High Blood Pressure
Understand and Prevent High Blood Pressure
(25) High Blood Pressure
I have been told to take a small dose of aspirin every day, but I also take high BP drugs for my BP. Are there any risks of taking aspirin when I have high BP as well?
(26) High Blood Pressure
My family came from Jamaica originally and my father has high BP. It seems to run in our family. Do black people differ from white people in the way that they respond to BP-lowering drugs?
(27) High Blood Pressure
Pain - particularly joint pain and arthritis
I’ve got to go on to tablets for high BP but also have arthritis and take ibuprofen for the pain. Will my treatment for arthritis affect what I am given for high BP?
Joint pains generally arise from osteoarthritis or inflammatory arthritis - most commonly rheumatoid arthritis, or gout. Treatment is usually with a non-steroidal anti-inflammatory drug (NSAID). There are many of these drugs, with some - such as ibuprofen (Brufen, Fenbid) - now available across the counter at chemists.
All the NSAIDs are usually effective for treatment of inflammatory arthritis and gout. Their effect on acute gout is usually dramatic. They can help people with osteoarthritis but their effect is usually less dramatic. They are also used in the treatment of period pains and heavy menstrual blood loss (‘menorrhagia’), and mefenamic acid (Ponstan) has been particularly promoted for this.
Most NSAIDs raise BP by an average of 5-6 mmHg diastolic pressure, roughly the same as the reduction produced by most BP-lowering drugs. They appear to cause salt retention.
Approximately, 40% of all people needing BP-lowering drugs also suffer from chronic rheumatic pains and NSAIDs are often given. You need to be aware of the effect of NSAIDs on your BP and ask your doctor for alternative treatment - paracetamol, which is not an NSAID, can provide very effective pain relief without any of the side effects on BP increase. Ibuprofen, which is available over the counter, has a much smaller effect than most other NSAIDs, averaging less than 2 mmHg. You should ask a pharmacist if the drug you are buying is likely to affect your BP or interact with your BP-lowering drugs.
I have severe rheumatoid arthritis treated with steroid tablets (prednisolone). Will this affect my treatment for high BP?
Steroid drugs (usually in the form of prednisone or adrencorticotrophic hormone - ACTH) are necessary and effective for severe, acute attacks of rheumatoid arthritis, particularly in the first few months after onset of the disease. In these circumstances they may not only relieve pain, but also reduce long-term joint damage. Although they raise BP by causing salt and water retention, and thus increasing blood volume, this is almost always a price worth paying, even for people with severe high BP.
In any case, these severe cases will usually be under the care of a hospital specialist, whose job it is to make a balanced decision in the light of all the evidence of your particular case. Long-term use of steroids for rheumatoid arthritis not only raises BP (seldom by very much), but weakens bone structure with a high risk of spontaneous fractures of the spine, which reduces breathing capacity and resistance to infections of all kinds. There are alternative disease-modifying drugs that are available and you can ask your doctor or specialist about them.
Rheumatologists normally keep people with rheumatoid arthritis off steroids for as long as possible. Raised BP, even in people with high BP, is one of the smaller risks of long-term steroids.
I have had several attacks of gout in the past and I am now on BP-lowering drugs. I have been told certain types of BP-lowering drugs can cause gout. Is this true?
Gout occurs when your body fails to get rid of one of its waste products, a substance called uric acid. Usually the kidneys get rid of the uric acid in your blood, and it is passed out in your urine. In you develop gout, you have a metabolic disturbance and too much uric acid is produced and accumulates as crystals in the joints of your body. This can result in severe pain, swelling, redness and tenderness of the affected joint, most often your big toe joint. It is a common problem and does tend to run in families. Uric acid levels in your blood can be raised by alcohol, some foods (liver is a good example) and by thiazide diuretics in high dosage. At low dosage (usually 2.5 mg bendrofluazide daily), there is rarely any effect on uric acid levels, and at 1.25 mg there is no effect at all. These low doses are just as effective in controlling BP. Gout was a particular problem in people taking high-dose thiazides but, as the BP-lowering benefits can be achieved with low-dose thiazides, the side effect of gout is much less common.
There is some evidence that, in people who have a tendency towards suffering gout (past history or family history),higher dosage thiazide diuretics double the risk of suffering a recurrence of gout. So thiazide diuretics will not be given to you – alternative BP-lowering drugs will be prescribed.
My mother has developed schizophrenia but she also has high BP. Will her condition affect what she is prescribed for hypertension?
Most people with schizophrenia are treated permanently with major tranquillizer drugs - the phenothiazines - either as tablets or depot injections once a month. These drugs have a powerful BP-lowering effect, which usually makes any other BP-lowering medication unnecessary.
Involuntary writhing movements, usually of the face and limbs, are a common complication of long-term treatment with phenothiazines. This effect is increased by methyldopa (Aldomet), which should therefore not be used to treat high BP in schizophrenics.
(28) High Blood Pressure
High BP and planning a pregnancy
I have had high BP for several years and would now like to plan a pregnancy. What precautions should I take?
The most sensible approach for a woman with known high BP planning a pregnancy is to seek pre-pregnancy advice from a well-informed doctor physician or specialist obstetrician. General advice will include maintaining a sensible balanced diet and normal weight for your height, taking regular exercise, stopping smoking and either stopping alcohol or keeping intake to a minimum. All women who are planning a pregnancy are advised to take extra folic acid (a vitamin that plays an important part in the development of the fetus) for 3 months before a planned pregnancy (e.g. before you stop using contraceptives) and for the first 3 months of pregnancy. Specific advice will relate to whether your high BP requires treatment, what BP-lowering drugs are safe to use in pregnancy, whether you could stop your medication for the early part of pregnancy and whether there are additional risks to your health or that of your baby because of your high BP. It is highly unlikely that you will be advised not to have a pregnancy because of high BP.
We hear a lot about how drugs taken in pregnancy can damage unborn babies – I’m especially thinking of thalidomide, but I know there are others. Can BP-lowering drugs be safely taken in pregnancy?
The time when we are most concerned about drugs affecting the fetus (the unborn baby) is in early pregnancy. Your pregnancy begins before you miss your period, but for the first week when the fertilized egg is moving down your fallopian tube, it is probably not at risk from drugs in your bloodstream. The important time for development is from the time of implantation up until the end of the third month, a period known as ‘organogenesis’ because all of the baby’s organs and structures are developing. After the first 3 months of pregnancy the baby is mostly just growing and is much less vulnerable to any effects from drugs.
If you are taking BP-lowering drugs, then you should take the earliest opportunity to discuss with your doctor (or whoever else is looking after your BP) whether or not you need to change your type of drug or whether it would be safe for you to stop treatment. Ideally this will have been planned before your pregnancy as discussed in the previous question.
Ever since thalidomide (which, incidentally, was a sleeping tablet and was used for morning sickness – it was not a BP-lowering drug), all drugs have been tested on animals (mostly rabbits or rats) to see if they might cause organ damage to the fetus during pregnancy. Because very large numbers of animals can be used, these tests are fairly sensitive, but because they are not on humans, we can never be entirely sure that they exclude risks to a human fetus. New drugs are rarely tested in pregnant women and often not even in women of reproductive age. We have to rely on more indirect evidence from population based studies and on reporting of bad outcomes (adverse event reporting) where pregnant women have inadvertently taken drugs.
Thousands of women and babies have been checked in this way for evidence of fetal damage from drugs taken in pregnancy and, on the whole, these studies have been reassuring. None of the common BP-lowering drugs has been shown to produce fetal damage, although many women have conceived while taking their regular BP-lowering medication. Unfortunately this is not the same as proving safety. Although damage on the scale of thalidomide is certainly not happening, serious damage to as few as 1 baby in every 1000 born is possible. We have to take this risk seriously, while at the same time not being alarmist. Naturally there is greatest experience and reassurance about safety with the older BP-lowering drugs. For this reason, you may be advised to change from a newer type of BP-lowering drug to a more old-fashioned one when planning a pregnancy or when you are seen in the early stages of an unplanned pregnancy.
What does this mean in practice?
There are three things to consider.
• BP-lowering drugs should be avoided in pregnancy, unless your raised BP is serious enough to justify this.
• Plan your pregnancies with the help of a well informed doctor or obstetrician and, if you do need BP-lowering drugs, you can be confident that you will be prescribed the safest possible choice.
• Discuss the possibility of temporarily interrupting your treatment with BP-lowering drugs during the weeks when you are attempting to conceive and during the first 13 weeks of your pregnancy.
I have tried different BP-lowering drugs for my hypertension and they haven’t always suited me. What options will I have in pregnancy?
You will obviously want to avoid any drugs that could cause additional risk to you or to your baby. Methyldopa is an old-fashioned drug, which, although it does have some side effects, has a good track record for safety and effectiveness at all stages of pregnancy. Beta-blockers are well tolerated and apparently without risk to the baby after 24 weeks; before this they may slow down the baby’s growth and should be given only if necessary. There is most experience with labetalol, but atenolol should be avoided as this agent was implicated in a small study showing impaired growth in fetuses.
The calcium-channel blockers are commonly used in later pregnancy, but there is much less safety data than for methyldopa or beta-blockers and they are best avoided in early pregnancy unless there are reasons for not being prescribed other types.
Diuretics, often the first choice for high BP, are ruled out because they may make pre-eclampsia worse (pre-eclampsia is discussed later in this chapter). However, this risk is probably theoretical and many women will have taken diuretics in early pregnancy with little evidence of side effects to themselves or their babies. However, you will probably not be given them in pregnancy. The drugs that really need to be avoided for your baby’s sake are the ACE inhibitors, which have known dangers for the developing baby (usually later in pregnancy) and newer agents that are completely unevaluated in pregnancy.
High BP in pregnancy
I have heard that BP falls in pregnancy. Why is this?
Yes, it normally falls during pregnancy. This is one of the reasons why you may be able to stop BP-lowering drugs for at least part of your pregnancy. If it rises, this is always important, because it may indicate that you have pre-eclampsia or eclampsia. Nurses, doctors, and midwives regularly measure your BP all through pregnancy looking for newly elevated BP or the development of pre-eclampsia.
Pregnancy normally lasts between 38 and 42 weeks. This is usually divided into three periods of development, called trimesters. The first 13 weeks (the first trimester) roughly corresponds to the time when the baby is being formed. The second trimester is from 14 to 27 weeks: it used to be the time when the baby was thought to be too immature to survive, but now some babies as young as 24 weeks do survive with intensive neonatal care. Babies were considered able to survive if they were born during the third trimester (which runs from 28 weeks of pregnancy until the birth), although before modern intensive care many failed to do so.
From whatever level it starts, your BP normally falls during the second trimester (from 14 to 27 weeks). It then usually rises slowly until your baby is born (which is normally at 38 to 42 weeks), although it may still be a bit lower than before you became pregnant. After your baby is born your BP rises slowly over the first 5 days to regain its usual level before your pregnancy. When you are pregnant, not only do you need oxygen, but so does your developing baby. Your body therefore makes more blood to carry enough oxygen for both of you, so the total volume of your blood rises rapidly during the first 12 to 13 weeks of your pregnancy. All other things being equal, a rise in blood volume should cause a rise in BP. To prevent this, your placenta (which nourishes your baby in your womb, links your blood supply with your baby’s, and is expelled in the afterbirth following the birth of your baby) releases hormones (mainly progesterone), which relax the walls of your veins and small arteries so that they become larger to make room for this increased blood volume, without any rise in your BP. Because of this, your heart doesn’t have to pump so hard and your BP falls.
Because your blood vessels are relaxed, they do not respond as quickly to instructions from your brain, so blood may remain in your legs when you get up out of a chair. Your BP then falls, and you may feel dizzy or faint. All this usually happens in the first 12 weeks or so when your circulation is changing most rapidly, but even later in pregnancy you may find yourself feeling faint in a hot room or if you get up too quickly from lying down. If this happens you should either sit or lie down and it will usually pass off quite quickly.
When I’m pregnant, how high must my BP be to be called high BP?
A BP of 140/90 mmHg or more is conventionally considered to be a high BP in pregnancy. The significance of these figures will depend on whether your high BP is new (i.e. developing for the first time in your pregnancy) or whether it was already high before you became pregnant.
Why is it important to know if my raised BP developed before I became pregnant or whether it is something new?
The difference between pregnancy in women with pre-existing high BP (i.e. having raised BP before you became pregnant) and high BP starting in pregnancy is simply the rate of change ofyour BP. Pre-existing high BP starts very slowly, in childhood or adolescence, with plenty of time for every part of your body to get used to it. High BP developing for the first time during pregnancy develops over a very short time, never more than a few weeks and occasionally even over a few hours. During this time you may get very serious damage to your small arteries, particularly in the kidneys, liver and brain. It may also affect the blood supply to the placenta and ultimately the oxygen supply to your unborn baby. The same kinds of damage may occur in preexisting high BP, but only at much higher levels of BP, and usually over much longer periods of time.
If I get high BP during my pregnancy, who should look after it, my doctor or my obstetrician?
If your BP rises for the first time during pregnancy, i.e. you didn’t have high BP before you were pregnant, then your obstetrician will take the decisions about your treatment, although your doctor and midwife also need to know what drugs (if any) you are taking. Because BP can change very quickly in pregnancy, your doctor or midwife should check your BP if at any time you feel ill, have pain in the upper part of your abdomen, or a prolonged headache. These are important warning signs of pre-eclampsia. Your antenatal clinic should give you your maternity notes so that you can show them to anyone you need to consult, although in some areas you may instead be given a card called a shared-care card on which all this information can be recorded. Don’t forget to take your notes with you whenever you go to the clinic or to see your doctor.
Not many women are both young enough to be pregnant and at the same time old enough to have BP high enough to need BP-lowering medication. This means that not many obstetricians see women with long-standing high BP who have already had treatment for months or years. However, this pattern is changing with more women delaying child bearing to an older age, and you may well have a choice of healthcare professionals who can offer care. If you are affected by high BP, then you need joint care, intelligently shared between your doctor or your hospital physician, your obstetrician and your midwife. Because your medication is likely to be changed during your pregnancy, you will need more frequent BP measurements than most women, and they will need to be very accurate.
I’m in my first pregnancy, and my BP has gone up a bit. My doctor says she’ll keep an eye on it but that I don’t need any drugs for it yet. If I do need to take BP-lowering drugs, when will I start on them?
Speaking generally, if BP rises for the first time after 36 weeks of pregnancy, then it is usually best to deliver the baby within a reasonable interval, so labour is brought on early (induced). This decision may be made without you needing BP-lowering drugs. If BP starts rising for the first time between 24 and 30 weeks, doctors usually try to control it with BP-lowering drugs so that the baby is more mature when born and has a better chance of surviving.
Between 30 and 36 weeks BP-lowering drugs may help to prolong the pregnancy and increase the likelihood of you being able to have a normal delivery and reduce the likelihood of the baby needing medical support in the intensive care unit.
Doctors vary in their opinions on how high your BP should be before you start treatment. There is good evidence that treatment benefits both mother and baby when systolic BP measures 170 mmHg or more or diastolic BP measures 110 mmHg or more. This level of high BP is an indication for admission to hospital and immediate stabilization on BP-lowering drugs. There is far greater variation in practice when BP is between 140/90 and
160/100, what is called mild to moderate hypertension. Some studies suggest that treatment of mild to moderate hypertension may reduce the chance of progression to severe hypertension; however, the counter argument is that there may be a negative effect on the growth of the baby. There is clearly a balance to be achieved in treating moderate hypertension in pregnancy between potential benefit and harm. You will need to discuss this with your obstetrician who can take account of your individual circumstances and what approach is likely to result in the best outcome for you and your baby.
(29) High Blood Pressure
Pre-eclampsia and eclampsia
Could you explain what pre-eclampsia is?
Pre-eclampsia is a complication of pregnancy characterized by high BP, protein in the urine and oedema (swelling). These features do not always present at the same time, which can make the diagnosis difficult. The early stages are often symptom less and detection relies, therefore, on regular antenatal checks of your BP and urine. The majority of women who develop preeclampsia will develop only a mild form and will recover well
with delivery of a healthy baby. However, it is potentially life threatening to you and your baby if it is allowed to develop and progress without detection or appropriate management. Mothers with pre-eclampsia can be stabilized but it is only curable by delivery, which puts some babies at risk of death or disability from prematurity.
We do know that, as with pre-existing high BP, there is an inherited tendency for pre-eclampsia to run in families, which is why midwives and doctors ask you about BP in your relatives, particularly in your mother or sisters. Pre-eclampsia is also more common in first pregnancies, in women over 40, and in women who already have raised BP before they get pregnant. Your risk of pre-eclampsia is usually assessed at this first antenatal visit and the appropriate pattern of antenatal care will be determined at that time. Visits will be increased if complications are identified as your pregnancy progresses.
I’m worried that I may get pre-eclampsia when I get pregnant as I already have high BP. Am I at greater risk than women who don’t already have high BP?
Pre-eclampsia is a condition in pregnancy that usually presents with high BP, protein in the urine and swelling (oedema). Your risk of pre-eclampsia is higher if you already have high BP but we don’t know by exactly how much. Depending on your age, weight and family history, your risk of pre-eclampsia can be anythingfrom 2 to 10 times that of a woman who did not have raised BP at the beginning of her pregnancy.
The problem is that, because most studies have been based on women attending hospital antenatal clinics, they often lack information about BP in women before their pregnancies began. If women are not seen for antenatal care until they are well into their pregnancies at 15–20 weeks (which is still fairly common in women at the highest risk of pre-eclampsia), and if there are no previous medical records about BP, then there is simply no
way of knowing whether a rather high BP is recent and important, or it is long-standing and therefore much less important. A lot of research on this subject has been weakened by this lack of information, so any conclusions have to remain rather uncertain.
The moral of this is that, if any doctor or nurse has at any time been concerned about your BP, you should make sure the details of this are available to whichever professionals become responsible for advising you during your pregnancy. This information will influence your subsequent risk of pre-eclampsia and how your antenatal care is planned.
Because I suffered from pre-eclampsia in my first pregnancy, I have been looking up the subject now that I am pregnant again. I have see the words ‘fulminating pre-eclampsia’, which sounds very daunting. What is fulminating pre-eclampsia?
Fulminating is yet another word that comes from the Latin, and roughly means ‘like lightning’. It can be applied to any illness or condition (not just pre-eclampsia) when it occurs suddenly and with great intensity (in other words, one which strikes like lightning).
Fulminating pre-eclampsia happens very rarely, but when it does, it is an emergency. The term is used to describe the extremely rapid development of pre-eclampsia, over hours or days rather than the more usual weeks. In this rare emergency, BP rises rapidly, large and increasing amounts of protein are passed in urine and fluid is retained so that the face swells upvisibly over a few hours. When this happens the brain can also becomes swollen, and there is then immediate danger of eclamptic fits. Drugs will be used to bring down BP and to prevent fits (usually given by a drip in a vein), and the baby will be delivered as soon as possible either by inducing labour or by caesarean section. Recent research has shown that the best available treatment for women who develop an eclamptic fit is with magnesium (Epsom salts) given into a vein or into a muscle. This hospital treatment decreases the risk of further fits and reduces the danger to both mother and baby.
I presume ‘pre-eclampsia’ just means ‘before eclampsia’, but what exactly is eclampsia?
The word eclampsia comes from the Latin, and literally means ‘flashing lights’. In practice it means fits (seizures) caused by brain damage, caused in turn by very high BP that develops very fast, usually in late pregnancy. Women suffering eclampsia usually see flashing lights just before a fit begins, hence the name. Soon after this, the sufferer suddenly loses consciousness, her whole body shakes symmetrically and uncontrollably, with clenched teeth and severe spasm of all muscles, all for only a minute or two but seeming much longer.
Eclampsia is very dangerous both to the mother and to the unborn child. Before modern antenatal care, deaths from eclampsia in pregnancy were common. They still happen, although very rarely – only in 10 pregnancies in every million. In nearly all cases eclampsia is preceded by pre-eclampsia - either by several weeks of slowly rising BP, or by dramatic warning signs (mainly pain in the upper abdomen caused by congestion of the liver), or by severe persistent headache. The existence of these changes and warning signs means that nearly all cases of eclampsia can be prevented by good antenatal care.
Because pregnancy is now normally well supervised, eclampsia has become very rare and, when it occurs, it may indicate a serious breakdown in health care. Eclampsia is treated by urgent admission to hospital, by giving drugs to control BP and seizures, and by delivering the baby asquickly as possible, after which BP usually falls rapidly to normal without any other treatment.
Does anyone know what causes pre-eclampsia and eclampsia?
Although eclampsia was first identified 150 years ago, its prime cause remains unknown. When we do understand the cause we shall probably find that we should actually be talking about causes in the plural. We already know that there are different patterns to pre-eclampsia, and that these are likely to have different underlying causes.
Pre-eclampsia is somehow related to the placenta. The placenta has its own arteries. In pre-eclampsia these arteries do not penetrate the wall of the uterus (womb) as well as in women without pre-eclampsia, and they seem to be narrowed by plaques of cholesterol and blood clots in much the same way as the coronary and leg arteries are in ‘ordinary’ high BP. This reduces placental blood supply, which somehow induces raised BP throughout the body, with reduced blood flow through the liver and kidneys (untreated, this can lead to kidney failure). The way the blood clots may also be affected and, again, if untreated, blood clotting could be prevented altogether, leading to severe bleeding before, during or immediately after the birth.
All these changes sound frightening but they are rare in modern practice, with regular antenatal supervision and prompt action at the first signs of pre-eclampsia.
I have just learnt that I am pregnant for the first time. How likely is it that I will get pre-eclampsia?
In Western countries about 5% of women expecting their first babies will get pre-eclampsia. In most women it will be in a mild form, but about 1 woman in 250 may get a more severe type of pre-eclampsia.
In some studies as many as a quarter of all women have been found to have some rise in BP during their first pregnancy, instead of the expected fall. However, the accuracy and reliability of BP readings can be affected by many different things, so these rises may be because of anxiety or the number of different people taking the BP measurements.
My mother and my sister both had pre-eclampsia in their first pregnancies. I’ve heard that it runs in families, so what are my chances of having it?
We do know that, as with pre-existing high BP, there is an inherited tendency for pre-eclampsia to run in families, which is why midwives and doctors ask you about BP in your relatives, particularly in your mother or sisters. Estimates vary between a 2-fold and 4-fold increase in your risk of pre-eclampsia with any existing family history. The highest risk is where both a mother and a sister had pre-eclampsia leading to a 10-fold increase in risk. Many of these studies are old, reflecting care when women were having babies in the 1930s and 1940s, and their daughters were having their babies in the 1960s and 1970s. Much has changed in the last 20–30 years, so we would expect the chances of developing pre-eclampsia or eclampsia to be fewer today with our improved antenatal care and earlier inductions when preeclampsia does occur.
It would be sensible for you to tell your obstetrician and the other people caring for you during your pregnancy about this family history of pre-eclampsia. The more they know about your medical history and background, the better they can look after you.
If I do develop pre-eclampsia, will it harm my baby?
The main risks to your baby relate to poor growth and prematurity. Babies born at a lower weight than expected for the stage of pregnancy may take a while to establish a good feeding pattern and steady weight gain. This may mean additional ‘top-up’ feeds as well as breastfeeding and occasionally the baby may need to be fed with a small tube passed into its stomach if he or she has difficulty sucking. Pre-eclampsia may cause premature birth, usually with a birthweight under 2.5 kg (5 lbs 8 oz), or your baby may need to be induced early to protect you, the mother. Either way, depending on the degree of prematurity, this does slightly increase the risk of harm to your baby. Babies who are very immature may need special care in a neonatal intensive care unit. In the very rare cases of severe pre-eclampsia early in pregnancy, there may be a risk of the baby dying or survival with disability.
In my last pregnancy one doctor said I had PIH, another said I had PRH, and the midwife said I had PET. What was going on?
At one time eclampsia and pre-eclampsia were together called toxaemia of pregnancy. There was no attempt to separate several different conditions affecting pregnant women, some of which were caused by problems unrelated to high BP. In recent years doctors have tried to make things clearer (or at least more specific) by trying out different names for high BP in pregnancy. Toxaemia is a term rarely heard today, but pre-eclamptic toxaemia (PET) is still used. Pregnancy-induced hypertension (PIH), pregnancy-related hypertension (PRH), pregnancy-associated hypertension (PAH), hypertension–oedema–proteinurea syndrome (HOP), hypertensive disease of pregnancy (HDP), gestational hypertension and gestosis are names that are all used to describe BP that is raised during the latter part of pregnancy and which gets better after the baby is born. This is all very confusing to the mother! If we must use abbreviations, the most sensible would seem to be PE (for preeclampsia), because eclampsia is real, and is what we are trying to prevent. However, this can be confused with pulmonary embolus (a clot in the lung and also a rare complication in pregnancy). If there is no protein in the urine, then you may well find the abbreviation PIH being used, and many doctors and midwives use PET (pre-eclamptic toxaemia) when there is protein in the urine.