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LEARNING OBJECTIVES

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

  • Describe each FDA pregnancy category using the US 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 hyperthyroidism, depression, mechanical heart valve requiring chronic anticoagulation for thromboembolism prophylaxis, and gestational diabetes.

  • Identify alternative therapies that are considered safe during pregnancy for the treatment of depression and 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.

PATIENT PRESENTATION

Chief Complaint

“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?”

HPI

Chloe Avett is a 34-year-old woman who reports experiencing two to three episodes of nausea per day with vomiting occasionally in the mornings and evenings. She typically wakes up feeling nauseous and will vomit one to two times a week. Her GI symptoms began about 2 weeks ago and have remained consistent, preventing her from going to work consistently or being able to work effectively. She states that she feels “run down” all the time and needs to start feeling better soon, or she will lose her job. She took a pregnancy test today, and it is positive. She is very concerned about her “blood thinner” medication, remembering that she could not take it with her previous pregnancy. She was diagnosed with depression 2 years ago and has not had any depressive symptoms in the last year—she has noted that since she incorporated exercise, she has seen improvement in her mood. She states she does not take her paroxetine anymore. Overall, she lives a healthy lifestyle, eating well (follows a vegan diet) and exercising three to four times a week.

PMH

Depression

History of multiple, unprovoked, lower extremity DVTs

Hyperthyroidism (diagnosed 9 months ago)

S/P gestational diabetes

FH

Mother alive with DM2 and HTN, father alive with celiac disease. Patient has one twin sister who is alive and well.

SH

Married, mother ...

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