Block 5: Pregnancy Flashcards
What are examples of teratogens?
- Alcohol
- Anticonvulsants
- Isotretinoin
- Quinolone
- Tetracyclines
- Androgens (estrodiol, progesterone, testosterone, raloxifene)
- Misoprotol
- Methotrexate
- Valproic acid/divalproex
- Paroxetine
- Lithium
- ACE/ARB
- Warfarin
- Dihydroergotamine, ergotamine
What is teratogen?
Drug that can cause structural or functional abnormalities in the fetus or child after birth?
Counseling for conception?
- Lifestyle mod
- Ideal weight
- Controlled existing medical conditions (Epilepsy, HTN)
- Currnet meds (terogenic)
- Immunization (Rubella before pregnancy, Flui, TDap)
- Vitamin and mineral supplementation (Folic acid 400mcg -> 800mcg, Vit D 600IU, Calcium 1000mg)
What is the purpose for folic supplements? Dose?
Avoid NTD (anecephaly, spina bifida)
Dose: 0.4-0.8 mg/conception 1-3 months prior and 1st trimester
Previous pregnancy resulting to NTD -> 4mg QD
Can we give live vaccines to pregnant women?
No: Live flu, MMR, Varicella, Zoster
What vaccines should be given to prengants?
Inactive flu, COVID, TDap (27-36 weeks)
What are the physiological change from pregnancy?
- ↑ CO
- ↑Renal perfusion and function
- ↑ Liver metabolism
- ↓ GI motility
- ↑ Weight gain
Due to the physiological changes, what types of nutrients is required?
Calories: +300/day
Protein: +10g/day
Calcium: 1200mg/day
Folic acid: 400 mcg/day
Iron: +30 mg/day from 2nd trimester on
PK/PD changes from pregancy?
- SHorter t1/2 renally eliminated drugs
- Larger Vd
- ↓ rate or extent of absorption with PO
Properties that influence drugs passing the placenta?
- <500Da readily cross, 600-1000 is slower
- Lipid soluble
- PPB, maternal albumin decrease and fetal albumin increases
- Fetal pH is slightly more acidic than maternal, weak bases cross placenta quicker
- Unionized state
- Thin placenta
- Increased uterine blood flow
What are the consequences of teratogens?
- Structural abnormalities
- Embryo-fetal/infant mortality
- Functional impairment
- Alterations to growth
What are factors that should be considered when initiating med during pregnancy?
- RB ratio
- Is drug necessary
- Most effective agent with least risk
- Lowest effective dose for short duration
- Health of mother without drug
- Stage of pregnancy
How should we evalute drug saftey?
TIming of exposure:
1. Conception to 14 days: all or nothing
2. 2-8 weeks: greatest risk is organogenesis, drastic structural malformations
3. 2-3rd trimester: less risky, effects on growth, neurological developments, mental developments, reproduction
What is the new labeling of FDA pregnancy categories?
8.1: Pregnancy, Labor, and Delivery (Pregnancy registry, risk summary, clincial considerations, data)
8.2: Lactation and nursing mothers (Risk summary, clinical considerations, data)
8.3: Female and males of reproductive potential (pregnancy testing, contraception, infertility)
First line for morning sickness?
Doxylamine succinate 10 mg
Pyridoxine HCl 10 mg
Meclizine, Dimenhydrinate, Diphenhydramine, Metoclopramide
Ondensetron if uncontrolled
First line for heartburn/GERD?
Calcium carbonate (Tums)
2nd line: Ranitidine (Zantac), Omeprazole
Treatment for constipation?
Stool softners, docusate
Bulk laxatives: Pysyllium, methylcellulose
2nd line: osmotic laxatives
CI: enemas, stimulants, castor oil, mineral oil
Tx for HA/pain?
First line: Tynelol
Second line: NSAIDs, Sumatriptan, Propranolol, opioids (rarely)
CI: NSAID/aspirin during 3rd trimester (premature closure of the ductus arteriosus)
Tx for VTE?
First line: Compression stockings, LMWH (enoxaparin)
Second line: UF heparin
Prophylaxis and therapeutic with LMWH or UFH should be DC 12-24 hr before C-section or delivery
CI: warfarin
Tx of epilepsy?
First line: lamotrigine
Take 4 mg of folic acid QD and Calcium/Vit D
Tx for UTI?
Cephalexin or ampicillin
CI: Bactrim (sulfa increases kernicterus, trimethoprim increases CV malformation and folate antagonism)
What are the teratogenic antibiotics?
- Quinolones: cartilage toxicity and arthropathies
- Tetracyclines: affect the calcification (hardening) of the bone and teeth
- SMX/TMP
Tx for morning sickness
Ginger, eating small meals
First line: Doxylamine, pyridoxine
Meclizine , Dimenhydrinate , Diphenhydramine, Metoclopramide
Ondansetron: last resort
Tx for heartburn?
First line: Calcium carbonate
Second liune: Ranitidine, omeprazole
Tx of constipation?
increase fluids, high fiber food and exercise
First line: Stool softeners e.g. docusateafter non pharm
* Bulk laxatives: Not absorbed e.g. psyllium, methylcellulose
Second: Osmotic laxative
CI: enemas, stimulants, castor and mineral oil
Tx for headaches?
First line: APAP
Second: Sumatriptan, propranolol
CI: NSAIDS/ASA for 3rd trimester
Tx for VTE?
First line: Compression stockings, LMWH
Second: UFH
Prophylaxis with LMWH or UFH should be discontinued 12–24 hours before cesarean section or vaginal delivery.
Therapeutic doses should be discontinued 24–36 hours before cesarean section or vaginal delivery
CI: warfarin
Tx for epilepsy?
First line: Lamotrigine
Take 4 mg of folic acid daily + calcium/vitD
Vitamin K 10 mg qd should be given the last month of gestation
Tx of UTI?
Tx: cephalexin or ampicillin
CI: Bactrim (TMP: folate antagonist)
Antibiotics that or CI with pregnancy?
Quinolones- cartilage toxicity and arthropathies
Tetracyclines- affect the calcification (hardening) of the bones and teeth
SMX/TMP
Types of gestation HTN?
Chronic hypertension
Gestational
Preeclampsia
Preeclampsia superimposed on chronic hypertension
Tx for chronic HTN?
Labetalol, methyldopa, nifedipine
IV: Hydralazine, labetalol
Goal: <160/110
HCTZ/diuretics—decreased placental perfusion (2nd line)
Tx for preeclampsia?
Delivery
Parenteral magnesium sulfate to prevent seizures
Labetalol, methyldopa, nifedipine are first-line therapies: IV hydralazine
Complications of gestational diabetes?
Maternal: Retinopathy, nephropathy, keto-acidosis, pregnancy-induced hypertension
Fetus: Congenital anomalies, hypoglycemia, spontaneous abortions, sudden death in-utero for the fetus,fetal macrosomia
Blood glucose targets in pregnant diabetic?
A1C 6.0–6.5%.
Fasting≤ 95mg/dL
1 hr post meal≤ 140mg/dL
2 hr post meal ≤ 120mg/dL
Tx for diabetes?
1st Line therapy non pharm: Lifestyle modifications-Diet and exercise
1st Line Treatment: insulin
2nd line: SU (Glyburide), metformin (not really)
What are you labor sx?
- Nesting/Burst of energy
- Lightening
- Braxton-hicks contractions
- Effacement/dilation
- Rupturing of membranes
- ‘bloody show’
Drug abuse Tx?
Methadone has been the gold standard for OUD in pregnancy.
Buprenorphine is also recommended
What is preterm labor?
Uterine contraction before 37 weeks
Bed rest, hydration, sedation
Prophylaxis for patients with a history of preterm labor
For patients with a history of preterm labor 16–36 week:
Makena (Hydroxyprogesterone caproate) IM
Are tocolytics commonly used?
There are currently no FDA approved drugs for tocolysis available
Examples of tocolytics?
- Terbutaline
- Magnesium sulfate
- NSAIDs
- Indomethacin
- CCB
How is labor induced?
- Stripping of membrane
- Rupturing of membrane
- Ripening the cervix
- Medications
What are oxytocic drugs?
Induce contraction
What is the drug of choice to induce labor?
ADR
Oxytocin
ADR: uterine rupture
Oxytonic drug examples?
- Oxytocin
- Misoprostol(Cytotec): cervical ripening
- Dinoprostone (Cervidil, Prepidil)
What drug is given postpartum or postabortion to decrease bleeding, but not to induce labor?
Ergot alkaloids-Ergonovine and Methylergonovine
What are the labor analgesia?
Meperidine, morphine, fentanyl, epidural
What are the stages of labor?
- Early labor, active labor, transition
- Birth
- Delivery of placenta
Tx for post partum depression
Non-drug therapy:
Emotional support
Psychotherapy
Patient education
Pharmacotherapy:
SSRI’s
TCAs
Breast feeding?
Advantages, Disadvantages
Advantages:
1. Boost baby’s immunity
2. Decrease infection incidence
3. Aids digestion
4. Maternal advantages
5. Time/cost
Disadvantages: Time
Drugs enter human milk if they are?
- Lipid soluable
- high concentration in the mother’s plasma
- Low in molecular weight (<200)
- Low in protein binding
- Ion trapping-pH of milk is slightly acidic compared to plasma, weak bases will concentrate in the milk
Patient counseling with lactation?
- Take oral medications immediately after nursing or just before the infant’s longest sleep period
- Single ingredient products at the lowest dose possible
- Advise against extra strength, maximum strength, and long-acting
- “Pump and Dump” milk
- inform their child’s pediatrician about all of the medications they are taking, including herbal products
Tx for mastitis?
Non-pharmacological Therapy:
Massage
Heat/Cold application
Keep breast-feeding
** Pharmacological Therapy:**
Pencillinase-resistant penicillins (Cloxacillin, Dicloxacillin, Oxacillin)
Cephalosporins (Cephalexin)
