Chronic hypertension controlled on meds - why induce?

[veronica44]

Hi all, I have not been back here a lot this pregnancy because it has been uneventful! Such a blessing to have no swelling, no preeclampsia symptoms, no bedrest this time...

I'm at 38 weeks right now, and feeling great. The BP has been well controlled on 100 mg twice a day labetalol, but I had two bad readings two weeks ago (~145/75) when I was under stress because it was my last week on the job. Now BP is back to 120/70.

But still doctors are pressuring me to induce at 39 weeks. Why? Can I refuse this early induction since things are going so well and I am being so closely monitored (NSTs biweekly, weekly fluid checks, growth scan every 3 weeks, preeclampsia labwork regularly)? What are your recommendations? Why not go into labor on my own if things are going so well here???

[sam10]

Congratulations on making it so far without any major issues. Have your doctors explained to you why they feel an induction at 39 weeks seems the right timing for you? I assume your labs are still fine? I am no expert, but I wonder if the doctors feel that they don't want to risk it.

[veronica44]

Hi, thanks, all my labs have been fine. Very low protein in urine, great platelet count etc. etc.

That is exactly their explanation "we don't want to risk it". But I don't feel right taking the baby early if there are no indicators for delivery.

[alviarin]

Yay for no pre-e (so far). My understanding is that your risks go up after 39 weeks. Definitely ask your docs about risks/benefits of inducing sooner vs. delivering later though.

I'm a chronic hypertensive on BP meds, and my OB and MFM are both recommending delivery at 38 weeks at the latest.

[caryn]

Because of HYPITAT.

Hypertension controlled by meds is still gestational hypertension, and white coat hypertension is also still gestational hypertension. It's my understanding that the ACOG is moving to recommend induction at 37 weeks for mild gestational hypertension: http://www.preeclampsia.org/forum/viewt ... 19&t=44954

What the docs tend to say when we explain that our pressures are spiking under stress is something like "That's nice, but other people under stress don't have those spikes and they mean that something about the way your body controls your blood pressure is broken, because otherwise *it wouldn't do that.*"

[veronica44]

Thanks everyone!

Caryn - so in other words a distinction is no longer being made so much between "chronic hypertension" and "pregnancy induced hypertension" - they are all falling under the umbrella of "gestational hypertension" and being recommended for early delivery due to the most recent research results - am I understanding this correctly?

I think that precisely what is lacking here is my doctors taking the time to explain clearly to me: these are the risks vs. benefits of carrying one more week. I'll be asking for that at my appointment today.

[blythe]

Ask about "superimposed" preeclampsia - my understanding is that 25% of women with chronic hypertension can develop superimposed PE, which is harder to diagnose and can therefore be more dangerous than "regular" PE. Take a look at this older thread http://www.preeclampsia.org/forum/viewt ... 12&t=39935 and ask your doctors if we're on target and how our information relates to your specific case. Also ask about post-partum PE, how they are factoring that risk into their recommendation to induce. Finally, PE can move very very fast. We've had women stay safely pregnant for weeks, we've also had women be "fine" at a noon appointment and in full organ failure at 2am that night, and no one can predict who will be the slow or fast moving case.

I'm very aware of the March of Dimes push for 39 weeks, and the research that says near-term (37-38) week babies may be slightly compromised from early delivery. As a mom of three 37-week babies that does worry me. But so far the research has only show small (significant = probably not by chance, not big) correlations. It could very well be that the deficits they're seeing are due to an entire gestation in a compromised pregnancy, not caused by the early delivery.

Ah - just re-read your post. 145/75, even under stress, *while medicated* would make me personally very nervous. What could your numbers be if you weren't medicated? BP is not a cause of preeclampsia, it's a reflection of underlying damage and disease progression. One reason some docs don't give bps meds is because they're concerned about "masking" bp symptoms that can tell them that you're getting worse. We've had women have seizures or HELLP or other serious complications with "just" high bps - no bad labs and not spilling protein.

But all that is definitely my bias after reading a lot and being on these boards. We collect worst-case experiences here. I don't have numbers, but I assume you have a very good chance - if 25% develop superimposed PE, then I assume 75% do okay - of doing fine if you prolong your pregnancy (though personally that nearly gives me a panic attack to even type that - I've just seen too many things that go wrong in that 25%).

Good luck at your appointment today! Please come back at let us know what they say!

[alexis]

I was in a similar situation. Chronic hypertension, superimposed PE first pregnancy, controlled on meds second.

In my case, I was having a planned repeat section. My OB was willing to do that anytime between 39 and 40. She didn't actually give me a hard deadline, but I can read her fairly well and believe I would've had real pressure to schedule by 40. For convenience reasons (and because my nerves were, frankly, shot) I scheduled at 39+0. My OB would not schedule before 39 unless my BP rose (yep, MoD campaign, though they were implementing it reasonably and would have delivered earlier had it gone up). Having done this, I would probably be more comfortable than many here with pushing to 40, but not past your EDD. You really, really have to weigh the benefits of a few extra days against the possibility of pushing your luck. 25% is the figure for superimposed preeclampsia, but that doesn't include a rise in BP above baseline.

Controlled hypertension is a grey area. As far as I could tell (my son is 9 months now) there isn't adequate evidence on delivery timing in this scenario. There are OBs who deliver at 37 and ones who go to 41.

I had one serious and unexplained spike at 32 weeks (160/110 on the repeat after lying down for an NST) which earned me 24 hours in L&D. We watched my BP go back to normal that afternoon and it never went up like that again. We don't know why it happened. The thing with being chronic is that we know our ability to control BP is broken, or we wouldn't take the meds. So, IME, an isolated spike isn't always treated the same for us. Not that it's waved off, but that it may not be a new problem, if you see what I mean. Just the same one we already had. That said, while I wouldn't take a single high reading in a chronic as evidence of any trend, we don't have great odds as a whole.

Ah ha--this came out after I delivered, perhaps it helps?
http://www.ncbi.nlm.nih.gov/pubmed/21054760

(I can't get fulltext, but assuming that conclusion is supported, it would put me more firmly on the 39 weeks side.)

[veronica44]

Thanks all, that helps a lot!

I decided to go ahead with the 39 weeks induction, and feel thankful I have made it this far with no problems. I'll keep you posted after I deliver, we are inducing on the 16th.
This board has been an amazing source of information. All I really wanted was the data to make an informed decision, the reasons to induce are solid.

Thank you very much, alexis, for the study link, I have been searching for hours for those exact stats and couldn't find them.

[Brghtgrl]

With my first pregnancy my bp was good up until my 39 week check up. It went up to 140 something/90 something. My Dr decided it was best to go and induce me that week before it had a chance to get any worse and baby and I were both still healthy. My Dr (and I agree with him) feels that it is best to induce while the bp is still controlled and everyone is still healthy so we can avoid all the other complications that could arise like an emergency c-section.