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MPharm2 SL22108 > Pregnancy + BF > Flashcards

Pregnancy + BF Flashcards

1
Q

What are the 8 benefits of breastfeeding for the baby?

A
  • Breast milk is nutritionally tailored to meet babies needs
  • Boost babies immune function – maternal hormones and immunoglobulins passed to baby to stimulate immune system
  • IgA important to protect mucosal barriers and reduces incidence of ear, G.I., respiratory and UTI infections
  • Reduces diarrhoea
  • Iron anaemias
  • reduces risk SIDs by 50%,
  • Improves cognitive development
  • Possible long term benefits of reduced risk of obesity, diabetes and osteoporosis
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2
Q

What are the 8 benefits of breastfeeding to the mother?

A
  • Lowers blood pressure and post-partum blood loss
  • Decreased risk of bone problems
  • Protection against breast cancer
  • Reduced risk of ovarian cancer
  • Reduced risk of postmenopausal cardiovascular disease
  • Improves mood
  • Bonding
  • Convenient, flexible and cost-effective
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3
Q

What are the 6 best pain killers to take while breastfeeding?

A

Paracetamol – Very low risk
Ibuprofen - very low risk
Diclofenac – very low risk
Tramadol – very low risk
Dihydrocodeine - low Risk
Morphine – opioid of choice - Infant monitoring required

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4
Q

Why is codeine not recommended during breastfeeding?

A
  • Codeine is metabolised to Morphine via CYP2D6
  • Some people will be have excess CYP2D6 and be ultra-rapid metabolizers
  • New-borns have a limited capacity for opioid elimination so accumulation can easily occur
  • Not practical to identify ultra-rapid metabolisers – needs to be done by genotyping and this is not readily available.
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5
Q

What are the recommendations around pregab + gabapentin?

A

Gabapentin and pregabalin are small molecules with low protein binding which enable them to pass into breast milk. Limited evidence shows only transfers in small amounts (Gabapentin estimated 1.3 to 3.8%, pregabalin estimated 7%)
Monitor side effects in baby – poor feeding, drowsiness, respiratory depression, G.I. disturbances

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6
Q

What are the recommendations for penicillins while breastfeeding?

A
  • Flucloxacillin, Pen V and Amoxicillin are all ok to use – lots of evidence and experience to support use
  • All acidic in nature so negligible quantities pass into milk
  • Lots of these are also used for treatment in neonates
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7
Q

What are the recommendations for nitrofuratoin while breastfeeding?

A
  • Excretion into breastmilk is clinically insignificant but
  • Not to be used in premature infants, younger than 2 weeks of age, G6PD deficiency, jaundice – risk of neonatal haemolysis
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8
Q

What are the recommendations for metronidazole while breastfeeding?

A
  • Excreted in moderate amounts (low molecular weight; low protein binding), fully orally bioavailable, short half-life, minimal risk accumulation. Ok to use short courses, monitor GI effects
  • Premature or new-borns are unable to metabolize metronidazole well so use minimum effective dose or see alternative
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9
Q

What are the recommendations for Gentamicin while breastfeeding?

A

Excreted in insignificant amount
Poorly absorbed from G.I.Tract
Used in Neonates

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10
Q

What are the recommendations for macrolides while breastfeeding?

A

Erythromycin
- Excreted in negligible amounts
- Potential risk of hypertrophic pyloric stenosis – avoid in 1st month life

Clarithromycin
- Excreted in negligible amounts
- Low risk – monitor for G.I Side effects

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11
Q

What are the recommendations for SSRIs while breastfeeding?

A

Paroxetine and Sertraline are SSRI’s of choice due to shorter half-lives and pass into milk in smaller amounts compared to others

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12
Q

What are the recommendations for tricyclics while breastfeeding?

A

Imipramine and nortriptyline are TCAs of choice as less sedating and reduce risk of infant sedation
Most can be used – limited evidence shows levels are low and because TCAs undergo first-pass metabolism the actual amount available for infant to absorb are substantially less.
Long half-lives could result in accumulation and increased side-effects

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13
Q

What are the recommendations for anxiolytics and sleeping pills while breastfeeding?

A

Use short-acting benzodiazepine – Lorazepam, oxazepam
Use lowest effective dose
Excreted in milk in clinically significant amounts – risk of sedation and poor sucking in infant
Use ‘Z’ drugs for sleeping disorders – zopiclone and zolpidem – again short half-life and small amounts in breastmilk
Withdrawal effects may occur in infant

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14
Q

What are the recommendations for Haloperidol while breastfeeding?

A

Haloperidol
- Excreted in milk in variable amounts, so could be clinically significant

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15
Q

What are the recommendations for Olanzapine while breastfeeding?

A

Olanzapine
- Doses up to 20mg daily produce low levels in breast milk
- Long half-life so need to monitor for signs of accumulation – sedation, poor feeding etc.

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16
Q

What are the recommendations for Risperidone while breastfeeding?

A
  • Excreted in small amounts, okay to use
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17
Q

What are the recommendations for Quetiapine while breastfeeding?

A

Quetiapine
- Excreted in clinically insignificant amounts

18
Q

What are the recommendations for Lithium while breastfeeding?

A

Lithium
- Excreted in milk in moderate amounts which could be clinically significant
- Plasma levels in infant can reach 10% to 60% of therapeutic levels in mother
- Use with caution – regular checks on infant for signs of lithium toxicity – monitor poor feeding, poor weight gain, changes in behaviour, diarrhoea, monitoring, tremor
- Can do infant lithium levels

19
Q

What are the recommendations for Methylphenidate while breastfeeding?

A

Methylphenidate
- Excreted in milk in clinically insignificant amounts or not at all
- No short or long term problems observed in infants exposed via breastmilk
- Monitor weight gain and irritability

20
Q

What are the recommendations for heparins while breastfeeding?

A

Heparins
- LMWH or Unfractionated both safe to use in breastfeeding
- large molecular weight so very little getting into breast milk.
- Also inactivated in the G.I Tract so unlikely to get into infants system

21
Q

What are the recommendations for warfarin while breastfeeding?

A

Warfarin
- Oral anticoagulant of choice in breastfeeding – Very highly protein bound so less ‘free’ drug to pass into milk

22
Q

What are the recommendations for DOACs while breastfeeding?

A

DOAC’s
- Limited information.
- All DOAC’s may pass into breast milk
- Dabigatran is one of the largest DOAC molecule and has a large volume of distribution so would be expected to pass into breast milk in low amounts. It also has very low oral bioavailability, so infant unlikely to absorb clinically significant amounts
- Rivaroxaban, pharmacokinetic data shows large Vd and small passage in to milk
- Apixaban and Edoxaban are not recommended
- Apixaban levels in milk appear to be quite high

23
Q

What must be watched for in infants while breastfeeding with anti-coagulants?

A

Bruising and bleeding – in vomit, urine, stools

24
Q

What are the recommendations for beta-blockers while breastfeeding?

A
  • Labetalol, metoprolol and propranolol are the beta-blockers of choice to use during breastfeeding
  • Very small amounts get into milk and they have shorter half-lives to lower risk of accumulation.
  • Atenolol – excreted in small to moderate amounts
  • Bisoprolol – used with caution – very limited published data and has low protein binding and high oral bioavailability so suggests would be excreted into breast milk and be absorbed by infant. Half-Life 9 to 12 hours and 50% excreted in urine so potential for accumulation
25
Q

What are the recommendations for CCBs while breastfeeding?

A
  • Nifedipine and Verapamil are the preferred choice
  • Published evidence and extensive experience of using and pharmacokinetics are favourable
  • Amlodipine – excreted in small amounts in milk and less favourable pharmacokinetics (long half-life and high oral bioavailability) – use with caution
  • Diltiazem – very little information so use with caution, would appear to be excreted in negligible amounts in milk.
  • Felodipine – No information amount in excretion in breast milk. Long half-life make it less favourable choice
26
Q

What are the recommendations for ACEis while breastfeeding?

A
  • Enalapril is ACE inhibitor of choice in breastfeeding – published evidence about excretion in milk, used therapeutically in infants and has most favourable pharmacokinetics (active metabolite is poorly absorbed orally and negligible amounts in milk)
  • Limited evidence shows milk levels of ACE inhibitors are low, most ACE inhibitors are also metabolised to their active metabolite whish is poorly absorbed orally, so any active metabolite in milk is unlikely to be absorbed significantly by the infant.
  • Lisinopril – is active compound – no info on excretion in milk
  • Perindopril – long half-life (30 to 120hrs) so risk of accumulation
  • Ramipril – limited data show minimal amounts in milk
27
Q

What are the recommendations for levetiracetam while breastfeeding?

A
  • variable amounts in breast milk but infant levels low or undetectable. Monitor for infant drowsiness
28
Q

What are the recommendations for lamotrigine while breastfeeding?

A
  • Lots of published evidence of use in breastfeeding
  • Significant amounts in milk – long-half life increases risk of accumulation
  • Daily dose of >500mg may mean halting breastfeeding
  • Mild thrombocytosis reported in some infants
  • Monitor for rash, apnoea, drowsiness and poor feeding
29
Q

What are the recommendations for carbemazepine while breastfeeding?

A
  • Very low risk and compatible with breastfeeding - Excreted in small amounts
30
Q

What are the recommendations for phenytoin while breastfeeding?

A
  • Very low risk, excreted in clinically non-significant amounts
31
Q

What are the recommendations for topiramate while breastfeeding?

A
  • Very low risk, moderate amounts excreted into breast milk, but no observed effects in infant
32
Q

What are the recommendations for valproate while breastfeeding?

A
  • Very low risk, excreted in clinically insignificant amounts
  • Risk of significant birth defects and developmental disorders, so not recommended to be used in women of child-bearing age (Pregnancy Prevention Programme 2018)
33
Q

What are the 8 physiological changes during pregnancy?

A
  • Changes in total BW and body fat composition.
  • Delayed gastric emptying and prolonged GI transit time.
  • Increase in extra cellular fluid and total body water.
  • Increased cardiac output, increased stroke volume, and elevated maternal heart rate.
  • Decreased albumin concentration with reduced protein binding.
  • Increased blood flow.
  • Increased glomerular filtration rate.
  • Changed hepatic enzyme activity (phase I, phase II metabolic pathways).
34
Q

How does absorption change during pregnancy?

A
  • Physiological changes could alter drug absorption
  • Bioavailability not altered during pregnancy
  • No difference in bioavailability during pregnancy compared with postpartum
35
Q

How does distribution change during pregnancy?

A
  • Increase in Vd could resulting in a decrease in Co (after loading dose), and decrease in Cmax (after multiple-doses)
  • If Cl decreased or unchanged: increase in Vd result in increased terminal elimination half-life
    if Vd and Cl are increased: increase, decrease or no change in terminal elimination half-life (which increase is the largest)
36
Q

How does metabolism change during pregnancy?

A
  • Hepatic Clearance altered by protein binding, metabolic enzymes and liver blood flow
  • CYP450, UGT and NAT have differential effects on metabolic enzymes
  • Altered activity of certain metabolic enzymes
37
Q

How does elimination of drugs change during pregnancy?

A
  • Altered GFR, active tubular secretion, reabsorption
  • Increased renal excretion unchanged drugs
  • GFR increased approximately 50% by the 1st trimester, continued increased throughout pregnancy
38
Q

How is pregnancy divided into trimesters?

A

1st - 0-13 weeks
2nd - 13-28 weeks
3rd - 28-40 weeks

39
Q

What 8 things can untreated asthma during pregnancy cause?

A

baby
- Fetal growth restriction
- Preterm birth
- Increased perinatal mortality
- Neonatal hypoxia

mum
- Hyperemesis
- Hypertension
- Pre-eclampsia
- Vaginal haemorrhage

40
Q

What is teratogenesis?

A

1-2% of babies born with a congenital abnormality
<1 in 20 attributed to drugs
- if a teratogenic agent is taken during the period of embryogenesis the result will be a malformation
- of later in pregnancy, function will be affected

41
Q

Why no anti-epileptics during pregnancy?

A

minor malformations associated with use of anti-convulsants during pregnacy
- lowset ears
- broad nasal bridge
- irregular teeth
- hypoplastic nails + fingers

42
Q

What are the top 10 banned drugs for pregnancy?

A
  • Valproate
  • Roaccutane
  • Aspirin
  • Ibuprofen
  • Vitamin A
  • Oral retinoids
  • ACEi
  • Tetracyclines + Trimethoprim
  • Warfarin
  • Lithium

MPharm2 SL22108 (7 decks)

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