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
