48. Drug Use in Pregnancy + Lactation Flashcards
Positive ____ lab result confirms pregnancy
human chorionic gonadotropin (hCG+)
____ trimester is when most organ development occurs making the embryo the most susceptible to birth defects caused by teratogens at this time
First (0-12 weeks)
____ is an organization that publishes guidelines for safe and effective drug use in conditions impacting women, including pregnancy
American college of obstetricians and gynecologists (ACOG)
A patient’s obstetric hx can be described using gravida para. Gravida (G) is ____ and Para (P) is ____
G = # of times pt has been pregnant
P = # of times pt has given birth
Example: G2, P1 = pregnant twice, gave birth once
___ is safe and sometimes effective strategy for prenatal smoking cessation
Behavioral intervention
What birth defects can folate deficiency cause?
Neural tube defects (defects of brain and spinal cord)
Adults should consume ___ of dietary folate equivalents (DFE) per day
400 mcg
During pregnancy, folate requirements increase to ____ DFE/day
600 mcg
What foods is folate (folic acid, vit B9) found in?
Fortified flour and cereals, dried beans, green leafy vegetables, and orange juice
Pregnant women from 19-50yo require ___ /day of calcium and 15mcg/day (___IU/day) of vitamin D
1000mg/day of calcium
15mcg/day (600IU/day) of vit D
Previous Pregnancy Categories Interpretation: A
No risk - Studies in animals and women showed no risk in first trimesters
Previous Pregnancy Categories Interpretation: B
Animal studies have not demonstrated fetal risk but no well-controlled studies available in pregnant women
Previous Pregnancy Categories Interpretation: C
Animal studies have shown harm to the fetus but no well-controlled studies in pregnant women
Use only if potential benefit outweighs risk
Previous Pregnancy Categories Interpretation: D
Positive evidence of risk to human fetus is available but benefits may outweigh risk with life-threatening or serious diseases
Previous Pregnancy Categories Interpretation: X
Use in pregnancy is contraindicated
What are the 2 immunizations routinely recommended for pregnant patients?
1) inactivated influenza vaccine (not life) - during any trimester at the beginning of flu season
2) single dose of Tdap during each pregnancy
Note: all live vaccines are contraindicated in pregnant pts
Common Teratogens: Acne
Isotretinoin, topical retinoids
Common Teratogens: Antibiotics
FQ, tetracyclines
Common Teratogens: Anticoagulants
warfarin
Common Teratogens: HLD, HF, HTN
Statins
RAAS inhibitors (ACEi/ARBs, aliskiren, sacubitril/valsartan)
Common Teratogens: Hormones
Most, including estradiol, progesterone (including megestrol), raloxifene, Duavee, testosterone, contraceptives
Common Teratogens: Migraine
Dihydroergotamine, ergotamine
Common Teratogens: Misc
Hydroxyurea, ribavirin, lithium, thalidomide, methotrexate, topiramate, misoprostol, weight loss drugs, NSAIDs, paroxetine, valproic acid/divalproex
____ is a complication of pregnancy that presents with elevated BP and evidence of organ damage (most often kidney/liver)
Preeclampsia
What is the only cure of preeclampsia?
Delivery of the baby
What does ACOG and ADA guidelines recommend to prevent preeclampsia?
Low-dose aspirin daily at the end of first trimester for pregnant women at risk for preeclampsia (e.g. type 1 or 2 DM, renal disease, hx of preeclampsia, chronic HTN)
Managing morning sickness, N/V in pregnant pts
Lifestyle first - eat smaller, more frequent meals, drink water, avoid spicy/odorous foods, take more frequent naps, reduce stress
Ginger may help
If lifestyle measures fail, ACOD recommends pyridoxine (vit B6) ± doxylamine first line
Rx: doxtylamine/pyridoxine (Bonjesta, Diclegis)
Managing GERD/Heartburn in pregnant pts
Lifestyle first- eat smaller, more frequent meals, avoid foods that worsen GERD
If symptoms occur while sleeping, elevate head of the bed and not eating 3 hrs prior to sleep
If lifestyle measures fail - antacids (calcium carbonate Tums)
Managing flatulence in pregnant pts
Simethicone (Gas-X, mylicon)
Managing constipation in pregnant pts
Lifestyle first - increase fluid intake, dietary fiber intake, and physical activity
If lifestyle measures fail - fiber (psyllium, calcium polycarbophil, methylcellulose) with lots of water
Docusate and PEG used to prevent/treat constipation
Managing cough, cold, allergies in pregnant pts
First line: cromolyn
Second line: first-gen antihistamines, chlorpheniramine (drug of choice) and diphenhydramine are commonly used
Avoid oral decongestants during 1st trimester
Avoid liquid formulations that contain alcohol
If nasal steroids are needed for chronic allergy in pregnant patients, what do you recommend?
All intranasal steroids are considered safe
Budesonide (Rhinocort Allergy) and beclomethsaone (Beconase AQ) are preferred
Managing pain in pregnant pts
First line APAP
Avoid NSAIDs including aspirin (except low-dose for preeclampsia)
Non-drug options: hot/cold packs, light massage, PT
Managing asthma in pregnant pts
Maintenance therapy: budesonide is preferred - also preferred steroid for infants; Respules are used in a nebulizer
Rescue therapy: inhaled albuterol
Managing HTN in pregnant pts
Labetalol, methyldopa, nifedipine
ACEi/ARBS, aliskiren, and Entresto are contraindicated in pregnancy
Low-dose aspirin recommended for preeclampsia prevention in high-risk groups
Managing DM in pregnant pts
Insulin preferred if not controlled with lifestyle
Metformin and glyburide are commonly used
Low-dose aspirin recommended for preeclampsia prevention in both type 1 and 2 DM
Managing infections in pregnant pts
Generally considered safe to use: PCN (including amox, amp), cephalosporins, erythromycin, and azithromycin
Do NOT use quinolones (cartilage damage) and tetracyclines (teeth discoloration)
Managing vaginal fungal infections in pregnant pts
Topical antifungals x7 days
Avoid fluconazole
Managing UTI in pregnant pts
Cephalexin
Ampicillin
Nitrofurantoin and SMX/TMP (last line during 1st trimester, should NOT be used in last 2 weeks of pregnancy)
Must treat bacteriuria even if asymptomatic
If a woman contracts toxoplasmosis during pregnancy, it can cause miscarriage, stillbirth, or damage baby’s brain/eyes.. Women can be tested prior to pregnancy with IgG test. If unsure, avoid dirty food and water, ___, and ____ with can contain the parasite
unpasteurized dairy products
cat feces (including contact with cat litter boxes)
Managing conditions requiring anticoagulation in pregnant pts
VTE treatment: LMWH preferred over UFH
VTE ppx: pneumatic compression devices ± LMWH
Avoid warfarin, DOACs not adequately studied (do not recommend)
Managing hypothyroidism in pregnant pts
Levothyroxine (will require 30-50% dose increase during pregnancy)
Managing hyperthyroidism in pregnant pts
Mild cases will not require treatment
If drugs necessary (i.e. Graves’ disease): propylthiouracil (PTU) preferred if trying to conceive or in 1st trimester
Can be switched to methimazole for remainder of pregnancy but both carry potential fetal risks + liver damage
Babies receiving breast milk partially or exclusively should receive ____ of vitamin D daily (not necessary for formula fed babies)
10mcg (400IU)
Breastfed babies require ___ daily of iron during months ____ d/t lack of iron in human milk (unlike formula)
1 mg/kg daily during months 4-6
Which pain meds should not be used by breastfeeding mothers d/t risk of excessive sleepiness, breathing difficulty, and/or death?
Codeine and tramadol
Breastfed infants have died, especially in mothers taking codeine who were CYP___ ultra-rapid metabolizers
2D6
In what pregnant pt population is breastfeeding not recommended?
If HIV infection, including those women receiving antiretroviral therapy
Meds to avoid when breastfeeding?
Amphetamines, amiodarone, ergotamines, lithium, metronidazole, phenobarbital, and statins
