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- [00:01]
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- [00:31]
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No one goes to Hank's for spreadsheets. They go for a darn good pizza. Lately, though, the shop's been quiet. So Hank decides to bring back the $1 slice. He asks copilot in Microsoft Excel to look at his sales and costs and help him see if he can afford it. Copilot shows Hank where the money's going and which little extras make the dollar slice work. Now Hanks has a line out the door. Hank makes the pizza, Copilot handles the spreadsheets. Learn more@m365copilot.com work foreign.
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Sometimes you hear something and the first response is oh, well that's interesting. I actually hadn't heard of that. It's a little weird, but I guess it could be a thing. That is some weird, wild stuff. So let me explain what's going on here. So this podcast idea comes from one of our podcast family members. So we're not giving any names because I she said I don't want to get the person that I'm talking about kind of in a bad bind. But I do have a question. So let me set this up and then we'll get into our typical content. So let's just say that there's a person called sj, I don't know, just threw that out there. And SJ is a brand new certified nurse midwife in a new practice. Okay, so you see the vibes here. So oh my gosh, I'm a brand new CNM in first time joining this group. And here's the question. Hey, this group, one of the other CNMs who seems legit, seems evidence based, seems to know what she's talking about. But I heard her tell a patient who has been diagnosed with gestational hypertension to go home and get online some urine dipsticks and check and monitor her home urine protein. And if it's above a certain color, meaning more than say two plus, then she needs to call us right away. So here's the question. Is patients self check for urine protein at home a thing for gestational hypertension? And so I heard this and I'm like, you know, that's actually a really good question. I Actually hadn't heard of that. I don't do that. But I could see where some of the confusion is because it is right out of practice bulletin 222 from ACOG, and yet it is not. Okay, so let me say that again. It is right out of Practice Bulletin 222, and yet it is still not. So I'm going to explain that in this episode. Is self checking for urine protein a thing for gestational hypertension? Notice it has to be for gestational, not preeclampsia, because if you're preeclampsia, then whether that's proteinuric or not, because remember, you can have preeclampsia without protein. You have preeclampsia with severe features. A sans protein without protein. Because that's, that's the thing here. In the past, the way I learned it was, oh, proteinuric hypertension was preeclampsia. Yes, that is still true and we're gonna talk about it. However, you can have preeclampsia without protein. In other words, you can be severe just by blood pressure criteria. You can be severe by two times liver function, not caused by something else. You can be severe by persistent symptomatology. So as we've discussed many times before, proteinuric hypertension in pregnancy after 20 weeks is prototypical preeclampsia. But you don't need the prot to have that diagnosis. So that's one of the disconnects here. Okay, so we're gonna talk about this because frequent and weekly urine protein assessment is actually mentioned by the college guidance, which is Practice Bulletin 222. However, however, ACOG states we're not really sure what the best kind of ambulatory management is for a patient without severe criteria. You just gotta, you know, have them be super observant of signs or symptoms. You need to be observant of objective things like abnormal liver enzymes or low platelets hemolysis. In other words, HELP syndrome or severe criteria as a severe blood pressure, as a distinct cutoff of 160 over 110 or greater. Okay, so I'm going to get into this because yes, weekly protein assessment is actually mentioned in ACOGs Practice Bulletin 222. However, this is where knowing the guideline and then kind of having some literacy interpretation can get a little bit weird and a little goofy. So let me just say this right now. No, no, it is not a thing. Having the patient check urine dipsticks for urine protein at home is not a good idea, and it is not recommended by the college. That's not what the college is talking about when it mentions weekly protein assessment for expectant management of gestational hypertension or preeclampsia without severe features. I'm going to read the Excerpt exactly from 222 here in just a minute when we come back after the break. But I thought this was fascinating because the truth is I was like, you know what, that's kind of interesting. I never thought about that before. I could see how it would sound like it'd be a thing and how this could also be very, very confusing and misleading. So that's where we're going. Is it a thing for patients to self check urine protein at home with gestational hypertension? Now this is right off the heels of our previous episode that talked about home blood pressure monitoring and we discussed that even though the data can be a little conflicting, with Bump one and Bump two being very disappointing, it is still standard of care to have patients check their blood pressure at home because it provides a safety net and is what a community standard has established. All right. Plus that's also very clearly mentioned in ACOGs practice bulletin 222. So it's right off the heels of that. And our podcast family member actually mentioned that. She's like, hey, this goes perfectly with your discussion on home blood pressure monitoring because this is in line with this is should patients check then urine protein at home? We already discussed checking blood pressures at home with the appropriate cup with instruction is a valid thing. Even though the data is conflicted and may not be traditionally quote unquote evidence based because of the data, it does not all move in the same direction. But what about home urine protein? Fascinating question. I had not thought of that. It's kind of weird wild stuff. Let's talk about it coming up next.
- [06:59]
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- [07:25]
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We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast. All right, let's go old school here real quick before we get into the data and it's going to be relatively quick. Who was that at the intro? Anybody remember that, that is some weird wild stuff. Anybody? That's Dana Carvey doing Johnny Carson. That's his famous Johnny Carson impression. Because Carson, man, the king of late night before Jimmy Fallon and all these others who are kind of schmucks, they don't know what it had. Johnny Carson had it, but that was one of his famous lines. Oh, that is some weird wild stuff. That, that, that. I did not know that. Come on now, Dana Carvey. That is some weird, wild stuff. All right, so, yeah, home protein checks by the patient. That is some weird, wild stuff. Is it a thing, though? So this is again, how, as I said in the intro, a perfect example of how you can, you know, kind of mess with and merge some of the very clear guidance and kind of make it less clear and kind of, for lack of a better term, kind of adulterate it, you know, change it, contaminate it to kind of suit our needs. And it's not a thing. Now, home monitoring for certain conditions obviously is a thing. We talk about home blood pressure monitoring in the past, as we said in the intro, that's legit. I mean, man, you can do a lot of things at home. Check for colon cancer as a screen. You can check for HPV using the teal Wand, not a sponsor. You can do at home STI tests. So why not check your urine protein at home? I mean, it makes a lot of sense. The problem is, is that the way that you check a urine protein at home, which is based on a urine dipstick. Urine dipstick has gone out the window. I did train with those two plus or more. That was the thing. But there's a lot of problems with urine dipstick. And then it went, of course, to the old gold standard of 24 hour urine collection, which is inconvenience. It's a pain in the ass. If you go out to the store and you have to pee, you're going to lose that little, you know, urine containment. So, yeah, it's an issue. Plus it has to be refrigerated. So you got to put it in your refrigerator, you know, your, your box of pee, your bottle of pee right next to your eggs or whatever. It's kind of gross. But the 24 hour urine collection is a thing. But that's largely been replaced by the spot urine to protein ratio. And that is where it's at. In other words, both the 24 hour urine and the spot protein to creatinine ratio are both quantification methods. They are both quantitative, not qualitative. Qualitative has a big Problem? We're gonna talk about that in just a minute, so let's first go to practice bulletin 222. Again, I wanna do this very quickly. Remember, this was from 2020 under the section Inpatient versus Outpatient Management. It states the following regarding surveillance for gestational hypertension. I'm read this directly. Okay? Now, it explicitly recommends weekly labs, platelets, creatinine, liver enzymes for both gestational hypertension and preeclampsia without severe features, and weekly proteinuria assessment. There it is. Weekly proteinuria assessment for gestational hypertension. Let me read this directly out of the bulletin. Here it is. Maternal evaluation consists primarily of frequent evaluation for either the development of or worsening of preeclampsia in women with gestational hypertension or preeclampsia without severe features. Weekly evaluation of platelet count, serum creatinine and liver enzymes is recommended. End quote. So let's stop there. Yeah, we should be doing weekly labs. Do that. We do it for those with preeclampsia without severe features or gestational hypertension. You gotta look for signs of help, even though that's controversial because sometimes help can develop very quickly and you're gonna miss it because help can develop within a period of 48 to 72 hours. So if you don't catch it just right, you can still miss it. But nonetheless, it's something about being a patient safety net, as we discussed in the previous episode. So there it is. That's weekly labs. Now here goes the part about proteinuria. Weekly checks. Here we go. Quote, in addition, for women with gestational hypertension, once weekly assessment of proteinuria is recommended. End quote. There it is. So don't forget, check labs, check protein, unless they already have a diagnosis of preeclampsia. Alright? And then of course, it goes on to say about fetal monitoring, don't forget that everybody with a hypertensive disorder pregnancy needs serial ultrasounds for rate of growth. And of course they need weekly surveillance. And then you need to do timed delivery appropriately according to ACOG's guideline guidance on late preterm and early term delivery. Most of these are out at 37 weeks. If you got severe criteria, of course, you do it as early as 34. And then help is get out when you can, ideally if stable enough for steroid benefit. But you don't necessarily have to wait for steroid benefit with help because you should fear the help. We have an episode called Fear the help. Okay, but wait, there's more. So this whole rationale of Proteinuria assessment for gestational hypertension, remember, but not for preeclampsia. That whole thought is that the development of new proteinuria in a patient with gestational hypertension would thereby reclassify them as preeclampsia. I mean, that makes sense. Proteinuric hypertension, even though you can still diagnose preeclampsia without proteinuria. And we've talked about that, of course, in the intro, it's not necessary for a diagnosis of preeclampsia. So that's one of the criticisms of doing this, is that, well, you can't forget the other stuff. And that's exactly right. You still gotta do weekly lab assessment and then check, of course, for weird symptoms that could go along to that. Weird symptoms, of course, are not just a new onset headache that is unresponsive to Tylenol and not accounted by another diagnosis. Weird visual disturbances, pulmonary edema or abnormal labs. We should do that. But it's not just about urine protein. That's right out of practice bulletin 222. Now, some defend the weekly lab checks that's in ACOG practice bulletin because it is true. Help can first develop without any signs or symptoms. That is true. Based on published data, this was out of 2020, up to 14% of women with help were asymptomatic at diagnosis. Now you can flip that to go, well, 86 were, that's true. But 14% is a really high number for something that's potentially devastating. So, yes, I am in favor of checking labs weekly in accordance with the college guidance, even though of course it has some issues. Help can develop very quickly. And so unless you catch it right out when you're drawing that blood work, they could be in the gaps between the two bookends of when you're checking in a week, and they can develop help in between. So nothing's perfect is the idea. Now back to the bulletin regarding home urine protein checks. There is nothing in there that says that this can be at home. ACOG states that it's either a 24 hour urine collection or a protein to creatinine ratio as the preferred quantitative methods. And here's the part about dipsticks with dipstick readings of 2 plus used only only if other quantitative methods are not available, end quote. But we do have quantitative methods available. That's why they're going into the clinic. Okay, so there is a role for telemedicine and we talked about that with the Bump one and bump two trials in the previous episode. But this is different. This requires quantification. Plus guys, here's the big one. We're gonna start wrapping this up. If you are very hydrated, okay? So a woman drinking a lot of water and she dilutes her urine, you can artificially lower your urine protein on a dipstick. Now conversely, if you're very concentrated and slightly dehydrated, your urine protein is going to be four plus or five plus. So there's a lot of factors there and contaminants and environmental factors that go into dipstick test, which is why it is definitely not preferred by the college and definitely not a thing to do that at home. However, people are looking at this to be fair because I don't want you telling me what about the U dip trial, Chava? The U DIP trial. I got it. Yeah, I found it. U DIP stands for urinary dipstick in pregnancy. Clever. Udip. The U Dip study, that's from 2022 in BJOG, a great journal. Urinary dipstick in pregnancy. Not as clever as the puke score for nausea and vomiting, but whatever. The U dip. So this was published out of Oxford University Hospitals to see if this thing was basically functional, right? It was Oxford university guy in St. Thomas's Hospital and Birmingham Women and Children's Hospital. And basically to see if patients could do this and if it correlated somewhat well to standard urine protein ratios. And they're like eh, you know what, it's not bad. It wasn't great, but it did relatively well. Had a sensitivity of like 0.7 which is Eh, kind of middle of the road. It's not great but yeah, again kind of middle of the road. So like yeah, this could be a thing. So good, so good, so good.
- [16:38]
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- [17:02]
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No, no, it's not going to be a thing. So u dip study was in 2022 looking if patients could do home urine protein test. So yes, there's something published about it, but it was more of a feasibility versus a true clinical utility study. So the main criticism of this is that urine protein dipsticks are highly, highly influenced by a patient's hydration status. Plus we need quantification methods like a urine protein, a creatinine of 0.3 or more than you're just proteinuric. Remember, you don't get any extra points. If you're super proteinuric, you're just proteinuric. Or if you are not, or a 24 hour urine protein of 300 milligrams in a 24 hour interval. So you don't need protein to be preeclamptic. You don't need urine dipsticks to check for this. This should be weekly, but it should be done by in office assessments. Have them leave a urine sample and send that off for urine protein and creatinine ratio. Now it's interesting because I did train with urine dipsticks, but that's when urine protein and creatinine ratio really wasn't that established. So as we wrap up this very quick episode, here's a clinical pearl. Urine dipsticks are notoriously imprecise. So even if though we're talking about home monitoring, if you are doing this using home, I mean using urine dipsticks in the clinic, please don't. There's other methods that are much more effective and reliable. So we really should not be using urine dipsticks for this. They are notoriously imprecise. And because they measure this concentration issue, patients who are dehydrated, it may show a false positive for high protein. And if they drank a gallon of water, it could show extremely diluted and low protein levels given a false negative. So take home answers. Should patients check their urine protein at home? Even though we do a lot of stuff at home, checking urine protein guys is not one of them. So thank you SJ for your query. Now you can pass that on to your compadre there in the clinic that stop doing home urine protein dipsticks. That is some weird, wild, wacky stuff. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community, Michael. Before I get into trouble, brother, come on now, let's take it home. This is Dr. Chapma's obgyn no spin podcast, Sam.