Drawing blood and preeclampsia

[cgoodi1]

Hi everyone,
I just wanted to know if people who have had preeeclampsia have trouble when blood is being taken from you. Ever since my hospitalization I've realized that it is really hard for anyone to take blood from me or to hook me up to an IV. I've been having a lot of blood tests and it's always the same thing. My tests have all come back negative for clotting disorders but I really think its odd. For example, today I went to go have blood drawn and one nurse couldn't find a vein in one arm, poked the other and nothing happened, then poked my hand and got a very small amount of blood but then the blood flow stopped. She then got me to sit in a chair with my legs reclined and then another nurse tried. She couldn't get any find any veins either and then tried the side of my hand which really hurt and again no blood. They then proceded to run my hands under warm water and finally got some blood from my hand. I wasn't dehydrated because I also had to give a urine sample so I was drinking plenty of water to prepare myself. Anyone else have the same problem or am I the only one. I'm wondering if my blood flow could have caused my loss. If it's that horrible no wonder my baby had iugr. My MFM said next pregnancy I'll be on lda and heparin and I'm starting to think it will help!

[JB]

Yes, this happens to me! Nurses sometimes have a hard time finding my veins anyway, depending on their experience level (phlebotomists at the blood bank tend to be the best because they do it nonstop all day), but it seems to be worse when my blood pressure is high. I have just gotten used to being poked a bunch whenever they need to put a needle in me. I was just in labor & delivery last week (for losing bladder control.. turned out my blood pressure was high) and the nurse wasn't able to get the IV in the vein on the first hand but was able to get it on the other one.

One of the most vivid memories of my PE experience with my daughter involved multiple needle sticks. After I delivered my daughter I was still hospitalized for about five days while my blood pressures remained high. At one point they were trying to get a needle in me (I really don't remember whether they were taking blood or administering intravenous meds) and couldn't do it. They had to call in an IV expert to do it, and wrapped both my arms with warm wet towels to try and get the veins to be more cooperative. In the middle of all this my daughter's neonatologist came in to tell me that her lung had collapsed and she was put back on the ventilator and needed chest tubes. I'll never forget that moment because my husband was at work (he had just started a new job two months earlier and had no sick leave or vacation yet) and my mom and mother-in-law were both at home resting up from the past two days of being at the hospital nonstop. That was the first time I really lost it and had a bit of a breakdown over everything that had happened. I was miserably sick, alone, and being poked and prodded by an IV specialist who was trying to make small talk while I bawled my eyes out over my daughter being ill. For some reason it didn't process in her brain that the news about my daughter might be more traumatic than a stupid IV and wasn't likely to be helped by her chatter. The nurses and neonatologist just looked at her like she was crazy.

[caryn]

One risk factor for preeclampsia is "low plasma volume" - or having less blood in your system than average. This just means you're the sort of person who's on the low end of average on the curve, probably because when your body developed in utero, you just grew with slightly smaller blood vessels than normal. And it makes you hard to stick. I'm also hard to stick, with low plasma volume.

They're not sure why this is a risk factor. Possibly our bodies can't handle the volume load of pregnancy, because there's nowhere to *put* the extra fluid. Possibly we could handle pregnancies that were content with smaller blood supplies but are making babies with men whose genes want to code for a bigger supply than we can ferry. They've tried expanding plasma volume to see if it lowers preeclampsia rates, but the data are very unclear and do something called "crossing the no-effect line" which generally means the thing in the study isn't causal, 'cause if it were messing with it would make things better.

Here's the Cochrane Review: http://www.ncbi.nlm.nih.gov/pubmed/10796272
and the study showing prepregnancy plasma volume correlated to preeclampsia risk: http://www.ncbi.nlm.nih.gov/pubmed/21508747

[cgoodi1]

Hi Caryn,
If that is the problem with me, do you know if there is any way they can help me? Would lda and heparin in that case help? I'm assuming no since there would still be no extra room... they would only increase the flow. I just wanted to know if the doctors would be able to help me in this case. I really want a rainbow baby next time!

[caryn]

Well, it's not the thing that's the problem with you - because it doesn't cause preeclampsia. It's just correlated with it! Some other underlying thing - in your case, your MFM thinks possibly an undiagnosed clotting disorder - is causing preeclampsia. That's why they're throwing LDA and heparin at you, in the hope that it will be prophylactic for whatever's going on.

We are a hard population to work with, because there are no known *causes* of preeclampsia except genetic ones. The current thinking is that preeclampsia is driven by what's called "shallow trophoblast invasion", which means that the placenta just doesn't dig in there as deeply as it would in a normal pregnancy. The reasons why are probably genetic ones.

Second pregnancies benefit from this. The first placenta remodels your spiral arteries and the second placenta can exploit this work, and embed more deeply. So second pregnancies are generally later and milder onset, regardless of what therapies are tried (or not tried.)

[cgoodi1]

Hi again Caryn,
My MFM just emailed me about a conference he went to. Below is what he wrote:

"I was at a research meeting where the work of Dr John Kingdom, a researcher at the U of Toronto was discussed. He is working on the mechanims underlying the potential benefits of low dose heparin in the prevention of recurrence of PE. His work is very promising. He postulates that heparine stimulates the release of molecules that had a vasodilatory effect, and that the benefit may not be via the anticoagulant effect. Just to say that his findings to date seem to support the role of low dose heparin in helping to prevent severe PE"

Perhaps the heparin in that case would help. I have been tested for blood clotting disorders and all of my tests came back normal. I do know around 5-6 weeks pregnant I did have some bleeding which perhaps could have signalled something was wrong. I also know that after delivery the placenta would not come out on its own. After 2 hours they had to take me in to have surgery to remove it.

I'm bringing my entire file to the doctor's on Monday and Wednesday of next week to discuss. Hopefully we'll get the green light to give it another go.

[caryn]

Heparin's a tricky one. Here's what our Medical Board (composed of the top people who research preeclampsia) has said about it as a therapy recently: viewtopic.php?f=19&t=42978

I'm guessing this is what your MFM refers to: • Heparins have some anti inflammatory action and to the extent that preeclampsia is an immune activated disease process - they might be helpful - but largely without supporting data. At the patient science/continuing medical education conference before Saving Grace last fall, a few of the doctors mentioned this study as a possible reason to avoid heparin: http://www.ncbi.nlm.nih.gov/pubmed/22082677

(the sFlt-1 molecule that it mentions has been implicated in preeclampsia)

and this recent study says it might not help regardless of whether or not it might harm: http://www.ncbi.nlm.nih.gov/pubmed/22289887

Primary outcome was a composite end point of late-pregnancy complications. Analysis was by intention to treat. The study was stopped for futility at the time of the first planned interim analysis. Among the 128 women eventually available for final analyses, 13 of the 63 (21%) randomized to nadroparin compared with 12 of the 65 (18%) on medical surveillance alone progressed to the primary end point.

The Experts (the members of our medical board who answer questions on the Ask The Experts forum) seem to want to wait for a big trial currently in process before they say anything more, because the data we currently have aren't conclusive one way or the other.

It sounds like you had a placenta that was struggling to hang in there. I really hope you and your doctors are able to find a plan that you're comfortable adopting!