Dr. Simi Gupta and Dr. Fox discuss high blood pressure in pregnancy, including chronic hypertension and pre-existing hypertension. Dr. Gupta reviews risks like high body weight and advanced maternal age, how hypertension is diagnosed, complications it may cause, and treatment options.
“Chronic Hypertension (High Blood Pressure) in Pregnancy” – with Dr. Simi Gupta
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right, Simi Gupta, Dr. Gupta, welcome back to the podcast. How are you doing?
Dr. Gupta: I’m doing great. Good morning. How are you?
Dr. Fox: I’m wonderful. We’re gonna be talking today about chronic hypertension in pregnancy or pre-existing hypertension and pregnancy. So, women who come into pregnancy or get diagnosed early in pregnancy with having a form of high blood pressure. This is something we see a lot of, yes?
Dr. Gupta: Yes. I feel like we probably do consults on this very regularly.
Dr. Fox: Apparently, it affects you know, like 1, or 1 to 2% of pregnant women in the U.S. And I guess maybe it’s just a factor that, you know, we’re “a high-risk practice,” or maybe we just see a different demographic of women. But it’s definitely higher than 1 to 2% in our neck of the woods.
Dr. Gupta: It’s true, it definitely feels that way. And you’re right, maybe it’s because this is what we get patients referred to us for, or it’s reality. But it does feel like a very common condition in pregnant women.
Dr. Fox: I think that one of the reasons is a huge risk factor, or risk factors for blood pressure, in general, high blood pressure is increasing age, and this is true in men and women. And increasing body weight, also true in men and women.
And so, you know, I guess in our practice, and sort of our geographic, I don’t think it’s more increased body weight, but more increased age. I think that women are having babies older and older, both their first child, but also maybe multiple children. And so we do see a lot of women in their late 30s, in their 40s, and even their 50s, and so a lot of them just naturally have higher blood pressure than they did in their 20s.
Dr. Gupta: Right, I would agree.
Dr. Fox: How do we define hypertension or high blood pressure? What does that mean like number-wise?
Dr. Gupta: So for pregnancy, we use a top number which is called the systolic number of 140 or higher, or a bottom number which is called the diastolic of 90 or higher. And if a patient has two blood pressures that have hit those numbers or higher then we consider them as having elevated blood pressures.
Dr. Fox: Right. And you mentioned at the beginning, that we’re talking about pregnancy. And I think that’s important because in life, right in non-pregnant individuals, there’s been a recent push to maybe take people with slightly lower blood pressures than that and put them sort of on warning or on notice that this is not normal if their blood pressure is borderline or hypertension.
In fact, recently, there was from the American Heart Association that if your blood pressure’s in the 130s over the 80s, that they would actually call that hypertension, they called it stage one. And then if you got to that 140 over 90 like we were talking about, they would call that stage two. And there’s even if you’re like, pre that, like in the 120s they call elevated.
And I think the point is in life, you know, hypertension is a chronic condition. And it’s not dangerous to have a blood pressure of 130 or 80, nothing is gonna happen to you acutely, but if you have it for 20 years, it might. And so the thought is sort of in primary care if people have these sort of borderline blood pressures to note it, to talk about it, maybe treat it, maybe not treat it.
But we don’t really do that in pregnancy because we’re talking about a much more short-term situation. So we really still stick at least for now to the 140 over 90 definition. And one of the other interesting things is we’re gonna diagnose someone with chronic hypertension, even if they’re already pregnant and have high blood pressure, which is a little bit unusual. Do you wanna talk a little bit about that may be as compared to diabetes, for example?
Dr. Gupta: Right. So we will diagnose somebody as having chronic hypertension or chronic high blood pressure, if they’ve had elevated blood pressures before becoming pregnant, or if they have elevated blood pressures at the beginning of the pregnancy. And for this purpose, we consider the first half or the first 20 weeks of pregnancy as the beginning of the pregnancy.
So even a patient who maybe never had high blood pressure prior to pregnancy, but their first few prenatal visits their blood pressures are high, we would consider them as having chronic hypertension.
Dr. Fox: Right. It’s interesting because we don’t really do the same for diabetes. Meaning if someone in the beginning of pregnancy, we screen them, we do a sugar test and it’s a little bit high, we usually tell them you have gestational diabetes. It might be pre-existing diabetes, we’re not 100% sure, and we’ll sort of, you know, dance around that and treat them sort of that way and sort of not.
But with blood pressure, we’re pretty confident that it’s not a pregnancy phenomenon. Meaning the reason their blood pressure is elevated is not because they’re pregnant. Whereas for diabetes, your sugar can go up because you’re pregnant. And the reason is, when you get pregnant, your blood pressure normally goes down not goes up. So someone…
Dr. Gupta: Exactly.
Dr. Fox: Yeah, you know, when someone gets pregnant, their blood pressure drops almost immediately because the blood vessels all relax in pregnancy. This is why a lot of women get lightheaded sometimes in pregnancy, or their legs swell even early in pregnancy sometimes. Or sometimes like, their veins are more visible because everything relaxes and blood pools.
So if someone has that their blood pressure should go down. And so if we see it elevated, even at the beginning of pregnancy, we’re like, no, no, this isn’t a pregnancy phenomenon it’s the opposite, right this is high despite the fact that it should be going down.
Dr. Gupta: Right, exactly. And that’s why we do pay very close attention to blood pressures during pregnancy.
Dr. Fox: And we’re gonna talk about the phenomenon where people don’t truly have blood pressure but when we check in the office, it’s a little bit high because we make them anxious, or doctor’s office, make them anxious, or pregnancy makes them anxious. So we’ll talk about that afterwards.
It happens a lot because not everybody sees a doctor or gets their blood pressure checked every six months or a year. And sometimes you know, someone comes to our office they’re pregnant, the last time their blood pressure was checked was a year and a half ago, and they come into our office and it’s you know, 135 over 94.
Like all right like that’s high, that’s a little bit higher than it should be. And like, “Well, I’ve never had high blood pressure before.” “Well, you know, you have it now.” Why do you even care, like, what’s the big deal if someone’s blood pressure is slightly higher than it should be?
Dr. Gupta: So we watch chronic hypertension or chronic high blood pressure because it can have effects on the mom during pregnancy, and it can also have effects on the baby or the fetus during the pregnancy. And so women who have high blood pressure, they need to be closely monitored to make sure that mom and baby are safe during the pregnancy. And that’s why we pay attention.
Dr. Fox: And I think that for most women who come into pregnancy either knowing they have a very mild form of high blood pressure, or we diagnose it early in pregnancy, most of them will do fine. Because you know, the issue with high blood pressure and why it would affect her or the baby the fear is that someone who has high blood pressure for a long time or very high blood pressure, it can damage their blood vessels sort of from the inside out. And those blood vessels are needed to sort of feed the placenta, to perfuse the placenta which gives oxygen and nutrients to the baby.
So someone who has really bad vascular disease and they get pregnant, it could be an issue. But someone who has a very mild form of high blood pressure in their 20s or 30s or early 40s, usually, they don’t have vascular disease yet. Usually, they’re okay. That’s something that could happen if it’s not treated, you know, when they’re 60, 70, 80 not so much then. So most of them do okay but they could have a form of that, and statistically, they do have a higher rate of complications.
And then there are some women who come into pregnancy who have really severe hypertension, and they’re on two or three medications already, and those are the people at higher risk. And do you find that like when you’re speaking to women early in pregnancy, that you counsel them differently based on how severe their high blood pressure is coming into pregnancy or their condition is?
Dr. Gupta: Yes, for sure. And that’s because as you mentioned, women who come into the pregnancy already on medication, or who’ve had high blood pressure for many, many years, or have the vascular complications as you said, are at a higher risk of pregnancy complications, than patients who maybe had some you know, mildly elevated blood pressures, but never required medication, or it’s a new diagnosis either in pregnancy or right before pregnancy. So even though we talk about the same risk, how concerned I am for a patient definitely depends on the severity of their high blood pressure.
Dr. Fox: Yeah, we follow them almost identically. And so probably for some of the women, we’re overdoing it, and for some of the women potentially, we’re underdoing it. But you know, we follow everyone sort of the same way but definitely, when we talk to them, it’s not cookie-cutter. We say, “All right, you know, your hypertension is pretty mild, we’re just picking it up, you’re not on medications.
You know, we’re gonna do all these things, but probably it’s gonna go really well.”
Versus someone who’s on three medications who already has kidney disease like that’s a much different scenario. And we’re a little more grim about that because there is a much higher chance of there being problems.
And I think one of the other fascinating things about pregnancy and high blood pressure, especially for women who know they have high blood pressure and have been managing it for a while and then get pregnant, is what happens to their blood pressure during pregnancy. Many of them don’t even realize how much it changes just from the physiology of pregnancy.
So how do you explain that to them? Meaning someone, they’ve never been pregnant before, they’re not expecting this and they come into pregnancy on a couple of medications. What do you tell them to expect is gonna happen to their blood pressure?
Dr. Gupta: As far as kind of the natural course of blood pressure during pregnancy for most women, it kind of starts off, you know, relatively at their baseline. And then when they get into the second trimester, their blood pressure usually naturally drops a little bit. And then it usually, or hopefully just comes back to the baseline in the third trimester.
So it’s important when I speak to patients to let them know that this is kind of the natural course of blood pressure during pregnancy. Because some patients feel like their blood pressures are improving in the second trimester, and maybe they don’t need their blood pressure medication, or that they’re getting better. And they just need to be aware that it might come back to its baseline in the third trimester. So we usually try to keep them on the same dose of medication and the same kind of watching and monitoring, even if their blood pressures get better in the second trimester.
Dr. Fox: And I think it’s interesting for two reasons like you said. The first is that there is gonna be an expected improvement in their blood pressures some time, you know, around the early second trimester, and it’s gonna last for several months. And some women who sort of come into pregnancy with high blood pressure and they’re not on medications, they’ll say, “No, no, my blood pressure has been normal for months.” We’re like, “Yeah, but it started out high, and it’s probably gonna come back there in the third trimester.”
And that’s the second point is sort of expect it to come back up. So either sort of, it’ll be mildly elevated again, or if let’s say they were on medication, and then they were able to go off it for a couple of months, that there’s a very high chance they will have to go back on it.
And as you said, we sort of expect it to come back to baseline. And we’ll talk about some women, it starts going higher than their baseline, and we have to figure out is that just a worsening of their high blood pressure, or is that a new diagnosis of preeclampsia. Again, which we’ll talk about when we’re sort of getting into the third trimester.
So when you’re seeing someone at the beginning of pregnancy, either you diagnose them with high blood pressure, or they already have high blood pressure, and you talk to them about what to expect, what is the sort of initial assessment that you do for them at the beginning of pregnancy?
Dr. Gupta: The first thing that I like to do is kind of establish whether or not they need medication, if they’re not already on medication, and if they are already on medication are their medications safe to take during pregnancy.
So as far as whether or not a patient needs medication, we actually allow patients to have a little bit of higher blood pressures during pregnancy than most physicians want them to have outside of pregnancy. And the reason for that is, we don’t wanna drop a woman’s blood pressure too low during pregnancy because we wanna make sure that they have adequately enough blood supply and blood pressure to get enough, you know, blood flow to the baby and to the uterus.
So if a woman’s blood pressures are kind of under 150 for a top number, or under 100 for a bottom number, we will usually just closely monitor them. But if they’re starting to get into the 150s for the top number, or the 100 for the bottom number, we usually will either start or increase their medication.
Dr. Fox: I actually wanna interrupt you for a second because I wanna focus on that aspect because that’s really, really important. And a lot of people are surprised by this. Because you know, you go to your general doctor and your blood pressure is you know, 140s over 90s, and like, “All right, you have high blood pressure, we’re gonna treat you.” The reason they do that is because again if you walk around with that blood pressure for 20 years, it can damage you know, your blood vessels, your heart, your kidneys, you know, whatever.
But for us, we’re talking about you know, five, six months, and there’s nothing bad that’s gonna happen to the mom, by walking around with a 140 over 90 for five to six months, she’s gonna be okay. And so it’s not like we need to treat her for that number for her health.
But if it starts getting towards 160 on the top, or 110 on the bottom, it can be dangerous to her own health, you know, things like you know, stroke or whatever, it could be dangerous. And so we’re trying to keep it out of that range. And that’s one of the reasons we don’t jump to treat women with medications if it’s in that mildly elevated range you know, 140s over 90s or something like that.
But the other thing you mentioned is also really important that there’s a downside potentially to treating someone. How do you explain that when you said the blood pressure might go down and it might affect the fetus, what’s going on there? Because I think that’s another important point of why we don’t try to drop her blood pressure to 100 over 60 when she’s pregnant.
Dr. Gupta: So for all women during pregnancy, their blood volume goes up a little bit. And the point of that is they need to have adequate blood supply, blood volume, and blood pressure in order to get enough blood to the uterus. And the blood going to your uterus is what essentially allows nutrients to cross over from mom to baby.
And if this blood pressure is too low, and there’s not enough blood volume going to the uterus, then it could affect the amount of nutrition that the baby is getting. So in that sense, we just need to make sure we’re not kind of unnecessarily dropping a woman’s blood pressures so low during pregnancy, that it becomes dangerous to the baby.
Dr. Fox: Yeah, and this is one of the areas where it’s really helpful for someone who has high blood pressure to be followed either by an obstetrician, or maternal-fetal medicine specialist who understands this or potentially someone who specializes in blood pressure, a cardiologist or internal medicine specialist who know about pregnancy. Because it’s different from when someone is not pregnant, sort of what’s the goal blood pressure.
And we’re definitely walking a tightrope that we don’t want them too low, we don’t want them too high. Whereas if you’re not pregnant, there’s not much of a downside to making someone too low unless they have symptoms from it. And so we’re really not trying to do that. And so we’re a little more hesitant to start medications unless again, we think that number is getting high enough that it’s actually gonna be acutely dangerous to the mother.
Okay, so that was sort of a sidebar about that. And then you talked about the safety of medications. How often is it that we have to change someone’s medication because of safety for blood pressure?
Dr. Gupta: So you know, if a patient has already spoken to their primary care physician, internal medicine physician, or cardiologist, they’ve often already been switched over to medication that is kind of considered safe to take in pregnancy. But for women where we might be seeing them for the first time, then we often have to switch patients because the commonly used medications when someone isn’t pregnant are different from what we usually use during pregnancy.
So during pregnancy, we commonly use two medications to treat blood pressure. The first is a medication called labetalol, which is a type of what we call a beta-blocker. The second medication is called nifedipine, or Procardia, and that’s called a calcium channel blocker. And the reason we commonly use these two medications is you know, for many years, and with different safety protocols, these have been considered the safest medications to use during pregnancy for both the mom and for the baby.
Dr. Fox: Fortunately, for women with mild hypertension, they tend to work…it tends to be pretty straightforward. A lot of doctors know about this. There aren’t a ton of medications that are like, crazy dangerous in pregnancy, there are some that it’s just not ideal and so we switch them off. So it’s unlikely someone’s gonna be pregnant on something that’s like, oh, my God, this is horrible. But we do try to switch them before pregnancy or early in pregnancy.
And like you said, pretty much anyone who takes care of women with high blood pressure knows about this, this isn’t so esoteric. And so for women who have high blood pressure, who are thinking of getting pregnant, it’s just important to either speak to your OBGYN or to your whoever manages your high blood pressure to say, “Hey, is the medication I’m on safe to take in pregnancy?” And they say, “Oh, yeah, you’re fine, you won’t have to switch,” then you’re okay and you should be good to go.
And if you need to switch, best to switch before pregnancy. But if you have to switch when you’re pregnant, that’s okay, too. Do you do any blood work or any other tests at the beginning of pregnancy?
Dr. Gupta: One, of course, is we wanna make sure you know, our patient, our mom is healthy during the pregnancy. So if they needed evaluation of their hearts through an EKG or an echocardiogram, if they needed evaluation of their kidneys, we may look into that either through blood work or checking their urine. So one is just to make sure mom is healthy going into pregnancy and doesn’t have any of those long-term vascular complications we spoke about that can be related to having high blood pressure for many, many years. So that’s one part of it.
The second part of it, and I think we will get into this a little bit more is one of the risks with having high blood pressure during pregnancy is some women develop a special kind of high blood pressure during pregnancy that is caused by the pregnancy and that’s called preeclampsia. And preeclampsia kind of has some characteristic or specific signs, for example, protein in the urine, abnormal labs related to the liver or to the kidneys. And so we like to know what those are for a patient kind of at the beginning of pregnancy or at baseline, so that if something changes during the pregnancy, we have something to compare it to.
Dr. Fox: Yeah, I think let’s talk about that now actually because there’s so much of what we do at the beginning of pregnancy because of that risk. And you know, I guess an average of women with hypertension maybe 25%, or 30%, will get preeclampsia. It definitely ranges those who have more mild hypertension it’s lower, in those with more severe hypertension, it’s higher. But it’s a lot higher than everybody else, right, meaning the chance of getting preeclampsia, in general, is about 5%. So it’s much, much higher if you have high blood pressure.
And it’s interesting, clinically, what happens is the blood pressure usually just keeps going up and up in the third trimester instead of sort off leveling of like we said before, or sometimes these blood tests become abnormal or something else is going on. And it can be a difficult diagnosis to make in the third trimester, right? If someone never had high blood pressure, the way we diagnose preeclampsia, which is usually in the third trimester is they now have new hypertension, their blood pressure is up, and they have new protein in the urine, right two new things.
But if someone starts with both of those things, high blood pressure, and protein in the urine, it’s very hard to diagnose in the third trimester because they already have it. So how do you know if it’s their initial condition, sort of rearing its head again, or if it’s this new condition, preeclampsia?
And since we know it’s gonna be difficult, one of the things we really like to do is figure out exactly where they are at baseline, what’s their blood pressure like in the beginning of pregnancy? You know, what are their blood tests like? How much protein is in their urine at the beginning?
So if in the third trimester we’re trying to figure out is this old or new, we can redo all those tests and compare it to the initial ones. And if they’re much worse, for example, like the protein in the urine, if it goes up by a lot, we’re much more confident that it’s preeclampsia. And that’s important because the management is different. And then how do we assess if there’s protein in the urine?
Dr. Gupta: So there’s basically two ways. One is just from a regular urine sample that a woman might leave at the beginning of their prenatal visit. So basically a quick look. But a more accurate way of looking at it is to actually have a woman collect their urine for 24 hours, and then send it off to the lab and see how much protein accumulates in their urine over a 24-hour period. And so that’s kind of the ideal way of measuring it.
Dr. Fox: Yeah, that’s kind of shocking to people who’ve never heard of this. That we give them this big like moonshine jug to take home. We’re like, “All right, you’re gonna pee in this thing for the next, you know, for 24 hours straight, and then bring it back.” They’re like, “Excuse me, I’m gonna do what? I’m gonna leave this where?” “In your refrigerator.” “Really?” It’s a little weird and some people replace it with that sort of spot test that you talked about.
But we still use the traditional one. I think it gives so much valuable information, particularly in this situation trying to figure out if someone’s getting worse, you know, where someone starts and where someone is later. And so we still do it. And it’s, I would say a little annoying but you know, whatever. It’s pretty valuable. So you know, if your doctor gives you one of these jugs to collect your urine for 24 hours I would do it, it’s an important test.
Dr. Gupta: Right, I agree.
Dr. Fox: And then the other parts about preeclampsia is the use of blood pressure medicine, right? If someone comes into pregnancy with let’s say, 140, over 90, and as we said before, we generally don’t give them medication for that, what’s interesting is that I think people find this really surprising is using blood pressure medicine early in pregnancy, sure, it’ll lower their blood pressure, but it won’t prevent them from getting preeclampsia. Meaning whether someone develops preeclampsia or not, is not related to whether we use medications early in pregnancy. They sort of think that, “Oh, if I lower the blood pressure, I’m gonna lower the risk of getting preeclampsia.”
And that’s not the case, which is part of the reason we don’t feel too inclined to give someone blood pressure medicine unless we think their blood pressure is a danger to them. Sure, blood pressure medicine can sort of mask preeclampsia, that the blood pressure won’t get so high, but if they get it, the blood pressure is gonna go up and up despite being on medicine.
Dr. Gupta: Right. And I think that’s important because you know, the common things we kind of think about to treat regular high blood pressure, chronic high blood pressure, whether that’s blood pressure medication, exercise, a healthy diet, all of which are important during pregnancy, those aren’t factors that will treat preeclampsia because preeclampsia is essentially caused by these vascular issues that affect the placenta. And so while we want people to be healthy during pregnancy, it’s not going to treat them in the same way if they ultimately do develop preeclampsia.
Dr. Fox: Yeah, and I think that is a really important point. The only thing that we do that helps prevent or lower the risk of preeclampsia once someone is already pregnant is really just give them baby aspirin from the beginning of pregnancy. So that’s one thing that we give to all women with chronic hypertension. We actually give it now to all women period, but that’s another discussion. But certainly for women with chronic hypertension.
I think that anyone listening around the country who has chronic hypertension and they’re pregnant, their doctor did or should have put them on a low dose aspirin in the beginning of pregnancy. How does that work? Why does that lower the risk of preeclampsia? And I know you’re not gonna know the answer because no one knows exactly, but talk about that for a little bit?
Dr. Gupta: Right, no one knows exactly for sure. But theoretically, taking a low dose aspirin…for anybody who’s listening to this may be thinking, “Well, I’ve been told I’m not supposed to take aspirin, or Advil, or medications like that during pregnancy.” This low dose you know, whether it’s 81 milligrams or 150 milligrams, this is considered safe to take during pregnancy.
But we think that it works because it helps the placenta implant in the first trimester which will decrease kind of the course of events that ultimately leads to preeclampsia later on in pregnancy. And part of why that’s important to know is because you really should be taking this low dose aspirin or baby aspirin in the beginning of the pregnancy, to prevent preeclampsia later on in pregnancy. Meaning it’s not designed to be used once your blood pressure is already going up and once we already think you have preeclampsia. It’s something to be used kind of as a preventative measure.
Dr. Fox: Yeah, that is a really important point that you take it in the beginning of pregnancy to prevent something at the end of pregnancy. Meaning it doesn’t lower your blood pressure, it doesn’t treat preeclampsia, it helps prevent it.
We also make sure women are taking the recommended amount of calcium every day. There’s some data that for…who don’t get enough calcium in their diet, that supplementing calcium might lower the risk of preeclampsia also. I think most women don’t get the recommended amount of calcium every day. It’s 1000 milligrams and a prenatal usually has about 150. And so unless you’re having two or three servings of dairy every day, you’re probably not getting enough calcium. So that’s another thing we talk about.
Do you recommend that everybody with high blood pressure follow with a blood pressure specialist during pregnancy, like a cardiologist or an internal medicine physician who sees a lot of hypertension?
Dr. Gupta: I think it’s a good idea in general for two reasons. One, it’s nice to kind of have established care with an internal medicine doctor or a cardiologist, just so that you can continue your care after delivery, and you have somebody who knows you.
But the second reason is, if your blood pressure does go up, if things do get complicated during pregnancy, it’s nice for a patient to have somebody who knows them and has already kind of seen them at their baseline or normal, than for a doctor to kind of see them for the first time once something is kind of already starting to happen. So while it may not be absolutely necessary, I think it’s good for a patient just for their kind of general medical care.
Dr. Fox: And I think sometimes that depends on exactly sort of what their situation is medically and where they’re going for their pregnancy. So, someone who has high blood pressure in the beginning of pregnancy or pre-existing, they’re gonna need to see somebody you know, once or twice a year for forever. And so if you get hooked up with that person when you’re pregnant, great. If you already have that person, great.
But it’s time to start thinking about that because even though we can manage someone with high blood pressure when they’re pregnant, it’s not like we can’t do it, we can adjust their medications and talk to them and do this. We’re not gonna be the ones taking care of them for the rest of their life and so it’s probably time to start thinking about that.
Now, we spoke about the risk of preeclampsia which is, you know, a lot of risk to the mother, some risk to the baby. But we also are concerned about certain risks to the baby. So what risks are we worried about to the baby for women with hypertension? And on the flip side, what risks are really not increased for women who have high blood pressure?
Dr. Gupta: So the big concern for the baby is…you know, I know we talk about the placenta a lot. But the placenta again is kind of essentially what provides nutrition for mom to baby. And the placenta is what might not work very well during the pregnancy for women with high blood pressure.
And so the types of things that might be associated with that are babies who are born at a lower birth weight, so we call that fetal growth restriction. So a baby is not growing well during pregnancy, it might be associated with a higher chance of the baby having less fluid around them during the pregnancy, which is called oligohydramnios. Or it might be associated with a higher chance of miscarriage or stillbirth later on in pregnancy.
Dr. Fox: Yeah, I mean, stillbirth generally that’s not gonna happen unless the other two are there meaning it’s usually not a sudden. Stillbirth usually, it’s if the baby is really growth restricted, it could you know, go downhill. Sometimes they have bleeding with placental abruption, but again usually, that’s if something is already off.
And so we do follow in pregnancy how the babies are growing a little bit more closely than we would in other pregnancies. Meaning we do a lot more ultrasounds to check the baby’s weight. And towards the end of pregnancy, we do a lot more ultrasounds to check the fluid, and movement, and whatnot. So that’s one thing that’s different, that women with high blood pressure will have many more ultrasounds than women without.
One of the nice things is that there is not an increased risk of things like birth defects, for example, there’s no increased risk of genetic abnormalities, there’s no increased risk generally of early miscarriage unless they’re really sick. I mean, having mild high blood pressure does not really increase the risk of miscarriage. It’s really much more so like you said things with the placenta which, namely is how is the baby growing and then preeclampsia which can affect.
And so, you know, other than having extra ultrasounds, there isn’t a lot we do that different in pregnancy, they have some more visits. We generally recommend women check their blood pressure at home if they’re able to either with an electric cuff or sometimes a manual cuff if someone can do it for them. And that’s because people can’t really tell if their blood pressure is going up. Usually, there’s not a lot of symptoms until it’s really high.
And so, you know, if someone is gonna come back and see us in two, three, or four weeks, we generally certainly in the third trimester want them to start checking their blood pressure at home, as a screen. And I found that to be really useful for a lot of reasons.
Dr. Gupta: I agree. I think it’s very important for any woman with high blood pressure to get a blood pressure monitor that they can use at home and that they know how to use and they feel comfortable using. And if they’re not sure how to use it, to bring it into their doctor’s office and just make sure they’re using it right.
Because as you said many times, you can’t tell if you’re having high blood pressure, and checking your blood pressure at home is the only way. Or sometimes you might feel a little funny or different and you don’t know if it’s related to your blood pressure. And having the ability to check your blood pressure at home is always nice information for if you’re calling your physician.
Dr. Fox: Yeah, totally, someone says, you know, my legs…you know, who has chronic hypertension and they’re 30 weeks, and they say my legs are a lot more swollen today, and my blood pressure is you know, normal, that’s a lot different. They call in and say my legs are a lot swollen and my blood pressure is a lot higher than normal. In the first one, we’re gonna say, you’re fine, put your feet up, have a good day. And the second one, we’re gonna be like, come to the office, come to the hospital immediately. And that’s very, very different.
And if we don’t know their blood pressure, frequently we’re gonna say, “Listen, you gotta come in and get your blood pressure checked,” because you can’t tell over the phone what someone’s blood pressure is there’s no symptom of it typically. And so I think that’s important.
And on the other side, it’s also important because you know, when we see someone every couple weeks, or every week, or every month, or whatever it is, and we’re trying to like track a pattern of their blood pressure, it’s really, really crude. I mean, we don’t actually get a good pattern, we just sort of see what it was in our office on that day, it’s different times a day, and they may be, you know, very rushed, they may be anxious, or this. Whereas, if they have their blood pressure checked every day or every other day at home and they bring it in, we can see what really is going on with their blood pressure over time, and not just these sort of random points in their pregnancy when they’re in our office.
Dr. Gupta: Exactly. And that’s very helpful especially if we need to talk about starting medication or changing medication. It’s not a decision we usually like to make off of a single blood pressure. So having patterns helps us make those recommendations.
Dr. Fox: And definitely when we talked at the end about this concept of white coat hypertension, that that comes up a lot. So someone has high blood pressure, chronic and they’re sort of stable, what would be the reasons we might deliver them early? And the second question is, if everything goes perfect, what is sort of the end of the line for them? When would we say it’s probably time to be delivered, even if everything is going fine?
Dr. Gupta: You know, a very good way women who have you know, well-controlled high blood pressure who don’t develop you know, complications during the pregnancy, they usually can go full term you know, hopefully, go into labor on their own close to their due date, and have a very kind of normal pregnancy. And we will usually for those patients recommend delivery sometime you know, around their due date, whether it’s 38 weeks, 39 weeks, or at their due date.
And the reason for that is once we kind of consider a baby fully cooked or fully ready, we don’t wanna take any of these risks of high blood pressure that we’ve spoken about like preeclampsia, etc. And it’s nice for women to go into labor on their own. So somewhere around 38, 39, 40 weeks.
On the other hand, the types of complications that women might develop that requires them to be delivered early may be preeclampsia. Again preeclampsia is that special kind of high blood pressure that can get worse during pregnancy and the only kind of treatment for it is delivery. So that might be a reason we deliver a patient early or if we are worried about the baby.
So if the baby is not growing well during the pregnancy. If on some of these monitoring with the ultrasound we feel like the baby doesn’t have enough fluid, or isn’t moving the way that it should be, that might be a second reason. And then the third is, if a woman’s blood pressure even if they don’t develop preeclampsia, it just becomes harder to control on the medications that we can use during pregnancy, we might end up needing to deliver a patient just to make sure that she’s safe.
Dr. Fox: I totally agree. And one of the interesting things is, the reason we typically want them deliver by their due date is at some point that placenta is gonna get worse on its own, even totally not related to their high blood pressure. All placentas start to decrease in function as you get at and past your due date. And so we don’t wanna sort of add placenta problem on top of placenta problem. So usually, once they get to their due date like it’s enough, it’s not worth the risk to stay pregnant anymore.
But other thing which is really interesting is, as you said, we’ll typically deliver early if there’s complications, even related just to their blood pressure, because almost always after they deliver, their blood pressure is gonna get better. If they have preeclampsia, it’s gonna get better, it’s all gonna resolve. But for some women, it’s the opposite. It’s really fascinating that for some women…and this is true for women without chronic hypertension also, their blood pressure is fine, fine, fine, fine, then we deliver them and suddenly, two days later, their blood pressure is shooting up.
It’s sort of like, it’s preeclampsia that’s developing from the placenta, but only after the placenta was removed. Which is a fascinating concept that the placenta can sort of like leave behind changes that affect a woman a few days, or even up to a few weeks after delivery. And so I always sort of warn women with chronic hypertension, that even though you’ve delivered, you really have to keep checking your blood pressure at home. Because even though it’s gone down, or might go down in the hospital, it could come up again, up to a week or two or three after delivery.
Dr. Gupta: That’s another benefit of having a blood pressure monitor at home is that you can check your blood pressure regularly even after you leave the hospital. Because as you said, you may develop blood pressure issues after you deliver.
Dr. Fox: And also for women who we diagnose their chronic hypertension at the beginning of pregnancy, and they never had it before, we always talk about the importance of following up for that. Meaning it is time to start seeing somebody, maybe they do need treatment when they’re not pregnant. Or maybe it is time to start some sort of, you know, diet or exercise regimen to try to treat the high blood pressure that way.
And so for someone who got through pregnancy and everything went well, that’s great, but it’s still probably time to start you know, looking at this a little bit closer. And now that we know that it’s going on because again, hypertension is a lifelong condition. Even if it’s mild, it’s something that needs to be addressed in someone’s lifetime because a mild problem over many, many years can build up and cause problems.
Dr. Gupta: Right, exactly.
Dr. Fox: Let’s shift to this concept of white coat hypertension. So number one, what does that mean? Like what’s a white coat have to do with any of this? And two what is it?
Dr. Gupta: White coat hypertension I know is a little bit of a funny term. But it basically is describing this phenomenon where you know, a patient goes to a doctor’s visit and their blood pressure is high when it’s initially checked. And whether that’s because they’re anxious in general, they’re nervous about what the doctor is gonna say, they’re nervous about their pregnancy, for whatever reason, when they get to the doctor’s office their blood pressure is high. As opposed to regular high blood pressure or chronic hypertension, where your blood pressure should kind of stay the same over a 15, 31-hour period. For women with white coat hypertension or kind of anxiety-related hypertension, when they’ve had a chance to relax, their blood pressures are normal. So that might be at the end of the visit, or might be when they check their blood pressure at home.
Dr. Fox: And the white coat is because doctors traditionally wear white coats. So it’s sort of like I see the doctor and I get freaked out. No, I don’t actually wear a white coat anymore so you know, I don’t know what you would call it, just Fox hypertension I guess I make people nervous. But it’s a real phenomenon and we see it a lot.
I mean, we see a lot of people who are young, they’re healthy, and they come into our office and every time they come into our office, their blood pressure is elevated. And they’re like, “But I don’t have high blood pressure.” And how do we figure out whether it’s the white coat hypertension versus real hypertension?
Dr. Gupta: And I think you know, why we see so many patients who either actually do or think they have white coat hypertension is because it’s actually really sometimes difficult to tell if they have it or not. Sometimes there’s easy ways of finding out. You repeat their blood pressure towards the end of the visit when they know the baby is okay and their blood pressure comes down. Or you ask them to just you know, kind of get to their appointment a little bit early so that they can relax a little bit before their blood pressure is checked. And you find out it normalizes that way.
And in some cases…and obviously, the best way is have them start checking their blood pressure at home. And if they’re checking their blood pressure accurately and at home it’s normal, that’s the best way to know it’s white coat hypertension.
In some cases where it’s really difficult to know we may send a patient to a cardiologist. And cardiologists actually have these kind of special tools where they can monitor a woman’s blood pressure more regularly, and kind of help us know if it’s white coat hypertension or not. But that’s usually not necessary, we can usually figure it out in one of the other ways.
Dr. Fox: That’s important because, you know, giving someone a diagnosis of high blood pressure has implications, you know, they’ve got a diagnosis, then it’s gonna follow them around for the rest of their life, and they’re gonna be worried about it. And we may deliver them early, even maybe different treatments or different tests. Versus if they’re just a little bit nervous and they come to the doctor which a lot of people are, that’s a totally different situation and they’re not really at the same risk.
So, you know, I see women and we’re not sure what’s going on, or I’m pretty suspicious that it’s this white coat, I’ll tell them, “Listen, just check your blood pressure at home, like once a day for a week, or whatever it is.” And it’s usually very obvious like, yeah, every day at home, it’s 110 over 70 when I come to your damn office, it’s 140 over 90, well, it’s my fault, then. No, but it is my fault that’s because of me. And I think that we generally, don’t worry as much about that situation.
Now times where it’s a little bit confusing is when they come to our office, it’s not a little bit high but it’s like really high, you know, it’s like 180 over 110. We’re like, whoa, like, that’s kind of high to be…you know, we’re really making you nervous here. Or when they check it at home and you know, it’s not perfect, it’s either sometimes a little bit high or really quite borderline.
And then I’ll tell them probably you have like a touch of hypertension and may be coming to the doctor’s office makes it worse. And then we just have to make a decision of how are we gonna follow the pregnancy. Are we gonna follow you like someone who does not have hypertension, or follow you like someone who does have hypertension? And you know, that’s a judgment call that the doctor makes.
But it is a phenomenon and sometimes we do one way, sometimes we do the other way. Like you said, usually, we can sort of figure it out, especially if someone could take their blood pressure at home. But it’s important, and also when people tell us about their history, you know, and they tell about their last pregnancy maybe it wasn’t with us, sometimes we’re trying to sort out whether it was real preeclampsia, or just that white coat hypertension, or chronic hypertension. And listen, that’s why we have jobs try to sort through all this and figure out what’s best.
Dr. Gupta: Right. And I think it’s also important because sometimes as you said, it is a judgment call. And if we ultimately make the judgment call where we say let’s err on the side of, you know, closely monitoring you and the baby as though you do have chronic hypertension, which again, may mean just these extra visits or ultrasound visits to keep an eye on the baby.
So if we’re not sure, and we wanna do this extra monitoring, it’s not because we want to give somebody a diagnosis of chronic hypertension or high blood pressure but just because we’re not sure, and it’s better to be safe.
Dr. Fox: Yeah. And also it’s we don’t do anything to them, right, we’re not giving them treatments or medications. And generally, if we’re gonna err on the side of caution, it’s gonna mean practically number one, she’s gonna continue to check her blood pressure at home, fine. Number two, we’ll do more visits and ultrasounds, which tends to be fine. And number three, we’re not gonna deliver her that early. The earliest, we would deliver her in that circumstance is near her due date. And in certain cases, if we think everything is fine her blood pressures are normal at home, we can let her potentially go past her due date. So it’s really not sort of a problem if we err on the side of caution for her. It may just mean some extra visits that’s really it. And most people are usually perfectly fine with that.
Excellent. All right, Simi, thank you so much for talking about hypertension in pregnancy. I think that again, most of the time, it’s a mild form, it’s just some extra testing, extra monitoring, checking blood pressure at home and everything is fine with the mother and baby.
Occasionally, it’s difficult as she has you know, really high blood pressure and she had a bunch of medications and requires a lot of work. And okay, that happens and we can usually get her through the pregnancy. And then it’s really just monitoring to make sure the baby’s okay, and she’s not developing preeclampsia. And if those are both fine she’s gonna go pretty much to her due date and have a normal healthy delivery.
Dr. Gupta: Right, exactly. That is a very good thing about high blood pressure is most women do very well with it during pregnancy. And in the other cases, the extra monitoring can help prevent many of the complications we spoke about.
Dr. Fox: Thanks for coming on the podcast, Simi, I appreciate it. Great topic you’re always wonderful to talk to and look forward to having you back.
Dr. Gupta: Thank you.
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