NSG 6005 SU WK 6 Management of Hypertension & GERD in Pregnancy Discussion

Guidelines: Respond to 2 peers. Support your responses with scholarly academic references using APA style format. Assigned course reading and online library resources are preferred. Weekly lecture notes are designed as overviews to the topic for the respective week and should not serve as a citation or reference. In your discussion question response, provide a substantive response that illustrates a well-reasoned and thoughtful response; is factually correct with relevant scholarly citations, references, and examples; demonstrates a clear connection to the readings In your participation responses to your peers, comments must demonstrate thorough analysis of postings and extend meaningful discussion by building on previous postings.

Peer 1 Amy Weber

Ms. BD is a 33-year-old G2P1 African-American female who presents to your clinic today complaining of unusual fatigue, nausea, and vomiting for the last five days. She has a medical history of chronic hypertension (HTN) that was diagnosed shortly after her first pregnancy two years ago and GERD. MS. BD’s blood pressure is controlled on Lisinopril-Hydrochlorothiazide 20/12.5mg by mouth twice a day, and GERD controlled on Bismuth Subsalicylate 262mg by mouth every 6 hours as needed. During the interview, you learn that she is single, sexually active, has one partner and that her menses is ten days late. She performed a home pregnancy the three days after missing her menstrual cycle, and the results were inconclusive. She states she feels terrible and needs relief. She has no other medical problems, symptoms, or concerns.

Assessment: Physical examination is unremarkable. BP128/68, HR is 74, Urine human chorionic gonadotropin (HCG) positive, beta HCG sent, potassium 4.2, blood
urea nitrogen (BUN) 14, creatinine is 0.6, Alanine aminotransferase (ALT) 29, White blood cells (WBCs) 6.5, hemoglobin (Hgb) 12.8, hematocrit (Hct) 39, and platelets 330,000.

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

Frequency and number of episodes of vomiting to help determine hydration status.

Anyone else in the household sick with similar symptoms? To rule out gastroenteritis as the cause of her symptoms.

PO intake to assess for hydration status and potential hypoglycemia.

Description of emesis to assess for any blood or bile in the vomit.

1. 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-hydrochlorothiazide is a combination drug that includes an angiotensin-converting enzyme (ACE) inhibitor and a diuretic that is prescribed for control of the patient’s hypertension. ACE inhibitors should not be used during pregnancy due to potential fetal abnormalities including the risk of death (Woo & Robinson, 2020). Diuretics may be used in pregnancy if prescribed prior to gestation.

Bismuth subsalicylate is an anti-diarrheal medication. This is a pregnancy category C medication, which means that there has been shown to be a negative affect on the fetus during animal studies, but adequate studies have not been done on humans (https://drugs.com). The safety of this medication has not been established for the use in pregnant women.

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

Assessing lab values when prescribing medications is important because medications are either metabolized in the liver or the kidneys. If the patient has poor hepatic or renal function, this could change the way the drug is metabolized. In the case that is presented, the patient’s lab values are within normal limits. If the patient were to continue the bismuth subsalicylate, monitoring of her liver and kidney function would be necessary, as this medication is metabolized in the liver and excreted in the kidneys (Woo & Robinson, 2020). Liver and kidney function studies would also be important to monitor with the use of the ACE inhibitor. Obtaining electrolytes, checking for hyponatremia and hyperkalemia, prior to initiating ACE inhibitors is indicated. “Hyperkalemia contraindicates use because reduced aldosterone secretion may worsen this electrolyte imbalance” (Woo & Robinson, 2020, p. 273).

1. 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 stop her lisinopril-hydrochlorothiazide as the ACE inhibitor is contraindicated in pregnancy. Hydrochlorothiazide alone is a pregnancy category B medication, so could be continued in pregnancy. In the case of using antihypertensive medication in pregnancy, it is important to evaluate the risk versus benefits of medication use and the severity of hypertension. According to the Journal of the American Heart Association (2019), calcium channel blockers have been the most widely used antihypertensive medication during pregnancy over the past 30 years (Malha & August, 2019). The medication recommended is nifedipine XL. Nifedipine is “widely accepted as safe in pregnancy, based on many years of experience (Malha & August, 2019, p. 2). The mechanism of action of nifedipine is a calcium-channel blocker, which causes relaxation of the smooth muscle vasculature. The route is oral (PO). Half-life of nifedipine is 2-5 hours. Calcium-channel blockers are metabolized in the liver, nifedipine is excreted 60-80% in the urine, and 15% in feces (Woo & Robinson, 2020). A contraindication would be an ejection fraction less than 40%. There are no black box warnings for nifedipine that I can find.

Bismuth subsalicylate is a pregnancy category C medication, so I would change it to a pregnancy category B medication for the safety of the fetus. Loperamide is one of the pregnancy category B medications that can be used. Loperamide slows gastric motility by binding to the opiate receptors in the intestines. Loperamide is given orally. The average half-life is 10.8 hours. “Loperamide is partially metabolized by the liver and enters enterohepatic recirculation” (Woo & Robinson, 2020, p. 486). Excretion is mainly in feces, with a small portion eliminated in the urine. Loperamide should be used cautiously in patients with irritable bowel syndrome (IBS) due to the risk of toxic megacolon (Woo & Robinson, 2020). There are no black box warnings that I can find with the use of loperamide.

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

Ethnopharmacology applies to this patient because she is African-American. “In general, the African American population has lower renin activity, and so the RAAS is not thought to play a major role” in hypertension (Woo & Robinson, 2020, p. 1210). With this in mind, ACE inhibitors would not be the best choice for antihypertensive medication therapy. It is also noted that salt sensitivity is the pathophysiology related to hypertension in many African Americans. Therefore, limitation of salt intake and possibly diuretic therapy would be considered in the treatment regimen.

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

The health maintenance education for this patient would be to limit salt intake, maintain a healthy weight, and exercise regularly. For her nausea/vomiting complaint I would educate the patient regarding staying hydrated and signs and symptoms of dehydration.

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

Given the fact that the patient is pregnant, I would refer her to an OB/GYN specialist to follow her pregnancy and ensure proper medication management while pregnant and during lactation after delivery.

References

FDA pregnancy risk information. (n.d.). https://www.drugs.com/pregnancy-categories.html

Malha, L., & August, P. (2019). Safety of antihypertensive medications in pregnancy: Living with uncertainty. Journal of the American Heart Association (8)15. https://www.ahajournals.org/doi/10.1161/JAHA.119.0…

Woo, T.M., & Robinson, M.V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5^th ed.). F.A. Davis.

Peer 2Haley White

Additional information that would be important from Ms. BD would be any known allergies, her social history, if she partakes in any alcohol consumption, tobacco products or any recreational drugs. I would also ask if she has any other pertinent medical problems that are not already known. Asking Ms. BD about her sexual and gynecology history is also very important since we know she is pregnant. It would be important to ask if Ms. BD has had any recent or past expose to sexually transmitted infections. I would also ask if Ms. BD had any complications during her last pregnancies such as hypertension or preeclampsia and what medicine was she prescribed if so.

Lisinopril-hydrochlorothiazide is an angiotensin-converterting enzyme inhibitor (ACEI) and an angiotensin II receptor antagonist (ARB) combination. ACEIs and ARBs are contraindicated in pregnancy. Lisinopril-hydrochlorothiazide is not a safe drug choice for Ms. BD since she is pregnant and should be discontinued right away. ACEIs and ARBs can cause fetal and neonatal morbidity and mortality, they are both classified as Pregnancy category C in the first trimester of pregnancy. Bismuth subsalicylate should also be avoided in pregnancy (Woo and Robinson, 2020).

Since lisinopril-hydrochlorothiazide as well as bismuth subsalicylate are both contraindicated in pregnancy, I would definitely change Ms. BD’s medication regimen. Acceptable hypertensive medications for pregnant women are beta blockers or calcium channel blockers. There are inconsistent reports of increased risks of preterm birth, fetal growth restriction and congenital malformations with beta blockers (UpToDate). I would look at prescribing a calcium channel blocker such as Nifedipine. Nifedipine is one of the most widely used calcium channel blockers in pregnant women. Nifedipine is an antihypertensive calcium channel blocker which inhibits the calcium ion which allows relaxation of the coronary vascular smooth muscle and coronary vasodilation, it also reduces peripheral vascular resistance which produces a reduction in arterial blood pressure. Nifedipine has a half-life of 2 to 5 hours in healthy adults, it is metabolized by the liver and excreted in the urine. Nifedipine is administered by oral route. Contraindications include hypersensitivity to nifedipine, severe hypotension, moderate or severe hepatic impairment, and severe gastrointestinal obstructive disorders. I would inform Ms. BD to discontinue the bismuth subsalicylate and instead I would recommend she take an over the counter antacids like tums or Maalox.

Along with the correct medication, physical activity as well as maintaining a proper diet is very important for pregnant women, especially Ms. BD who has a diagnosis hypertension prior to pregnancy. I would recommend that Ms. BD follow an anti-reflux diet. To help relieve Ms. BD’s GERD symptoms I would recommend that she avoid lying down within 3 hours pf eating, avoid wearing tight-fitting clothing. I would also recommend she avoid food that make symptoms worse such as coffee, cola, tea, citrus, chocolate, and fatty foods.

I would refer Ms. BD to her obstetrician. It is important that Ms. BD have access to proper prenatal care and having her blood pressure monitored during her pregnancy is critical to her health as well as the health of her baby.

August, P., Lockwood, C., Bakris, G. (2021). Treatment of hypertension in pregnant and

postpartum women. UpToDate. https://www.uptodate.com/contents/treatment-of-hyp…

UpToDate (2021). Patient education: acid reflux (gastroesophageal reflux disease) during pregnancy (The Basics). https://www.uptodate.com/contents/acid-reflux-

gastroesophageal-reflux-disease-during-pregnancy-the-

basics?search=gerd%20in%20pregnancy&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2

Woo, T., Robinson, M. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5^th ed.). Philadelphia, PA: F.A. Davis