Is there any additional subjective or objective information you need for this client? Explain.

Discussion #1

Is there any additional subjective or objective information you need for this client? Explain.

Additional objective information would include Ms. BD’s height and weight and allergy history.  I would also order a quantitative hCG blood test to know gestational age and therefore the length of exposure to the Prinzide.  Additionally, I would order a clean catch urine.  Finally, I would inquire about compliance with medication, ethnic background and family history.  

Is Prinizide safe in pregnancy? What are the possible complications to the pregnant woman and her fetus?

Prinzide is a Category D drug, that according to Kattah & Gorovic (2013), should be discontinued and changed to a pregnancy safe medication immediately.  Taking prinzide during the first trimester is associated with congenital heart defects and kidney abnormalities, while second and third trimester exposure is associated with fetal injury or death. 

Why is it important to assess the above laboratory values? How might this information impact your treatment plan?

It is important to assess the above laboratory values for several reasons.  First, her blood pressure and pulse will guide the use of medications to control her blood pressure.  Secondly, testing kidney function and potassium is necessary because prinzide is a combination of lisinopril and hydrochlorothiazide.  Impaired renal function decreases elimination of lisinopril and hydrochlorothiazide which is excreted through the kidneys, and ACE inhibitors can cause an increase serum potassium.  Finally, some antihypertensive medications can cause anemia and HELPP syndrome, therefore it is imperative to collect a CBC and monitor hemoglobin, hematocrit and platelets.  This information impacts decision-making for alternate medications and to assess the patients current state of health.  

Would you make any changes to Ms. BD’s blood pressure medications? Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.

Kattah & Gorovic (2013) report that there is insufficient evidence to support managing chronically hypertensive pregnant women with blood pressure that is lower than 140/90 mm Hg with the use of antihypertensive medication.  In my opinion, the antihypertensive medication prinzide should be stopped and since prinzide does not produce rebound hypertension, Ms. BD’s blood pressure should just be monitored.  I would hold off on starting any new medications to see how the patients blood pressure trends.  This is important because blood pressure during the first and second trimesters tend to trend lower (Rebelo, Farias, Mendes, Schlüssel & Kac, 2015).

According to Brown & Gavoric (2014), methyldopa, labetalol, beta blockers (except atenolol), nifedipine and a diuretic in chronically hypertensive patients are considered appropriate.  If antihypertensives are being restarted in women with chronic hypertension, methyldopa is recommended as first line therapy (Hoeltzenbein, Beck, Fietz, Wernicke, Zinke, Kayser, Padberg…& Schaefer, 2017).  Therefore, if I were to restart Ms. BD on medication, I would recommend methyldopa.

Methyldopa is considered safe (category B) for use during pregnancy, though there are limited studies related to the affects on the fetus during the first trimester.  Methyldopa stimulates the central alpha-adrenergic receptors by a pseudo neurotransmitter that causes a decrease in sympathetic flow to the heart, kidneys, and peripheral vascular system (Brown & Garovic, 2014).  This medication is taken by mouth, peaks within 2-4 hours, and has a half-life of 1.5-2 hours respectively.  Methyldopa is metabolized in the intestines and liver and is excreted through urine completely within 36 hours.  

Hypersensitivity to methyldopa and/or a component of the formula; hepatic disease or previous hepatic compromise that is associated with use of methyldopa, and concurrent use of MAO inhibitors are all contraindications for taking methyldopa.  

What health maintenance or preventive education is important for this client based on your choice medication/treatment?

I would discuss lifestyle modifications first that will assist in lowering blood pressure naturally, including exercise and nutrition, as well as monitoring and recording her blood pressure to trend.  Also, methyldopa may increase the patients need for vitamin b12 and folate.  Additionally, I would educate the patient on side effects such as fatigue and headache and would instruct the patient to report signs of hepatic complications (darkening urine, light-colored stool, easy bleeding/bruising, weight gain, and jaundice). 

Would you treat this patient or refer her? Where would you refer this patient?

Because of the exposure to Prinzide and needing ultrasound and fetal echocardiogram at 18 weeks gestation, would to me make this more of a high-risk scenario, and thus require a referral to an ob/gyn and possibly a cardiologist.

Discussion #2

Is there any additional subjective or objective information you need for this client? Explain.

Hypertension during pregnancy is the main health concern because of the risk of the mother and the baby. Therefore, Ms. BD would need to provide information about other health histories such as any known drug allergies, gynecological history, any recent pain such as headache, and any exposure to sexually transmitted diseases. Physical exam of height, weight, body mass index and urinalysis should be performed to evaluate the progression of the pregnancy. Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook (2017) mentioned that routine initial prenatal visits are a complete history, a comprehensive physical examination to confirm that clinical information associates the timing of the pregnancy. 

Is Prinizide safe in pregnancy? What are the possible complications to the pregnant woman and her fetus?

 Prinzide is a category D drug, it should not be used during pregnancy due to adverse effects it can cause to the fetus such as skull hypoplasia, anuria, hypotension, renal failure, and death. This medication should be discontinued as soon as pregnancy is detected (Karch, 2017).

Why is it important to assess the above laboratory values? How might this information impact your treatment plan?

 Laboratory values should be assessed during pregnancy to obtain a baseline to monitor progress. The reason for checking the hgb and hct is to check for anemia, WBC’s to check for infection, and platelets to check for blood clotting. A urinalysis is to check for urinary tract diseases or infections, as well as checking for glucose or protein in the blood which could indicate a sign of diabetes mellitus. These tests can help find conditions that can increase the risk of complications for mother and fetus (American College of Obstetricians and Gynecologists (ACOG), 2017). Proteins levels in urine are measured and compared throughout pregnancy. According to ACOG (2017), high levels of protein in urine is mostly a sign of preeclampsia. Preeclampsia is a serious complication beginning high blood pressures which can happen later in pregnancy or after the baby is born. BUN, creatine, potassium, and ALT are used to measure renal and liver functions. Since the patient is taking blood pressure medications and these meds are excreted through the kidneys and metabolized by the liver. It is extremely important to measure these labs.

Would you make any changes to Ms. BD’s blood pressure medications? Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.

I would immediately stop the prinzide. Hypertension medications that are commonly used to treat severe chronic hypertension in pregnancy are labetalol methyldopa, hydralazine, and nifedipine (Leeman, Dresang and Fontaine, 2016). I would prescribe her labetalol because it’s a category C medication. According to Drugs.com, Labetalol is a beta-blocker that affects the heart and circulation (blood flow through arteries and veins). It is used for the treatment of hypertension during pregnancy because of the low number of side effects to both the mother and child (Drugs.com). Pharmacokinetics refers to the absorption, distribution, metabolism, and excretion of a drug.  Labetalol is metabolized by the liver (Drugs.com). A black box warning or boxed warning is the U.S. Food and Drug Administration’s most serious warning for drugs that may cause serious injury or death (Llamas, 2018). Labetalol’s onset is within 20 minutes but peaks anywhere between one to four hours and lasts anywhere between eight and twelve hours, its half-life is three to eight hours and is eliminated in bile and feces, and about 50-60% is excreted through urine (Woo and Robinson, 2015). 

What health maintenance or preventive education is important for this client based on your choice medication/treatment?

I would educate the patient about diet modifications to limit sodium intake, to monitor the blood pressure daily and report any abnormalities. I would tell her to not stop taking the BP medication without consulting me, I would warn her about the side effects of the medication such as dizziness, lightheadedness, loss of appetite, nightmares, depression, and sexual impotence (Karch, 2017). I would ask her to report any problems like difficulty breathing, night cough, extremities swelling, slow pulse, confusion, depression, rash, fever, and sore throat (Karch, 2017).

Would you treat this patient or refer her? Where would you refer this patient?

 Since all her labs are within normal limits, I would continue to treat her for the blood pressure, but I refer her to see an obstetrician/gynecologist to monitor her pregnancy.