What is normal treatment plan for PIH only?

[growlie]

Hi friends,

I am on my third week of bed rest for gestational hypertension. So far my lab work has all been normal and no or only trace protein. I am feeling some anxiety becauseI have not been able to see "my" OB, although I have seen 4 of the doctors in the practice. It is my understanding that "my" OB will make the actual treatment plan, but I don't see her again until next Friday, so I am looking for any insight until then.

I am 35 w 2 days at this point. Around 32 weeks I started having swelling and some pitting edema in ankles/feet but normal BP. I was scheduled for the next week for a BP check. I ended up calling the on call dr. a few days before the checkup because my swelling seemed worse and my home BP cuff indicated readings in the 140s/90s. I usually am 120/70-80. She had me go to L&D where I was monitored, given a jug for 24 hr collection, and sent home. On my scheduled check up, BP was 140s/90s and I was sent back to LD and admitted because the 24 hr urine was not back yet. I had labile blood pressure readings. The blood work was good. Apparently labcorp messed up the 24 hr catch and didnt record total volume, so I had another one done. I don't know what the number was but was told it was good and I could go home. Dipstick was negative.

2 days later I was seen for BPP. Baby scored 10/10. I lost 7 lbs of fluid from a weekend of bedrest. BP was down a bit to 138/85 or so. Bloodwork drawn and urine dipped. I was told to come back 3 or 4 days later for another NST and BP check. Urine dipped, no blood work. BP was better - 128/82

Is it strange that they have not done another 24 hr urine? I thought the dipsticks were not very accurate. What does the bloodwork tell them, and does it replace the 24 hr urine? I can see my blood work from the dr's office but not the hospital. It was a CBC that was ordered.

Today I am scheduled for another NST with a midwife and then to go to the ultrasound after that. I am not sure whether I will see an OB today or not. There is a MFM doctor who read the first BPP and she is to read this one. I don't know if I will get the BPP results before leaving or what.

Then I don't have another appointment until next Friday (7/20) but thankfully it is with MY doctor and I plan to ask for a specific treatment plan. I am fully aware that things could change but I'd really like to know what to expect if things continue the way they are now .

Of the 4 OB's I've seen since this all started, I've been told
are n
1) induce at 37 or 38 weeks but not stop labor if it started on its own
2) induce around 38 weeks
3) induce 38-39 weeks
4) induce at end of 39 weeks

I am sure some of the variance has to do with the big push by March of Dimes and ACOG, but I am also familiar with the study about better maternal outcomes with induction for PIH.

No one has told me they'd just let me go as long as mom and baby were healthy. Is induction (assuming natural labor doesn't start) a forgone conclusion with PIH?

Thank you in advance for any advice or insight. I am a first time mom and just trying to be the best advocate I can be for my health and my baby's.

[alviarin]

Unfortunately I don't think there is a "normal" plan yet, recommendations vary a bit from doc to doc as you have seen. However it seems like more doctors are reccomending delivery at 37 weeks in part due results of the HYPITAT study. Also it will be interesting to see what new guidelines might come out of ACOG's Hypertension in Pregnancy Task Force: http://www.preeclampsia.org/forum/viewt ... 19&t=44954.

My personal experience with labile BPs and OB recommendations:
1) My first OB scheduled an induction at 38 weeks since my pressures wouldn't get better and might get worse. He was right, since day of induction I developed rapidly worsening pre-eclampsia and narrowly avoided an emergency-c section.
2) During my second pregnancy, when my pressures started acting up again, my MFM said it meant I was heading for pre-e again, chronic hypertension later in life, or both. Unfortunately it was both! We induced for mild pre-e at 37 weeks and my pressures spiked after delivery and I was eventually diagnosed with chronic hypertension.
3) During this pregnancy, on BP meds now for chronic hypertension, my MFM is recommending delivery at 37-38 weeks. My OB is hoping we can get to 38 weeks, but of course if pre-e rears it's ugly head again we'll deliver sooner. We ran a baseline 24 hour urine in early pregnancy, and if anything changes symptom or pressure-wise we'll run another one.

Bloodwork will tend to pick up criteria for severe pre-e or HELLP syndrome, but it won't pick up milder cases of pre-e. And protein dipsticks can be slightly off sometimes. So a 24 hour urine test is still considered the "gold" standard for diagnosis of pre-e.

What does the MFM reccomend in terms of monitoring and setting a delivery date? They tend to see more patients with hypertension and preeclampsia.

I hope this helps, keep the questions coming.

[growlie]

Well, I am replying from the hospital. My BP was high although no higher than it has been and saw MFM who sent me back to L and D for monitoring. FINALLY saw my OB who wanted labs and a new 24 hr urine. Although I am not crazy about spending another night in the hospital, they will get the results of the 24 hr much much faster. p'

Assuming protein is less than 300 and bp's arent crazy, I should be able to go back home.

Dr's offi cial plan is if I get mild pre=e, induce at 37 wks. If not, induce at 38 wks for PIH. If I get severe pre-e, get the baby out immediately.

[alviarin]

Sorry you are in the hospital, but glad you got a chance to talk to *your* OB and discuss "the plan".

Did you get the results of your 24-hour yet?

[angieb]

Sorry you are in the hospital but glad they are keeping a close eye on you. Fingers crossed you can make it several more weeks.

I would want/expect weekly 24 hour urines from here on out. I have a friend who gave a completely clear, not even trace protein, urine sample at the dr, but had several signs of issues (swelling, mildly high bp, etc.) and her protein levels came back at 250. (So not pre-e yet but I was surprised she didn't even have trace protein in-office.) There is another poster here who had a 24 hour urine in the 400's after a normal dip test in office. So yeah, I think with no other signs of pre-e/pih, in office tests are fine for the general population, but once there are issues, they are slightly better than worthless.

[growlie]

I just finished my 24 hr at 7:30, and expect it to take a few hours for results. My OB came to visit after office hours and she said they don't like to discharge anyone at night, so we will wait and they will re-draw the labwork (blood) in the morning and use the 24 hr and the blood results to determine whether I can go home on bedrest or have to stay here longer. My labs yesterday were unchanged except uric acid went from a 4.2 to a 5.2. Platelet level good and everything else was good. Haven't seen the actual numbers from yesterday.

I'm in a different room this time with a different bed that is really uncomfortable. For the first 24 hours, they could not give me any of my medicine for some unknown reason, and I have food allergies that the cafeteria has not been able to figure out how to accomodate yet. They also stuck me 3 times before giving up and calling the lab. One of the times they put in a hep lock but they weren't actually in a vein at all. No idea why that was left there, as they couldn't get any blood from it. I know this is for the best, but I am having a much less pleasant experience this time around.

I am grateful to be at 35 + 3 and that on the BPP yesterday the baby looks perfect. Hoping for a couple more weeks.

[growlie]

I also think the big problem was that "my" OB was on vacation and the others in the group that saw me did not take any ownership over managing my condition while she was gone. I saw 4 or more OBs, a midwife and nurse practitioner. I think they all basically just made sure it wasn't an emergency right then and there, and punted the problem down the hall a few days. Until I found this forum (yesterday) I really didn't know how to best advocate for myself. During my appt I did ask why we weren't doing 24 hr urines, labs, etc regularly with the symptoms I've had. The midwife said she would send a message to the maternal fetal medicine dr who was doing my BPP, so I guess she didn't know the answer.

"My" OB came back over here after office hours to check on me today, and will come tmw before she goes to the office to check on the labs and 24 hr urine. I am glad she is back from vacation, because I feel like she is actually watching me carefully.

I'm wondering though based on what I have been reading, what is the argument for and against inducing at 37 weeks for "pih only" versus 38 weeks? I thought I had read recommendations to go ahead at 37 weeks. (There is no debate if I have pre-e I will be induced at 37 or severe pre-e be induced like yesterday).

[growlie]

I'm sorry for the triple post...but I have another question. When an automated BP cuff in the hospital kind of stops mid squeeze, then starts over and squeezes a lot tighter, and then finishes doing its reading....is that really accurate? I had that happen repeatedly in L and D last night, and it just happened again and my reading was 168/82 which is the highest top # I have ever seen.

[growlie]

My 24 hr urine came back at 154. Nurse said not to get my hopes up about going home even with perfect labs b/c last BP reading was something like 168 over 84.

[blythe]

I'm glad "your" OB is back and that your treatment plan is more clear!

I'm not sure about the difference between their 37 or 38 week plans - my understanding is that HYPITAT says 37 weeks for any hypertension in pregnancy. That is definitely a question for your doctors - how the HYPITAT study relates to your case, if at all.

My understanding is that "normal" protein is 0-150, and diagnostic for PE is 300mg. My sense is (and I'm definitely no doc) - is that most docs prefer to have 0 protein, but don't get too worried until the protein gets much higher. Other questions for your docs - how will they monitor your protein from now on, and how will the treatment plan change if you hit diagnostic criteria.

The blood pressure cuff issue - I'm almost positive is correct. That "extra" inflate was actually how I knew that I was about to see a higher reading. Someone else can surely explain this better, but my understanding is that the machine is set to "expect" a similar bp reading as it got previously, so only inflates at first to reach that reading. But if your bp is actually higher, it has to re-inflate to be able to correctly read the higher reading.

Our experts consider readings either 160+ systolic or 100+ diastolic "severe". Even though it may keep you in the hospital longer (whether to get you stabilized on bp meds - ask if they think meds will be appropriate for you, they may not be - or to deliver), I'm glad they're taking your bps and symptoms seriously.

Hang in there and keep asking questions!