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Case study 1:
Gloria Smart is a 75-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 55, 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 54. 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.
What is your differential diagnosis?
2. HELLP syndrome
3. Placenta Abruptio
Why did you make this diagnosis decision?
- Preclampsia is an actual diagnosis for this patient because the patient has history of chronic hypertension during pregnancy. Now that the patient has conceived, the doctor had placed her on Procardia to manage her blood pressure. The patient has higher risk of preeclampsia which is related to her history of cardiac disease and chronic hypertension. Preeclampsia can indicate some signs of severity when the systolic blood pressure levels are greater than 160mmHg and/or diastolic blood pressure levels are greater than 110mmHg; or when there is concomitance of eclampsia or HELLP syndrome. (Mayrink, Costa, & Cecatti, 2018). “Chronic hypertension during pregnancy can result to adverse outcomes which include preeclampsia, cesarean delivery, cerebrovascular accidents, fetal growth restriction, preterm birth, and maternal and perinatal death” (Battarbee, Sinkey, Harper, Oparil, & Tita, 2020). There is a high rate of morbidity and mortality due to preeclampsia.
The physiological and medical condition can require emergent treatment and it is based on clinical presentation.
- HELLP syndrome is a complication of pregnancy characterized by hemolysis, elevated liver enzymes, and a low platelet count. This is a differential diagnosis for this patient because the information given indicates that liver function tests LFTs level is elevated and the platelet level is 50,000 which indicates low level. HELLP syndrome usually manifest before 37 gestational week and shortly after the childbirth. Studies show that HELLP syndrome and hypertensive disorder accounts for morbidity and mortality rate in United States. HELLP syndrome in its clinical presentation is like other conditions, such as benign thrombocytopenia of pregnancy, acute fatty liver of pregnancy, viral hepatitis, and others (Rimaitis et al., 2019). HELLP syndrome can be life-threatening to mother and fetal and can lead to multi organ dysfunction disorder.
- Placenta Abruptio- Placental abruption is the early separation of a placenta from the lining of the uterus before completion of the second stage of labor (Schmidt, Skelly, & Raines, 2020). It is one of the causes of bleeding during the second half of pregnancy. Placental abruption can lead to potential complication in pregnancy. The maternal age of 75 years old with history of chronic hypertension prior to pregnancy can put the patient and fetus to a high risk for placental abprutio (Schmidt, Skelly, & Raines, 2020).
What is your treatment plan?
The treatment plan for the patient is to immediately initiates IV magnesium sulfate to prevent seizure. Also, administer several doses of IV labetalol to control blood pressure control. Another treatment for placenta abruptio is to increase fluid and keep the patient well hydrated “most women will receive intravenous (IV) fluids and supplemental oxygen as well as continuous maternal and fetal monitoring” (Schmidt, Skelly, & Raines, 2020). It is important to monitor blood pressure and other medical condition during pregnancy.
What resources did you use to meet your best practice guidelines?
The resources used are evidence-based research which provides clinical guidelines for nurses, while treating patient with preeclampsia, HELLP syndrome and placental abruptio. The international journal research and public health.
The ethical issues on the case scenario are to acknowledge the patient’s decision with been biased. It is important for nurse practitioner to respect patient’s decision with their choice of contraception. The intention of medical practitioner is to vividly screen older women to ensure that they are medically and physiologically capable of attaining successful pregnancy. The ethical value is to ensure patient’s right and decision-making is being recognized. Many studies have shown that patient with the age of 50, were at increased risk for pre-eclampsia, gestational diabetes, and a majority will deliver by cesarean section. The rates of spontaneous abortion and multiple gestation rate (Harrison et al., 2017). Advanced maternal age women should be notified about the risks and benefits of conceiving at late stage. Also, there are Pregnancies in post-menopausal women who are considered safe due to absence of preexisting medical comorbidities. Many prenatal screenings, such as genetic counseling, amniocentesis, or serial ultrasounds; have been suggested as potential necessities for advanced maternal age pregnancies. Patients need to be aware that maternal fetal specialist may be referred during pregnancy.