New Here! PIH - induce? WDYT?

[brieanneb]

Hi friends!

background info -
I'll be 37 weeks with my third kiddo on Thursday.
2/1/08 - DD born at 39 weeks after a 3 day induction for suspected Pre-E (I don't remember the details, BP readings or anything). DD had a slow start and was in the NICU for 3 days. No epidural - I have a little PTSD from this labor and delivery.
4/23/10 - DS born at 39 weeks with no epidural - nice hippy, natural birth - LOVED it. Was on atenonol my entire PG and had no complications.

So the weekend of 7/15 I start to feel funny and I know that my BP is up - I take it at home and sure enough it is. Midwife appointment on Tuesday 7/17 - BP is 130/90 at appointment - 24 hour urine and bloodwork ordered. 24 hour urine was 145 and bloodwork was good, put on modified bedrest, NST (baby looked perfect).

7/18 BP is 166/89

Friday 7/20 NST and midwife appointment BP 130/88 put on 25 mg atenonol once daily, consulting ob suggests inducing but I am hesitant because I wasn't full term yet. Everyone agrees we can wait and see.

Friday night 7/20 - BP is way up so I go into L&D, they keep me overnight, labs still look good - BP fluctuates while I am there from 130-160/75-95 Again they suggest inducing but I ask if I can wait and see since I am still not 37 weeks. All the monitoring of the baby while I was there was good.

Monday 7/23 BP still up in the 135ish/high 80's, protein dip +1 (usually trace). Atenonol is upped to 50mg in the AM, 50mg in the PM. BP's at home are fluctuating in the 150/90's. Started increased atenonol dosage Monday night. NST is good, in the first 20 minutes there is one small deceleration so they leave me on for another hour and baby looks great. DR mentions induction again, doesn't come out and suggest it but asks me how I feel about it and I tell her I'd like to wait as long as possible.

Today 7/24 BP's are in the 140/high 80's low 90's, I feel like crap from the increased meds, tired and lethargic - hating it.



I go back to the DR on Friday (now seeing an OB, no more midwife for me ) I am starting to feel like I just want to have the induction and be done with this. I am sick of checking my BP at home, sick of 'modified bedrest' with a four year old and a two year old, sick of worrying about my baby and my own health, sick of wondering if my headache is because i've been wearing a ponytail for too long or because my BP is going to cause me to have a stroke. Am I nauseous because I am super pregnant or is it because there is something really wrong?

What do you think? Based on all my information (sorry for so much!!) would you just submit to an induction or would you try to squeeze out a few more weeks and get closer to your due date? It seems like the atenonol isn't working right? Any ideas? Observations? Suggestions?

Thank you in advance

[brieanneb]

Do you think they'll suggest an induction if things stay the same? Sometimes it seems like they really want to do it?

[alexis]

There was a study called HYPITAT that suggested that there was no benefit to expectant management of gestational hypertension and mild preeclampsia past 37 weeks--delivery results in better outcomes. Based on that, many OBs have been inducing (or repeat-sectioning) for hypertension or PE at 37 weeks (if it begins before that point) or whenever it appears (if after) rather than waiting till 39, as the guidelines are for "elective" inductions/sections.

As you probably know, the atenolol will keep your BP under control, but it doesn't change the overall trajectory. In other words, if you're going to develop full fledged preeclampsia, this will happen even if they control your BP to normal levels. It's not that the atenolol isn't working--it's that it can't alter the underlying problem. From the sound of it, your blood pressure is continuing to increase, so your OB is just trying to keep pace with it. It's a little like taking Tylenol for a headache (maybe not the best analogy...)--the pain goes away, but whatever's causing the headache doesn't. Atenolol treats the symptom of the high blood pressure, but not the disease that causes it.

Were your pressures normal otherwise this pregnancy? (I ask because you said you were on meds for your entire second--it's considered chronic hypertension if it appears before 20 weeks, even if you don't stay medicated when not pregnant, AIUI.)

[angieb]

I'd induce.

FWIW, DS was born at 36+2 and spent no time in the NICU at all.

[hillary8l8]

I was induced at 37+2 with my daughter....had her on 37+4 for PIH. She did really well, and went home after 2 days. I wouldn't have had it any other way.

[brieanneb]

Were your pressures normal otherwise this pregnancy? (I ask because you said you were on meds for your entire second--it's considered chronic hypertension if it appears before 20 weeks, even if you don't stay medicated when not pregnant, AIUI.)

Thank you so much for taking the time to reply! So my first two pregnancies I was taken care of at the same practice, then we moved and so this pregnancy has been taken care of at a new practice. With #2 I never had any high BP readings - they put me on the atenonol as a preventative measure and honestly I was really happy with that pregnancy and how it all went. When I'm not pregnant I actually have low blood pressure - so strange huh? During the first 34 weeks of this pregnancy my bp was about 100/70.

[lemons]

Quoting from your original post (underlining is mine):

7/17 - BP is 130/90, 24 hour urine was 145 and bloodwork was good
7/18 - BP is 166/89
7/20 - BP 130/88 put on 25 mg atenonol once daily
7/20 - BP 130-160/75-95
7/23 - BP 135/high 80's, protein dip +1 (usually trace). Atenonol is upped to 50mg in the AM, 50mg in the PM. BP's at home are fluctuating in the 150/90's. Started increased atenonol dosage Monday night. NST is good, in the first 20 minutes there is one small deceleration
7/24 BP 140/high 80's low 90's

Since your protein levels have not yet reached the diagnostic level for preeclampsia (greater than 300mg/24hour), you would either be considered to have chronic hypertension or gestational hypertension. And from the information that you have given, it sounds like gestational hypertension at this point. Your BP has been recorded at or above 160 twice (7/18 and 7/20) and has stayed high (150/90) while on BP meds.

Taking all of the information that you have provided into consideration, I ask you to carefully consider the following information and to have a serious conversation with your OB about the benefits of waiting longer to induce versus the risk to baby from continuing your pregnancy:

(1) Placental abruption can happen at systolic BPs of 160. Stroke can happen at systolic BPs of 160. Both can happen with no other warning. And both can have tragic consequences for both you and baby.

(2) Physician's prescribe BP meds to lower mom's blood pressure, but as a side effect this can also lower the blood flow to the placenta and baby. BP meds are not used to "cure" hypertension during pregnancy, they are used to let baby bake as long as safely possible, knowing the risk to benefit ratio. And this ratio falls in favor of delivery no later than 37 weeks according to the HYPITAT study (as alexis said).

(3) Decelerations are a sign that baby is not in the happiest of states. So, while overall the NST was positive, this could be a sign that baby is occasionally having a hard time.

I know that there are a lot of factors to consider and none of us want to be in the position you are in- you have a choice to make and I hope that you are able to have a frank and open-minded conversation with your physician about the best way to move forward. Good luck and best wished to you and baby!

[tree]

I think you also want to mention your nausea and headache when you speak with your doctor. Our experts call third trimester nausea an under appreciated symptom of PE. It could be a red flag for your doctors, especially when combined with BPs, headache, generally feeling terrible, etc. If nothing else, they might want to keep an eye on you in the hospital. You have done a good job to get the baby to almost 37 weeks.
I agree with lemons that this is the time to have a frank discussion with your doctors about the risks and benefits of inducing vs. expectant management. The HYPITAT data show that that deliver at 37 weeks results in better outcomes for mother and baby, and you will be there tomorrow. Good luck!

[alviarin]

Definitely talk to your doc about your symptoms, and the HYPITAT trial.

In your shoes, with the recent 1+ dip I'd also request a 24 hour urine collection to check for preeclampsia. A 1+ can correspond to diagnostic amounts of protein (though not always) so better to double-check and make sure.

[angieb]

Definitely talk to your doc about your symptoms, and the HYPITAT trial.

In your shoes, with the recent 1+ dip I'd also request a 24 hour urine collection to check for preeclampsia. A 1+ can correspond to diagnostic amounts of protein (though not always) so better to double-check and make sure.

Yep, I definitely agree about the 24 hour urine too. Just a few weeks ago I have a friend who had a totally clear diptest/in office urine sample, not even trace protein, and was spilling 250 mg in a 24 hour urine (which is still not diagnostic but higher than what they generally consider normal.)