Chronic high bp and searching for provider

[dancerwritermom]

I hope this question belongs here...I did not post in health and healing because my question relates specifically to pregnancy and childbirth, and I did not post in TTC because most of the posts there are about BFPs, which is super exciting but I'm not to that stage yet!!!

I want to TTC next year (I'll be 35) and would like to get my high bp under control and need a care provider. Our birth center will not accept clients with chronic hypertension. I want to bring a child into the world with the loving support of my partner rather than the support of drugs and machines and a medical team. I have wanted a natural birth ever since the medically managed birth of my daughter. You name an intervention, I had it. In addition, my partner does not have biological children and he is totally committed to this experience, to raising them naturally from conception onward.

My story: I had two normal pregnancies (with the exception of high bp toward the very end of my first). Last fall I went to a family doctor for STD testing because my ex-husband cheated on me and I was starting a new relationship and wanted to be sure I was completely healthy. I was, except for high bp. I checked it at pharmacies over the next few months, and it was consistently stage 2 high (around 170/110). I started Toprol two months ago and now it hovers around 120/80. I eat well, exercise regularly, I am not overweight, do not smoke, and am not on hormonal birth control. I do have a family history of high blood pressure but beyond that I can't think of a reason why I have it. My bloodwork (CBC, chemistry panel) and EKG were normal.

So do I have to get a high-risk provider??? Has anyone used a midwife with chronic high bp or do they simply not accept those clients?

[chellebee]

In my experience/state, LM's won't take you if you are over 140/90. They also won't take you if you are on bp meds. There are CNM's here that will do hospital births with you and it looks like as long as your bp remains under control with the meds, you can stay in your care. I have heard different comfort levels with them, but averaging 150/100 as a max before you to go back up OB or peri.

I have to wonder how accurate the 170/110 readings are for you since you said those are pharmacy readings. Those are so notoriously off--the readings are usually too high. I have had good luck with a good home cuff. Another thing you might be interested in is acupuncture. Depending on what your underlying issue is, acupuncture can be AMAZING for bp. I have been able to get mine down into a normal level and maintain it so far in this pregnancy with acupuncture, well enough to be under LM care. IMO, it's worth a shot, especially since you're not pregnant yet!

[AlexisT]

170/110 is very high. You'd probably need to remain medicated during pregnancy. Unfortunately, many hospital CNMs are not able to take clients who remain on antihypertensives, even though (according to the MFM I consulted) chronic hypertension should continue to be managed by your PCP, not your OB, unless complications such as preeclampsia develop. (I've been told that I cannot be seen by any of the hospital midwives in my area, though in my case, I also experienced severe preeclampsia in my first pregnancy.)

Women with chronic hypertension have an estimated 20-25% chance of developing superimposed preeclampsia, in addition to other complications (higher risks of IUGR, placental abruption, and stillbirth). It all adds up to you being a higher risk pregnancy, and for good reasons.

I would look for a natural birth friendly OB and hospital, if a CNM cannot take you. (Sorry, just re-read and saw your weight is normal - ignore that.) How is your salt intake? Not everyone is salt-sensitive (I'm not) but it does help to get your baseline as good as possible before getting pregnant.

[dancerwritermom]

The 170/110 was in the doctor's office. At the pharmacy it was as high as 190/110.

I had not considered accupuncture...also how about magnesium? I have heard good things about that.

A hospital birth with a CNM would be a good option...there is actually an OB group in a neighboring county that has midwives...I'm going to look them up now--thanks for reminding me of that option!

[Kidzaplenty]

[Defenestrator]

I would recommend trying to find a CNM practice that has a good working relationship with MFM doctors, maybe at a teaching hospital. I think that you could be seen by CNMs at my local hospital, with occasional consults with the MFM doctor or your PCP for the meds.

I have taken on women who were medicated for chronic hypertension in the past in my homebirth practice, and they had enough complications that I can't really recommend going that route. If those same women got pregnant again I would probably work with them as long as I felt they had really good informed consent, but even if there aren't the big scary problems in a pregnancy with chronic hypertension like pre-eclampsia or placental abruption, women who have high bp's at birth tend to bleed more and their anti-hypertensive drugs interfere with their bodies' adaptive processes if they do bleed too much, so the bleeding is more likely to have a strong impact on them or endanger them.

[dancerwritermom]

Woo hoo! I left a message yesterday with a local CNM practice that delivers in a hospital as well as a birth center, and has an OB that they consult with. She called back today and was very nice. She said since I am otherwise healthy and had two uncomplicated vaginal deliveries, and since my BP is easily controlled with meds, that I should come in for my next annual GYN exam and that they would keep me on during a future pregnancy as long as my BP remained under control on the meds. Regardless, I would need to deliver in the hospital but she would attend unless my BP got out of control. In that case, she would refer me to the OB that she works with and I would deliver under his care. She added that he is not a fan of a lot of interventions or otherwise she would not be working with him.

AND this place takes my insurance as well as most major insurances in my area. I feel SO lucky to have this group in my area. The other local group delivers only in a birth center or at home so they would not accept me.

[dancerwritermom]

Alexis...good question about the salt. When I got divorced I started eating in restaurants more often, mainly because I was stressed out about being a single mom and it was easier and more fun to say, "Hey, let's go out for dinner!" But since I have been in a new relationship I have been doing better. He is a health nut and we inspire each other. We shop at Trader Joe's and Whole Foods a lot like I used to, and eat fewer carbs and more whole foods, make stuff from scratch, etc. It was just an adjustment to be the only adult in the house after being married for 10 years and go in the kitchen and make a big healthy meal for two kids and me.

So eating better, combined with the women's multi-vitamins from GNC and maybe some extra magnesium may help. Also I was on Zoloft for a little while (I was on it for two years with no high bp) and now I am weaning off of it so that may make a difference in the bp too.

[Bokonon]

Wow, that's really high blood pressure! I would also highly recommend acupuncture. After having severe preeclampsia, my BP was still higher than my normal and hovering around 120s-130s/80s. After 3 acupuncture sessions, it dropped down to my normal of 100/60, and has stayed there.

Good luck to you!

[beanma]

Gosh, I had no problem. I've had essential hypertension for...oh, 16 or 17 yrs. Runs in my family, too. I was on HCTZ pre pregnancy and am now on Lisinopril and HCTZ. I've had readings that high and while it's definitely something to get under control (sounds like you have) it's not _that_ high. In pregnancy it would be alarming, but a regular care provider is not going to freak out over those numbers.

I'm not familiar with your meds. Make sure they're compatible with pregnancy. Your pregnancy care provider should monitor your BP, not another doctor. Pregnancy can cause many shifts in BP, both upward and downward. Typically, the second trimester can cause a drop in BP. I was able to go off meds entirely for both of my pregnancies, but after my 2nd I had a rise in blood pressure in the few days after delivery. You should continue to be monitored closely after delivery also. You can develop pre-eclampsia post partum. My first dd1 was delivered in a hospital, but my 2nd was a birth center birth attended by midwives and they never batted an eye at my BP. It was really a non-issue and I was 39 yrs old (advanced maternal age) at the time of delivery. I don't know why you're getting such a hard time about it. I had no problems at all with my BP. It did go up after delivery, but it was never an issue of great concern. I did have to go back on meds at some point.

Anyway, one other thing I wanted to add. My thyroid is also low and I'm on meds for that, too. If your thyroid is low/undertreated it can cause both high bp and high cholesterol, so it might be worth it to get your thyroid levels checked.

[dancerwritermom]

Interesting, beanma. I had thyroid cancer 14 years ago and I take replacement hormone...my dose has remained steady and my blood levels have remained steady. Never had any problems. I do need to get it re-checked in the next month or so...but my understanding is that high thyroid levels (low TSH) = high bp and low thyroid levels (high TSH) = low bp. Is that right?

How high was yours? Mine was too high to treat with HCTZ.

[beanma]

Hmmm...not sure if you've got that right about the thyroid. I think maybe both low and high TSH, etc, can affect BP. I am hypo (low) and if it's not adequately treated my bp and cholesterol go up. My dose was adjusted last summer in an effort to get my cholesterol down (it was 270+!) and it did come down 70 pts to about 200. My TSH was about 3 which was within normal range, but we made a slight adjustment (at my request) to get it closer to 1 and the cholesterol came down, plus I felt a bit better. I'm so used to be cold and tired that it can creep up on me and I don't really pay attention to it. I haven't had to have it adjusted that much in the 16+ years I've been on. I think I started at 75mcg and worked my way up now to 100mcg.

About that time my BP was high (170/110) and the midwives who I had continued to see for years for well woman care were freaked out because BP that high in pregnancy is very significant—not that I was pg, but their experience with BP readings like that was "transfer to the hospital". I had to scramble to find a new doc because my issues—while nothing really unusual—were getting out of their comfort level. They brought in a consulting doc while I looked for a new doc and I suggested to the consulting doc that if they wanted to add a med they might try Lisinopril (ACE inhibitor) (10mg) because my sister takes it and tolerates it well. They did add Lisinopril (10mg), but kept me on the HCTZ (25mg), also.

A note here about my sis, she's very petite and has been a marathon runner for many years and has essential hypertension and high cholesterol and hypothyroidism. I am not a marathon runner, and could be definitely more fit though I'm not more than 10-15lbs over my ideal weight, so I have felt if she has high bp I'm not likely to get mine under control by just diet and exercise since my diet is pretty good.

Anyway, the consulting doc said okay. So I started on the Lisinopril and then I found a new doc. She agreed to adjust the synthroid/levothyroxine dose (from 88 to 100mcg). Consequently I needed to halve the Lisinopril (to 5mg) cause it was sending my BP too low and I was barely able to function (96/68). I really felt as bad as if my thyroid were off—just horribly, horribly sluggish like "I think I can make it up the stairs" kind of sluggish. My BP now is about 110/75 which is quite low for me. I used to be consistently 120something/80something. I have wondered if I went off the Lisinopril what my BP would be, but it's not really an experiment I feel strongly about since the Lisinopril isn't having any side effects that I've noticed.

Anyway, I'm just surprised you had to hunt around so much to find a midwife who would take you with high BP if it's well controlled. Maybe it's because of your previous pregnancy where your BP went up? Neither the OB who provided me care during my first pregnancy, nor the midwives at the birth center where I had my second batted an eye at my BP history since it was under control. I've had high BP since, gosh, mid 90s? I'm pretty sure I was in my late 20s, but maybe I was in my early 30s. Anyway, it's been so long I can't remember now and I'm 46. I'm not in a particularly midwife friendly state, either, but I am in a crunchy area.

Glad you've found someone who will take you on. Do make sure the med you're on is okay during pregnancy. They might want to change you around before you TTC if it's not. HCTZ wasn't really ideal for pregnancy since it's a diuretic and they want you to keep up your fluids during pg, but it wasn't a threat to the baby. They had me stop it and try something else with my first, but the pregnancy had already started to drop my BP and the meds knocked it so low I could barely walk up the driveway. I monitor it periodically at home (if it's being ornery) and it was about 96/68 so I stopped the meds and watched it and talked to the nurse practitioner who advised that was the right thing to do. It never went back up during that pg and nursing kept it down, too. DD1 nursed a LOT! IIRC, I didn't have to go back on meds until 3 years later after dd2 was born.

hth, sorry I wrote a novel!

[AlexisT]

Toprol XL is a beta blocker. It's not one of the preferred pregnancy meds, but it's okay. Category C. I was told by an MFM that none of the meds really start affecting the baby until the 2nd trimester. Beta blockers are recommended for childbearing women for this reason, even though they are not that effective at controlling hypertension. (I am also on Toprol XL and have chosen to stay on it while TTC--ideally I would be on an ACE inhibitor.)

ACE inhibitors (and ARBs) are the big no-nos in pregnancy.

Defenestrator: Not all MFMs will handle chronic hypertension. My RE referred me to MFM for preconception counseling and I got told that they don't touch it unless complications develop. In his view, chronic hypertension is an issue for your PCP to manage, even in pregnancy--it's fundamentally not an obstetric problem. It can be a mess and I have a sinking feeling about it.

My internist would hit the roof if I showed up with a diastolic of 110. That is serious hypertension, pregnancy or not.

[dancerwritermom]

Thanks so much beanma and alexis for the extensive information!

The midwife did say that my PCP would handle my bp during pregnancy. And she said toprol is okay but there are better meds. She may have mentioned Lisinopril...anyway I have to get back to work at the moment instead of poking around on MDC but I wanted to acknowledge that I read all that you wrote and really appreciate it.

[AlexisT]

Lisinopril is a better med generally (if you are under 55 and not of African descent, ACE inhibitors are the BP med of choice), but NOT for pregnancy. ACE inhibitors have been linked to birth defects.

The best tested meds in pregnancy are Aldomet (methyldopa), labetalol, and Procardia/Adalat (nifedipine).