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*PSA > Prescribing in pregnancy & women of child-bearing age > Flashcards

Prescribing in pregnancy & women of child-bearing age Flashcards

1
Q

who should you consider when prescribing in pregnancy?

A

the mother & the foetus

also think of pregnancy in women of childbearing potential

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2
Q

what is the weigh up of prescribing in pregancy/women with child bearing age

A

both disease and drugs have the potential to cause foetal harm or carry risks to mother & foetus - the benefits and risks of continuing vs discontinuing medication must be carefully weighed and discussed with risks minimised
e.g. women with chronic disease may need long term control - HTN, asthma, epilepsy, DM

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3
Q

what are the possible drug effects within 20 days after fertilisation?

A

all or nothing effect
(death or no effect)
the foetus is highly resistant to birth defects

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4
Q

what are the possible drug effects 3-8 weeks after fertilisation?

A

possibly no effect
miscarriage
obvious birth defect
permanent but subtle effect only evident in later life
the status of the foetus is that it is developing organs and is particularly vulnerable to birth defects

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5
Q

what are the possible drug effects in 2nd and 3rd trimesters?

A

the status of the foetus is that organ development is complete
there are changes in the growth and function of normally formed organs and tissue - e.g. pathophysiology change
unlikely to cause obvious birth defect
unknown LT SE

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6
Q

When in pregnancy can you not use trimethoprim?

A

1st trimester (e.g. <12wks)

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7
Q

When in pregnancy can you not use warfarin?

A

all the time

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8
Q

When in pregnancy can you not use heparin?

A

3rd Trimester (>wk 28)

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9
Q

When in pregnancy can you not use tetracyclines, aminoglycosides, fluroqinolones?

A

T2 (wks 13- wks 28)

& T3 (>28wks)

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10
Q

When in pregnancy can you not use nitrofurantoin?

A

T3 (>28wks)

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11
Q

when in pregnancy can you not use opioid analgesics?

A

T1 and T3

so its ok to use in T2 from 13-28wks

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12
Q

When in pregnancy can you not use NSAIDs?

A

T3 >28wks

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13
Q

When in pregnancy can you not use ACEi?

A

T2

(13-28wks)

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14
Q

When in pregnancy can you not use benzodiazepines?

A

1st and 3rd trimester (<12 or >28wks)

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15
Q

When in pregnancy can you not use SSRIs, SNRIs or tricyclics?

A

T3 (>28wks)

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16
Q

When in pregnancy can you not use systemic corticosteroids (ideally)?

A

T1 e.g. <12wks

e.g. possible increasd risk of oral cleft if systemic steroid given weeks 4-12 (e.g. in asthma)

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17
Q

What antiepileptic is recommended for use in pregnancy?

A

Lamotrigine

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18
Q

When are phenytoin and carbamazepine not recommended for use in pregnancy?

A

T1 and T3

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19
Q

When is valproate not recommended for use in pregnancy?

A

T1

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20
Q

What are the risks of leaving a UTI untreated in pregnancy?

A

preterm birth

low birth weight

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21
Q

What are the risks of leaving asthma untreated during pregnancy?

A 
to mother:
hyperemesis
HTN
pre-eclampsia
vagina haem
complicated labour
to child:
foetal growth restriction
preterm birth
increased perinatal mortality
neonatal hypoxia

TF in asthma maintain normal treatment!

22
Q

What is FDA risk classification A?

A

controlled studies in humans show no risk

23
Q

What is FDA risk classification B?

A

no controlled studies done in humans but animal studies show no risk

24
Q

What is FDA risk classification C?

A

no controlled studies done in animals or humans

25
Q

What is FDA risk classification D?

A

Evidence of human risk to foetus however benefits may outweight risks in certain circumstances (e.g. emergency)

26
Q

What is FDA risk classification X?

A

controlled studies in both animals and humans demonstrate foetal abnormalities;
the risk in pregnant women outweighs any possible benefit

27
Q

What do you do when the drug treatment is unavoidable?

A

use the safest possible drug - usually these are the ones that have been around for a long time and have not been associated with foetal malformations
use the smallest effective dose
consider prophylactic measures to reduce the risk of foetal haem
in an emergency –> just treat! need to save the mothers life if the baby is going to have one…

28
Q

how do you prescribe trimethoprim in pregnancy?

A

2nd line 200mg BD
after nitrofurantoin (50mg QDS)
give folic acid 5mg OD with it if it is the first trimester of pregnancy (do not use if woman is folate deficient)
3rd line is cefalexin

29
Q

What do you use for induction of labour for medical reasons or stimulation of labour in hypotonic uterine inertia?

A

oxytocin

30
Q

What is the mechanism of action of oxytocin?

A

contractile protein actomyosin under the influence of the Ca2+ dependent phosphorylating enzyme myosin light chain kinase causes uterine motility
oxytocin promotes contractions by increasing the intracellular Ca2+ which in turn activates myosin light chain kinase
oxytocin has specific receptors in the uterus muscle lining w/ receptor concentration increasing during pregnancy to reach a maximum in early labour at term

31
Q

What are the common side effects of oxytocin?

A

arrhythmias
headache
nausea and vomiting

32
Q

What are the rare side effects of oxytocin?

A

anaphylaxis

hyponatraemia assoc with high doses w/large infusion volumes

33
Q

What are the warnings with oxytocin?

A

dont use in any conditions where spontaneous labour is inadvisable and/or in cases where vaginal delivery is inadvisable
avoid rapid intravenous injection - this may transiently reduce blood pressure

34
Q

What are the important interactions of oxytocin?

A

if you give high dose oxytocin IV for prolonged period and there is a large volume of fluid e.g. missed miscarriage or PPH then it may cause water intoxication with low Na. To avoid use electrolyte containing diluent e.g. not glucose, increase oxytocin concentration to reduce fluid, restrict fluid intake

35
Q

What are the non-pharmalogical methods of pain relief during labour?

A

education about labour reduces fear
having a supportive birth partner
breathing exercises and relaxation techniques
acupuncture, homeopathy and hypnosis for pt choice
TENS - safe and useful especially in shorter labour and postpones the use of stronger painkillers
water birth: labouring in water has been shown to reduce need for regional anaesthesia

36
Q

What are the pharmacological options of pain relief in labout?

A

Nitrous oxide
Narcotics e.g. pethidine and diamorphine + anti emetic
pudendal nerve block (S2,3,4)
Local anaesthetic (lidocaine)

37
Q

what are the quantities of nitrous oxide?

A

50% in O2 = entonox

has short onset and half life

38
Q

What are the CI of NO?

A

pneumothorax

39
Q

What are the SE of NO?

A

N&V

feeling faint

40
Q

What are the SE of narcotics e.g. pethidine and diamorphine + anti emetic?

A 
Mum SE:
drowsiness 
N&amp;V
Baby SE:
Short term respiratory depression
drowsiness which may last 7vral days
interfere with breast feeding
41
Q

What are the CI of narcotics use in labour?

A

birth pool

42
Q

What do you use for pudendal nerve block (S2,3,4)?

A

8-10mL of 1% lidocaine injected 1cm just below & medial to ischial spine
- is used with perineal infiltration for instrumental delivery but analgesia is insufficient for rotational forceps

43
Q

When do you use lidocaine as local anaesthetic in pregnancy?

A

give into the perineum before episiotomy at time of delivery and before suturing vaginal tears

44
Q

What types of regional anaesthesia are there?

A

epidural (T10-S5)
combined spinal epidural (CSE)
spinal anaesthesia

45
Q

How is epidural anaesthesia used?

A

consent is needed
you regularly top up
epidural anaesthesia can help lower BP in PET

46
Q

how is combined spinal epidural used?

A

quicker pain relief

can be prolonged

47
Q

how is spinal anaesthesia used?

A

used for most C-sections
relatively easier to insert than epidurals
produce a reliably dense block but because they are single injections, they may wear off if the procedure is prolonged (>2h) and
can cause more profound hypotension compared with epidural (good in PET?)

48
Q

What is the technique of epidural anaesthesia?

A
  • L4-L5 normally used
  • insert wide bore access and gain consent
  • inserted with woman lying on her side
  • use full aseptic technique
  • once in, monitor BP every 5 min (x4) for 20m #
  • record block height and density
  • use continuous fetal monitoring - may see foetal bradycardia just after because of maternal hypotension –> IV fluid almost always recovers
  • top up EA 2 hrly
    recall anaesthetist if inadequate pain relief w/i 30m
  • NB: epidural takes longer than spinal to take effect (if want this for LSCS)
49
Q

What are the complications of epidural anaesthesia?

A 
failure to site
patchy block
hypotension
dural puncture (<1:1000)
post dural puncture headache
transient or permanent nerve damage (extremely rare) 
increased risk of operative delivery
50
Q

What are the contraindications to epidural anaesthesia?

A

Platelet count <74x10^9
recent LMWH
sepsis

51
Q

What do you do with your block if a patient has had LMWH?

A

wait 12h after heparin dose before inserting block or removing catheter
–> 24 h if was a therapeutic rather than prophylactic dose

52
Q

How long do you have to wait after a block before the next dose of LMWH?

A

4h

*PSA (3 decks)

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