PIH management- is OB being too relaxed?

[mommy2aprincess]

Hi all! I am so glad I found this forum...I have learned so much from reading the posts already!

I'll try and explain what is going on with me without it being too long...thanks in advance for reading!!! I appreciate the help so much!

I will be 36 weeks pregnant tomorrow. My BP has been running high for me at some of my prenatal appointments (mostly in the 130s/70-80s, my pre-pregnancy was around 110/60). I have had trace protein on the dipstick for a couple of appointments but nothing more than that. I went and bought a home cuff so that I could keep an eye on it. My readings from July 14-19 were all in the 115-120/70-80 range but then from July 20th til now, they have ranged from 127-169/75-90. I called and went in for a blood pressure check yesterday because I was concerned that I had a headache. My pressure at the office was 162/77 so they sent me to L&D for monitoring and blood work. I was semi-reclined in the bed for over an hour and my pressures ranged from 140s-186/70-80. All but a couple of them were in the 160s/70s, with one reading in the 140s and one at 186 (Yikes!). At that point, the nurse came in and had me lay on my left side for the rest of the time. All of my readings were then in the 150s/70-80 except for the very last one was 140something/70something. On my discharge papers, only the last reading is noted and I don't feel that gives an accurate representation of what occurred so I hope they reported more than that to the OB and kept the full monitoring strip in my chart too! The nurse called the OB and I thought that they may want to monitor it longer based on all the 160s readings but when she came back in she said, "Ok, he says you can go home now." They didn't even send me with a 24 hour urine collection jug or anything. I asked her if the pressures didn't matter since all the bloodwork came back okay and she said that in her eyes I definitely have one piece of preeclampsia (the PIH portion) and that she would recommend that I stay on bedrest and call if ANYTHING changes (funny thing is, the Dr. never even told me to be on bedrest so it was good she added that herself! The nurse seemed much more concerned about it than the Dr. though.). So, I came home and laid in bed all night and have been here today besides bathroom breaks. My pressure has been lower so far staying between 135-145/70-80 (so almost all under the 140/90 that means PIH). I will go back to the OB tomorrow for a blood pressure check. That is where I worry. When you go in for just a blood pressure check, you don't even see the Dr. if the reading that they get isn't very concerning. So, if I go in and they get a good reading at that one point in time (and my urine still has only trace protein), they will say, "Ok, you're good to go, see you next week" and send me on my way. Even if my reading is under 140/90, based on the readings at the hospital yesterday (and over the 3 days before that at home), don't I need to be watched more closely? And doesn't baby need to be checked on? I am scared to death about him not getting enough oxygen/nutrients because of this (or worse, having the placenta abrupt or something).

So, I guess my questions would be:
Does it matter as much since my diastolic is staying down or is a high systolic on its own concerning as well? I guess I'm trying to figure out why the OB doesn't seem worried about it.
Does the blood pressure not matter as much since the bloodwork and protein were good? Does the PIH alone need closer monitoring and testing or just when it is paired with bad bloodwork/spilling protein?
If my pressure comes back lower tomorrow (below 140/90) which it may since it has been down so far today, do I need to ask to see the Dr. anyway and push for additional testing?
If so, what testing would you recommend? (I'm thinking 24 hr urine, growth ultrasound and BPP for baby?)
If my blood pressure stays down all today and continues like that tomorrow, couldn't it shoot back up at any time? That is what worries me.
I want more than anything to make it to full term and let baby decide when he is ready to come out, especially since I am planning a natural birth and that is harder with induction. However, even more so, I want to do what is best for the health of baby and me even if that means delivering early! Do you think we need to talk induction? What if my numbers stay down from now on, would it be okay to just monitor or do those few days of high readings still mean it's not worth pushing it?
What additional questions or concerns should I bring up with the Dr.?

THANK YOU SO MUCH IF YOU READ ALL THAT!!!!

[blythe]

Welcome! I'm glad you found us but sorry you needed to!

Keep in mind I'm not a doc, I've just read a lot. Please ask your doc if my answers fit in *your* case!

A few random thoughts from your narrative - diagnostic bp is just two readings taken at least 6 hours apart of 140 systolic or 90 diastolic or higher plus 300mg protein in a 24hour urine collection. The dipsticks are notoriously unreliable. It doesn't matter that some of your bps are lower than 140/90. It's good that they aren't *all* high, but I would still be cautious and concerned.

[i]Does it matter as much since my diastolic is staying down or is a high systolic on its own concerning as well? I guess I'm trying to figure out why the OB doesn't seem worried about it.
My understanding is that systolic is more susceptible to activity, but those are *high* numbers. Our experts consider 160 systolic *or* 100 diastolic to be severe PIH. If you have just 300mg protein in a 24-hour urine collection as well you would be diagnostic for severe PE.

Does the blood pressure not matter as much since the bloodwork and protein were good? Does the PIH alone need closer monitoring and testing or just when it is paired with bad bloodwork/spilling protein?
Good bloodwork just means that you don't have HELLP, a fast-moving and severe form of PE - and it's always possible that you could still develop it. In your shoes I'd ask if and when they would medicate your bp. My doctor gave me bp meds when I was in the 150/100s. The caution with bp meds is they can decrease bloodflow to the baby, so they watch you and baby carefully if they give them. Women can still have strokes, seizures, abruptions - scary outcomes with "just" PIH, but they are more likely when you are also spilling diagnostic amounts of protein.

If my pressure comes back lower tomorrow (below 140/90) which it may since it has been down so far today, do I need to ask to see the Dr. anyway and push for additional testing?
I would remind the doctor of your readings in the hospital - usually docs seem to get extra worried when bps don't come down to normal when you're resting.

If so, what testing would you recommend? (I'm thinking 24 hr urine, growth ultrasound and BPP for baby?)
I would definitely ask if all three of those are appropriate in your case, and I would especially push for the 24-hour. I would also want an NST at the least, I think the BPP and growth ultrasound are reasonable to at least ask for. I would also ask for repeated bloodwork - and ask how often they would like to repeat it. How is baby moving?

I feel strongly enough about the 24-hour that in your shoes I would ask if it's appropriate, and if they decline, ask them to explain their reasoning, and to make a note in your chart that you asked for it and they declined, and ask for a copy of the note. The 24-hour is the way to make sure you are or are not spilling enough protein to make you diagnostic for PE. Complications can happen with PIH and PE, but if you are fully diagnostic for PE, we can parse out the research better on outcomes and treatment.

If my blood pressure stays down all today and continues like that tomorrow, couldn't it shoot back up at any time? That is what worries me. Your bp could bounce around a lot, highs and lows. I would want to know what your doctors' criteria for delivery would be. I would also ask your doctor how the HYPITAT study would fit with your case (google / search the forums for HYPITAT ).

[i]I want more than anything to make it to full term and let baby decide when he is ready to come out, especially since I am planning a natural birth and that is harder with induction. However, even more so, I want to do what is best for the health of baby and me even if that means delivering early! I did inductions without drugs for all three of my deliveries. You have to be more flexible with the medical interventions you accept but it's very possible, feel free to search my earlier posts, I got kind of long winded about it . Keep in mind that you might need magnesium sulfate as a precaution against eclamptic seizures, I had it with baby #1 and felt horrible on it and it can make inductions a lot harder, (though some women don't notice or even feel better on it) but discuss it with your doctor and if you need it it can be lifesaving. If you need more info on natural birth hopes with inductions let me know and I'll try to remember some other posts and tips.

Do you think we need to talk induction? What if my numbers stay down from now on, would it be okay to just monitor or do those few days of high readings still mean it's not worth pushing it?[/i] [/i] See HYPITAT . Women with hypertension who were induced at 37 weeks had less c-sections and their babies did fine, women who waited had more sections and health complications and their babies did fine. PIH / PE can bounce around hour to hour, day to day, but eventually it will go up and stay up and you will get very sick. It's even possible for your baby to have more issues inside you due to the disease, sometimes faster than you get sick, and will do better "out" than "in". PIH / PE can also get bad fast - we've had women get very sick within hours, and there is no way to predict who will be the fast-moving cases.

As always, watch your signs and symptoms and especially look out for headache that doesn't go away with tylenol, URQ pain, visual disturbances, and decreased baby movement. Check with your doc for what bp #s, symptoms, etc. that they would want you to call L&D again, and when they would want you to go straight in.

And - bedrest won't stop the progression of the disease, but might keep your pressures a little lower for your protection. Those 180s are especially high. I would really ask your doc about those.

What additional questions or concerns should I bring up with the Dr.?[/i][/i] My brain is almost done for the night . I hope I made sense, let me know if I need to clarify anything or said anything wrong! And hopefully other folks will jump in soon!

Good luck and let us know how your bp check / appointment goes!

[mommy2aprincess]

Heather- THANK YOU SO MUCH FOR YOUR RESPONSE! I really appreciate it!

I had a morning appt with the Dr. and my blood pressure was fine as it usually is in the a.m.. I don't know why the systolic spikes up like that even with being on bedrest. It's not even during stressful times (one time I woke up from a nap and had a headache so I took it and it was 169/77 or something like that). It's strange to me that it jumps up unrelated to activity, stress, etc. Also weird to me that the diastolic is staying fine, mostly in the low 70s even!

I asked the Dr. specifically about the 24-hour urine since the numbers at the hospital had been so high. I even asked if it would be good to at least get a baseline so we would know if it was progressing toward preeclampsia. He just kind of blew me off and gave some answer that made no sense to my husband or I. Something about how if it was high, then we would just induce me right away so there was no point in doing it because my bloodwork was fine and we would test my urine at each appointment anyway. I don't know, I asked a couple of times and felt like he just ignored it.

He did end up prescribing labetalol which I am hesitant to take because of the decreased flow to the baby. If my blood pressure was always running high, I would see the benefit in bringing it down to a safer level overall for me. But since it spikes up and down so much and since my diastolic isn't high to begin with, will the labetalol reduce the periods where the readings are fine to begin with (or reduce the diastolic) to the point that the baby isn't getting enough blood flow? How low is too low for both the systolic and diastolic? What kind of monitoring and how often is recommended if on BP medication? The other thing that scared me and it could just be a fluke but I took the labetalol around noon yesterday and today as he prescribed since my BP is mostly only high during the afternoon and evening. Usually baby is *very* active in the evenings and he was so quiet yesterday. He still moved enough to get 10 small movements in an hour so I didn't call but usually during that time I can get 10 movements in 5-10 minutes so it was a marked difference. This afternoon seems to be following the same pattern. Is that common on the labetalol?

I'm sooo glad to hear from someone that had natural deliveries even with induction! That is so reassuring to me! I will search your other posts and would also love any info/tips you have regarding natural birth with induction!

I go back on Monday so I will ask what he is envisioning as far as monitoring/induction. I forgot to ask at the last appointment. It seemed like he was just going to monitor until baby comes unless things change (He did mention that if I come in and have a 1+ on the dipstick that he would want to talk about induction). If things look fine, I'm not positive what the plan is though.

I will keep an eye on the signs. The only one that concerns me right now is that baby seems to slow down when the labetalol is in my system....don't know if it's related though.

Thanks again for all your help!!!!

[laura681]

How are you now? I think you are right on target and you need to go with your gut! When you go in for a BP check you need to see the doc for sure. If you have trace proteins then demand a 24 hour urine test. If you get any other symptoms of PE then you need to call the doctor. If they don't give you the level of care that you feel is appropriate you should quickly try to find another doctor or ask to be referred to a Maternal Fetal Medicine specialist. I know you want a natural birth, but your health and the health of your baby are the most important!

[blythe]

Laura is right - an MFM consult would be what I would want as well, sorry that suggestion fell out of my head! You can even do a natural birth with an MFM, they are as variable as regular OBs on their comfort level with going "natural".

If you haven't already had your baby already... a few more thoughts.

The research doesn't support bedrest. We think that maybe it helps certain women - maybe chronic hypertensives? - but the research just doesn't reflect that as of yet. If your doctor recommends it absolutely follow their advice, but realize that "your mileage may vary". My doc had me on modified bedrest - if activity made my bp go up I needed to slow down. On the other hand, one of my most stressful, active days after I was diagnosed resulted in 100s/70s. Bp is a reflection of the underlying disease - in your shoes I would definitely tell your doctor how your bp is reacting to activity and rest.

I have no idea about your low diastolic . My completely no-a-doc guess is that it's just your particular genetic roll of the dice. Another question for your doctor!

The 24-hour urine confuses me, too. It sounds to not-a-doc me like he doesn't want to induce unless you had bad bloodwork. In your shoes I would really press him on the HYPITAT study. There may be good medical reasons for your particular case that make HYPITAT's conclusions not apply to you, but I would want those reasons spelled out.

If he prescribed labetalol I would take it, I would just ask him what bps he would consider too low and to modify your dosage, and ask how often NSTs should be done. And definitely call when baby's movement is less than 10 in an hour. Toward the end of pregnancy movement will slow down anyway, but I always feel better when a doc or L&D tells you that rather than not-a-doc me!

Sorry if this is repeating myself or if I haven't answered your questions very well, I'm more than a bit harried at the moment... I hate neglecting the forums, real life is interfering greatly! But I did want to get back to you and see how you were and offer more thoughts!