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.
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.
Gloria then sees an infertility specialist and discusses IVF and donor eggs. 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.
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.
- Review the given case study and address the following:
- Summary of case study
- What is your differential diagnosis?
- Why did you make this diagnosis decision?
- What is your treatment plan?
- What evidence-based research can you provide to support your decision (choice for differential diagnosis and plan/intervention)?
- What resources did you use to meet your best practice guidelines?
- Address the ethical dilemmas and/or other issues for your case study:
- Ethical issues
- Psychological issues
- Physical issues
- Financial issues
Summary of case study: Gloria Smart, a 55-year-old female with a history of cardiac stent placement at age 50, mild hypertension, and current medications including Zocor, Plavix, and lisinopril, presents for regular gynecological care. She has a history of tonsillectomy and bunion surgery, maintains a full-time job, is up-to-date with colonoscopies, has a normal gynecological history, and is physically active with a BMI of 26. Gloria has never been pregnant, and her partner has never had a child. She and her fiancé desire to have a child and have undergone IVF with donor eggs, resulting in her current pregnancy. At 12 weeks gestation, they report elevated blood pressure readings at home (160/92) and complain of right-sided rib pain and facial swelling.
- Preeclampsia: Given Gloria’s elevated blood pressure readings, facial swelling, and pitting edema in her legs, preeclampsia should be considered. Preeclampsia is a pregnancy-related condition characterized by high blood pressure and signs of organ dysfunction, often accompanied by edema and other symptoms.
- Gestational hypertension: This is another possibility considering Gloria’s age and pregnancy. Gestational hypertension is elevated blood pressure that develops during pregnancy, without the presence of proteinuria or other signs of preeclampsia.
Diagnosis decision: The elevated blood pressure, facial swelling, and pitting edema are concerning signs of preeclampsia, which is a life-threatening condition during pregnancy. This diagnosis is supported by Gloria’s age, pregnancy, and her history of mild hypertension.
- Immediate referral to a maternal-fetal medicine specialist for further evaluation and management of preeclampsia.
- Close monitoring of blood pressure, urine protein levels, and fetal well-being.
- Consideration of antihypertensive medications to control blood pressure and prevent complications.
- Evaluation and management of the right-sided rib pain, which could be related to preeclampsia or other pregnancy-related issues.
- Discussion with Gloria regarding the potential need for early delivery if her condition worsens or if the fetus is at risk.
Evidence-based research: The diagnosis of preeclampsia in a pregnant woman is based on clinical signs and symptoms, including elevated blood pressure, proteinuria, and other organ involvement. The American College of Obstetricians and Gynecologists (ACOG) provides guidelines for the diagnosis and management of preeclampsia. Immediate referral to a maternal-fetal medicine specialist is standard practice for pregnant women with suspected preeclampsia.
- American College of Obstetricians and Gynecologists (ACOG) Guidelines for Preeclampsia: These guidelines provide evidence-based recommendations for the diagnosis and management of preeclampsia during pregnancy.
- Consultation with a maternal-fetal medicine specialist: Collaborating with a specialist with expertise in high-risk pregnancies is essential for the appropriate management of preeclampsia.
- Informed consent: Ensuring that Gloria is fully informed about her condition, treatment options, and potential risks to herself and the fetus is crucial.
- Autonomy and decision-making: Respecting Gloria’s autonomy in deciding her course of treatment while considering the best interests of both her and the fetus.
- Fetal well-being: Balancing the health of the mother and the potential risks to the fetus in making decisions about timing and mode of delivery.
- Stress and anxiety: Gloria and her fiancé may experience heightened stress and anxiety due to the complications during pregnancy and the upcoming wedding.
- Coping with pregnancy at an older age: Gloria may have psychological concerns related to her age and the potential risks associated with pregnancy.
- Preeclampsia complications: Monitoring for complications such as severe hypertension, seizures (eclampsia), and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is essential.
- Management of hypertension and edema: Proper control of blood pressure and addressing edema are crucial to prevent further complications.
- Medical costs: Gloria may face increased medical expenses related to the diagnosis and management of preeclampsia, including consultations with specialists and potential hospitalization.
- Impact on work: Gloria’s decision to continue working may be affected by her health condition, potentially impacting her income and financial stability.
Overall, a multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, and mental health professionals is essential to address the ethical, psychological, physical, and financial aspects of Gloria’s complex medical situation.