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Pregnancy Induced Hypertension – A Case Summary
By: Lisa Murray-Doran B.Sc., N.D.
EH, a 35 year old primipara presented at my office at 37 weeks +3 days. She reported a steady increase in her blood pressure over the past 3 weeks with the most recent reading being 170/94.
EH had stopped work and had been bed resting for 2 weeks now, and BP continued to be elevated upon rising from bed and with any form of activity. Resting BP was still very high, and a liver enzyme test had returned with SGOT being increased to 71. Her obstetrician had now recommended Altamet to bring down blood pressure, and a pitocin drip induction, which she was now scheduled for at 38 weeks. A non-stress test had been performed the day that she attended at my office with very good results. EH wanted to avoid any pharmeceutical medications during her pregnancy, and she wanted to avoid an induction due to an increased risk of a cesarean section with pitocin induction.
On physical exam, B.P. was 165/90, +2 hyperreflexia was noted, edema of the face, hands, feet and pretibial pitting edema of +2 was noted, trace protein was detected in the urine.
Basically we were being given four days to bring her BP to acceptable levels and my goal was to be aggressive with treatment. I recommended that a birth pool be rented and that warm(not hot) full body baths be enjoyed three times daily. I recommended that EH continue her regime of bedrest and I recommended supplementation of Calcium 1500mg and magnesium 700 mg, and vitamin E 800 IU. I recommended increasing vegetable source protein in her diet, as well as cold water fish. Due to the association of pregnancy induced hypertension and the liver, I recommended a gentle liver detoxification and support program with a Taraxacum officinale and Silybum marianum tincture 40 gtt tid, I also recommended liver foods such as carrots, beets, lemon and dandelion greens to help support and gently detoxify the liver.
At day two of treatment another non stress test was performed and the fetus was doing well. BP was still elevated at around 160/90. At day four of treatment BP was 130/84, no significant edema was noted and there was no protein detected in the urine. A liver function test at this point indicated that SGOT levels had fallen to within normal levels. EH’s OB agreed to allow the pregnancy to continue, under his close observation for one more week without induction or BP meds. At this point I perscribed red raspberry leaf tea 6-8 cups a day to tonify the uterus, Mother’s Cordial (Caulophyllum, Cimicifuga, Viburnum opulus and Mitchella – equal parts) 60 gtt tid to soften and prepare the cervix, evening primrose oil, which contains prostaglandins and will promote uterine contractions, 3000mg a day and homeopathic Caulophyllum 200 C one dose daily to soften and prepare the cervix for dilation.
At 39 weeks, still continuing treatment, her OB once again approved allowing the pregnancy to continue without induction under daily supervision of BP.
At 40 weeks a bio-physical profile was performed and the fetus was doing very well with a score of 8. BP continued to be around 130/80, no significant edema and no protein in the urine was noted. At this point her OB recommended that if she continued past dates longer than 2 days that he would recommend a prostaglandin gel induction attempt. I counselled EH that everything looked normal, that BP was within, normal range and that the fetus was thriving and I recommended that she wait until labour began spontaneously.
At 40 weeks +2 days, against her OB’s advice EH decided to allow labour to begin spontaneously.
At 40 weeks + 3 days BP was 140/90, protein was +2 in urine and pretibial pitting edema was +2, cervix was closed with no effacement occuring. EH agreed to OB’s advice and scheduled a pitocin drip nduction at 40 weeks +5 days. EH at this point requested any kind of Naturopathic intervention that I could suggest regarding initiating labour. I councelled that because the cervix was still closed and no effacement was occuring that I would recommend waiting for a day to see if there was any change in her cervix before attempting acupuncture. I recommended that she place 2 evening primrose capsules close to her cervix three times daily, nipple stimulation or intercourse, increasing the homeopathic Caulophyllum to 3 times daily, and increasing the Mother’s Cordial to 60gtt four times daily, with the warning that Caulophyllum tincture may sometimes cause nausea. EH and I also discussed that it was very common for primipara’s to go postdates and that there may be a reason for these last few days. I advised against impatience, as babies have their own schedule and that these naturopathic interventions, even though they are natural, are still interventions. I advised that she have a long relaxing bath and have a talk with her unborn baby, reassuring him that it was safe to be born and that he was welcome to come now. I stressed the importance of trying to relax at this point, even though a deadline seemed to be looming over her head
At 40 weeks +4 days I assessed that EH’s cervix was 25% effaced, but no dilation was occuring. BP was 135/80 and there was a trace of protein. We met twice this day to do acupuncture on BL 31, BL 32, BL 33, BL 34, SP6, KI 3, LI4. EH was still not noticing any uterine activity, fetal heart tones were difficult to distinguish with a fetoscope due to the placenta being anterior, however fetal movement was noted by both mom and myself.
At 40 weeks +5 days EH managed to convince her OB to give her one more day to spontaneously go into labour. BP was 135/90, effacement now 50% and 1 cm dilated. During the night she had noted significant uterine activity with braxton-hicks contractions that would wake her. We repeated the Acupuncture two times this day, increased Mother’s Cordial to 40 gtt once an hour for 3 hours and then 60 gtt three times more that day. EH experienced some contractions with the acupuncture and in the evening some bloody show was noted. We discussed the OB appointment in the morning and EH felt that at this point if she had not gone into labour by 10 am the next day that she would agree to the pitocin drip induction. I recommended that she request a series of prostaglandin gel applications as a good alternative to see if they would have any effect as I felt that labour was very close and we simply needed patience. EH agreed to inquire about the gel applications and at this point I recommended Susan Weed’s castor oil protocol 2 oz every 3 hours for 3 doses with a hot shower between each dose before she went to bed that evening.
When I spoke to EH on the phone the morning of 40 weeks +6 days she reported mild diarrhea and no cramping or contractions in the night and no more bloody show. At 10:35 am she got the first application of prostaglandin gel applied to her cervix with instructions to return at 3:30 for the next application. At 12:35 pm EH began experiencing some mild contractions, by 3pm the contractions were stronger but irregular. I recommended that they skip the next gel application as labour had begun and it seemed unnecessary. They agreed. By 4:30pm contractions were strong and regular. At 7pm I did a home visit, contractions were strong and 45-60seconds long and 3-5 minutes apart. BP was 130/85, once again with my fetoscope fetal heart tones were difficult to distinguish due to an anterior placenta, however fetal movement was noted my both mom and myself. Bloody show and mucous were both noted. EH was labouring in her birth pool with the support of her partner and her doula that she had hired. No internal was done at this point because I felt that although uterine contractions were regular that the signs of labour past 5cm were not there and I did not want labour to become a numbers game (in terms of dilation) for her. I encouraged her, letting her know that she was doing really well and that her contractions were good and strong, and seemed more intense than perhaps other labours because any form of synthetic induction tends to result in very intense contractions.
At 11:30 pm EH transferred to the hospital with her husband and her doula and she was 8 cm. At 1:30 am she was fully dilated and labour arrested at this point. EH waited until 6am with no contractions. At 6:30 am, 40 weeks +7 days her son, weighing 7lbs 5 oz was born assisted with forcepts. Everyone was healthy and happy with the birth experience.
This, to me was a very interesting case because it not only illustrated how dramatically pregnancy induced hypertension can respond to gentle interventions such as clinical nutrition and hydrotherapy but it also illustrated to me how much pressure is put on moms to deliver on their due date and how much negotiating must go on with the OB to actually allow them to birth normally. EH was very determined about having a vaginal, natural childbirth. Many women would have accepted their OB’s advice and would have had an attempted induction at 38 weeks which, according to statistics, most probably would have resulted in a c-section. My feeling is that if EH could have been convinced to wait a few more days with careful monitoring of her BP and fetal well-being that labour would have begun spontaneously and that the baby would have decended into the pelvis more appropriately and a forcepts delivery could have been avoided. These patients must be councelled to trust their bodies because the process of birth is so much part of a woman’s inate intelligence or vital energy – all women will eventually go into labour on their own! The trust that a woman is capable of birthing her baby without assistance is very much undermined in common obstetrical practises – many OB’s simply do not see pregnancy and birth as a normal life process. The most important part of this case is that EH is profoundly satisfied with her own birth experience. She knows in her heart that she made her own best choices in her pregnancy and birth and she feels that she had much of the control for the decisions that were made.