Eight hours after Melissa Mastrippolito held her first child for the first time, the 36-year-old nurse decided to get out of her bed at Chester County Hospital to use the bathroom.
It was almost 9 p.m. on Saturday, July 14, 2018. Mastrippolito had been lying low since the birth of Nicholas Richard Mastrippolito because the grueling labor and postpartum bleeding had wiped her out.
As she stood up, she felt faint and scrambled back onto the bed.
Abruptly, a wave of nausea ripped through her. As she retched and pounded the call button, pain exploded under her right ribs. Next came a headache so sudden and savage, she was too stupefied to speak with two nurses who rushed in. Then she couldn’t breathe. She was suffocating.
“I’m going to die,” Mastrippolito gasped as her husband, Rob, watched in horror. “I’m dying.”
A nurse repeatedly tried to take Mastrippolito’s blood pressure, but it was so gravely high that the inflatable cuff kept popping off her arm.
Preeclampsia, a disorder marked by dangerously high blood pressure, is one of the most feared and least understood complications of pregnancy. It strikes only 5 to 7 percent of pregnant women, yet is a leading cause of maternal and neonatal death and disability.
In rare, unpredictable cases, preeclampsia morphs into the even deadlier syndrome that overwhelmed Mastrippolito. Called HELLP, it was first recognized as a distinct variant of preeclampsia in 1982.
Deaths and near-deaths in childbirth have been getting a lot of scrutiny recently in the United States, where maternal mortality rates have been climbing for three decades. In fact, this is the most dangerous nation in the developed world to have a baby. But addressing the peril can be enormously challenging, as Mastrippolito’s experience demonstrates.
Her caregivers – and she herself, an experienced nurse – had missed or misinterpreted signs foreshadowing her crisis on that Saturday night a year ago. As a result, her liver and kidneys were beginning to shut down. Her lungs were choking with fluids. Her blood was losing its power to clot. And her brain was in danger of bleeding – a stroke.
Mastrippolito’s obstetricians declined to discuss her case with The Inquirer. Chester County Hospital would only issue a statement: “Patient safety is our top priority. We continually monitor and evaluate our protocols.”
In Mastrippolito’s view, she was saved by two things: One of her obstetricians recognized just in time that she had HELLP syndrome, and quickly treated her. And luck.
She decided to open her entire medical record to The Inquirer and share her hard-won insights in hope of educating other women.
“I will be a more assertive and educated patient,” she said. “As part of that, I want to advocate for expectant mothers.”
Every year in the United States, about 700 women die and 50,000 are horribly injured in childbirth. The debate about why has focused on changing demographics (more pregnant women are older and sicker); on better reporting of pregnancy-related deaths; and on inadequate medical care, especially of poor, black patients.
Mastrippolito, though at 36 older than most women in their first pregnancy, was healthy. As a nurse at a pediatric outpatient center, she was medically savvy. She and Rob, 44 — a municipal worker for their township of Newlin and a talented guitarist — got married in June 2017 and settled into his childhood home, on a former mushroom farm and cannery in Coatesville. They had no trouble getting pregnant just five months later. The pregnancy went smoothly.
The couple had total confidence in Chester County Ob/Gyn Associates, where Mastrippolito received prenatal care, and in Chester County Hospital, where the practice delivers its patients. The couple have many ties to the hospital, which became part of the University of Pennsylvania Health System in 2013.
Mastrippolito’s grandfather, a family doctor, once served as chief of staff at Chester County Hospital. Her aunt was a labor and delivery nurse there, and her mother has been on the nursing staff for 30 years. She even worked there herself during nursing school, and for a while afterward.
“Rob and I were both born at Chester County,” she added.
As her due date neared, Mastrippolito had stubborn headaches that Tylenol couldn’t touch. She didn’t mention it at her prenatal visits.
“I figured it was my allergies," she said.
Nor did she express how utterly exhausted and unwell she felt at the visit before she went into labor. She chalked it up to the hot weather and her 50-plus-pound weight gain. She wasn’t bothering to track her weight gain at home, but she could see her legs getting more and more bloated.
Much later, when she reviewed her medical records, she discovered that she had gained seven pounds in the final week, a possible preeclampsia red flag that her doctors missed. She also learned that the headaches and exhaustion she had brushed aside were potential danger signs. Add that to the slight risk factors beyond anyone’s control -- her age and a first pregnancy.
Her blood pressure, usually on the low side, was 130/80 at that last prenatal visit — a little higher than guidelines say is normal, but not unduly alarming. A urine test to check for protein, a signal of kidney trouble, was normal.
On Friday, July 13, her water broke and she went into labor. She and her husband arrived at Chester County Hospital shortly before 4 a.m. on Saturday.
That’s when the first unmistakable sign of an emergency appeared: Her blood pressure was 163/94, according to her records.
Expert guidelines set the threshold for “severe” preeclampsia at a systolic (the upper number) pressure of 160, or a diastolic pressure of 110. “Notify physician after one severe value is obtained,” instructs the American College of Obstetricians and Gynecologists (ACOG).
Spectrum of disease
The U.S. incidence of preeclampsia has risen 25 percent over the last 20 years, a trend researchers link to increases in obesity, diabetes, and maternal age. Preeclampsia usually develops during the second half of pregnancy, often putting the health of the mother and her fetus at odds because delivery is the only way to resolve the disorder. But it occasionally persists despite delivery, and it can develop in the hours or days after childbirth.
As preeclampsia progresses, it can injure major organs, and can turn deadly quickly. The brain is particularly vulnerable; blood hammering the walls of cerebral vessels can trigger a rupture that becomes a hemorrhagic stroke.
The standard preeclampsia therapy is blood-pressure-lowering medication to prevent stroke, and magnesium sulfate to prevent seizures. Eclampsia, from the Greek word for lightning, is the term for seizures during pregnancy.
However, diagnosing preeclampsia is challenging because it’s a spectrum of disease with varying features that may be mistaken for other conditions. ACOG used to define preeclampsia as high blood pressure plus protein in the urine. But telltale protein might not show up, so in 2013, ACOG made it just one of six signs of organ dysfunction — including resistant headache — that doctors should watch for.
“Clinical judgment makes this messy,” said Preeclampsia Foundation chief executive Eleni Z. Tsigas, who lost a daughter delivered prematurely because of preeclampsia. “Preeclampsia does not have an on-off switch. Diagnosing it is not as simple as ‘You have this’ or 'You don’t.’ ”
Research has found rays of hope. Low-dose aspirin cuts the chance of the disorder in high-risk women such as those with chronic hypertension or diabetes. And a blood biomarker screening test under development in the United States and already available in Europe can be used to rule out preeclampsia — for one week — in women suspected of having it.
For now, the biggest red flag of a preeclampsia emergency, experts agree, is severe high blood pressure. After two severe readings — which can be taken within minutes of each other — the woman should be put on blood pressure and seizure medications.
Still, no guidelines can cover every scenario, and there are gray areas. For example, ACOG does not recommend treating pregnant women who have mild to moderate hypertension, because therapy may restrict fetal growth, and hasn’t been shown to prevent progression of preeclampsia.
“The idea was to standardize the approach to treatment,” said Peter S. Bernstein, a maternal-fetal medicine specialist at Montefiore Health System in the Bronx and a developer of ACOG hypertension guidelines. “But it’s hard to write a guideline that is perfectly clear in every situation."
Mastrippolito had hoped for a natural birth. But she was so exhausted when she was admitted to the hospital — where she learned her birth canal had barely opened — that she opted for epidural anesthesia to numb her below the waist, hoping to get some rest.
In retrospect, she sees that as a fateful choice. By relieving pain, an epidural can lower blood pressure and mask the worsening of preeclampsia.
The nurse who first cared for Mastrippolito didn’t mention the initial alarming blood pressure reading of 163/94, and in the throes of contractions every two minutes, Mastrippolito didn’t ask. Her medical records do not say that a doctor was alerted.
Mastrippolito didn’t have another severely high blood pressure reading during labor. And the standard initial blood tests showed no signs of anemia or blood-clotting problems.
Yet even after the epidural pain relief kicked in, an automatic cuff registered systolic readings at or above 140 through much of her nine-hour labor; diastolic readings were at or above 90 on eight occasions.
At 1:35 p.m. on Saturday, Mastrippolito and her husband rejoiced. Their son debuted at a robust 7 pounds, 8 ounces, 21 inches long.
As Mastrippolito snuggled the newborn, a complication developed: Part of the placenta clung to her uterus. The obstetrician on duty from Chester County Ob-Gyn, Lydia Slavish, spent the next hour manually detaching it. That triggered a gush of bleeding, so Slavish ordered an injection of Methergine, a blood-vessel-constricting drug that is standard for controlling postpartum hemorrhage.
At 2:43 p.m., Slavish left orders to be notified if Mastrippolito showed signs of trouble, such as a systolic pressure above 150.
Seven minutes later, the automatic cuff measured 155/94. The medical records do not say Slavish was informed.
Mastrippolito remembers the nurse telling her and her husband that her pressure was a bit high but that Methergine can cause a spike.
It all begins with the placenta
Although preeclampsia remains mysterious, it is believed to start with abnormal development of the placenta, which supplies oxygen and nutrients to the fetus. Basically, the placenta doesn’t attach correctly to the uterus and becomes starved for blood. Animal experiments have shown this triggers hypertension and, ultimately, multiple organ failure.
Mastrippolito’s uterine bleeding tapered off. Shortly after 4 p.m. on Saturday, she was transferred from labor and delivery to the maternity unit, where family and friends gathered to photograph and cuddle the newborn.
A maternity-unit nurse remarked that Mastrippolito’s blood pressure was sort of high after checking it. The new mother repeated what she’d been told about Methergine’s effect.
The records have no blood pressure readings at all between 6:30 p.m., when the Methergine should have worn off, and 8:50 p.m. — when Mastrippolito got out of bed to go to the bathroom. Standing up was enough exertion to make her already-high blood pressure soar, unleashing the devastating cascade of HELLP syndrome.
After Mastrippolito pounded the call button, there was a flurry of activity — including the untimely arrival of the pizza her husband had ordered.
She has little memory of those excruciating minutes, but she now thinks the nurses should have called the hospital’s Rapid Response Team, a critical-care crew that rushes to the bedside when patients who are not in intensive care show sudden deterioration that could lead to respiratory or cardiac arrest.
Instead, the nurses gave Mastrippolito a nausea drug, a pain medication, and put her on oxygen. Then they wheeled her — in her bed with the pizza at her feet — back to the labor and delivery unit, where Slavish was caring for patients.
Slavish’s medical notes show she immediately recognized HELLP syndrome. She ordered blood tests to evaluate Mastrippolito’s organ dysfunction and the two preeclampsia medications to ward off stroke and seizures.
ACOG guidelines say hospitals should have systems in place to start those crucial drugs within 30 to 60 minutes of confirmed severe hypertension.
But Mastrippolito had chest pain and her blood oxygen level was low, despite the extra oxygen –— signs of a lung blood clot, which could be deadly in minutes. So the drugs were not administered right away. Slavish sent Mastrippolito for a CT scan that showed fluid in the lungs, but ruled out a pulmonary embolism.
At 10 p.m., a little more than an hour after the start of her blood pressure crisis, Mastrippolito began getting intravenous magnesium sulfate, the anti-seizure drug. An additional 43 minutes passed before she was given the blood pressure drug, a pill called Procardia.
Around then, Slavish shared her diagnosis with the couple.
Dazed by drugs and the ferocious pain in her head, Mastrippolito vaguely recalled hearing about HELLP, once, in nursing school.
Signs of a stroke
HELLP develops in less than 0.5 percent of pregnancies, including 10 to 20 percent of women with severe preeclampsia, studies suggest. Like preeclampsia, HELLP — an acronym for hemolysis, elevated liver enzymes, and low platelets — is blamed on abnormal placenta implantation.
But the brunt of the impact is in the liver and blood. In simple terms, red blood cells are destroyed, so they can’t ferry enough oxygen to vital organs. Platelets, essential for clotting, also break down. Debris from this cellular implosion damages the liver, which enlarges, causing the stabbing pain Mastrippolito felt under her ribs.
On Sunday morning, Mastrippolito’s lab tests showed the hallmarks of HELLP. Pamela Kurey, the obstetrician on duty, ordered retesting at 2 p.m. and, if necessary, a blood transfusion.
“Need to keep a very close eye on this patient,” Kurey noted.
Mastrippolito was too sick to breastfeed or pump milk for her son, who was being given formula. Her headache had barely subsided. Her eyes hurt, she felt dizzy, and she had double vision.
Thomas Sinclair, an internal-medicine doctor who examined Mastrippolito that morning, talked to Kurey about the possibility of bleeding in the brain. He recommended the patient have a head CT scan to rule out a cerebral hemorrhage.
“But OB favors holding on imaging unless headache gets worse,” Sinclair noted in the records.
Mastrippolito’s husband saw that her left eyeball had rotated outward. “Look at her eyes. What’s wrong with them?” he pestered four care providers on Sunday.
He and his wife were told magnesium sulfate could cause visual disturbances.
On Monday morning, the magnesium was discontinued and Mastrippolito was told it would take about an hour to wear off. She covered her left eye to watch the wall clock. Hour after hour passed. Her double vision was still so bad, she asked for an eye patch.
It was Monday evening when Manuel J. Ferreira, the obstetrician on duty, finally ordered a head CT. Mastrippolito later learned that a nurse she knew personally had heightened concern by telling Ferreira that Mastrippolito didn’t normally have a “lazy eye.”
The CT showed a possible small hemorrhage, so Ferreira ordered an MRI, which bolstered that suspicion.
Around 11 p.m., Ferreira explained the next step, which left the exhausted new parents in tears, feeling terrified and torn.
Mastrippolito was taken by ambulance to the Hospital of the University of Pennsylvania, where she was admitted to the neurology-neurosurgery intensive care unit for more evaluation. Rob joined her there.
They left their 2-day-old son overnight in the nursery at Chester County Hospital.
It would be two more days before Mastrippolito — almost as helpless and dependent as her son — would be reunited with him.
‘I’m so lucky’
While recovering, Mastrippolito began doing research about HELLP syndrome. She ran across a story in ProPublica with similarities to her own.
A nurse, Lauren Bloomstein, delivered her first child in the New Jersey hospital where she worked, then developed HELLP. In Bloomstein’s case, however, the syndrome was not promptly diagnosed or treated and she died of a massive cerebral hemorrhage.
“I’m so lucky,” said Mastrippolito, now 37. “My brain stopped bleeding on its own. Lauren’s didn’t.”
Diagnostic tests at Penn showed that Mastrippolito’s bleeding was not caused by a ruptured vessel, but rather by spasms that made the vessels constrict and leak — a rare but recognized complication of preeclampsia.
That is not to imply her recovery was quick or easy.
She needed two transfusions while at Penn. She went home on Wednesday, July 18, barely able to walk. Penn gave her a blood pressure monitor to use twice a day, and she took a drug to relieve the brain vessel spasms. She had balance problems, language deficits, and double vision. Doctors said they would probably go away.
Gradually, they did. Nicholas was 6 weeks old when his mother shed her black eye patch.
For the rest of her life, Mastrippolito faces higher risks of cardiovascular disease, heart attack, and stroke. Her hope of having another child has to be weighed against the 40 percent chance that HELLP would recur.
To find support, and learn how to give it, Mastrippolito joined End Preeclampsia. Last month, she pushed Nicholas in his stroller as part of a Preeclampsia Foundation fund-raising walk.
Now a toddler, Nicholas will be the star when family and friends gather in a week for a first birthday barbecue. His parents give thanks that he was unscathed by preeclampsia.
“I feel very grateful to be alive,” Mastrippolito said. “I’m cherishing every moment with my son and husband.”