Drug Use in Pregnancy and Lactation

Question 1

What weeks of pregnancy are considered the first trimester? What happens?

Answer 1

0-12 weeks

Most organ development occurs - baby is most susceptible to birth defects caused by teratogens

Question 2

What oranization publishes guidelines for safe and effective drug use in conditions impacting women, including pregnancy

Answer 2

American College of Obstetricians and Gynecologists (ACOG)

Question 3

What vitamins should be supplemented in pregnancy?

Answer 3

Folate (B9) 600 mcg/d (400mcg/d pre pregnancy)
Vitamin D 600 IU/d
Calcium 1000 mg/d

Question 4

What do the pregnancy categories A, B, C, D, and X mean?

Answer 4

Previous categories
A: No risk; fetal harm remote
B: Animal studies have not determined fetal risk, no studies in humans
C: Animal studies show harm, no studies in humans, only use if benefit>risk
D: positive evidence of risk to fetus, benefits may > risks
X: risks clearly outweigh potential benefits; CONTRAINDICATED

Question 5

What are the updated pregnancy sections in package inserts?

Answer 5

Pregnancy: risk summary that includes risk of adverse developmental outcomes
Lactation: includes if drug/metabolites get into milk
Female/male reproductive potential: includes effects on fertility and requirements for pregnancy testing and contraception

Question 6

What immunizations are recommended for pregnancy?

Answer 6

Inactivated flu during flu season

Single dose of Tdap for each pregnancy

Question 7

What acne medications are teratogenic

Answer 7

Isotretinoin

Topical retinoids

Question 8

What antibiotics are teratogenic

Answer 8

Quinolones

Tetracycline

Question 9

What anticoagulants are teratogenic

Answer 9

Warfarin

Question 10

What dyslipidemia, HTN, and HF drugs are teratogenic

Answer 10

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

Question 11

What hormones are teratogenic

Answer 11

Most

Estradiol, progesterone, raloxifene, Duavee, testosterone, contraceptives

Question 12

What migraine medications are teratogenic

Answer 12

Dihydroergotamine

Ergotamine

Question 13

What miscellaneous medications are teratogenic

Answer 13

Hydroxyurea
Lithium
Methotrexate
Misoprostol
SAIDs
Paroxetime
Ribavirin
Thalidomide
Topiramate
Weight loss drugs
Valproic acid/Divalproex

Question 14

What medication does ACOG recommend to give women at risk of preeclampsia? What women are at risk?

Answer 14

Daily low-dose aspirin at the end of the first trimester

Risk: type 1 and 2 diabetes, renal disease, hx of preeclampsia, chronic HTN

Question 15

Preferred management of morning sickness and N/V in pregnancy

Answer 15

Lifestyle first: smaller, more frequent meals, water, avoid trigger foods
Second line: Pyridoxine (B6) +/- doxylamine
Ginger “possibly effective”

Question 16

Preferred management of GERD/Heartburn in pregnancy

Answer 16

Lifestyle first: smaller, more frequent meals, avoid trigger foods, elevate head of bed, don’t eat 3 hours prior to sleep
Second line: Tums
Can add on H2RA or PPI

Question 17

Preferred management of flatulence in pregnancy

Answer 17

Simethicone

Question 18

Preferred management of constipation in pregnancy

Answer 18

Lifestyle first: increase fluid, dietary fiber, activity

Second line: Fiber (psyllium, calcium polycarbophil), docusate

Question 19

Preferred management of cough, cold, allergies in pregnancy

Answer 19

First line: cromolyn
Second line: first-generation antihistamines; chlorpheniramine (DOC) and diphenhydramine, budesonide and beclomethasone intranasally
Avoid liquid formulations that contain alcohol

Question 20

Preferred management of pain in pregnancy

Answer 20

Non-pharm options: hot/cold packs, massage
First line pharm: APAP
Do NOT use: NSAIDs

Question 21

Preferred management of asthma in pregnancy

Answer 21

Maintenance: Budesonide DOC
Rescue: albuterol

Question 22

Preferred management of iron deficiency anemia in pregnancy

Answer 22

supplemental iron, prenatal vitamins with iron

Question 23

Preferred management of HTN in pregnancy

Answer 23

Labetalol
Methyldopa
Nifedipine
Do NOT use: RAAS agents

Question 24

Preferred management of diabetes in pregnancy

Answer 24

Lifestyle
Insulin DOC
Metformin and glyburide commonly used

Question 25

Preferred management of infection in pregnancy

Answer 25

Safe: PCN, cephalosporins, erythromycin
Vaginal fungal infections: topical antifungals x 7 days
UTI: cephalexin 500 q6h x 7d; Ampicillin 500mg q6h x 7 d; macrobid and bactrim last line during first trimester and should not be used in last 2 weeks of pregnancy

Question 26

Preferred management of conditions requiring anticoagulation in pregnancy

Answer 26

VTE treatment: LMWH preferred, UFH
VTE prophylaxis: pneumatic compression devices +/- LMWH

Note: Warfarin is teratogenic but can be used after 13th week until a few weeks before delivery

Question 27

Preferred management of hypothyroidism in pregnancy

Answer 27

Levothyroxine

30-50% dose increase during pregnancy

Question 28

Preferred management of hyperthyroidism in pregnancy

Answer 28

Mild - no treatment

Propylthiouracil (PTU) preferred if trying to conceive or in 1st trimester, can continue or switch ot methimazole

Question 29

How long is it recommended to breastfeed?

Answer 29

6 months as long as it is mutually desired by mom and baby

Question 30

How much vitamin D and iron do babies need?

Answer 30

Vitamin D: 400 IU/d if breastfed (formula probs has)

Iron: 1mg/kg/d during months 4-6 if breastfed

Question 31

What can be used to treat postpartum pain?

Answer 31

APAP or ibuprofen (safe while breastfeeding)

Do NOT use: Codeine and tramadol

Question 32

When is breast feeding not recommended?

Answer 32

If mom has HIV infection

Question 33

What medications should be avoided during lactation

Answer 33

Chemo
Amphetamines
Amiodarone
Ergotamines
Lithium
Metronidazole
Phenobarbital
Statins