Pharmacology of Pregnancy and Lactation Flashcards by Rachel Oakman

Physiological changes of pregnancy may alter drug disposition and effect through:

Direct Effects - ex. Placental transfer
Indirect Effects - Changes in placental and uterine function
Even after delivery drugs may affect breastfeeding

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Most Common Medications Taken During Pregnancy

Antiemetics
Antibiotics
Analgesics

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At least 10% taking drugs with long term effects on CNS

Antidepressants
Anticonvulsants
Antipsychotics

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Concerns of Medications during Pregnancy

Teratogenicity Effects ( not only congenital abnormalities but non-birth development such as puberty)
Fetal Loss
Congenital Malformation
Fetal Growth Restriction
Preterm Labor

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Recently recognized mothers who are ultra-rapid metabolizers of codeine may transfer morphine through breast milk :

to cause neonatal CNS depression and even death

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Major physiologic changes during pregnancy alter drug disposition

Absorption and Uptake
Oral absorption and bioavailability not usually affected by pregnancy
Intestinal motility decreases
Gastric emptying only delayed during labor or administration of opioids
Reduced FRC (functional residual capacity)
Increased minute ventilation increases pulmonary uptake of inhalational anesthetic agents

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Distribution

Peripheral delivered drugs are delivered more quickly
Onset of IV and inhalational dependant on time course of their cerebral drug concentrations (amount of concentrated drug to brain) A delay in the increase in arterial and brain anesthetic concentration will result from increased peripheral perfusion
Increased peripheral perfusion will increase the return of drug during elimination phase

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_____ binding changes more important clinically

Protein

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Increased concentrations of free drug (not protein bound) which is offset by

increased clearance (increased GFR)

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______ and ____ require monitoring and modification of dose because of changes in protein binding

Theophylline, phenytoin

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Most drugs are metabolized in the ____

liver

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Rate of metabolism depends on __________

hepatic blood flow

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Although CO increases it is not clear if

blood flow to liver increases

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Most cytochrome (CYP) P450 isoenzymes ______

increase

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drugs Increases Metabolism

Phenytoin
Morphine
MIdazolam

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Drugs that Decreases Metabolism

Caffeine

Theophylline

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Drugs metabolized by the liver may require __________in dose, depending on the metabolic pathway involved.

increases or decreases

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Drugs excreted unchanged by the kidneys often require an ______dose.

increased

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No anesthetic drugs have been shown to be teratogenic

true or false

true

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There is no know teratogenic risk associated with the use of _______which is preferred mild analgesic and antipyretic during pregnancy

acetaminophen

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NSAIDs have been associated with

an increase risk for some birth defects

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Aspirin usually avoided in the third trimester because of fetal risk for:

Renal injury
Oligohydramnios
Intrauterine constriction of the ductus arteriosus

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Opioids are not considered to have a _______ ____

teratogenic risk

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Tramadol has analgesic effects from weak opioid activity and inhibition of _________ and _________uptake Tramadol exposure in early pregnancy was associated with a higher number of spontaneous abortions and it should be avoided in the first trimester

serotonin and norepinephrine

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Some studies have suggested that first-trimester exposure to ______ increases the risk for cleft lip with or without cleft palate, neural tube defects, intestinal atresia, and limb defects. Other reports have not suggested an increase rate of congenital abnormalities after fetal exposure to benzodiazepines

diazepam

_____has the highest teratogenic risk followed by _______, _____, and _______.

Valproate, phenytoin, phenobarbitone and topiramate

_________is the most common serious neurologic problem during pregnancy. (preeclampsia and clampsia are a lecture in themselves)

Epilepsy

Psychotropic drugs that do not appear to be associated with congenital abnormalities or neurodevelopmental problems

Tricyclic antidepressants

Psychotropic drug that should be avoided

Monoamine oxidase inhibitors (MAOIs)

A Psychotropic drug as a class that increase the rate of cardiac malformations and risk complications.

Serotonin reuptake inhibitors (SSRIs)

________ therapy is associated with a small increased risk for cardiac defects, especially Ebstein’s anomaly

Lithium

Safe cardiovascular drugs safe in pregnacy

methyldopa, labetalol, calcium entry-blocking agents, and hydralazine

(cardiovascular drugs)Other beta-adrenergic receptor antagonists (apart from labetalol) is less clear, although _______ and _______ are often used during pregnancy

atenolol and metoprolol

(cardiovascular drugs) _______ should be avoided

Spironolactone s

(Cardio drugs) ___________ and ____________ should be avoided. This drugs can cause fetal renal failure and oligohydramnios, which may result in fetal limb contractures, craniofacial deformities, and pulmonary hypoplasia.

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)

(Cardiac drugs)_________ there is no clear increase in malformations. This agent is most often used

Amiodarone

(Respiratory Drugs) ________, and _________have not been associated with congenital malformations.

B2adrenergic receptor agonist and corticosteroids

(Respiratory Drugs) _____ is the preferred short acting B2adrenergic receptor agonist and ________is the preferred long-acting B2adrenergic receptor agonist

Albuterol, salmeterol

(Respiratory Drugs) _______and _______ are considered safe

Montelukast. zafirlukast

(Respiratory Drugs) _______is not recommended

Zileuton

(Respiratory Drugs) _____ and ______ have no adverse fetal effects

Theophylline and aminophylline

(Anticoagulants) Pregnant women have ___times the normal risk for venous thromboembolism and thrombosis is a significant cause of maternal death

(Anticoagulants) _______________ is the preferred over unfractionated heparin (UFH) because it is easy to administer and does not require monitoring.

Low-molecular-weight (LMWH)

(Anticoagulants) _____is less likely to cause heparin induced thrombocytopenia

LMWH

(Anticoagulants) The shorter half life of UFH means that it is ___________-

easier to reverse

(Anticoagulants)Warfarin is a vitamin K antagonist that can cause an__________,especially in 1st trimester

embryopathy

(Anticoagulants)______ and ______ (direct thrombin inhibitor) appear to be safe

Fondaparinux and argatroban

(Anticoagulants) cross the placenta and are not recommended

Rivaroxaban and the thrombin inhibitor dabigatran (Pradaxa)

(Antiemetics) ACOG (American College of Obstetricians and Gynecologists) recommends __________with or without________-as the initial drug of choice

vitamin B6 (pyridoxine) , doxylamine (antihistamine)

(Antiemetics) If symptoms persist then antihistamines, ________ and ______ and________

diphenhydramine and promethazine and dopamine antagonists such as prochlorperazine

(Antiemetics) __________ receptor antagonist) has been used for refractory vomiting during pregnancy

Ondansetron (5-hydroxytryptamine

Anti-diabetic Treatment of gestational diabetes mellitus with _______, ______, or ______ is safe with debate of which should be first line drug of choice.

insulin, metformin or glyburide

Anti-Infective Drugs | should avoid

tetracylines (after 5th week or pregnacy) | Fluroquinolones, doxycycline, primaquine, atovqyone-progunil

Anti-Infective first line

penicillins and cephalosporins

Anti-Infective avoid during 1st trimester

Metronidazole, sulfamethoxazole

Anti-Infective Short term use of __________ is acceptable but streptomycin is avoided because of risk for congenital deafness after first trimester

aminoglycosides

Anti-Infective Pregnant women should avoid traveling to malaria endemic areas but ________ and ________ can be used.

chloroquine or mefloquine

Safe Anti-Infectives

Sulphonamides, nitrofurantoin,

Highly Teratogenic Drugs include:_________________ | These drugs so high risk that two form of birth control are recommended when taken

Thalidomide, ribavirin, isotretinoin , acitretin, valproate

breastfeeding (Most anticonvulsants are considered safe but _________ AND _______ in infants eliminate slowly and could accumulate

phenobarbital and diazepam

How soon can you breastfeed after breastfeeding?

immediately

Is ketamine safe for breastfeeding?

should be avoided due to limited information about effects.

are NSAIDs safe for breastfeeding?

yes

are benzo's safe for breastfeeding?

yes

are LAs safe for breastfeeding?

yes

is morphine, codeine, tramadol, meperdine safe for breastfeeding?

yes in normal doses