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SIU6 Special patient group > Pregnancy and breastfeeding > Flashcards

Pregnancy and breastfeeding Flashcards

1
Q

ABSOLUTELY CONTRA-INDICATED DRUGS in pregnancy!

A

cytotoxic - methotrexate
vitamin A analogues - isotretinonin (acne)
cardiovascular - ACEI, spironolactone
endocrine - radioactive iodine, sex hormone
antibiotics - trimethoprim esp in 1st trimester (folate antag–> cofactor for NUD)
antifungal, anti-helminthics-parasite -
griseofulvin, mebendazole (toxicity in animal studies)

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2
Q

prescribing for pre-exisiting diabetic pregnant patients

What will happen to their BGL during pregnancy?

A

Glucose tolerance decreases due to ANTI-INSULIN effects of human placental lactogen, glucagon and cortisol. So BGL will rise during pregnancy.

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3
Q

What will you need to do according to the change in BGL during pregnancy?

A

Alter insulin doses almost daily. More frequent BGL monitoring. More frequent doses of insulin, or use metformin. >=4 insulin injections daily (2 basal +3 IR)/ insulin pump

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4
Q

What will be the result of having a baby whilst BGL is high?

A

OVERWEIGHT baby

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5
Q

what anti-epileptic meds are teratogenic?

A

Carbamazepine, valproate, phenytoin and phenobarbital are all teratogenic

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6
Q

which of the AE meds can cause NTD?

A

valproate and carbamazepine

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7
Q

which of the AE meds can cause cong cardiac defect?

A

valproate and phenytoin

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8
Q

phenytoin usage in preg can cause what conditions?

A

cardiac defect and orofacial clefts linked

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9
Q

what factor (in AE med usage) can increase the malformation risk in baby?

A

polypharmacy 6-7% for one drug, 15% for two and up to 50% for three

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10
Q

what amount of negative effects of AE drugs depends on?

A

dose, increased effect with increased dose

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11
Q

is lamotrigine safe to use in preg epileptic pt?

A

dose dependent effect on baby
only safe if <200mg BD
new drug, better than valproate and caba,

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12
Q

Evidence weak but we do advise all epileptic women esp. those on any of AE drugs to take what supplement?

A

5mg folic acid daily for at least 3 months pre-conception

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13
Q

how do we adjust the dose for thyroxine for preg pt who have hypothyrodism?

A

increase pre-pregnancy dose slightly during pregnancy

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14
Q

why do we need to increase thyroxine dosage in preg pt

A

Small amounts of thyroxine cross placenta and the foetus depends on maternal thyroxine until 12 weeks

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15
Q

what is pre-eclampsia

A

disease specific to pregnancy
high blood pressure and proteinuria
mother can have fits / strokes or die
baby severely growth restricted or die due to reduced blood supply

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16
Q

what can we do to minise the risk for baby in a pre-eclampsia mother

A

(c-cession, artificial early birth as baby stopped growing)

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17
Q

antihypertensives that can be used in preg pt?

A

Αlpha-methyl dopa
Nifedipine- give tds not bd due to increased vd =off label
Labetalol (orally and IV) rescue drugs
Hydralazine when BP is TOO HIGH rescue drugs

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18
Q

what type of antihypertensives are absolutely contraindicated?

A

ACE inhibitors, diuretics and ATII receptor blockers are contra-indicated

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19
Q

inappropriate medications use in each stage of preg can cause what type of prob for the baby?
- 1st trimester

A

congenital (anatomical) abnormalities.

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20
Q

inappropriate medications use in each stage of preg can cause what type of prob for the baby?
- 2/3 trimester

A

affect growth and functional development.

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21
Q

medications use in end of preg, in labour can have an effect on what?

A

Medications given at the end of pregnancy / in labour may affect the neonate.

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22
Q

3 rules in preg prescribing

A
  • use old med which are known to be safe (even tho lamo is new)
  • use smallest effective dose
  • ideally med should be stopped or changed pre-conceptally (before trying to have baby)
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23
Q

what are the three trimesters in preg?

A

1st trimester - 0-13w
2nd - 13-28w
3rd - 28- 40w

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24
Q

describe how is drug absorption affected by preg?

A

reduced absorption

  • morning sickness
  • progesterone reduce gastric emptying, slows the absorption, lowers the peak conc, a bigger prob in single use rather than long term
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25
Q

describe how is drug distribution affected by preg?

A

increased body water volume
decreased albumin production, increase preg steroid which displaces drugs from protein binding sites. increased ‘free’ fraction

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26
Q

describe how is drug metabolism affected by preg?

A

preg affects cyp450 enzymes- metab of other drugs eg induce enzymes that metabolise lamotrigine - higher dose needed

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27
Q

describe how is drug elinimation affected by preg?

A

higher cardiac output, increased 50% of GFR
drugs that are renally excreted eg penecillin will be excreted faster
amoxicillin- given 500mg tds instead of 250mg tds due to increased cl

28
Q

what could be the reason for NUD in baby? (rmb: cong impairment is multifactorial)

A

sodium valproate and cofactor folate deficiency

29
Q

how does mol cross placenta? what molecular factors are important in this?

A

simple diffusion

MW and conc grad

30
Q

what does BUMPS stand for

A

best use of medicines in pregnancy

31
Q

what does UKTIS stand for

A

uk technology information service (MI specialist service)

32
Q

why is NSAID should be avoid in 3rd trimester?

A

In a fetus the ductus arteriosus allows blood to bypass it’s non-functioning lungs.
NSAIDs given in third trimester can prematurely close this blood vessel which can lead to serious fetal and neonatal complications eg, pulmonary hypertension

33
Q

Nitrofurantoin at term must be avoided due to

A

he risk of haemolytic anaemia in the newborn.

34
Q

Drug pharmacokinetics change in the mother during pregnancy, when does it revert?
what med might be an issue?

A

as soon as given birth (post-natal)
lamotrigine metabolising enzymes induced in preg, higher doses needed. normalised level enzyme postpartum, so REDUCE the dose to avoid toxicity

35
Q

what other meds doses might be increased in preg?

A

AE- lamotrigine
AH- labetolol, nifidepine
levothyroxine

36
Q

how can we amend nifidepine dosage in post-partum?

A

TDS to BD due to reduced Vd

37
Q

high BP is common in preg, how long does it take for BP to normalised post-partum?

A

after SIX weeks of giving birth

38
Q

trimester exposure:

at the v beginning first x days

A

First 17 days = ‘all or nothing principle’

39
Q

when is embryonic phase

an exposure will result in what

A

Day 18-55 (8w) (embryonic phase) congenital malformations can occur.

40
Q

when is fetal phase?

an exposure will result in what

A

Day (8w) 56 onwards (fetal phase) medicines may affect the growth and functional development (e.g. hearing) of the fetus or have toxic effects on fetal tissues.

41
Q

WHO recommends exclusive breastfeeding for the how many months of life

A

WHO recommends exclusive breastfeeding for the first six months of life

42
Q

ADVANTAGES OF BF FOR BABY (1) Immune Function

A
  • provide maternal igG
  • provide igA (cant be obtained from formula milk) only obtained after colostrum and breastfeed
  • provide igM in response to infections
43
Q

Receiving IgA reduces incidence of:

A
  • necrotising enterocolitis
    (IgA especially important to protect mucosal barriers)
    -Ear, gastrointestinal, respiratory and urinary tract infections
44
Q

how does breast milk help reduce infections?

A

provide ig and hormones that stimulates their iMS

45
Q

BF also reduces incidence of:

A
  • diarrhoea
  • anaemias
  • risk of sudden infant death syndrome (SIDs) by 50%
46
Q

how does BM (breast milk) reduce iron related anaemia?

A

Iron in breast milk more easily absorbed by baby than formula milk

47
Q

Possible long-term health benefits of BM

A

reduced risk of adult obesity diabetes

osteoporosis

48
Q

ADVANTAGES OF BF FOR MOTHER

A

reduce - BP

  • blood loss postpartum - anaemia
  • risk of osteoporosis
  • stress, improve mood
  • ovarian, breast cancer
  • bonding with baby
  • cheap, convinient
49
Q

why is baby’s age important in predicting if a drug will/will not pass through BM to reach inside them?

A
  • during the first 48h of life,
  • large gap between alveolar cells
  • allow maternal ig, protein,wbc to pass through
  • easier for drugs to get through as well
50
Q

who is metabolising the drugs?

  • in utero
  • BF
A
  • in utero, drugs are metabolised by the mother

- drugs exposed in BM, baby have to metabolise them

51
Q

4 drug properties that helps predict if a drug will pass through BM or not

A

to be passed through BM

  1. MW <300
  2. lipid solubility (high)
  3. protein bound (low)
  4. acid-base (more basic)
52
Q

if BM acidic or basic?

A

slight acidic compare to blood

53
Q

which type of meds will have a higher conc in BM adn why? weak acid or weak base?

A

BM is weakly acidic

weak base drugs will have a higher conc because it will get ioinsed in milk

54
Q

which 2 drugs are high protein bound? what is the implication on BM passage?

A

sodium valpoate 94%
warfarin 99%
theoretically safe to use in BF but monitor s/e eg hepatic function, bleeding/bruise
it is prob safer in full term baby

55
Q

what type of liquid is BM? what is the implication on drug passage?
what type of med will have high conc in bm?

A

fat in water emulsion
high lipid solubility will dissolve in the fatty globules in milk
all CNS penetrating medications will have a higher concentration in breast-milk.

56
Q

lipid solubility is not a good predictor of drug accumulation in the milk.
WHY?

A

Fat is small proportion of milk volume

57
Q

what is the MW restriction on the passge in BM for durgs?

on what occasion does MW restriction not apply?

A

<300 allowed through
>600 diff to pass mem, eg insulin, heparin
during the first 48h of life, where alveolar gaps are large and more drugs will go through

58
Q

why is lithium contraindicated?

A
  • serious SEs (tremour/ involuntary movements) have been documented in BF babies, who can get about 56% of the maternal dose.
59
Q

FACTORS PRODUCING POOR EXCRETION INTO BREAST MILK

A

High molecular weight- excep: first 48hrs
Highly protein bound- bond to placenta blood
Weak acid- acidic milk
Short acting medication or preparation
No active metabolites
(fat doesnt count bc sm proportion)

60
Q

when is the best time to take med whilst BF

A
  • take dose STRAIGHT AFTER BF

- take at NIGHT (less BF at night)

61
Q

which SSRI is better option for BF mum? why?

A
  • paroxetine not fluoxetine
  • shorter half life
  • fluoxetine has longer half life and has active metabolites that last for 7-15 days
62
Q

what are the alternative options for codeine use in BF?

A

dihyrocodeine or tramadol

63
Q

can you give warfarin or dalteparin to a mum who is BF a pre-term baby?

A

YES- warfarin highly protein bound + delteparin high MW
BUT - pre-term baby (not fully developed hepatic/renal metabolism- more at risk [also they will benefit more from BM])
- give oral vitK
- monitor

64
Q

can BF mum use nitrofuratoin?

A

low in BM but depends on baby’s age-
CI if <1m + C-6-PD deficiency (can’t metab) due to potential haemolysis in infant
if full term healthy: can use after 8 d of birth

65
Q

DRUGS USED TO STIMULATE LACTATION (galactagogues) for pre-mature baby

A

dopamine D2 antagonist domperidone

66
Q

DRUGS USE TO SUPPRESS LACTATION used if still birth late preg

A

dopamine receptor agonist carbigotine

SIU6 Special patient group (6 decks)

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