A few years ago, I was reviewing the records for my New OB patient, Ida Know. She was in her late 30s and this was her forth baby. She had her first two in her 20s, but remarried another man and had her third child two years earlier. During that pregnancy, she developed severe pre-eclampsia and was delivered at 34 weeks. As I looked deeper into her records, she was actually noted to have chronic hypertension with super imposed pre-eclampsia. Six months before this visit, she went to her primary care provider for a routine physical and her blood pressure was elevated at 160/100. Ida expressed that she wanted to become pregnant again, and her doctor discussed the importance of controlling her blood pressure first. He increased the dose of her Labetalol and recommended a follow up visit in two months. Ida thought stopping the medication all together was a better idea.
Sure enough, she conceived quickly and she was 10 weeks at the time of her first visit. Her blood pressure was 180/120. I had to send her to Urgent Care for supervised blood pressure lowering as well as to her Primary Care to evaluate for end organ damage. She would ultimately require maximum doses of Labetalol and Hydralazine, but super imposed pre-eclampsia set in at week 29, and she was delivered at 32 weeks. Ida didn't really have an answer for why she stopped her blood pressure meds, except that she thought it would be better for her baby. An emergency early delivery at 34 weeks didn't teach her anything about the importance of blood pressure management? I ,walked into my colleague's office, and asked the rhetorical question; "why are people so stupid?"
After Dr STIUTK confronted me about my own blood pressure issues, I decided that I would not stick my head in the proverbial sand, but I did need more data. I started checking my own measurements everyday at alternating times and found my readings were in the low 130s/high 120s over low 90s/high 80s. While admitting that I do have mild hypertension, it isn't that bad. I began taking the Labetalol at 50 mg twice daily and found that my numbers hadn't changed much at all. I started to make the argument that I didn't really need the medication; it wasn't exerting much of an effect and my blood pressure wasn't that bad! My Primary Care thought otherwise, and recommended increasing to 75 mg BID. Around that time, I started my luteal phase Lupron, and noted that my readings had bumped up to 140s/100s. It was time to leave denial and start taking my medication like a good girl.
The medical assistant who works primarily with my Lead Physician recently asked how I was doing and what my next steps were. I brought her up to speed on the plan, including addressing my blood pressure issues. "Well, you know you'll eventually need to be on medication anyway, so you might as well start it now." she stated flatly. "Don't be like Ida Know" she added for extra emphasis. I truly respected her for being so candid and upfront with me. Mostly because I know she is right. " Yeah" I replied, "My birth plan will be getting sectioned for pre-eclampsia." We both laughed a little, but silently acknowledged the probable truth in that statement. The hardest aspect about admitting I have hypertension is that it makes me feel as if I am too old and too unhealthy to be attempting a pregnancy. I can't reverse time, but I can lower my blood pressure readings.
Meanwhile, I went into my RE's office for my laminaria placement. Laminaria are small sticks of seaweed that expand as they absorb cervical mucus and promote cervical dilation. They are primarily used to prep patients scheduled for a second trimester D&C procedure, and my RE felt placing one could help make my transfer go smoother. "Did you take anything?" asked New Girl as she ushered me to the exam room. "No" I replied, surprised by her question. I was only having one stick inserted in my cervix. I used to place 4 or 5 and I never pre-meded any patients, nor do I recall anyone reporting much pain. "Well, you might want to..." she suggested.
The placement was rather easy and practically painless. As I was forbidden from doing any exercise (which could displace the laminaria) I decided to take a glass of wine when I got home. A few hours later, the cramping took effect. O-M-G, holy mother fucker, it hurt. I took 800 mgs of Motrin. When that didn't touch the pain, I went with the Tylenol with Codeine tablets left over from my Hysteroscopy. Still no response, I tried the Vicodin which was prescribed for my D&C. Plus, I took my daily baby aspirin. I applied a Therma.Care heat wrap to my back and snuggled under a heating pad. Feeling nauseated from the pain, the drugs, or both, I popped a Zofran. I was still uncomfortable by 1 AM, so I downed two more Vicodin and finally fell asleep. I set my alarm for 5 AM, just so I would wake up to take another 800 mg of Motrin. By the time I rose to get ready for work, I was finally pain free.
So, maybe I'm not as tough as I think I am. While I never had any particular aspirations to do the whole unmedicated natural birth thing, there was something in the back of my mind that wondered if I could. After emptying my medicine cabinet just to get through a night with laminaria; not only is that answer a resounding 'no', but avoiding labour pains with a Ceasaerean delivery sounds appealing. Except the discomfort comes later during the post-op recovery, and no one offers you an epidural. You have to suck it up and care for an infant.
However, I may be (just maybe) as smart as I think I am. At the beginning of my cycle, I reminded my RE of our discussion to alter my estrogen priming. He started me off with only one 0.1 mg patch, rather than two. On CD 10, my lining was only 8.5 mm, which is more aligned with my fellow bloggers, and is less than all my prior measurements, which were above 10 mm at this point in time. I was planning to only increase my patches to two rather than three, which is what my RE instructed me to do. He is also having me come in for a final lining check before I start my progesterone. Even if it still doesn't pay off in the end, I feel really confident about the adjustments during this cycle.