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PHAY0085 > Pregnancy and Lactation [COMPLETE] > Flashcards

Pregnancy and Lactation [COMPLETE] Flashcards

1
Q

What are some common conditions that can affect women during the antenatal period? (8)

A

Emesis
Hyperemesis
Pregnancy induced hypertension
Pre-eclampsia
Eclampsia
VTE
Gestational diabetes
Infection

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2
Q

What is eclampsia?

A

Develops from pregnancy induced hypertension and pre-eclampsia
Can lead to seizures during pregnancy
Danger to foetus - may need emergency C section as early as 30 weeks

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3
Q

What is gestational diabetes?

A

Diabetes that arises during pregnancy but resolves after birth which can pose a risk to both mother and baby (growth)

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4
Q

Why does gestational diabetes occur?

A

due to placental hormones - insulin resistance can occur

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5
Q

How is gestational diabetes detected?

A

Oral glucose tolerance test - 75g glucose drink
Blood sugar checked before and after to see if there is insulin resistance

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6
Q

How is gestational diabetes managed ?

A

Diet

If not managed by diet then metformin or insulin

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7
Q

When is a pregnancy considered to be at term?

A

37 weeks onwards

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8
Q

What conditions may effect a mother in the postnatal period?

A

Pain (tears, stitches, c-section initial healing 6 weeks but may take up to 18 months to fully heal)
Infection
Transition to pre-pregnancy medications that were altered
Breastfeeding

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9
Q

How do we manage medications in pregnant women?

A

Minimise and avoid unnecessary risk
Consider mother’s long term condition
Optimise safe treatment
Counsel patients
Use resources to make decisions

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10
Q

What are some common medications used during pregnancy?

A

Folic acid
Vitamins (especially Vit D)
Iron
Aspirin - pre-eclampsia, migraines
Metformin and/or insulin
Labetalol/Nifedipine
Cyclizine/metoclopramide
Antacids, PPIs
Vaccinations - flu, whooping cough, COVID, RSV

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11
Q

What is the aim of giving vaccines such as whooping cough or RSV to pregnant women?

A

Protecting mother but also passing antibodies on to baby until they caan get their own vaccines around 8-12 weeks.

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12
Q

What is teratogenicity?

A

The ability of a drug/agent to cause foetal abnormalities or deformities. They do this by crossing the placenta and directly or indirectly causing structural abnormalities which may not always be apparent until later on in life

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13
Q

What is foetal response to a teratogen dependent on? (5)

A

Dose (e.g. higher dose of carbamazepine = higher risk)
Route
Timing of exposure (what trimester???)
Genetic and environmental factors
Number of concomitant drugs?

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14
Q

What was thalidomide used for before its teratogenic effect was discovered?

A

Morning sickness

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15
Q

What are some other non-medication teratogens?

A

Alcohol
Chemicals
Infections (e.g. Zika virus)

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16
Q

What are the three stages of human development in the womb?

A

Pre-embryonic (conception to 17 days post-conception)
Embryonic (day 18 to 55)
Foetal (8 weeks to term)

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17
Q

What is the effect of drug exposure in the pre-embryonic stage?

A

‘All or nothing principle’ - can effect ability of embryo to attach to uterus so either death or survival

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18
Q

What is the effect of drug exposure in the embryonic stage?

A

Greatest vulnerability as tissue is rapidly differentiating and major organs are being formed - permanent malformations can occur

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19
Q

What is the effect of drug exposure in the foetal stage?

A

Major organ and structures already formed but cerebral cortex and glomeruli are still developing and can be damaged. Functional abnormalities such as deafness can occur.

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20
Q

Why would we avoid medication as much as possible in the first trimester?

A

Greatest period of susceptibility and vulnerability to teratogenicity

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21
Q

What can happen if teratogenic medications are taken during the second and third trimester?

A

Growth can be affected
Functional defects -sensory, metabolic and intellectual

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22
Q

Give an example of a drug if taken at the end of pregnancy or during labour that can have an effect on the neonate after delivery

A

Benzodiazepines - baby can have withdrawal effects

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23
Q

What is the transport of drugs across the placenta dependent on?

A

Molecular size
Degree of ionisation
Protein binding
Lipid solubility

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24
Q

What kind of drugs are more likely to cross the placenta?

A

Non-ionised lipid soluble drugs such as labetalol
Low MW drugs
INFLIXIMAB is a HIGH MW drug that can cross the placenta

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25
What are some examples of harm that could occur in pregnancy due to medication?
Malformations Spontaneous abortion - isotretinoin Intra-uterine growth restriction - beta blockers Prematurity - statins Stillbirth - warfarin Neonatal side effects - Sedatives Withdrawal - opioids/benzodiazepines Impaired neurodevelopment - Sodium valproate
26
What harm can isotretinoin cause in pregnancy?
Spontaneous abortion
27
What harm can beta-blockers cause in pregnancy?
IUGR (Intra uterine growth restriction)
28
What harm can statins cause in pregnancy?
Prematurity
29
What harm can warfarin cause in pregnancy?
Stillbirth
30
What harm can sedatives cause in pregnancy?
CNS depression in neonate
31
What harm can opioids and benzodiazepines cause in pregnancy?
Withdrawal symptoms in neonate after birth
32
What harm can sodium valproate cause in pregnancy?
Impaired neurodevelopment
33
What are the four mechanisms via which harm can occur in pregnancy?
Passive diffusion (through placenta) Damage to placenta such as vasoconstriction or medical conditions that mean it cannot function like it should Damage to uterus - e.g. medications causing it to contract Harm to mother such as illness
34
What are some known teratogens? (15)
Thalidomide Methotrexate Isotretinoin ACEi and ARB Statins Fluconazole NSAIDs Live vaccines e.g. MMR . flu nasal Lithium Tetracyclines Chloramphenicol Warfarin DOACs Spironolactone Valproate
35
Women and girls of childbearing potential taking isotretinoin must....
be on a pregnancy prevention programme
36
What is the guidance regarding NSAID use in pregnancy?
Avoid in 3rd trimester except for low dose aspirin (75-150mg) used for pre-eclampsia if benefits outweigh risk
37
What is the guidance regarding lithium use in pregnancy?
Avoid if possible in 1st trimester Dose requirements may change in 2nd and 3rd trimester Closely monitor serum lithium
38
What is the guidance regarding tetracycline use in pregnancy?
Avoid in 2nd and 3rd trimester due to effect on teeth and bones of foetus
39
What is the guidance regarding chloramphenicol use in pregnancy?
Only to be used in life threatening infections
40
When may warfarin be used in pregnancy?
prosthetic heart valve disease
41
Valproate teratogenicity
Highly teratogenic 30-40% risk of neurodevelopmental disorders 10% risk of congenital malformations
42
Guidance regarding valproate use in women and girls of child bearing potential? (5)
Do not stop taking without speaking to a specialist first Inform patient of risks Must meet conditions of a pregnancy prevention programme - negative monthly pregnancy test and contraception (e.g. IUD, birth control, condoms) If newly initiated in females under 55 needs to be approved by two specialists Box has warnings - no part packs
43
Guidance regarding valproate use in men under 55?
Risk of male infertility If newly initiated in males under 55 needs to be approved by two specialists Men should use effective contraception during and 3 months after treatment due to potential risk of neurodevelopmental disorders if father is taking
44
What happen to the PK of drugs during pregnancy and what is the effect of this?
Anatomical and physological changes can impact the PK of drugs -> impacts drug efficacy and toxicty
45
What happens to gastrointestinal absorption during pregnancy?
Prolonged gastric and intestinal emptying Less gastric acid secretion increased gastric pH and mucus Affects ionisation and absorption of weak acids and bases
46
What happens to lung absorption during pregnancy?
Increased CO and tidal volume Increased alveolar uptake of inhaled meds (not for inhalers) and may need to lower dose of volatile anaesthetics
47
What happens to distribution during pregnancy? (VOLUME OF DISTRIBUTION)
50% increase in plasma vol Increase in fat stores Vd of drugs increases , peak serum conc decreases Vd of drugs distributed in adipose tissue increases
48
What happens to distribution during pregnancy? (PROTEIN binding)
Dilution hypoalbuminemia in late pregnancy Steroid and placental hormones occupy protein binding sites Lowers protein binding of some drugs --> more free drug but net effect low due to excretion Consider highly protein bound drugs such as phenytoin
49
What happens to hepatic metabolism and elimination during pregnancy?
Increased hepatic blood flow - Faster elimination of high extraction drugs Increased progesterone - Increased metabolism of some drugs, decreased elimination of others Increased oestrogen - Interferes with clearance of drugs excreted into biliary system
50
What happens to renal elimination during pregnancy?
Increased renal plasma flow and GFR - increased elimination of drugs that are eliminated unchanged , lower Css as it takes longer to get to steady state Increased activity of renal tubular P-gp - Lowered concentration of drugs transported by renal system
51
What should be done post-delivery to medications that the woman was on before pregnancy?
Adjust doses as appropriate - e.g. lamotrigine needs to REDUCED as dose is increased during pregnancy but hormones change as soon as baby is born
52
What are some factors that need to be considered when thinking about paternal exposure to medications?
Medicines Environmental factors - smoking, radiation, heavy metals, organic solvents, pesticides How long to wait between stopping medication and trying to conceive Effective contraception during and after treatment
53
What are some medications that require use of effective contraception after treatment due to paternal exposure to teratogens/medication that could be harmful in pregnancy?
Valproate - 3 months Cytotoxic agents usually 6 months (2 spermatogenic cycles) Cyclophosphamide - 3 months Rituximab - 12 months
54
What questions would be asked to a patient when information gathering to decide what medication would be appropriate in a possible pregnancy?
Pregnant vs planning to get pregnant Age of mother Stage of pregnancy (weeks gestation) Allergies, PMHx, DHx, SHx Co-morbidities in mother AND baby Monitoring already being carried out Obstetric history Breastfeeding concurrently Indication and need for medication
55
What are sone resources that could be used to make a decision about if a medication is appropriate during pregnancy?
BNF (limited data) SPC (limited data) UKTIS Bumps SPS
56
How should women who are pregnant or planning to be pregnant be counselled on medications?
Potential consequences of using during pregnancy - risk to child vs benefit of treating maternal condition How likely the woman and child are to be affected What can be done to manage risks
57
What are the benefits of breastfeeding? (4 mother, 5 baby)
Economical Convenient Improves bonding Lowers risk of OBU cancer , osteoporosis, CVD, obesity Immunological status Nutritionally complete for 6 months More easy to digest Lowers risk of allergy Lowers risk of SIDS, obesity, and CVD in adulthood
58
What are some issues with breastfeeding?
Puts mother under pressure Breastfeeding in public Return to work Pain Extra calories Diseases/medication use Premature babies may need supplemented formula (e.g. if phosphate or calorie deficient) Mothers of premature babies may stop lactating Medical needs
59
What is breast milk made up of and how does its composition change?
Fat droplets in an aqueous phase containing proteins, lactose and electrolytes Composition can change based on: duration of feed (longer feeds = heavier milk = more stuff in the milk) time of day needs of baby
60
Where can medication be present in the present in breast milk?
Lipid phase - fat droplets Aqueous phase Bound to milk proteins
61
Why do we need to look at the effect medicines have in lactation?
Usually outside of licensing - potential risk but no robust evidence Need to support and reassure mother Need to consider effects on mother and baby such as inhibition of milk production or of sucking reflex
62
In the first few days after birth how do drugs enter the breast milk?
Wide intracellular gaps between the mother's milk ducts so that immunoglobulins can pass through to give baby immunity but also means that drugs can also pass through so baby is more vulnerable to effects
63
What happens once intracellular gaps between milk ducts close?
Drugs must cross cellular membranes so it is harder for them to get to infant
64
Pharmacokinetic considerations in lactation (10)
Oral bioavailability Plasma protein binding Milk to plasma ratio Fat solubility Molecular weight Absorption from infant gut First pass metabolism Neonatal clearance Toxicity of the drug
65
PK CONSIDERATION Oral bioavailability in lactation.
If negligible then baby will not absorb drug e.g. insulin, infliximab and LMWH
66
PK CONSIDERATION Plasma protein binding in lactation
Highly protein bound = less transfer into milk e.g. ibuprofen is 99% protein bound
67
PK CONSIDERATION Milk: plasma ratio in lactation.
Lowe M:P smaller amount of drug in milk (most drugs <1) - iodine has a M:P of 26 so would avoid iodine dressings Sertraline M:P is 0.89 - first line treatment in breastfeeding
68
PK CONSIDERATION Fat solubility in lactation.
Lipophilic drugs will dissolve in fatty globules and can pass the lipid alveolar epithelium into milk e.g. benzos and amitriptyline
69
PK CONSIDERATION Molecular weight in lactation.
Large molecular weight = low oral bioavailability so unlikely that baby will absorb ALCOHOL has a low MW
70
PK CONSIDERATION Absorption from infant gut in lactation.
Drug may enter milk but not significantly absorbed from the infants gut - gentamicin, insulin, dopamine
71
PK CONSIDERATION First pass metabolism in lactation.
If drug undergoes first pass metabolism then only a limited amount is absorbed by baby e.g. morphine
72
PK CONSIDERATION Neonatal clearance in lactation.
As neonatal kidney and liver function is not optimal drugs (Especially those with a long half-life such as fluoxetine) can accumulate - consider shorter acting alternatives
73
PK CONSIDERATION Toxicity of drug in lactation.
Avoid drugs that are toxic in even small amounts such as cocaine and some cytotoxic agents Some medication are unlikely to be harmful unless huge dose - iron, potassium
74
How is relative infant dose calculated?
infant daily dose (mg/kg) / mother's daily dose (mg/kg) x 100
75
PK CONSIDERATION Relative infant dose in lactation
< 10% compatible 10-25% caution >25% unacceptable ranges may need to be changed in mixed feeding or if drug has unusually high or low clearance sertaline is 0.4-2.2%
76
What information gathering would be needed to help a mother make an informed decision about taking medication during breastfeeding?
Details about mother AND baby PMHx, DHx, SHx Age of baby (corrected age - premature or full term?) Circumstance of birth (natural or c-section) Frequency (dependent on age) type of feeding (EBF, expressed bottle. formula, mixed) quantity of feeding
77
What is the overall guidance on medication administration during breastfeeding?
Only essential drugs Lowest effective dose Consider licensing Resources to help professional judgement -SPS , Lactmed
78
What to consider when managing the risks of medication use during breastfeeding? (before actually taking the medication - 4)
Is it essential? Are there alternative non-pharmacological and pharmacological options? Can breastfeeding be interrupted temporarily (avoid disruptions if possible) - short courses as can take 4-6 weeks to establish, pump and dump to discard affected milk Timing - e.g shorter half life drugs used between feeds
79
How should we manage the use of a drug with potential neonatal side effects during breastfeeding? (when we know the medication is actually being taken - 6)
Monitor baby Avoid multiple drugs with similar side effects Minimum effective dose Dosage forms that limit systemic exposure Avoid new drugs - less info Avoid meds with long half-lives
80
Codeine in breastfeeding?
Avoid in breastfeeding - metabolism into morphine particularly a risk for ultra rapid metabolisers Dihydrocodeine is preferred
81
Medication that can cause drowsiness in breastfeeding?
Meds like chlorphenamine can cross BBB and cause a sedative effect in baby
82
Antibiotics in breastfeeding?
May cause temporary lactose intolerance but should not stop breastfeeding. If its licensed for children then generally can be given in breastfeeding
83
SSRIs in breastfeeding?
Sertraline and citalopram well studied Little passes into milk so okay to use Do not stop breastfeeding as depression can be exacerbated by loss of oxytocin
84
Lithium in breastfeeding
Contraindicated
85
Methadone in breastfeeding?
Highly plasma protein bound RID 1.9-6.5% Can be used if prescribed by specialist services
86
Herbal remedies in breastfeeding?
Limited data so would avoid/do not reccomend
87
What should pharmacists do when counselling breastfeeding mothers about their medications?
Give patient enough information to make an informed decision Explain why a med can be used safely and professional advice could differ to leaflet Make sure mother is involved in discussions and decision making process

PHAY0085 (15 decks)

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