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).

I take it you live / work in Scotland, mears ? Do you work within a hospital or in a birthing centre ? (And is it an NHS facility ?) (pls. ignore if you prefer to keep this private - I would understand).

Can I ask if you've ever met / worked with any male midwives ? Did your clients like / dislike this 'difference,' in your experience ?

ooooh... juicy para:

"One of the most recent, UK trials included in Duley?s meta-analysis is that of Pickles et al 34,35 who conducted a randomised trial of labetalol vs. placebo in women with ?mild to moderate pregnancy induced hypertension (PIH)? (diastolic 90 - 105mmHg). This trial examined both neonatal (birthweight) and maternal (in-patient days, proteinuric pre-eclampsia and perceived need for induction) outcomes. The results of this study were in accord with those of Duley?s meta-analysis in that the treated group experienced significant falls in BP and were significantly less likely to develop proteinuria. However, gestational age at delivery, onset of labour and mode of delivery were unaffected suggesting that obstetric intervention (perceived need for early delivery) was uninfluenced by pharmacological treatment. These authors concluded: ?our results add to the growing consensus that while mild to moderate PIH must be carefully monitored, pharmacological treatment of the disease does not materially influence outcome?. They concede however, that for disease presenting before 32 weeks gestation, the reduction in the development of proteinuria associated with anti-hypertensive therapy may be advantageous. "

I work in a consultant led unit that has a midwifery unit attached to it. That means low risk women are looked after by midwives only. If problems arise they can be easily transferred through to the obstetric side for medical management. We do not have epidurals in the midwifery unit but women can be managed by midwives only in the obstetric unit if the only reason they are there is for pain relief by epidural. We have a pool and have increasing numbers of waterbirths.

I have worked with one male midwife who is now the chief nurse for Scotland! We had another male midwife but I never worked with him - was off having babies of my own. Women liked having a male midwife I have to say. No problems as far as I am aware.

Your setup sounds interesting - and the mws assisting (leading ?) on the obstetric side where client presents with a normal pg but wanted an epi sounds very sensible.

I presume the waterbirths are all within the 'midwifery unit' ?

Nice to hear male midwives were appreciated. Can I ask a dumb question simply to save some lazy google work... is a midwifery qualification based on some kind of 'basic' nursing diploma plus subsequent midwifery specialisation, or is training structured differently to that ? (Oh, and how many years ?)

TIA.

Here ois another wee link for you

Midwives are now trained directly over 3 years. When I did midwifery back in 1983, there were no direct entry courses. You needed to train as a nurse first then do an 18 month course to become a midwife.

There is great debate whether that was good or bad. I personally find that my nurse training was useful. There is the argument that pregnancy is a normal event and that nursing gives it a 'sickness' element. Many nurses did midwifery to give them an extra course for promotion later, and did not stay in the profession.

I always wanted to be a midwife so did nursing as a means to get to do midwifery.

Should have said also that women who are 'high risk' can use the pool as well. The consultant liaises with the senior midwife. We have had women with previous C/S deliver in the pool.

hello

im going to be training as a midwife hub,

doing 2 year access to health at college and then midwifery at uni for 3 years.

or you can train as a nurse for 3 years first and then do midwifery for 18 months

midwifery is very hard to get onto as there are limited places so alot of people on my course are going for nursing first (although for alot of them the bursary is a deciding factor)

Hmmm... I think I'll stick to the psych side of 'caring' then...

but thanks to both of you for the info.

The waterbirth VBAC sounds fun, mears.

Good luck with your studies, huggy !

What is your profession then hub2dee?

Nothing as organised as a 'profession' mears.

Did a psych degree then worked in IT - all sorts of rôles from support to sales to marketing to system architecture and 'new media' development. Mainly in the data communications space.

(Sounds thrilling, huh ?)

I've recently been working on systems to manage intelligent buildings (control of lighting circuits, multi-room music playout systems etc. etc.) and I may launch a business doing that (or one of a few other projects in my head), but I am more than aware of the work it would involve and would like time for the growing family, so have been contemplating some different directions including a return to my psychology origins - perhaps as a psychotherapist - but am not sure really.

I think midwifery could be interesting - maybe the business side of it as I am interested in the concept of independent midwifery integration within the NHS... but I recognise I have no experience in this area.

(I think it will be a rather long time before full continuity of care could be offered to every pregnant woman within a publicly funded system, yet at the same time so many great midwives feel they are unable to work within the constraints of the system so they either leave and do something different or practice as IMs... but with no access to NHS 'active birth' (except as a birth partner) or to NHS 'medicalised birth' as same. It seems slightly stupid to me, but perhaps I do not grasp the finer points and considerations at play.

I'd be interested in your comments / corrections / ideas on this BTW.

Male or female, I wouldn't care as long as he/she were helping me get the baby OUT!

expat - I'm starting a thread with a yes / no poll on male midwives, just out of curiosity. Can I use your response in an (attributed) quote ?

No response yet... I'll just go ahead, hope you don't mind.

Poll on male midwives here .

I totally agree with you hub2dee. I personally would much rather practice like a IM but I would not want to practice without insurance which is what the majority do. I would like to see a change in the way care is organised and have better continuity. The only thing wrong with that is midwives are at risk of sufferingburnout when they work like that. Needs to be very finely balanced - midwives have families too and cannot be at everyone else's beck and call. The thing to do is have a very manageable caseload. Can be done, just needs creative thinking.

hiya mears, glad I didn't put my great big foot in it and say something that was overtly dim.

Contributing financially towards your care is one way (and I appreciate this is an enormous can of worms, and that not everyone can afford this), but when Dee was in overnight the other week, I'd have been happy to contribute £50 - £100 for a midwife / nurse to provide evening monitoring services etc. rather than leave her somewhere which was short staffed so focussing limited resources on only the most urgent patients (which she wasn't).

I agree the caseload management is probably key to the whole thing... after all, whenever you have an antenatal appointment, you're seeing someone - some 'resource' from the NHS - might as well be the same one, or from a small team you get to know...

I understand continuity of care (and the randomness of when a woman will give birth) is very challenging to manage and has a big impact on the midwives' family lives. IMO I expect we'll see more groups of IMs incorporating into private teams which I hope will buy NHS 'space' in the same way that a private consultant operating within different hospitals does.

(Apologies in advance if my scant understanding of health provision means I'm talking rubbish).

If it helps anyone in the future looking at how maternal hypertension varies / develops, I'll keep posting occasional summaries of how DW does at the clinics...

@ hossie today, Dee had 157 / 98 by digital and 140/80 by manual !!! Within a few mins of each other.... there are truly either very big differences in BP from minute to minute or those digital machines might not be all they're cracked up to be.... spoke to woman there who said her results were also aways radcially different on the digital machine (I know there should perhaps be 20 mins between readings)...

++ protein (concentrated urine)... not looking great...

...Anyway, we had another scan, baby fine for size, stomach growing (apparently stomach not growing / slimming down can happen as blood gets diverted to the more important brain)...

... and we went back 2 hours later (after Dee had drunk more water so urine much clearer and no protein at all ! (Also bloods back from Friday absolutely fine)... BP had dropped to 133/89, which are better numbers.

I thought all this proteinuria was a lot more stable / predicatable than ++ to zero in a few hours with a few glasses of water ! (something to consider next time anyone gets tested perhaps ? !!!)

Back in a few days...

hub - one off BPs are best not taken by automated BP machines as they can be inaccurate. They are better used for 'serial' BPs where you are looking at the trend. Manual BP reading is the recommended method of reading BP as the machines can actually underestimate (although in this case it was other way around but that could be because it was one-off and machine not calibrated itself properly)

By the way, found an update to the last paper I posted a link to for you.

I didn't really appreciate this, especially as I don't think we had seen a manual machine used in ANY of our umpteen antenatal checks at the hospital.

I thought the woman we chatted to was being a bit picky requesting her bp was checked manually, but I can see it might be a much better thing to do - and also gives proximity to a human (rather than those rather foreboding digital machines). (BTW if lady from Day Assessment Unit at Royal Free hossie is on MN, dw and I thought you seemed lovely).

Thanks for this advice mears. BTW - this ++ protein to zero in just a few hours with several glasses of water... does that sound common / feasible ? (We made sure the mw testing hadn't got Dee's and this other woman's sample mixed up !). Can I trouble you (again) to ask under what conditions 24 hour urine collection is deemed useful ? I deffo don't want DW to have yet more testing, but if it would give a better view of kidney functioning etc. etc. then perhaps it would be good.

Have a lovely day.

That's a rather interesting document mears !

• aspirin / calcium carbonate usage reconsidered

also:

"Antihypertensive drug treatment is not usually indicated for women with non-proteinuric gestational hypertension. However, a diastolic BP >105mmHg represents an appropriate level at which to initiate anti-hypertensive therapy as protection against intracerebral haemorrhage. A lower threshold may be considered where the disease has arisen at < 28 weeks gestation. Grade A "

(Dee's didn't get that high although I appreciate these are guidelines...)

Hmmm...

"There is general agreement that severe hypertension (ie diastolic BP >110mmHg) should be treated to protect the pregnant woman from the risk of intracerebral haemorrhage. However, there is less agreement about drug treatment in milder hypertension. Reduced intravascular volume and poor perfusion are key pathophysiologic changes in the hypertensive disorders of pregnancy and ill-advised efforts to ?normalise? blood pressure may further reduce placental perfusion"

Hmmm... so much of life appears science when infact it is art, hey...

Thanks again.

Hub2Dee - I was admitted to hospital at 38wks with ds. I had BP of 150/101 when it had been 115/65 throughout the pregnancy. I also had protein ++.

I was put on a 24 protein analysis..... lovely so it is! Everytime I drank something I had to note it down. And every time I peed I had to collect it in a measureing cylinder... note down the volume then pour it into a big collecting bottle! Glamorous or what. And there were 4 of us sharing a room and toilet all doing the same thing.... the bottle had our names on them. It was acutally quite funny.

Just wanted to let you know what it involved...
Incidentally I was kept in for a week as my BP kept fluctuating.... then thankfully went into labour spontaneously at 39+2 days!

Where there is persistant proteinuria on a +++ basis, 24 hour collection can be done. TBH it is not something that I see done as often as we used to in the past. A single sample can be sent for protein estimation and depending on that, a 24 hour collection can be done.

Urine can be contaminated by vaginal discharge. The sticks can need replaced - they can be inaccurate too.
Could be that first sample was contaminated or concentrated urine can alter the reading on the stick.

In the old days as a student midwife I remember having to teat urine up with a bunsen burner and add a reagent. If it turned pruple you had to set up another test (Esbachs I think it was called) and then measure the sediment which was the protein. It was a woner I never set the hospital on fire!

I probably gave you a bum steer there. Depends when proteinuria appeared and what other symptoms are there.I will actually ask what we do regarding 24 hour urine at daycare as I meet women when they are being prepared for delivery. When women are inpatients for more intensive monitoring they may do 24 hour urine. Will get back to you.

With my first child I was admitted to hospital at 30 wks with PIH. My BP fluctuated wildly and there was really nothing I or the hospital could do to control it. Also found Bp could be different depending on which arm it was taken on and whether it was manual or by machine. With Bp readings was told if the bottom figure was over 90 this was cause for concern. I was basically monitored in hospital until 34wks when the babies lungs would be more developed and able to cope and then given an emergency C-section. I was on 800g a day of labetalol and on four occasions had to be given something alot stronger( can't remember what it was called) in the middle of the night to bring my Bp down. Although admitted with PIH it turned into PE whist in hospital. My urine was tested every day and I did numerous 24 hr urine tests. I even did a urine test where there was acid in the bottle and I collected it for 24 hrs. This was to check kidney function as the protein levels fluctuated so much they thought there might be something else wrong with my kidneys. I had my blood tested every 3 days and was on a doppler machine and Bp machine for 2 hrs every a.m and p.m. I had a baby scan every week to check flow through the cord and the amount of amniotic fluid. Growth was checked every 2 weeks. Not much notice was taken of these results as my consultant said he couldn't guarantee they were accurate unless the scans were always done by the same person. I never had any flashing lights and the only part of my body which swelled was my face and neck. Ds was born 6 weeks early and kept on scbu for 3 weeks until his breathing, feeding and weight stabilised. He was born in November 2003 and I had to continue taking the Bp tablets until May 2004 because you have to be weaned off them. All in all bit of a nightmare scenario but you did say in your original post you wanted any experiences. Ds is perfectly fine and suffered no ill effects from being premature however I did get PIH 36 wks into my second pregnancy but was allowed to stay at home and was induced at 39 wks. I was also monitored more closely and given more appointments and scans the second time around. Did realise while in hospital no 2 cases of PE are the same and wondered whether anything I had done had caused it. I don't drink or smoke and am normally a healthy person I was just told that these things happen and are most common in first pregnancies. Hub2dee know this is a worrying time but hope everything works out fine.

Thank you kazoo / Queenflounce for your input. It is interesting to see how things can pan out and useful to be aware of the different possible implications / treatments. I am sure that with close monitoring and lots of relaxation, DW and bean will be fine.

Thanks again mears for having a think about all this. It's fascinating also to get an understanding of how things were done in the 'old days'... I appreciate all this manual testing / heating must have been slow, but the current dipstix fail to account for SG and alkilinity I believe, so they give a great 'quick' reading but perhaps don't reveal the full picture as much as old manual testing or lab-based urine analysis...

BTW, DW is doing well, feeling kind of sluggish and a bit foggy, but otherwise fine.