Summary
For this week’s discussion, the case study I have chosen to address involves a 55-year-old female. The patient presents with a history of mild hypertension. Her medications include Zocor, Plavix, and Lisinopril. She works out five days a week, has never been married, has no obstetrical history, does not smoke, drinks an occasional glass of wine, and began to have menopausal symptoms at 52 years old. During her annual visit, she mentions that she and her fiance of two years plan to marry and would like to start a family. The patient is cautioned that her current medications and cardiac history could cause pregnancy complications. As a precaution, she is encouraged to start a daily dose of 800 mcg of folic acid and is referred to maternal-fetal medicine to discuss options. On her second IVF cycle, the patient becomes pregnant. At a follow-up visit, a baseline CMP and 24-hour urine are obtained. The patient and her fiancé returned to the office with a blood pressure of 160/92, a repeated pressure of 160/ 88, right-side abdominal pain, 2+ pitting edema to the legs, and facial swelling. She is admitted to the hospital. Her LFTs are quadruple and her platelets are 50,000. She is started on IV magnesium sulfate and given several doses of IV labetalol. Unfortunately, her placenta abrupted that day and she delivered a male infant who lived about 20 minutes. She also experienced anuria and difficulty maintaining her blood pressure, patient was discharged home on Day 11.
Differential diagnosis
Chronic Hypertension
Why This Diagnosis Decision
According to Espeche and Salazar (2023), hypertensive disorders in pregnancy are classified into two categories chronic hypertension and gestational hypertension. Women who have a history of hypertension before becoming pregnant are diagnosed as having chronic hypertension (Espeche & Salazar, 2023). The classification of gestational hypertension is assigned to women who only have hypertension during pregnancy. The women in this classification do not develop protein in their urine, do not have cardiac or nephralgic histories, and the diagnosis is typically made after twenty weeks of pregnancy (Espeche & Salazar, 2023). Pregnant women with a history of hypertension and or are of advanced maternal age have an increased risk of developing placental abruption (Khan et al., 2022).
Treatment Plan with Evidence-Based Research and Resources Used
According to The American College of Obstetricians and Gynecologists, the classification of mild hypertension is a BP, 140-159/90-109 mm Hg and severe hypertension is a BP ≥ 160/110 mm Hg (Braunthal & Brateanu, 2019). It is currently acceptable for providers to discontinue hypertensive medications for women who have mild hypertension before becoming pregnant (“SMFM Statement: Benefit of Antihypertensive Therapy for Mild-To-Moderate Chronic Hypertension during Pregnancy Remains Uncertain,” 2015). However, this decision can be individualized for each patient. If the benefit of pharmacological treatment outweighs the risk, providers have the option to prescribe antihypertension medication for the duration of pregnancy or can restart medications after the first trimester, if blood pressure readings increase. Due to this patient’s age and cardiac history, my treatment plan would have included switching the patient from Lisinopril to Labetalol. I would discontinue the patient’s Zocor and Plavix as these medications are not recommended during pregnancy. Additionally, because of her history of hypertension, I would add prophylaxis low-dose 81mg aspirin daily (Davidson et al., 2021). After changing the patient’s medications, I would want the patient to start a blood pressure log and return for a blood pressure check in two weeks to monitor the effectiveness of the medication. These best practice guidelines were researched using Walden University’s Library and Google Scholar.
Dilemmas and/or other issues
Daily, nurse practitioners make decisions in the best interest of their patients. However, there are times when what a patient wants and what is in their best interest do not coincide. One dilemma, in this case, is the balance of trying to fulfill the patient’s desire for pregnancy while knowing that because of her age and medical history, the chance of a successful pregnancy is not likely. The loss of a pregnancy can have lasting psychological effects as well. The patient could develop depression or feel less like a “woman” because she is unable to physically carry a pregnancy and give birth. Depending on the patient’s financial situation, adoption or additional IVF attempts may not be an option due to their out-of-pocket cost.
References
Braunthal, S., & Brateanu, A. (2019). Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Medicine, 7(7), 205031211984370. https://doi.org/10.1177/2050312119843700
Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Silverstein, M., Simon, M. A., Stevermer, J., Tseng, C.-W., & Wong, J. B. (2021). Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality. JAMA, 326(12), 1186. https://doi.org/10.1001/jama.2021.14781
Espeche, W. G., & Salazar, M. R. (2023). Ambulatory Blood Pressure Monitoring for Diagnosis and Management of Hypertension in Pregnant Women. 13(8), 1457–1457. https://doi.org/10.3390/diagnostics13081457
Khan, S., Chughani, G., Amir, F., & Bano, K. (2022). Frequency of Abruptio Placenta in Women With Pregnancy-Induced Hypertension. Cureus, 14(1), e21524. https://doi.org/10.7759/cureus.21524
SMFM Statement: benefit of antihypertensive therapy for mild-to-moderate chronic hypertension during pregnancy remains uncertain. (2015). American Journal of Obstetrics and Gynecology, 213(1), 3–4. https://doi.org/10.1016/j.ajog.2015.04.013
Thank you for your post, I found it insightful. Your differential diagnosis of chronic hypertension seems appropriate given the patient’s medical history. It’s evident that managing hypertension during pregnancy is crucial to ensure the best outcomes for both the mother and the baby.
I agree with your treatment plan to switch the patient from Lisinopril to Labetalol, as the former is not recommended during pregnancy due to potential risks to the fetus. Additionally, discontinuing Zocor and Plavix is essential, as these medications are also contraindicated during pregnancy. In this case, the treatment plan for the 55-year-old patient with mild hypertension and a desire to start a family requires thoughtful consideration. Prophylactic low-dose aspirin can help prevent complications like preeclampsia (Haahr et al., 2020). Regular blood pressure monitoring is crucial throughout the pregnancy. In your discussion, you highlighted some of the dilemmas that healthcare providers may encounter when balancing a patient’s desires with their medical history and potential risks. Indeed, it can be challenging when a patient wishes to pursue pregnancy despite the potential complications associated with their age and medical conditions. Ethical dilemmas arise in balancing the patient’s autonomy with beneficence and providing informed consent regarding potential risks and challenges. Emotional support must be offered to address the psychological impact of unsuccessful pregnancies. Financial constraints and the consideration of surrogacy or gestational carriers are additional ethical considerations. Overall, patient-centered care, open communication, and sensitivity are vital in navigating these complex decisions to ensure the patient’s well-being and best interests are prioritized. It’s crucial for healthcare providers to have open and honest discussions with patients, laying out the potential risks and benefits clearly, so that the patient can make an informed decision.
In such cases, offering counseling and support to patients who may face difficulties in achieving a successful pregnancy is essential. Mental health support is crucial for those experiencing the loss of a pregnancy, and healthcare providers should be prepared to address the emotional aspects of these situations. Additionally, considering alternative options such as adoption or fostering can be discussed with the patient. Adoption can provide a fulfilling path to parenthood, and some patients may find it to be a suitable option (Poorchangizi et al., 2019). Lastly, it might also be worth discussing the option of using a gestational carrier with the patient, given her desire to have a family. This approach allows the patient to have a biological child without undergoing pregnancy themselves, which can be an option for individuals who are unable to carry a pregnancy safely. Overall, your initial post provided a thorough analysis of the case study, and your proposed treatment plan was well-supported by evidence-based research. Addressing the ethical dilemmas and providing emotional support to the patient are essential aspects of patient care in such challenging situations.
References
Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing ethics, 27(1), 258-272. https://doi.org/10.1177/09697330198329
Links to an external site.
Poorchangizi, B., Borhani, F., Abbaszadeh, A., Mirzaee, M., & Farokhzadian, J. (2019). Professional values of nurses and nursing students: A comparative study. BMaC medical education, 19, 1-7. https://doi.org/10.1186/s12909-019-1878-2
Summary:
Gloria Smart is a 55-year-old female who presents to your office today for regular gyn. care. You read her medical history and note she received a cardiac stent at age 50, has mild hypertension, and is on Zocor, Plavix, and Lisinopril. Surgical history is remarkable for tonsils as a child and bunion surgery. She works full time, by choice, because it “makes me feel young.” She is up to date with colonoscopies. Gyn. history normal pap history, last DXA within normal limits, normal mammogram. BMI is 26. First menses age 14 and menopause age 52. She works out at her local gym 5 days a week. Social history is negative for tobacco and recreational drugs. She has an occasional glass of wine. She has never married and has been with her current partner for 2 years and will be getting married in 2 months. She has never been pregnant, and her partner has never had a child.
Differential Diagnosis
Primary Dx: Placental abruption (PA) is a separation of the placenta from the uterine wall occurring with the fetus still present in the uterine cavity. It contributes to numerous neonatal and maternal complications, increasing morbidity and mortality. (Baczkowska, 2022). The risk of having placental abruption is higher in older females that suffer from hypertension. The pathophysiology of AP is due to acute decompression when ruptured gestational membranes a represent. Gloria is 55 and already suffers from mild hypertension. Pregnancy affects everyone differently and in her case even though she works out regularly and takes her medications as prescribed she has non modifiable risk factors for developing this.
Placenta Previa: Placenta Previa is the complete or partial covering of the internal os of the cervix with the placenta. It is a major risk factor for postpartum hemorrhage and can lead to morbidity and mortality of the mother and neonate. (Anderson-Bagga, 2022). Risk factors that correlate with placenta previa are advanced maternal age, multiparity, smoking, cocaine use, prior suction, and curettage, assisted reproductive technology, history of cesarean section(s), and prior placenta previa. (Anderson-Bagga, 2022). Gloria is an advanced maternal age, and depending may or may not have uterine scaring just over time that can add to the placenta covering the cervical os. Advanced maternal age (age greater than 35 years old), the relationship between advanced maternal age and placenta Previa may be confounded by higher parity and a higher probability of previous uterine procedures or fertility treatment. However, it may also represent an altered hormonal or implantation environment. (Anderson-Bagga, 2022).
Uterine Rupture: Uterine rupture is the tearing of the uterine wall and the loss of its integrity through breaching during pregnancy, delivery or immediately. (Togioka, 2023). Increased hypertension and antihypertensive medications has an independent, positive association with risk for clinically detected uterine leiomyomata (Togioka, 2023). Which in combination over time can weaken the uterus making a patient like Gloria at a higher risk for a Uterine Rupture during vaginal delivery.
Why did you make this diagnosis decision?
The decision to pick the three differential diagnoses is due to the evaluation of the patient’s medical history. Gloria’s medical history indicates she received a cardiac stent at the age of 55. Cardiac stent is normally a procedure done to enable opening up of the clogged arteries that enabling sufficient supply of blood to the heart. The blockage of blood vessels is caused by high amount of cholesterol in the body. The high amount of cholesterol in the body causes narrowing of arteries resulting to high blood pressure (Fowler, et al., 2012). The narrowing of blood vessels is also associated with diabetes, which Gloria denies at this time. Gloria also has to take Zocor to manage the cholesterol levels. The medical history also indicates she underwent a surgery for her tonsils at the age of 16. This observation made me conclude the patient probably has aortic coarctation which likely was inherited from her parents. Also, the occurrence of mild hypertension suggests that the patient has aortic coarctation. The uses of ACE inhibitors such as Lisinopril are medications taken to manage conditions such as renal artery stenosis thus making this condition the differential diagnosis. Gloria works out 5 days a week also indicating that the she has adapted to healthy living that makes her effectively cope with her medical condition. Along with her medical history, risk factors, as well as age, when she came into the office with her fiancé complaining that her blood pressure wouldn’t go down she had a swollen face and 2+ pitting edema all of these diagnoses fit in that perfect storm of events.
Treatment Plan
The onset of placental abruption is often unexpected, sudden, and intense and requires immediate treatment. Prehospital care for the patient with a suspected placental abruption requires advanced life support and transport to a hospital with a full-service obstetrical unit and a neonatal intensive care unit. Following arrival at the hospital, most women will receive intravenous (IV) fluids and supplemental oxygen as well as continuous maternal and fetal monitoring, while the history and physical is completed. Subsequent treatment will vary based on the data collected during the assessment, the gestation of the pregnancy, and the degree of distress being experienced by the woman and/or the fetus. (Schmidt, 2022).
LABS
Type and screen for transfusion
RH immune globulin factor
CBC with platelet count
Fibrinogen levels
PT/ PTT
Bedside maternal clot test: Red-top tube of maternal blood with poor or non-clotting blood after 7 to 10 minutes indicates coagulopathy.
Fetal-maternal hemorrhage test (e.g., Kleihauer-Betke test); >30 mL fetal blood indicative of large fetal blood loss: 300-μg dose of RhoGAM will cover up to 30 mL whole fetal blood in maternal circulation.
Bedside ultrasound has low sensitivity and is only helpful in cases of a large abruption.
Abnormalities of maternal serum aneuploidy analytics (AFP, HCG, PAPP-A, estradiol) increase abruption risk by 10-fold.
Ultrasound: Appearance or abnormality depends on size and location of the bleed. With acute bleed that is overt, nothing may be seen as no persistent retro placental accumulation. Will fail to detect at least 50% of abruptions Retro placental clot is diagnostic of abruption.
Follow-Up Tests & Special Considerations
DIC can result from a large abruption. Best to stabilize patients without awaiting for DIC labs.
Can send PT/PTT, fibrinogen levels at clinician discretion when stable or following resolution of DIC
Fibrinogen levels climb to 350 to 550 mg/dL in the 3rd trimester and must fall to 100 to 150 mg/dL before PTT will rise. Fibrin split or degradation products are elevated in pregnancy and are not specific in assessing DIC.
If incidental abruption is found in a patient at term, delivery is reasonable. A preterm patient with an incidental abruption may be managed conservatively if stable. (Schmidt, 2022). If the collected data results in class 2 (moderate) or class 3 (severe) classification and the fetus is viable and alive, delivery is necessary. Because of the hypertonic contractions, a vaginal birth may occur rapidly. Given the potential for coagulopathy, vaginal birth presents less risk to the mother. However, if there are signs of fetal distress an emergency cesarean birth is necessary to protect the fetus. During the surgical procedure, careful management of fluids and circulatory volume is important. Post-operatively the patient needs to be monitored for postpartum hemorrhage and alterations in the clotting profile. A neonatal team needs to be present in the delivery room to receive and manage the infant. (Schmidt, 2022).
What evidence-based research can you provide to support your decision (choice for differential diagnosis and plan/intervention)? I gathered information from the National Library of Medicine, National Institute of Health, Pub Med, MD Guidelines, and Cochrane Institute. They are reputable sources that provide access to a wide range of peer-reviewed articles and meta-analysis studies. By utilizing these sources, I was able to gather information on the signs, symptoms, risk factors, diagnostic criteria, and management strategies for the differential diagnoses.
What resources did you use to meet your best practice guidelines? The resources I used to meet the best practice guidelines for this patient include the American Heart Association and the National Institutes of Health.
Ethical Dilemmas
Ethical issues: Even though the patient is advanced in age, it is important not to dismiss their autonomy, but rather listen, and provide education as much as possible; ultimately the decision should be that of the patient (Harrison et al., 2017). With the use of assisted reproductive technologies (ARTs) such as in-vitro-fertilization (IVF), it is possible for menopausal women to become pregnant with the use of a donor egg but the risk for maternal and fetal complication is significantly increased (Harrison et al., 2017).
Psychological issues: The process of conceiving a child at an advanced age is linked to high level of stress which should be avoided during pregnancy. Increase stress can further increase the patient’s blood pressure and increased maternal and fetal complication (Vasanthakumari, & Retnamma, 2017).
Physical issues: Ms. Thomas still works full time by choice which can increase fatigue and physical demands on the patient’s body. Patient should be educated to cut down on work hours while trying to conceive.
Financial issues: Medical insurance options should be discussed with the patient because IVF in any population is very costly with low success rate which is further decrease with age (Harrison et al., 2017)
Resources:
Anderson-Bagga FM, Sze A. Placenta Previa. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539818/
Links to an external site.
Bączkowska, M., Kosińska-Kaczyńska, K., Zgliczyńska, M., Brawura-Biskupski-Samaha, R., Rebizant, B., & Ciebiera, M. (2022). Epidemiology, Risk Factors, and Perinatal Outcomes of Placental Abruption-Detailed Annual Data and Clinical Perspectives from Polish Tertiary Center. International journal of environmental research and public health, 19(9), 5148. https://doi.org/10.3390/ijerph19095148
Links to an external site.
Fowler, F. J., Jr, Gallagher, P. M., Bynum, J. P., Barry, M. J., Lucas, F. L., & Skinner, J. S. (2012). Decision-making process reported by Medicare patients who had coronary artery stenting or surgery for prostate cancer. Journal of general internal medicine, 27(8), 911–916. https://doi.org/10.1007/s11606-012-2009-5
Links to an external site.
Harrison, B. J., Hilton, T. N., Rivière, R. N., Ferraro, Z. M., Deonandan, R., & Walker, M. C. (2017).Advanced maternal age: ethical and medical considerations for assisted reproductive technology. International journal of women’s health, 9, 561-570. https://doi.org/10.2147/IJWH.S139578
Links to an external site.
Vasanthakumari, K. P., & Retnamma, N. V. (2017). Outcome of Pregnancy in Elderly Primigravida. Journal of Medical Science and Clinical Research, 5(1), 29523-28
Schmidt P, Skelly CL, Raines DA. Placental Abruption. [Updated 2022 Dec 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482335/
Links to an external site.
Togioka BM, Tonismae T. Uterine Rupture. [Updated 2023 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559209/
