There are few times that I become gravely concerned about the way medicine is practiced and this is one of them. A recent medical study in the Journal of Hypertension reported some startling facts: pregnant women are receiving blood pressure medication that might be harmful to their babies.
When physicians decide to specialize in obstetrics, we know exactly what we’re getting into. We have two patients, both mother and unborn baby and we don’t want either to die. Each year 4 million babies are born in the U.S. and between 6 to 8% of their mothers will have high blood pressure. Why are physicians and healthcare providers concerned about high blood pressure? Because if untreated, it can cause a stroke leading to death.
During pregnancy, a patient can have there are 3 types of high blood pressure: (1) chronic hypertension that occurs before 20 weeks, (2) gestational hypertension that occurs after 20 weeks but is not associated with protein in the urine and (3) pre-eclampsia that occurs after 20 weeks and is associated with protein in the urine. Pre-eclampsia, if untreated can lead to seizures (also known as eclampsia) and strokes. It is one of the most common reasons for death as a result of pregnancy. The treatment for pre-eclampsia is the delivery of a baby because the placenta is causing a problem. If the patient’s blood pressure is extremely high and life-threatening, medicine is also given to prevent the woman from having a stroke until she is delivered.
On the other hand, chronic hypertension is treated with medication during pregnancy to prevent strokes from occurring. But what type of medicine? The FDA classifies medicines in 5 categories from “A” to “X” to describe how they will affect the unborn baby. Category A poses no harm to the baby and Category X should never be given because it has been proven to cause birth defects. The blood pressure medication Lisinopril is a category X medication. It should never, never be taken during pregnancy.
Pregnant moms please read those labels and ask questions before taking medication. A healthy pregnancy doesn’t just happen. It takes a smart mom who knows what to do.
According to CDC, there has been a 54 percent increase in the number of pregnant women who’ve had strokes in 1995 to 1996 and in 2005 to 2006. While this may surprise some researchers, it certainly would not surprise clinicians who take care of pregnant women who have risk factors such as obesity, chronic hypertension or a lack of prenatal care. Ten percent of strokes occur in the first trimester, 40 percent during the second trimester and more than fifty percent occur during the post partum period and after the patient has been discharged home. Hypertension was the cause of one-third of stroke victims during pregnancy and fifty percent in the post partum period. Hypertension accounted for one-third of stroke cases during pregnancy and fifty percent in the post partum period. Many stroke cases might be prevented if blood pressure problems were treated appropriately during pregnancy.
Pregnant women who have high blood pressure during the first trimester are treated with medication and are classification as having chronic hypertension. The problem occurs when patients begin their prenatal care late and have high blood or when a diagnosis of pre-eclampsia is missed. Pre-eclampsia is a clinical condition that includes high blood pressure, protein in the urine and swelling of the hands, face, ankle or feet. Should patients be treated with medication or should their babies be delivered? The diagnosis may not be straight forward. The patient’s blood pressure could be high but there’s no protein in the urine. Or the patient may have high blood pressure that returns to normal with bed rest. Or the patient is only 26 or 27 weeks but has high blood pressure and a diagnosis of pre-eclampsia but the practitioner is hesitant to deliver the baby based on its prematurity. Or the patient is hospitalized for high blood pressure and then the blood pressure returns to “normal” so the healthcare provider inadvertently sends the patient home. Or the patient had high blood pressure, delivered a baby, is sent home and then has a seizure and ultimately a stroke.
What should a pregnant mom do to prevent a stroke? If you have blood pressure problems during your pregnancy, insistent on obtaining a consultation from a high-risk obstetrician (aka maternal fetal medicine specialist) even if you think your present obstetrician or midwife is managing your prenatal care appropriately. A second opinion never hurts and in some cases, it can save a life. Two heads are always better than one.
With the advent of 3-D and 4-D, ultrasound, we “see” the behavior of the fetus in much more detail but research of its life in the womb can now predict how it will affect our health as an adult. Fetal origin research is a hot topic of discussion that was discussed in this Sunday’s New York Time, by Harvard University Professor, Dr. Jerome Groopman.
The discussion of maternal lifestyle and its affect on the fetus is nothing new. Most pregnant women are aware that smoking causes small babies, premature births and placental separation, commonly known as placenta abruptions. Drinking alcohol can cause the Fetal Alcohol Syndrome that includes mental disabilities. Marijuana affects the fetal heart rate. Cocaine and crack abuse causes placenta abruption, pregnancy induced hypertension and irregular maternal heartbeats that sometime cause death. Untreated sexually transmitted infections can cause premature birth and potential infant blindness and obesity can cause gestational diabetes in addition to a myriad of other health issues.
What IS new is the association between fetal conditions in the womb that and chronic adult diseases. A federal study by the National Institute of Child Health and Human Development (NICHD) demonstrated that intrauterine growth restriction (IUGR), is associated with babies who develop hypertension and heart disease as adults. IUGR is a pregnancy-related condition where the fetus stops growing or grows at a slower pace than expected. Babies with IUGR are usually delivered early because they stop growing inside the womb and are at risk for dying because of a lack of nutrition.
A British physician, Dr. David Barker, published a study in 1989 suggesting that a mother’s poor nutrition can increase the risk of heart disease of the child decades later. Although scientists initially scoffed at his theory, science ultimately proved him to be correct. The Barker Theory, as it has come to be known, is presently used in an attempt to unravel the mystery of chronic illnesses such as coronary heart disease, stroke, Type 2 Diabetes and obesity, osteoporosis, breast and ovarian cancer.
Can life in the womb affect our lives years later? Probably. Should pregnant women panic if they develop IUGR? Absolutely not. Knowing the future risk factors of a baby empowers its mother to run interference with lifestyle changes and interventions before he or she becomes an adult. Nothing is ever written in stone. To be forewarned is to be forearmed.
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
I really didn’t want to go work that day. I was battling the healthcare blues. Nor did I want to see my first patient.
She was big, angry and intimidated the hell out of my staff; and she wasn’t used to being up so early. She eyed me as I walked past the exam room and I had eyed her as well. My staff was considering calling security.
I entered the exam room then calmly sat down; feeling her stares piercing the back of my head. I reviewed her chart. It was complicated. And she was waiting for me to pass judgment so that she could rip me to shreds. But there would be no judgment from me that day. I had seen her anger reflected in the eyes of my own mirror. I knew what it was like to feel her pain.
Her health problems were a mile long; each one compounding the other. And her lifestyle certainly didn’t help. The first order of business was to lower her alarming blood pressure before she ended up having a stroke. She had been given five different medications in the ER; all inappropriate for a pregnant woman. Thankfully she hadn’t taken any. We called the social worker, who came right away and then we began to chisel away at her problems. She had fallen short of life’s expectations and had alienated her family, but this pregnancy had given her the courage to try again. She was not young and neither was her partner. The baby represented their second chance for redemption.
By the end of her visit, I gave her a hug. She clutched her new prescriptions with pride. She entered our clinic as an angry woman but departed with a smile. And I remembered — why I became a physician.