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Health.1 > Pregnancy and breastfeeding > Flashcards

Pregnancy and breastfeeding Flashcards

1
Q

Describe the significant factors affecting the pharmacokinetics and pharmacodynamics of drugs in pregnancy and breastfeeding

Recognise the importance of providing effective advice to women pre-conception, during pregnancy and whilst breast-feeding

Know where to find information to inform your discussions regarding the safety of taking medicines whilst pregnant / breast feeding

A
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2
Q

whats the high risk time for fetus?

A

first trimester- where women also enter well before realising pregnant

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3
Q

drugs pregnant women in Europe often may take? epidemiology

A

legal: POM, P, GSL

also illicit drugs, alcohol, smoke

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4
Q

what types of drugs prescribed in pregnancy to treat problems

A

minor ailments:

  • analgesics
  • antibiotics
  • for migraine

pregnancy induced disorders

chronic problems:

  • asthma
  • epilepsy
  • depression/psychiatric
  • HIV
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5
Q

what to consider regarding drugs for chronic disorders in pregnancy? Examples

A

dont stop them as disease itself may adversely affect pregnancy/ become worse
(epilepsy,diabetes,hypertension)
e.g. epilepsy=fit, fetus damaged

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6
Q

what proportion of med molecules are genuine human teratogens?

A

< 30 med molecules = genuine human teratogens

important to counsel patient as could = excess harm

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7
Q

3 specific OTC meds that may be taken in pregnancy?

A

paracetamol, alginates, osmotic laxatives (lactulose)

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8
Q

what OTC meds to AVOID in pregnancy?

A

ibuprofen, cough and cold formulations, antihistamines, nasal decongestants

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9
Q

reasons meds adherance may decrease in pregnancy?

A

doubt about drug use, side effects, complaints for drugs prescribed disappear- sometimes imporve

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10
Q

importance of pre-conception counselling and what to address?

A

biomedical/behavioural issues posing a risk to the health of woman or foetus

‘window of oppurtunity’ before pregnancy confirmed- discuss risks/benefits of drug therapy and begin prophylaxic (folic acid) and immunisations where req.

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11
Q

type of pharmaceutical interventions to make in pre-conception counselling

A
  • prophylactic drugs (can prevent adverse consequences during pregnancy)
  • appropriate immunisation
  • ensure can make informed decisions about therapeutic drugs too
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12
Q

reason for prescribing folic acid

A

needed for proper haematopoeisis, lowers risk of fetus having neural tube defect

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13
Q

what to consider and advise regarding other vitamin supplements in pregnancy?

A

some may cause ADRs in pregnancy e.g. high dose Vit A = teratogenic.
give appr advice

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14
Q

when folic acid prescribed and why then?

A 
first trimester (until wk 12)
as when neural tube and CNS developing in fetus
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15
Q

what can increase risk of NTD (neural tube defects) based on? (3)

A
  • partner w/ NTD, previous child w/ NTD, family history of NTD
  • anti-epileptic drugs or diabetic
  • BMI >30kg/m2 obese
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16
Q

folic acid dose prescribed for

a) normal risk NTD
b) high risk NTD

A

a) Folic acid 400mg daily until trim 1/wk12

b) folic acid 5mg daily

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17
Q

What should women seeking emergency contraception, who have used cytochrome P450 3A4 (CYP3A4) enzyme inducers within the last 4 weeks use ?

A
  • preferably non‐hormonal emergency contraceptive (a copper IUD)
  • if this is not an option, double the usual dose of levonorgestrel from 1.5 milligrams to 3 milligrams (i.e. 2 packs)
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18
Q

5 enzyme inducer drugs? that hence reduce plasma levonorgestrol (emergency contraception) conc?

A
  • Antiepileptics (e.g. barbiturates, primidone, phenytoin, carbamazepine)
  • Anti‐tuberculosis (e.g. rifampicin, rifabutin)
  • HIV medicines (e.g. ritonavir, rifabutin)
  • Antifungals (e.g. griseofulvin)
  • Herbal remedies that contain St John’s Wort
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19
Q

pregnancy affect of absorption of drug (3)

affect of nausea+vomiting

A

Nausea and vomiting:

  • ↑ gastric pH
  • ↑ gut transit time
  • ↓ gastric emptying

Increased absorption from IM injections + inhalation

Change in bioavailability

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20
Q

pregnancy affect on metabolism of drug

A
  • hepatic blood flow
  • P450 (increased/decreased)
  • UGT (enzymes - increased)
  • P glycoprotein
  • N-demethylation
    overall change in drug metabolism
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21
Q

pregnancy affect on distribution of drug

A

Increased:

  • ECF
  • plasma volume
  • pH
  • fat
  • volume of distribution

Decreased:

  • albumin
  • concentration

Change in drug protein binding

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22
Q

pregnancy affect on elimination of drug 2

A
  • renal blood flow & GFR
  • hepatic blood flow & cholestasis

overall change in drug elimination

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23
Q

changes not clinically significant for most drugs BUT what drugs to carefully monitor?

A

drugs w narrow therapeutic index:
e.g. antiepileptics, enoxaparin

  • may alter dosing
  • monitor drug conc/clinical effects
  • effect may be delayed after oral dose/ enhanced after IM
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24
Q

Critical periods in human development

A
  • Important during first 12 weeks during embryogenesis

- may even be potential harm pre-implantation

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25
Q

What is a teratogen?

A

substance, organism, physical agents/ deficiency state capable of inducing abnormal structure or function:

  • Gross structural abnormalities
  • Functional deficiencies
  • Intrauterine Growth Restriction (IUGR)
  • Behavioural aberrations
  • Demise

some seen later in life

26
Q

In the context of pharmacodynamics & teratology, how does the predictability of maternal and foetal effects compare?

A
  • Maternal effects are largely predictable

- Foetal effects are less predictable

27
Q

What percentage of congenital malformations do drugs account for?

A

2-3%

difficult to separate effect of condition form that of drug

28
Q

In the context of pharmacodynamics & teratology, what does susceptibility depend on? (2)

A
  • genotype of mum and baby
  • developmental stage

partly environmental?

29
Q

What are the US FDA pharmaceutical pregnancy categories?

A

Category A, B, C, D , X

30
Q

What is teratogenicity?

A

the potential for a drug to cause foetal malformations and affects the embryo 3‐8 weeks after conception
drugs can cause congenital malformations

31
Q

During which weeks of the 1st trimester is the highest risk and why?

A

3rd to 8th - organ systems are formed

32
Q

What is meant by the ‘all-or-nothing effect’ in the context of teratogenicity? And when

A

this is the pre-embryonic phase (days 0‐14 after conception) which can lead to recovery or spontaneous loss (abortion)

33
Q

What is fetotoxicity?

And when does it happen

A

when drugs can affect growth and functional development or have toxic effects on tissues

2nd and 3rd trim-where organs formed

34
Q

How can drugs adversely affect the foetus in the 2nd and 3rd trimester? (3)

A
  • cause fetotoxicity
  • some functional effects (some reversible) may extend into neonatal period
  • adverse effects on neonate if given shortly before or during labour e.g. diazepam or pethidine may affect the neonate
35
Q

What should we assume about all drugs when prescribing in pregnancy?

A

all drugs will be able to cross the placenta unless they have a high MW

36
Q

What do we avoid when prescribing in pregnancy?

A
  • prescribing in 1st trimester if possible
  • medicines known to be harmful
  • prescribing unless the benefit to mother outweighs risk to foetus e.g. antiepileptics for management of epilepsy
37
Q

What drugs/ classes should be avoided in the 1st trimester of pregnancy? 8

A
  • Androgens
  • cytotoxic drugs
  • lithium
  • quinolone antibiotics
  • retinoids
  • sodium valproate
  • thalidomide
  • warfarin
38
Q

What drug classes should be avoided in the 2nd & 3rd trimester of pregnancy?

A
  • ACEi and ARBs (Angiotensin receptor blockers)
  • aminoglycosides
  • NSAIDs, aspririn
  • opiates, benzodiazepines
  • sulphonamides
  • tetracyclines
39
Q

Why do doses need to be adjusted in pregnancy? (2)

A
  • physiological changes of pregnancy = maternal
    drug conc is lower than non‐pregnant women taking
    the same dose
  • foetal and placental metabolism affects drug conc
40
Q

Explain how enoxaparin and lamotrigine need to be adjusted during pregnancy

A
  • Renal elimination of enoxaparin requires ↑ dose
  • Lamotrigine metabolism significantly enhanced requires ↑↑dose

careful:conc of bound and free drug may vary

41
Q

Pregnancy Prevention program (PREVENT) example of Valproate

A
  • New guidance (2018): valproate medicines (Epilim®, Depakote®) must no longer be used in women or girls of childbearing potential unless a Pregnancy Prevention Programme is in place
  • Annual risk assessment MUST take place for all premenopausal
    women
42
Q

What 3 recommendations have been made based on sodium valproate’s discovered risk?

A
  • Communicate risks- are aware prior to family planning decisions
  • Establishing specialist centres for families affected by teratogenic medication.
  • Measures to reduce and monitor effects of other medications which are regularly taken during pregnancy, and considered to have teratogenic potential, or known risk above that of the general population.
43
Q

What will the BNF typically say about all drugs when prescribing while pregnant?

A
  • Drugs can have harmful effects on the fetus at any time…
  • Drugs can produce congenital malformations (teratogenesis)
  • ….only if expected benefit to the mother > risk to the foetus
44
Q

What are 4 good info sources when looking at drugs and pregnancy?

A
  • BNF (absence of info doesn’t mean safe)
  • Summary of Product
    Characteristics (medico‐legal statements about
    pregnancy and breastfeeding)
  • consult TOXBASE (www.toxbase.org)
  • UK teratology information service (www.uktis.org)
45
Q

What is the recommended length of exclusive breastfeeding?

A

until 6 months

46
Q

Why is avoiding breastfeeding to take prescribed drugs not a no harm option?

A

benefits of breastfeeding will be lost (immunity, reduced risk of allergy in infant)

47
Q

What does the safety of drug use whilst breastfeeding depend on? (6)

A
  • the passage of a drug into breast milk
  • subsequent absorption in the infant
  • the adverse drug reaction profile
  • infant age
  • infant co‐morbidities
  • effective clearance of the drug
48
Q

How do drugs interact with breast milk?

A
  • they can be excreted into it

- most drugs pass in small quantities and are not a concern

49
Q

What age group of infants are at a greater risk from exposure to drugs via breast milk and why?

A
  • neonates (and particularly premature infants)

- immature excretory functions and the consequent risk of drug accumulation

50
Q

When prescribing in breastfeeding, what can we infer the potential of harm to the infant from?

A

– the amount of active drug delivered to infant in breast milk

– efficiency of absorption, distribution and elimination of drug by infant (infant pharmacokinetics)

– the effect of the drug on infant (infant pharmacodynamics)

51
Q

Why is timing of med important when prescribing in breastfeeding? (2)

A
  • related to feeding
  • mother may express milk prior to taking drug so can feed infant while conc of drug is highest to avoid peak levels in milk
52
Q

Which drugs are considered to be compatible with breastfeeding and why?

A

drugs associated with reduced passage into breast milk as:

  • High MW (e.g. insulin, heparins)
  • High protein binding (e.g. warfarin, NSAIDs)
  • Low lipid solubility (e.g. loratadine)
  • Lower pH (e.g. amoxicillin; as pH of plasma is about 7.4 and that of breast milk is 6.9 the conc of acidic drugs in breast milk will be low)
53
Q

What should be avoided when prescribing in breastfeeding?

A
  • unnecessary drug use (including OTC meds)

- the use of drugs known to cause toxicity in adults or children

54
Q

When prescribing in breastfeeding, you should choose a regimen + route which presents the XXX amount of drug.

A

When prescribing in breastfeeding, you should choose a regimen + route which presents the minimum amount of drug

multidose regimens and MR preps may have increased risk

55
Q

What drugs should be avoided in breastfeeding (and what are their adverse effects)?

A
  • Amiodarone
  • Antithyroid drugs
  • Benzodiazepines
  • Li salts
  • radioactive iodine
  • Statins
  • Sulphonamides
56
Q

Special case of codeine/tramadol in breastfeeding

potentially serious ADR

A
  • some breastfeeding women can ultrarapid CYP2D6 metabolisers
  • can = ultra-rapid conversion of codeine to morphine and tramadol to M1 leading to high/unsafe levels in breast milk
  • can = serious ADRs in infants (excess sleepiness, difficulty breastfeeding, serious breathing problems →death)
  • contraindicated in breastfeeding therefore
57
Q

How do dopamine affecting drugs affect breastfeeding?

A
  • affect lactation by changing plactin
  • dopamine agonists (e.g. cabergoline) decrease milk production
  • dopamine antagonists (e.g. domperidone) may promote lactation when inadequate
  • some drugs can also inhibit infant’s suckling reflex (e.g phenobarbital)
58
Q

why progesterone recommended over oestrogen as initial contracetption

A

early postpartum use of oestrogen may reduce milk volume- progesterone rec as initial contraception

59
Q

What are 4 good sources to check for drugs and breastfeeding?

A
  • BNF
  • UK Drugs in Lactation Advisory
    Service (UKDILAS - general guidance and drug
    monographs)
  • United States National Library of Medicine Lactmed database (http://toxnet.nlm.nih.gov/cgi‐ bin/sis/htmlgen?LACT)
  • Specialist Pharmacy Service
60
Q

Statement concerning the safety of drug use in pregnancy and breastfeeding

A

A drug that is safe to use during pregnancy does not necessarily mean that it is safe to use in breastfeeding (and Vice Versa)

61
Q

Is flucloxacillin excreted in breast milk likely to be harmful to the baby

A

Babies can be prescribed flucloxacillin
Flucloxacillin changes gut microbiota which will cause runny nappies at most and might make the breastmilk taste off
For flucloxacillin excreted in small amounts the risk is acceptable to continue breast feeding
consider that the small amount present could affect frequency of babies stools

62
Q

Is co-codamol advised in breastfeeding women?

A

Codeine gets metabolised to morphine – different people metabolise it at different rates
Paracetamol or ibuprofen is used instead

Health.1 (12 decks)

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