Maggie McKay (Host): Welcome to Conversations like No Other, presented by Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad, everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm your host, Maggie McKay.

Today, we have with us Chelsea Benell, nurse practitioner with the Cardiac Screening and Outreach program to talk about pregnancy and hypertension. Thank you so much for being here today.

Chelsea Benell: Thanks for having me, Maggie.

Host: So, let's dive right in. What exactly does it mean when we hear the term hypertensive disorder of pregnancy?

Chelsea Benell: So, you know, a hypertensive disorder of pregnancy is very much what the name implies. It is having high blood pressure. Typically, we look at the number of 140/90 or greater to watch out for before, during, or even after a pregnancy. Hypertensive disorders of pregnancy are actually one of the leading causes of maternal and perinatal mortality worldwide. Sixteen percent of maternal deaths can be attributed to hypertensive disorders. There are actually several subsets and definitions that fall under this umbrella term. And I would like to walk you through each of these categories carefully, because it is important to understand the differences and that there's sort of a progression in severity.

So first, I'll mention chronic hypertension, which is high blood pressure that occurs before 20 weeks' gestation. This can be hypertension or high blood pressure that exists even before a woman becomes pregnant. And then, we kind of move on to gestational hypertension, which is blood pressure greater than or equal to 140/90 on two occasions, at least four hours apart after that 20 weeks of gestation during a woman's pregnancy, in a woman with previously normal blood pressure. And this occurs actually without any protein in the urine or other severe features that's gestational hypertension.

Then, we move on to preeclampsia, which can be with and without severe features. So, I'll first talk about preeclampsia without severe features, which is defined as blood pressure greater than or equal to 140/90 on two or more separate readings, at least four hours apart after 20 weeks' gestation in a woman with previously normal blood pressure. And we see protein in that patient's urine or a low platelet count, impaired kidney function, impaired liver function, pulmonary edema, or new-onset headache that does not respond to medications, visual disturbances like floaters or blurry vision. It is important to note that the management of gestational hypertension and preeclampsia without severe features is relatively the same, but both importantly require increased surveillance.

So then, preeclampsia can occur with severe features and that is defined as blood pressure greater than or equal to 160/110 on two or more occasions, at least four hours apart, and having any of the following: low platelet count, impaired kidney function, impaired liver function, pulmonary edema, headache that doesn't respond to medications or visual disturbances like floaters or blurry vision. It is a common misconception that the risk of pregnancy-induced hypertension. And preeclampsia is gone once the baby's born. Hypertension and preeclampsia often develops in the postpartum period as well.

And I'd like to define two other more severe forms of preeclampsia that people might hear. One is actually HELLP syndrome, H-E-L-L-P syndrome. This is a severe form of preeclampsia and it stands for hemolysis, elevated liver enzymes, and low platelet count. It is associated with increased rates of maternal morbidity and mortality. And certain diagnostic criteria are used to help diagnose HELLP syndrome as noted in the definition of the diagnosis. Characteristic of this is pain in the right upper area of the abdomen, generalized malaise in about 90% of cases, and then nausea, vomiting in about 50% of cases.

And then, finally, the last and most severe form of hypertensive disorders of pregnancy is eclampsia, which is defined by new-onset seizures in the absence of other causative conditions such as epilepsy or brain bleed, or drug use, et cetera. This can occur before, during, or after labor. And in many cases, the seizures are actually proceeded by signs such as persistent headaches or blurry vision, sensitivity to light, or even a change in mental status. However, some women do not demonstrate these classic signs of even hypertension before the episode would happen.

Host: Well, how do these diagnoses differ from regular or chronic hypertension?

Chelsea Benell: So as I kind of mentioned before, a chronic hypertension is high blood pressure that you develop before getting pregnant or that develops in the first half of that pregnancy, before that 20-week mark. Some women that develop gestational hypertension or have preeclampsia will require medications to manage their blood pressure even after delivery. Sometimes the blood pressure normalizes, and other times they go on to be diagnosed with, you know, chronic hypertension.

Host: Why does blood pressure become such a big concern during pregnancy?

Chelsea Benell: So, high blood pressure during pregnancy is both a concern for the pregnant person and for the unborn fetus or baby. Pregnancy causes the body to make more blood to support the growing fetus. If blood pressure goes up during pregnancy, extra stress is placed on the heart and kidneys. This can lead to heart disease, kidney disease, and stroke. It also increases the risk of developing preeclampsia, having preterm birth, low birth weight, placental abruption or rupture of the placenta and cesarean birth. High blood pressure also reduces blood flow to the placenta, which is how a fetus gets its nutrients and oxygen. This restricted blood flow can thus prevent the baby from growing or getting enough of the nutrients and oxygen that it needs.

Host: Chelsea, who is the most at risk for pregnancy-related hypertension?

Chelsea Benell: So, there are actually several varying factors that may make a woman higher risk for developing hypertensive disorders of pregnancy. And so, I kind of want to break those down into some categories. There are factors in a woman's medical history that increase the risk for developing hypertensive disorders of pregnancy, such as having chronic hypertension; preexisting diabetes, either type 1 or type 2; chronic kidney disease. Certain autoimmune diseases such as lupus or antiphospholipid syndrome, having a history of preeclampsia or other hypertensive disorders in prior pregnancies, as well as a family history of people having preeclampsia. You know, if a woman has a sister or a mother who had preeclampsia, that does increase her risk. And things like thrombophilia, either inherited or required, which is a tendency for the blood to clot in the body.

We can further look at risk in the obstetric and gynecologic history of a patient. Things such as nulliparity, which is a woman's first pregnancy; multiple gestations carrying twins or triplets; short or long interpregnancy intervals, you know, pregnancies that are occurring less than 18 months apart or more than 10 years apart; and the use of assisted reproductive technology such as IVF; as well as history of having gestational diabetes.

And then, there are other factors such as demographic factors that would increase the risk as well. We look at things like advanced maternal age, greater than 35 years when you're in a pregnancy, adolescent pregnancies, African-American ethnicity. You know, we do have evidence to suggest that they're at higher risk for severe adverse outcomes.

And, finally, lifestyle and overall health contribute to risk here as well. For example, having obesity or a high BMI greater than or equal to 30, smoking or substance use, low socioeconomic status or limited access to prenatal care, and then sleep apnea as well as a risk factor.

Host: How much does family history play a role in developing high blood pressure during pregnancy?

Chelsea Benell: So, as I mentioned before, you know, that is an important factor that we look at, having a family history. So, having a mom or a sister that had preeclampsia in their pregnancies does increase that patient's risk of developing it in theirs. It doesn't necessarily mean it's going to happen, but it is one of those risk factors that we take into consideration.

Host: And how is pregnancy-related hypertension typically diagnosed and treated?

Chelsea Benell: So, pregnancy-related hypertension such as gestational hypertension, preeclampsia, postpartum preeclampsia, they're all diagnosed by an OB provider. As we talked about earlier, these diagnoses are typically made after 20 weeks' gestation. They are treated by very close monitoring of blood pressure values. We watch for urine protein, and we look at lab work. Sometimes women are started on blood pressure medications such as labetalol or nifedipine during the pregnancy. Sometimes delivery of the baby is indicated, depending on several factors including, but not limited to gestational age, whether or not maternal organ systems are impacted, whether or not the growth or health of the baby is impacted, et cetera.

I think it's important to mention this because many people might be wondering, what causes preeclampsia? The exact cause really involves several factors and is really quite complex. But experts believe that the process begins in the placenta, which as I mentioned, is the organ that nourishes and provides blood and oxygen to the growing fetus. And early in a pregnancy, new blood vessels are developing and evolving in order to do this. And so, it's suspected that in a woman with preeclampsia, these blood vessels don't seem to develop or function properly, and issues with how well the blood circulates in the placenta can lead to dysregulation of the blood pressure in the mom.

Host: And let's talk about signs or symptoms. What are they? What should pregnant women never ignore when it comes to high blood pressure?

Chelsea Benell: This is so important. So of course, we want women to pay attention to their blood pressure values when they're pregnant. Typically, blood pressure is checked at every single OB appointment. The OB provider will make note of any elevated readings and advise a plan from there. Sometimes women are instructed to have an at-home blood pressure monitor so that they can keep track and review a log with their provider.

Typically, the number we are concerned with is anything 140/90 or greater. In terms of symptoms, any blurry vision, floaters, headaches, severe swelling of the face, hands or feet, chest pain, shortness of breath, nausea, vomiting, or abdominal pain that is particularly located between the breast or under the right breast should be reported to the OB provider.

It's also important to note that postpartum women should watch out for these blood pressure values and symptoms and communicate with their providers accordingly in that postpartum period, especially within the first six weeks after delivering the baby.

Host: And you mentioned lifestyle earlier. Are there lifestyle changes or preventative steps that someone can take before, during, or after pregnancy to reduce risk?

Chelsea Benell: Also so important. So for some aspects, yes, there are. Living as heart healthy a lifestyle before, during, and after pregnancy can help reduce the incidence of being overweight or obese, which we talked about as a risk factor, having type 2 diabetes; reduce the risk of having chronic hypertension.

Of course, avoiding smoking and substance use helps reduce risk as well. Other heart-healthy behaviors that can help reduce overall risk of developing hypertensive disorders of pregnancy include things like optimizing diet. You know, the ideal diet for heart health is a Mediterranean plant-forward diet. We also use the term DASH diet, which stands for dietary approaches to stop hypertension. It's really all synonymous. This diet is very rich in fruits and vegetables, plant-based proteins like beans, all kinds of beans, black beans, you know, kidney beans, chickpeas, lentils, tofu, those sorts of plant-based proteins. Fish, which is high in omega-3 fatty acids is really good for our hearts. Nuts and seeds. We want to focus on high fiber and whole grains, which are found in things like barley, oatmeal, quinoa, farrow. We want to increase the intake of monounsaturated fatty acids in foods such as extra virgin olive oil, canola oil, avocado oil. It is best to limit foods high in saturated fats, such as red meat and full fat dairy products.

The focus should be on avoiding ultraprocessed foods, excessive alcohol and then high sodium foods. We want to limit sodium intake to less than 2000 milligrams per day. Examples of foods high in sodium, I think, are really important to note. That's anything that's ultraprocessed, that comes in a package with a really long list of ingredients, things like cold cuts and cured meats, pizza breads and rolls. Bagels are super high in sodium. Burritos and tacos, all the delicious things. Those are some of the foods I like to mention as kind of hidden sources of sodium. Otherwise, anything that's really packaged and processed very high in sodium.

Additionally, of course, you know, physical activity is super important when it comes to heart health. We aim for 150 minutes per week of moderate intensity physical activity. That's what the American Heart of Association recommends. Things such as brisk walking, biking, swimming. We also do recommend incorporating strength training two to three times a week to maintain balance coordination, bone and muscle health, and prevent osteoporosis down the road, especially for women. And then, if women partake in high intensity physical activity, things like CrossFit, cycling, classes running, then really 75 minutes per week is what's recommended.

And also, I like to talk about, you know, stress management doing things such as yoga, meditation, deep breathing, walks, talking to friends, whatever helps that person feel less stressed is really, really important for heart health. Then, sleep optimization is another thing. So, seven hours per night of uninterrupted high quality sleep is what is recommended. This is a funny topic to talk about with new moms, of course, because newborns wake up very often and their sleep might not be the greatest. It's important to know that it's something we want to focus on, even maybe if in that one season of life it doesn't look perfect, we aim for improvement and we know that it impacts our overall health and what the goal is.

And as I mentioned earlier, you know, striving for optimal interpregnancy intervals is something to consider. All of these things are the things that we have within our control, whereas there may be some other risk factors that aren't, these are the ones we really have control over modifying.

Host: So in closing, Chelsea, what is it that you want people to know about hypertensive disorders of pregnancy?

Chelsea Benell: So as a nurse practitioner with a particular interest and passion for prevention of cardiovascular disease, which is the leading cause of death of men and women in our country. I want people to understand that hypertensive disorders of pregnancy present a real danger to women and are associated with increased risk for developing cardiovascular disease later in life. The field of medicine is ever-evolving. And over the years, research has shown us that these diagnoses can be linked to higher rates of cardiovascular disease such as heart attacks and strokes. Something I also want to raise awareness about is that postpartum hypertension and preeclampsia can happen.

Many people think these conditions are only a concern during a pregnancy, but we have learned that there is risk of them developing up to as late as one year postpartum. The latest research suggests that a woman is at the greatest risk of developing postpartum hypertension or preeclampsia actually in the first six weeks after delivery. So, that is the period of time where surveillance should be higher, particularly for women who've had a hypertensive disorder during the pregnancy, or who had elevated blood pressures noted consistently during their time in the hospital after having a baby.

Our team of nurse practitioners in this cardiac screening program have developed a very unique program I'm very proud of that was recently recognized by the American College of Cardiology. Our program provides education and surveillance for any woman that has had a hypertensive disorder of pregnancy. We educate them extensively in the hospital prior to discharge on what to look out for once they get home from the hospital in terms of symptoms and blood pressure values to report to their physician. We provide blood pressure monitors for them to take home and ensure that they know how to use them. And this is supported by foundation funds and donations.

And then, we also do a call with these patients at one week and 30 days after discharge to see how their monitoring is going. Ask about the presence of any alarming symptoms. We answer follow-up questions, and we reinforce all of this vital education. This new and innovative program has been overwhelmingly well received. Patients have noted consistently that they feel empowered, they feel supported and cared for during this very vulnerable time. Our team is also in the process of planning activities to keep patients engaged such as healthy cooking classes, walking and exercise groups, as well as offering them a comprehensive cardiovascular disease risk assessment at one year postpartum. All this is in an effort to make sure they stay healthy for possible future pregnancies and far beyond that.

Host: Well, thank you so much, Chelsea, for sharing your expertise. This has been so educational. I learned a lot myself. And I think it's going to be very helpful to pregnant women.

Chelsea Benell: Oh, I'm so glad. Thank you so much for having me, Maggie.

Host: Absolutely. Again, that's Chelsea Benell. For more information about Obstetrics and Gynecology at Valley, please visit valleyhealth.com/obgyn.

For more information about heart care at Valley, please visit valleyhealth.com/heart. Thanks for listening to Conversations Like No Other presented by Valley Health System in Paramus, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-447-8125 or email valleypodcast@valleyhealth.com.