SCENARIO : Sarah Johnson Hypertension in Pregnancy
Problem: Sarah Johnson, a 32-year-old pregnant female at 24 weeks gestation, presents with a history of hypertension, previously treated with Lisinopril, which was discontinued due to pregnancy. Her current blood pressure of 150/95 mmHg indicates uncontrolled hypertension.
Background: Hypertension in pregnancy is a significant risk factor for maternal and fetal complications, including preeclampsia, preterm birth, and fetal growth restriction (Agrawal & Wenger, 2020). ACE inhibitors like Lisinopril are contraindicated in pregnancy due to their teratogenic effects, requiring alternative treatment.
Treatment Goals: The goal is to reduce Sarahs BP to below 140/90 mmHg, minimizing the risk of complications while maintaining safety for both the mother and fetus (Garovic et al., 2022). Medications that are safe in pregnancy must be selected.
Medication Options: First-line antihypertensive drugs during pregnancy include methyldopa, labetalol, and nifedipine (Conti-Ramsden et al., 2024).
Methyldopa: It acts centrally by inhibiting sympathetic outflow, reducing BP. It is safe in pregnancy but may cause sedation, which can affect patient adherence.
Labetalol: A combined alpha and beta-blocker that reduces BP without significantly affecting uteroplacental blood flow.
Nifedipine (extended-release): A calcium channel blocker that can also be used, especially in cases of severe hypertension.
Given Sarahs elevated BP, labetalol is preferred for its efficacy and safety profile.
Medication Order:
Drug: Labetalol 100 mg
Dose: 100 mg
Route: Oral
Frequency: Twice daily (BID)
Special instructions: Titrate dose upward every 1-2 weeks, as needed, to achieve target BP
# Dispensed: 30-day supply
Refills: 1
Monitoring:
Weekly BP checks to ensure the treatment is effective.
Monthly blood work to assess kidney function (BUN, creatinine) and electrolytes, particularly potassium, as labetalol may affect renal function.
Fetal monitoring: Growth ultrasounds should be performed every 4 weeks to assess fetal development, especially if BP control remains challenging.
Patient Education:
Sarah should be informed about the importance of adhering to the prescribed medication and attending regular prenatal visits.
Educate her on monitoring for any signs of preeclampsia, such as headaches, visual disturbances, or sudden swelling, which require immediate medical attention.
References
Agrawal, A., & Wenger, N. K. (2020). Hypertension during pregnancy. Current hypertension reports, 22(9), 64.
Conti-Ramsden, F., de Marvao, A., & Chappell, L. C. (2024). Pharmacotherapeutic options for the treatment of hypertension in pregnancy. Expert Opinion on Pharmacotherapy, 25(13), 1739-1758.
Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., 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.
SCENARIO 2: Lydia Gonorrhea and Chlamydia
Problem: Lydia, a 24-year-old female, presents with a 1-week history of vaginal discharge and is diagnosed with gonorrhea. She has a sulfa drug allergy and a history of unprotected sexual activity with a new partner.
Background: Gonorrhea is a sexually transmitted infection (STI) that can lead to problems such as pelvic inflammatory disease (PID), infertility, and chronic pelvic pain if left untreated (Dombrowski, 2021). It often coexists with chlamydia, so treatment should cover both infections.
Treatment for Gonorrhea:...
…diagnosed with acute otitis media (AOM). The first-line treatment is amoxicillin, but there is a concern for a potential allergic reaction if a rash develops.
Background: AOM is a common infection in young children caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis (Orders, 2023). The typical treatment is high-dose amoxicillin due to its effectiveness against these organisms.
Medication Order for Amoxicillin:
Drug: Amoxicillin 400 mg/5 mL
Dose: 90 mg/kg/day
Route: Oral
Frequency: Twice daily (BID) for 10 days
Special instructions: Shake well before use
# Dispensed: 150 mL (to last 10 days)
Refills: None
Calculation: 90 mg/kg/day for 15 kg = 1350 mg/day 2 = 675 mg/dose. Amoxicillin is available in 400 mg/5 mL, so JT should receive 8.4 mL BID.
Alternative in Case of Allergy: If JT develops a rash, which is a common allergic reaction, he can be switched to cefdinir, which is a cephalosporin safe for penicillin-allergic patients (El Feghaly et al., 2023).
Medication Order:
Drug: Cefdinir 250 mg/5 mL
Dose: 7 mg/kg/dose
Route: Oral
Frequency: BID for 10 days
# Dispensed: 150 mL
Refills: None
Calculation: 7 mg/kg for 15 kg = 105 mg per dose, corresponding to approximately 2.1 mL BID.
Patient Education:
Educate JTs mother on completing the entire course of antibiotics, even if symptoms improve, to prevent recurrence or resistance (Spoial? et al., 2021).
Monitor for allergic reactions such as rash, especially if switching to cefdinir.
Encourage hydration and monitor JT for other symptoms, such as fever or irritability, which may indicate the need…
