Hypertensive Disorders of Pregnancy

 In the next episodes, I'm going to have friends sharing their experience with HELLP syndrome during their pregnancies. Today I will be sharing a little bit more about HELLP syndrome and other hypertensive disorders of pregnancy. If you're already lost, don't worry. I'm going to break it down for you.  

This episode is not intended to provide medical advice. Please speak to your medical provider before making any medical decisions. Additionally, it is important to keep in mind that evidence-based practice evolves. As our knowledge of science improves to the best of my ability, I will be presenting the most current  recommendations at the time the podcast is recorded, but that may not necessarily reflect the best practices at the time the podcast is heard.  

So let's start with hypertensive disorders of pregnancy. What does that mean? Hypertension means high blood pressure. So hypertensive disorders of pregnancy are all the possible disorders specific to pregnancy that fall under the category of high blood pressure. So what is high blood pressure? According to ACOG definitions, blood pressure is the force of blood pushing against the walls of the arteries, which are the blood vessels that carry oxygen from your heart to your lungs.

This is an important job because in the lungs, the blood picks up oxygen and carries it to your organs and tissues where it is dropped off, and then your veins carry your blood back to your heart. To start the process all over again. It is important to maintain blood pressure at an optimal range during pregnancy because blood pressure that is too high or too low can negatively impact the blood flow to your baby and thus the ability for your baby to receive the oxygen and nutrients it needs. 

When you take your blood pressure, there are two numbers that come up. Blood pressure is written with a number a slash, and then another number. And when blood pressure is reported, the clinician will say the first number. Over the second number. 

For instance, one 20 over 70. The first number or the top number, is called the systolic blood pressure. It is the larger number. The systolic blood pressure is the measure of the pressure of the blood against the walls of the arteries. When the heart contracts. The second number or the bottom number is called the diastolic blood pressure. It is the smaller number. 

The diastolic blood pressure is the measure of the blood pressure against the artery walls when the heart relaxes. So now that we have a better idea of what blood pressure is, let's talk about the ways that it can affect pregnancy. 

Worldwide  hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality. What does that mean? That means that problems with high blood pressure are one of the leading causes of death during pregnancy and the postpartum period. The global incidence of preeclampsia is two to 8%. 

And 16% of maternal deaths are due to hypertensive disorders. In order to screen for hypertensive disorders of pregnancy, your prenatal care provider will check your blood pressure at every visit. Now in a previous bonus episode of this podcast, Mike Goldstein discussed the hematologic changes of pregnancy. And if you haven't listened to that episode, be sure to go back and do so because it was great. 

The air date of that episode was November 25th, 2022. If you listen to that episode, you may remember that during pregnancy blood volume increases in order to support the demands of the baby. But the increased blood volume that occurs during pregnancy in order to nourish the baby increases demands on the maternal organs, specifically to the heart and kidneys. 

And if a pregnant person has one of the hypertensive disorders of pregnancy, this places increased stress on the maternal heart and kidneys. This stress can cause maternal complications, including heart disease, kidney disease, and stroke. Risks to the baby include preterm birth, increased risk of C-section delivery, and placental abruption, which is when the placenta detaches from the wall of the uterus resulting in maternal and fetal bleeding. 

So now that we have an idea of what blood pressure is and what happens to blood volume during pregnancy, let's learn about hypertensive disorders of pregnancy. 

There are three different categories of hypertensive disorders of pregnancy and they include the following: chronic hypertension, gestational hypertension, and preeclampsia, which can develop into eclampsia and/or HELLP syndrome. So let's start with chronic hypertension. 

Chronic hypertension is high blood pressure that is diagnosed before pregnancy or within the first 20 weeks of pregnancy. It is important to note that if you're taking medication for high blood pressure before you get pregnant, and while you are on the medication, your blood pressure reading is normal, you still have chronic hypertension. Your normal blood pressure reading while on blood pressure medication just means that the medication meant to control your high blood pressure is working. So do not stop taking your medication unless your doctor instructs you to do so. Chronic hypertension can impact maternal health by increasing stress on the heart and kidneys, and can lead to kidney disease, heart disease, and stroke. It also increases risk for preeclampsia, preterm birth, placental abruption, and C-section. This is why it is important to keep your blood pressure under control. 

Chronic hypertension can impact your baby's health by reducing blood flow to the placenta, which can lead to decreased nutrients and oxygen to the baby, which increases the risk for what is called intrauterine growth restriction, which means the baby's growth is restricted in the womb due to limited nutrients. 

In the first half of a normal pregnancy, the maternal blood pressure typically goes down. If your blood pressure is 140 over 90 or greater your medical provider may recommend blood pressure medication. Additional precautions for chronic hypertension during pregnancy may include monitoring your blood pressure at home, ultrasounds to track your baby's growth, and additional tests may occur in the third trimester if any growth problems are noted. Usually birthing people with chronic hypertension will be scheduled to deliver between 37 and 39 weeks. If the pregnancy remains stable up until that time. If you or the baby experienced complications delivery may have to occur sooner. After delivery, it is recommended that postpartum people with chronic hypertension continue to monitor their blood pressure in order to decide if medication is needed or if medication dose needs to be changed. Do not stop your blood pressure medication unless instructed by your medical provider. Additionally, your OB can tell you if your blood pressure medication is safe to take while breastfeeding. 

The next hypertensive disorder of pregnancy is gestational hypertension. Gestational hypertension is diagnosed in birthing people with a systolic blood pressure of 140 or higher that's 140 or higher and/or a diastolic blood pressure of 90 or higher beginning after the first 20 weeks of pregnancy. 

This is how we differentiate between chronic and gestational hypertension. So remember: Chronic hypertension is diagnosed before 20 weeks gestation of pregnancy, and gestational hypertension is when high blood pressure first occur after 20 weeks gestation of pregnancy. 

So birthing people diagnosed with gestational hypertension are usually monitored weekly for signs of preeclampsia and/or severe range blood pressure. 

Severe range is a systolic blood pressure of 160 or higher and, or a diastolic blood pressure of 110 or higher. And this can cause serious complications such as stroke. Gestational hypertension goes away usually after childbirth, but it may increase the risk of developing high blood pressure later in life. 

Okay. So those two hypertensive disorders of pregnancy are pretty straightforward and easy to explain. The next to get a little bit more complex. 

Preeclampsia ACOG defines preeclampsia as a serious disorder of pregnancy that can affect all the organs of the body. It usually develops after 20 weeks of pregnancy, but it can also develop in the weeks after childbirth. 

The signs and symptoms of preeclampsia include: swelling of the hands or face, a headache that doesn't go away, seeing spots or other visual changes, right upper abdomen or shoulder pain, nausea and vomiting in the second half of pregnancy, sudden weight gain, and difficulty breathing. If you have any of these symptoms, especially in the second half of pregnancy, be sure to call your obstetric provider right away. It is also important to be aware that preeclampsia yet can also develop quietly without symptoms, so it's very important to get routine prenatal care. 

Preeclampsia is often diagnosed by a high blood pressure reading as the first sign. Usually it is confirmed with a second high blood pressure reading. To confirm preeclampsia, there are usually additional lab tests, including urine tests to check for protein, and blood tests to check liver and kidney function and platelet levels. 

We don't completely understand why some birthing people develop preeclampsia, but we have an idea of what can put them at risk for preeclampsia. Having just one of the following may put a pregnant person at moderate risk for preeclampsia: Being pregnant for the first time; Being pregnant more than 10 years after your previous pregnancy; A body mass index or BMI greater than 30; Family history of preeclampsia, which includes a mother or a sister; Being aged 35 and older; Complications with previous pregnancies, such as a baby with low birth weight, In vitro fertilization; Black race due to stressors, such as racism and other inequities that increased stress hormone and thus increased the risk of illness; Lower income also due to increased stress levels and risk of illness. 

The following factors may put a pregnant person at high risk for preeclampsia: Preeclampsia in a previous pregnancy; Carrying multiples, which means twins, triplets, et cetera; Chronic hypertension; Kidney disease; Diabetes; auto immune disease; or having more than one of the risk factors that put someone at moderate risk. 

It is possible to attempt to prevent preeclampsia. If you have moderate or high risk, your OB may recommend that you take aspirin during your pregnancy in order to attempt to prevent preeclampsia. If you are concerned that you may be at risk for preeclampsia talked to your doctor. Do not begin taking aspirin without discussing it with your provider. 

A diagnosis of preeclampsia means that action will be taken to limit the possible complications and deliver the healthiest baby possible. The course of action is something that patient and OB will discuss. For preeclampsia without severe features, this likely includes blood pressure monitoring and kick counts at home, which is monitoring your baby's movement, and weekly or biweekly visits to the OB/GYN. Once the pregnancy reaches 37 weeks, the decision of when to deliver will be discussed. Usually this means a 37 week induction, unless there are other complications. If the baby is showing signs of distress delivery may occur sooner than 37 weeks. A diagnosis of preeclampsia means increased risk of kidney disease, heart attack, stroke, and high blood pressure later in life. Additionally future pregnancies are increased risk of preeclampsia. 

Now we're going to talk about additional complications of preeclampsia. The first complication we will talk about is preeclampsia with severe features. 

Severe features of preeclampsia include a low platelet count. Abnormal liver or kidney function. Right. Upper abdominal pain. Visual changes. Float in the lungs. Severe headache that does not go away with Tylenol. Systolic blood pressure of 160 or greater, and, or a diastolic blood pressure of 110 or greater. If you develop preeclampsia with severe features, you may need to deliver your baby sooner than expected. If you are greater than 34 weeks pregnant, Your OB may start talking to you about delivery. You will likely receive corticosteroid injections in order to help your baby's lungs mature. You will likely also receive medication for your blood pressure and magnesium to lower your risk of seizures.  

A person with preeclampsia is at risk of developing further complications, including eclampsia stroke or HELLP syndrome.  Let's first talk about eclampsia or seizures. It clamps yet occurs when a patient with preeclampsia has a seizure, the seizure is treated with magnesium and sometimes seizure medication as soon as possible. The severity of the seizure and the response of the baby after the seizure will determine how quickly and by what method the baby will be delivered. 

The next complication we're going to talk about is stroke. Anytime you have severe range, blood pressures, your risk of stroke increases. A cog defined stroke as a sudden interruption of blood flow to all or part of the brain. It's caused by a blockage or bursting of a blood vessel in the brain. Uh, stroke often results in loss of consciousness and temporary or permanent paralysis. Uh, stroke is a medical emergency. According to the CDC, the symptoms of stroke include sudden numbness or weakness in the face, arm or leg, especially on one side of the body. Sudden confusion, trouble speaking, or difficulty understanding speech. 

Sudden trouble seeing in one or both eyes. Sudden trouble walking. Dizziness loss of balance or coordination. Sudden severe headache with no known. Cause Call 9 1 1 right away. If you or someone else has any of these symptoms. 

An acronym to remember is act fast, F a S T to identify a stroke and save a life fast, stands for face. Arm's speech and time. If you have any of the facial symptoms listed above. If you have weakness in either of the arms, if you have difficulty speaking, you have a very short amount of time to get to the hospital. So as soon as you identify those symptoms, you need to call 9 1 1. 

The next complication of preeclampsia we're going to talk about is HELLP syndrome, Which is the syndrome that will be featured in the next few episodes of the podcast. 



So preeclampsia can turn into help syndrome. However new evidence suggests that help syndrome might be a separate disorder because 15 to 20% of HELLP syndrome patients have no high blood pressure or protein in the urine. Prior to developing HELLP syndrome. The acronym help. H E L L P stands for. Homolysis elevated liver enzymes and low platelet count. This is considered a medical emergency. And HELLP syndrome, red blood cells are damaged or destroyed. This damage interferes with blood clotting. 

It can also cause chest pain. 

Right. Upper abdominal pain. And bleeding in the liver. 

This is a life-threatening condition and women who develop HELLP syndrome may have lifelong complications. Additionally, having helped syndrome in one pregnancy can increase your risk for reoccurrence in subsequent pregnancies. 

HELLP syndrome should be treated in a hospital with a neonatal intensive care unit. Also known as NICU. Appropriate for the gestational age of the pregnancy. Your health and the baby's health will be monitored. And this will determine when to deliver. Treatment of HELLP syndrome includes Ivy magnesium therapy. To protect the mom from seizures and protect the baby's brain. 

A plan will be made for when to deliver. If the baby is less than 34 weeks in mom and baby are stable enough at the time of diagnosis. Uh, beta methadone injection. Which is a corticosteroid injection. Maybe started to speed up the baby's lung development. 

Patients with HELLP syndrome have a 19% to 27% risk of developing. HELLP syndrome. In subsequent pregnancies, the risk can be diminished by maintaining a healthy lifestyle. And appropriate prenatal care. 

HELLP syndrome may also have an insidious or atypical onset. With up to 15% of patients without high blood pressure or protein in the urine. In HELLP syndrome, The main presenting symptoms. Our upper right. Abdominal pain. And generalized malaise in up to 90% of cases. And nausea and vomiting in 50% of cases.  





 Now that we've discussed all the hypertensive disorders of pregnancy, I'm going to share a little bit of other information. The first information I'm going to share with you is something that we call urgent, maternal warning signs. These  list of symptoms. That if you experience, you need to report to your healthcare provider right away. Headache that does not go away or gets worse over time. Dizziness or fainting. Thoughts about hurting yourself or your baby? 

Changes in your vision. Fever of a hundred 0.4 or greater. Trouble breathing. Chest pain or fast beating heart. Severe belly pain that doesn't go away. Severe nausea and vomiting, not like morning sickness. 

Babies movements stopping or slowing. 

Vaginal bleeding or fluid leaking during pregnancy. 

Swelling redness or pain in your leg. Extreme swelling of your hands or face. Or overwhelming tiredness. 

If you have any of these symptoms during or after your pregnancy. Contact your healthcare provider and get help right away. If you can't reach your healthcare provider. Go to the emergency room. And remember to say that you are either pregnant or have been pregnant within the last year. This information is from safer birth.org. And the hospitals that I work at are posting these symptoms everywhere. And including them in all of their discharge paperwork. 



lastly, I want to share the results of some studies. That are pertinent because the friends that I'm interviewing for the help syndrome episodes. We're all living in Colorado at the time that they developed help syndrome. They were all at high altitude And in the past decade or so.  there have been retrospective studies, which means that Medical records have been accessed in order to see the demographics of patients that have experienced hypertensive disorders of pregnancy. In these studies, it is starting to become clear That being at high altitude, such as being in Colorado. Places women at greater risk for hypertensive disorders of pregnancy.  





 In particular, there is one study in pub med that came out in April of 2022. That studied women across a 10-year period of time in Colorado. 2007 to 2016. And the results showed that statewide high altitude residents had a 33% increased frequency of each of the hypertensive disorders of pregnancy. 

Additionally the frequency of low birth weight infants five minute app Gar scores of less than seven in NICU admissions were also greater. at higher than lower altitude. So the conclusion of this study is that residents at high altitude. Increases the risk of hypertensive disorders of pregnancy. 

And the study recommends increased clinical surveillance for those who are at high altitude at the time they are pregnant. Additionally, at least one of the friends that I interviewed had a mutation in the MTHFR gene. 

This gene provides instructions to make an enzyme called methylene tetrahydrofolate reductase. This enzyme helps to process amino acids that are building blocks of proteins. There are studies that show that variations or differences in the MTHFR gene are associated with increased risk for many common conditions Like heart disease, stroke, high blood pressure and preeclampsia. MTHFR is a gene that helps metabolize folic acid. Which leads to the breakdown of an amino acid called homocysteine. Homocysteine is increased in heart disease, stroke, high blood pressure and preeclampsia. 

So without the MTHFR enzyme, metabolizing folic acid and breaking down homocysteine, Someone may have extra homocysteine in their system leading to increased risk of heart disease, stroke, high blood pressure and preeclampsia

The reason that I'm sharing all this is because. Again, as I said, All of the friends that I interviewed were at high altitude. And so that may have, according to studies increase their risk for preeclampsia. And the help syndrome that developed. And at least one of the friends interviewed, had a mutation in the MTHFR gene, which also. May have increased her risk for preeclampsia and HELLP syndrome. 

So the reason that I explained all of this is because I want you to have an idea of we're talking about when we listen to the next episodes. Where my friends tell their stories with help syndrome. And I also want to bring awareness to other birthing people so that they know Why their provider.  

May be checking their blood pressure frequently, checking their urine frequently. Why it's important to do prenatal visits. Regularly and to get appropriate prenatal care. And So that birthing people know the risk factors that they might have. for hypertensive disorders of pregnancy. 

If you have any of the risk factors that I listed, or if you have any of the symptoms that I talked about today, please see your healthcare provider. Please make them aware and take the appropriate actions because These are serious disorders. That can be treated. and if you act soon enough, it could save your life or your baby's life. 

Thank you for listening today and be sure to tune in to the next episodes where my friends share their personal experiences with HELLP syndrome.  





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You're in luck because I'm offering this as a free service in 2023. To get details on how to schedule a free session with me, email me@birthjourneysarenatgmail.com.