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pharmacotherapy 3270 > pregnancy and breastfeeding > Flashcards

pregnancy and breastfeeding Flashcards

1
Q

how is absorption of drugs affected in pregnancy? (e.g. GI motility, gastric pH and pulmonary alveolar drug uptake)

A

-GI motility is decreased
-gastric pH is increased therefore more basic
-pulmonary alveolar drug uptake is increased

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2
Q

how is the metabolism of drugs affected in pregnancy? (e.g. hepatic metabolism)

A

-CYP 3A4 and 2D6 enzymes are increased
-CYP 1A2, xanthine oxidase and N-acetyltransferase is decreased

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3
Q

how is the distribution of drugs affected in pregnancy? (e.g. Vd and albumin binding)

A

-Vd is increased
-albumin binding is decreased

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4
Q

how is the elimination of drugs affected in pregnancy? (e.g. renal blood flow and GFR)

A

-renal blood flow is increased
-GFR is increased

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5
Q

what are the three main questions that should be asked when assessing risk for drugs in pregnancy.

A
  1. can the drug cross the placental barrier
  2. is the fetus at a vulnerable developmental stage
  3. is the drug teratogenic
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6
Q

when is the fetus fully functional (in weeks)

A

18-20 weeks

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7
Q

what gets transferred from mom to baby?

A

-oxygen and nutrients
-antibodies

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8
Q

what gets transferred from baby to mom?

A

-CO2
- waste products

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9
Q

when do antibodies get transferred to the fetus?

A

after week 28

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10
Q

what characteristics prevent drugs from crossing the placental barrier?

A

-high molecular weight
-strong ionization
-high protein binding
-high water solubility (therefore lipophilic drugs cross more rapidly)

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11
Q

what molecular weight of drugs cross the placental barrier readily?

A

<500 Da

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12
Q

what molecular weight of drugs cross the placental barrier more slowly?

A

600-1000 Da

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13
Q

what molecular weight of drugs do not cross the placental barrier in significant amounts?

A

> 1000 Da

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14
Q

what are two examples of drugs that do not cross the placental barrier in significant amounts?

A

heparin and insulin

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15
Q

is the fetal or maternal pH more acidic?

A

fetal

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16
Q

do weak acids or weak bases cross the placental barrier?

A

weak bases - once in fetal circulation, become ionized and less likely to diffuse back

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17
Q

what is an example of a class of lipophilic drugs that cross the placental barrier

A

opioids!!!!!!

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18
Q

what period of fetal developing is there the greatest risk and why?

A

3-8 weeks due to organogenesis - formation and differentiation of organs and organ systems

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19
Q

of, relating to, or causing developmental malformations

A

teratogenic

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20
Q

what 5 things should be considered when determining if a drug is teratogenic?

A

-studies
-biological plausibility
-pattern of anomalies
-duration, dose and health of mother and baby
-time of exposure (what developmental stage is fetus exposed)

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21
Q

what kind of studies are conducted to determine if a drug is teratogenic?

A

-animal studies
-cohorts
-pregnancy registries
-case reports

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22
Q

true/false: the baby is only susceptible to teratogenic effects from drug therapy during the first three months of the pregnancy

A

false - first three months is the most risk for congenital malformations but fetus is always developing throughout the pregnancy therefore always a risk

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23
Q

when can neural tube defects occur (in weeks) if the fetus is exposed to a teratogen

A

3-4 weeks

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24
Q

a condition that affects the spine and is usually apparent at birth. It is a type of neural tube defect (NTD)

A

spina bifida

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25
Q

what will occur if a fetus is exposed to a teratogen at weeks 5-6

A

-small eyeballs
-heart abnormalities
-facial cleft

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26
Q

what will occur if a fetus is exposed to a teratogen at week 6

A

-mixed sexual characteristics
-cleft lip/palate

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27
Q

what will occur if a fetus is exposed to a teratogen at weeks 7-8

A

-heart valve malformations
-shortness of the head
-short fingers/toes

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28
Q

this is an example of a teratogen that was used in the 50’s and 60’s as a sedative/anxiolytic. it was widely used in the 1st trimester of pregnancy. several years later there was a strong relationship between this drug and limb malformations in the babies

A

thalidomide

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29
Q

what other effects may occur if the fetus is exposed to a teratogen?

A

-fetal loss
-limb deformaties
-cognitive/behavioural problems
-low birth weight
-carcinogenesis
-fetal/neonatal toxicity or withdrawl

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30
Q

_____ is a drug that caused vaginal cancer in babies once they became adolescents. it was used to prevent miscarriages and still births

A

DES - diethylstilbesterol

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31
Q

what are some discriminating features of fetal hydantoin syndrome?

A
  • flat midface
  • short nose
    -indistinct philtrum
  • thin upper lip
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32
Q

exposure to this teratogen may cause:
- developmental delay
- dysmorphic craniofacial features
- short fingers

A

phenytoin (anti-seizure medication)

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33
Q

exposure to this teratogen may cause:
- prenatal and postnatal growth retardation
-facial abnormalities
-CNS dysfunction

A

alcohol

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34
Q

a drug is more likely to cross the placenta if it has:
a) high molecular weight >500 Da
b) low protein binding
c) high water solubility
d) properties of a weak acid

A

B - low protein binding

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35
Q

what are some known examples of teratogens to watch out for

A
  • ACE inhibitors
  • tetracyclines
  • corticosteroids (systemic)
  • cannabis
  • cocaine
  • Ethanol
  • misoprostol
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36
Q

can acetaminophen be used in pregnancy?

A

in low doses for short period of time it can be used - not recommended if not needed

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37
Q

how can the risks be minimized in terms of teratogenic drugs

A
  • avoid drugs with known teratogenic effects
    -use single entity drugs
  • use drugs that have difficulty crossing the placenta
  • use lowest effective dose
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38
Q

what can you do to minimize the risk of teratogenic effects for planned pregnancy?

A
  • taper and discontinue unecessary drugs
  • switch to a safer alternative
  • if poss. wait until medical condition is resolved before getting pregnant
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39
Q

what is folate/folic acid necessary for?

A

preventing neural tube defects

40
Q

folic acid can be found in our diet. how much is bioavailable?

A

50%

41
Q

folic acid can also be supplemented. how much is bioavailable?

A

100%

42
Q

what foods is folate/folic acid found in?

A

dark leafy greens, oranges, fortified grains and corn

43
Q

what individuals put the fetus at high risk for neural tube defects?

A

women or men with
- personal history of NTD
- previous pregnancy with NTD

44
Q

what individuals put the fetus at moderate risk for neural tube defects?

A

women or men with:
- family history with NTD (second or third degree relative)

women with:
- maternal diabetes (I or II)
- GI malabsorption conditions (e.g. Crohns, celiac, kidney disease, alcohol misuse)
-teratogenic meds

45
Q

what individuals put the fetus at low risk for neural tube defects?

A
  • no history of NTD
46
Q

what is the dosing of folic acid for those with low risk of NTD

A

0.4mg 3 months before conception until 4-6 weeks postpartum or when completed breastfeeding

47
Q

what is the dosing of folic acid for these with moderate risk of NTD

A

1mg 3 months before conception and 3 months after conception until 4-6 weeks postpartum or when completed breastfeeding

48
Q

what is the dosing for folic acids for those with high risk of NTD

A

4-5mg 3 months before conception and 3 months after conception and then 0.4-1mg until 4-6 weeks postpartum or when completed breastfeeding

49
Q

what are some unintended effects of supplementation of folic acid?

A
  • mask vitamin B12 anemia
  • make asthma in baby
  • increase colorectal cancer in mom
  • increased probability of twins (also caused by shitty diet)
50
Q

what is the recommended dose of iron in pregnancy

A

16-20mg

51
Q

what benefits does iron supplementation have?

A
  • supports baby’s Brian development
  • builds baby’s iron stores in third trimester
  • lowers risk of anemia in mom
    -may lower risk of low birth weight in baby
52
Q

what is the recommended dose of calcium in pregnancy?

A

<18 years: 1300mg/day
>18 years: 1000mg/day

53
Q

what is the recommended dose of vitamin D in pregnancy?

A

600 units/day

54
Q

what benefits does calcium and vitamin D supplementation have

A
  • supports fetal skeletal development
  • maintains maternal stores
  • reduces the risk of hypertension and pre-ecclampsia
55
Q

what is the recommended dose of iodine in pregnancy?

A

150mcg/day

56
Q
  • increased requirement to maintain maternal metabolism
  • essential for baby’s neurological development
A

iodine

57
Q

what benefits does supplementing with a multivitamin have (e.g. folic acid + multivitamin)?

A
  • decreased risk of congenital anomalies (heart, oral facial clefts, limb defects)
    -decreased risk o paediatric cancers (brain tumours and leukemia)
58
Q

this vitamin can be teratogenic if > 10,000 units or 3000 mcg/day

A

A

59
Q

this type of immunization have the same adverse reactions in pregnant and breastfeeding women as they do in the regular population

A

inactivated vaccinations

60
Q

this type of immunization should generally NOT be given during pregnancy because of a theoretical risk of disease transmission to the baby

A

live vaccinations

61
Q

what are some signs of a miscarriage

A
  • heavy bleeding (soaking 2 pads an hour)
  • cramping
  • fever
  • weakness or other signs of infection
62
Q

what might you use to treat a patient experiencing pain with a miscarriage

A

acetaminophen or ibuprofen

63
Q

what might you use to treat a patient experiencing nausea with a miscarriage

A

dimenhydrinate (gravol)

64
Q

what medication is used to help carry out a miscarriage

A

misoprostol and mifepristone

65
Q

how many ducts are there per nipple

A

15-25

66
Q

true/fasle: size is related to milk production

A

false

67
Q

know the oxytocin/prolactin cycle

A
  1. infant starts suckling
  2. stimulation of nerve endings in moms nipple/areola sends signal to hypothalamus/pituitary
  3. pituitary releases oxytocin and prolactin
  4. hormones travel via blood stream to mammary gland to stimulate milk production and let down
68
Q

know the function of prolactin and oxytocin

A

oxytocin: milk ejection reflex (milk letdown)
prolactin: milk production

69
Q

when does lactation occur?

A

30-40 hours after birth

70
Q

this is the first milk produced - yellow in colour. delivery occurs until days 2-5. also known as “liquid gold” thick and small in quantity
. high in immunoglobulins/antibodies

A

colostrum

71
Q

this type of milk occurs from days 2-5 until days 10-14 - light yellow in color. high in fat, lactose, water-soluble vitamins

A

transitional milk

72
Q

what type of immunity is the transfer of immunoglobulins/antibodies from mom to baby via milk?

A

passive immunity

73
Q

has a white to blue tinge, 90% water and 10& fats, carbs and proteins

A

mature milk

74
Q

this is a type of mature milk; beginning of a feed. higher in lactose, water, vitamins and protein

A

foremilk

75
Q

this is a type of mature milk; after initial milk release. higher in fat

A

hindmilk

76
Q

what are some beneficial effects of breastfeeding for baby?

A
  • decrease in gastroenteritis
  • decrease in DM
  • decrease in cancer
77
Q

what are some beneficial effects of breastfeeding for mom

A
  • decrease in postpartum bleeding
  • more rapid uterine involution
  • burns 500-600 calories/day
  • decreased risk of postpartum depression
78
Q

what are some contraindications to breastfeeding

A
  • galactosemia (rare disorder where baby cannot tolerate breastmilk)
  • if the mom has the following conditions: HIV, herpes on both breasts, TB
79
Q

what are the three main questions for assessing the risk of drugs in breast milk

A
  1. is the drug secreted into the breastmilk
  2. is it harmful for the baby to ingest this particular drug at this concentration
  3. can the drug decrease or stop lactogenesis
80
Q

what type of transport are drugs usually secreted into the milk by?

A

passive diffusion

81
Q

what four factors determine if the concentration of a drug in breastmilk EXCEEDS that in plasma

A
  • low molecular weight
  • lipophilic
  • low protein brining
  • long half life
82
Q

true/false: most drugs have a milk:plasma < 1

A

true

83
Q

true/false: in general, RID (relative infant dose) < 10 % is thought to be safe

A

true

84
Q

what are some substances harmful to lactogenesis

A
  • alcohol
  • nicotine
    -estrogen (oral contraceptives)
  • pseudoephidine
  • dehydration due to vomitting or diarrhea
  • dopaminergic agents (buproprion)
85
Q

how can we determine if baby is getting enough milk

A
  • appropriate gains in weight, length and head circumference
  • hear swallowing when fedding
  • breasts feel softer after feeding
  • no signs of dehydration (urine and stools)
86
Q

what are non-charm options if not getting enough milk

A
  • try and get the best possible latch, latch is KEY for successful breastfeeding
  • increase duration and frequency of feeds
  • feed lying on side
  • breast compressions
  • switch sides
  • refer to lactation consultant
87
Q

what pharmacological treatment may be recommended for milk insufficiency

A

-domperidone
-metformin
-metoclopramide

88
Q

this is a dopamine type 2 receptor blocker which is located in the pituitary gland and increases prolactin production - does not readily cross the BBB. acts on parts of the CNS outside the BBB (CTZ of the medulla -> anti nausea effects). before using, screen for comorbities and QT prolonging drugs

A

domperidone

89
Q

herbal; taste and door resemble maple syrup. ADR = diarrhea, increased asthma symptoms, decreased blood glucose

A

fenugreek

90
Q

herbal; low oral bioavailability. ADR = mild diarrhea, headache, skin reactions

A

milk thistle

91
Q

what are some non-charm options for milk oversupply or engorgement

A
  • decreased nipple stimulation (suckling, pumping, etc)
  • well fitting bra
  • expressing some milk to relieve symptoms
  • cold cabbage leaves for pain/swelling
92
Q

what is the most common cause of nipple pain

A

poor latch

93
Q

know the management for nipple pain

A
  • warm nipple after feeding
  • expose nipples to air as much as possible
  • protect nipples from rubbing on clothing after feeding with breast shells
  • ointment: jack newmans all purpose nipple ung
94
Q

what should the mother do if baby cannot be put to breast due to pain

A
  • may be able to take a 3-5 day break tp heal
  • avoid rubber nipples on bottle thus finger or cup feed
95
Q

what conditions should be ruled out regarding nipple pain?

A
  • yeast infection: treat with jack Newmans APNO, fluconazole or grapefruit seed extract
    -mastitis: redness, pain, fever, chills, ashiness, fatigue. usually caused by staph aureus. medical emergency

pharmacotherapy 3270 (3 decks)

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