When would OBs want to start BP meds?

[p+h]

Hi everyone,

I'm 12 weeks into my second pregnancy (first pre-e diagnosed at 36+5 after some weeks of rising BP), and starting to worry. I've had several readings over the course of yesterday of about 118/90. During my last pregnancy we and our MW were watching my pressure rise after 30 weeks, and sought Dr care when it got to 160s/90s consistently. I'm very worried that at 12 weeks I'm already seeing this diastolic number of 90.

I have never been on BP meds, except during my induction and delivery at the end of 36 weeks. And having gone from HB midwife to, oh gosh, let's get you to the hospital last time, I'm feeling very nervous about anything in between.

I'm going for an Ultrasound and MFM consult today. My hope was to get some great news that would help us feel good about pursuing a home birth this time, but now I'm worried they will want to prescribe meds and start me on a high-risk visit schedule or something.

In anyone's experience, when are BP meds recommended? I'm hoping if I'm not to that level yet, they will say ok watch it, and the protein, and call us if it gets to XX/XX.

Of course my appointment is in just hours, and I'm feeling very clueless. Trying to remember, this is still just the information gathering stage, I'm not going to be thrown in the back of an ambulance and carted off .

[alexis]

Hypertension prior to 20 weeks is generally considered to be chronic hypertension (which may be unmasked by pregnancy--I believe we have posters here who see their BP rise in every pregnancy, but have normal pressures outside of it).

As a chronic, my experience has been that while it does not get you a full "high risk" schedule (this has a specific definition, at least per insurance) it does mean extra monitoring and visits because chronic hypertension itself is potentially dangerous, even if superimposed preeclampsia does not develop. I have been OB led for both pregnancies (UK and US).

The question of when to begin meds hasn't been settled. There seems to be agreement that the benefit definitely outweighs the risk for severe hypertension (I've seen a couple of cut-offs, from 160/100 to 170/110). The benefit for mild hypertension is unclear. In addition, there is a theory that the fetus is "set" to the pressure at the beginning of pregnancy, and you don't want it to stray too far from there. So if you actually begin pregnancy at 140/95 (as I did with my first) you don't then try to drop it to 120/80. I saw a target of 140/90 mentioned for women who were beginning antihypertensive therapy in pregnancy, though I have known of OBs who set a slightly lower one. There's less emphasis on tight control in pregnant women.

[p+h]

Thank you so much, Alexis. That is such helpful information. I'm happy to say that two OBs today told me they wouldn't medicate the pressure I have, and are fully aware of my desire to continue care with my MW. But it's nice to hear those ranges.

[cc]

P+H - so are you planning a homebirth? I'm in a similar situation of trying to decide where to have care (I've moved away from my previous m/w and birthing center) - a doc vs m/w. I would really prefer a m/w in a birthing center but things are so different here that I'm having a hard time finding someone who wouldn't transfer me at the very end. If you get on meds will your m/w transfer you to a doc?

[alexis]

Not the OP, but my experience has been that medicated hypertension is frequently risked out to OB, though occasionally, a CNM may continue care in cooperation with an OB. In my first pregnancy, I was on the NHS and was under consultant (OB) care and booked for consultant unit (hospital L&D) delivery. My trust risked all hypertensive patients out of midwifery care, gestational or chronic, regardless of medication. Second pregnancy was a university based group practice in the US and I was booked for OB only.

There are a couple of reasons for this:

1) A hypertensive patient is no longer a simple low risk pregnancy, especially if her hypertension has reached levels that require medication.
2) A hypertensive patient may require more frequent or intensive monitoring than a midwife-only practice can offer. (Regular non-stress testing, BPPs, growth u/s)
3) Hypertensive patients (and their babies) are at increased risk of complications during both pregnancy and labor.