Background
Gloria Smart is a 55-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 50, 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 52. 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.
Decision Point One
Gloria relates as you start to talk to her that she and her fiancé have been talking about it, and they would like to have a child. She wants a referral and some guidance.
Q: What anticipatory guidance should you consider?
A: She has some things in her history that she needs to consider.
CORRECT
Rational:
First, she has a significant cardiac history and is at high risk for cardiovascular complications. Additionally, Zocor and lisinopril are both category x drugs, and it is unknown whether Plavix is safe in pregnancy.
Decision Point Two
You discuss with Gloria about the issues with her medical problems and the issues with her current medications. You recommend that she set up an appointment with a maternal-fetal medicine specialist to discuss this and make recommendations for them.
Q: Are there any other preconceptual recommendations you would make for her (or another woman considering pregnancy)?
A: Begin folic acid 400 mcg to 800 mcg daily. Discuss risks of alcohol and pregnancy.
CORRECT
Rational:
All women should consider preconceptual folic acid supplementation to help prevent neural tube defects. Gloria speaks with the maternal-fetal medicine specialist, who then speaks with her cardiologist. She is taken off her cholesterol meds, has her blood pressure meds changed to Procardia, stops the Plavix, and starts a baby aspirin daily. Her cardiac stress test is good, and her kidney function is reported as normal.
Decision Point Three
Gloria then sees an infertility specialist and discusses IVF and donor egg. She and her fiancé proceed and she gets pregnant on her second cycle. She is referred back to you at 12 weeks to be co-managed with the maternal-fetal medicine specialist.
Q: What specific issues do you need to think about?
A: Baseline CMP and 24-hour urine.
CORRECT
Rational:
As she has chronic hypertension and known cardiac disease, she is at a higher risk for preeclampsia. You need to see what her normal is at the beginning.
Decision Point Four
Gloria and her fiancé present to your office with a complaint that her blood pressure has been up at home when they check it with their BP cuff. Her fiancé thinks it might be related to a pain she has in her ribs on the right side that started after they went out Chinese food. They also ask if you can give her something to help with her “swelling” as her face won’t look good at the planned marriage in 2 weeks. Her BP is 160/ 92, with a repeat 160/ 88. You note that she has 2+ pitting edema in her legs and that her face appears slightly swollen.
Q: What is your next consideration?
A: Explain to the patient and family the concerns for her high blood pressure and need for immediate treatment to prevent stroke and/or placental abruption.
