Let's talk about pre-e - Page 2

[onlyboys]

No, they are not stupid, but like any student they zone out, they compress the info in their head, they take inadequate notes, they store items that are more important to them than others. In short, they are not experts in the field. I'm not at all implying to "dumb it down" or anything of the sort, I certainly don't, but I am very careful not to throw absolutes out there.

Women internalize what we say to them. Even if they misconstrue it. For example, in a video I show, it mentions that transition labor can be anywhere from 20 minutes to 3 hours. A client internalized that transition was 20 mins and THAT'S ALL she would hear. No matter what I said, no matter what the midwife said to her, that's what she heard. (Funnily, when her labor got here, she kept waiting for transition, saying things like, "I don't want to do transition! Take me home!" when she was in transition. She kept waiting for it to "get bad." )

Does this make sense? I think being a little cautious what we say, especially about complications and prevention of such can go a long way to ensuring a mama feels like she's not at fault for the outcome. In the case of pre-e, she almost certainly isn't.

[SublimeBirthGirl]

When it comes to birth, I very rarely speak in absolutes.

[pamamidwife]

I think the issue here is nutrition. If women get enough calories (regardless of the source) and protein (but I feel like suggesting women eat 75+ grams of protein a day is overkill), then they're likely to have a nicely expanded blood volume.

HOWEVER, we must remember that pre-e signs start with a contracted blood volume. It's not about needing more protein, though additional calories and better nutrition can help that. With Dr Brewer, his diet really focused on a variety of foods and more calories and it seems all people take away from it is high levels of protein. He also was doing these suggestions in a time where women were told to control their weight gain in pregnancy, not eat much, etc. Of course there will be better outcomes.

I'm just not sold on telling any one woman that she can prevent pre-e. I'm not even sure anyone really knows why it happens - but if it does start with the implantation of the placenta and shows up with a contracted blood volume, why do many well-nourished women get it?

For me, the issue isn't about focusing on pre-e prevention (because I don't think we can do much, although increasing protein when you see a contracted blood volume might hold it off for awhile), but what we define as pre-e. I hear of women in their last month of pregnancy diagnosed with pre-e without clinical signs other than a rising bp and some protein in a urine dip. I hear providers use PIH and pre-e interchangably.

I think there is so much unknown. Definitely if it feels like women are being proactive consuming certain levels of protein, they should do that. But I could never present the idea that high levels of protein would prevent pre-e.

Laura, I also get what you're saying, too. There are no absolutes in birth. But many midwives think so and still recommend 100grams/protein a day! I think 60-80 grams a day is pretty normal for many women in our culture...but I don't recommend it or have people count their protein intake.

[Marilyn82]

Interesting thread. I have a personal vendetta against the catch-all 'Pre-e' being used synonymously with PIH and just normal hypertension ("OMG, shes 39 weeks and just had an argument with her husband and was rushing to her appointment and egads she has higher than normal blood pressure with a *gasp* trace amount of protein, ready the cesarean table! She obviously has severe preeclampsia! What, you feel fine? You think you are just stressed? You are not qualified to make that decision, now here put on this gown" ).

But seriously, I have always thought that all the Brewer diet really did was encourage women eat more variety and therefore nourish their body systems. I think nourishment is key, and you could probably get the same amount of nourishment eating smaller amounts of high quality protein rather than what is found in the typical American diet. Any time you focus on nourishing your body systems, your body will work more to it's full potential. Seems like common sense to me. Just my thoughts on it That being said, some women prefer having guidelines so it seems to help them make better choices, If it works for them and it helps them be proactive (like Pam said) than great. For myself, I always have to have some kind of eating plan that I follow, because I personally feel more comfortable with some kind of structure to it, but I know thats just who I am :0)

[riomidwife]

well, while we're on the subject of proper diagnosis, I'd like to encourage midwives to use proper terminology. People use "PIH" and "Preeclampsia" interchangably, and they are completely different animals physiologically.
The term "PIH" was revised to "Gestational Hypertension" years ago. I know, I know, the word police...and I know so many midwives still use "PIH" but can I propose that we all get current and use the correct terms?

[SublimeBirthGirl]

fwiw, the class I teach uses Brewer as a basis for nutrition, and of course that means not just protein, but eating a varied diet. We changed some things, like encouraging healthier fats as opposed to saturated fats like butter, etc. I've never, ever told anyone that if they eat enough protein they won't get pre-e. I just say that there is some evidence that a healthy diet with enough nutrition may decrease the risk.

I also believe pre-e is overdiagnosed. I have seen way too many women scared into inductions for BP that is elevated but not even very scary with the whole pre-e threat.

[Malga]

I just did quite a bit of studying on pregnancy induced hypertension disorders due to the fact that I have had a number of clients at my new job as a nurse on Mag with pre-e. Anyway from an objective standpoint here is the latest guidelines:



Chronic HTN (hypertension), gestational HTN, Pre-e, severe pre-e, HELLP, and eclampsia can be parts of a disease process, a continuum so to speak.

Chronic HTN is defined as hypertension diagnosed before 20 wks gestation or HTN continued beyond 42 days postpartum. HTN is defined as a systolic blood pressure (SBP) of greater than 140 OR a diastolic blood pressure (DBP) greater than 90. The or is important because even if one value is normal you can have the diagnosis with just one value above normal. Severity is determined by the higher value. This predisposes you to getting the other disorders along the continuum. 7 times higher liklihood of developing pre-e.

Preeclampsia is defined as gestational hypertension plus proteinuria (>300 mg protein on random specimen or >1+ on dipstick). In absence of proteinuria, suspect if headache, blurred vision, abdominal pain, or abnormal lab tests present with HTN.

Severe Pre is the diagnosis of pre-e plus one of the following:
-SBP of 160 or greater
-DBP of 110 or greater
-proteinuria>2g in 24 hours
-creatinine>1.2mg/dL
-platlets less than 100,000
-increased LD
-increased ALT or AST
-persistant headache, visual disturbances, or epigastric pain (if these signs are present then underlying organ changes are already present--like liver is already swelling leading to epigastric pain)

HELLP
Hemolysis
Elevated
Liver enzymes
Low
Platlet Count
This is a continuum of severe preeclampia.

Eclampsia is a seizure or coma with pre-e present. Tx is to ensure airway, oxygen, Mag, Amobarbital Sodium, and suction/X-Rays because aspiration is leading cause of mortality/morbidity, check cervix and fetal status. After eclampsia is present then Foley's Rule of 13: 13% mortality rate, 13% abruption, 13% seize again after Mag, 13% seize after 48 hours postpartum.

HTN complications include: abruption, DIC (coagulation issue), cerebral hemorrhage, stroke, hepatic/renal failure, hepatic rupture.

Prevention there are many theories of prevention that of course need more research, but some promising therapy include exercise, Calcium supplementation, protein, antiplatlet therapy.

Sorry this is so long but I love learning, knowledge is power ! Its important to understand new research on this because I see a lot of bad practice in the hospital and I want to be able to question treatment or lack of. For example chronic HTN really seems to through people off. Also in normal pregnancy systolic blood pressure shouldn't change much and diastolic gradually decreases 10-15 mm Hg over first trimester and then gradually increases to nonpregnant baseline values at term. So, it isn't true that BP should go up in pregnancy is should go down and then to normal baseline.

[riomidwife]

Originally Posted by Malga

For example chronic HTN really seems to through people off.

I agree, it's often misdiagnosed as GH or preeclampsia.

Other important definitions:

Gestational hypertension*
A blood pressure increase to >140 mm Hg systolic OR >90 mm Hg diastolic that is first diagnosed after 20 weeks gestation and without proteinuria.
Gestational hypertension that resolves by 12 weeks postpartum is retrospectively labeled ‘transient hypertension’

Preeclampsia superimposed on chronic hypertension
In a woman with preexisting hypertension, a sudden increase in blood pressure, new onset or acutely worse proteinuria, thrombocytopenia, or elevated liver enzymes after 20 weeks gestation.

[Malga]

Preeclampsia superimposed on chronic hypertension
In a woman with preexisting hypertension, a sudden increase in blood pressure, new onset or acutely worse proteinuria, thrombocytopenia, or elevated liver enzymes after 20 weeks gestation.

Exactly. I had a women that was only 28 weeks the other day and had this. But, the providers were not addressing it as they should (I thought) because they seemed to only focus on her chronic hypertension. But, she also had greater than 300 g protein in urine, then her SGOT and SGPT (liver labs) went above normal, she had a headache, N/V, and epigastric pain!!!! They did finally transfer her to a tertiary care center, but I thought she looked like she could seize at any moment! Scarey. Her BP got as high as 200/120! Anyway, its good to be vigilant.

[pamamidwife]

Originally Posted by elriomidwife

well, while we're on the subject of proper diagnosis, I'd like to encourage midwives to use proper terminology. People use "PIH" and "Preeclampsia" interchangably, and they are completely different animals physiologically.
The term "PIH" was revised to "Gestational Hypertension" years ago. I know, I know, the word police...and I know so many midwives still use "PIH" but can I propose that we all get current and use the correct terms?

I'm game - but how is pregnancy-induced hypertension different from gestational hypertension? aren't they both saying that the pregnant state is what increases the bp? Is it just the term - like using "sonogram" vs "ultrasound" as a more accurate term? help!

I also have an issue re: describing HELLP as an advanced form of Pre-e. In one client, I had some very clinical signs of pre-e that were not present when suddenly she had HELLP syndrome. Can someone explain? Is it that the signs happen so fast that I missed it? With her elevated bp and facial swelling, I did blood work and nearly all her bloodwork ruled out pre-e, which made the diagnosis crazy for me. It wasn't until we took her into the hospital that they diagnosed HELLP syndrome. Still, why do the clinical pieces look different? Or was my client's just a rare instance??

[riomidwife]

Originally Posted by pamamidwife

I also have an issue re: describing HELLP as an advanced form of Pre-e. In one client, I had some very clinical signs of pre-e that were not present when suddenly she had HELLP syndrome. Can someone explain?

Huh. IME most people/experts consider HELLP to be a variant of preeclampsia.

What bloodwork did you do? I've found that midwives do a wide variety of "panels" for GH. HELLP is very mysterious and can sneek up on you fast. Sometimes there is no hypertension (by definition) too.

As for the semantics of GH and PIH, yes, they are essentially the same thing.....but PIH is no longer "correct" terminology, even though many midwives still use it. As a pp said, so many people use PIH and preeclampsia interchangably. ARGH! So I think using "GH" might help us get away from that.

[Jenlaana]

Originally Posted by SublimeBirthGirl

I also believe pre-e is overdiagnosed. I have seen way too many women scared into inductions for BP that is elevated but not even very scary with the whole pre-e threat.

I have dealt with this in every pregnancy. In 2 pregnancies I had protein (although not sure if it was "trace" but I know the 24 hr was not outside of the range of normal, but the regular ones kept coming back wrong)

What is the criteria for pregnancy induced hypertension exactly? If a BP is always high from the start at an office (based on white coat hypertension) and goes up a max of about 10 pts top and bottom (140/90 to 150/100) is it pregnancy induced hypertension? (just 2 weeks before was 118/70 at a GP before I knew I was pregnant and has been 140/90ish when I take it at home generally)

The problem with pre-e/gestational hypertension IMO is that its so open to interpretation that its hard to know what the right route is. I've had doctors freak out at 140/90 and some not freak until 150/100. I actually had a doctor make the "stroke face" at me with the tongue hanging out and everything yesterday, when I wanted to talk about statistics and side effects before agreeing to meds and induction.

I understand that its a dangerous thing when it gets out of control, but what is the actual line over which we should not tread? Is there any data anywhere to suggest what that line is?

[Contented73]

What a great conversation. In this particular case, protein levels were a bit more than trace (sorry, I don't remember what the scale is) and bp was elevated as compared to all her previous bp readings -- although not awful. (I remember thinking at the time, oh, that's pretty much how high my bp is at the end of pregnancy). She had pretty significant swelling (it was 100 degrees out. eeks) but no other symptoms. The midwives called for an emergency transport and induction. It all turned out fine, really. However, it just seemed weird to me that it was such an emergency situation. Her blood counts in the hospital during the (looong) induction kept coming back perfect (maybe because of the mag?). I would never ever question the midwives decision in a situation like this (I'm just a doula), and I fully supported my clients induction....but I do have to say that I was scratching my head a little bit over the whole thing. Made me want to learn a bit more about pre-e.

[AlexisT]

Originally Posted by pamamidwife

I think it's nearly impossible to just suddenly get pre-e at 39 weeks. without any other signs/symptoms prior?

Mine was pretty stealthy. I had slightly but not worryingly elevated BP throughout pregnancy and 1 abnormal dip at 21 weeks. After that, all normal till 38 weeks when all hell broke loose. My dip came up with 4+ protein and I got booked in for monitoring and 24 hour urine collection. I don't have my labs handy, but my labs were consistent with pre-e and I had hyperreflexia. BP never went over 140/90 (my normal is 125/80 or so) and I wasn't noticeably swollen. 2 days later they cut me open.

I get plenty of protein; that shouldn't have been an issue.

[riomidwife]

Originally Posted by Jenlaana

If a BP is always high from the start at an office (based on white coat hypertension) and goes up a max of about 10 pts topand bottom (140/90 to 150/100) is it pregnancy induced hypertension? ......

In the past, an increase of 30 mm Hg systolic or 15 mm Hg diastolic has been used as diagnostic criteria. This increase is no longer considered diagnostic for two reasons. First, most pregnant women will have a normal rise in blood pressure between second and third trimesters as is returns to baseline levels. Second, all available evidence demonstrates that women with this normotensive rise in blood pressure are very unlikely to have adverse hypertension related outcomes. Still, the collective opinion of both the NHBPEP and ACOG is that these women should be observed cautiously,
especially in the presence of proteinuria or increased serum uric acid.

>>>>I've had doctors freak out at 140/90 and some not freak until 150/100. what is the actual line over which we should not tread?

This is one of those cases where there is no exact "line." Diagnosing preeclampsia is just as much an art as it is a science. Some providers won't bat an eye at 150/100, while another may be running the mag before you can say preeclampsia. IME provider thresholds for worry and induction vary region to region. Also, someone has had a client seize at 136/92 they are obviously going to be more liberal with their inductions and treatment.

[riomidwife]

Originally Posted by Contented73

What a great conversation. In this particular case, protein levels were a bit more than trace (sorry, I don't remember what the scale is) and bp was elevated as compared to all her previous bp readings -- although not awful...... The midwives called for an emergency transport and induction.

Keep in mind that in some states, midwives must transfer care in certain situations if they want to practice within the law, and/or within their state's midwifery guidelines. In practice this can mean transfer for things that we don't believe are imminently dangerous.

BTW, dipsticks cannot be relied upon for an accurate assessment of proteinurea. A mama could have +1 on a dip and in reality be spilling 500 or nothing! You really need to do a 24 hour catch in order to see what's happening.

[dcgrl]

There was this really fascinating article in the New Yorker in 2006 that discusses the work of a kidney specialist and the discoveries he made about pre-eclampsia. He studied pre-eclamptic placentas and healthy placentas, along with the blood of women suffering from mild to severe pre-e. Basically he found women with pre-eclampsia have more of a certain protein (soluble FLT) and less of two others (VEGF and PIGF) than healthy women.

http://www.newyorker.com/archive/200...?currentPage=1