Pregnancy & Lactation Flashcards
Placental transport factors
Molecular weight
-<400-600 Da crosses placenta. Most drugs are 250-400 Da
Protein binding
-Less protein binding in fetus = more free drug
Blood flow
-Equivalent between mom & baby, so fetal drug conc 50-100% maternal
FDA labeling for pregnancy risk
- Pregnancy
Fetal risk summary
Clinical considerations
Data section
Information for exposure registries - Lactation
- Females and males of reproductive potential
Selected known teratogens
ACE/ARB
Anticonvulsants
Isotretinoin
Lead
Lithium
Methimizole
Methotrexate
Paroxetine
Statins
Tetracycline
Thalidomide
Warfarin
Resources for Pregnancy Medication Use
-Drugs in Pregnancy & Lactation (on Facts, Lexi)
-TERIS (Teratogen Information System) & Shepard’s Database (Micromedex)
-Diseases, Complications, Drug Therapy in Obstetrics (textbook - chronic disease management in pregnancy)
-OTIS (organization of Teratology Information Specialists): MotherToBaby (has information sheets)
-Micromedex: REPROTEXT and REPROTOX (pregnancy, teratogenicity, lactaction, medication use)
Decrease Milk Supply
Androgens
Bromocriptine (DA agonist)
Ergot alkaloids
Estrogen
Levodopa (increase DA)
MAOIs
Pyridoxine
Sympathomimetics
Increase Milk Supply (galactagogues)
Amoxapine
Antipsychotics (DA antagonist)
Cimetidine
Methyldopa
Metoclopramide
Reserpine
How to minimize effect of drugs during breastfeeding
-Choose drugs w/ short half lives
-Administer immediately after a feed or before long sleep period
-Consider if drug given to neonates
-Consider age/health of neonate
-Short-term drug: pump & dump
Contraindicated in breastfeeding
Amphetamines
Antineoplastics
Benzos
Bromocriptine
Cocaine, drugs of abuse
Ergotamine
Kava
Lithium
Nicotine
Pain (oxycodone, pentazocine, meperidine)
Yohimbe
Herbs lacking safety data
Relatively safe agents in breast feeding
Analgesics - ibuprofen, APAP
ABX (PCN, cephalosporins, erythromycins)
Caffeine, in moderation
Insulin
Resources for lactation
- LactMed - provides safety & alternatives
- Drugs in Pregnancy & Lactation - textbook, Facts
- Hale T. Medications & Mother’s Milk - ranked L1 to L5, with L1 safest
- Micromedex REPROTEXT and REPROTOX
- OTIS: MotherToBaby
Management of Morning Sickness
First line:
-Diclegis (DR) or Bonjesta (ER)
-Alt: Pyridoxine
-Dimenhydrinate
-Diphenhydramine
-Zofran (if not controlled w/ first line. possible cardiac birth defects. Avoid during first 10 weeks)
-Metoclopramide (if N/V not controlled w/ first line)
-Phenothiazines (if N/V not controlled w/ first line) (promethazine, prochlorperazine)
Heartburn management in pregnancy
Antacids (magnesium hydroxide, aluminum hydroxide, calcium carbonate)
Sucralfate (not absorbed)
Second line: famotidine, PPI
Constipation management in pregnancy
Increase fiber & fluid intake, exercise
Stool softeners, bulk laxatives
Stimulants are not first line.
Avoid mineral oil
Hemorrhoid management in pregnancy
Treat constipation
Sitz bath
Avoid topical anesthetics & steroids
Headache mangement in pregnancy
APAP, rest
Avoid Aspirin, NSAIDS, ergotamine, triptans
Prophylactic VTE management in pregnancy
Lovenox 40mg SC daily
Dalteparin 5000 units SC daily
Tinzaparin 4500 units SC daily
Heparin
1st tri: 5000-7500 units SC q12h
2nd tri: 7500-10000 units SC q12h
3rd tri: 10000 units SC q12H
Anticoagulants to avoid in pregnancy
warfarin
DOACs
Therapeutic VTE management pregnancy
Lovenox 1mg/kg q12H
Dalteparin 200 units/kg SC daily
Tinzaparin 175 units/kg SC daily
Heparin 10000 units SC q12H
VTE management prior to delivery
-At 36 weeks, may transition from lovenox to heparin for ease of anesthesia induction. Lower risk of epidural or spinal hematoma. Greater ease of heparin reversal w/ protamine
-D/C LMWH or UFH ppx 12 hours before delivery
-D/C LMWH or UFH therapeutic 24 hours before delivery
VTE management after delivery
Anticoagulation for 6 weeks postpartum
Two-step approach to diagnose gestational diabetes
50 g OGTT; if >= 130 or 140, then 100g test
100g: (two ranges, went with lower one)
fasting >95
1 hr >180
2 hr > 155
3 hr >140
One step approach to diagnose gestational diabetes
75g OGTT
fasting >92
1 hr >= 180
2 hr >= 153
Preferred treatment for GD
Insulin, start at 0.7-1.0 unit/kg/day
Does not cross placenta
Alternative treatment for GD
Metformin, possible premature birth
Glyburide, but increased risk of hypoglycemia and macrosomia in infant, so not preferred
Gestational hypertension
BP >= 140/90, occurring at least 4 hours apart on 2 different occasions with previously normal BP and no proteinuria or pathologic edema
Preeclampsia
HTN + proteinuria (>=300, protein/creatinine ratio >=3.0, dipstick reading 2+)
OR
SBP >=160, DBP >=110
Thrombocytopenia
New liver/renal impairment
Pulmonary edema
Unresponsive headache
Visual changes
Eclampsia
Preeclampsia + tonic-clonic seizures
Prevention of preeclampsia
Aspirin 81-162mg/day from 11-36 weeks
If high risk (hx preeclampsia, multifetal gestation, chronic HTN, T1-2DM, renal disease, autoimmune diesease), start at 12 weeks and continue daily until delivery
Preeclamspia treatment
Term: deliver
Preterm: bedrest
Severe: magnesium sulfate IV to prevent seizure
BP management: labetalol, nifedipine ER
Emergent therapy: IV labetalol, IV hydralazine, nifedipine (but caution w/ magnesium, can cause hypotension, reduced HR & Contractililty)
PPX of preterm labor
If history of preterm labor
PPX at 16-26 weeks
17-hydroxyprogesterone caproate 250mg IM weekly
Terbutaline
Tocolytic (inhibit contractions)
B-agonist
Given SC (NOT PO)
May cause hypotension, tachycardia - do not give longer than 48 hours
Magnesium sulfate as tocolytic
Given to inhibit uterine activity by antagonism of calcium
Monitor closely for toxicity - therapeutic range is 5-8, and toxicity may occur close to that. Respiratory or cardiac depression.
DOC for pt w/ diabetes
Magnesium sulfate reversal agent
calcium gluconate IV
NSAID for tocolytic
Indomethacin - limit to 72 hours
CCB for tocolytic
Nifedipine - limit to 48 hours
Medication abortion
Use up to 10 weeks gestation
Mifepristone 200mg x1
Misoprostol 800mcg x1. Place 2 tabs in each cheek for 30 minutes, then swish with water and swallow. 24-48 hours after mifepristone
