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Endocrine Module > Teratogenesis, Pregnancy, and Postpartum Issues > Flashcards

Teratogenesis, Pregnancy, and Postpartum Issues Flashcards

1
Q

What factors influence teratogenic potential?

A
  1. Duration of Use
  2. Susceptibility of Fetus
  3. Placental Transfer
  4. Timing of Exposure
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2
Q

What is the mechanism of Placental Transfer?

A

Passive Diffusion

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3
Q

What factors influence rate and extent of passive diffusion?

A
  1. MW
  2. Protein Binding
  3. Lipid Solubility
  4. Ionization
  5. Concentration Gradient
  6. Uterine Blood Flow
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4
Q

In terms of MW, what are the sizes that cross and do not cross the placenta?

A

<500 daltons, readily cross
>1000 daltons, do not cross in significant amounts

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5
Q

Do highly protein bound drugs cross the placenta?

A

NO

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6
Q

Ionized or Unionized drugs cross the placenta?

A

Unionized

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7
Q

The Pre-Embyronic Stage is 0-14 days after fertilization, what is the teratogen effect?

A

Teratogen exposure produces ALL or NOTHING effect

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8
Q

The Embryonic Stage is 14-56 days, what is the teratogen effect?

A

MOST Susceptible = MAJOR structural anomalies

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9
Q

The Fetal Stage is 57 days - term, what is the teratogen effect?

A

Anomalies more likely to involve growth and functional aspects

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10
Q

What are the limitations of the OLD FDA Categories?

A

Derived from animal data
No distinction between drugs in the same class
Majority in Category C
Lacks informative data

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11
Q

What does the REVISED FDA labeling include?

A
  1. Removed letter category
  2. Pregnancy Subsection
  3. Lactation Subsection
  4. Females and Males of Reproductive Subsection
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12
Q

What are agents to avoid DURING pregnancy?

A
  1. ACE/ARBs/Renin Inhibitors
  2. DOACs
  3. Isotretinoin
  4. NSAIDs
  5. Retinoids
  6. Thalidomide
  7. Trimethoprim
  8. Valproic Acid
  9. Warfarin
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13
Q

What is the concern with Thalidomide and does it have a REMs?

A

Contraindicated in Pregnancy
YES

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14
Q

What are the requirements for the REMS of Thalidomide?

A
  1. Prescription filled <7 days and no more than a 4-week supply at one time
  2. Patients required to use contraceptive measures
  3. Females must have neg pregnancy test within 24 hrs prior to starting treatment
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15
Q

What is the concern with Lenalidomide and does it have a REMs?

A

Contraindicated in pregnancy
YES

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16
Q

What is the concern with Retinoids?

A

Contraindicated in pregnancy

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17
Q

When is the greatest risk for Retinoids?

A

At 4-7 weeks gestation and risk persists after stopping therapy

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18
Q

What is the contraception requirement for Isotretinoin?

A

Contraception 1 month following DC

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19
Q

What is the contraception requirement for Acitretin (Soriatane)?

A

Contraception for 3 years following DC

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20
Q

What is the iPLEDGE Program?

A

REMs for Isotretinoin, requires all patients, prescribers, pharmacists, and wholesale distributors to register

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21
Q

For iPLEDGE patients must complete an informed consent with pick prescription within?

A

30 days for men and women who cannot get pregnant
7 days for women of childbearing potential

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22
Q

For females of childbearing potential, iPLEDGE requires what?

A

2 negative pregnancy tests before starting, negative pregnancy test every month, and use of 2 forms of contraception

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23
Q

Can you donate blood while taking Isotretinoin?

A

NO

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24
Q

How does the dating of pregnancy (gestation) work?

A

Gestation age refers to age of fetus beginning the first days of the last menstrual period which is ~2 weeks prior to fertilization

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25
Q

Prematurity is defined as?

A

<37 weeks gestation

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26
Q

Late Pretrerm is defined as?

A

34-36 weeks gestation

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27
Q

Gravidity (G) means what?

A

Number of pregnancies

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28
Q

Parity (P) means what?

A

Number of pregnancies that exceed 20 weeks of gestation and outcome of each pregnancy

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29
Q

What are the PK changes in pregnancy?

A
  1. Delayed gastric emptying, INCREASED gastric pH
  2. Decreased motility
  3. Increased total body water
  4. Increased body fat
  5. Increased cardiac output
  6. Increased GFR
  7. Decreased plasma albumin
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30
Q

Increase in gastric pH causes what?

A

Increase availability of acid-labile drugs or decrease availability for drugs that require acidic environment

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31
Q

Decrease gastric emptying causes what?

A

Delay time to peak concentration after admin

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32
Q

Decrease in GI motility causes what?

A

Increased absorption of enteral meds

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33
Q

Increase in total body water causes what?

A

Increase volume of distribution for hydrophilic meds = increase dose

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34
Q

Increase body fat causes what?

A

Increase volume of distribution for lipophilic meds

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35
Q

Increase cardiac output causes what?

A

Increase hepatic blood flow = increase hepatic metabolism

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36
Q

Increase GFR causes what?

A

Increase clearance of renal eliminated drugs

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37
Q

Decrease plasma albumin causes what?

A

Increase free drug for drugs that are highly protein bound

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38
Q

What Vitamins and Supplements should be taken?

A
  1. Pre-Natal Multi-Vitamin
  2. Iron
  3. Folate
  4. Calcium/Vitamin D
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39
Q

What is the minimum amount of iron that should be taken?

A

30 mg

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40
Q

What amount of iron is recommended during pregnancy?

A

30 mg/day
60-120 if iron deficiency anemia is present

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41
Q

What amount of iron is recommended in prenatal vitamin?

A

30-90 mg of elemental iron

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42
Q

What is the recommended amount of folate for all women of child-bearing age?

A

0.4 mg/day

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43
Q

What is the recommend amount of folate for women during pregnancy?

A

0.8 mg/day

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44
Q

What is the recommend amount of folate in prenatal vitamins?

A

0.8-1 mg of folic acid

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45
Q

What is the recommend amount of calcium and vitamin D for pregnancy?

A

1000 mg of calcium and 600 IU of vitamin D

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46
Q

When is dietary modifications recommended to treat diabetes in pregnant women?

A

Type 2 DM

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47
Q

What is the first line choice treatment of type 1 and 2 diabetes in pregnant women?

A

Insulin, does not cross placenta

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48
Q

If insulin is not used in Type 2 DM, what oral agents are recommended?

A

First Line: Metformin
Second Line; Glyburide

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49
Q

What is the concern with Glyburide in pregnant women?

A

May result in more neonatal hypoglycemia

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50
Q

What is chronic hypertension defined as in pregnancy?

A

Diagnosed before pregnancy or before 20 weeks gestation

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51
Q

What is the treatment for Mild-Mod Hypertension 140-149/90-108 mmHg?

A

Watch and Wait
Decrease salt, protein, stress

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52
Q

What is the treatment for CHRONIC Severe Hypertension >160/100 mmHg?

A

1st Lne: Labetalol PO or Nifedipine ER PO
2nd/3rd Line: Methyldopa PO or HCTZ PO

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53
Q

What is the goal BP for CHRONIC Severe Hypertension?

A

120-159/80-106 mmHg

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54
Q

What is the treatment for ACUTE Severe Hypertension >160/100 mmHg?

A

Hydralazine IV, Labetalol IV, Nifedipine IM
Start within 60 mins, not one is 1st line, if one doesn’t work at max dose move on to the next

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55
Q

When do you avoid ACE/ARBs in pregnancy?

A

2nd/3rd, with concern in the first

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56
Q

When do you avoid MRAs in pregnancy?

A

1st

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57
Q

What is the FDA box warning for ACE/ARBs?

A

DC use as soon as possible once pregnancy is detected

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58
Q

What is the drug of choice for asthma that is a beta agonist?

A

Albuterol

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59
Q

What is the drug of choice for asthma that is an inhaled corticosteroid?

A

Budesonide

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60
Q

What is the drug of choice for asthma that is a long-acting beta agonist?

A

Salmeterol/Formoterol

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61
Q

What are the anti-epileptic agents?

A

Valproic Acid, Phenytoin, Phenobarbital, Carbamazepine, and Topiramate

62
Q

What does Valproic Acid cause?

A

Neural tube defects
Facial Cleft

63
Q

What does Phenytoin cause?

A

Cleft palate
Limb defects

64
Q

What does Phenobarbital cause?

A

Cardiac malformations

65
Q

What does Carbamazepine cause?

A

Cleft palate

66
Q

What does Topiramate cause?

A

Cleft palate

67
Q

How do you manage epilepsy when pregnant?

A

Monotherapy at lowest effective dose, AVOID valproic acid, phenobarbital, and phenytoin if possible

68
Q

What is the recommended folate supplementation for patients with epilepsy?

A

1 mg/day for w/epilepsy
4 mg/day for patients on carbamazepine or valproic acid

69
Q

When is nonpharmacologic psychotherapy appropriate treatment for depression in pregnant women?

A

Effective for most with mild to moderate depression

70
Q

What is the drug of choice for depression in pregnancy?

A

SSRIs are drug of choice
Sertaline and Fluoxetine
AVOID paroxetine and citalopram

71
Q

What is the alternative drug for depression in pregnancy?

A

Tricyclic Antidepressants
Desipramine and Nortiptyline

72
Q

What are the neonatal effects of SSRIs?

A

Persistent Pulmonary Hypertension of the newborn
Poor neonatal adjustment syndrome

73
Q

What are the pregnancy-induced conditions?

A
  1. N/V
  2. Constipation
  3. GERD
  4. Gestational Diabetes
  5. Gestational HTN
  6. Preeclampsia
  7. Thromboembolism
74
Q

What is the treatment goal for N/V (hyperemesis gravid arum)?

A

Decrease symptom severity and frequency, prevent and treat complications, and minimize potential fetal effects

75
Q

What is the treatment algorithm for N/V?

A
  1. Dietary Changes
  2. Vitamin B6 and Doxylamine
  3. Add Dimenhydrinate, Diphenhydramine, Promethazine, or Prochlorperazine
  4. Add Metoclopramide or Ondansetron
  5. Add Chlorpromazine or Methylprednisolone

Add On: Ginger Extract

76
Q

What are the precautions of Promethazine second line drug for N/V?

A

Dystonia, sedation, extrapyramidal reactions

77
Q

What are the precautions of Prochlorperazine second line drug for N/V?

A

Dystonia, sedation, extrapyramidal reactions

78
Q

What are the precautions of Metoclopramide second line drug for N/V?

A

Caution with use at < 10 weeks gestation, prolong QT interval

79
Q

What are the precautions of Ondansetron third line drug for N/V?

A

Caution with use at < 10 weeks gestation, prolong QT interval

80
Q

What are the precautions for Pyridoxine/Doxylamine (Diclegis) combination for N/V?

A

Delayed release tablet, sedation

81
Q

What are the precautions for Pyridoxine/Doxylamine (Bonjesta) combination for N/V?

A

Extended release tablet, sedation

82
Q

What is the first line option for N/V?

A

Pyridoxine

83
Q

What are the OTC meds for N/V?

A

Diphenhydramine, Doxylamine, Meclizine, Pyridoxine, and Ginger

84
Q

What is first line therapy for constipation in pregnancy?

A

Nonpharmacologic, dietary changes

85
Q

What are the first line agents for constipation in pregnancy?

A

Antacids, H2 Antagonists, and PPI

86
Q

What are the Antacids, and which one is most recommended?

A

Calcium Carbonate (most)
Aluminum Hydroxide (least)
Magnesium Hydroxide

87
Q

What are the H2 Antagonists, and which one is most recommended?

A

Ranitidine (no)
Famotidine (most)
Cimetidine (avoid)

88
Q

What are the PPIs and which one is most recommended?

A

Lansoprazole
Omeprazole (most)
Pantoprazole

89
Q

What drugs should be avoided in constipation with pregnancy?

A

Antidiarrheal/Antisecretory Bismuth Subsalicylate and Antacid Sodium Bicarb

90
Q

Why do you avoid Bismuth Subsalicylate?

A

Closure of ductus arterious

91
Q

Why do you avoid Sodium Bicarbonate?

A

Maternal/Fetal metabolic alkalosis

92
Q

What are the risk factors for Gestational Diabetes?

A
  1. Age >25
  2. Overweight
  3. Ethnic group with high incidence DM
  4. FH of DM
  5. History of abnormal glucose test
93
Q

When should screening with oral glucose tolerance test OGTT occur?

A

24-48 weeks gestation

94
Q

What is the drug of choice for gestational diabetes?

A

Insulin

95
Q

What is the alternative oral agent for gestational diabetes?

A

Metformin

96
Q

What is the classification for Gestational Hypertension?

A

Increase BP SBP>140 mmHg or DBP> 90 mmHg, after 20 weeks gestation

97
Q

What is Preeclampsia?

A

Increase BP with proteinuria, Increase BP with thrombocytopenia, renal/hepatic insufficiency, pulmonary edema, or new onset headache

98
Q

What is Eclampsia?

A

Tonic clonic seizures with preeclampsia

99
Q

Is Eclampsia a medical emergency?

A

YES, requires intubation to protect airway, seizures can occur antepartum, intrapartum, or postpartum

100
Q

What are the HELLP Complications for Preeclampsia?

A

H: Hemolysis
E: Elevated L: Liver Function tests
L: Low P: Platelets

101
Q

What are the risk factors for Preeclampsia?

A
  1. Chronic HTN
  2. Chronic Renal Disease
  3. Maternal Age >40
  4. Multiple Gestation
  5. Preeclampsia in a previous pregnancy
  6. Gestational diabetes or diabetes
  7. Obesity
102
Q

Management of Severe Preeclampsia applies to what patients?

A
  1. BP <160 SBP or >110 DBP on two occasions 4 hours apart
  2. Thrombocytopenia
  3. Impaired hepatic function
  4. Renal insufficiency
  5. Pulmonary edema
  6. New onset HA/or visual disturbances
103
Q

What should be used to manage BP in Severe Preeclampsia?

A

IV Labetalol or Hydralazine

104
Q

What should be used to manage Seizure Prevention in Severe Preeclampsia?

A

Magnesium Sulfate

105
Q

What is the goal range for magnesium concentration for prevention of eclampsia?

A

4-7 mEq/L

106
Q

What can be used for prevention of preeclampsia?

A

Low dose ASA may be used after 12 weeks of pregnancy for women at high risk for preeclampsia

107
Q

How does the ASA dose change for patients with Type 1 or 2 DM?

A

100-150 mg/day

108
Q

What is the preferred treatment for Thromboembolism in Pregnancy?

A

LMWH

109
Q

What is the alternative first line treatment for Thromboembolism in Pregnancy?

A

UFH

110
Q

When can Warfarin be used in pregnancy?

A

TERATOGEN, avoid unless used in women with mechanical heart valves (teratogenic risk decrease with doses <5mg)

111
Q

Drug of Choice for Pain in Pregnancy?

A

Acetaminophen

112
Q

Alternative Choice for Pain in Pregnancy?

A

NSAIDs, avoid in 1st/2nd trimester

113
Q

Drug of Choice for Allergies in Pregnancy?

A

Chlorpheniramine or Intranasal Corticosteroids

114
Q

Alternative Choice for Allergies in Pregnancy?

A

Diphenhydramine, Loratadine, and Cetirizine

115
Q

Drug of Choice for Cough/Congestion in Pregnancy?

A

Oxymetazoline (nasal)
Pseudoephedrine (oral)
Dextromethorphan

116
Q

Alternative Choice for Cough/Congestion in Pregnancy?

A

Guaifenesin, avoid due to congenital effects

117
Q

Drug of Choice for UTI in Pregnancy?

A

Amoxicillin-Clavulanta or Nitrofurantoin

118
Q

Alternative Choice for UTI in Pregnancy?

A

Cephalexin
Bactrim (avoid in 2nd/3rd trimester)

119
Q

Drug of Choice for Diarrhea in Pregnancy?

A

Stool bulking

120
Q

Alternative Choice for Diarrhea in Pregnancy?

A

Loperamide, use sparingly

121
Q

What is defined as preterm labor?

A

Cervical dilation and/or uterine contractions at <37 weeks gestation

122
Q

What are Tocolytic Agents used for?

A

Postpone delivery long enough (up to 38 hours) to allow for: administration of antenatal corticosteroids or transport of mother

123
Q

What is the tocolytic beta agonist?

A

Terbutaline, not ideal due to hypotension, arrhythmias, and hyperkalemia

124
Q

What is the tocolytic CCB?

A

Nifedipine, predominant agent
May cause hypotension

125
Q

What is the tocolytic NSAID?

A

Indomethacin, predominant agent
May cause premature closure of ductus arterioles

126
Q

What is the tocolytic magnesium?

A

Magnesium Sulfate, limited efficacy

127
Q

What are the antenatal steroids that are utilized to accelerate fetal lung maturation?

A

Betamethasone or Dexamethasone

128
Q

When is Betamethasone 12 mg IM or Dexamethasone 6 mg IM recommended?

A

Risk for delivery >24 to <34 weeks
Risk for delivery at >34 to <37 weeks with no previous course

129
Q

What are the Cervical Ripening Agents?

A

Misoprostol (intravaginal/oral)
Dinoprostone (intravaginal/intracervical)

130
Q

Dinoprostone Gel (prepidil) is what route?

A

Intracervical

131
Q

Dinoprostone Vaginal (Cervidil) is what route?

A

Intravaginal

132
Q

What drug stimulates/induces labor?

A

Oxytocin

133
Q

How does drug excrete into breast milk?

A

Passive Diffusion

134
Q

Maternal Serum Concentration in relation to breast milk

A

High maternal concentration = greater passive diffusion into milk

135
Q

Lipid Solubility in relation to breast milk

A

Higher lipid solubility = greater transfer into milk

136
Q

Protein Binding in relation to breast milk

A

Higher protein bound = less transfer into breast milk

137
Q

Ionization in relation to breast milk

A

Unionized = greater transfer into milk

138
Q

Molecular Weight in relation to breast milk

A

Low MW = greater transfer into milk

139
Q

Acid/Base in relation to breast milk

A

Weak bases can be ionized when in breast milk

140
Q

What drugs are contraindicated or use with caution in lactation?

A
  1. Bromocriptine
  2. Chemotherapy
  3. Codeine
  4. Cyclophosphamide
  5. Cyclosporine
  6. Iodine
  7. Lithium Carbonate
  8. Methotrexate
  9. Radiopharmaceutical
  10. Tetracyclines
141
Q

What are acceptable meds for pain with lactation?

A

Acetaminophen or Ibuprofen
NOT ASA

142
Q

What are acceptable meds for allergies with lactation?

A

Loratadine or Diphenhydramine
Can dry up milk supply

143
Q

What are acceptable meds for cough/congestion with lactation?

A

Nasal Decongestants or Dextromethorphan
NOT Psuedoephedrine

144
Q

What are acceptable meds for heartburn/reflux with lactation?

A

Antacids/Famotidine/Pantoprazole
NOT bismuth subsalicylate or cimetidine

145
Q

What are acceptable meds for constipation with lactation?

A

Bulking Agents, Docusate, Bisacodyl, PEG
NOT Senna

146
Q

What are acceptable meds for diarrhea with lactation?

A

Bulking Agents or Loperamide
NOT bismuth subsalicylate

147
Q

What medications can cause low milk production?

A
  1. Bromocriptine
  2. Estrogen Containing contraceptive
  3. Oral Decongestants
  4. Antihistamines
  5. Nicotine
  6. Diuretics
148
Q

What is a pharmacologic therapy for low milk production?

A

Metoclopramide

149
Q

What is the management for Mastitis?

A
  1. Antibiotics for 10-14 days (cephalexin)
  2. Anti-Inflammatory Medications for Pain (ibuprofen)
  3. Nonpharmacologic Therapy
150
Q

What is pharmacologic therapy for postpartum depression with lactation?

A

Sertraline First Line
Paroxetine or Nortriptyline Second Line
Fluoxetine CAUTION

Endocrine Module (16 decks)

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