HBP Advice/Opinions Needed

[dkm]

Let me start with some background information:

My wife and I are expecting our first baby boy this month. She is 36 weeks and 1 day. We have had two previous miscarriages that were unexplained. We are with high risk, maternal fetal medicine doctors. She has been on Aldomet since 15 weeks for her HBP. She is taking the maximum doseage of 500mg 4 times a day. For the past couple of weeks her body seems to not be responding to the medicine and her BP has consistently been above 140/90. I have confidence in the Doctors, but we are now wondering about some of the decisions being made right now and would like to get some advice/opinions.

On Friday, my wife was having blood pressure readings at home of 148/98 and 146/95 about 2 hours apart and sever swelling in her hands and feet/ankles so the nurse suggested that we go to the Maternal Evaluation Unit and get checked out. We went and her pressures there rose to as high as 158/108 and averaged right around 150/100 during the 6 hours we were there. The pressures settled to 144/84 and they decided to send us home based on a NST and CST showing that the baby was okay.

We went to our normal visit on Monday and her first reading was 148/98, they waited another hour, then another nurse took it and it was 148/100 so they decided to send us back to the MEU. We spent some time in MEU, taking BP and having NSTs run. Her pressure never dropped and the baby's heart rate dropped while she was having two strong contractions. At that point, she was having 3 contractions every 10 minutes and they were the strongest that she had experienced to date. Based on that, they decided to admit her to the Hospital for observation. She had a 24 hour urine sample, BP monitoring and fetal heart rate monitoring every 4 hours. The urine and blood work all came back negative, but her BP never dropped below 148/98 except Monday night while she was sleeping and then it was 138/88. Consistently throughout the visit, the BP was around 150/100 and was even as high as 158/112. After keeping us until this morning, they decided to discharge her from the hospital on bed rest orders stating that they could not deliver because they didn't have a good reason to deliver at 36 weeks. We asked if they would deliver at 37 and they would not commit to that either. They said to call or come back in if her pressure rose above 150 or above 110 again and they would re-admit her for monitoring. When we got home, it was 144/107.....

We have our normal visit coming up again on Monday and are pretty sure we are going to be sent back to MEU and nothing will happen again. As of now, the Dr has the induction scheduled for the 22nd, three weeks from now, I just can't believe that it would be safe for Mom or Baby to wait that long.....

My question is, is this normal? We just don't understand why you wouldn't want to take a healthy, over 6 pound baby out of a potential stressfull situation? Are we overreacting? We have already lost 2 babies and don't understand why there isn't more urgency around this situation. Sorry for being so long winded and thanks in advance for your thoughts/opinions.

Donald

[jen44]

Hi Donald,
I completely understand your concern and agree with you. My last pregnancy was very much like your wife's and I was induced at 36 weeks with severe PIH to avoid any further complications - at 36 weeks baby is normally very well developed and 37 is considered term so I don't understand doctors who play with fire by waiting until it turns into full blown PE or not... but that's just my own opinion. I am surprised they aren't adding another BP med to lower her pressures though, at least to keep them down to a nice level. Even without proteinuria, PIH is a dangerous condition and needs to be monitored closely. I am not one of the experts here though, I am sure others will come along soon with good advice on how to handle your wife's doctors and what to do next.

[onesock]

I don't know that I understand what the reasoning would be behind your doctor's decision to wait past 37 weeks...maybe he needs a gentle reminder that those high pressures that your wife is presenting with are on the *maximum* dose of aldomet. This sounds very much like my second pregnancy...I too was on 2 grams of aldomet/day and still had high bp's like you mentioned...as soon as I hit 37 weeks, my son was born, via c-section. It is a balancing act between whether mom will be safer with baby out, as babies at 37 weeks are considered term and usually do great. Maybe you could suggest an amnio for fetal lung maturity? BEST of luck to you.

[blythe]

Donald, we're not doctors and I hate to second guess your care providers and add to your doubts at such a stressful time... That being said, I absolutely understand your desire to induce at 36 weeks - my doctor agreed to an induction for me at 36 1/2 weeks with my second when my bp hit diagnostic levels, rather than wait for more symptoms. However, your wife developed chronic hypertension early in her second trimester, and that's at least one reason the management of your wife's pregnancy is going to look at lot different than someone like myself. Her doctors are probably waiting for more signs of "superimposed" PE (Caryn just had a great explanation just today about what that is - http://www.preeclampsia.org/forum/viewtopic.php?t=31102 ), such as over 300mg protein in a 24 hour collection, visual disturbances, upper-right quadrant pain that shows up as liver failure in bloodwork, headache that doesn't go away with tylenol... I strongly recommend that you and she familiarize yourselves with the "signs and symptoms" http://www.preeclampsia.org/symptoms.asp and continue to trek to L&D for reassurance - or delivery.

Women with chronic hypertension in pregnancy (and your wife qualifies according to the definition - hbp before 20 weeks gestation, even if her bp is normal outside of pregnancy) are often allowed to run much higher pressures before the doctors get really concerned. I would be interested to hear what your doctors think about adding another bp med - many of our members seem to benefit from med changes when their pressures start to rise like that. Those diastolics (lower number, how hard the heart is beating at rest) over 105 make non-doc me really queasy - my understanding is that when the heart is beating that hard she is at risk for a stroke, pre-eclampsia or not.
http://acogjnl.highwire.org/cgi/content/abstract/105/2/246 (though this study was on a population of severely pre-eclamptic and eclamptic women, not women with chronic htn in pregnancy like your wife. I'm having trouble finding a study to back up my statement of "over 105" as especially dangerous... so again, not a doctor here, but I have been reading stories on this board for quite a few years now and diastolics that high just always seem bad.)

All that aside, the decision to induce at 36 weeks is not as clear-cut as it might seem. Although one of our members just had a 34-weeker room in with her and go home immediately, my 37-weeker spent 4 days in the NICU and definitely seemed like a "preemie" in many respects. As Wendy said, your doctors are walking a tightrope between giving baby more time and keeping mom healthy.

Please keep asking questions, and invite your wife to join us as well!

[dkm]

Thanks to everyone for their replies so far. Blythe, the Doctors are saying that they do not want to change the meds because the baby is doing too well and they don't want to jeopardize his health.

Kristi has had what she describes as "pressure in her head" and spots/floaters in her vision, but they are not consistent. The Doctors have basically ignored that or "that's because you're pregnant".

Thanks and keep the comments, stories coming. We appreciate it.

Donald

[onesock]

The "pressure in her head" description is concerning to me, as are the floaters. I know that you said that they are not consistent, but how often does it happen and is it relieved by tylenol? Another thing, are the checking her reflexes, in particular, for clonus, which is the one where they push her foot towards her body? If so how are they? If not, I would make sure that it is being done...it can be an indicator of worsening PE. Just one more thing :) Has she had steroid shots for the baby's lung development?

[blythe]

Okay, my understanding is that lowering bp too much can impair blood flow to the placenta, which can cause big problems for the baby. In Kristi's shoes, I'd keep a log of my pressures and bring them to each appt and revisit the extra med possibility each time - that's just me, though. I'm guessing she goes back for a Non-Stress test about twice a week at this point?

The "pressures in her head" and spots in her vision *could* mean cerebral swelling, so please do keep a close eye on those symptoms. Many of our members report headaches when their bps get high, though everything I've read says high bp is symptomless - another question for your docs.

Although the doctors won't commit to an earlier induction, my guess is that will change their minds if Kristi's symptoms get worse. Please continue to advocate for your wife! Having an involved, caring husband is a godsend during complicated pregnancies like ours!

[blythe]

Hmmm, good thought Wendy, but I doubt steroids were indicated in this case. Steroids for the baby's lung development are sometimes given around 30-34 weeks when the pregnancy looks especially compromised. My understanding is that they are not helpful after 34 weeks...

[onesock]

Blythe,
I just thought that maybe since she has been on bp meds since 15 weeks, if her doc had given them to her earlier, it may indicate that he is not as against an earlier delivery than it appears.:) Just trying to get into this doc's head :P

[dkm]

They have not checked her reflexes and the pressure does usually go away with tylenol, but is daily, the floaters are less common. We do keep a log of the BPs, but they don't really pay too much attention to them. They have not done steriod shots or an amnio at this point. At the last ultrasound, Friday, the baby was showing at 6.3 pounds. She has been on a weekly appointment for about a month now and they do a NST and/or CST at those visits depending on whether or not she is contracting on her own or not. On Friday, the baby did react negatively to the NST, but then rebounded well.

We called the nurse this morning and they basically said that they have no intentions of moving her induction up before the 22nd, she is 36 weeks and 2 days today and will be 36 and 6 days on Monday when we go back. The nurse said that what they are hoping for is her going into labor on her own. As of Friday, she was fingertip dilated and if she is 2 or 3 cm dilated on Monday, they might deliver.

I am definetely an advocate, but I do feel that the Doctors do not want my questions/opinions. Yesterday, they would rarely even look at me when I asked questions when they were in the Hospital Room. It really irritated me. I am a very business minded man and am very analytical at work and in life, so I don't see the benefits that are outweighing the potential negatives....

Thanks!

Donald