My postpartum blood pressure spike [PODCAST]

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“I think about my preeclampsia-specific and general knowledge gaps. I could not recall learning about postpartum preeclampsia in my prenatal classes. I wasn’t given any written instructions on what symptoms to expect with my blood pressure returning to normal. My husband and I also would have benefitted from a pumping tutorial (side note: the lactation consultant said not to just power up to top suction) and a quick lesson on making formula bottles. A more empowered mom and family might be less tempted to dismiss a postpartum headache.”

Maria Petty is a nurse practitioner.

She shares her story and discusses her KevinMD article, “My blood pressure spike on postpartum day 3.”

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Transcript

Kevin Pho: Welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Maria Petty. She’s a nurse practitioner, and we’re going to talk about her KevinMD article, “My blood pressure spike on postpartum day 3.” Maria, welcome to the show.

Maria Petty: Thank you so much, Kevin, for having me.

Kevin Pho: So we’ll get into the article in a little bit. First, briefly share your story and journey to where you are today.

Maria Petty: Sure. I am fortunate to have wanted to be in health care for a long time. I grew up with my mom and my grandparents, and my grandmother was on dialysis and my grandfather had diabetes. Watching their chronic disease management, I was always fascinated by that. I went to the University of Pennsylvania. I graduated from nursing school in the middle of a recession, so I planned to do what many nurses do, you know, work for a few years in a hospital and then go back and get a master’s and become a nurse practitioner. But I actually went straight through and got my master’s right after getting my bachelor’s.

I took the board exam, and I started working as both a nurse practitioner and a registered nurse for a hospice and palliative care company. I would not necessarily recommend working in two roles for the same company at the same time. I could probably write a whole other article about that. I then started working in skilled nursing facilities and then transitioned to primary care, and I’ve been working in primary care for about six years: one year in the private sector and then, for about the past five years, within the VA system.

Kevin Pho: So tell us about some of the rewards and challenges of working as a primary care clinician at the VA.

Maria Petty: Sure, thanks for asking. It is so awesome to watch people get better and to walk with them through that journey. Post-COVID, it’s more air high fives and air fist bumps, but watching somebody’s diabetes control get better, watching them lose some weight, stuff like that, it does make me happy still, and I hope it always does. It’s difficult, too, to walk with people through hard times, with people losing people in their personal life or suffering health challenges. I feel that’s a rewarding part of the journey too, to learn how to be with people even when you can’t make things better.

And what makes the veteran population so special: They are some of the most giving, serving, generous people I have ever met. And just hearing some of their stories. I try not to ask outright all the time, because I know for a lot of people, they suffered a lot of trauma, whether or not they were a combat veteran. But hearing their stories, and also, they crack me up, actually. Some of them ask me if I’m pregnant again, and I’m like, “No, that’s just chocolate that I’ve been enjoying after the birth of my second son.” So some of them have a very forthright way of speaking, which makes me laugh.

Kevin Pho: All right, so let’s go ahead and hear about the story that you wrote on KevinMD. It’s titled “My blood pressure spike on postpartum day 3.” Now, for those who didn’t get a chance to read your story and article, just walk my audience through it. Share the story and why you decided to write it.

Maria Petty: Sure. It was July 22, 2019, and my first son, Russell, was three days old. I was home, and I started to have this headache, and it wasn’t that bad. But my friend, actually a dear friend of mine, had postpartum preeclampsia about five months earlier, and I did not even recall learning about it in school. I may have, and I don’t see a lot of postpartum people in my practice. I just remembered her story, and I thought, “I’m a primary care nurse practitioner. I should at least walk the walk, not just talk the talk. Let me take my blood pressure.”

My mother-in-law was coming over anyway, and she had a blood pressure cuff at home. I texted her, “Hey, can you just bring over your blood pressure cuff?” I take my blood pressure. It’s high, but not scary high. It was like 142 over 90. I call the on-call OB, who sounded stressed and busy. She was like, “Did you take any Tylenol for your headache?” I’m like, “I did. I took two.” And she’s like, “Why don’t you take three?” And I’m like, “I don’t know. I just don’t feel right.” And she’s like, “You’re saying all the right things, so go back down to OB triage. I ordered you some labs, and they’ll take your blood pressure.”

And I remember just crying and being like, “Oh, gosh, I feel so silly. I’m probably fine. I know I’m just anxious.” And I hadn’t ever made a formula bottle before; I was breastfeeding. So I remember trying to make this formula bottle and not even knowing the scoop was in the middle of the formula, so I’m clawing through the formula can with a butter knife to make a formula bottle.

Anyway, my husband takes me to triage. My milk is coming in, so I’m very engorged, and this is starting to get painful. I had never pumped, so you can imagine the scene in this small triage room, trying to hook the flanges up. My husband’s trying to milk me like a cow. I’ve got the blood pressure cuff, I’ve got the flanges, and it’s just a scene in there. And my blood pressure just keeps climbing, and it’s 160 over 110, 180 over 120. I start to have blurry vision. The doctors thought it was good that I came when I did. It was so fast. It just blew my mind.

I got great care. They admitted me. I was on an IV magnesium drip for 24 hours, per protocol, to prevent seizures. They started me on oral labetalol to get my blood pressure down, and it came down somewhat. I remember the resident came in, and she’s like, “OK, we’re going to give you this labetalol to go home, and it’s probably going to make you more tired and feel a bit more depressed.” I’m like, “Oh, that’s awesome. I’m not already exhausted.” I didn’t say that; it was internal.

But I went home. They had to uptitrate the labetalol to, I think it was 300, three times a day. And over the next few weeks, I got great care. My LFTs, liver function tests, had gone up, so they were rechecking those, and those had come back down on their own. I never had any of the HELLP syndrome or super scary outcomes, thankfully. My blood pressure seemed to come down almost as quickly as it came up. I remember they told me, “OK, yeah, cut down from three times a day to twice a day.” But I remember one day I was home, and I was so grateful my husband was home, because I felt like I was going to faint. My blood pressure was about 80 over 50. I knew what to do: get my feet up and have some salt, compression stockings, water, and I just stopped taking the medicine totally.

And thankfully, everything’s fine. I’m fine, my son is fine, and I did get great care. I’m not trying to throw anybody under the bus by any means. Wonderful nurses, wonderful doctors. But I just thought I saw some places where things could have been improved, and I’m very grateful to you for allowing me to share my story in this fashion.

Kevin Pho: So up until that point, the pregnancy and the delivery were pretty much normal? You didn’t have a past history of high blood pressure going into this?

Maria Petty: I did not have any past history of high blood pressure, and no family history of maternal high blood pressure or preeclampsia starting before birth. The only measure that was abnormal was that a late third-trimester ultrasound did show mild intrauterine growth restriction. The doctor who did my ultrasound actually said, “Oh, I’m not even worried about that,” but my OB was like, “Oh, let’s do a fetal non-stress test.” I later read that mild intrauterine growth restriction can be associated with preeclampsia or postpartum preeclampsia, but I did not know that at the time.

Kevin Pho: So you said that postpartum preeclampsia wasn’t something that you necessarily learned during your training. I’m glad you got through this OK. In general, how common is this?

Maria Petty: Sure. So it affects less than 1 percent of pregnancies. You know, I know it doesn’t affect a high amount of people, but the poor outcomes are so utterly preventable. And I think a blood pressure cuff is pretty cheap, and if insurance companies can cover breast pumps, which they can and they do, I personally think, and I’d have to parse out the numbers, of course, but I’m hoping, my goal would be to see every single pregnant woman have a blood pressure cuff in the future, and just the knowledge that it doesn’t even have to be a bad headache to warrant taking your blood pressure.

The hospital did give you these magnets, I think from Cleveland Clinic. They were great. It says, “Oh, yeah, if you have a severe headache, call your OB.” But I didn’t. So that’s just something that I want people to know.

Kevin Pho: All right, so yeah, you said that a few things could have been done differently after your experience. You mentioned a few. I guess in an ideal world, what exactly would you have done differently?

Maria Petty: Oh, sure. And I just want to say, too, with utter humility, I mean, I know I have made mistakes every single day. I’m always learning too. So I got great care; I’m not trying to throw anybody under the bus. Just, number one, I would tell every woman who’s having a baby: If you feel any different, check your blood pressure. If you don’t have a cuff, just go on and buy one if you can.

Also, two, I think shared decision-making, I feel, is a fancy, or not fancy, but a buzzword that we’re accustomed to hearing. And I know, gosh, those doctors are so busy in the hospital, but if they said, “Oh, hey, there’s labetalol, or there’s also nifedipine, which is also commonly used to treat postpartum preeclampsia, and it seems to have a better side effect profile. Would you rather try that instead?” If I ever go through this again, I will certainly ask for nifedipine instead. Or, and I know this could be a whole other article, but I would say, “Hey, you know what? I think I’m going to opt not to breastfeed, and I’ll try another agent altogether, because I just really can’t afford to feel the way I did.” And there’s no guarantee; I could have felt the same way on something else.

And then my third thing was providing some written education about expected side effects of a medication or of a disease process. And I think about this: How many hundreds of times have I prescribed something and then said, “Oh, yeah, you might get a little swelling from this or a little tired from that,” but not written it down? And I’m trying to incorporate that in my practice, even if it’s real quick and fast: “Just call me if you get swelling from this, or call me if you get XYZ from that.”

And thankfully, I had the knowledge, and I have great family support. My husband’s fantastic. I live close to my mom and my mother-in-law and my dad. And for people who didn’t have that support and felt dizzy all alone with their baby, not even knowing what to expect, not knowing that the dizziness was from the medicine, there are just so many opportunities for things to go wrong.

And I realized, too, I was open about the fact that I was a health care provider, a nurse practitioner, so it’s possible that the nurses and doctors were a little less forthcoming with me, or a little bit more wanting to talk shop and stuff, instead of being like, “Oh, yeah, she’ll already know about side effects.” But at least in the postpartum space, I feel very much like a regular patient, because it’s not my specialty. I think providing those written things, or, if you’re treating people for postpartum preeclampsia or something else frequently, having some pre-made sheets ready to go that the nurses can hand out, I think would just be a small but effective way to help disseminate some of this knowledge.

Kevin Pho: So how long did this whole episode last? You mentioned this story happened about three years ago. How long was your blood pressure high for?

Maria Petty: Sure. So I was admitted to the hospital for two overnights, and then my blood pressure was high, I think, for about three to four weeks after. I’m so grateful that they instituted a two-week follow-up, because they used to just do a six-week postpartum visit, and by six weeks, my blood pressure was back down to normal, and it’s been normal since. It was normal through my second pregnancy. Thankfully, they did have me take aspirin, 81 milligrams daily, to help prevent preeclampsia again through my second pregnancy, and it seems like it did the trick, thankfully.

But I’m very grateful they do have a two-week follow-up, because at that time, my blood pressure came down a bit, and I think they cut me down from three-times-a-day dosing to twice-a-day dosing of the labetalol at that time, because they’re like, “Oh, yeah, your blood pressure is going to come down.” So it was like that, and then I forget exactly when it really dipped down. It was probably about four weeks.

Kevin Pho: And you’re only on the blood pressure medicine for that four- to six-week period?

Maria Petty: Exactly, yep.

Kevin Pho: All right, so we’re talking to Maria Petty. She’s a nurse practitioner, and she’s sharing her story in her KevinMD article, “My blood pressure spike on postpartum day 3.” Maria, what are some of your take-home messages that you want to leave with the KevinMD audience?

Maria Petty: Sure, thank you so much. If you, your patient, or anybody you love is pregnant or up to six weeks postpartum and doesn’t feel right, please have the blood pressure checked. And this whole episode was a great reminder for me to engage in shared decision-making with my patients, you know, to talk about possible side effects of medications and disease processes.

Also, I meant to just say, real quick, this whole journey has led me to work with MoMMAs Voices. It’s an umbrella organization of other maternal health organizations that partner with state perinatal quality improvement initiatives, and other advocacy work. The Preeclampsia Foundation, I shared my story with them. They actually paid for a course for me to work on sharing my story in a more professional format. And I’m really grateful for your time, Kevin. Thank you so much.

Kevin Pho: Maria, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Maria Petty: Thanks a lot. Take care.

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