48. Drug Use in Pregnancy + Lactation

Question 1

Positive ____ lab result confirms pregnancy

Answer 1

human chorionic gonadotropin (hCG+)

Question 2

____ trimester is when most organ development occurs making the embryo the most susceptible to birth defects caused by teratogens at this time

Answer 2

First (0-12 weeks)

Question 3

____ is an organization that publishes guidelines for safe and effective drug use in conditions impacting women, including pregnancy

Answer 3

American college of obstetricians and gynecologists (ACOG)

Question 4

A patient’s obstetric hx can be described using gravida para. Gravida (G) is ____ and Para (P) is ____

Answer 4

G = # of times pt has been pregnant
P = # of times pt has given birth

Example: G2, P1 = pregnant twice, gave birth once

Question 5

___ is safe and sometimes effective strategy for prenatal smoking cessation

Answer 5

Behavioral intervention

Question 6

What birth defects can folate deficiency cause?

Answer 6

Neural tube defects (defects of brain and spinal cord)

Question 7

Adults should consume ___ of dietary folate equivalents (DFE) per day

Answer 7

400 mcg

Question 8

During pregnancy, folate requirements increase to ____ DFE/day

Answer 8

600 mcg

Question 9

What foods is folate (folic acid, vit B9) found in?

Answer 9

Fortified flour and cereals, dried beans, green leafy vegetables, and orange juice

Question 10

Pregnant women from 19-50yo require ___ /day of calcium and 15mcg/day (___IU/day) of vitamin D

Answer 10

1000mg/day of calcium
15mcg/day (600IU/day) of vit D

Question 11

Previous Pregnancy Categories Interpretation: A

Answer 11

No risk - Studies in animals and women showed no risk in first trimesters

Question 12

Previous Pregnancy Categories Interpretation: B

Answer 12

Animal studies have not demonstrated fetal risk but no well-controlled studies available in pregnant women

Question 13

Previous Pregnancy Categories Interpretation: C

Answer 13

Animal studies have shown harm to the fetus but no well-controlled studies in pregnant women
Use only if potential benefit outweighs risk

Question 14

Previous Pregnancy Categories Interpretation: D

Answer 14

Positive evidence of risk to human fetus is available but benefits may outweigh risk with life-threatening or serious diseases

Question 15

Previous Pregnancy Categories Interpretation: X

Answer 15

Use in pregnancy is contraindicated

Question 16

What are the 2 immunizations routinely recommended for pregnant patients?

Answer 16

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

Question 17

Common Teratogens: Acne

Answer 17

Isotretinoin, topical retinoids

Question 18

Common Teratogens: Antibiotics

Answer 18

FQ, tetracyclines

Question 19

Common Teratogens: Anticoagulants

Answer 19

warfarin

Question 20

Common Teratogens: HLD, HF, HTN

Answer 20

Statins
RAAS inhibitors (ACEi/ARBs, aliskiren, sacubitril/valsartan)

Question 21

Common Teratogens: Hormones

Answer 21

Most, including estradiol, progesterone (including megestrol), raloxifene, Duavee, testosterone, contraceptives

Question 22

Common Teratogens: Migraine

Answer 22

Dihydroergotamine, ergotamine

Question 23

Common Teratogens: Misc

Answer 23

Hydroxyurea, ribavirin, lithium, thalidomide, methotrexate, topiramate, misoprostol, weight loss drugs, NSAIDs, paroxetine, valproic acid/divalproex

Question 24

____ is a complication of pregnancy that presents with elevated BP and evidence of organ damage (most often kidney/liver)

Answer 24

Preeclampsia

Question 25

What is the only cure of preeclampsia?

Answer 25

Delivery of the baby

Question 26

What does ACOG and ADA guidelines recommend to prevent preeclampsia?

Answer 26

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)

Question 27

Managing morning sickness, N/V in pregnant pts

Answer 27

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)

Question 28

Managing GERD/Heartburn in pregnant pts

Answer 28

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)

Question 29

Managing flatulence in pregnant pts

Answer 29

Simethicone (Gas-X, mylicon)

Question 30

Managing constipation in pregnant pts

Answer 30

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

Question 31

Managing cough, cold, allergies in pregnant pts

Answer 31

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

Question 32

If nasal steroids are needed for chronic allergy in pregnant patients, what do you recommend?

Answer 32

All intranasal steroids are considered safe Budesonide (Rhinocort Allergy) and beclomethsaone (Beconase AQ) are preferred

Question 33

Managing pain in pregnant pts

Answer 33

First line APAP Avoid NSAIDs including aspirin (except low-dose for preeclampsia) Non-drug options: hot/cold packs, light massage, PT

Question 34

Managing asthma in pregnant pts

Answer 34

Maintenance therapy: budesonide is preferred - also preferred steroid for infants; Respules are used in a nebulizer Rescue therapy: inhaled albuterol

Question 35

Managing HTN in pregnant pts

Answer 35

Labetalol, methyldopa, nifedipine ACEi/ARBS, aliskiren, and Entresto are contraindicated in pregnancy Low-dose aspirin recommended for preeclampsia prevention in high-risk groups

Question 36

Managing DM in pregnant pts

Answer 36

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

Question 37

Managing infections in pregnant pts

Answer 37

Generally considered safe to use: PCN (including amox, amp), cephalosporins, erythromycin, and azithromycin Do NOT use quinolones (cartilage damage) and tetracyclines (teeth discoloration)

Question 38

Managing vaginal fungal infections in pregnant pts

Answer 38

Topical antifungals x7 days Avoid fluconazole

Question 39

Managing UTI in pregnant pts

Answer 39

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

Question 40

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

Answer 40

unpasteurized dairy products cat feces (including contact with cat litter boxes)

Question 41

Managing conditions requiring anticoagulation in pregnant pts

Answer 41

VTE treatment: LMWH preferred over UFH VTE ppx: pneumatic compression devices ± LMWH Avoid warfarin, DOACs not adequately studied (do not recommend)

Question 42

Managing hypothyroidism in pregnant pts

Answer 42

Levothyroxine (will require 30-50% dose increase during pregnancy)

Question 43

Managing hyperthyroidism in pregnant pts

Answer 43

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

Question 44

Babies receiving breast milk partially or exclusively should receive ____ of vitamin D daily (not necessary for formula fed babies)

Answer 44

10mcg (400IU)

Question 45

Breastfed babies require ___ daily of iron during months ____ d/t lack of iron in human milk (unlike formula)

Answer 45

1 mg/kg daily during months 4-6

Question 46

Which pain meds should not be used by breastfeeding mothers d/t risk of excessive sleepiness, breathing difficulty, and/or death?

Answer 46

Codeine and tramadol

Question 47

Breastfed infants have died, especially in mothers taking codeine who were CYP___ ultra-rapid metabolizers

Answer 47

2D6

Question 48

In what pregnant pt population is breastfeeding not recommended?

Answer 48

If HIV infection, including those women receiving antiretroviral therapy

Question 49

Meds to avoid when breastfeeding?

Answer 49

Amphetamines, amiodarone, ergotamines, lithium, metronidazole, phenobarbital, and statins