What is the best management approach for a pregnant 27-year-old with generalized seizure disorder, vitamin D deficiency, mixed anxiety and depressive disorder, elevated LDL cholesterol level, and hypertension, who is taking levetiracetam (Keppra), sertraline (Zoloft), propranolol (Inderal), ciprofloxacin-dexamethasone (Ciprodex), fluticasone propionate, and vitamin D3?

Management of Hypertension in Pregnancy with Multiple Comorbidities

This patient requires immediate hospitalization and urgent antihypertensive therapy, as her blood pressure of 152/96 mmHg meets criteria for treatment initiation in pregnancy, and propranolol should be switched to a safer beta-blocker like labetalol or methyldopa. 1, 2

Immediate Blood Pressure Management

Urgent medication adjustment is required:

• Discontinue propranolol immediately and switch to labetalol or methyldopa, as propranolol is acceptable but labetalol and methyldopa are preferred first-line agents for hypertension in pregnancy 1, 2
• Initiate treatment at BP ≥140/90 mmHg for pregnant women with any hypertension, as this patient's 152/96 mmHg clearly exceeds this threshold 1, 2
• Target blood pressure should be 110-135/85 mmHg to reduce maternal risk while maintaining adequate uteroplacental perfusion 1, 2
• First-line oral agents include methyldopa, labetalol, or long-acting nifedipine 1, 2

The European Society of Cardiology specifically recommends labetalol or methyldopa for long-term management of supraventricular arrhythmias and hypertension in pregnancy, making labetalol an ideal choice given this patient's anxiety disorder 1.

Critical Medication Review and Contraindications

Several medications require immediate attention:

Sertraline (100mg)

• Continue sertraline as the benefits of treating maternal depression/anxiety typically outweigh risks, and untreated psychiatric illness poses significant maternal and fetal risks 3
• Monitor for neonatal adaptation syndrome in the third trimester

Levetiracetam (750mg)

• Continue levetiracetam as seizure control is critical in pregnancy; uncontrolled seizures pose greater risk than medication exposure 4
• Levetiracetam has relatively favorable pregnancy data compared to older antiepileptics 4
• Enroll patient in the North American Antiepileptic Drug (NAAED) pregnancy registry by calling 1-888-233-2334 4

Ciprofloxacin-Dexamethasone Otic

• Discontinue if possible - while topical otic preparations have minimal systemic absorption, ciprofloxacin is generally avoided in pregnancy when alternatives exist 3
• If ear infection persists, consider amoxicillin or first-generation cephalosporin 3

Fluticasone Nasal

• Continue fluticasone - topical intranasal steroids are low-risk in pregnancy 3

Vitamin D3 (50,000 IU)

• Continue vitamin D supplementation - correcting deficiency is important for maternal and fetal bone health

Monitoring and Risk Stratification

Close surveillance is essential:

• Weekly blood pressure monitoring until stable on new antihypertensive regimen 1, 2
• Assess for preeclampsia symptoms at each visit: headache, visual changes, right upper quadrant pain, sudden edema 1
• Urine protein assessment (24-hour collection or protein-to-creatinine ratio) to evaluate for preeclampsia 1, 2
• Serial growth ultrasounds every 3-4 weeks to monitor for intrauterine growth restriction 1
• Baseline and periodic liver function tests, complete blood count, and creatinine 1

Delivery Planning

Delivery timing depends on blood pressure control and complications:

• If severe hypertension develops (≥170/110 mmHg), immediate hospitalization is required with IV labetalol, oral nifedipine, or oral methyldopa 1, 2
• Induce delivery if gestational hypertension with proteinuria develops with adverse conditions (visual disturbances, coagulation abnormalities, fetal distress) 1, 2
• Plan delivery at a facility with appropriate maternal-fetal medicine and anesthesia capabilities 5

Postpartum Considerations

Long-term cardiovascular risk management:

• Monitor blood pressure for 72 hours in hospital and 7-10 days postpartum 1
• Switch methyldopa to alternative agent postpartum if used, as it increases risk of postpartum depression 1
• Counsel on increased lifetime cardiovascular risk - women with gestational hypertension have 4-fold increased risk of future hypertension and 2-fold increased risk of ischemic heart disease 1
• Recommend annual cardiovascular risk assessment lifelong 2
• Lifestyle modifications including weight management, DASH diet, sodium reduction, and regular exercise 1

Common Pitfalls to Avoid

• Never use ACE inhibitors, ARBs, direct renin inhibitors, or mineralocorticoid receptor antagonists - these are absolutely contraindicated due to fetotoxicity 1
• Avoid atenolol - specifically contraindicated for any arrhythmia or hypertension in pregnancy 1
• Do not delay treatment waiting for BP ≥160/110 mmHg - treatment threshold is 140/90 mmHg in pregnancy with comorbidities 1, 2
• Do not restrict salt intake - may induce low intravascular volume, particularly near delivery 1