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True or false: Polycystic ovary syndrome (PCOS) may contribute to the pathogenesis of hypertension.
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Recall that a 24-year-old G7P5107 presented to the labor and delivery suite of a community hospital at “8 months pregnant in labor.” She had no prenatal care and did not recall her last menstrual period.
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The patient was admitted to the antepartum ward. Serial BP measurements ranged between 174-196 and 120-140 mmHg, but were in the range of 100-110/70-80 mmHg after an oral antihypertensive was started. All prenatal labs and cultures were obtained and were normal, including LFTs. She was prescribed methyldopa. The patient was discharged on hospital day 4. A prenatal office appointment was scheduled with twice weekly non-stress tests.
- Obstetric history: Significant for 6 vaginal deliveries, reportedly without complications other than 1 set of twins and a preterm birth at “8 months” that did not require a stay in a special care nursery.
- Medical history: Significant for chronic hypertension, which has been treated sporadically since age 20 years. She has had no surgeries.
- Family history: Significant for maternal and paternal hypertension and diabetes; the mother died at age 62 years following a “heart attack” and the father died at age 54 years with a “burst aorta.”
- Personal history: She smokes 1-2 packs of cigarettes/day; drinks 2-3 beers/day, but denies alcohol consumption when she realized she was pregnant; unemployed, unmarried, lives with her 7 children (2-8 years of age).
- Examination: BP: 180/130 mmHg; minimal swelling of the ankles; estimated gestational age: 34-4/7 weeks based on biometrics; cervix was 1-2 cm dilated and 50% effaced. No proteinuria on the admission urine specimen. The fetal heart tracing was reactive. The tocodynamometer revealed that she was acontractile with uterine irritability.
The patient kept her prenatal appointments and non-stress tests until delivery of a healthy male weighing 6.75 pounds at 38-3/7 weeks’ gestation. The ante-, intra-, and post-partum blood pressures were well-controlled. She declined a postpartum tubal ligation and other forms of contraception. She was switched to atenolol + HCTZ postpartum with good blood pressure control and was provided prescriptions and a 6-week follow-up appointment at the time of discharge.
Four weeks’ postpartum, the patient’s 8-year-old son called the office and told the receptionist “mommy is talking funny.” The office RN tried to speak with the patient, but she was unintelligible. An ambulance was dispatched; on initial evaluation at the hospital ER, the patient was noted to have a left-sided hemiparesis and an expressive aphasia. Mental status and level of consciousness were difficult to establish. BP, 210/140 mmHg; RR, 20; pulse was 84. She was afebrile.
A non-contrast CT of the head was ordered. During the scan, the patient went into cardiopulmonary arrest and could not be resuscitated.
Which antihypertensive is clearly superior in the primary prevention of stroke?