Pregnancy contraindicated drugs

Question 1

A 27 year old lady who is 32 weeks pregnant visits her GP concerned about breastfeeding. Which of the following situations would be acceptable for her to breastfeed?

A. Taking ibuprofen for back pain

B. Maternal HIV infection (viral load undetectable)

C. Herpes simplex lesions on the mother’s breasts

D. Neonatal galactosaemia

E. Maternal multi-drug resistant tuberculosis infection

Answer 1

A. Taking ibuprofen for back pain

Ibuprofen is considered safe for breastfeeding infants as only very small quantities appear to be excreted into breast milk after maternal ingestion. Furthermore, it is considered to be one of the analgesics of choice in breastfeeding mothers

Not B: Maternal HIV infection (viral load undetectable)

In the UK and other high-income settings, the safest way to feed infants born to women with HIV is with formula milk, as there is a small on-going risk of exposure to HIV with breastfeeding

Question 2

Antibiotics & breastfeeding:

Answer 2

1. Antibiotics that are safe to use in breastfeeding mothers include: penicillin-based antibiotics, beta-lactam antibiotics, trimethoprim, azithromycin, cephalosporins, clarithromycin, erythromycin
2. IV gentamicin and meropenem can also be given
   Tetracyclines although previously contraindicated - may be given in short courses, however caution is advised
3. Most antibiotics can produce excessively loose motions in the baby, with the appearance of diarrhoea. Some infants appear more unsettled with tummy aches or colic. These effects are not clinically significant and do not require treatment.
4. Antibiotics which are cautioned or **contra-indicated ** include: ciprofloxacin (potential joint problems), nitrofurantoin (G6PD deficiency), teicoplanin, clindamycin (antibiotic-associated colitis), co-trimoxazole.

Question 3

what’s the preferred opiate if mothers need strong analgesia:

Answer 3

Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as the drug after caesarean section.

Question 4

which NSAID should be avoided in breastfeeding women? why?

Answer 4

Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.

Question 5

what supplement should be recommended for breastfeeding women?

Answer 5

Breast milk is low in Vitamin D
Vitamin D supplements are recommended for all pregnant women and for breast-feeding women

Question 6

Hep B/C vertical transmission?

Answer 6

There is no risk for mother to child transmission of Hepatitis B provided the infant has received appropriate HBV immunoprophylaxis

Question 7

medical advantages of breastfeeding for mothers/child:

Answer 7

Child

1. Safe, clean and contains antibodies which help protect against many common childhood illnesses
2. Breastmilk provides all the energy and nutrients needed for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year, and up to one third during the second year of life.
3. Children likely to perform better on intelligence tests
4. Less likely to be overweight or obese
5. Less prone to diabetes

Mother

1. Reduction in breast cancer risk
2. Reduction in diabetes risk
3. Reduction in ovarian cancer

Question 8

Summary table of drugs contraindicated in pregnancy:

Answer 8

The following drugs should be avoided:
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone

Question 9

what are complications of phenytoin/carbamazepine in pregnancy:

Answer 9

oIUGR
o Microcephaly
oCleft lip / palate
oMental retardation
oHypoplastic fingernails
oDistal limb deformities

Question 10

A 28 year old G2P2 is nearing term and has planned to breastfeed her baby after delivery. She is wondering which of her medications is safe to continue during breastfeeding.

Which of the following is safe to continue during breastfeeding?

A. Methotrexate

B. Salbutamol

C. Tetracycline

D. Sitagliptin

E. Lithium

Answer 10

B. Salbutamol

Salbutamol is a beta-agonist taken to relieve symptoms of asthma. According to the BNF, inhaled drugs for asthma can be taken normally during breast-feeding

Not D: Sitagliptin is a DPP-4 inhibitor used in the treatment of diabetes mellitus type 2. BNF advises to avoid use in breastfeeding as it is present in breast milk and risks infant toxicity

Not A: Methotrexate

Methotrexate is a chemotherapy agent and immunosuppressant and is used in a wide variety of diseases. It is to be avoided during breastfeeding as it is present in milk and poses a risk of toxicity to the infant

Not C: Tetracycline

Tetracycline is an antibiotic used to treat appropriate infections. It should be avoided during breastfeeding as there is a risk of discolouration of teeth and absorption in the infant

Not E: Lithium

Lithium is an anti-psychotic, commonly used for bipolar disorder treatment. Lithium is to be avoided during breastfeeding as it is present in milk and poses a risk of toxicity to the infant

Question 11

what are some issues associated with breastfeeding?

Answer 11

Cracked/sore nipples
Blocked duct and breast engorgement
Mastitis/abscess
May require oral antibiotics
An abscess may require aspiration or incision/drainage
Breastfeeding should continue during treatment
Thrush and breastfeeding/ductal candidiasis
Insufficient milk

Question 12

what antibiotics can be used in breastfeeding mothers?

Answer 12

-Antibiotics that are safe to use in breastfeeding mothers include: penicillin-based antibiotics, beta-lactam antibiotics, trimethoprim, azithromycin, cephalosporins, clarithromycin, erythromycin

-IV gentamicin and meropenem can also be given

-Tetracyclines although previously contraindicated - may be given in short courses, however caution is advised

-Most antibiotics can produce excessively loose motions in the baby, with the appearance of diarrhoea. Some infants appear more unsettled with tummy aches or colic. These effects are not clinically significant and do not require treatment.

-Antibiotics which are cautioned or **contra-indicated ** include: ciprofloxacin (potential joint problems), nitrofurantoin (G6PD deficiency), teicoplanin, clindamycin (antibiotic-associated colitis), co-trimoxazole.

Question 13

What analgesia can be used in breastfeeding mothers?

Answer 13

Paracetamol and ibuprofen form the basis for safe analgesics for breastfeeding mothers.

NSAIDs are safe to use in breastfeeding mothers.

Stronger drugs are available but should be taken with caution and babies observed for drowsiness.

Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as the drug after caesarean section.

Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.

Codeine is no longer recommended as routine medication for breastfeeding mothers (MHRA June 2013, BNF) with particular caution where the mother has never taken the drug before or has found that the drug causes her to be drowsy, dizzy or experience severe constipation.

Question 14

what can be used to suppress lactation?

Answer 14

Cabergoline can be given to women who want to suppress lactation. It works by inhibiting prolactin secretion

Question 15

ace inhibitors & arbs in pregnancy (causes):

Answer 15

Medications that block the renin-angiotensin system (ACE inhibitors and ARBs) can cross the placenta and enter the fetus. In the fetus, they mainly affect the kidneys, and reduce the production of urine (and therefore amniotic fluid). The other notably effect is hypocalvaria, which is an incomplete formation of the skull bones.

ACE inhibitors and ARBs, when used in pregnancy, can cause:

1. Oligohydramnios (reduced amniotic fluid)
2. Miscarriage or fetal death
3. Hypocalvaria (incomplete formation of the skull bones)
4. Renal failure in the neonate
5. Hypotension in the neonate

Question 16

opiate use in pregnancy & effect on foetus:

Answer 16

The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth. This is called neonatal abstinence syndrome (NAS).

NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.

Question 17

warfarin use in pregnancy & effect on foetus:

Answer 17

Warfarin may be used in younger patients with recurrent venous thrombosis, atrial fibrillation or metallic mechanical heart valves. It crosses the placenta and is considered teratogenic in pregnancy, therefore it is avoided in pregnant women. Warfarin can cause:

1. Fetal loss
2. Congenital malformations, particularly craniofacial problems
3. Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding

Question 18

sodium valproate use in pregnancy & effect on foetus:

Answer 18

The use of sodium valproate in pregnancy causes neural tube defects and developmental delay.

There are strict rules for avoiding sodium valproate in girls or women unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant. There is a specific program called Prevent (valproate pregnancy prevention programme) to ensure this happens.

Question 19

lithium use and pregnancy/monitoring:

Answer 19

Lithium is used as a mood stabilising medication for patients with bipolar disorder, mania and recurrent depression. It is avoided in pregnant women or those planning pregnancy unless other options (i.e. antipsychotics) have failed.

Lithium is particularly avoided in the first trimester, as this is linked with congenital cardiac abnormalities. In particular, it is associated with Ebstein’s anomaly, where the tricuspid valve is set lower on the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle.

When lithium is used, levels need to be monitored closely (NICE says every four weeks, then weekly from 36 weeks). Lithium also enters breast milk and is toxic to the infant, so should be avoided in breastfeeding.

Question 20

SSRI use in pregnancy:

Answer 20

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants in pregnancy. SSRIs can cross the placenta into the fetus. The risks need to be balanced against the benefits of treatment. The risks associated with untreated depression can be very significant. Women need to be aware of the potential risks of SSRIs in pregnancy:

1. First-trimester use has a link with congenital heart defects
2. First-trimester use of paroxetine has a stronger link with congenital malformations
3. Third-trimester use has a link with persistent pulmonary hypertension in the neonate4.
   Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management

Question 21

SSRI use in postpartum depression:

Answer 21

*paroxetine is recommended by SIGN because of the low milk/plasma ratio

**fluoxetine is best avoided due to a long half-life

Question 22

Isotretinoin (Roaccutane) use in pregnancy:

Answer 22

Isotretinoin is a retinoid medication (relating to vitamin A) that is used to treat severe acne. It should be prescribed and monitored by a specialist dermatologist.

Isotretinoin is highly teratogenic, causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.

Question 23

why are NSAIDs avoided in pregnancy:

Answer 23

Examples of non-steroidal anti-inflammatory drugs (NSAIDs) are ibuprofen and naproxen. They work by blocking prostaglandins. Prostaglandins are important in maintaining the ductus arteriosus in the fetus and neonate. Prostaglandins also soften the cervix and stimulate uterine contractions at the time of delivery.

NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis). They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.

Question 24

beta-blockers & pregnancy (which one to use)

Answer 24

Beta-blockers are commonly used for hypertension, cardiac conditions and migraine. Labetalol is the most frequently used beta-blocker in pregnancy, and is first-line for high blood pressure caused by pre-eclampsia.

Beta-blockers can cause:

1. Fetal growth restriction
2. Hypoglycaemia in the neonate
3. Bradycardia in the neonate