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So our on call team got a patient admitted to through the ER who was about seven days postpartum. She did not have preeclampsia or any hypertensive disorder in pregnancy during her delivery. But she came back to the hospital, thankfully, because, you know, every time we discharge a patient, we give them good education, like, hey, anything feels weird, you just feel off, something's not going away, some kind of pain issue. Just come on back, don't mess with it. Come on back. So she was at home, remember seven days postpartum, and had this really, you know, unresolving headache. It just didn't really get better. Lying down or sitting up didn't affect it in either way. She's like, you know what, this is weird, I should go in. Of course she did go into the er and we're thankful for that. Well, in the er, her blood pressure was in the severe range. We're talking about systolics of 160 to 170 or so. And her headache obviously now could be explained as she was within a week postpartum as preeclampsia with severe features. So she was given acute PRN antihypertensive meds to bring her pressures down. She was transferred up to labor and delivery to start mag. All of that was correct. However, here is the conundrum. So it's one of these issues and we're very thankful for our folks in the er. They do a great job. I couldn't do it. So we're very thankful for our emergency room staff. But because she had this weird headache and the ER did what they did and of course they ordered a head ct. Now, now hold on for a minute. Now there's no neurological issues. There was no facial droop. Nothing else was going on. But you know, and I could see high blood pressure. A week postpartum headache, preeclampsia was severe, but just to make sure, they checked the box and you know, they did the mandatory CT scan. So she got the head ct. Great. Thankfully, no infarct. Everything looked okay, it was fine. They checked the box and I'm okay with that. However, I mean, if it looks like duck, it quacks like a duck. You got high blood pressure, you're seven days postpartum and you got a headache. Chances are you got preeclampsia with severe features. Now, if you don't have high blood pressure and you have a weird headache, you got to get a CT or an MRI of the brain just to make sure it's not a sagittal sinus thrombus, some kind of weird infarct. I mean, stuff happens, so that's okay. But if it's got high blood pressure within a reasonable amount of time postpartum and the headache seems pretty compatible with preeclampsia, I would be okay with skipping the head CT nonetheless. Checkbox. It was done and it was fine. But that's not the big issue. I'm okay with the head ct. That's fine. The issue was they said, oh, my goodness, will this blood pressure so high. Clearly that's a risk factor for some kind of cardiac decompensation, because we don't want to miss anything. And I agree. I'm okay with that. We don't want to miss anything. And so they got a BNP and a pro pro bnp. Now, we're going to talk about that in this episode. That's where we're going. That's what our focus is talking about. Beta type natural peptide, either in its BNP form or the pro BNP form. They're different, okay? And their interpretations are different, although their clinical implications are basically the same. But one is more for a chronic marker, one hangs around longer, that is the pro BNP type. The BNP is more of an acute marker, doesn't hang around into the, in the bloodstream that fast. It's more of an acute change. Whereas pro BMP is more of a chronic finding. Okay. Both are important, but they're different molecules, both structurally and in their interpretation in the blood. So here's where I'm going. So they got a BMP and a pro bnp. Now, even though we're going to get into this after the intro, in general, BMP has lower concentrations in the blood because it goes away a lot faster. And the max is around 100. That's pretty much normal. Even though most of it, it's like the double digits, it can be up as high as about 100 in pregnancy. That's okay. Probnp can be up a little bit larger because it hangs around in the circulation a little bit more. So normal can be like around, oh, 150, maybe up to 200 based on which lab you have. Right. So in general, pro BMP levels, and we're going to get into that in this episode, tend to be a little bit higher in concentration than regular acute BMP. All right, fine. Having said that, her BMP, her acute marker, remember normal is around 100 or so was 800. How about that? That's pretty impressive. And her pro BMP, which in pregnancy can be maybe as higher, around 200, maybe 250 or so, was over a thousand. Actually, it was 1800. So that's a lot. Okay, so here's where I'm going. So the point is, she is admitted for labor and delivery from. For mag. That's the correct thing. But one of the questions was, oh my goodness, is this like an impending. Like, is she having a heart attack? Is this cardiac failure? What's going on? And so this was a great discussion for our team. How do we interpret BMP or the longer lasting pro BMP in a patient with preeclampsia with severe features? Now here's where we're going to go here, guys. It actually is a pretty good test for preeclampsia with severe features because it reflects the, the side effect of heart strain when the peripheral vasculature at the systemic side is clamped up. Okay, so it's a marker of some cardiac dysfunction, although it doesn't necessarily mean heart failure. Now, for sure, an elevated BMP and pro BMP can mean heart failure, especially if she presents with shortness of breath. She's got JVD distension, there's big infiltrates in her chest X ray. If she looks clinically like heart failure, that's where the BMP can be sensitive for that. But this patient had no symptoms of shortness of breath, no chest pain, and the EKG just showed typical pregnancy related changes. So here's a question. Oh, my goodness. Do we need cardiology? Do we need. What's going on? Relax, relax. This is a side effect of preeclampsia with severe features. And having it elevated in the proper clinical context like this, no chest pain, no shortness of breath, normal EKG findings and high blood pressure in the peripartum interval with a headache that's pretty darn specific for preeclampsia with severe features. We're going to get into that. That's the purpose of this episode. BMP or pro BMP in preeclampsia with severe features. What do we do with that? What does that mean? And when can we expect that to go away? The short Answer when you get into it in this episode is it's going to take a while because there's a lot of cardiac remodeling and there's a lot of changes that are going on with the vasculature that even though the patient deescalates with anti hypertensives and her 24 hours of mag and that in acute interval wears off, it may take weeks for the BMP or the pro BMP to actually normalize. BMP will actually normalize a little bit quicker because again, it gets used up in the circulation a lot faster. Whereas procedure pro BMP will last longer and it could last weeks. So here's a point. While it can be a marker of heart failure, it doesn't always mean heart failure. And in this case, it just kind of proved the point that she had preeclampsia with severe features. So that's where we're going just to explain a little bit about brain natiuretic peptide, because that's a weird thing. Okay. People call it beta types, not beta type. It's actually B as just the letter B, not beta, but it's B as in brain. That was was it was first described. Although that's absolutely not where it's primarily made, is primarily made in the heart. But the B in BNP or pro BNP does actually stand for its original identification, which is brain. All right, so we're going to talk about brain natriuretic peptide, which ironically has nothing to do with the brain, has to do with cardiac dysfunction, which we already know is part of preeclampsia with severe features. We're gonna get into it trying to make this very quick. Just some clinical points for learning. As I mentioned before, sometimes our podcast ideas come from real world scenarios. And in this case, you know, there was this concern of does she need cardiology? Well, she may later on because it's a risk factor for future cardiovascular disease. But right now, as long as she is otherwise asymptomatic from a cardiac standpoint, she has good O2 sats and EKG looks normal. That is actually reflective not of cardiac failure, but of preeclampsia with severe features. So that's where we're going. I think I've set it up enough now that I've done all that. Let's get out of our intro and we'll be right back in just a moment. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OB GYN, no Spin podcast. So good. So Good. So good.
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You know, I'd rather the ER be super proactive and look for stuff than miss things. The problem is then you get a test and you're kind of stuck with it. So now we got a patient with a BMP of 800 and a pro BMP of 1,800 that we're gonna have to trend. It's okay, it's all right. But it does raise this question that kind of lingers. And it's all in documentation and we explain it to the patient. You've got a cardiac test that's actually way off the scale, but it's actually part of this high blood pressure preeclampsia with severe feature issue. And I don't think it means that you're at any risk of a heart attack or cardiac decompensation, though we got to watch you very closely, so it doesn't mean heart failure. Now let's backtrack to the ER intro. Her EKG showed non specific pregnancy changes. She did have a troponin. Everything was fine. So this raises the point here. What is going on with BNP or the pro BNP variety of this serum biomarker with preeclampsia with severe features? Well, the short answer is these are very good, very sensitive tests to look for cardiac strain and some kind of cardiac dysfunction. All right. Which can obviously happen with heart failure, but it's not specific specific to heart failure since it can rise again in something like preeclampsia with severe features, as well as sometimes a PE that can throw off your BMP and your pro BMP because of the heart strain, even some infections. If the heart goes through a lot of cardiac stress that can throw off these, these two biomarkers. So even though it was first described in the brain, we know that primarily this is from the cardiac cells. These are released in, in times of cardiac stress, which could be an mi, could be cardiomyopathy, or like in this case, could be preeclampsia with severe features. Now let's take away the blood pressure and the headache for a minute. And the patient presents seven days postpartum with shortness of breath and maybe a little bit of chest pain. First of all, of course, rule out pe. So spiral ct, do what you got to do, but you gotta rule that out. Cause that's your most morbid issue. Once that is ruled out, part of the evaluation is to get an EKG and you can check a BMP or a pro bmp, knowing of course that there are a little different. BMP is better as an acute marker. Pro bmp, sometimes it's called the NT pro bmp. That tends to be a little bit higher in concentration, so they have different cutoffs. And that one lingers a little bit longer, especially with chronic diseases. Okay. Now even though in pregnancy the levels do rise, they tend to stay in the normal range, except for preeclampsia with severe features, which drives up both of these markers. And the reason is when you have preeclampsia with severe features, the afterload that the heart has to deal with gets reflected back into the cardiac muscles, into the heart. And even without heart failure, that normal strain, I mean, it starts kicking out and just kicking out BMP and the pro bmp, so the levels can rise. Okay, so the question that was posed to us is do we need cardiology? Well, not right now. I mean, I mean it's, it's a secondary cardiac issue because she does have a cardiovascular problem, but that's vasospasm from her preeclampsia with severe features. And remember, as we have talked about in the past, once you develop de nouveau preeclampsia postpartum, that's a different pathophysiology. You tend to be sicker in that scenario because you're no longer pregnant. Right. The quote unquote cure, which we know it's not a cure, but that's how we learned it. Historically, the cure for hypertensive disorders or pregnancy was delivery. So if you're already delivered and then you get preeclampsia severe, that's a whole other issue. You've got some really weird hyper reactive and spastic vasculature that still needs mag, still needs antihypertensive therapy, still needs volume reduction like preload reduction, like Lasix, which is what we gave the patient to take away some of the stress of the heart from preload. But that's a different pathology. Postpartum de nouveau. Hypertensive disorders of pregnancy, they tend to be sicker, okay? And they also tend to have higher BMP and pro BNP levels, like with this patient. Now, remember what I told you? Her BMP level was 800. Yo, that's a lot. And her pro BNP level was 800, 1800. That's a lot. But it doesn't necessarily mean that she's in cardiomyopathy because she did not have shortness of breath and no chest pain. So both of these tests, BMP elevation is an. Actually a pretty good biomarker of cardiac dysfunction, but it's called subclinical dysfunction and it's not exclusive of heart failure. Okay? Not exclusive to heart failure. So this actually goes hand in hand with her headache and her severe blood pressure elevation. So we gave her antihypertensives, we gave her mag, we gave her some Lasix to drop her preload. And this beta, this bmp not. See, I fell forward again. I said beta. It's brain. Brain atrioretic peptide and the pro BMP variety, those can be elevated for weeks. Now, we are trending it just because we want to see what if it's trying to hopefully trend down a little bit, but may not be completely down to normal for weeks thereafter. So let me just answer the question about echo, okay? There's nothing wrong with ordering a cardiac echo on a patient like this because those BMP levels are extremely high. However, there's the issue of just ordering the test because you're looking at the lab versus treating her clinically. Clinically, she's fine. And we know she's gonna have normal ejection fraction because she's not symptomatic. But it's totally reasonable at that point to get that echo as a quote unquote baseline, okay. With this acute episode, so that if something happens down the road, we can compare it later as. As a subsequent follow up study. So I'm okay getting an echo not because she's symptomatic, because she's not, but as a baseline. So that should something happen later on, we can use that for comparison. So we. I talked with the team. This happened just today in this point of reference. We're doing this on the 16th of September. September. Okay, 16th of September. Which is what Mexico, Independence Day. Right. We're in Texas, so that's. That's a big deal because we have a lot of influence from Mexico. So Jesse says, septiembre. But you know that. What am I talking about? That has nothing to do with what we're talking about. Go get your margarita before September 16th is over. Anyway, isn't that Mexican Independence Day from Spain? Michael says, yeah, so what does he know? That he said, yeah, I think that's what it is. Anyway, totally unrelated. What am I talking about? This. Oh, this happened today on September 16th. And so tomorrow when we go back on service, yeah, it's totally reasonable to get an echo, but know why you're ordering it. And that's why I'm gonna tell the patient I'm doing this. Not because I think you're in cardiomyopathy. There's no clinical evidence of that. But I can use this as a snapshot now so we can track that later on. Okay, now, now that we said that, let's briefly get into these levels in normal pregnancy, gestational hypertension, and then preeclampsia. Focusing on preeclampsia with severe. Okay, because this is the question, is there a continuum of rise here in these values? In other words, is it normal with normal pregnancy? The answer is yes. What about regular hypertensive disorder like gestational or preeclampsia with severe features? That's a good question. So we're going to answer that when we come back. 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Again, the strong coffee company with the link in show notes for 20% off whatever you order online. All right, so as you would think, these two biomolecules, these two biomarkers do act as a type of signal of worsening disease. So there is in fact a continuum. Normal pregnancies have normal BMP and pro BMP levels, whereas preeclampsia with severe features have significantly higher levels compared to those with either gestational hypertension or even preeclampsia without severe features. So there is indeed a continuum of rise of both of these two peptides, these two biomarkers in the serum, so normal, those are comparable to somebody in a normal non pregnant range. Gestational hypertension, the same thing, they don't tend to bump preeclampsia, they're on the higher end of normal, but still typically should fall in the normal range. However, preeclampsia with severe features does have both a statistically and clinically significant increase in both BMP and N terminal BRO pmp. So both of these do rise as a continuum being the highest with severe features. Now some have looked at this thing as a test to kind of predict the development or the deterioration of a hypertensive disorder in pregnancy, similar to like the soluble light Tyrosine Kinase 1 and the placental growth factor ratio that we've talked about before, like the Thermo Fisher test. And you know what, there is some data to that that you can actually trend both of these and as they rise, especially bmp, which is more of an acute marker, it is a potential flag for decompensation into preeclampsia with severe features. But just to be clear, as of right now, neither ACOG nor SMFM include BMP levels or pro BMP levels as part of prognostication for preeclampsia with severe. It's just like the Fisher test, right? Soluble like Tyrosine Kinase 1 over placental growth factor, which we have talked about. That ratio of pro angiogenic versus vasoconstrictive substances. We've talked about that. Those are just. It's just another test as a predictor. Okay. But you can use this if you have a concern about what's going on and you're not sure if it's preeclampsia with severe features. You can order BMP and pro bmp, because if it's preeclampsia with severe, those should be much higher than the control norm. Okay, now remember, in our case this was kind of the outlier, although I've seen it many times before. Whereas BNP was 850 and then the pro BMP was 1800. Incredibly high. And those are bad. I mean, that's a sign of a lot of cardiac stress. That's why we don't ignore that. So again, we're giving preload reduction, giving her anti hypertensive meds. We put her on ProCardia XL, nifedipine XL and we're giving her mag and we're going to watch her very closely. But if we think that by time of discharge that those two biomarkers are going to be completely normal, that's just not how it works. Okay? Now they can trend down, but may take weeks as that cardiac remodeling kind of recoups and recuperates as the entire vasospasm resolves. Okay? Now it is possible they go back to normal if they're not that elevated. But I don't see, these years are so high that we may have to trend those as an outpatient. Okay, so I just found this interesting because this happened again just to us today for a patient who was admitted last night with severe range blood pressure and a headache. Classic for preeclampsia with severe features in the first week post postpartum. But this BMP which automatically raised the flag is. Do we need cardiology? Hey, you can get cardiology, it's fine. Or now in the new specialty of cardio obstetrics. But. But it's probably not necessary because we know we can explain this with a clinical picture at hand. Nothing wrong with getting cards. It's just there's nothing for them to do. They're going to go, hey, continue current management. So I didn't require, I didn't request that plus I pretty comfortable with what's going on here, so. Yes. Beta type. Dang it. I did it again. B type, not beta. B type. Natriuretic peptide is definitely elevated in preeclampsia with severe features without overt heart failure. Nothing wrong with getting an echo. And some hospitals, because I know I've worked with other locations as they get their maternal level of care designation, when this has been discussed for cardiomyopathy, you can get an echo. Nothing wrong with that. But if their patient is clinically, well, in the proper context, that looks like preeclampsia severe. That just goes hand in hand with this clinical picture. So again, we're going to get an echo tomorrow, likely just to check the box as a point of reference, so if something happens later on, we can compare it to this one. But it's very, very clear that this is just a reflection of normal and expected cardiac strain and the subclinical dysfunction that happens with systemic peripheral vascular constriction, I.e. postpartum preeclampsia with severe features. Okay, so anyway, I just, I thought it was interesting we talked about this with the team because they had never seen one of it that high, though I have seen it that high a handful of times. And thankfully these actually get better with within the first two, sometimes three weeks as her blood pressure gets better controlled and this is followed as an outpatient. Okay, so anyway, BMP and pro BMP with preeclampsia, it's more of an issue with severe features, although there is a continuum of rise. Tends to be still elevated, but in the normal range with gestational. Same with preeclampsia without severe features and the preeclampsia with severe, both BMP and pro BMP levels can be off the chart. We're talking significantly off the chart. Several fold or several magnitude abnormal. All right, Podcast family, I thought that was neat. Just throw that out there. See that? If you find that helpful, next time you see a patient with elevated BMP or pro BMP with preeclampsia of severe, then just kind of goes hand in hand with that diagnosis. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've said all that, now let's take it home. Podcast family, we're thankful for all of the support that you've given us throughout the years. This has been the OB GYN no Spin podcast. We'll see you on the next episode. Sam.