History and Physical

Journal Article Summary

Article: Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial

Lancet Journal

• This is a RCT that focused on comparing three oral anti-hypertensive medications (Labetalol, Nifedipine and Methyldopa) for acute treatment of hypertension in pregnancy.  The 1* Outcome measured was BP control (120-150 Systolic BP or 70-100 mm Hg Diastolic BP) within 6 hours with no adverse outcomes.
• It is a multicenter parallel group RCT; the oral anti-HTN were compared in 2 public hospitals in Nagpur, India.
• Inclusion Criteria: pregnant women at the gestational age of at least 28 weeks with severe HTN (Systolic BP ≥ 160 mm Hg or Diastolic BP ≥ 110 mm Hg) who are able to swallow oral medications.
• Exclusion Criteria: impending eclampsia, active labor, younger than 18 years old, indication for an emergency c-section, known fetal anomaly, history of asthma or actively wheezing, or have signs of heart failure.
• 894 Patients were randomly assigned to receive 10mg oral Nifedipine (298 patients), 200mg oral Labetalol (295 patients), 1000mg Methlydopa (301 patients).
• Results found that for pregnant women with severe hypertension, oral nifedipine retard was more effective than methyldopa at achieving a primary outcome of blood pressure control without adverse events within 6 h when additional medications were used. Oral nifedipine retard and labetalol, as single drugs, were significantly more effective than methyldopa. The frequency of primary outcome attainment was high and maternal adverse events were low in all three treatment groups.
• Labour and delivery outcomes did not vary between groups (2/3 of women in each group delivered by c-section because of failed inductions of labour and FHR abnormalities). The incidence of stillbirth, neonatal death, and neonatal morbidities did not vary between groups.
• However, more neonates born to women assigned to the nifedipine group were admitted to the intensive care unit, primarily because more low or very low birthweight babies were born to mothers in the nifedipine group.
• Implications of the study: For institutions that have limited resources, oral antihypertensive medications can be used for managing severe hypertension. The World Health Organization (WHO) currently includes only intravenous hydralazine and methyldopa in its most recent essential drugs list for addressing severe hypertension during pregnancy. Nifedipine is solely mentioned as a remedy for preterm birth.
• I chose this study because there are not enough studies that directly compared the three most commonly used oral antihypertensives: labetalol, methyldopa, and nifedipine. A Cochrane review of drugs for treatment of very high blood pressure during pregnancy also found insufficient data to recommend a specific drug, and it concluded that the choice of antihypertensive should depend on clinicians’ experience and familiarity with the drug.
• Limitations of the study: it was not possible to mask the participations, study investigators and care providers. Another limitation of the study was their definition of severe HTN, which was defined as Systolic BP ≥ 160 or Diastolic BP ≥ 110. There are multiple categories of hypertensive disorders in pregnancy:
  • Gestational HTN which is new onset Systolic BP ≥ 140 and/or Diastolic BP ≥ 90 after 20 weeks gestation in a previously normotensive individual with no proteinuria, no signs or symptoms of preeclampsia related end organ dysfunction.
  • Preeclampsia which is new onset systolic BP ≥140 and/or Diastolic BP ≥ 90 after 20 weeks gestation with proteinuria, protein: creatinine ratio ≥ 0.3, urine dipstick reading ≥2+.
  • Preeclampsia with severe features occurs with systolic BP ≥ 140 and/or Diastolic BP ≥ 110 with thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, persistent cerebral or visual disturbances.
  • Chronic (Preexisting) Hypertension which is when HTN is diagnosed or present before pregnancy or before 20 weeks of gestation.

Source:

Easterling, T., Mundle, S., Bracken, H., Parvekar, S., Mool, S., Magee, L. A., von Dadelszen, P., Shochet, T., & Winikoff, B. (2019). Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet (London, England), 394(10203), 1011–1021. https://doi.org/10.1016/S0140-6736(19)31282-6

Site Evaluation Presentation Summary

In my seventh rotation, PA Carlos Melendez served as my site evaluator. During the site evaluation, I presented three H&Ps based on my time in Labor and Delivery, Clinic, and GYN. The first H&P was from my time in Labor and Delivery, it involved a 28 year old 30 week pregnant female who presented to triage with complaints of blood in her toilet bowel this morning. During her visit she placed on a continuous external fetal monitor along with toco monitoring. There was no evidence of preterm labor with FFN negative, VE closed/unchanged, and her lower abd pain resolved s/p IV fluids. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

The most unforgettable experience occurred when I witnessed my initial C-section procedure. The patient was categorized as of advanced maternal age and had previously undergone five C-sections. She was scheduled to be induced that day. It’s challenging for anyone to truly grasp the significance of bringing a baby into the world. What left a lasting impression on me was the flawless coordination and collaboration between the pediatric and obstetric teams, particularly as the infant developed respiratory distress syndrome.

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

The most challenging aspect of my role was collecting a detailed medical history from OB patients during their follow-up appointments and aligning it with the required screenings based on their gestational age. I discovered that maintaining a chart is a valuable tool to ensure that patients receive the appropriate screenings according to their pregnancy stage.

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

During this rotation, it was individuals who were reluctant to disclose details about their sexual history or past pregnancies that I found challenging. I observed that some healthcare providers opted for one-on-one OB visits with patients, excluding family members from the room, which I believed was a crucial factor to take into account. Certain patients hesitated to share comprehensive information when their partners, significant others, or family members were present. I also gleaned that emphasizing the significance of confidentiality in certain situations could help patients feel more comfortable.

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

In my upcoming Ambulatory Care rotation, I aim to engage in a greater number of medical procedures and enhance my proficiency in interpreting EKGs. My strategy involves communicating my interest in performing additional procedures to the supervising provider. Along with reviewing videos on EKG interpretation.