WU Differential Diagnoses Treatment Case Study Discussion Responses

Respond to at least two of your colleagues’ posts (from a different group) on two different days and provide additional insight that might be useful and appropriate for the issue addressed. Use your learning resources and/or evidence from the literature to support your position.

Please respond to the two case study below

Summary of Case Study #1

Case study #1, involves a 55-year-old nulliparous African American female who comes to the office requesting a referral and guidance for fertility. PMHx; Cardiac stent, age 50, Hypertension, menopausal at age 52. Past surgical Hx; tonsils as a child and bunion surgery. The patient lives a healthy lifestyle, BMI of 26, works out 5 days a week and denies the use of tobacco, illegal substances, and drinks an occasional glass of wine. The patient is currently engaged to a man who she has been dating exclusively for the last 2 years and they are to get married in 2 months. The patient was referred to maternal fetal medicine (MFM) due to current medication regimen for hypertension Zocor, Plavix, and lisinopril being in categories of drugs not recommended for use in pregnancy. Maternal fetal medicine consulted with her cardiologist who changed the patient’s blood pressure meds to Procardia and discontinued her cholesterol meds which is appropriate in pregnancy. The patient also started folic acid 400mcg PO daily, in preparation of pregnancy. The patient was then assessed by a fertility specialist. The patient and her fiancé decide to do IVF treatment and use a donor egg. The patient becomes pregnant after her second cycle of treatments. The patient returns to the office at 12 weeks gestation to be comanaged by the office and MFM. A baseline CMP and 24-hour urine is completed due to the patient’s history of HTN. The patient and her fiancé then visited the office with c/o elevated blood pressure readings at home, right sided abdominal pain, and swelling. Upon assessment the patient’s blood pressure was 160/92 with a repeat value of 160/88. The patient also has facial swelling and 2+ pitting edema of the lower legs. The patient was sent to the hospital for immediate treatment to prevent stroke and/or placental abruption. The patient started showing signs of HELLP syndrome with elevated liver enzymes and a low platelet count. The patient was treated with IV Labetalol to lower BP. The patient had a placental abruption and gave birth to a male child who survived for 20 min before demise. The patient was hospitalized for 11 days before being discharged, during her hospitalization management of her blood pressures were achieved.Differential DiagnosesMy differential diagnoses are 1. Preeclampsia, 2. Poor fetal growth, and 3. Premature birth. I chose preeclampsia as this patient’s main diagnosis due to her history of uncontrolled hypertension. According to Garovic et al., (2022), African American women have genetic markers that may increase their risk for preeclampsia. I choose poor fetal growth and premature birth because these are risks factors due to the patient’s advanced maternal age and history of hypertension. According to Sehgal et al., (2021), hypertension in pregnancy can cause fetal growth restriction in the <10th percentile. According to the Center for Disease control and Prevention (CDC), (2022), premature births occur because the mother’s high blood pressure causes a decrease in oxygen and nutrients needed by the fetus to grow.Treatment PlanMy treatment plan would be to have the patient do biweekly prenatal visits for an in office blood pressure check in addition to at home readings. I would start the patient on a daily dose of Aspirin. According to Beech and Mangos, (2021), at 12-16 weeks gestation a patient with a high risk for preeclampsia should be started on Aspirin 81-150mg PO daily until 36 weeks gestation to decrease the chances of preterm birth. I would establish a threshold for treatment of hypertension. According to Garovic et al., (2022), of the American Heart Association, the threshold for blood pressure in pregnancy for an African American woman is lower than other races at 133/85. If the patient has blood pressure readings over this threshold, then the patient would need to go to the hospital for treatment. During the pregnancy the health of the baby will be monitored by fetal growth measurements and fetal kick counts later in the pregnancy. This is very important because hypertension and advanced maternal age are risk factors for poor fetal growth and premature birth.Evidence Based Research and Resources Used in My Decision Making.The evidence-based research that I used to make my differential diagnoses and treatment decisions came from the American Heart Association, and The American College of Obstetricians and Gynecologists. The resources that I used for best practice guidelines came from the Center for Disease Control and Prevention, The American Heart Association, The American College of Obstetricians and Gynecologists- Chronic Hypertension and Pregnancy (CHAP) trial, and Uptodate.Ethical Dilemmas and IssuesThis case study brought up many ethical dilemmas as well as physiological, psychological, and financial issues. The ethical dilemmas in this case study involve how to support patients who are considered advanced age in pregnancy and considering the quality of life for a child with advanced age parents. According to Glitch et al., (2021), patients who are considered advanced maternal age have physical issues that make pregnancy difficult such as having a womb inadequate of carrying a fetus to term, complications with vaginal birth leading to an increased chance of c-section delivery. Also, the fetus of an advanced age woman can have possible genetic abnormalities, poor fetal growth, and premature birth. Psychological issues include developing depression from failed IVF attempts or miscarriages after successful implantation. The financial issues of advanced maternal age include the expensive cost of multiple IVF treatments that may not be covered by insurance and the lifelong financial responsibility of caring for a child with genetic abnormalities of health complications from premature birth.ReferencesBeech, A., & Mangos, G. (2021). Management of hypertension in pregnancy. AustralianPrescriber, 44(5), 148-152 https://doi.org/10.18773/austprescr.2021.039Center for Disease Control and Prevention. (2022). High blood pressure during pregnancy.https://www.cdc.gov/bloodpressure/pregnancy.htmGarovic, V.D., Dechend, R., Easterling, T., Karumanchi, S.A., Baird, S.M., Magee, L.A., Rana,S., Vermunt, J.V., August, P. (2022). Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the american heart association. Hypertension, 79(2), e21- e41. https://doi.org/10.1161/HYP.0000000000000208Glick, I., Kadish, E., Rottenstreich, M. (2021). Management of pregnancy in women of advancedmaternal age: improving outcomes for mother and baby. International Journal ofWomen’s Health, 13:751-759. https://doi.gov/10.2147/IJWH.S283216. Sehgal, A., Alexander, B.T., Morrison, J.L., South, A.M. (2020). Fetal growth restriction andhypertension in the offspring: mechanistic links and therapeutic directions. The Journal of Pediatrics, 224:115-123.e2. https://doi.gov/10.1016/j.jpeds.2020.05.028.Infertility in an older female patient is the case study that I have chosen to review. The case study concerns a middle-aged, menopausal woman, Gloria Smart, age 55, G0 P0, who wishes to conceive a child via in-vitro fertilization treatment (IVF) with her fiancé. The patient has a history of cardiovascular stent placement and hypertension. The patient’s age, co-morbidities, and daily medications place the patient at high risk for complicated cardiac events, placental abruption, and pregnancy loss if conception occurs. Mrs. Smart was up to date on recommended screenings and does not partake in risk factors, such as tobacco or illicit drug use, although she does drink alcohol occasionally. The patient’s BMI was slightly elevated, falling in the overweight index even though she exercises at her local gym five days a week. Patient counseling on IVF, educating the patient on behaviors that will increase her chances of having a successful pregnancy, and reducing complications, if the pregnancy occurred were included in the patient’s care. Gloria Smart was educated on the importance of limiting alcohol while attempting to conceive. Ms. Smart and her fiancé were referred to a maternal-fetal medicine specialist to modify her category x medications and make recommendations to the couple n IVF and how to increase her chances of conceiving. The maternal-fetal medicine specialist collaborated with the patient’s cardiologist to change her category x medications, Zocor and lisinopril. The patient’s Zocor was discontinued, the lisinopril was changed to Procardia, and the Plavix was exchanged for baby aspirin. Gloria’s cardiac stress test and renal function tests were normal. The couple then was seen by an infertility specialist to discuss IVF and the donor egg method, ultimately deciding to proceed with the process. Gloria becomes pregnant on her second cycle and is sent back to the nurse practitioner for co-managed care with the maternal-fetal medicine specialist. Due to Gloria’s increased risk for preeclampsia due to her chronic hypertension and cardiac disease, a baseline CMP and 24-hour urine were ordered. After Gloria was sent back to the nurse practitioner, she presented to the clinic complaining of elevated blood pressure, which was taken home with her BP cuff. Gloria also has right-sided abdominal pain that developed after eating Chinese food and “swelling” in her face. Upon arrival at the clinic, Gloria’s blood pressure was elevated at 160/92. Her blood pressure was 160/88 when it was repeated. Pitting edema (2+) was noted in Gloria’s bilateral lower extremities, and her face is slightly swollen. Due to Gloria’s elevated blood pressure, liver function tests (LFTs) and platelet counts were ordered and obtained. Her LFTs were four times higher than the normal values, and platelets were considerably lower than the normal value at 55,000. Gloria and her family were advised of the concerns due to her high blood pressure and the necessity for immediate treatment to prevent stroke and placental abruption. Intravenous (IV) magnesium sulfate and IV labetalol were given to her to decrease the elevated blood pressure. Gloria, regrettably, had a placenta abruption later in the day and delivered a male infant who lived for only 20 minutes. Further complications of anuria and the inability to maintain her blood pressure, were seen in Gloria’s care after delivery. Gloria was discharged to home on day eleven. Female infertility and chronic hypertension were the primary diagnoses, and male infertility was the differential in this case study. This primary diagnosis was chosen due to the patient’s advanced age, menopausal status, and cardiovascular co-morbidities. Older women are more prone to have preexisting co‑morbidities that further complicate their pregnancy and outcome. Obstetric and perinatal complications commonly reported in IVF-accomplished pregnancies in older female patients include pregnancy‑induced hypertension, placenta previa, preterm labor, and gestational diabetes. It is also observed that these mature women also have a higher rate of cesarean section delivery and obstetric hemorrhage (Aziken & Osaikhuwuomwan, 2021). Among patients pursuing infertility treatment, male issues are the lone cause in approximately 20% of cases and are implicated in an additional 30% to 40% in combination with female causes (Rumbold et al., 2019).The treatment plan for the patient in this case study is prescribing Ms. Smart a daily, pre-conceptual folic acid supplementation of 400 mcg to 800 mcg by mouth daily to reduce the chance of developing neural tube defects. Oral antihypertensive therapy should be prescribed and closely monitored. Common medications given in pregnancy include oral labetalol and calcium channel blockers such as the Procardia that was prescribed in this case. Labetalol can be introduced at 200 mg orally every 12 hours and increased up to 800 mg orally every 8-12 hours as needed, not to exceed 2400 mg/d. Oral long-acting nifedipine, 30-60 mg/d, can also be prescribed (Publications & guidelines 2022). Resources that were utilized for information on preeclampsia and hypertension during pregnancy include best practices on the Society for Maternal-Fetal Outcomes website and the Preeclampsia Foundation website at www.preeclampsia.org (Website, 2022). Issues that are involved in this case study include ethical, physical, and financial issues due to performing IVF treatments in patients with an increased risk of spontaneously aborting the fetus. Gloria Smart is a menopausal patient with chronic hypertension and cardiovascular disease. These risk factors will likely induce high blood pressure during pregnancy and increase the risk of placenta abruption. These treatments in older patients are also not cheap, sometimes requiring several treatments before pregnancy may occur. Physically, pregnancy can deteriorate Gloria’s cardiovascular status and possibly cause a stroke if the symptoms can not be controlled.Infertility in an older female patient is the case study that I have chosen to review. The case study concerns a middle-aged, menopausal woman, Gloria Smart, age 55, G0 P0, who wishes to conceive a child via in-vitro fertilization treatment (IVF) with her fiancé. The patient has a history of cardiovascular stent placement and hypertension. The patient’s age, co-morbidities, and daily medications place the patient at high risk for complicated cardiac events, placental abruption, and pregnancy loss if conception occurs. Mrs. Smart was up to date on recommended screenings and does not partake in risk factors, such as tobacco or illicit drug use, although she does drink alcohol occasionally. The patient’s BMI was slightly elevated, falling in the overweight index even though she exercises at her local gym five days a week. Patient counseling on IVF, educating the patient on behaviors that will increase her chances of having a successful pregnancy, and reducing complications, if the pregnancy occurred were included in the patient’s care. Gloria Smart was educated on the importance of limiting alcohol while attempting to conceive. Ms. Smart and her fiancé were referred to a maternal-fetal medicine specialist to modify her category x medications and make recommendations to the couple n IVF and how to increase her chances of conceiving. The maternal-fetal medicine specialist collaborated with the patient’s cardiologist to change her category x medications, Zocor and lisinopril. The patient’s Zocor was discontinued, while the lisinopril was changed to Procardia, and the Plavix was exchanged to baby aspirin. Gloria’s cardiac stress test and renal function tests were normal. The couple then was seen by an infertility specialist to discuss IVF and the donor egg method, ultimately deciding to proceed with the process. Gloria becomes pregnant on her second cycle and is sent back to the nurse practitioner for co-managed care with the maternal-fetal medicine specialist. Due to Gloria’s increased risk for preeclampsia due to her chronic hypertension and cardiac disease, a baseline CMP and 24-hour urine were ordered. After Gloria was sent back to the nurse practitioner, she presented to the clinic complaining of elevated blood pressure, which was taken home with her BP cuff. Gloria also has right-sided abdominal pain that developed after eating Chinese food and “swelling” in her face. Upon arrival at the clinic, Gloria’s blood pressure was elevated at 160/92. Her blood pressure was 160/88 when it was repeated. Pitting edema (2+) was noted in Gloria’s bilateral lower extremities, and her face is slightly swollen. Due to Gloria’s elevated blood pressure, liver function tests (LFTs) and platelet counts were ordered and obtained. Her LFTs were four times higher than the normal values, and platelets were considerably lower than the normal value at 55,000. Gloria and her family were advised of the concerns due to her high blood pressure and the necessity for immediate treatment to prevent stroke and placental abruption. Intravenous (IV) magnesium sulfate and IV labetalol were given to her to decrease the elevated blood pressure. Gloria, regrettably, had a placenta abruption later in the day and delivered a male infant who lived for only 20 minutes. Further complications of anuria and the inability to maintain her blood pressure were seen in Gloria’s care after delivery. Gloria was discharged to home on day eleven. Female infertility and chronic hypertension were the primary diagnoses, and male infertility was the differential in this case study. This primary diagnosis was chosen due to the patient’s advanced age, menopausal status, and cardiovascular co-morbidities. Older women are more prone to have preexisting co‑morbidities that further complicate their pregnancy and outcome. Obstetric and perinatal complications commonly reported in IVF-accomplished pregnancies in older female patients include pregnancy‑induced hypertension, placenta previa, preterm labor, and gestational diabetes. It is also observed that these mature women also have a higher rate of cesarean section delivery and obstetric hemorrhage (Aziken & Osaikhuwuomwan, 2021). Among patients pursuing infertility treatment, male issues are the lone cause in approximately 20% of cases and are implicated in an additional 30% to 40% in combination with female causes (Rumbold et al., 2019).The treatment plan for the patient in this case study is prescribing Ms. Smart a daily, preconceptual folic acid supplementation of 400 mcg to 800 mcg by mouth daily to reduce the chance of developing neural tube defects. Oral antihypertensive therapy should be prescribed and closely monitored. Common prenatal hypertensive medications include oral labetalol and calcium channel blockers such as the Procardia prescribed in this case. Labetalol can be introduced at 200 mg orally every 12 hours and increased up to 800 mg orally every 8-12 hours as needed, not to exceed 2400 mg/d. Oral long-acting nifedipine, 30-60 mg/d, can also be prescribed (Publications & guidelines 2022). Resources for information on preeclampsia and hypertension during pregnancy include best practices on the Society for Maternal-Fetal Outcomes website and the Preeclampsia Foundation website at www.preeclampsia.org (Website, 2022). Issues that are involved in this case study include ethical, physical, and financial issues due to performing IVF treatments in patients with an increased risk of spontaneously aborting the fetus. Gloria Smart is a menopausal patient with chronic hypertension and cardiovascular disease. These risk factors will likely induce high blood pressure during pregnancy and increase the risk of placenta abruption. These treatments in older patients are also not cheap, sometimes requiring several treatments before pregnancy may occur. Physically, pregnancy can deteriorate Gloria’s cardiovascular status and possibly cause a stroke if the symptoms can not be controlled.ReferencesAziken, M. E., & Osaikhuwuomwan, J. A. (2021). Pregnancy in older women: Analysis of outcomes in pregnancies from donor oocyte in- vitro fertilization. Journal of Human Reproductive Sciences, 14(3), 300. https://doi.org/10.4103/jhrs.jhrs_209_20.Publications & guidelines: Smfm.org - the society for maternal-fetal medicine. Publications & Guidelines | SMFM.org - The Society for Maternal-Fetal Medicine. (2022). Retrieved October 26, 2022, from https://www.smfm.org/publications/91-evaluation-and-management-of-severe-preeclampsia.Rumbold, A. R., Sevoyan, A., Oswald, T. K., Fernandez, R. C., Davies, M. J., & Moore, V. M. (2019). Impact of male factor infertility on offspring health and development. Fertility and Sterility, 111(6), 1047–1053. https://doi.org/10.1016/j.fertnstert.2019.05.006.Website. (2022). Preeclampsia - best practices. Preeclampsia Foundation - Saving mothers and babies from preeclampsia. Retrieved October 26, 2022, from https://preeclampsia.org/best-practices.