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Year Three - Reproductive System > Pregnancy Pharmacology > Flashcards

Pregnancy Pharmacology Flashcards

1
Q

What is pharmacokinetics?

A

It describes ‘what the body does to the drug’

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2
Q

What are the four basic pharmacokinetic processes?

A

Absorption

Distribution

Metabolism

Excretion

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3
Q

During pregnancy, how is the absorption of drugs via the oral route affected? Why?

A

Decreased

This is due to a decrease in gastric emptying and gut motility

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4
Q

During pregnancy, how is the absorption of drugs via the intramuscular route affected? Why?

A

Increased

This is due to an increased blood flow

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5
Q

During pregnancy, how is the absorption of drugs via the inhalation route affected? Why?

A

Increased

This is due to an increased cardiac output and decreased tidal volume

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6
Q

During pregnancy, how is the distribution of drugs affected? Why?

A

Increased

This is due to the fact that there is an increase in plasma volume and fat

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7
Q

During pregnancy, how is the fraction of free (active) drugs affected? Why?

A

Increased

This is due to a greater dilution of plasma, decreasing the relative amount of plasma proteins

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8
Q

During pregnancy, how is the metabolism of drugs affected? Why?

A

Increased or reduced

This is due to the fact that oestrogen and progesterone can induce or inhibit liver P450 enzymes

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9
Q

During pregnancy, how is the excretion of drugs affected? Why?

A

Increased

This is due to the fact that GFR is increased in pregnancy by 50%

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10
Q

How do drugs enter fetal circulation?

A

Placenta

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11
Q

What are the three factors which affect the placental transfer of drugs?

A

Molecular Weight

Polarity

Lipid Solubility

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12
Q

How does molecular weight affect the placental transfer of drugs?

A

The smaller molecular weight molecules cross the placenta more readily

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13
Q

How does polarity affect the placental transfer of drugs?

A

The unionised molecules cross the placenta more readily

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14
Q

How does lipid solubility affect the placental transfer of drugs?

A

The lipid soluble molecules cross the placenta more readily

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15
Q

Why does the distribution of drugs differ in the foetus compared to the mother?

A

Fetal circulation is different, with relatively more blood flow to the brain in comparison to the mother

The fetus also has little fat in comparison to the mother

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16
Q

How does the fraction of free (active) drugs differ in the foetus compared to the mother? Why?

A

It is greater in the foetus

This is due to there being less protein binding

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17
Q

Why does the metabolism of drugs differ in the foetus compared to the mother?

A

Reduced enzyme activity

The different exhibition of P450 isoenzymes

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18
Q

In the fetus, what does enzyme activity increase with?

A

Gestational age

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19
Q

How do excretions from the foetus exit? How can this lead to drug toxicity?

A

Excretions exit into the amniotic fluid, which the fetus then swallows

This leads to recirculation, which can potentially lead to drug toxicity in the fetus

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20
Q

What is pharmacodynamics?

A

It describes ‘what the drug does to the body’

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21
Q

In what two ways does pregnancy affect pharmacodynamics?

A

It affects the site of drug action

It affects the receptor response of drugs

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22
Q

Why is it important that medications are reviewed once a patient becomes pregnant?

A

During pregnancy, medications impose a risk of teratogenicity and fetotoxicity

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23
Q

When does teratogenicity tend to occur?

A

First trimester

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24
Q

When does fetotoxicity tend to occur?

A

Second and third trimester

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25
Q

What nine drug classes need reviewed during pregnancy?

A

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Beta-Blockers

ACE Inhibitors & Angiotensin II Receptor Blockers (ARBs)

Opiates

Anticoagulants

Anticonvulsants

Antipsychotics

Selective Serotonin Receptor Inhibitors (SSRIs)

Retinoids

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26
Q

List two examples of NSAIDs

A

Ibuprofen

Naproxen

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27
Q

How do NSAIDs work?

A

They block the hormone prostaglandins

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28
Q

What are the two functions of prostaglandins during pregnancy?

A

It maintains the ductus arteriosus

It softens the cervix and stimulates uterine contractions at the time of delivery

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29
Q

What advice is given regarding NSAIDs during pregnancy?

A

They are generally avoided, unless really necessary

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30
Q

In which trimester is NSAIDs particularly avoided during pregnancy?

A

Third trimester

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31
Q

Why are NSAIDs avoided during pregnancy (two reasons)?

A

They can cause premature closure of the ductus arteriosus in the fetus

They can delay labour

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32
Q

Through which mechanism do NSAIDs produce teratogenic effects? Describe this mechanism

A

Enzyme mediated teratogenesis

This means that these drugs interact with specific receptors and enzymes to damage fetal development

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33
Q

What beta-blocker is most frequently prescribed during pregnancy?

A

Labetalol

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34
Q

What advice is given regarding beta-blockers during pregnancy?

A

There are certain beta blockers prescribed during pregnancy, however it is important to advice patients of the possible teratogenic effects

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35
Q

What are the three teratogenic effects of beta-blockers?

A

Fetal Growth Retardation

Neonatal Hypoglycaemia

Neonatal Bradycardia

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36
Q

How do ACEI and ARBs work?

A

They block the renin-angiotensin system (RAAS).

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37
Q

What are the four teratogenic effects of ACEIs and ARBs?

A

Renal Dysfunction

Growth Retardation

Hypocalvaria

Oligohydramnios

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38
Q

What is hypocalvaria?

A

It is incomplete skull bone formation

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39
Q

Can opiates cross the placenta?

A

Yes

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40
Q

Does opiate misuse interfere with pregnancy or labour?

A

No

The effects occur after delivery

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41
Q

What is the teratogenic effect of opiates?

A

They can cause withdrawal symptoms in the neonate after birth

This is referred to as neonatal abstinence syndrome (NAS)

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42
Q

When does neonatal abstinence syndrome (NAS) present?

A

Between 3 – 72 hours after birth

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43
Q

What are the four clinical features of neonatal abstinence syndrome (NAS)?

A

Irritability

Tachypnoea

High temperature

Poor feeding

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44
Q

When does heroin withdrawal occur in the neonate?

A

Immediately after delivery

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45
Q

When does methadone withdrawal occur in the neonate?

A

Three weeks after delivery

46
Q

What anticoagulant is particularly avoided during pregnancy?

A

Warfarin

47
Q

What are the three teratogenic effects of Warfarin?

A

Fetal Loss

CNS Malformations

Haemorrhage

48
Q

What three anticonvulsants are particularly avoided during pregnancy?

A

Sodium valproate

Carbamazepine

Phenytoin

49
Q

What advice is given regarding anticonvulsants during pregnancy?

A

They are strictly avoided in women of childbearing age unless there are no suitable alternatives

In cases, where they are prescribed, there are strict guidelines to ensure that these patients don’t become pregnant

50
Q

What are the two teratogenic effects of anticonvulsants?

A

Neural tube defects

Developmental delay

51
Q

Through which mechanism do anticonvulsants produce teratogenic effects? Describe this mechanism

A

Folate antagonism

Folate metabolism is a key process in DNA formation and new cell production. However, anticonvulsant drugs block enzymes in this metabolic pathway and thus cause fetal malformations.

52
Q

What antipsychotic is particularly avoided during pregnancy?

A

Lithium

53
Q

What advice is given regarding lithium during pregnancy?

A

It is avoided in pregnant women or those planning pregnancy, unless other options have failed

If Lithium is prescribed, close monitoring is required

Lithium also enters breast milk and is toxic to the infant, so should also be avoided in breastfeeding

54
Q

How often should lithium levels be monitored during pregnancy?

A

Every four weeks

Weekly from 36 weeks

55
Q

In which trimester should lithium be particularly avoided?

A

First trimester

56
Q

What is the teratogenic effect of lithium?

A

Congenital cardiac abnormalities, specifically Ebstein’s anomaly

57
Q

What is Ebstein’s anomaly?

A

A condition in which the tricuspid valve is set lower on the right side of the heart, causing a bigger right atrium and a smaller right ventricle

58
Q

What are the most commonly prescribed antidepressants during pregnancy?

A

SSRIs

59
Q

What advice is given regarding SSRIs during pregnancy?

A

Despite there being teratogenic effects associated with these drugs, the benefits of treatment outweigh risks

60
Q

What is the teratogenic effect of SSRIs during the first trimester?

A

Congenital heart defects

61
Q

What is the teratogenic effect of SSRIs during the third trimester?

A

Neonatal pulmonary hypertension

62
Q

What is the teratogenic effect of SSRIs in neonates?

A

Withdrawal symptoms

63
Q

Which SSRI has a strong association with congenital malformations in the first trimester?

A

Paroxetine

64
Q

What retinoid is particularly avoided during pregnancy?

A

Isotretinoin (Roaccutane)

65
Q

What advice is given regarding roaccutane during pregnancy?

A

It is a highly teratogenic drug, which requires women to be on reliable contraception before, during and one month after taking this medication

66
Q

What are the six teratogenic effects of retinoids?

A

Aortic Arch Anomalies

Ventricular Septal Defects

Craniofacial Malformations

Oesophageal Atresia

Pharyngeal Gland Abnormalities

Miscarriage

67
Q

Through which mechanism do retinoids produce teratogenic effects? Describe this mechanism

A

Neural crest cell destruction

Neural crest cells are cells induced at the border of the neural plate, which differentiate into multiple cell types contributing to the peripheral nervous system and the cranio-facial structure

68
Q

Through which mechanism do methotrexate and trimethoprim produce teratogenic effects? Describe this mechanism

A

Folate antagonism

These drugs block the conversion of folate to tetrahydrofolate by binding irreversibly to the tetrahydrofolate reductase enzyme

69
Q

What are the three teratogenic effects of methotrexate and trimethoprim?

A

Neural tube defects

Cranial-facial defects

Limb defects

70
Q

Do drugs consumed by the mother present in breast milk?

A

Yes

71
Q

How do we determine generally if a drug is safe during breastfeeding?

A

Drugs licenced and safe in paediatric use, especially in those under the age of two, are thought to be safe in breastfeeding

72
Q

What advice is given in regards to drugs during breastfeeding?

A

In some cases, it is possible to postpone drug treatment until the baby is weaned

If there are no alternatives and the drug needs to be prescribed, then we advise the mother to take the medication immediately after feeding the baby and to avoid breastfeeding during peak drug effect.

It is also advised that clinicians prescribe drugs with pharmacokinetic properties that reduce infant exposure

73
Q

What three pharmacokinetic properties reduce infant exposure to drugs during breastfeeding?

A

Short half-life

Highly protein bound

Low lipid solubility

74
Q

What are eleven drugs should be avoided during breastfeeding?

A

Tetracycline

Isoniazid

Barbiturates

Diazepam

Methadone

Iodine

Propylthiouracil

Amiodarone

Lithium

Radioiodine

Coedine

75
Q

What is the teratogenic effect of tetracycline during breastfeeding?

A

Permanent tooth staining

76
Q

What is the teratogenic effect of isoniazid during breastfeeding?

A

Pyridoxine deficiency

77
Q

What are the three teratogenic effect of barbiturates during breastfeeding?

A

Lethargy

Sedation

Poor Suck Reflexes

78
Q

What is the teratogenic effect of diazepam during breastfeeding?

A

Sedation

79
Q

What is the teratogenic effect of methadone during breastfeeding?

A

Withdrawal symptoms

80
Q

What are the two teratogenic effects of iodine during breastfeeding?

A

Thyroid suppression

Cancer risk

81
Q

What is the teratogenic effect of propylthiouracil during breastfeeding?

A

Thyroid suppression

82
Q

What is the teratogenic effect of codeine during breastfeeding?

A

Infant opiate toxicity

83
Q

What two ingredients contained in herbal medicines pose a risk to the infant?

A

Fenugreek

Comfrey

84
Q

What ingredient contained in herbal medicines poses a risk to the infant and mother?

A

Pyrrolizidine alkaloids (PAs)

85
Q

What is the first line treatment option for nausea and vomiting during pregnancy?

A

Antihistamines (cyclizine)

Phenothiazines (prochlorperazine)

86
Q

What is the second line treatment option for nausea and vomiting during pregnancy?

A

Ondansetron

Metoclopramide

87
Q

What is the first line treatment option for hypertension during pregnancy? What class of drug is this?

A

Labetalol

Betablocker

88
Q

What is the second line treatment option for hypertension during pregnancy? What class of drug is this?

A

Nifedipine

Calcium channel blocker

89
Q

What is the third line treatment option for hypertension during pregnancy? What class of drug is this?

A

Methyldopa

Alpha-2 adrenergic agonist

90
Q

What is the first line treatment option for epilepsy during pregnancy?

A

Lamotrigine

91
Q

What other drug do we prescribe epilepsy patients during pregnancy, apart from anti-epileptics?

A

These patients also require a higher dose of folic acid (5mg) compared to other pregnant patients

92
Q

What advice is given in regards to treating diabetic patients during pregnancy?

A

All oral antidiabetic drugs, except metformin, should be discontinued before pregnancy and substituted with insulin therapy

93
Q

What advice is given in regards to treating diabetic patients with metformin during pregnancy?

A

Diabetic patients can be treated with metformin as an alternative to insulin in the preconception period and during pregnancy

It can be continued immediately after birth and during breast-feeding

94
Q

What advice is given in regards to treating diabetic patients during breastfeeding?

A

Insulin and metformin can be prescribed

All other antidiabetic drugs should be avoided while breastfeeding

95
Q

What is the first line treatment option for thromboembolism during pregnancy?

A

Low molecular weight heparin (LMWH)

96
Q

What advice is given in regards to treating asthma patients during pregnancy?

A

Asthma medications can be used as normal, and patients should be counselled about the importance and safety of taking their medications to maintain good control

97
Q

What asthma medication requires close monitoring during pregnancy? Why?

A

Theophylline

Due to its potential toxicity

98
Q

What is the first line treatment option for migraines during pregnancy?

A

Paracetamol

99
Q

What is the second line treatment option for migraines during pregnancy?

A

Sumatriptan

Ibuprofen

100
Q

When can ibuprofen be considered as a second line treatment option for migraines during pregnancy?

A

It should only be considered as a treatment option in the first and second trimesters

101
Q

What is the first line treatment option for depression during pregnancy?

A

Selective serotonin receptor inhibitors (SSRIs)

102
Q

What advice is given regarding penicillin antibiotics during pregnancy and breastfeeding?

A

They are generally considered safe

However, it is important to check with the patient that they haven’t encountered an allergic reaction to penicillin in the past

103
Q

What advice is given regarding cephalosporin antibiotics during pregnancy and breastfeeding?

A

They are generally considered safe

104
Q

What advice is given regarding macrolide antibiotics during pregnancy and breastfeeding?

A

Erythromycin is the only macrolide antibiotic considered safe

105
Q

What advice is given regarding tetracycline antibiotics during pregnancy and breastfeeding?

A

Tetracycline antibiotics should not be prescribed, unless absolutely necessary

106
Q

What are the two teratogenic effects of tetracycline antibiotics?

A

Skeletal development defects

Discolouration of teeth

107
Q

What advice is given regarding sulphonamide antibiotics during pregnancy and breastfeeding?

A

Sulphonamide antibiotics should not be prescribed, unless absolutely necessary

108
Q

What are the teratogenic effects of sulphonamide antibiotics? In which trimester are they particularly harmful?

A

They act as folate antagonists, causing neural tube defects, cranio-facial defects and limb defects

First trimester

109
Q

What advice is given regarding aminoglycoside antibiotics during pregnancy and breastfeeding?

A

Aminoglycoside antibiotics should not be prescribed, unless absolutely necessary

110
Q

What are the teratogenic effects of aminoglycoside antibiotics?

A

They have damaging effects on the auditory and vestibular nerves

Year Three - Reproductive System (52 decks)

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