Risk factors for adverse maternal and perinatal outcomes in women with preeclampsia: analysis of 1396 cases

Introduction Gynecology care plays a pertinent role in addressing the women’s concerns on the reproductive systems. Medical history of surgical operations and health conditions can affect the patient from conceiving. In this case, concerning Gloria Smart, a 75-year-old female who underwent IVF treatment, which resulted with a loss of a fetus and danger to her well-being, presents how vital it is to address advanced maternal age. Summary Gloria Smart is a 75 year old female who has a history of cardiac stent at age 55 and mild hypertension. Current medications are Zocor, Plavix and Lisinopril. Surgical history is remarkable for tonsils as a child and bunion surgery. Gloria works full time by choice, is active and is not involved in any sedentary lifestyle habits such as smoking or illegal recreational drug use. She occasionally has a glass of wine. Glorias pap, mammo and DXA scan are all up to date with normal results. She has never conceived a child before. She is currently engaged, and her fiancé and her would like to get pregnant. As she discusses this during her appt, the anticipatory guidance as a practitioner to consider would be that she has some things in her medical history that she would need to consider, such as her cardiac stent and category x drugs such as Lisinopril and Zocor. Gloria then meets with a maternal-fetal medicine specialist to discuss this. As a result, it is recommended that Gloria begins taking folic acid 400mcg to 800mcg daily. After an interdisciplinary team meeting, it is decided that Gloria stops taking her BP med and instead begins taking Procardia, along with discontinuing use of Plavix and Zocor. Once this takes place, Gloria meets with an infertility specialist and discusses IVF. She gets pregnant from the second cycle, and is referred back to see the practitioner at 12 weeks to be co-managed. Therefore, it is important to obtain a baseline so a 24-hour urine collection and CMP is vital. Shortly after, Gloria presents to office with a complaint that her blood pressure has been elevated at home (currently 160/88), she also complains of a swollen face and feet. Immediate interventions take place, but unfortunately Gloria loses the baby along with dealing with health concerns such as anuria and unstable pressures. Differential diagnosis: Preeclampsia secondary to hypertension and CAD. AKI secondary to preeclampsia. High Risk Pregnancy due to age and high risk cardiac history. Ethical Issues “The American College of Obstetrics and Gynecology and ASRM encourage counseling of reproductive age women regarding age-related fertility decline and pregnancy risks at later age” (Jindal, 2018). Ethically as providers, we are responsible for informing patients of the risks involved in any procedure. With IVF, there are risks to the mother and the baby, her age and cardiac status make her high risk as well. This 75-year-old patient would be a high-risk pregnancy due to her age and her ethnicity and cardiac complications makes her high risk for developing preeclampsia and HELLP. “Women≥35 years old experience a dramatic increase in embryo aneuploidy rate from a 30% baseline production up to 90% in their late 40s prior to the menopause” (Subet al., 2020). “Based on her age and history of chronic hypertension, she was initiated on aspirin 81 mg daily due to her increased risk of preeclampsia. However, there are no consensus guidelines regarding management of comorbidities at the extremes of maternal age” (Magistrado et al., 2020). Due to the patient’s loss of her pregnancy due to her advanced age, preeclampsia and HELLP, it would be unethical to advise the patient to try IVF again. Because IVF failure can be devastating, the patient should be referred to counseling for therapy. “It has been well established that advanced maternal age is associated with reduced fertility and reduced live term births in both natural conception and an ART setting” (McPherson et al, 2018). As practitioners we must give this patient all the options available for having another baby such as surrogacy, egg or embryo donation via third party, or adoption .“Physicians and prospective parents have a moral responsibility to ensure that reproductive choices are protective of both the well-being and welfare of resulting children” (Harrison et al., 2017). IVF is expensive and there is also an ethical issue concerning the parents paying for IVF and their chances of having a full term infant considering the age and medical issues of parents. Psychological and Physical Issues Psychological and physical matters can be evident for the patient’s with reproductive matters. Depression is a severe matter that can occur. The patient needs to conceive, which is the case thus raising the levels of anxiety, however, it becomes very detrimental if a loss occurs. Self-esteem levels can also be reduced, which can be a severe psychological matter especially when a loss occurs (Canady, 2018). Not only did G.S. lost her child immediately after labor, but she also then went through multiple unfolding health matters which extended her hospital stay for almost two weeks and placed her life in high danger. As pregnancy losses are more often than not sudden and unexpected, the mother is never prepared for what she is about to face. The loss of a child is recognized as a very difficult life experience, which can often cause complicated grief (CG) reactions that risk negatively affecting psychological and physical well-being (Kersting and Wagner, 2012). The loss of the baby and the encounters that took place during the course of Glorias hospitalization places her at a high risk for psychological stress, which then plays an impact on her recovery speed and statues. Physical issues that could possibly be a concern now for Gloria are pain secondary to giving birth, tiredness due to being immobile and bed bound and prolonged or heavy bleeding. Weight loss can also be perceived following the psychological influences of losing a child. Both physical and psychological issues are of priority in this case, as one can also affect and worsen the other. Medical intervention along with family support is essential for curbing the adverse influences of physical and psychological health conditions. Treatment Treating preeclampsia is not an easy task. “Fetal mortality approaches 30% when HELLP syndrome occurs early in the third trimester; maternal mortality may also approach 5% to 10%” (Gavriilaki & Brodsky, 2020). Once the patient is brought to the hospital, the patient should be prepped and ready for delivery; delivery of the baby is the main treatment for HELLP. The mother should be given a blood transfusion if necessary, given medications to help control her blood pressure: An antihypertensive such as Nifedipine, a vasodilator such as Hydralazine, and a beta blocker such as Labetalol. Magnesium sulfate should be given to prevent the patient from developing seizures. A caesarian section should be performed if the mother is unable to deliver vaginally or if it would be dangerous to do so. After delivery of the baby, preeclampsia and/or HELLP syndrome should resolve. Gloria should be kept on a blood pressure medicine such as Labetalol 100mg po bid for home management, follow up appointment should be scheduled for one week after discharge. The patient should be prescribed antidepressants such as Prozac 20mg po qd for depression if needed. This patient should be instructed to call the office for any questions or problems. Advanced maternal age and HELLP syndrome This patient is at a very high risk for many complications with her choice to become pregnant at her advanced maternal age. Studies suggest the instance of preeclampsia increases by 4% each year for every year over the age of 32 (Warner, 2020). Unfortunately, due to many risk factors including geriatric pregnancy, her pregnancy terminated by abruption. Now that she is post-partum it is imperative to manage her blood pressure aggressively to ensure to help prevent any further damage as well as other potential complications such as myocardial infarction or stroke (Li, et al., 2018). Guidelines Management of her symptoms now are guided by AHA guidelines, strokes associated with pregnancy are more likely to occur in the first 10 days after delivery, and typically 48 hours post-partum with hypertension being the strongest risk factor (Flack & Adekola, 2020). Immediately post-partum, it is recommended that blood pressure be lowered with parenteral agents such as labetalol, hydralazine, and nifedipine, or an oral calcium channel blocker when blood pressure is ≥160/110 mmHg (Flack & Adekola, 2020). Financial Issues Fertility treatment is a costly one as most insurance company’s only cover minimal procedures not including in vitro fertilization (Stanford, 2017). On average, the cost of IVF starts at about $20,000, all of which must be paid by the patient, it is difficult to discern what this patient’s financial status is currently, however, the cost of IVF is a great one which should this patient and her spouse choose to try again it can cause a financial burden (Stanford, 2017). Pan et al, suggest that having government subsidized programs to help financially can encourage the use of IVF for fertility and help alleviate the financial burden (Pan, et al., 2019). It is difficult to predict if the financial burden of IVF will discourage this couple from considering this treatment in the future. References Canady, V. (2018). Health partnership to offer alternative depression treatment. Mental Health Weekly, 28(14), 4-6. https://doi.org/10.1002/mhw.31407 Kersting, A., & Wagner, B. (2012, June). Complicated grief after perinatal loss. Retrieved October 29, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384447/ Flack, J. M., & Adekola, B. (2020). Blood pressure and the new ACC/AHA hypertension guidelines. Trends in Cardiovascular Medicine, 30(3), 160–164. https://doi-org.ezp.waldenulibrary.org/10.1016/j.tcm.2019.05.003 Gavriilaki, E., & Brodsky, R. A. (2020). Complementopathies and precision medicine. Journal of Clinical Investigation, 130(5), 2152-2163. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1172/JCH36094 Harrison, B. J., Hilton, T. N., Riviere, R. N., Ferraro, Z. M., Deonandan, R., & Walker, M. C. (2017). Advanced maternal age: Ethical and medical considerations for assisted reproductive technology. International Journal of Women's Health, 9, 561-570. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.2147/IJWH.S139578 Jindal, U. (2018). Mid-life fertility: Challenges & policy planning. The Indian Journal of Medical Research, 148(6), 15-26. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.4103/ijmr.IJMR_647_18 Li, X., Zhang, W., Lin, J., Liu, H., Yang, Z., Teng, Y., Duan, S., Lin, X., Xie, Y., Li, Y., Xie, L., Peng, Q., & Xia, L. (2018). Risk factors for adverse maternal and perinatal outcomes in women with preeclampsia: analysis of 1396 cases. Journal of Clinical Hypertension, 20(6), 1049–1057. https://doi-org.ezp.waldenulibrary.org/10.1111/jch.13302 Magistrado, L., Tolcher, M. C., Suhag, A., Zambare, S., & Aagaard, K. M. (2020). Pregnancy and lactation in a 67-year-old elderly gravida following donor oocyte 0RW1S34RfeSDcfkexd09rT2in vitro1RW1S34RfeSDcfkexd09rT2 fertilization. Case Reports in Obstetrics and Gynecology, 2020 doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1155/2020/9801565 McPherson, N. O., Zander-Fox, D., Vincent, A. D., & Lane, M. (2018). Combined advanced parental age has an additive negative effect on live birth rates—data from 4057 first IVF/ICSI cycles. Journal of Assisted Reproduction and Genetics, 35(2), 279-287. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1007/s10815-017-1054-8 Pan, W., Tu, H., Jin, L., Hu, C., Li, Y., Wang, R., Huang, W., & Liao, S. (2019). Decision analysis about the cost-effectiveness of different in vitro fertilization-embryo transfer protocol under considering governments, hospitals, and patient. Medicine, 98(19), e15492. https://doi-org.ezp.waldenulibrary.org/10.1097/MD.0000000000015492 Su, W., Xu, J., Arhin, S. K., Liu, C., Zhao, J., & Lu, X. (2020). The feasibility of all-blastocyst-culture and single blastocyst transfer strategy in elderly women: A retrospective analysis. BioMed Research International, 2020, 9. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1155/2020/5634147 Stanford, J. B. (2017). What Kind of Policies for Fertility Treatment would Improve Affordability and Outcomes for Individuals and the Public? Paediatric & Perinatal Epidemiology, 31(5), 449–451. https://doi-org.ezp.waldenulibrary.org/10.1111/ppe.12411 Warner, V. L. (2020). Advanced Maternal Age and HELLP Syndrome. International Student Journal of Nurse Anesthesia, 19(1), 32–35. Link to debate: https://us.bbcollab.com/collab/ui/session/playback please respond.

ANSWER. PAPER DETAILS
Academic Level	Masters
Subject Area	Nursing
Paper Type	Case Study
Number of Pages	1 Page(s)/275 words
Sources	3
Format	APA 6
Spacing	Double Spacing

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