Checking BP/preeclampsia signs in labour

I'm wondering (possibly a bit late!) what the best thing to do is re making
checks of blood pressure and other possible signs of pre-eclampsia in
labour.

The background: I am apparently at somewhat higher risk than average of
pre-eclampsia because of my age (37) and because I had a high hCG level in
the second trimester. The latter is very much a research issue (which I
wish I didn't know about, since I never consented to have the hCG level
checked in the first place, but that's another story) so it's hard to say
how much extra risk I have; probably not much. I'm 40 weeks pregnant today,
and so far I've had no signs of pre-eclampsia whatsoever; no protein in my
urine, no swelling at all, BP which when I take it with my own monitor
after a leisurely breakfast is generally 10x/6y for some digits x and y;
it's been creeping up very slowly from around 100/60 in the late second
trimester, but this is AIUI totally normal. However, I know from a few
experiments that it can come out much higher at other times of day
(diastolics in the 80s, sometimes even the high 80s, and this is from only
a few checks) depending on what I've been doing. In particular, I think
from taking it when I had bad back pain that it goes up easily in response
to pain.

I'm planning a homebirth with an independent midwife. My midwife says that
she would normally take my BP a couple of times in labour, more if there
was any concern or it was a long labour. She is however perfectly happy for
me to decline to have it checked (at all or so much) provided I understand
the risks and benefits.

So, that's what I want to do. I know that pre-eclampsia can, rarely, come
on out of the blue in labour, and that if it does that's a very serious
situation. So I do want to be checking for that somehow. But given the
volatility of my BP, I am just not sure that checking my BP under stressful
circumstances is really the best way to do it. The obvious alternative
would be to check for protein in my urine, and only check BP if that check
was positive. My midwife said this would be OK, but pointed out that it
might be hard to get an uncontaminated sample of urine because of blood,
amniotic fluid etc. around so one might get false positives.

The other thing I'd like to understand is how big a rise in BP would have
to be before it was genuinely worrying enough to transfer to hospital. One
time when my midwife took my BP herself (in the afternoon, when I was in
pain), it was something/80, and she got really quite twitchy about this,
came back the next day to recheck etc.,; so I am not 100% convinced that
she might not overreact to the kind of rise which might actually be quite
normal in labour; I worry that I might end up transferring to hospital
"just in case" unnecessarily. But on the other hand, I don't want to take
the risk that I might underreact...

I suppose the main questions a

- what protocols have people encountered for checking BP and other signs of
pre-eclampsia during labour?

- in the absence of proteinuria, what BP would be worrying enough to be a
good reason for transfer?

- same question in the presence of proteinuria?

- are the other signs of pre-eclampsia (epigastric pain, headaches, visual
disturbances etc.) the same in labour as in pregancy? Can pre-eclampsia
still show up without any of those signs?

- is the wide variation (20+ points range of diastolic pressure) in my BP
unusual and/or a cause for concern, or is it normal?

- just how unusual is it for pre-eclampsia to show up out of the blue in
labour?

- is pre-eclampsia actually the only concern here, or are there other
possible BP-related problems too?

Any comments?

Sidheag
edd today!

"Sidheag McCormack" wrote in message
...
I didn't have pre-eclampsia, but I did have transient gestational
hypertension, so I might be able to answer some of these based on that
experience.

- what protocols have people encountered for checking BP and other signs
of
pre-eclampsia during labour?

During my labor with Vernon, my BP was monitored half-hourly at the same
time as the fetal heartbeat was checked.

- in the absence of proteinuria, what BP would be worrying enough to be a
good reason for transfer?

This is practitioner-dependent. I was already in hospital, and was told
their protocol would be to put me on magnesium sulfate during labor (to
prevent seizures) if I had diastolics consistently in the 100s or higher.
Fortunately, except for a single 103, they stayed in the 90s. Generally
speaking, I would freak out if I had occasional readings during labor as
high as the 170s over the upper 90s/low 100s, but systolics the 180s and/or
diastolics in the high 100s/110s would definitely have me transporting if I
were doing a home birth.

- same question in the presence of proteinuria?

Sorry, can't answer this one. That said, I never had my urine checked for
protein during labor, so I'm not sure how you'd know.

- are the other signs of pre-eclampsia (epigastric pain, headaches, visual
disturbances etc.) the same in labour as in pregancy? Can pre-eclampsia
still show up without any of those signs?

No idea.

- is the wide variation (20+ points range of diastolic pressure) in my BP
unusual and/or a cause for concern, or is it normal?

Personally, I don't think diastolics in the 80s are the *least* bit
concerning for a woman in the final weeks of pregnancy, even if her
diastolics were in the 60s to begin with. My understanding is that it's
typical for BP to drop during the first/second trimester and then rise in
the third trimester. Face it, come the third trimester, your heart has to
work extra hard to get all the extra blood around the body and sustain the
fetus. My diastolic BP in *all* of my pregnancies started in the 60s and
gradually rose to the 80s at term. No one blinked an eye about it until my
third pregnancy, when my BP was up to the 150-160/90-100 at the 35th week. I
never had proteinuria, though, or any other signs of pre-eclampsia, and
ended up going on for 5 weeks with these BPs without ever developing
pre-eclampsia. (I was 37 at the time, FWIW.)

- just how unusual is it for pre-eclampsia to show up out of the blue in
labour?

No idea. I should think it's quite rare (though one of our former regulars
who still posts occasionally at mkb actually developed full blown eclampsia
following the birth of her fourth child).

- is pre-eclampsia actually the only concern here, or are there other
possible BP-related problems too?

Well, very high blood pressure *can* cause seizures even in the absence of
pre-eclampsia, so you definitely don't want to go there. Blood pressure
that's too high can also restrict the flow of blood to the placenta, so one
of the things they tend to watch for in women with transient gestational
hypertension is placental calcification, drops in amniotic fluid, and other
signs that the baby isn't doing well. There's at least some possibility of
IUGR due to hypertension during pregnancy, but when you're already at term,
it's not really something to worry about. Also, some women never spill
protein even when they have true pre-eclampsia, so it's fairly typical to
order routine blood work to check for enzymatic signs of liver problems and
other potential pre-eclampsia markers if a woman develops true high blood
pressure in pregnancy. (You don't *have* true high BP yet, BTW--your
readings are borderline.)

All of the studies I read when I was dealing with my pregnancy-related
hypertension suggested that there was *no* difference in outcomes for babies
or mothers when high BP was the *only* issue. In the absence of signs of
true pre-eclampsia, high blood pressure in pregnancy appears to be largely
benign. It's also worth noting that studies suggest that if high BP comes on
as a harbinger to full-blown pre-eclampsia, the average time it takes to
progress from high BP alone to proteinuria and other signs of pre-eclampsia
is 6 days. So the longer you go with high BP and *no* signs of
pre-eclampsia, the less likely it appears to be that you'll actually develop
it.

Good luck and HTH!
--
Be well, Barbara
(Julian [6], Aurora [4], and Vernon's [19mo] mom)

This week's special at the English Language Butcher Shop:
"Together we help the future grow." -- School slogan

Daddy: You're up with the chickens this morning.
Aurora: No, I'm up with my dolls!

All opinions expressed in this post are well-reasoned and insightful.
Needless to say, they are not those of my Internet Service Provider, its
other subscribers or lackeys. Anyone who says otherwise is itchin' for a
fight. -- with apologies to Michael Feldman

- same question in the presence of proteinuria?

Sorry, can't answer this one. That said, I never had my urine checked for
protein during labor, so I'm not sure how you'd know.

and if you did it would be very inaccurate, any amniotic fluid in the
urine shows up exactly the same as genuine proteinuria

On 13 Oct 2003 16:59:02 +0100, Sidheag McCormack
wrote:

Any comments?

Well, I had severe pre-eclampsia, and I am glad to see that you are
thinking about this.

However, my pre-eclampsia came on before I was in labor at 37w6d. DD
was taken by c-section because she was not engaged and induction
failed. Since I was delivering in a hospital, I am sure that our
experiences would be different. However, I will be happy to tell you
what they did to monitor my PE.

I also found an excellent site with excellent information that may
help with some of your questions. The main page is:
http://www.preeclampsia.org/

The 2 pages that may be the most helpful a
http://www.preeclampsia.org/symptoms.asp
http://www.preeclampsia.org/FAQ.asp


--
Daye
Momma to Jayan
"Boy" EDD 11 Jan 2004
See Jayan: http://jayan.topcities.com/

Circe writes:

C I didn't have pre-eclampsia, but I did have transient gestational
C hypertension, so I might be able to answer some of these based on that
C experience.

I was hoping you would :-)

C During my labor with Vernon, my BP was monitored half-hourly at the same
C time as the fetal heartbeat was checked.

Yikes - but it made sense to check it so often because your BP was worrying
before labour, I guess.

S - in the absence of proteinuria, what BP would be worrying enough to be
S a good reason for transfer?

C This is practitioner-dependent. I was already in hospital, and was told
C their protocol would be to put me on magnesium sulfate during labor (to
C prevent seizures) if I had diastolics consistently in the 100s or
C higher. Fortunately, except for a single 103, they stayed in the 90s.
C Generally speaking, I would freak out if I had occasional readings
C during labor as high as the 170s over the upper 90s/low 100s, but
C systolics the 180s and/or diastolics in the high 100s/110s would
C definitely have me transporting if I were doing a home birth.

That's about what I was thinking, and it gives me quite a lot of "headroom"
above even the highest figures I've ever recorded. Good.

S - same question in the presence of proteinuria?

C Sorry, can't answer this one. That said, I never had my urine checked
C for protein during labor, so I'm not sure how you'd know.

Well, I could be asking for my urine to be checked (or even checking it
myself, since I have some sticks) - always understanding that a positive
reading might not be information since it'd be likely to be caused by
contamination, it still seems to me that a negative reading would be
somewhat reassuring, especially if BP were marginal. I know that there are
women who don't have proteinuria even with serious pre-eclampsia - but it
all goes into the probability calculation, which might be useful if it's
hard to tell whether one should be suspecting pre-e or not.

C Personally, I don't think diastolics in the 80s are the *least* bit
C concerning for a woman in the final weeks of pregnancy, even if her
C diastolics were in the 60s to begin with. [...] (You don't *have* true
C high BP yet, BTW--your readings are borderline.)

I'm not really worried, I'm more worried that my midwife might get worried
:-) The main thing that reassures me - though I'm not sure to what extent
it should - is that I'm still getting diastolics in the 60s every day, even
though at other times of day they may be in the 80s. Most of what I've read
suggests that unless it's sky high (so that it's dangerous right then),
"high BP" doesn't actually count as such unless it stays high consistently.
(E.g. standard management of a single high BP reading always seems to be to
ask the woman to rest and take it again a few hours later, and not worry
unless the later reading is also high. So far, it's very clear that that
protocol would always give me a low BP reading the second time round - but
in labour, resting for a few hours is not really an option :-) Given
readings like this morning's 98/69, I'm not inclined to think of myself as
someone with even borderline high BP. But what I'm trying to get a handle
on here is where the boundary between confidence and complacency is...

Good luck and HTH!

Thanks, and yes it does, somewhat.

Sidheag
edd yesterday

Anne Rogers writes:

- same question in the presence of proteinuria?

Sorry, can't answer this one. That said, I never had my urine checked
for protein during labor, so I'm not sure how you'd know.

and if you did it would be very inaccurate, any amniotic fluid in the
urine shows up exactly the same as genuine proteinuria

So a + would not be very informative, true, since you wouldn't be able to
tell whether it was genuine or not. Still seems to me that a - would be
worth having though; it still wouldn't prove anything, because of some
women having pre-e without proteinuria, but it would be a little piece of
evidence decreasing the likelihood of pre-e.

Sidheag
edd yesterday

Daye writes:

Well, I had severe pre-eclampsia, and I am glad to see that you are
thinking about this.

However, my pre-eclampsia came on before I was in labor at 37w6d. DD was
taken by c-section because she was not engaged and induction failed.
Since I was delivering in a hospital, I am sure that our experiences
would be different. However, I will be happy to tell you what they did
to monitor my PE.

I also found an excellent site with excellent information that may help
with some of your questions. The main page is:
http://www.preeclampsia.org/

It is a great site, so I've quoted the URL again. However, the questions I
was asking were really the residue after I'd read all of that sort of thing
I could find!

Looking at Medline etc. I could really find nothing about pre-eclampsia
that begins during labour, which is what I'm most interested in (the
decisions about what to do if it shows up between now and labour being
rather easier). Maybe it's just too rare to be easy or motivating to
research, which would in itself be good news! (My midwife has seen one case
of it in her career so far: clearly it was a scary experience for all
concerned, though the outcome was good.)

I did, however, find a study that is suggestive that the high hCG level
that made us think I'm at higher than average risk may not be something I
should still be concerned about at this stage - it provided some evidence
that high second-trimester hCG is associated with early-onset
pre-eclampsia, which clearly I don't have, rather than with late-onset
pre-eclampsia. So maybe I should go back to assuming that I'm at the same
risk as anyone else of my age and parity, i.e. really pretty low, having
got this far with no signs.

Thanks,

Sidheag, as always trying to worry without being paranoid :-)
40w1d

Sidheag McCormack ...

I suppose the main questions a

Hi. I didn't have pre-eclempsia but I did have high blood pressure.
I can't answer all your questions but I'll share my experiences on
some :-)

- what protocols have people encountered for checking BP and other signs of
pre-eclampsia during labour?

Blood pressure checks when they checked the fetal heart rate which was
about every hour....a little less often in the beginning.

- in the absence of proteinuria, what BP would be worrying enough to be a
good reason for transfer?

I started out in the hospital so I don't know what the transfer rate
would be. During the later half of my pregnancy my doctor was clear
it needed to not go higher then 140/90 give or take a few points. I
did manage to stay in that range. I believe it did creep up during
labor but it never wildly spiked up. If there was concern about this
from the doctors and nurses they never let on to me about it.

- same question in the presence of proteinuria?

I wasn't tested during labor but right before I was induced I think.
I did have trace amounts of protein in the last month or so. I was
told that trace amounts don't really mean much.

- is the wide variation (20+ points range of diastolic pressure) in my BP
unusual and/or a cause for concern, or is it normal?

My blood pressure goes sky high with lots of internal stress or with
pain. Hunter was not weaned yet when I had my first appt. My blood
pressure was 160/110. STRESSS :-) I hurt by back earlier this
year...it was up in that range again. Oddly enough I didn't really
have that same issue with labor pain (and I did not have pain meds).

- is pre-eclampsia actually the only concern here, or are there other
possible BP-related problems too?

I'm not really sure. I think it depends on labor management and
medications you might receive.

Good luck...FWIW in my totally useless opinion your blood pressure
sounds fine :-)

--

Nikki
Mama to Hunter and Luke

Nikki writes:

Blood pressure checks when they checked the fetal heart rate which was
about every hour....a little less often in the beginning.

Are you sure about that? It would be usual to check the fetal heart rate
more often than every hour (but if midwives are good, it's quite common for
women not to particularly notice it being done).

My blood pressure goes sky high with lots of internal stress or with
pain. Hunter was not weaned yet when I had my first appt. My blood
pressure was 160/110. STRESSS :-) I hurt by back earlier this year...it
was up in that range again. Oddly enough I didn't really have that same
issue with labor pain (and I did not have pain meds).

That's interesting.

Good luck...FWIW in my totally useless opinion your blood pressure
sounds fine :-)

Thanks! Your opinion is not useless at all :-)

Sidheag
edd yesterday

On 14 Oct 2003 12:14:19 +0100, Sidheag McCormack
wrote:

I did, however, find a study that is suggestive that the high hCG level
that made us think I'm at higher than average risk may not be something I
should still be concerned about at this stage - it provided some evidence
that high second-trimester hCG is associated with early-onset
pre-eclampsia, which clearly I don't have, rather than with late-onset
pre-eclampsia. So maybe I should go back to assuming that I'm at the same
risk as anyone else of my age and parity, i.e. really pretty low, having
got this far with no signs.

Well, we're the same age, Sidheag, and the same parity, and my BP has
varied between 100/60ish to 120/80ish (sometimes up, sometimes down)
and no-one's mentioned that I might be at risk of pre-eclampsia. The
hospital was fairly conservative about a lot of things but my BP was
never a worry. The community midwives are very laid back and have
mentioned that my BP does vary, but have no problems with it.

I'd assume your risks are about the same as mine and not worry too
much. Easy to say...
--
EDD 1/11/03
37 weeks