Overview

Pregnancy comes with many challenges, including navigating prenatal care and working with your provider to make the best decisions for you and your baby. This can be especially difficult when you feel unheard or when your doctor or midwife’s recommendations don’t align with your own understanding of your health. In this episode, we help an expecting mom who has white coat hypertension but has been labeled with gestational hypertension, leaving her frustrated and concerned about the possibility of an unnecessary induction. At some point in your pregnancy, you may find yourself in a situation where you and your provider don’t see eye to eye. Learn practical tools to communicate effectively, ask the right questions, and make informed choices about your care so you can confidently navigate these conversations.

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Transcript and Resources

Hi Vanessa,

I love your podcast. I am a FTM and it has helped a ton with all of the questions and curiosities I’ve had thus far during my pregnancy. I am currently 31 weeks. Curious if you have any tips for my situation…I have white coat hypertension, and before being pregnant, my general practitioner recommended I monitor my blood pressure at home since, in office settings, it is typically elevated and way higher than my at-home readings, which are always normal (around 110/70).

When I go to my prenatal appts, of course, I’m always freaked out about them taking my BP, and some of the nurses will write down my at-home readings, but my OB is very strict with having them take it in the office, which I understand from a policy standpoint. The other week, my OB sent me to labor and delivery to be monitored, and of course, all tests came back normal. Due to the added stress of the day, some of my readings continued to be elevated at the hospital. The nurse sent me home with a blood pressure monitor and signed me up for an app so my OB can see my at-home readings twice a day. Of course, when I returned home, my blood pressure was back to normal, which is so frustrating! No matter how much they tell me to “Relax” in the clinic, it does not help.

The nurse mentioned that they labeled me as gestational hypertension, even though that boils my blood, because the only time it’s ever elevated is in the clinic. The nurse agreed, after I showed her my at-home readings, that it didn’t seem like a fair diagnosis, but that’s just what they have to do, says the “system.” She said it might actually “help” because when I go into the clinic for my prenatal appts and if my BP is elevated (below 160), they wouldn’t send me into the hospital for monitoring since I have the “label” of gestational hypertension, regardless of whether that’s inaccurate or not. She also mentioned that my OB might want me to be induced at 37 weeks, which really terrified me because I know my body and I know how I feel at the clinic vs. during all other times of my day.

I know I don’t have high BP, and I don’t want to be induced at 37 weeks. She said I’d for sure have a choice as to whether I agreed to it or not, and she also said my OB is a reasonable person and, with my at-home readings, might not even recommend being induced early. I am, of course, worried now about my next appointment to see what my OB says or what she recommends. Do you have any tips as to how I can navigate this situation as I feel completely misdiagnosed and unheard. I know many people suffer from white coat hypertension, and I just want a healthy baby, so of course, I’d do anything to make sure that happens, but not if it’s based on one BP reading in a clinic setting vs. all my other normal at-home readings. Thanks for any advice you may have.

Thank you for your email. I am so glad the podcast has been helpful. It can be incredibly frustrating to feel misdiagnosed and unheard. Especially in your case when you have a history of this issue and data that contradicts what’s happening at the doctor’s office. Let’s break this down, explore your options, and discuss tips to advocate for yourself.

White Coat Hypertension

White coat hypertension is a well-documented phenomenon, and many people experience it. This condition occurs when blood pressure readings are higher in a clinical setting than at home or in other relaxed environments. This happens because doctor’s offices and hospitals can be stressful, leading to temporary spikes in blood pressure.

I completely understand your frustration that your OB insists on in-office blood pressure readings. While their policies are in place to ensure that they catch any potential issues, they don’t always account for individual differences. The good news is that you’ve been monitoring your blood pressure at home, and your readings there are consistently normal. That’s valuable data that should be taken into consideration.

What is Gestational Hypertension?

Let’s cover some background, which may give you a better understanding of where your OB is coming from. Hypertension is high blood pressure. The issue with high blood pressure is that the force of blood flowing through your veins is too high, requiring your heart to work harder. Over time, this can damage the circulatory system and is a significant contributing factor to heart attack, stroke, and other health threats. Hypertensive disorders affect as many as 10% of all pregnancies worldwide and are responsible for approximately 10% of all maternal deaths in the United States.

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia, preeclampsia with severe features, HELLP (hemolysis, elevated liver enzymes, and low platelet count), and eclampsia. High blood pressure during pregnancy can put extra stress on your heart and kidneys, which can lead to heart disease, kidney disease, and stroke. As well as increase your risk for preeclampsia, preterm birth, placental abruption, and cesarean birth. High blood pressure can also reduce blood flow to the placenta, affecting the flow of oxygen and nutrients to your baby. You can see why your care provider closely monitors your blood pressure throughout your pregnancy and takes a blood pressure reading at each appointment.

Gestational hypertension occurs when you have normal blood pressure before you are pregnant, and in the second half of your pregnancy, your systolic blood pressure is above 140 mm Hg, or your diastolic blood pressure is above 90 mm Hg. However, in your case, your elevated readings only occur in the clinic, and your home readings are consistently within the normal range. That puts you in a complicated position. Your medical team has protocols they follow; sometimes, those protocols don’t perfectly fit the individual situation.

Research on White Coat Hypertension During Pregnancy

A systematic review and meta-analysis shows that women with white coat hypertension had a significantly increased risk of developing preeclampsia, delivering small for gestational age newborns, and preterm birth compared to women with normal blood pressure. Although, those with white coat hypertension had a significantly lower incidence of all of these conditions compared with women with gestational hypertension.

The findings were similar to those of another scientific review. Researchers found women with white coat hypertension before 20 weeks’ showed a 5-fold greater risk of preeclampsia than women with normal blood pressure. In the majority of available data based upon the diagnosis of white coat hypertension at any time in pregnancy, these women had a 2–3-fold increased risk of preterm birth and small for gestational age infants compared to women with normal blood pressure. The takeaway here is that white coat hypertension is not as serious as gestational hypertension, but it may increase your risk of some adverse outcomes.

According to the International Society for the Study of Hypertension in Pregnancy, white coat hypertension should only be considered as a diagnosis in women before 20 weeks of gestation. Blood pressure elevation present only with care providers in later pregnancy is considered pregnancy-specific.

Inducing Labor for Hypertension

It is common to recommend induction at 37 weeks if you have gestational hypertension or preeclampsia without severe features. This recommendation is based on a randomized controlled trial that found that inducing labor before 37 weeks in women with gestational hypertension or preeclampsia without severe features improved maternal outcomes. Any decision to induce labor early involves weighing the risks and benefits and taking into account the particulars of your condition. See this episode for a deep dive into inducing labor, including the evidence, how it works, and the risks and benefits of every different method of labor induction. However, your situation is unique because your at-home readings indicate you do not have high blood pressure.

Informed Consent

It’s reassuring that the nurse told you that you would ultimately have a choice in whether or not you agree to an induction. True informed consent means that you fully understand the procedure, intervention, or treatment, are made aware of all the risks and benefits, and can opt in or opt out. The last part of that is tricky. The truth is that you can opt out of anything. That said, going against a doctor’s recommendation can sometimes create tension. This is where having open communication is really important.

The BRAIN acronym may be a helpful tool if you have a conversation with your doctor about inducing labor at 37 weeks.

  • Benefits: What are the benefits of induction at 37 weeks in your case?
  • Risks: What are the risks of induction versus waiting for labor to start naturally?
  • Alternatives: Are there other alternatives, like increased monitoring instead of induction?
  • Intuition: What does your intuition tell you about this decision?
  • Nothing: What happens if you do nothing and do not induce labor?

This framework can help you have a productive conversation with your doctor and thoroughly weigh the pros and cons. You may also consider asking what the benefits and risks are of inducing labor at 37 weeks if you are misdiagnosed with hypertension. ACOG supports elective induction at 39 weeks for low-risk women without any complications. Inducing labor two weeks earlier would not be supported if you do not have hypertension.

Advocating for Yourself

It can be challenging to advocate for yourself, especially with someone qualified to be an expert and generally seen as an authority figure. Doctors can be intimidating to stand up to, especially if you are working with a doctor or midwife who does not appreciate you questioning their practices or who brushes off your concerns. It is much easier to be agreeable, not ask anything, and follow your care provider’s recommendations. Thankfully, you can use many simple strategies to make advocating for yourself easier and more comfortable.

Prepare for Your Next Appointment

I completely understand that you’re anxious about what your OB will say at your next appointment. You may consider reaching out before your visit to express your concerns and provide your at-home blood pressure readings in advance. This could help frame the conversation and ensure your doctor has all the necessary information before making recommendations. It may be more effective to put your concerns in an email than to recall everything during an in-person conversation. You may also consider scheduling a separate appointment to discuss this issue. This would allow more time to focus on this topic rather than fitting it in along with everything else that takes place in a prenatal appointment.

Get a Second Opinion

If you feel like your OB isn’t considering your home readings and is misdiagnosing you, you can get a second opinion. You can request to meet with another doctor or a maternal-fetal medicine specialist. You could also reach out to your general practitioner, who is aware that you have a history of white coat hypertension. You could ask if they would be willing to contact your OB or write a letter advocating for you. They may also have valuable advice for communicating with your OB.

Enlist a Support Person

If you need help advocating for yourself, bring a support person to your appointment. Ideally, your partner attends every prenatal appointment with you. Ask a friend or family member to join you if you do not have a partner. Having someone by your side can instantly make you feel less alone and empower you to speak up. If you need to, you can even ask your support person to raise a question for you. If you cannot have someone physically present, you can have them join you via Facetime or on a call on speakerphone.

Change Your Doctor

Remember that you hire your doctor or midwife. You can also fire them and find another provider if you don’t feel you are getting the attention or support you need. Switching providers is easiest earlier in your pregnancy and can be more challenging further on, especially with nine weeks to go. You can always explore your options and stay with your current provider if you don’t find a better fit. This may not be the ideal solution in this particular case, and it may be better to work through this issue with your OB.

Final Thoughts

Based on the information you shared, it sounds like you are experiencing white coat hypertension. While this condition is not as concerning as chronic or gestational hypertension, research suggests it may still be associated with some increased risks. Understandably, your doctor wants to follow standard protocols, but it’s also completely valid for you to feel frustrated when those protocols don’t fully account for your individual circumstances. Ultimately, your OB should tailor their recommendations to your situation, considering your in-office and at-home blood pressure readings.

Regardless of their recommendation, you have the final say in your care, including whether or not to proceed with an induction. Hopefully, the strategies we discussed will help you feel more confident in advocating for yourself and having an open, productive conversation with your doctor.

Additional Resources

Thank you to the amazing companies that have supported this episode.

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