Cases

Chapter 15 Pharmacology and medicines management

Case 1: Methadone treatment regime

Jill is 24 years old and is a primigravida; she is 40 weeks pregnant and has been admitted to the labour ward with a history of regular painful contractions for 3 hours. As part of the labour assessment, on vaginal examination Jill is found to be in active labour. Jill has a history of substance misuse since she was 16 years old, including street heroin, which in the last two years she has moved to injecting. Currently Jill is on methadone 400 mg daily. She has tried to stop using many times, but has until now been unsuccessful. She is currently on a methadone treatment regime, but admits to topping this up occasionally with heroin. However, she has managed recently to stop topping up. Jill has taken her dose of methadone this morning, which was unsupervised, but it has made her feel quite sick and she has vomited several times whilst being admitted to the ward. Jill's blood-borne virus screening is negative. Jill has been attending her antenatal appointments with the specialist substance misuse midwife, she is also receiving support for anxiety and depression via the perinatal mental health team. Jill is not planning to breastfeed. Jill is asking for pain relief; she does not want to have an epidural and wants to know what other options there are.

Questions

• a) What would you suggest as pain relief for Jill and why?

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  Correct answer:
  When meeting with Jill the substance misuse midwife will have discussed the issue of pain relief and the options available. The midwife caring for Jill in labour will need to discuss non-pharmacological methods which can be used such as water, TENS and relaxation techniques, including the advantages and possible side effects of these methods. It may be that Jill already has an idea of what she wants, but it is important to still have this discussion so that Jill is making an informed choice. Entonox can also be used later on in the labour to assist with pain relief and relaxation.
  Opioids can be used as there is no evidence that this could cause a relapse, however, as Jill could have developed a tolerance to this group of drugs it may be that the initial usual dose is not adequate. If this is the case then this can be carefully increased to aid pain relief. Advice from an obstetric anaesthetist needs to be sought if giving opioids. Jill needs to be made aware of the possible impact on the fetus, and the fetal wellbeing needs to be carefully assessed.
  Jill will need to be given her usual doses of methadone during labour, although the fact that the dosage this morning was not supervised means that the midwife cannot be sure what dosage Jill has taken. Sudden withdrawal can cause fetal distress.
  If Jill continues to request further analgesia, then eventually she may request an epidural; there is no contraindication to this for women who are substance misusers. It is important that intravenous access is available, as Jill has previously injected heroin and this can cause problems with IV access. If analgesic effect is inadequate then further local anaesthetic should be given rather than opioids.
  Any form of pain relief can be supplemented with paracetamol or a non-steroidal anti-inflammatory drug.
  Jill will need to be given an anti-emetic for the nausea and vomiting. It may be necessary to give this via the intramuscular or intravenous route as giving the medicine orally could cause further vomiting.
  (British Pain Society 2007, Royal Cornwall Hospital NHS Trust 2012)

Case 2: Pregnancy induced hypertension

Catherine is 34 years old, she is a primigravida, and she is attending the antenatal day unit (ADU) on the request of her community midwife, who has recorded her blood pressure BP as 150/95 mmHg. Catherine is feeling well, she has no history of headaches, visual disturbances, and her urinalysis has detected no abnormalities. The doctor on ADU prescribes labetalol for Catherine to lower her BP. You notice in Catherine's records that she is an asthmatic. Catherine has no other past medical history of note and is otherwise fit and healthy. Catherine's asthma is currently being treated with Salbutamol 100 mcg as required (PRN) and Qvar 100 mcg twice daily (BD).

Questions

• a) What are the implications for asthmatics when prescribed labetalol?

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  Correct answer:
  Labetalol as a beta blocker and should not be given to asthmatics; side effects include bronchospasm, increased airway reactivity and resistance to the effects of inhaled beta receptor agonists. Beta receptors occur on respiratory passages as well as blood vessels. So whilst the drug has an impact on the blood vessels which reduces the blood pressure, the affect on the respiratory passages is to cause constriction. Alternatives to this drug are calcium channel blockers which are more selective and act on the cardiovascular and circulatory system. They prevent calcium entering the muscle cells and therefore reduce the amount of force that the muscle cell can generate and thereby reducing the blood pressure. An example of this type of drug would be Nifedipine (Jordan 2010).

Case 3: Drug error

Chloe Smith has been given Dalteparin 7500 units, as a precautionary measure against thrombo embolism as Chloe has a BMI of 40 and is 1 day postnatal after a normal vaginal birth. After being given the drug, Chloe queries with the midwife why she is having this drug? On looking at the prescription chart, Chloe has had this drug given regularly for the last few days, so the midwife is surprised that the woman is not aware of why she is having the drug. However, on closer inspection it is clear that this is not the right patient, and that the date of birth is different. On investigating this further there are two patients on the ward with the same name and the wrong patient has been given the Dalteparin on this occasion.

Questions

• a) What is the correct course of action after such an error and how could this be prevented?

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  Correct answer:
  The person in charge of the ward must be informed and the supervisor of midwives on call.
  The mistake needs to be discussed with the patient who was given the drug in error; this should include an apology and the action that is to be taken. A doctor needs to be informed of the error and the woman's records reviewed to assess any possible side effects or implications for the woman's treatment.
  The supervisor of midwives will meet with the midwife who gave the drug in error to discuss what happened and why, and to assess if any further action is necessary.
  A critical incident form is completed so that this error can be reviewed by the risk management team of the Trust.
  The drug chart for the second Chloe Smith needs to be reviewed and she will need to be given her missing dose of Dalteparin, after discussion with the doctor regarding any impact of the delay in receiving the drug. The patient should have an apology for the delay in giving the medication.
  When dealing with clients with similar or the same names, if possible they should not be on the same ward. If it is not possible then they should be as far away from each other as possible and it should be indicated on the client's records that a careful check needs to be made as there is a woman with the same or similar name within the system; this must include the drug chart.