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243 Pregnancy Flashcards

0
Q

How could we overcome the problem of morning sickness effecting absorption?

A

Change the timing of the dose

Can also give with an anti-emetic

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1
Q

How may pregnancy effect drug absorption?

A

Morning sickness- a tablet may not stay down in the stomach long enough to be absorbed.
Progesterone slows gastric emptying and can therefore leas to slower absorption and lower peak concentration.
This is a bigger problem for SINGLE doses rather than long term meds- these will build up over time

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2
Q

What does total body water increase by in pregnancy?

A

By About 81

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3
Q

What does increasing total body water mean for drugs in preggers women?

A

It should dilute the concentration of any drug, but as serum albumin falls and pregnancy steroids displace drugs from their binding proteins “free drug” levels may rise.

Example of drug effected: Thyroxine
Also assays are needed for anti-epileptic drugs

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4
Q

How does pregnancy effect enzymes? An example of a drug involved?

A

Pregnancy effects metabolism of drugs acting through cytochrome p450 enzymes

An important example is the enzyme which inactivates lamotrigene. This is induced by pregnancy.
So doses of lamotrigene need to be increased to get the same effect

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5
Q

How does pregnancy effect drug excretion?

A

A higher cardiac output (51 becomes 71) leads to an increase of 50% in GFR
Renally excreted drugs like penicillin are excreted faster
(Therefore in pregnancy we will use 500mg ampicillin tds not 250mg tds)

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6
Q

The increased GFR in pregnancy due to increased cardiac output causes physiological __________.?

A

Causes physiological glycosuria

Excretion of glucose in the urine

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7
Q

Beta Blockers are less likely to cause _______ because of the tachycardia which exists in pregnancy. This is due to physiological changes in pregnancy.

A

Less likely to cause bradycardia because it’s cancelled out by the tachycardia

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8
Q

Calcium channel blockers are less likely to decrease the total ________ resistance because this is already reduced in pregnancy.

A

Total peripheral resistance

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9
Q

What is teratogenesis?

A

Where a baby is born with a congenital abnormality (means a defect present at birth)
This can be induced by a drug
1-2% of babies are born with a congenital abnormality
Under 1 in 20 of these can be due to drugs

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10
Q

What two drugs, if they are given to a pregnancy woman, will result in the majority of fetuses being born with birth defects.

A

Methotrexate

Thalidomide

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11
Q

Most congenital abnormalities are multi-factorial, what does this mean?

A

A lot of drugs risk of teratogenicity is small.
(Example Valproate is linked with NTD’s in 1-2%)
Therefore if a baby is born with an abnormality it’s usually die to another factor such as Folate deficiency being a cofactor for NTDs.

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12
Q

How do most drugs cross the placenta into the baby? 

A

By simple diffusion.

This depends on concentration gradient and molecular weight.
Most drugs given to a mother will reach the fetus.

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13
Q

What’s one drugs that won’t eventually reach the foetus when given to the mother?

A

Heparin.
MW= 15000
Too big to cross into the foetus.

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14
Q

What drugs accumulate in the fetus due to fetal metabolism, therefore should be avoided in pregnancy?

A

Iodine
Gets concentrated in fetal thyroid

Labetalol
Accumulates in amniotic fluid of the baby

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15
Q

When is the maximum susceptibility period in pregnancy for teratogenic effects to occur?

A

Between 3-11 weeks of pregnancy, this is during organogenesis (when a mass of cells turn into organs)

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16
Q

Why does glucose tolerance decrease with advancing gestation? (Diabetes)

A

Because of the anti-insulin effects of the placentas substances:
lactogen, glucagon and cortisol

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17
Q

Increased oestrogen levels in pregancy increase serum levels of Globulin, which binds_______,________ and ______?

A

Thyroxine
Corticosteroids
Sex steroids

Note: free levels of hormone do not change

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18
Q

Why is it important to control diabetes In pregnant women?

A

Poorly controlled diabetics have a high incidence of congenital abnormalities

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19
Q

HOW can we optimise blood glucose control in pregnant diabetic women?

A

Using either more frequent doses of insulin OR Metformin
Usually over 4 daily injections of insulin is required.
Increase the frequency of Blood sugar monitoring

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20
Q

What abnormality can Phenytoin use cause in ?

A

Orofacial clefts

Eg cleft lip / palate

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21
Q

What two epilepsy drugs are most likely to cause NTDs?

A

Valproate

Carbamazepine

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22
Q

What epilepsy drugs are most likely to cause cardiac defects in ?

A

Valproate and phenytoin

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23
Q

The risks of epilepsy drugs causing abnormalities increases with polypharmacy.
___% likely for just one AED
___% likely for two AEDs
___% likely for three AEDs

A

6-7% for one
15% for two
Up to 50% for three

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24
For what AED is the risk of causing abnormalities dose dependent?
Valproate
25
Can you tell me some of the minor abnormalities associated with use of anti-convulsants in preganancy?
Low set ears  Broad nasal bridge Irregular teeth Hypoplastic nails and digits  But then again, even UNTREATED epilepsy is associated with an increased risk of congenital abnormality!!
26
What must women on epilepsy treatment receive pre-conception due to the mechanism of AEDs causing abnormalities being folate deficiency?
Must receive 5mg folate daily for at least 3 months pre-conception Especially if any of the ones mentioned eg valproate, phenytoin, carbamazepine must be used
27
So, if these AEDs are causing abnormalities, should we take women who are pregnant off them and potentially not control their epilepsy?
No Overall benefit of treatment outweighs the risk eg woman fitting and rolling over onto stomach damaging baby. Newer anti-epileptics such as lamotrigene and gabapentin do not appear so risky but they aren't entirely risk free!!
28
What are the hepatic enzyme inducing drugs to watch out for in pregancy?
Drugs such as carbamazepine, phenytoin, and phenobarbitone
30
What is hyperthyroidism?
Over active thyroid. Produces too much thyroid hormone, if too much thyroid hormone then every function of the body tends to speed up. Some of the symptoms include nervousness, irritability, heart racing etc
31
What drug do we need to give daily, orally in the last 4 weeks of pregnancy, if a woman is taking hepatic enzyme inducing drugs, such as carbamazepine, phenytoin and phenobarbitone?
Need to give Vitamin K 10-20mg daily orally in LAST FOUR WEEKS of pregnancy. This is because the baby is at risk of haemorrhagic disease. Note: if corticosteroids are being given for fetal lung maturity, then dose needs to be increased.
32
What is hypothyroidism?
Where patient has an underactive thyroid Not enough thyroid hormone is produced. Symptoms: tiredness, poor ability to tolerate cold, weight gain
34
Radioactive _____ in treatment of HYPERthyroidism in pregnancy is absolutely contraindicated
Radioactive Iodine
35
Both Carbaimazole and propylthiouracil cross the placenta in pregnancy, therefore will get into baby. What are these used to treat?
Used for HYPERthyroidism Propylthiouracil crosses the placenta less than these
36
What are completely safe to treat HYPERthyroidism in the short term if required to control the pregnant mothers symptoms?
beta blockers safe in short term
37
How do we manage hypothyroidism in preganancy?
Aim to keep the mother euthyroid (normal thyroid function) during pregnancy. Usually a pre-pregnancy dose will do this If you're monitoring how good your replacement therapy is rememeber that TSH (thyroid stimulating hormones) risk in the third trimester of pregnancy.
38
When do levels of TSH (thyroid stimulating hormone) rise in preganancy?
In the THIRD trimester
39
When prescribing for hypertension in pregancy, what do we need to differentiate between?
Pre-existing hypertension (existed before preganancy due to some other reason) Benign gestational hypertension (hypertension occurring during pregancy) pre-eclampsia (High blood pressure and lots of protein in the urine)
40
What is pre-eclampsia?
Hypertension existing with protein in the urine
41
When is there a fall in blood pressure during normal pregnancy?
The mid-trimester fall
42
What are the anti hypertensives commonly seen in preganancy? (Hint: you have seen one of these in dispensing!)
Alpha methyl dopa Nifedipine Labetolol (orally and IV) Hydralazine
43
What antihypertensives classes are contraindicated in preganancy?
ACE inhibitors ARBs Diuretics
44
When are drugs most likely to cause congenital abnormalities in a Child?which trimester!
First trimester
45
During the second and third trimesters drugs may affect _____ & __________
May affect growth and functional development May have toxic effects on fetal tissues Growth effects may effect: kidneys and brain Functional effects: include deafness
46
When prescribing in preganancy, we also should think about paternal medication. Can you possibly think of any examples?
Finasteride: used for prostate problems Gets excreted in semen Can effect male fetal development
47
Can omeprezole be used in pregnancy today?
Yes, updates to the SPC state it's now safe in pregnancy. | Losec can be used (type of Omeprazole)
48
What pharmacokinetic changes are present in a pregnant woman?
Increase in plasma volume Reduction in serum albumin Increase in renal function All these parameters quickly go back to normal after lady has given birth Eg Lamotrigine dose must be reduced after birth to avoid toxicity
49
What types of laxatives should be avoided in unstable or near term pregnancys? Why?
Stimulant laxatives due to uterine contractions
50
What is first line for heart burn in pregnancy?
Antacids/ alginates such as Gaviscon
51
Second line for heart burn in pregnancy?
GP / Hospital to treat with second lines if first line (antacids / alginates) haven't worked. h2 Receptor antagonist first line: Ranitidine PPI of choice: Omeprazole
52
What is used first line for pain relief in pregnancy ?
Paracetamol
53
NSAIDS can potentially be used up to week ____ of pregnancy especially NSAID ______. After this they can cause bleeding complications In general NSAIDS are usually avoided in preganancy
NSAIDS can potentially be used up to week 30 of pregnancy especially NSAID Ibuprofen. After this they can cause bleeding complications In general NSAIDS are usually avoided in preganancy
54
Note: frequent paracetamol use during late preganancy (20-30 weeks) has been associated with an increased incidence of wheezing or childhood asthma.
However Data ARE conflicting
55
A woman presents at your pharmacy with morning sickness | What can you give / advise?
Not really anything to give for nausea and vomiting GINGER Biccys are good!  Advise to eat little and often P6 Accupressue (wristband) Avoid dehydration Can use DIORALYTE to correct fluid and electrolytes lost
56
Why does Hypermesis gravadium need hospital admission?
It is unstoppable vomiting in a pregnant woman It can cause fluid and electrolyte disturbance and nutritional deficiency It needs drugs that should only be given under supervision
57
When a woman is admitted for treatment of Hypermesis gravadium, what is usually given first line?
1st line: Antihistamines 2nd line: metoclopramide/ Prochlorperazine If vomiting still occurs: try Ondanasetron This is in BNF
58
WHO recommends breast feeding for the first ___months of life as it provides perfect nutrition
First six months
59
One advantage of breast feeding is increased immune function for the baby. Why is this?
Mothers IgG antibodies can cross the placenta IgM can also be produced to respond to infection IgA produced also (but only if baby receives Colostrum- the first milk after birth) and breast milk
60
What is colostrum?
Milk formed in late pregnancy in mothers breasts | It's the first milk given to the child after birth
61
What are some advantages to a baby of being breast fed?
``` Less incidence of: diahorrea Iron related aneamias Respiratory infections Otitis media Neonatal septicaemia Protects against sudden infant death syndrome ```
62
What are the advantages to the mother of breast feeding?
``` Decreased risk of : ovarian cancer Breast cancer Hip fracture Osteoporosis Reduced blood loss post birth ```
63
When considering drugs and breast feeding, things like age of baby, weight, hepatic / renal function, babies medication, baby exposed to medication debuting pregnancy or in breast milk yet need to be considered. Why does age need to be considered?
Age is really important during first few days of life as it's much easier for medication to pass into mothers Breast milk at this point. This is due to large gaps between alveolar cells
64
Metronidazole Breast feeding information:
BNF states there's a significant amount in milk Manufacturer advises to avoid large single doses BNF for children advises the same as above and also adds that metronidazole and breast milk are otherwise compatible- may even give milk a better taste!
65
What has pH got to do with breast milk and drugs?
Breast milk is slightly more acidic than blood This means Weak acids such as penicillins will have levels in breast milk of less than half that in maternal plasma. Weak bases will become ionised in milk. Eg isoniazid may have levels in breast milk greater than in maternal plasma So pHs of drugs will determine whether they are at lower or higher concentrations in breast milk
66
What are the 5 factors producing poor excretion into breast milk?
``` High molecular weight (over 600) Highly protein bound Weak acids Short acting medication or preparation (peaks rapidly and gets eliminated from maternal plasma) No active metabolites ```
67
Most medication causes no harm to breast fed babies. There are however a few absolute contraindications What are these?
Antineoplastic medications Iodides Amiodarone Lithium Toxicity can occur if any of these medications enter breast milk in pharmacological quantities
68
Why with SSRIS is it better to choose fluoextine with a short half life over paroxetine with a long half life?
Longer half life fluoextine has an active metabolite with a long half life Also premature babies generally have not so good excretory functions, this can make their half life much greater. This can lead to drug accumulation and adverse events
69
Can codeine be used in breast feeding mothers?
No it should not be used | It can pass to the baby through breast milk and potentially cause harm
70
Any alternatives to codeine for a breast feeding mother?
Tramadol- this is considered as an acceptable alternative in breast feeding based on low levels in breast milk, when given at the lowest effective dose for the shortest duration of time
71
What drug can improve milk production if necessary in for example premature babies?
Domperidone | Does so by increasing prolactin secretion
72
What drugs can cause an inhibition of lactation I.e stop as much Breast milk being produced so should be AVOIDED by mothers wishing to breast feed?
Diuretics Anabolic steroids Moderate/ heavy alcohol intake 

Pharmacy flashcards (52 decks)

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