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Women's Health 2 > Pharm - Pregnancy > Flashcards

Pharm - Pregnancy Flashcards

1
Q

What are the three timeframes that impact the likelihood of teratogenic effect

A
  1. Pre-embryonic period (0-14 days)
  2. Embryonic period (14-56 days)
  3. Fetal period (57 days to delivery)
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2
Q

What is impact of teratogen exposure during pre-embryonic period

A

exposure usually all or none effect; either dies or is damaged and then regenerates completely (sub-lethal exposure)

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3
Q

What is impact of teratogen exposure during embryonic period

A

organogenesis takes place, embryo must susceptible to teratogens; major structural changes or damage can occur

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4
Q

What is impact of teratogen exposure during fetal period

A

histogenesis and functional maturation, minor structural changes can occur but most anomalies are more likely to involve growth and functional aspects such as development of the brain and reproductive organs

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5
Q

Do most meds cross the placenta?

A

yes

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6
Q

List the 11 teratogenic drugs we need to know AND their FDA class

A
  • ACE Inhibitors and ARBS: D
  • Methimazole: D
  • Atenolol: D
  • Carbamezepine: D
  • Methotrexate: X
  • Paroxetine: D
  • Phenytoin: D
  • Systemic retinoids: X
  • Tetracycline: D
  • Valproic Acid: D
  • Warfarin: X
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7
Q

Why is iron important during pregnancy

A

Required to expand maternal red cell mass and for the fetus and placenta

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8
Q

What two pregnancy related supplements are based on the elemental content?

A

iron

calcium

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9
Q

Which form of iron supplement is most common, why?

A
  • ferrous sulfate (20% elemental iron)

- least expensive and MC used form of iron

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10
Q

What is supplementation recommendation for

  • a non anemic woman?
  • a woman with iron deficient anemia or risk of iron deficiency
A
  • 15-30 mg/day

- 60-120 mg/day

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11
Q

RF for iron deficiency during pregnancy

A
  • multiple gestation
  • closely spaced pregnancies
  • diet low in red meat and ascorbic acid
  • chronic aspirin/NSAID use
  • donate blood > 3/year
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12
Q

Why is folic acid important during pregnancy?

A

plays role in neural tube closure (by 6 weeks gestation)

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13
Q

Folic acid recommendations

  • normal pregnancy
  • high risk
A
  • 0.4 mg/day

- 4 mg/day (starting 1 month prior to conception and at least 3 months into pregnancy)

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14
Q

How to supplement 4 mg of folic acid

A
  • Can’t just take extra prenatal pills, will risk toxicity of other vitamins.
  • Must use a folic acid supplement
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15
Q

Calcium recommended supplementation during pregnancy

A
  • ≥19 yo: 1,000 mg/D

* <19 yo: 1,300 mg/D

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16
Q

What is most commonly type of calcium supplement used

A

calcium carbonate - higher amt of elemental calcium

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17
Q

Treatment of mild n/v during pregnancy

A
  • Reassurance, lifestyle changes or medication. Want to avoid dehydration, hypokalemia, metabolic alkalosis
  • Frequent small meals, avoid strong smells. Bland fods higher in carbs and lower in fats usually better tolerated (French baguette and white potatoes!!)
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18
Q

First line therapies for n/v in pregnancy if lifestyle isn’t working

A
  • Vitamin B6 (pyridoxine)
  • Add doxylamine if not well controlled on pyridoxine alone
  • Combo product: Diclegis: pyridoxine/doxylamine delayed release. Scheduled doses, not PRN
  • Ginger (helps with nausea, not vomiting)
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19
Q

Second line therapies for n/v in pregnancy

A
  • DC pyridoxine and doxylamine
  • Start antihistamines (H1 antagonists)
    • Meclizine (also for vertigo)
    • Dimenhydrinate or diphenhydramine (drowsiness)
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20
Q

Third line therapies for n/v in pregnancy

A
  • Dopamine receptor antagonist if antihistamines are inadequate
    • Phenothiazine: Prochlorperazine
    • Benzamide: Metoclopramide (Reglan)
  • ADR: sedation
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21
Q

Fourth line therapies for n/v in pregnancy

A
  • 5-HT3 serotonin receptor antagonists
    • Ondansetron (Zofran)
    • Small risk of congenital anomalies – use with caution.
    • Can cause QT prolongation, esp with arrhythmia RF
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22
Q

Hyperemesis gravidarum

- risk

A

Dehydration and malnutrition

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23
Q

Hyperemesis gravidarum

- tx

A
  • hospitalization
  • IV fluid
  • electrolytes
  • antiemetics
  • sedation
  • parenteral nutrition support
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24
Q

First line treatment for constipation in pregnancy

A

Nonpharm:

  • increase exercise
  • fluids
  • fiber (cereals, fruits, vegetables, beans, wheat bran)
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25
Q

Second line treatment for constipation in pregnancy

A

laxatives

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26
Q

List the laxatives used in pregnancy in order of preference

A
  1. Bulk-producing
  2. Osmotic
  3. Stimulant

*most not absorbed out of gut so considered safe with ST use

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27
Q

Bulk-producing laxatives used in pregnancy

A
  • Psyllium, calcium polycarbophil, methylcellulose
  • Dilute in water and take before meal or at bedtime
  • Increase fecal water content/volume, decrease colonic transit time, improve stool consistency
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28
Q

Osmotic laxatives

A
  • only use short term or occasionally
  • Polyethylene glycol (Miralax) is best option for chronic constipation
  • Lactulose or sorbitol other options
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29
Q

Stimulant laxatives

A
  • Use if fail to respond to bulk or osmotic laxatives
  • MoA: affects fluid changes in large intestine and/or GI motility, can result in diarrhea → dehydration and electrolyte disturbances
  • 2-3 X week is safe and effective for most patients
30
Q

List the three stimulant laxatives used in pregnancy

A
  • senna (best option)
  • bisacodyl
  • cascara
31
Q

List 4 laxatives to avoid in pregnancy

A
  • Castor oil
  • Saline osmotic laxatives (magnesium and phosphosoda)
  • Mineral oil
  • Aloe
32
Q

use of stool softeners in pregnancy

A
  • questionable efficacy, marginal value

- low risk

33
Q

GERD in pregnancy - tx of mild sx

A

• Lifestyle changes and diet modifications

  • Elevate head of bed 6”
  • Avoid eating late at night/close to bedtime
  • Avoid salicylates, caffeine, alcohol (duh!), nicotine, and foods that cause reflux
34
Q

GERD - first line threapy

A

Antacids

  • calcium containing are best option
  • don’t take with iron, need normal gastric pH to absorb iron
35
Q

What antacids should be avoided during pregnancy

A
  • magnesium containing antacids late in pregnancy d/t tocolytic properties
  • magnesium trisilicate
  • sodium bicarbonate (Na+ overload, alkalosis and fluid overload)
36
Q

What is alternative to antacids for GERD in pregnancy

A

sucralfate - binds to erosions, stays local

37
Q

What is next step if antacids/sucralfate dont’ control GERD

A

use systemic meds. Avoid during 1st trimester if possible

38
Q

List the systemic meds used to treat GERD in pregnancy in order of preference

A
  1. H2-receptor antagonists
  2. Promotility drugs
  3. PPI
39
Q

What H2-receptor antagonists are used to great GERD in pregnancy

A
  • Ranitidine first (documented safety - Famotidine (limited data but appears safe)
40
Q

What H2-receptor antagonists should be avoided in the tx of GERD in pregnancy

A

nizatidine (axid)

41
Q

What promotility drug should be used to treat GERD in pregnancy

A

Metoclopramide - increases lower esophageal sphincter tone

42
Q

What PPIs can be used in pregnancy

A
    • Limited data on safety in pregnancy
    • Avoid during first trimester
  • Lansoprazole and pantoprazole Class B
  • Omeprazole class C
43
Q

What are 4 conservative treatment of hemorrhoids in pregnancy

A
  • Fiber supplements
  • Fluids
  • High fiber diet
  • Switch iron supplements to slow release formulation
44
Q

What ingredients are skin protectants used in meds to treat hemorrhoids

A
  • aluminum hydroxide
  • cocoa butter
  • glycerine
  • kaolin
  • lanolin
  • mineral oil
  • petrolatum
  • zinc oxide
  • calamine
45
Q

What ingredients are topical anesthetics used in meds to treat hemorrhoids

A

-caines and pramoxine

46
Q

What ingredient is an astringent used in meds to treat hemorrhoids

A

witch hazel

47
Q

What ingredient is an anti-inflammatory used in meds to treat hemorrhoids

A

hydrocortisone

48
Q

What products should be avoided to treat hemorrhoids in pregnancy

A

products containing local vasoconstrictors (epinephrine or phenylephrine)

49
Q

What is the role of methyldopa in the treatment of HTN in pregnancy

A
  • Widely used for many years but rarely used anymore

* Con: slow onset of action, most women don’t reach bp goals

50
Q

What is the best beta blocker to use to treat HTN in pregnancy

A

Labetalol
• Both alpha and beta adrenergic blocker
• May preserve uteroplacental blood flow better than traditional BB
• Faster onset than methyldopa
• Generally safe in pregnancy, associated with hepatotoxicity
• Avoid other BB due to adverse effects on fetus

51
Q

What is the CCB recommended for use to treat HTN in pregnancy

A

Nifedipine

- use the sustained release, not the regular release

52
Q

What four classes of drugs should NOT be used to treat HTN in pregnancy

A
  • ACE inhibitors
  • ARBs
  • direct renin inhibitors
  • mineralocorticoid receptor antagonists
53
Q

What is the goal of glucocorticoid use in pregnancy? What two meds are used?

A
  • Reduce the incidence and severity of respiratory distress syndrome in the infant
  • Betamethasone and dexamethasone
54
Q

What are two antihypertensive drugs of choice for the acute treatment of severe hypertension

A
  • IV Hydralazine (drug of choice)

* IV Labetalol

55
Q

What is magnesium sulfate used for in pregnancy?

A
  • prevention and treatment of eclamptic seizures (also as a tocolytic)
56
Q

Loading and maintenance dose of mag sulfate

A
  • Loading dose: 4-6 g IV

* Maintenance dose: continuous infusion 2 g/hour (via controlled pump to avoid accidental OD)

57
Q

What are three monitoring parameters for toxicity of mag sulfate, at what drug level will toxicity occur

A

• Deep tendon reflex (first sign usually)
- 8-12 mg/dL

• Respiratory rate (arrest is risk)
- >13 mg/dL

• Urine output

58
Q

What organ function is necessary for the use of magnesium sulfate

A

renal function

59
Q

What is used to reverse magnesium sulfate toxicity?

A

calcium gluconate

- Can reverse hypocalemia and hypocalcemic tetany d/t elevated magnesium levels

60
Q

First line therapy for GDM

A

diet and lifestyle (move)

61
Q

Glycemic goals for GDM

A
  • <140 mg/dL 1 hour post-prandial

* <120 mg/dL 2 hours post-prandial

62
Q

What is the preferred drug to treat GDM

A

insulin

63
Q

How to start insulin therapy for GDM

A

• Start with postprandial rapid or fast acting

  • Humalog and Novolog have been investigated in pregnancy
  • Regular is ok too
  • Analogs preferred over regular
64
Q

What to do if fast/rapid acting insulin not sufficient to control postprandial glycemia

A

add basal

  • Levemir or NPH
  • NOT Lantus
65
Q

What two oral meds to use to treat GDM, what is downside to oral meds in general?

A

• Glyburide – sulfonyurea (Higher rates of maternal and neonate hypoglycemia)
• Metformin (Less macrosomia and lower gestational weight gain vs. glyburide)
* In general, might not be powerful enough to control glycemia

66
Q

What two situations do not create Rh factor related risk

A
  • Mom is Rh+

- Mom and Dad are both Rh-

67
Q

When to administer RhoGAM

A
  • Mom is Rh- and baby is Rh+
  • Any antepartum fetal-maternal hemorrhage
  • Actual/threatened pregnancy loss at any stage of gestation
  • Ectopic pregnancy

*goal - prevent Rh immunization

68
Q

List the 3 agents used to ripen the cervix and when to terminate use prior to starting oxytocin

A

Prostaglandins E2
• Prepidil Gel: (delay oxytocin min 6-12 hours after last dose of Prepidil)
• Cervidil Vaginal insert (remove 30-60 min prior to oxytocin)

Prostaglandins E1
• Misoprostil (delay oxytocin min 4 hours after admin of misoprostil)

69
Q

Why treat asymptomatic bacteriuria in pregnancy?

A
  • 30-40% will develop symptomatic UTI and pyelonephritis

- Risk if untreated: preterm birth, low birth weight, perinatal mortality

70
Q

7 Treatment options for UTI in pregnancy. Note times to avoid if applicable

A
  • Amoxicillin/clavulanate
  • Cephalexin
  • Cefpodoxime
  • Amoxicillin – resistance may limit use
  • TMP/SMX – avoid 1st trimester and at term
  • Nitrofurantoin: don’t use if suspect pyelonephritis, avoid at term
  • Fosfomycin: don’t use if suspect pyelonephritis
71
Q

Treatment of pyelonephritis in pregnant women

A
  • Parenteral, broad spectrum beta-lactams (ceftriaxone, cefepime, aztreonam)
  • Can use low dose suppressive therapy for remainder of therapy to prevent recurrence: nitrofurantoin or cephalexin

Women's Health 2 (9 decks)

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