Debra, age 28, is pregnant with her first child. She does manual labor in a warehouse earning slightly above minimum wage. She has no work-related benefits or health insurance. For years she has only sought care at an urgent care or emergency department (ED) if ill. She has not started prenatal care due to lack of finances.
At 30 weeks gestation, Debra presents to the ED with shortness of breath. The ED physician notes elevated blood pressure and refers her to the OB/GYN/midwife service at the hospital. He explains that women often get short of breath during pregnancy. Debra confides in the ED nurse that she is very embarrassed about having no finances for prenatal care. The ED nurse contacts the social worker who helps Debra apply for pregnancy Medicaid.
Four weeks pass before the Medicaid paperwork is completed and Debra is scheduled to see a provider at the local hospital. The nurse-midwife is very concerned about her elevated blood pressure (148/86) and begins evaluation for preeclampsia. She orders blood work, urine analysis, fetal nonstress test, and an ultrasound for a biophysical profile. Debra’s lab testing shows no signs of preeclampsia, so after collaboration with one of the group’s physicians, the midwife asks Debra to keep a daily blood pressure log, checking it at the free blood pressure machine at the local pharmacy. She also educates Debra on warning signs of preeclampsia and schedules her to come back in three days.
The next day Debra returns to work. That afternoon she feels an increase in fatigue, weakness, and shortness of breath. She collapses at work and her supervisor calls an ambulance. When she arrives at the ED, Debra asks for her midwife who hastily goes to the ED. The ED provider, a nurse-practitioner, orders a 12-lead ECG that shows signs of left ventricular hypertrophy, prompting a cardiology consult.
A STAT echocardiogram reveals a dangerously decreased ejection fraction. Debra is diagnosed with PPCM.
The cardiologist refers Debra to maternal-fetal medicine who quickly evaluates her and recommends immediate cesarean delivery. The midwife stays with Debra as she delivers a preterm, low-birth-weight infant. The baby, Janelle, is admitted to the neonatal intensive care unit (NICU), and Debra is transferred to the cardiac intensive care unit for monitoring and diuresis. The diuretics inhibit her milk supply to an insignificant amount and fatigue prevents her from being able to see Janelle in the NICU more than once a day. Her aunt, Debra’s only family support, travels 200 miles to help Debra and care for Janelle after discharge from the NICU.
Debra does not recover and is transferred to the transplant center several hours away. She requires an invasive pulmonary artery catheter to adjust the doses of her inotropic medications while awaiting a heart transplant. Eight months after her diagnosis, she receives a transplant. While recuperating from the transplant. Debra spends another two months at this site being monitored for transplant rejection.
Debra’s aunt has cared for Janelle for almost a year now. Debra has faced adjustment to
motherhood, caring for her new heart and managing her drug regimen several hours from home. She lost her job and now must find employment so she can provide for her child. Coworkers and friends have helped with fund-raising, and some charitable organizations have provided some assistance.
Debra’s limited savings are exhausted with helping her aunt care for Janelle and paying some of the uncovered medical bills. This family has no safety net, and the future is uncertain.
157 Case Study
▸ Conclusion
PPCM has the potential for devastating, life-altering changes for childbearing women and their fam- ilies. With current knowledge of the risk factors for PPCM, healthcare providers and public health workers need to focus on the prevention, identification, and management of hypertension before and during pregnancy with special attention to the impact of disparity in access to health care.
References
Abalos, E., Duley, L., & Steyn, D. (2014). Antihypertensive drug therapy for mild to moderate hypertension during pregnancy.
Cochrane Database of Systematic Reviews, (2).
American Heart Association. (2017). Why high blood pressure is a “silent killer.” Retrieved fromhttp://www.heart.org /HEARTORG/Conditions/HighBloodPressure/UnderstandSymptomsRisks/Why-High-Blood-Pressure-is-a-Silent -Killer_UCM_002053_Article.jsp#.Wa3pwj597IU
Armstrong, K., Ravenell, K., McMurphy, S., & Putt, M. (2007). Racial/ethnic differences in physician distrust in the United States. American Journal of Public Health, 97(7), 1283–1289.
Bello, N., Rendon, I. S. H., & Arany, Z. (2013). The relationship between pre-eclampsia and peripartum cardiomyopathy:
A systematic review and meta-analysis. Journal of the American College of Cardiology, 62(18), 1715–1723.
Bibbins-Domingo, K., Pletcher, M. J., Lin, F., Vittinghoff, E., Gardin, J. M., Arynchyn, A., . . . Hulley, S. B. (2009). Racial differences in incident heart failure among young adults. New England Journal of Medicine, 360(12), 1179–1190.
Blackburn, S. (2013). Maternal, fetal, and neonatal physiology (4th ed.). Maryland Heights, MO: Elsevier.
Carlin, A. J., Alfirevic, Z., & Gyte, G. M. (2010). Interventions for treating peripartum cardiomyopathy to improve outcomes for women and babies. Cochrane Database of Systematic Reviews, (9).
Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-related mortality in the United States, 2011–2013. Obstetrics & Gynecology, 130 (2), 366–373.
Fuster, V., Walsh, R., & Harrington, R. (Eds.). (2011). Hurst’s the heart (13th ed.). New York, NY: McGraw-Hill Medical.
Garcia, T. & Holtz, N. (2000). 12-Lead ECG. Sudbury MA: Jones and Bartlett.
Gentry, M. B., Dias, J. K., Luis, A., Patel, R., Thornton, J., & Reed, G. L. (2010). African-American women have a higher risk for developing peripartum cardiomyopathy. Journal of the American College of Cardiology, 55(7), 654–659. https://
doi.org/10.1016/j.jacc.2009.09.043
Gu, A., Yue, Y., Desai, R. P., & Argulian, E. (2017). Racial and ethnic differences in antihypertensive medication use and blood pressure control among US adults with hypertension: The national health and nutrition examination survey, 2003 to 2012. Circulation Cardiovascular Quality and Outcomes, 10(1), e003166.
Health Resources and Services Administration. (2015). Child Health USA 2013. Retrieved fromhttps://mchb.hrsa.gov /chusa13/health-services-utilization/p/barriers-to-prenatal-care.html
Hilfiker-Kleiner, D., Haghikia, A., Nonhoff, J., & Bauersachs, J. (2015). Peripartum cardiomyopathy: Current management and future perspectives. European Heart Journal, 36(18), 1090–1097.
Kälble, F., Schaier, M., Schäfer, S., Süsal, C., Zeier, M., Sommerer, C., & Morath, C. (2017). An update on chemical pharmacotherapy options for the prevention of kidney transplant rejection with a focus on costimulation blockade.
Expert Opinion on Pharmacotherapy, 18(8), 799–807.
Kolte, D., Khera, S., Aronow, W., Palaniswamy, C., Mujib, M., Ahn, C., . . . Fonarow, G. (2014). Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: A nationwide population-based study. Journal of the American Heart Association, 3(3), e001056.
Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews, (8).
Kuzawa, C. W., & Sweet, E. (2009). Epigenetics and the embodiment of race: Developmental origins of U.S. racial disparities in cardiovascular health. American Journal of Human Biology, 21(1), 2–15.
Lackland, D. T. (2014). Racial differences in hypertension: Implications for high blood pressure management. American Journal of Medical Science, 348(2), 135–138.
Markus, A. R., Andres, E., West, K. D., Garro, N., & Pellegrini, C. (2013). Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform. Women’s health issues: Official publication of the Jacobs Institute of Women’s Health, 23(5), e273–e280.
Mielniczuk, M., Williams, K., Davis, D., Tang, A., Lemery, R. Martin, S., . . . Birnie, D. (2006). Frequency of peripartum cardiomyopathy. American Journal of Cardiology, 97(12), 1765–1768.
National Foundation for Transplants. (2017). Frequently asked questions. Retrieved from http://www.transplants.org/faq#n308 158 Chapter 13 A Systematic Review of Cardiomyopathy and Peripartum Mortality
Neckermann, C. (2017). An international embarrassment: The United States as an anomaly in maternity leave policy. Harvard International Review, 38(4), 36–39. Retrieved from https://frontier.idm.oclc.org/login?url=http://search.ebscohost.com /login.aspx?direct=true&db=buh&AN=123620525&site=ehost-live
Sailasree, S., Srivastava, S., & Mishra, R. (2017). The placental gateway of maternal transgenerational epigenetic inheritance.
Journal of Genetics, 96(3), 465–482.
Shani, H., Kuperstein, R., Berlin, A., Arad, M., Goldenberg, I., & Simchen, M. J. (2015). Peripartum cardiomyopathy—Risk factors, characteristics and long-term follow-up. Journal of Perinatal Medicine, 43(1), 95–101.
Singh, T. P., Givertz, M. M., Semigran, M., Denofrio, D., Costantino, F., & Gauvreau, K. (2010). Socioeconomic position, ethnicity, and outcomes in heart transplant recipients. American Journal of Cardiology, 105(7), 1024–1029.
Tobis, J. M. (2017). Cardiac transplant vasculopathy. Catheterization and Cardiovascular Interventions: Official Journal of the Society for Cardiac Angiography & Interventions, 90(1), 56–57.
United Network for Organ Sharing. (2017). Data. Retrieved from https://www.unos.org/data/
U.S. Department of Health and Human Services. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research: The national commission for the protection of human subjects of biomedical and behavioral research. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html van Valen, R., Zuijdendorp, H. M., Birim, Ö., Brugts, J. J., & Bogers, A. J. (2017). Challenges in destination LVAD therapy,
management of mediastinitis and device infection: A case report. Heart, Lung & Circulation. https://doi.org/10.1016/j .hlc.2017.06.720
World Health Organization. (2017). Maternal mortality ratio. Retrieved from http://www.who.int/healthinfo/statistics /indmaternalmortality/en/
159 References
▸ Introduction
The research question investigated was the process that adult male quadriplegics use to achieve suc- cess following a spinal cord injury (SCI). Individuals who have suffered an SCI must be able to posi- tively adjust to their injury in order to achieve a stable level of psychological and social functioning, which is why the resilience theory supported this qualitative research study conducted specific- ally on the SCI population. To conduct this research, the researchers assumed that the participant told the truth as he saw it. In this study, the conceptual definition of the term spinal cord injury was defined as an injury of the spinal cord that causes motor and/or sensory loss to the upper and/or lower extremities. Another important term for this study was quadriplegia, which is an injury of the cervical spinal cord between the C1 and C8 segments, including the organs (Nas, Yazmalar, Sah, Aydin, & Ones, 2015). An expected limitation to the study design was that due to the participant’s injury, he may not have remembered details related to his injury.
OBJECTIVES
At the end of this chapter, you will be able to:
1. Review the dynamics of quadriplegia.
2. Identify key steps in conducting a life history.
3. Review the challenges and successes of an individual quadriplegic.