16. Drug Use In Pregnancy

Question 1

A drug is categorized by the FDA as Pregnancy Category D. Select the correct definition for the meaning of Pregnancy Category D:

A. Studies in animals or humans show fetal abnormalities; use in pregnancy is contraindicated.
B. Positive evidence of fetal risk is available, but the benefits may outweigh the risk if life-threatening or serious disease.
C. No controlled studies in humans have been performed and animal studies have shown adverse events, or studies in humans and animals are not available; give only if potential benefit outweighs the risk.
D. Either animal studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the 1st trimester.
E. Controlled studies in animals and women have shown no risk in the 1st trimester, and possible fetal harm is remote.

Answer 1

B. Use caution: some “D”s are more dangerous than other “D”s and it is not acceptable to take chances with the health of the baby unless there is no other option.

Question 2

What is the preferred treatment for heartburn during pregnancy?

A. Omeprazole
B. Calcium
C. Famotidine
D. Lansoprazole
E. Simethicone

Answer 2

B. Antacids, and in particular calcium, is first-line for heartburn (GERD, or reflux) in pregnancy. Chewable calcium, such as in Tums or store-brands, is the usual recommendation. Simethicone (Mylicon, Mylicon infant drops) can be recommended in pregnancy (and in infants) for gas; it is not for heartburn.

Question 3

What are preferred treatments for nausea, including morning sickness, during pregnancy? (Select ALL that apply.)

A. Vitamin B6
B. Pyridoxine
C. Metoclopramide
D. Ondansetron
E. Prochlorperazine

Answer 3

A, B.

Question 4

It is common for women to get anemic during pregnancy and the iron in the prenatal vitamin or as a separate supplement can be important. What is the best way to get the highest amount of iron absorbed from a supplement?

A. Take the iron with a glass of milk.
B. Take the iron with an antacid.
C. Take the iron with an H2-blocker.
D. Take the iron with a proton pump inhibitor.
E. Take the iron on an empty stomach.

Answer 4

E. While it is true that iron is absorbed better on an empty stomach, it is also accurate that many women are nauseated (most often in the morning) during pregnancy and taking an iron-containing vitamin usually worsens the nausea. It may be useful to move the iron-containing prenatal vitamin to a time later in the day.

Question 5

A pregnant woman at 28 weeks gestation has a UTI infection that is sensitive to amoxicillin, fosfomycin, sulfamethoxazole-trimethoprim and nitrofurantoin. Of the following antibiotics, which option is not preferred in pregnancy due to safety risks if other, safer options are available?

A. Amoxicillin
B. Fosfomycin
C. Sulfamethoxazole-trimethoprim
D. Nitrofurantoin
E. UTI treatment is not recommended during pregnancy; wait until after delivery to treat

Answer 5

C. Sulfamethoxazole-trimethoprim can cause hyperbilirubinemia and kernicterus in the 3rd trimester (Pregnancy Category C but is not used near-term due to higher risks).

Question 6

Which of the following are acceptable treatment options for vaginal trichomoniasis during pregnancy? (Select ALL that apply.)

A. Metronidazole, oral 2 grams x 1
B. Metronidazole, oral 500 mg BID x 7 days
C. Ceftriaxone, IM
D. Tinidazole, topical
E. Clindamycin or metronidazole, topical formulations

Answer 6

A, B. Another option is metronidazole, oral 250 mg TID rather than 500 mg BID, either for 7 days duration. If one day course can be used it is preferable, but side effects from the larger dose need to be considered.

Question 7

It is best to avoid all drugs, if possible, during this stage of pregnancy; in this stage of pregnancy the risk of severe birth defects is highest:

A. First trimester
B. Second trimester
C. Third trimester
D. 30 days prior to delivery (approximately 4 weeks)
E. 7 days prior to delivery

Answer 7

A. It is best to avoid all drugs if possible during 1st trimester (when organogenesis, or organ development occurs) and to use lifestyle recommendations first, to see if you can avoid the use of over-the-counter or prescription agents. If using OTC agents it is best to recommend only ACOG-first line recommendations; otherwise, have the patient consult with her OB-GYN.

Question 8

A pharmacist will provide information on medical rounds for a patient who is pregnant and requires treatment for venous thromboembolism. (Select ALL that apply.)

A. Unfractionated heparin is the preferred treatment in all stages of pregnancy, and prior to the last month or if delivery appears imminent, low molecular weight heparin use is acceptable.
B. Pneumatic compression is never used in pregnancy due to risk to the fetus from a dislodged clot.
C. Warfarin is acceptable to use after the first trimester only if heparin use is contraindicated due to HIT.
D. Clopidogrel is the treatment of choice for VTE in pregnancy.
E. Only aspirin is recommended in pregnancy if treating DVT.

Answer 8

A. Pneumatic compression is not a risk to the fetus, as the fetus is not located where the compression will occur! These devices can be used prior to delivery in women with thrombosis if they require a C-section. In this case, agents that increase bleeding risk are avoided. Warfarin is pregnancy category X; contraindicated for use in any stage of pregnancy.

Question 9

What is the preferred treatment for allergy symptoms (runny nose, itchy eyes) during pregnancy?

A. Oxymetazoline nasal spray
B. Pseudoephedrine
C. Chlor-Trimeton
D. Phenylephrine
E. Fluticasone nasal spray

Answer 9

C. Chlorpheniramine (Chlor-Trimeton) is a first generation antihistamine, and is preferred in pregnancy. Other first-generation agents are used, such as diphenhydramine (Benadryl). Pharmacists generally recommend their own store’s “brand” to save the patient money over brand-name products.

Question 10

A pharmacist is asked questions regarding asthma medication use during pregnancy and in infants. Select the correct statements. (Select ALL that apply.)

A. Ciclesonide is the preferred inhaled steroid for use in pregnancy.
B. Budesonide is the preferred medication for infants with asthma, in the Respules inhalation formulation.
C. All pregnant women with asthma should have an albuterol inhaler.
D. All pregnant woman should be preferably treated with the Advair Diskus.
E. Asthma, unless it is rated as moderate or severe, should not be treated during the first trimester.

Answer 10

B, C. Budesonide is the preferred steroid for use by the pregnant mother as well; it comes as the Pulmicort Flexhaler and as the Pulmicort Respules (solution for use in a nebulizer).

Question 11

Select the correct statements regarding treatment of hypothyroidism during pregnancy: (Select ALL that apply.)

A. Do not treat hypothyroidism except if the mother’s life is at risk; the treatment could cause birth defects, in all trimesters.
B. Levothyroxine is the treatment of choice for hypothyroidism in pregnancy.
C. Hypothyroidism is always treated in pregnancy, and the dose will need to be increased as the Vd increases.
D. Levothyroxine is pregnancy category A.
E. Levothyroxine is pregnancy category B.

Answer 11

B, C, D. Hypothyroidism in pregnancy is always tested for and treated if present.

Question 12

A woman has been instructed by her doctor to get a folic acid 1 mg tablet and to take one daily. She has looked on the pharmacy shelf and cannot locate this dose. She goes to ask the pharmacist who provides this information: (Select ALLthat apply.)

A. You can purchase a 400 microgram dose over-the-counter.
B. You can purchase an 800 microgram dose over-the-counter.
C. Another name for folic acid is vitamin B9.
D. One milligram is the same thing as 1000 micrograms.
E. Folic acid is a fat-soluble vitamin.

Answer 12

A, B, C, D. Prescription prenatal vitamins (PrimaCare ONE, Zenate, others) usually contain 1,000 mcg, or 1 mg, of folic acid. Some prescription products vary; others contain 800 mcg. There are now some 1 mg products available over-the-counter.

Question 13

A pharmacist will provide information on treatment options for hyperthyroidism during pregnancy. (Select ALL that apply.)

A. Propylthiouracil is Pregnancy Category D and is used during the first trimester.
B. Methimazole is Pregnancy Category D and is used during the first trimester.
C. Methimazole is Pregnancy Category D and is used after the first trimester.
D. Methimazole has a higher risk of hepatotoxicity than propylthiouracil.
E. Both agents can cause serious liver damage.

Answer 13

A, C, E. Propylthiouracil is used in the first trimester and if trying to conceive, although it is highly preferable to get rid of the hyperthyroidism first, since both drugs used are teratogenic, in addition to causing much nausea, and are liver-toxic.

Question 14

A drug is categorized by the FDA as Pregnancy Category A. Select the correct definition for the meaning of Pregnancy Category A:

A. Studies in animals or humans show fetal abnormalities; use in pregnancy is contraindicated.
B. Positive evidence of fetal risk is available, but the benefits may outweigh the risk if life-threatening or serious disease.
C. No controlled studies in humans have been performed and animal studies have shown adverse events, or studies in humans and animals are not available; give only if potential benefit outweighs the risk.
D. Either animal studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the 1st trimester.
E. Controlled studies in animals and women have shown no risk in the 1st trimester, and possible fetal harm is remote.

Answer 14

E.

Question 15

A pregnant woman has an infection that is sensitive to amoxicillin, cephalexin, azithromycin, erythromycin and clarithromycin. Of the above antibiotics, which is considered the least safe in pregnancy?

A. Amoxicillin
B. Cephalexin
C. Azithromycin
D. Clarithromycin
E. Erythromycin

Answer 15

D. Generally considered safe to use in pregnancy are penicillins (including amoxicillin and ampicillin (both Pregnancy Category B), cephalosporins, erythromycin and azithromycin, also both Pregnancy Category B. Clarithromycin, which is Pregnancy Category C, is not preferred.

Question 16

Which organization sets most of the recommendations for drug use during pregnancy?

A. ADA
B. ACOG
C. AHA
D. AMA
E. NCEP

Answer 16

B. The American College of Obstetricians and Gynecologists (ACOG) sets the recommendations for the safe and effective use of medications for most female conditions, including pregnancy.

Question 17

Select the lifestyle changes that might help reduce constipation during pregnancy (and at other times as well): (Select ALLthat apply.)

A. Increasing fiber in the diet.
B. Adequate fluid intake.
C. If the woman will not increase water intake, suggest green or black tea as an alternative.
D. Physical activity can be helpful, using forms that are safe during pregnancy.
E. Changing from white rice to brown rice, or from white bread to whole grain bread.

Answer 17

A, B, D, E. Caffeine-containing drinks are not counted as positive fluid intake, but are neutral; although they do increase fluid intake, they cause mild diuresis.

Question 18

What is the preferred treatment for constipation during pregnancy?

A. Stool softeners, such as docusate
B. Fiber, such as psyllium
C. Stimulant laxatives, such as senna
D. Osmotic laxatives, such as polyethylene glycol
E. Glycerin suppositories, as-needed

Answer 18

B. Fiber is first-line for constipation in pregnancy. If dietary fiber is adequate, that would be preferable, but often supplemental fiber is required.

Question 19

Julia is a 17 year-old female who enters the pharmacy to pick up her birth control pills. The pharmacist would provide a benefit by ensuring that Julia is receiving adequate intake of this B vitamin:

A. Vitamin B2
B. Vitamin B6
C. Vitamin B9
D. Vitamin B12
E. Vitamin E

Answer 19

C. Folic acid, vitamin B9, is in many healthy foods, including fortified cereals (some of which are not healthy), dried beans, leafy green vegetables and orange juice. An OTC multivitamin that contains 400-800 mcg of folic acid can be recommended.

Question 20

A pharmacist is consulted regarding acceptable treatment options for a pregnant woman with a chlamydia infection. (Select ALL that apply.)

A. Biaxin can be used if the woman has an allergy to beta lactams.
B. Amoxil is a preferred agent.
C. If Zithromax is used in a high-dose, it will also treat gonorrhea.
D. Vibramycin is the preferred agent for chlamydia, in all trimesters.
E. Zithromax is a preferred agent.

Answer 20

B, C, E. Clarithromycin is not a safe macrolide for use in pregnancy. If azithromycin is used at a 2 gram x 1 dose (versus 1 gram x 1 for chlamydia alone), the dose would be adequate to treat both chlamydia and gonorrhea.

Question 21

Beth is in the third month of pregnancy. She has a condition that is usually treated with a Pregnancy Category X drug. Select the correct statement concerning Pregnancy Category X:

A. The drug is contraindicated in pregnancy, under all circumstances.
B. The drug can be used if the mother’s life is in danger.
C. The drug can be used if the life of the fetus is in danger.
D. Pregnancy Category X means the drug is safe to use in the 1st trimester only.
E. Only hormone products are Pregnancy Category X.

Answer 21

A. Pregnancy Category X means that studies in animals or humans show fetal abnormalities; the use in pregnancy is contraindicated in all stages.

Question 22

Jada is pregnant with her second child. She is in the pharmacy to pick up her prenatal vitamin prescription. The pharmacist asks Jada if she is consuming adequate dairy products. Jada replies that she does not like to drink milk because it gives her an upset stomach. Select the correct statements: (Select ALL that apply.)

A. The prenatal vitamin contains about 200 milligrams of calcium; Jada requires about five times this amount.
B. If the mother does not consume adequate calcium, the child will build his or her skeleton by depleting the mothers.
C. Jada can purchase milk that contains the lactase enzyme, such as Lactaid, that should not cause stomach upset.
D. Perhaps Jada can get the additional calcium from calcium supplements; choose one that contains vitamin D.
E. The prenatal vitamin contains enough calcium, but many women do not choose to use it due to nausea from the iron component.

Answer 22

A, B, C, D. If the patient uses a calcium supplement, she should take it at a different time than the prenatal vitamin. Calcium absorption is saturable; more is absorbed if the doses are spread out. Prenatal vitamins contain iron, which does cause nausea and constipation, but is recommended and contains some calcium (usually 200 mg).

Question 23

A pregnant woman has a bacterial vaginosis infection. Which of the following antibiotics are acceptable treatment options? (Select ALL that apply.)

A. Clindamycin oral
B. Clindamycin topical
C. Metronidazole oral
D. Metronidazole topical
E. Ciprofloxacin

Answer 23

A, C. Pregnant women with bacterial vaginosis more often have babies who are born premature or with low birth weight and are therefore treated. The drugs of choice are clindamycin or metronidazole. Both are used; however, clindamycin is preferred in pregnancy, especially in the 1st trimester. Topical therapy for bacterial vaginosis is not recommended during pregnancy.

Question 24

Select the lifestyle changes that might help reduce heartburn during pregnancy: (Select ALL that apply.)

A. Elevating the head of the bed with 2-3 pillows.
B. Splitting large meals into smaller, more frequent meals.
C. Avoiding foods that worsen the heartburn (often this is spicy/odorous foods, caffeine, mints, fatty foods).
D. Not eating three hours prior to bedtime.
E. Taking antacids such as Maalox.

Answer 24

B, C, D. “Lifestyle” means non-drug modalities. Do not use pillows, rather use a wedge to elevate the patient.

Question 25

It is October and in the prime of influenza vaccine season. Kathleen is pregnant (at week 30) and has gone to see her physician for a check-up. Choose the correct statements: (Select ALL that apply.)

A. She should receive the influenza shot now.
B. She should receive the influenza nasal vaccine now; in pregnancy, women feel pain more acutely.
C. She should receive the Tdap vaccine now.
D. She should receive the shingles vaccine now.
E. She should receive the Hib vaccine immediately after delivery.

Answer 25

A, C. Pregnant women cannot use live vaccines.

Question 26

A pregnant female approaches the pharmacy counter with a bottle of ibuprofen. She informs the pharmacy intern that she has a headache from spending too many hours on a computer and that she has been told that ibuprofen is the safe to take during pregnancy, but not in the third trimester. What is a correct statement to tell this patient?

A. She is correct; it is best to say that ibuprofen should be avoided during weeks 12 and after.
B. She is correct; it is best to say that ibuprofen should be avoided during weeks 27 and after.
C. Naproxen is the safest option in pregnancy, if an NSAID is chosen.
D. Acetaminophen, such as in Tylenol and store-brands, is safest in pregnancy and NSAIDs are not recommended in most cases.
E. The prescription drug etodolac is the safest NSAID option in pregnancy.

Answer 26

D. Acetaminophen is the analgesic/antipyretic drug of choice in pregnancy, and is pregnancy Category C. NSAIDs (e.g. ibuprofen, naproxen) are pregnancy category C during the 1st and 2nd trimester and are pregnancy category D during the 3rd trimester.