Pregnancy in Practice - Chronic Conditions

Question 1

What do you need to consider when prescribing/choosing medications?

Answer 1

• How to minimise potential s/e
• Previous responses to drugs
• Risks of discontinuation symptoms
• Patient preference
• Drug Safety
• Non-pharmacological alternatives
• Pregnancy stage
• Benefits vs. Risks
• Use lowest effective dose in shortest duration of time.

Question 2

Give examples of mental health issues.

Answer 2

• Depression
• Schizophrenia
• Parkinson’s Disease
• Dementia
• Epilepsy etc.

Question 3

Give examples of interventions for Depression

Answer 3

• CBT
• TCAs
• SSRI’s
• Venlafaxine

Question 4

Give examples of interventions for Depression.

Answer 4

• CBT
• TCAs
• SSRI’s
• Venlafaxine

Question 5

Give examples of interventions for Schizophrenia

Answer 5

• Antipsychotics
• Raised prolactin levels * Clozapine
• Olanzapine
• Lithium
• Valproate

Question 6

Give examples of interventions for BPAD.

Answer 6

• Anti-depressants e.g. TCAs, SSRI etc.

Question 7

Explain the general relationship between pregnancy and epilepsy.

Answer 7

• Approx. 3000-5000 babies are born to epileptic women.
• 10% of those have congenital malformations
• Increased risk of Neural Tube Defects (NTD)

Question 8

Explain how treatment is introduced for epileptic women.

Answer 8

Folic Acid 5mg daily to reduce risk of NTD.

Question 9

What does the MHRA state about using Valproate and prescribing drugs for epilepsy in pregnant women?

Answer 9

• Avoid multiple agents.
• Monotherapy with most effective medication taken at lowest effective dose.
• Avoid use of Sodium Valproate - known teratogenic.

Question 10

What is the pregnancy prevention programme (PPP)?

Answer 10

• Includes evaluating individual circumstances in every case.
• Use ‘highly effective’ methods of contraception:
  – Long-acting reversible contraception (LARC)
  – Copper intra-uterine device
  – Progesterone-only implant

Question 11

What does pharmacy regulation state about prescribing valproate?

Answer 11

• Must not be used in pregnancy.
• Only used in girls & women when there’s no alternative & a pregnancy prevention programme in place.

Go to this website for further details:
https://www.gov.uk/guidance/valproate-use-by-women-and-girls#history

Question 12

What are the requirements to ensure Valproate prescribing?

Answer 12

Refer to the checklist in Slide 10 of the Drug Use in Pregnancy lecture.

Question 13

What are the requirements to ensure compliance in the pregnancy prevention programme?

Question 14

What counselling points do you need to give to patients taking Valproate?

Answer 14

Refer to Slide 11 - Patient Card for Sodium Valproate.

Question 15

What action should be done if the pregnant woman is suffering from Hypothyroidism?

Answer 15

– Ideally - optimal control prior to pregnancy
– Dose adjustments likely to be required
– Monitoring

Question 16

What action should be done if the pregnant woman is suffering from Hyperthyroidism?

Answer 16

– Monitoring
– Propylthiouracil
– Carbimazole

Question 17

What is the possible complication of pregnant women diagnosed with Diabetes Mellitus?

Answer 17

Increased risk of developing NTD. Give Folic Acid 5mg daily.

Question 18

Which type of Diabetes is common is pregnancy?

Answer 18

Gestational Diabetes

Question 19

What supplement is recommended to take during pregnancy?

Answer 19

• Folic Acid 5mg daily

Question 20

What supplement is recommended to take during pregnancy?

Answer 20

• Folic Acid

Question 21

What is the risk of Diabetes Mellitus to the mother and developing foetus?

Answer 21

• Miscarriage
• Pre-eclampsia (hypertension)
• Pre-term labour (Premature birth)

Question 22

What advice is given if diabetes is established?

Answer 22

Adjunct or Alternative to Insulin: Metformin

Question 23

What type of Insulin is safe for use in pregnancy?

Answer 23

• Rapid acting
• Isophane (NPH) insulin

Question 24

What other medications do you need to consider for Diabetes especially in pregnancy?

Answer 24

ACEi’s + ARBs:
- Hypertension
- Gradual progression of nephropathy.
- Discontinue before pregnancy or ASAP after confirmation.

Statins:
- Discontinue before pregnancy or ASAP after confirmation.

Question 25

Explain the management process for chronic hypertension.

Answer 25

• Pre-pregnancy advice
• Specialist referral
• Lifestyle:
  
  • Weight management
  • Exercise
  • Healthy eating
  • Restrict sodium intake
• Review medication
• ACE inhibitors/ARBs - discontinue before pregnancy or ASAP after confirmation.
• Thiazide and thiazide-like diuretics
• Target BP:
  
  • <135/85 mmHg

Question 26

What pharmacological treatment options are available for chronic hypertension.

Answer 26

• Labetalol
• Nifedipine
• Methyldopa

Question 27

What is the general relationship between postnatal care and hypertension?

Answer 27

• Monitor BP after birth
• Target <140/90 mmHg
• Review antihypertensive treatment

Question 28

What type of counselling is given to women with asthma?

Answer 28

– Ensure asthma is well controlled
– Counsel women regarding the safety and importance of continuing asthma medication during pregnancy.

Question 29

What types of drugs used for asthma are safe to use in pregnancy?

Answer 29

Beta 2 agonists
Inhaled Steroids
Oral Steroids i.e. Prednisolone - ideal.

Question 30

Give examples of services available to stay well during pregnancy.

Answer 30

• Smoking Cessation (if they smoke)
• Flu Vaccine
• Asthma review
• Medication Adherence.