Courtney Malveaux gives son Jake a lift while Mary watches with their younger son, Richard. Jay Paul photos
A collage of photos decorates the refrigerator in Courtney and Mary Malveaux's inviting western Henrico County home. One photo is of their 2-year-old son, Jake, playing with his cousin, and another is of their almost-3-month-old son, Richard. Jake likes to point at the pictures, trying to name the faces. He's learned to identify Richard, although sometimes he calls him "baby" or "my baby." And he's just beginning to understand that in another photo, the yawning, sweet-faced 1-month-old infant, with a feeding tube extending from his mouth, is his other brother, Bennett.
"He understands the word ‘brother,' but I am not sure he truly understands the concept," Mary says.
Jake doesn't quite comprehend that Bennett passed away when he was 6 months old, due to premature birth complications. But Mary says that even now — more than three years later — she and her husband consider Bennett to be a very real member of the Malveaux family.
"We really are a family of five because for us, Bennett will always be a part of our lives," Mary says. "Just having additional children does not take the place of another child. Bennett enriches our lives in a lot of ways and you cannot simply replace that by someone else."
At least part of Mary's experience is shared by hundreds of thousands of other women in the United States. High blood pressure, which Mary was diagnosed with, is known medically as hypertension and affects about one in three adults, according to the National Center for Health Statistics. And hypertension among pregnant women is one of the reasons an enormous number of babies — about 500,000 a year — are born prematurely, according to research by the National Institutes of Health.
One of Mary's obstetricians, Dr. Karen Jefferson of the Virginia Women's Center, says some 20 percent of her patients have high blood pressure.
Dr. James T. Christmas, director of maternal and fetal medicine at Commonwealth Perinatal Associates, says high blood pressure "is probably the single most common medical complication in pregnancy."
In some cases, women are hypertensive before becoming pregnant and in other cases, they develop the condition as a complication of their pregnancy, Christmas says. The number of hypertensive pregnancies has increased, he says, in part because adults develop the condition as they age, and many women are delaying childbearing until they're in their 30s and 40s.
He adds that there's a general misconception that high blood pressure during pregnancy is not a serious problem.
"I believe that should be evaluated before pregnancy," Christmas says. "People take pregnancy more casually than they should."
BIOLOGICAL RISK FACTOR
When Mary and Courtney got married almost five years ago, they were thrilled about having children. "We were definitely ready to start a family," Mary says. "I was excited."
Several years before, in what Mary calls a fluke, she discovered she had high blood pressure. She handles civil litigation for Richmond's Brenner, Evans and Millman law firm, a job that hardly "alleviates stress," she says. The firm has a nurse on hand to help monitor employees' health. Mary found out about her hypertension because she noticed a colleague getting a blood-pressure reading and decided to get tested as well.
After visiting an internist about her hypertension, she began taking medication regularly and made sure her diet was balanced. She remained active, running three or four times a week and enjoying adventurous sports, among them, whitewater rafting and skiing. Courtney and Mary were both in their late 30s, and Mary says she didn't realize her blood pressure could complicate her pregnancy.
During a recent interview, her eyes filled with tears and she looked away as she explained, "I do not think I thought about it because of the shape that I was in — that it would be as big of an issue."
It was about four weeks after conception when Mary realized she was pregnant. "We were really excited," she says. "It is a fun feeling. It's all sorts of things wrapped up into this one thing — that you are excited, but a little nervous because you will be responsible for someone else."
After checking her high-blood-pressure medication, she found that it was unsafe to take during pregnancy. Immediately, Mary stopped the medication and visited her doctor.
High blood pressure occurs when blood vessels squeeze too hard, restricting blood flow. During pregnancy, blood vessels are supposed to relax and expand "to allow for adequate blood flow to allow nutrients through the placenta," Christmas says. And vessels in the placenta should be wide open so that blood flows easily between mother and baby.
If that doesn't happen, both the mother and baby are at risk, says Dr. Lisa Troyer, a specialist in maternal and fetal medicine and obstetrics at the Virginia Women's Center.
"The developing fetus is very smart," Troyer says, explaining that if there is not enough blood flowing, the baby's body will send it to whichever organ needs it most.
"The liver says I do not need it," Troyer says. "Blood shunts away from the kidney and abdomen and goes to the brain and the heart." So the brain and heart are protected, but the rest of the body suffers, she says.
Jefferson explains that the gastrointestinal system is the first to be compromised. If the kidney and abdomen don't get enough blood, "they don't make urine and amniotic fluid goes down," Troyer says. The amniotic fluid, the liquid that surrounds the baby in the uterus, is directly affected by the blood flow and is a reflection of the health of the placenta.
When Mary was about five months pregnant, she began having trouble with a low level of amniotic fluid. Until then, Mary had been taking a pregnancy-safe blood pressure medication, and almost every day, her blood pressure was checked.
Sometimes she felt poorly and noticed swelling, as her blood pressure lapelled — a "lovely medical term," Mary says, which means "your blood pressure is really all over the map." Whenever that happened, she would make an appointment with Jefferson.
"Everything looked good at first, then it started affecting my amniotic fluid level," she says, her tone wavering with emotion. "High blood pressure is just something that can beat up the [umbilical] cord and the placenta."
Her doctors prescribed bed rest — the usual remedy because more blood can go to the baby when the resting mother needs less. Bed rest helped prolong Mary's pregnancy, but she also was hospitalized for about 10 days. She was put on IVs and oxygen to see if the uterus would respond well. At 26 weeks — about three months early — the blood flow to Mary's baby had dropped so much that the infant had to be delivered through cesarean section.
"If you left that baby in there, it was going to die in the next few days in utero," Troyer says.
It was right before Thanksgiving — Nov. 20, 2006 – when Bennett was born, weighing little more than 1 pound. He was given Mary's maiden name.
"There was a lot of faith," Mary says, referring to the many days she spent with Bennett in the Newborn Intensive Care Unit (NICU). "I don't think it ever occurred to me that the outcome would be anything but OK."
When she was released from the hospital about 10 days later, Mary had yet to hold her boy. She couldn't touch him because his underdeveloped nervous system was hypersensitive.
Bennett was about 3 weeks old when nurses told Mary and Courtney they could hold him in what's known as a "kangaroo hold."
"It's skin on skin," Mary says. "Basically you place the baby on your chest. You are amazed to get to hold such a small, little being. … That was wonderful."
Opening her right hand, Mary demonstrates Bennett's size. His body fit into her palm; his legs extended a bit. "My husband had a picture of his wedding ring around [Bennett's] arm," she says.
The infant's biggest health complication was lung development. "We just thought that with time and with growth and with weight, that he would get better," Mary says.
The days turned into weeks, the weeks into months. The NICU nurses became like family for the Malveauxes. The couple visited Bennett every evening together and as frequently as possible during the day.
As they watched their son grow, Mary says that she marveled at Bennett's big brown eyes. "He just had really large, expressive eyes and [would] really take in so much of what was around them," she says. Mary adds that she remembers watching her husband hold Bennett — "just the look of love."
Their son responded to people and enjoyed being held, she says. "It is a very scary time, but there are also moments of great joy."
Right before he was to be released to go home, Bennett took a turn for the worse. After 175 days in the NICU, he passed away on May 13, 2007.
"I would never wish the loss of a child on anyone," Mary says. After a pause, she continues talking, her voice quaking gently but firm. "It is a truly traumatic thing and it stays with you. We are grateful for having had him, even though it was such a painful loss."
For babies born prematurely to mothers with high blood pressure but no kidney problems, the death rate is less than 1 percent, Christmas says. Still, it's "more common than we would like it to be."
The death rate is higher, 2.8 percent, for babies born to mothers who have chronic hypertension issues but are not managed appropriately by a high-risk team of physicians, Troyer says. Among babies born as early as Bennett, the death rate is about 20 percent, Troyer says. Most often, their biggest problems are underdeveloped pulmonary systems, brain hemorrhages, infections and death of internal tissue.
When parents lose children, Troyer says, she grieves with them. "My heart breaks for them because sometimes they do everything they could and it just did not get better."
Mary says that as she grieved, she felt guilty, as if there were something she could have done. "You feel you are to blame. … I am not sure that ever goes away."
She and her husband healed gradually, drawing closer as they worked through Bennett's death. Mary visited Dr. Martin Starkman, a nephrologist at St. Mary's who specializes in kidney care. Starkman confirmed that her kidneys were functioning normally and he began to regularly monitor her blood pressure.
Mary says she woke up one day and was ready to try again.
"It was a very gradual thing," she says. It was a feeling of "just realizing that I was ready to open myself up to that journey, to do this again."
PREPARING FOR PREGNANCY
This time, Mary consulted with physicians before trying to become pregnant.
"It does take a little bit of the spontaneity out of the equation," she says, and it involves other people in a personal matter. "But it is worth it."
For Mary, the biggest piece of the process was setting up a team of doctors who vigilantly watched her and helped her do everything possible even before conception to have a healthy baby.
"It did not feel sterile or intrusive as maybe it would seem," she says. "That part is worth the tradeoff of getting a healthy, happy baby."
Research has shown that common blood-pressure medications, including the classic ones known as ACE inhibitors, are associated with birth defects, Christmas says. Jefferson explains that studies have found that the inhibitors may cause birth defects, including extra digits, or impair the development of the heart and lungs.
Troyer says the inhibitors and some other blood-pressure medications can damage development of a baby's organs, including kidneys, even in the early weeks of pregnancy — before many women realize they are pregnant.
When Mary visited Starkman, the kidney specialist, he made sure that her medication was appropriate for conception, pregnancy and nursing. Nor did Mary have to worry about diet or weight. In fact, Jefferson advised her to be slightly less active, which is unusual. Rather than run, she rode a stationary bike or walked, and she lifted lighter weights at the gym.
(For many women, being overweight is the main cause of hypertension. Jefferson often recommends that patients lose 10 to 20 percent of their body weight, which can make a huge difference in the outcomes of their pregnancies. In addition, limiting intake of carbohydrates, eating healthy foods, such as brown rice, fruit and vegetables, and drinking lots of water is vital for pregnant women.)
Mary also took prenatal vitamins and baby aspirin, which help increase blood flow to the placenta. She maintained her healthy lifestyle, but most important, she kept up with regular doctors' appointments and communicated with her medical team.
In the fall of 2007, the Malveauxes found out that Mary was once again pregnant. She saw Jefferson at least once a week for blood tests and nonstress tests, which monitor a baby's heartbeat. She also saw Troyer frequently.
"They knew when to start watching me because they had a roadmap of where things went wrong," Mary says. "Between weeks 25 and 26, they knew they wanted to focus and watch me. … They were hypervigilant."
At week 31, Mary's amniotic fluid levels went down and she used bed rest — while working a little bit from home — to delay the birth. Bed rest was not easy for Mary, a detail-oriented, active lawyer. But she learned to focus on the greater goal.
"The easiest way for me was to take it day by day until you tick off the weeks," Mary says. "It was not a crisis situation. It was so managed. It was very defined."
In the summer of 2008, Mary gave birth to Jake. He was born at 36 weeks, only one week shy of full term, and his lungs were fully developed. "The thing I remember was just waiting to hear him cry," she says. "It's an indescribable joy. It's a blessing. I do not know how else to put it."
With a laugh, Mary says that at first, she wanted the hospital staff to come home with them. "You have no clue what you are doing," she says, adding that she thought, "I cannot believe they are letting him come home with me."
Nearly two years later — in May of 2010 — Mary is running her hand gently down the back of her swaddled son. But this child isn't Jake. It's the Malveauxes' third son, Richard.
"He was by far the easiest pregnancy," she says. "I cannot answer what made it the easiest … [but just] knowing that you can do it. The doctors really knew me and knew what to expect."
The Malveauxes are now a family of five.
Mary calls herself a private person and says that she was hesitant at first to share her story, because Bennett's death is not something she often discusses openly. And yet she did. Why?
"As an illustration of what can happen," she says, and to demonstrate to others that healthy pregnancies, even with hypertension, "can be done."
Mary says she wishes someone had talked to her about the importance of investigating her family history and understanding her condition before she had children.
"In the African-American community, there is a higher level of premature births and some of it is related to blood-pressure issues," Mary says. "I think it is very important that people — no matter what their backgrounds are — be very aware of the genetics that are part of their family makeup. And I wasn't."
Christmas says that no one completely understands why high blood pressure affects African-Americans more than other people. He says genetics may play a role.
The Centers for Disease Control and Prevention (CDC) report that nationwide, African-Americans develop high blood pressure earlier in life, 10 percent more often than Caucasians and 20 percent more often than Mexican-Americans.
Although Mary's only brother does not have high blood pressure, her father did. He passed away when she was 13, but she knows that the onset of his condition occurred early in his life, and he died before age 50.
"If I could go back, what I think I would have done is sat myself down and said, ‘Don't think because you are in good shape and you run and you do all these things that blood pressure may not be an issue for your pregnancy.' "
Jefferson and Troyer describe Mary as exemplary for facing her situation and doing all she could to make her pregnancies a success.
"She did an excellent job empowering herself to do what she could and she really left the rest up to God," Jefferson says.
As a 42-year-old mother of a baby younger than 3 months old, Mary says with a smile that she's unsure about whether she and her husband will have more children. But for now, when people ask the couple how many children they have, they often say three sons.
"You always wish that [Bennett] could be here," Mary says. "So that part simply does not change. …[But] either you can be bitter [about] it or grateful for the time we spent, and sometimes you go through both emotions."