Reply to my peers

Discussion Question 1

1. List the additional questions you would need to ask this patient. Explain.

Assessment any other symptoms: Headache, check protein in urine, dizziness, Blurred vision, Swelling Hands and BLE. All above symptoms are signs of HTN crisis and Gestational HTN.  

2. What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus?

Lisinopril-HCTZ are class D for pregnant women. This medication should be stopped immediately once pregnancy is confirmed. Lisinopril has shown to cause Fetal and neonatal morbidity and death in the second and third Trimester. 

Bismuth Subsalicylate should be stopped as it has shown to cause increased risk for bleeding in pregnant women in the second and third trimester. Class C in first and second trimester, D in third trimester due to closer to EDD. 

3. What is the importance of assessing laboratory values when prescribing medications? How might the laboratory values, in this case, impact your treatment plan?

Due to the urine beta HCG test- confirmation of pregnancy was made. This Lab test alone will change the treatment plan. This patient must be stopped from Lisinopril- HCTZ and Bismuth Subsalicylate. She can no longer be managed by PCP due to PMH of HTN and current pregnancy. 

4. Would you make any changes to Ms. BD’s blood pressure and GERD 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 advise Ms. BD to stop both of the above medications and education her on risk for her and his pregnancy. As both medications are not recommended for pregnant women. I would also consult with Maternal fetal medicine on treatment plan until she is seen by them. Labetalol appears to be the HTN drug of choice for pregnancy with Metoprolol and atenolol appearing to be safe and effective in late pregnancy (Woo et al., 2020). Labetalol is common and safe in pregnancy. Mechanism of action: blocking alpha- and beta-adrenergic receptors, resulting in decreased peripheral vascular resistance without significant alteration of heart rate or cardiac output. Half-life: 3 to 8 hours. Metabolized from the lover and eliminated through the kidneys. In pregnancy there is no contraindications for Labetalol (Woo et al., 2020). 

5. How does ethnopharmacology apply to this patient if she were NOT pregnant? Explain.

Ms. BD is an African American woman that has chronic HTN and developed gestation HTN with prior Pregnancy. Due to genetics and PMH she is at higher risk for developing complications causing poor BP management and poor outcome to her and her unborn child. 

6. What health maintenance or preventive education do you provide in this client case based on your choice of medications/treatment?

I would educate patient on needing to f/u with Maternal Fetal Medicine, my telephone consultation with MFM physician and their recommendation to stop lisinopril-HCTZ and Bismuth Subsalicylate due to risk for her and fetus. Educate Ms. BD on Labetalol and the common and safe use in pregnancy. Diet management could be another possible alternative if patient wishes to stop all medication and not start anything new due to pregnancy. I woud advise patient to take labetalol until discussing further treatment plans with MFM physician. Appt with MFM would be made prior to patient leaving office.

7. Would you treat this patient or refer her? Explain. If you refer, where would you refer this patient?

In my professional opinion, I believe Ms. BD should be sent to a Specialist for management of her Chronic HTN and pregnancy. Maternal fetus specialist. This is beyond the primary care specialty. Prior to patient leaving office, I would consult with a local Maternal fetus medicine physician for guidance on Treatment until Ms. BD is seen by him/her. 

 

Reference:

Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse prescribers. F.A. Davis Company.