood pressure in pregnancy

Concerns about pre-eclampsia in future pregnancies

Some women we spoke to had already decided that they didn’t want any more children, and this decision was mostly or entirely unrelated to their experience of having had pre-eclampsia. But for those women who were considering another pregnancy, the concern about developing pre-eclampsia again could be a worry. It even put some off wanting to have another child. But for others, their experience motivated them to try again in the hope of a ‘healthy’ baby or a ‘better’ pregnancy and birth.
Risks of problems in future pregnancies

A key issue for women and partners was whether having had pre-eclampsia meant it would happen again in another pregnancy. There was a lot of uncertainty about this. Most women thought high blood pressure problems including pre-eclampsia were more likely to affect them because of their previous history. Women who were not given a clear or definite diagnosis from their last pregnancies sometimes felt frustrated about this. Claire felt that a diagnostic label was important for finding out the risks of it affecting future pregnancies, as there were different statistics for different terms (e.g. pre-eclampsia vs HELLP syndrome). 

Some women had heard statistics or percentages of the chances of developing pre-eclampsia or HELLP syndrome again from medical professionals and many searched online. Women interpreted statistics on risks differently. While for some, a slightly higher risk was not a major concern; for others, any increased risk at all was still too much. Helen X had heard that there was a 20-30% chance of her developing HELLP a second time “which is much higher than what I’d like […] I don’t like all of these ‘what ifs’”. For some women, statistics were not helpful. Because “every pregnancy is different”, Emma didn’t think statistics on risk offered much certainty. Angela saw risks as one of those “questions which I actually think can’t be answered really”.
Sometimes possible risks in future pregnancies were raised when women were being discharged or at an early check-up appointment. This was helpful for flagging up that their health might be a consideration in any future pregnancy. Some women who were advised to visit their doctors or go back to the hospital to see the consultant before they started trying to conceive or soon after they became pregnant appreciated the guidance. Samantha X said this made her feel less uncertain about trying again for another baby. Mairi thought it should be standard to give women who have had blood pressure problems information about future pregnancies. She felt it would have been good to talk to a consultant about this before she was discharged from hospital and she ended up asking for an appointment three months later to get this information. 

However, many women said they were not in the ‘headspace’ to think about having another baby for some time after having a pregnancy with high blood pressure problems. Helen X remembered everything was “just such a whirlwind” at the time. Stephen thought a gap of about three months was about right for getting the information about future pregnancies: “a little bit of distance […can help] put it into context”. Despite different views on the timing, most women and partners agreed that there should be some opportunity or way to get information about future pregnancies (see also the section on information).
Decision-making about another pregnancy

Women made different decisions about whether to have another pregnancy after one affected by pre-eclampsia or HELLP syndrome. The possibility of being ill in another pregnancy was a big factor. Josie said the main thing putting her off another pregnancy was the chance that her baby may need to stay in hospital and they would be apart. Tracey didn’t want another baby initially: “I didn’t want to leave her [my daughter] without a mum”. Sometimes women spoke about other factors shaping the decision too, such as their age. Helen X thought this decision would be “really difficult”. Some women were very sure that they did not want another pregnancy. As Olivia explained, “this is never happening again. I’m never putting myself in that position ever again […] the thought of being pregnant actually gives me cold shivers”. Sometimes there were tensions between women and their partners on the decision. Hanna thought her husband was more reluctant than her about a second pregnancy.
Extra medical support in future pregnancies

Most women who went on to have another pregnancy after pre-eclampsia or HELLP syndrome said they received extra support from doctors and midwives. This included extra monitoring and medical appointments. Sometimes it meant that appointments were at the hospital with a doctor, rather than or in addition to seeing community midwives and GPs. Emma saw a consultant in her second pregnancy at 16 weeks and then her local community midwife, who was “well-informed of my history” and very supportive. Philippa said “it was quite nice to know they were going to be looking after us a bit more [… and giving] medical attention right the way throughout”. Women who felt their concerns hadn’t been listened to in a previous pregnancy were sometimes cautious though. Paige felt that, although she could flag issues, she couldn’t force doctors to prescribe her medicines or look after her in hospital if problems did develop. 

Some women did have high blood pressure problems again in following pregnancies and the monitoring helped pick up problems quickly. Other women didn’t develop blood pressure problems and so the extra monitoring could feel unnecessary. In her second pregnancy, Amy’s blood pressure stayed “perfectly normal. In fact, my midwife described me as utterly boring this time which I wasn’t offended by”. Janine recalled how “every week, blood pressure’s the same, urine’s negative, centimetres are the same for the weeks gone, and I thought ‘blinking typical’”.
Aileen, Munirah and Emma were all advised to start taking aspirin when they became pregnant. Aileen’s doctor explained that it can help reduce the chances of developing high blood pressure problems in pregnancy but that “it has no guarantee”. 

There were some other changes some women said they would make or had made in following pregnancies. This included requesting a planned caesarean section, transferring care to a different hospital than last time, and/or starting maternity leave earlier.
Reflections on following pregnancies

Women often said they were worried in next pregnancies. Janine’s friends tried to reassure her that it would probably be fine, but this was of limited impact. Other health complications—such as previous miscarriages, morning sickness and gestational diabetes—could add to their worries. But a few women said they felt less concerned in following pregnancies. For Philippa, “having done it [pregnancy and birth] before, I think you naturally don’t worry as much the second time”. Some women thought they were more prepared for a high blood pressure problem if it developed a second time. Paige said that, “now it’s happened once, I know what signs and symptoms to look out for; I know swelling that severe is not normal. If my blood pressure does keep going up then I won’t be just dismissing it”.
For some of the women we interviewed, high blood pressure problems did develop in their following pregnancies. This could be disappointing and frightening. As Ruth X recalled, “I’d painted this picture in my head about having a nice normal pregnancy and it wasn’t going to be anything like last time […] So when it did all start happening, I think my emotions were very much up and down”. Having high blood pressure problems in a subsequent pregnancy was also hard for women with young children already at home.
Rebuilding confidence after pre-eclampsia

For some women, a later pregnancy without problems helped re-build their confidence. As Hanna explained, “I gained so much from it […] I made the right choice to have a second baby”. Compared to her first birth of an emergency caesarean section under general anaesthetic, Tracey’s second pregnancy and birth was a much more positive experience: “you can hear what’s happening; there wasn’t the panic. It was quite nice to have him delivered and I could see him straight away”. Philippa had pre-eclampsia when pregnant with her first baby whereas the second was “a really easy pregnancy […] with absolutely no complications whatsoever”. For women who had previously had emergency caesarean sections, planned caesarean sections could feel quite ‘slow’. Some women were hopeful about future pregnancies and Melissa said she would “like to have a natural birth without being induced”.

Mairi had a caesarean section with her second baby, and this time it felt like it came too slowly. Mairi thought this difference the second time boiled down to the fact that “because nothing was going wrong, you just become one of the normal ones; you just have to hang on and they were extremely busy that day”. Having had caesarean sections both times wasn’t a worry for Mairi though: “I would never allow myself to get caught up in the whole, 'I haven’t done the proper female thing of having a proper birth.' […] I'm obviously not very good at giving birth, so that’s fine, I'm alright with that”.
A following pregnancy sometimes raised questions about whether a previous one affected by high blood pressure problems could have been different: whether something (such as picking up symptoms or having an induction earlier) might have stopped things becoming so seriously, but also realising when a situation could have been a lot worse. As Betty explained, “there were other things I would have preferred [for my baby’s birth] but I'm just very grateful that everything happened the way it did”.

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