Please suggest medication to prevent gestational hypertension and supplements taken during pregnancy.

Question

Hello doctor,

I am currently in my third pregnancy and 20 weeks pregnant. My first pregnancy was characterized by gestational hypertension in late pregnancy. In my second pregnancy, I experienced gestational hypertension with fetal growth restriction. The child was also born with microcephaly. There were no genetic tests or infection tests that explained the microcephaly. It was possibly due to growth restrictions. I have never had any protein in my urine, and all kidney and liver tests throughout have been normal. I have noted that my blood pressure has elevated more after each pregnancy, particularly my diastolic pressure. Before my first pregnancy, my diastolic never exceeded 70 mm Hg in the office. Now I am lucky if I get a reading under 90 mm Hg in the office. However, it is acceptable in the ambulatory readings. Before my third pregnancy, my ambulatory blood pressure reading was 104/73 mm Hg on average, 104/77 mm Hg during the daytime, and 90/50 mm Hg at nighttime. My last ambulatory BP reading at 16 weeks was 108/76 mm Hg on average, 110/82 mm Hg during the daytime, and 90/50 mm Hg at nighttime. I have noticed my diastolic pressure to be 90 mm Hg in the evening on my home machine.

I am worried this pregnancy will result in worse outcomes than ever before. I have struggled to gain access to a specialist in my early pregnancy, and my general practitioner (GP) seems clueless about these things. Because of poor support in my previous pregnancy, I have extensively researched preventive measures for pre-eclampsia and fetal growth restriction. Still, I need expert advice. Upon my insistence, I have been prescribed 81 mg Aspirin from 12 weeks, which I also took during my first pregnancy. I wish to do more prevention if possible. Please enlighten me as to what treatment combination is best. Nitric oxide supplementation might benefit, particularly in avoiding growth restriction. I try to eat a beetroot daily.

I am taking three grams of L-Arginine from 20 weeks and 81 grams of Aspirin. I have read that caution should be taken when supplementing L-Arginine with blood thinners. Is it fine to combine these two medicines, or should I discontinue them at some point before delivery?
Do I have to take vitamin-C together with L-Arginine?
I am concerned about interactions between all these medications, which I do not fully understand. Please advice. Do you have any other suggestions for supplementation?

I have to mention that I have grandparents, aunts, and uncles on both sides of the family who have had brain hemorrhages at a young age. Neither of my parents nor siblings has experienced this, though. I was taken for a screening brain magnetic resonance imaging (MRI) because of this a couple of years ago, and there was no indication of any aneurysms in my brain. However, I have mild cerebral palsy, probably had a brain bleed in the uterus, and was also growth restricted before birth.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

Thanks for the query.

It is understood that you are 20 weeks into your third pregnancy. In the previous two pregnancies, you experienced gestational hypertension and intrauterine growth restriction (IUGR) in the last pregnancy with microcephaly. Still, you never had pre-eclampsia or eclampsia, as quoted your urine proteins were always normal, and your blood pressure (BP) was above 140/90 mm of Hg but never touched systolic 180/200 mm of Hg and diastolic 100/110 mm of Hg. Therefore, intrauterine growth restriction (IUGR) in the second pregnancy, as gestational hypertension started in the third trimester, is unlikely to be blood pressure (BP) induced but rather likely to be nutritional. The microcephaly (not caused by IUGR or gestational hypertension) is likely to be a TORCH infection (toxoplasmosis, rubella cytomegalovirus, herpes simplex, and human immunodeficiency virus). So TORCH infection needs to be ruled out in this pregnancy as well in your case.

Now, at 20 weeks of gestation in this pregnancy, the following should be your future steps for monitoring: Consult your specialist doctor, talk to them, and take medications with their consent.

Ultrasound for fetal growth parameters and anomaly scan at 20 to 22 weeks to rule out any anomaly in the child and if the growth corresponds to the gestation period.
If the growth is adequate and blood pressure (BP) is always less than 140/90 mm of Hg, then even tablet Ecosprin (Aspirin) can be stopped as implantation of the embryo has already been completed.
Alternate day blood pressure (BP) recording and weekly weight gain recording have to be maintained. Suppose any growth restriction is noticed by the late second or early third trimester with a rise in blood pressure (BP) instead of the tablet Ecosprin (Aspirin), a tablet of Aliveher 25 mg (sildenafil citrate) can be started. To improve uteroplacental insufficiency (which is the cause of IUGR in pregnancy hypertension), pregnancy antihypertensives like tablet Lablol 100 mg (Labetalol) dose has to be titrated along with blood pressure (BP).
Repeat ultrasonogram (USG) at 32 weeks for a growth scan and fetal echocardiography with uterine and umbilical artery doppler studies to see if the pregnancy is progressing normally.
L- Arginine is instituted in the treatment regimen when IUGR is established or if the femur length (FL) and abdominal circumference (FL/AC) ratio on the fetal scan is equal to or more than 0.24. Else there are no prophylactic indications. In addition, of course, you should be on iron, calcium supplements, and multivitamins throughout pregnancy. Also, vaginal infections need to be checked along with urinary infections.
Vitamin-C is usually not recommended exogenously for fetal growth. Still, it has a role in preventing or delaying the onset of gestational hypertension, the chances of which are believed to increase by ten percent in each pregnancy.

Let me know if anything else is your concern.

Hope this helps.

Thank you.