Medication use in Pregnancy & Lactation Flashcards
CURRENT FDA labeling requirements:
- Pregnancy (includes labor and delivery)
- Lactation (includes nursing mothers)
- Females and males of reproductive potential
______% of medicines approved since 1980 have enough information to determine their safety during pregnancy
Fewer than 10
The FDA estimates that ____ % of all birth defects are caused by medications
<1
When prescribing medications to pregnant people here are some things to consider:
○ Minimize the number taken
○ Limit use to situations with significant benefit
○ Choose the med with the best safety profile
○ Use at the lowest dose and for the shortest duration possible
Regarding medication use, Avoid fetal drug exposure, when possible, especially in the _____
first trimester
Placenta general functions
- Gas exchange (wholly responsible for O2 and CO2 transfer)
- Metabolic transfer
- Endocrine function
- Immunological functioning
Medication use in pregnancy is considered when the drugs _____
benefits outweigh known risks
Drugs that Do Not Cross the Placenta do not:
● Do not have direct toxic effect
● Do not have teratogenic effect
T/F Drugs that Do Not Cross the Placenta will not harm the fetus
F
How can Drugs that Do Not Cross the Placenta harm the fetus?
- Constricting Placental Vessels
a. Impairs gas and nutrient exchange - Producing Severe Uterine Hypertonia (uterine contractions)
a. Results in anoxic injury - Altering Maternal Physiology
a. I.e. hypotension
A drugs penetration of the placenta depends on:
● Drug’s Molecular Weight
● Extent of its binding to another substance
○ I.e. - carrier protein
● Area available for exchange across
placental villi
● Amount of drug metabolized by the
placenta
Molecular Weight importance in drugs that do/dont cross the placenta
● Drugs with molecular weight <500 daltons
○ Readily cross the placenta (into fetal circulation)
● Drugs with high molecular weight (I.e. protein-bound drugs)
○ Usually do not cross the placenta
Drug effects on developing fetus at < 20 days post-fertilization
■ “All or nothing effect”
● Kills the embryo or has no effect
● Teratogenesis unlikely
Drug effects on developing fetus at 20-56 days post-fertilization
Teratogenesis=most likely to occur!
● Spontaneous abortion
● Sublethal gross anatomic defect (teratogenesis)
● Covert embryopathy (manifests later in life)
● No measurable effect
Drug effects on developing fetus in the 2nd/3rd trimesters
■ Teratogenesis unlikely
■ Altered growth and function of normally formed organs
Treatment of vaginal candidiasis during pregnancy
● TOC - Topical Clotrimazole or
miconazole X 7 days vaginally
● Avoid oral azole particularly in the first
trimester
○ May increase risk of miscarriage and
its impact on birth defects is unclear
Thalidomide effects on pregnancy
Prescribed for nausea and morning sickness in pregnancy
● 100,000 infants worldwide born with Phocomelia (malformation of limbs) only 40% survived
Which drug caused Phocomelia
(malformaiton of limbs)?
Thalidomide
Bacterial vaginosis treatment during pregnancy & risks
● TOC: Oral or topical metronidazole
○ Some providers avoid metronidazole in first trimester (b/c crosses placenta), but
meta-analysis has not found any relationship to birth defects. It is mutagenic in bacteria and carcinogenic in mice but there is no human evidence of harm
Pregnant pts + common cold = _____
↑↑ risk of rhinosinusitis and
eustachian tube dysfunction
Acute Sinusitis treatment in pregnancy (bacterial) & what to avoid
○ If using an antibiotic follow traditional sinusitis treatment plans. PCN and cephalosporins are the safest classes
● Beclomethasone (Beconase AQ) or Budesonide (Rhinocort) nasal sprays
● Oxymetazoline (Afrin) nasal spray (max. 3 days)
● Rhinorrhea
○ Ipratropium bromide nasal spray (Atrovent) or cromolyn nasal sprays (Nasalcrom
○ Avoid:
■ Doxycycline (teeth staining)
■ Levofloxacin (cartilage abnormalities)
Strep Pharyngitis treatment in pregnancy & risks
● TOC: Penicillin, amoxicillin or cephalosporins
no risks mentioned
Oral decongestants use in pregnancy
avoid during first trimester
○ TOC for seasonal allergies in 2nd -3rd trimester -
Pseudoephedrine 60 mg max 4x/day
beta-blocker that is not contraindicated with pregnancy
labetalol
ACE/ARBS safety in pregnancy
● ACE Inhibitors and ARBs are Contraindicated
○ Because of potential for teratogenesis
■ Growth retardation, renal failure, persistent PDA, fetal
hypotensive syndrome
Treatment options for acne in pregnancy
○ Oral or topical erythromycin
○ Topical clindamycin
○ Topical azelaic acid
○ Benzoyl Peroxide - limited use; (less recommended, USE caution or if other
treatment options fail)
● Many treatments for acne are contraindicated in pregnancy (XXXXX)
Migraine treatment in pregnancy
MUST r/o preeclampsia in every >20 wks gestation pt
● Migraine
○ TOC: Acetaminophen
○ 2nd line: acetaminophen combo treatments
■ I. e. - acetaminophen/metoclopramide; acetaminophen/codeine;
acetaminophen/caffeine/butalbital
○ 3rd line: NSAID
Safe Hypertension treatments during pregnancy
● First choice: Labetalol (beta-blocker) - (Bronchospasm SE)
● Nifedipine (long acting CCB)
● Oral Hydralazine (direct vasodilator)
○ Only as “add-on” therapy d/t reflex tachycardia
● ACE Inhibitors and ARBs are Contraindicated
Vertigo treatment with pregnancy
● TOC: Meclizine (for non-pregnant pts, it’s antihistamines)
Depression treatment in pregnancy
● Initial: CBT
● Rx TOC - SSRI’s predominantly - sertraline (can also use during lactation)
- Avoid paroxetine and Fluoxetine
● If resistant to SSRI, switch to a different SSRI and/or change their current dose of the SSRI. if still refractory switch to an SNRI (typically venlafaxine)
● MAOI’s contraindicated
Anxiety treatment in pregnancy
● Usually antidepressants are the optimal choice
● However, if anxiety is severe:
○ Combo antidepressant with Benzo (for a short bridge duration < 2 weeks)
■ Clonazepam
■ Lorazepam
Nausea & Vomiting prevention in pregnancy:
● Prevention: folic acid
● Basics: Hard candy, small meals, ginger, take ½ prenatal vitamin or take vit w/o iron
● Avoid environmental triggers
● Acupuncture and acupressure (no evidence - but has placebo effect for some)
Nausea treatment in pregnancy
○ Pyridoxine (Vit B6) monotherapy
○ TOC (if monotherapy fails): Pyridoxine (Vit B6)-doxylamine succinate combo
therapy (Diclegis/Bonjesta)
Treatment for Nausea if vomiting persists
○ Diphenhydramine 25-50 mg Q4-6h
○ Meclizine 25 mg Q6h
○ Consider adding a dopamine antagonist (Prochlorperazine (Compazine),
promethazine, or metoclopramide (Reglan))
Vomiting + hypovolemia treatment in pregnancy
○ Fluid replacement
○ IV antiemetic therapy in ED (often Ondansetron/Zofran)
○ Add Thiamine supplement to IV fluids (prevent Wernicke’s encephalopathy)
○ Home on Ondansetron (Zofran) = > 10 wks, use CAUTION if prior to 10 wks
Zofran safety in pregnancy
use CAUTION if prior to 10 wks
Headache and Pain treatment in pregnancy and lactation
● Acetaminophen: safe in all 3 trimesters and lactation
Maximum recommended dose: 3000 mg/day
● Aspirin: Avoid unless prescribed
● NSAIDS: 1st Tri = miscarriage; 3rd Tri premature PDA closure, renal
toxicity. Avoid in pregnancy
Lactation: Ibuprofen preferred
Post-Partum: Naproxen frequently used
Antibiotics without KNOWN teratogenic effects
● Penicillins
● Cephalosporins
● Specific macrolides
○ Erythromycin
○ Azithromycin = usually best option
○ Clindamycin
● Augmentin
● Metronidazole
○ Avoid 1st trimester
Antibiotics contraindicated in treatment
○ Aminoglycosides (Gentamicin etc…)
■ Ototoxicity and nephrotoxicity
○ Chloramphenicol
■ gray baby syndrome
○ Fluoroquinolones (levofloxacin, cipro etc…)
■ Fetal cartilage damage
○ Tetracyclines (doxycycline)
■ Maternal hepatotoxicity
■ Inhibition of fetal bone and fetal
discolored teeth
Specific caution with bactrim in pregnancy
Bactrim (trimethoprim-sulfamethoxazole)
■ Avoid in 1st tri - interferes with folate synthesis
Specific caution with Nitrofurantoin in pregnancy
■ Avoid in 3rd tri (if possible) - May lead to kernicterus
(bilirubin induced brain dysfunction)
Specific caution with macrolides in pregnancy
■ Erythromycin
■ Clarithromycin
1. Don’t use unless there are no alternatives
Specific caution with metronidazole in pregnancy
Avoid use in 1st trimeste
Which antibiotic can cause gray baby syndrome?
Chloramphenicol
Tetracyclines (doxycycline) safety in pregnancy
Contraindicated
Maternal hepatotoxicity
■ Inhibition of fetal bone and fetal
discolored teeth
Which antibiotic can cause Ototoxicity and nephrotoxicity in pregnancy?
Aminoglycosides (Gentamicin etc…)
