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Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

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Case study summary

The subject of our case study is Gloria Smart, a 55-year-old woman who has a history of bunion surgery, mild hypertension, and a cardiac history. She is looking for preconception counseling since she and her boyfriend want to start a family. Her prescription regimen, which includes lisinopril and Zocor, leads to a recommendation for a maternal-fetal medicine specialist. Gloria starts taking pre-conceptional folic acid and modifies her medication. In need of reproductive support, she chooses to use donor egg in IVF, becoming pregnant on the second cycle. Gloria is now being co-managed by her obstetrician and a maternal-fetal medicine specialist, and at 12 weeks, she is experiencing increased blood pressure and swelling. She has a late-term placental abruption in spite of assistance, giving birth to a male baby who lives a brief life. Gloria had a difficult time controlling her blood pressure, experienced anuria, and required a lengthy hospital stay following her delivery. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

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Differential diagnosis

Gloria presents with multiple differential diagnoses, including high blood pressure, rib pain, facial swelling, and 2+ pitting edema. Preeclampsia, which is characterized by pregnancy-related hypertension, edema, and proteinuria, is the first cause for concern given her history of persistent hypertension (Fox et al., 2019). The severe form of preeclampsia known as HELLP syndrome, which combines low platelet counts, elevated liver enzymes, and hemolysis must also be taken into account. Concerns are also raised about two uncommon but dangerous pregnancy-related conditions: thrombotic thrombocytopenic purpura and acute fatty liver of pregnancy. Concerns about a pulmonary embolism or other cardiovascular issues may also be raised by the rib pain and facial puffiness. A comprehensive examination is essential for an accurate diagnosis and quick action to minimize risks, especially given Gloria’s complicated medical history and pregnancy-related concerns (Fox et al., 2019). Preeclampsia therefore remains the main differential diagnosis in this case. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Reason for this decision

Gloria’s medical history and clinical presentation support the diagnosis of preeclampsia. Her face swelling, new-onset rib pain, high blood pressure, and 2+ pitting edema are all consistent with preeclampsia. She was already at a higher risk of this pregnancy-related complication because of her continuing hypertension. Her considerably increased blood pressure (160/92) and the appearance of 2+ pitting edema highlight the potential severity of preeclampsia. These signs and face swelling point to the systemic vascular alterations that characterize preeclampsia. The diagnosis is further supported by the fact that the late-term placental abruption and fetal death are consistent with severe instances of the illness (Sanford et al., 2021). Gloria’s presentation and subsequent challenges are most likely explained by preeclampsia, which is supported by the exclusion of other hypotheses such as HELLP syndrome and an examination of her entire clinical picture. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Treatment plan

Gloria has been diagnosed with severe preeclampsia; her immediate medication plan focuses on managing her hypertensive crisis and preventing further complications. To prevent seizures, which are a common risk in severe preeclampsia, she will begin IV magnesium sulfate. Her high blood pressure is managed with intravenous antihypertensive drugs, such as Labetalol, to lower the risk of complications like strokes and placental abruption. Her low platelet count and abnormal liver function tests, which are suggestive of HELLP syndrome, make vigilant monitoring of her hematological parameters imperative. She had a placental abruption at a late term, therefore delivery is imminent. Depending on the gestational age, an emergency cesarean section or labor induction may be required (Shah, 2023). Following delivery, it is critical to have supportive treatment and ongoing monitoring, especially considering the possibility of persistent hypertension and problems related to HELLP syndrome (Sanford et al., 2021). A multidisciplinary strategy encompassing  maternal-fetal medicine, obstetrics, and critical care is required for treating both Gloria’s immediate and postpartum care.

Evidence-based research supporting the above decision

The diagnosis and treatment of preeclampsia are supported by scientific evidence from groups like the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG). In line with Gloria’s situation, ACOG recommends thorough fetal surveillance, regular blood pressure monitoring, and an examination of proteinuria in pregnant women with chronic hypertension. Both ACOG and NICE guidelines imply that magnesium sulfate is a well-established treatment for seizure prevention in severe preeclampsia. Pregnancy-related hypertension should be managed with antihypertensive drugs such as Labetalol. The research on HELLP syndrome also emphasizes the significance of early detection and treatment, which includes delivery and blood pressure management in extreme cases. In general, the evidence-based approach depends on accepted standards and obstetric community consensus on research to guarantee the best possible care for pregnant patients with hypertension problems. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Resources used to meet practice guidelines

I consulted credible sources, including the guidelines of the American College of Obstetricians and Gynecologists (ACOG), the recommendations of the National Institute for Health and Care Excellence (NICE), and academic studies published in peer-reviewed journals, in order to comply with best practice guidelines. These resources offered evidence-based guidance on the identification and treatment of HELLP syndrome, preeclampsia, and associated pregnancy problems (Shah, 2023). By using these reliable resources, the treatment plan for Gloria was guaranteed to be in line with the most recent recommendations for obstetric care.

Ethical dilemmas

The case raises moral questions about the health of the mother and fetus. Gloria’s complicated medical history and her desire for autonomy in pursuing a pregnancy create ethical concerns concerning assisted reproductive technologies. Determining the best time and method of delivery while taking into account the risks to the mother and the fetus is part of managing severe preeclampsia (Shah, 2023)Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment. In addition, it is important to be sensitive and truthful while discussing the pregnancy’s prognosis and any potential difficulties with Gloria and her boyfriend. When allocating resources and providing end-of-life care for a premature baby, ethical issues also come up. These issues call for patient-centered, compassionate decision-making.

Conclusion

Gloria’s story, in conclusion, emphasizes the complicated interplay between medical complexity, evidence-based decision-making, and ethical issues in obstetric treatment. The journey highlights the vital need for comprehensive, patient-centered interventions, from preconception counseling to the difficulties of severe preeclampsia. The example highlights the need of multidisciplinary collaboration and ethical decision-making in navigating complicated obstetric settings and provokes thought on the delicate balance needed in managing mother and fetal health.

References

Fox, R., Kitt, J., Leeson, P., Aye, C. Y. L., & Lewandowski, A. J. (2019). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of clinical medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625

Sanford, B. H., Labbad, G., Hersh, A. R., Heshmat, A., & Hasley, S. (2021). Leveraging American College of Obstetricians and Gynecologists Guidelines for Point-of-Care Decision Support in Obstetrics. Applied clinical informatics, 12(4), 800–807. https://doi.org/10.1055/s-0041-1733933

Shah B. N. (2023). National Institute for Health and Care Excellence (NICE) guidance on heart valve disease. Heart (British Cardiac Society), 109(11), 817–822. https://doi.org/10.1136/heartjnl-2022-321095  Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Background

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.

Decision Point One

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.

What anticipatory guidance should you consider?

She has some things inCORRECT
She Has some things in her history that she needs to consider

First, she has a significant cardiac history and is at high risk for cardiovascular complications. Additionally, Zocor and lisinopril are both category x drugs, and it is unknown whether Plavix is safe in pregnancy.

Decision Point Two

You discuss with Gloria about the issues with her medical problems and the issues with her current medications. You recommend that she set up an appointment with a maternal-fetal medicine specialist to discuss this and make recommendations for them.

Are there any other preconceptual recommendations you would make for her (or another woman considering pregnancy)?

Begin folic acid 400 mcg to 800 mcg daily. Discuss risks of alcohola CORRECT
Begin Folic Acid 400mcg to 800mcg daily. Discuss risks of alcohol and pregnancy

All women should consider preconceptual folic acid supplementation to help prevent neural tube defects. Gloria speaks with the maternal-fetal medicine specialist, who then speaks with her cardiologist. She is taken off her cholesterol meds, has her blood pressure meds changed to Procardia, stops the Plavix, and starts a baby aspirin daily. Her cardiac stress test is good, and her kidney function is reported as normal pregnancy. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

Decision Point Three

Gloria then sees an infertility specialist and discusses IVF and donor egg. 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.

What specific issues do you need to think about?

Baseline CMP and 24 hour urine

As she has chronic hypertension and known cardiac disease, she is at a higher risk for preeclampsia. You need to see what her normal is at the beginning.

Decision Point Four

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.

What is your next consideration?

Explain to the patient and family the concerns for her high blood pressure and need for immediate treatment to prevent stroke and/or placental abruption.

Extreme hypertension is related to strokes in women and complication from preeclampsia /hypertension in pregnancy/HELLP is the second leading cause of death in women world wide. Her LFT’s are quadruple normal and her platelets are 50,000. She is started on IV Magnesium Sulfate and given several doses of IV Lebetalol to get her BP under control. Unfortunately she abrupted late that day and delivered a male infant who lived about 20 minutes. After a rough course, including anuria and difficulty maintaining her pressures, she was eventually discharged and went home on day 11. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

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JUST FOR THOUGHT

What would you do in this situation? Is it right to dismiss her desire or should you facilitate it? How do you see your role here as an Advanced Practice Nurse? What ethical dilemmas and/or other issues do you need to consider?

ETHICAL ISSUES

PSYCHOLOGICAL ISSUES

PHYSICAL ISSUES

FINANCIAL ISSUES

Extreme t day and delivered a male infant who lived about 20 minutes. After a rough course, including anuria and difficulty maintaining her pressures, she was eventually discharged home on Day 11. Evidence-Based Decision-Making And Ethical Issues In Obstetric Treatment

 

 

 

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