What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus?

Discussion Question 1 For these questions, please read the following case study and then respond to the questions noted below. Ms. BD is a 33-year-old G2P1 African-American female who presents to your clinic today complaining of unusual fatigue, nausea, and vomiting for the last five days. She has a medical history of chronic hypertension (HTN) that was diagnosed shortly after her first pregnancy two years ago and GERD. MS. BD's blood pressure is controlled on Lisinopril-Hydrochlorothiazide 20/12.5mg by mouth twice a day, and GERD controlled on Bismuth Subsalicylate 262mg by mouth every 6 hours as needed. During the interview, you learn that she is single, sexually active, has one partner and that her menses is ten days late. She performed a home pregnancy the three days after missing her menstrual cycle, and the results were inconclusive. She states she feels terrible and needs relief. She has no other medical problems, symptoms, or concerns. Assessment: Physical examination is unremarkable. BP128/68, HR is 74, Urine human chorionic gonadotropin (HCG) positive, beta HCG sent, potassium 4.2, blood urea nitrogen (BUN) 14, creatinine is 0.6, Alanine aminotransferase (ALT) 29, White blood cells (WBCs) 6.5, hemoglobin (Hgb) 12.8, hematocrit (Hct) 39, and platelets 330,000. List the additional questions you would need to ask this patient. Explain. What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus? What is the importance of assessing laboratory values when prescribing medications? How might the laboratory values, in this case, impact your treatment plan? Would you make any changes to Ms. BD’s blood pressure and GERD medications? Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings. How does ethnopharmacology apply to this patient if she were NOT pregnant? Explain. What health maintenance or preventive education do you provide in this client case based on your choice of medications/treatment? Would you treat this patient or refer her? Explain. If you refer, where would you refer this patient? Rubrics SUO Discussion Rubric (20 Points) - Version 1.2 sample paper List the additional questions you would need to ask this patient. Explain. Considering the details of the case study provided, there are several questions I would need to ask this patient. Given the positive human chorionic gonadotropin (HCG) result, questions pertaining to her current and past pregnancy seem appropriate. To start with, when was her last menstrual cycle? In the absence of beta HCG levels, the date of the last menstrual period (LMP) is important because the average pregnancy lasts approximately 280 days from the fist day of the LMP (Edwards & Itzhak, 2020). Also, did she experience any complications with her first pregnancy like fatigue, nausea, and vomiting? Is so, how long did these symptoms last and what relieved them? Furthermore, does she need a referral to an obstetrician for prenatal care? What about her support system, does she have anyone she can rely on for help with the pregnancy and other child? Now, chronic hypertension during pregnancy can be dangerous if not controlled. For the mother it can lead to pre-eclampsia, eclampsia, or even stroke, while the infant can suffer from low birth weight because the hypertension starves the infant of the oxygen and nutrients it requires for optimal growth (“High blood pressure”, 2020). For these reasons, women with uncontrolled hypertension experience high-risk pregnancies. In view of this, does she see her primary care provider regularly or check her blood pressure on a regular basis? Also, has she been taking her medications since she has been sick because abruptly stopping hypertensive medications can be dangerous as well. What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus? The safety profile of medications prescribed to pregnant women are important because some are teratogenic to fetuses, resulting in abnormal development (Woo & Robinson, 2016). Regarding the use of Lisinopril-Hydrochlorothiazide, ACE inhibitors are not recommended during the first trimester of pregnancy due to teratogenicity (“Zestoretic”, 2020). ACE inhibitors should be stopped as soon as possible, with safer medications initiated. While there is limited data on hydrochlorothiazide during pregnancy, it crosses the placental barrier and thereby increases the risk for lower plasma volumes and placental hypoperfusion (“Zestoretic”, 2020). With respect to bismuth subsalicylate use during pregnancy, existing literature does not indicate teratogenic effects. However, salicylates should be avoided during pregnancy in general, especially during the third trimester probably due to risk of bleeding during delivery (Hazard Vallerand et al., 2017). What is the importance of assessing laboratory values when prescribing medications? How might the laboratory values, in this case, impact your treatment plan? As always, laboratory values potentiate safe and effective medication therapy. To me, this is never more important than when prescribing medications for pregnant women. Although not indicative of the safety margin of every medication, this patient’s blood urea nitrogen and creatinine are within normal ranges indicating her body is eliminating her current medications effectively. Therefore, the laboratory results mentioned in the case study would not impact the treatment plan. Even so, laboratory results are imperative when patients are at risk for drug induced toxicity with drugs like Gentamycin. Also, she needs to undergo laboratory testing for sexually transmitted diseases as well since they can also be harmful during pregnancy. Would you make any changes to Ms. BD’s blood pressure and GERD medications? Since we have established this patients’ current hypertension medicine is not safe during pregnancy, this medication would have to be changed to protect the growing fetus. Also, it is early in her pregnancy and I see no need to change the bismuth at this stage. Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings. Hydralazine, labetalol, and nifedipine are all considered first-line treatments for hypertension during pregnancy with nifedipine considered the safest (Alavifard et al., 2019). Nifedipine is a calcium channel blocker routinely prescribed for hypertension, angina pectoris, and vasospastic angina. The mechanism of action for nifedipine is that it inhibits calcium transport into myocardial and vascular smooth muscle cells, inhibiting excitation-contraction coupling and subsequent contraction (Hazard Vallerand et al., 2017). Nifedipine is given by mouth in capsule or extended-release tablet form with a half-life between two to five hours (Hazard Vallerand et al., 2017). Additionally, the drug is metabolized by the liver and excreted in urine and feces (Hazard Vallerand et al., 2017). Contraindications include hepatic or renal impairment, history of ventricular arrythmia or heart failure, AV blocks, and consistent systolic blood pressure readings below 90 mm Hg (Hazard Vallerand et al., 2017). How does ethnopharmacology apply to this patient if she were NOT pregnant? Explain. Ethnopharmacology applies to this patient because she is an African American taking an ACE inhibitor, namely Lisinopril. Unfortunately, African American races have an increased risk for ACE inhibitor associated angioedema. In fact, evidence advises patients who develop angioedema related to ACE inhibitors are more likely to be young and African American (Banerji et al., 2017). Therefore, the patient should be advised to be on the alert for and report any unusual swelling or shortness of breath to her provider. What health maintenance or preventive education do you provide in this client case based on your choice of medications/treatment? To maintain optimum blood pressure, this patient should watch her salt intake, eat plenty of whole grains, lower her stress levels, engage in light exercise, refrain from smoking or drinking alcoholic beverages, and take her medications as prescribed. Also, she should make sure to follow up with her obstetrician of choice. Would you treat this patient or refer her? Explain. If you refer, where would you refer this patient? While I would treat this patient initially for her chief complaint, I would refer her to an obstetrician with more specialized knowledge and training in caring for women with high-risk pregnancies. In my opinion, this would provide her with the greatest chance for a healthy pregnancy with positive outcomes. References Alavifard, S., Chase, R., Janoudi, G., Chaumont, A., Lanes, A., Walker, M., & Gaudet, L. (2019). First-line antihypertensive treatment for severe hypertension in pregnancy: A systematic review and network meta-analysis. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health, 18, 179–187. doi.org: 10.1016/j.preghy.2019.09.019 Banerji, A., Blumenthal, K. G., Lai, K. H., & Zou, L. (2017). Epidemiology of ACE inhibitor angioedema utilizing a large electronic health record. The Journal of Allergy and Clinical Immunology: In Practice, 5(3), 744-749. doi.org: 10.1016/j.jaip.2017.02.018 Edwards, K. I., & Itzhak, P. (2020). Estimated Date of Delivery (EDD). https://www.ncbi.nlm.nih.gov/books/NBK536986/ High blood pressure during pregnancy. (2020). https://www.cdc.gov/bloodpressure/pregnancy.htm Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers, 4th ed. [Vital Source digital version]. F. A. Davis Company. Zestoretic 20. (2020). https://www.medicines.org.uk/emc/product/5502/smpc#PREGNANCY Read: Dyslipidemia/VTE/Stroke Discussion 

ANSWER. PAPER DETAILS
Academic Level	Masters
Subject Area	Nursing
Paper Type	Admission - Application Essay
Number of Pages	1 Page(s)/275 words
Sources	4
Format	APA
Spacing	Double Spacing

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