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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe each FDA pregnancy category using the U.S. Food and Drug Administration Drug Classification System and the new Pregnancy and Lactation Labeling Rule (PLLR).1

  • Determine the factors (clinical vs pharmacologic) that should be considered when treating a pregnant or lactating patient.

  • List the risks and benefits associated with medication use during pregnancy for hypertension, depression, and mechanical heart valve requiring chronic anticoagulation for thromboembolism prophylaxis.

  • Identify alternative therapies that are considered safe during pregnancy for the treatment of depression and hypertension, and for thromboembolism prophylaxis in a patient with a mechanical heart valve.

  • Design a pharmacotherapeutic plan for a pregnant patient with depression, hypertension, and a mechanical heart valve including treatment options, appropriate monitoring, and therapeutic goals.

  • Educate a patient on the treatment options, benefits, risks, and monitoring of antidepressants, antihypertensives, and anticoagulants during pregnancy.

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PATIENT PRESENTATION

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Chief Complaint

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“I have been nauseated and vomiting for the past week. I took a pregnancy test yesterday, and it was positive! How am I going to handle a pregnancy at this age? Plus, I am taking a lot of different medications. Could I have harmed my baby?”

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HPI

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Laurel Livingston is a 44-year-old woman who reports experiencing two to three episodes of nausea per day with vomiting occasionally in the evenings. Her GI symptoms began about 2 weeks ago and have remained consistent, preventing her from going to work. Around the same time that her GI symptoms began, she started having frequent, painful urination, and was diagnosed with a UTI. She is on day 5 of 7 of antibiotic treatment with nitrofurantoin. She states that she feels “run down” all the time and needs to start feeling better soon, or she will lose her job. In addition, she is extremely concerned about her “blood thinner” medication, remembering that she could not take it with her previous three pregnancies. Due to the death of her brother 5 years ago, Laurel was prescribed an antidepressant and is currently stable (no depressive episodes for the past 3 years). She eats well, exercises, and admits stopping her birth control due to weight gain.

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PMH

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  • Depression

  • Mechanical prosthetic heart valve

  • Hypothyroidism

  • Hypertension

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FH

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Mother alive and well; father died of pancreatic cancer at the age of 67. Patient has one sister, age 45, who is alive and well; brother died in car accident 5 years ago at the age of 32.

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SH

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Married, mother of two daughters, ages 10 and 13 (both healthy), and one son, 6 years old with cerebral palsy. She is a physical therapist at the local community hospital. She runs three times a week and follows a strict low-fat diet. She ...

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