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Y4 Obstetrics and Gynaecology > Prescribing in pregnancy > Flashcards

Prescribing in pregnancy Flashcards

1
Q

Give a few examples of ways in which prescribing drugs can be avoided in pregnancy ?

A
  • Physio instead of NSAID’s
  • CBT instead of anti-depressants
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2
Q

When should you prescribe drugs in pregnancy ?

A

If the benefit from prescribing the drug outweighs the risk

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3
Q

Why is careful documentation of drugs prescribed during pregnancy needed ?

A

Because most drugs are not licensed for use in pregnancy

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4
Q

What are the attitudes of most mothers & doctors to prescribing in pregnancy ?

A

Drs are reluctant to prescribe & women are reluctant to take drugs during pregnancy

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5
Q

What is pharmacokinetics ?

A

This is the study of the movement of drugs within the body i.e. what the body does to the drug after its taken

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6
Q

What are the 4 main componets of pharmacokinetics ?

A
  • Absorption
  • Distribution
  • Metabolism
  • Excretion
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7
Q

How is the absorption of drugs affected in pregnancy ?

A

It may be affected by morning sickness (may vomit after taking drug ==> not enough time for full dose to be absorbed)

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8
Q

How is the distribution of drugs affected during pregnancy ?

A
  • Volume of distribution is increases - due to increased plasma volume & fat stores
  • It also increases due to decreased protein binding resulting in increased free drug
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9
Q

How is the metabolism of drugs affected during pregnancy ?

A

There is increased liver metabolism of some (not all) drugs e.g. phenytoin ==> these drugs may have a shorter action time & are eliminated faster

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10
Q

How is the exrection of drugs affected during pregnancy ?

A

Elimination of renally excreted drugs increases due to the increased GFR during pregnancy

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11
Q

Due to the changes in pharmacokinetics during pregnancy what may you need to do with some drugs during pregnancy ?

A

May need to check concentrations and alter dose during pregnancy and after delivery e.g. Lithium, digoxin

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12
Q

Define pharmacodynamics

A

This is what a drug does to the body i.e. the biological effects & mechanism of action of a drug

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13
Q

Are there many changes to the pharmacodyanmics of a drug during pregnancy ?

A

No - except they may become more sensitive to some drugs during the 2nd trimester e.g. risk of hypotension with antihypertensives in 2nd trimester (think cause BP is dropping during this period)

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14
Q

What pre-conception management is required for chronic conditions?

A
  • Counselling regarding chronic condition
  • Aim to optimise theraputic control & choose the safest drugs
  • Also review if drug therapy is needed
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15
Q

How is the risk of neural tubual defects (NTD) in a pregnancy assessed?

A

Couples are assessed as high-risk if:

  1. Either partner has a NTD, or had a previous pregnancy with a NTD or a family history of NTD’s
  2. The women is taking ant-epileptic drugs
  3. Women has coeliac disease or anyother malabsorptive state, diabetes, sickel cell anaemia, or thalassaemia
  4. Women with BMI ≥ 30
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16
Q

What should women considered at normal risk of a NTD pregnancy take?

A

400 micrograms of folic acid daily 3 months prior (12wks) & continue until 3 months into pregnancy

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17
Q

What should women considered at high risk of a NTD pregnancy take?

A

5mg of folic acid daily 3 months prior & continue until 3months of pregnancy

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18
Q

What is the risk of taking drugs during the 1st trimester (upto week 12+6) of pregnancy ?

A

There is a risk of early miscarriage ==> recommened to avoid drugs during this period unless maternal risks outweigh the benefits

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19
Q

What is the period of greatest teratogenic risk during pregnancy ?

A

The 4th to 11th week

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20
Q

Match the following teratogenic drugs to the potential problems they can cause:

  • ACEi/ARB
  • Anti-epileptics esp Na valproate
  • Cytotoxics e.g. methotrexate, cyclophosphamide, azathioprine, rheumatoid arthritis drugs, cancer drugs, antibiotics etc
  • Androgens e.g. testosterone
  • Lithium
  • Retinoids
  • Methotrexate
  • Warfarin

Causes renal hypoplasia, causes virilisation of female fetus, causes cardiac, facial, limb & NTDs, causes multiple defects, abortion, causes cardiac defects, causes skeletal defects, causes ear, CV & skeletal defects, causes limb & facial defects

A
  • ACE inhibitors/ARB - Renal hypoplasia
  • Androgens - Virilisation of female foetus
  • Antiepileptics - Cardiac, facial, limb, neural tube defects
  • Cytotoxics - Multiple defects, abortion
  • Lithium - Cardiovascular defects
  • Methotrexate - Skeletal defects
  • Retinoids - Ear, cardiovascular, skeletal defects
  • Warfarin - Limb and facial defects
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21
Q

How may drugs affect the fetus during the 2nd and 3rd trimesters ?

A

They may affect growth of the fetus, functional development (intellectual impairment, behavioural abnormalities) or have toxic effects on fetal tissue

22
Q

How may drugs adversely affect labour ?

A
  • Affect Progress of labour
  • Adaptation of foetal circulation e.g. Premature closure of ductus arteriosus
  • Suppression of foetal systems e.g. Opiates – respiratory depression
  • Bleeding e.g. Warfarin
23
Q

How may drugs adversley affect the baby after delivery ?

A
  • Withdrawal syndrome e.g. from opiates, SSRI
  • Sedation
24
Q

How is the compliance of asthamatics and epileptics with their medication during pregnancy ?

A
  • Many women avoid taking their asthma inhalers in pregnancy
  • Up to 20% of women discontinue antiepileptic medication in pregnancy
25
Q

The incidence of congenital malformations higher in untreated women with epilepsy than women without epilepsy - T or F?

A

True

26
Q

How many epileptic women experience increase seizure frequency during pregnancy and why is this?

A

10%, due to:

  • Non-compliance
  • Changes in plasma concentrations of drugs caused by Persistent vomiting, Increased clearance
27
Q

What are frequent seizures in epileptic pregnant women associated with ?

A

Lower verbal IQ in child, hypoxia, bradycardia, antenatal death, maternal death

28
Q

Why is monotherapy preferred in pregnant epileptic women?

A

Because the risk of congenital malformations increases as the number of epileptic drugs increases e.g. when on 4 it is as high as 20-30%

29
Q

What 2 anti-epileptic drugs should be avoided and why?

A
  • Na valproate - due to risk of NTD’s
  • Phenytoin - due to greater risk of lots of defects
30
Q

What percentage of babies born from women taking anti-epileptic medications will not have major congenital malformations ?

A

96%

31
Q

The benefits of epilepsy treatment outweigh the risks of no treatment during pregnancy in general - T or F?

A

True

32
Q

What are the only 2 diabetic controlling drugs safe for use in pregnancy ?

A

Insulin & metformin

All others should be discontinued prior to pregnancy & insulin should be started

33
Q

What is the treatment of diabetes during pregnancy ?

A

If managed on metformin with good stable BG prior to pregnancy then continue with its use in pregnancy, otherwise use insulin for every other scenario in pregnancy

34
Q

What is the risk of poor diabetic control during pregnancy ?

A

Increases risk of congenital malformations & IUD

35
Q

Which diabetic drug is especially not safe during pregnancy ?

A

Sulphonylureas

36
Q

What anti-hypertensive drugs should be avoided during pregnancy ?

A

ACEi/ARB’s

37
Q

Why is care taken especially in the 2nd trimester to not cause hypotension in those being treated for HTN?

A

because BP decreases upto a nadir at 22-24 weeks

38
Q

What is the treatment of HTN in pregnancy ?

A
  • 1st line = Labetalol (avoid in asthma)
  • 2nd line = nifedipine (can give bad headaches) or methyldopa
  • 3rd line = Hydralazine or doxazocin
39
Q

What can beta-blockers do in late pregnancy ?

A

They may inhibit fetal growth (more worried about this with newer ones, hence labetalol is fine)

40
Q

What is the treatment of nausea & vomiting in pregnancy ?

A

If required treat with cyclizine

41
Q

What is the treatment of UTI’s during pregnancy ?

A
  • 1st or 2nd trimester give nitrofuratoin
  • 3rd trimester give trimethoprim

2nd line for any trimester is cefalexin

42
Q

What is the treatment of heartburn during pregnancy ?

A

Antacids

43
Q

Why is warfarin avoided during pregnancy and labour ?

A

It is teratogenic in early pregnancy & carries risk of haemorrhage in late pregnancy and delivery

44
Q

Most drugs enter breast milk, especially Small molecules and Fat soluble (lipophilic) drugs. Few enter in sufficient quantities to cause a problem - T or F?

A

True

45
Q

What drug when used when breastfeeding can result in suckling difficulties in the baby?

A

Phenobarbitone

46
Q

What problems can amiodarone cause when used in pregnancy?

A

Neonatal hypothyroidism

47
Q

What can cytotoxics cause when used in pregnancy ?

A

Bone marrow suppression

48
Q

What can benzos cause when used in pregnancy ?

A

Drowsiness

49
Q

What problem may Bromocriptine cause when used in pregnancy ?

A

It can suppress lactation

50
Q

What drug is avoided in children < 8 and why ?

A

Tetracyclines because they can cause staining of bones & teeth

51
Q

What malformations is phenytoin associated with when used in pregnancy ?

A

Cleft lip & palate

52
Q

What malformations is Na valproate associated with when used in pregnancy ?

A

NTD’s e.g. spina bifida, ancephaly

Y4 Obstetrics and Gynaecology (63 decks)

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