Pregnancy and Lactation Dr. Dowling Flashcards
EXAM 2
Which drugs are less likely to pass the placenta?
EXAM Q
-hydrophilic
-ionized
-high-protein-bound
-larger MW (>600 Daltons)
-when clinical data is not available, evaluate thee risk by predicting if the drug is able to pass the placenta
Which drugs may be used for medication-induced abortion?
-Mifepristone
-Misoprostol
Which common drugs should NOT be used during pregnancy?
-EtOH, nicotine
-Isotretinoin
-Methotrexate
-Mifepristone, Misoprostol
-NSAIDs
-RAAS inhibitor
-Phenytoin, Valproic acid
-Warfarin
When should Folic acid supplementation be initiated?
-consider for all women of childbearing age
-start at leat 3 months before conception and continue to 12 weeks gestation (which is beyond the early fetal development phase)
What is the recommended dose for folic acid supplementation?
0.4 mg (400 mcg) for most women
4mg daily for high risk of NTD (neural tube defect)
-previous NTD
-diabetes
-smoking
-BMI > 35 kg/m2
-antiepileptic drug use
Which supplements should a prenatal vitamin contain?
-Vitamin D
-Calcium
-Iron
-Folic acid
What are the recommended doses of iron for women?
18 mg per day for non-pregnant women
27 mg per day if pregnant
What are the recommended doses of Calcium for women?
1000 mg/day
What are the recommended doses of Vitamin D for women?
600 mg/day
Which vaccines are recommened for women
Hepatitis B
MMR (Live)
Varicella (Live)
Influenza - administere at the start of the season, in pregnant patients or those who try to conceive, use inactivated if pregnant
Which of the recommended vaccines are live vaccines?
MMR
Varicella
-> dont administer during pregnancy, wait until after pregnancy, due to an immunocompromised state (immune system is downregulated to prevent from targetin the fetus)
Which vaccine should be administered during pregnancy?
Tdap (Tetanus, Dipheteria, Pertussis)
-> for every single pregnancy
-> Pertussis especially bears a high risk for newborns
during 27-36 weeks
(normal window is 10 years)
When is the typical onset of gestational diabetes (GDM)?
midst pregnancy - 24-28 weeks
What is the first-line treatment for gestational diabetes?
patients get tested midst pregnancy
-> if positive: non-pharmacoligocal treatment
-nutrition and exercise for 1-2 weeks
Which meds are preferred in gestational diabetes?
-insulin is preferred (best studied for safety in pregnancy)
-metformin and glyburide are acceptable oral alternatives
What is the time of onset for HTN during pregnancy?
20 weeks or later
How is HTN of pregnancy diagnosed?
Patient with no preexisting HTN and with 2 readings of >140/90
When is medical treatment for HTN of pregnancy initiated?
After 2 readings of >160/110
severe HTN
Background: we wait until severe HTN to balance risk and benefits: side effects of antihypertensive meds such as hypotension
Which antihypertensive drugs are preferred for HTN of pregnancy?
-labetalol, nifedipine ER (BID)
2nd line: HCTZ, methyldopa
AVOID: RAAS inhibitors: ACEi, ARBs, renin inhibitors
How much should the dose of levothyroxine be increased in pregnant patients with hypothyroidism?
increase the dose by at least 25%
Which antidepressants are preferred in pregnant patients?
SSRIs (fluoxetine, sertraline)
-> paroxetine somewhat associated with cardiac malformation
if a pateint’s depression is controlled -> keep the antidepressant during pregnancy
pregnancy is an intense hormonal experience time, discontinuation can trigger depression and suicidal ideation
What is Eclampsia?
emergency situation
Preeclampsia (HTN and Proteinuria(loss of protein in the urine))
+
Seizures
= Eclempsia
What else should be monitered if a patient presents with HTN during pregnancy?
check for proteinuria
-> Interfere (treat HTN) to prevent seizures if high levels of protein in the urine (Eclempsia)
When is the predicted onset of Eclempsia during pregnancy?
-typically after 20 weeks (like HTN)
-postpartum: up to 6 weeks after delivery
When is an acute treatment for HTN during pregnancy appropriate?
> 140/90 and proteinuria
How is Preeclampsia treated?
Urgent HTN: IV or immediate release (oral)
-IV labetalol
-oral nifedipine IR
-IV/IM hydralazine
What other interventions can be considered to prevent the progression from Preeclampsia to Eclampsia during active labor?
IV mag sulfate (short-term)
-usually during active labor and 12-24 hr postpartum
What is the prophylaxis treatment for Preeclampsia?
Aspirin 81 mg daily
-after 12 weeks -> throughout the pregnancy
REMEMBER: NSAIDs are contraindicated in pregnancy, Aspirin is exception
What are the high-risk factors that determine initiation of prophylaxis for Preeclampsia?
Any high-risk factors -> start Preeclampsia prophylaxis
-prior case of preeclampsia
-non-singleton pregnancy (twins, triplets)
-chronic HTN
-pre-gestational diabetes
-renal disease
-autoimmune disease
What are the moderate-risk factors for Preeclampsia?
2 or more of moderate risk factors -> treat Preeclampsia
-Family history of Preeclampsia
-Nulliparity (never given birth before)
-Pre-pregnancy BMI > 30
-age > 35 (geriatric pregnancy)
->10 years between pregnancies
-previous poor birth outcome
When to initiate Aspirin for Preeclampsia prophylaxis?
-one high-risk factor
-2 or more moderate risk factors
-wait until week 12! -> so we pass the early fetal development stage
What are the first-line meds for N/V in pregnancy (morning sickness)
-Ginger (supplement, candy): 4 times daily
or
-B6 (pyridoxine) + doxylamine: up to 4 times daily
-> Bonjesta, Diclegis
What are the first-line meds for pain in pregnancy?
Acetominophen
NSAIDs should be avoided during the first 20 weeks (but often we don’t know the exact gestational age)
Exception: with Aspirin and preeclampsai prophylaxis
What are the first-line meds for VTE during pregnancy?
Low-molecular-weight heparin
-pregnancy is a hypercoagulable state
-> risk of blood clots (5x higher than normal)
AVOID Warfarin!
What is the purpose of tocolytic therapy?
postpone early labor by 48h to 7 days
-> we want to keep the baby in the womb bc it still developing
Meds used for tocolytic therapy
Nifedipine
Terbutaline (beta agonist)
Indomethacin
Magneisum sulfate
Which drug helps with fetal lung maturation in early labor?
Steroids:
Betamethasone
Dexmethasone
Which drug is indicated for cervical ripening?
Misoprostol (Prostaglandin E1 analog)
Dinoprostone (Prpstaglandin E2 analog)
-> helps with the dilation of the cervix
Which drug is indicated for labor induction?
Oxytocin
Which drug is indicated for comfort during labor?
Epidural: anesthetic injection in the epidural space (back)
Opioid or anesthetic (ex: fentanyl + bupivacaine)
When should breastfeeding be initiated?
1st hour of birth -> continue for the first 6 months
-> greatest potential impact on reducing childhood mortality
-consider pumps, formulas for those who do not prefer to breastfeed
What is the best way to schedule drug intake during the phase of breastfeeding?
use the time when they are not breastfeeding
-> take once daily tablets prior to baby’s longest sleep of the day
(we want to limit the time of drug exposure to the baby)
multiple daily dosing: after breastfeeding
Common drugs that are not compatible with breast milk
Amiodarone Lithium
Amphetamines Nicotine
Certain Beta-blockers
(acebutolol, atenolol, sotalol)
Chemotherapeutics
Illicit drugs
Lamotrigine
Lithium
Nicotine
Phenobarbital, Primidone
Statins
Tetracyclines
Common drugs that may decrease milk production
-Estrogen
-Pseudoephedrine
-Clomiphene (used to induce ovulation)
-Ergot derivatives (bromocriptine,
cabergoline, ergotamine)
How are Lactation disorders treated?
1st line: non-pharmacological treatment
2nd line:metoclopramide: but
GI distress, extrapyramidal symptoms (can’t sit still, parkinson-like symptoms), methemoglobinemia in infants -> mostly not recommended
What is the treatment for Mastitis?
infected mammary gland
-1st line: dicloxacillin
alternative: cephalexin
add ibuprofen (not contraindicated in breastfeeding)
What is the treatment for Nipple candidiasis?
1st line:
topical micanozole or clotrimazole
applied to the nipples after each feeding
+
oral nystatin for infant’s mouth (it passed from the mom to the baby)
Which hormone drops significantly after delivery?
Progesterone by 85%
more severe -> postpartum depression
