chronic; should I see a MFM?

[expert@preeclampsia.org]

I am 33 years old and have chronic (essential) hypertension. Outside of times where I am trying to conceive, I am well controlled with Lisinopril with HCTZ. With my first pregnancy (4 years ago), I had blood pressure problems beginning around 28 weeks. I was placed on bed rest and then induced at 35 weeks (although my baby girl weighed 8 pounds, was 20" tall and completely healthy - I believe my due date was wrong.) During my pregnancy I had blood in my urine. My blood pressure problems only worsened after delivery. I was on labatelol for over a week in my effort to breastfeed, but got so out of control I finally landed in CCU with an internist taking over my case. I was on a cocktail of 7 different blood pressure meds for control. Of course I eventually weaned myself to 2. I believe that part of my problem was due to improper care post partum by my ob/gyn doctors. Please note that I was never preeclamptic, and a renal ultrasound post partum showed that everything was functioning normally. One other note, I had chronic hypertension before my 1st pregnancy but was unaware of it (I had high blood pressure before 9 weeks gestation) and was not controlled by medication.

I would now like to have another child but of course am aware of the risk. Since my first pregnancy, I have lost 30 pounds - I am 5' 11" and 170 pounds - a "healthy" weight as determined by BMI calculator. I have switched my blood pressure medicine to aldomet and am controlled on 250 mg 3/day. My ob/gyn and internal medicine doctors have given me the green light to get pregnant. I am trying to evaluate my true risk - sometimes when I look at information I feel very reluctant and overwhelmed, at other times I feel as if I can make it. I have two specific questions I would like your help on as I am trying to decide:

1) I am consulting a perinatologist for prenatal counsel, but I live in a small town in Northwest Arkansas and am 3 hours away from the closest perinatologist (Little Rock). Is it wiser for me to use my ob/gyn here? I am very confident in my ob/gyn here but of course he does not officially have perinatology experience. But we have discussed my pregnancy at length and have a solid post-partum plan and he has taken all of my information from my 1st pregnancy to help us with the 2nd. I am not sure how beneficial a perinatologist 3 hours away might be - how might that work?
2) I get somewhat confused on how my absence of preeclampsia in my first pregnancy might affect my 2nd. Since I was not preeclamptic with first is that a "good" sign - meaning it is unlikely I will develop it with my 2nd? Or does the existence of my chronic hypertension mean I have increased risks for super-imposed preeclampsia in my 2nd as well (regardless of what my 1st pregnancy was like)?

Thank you for any help you might be able to provide. I would love another child but am wanting to make sure I am as responsible as possible before taking the risk. Thank you again!

[expert@preeclampsia.org]

A patient with chronic hypertension is at greater risk of developing preeclampsia in any pregnancy. You appear to be what is labelled a high risk chronic hypertensive (versus a low risk) based on just your past history, especially the early pregnancy severe hypertension.

Recommend sticking with your OBGYN for most care and seeking consultation early in pregnancy (first 14 weeks) with a maternal-fetal medicine specialist in Little Rock who will get to care for you later in pregnancy should you develop complications. Essential components of your care include early ultrasound to date your pregnancy, baseline blood and urine chemistries to baseline your kidney function for comparison purposes later in pregnancy, dietary considerations, multivitamins with folic acid started before efforts to conceive, and possible change to other antihypertensives before midgestation occurs at 18-20 weeks.

A maternal-fetal medicine subspecialist is an OBGYN with 2 or 3 extra years of training to manage high risk pregnancy, appropriate to your circumstances. Were you close to Little Rock, you would be appropriate to have MFM care throughout pregnancy. Your OBGYN at home will likely see you every two weeks to monitor things, will recommend that you keep a daily log of blood pressure measurements using a home device, keep daily weights, and so forth.