Chapter 40 Hypertension Instructor Case Study
Nancy is a chronic hypertensive patient who has been seen at your clinic for 5 years. She is happy today when she reports that she is 2 months pregnant and would like a referral to a nurse midwife for prenatal care. She has never had issues with her blood pressure after she quickly adapted to a calcium channel blocker and diuretic for her treatment. She does get a bit of dependent edema at the end of the day that remains less than 1+ and typically “gives me an excuse to put my feet up!” She comes with a sheaf of printouts about pre-eclampsia from the Internet. She is asking for a urine sample to check for protein because she “does not want a C- section.”
- Would Nancy fit the mold for referral to a midwife for routine pregnancy care? Consider your nurse practice act for degree of complexity handled by certified nurse midwives in your state.
- Is she correct in her assumption that she has pre-eclampsia? Compare and contrast the presentation of pregnancy-related edema and the side effects of calcium channel blockers (SE of CCBs).
- Is she currently on any medications that must be stopped today before she sees an obstetrician/gynecologist? Review how prescribers can find information on pregnancy categories.
- What are the categories of hypertension (HTN) medications typically given to women with pre-existing HTN who become pregnant? There are both classic medications and newer therapies to consider.
Hypertension in Pregnancy: A Case Study Analysis
Introduction
Nancy, a chronic hypertensive patient, presents with a new development of pregnancy and seeks a referral to a nurse midwife for prenatal care. This case study delves into the considerations surrounding Nancy's pregnancy, including the appropriateness of midwife care, evaluation of pre-eclampsia concerns, medication management, and the categorization of hypertension medications for pregnant women with pre-existing hypertension.
1. Referral to Nurse Midwife
In determining whether Nancy is suitable for referral to a nurse midwife for routine pregnancy care, it is essential to consider the complexity of her hypertension management. The nurse practice act in each state dictates the scope of practice for certified nurse midwives (CNMs). In cases where hypertension is well-controlled with established medications and minimal complications, CNMs may be well-equipped to provide prenatal care. However, close collaboration with an obstetrician is crucial for monitoring and managing any potential complications that may arise during pregnancy.
2. Evaluation of Pre-Eclampsia Concerns
Nancy's concern about pre-eclampsia warrants further evaluation. Pre-eclampsia is characterized by high blood pressure and proteinuria after 20 weeks of gestation. It is essential to differentiate between normal pregnancy-related edema and symptoms of pre-eclampsia. Pregnancy-related edema is common and typically manifests as mild swelling, whereas pre-eclampsia presents with elevated blood pressure, proteinuria, headaches, and vision changes. Calcium channel blockers (CCBs), commonly used in hypertension management, may also cause edema as a side effect, which can be confused with pregnancy-related swelling.
3. Medication Management
Before Nancy sees an obstetrician/gynecologist, it is crucial to review her current medications for hypertension. Certain medications, such as ACE inhibitors and ARBs, are contraindicated in pregnancy due to potential risks to the fetus. Prescribers can refer to resources like the FDA Pregnancy Categories or the latest guidelines on managing hypertension in pregnancy to determine the safety of medications during gestation.
4. Hypertension Medications in Pregnancy
For women with pre-existing hypertension who become pregnant, the choice of antihypertensive medications is critical to ensure maternal and fetal well-being. Commonly used categories of hypertension medications in pregnancy include:
- Methyldopa: A classic antihypertensive often considered first-line in pregnancy due to its safety profile.
- Labetalol: A beta-blocker that is effective in managing hypertension during pregnancy.
- Nifedipine: A calcium channel blocker that may be used as an alternative if needed.
- Hydralazine: Another option for blood pressure control in pregnancy.
Newer therapies such as certain beta-blockers and vasodilators may also be considered under close monitoring by healthcare providers to maintain blood pressure within a safe range throughout pregnancy.
Conclusion
Navigating hypertension in pregnancy requires a comprehensive approach that considers the unique challenges and risks associated with managing chronic hypertension during gestation. By carefully evaluating factors such as medication safety, pre-eclampsia concerns, and appropriate referral for prenatal care, healthcare providers can optimize outcomes for both the mother and the developing fetus. Collaborative care involving nurse midwives, obstetricians, and other specialists is key to ensuring a successful pregnancy journey for patients like Nancy with pre-existing hypertension.