Maternal hypertension anyone ?

[hub2dee]

Hi all,

dw is 31+4 (edd 2nd August) and has been 120/80 throughout pg. Thursday night she had shivers and headaches so MIL (retired doc) checked BP. This was high so we went to the hossie late at night for the pros to check her over. SIL has just visited from the States and was due to leave a couple of days later (they're v. v. close), and the emotional stress could be a contributing factor.

They traced the baby (little one is fine, supported by a scan the next day) and did occasional bp checks. Pressure remained high (I was stressed, and didn't note any readings, but IIRC it was around 160 - 195 / 87 - 97), so they kept her in overnight and BP but was closer to normal the next day. Urine and bloods on admission returned normal, 'slight trace nothing to worry about' (proteinuria) in the AM.

As dw has a few risk factors for PE (MIL's a food-controlled diabetic, dw is overweight), and I wasn't super happy with the monitoring at the hospital or the 'wait till Monday and we'll see',. I chose to check BP at home with an upper-arm digital cuff. (I'm aware this is sometimes not considered helpful, but I'm not prepared to risk missing very high BP / early PE).

She has remained between 150 - 160 over around 90 this weekend. She had headaches and vomitted a few times the night before last, but no visual disturbances / upper right chest pain.

1. Does anyone have experience of developing maternal hypertension in their pg, and can you advise what levels they 'mointored closely' and at what level they sought to medicate ?

2. Mears, I searched archives for previous posts you'd made on hypertension, and noticed you made the point essential hypertension can be separate from PE and does not necessarily imply PE is inevitable. I also found from a post a few years ago a useful link to a BP article in midwiferytoday. Can I ask what the current mindset is regarding maternal hypertension / levels / duration before medication, and if you had any experience with clients who did better on particular meds than others ? (Also, once meds start is it likely to be until birth, or is it feasible to gradually reduce dose to zero after a given period to evaluate if the medication in still necessary). DW doesn't smoke / drink and has had no caffeine since falling pg).

Thanks for any input, apologies for the long post.

(Slightly worried hub).

Thanks all. Checked BP just now and it was high (ie. the nice low reading this afternoon at the hossie didn't endure), so dw has taken the pill.

I think part of the anxiety is the woman spends so much time of the pregnancy not taking anything - fags, alcohol, pretty much any medication except paracetamol, being careful with raw fish, or cat poo, or unripe cheeses etc. and now, with just 8 weeks to go, it's time to consider some medication...

I'm sure it's all perfectly safe, but she's my precious one, and so is bean.

Hopefully the meds will do wonders and things will calm down in the next few days !

Thanks again for the various input you've offered.

I had raised bp from about 35 weeks, which got steadily higher, and progressed to PE by about 38 weeks. Only mild though, so ds wasn't induced, but bp went through the roof during labour, even with an epidural, so ended up with a c/s (they gave me an epidural as one of the side effects is to lower bp - not good normally, but good if you've got a high bp to start with).

I took labetalol - twice a day, 100mg a time. DS was fine, and was still bf. My bp was raised for about 6 mths afterwards, so I steadily decreased the dosage after that, and now it's back to normal.

My main symptom of a bp spike was a severe headache. I booked in with a bp of something over 75, and was always admitted to hosp when bp was found to be over 100 (although on one occasion was allowed out at 99!)

Can't remember what it got to in labour, but it was shocking. 120-140 was usual for the bp spikes.

Nobody (midwifes / GP etc) seemed suprised by the choice of medication, and were surprised that it wasn't started sooner.

HTH a bit, and that your wife feels better. FWIW my bp didn't seem to be raised by normal activity - was still walking miles and doing housework etc, just generally high and these spikes. It would be exactly the same with bedrest in hospital. Don't know if it's poss, but to eradicate the poss of white coat syndrome, they left the cuff on me all night at the hosp, and monitored my bp as I slept.

Thanks for your post Laura032004. More useful info. Whether it's a bit sad / paranoid I don't know, but I find it helpful to compare her situation / stats / timing of the meds with others, so thanks for posting.

DW is in a nice bath (not too hot), and I'm going to sign off to give her some extra cuddles.

Night.

OK at the mo, thanks for asking. Dee has periods of not feeling well, and generally feels somewhat off colour, but she's been resting for more or less one whole week, and I have been a diligent slave.

She's been good so far today and we're seeing someone at the hossie tomorrow. Am sure everything will sort itself in due course. I'm bust trying to learn a little more about Pregnancy Induced Hypertension. Thrilling stuff.

Glad to hear dee's getting better hub

she's lucky to have such a supportive hubby - well done you

love huggy xx

Update: DW is doing well, although BP remains high. Bloods / urine still test fine which is great. Thanks for your good wishes. We have another scan after the weekend and will be attending Day Assessment unit twice a week ! Still, it's fab they're taking such great care of us (Royal Free, London FWIW).

In case anyone finds this thread one day looking for further info on raised blood pressure in pregnancy, I'm summarising my main findings below. Please check these with your doctor !

OK, DW's baseline bp was 120/80. As a general guide, they say let's monitor it more closely if it's regularly at 90. Let's consider medication if it gets much higher, We'll possibly keep you in overnight if it's around 100, 110 is a very high level that may require 'immediate' intervention. (Note these comments were made to us when no proteinuria and all bloods returned normal. I imagine comments / treatment / advice would be different if there were further factors to consider).

Other stuff I've learnt... bp meds can take several days to kick in and may only 'stabilise' pressure rather than reducing it (particularly in early days of treatment), dose / frequency tends to only be increased gradually, higher BP means more frequent scans and general checks to make sure mum and baby OK (check they look at amniotic fluid and do doppler blood flows not just sizing), raised BP (depending of course on level) does not necessarily imply a cs will be necessary, nor does it mean PE is a certainty. They will watch very closely though to catch any pre-eclamptic indicators. Dee was advised not to do any exercise and take it really easy, stop working etc.

Anyone with specific comments / advice / corrections is welcome to post ! You should deffo check out this sort of thing with your mw / doctor, but hope the above is helpful.

Sorry I missed this thread before. In answer to your question, it is most likely that Labetalol will have to be increased if BP contiues to be high. It can be increased in frequency and dosage. Once started in pregnancy it does not get stopped before delivery. BP can take 6 weeks to return to normal after delivery if it is PE.
There should be monitoring of proteinuria and other blood tests to check platelet and urate levels amongst other things.
There are lost of things to be taken into consideration when planning delivery - depends how far pregnancy is. Women with high blood pressure actually ofetn labour quickly but that is not always the case. If it is decided delivery is necessary the medical staff will plan delivery by C/S if cervix is not favourable for labour.
Hopefully Dee will respond to meds and keep BP controlled. Labetaolo can initially make you feel sluggish and tired. Gets better as body adjusts to it. Sounds as though you are in good hands. Please do not take BP yourselves at home - just increases anxiety which in turn increases BP.

No worries, mears, I wasn't 'expecting' an answer (and actually felt a bit rude putting your name in my original post... I did it only so that if you search on your name you might spot it).

Thank you for your input.

The doc today, when we disucssed BP implications on birth plans, suggested that it may be appropriate to induce at around 38 or 39 weeks, so of course I clarified this a little further and this suggestion was dependent on any reduction in the growth (by scan) or health (by CTG etc.) of the baby, so we'll just carry on with these regular checks and see how things go.

BTW, can you clarify your comment re: 'plan delivery by C/S if cervix is not favourable for labour'... do you mean if the cervix doesn't ripen and efface either naturally, or in response to interventions for induction (or have I got the wrong end of the stick) ?

Hub, you're a marvel. DH wouldn't know a cervix ripened and effaced - he only just knows it's something ladies have In fact, just asked him which part of a "lady's" body ripens and effaces during labour and he's offered "her feet" and "her fanny" as answers!

Glad Dee is taking it easy - sounds like she's in good hands. Hugs to you both xxxxxxxxxxxx

Thankyou for your kind words

When deciding on mode of delivery, the cervix is assessed to see how likly it is that labour can be inuced. If the cervix is very long (3-4cm), hard and not dilated at all it is unlikely that prostin gel will have much effect. If it is soft and a bit shorter, prostin gel may well make it more ripe for induction. To be induced, the cervix needs to be soft, effacing and 1-2 cm dilated in order to break the waters. Sometimes repeated doses of prostin need to be given to get the required change in the cervix. There should be 6 hours between doses. Depends on what the blood pressure is doing at the time. If all else is well, then it may be that it is OK to try and get labour going with prostin.

As I said earlier, women with high BP often labour quickly once started. It all depends on the whole clinical picture presenting on the day. Epidural is also recommended for labour as it helps keep the blood pressure in control.

Yeah, we learnt that epis lower bp in NCT the other day. (I think Dee liked that thought ).

Thank you for the description of how the cervix can appear / react - V. useful.

Would you agree with my simplistic analysis that in PIH if no IUGR can be seen, and baby seems to be happy, that induction is not (generally) necessary ? Or, in your experience, is it better to induce in PIH as it is less stressful / risky for both mother and child than simply 'waiting it out'.

(That sentence doesn't read very nicely, sorry).

DW also liked the 'high BP > tend to labout quickly' line too.

BTW - if the bp stays high till birth, and the team feels a 'normal' delivery is OK, would it be feasible to be free of the monitoring machines for a fair amount of time so the mother can attempt to move around / find comfortable positions ? (Or is the risk of a BP spike / distressed baby too great to cease tracing for any significant length of time ?). (Assuming Dee opts for a mobile epi).

hunker: hi there.You get to learn that it isn't just bananas which ripen if you are desparately curious, have a fast Internet connection, and have too much time on your hands. Thanks for the hug. Whatever happened to Bubble99's open day ?

If BP was high in labour then I would ythink mobile epidural wouldn't really be an option. BP tends to be better when resting - especially lying on left side.

We do not do mobile epidurals where I work so I could be wrong there. Monitoring is usually continuous with epidural, never mind BP issue.

Usually where BP is a problem induction is advised around 38 weeks as baby is mature and delivery is cure for PIH. It could be asking for trouble to prolong a pregnancy unnecessarily. Better to get baby delivered if poss. Depends whether it is PIH or essential hypertension though. Essential hypertension isn't so much of a problem but in can have PIH superimposed. Depends what blood picture is like really.

Some great points. Thanks also for clarifying the monitoring protocol too.

The 38 week thing is interesting... people obviously live with high blood pressure for long periods of time (often unknowingly), so I find it intriguing that it is still deemed most beneficial to induce to cure the PIH. I suppose the point is addressed in your next sentence... "it could be asking for trouble".... ie. you never know when the high BP might impact the mother's / baby's health... but then why not simply continue regular monitoring ? (perhaps bi-weekly scanning is not economically viable ? Or have I missed the point ?)

I looked through archives searching for posts on hypertension. Could I ask you to outline the difference between essential hypertension and PIH ? (Is it simply that essential existed before the pg and will exist after whereas PIH is caused by pg and cured by delivery ?)

Also (apologies if I am sucking your brain dry and you want to enjoy a quiet weekend) can both 'develop' / 'escalate' into PE ?

TIA for any advice, mears.

Essential hypertension is where the blood pressure is raised (often at booking visit) but where there are no other symptomes of PIH.

PIH also has associated with it proteinuria and oedema (swelling)

PIH can lead onto eclampsia which comes from Greek language meaning 'lightening bolt' i.e. out of the blue. This means blood pressure dramatically rises and mother fits like an epileptic fit which has implications for both mother and baby. If BP goes really high mother could have a stroke.

This is why induction is a good idea when baby is mature where there is PIH. Pre-ecampsia is where there is PIH and protein in the urine. PIH is what it says - pregnancy induced hypertension. When pregnancy ends, blood pressure will return to normal.

Don't know whether this site might help you re information regarding pre-eclampsia.

Does Dee have protein in her urine?

If not, then the BP will be observed and she could go beyond 38 weeks, all else being well.

Morning mears,

Thanks for replying. Dee does not have proteinuria at the moment (phew). She had a ++ protein and raised leucocytes around week 20 which went away after one week on anti-biotics, so a probable UTI (bloods otherwise normal).

She had slight swelling to the ankles around the time the BP started to rise. This disappeared after a few days (probably at the same time as starting BP meds and taking it easy). Her ankles are now as delicate as they ever were and although she took wedding rings off etc. for a few days as friends warned about swelling, she's put them back on as she has no swelling at all and loves her (tasteful) bling.

She is now resting / reading /snoozing quite a bit, spending quite a lot of time with her feet up, making suggestions to her slave.

"Hmmm... can I have a nice breakfast, I fancy baked beans... oh, and a glass of milk for my Labetalol"

Thanks for the link, I'd visited APEC.

I've looked at the blood results and Urea and Creatinine are highlighted as low, everything else (inc. Urate, and other non liver / kidney blood tests) are normal, which is great news. From what I can tell it is normal for urea level to be lower in pg anyway, though I haven't looked up anything about Creatinine.

It's great that if the BP and protetinuria continue to be acceptable she should be able to carry close to term, and I can better understanding the need for the monitoring. Thanks again for your comments - much appreciated.

Morning. I am posting a link for you that is a guideline only for PIH just to give you a bit more info on the management . When you read it through you will see it is a suggested guideline but medical staff make their own judgements. It is a bit old now but management has remained the same. Labetalol is definately the most often used drug although the paper mentions methyldopa.

If no protein develops, bloods remain normal and the BP stays controlled, then labour need not be induced. HTH.

OMG, mears, what a doc !!!!!

"Hope that Helps" ? And how.

Thank you very much for taking the trouble to find this. I've actually browsed some of the clinical guidelines for a bunch of things (was it from NICE ?) - but hadn't seen anything on hypertension.

BTW - Unrelated quickie: On a postnatal ward, could you guess the number of midwives vs. nurses ?

Got them here

Scotland does not actually come under the guidance of NICE however, national guidance is usually adopted, rather than reinventing the wheel.

We are governed clinically by NHSQIS Just a bit of unecessary added info for you there.

Glad you found that information helpful.

In answer to your other question, I don't know the answer. We only employ midwives in the postnatal wards. Nurses cannot do full post natal examinations. They can do temp, blood pressure and pulse but it is the role of the midwife to examine fundus (height of uterus) postnatally. I personally do not like care being fragmented by different professionals. In the labour ward we have anaesthetic nurses who will assist with immediate post natal care, doing observations and bedbathing etc.

Are there nurses in your postnatal wards? In England there is a serious shortage of midwives so I would imagine there would be.

LOL... you just know I'm an info hound, mears.

I'm on page 18. It's a fab doc because it shows me how hypertension is handled in terms of 'accepted best practice'... what the cut off levels are for more frequent monitoring etc. etc. etc. It's an easy read and allows me to learn about what might need to be considered if the BP goes up, implications for birth etc. It's a really good 'background' for me and I'm appreciative you posted the link.

Thanks. X

I'm not sure about nurses / midwives TBH... it's just that when Dee stayed overnight last week she overheard them rowing about only 3 out of 7 staff turning up for work.

Understandably, perhaps, her monitoring was somewhat lax and my attempts to get a doc to check / discharge her were not very appreciated - despite me doing it in a polite and understanding way (IMO).

You're welcome

That's a real shortage that day whether it be nurses or midwives. Unfortunately when things like that happen, emergency cases take priority. Hope that doesn't happen too often.