2) prescribing in pregnancy

Question 1

What percentage of pregnant women use prescribed or OTC medicines?

Answer 1

Up to 90%.

Question 2

Why is prescribing in pregnancy challenging?

Answer 2

Few medicines are specifically licensed, and inappropriate use or avoidance can impact health outcomes.

Question 3

How does the placenta affect drug transfer?

Answer 3

Most drugs cross due to lipid solubility; placental thinning increases exposure.

Question 4

What factors determine drug safety in pregnancy?

Answer 4

The benefits to the mother and fetus versus the risks of withholding treatment.

Question 5

What is a teratogen?

Answer 5

An agent that causes structural or functional abnormalities in a fetus due to maternal exposure.

Question 6

What percentage of live births are associated with congenital anomalies?

Answer 6

2-3% of live births.

Question 7

Which drugs are known teratogens?

Answer 7

Sodium valproate, methotrexate, ACE inhibitors, warfarin, hypoglycemics.

Question 8

What are potential adverse effects of teratogens?

Answer 8

Fetal malformations, stillbirth, growth retardation, neonatal side effects, neurodevelopmental defects.

Question 9

Why is isotretinoin strictly contraindicated in pregnancy?

Answer 9

It is a powerful teratogen causing CNS, cardiac, and facial abnormalities, cleft palate, and spontaneous abortion.

Question 10

What measures are part of the isotretinoin Pregnancy Prevention Programme?

Answer 10

Pregnancy testing, contraception, prescribing restrictions, education, and warnings for both male and female patients.

Question 11

What factors influence fetal damage from medicines?

Answer 11

Stage of pregnancy, drug dosage, frequency, other agents, maternal nutrition, genetics.

Question 12

What is the effect of drugs in the pre-embryonic stage (0-17 days)?

Answer 12

‘All or nothing’ effect; drugs may still be present in the next stage.

Question 13

Why is the embryonic stage (18-56 days) critical?

Answer 13

Major organ formation occurs, posing the highest risk for malformations.

Question 14

What are the concerns during the fetal stage (weeks 8-38)?

Answer 14

Drug effects on maturation, development, and growth.

Question 15

Why are drugs in the term stage (weeks 38-42) significant?

Answer 15

They impact labor or neonatal outcomes post-delivery.

Question 16

How does increased total body water affect drug pharmacokinetics?

Answer 16

Increases volume of distribution for hydrophilic drugs.

Question 17

How does increased renal blood flow affect drug clearance?

Answer 17

Increases renal clearance, shortening drug half-life.

Question 18

Why does decreased plasma albumin affect drug levels?

Answer 18

Increases free drug fraction, potentially enhancing drug effects.

Question 19

What key pre-pregnancy care measures should be taken?

Answer 19

Effective contraception, chronic disease management, folic acid, smoking cessation, alcohol avoidance, vaccinations.

Question 20

Why is folic acid recommended in pregnancy?

Answer 20

Prevents neural tube defects; normal dose is 400 mcg, but 5 mg for high-risk women.

Question 21

What is the recommended vitamin D intake in pregnancy?

Answer 21

10 mcg daily.

Question 22

What are the general prescribing principles in pregnancy?

Answer 22

Use non-drug treatments where possible, lowest effective dose, safest drug, avoid unnecessary medications, monitor closely.

Question 23

What is the impact of uncontrolled asthma in pregnancy?

Answer 23

Increases risk of preterm labor, intrauterine growth retardation, hypertensive disorders.

Question 24

How is asthma treated in pregnancy?

Answer 24

Short- and long-acting beta agonists, inhaled steroids, theophyllines, oral steroids if necessary.

Question 25

What is gestational diabetes?

Answer 25

Glucose intolerance with onset or first recognition in pregnancy.

Question 26

What are risk factors for gestational diabetes?

Answer 26

Obesity, weight gain, age, family history of diabetes.

Question 27

How is gestational diabetes managed?

Answer 27

Diet and exercise first; 10-20% require oral hypoglycemics or insulin.

Question 28

What is the preferred oral anti-diabetic in pregnancy?

Answer 28

Metformin; all other oral anti-diabetics should be discontinued in favor of insulin.

Question 29

What are the three types of hypertension in pregnancy?

Answer 29

Chronic hypertension (<20 weeks), pregnancy-induced (>20 weeks, no proteinuria), pre-eclampsia (>20 weeks, with proteinuria).

Question 30

What are the preferred antihypertensives in pregnancy?

Answer 30

Labetalol (first-line), nifedipine (second-line), methyldopa (alternative).

Question 31

Which antihypertensive drugs should be avoided in pregnancy?

Answer 31

ACE inhibitors, angiotensin-II receptor blockers, diuretics.

Question 32

Why is pre-conception counselling important for epilepsy?

Answer 32

To optimize drug therapy, avoid teratogenic drugs, and ensure the lowest effective dose.

Question 33

Which anti-epileptics are preferred in pregnancy?

Answer 33

Lamotrigine and levetiracetam.

Question 34

Why is valproate use restricted in pregnancy?

Answer 34

It has the highest risk of major congenital malformations, including neural tube defects.

Question 35

How is depression managed in pregnancy?

Answer 35

Mild cases: psychological therapy; moderate-severe: SSRIs if clinically indicated.

Question 36

What is the main SSRI concern in pregnancy?

Answer 36

Paroxetine should be avoided due to potential cardiac malformations.

Question 37

Can paternal drug exposure affect pregnancy outcomes?

Answer 37

No strong evidence, but some drugs (e.g., methotrexate, finasteride) may pose risks.

Question 38

Where can healthcare providers find reliable information on prescribing in pregnancy?

Answer 38

NICE, UK Teratology Information Service, Best Use of Medicines in Pregnancy, SmPCs.

Question 39

Which SSRIs are preferred during pregnancy?

Answer 39

Sertraline and citalopram are preferred. Avoid paroxetine due to higher risk of congenital anomalies.

Question 40

What is the treatment of choice for type 2 diabetes in pregnancy?

Answer 40

Metformin is safe and effective. Switch sulfonylureas to insulin if glycaemic control is suboptimal.

Question 41

Why is sodium valproate avoided in pregnancy?

Answer 41

It has a high risk of teratogenicity (10% malformations) and neurodevelopmental issues (30–40%).

Question 42

How is epilepsy managed in pregnancy?

Answer 42

Use monotherapy with the lowest effective dose. Prefer lamotrigine or levetiracetam; avoid abrupt withdrawal.

Question 43

What antihypertensives are safe in pregnancy?

Answer 43

Labetalol, methyldopa, and nifedipine MR are safe. Avoid ACE inhibitors, ARBs, and diuretics.

Question 44

How is hypothyroidism managed in pregnancy?

Answer 44

Increase levothyroxine dose by 30–50% at confirmation of pregnancy. Monitor TSH and FT4 each trimester.

Question 45

What is the treatment approach for hyperthyroidism during pregnancy?

Answer 45

Use propylthiouracil in the first trimester, then switch to carbimazole in second and third trimesters.

Question 46

Why is aspirin used during pregnancy in some women?

Answer 46

Aspirin 75 mg daily from 12 weeks reduces the risk of pre-eclampsia, especially in high-risk women.

Question 47

What are the pharmacokinetic changes in pregnancy affecting drugs?

Answer 47

Increased GFR, plasma volume, fat stores; decreased albumin; altered CYP/UGT activity affects drug clearance and distribution.