Therapy Of Certain Disorders During Pregnancy Flashcards
Physiologic changes in pregnancy begin in the __ trimester and peak during the __ trimester.
First; Second
What lowers the concentration of drugs excreted by the kidney during pregnancy?
1) Increased plasma volume
2) Increased cardiac output
3) Increased GFR
(All by 30-50%)
Plasma albumin concentration in pregnancy ___(increases/decreases) due to:
Decreases; Dilution
Hepatic perfusion in pregnancy __(decreases/increases), which may __(decrease/increase) hepatic extraction of drugs.
Increases; increase
What may alter drug absorption in pregnant women (GI)?
1) Nausea
2) Vomiting
3) Delayed gastric emptying
4) Increased gastric acid
High levels of ___ in pregnancy may affect hepatic enzyme activity.
Estrogen and progesterone
Which diseases have the potential to cause adverse pregnancy consequences?
1) Gestational diabetes
2) Gestational hypertension
3) Venous thrombo-embolism
What is the first step for managing constipation during pregnancy?
1) Moderate physical exercise
2) Increased dietary intake of fibers and fluids
3) Supplemental fiber and/or stool softener
What are some bulk-forming agents?
1) Psyllium
2) Methylcellulose
3) Polycarbophil
Why are bulk-forming agents safe for long-term use?
Because they are not absorbed
What are some osmotic laxatives?
1) Polyethylene glycol
2) Lactulose
3) Sorbitol
What are some stimulant laxatives?
1) Senna
2) Bisacodyl
Which laxatives shouldn’t be used during pregnancy because of electrolyte imbalances?
1) Magnesium
2) Sodium salts
Which laxative shouldn’t be used during pregnancy because it stimulates uterine contractions?
Castor oil
Which laxative shouldn’t be used during pregnancy because it impairs fat-soluble vitamin (ADEK) absorption, and may cause severe bleeding in the newborn?
Mineral oil
What does castor oil cause during pregnancy?
Stimulates uterine contractions
Treatment for GERD during pregnancy?
1) Lifestyle and diet changes
2) Antacids
3) Sucralfate
4) H2-receptor blockers (ranitidine)
Why is Sodium bicarbonate not a suitable option for GERD during pregnancy?
Sodium overload
Why is magnesium trisilicate not a suitable option for GERD during pregnancy?
No data available on safety
When does nausea and vomiting of pregnancy begin?
Within 4-6 weeks of gestation
When does nausea and vomiting of pregnancy peak?
Between weeks 8-12
When does nausea and vomiting of pregnancy resolve?
By 16-20 weeks
Treatment for nausea and vomiting of pregnancy?
1) Dietary modifications
a) Eating frequent small soft meals
b) Avoiding fatty and spicy meals
2) Ginger
3) Pyridoxine (vitamin B6) and/or antihistamines (doxylamine) are effective and are first-line agents (Pyridoxine - doxylamine)
Why are Metoclopramide and phenothiazines not suitable options for nausea and vomiting during pregnancy?
1) Sedation
2) Extrapyramidal adverse
effects (dystonia)
Why is Ondansetron (serotonin 5-HT3 receptor antagonist) not a suitable option for nausea and vomiting during pregnancy?
May cause oral clefts
Corticosteroids for nausea and vomiting during pregnancy are reserved for use after the ___ trimester. Why?
First; Risk of oral clefts
Gestational diabetes (GDM) is diabetes diagnosed during the:
Second and third trimesters
GDM first-line therapy?
Nutritional education
What is the drug of choice for GDM and why?
Human insulin; does not cross the placenta.
Risks of GDM include:
1) Fetal loss
2) Risk of congenital malformations
3) Macrosomia
What are the hypertensive disorders of pregnancy?
1) Gestational hypertension
2) Preeclampsia/eclampsia
3) Chronic hypertension
4) Chronic hypertension with superimposed preeclampsia
Treatment of hypertensive disorders of pregnancy?
1) Methyldopa
2) Hydralazine
3) Labetelol
4) Magnesium sulfate (when preeclampsia is present)
Preeclampsia develops after:
20 weeks of gestation
Preeclampsia consists of:
1) Renal failure
2) Maternal morbidity/mortality
3) Preterm delivery
4) Intrauterine growth retardation
Preeclampsia treatment?
1) Treatment of hypertension
2) Low-dose aspirin 60-81 mg/day beginning late in the first trimester in women at risk of preeclampsia.
What is the only cure for preeclampsia?
Delivery of the placenta
What is eclampsia?
Seizures on top of preeclampsia (Medical emergency)
Eclampsia may be prevented by:
1) Low dose aspirin
2) Magnesium sulfate
Which drugs should be avoided in eclampsia?
1) Diazepam
2) Phenytoin
Treatment of acute Venous Thrombo-embolism (VTE) in pregnancy?
Low-molecular-weight heparin (LMWH)
How long should a pregnant woman take LMWH for a VTE?
Throughout pregnancy and for 6 weeks after delivery (minimum duration of therapy should be >3 months).
Which drugs should be avoided UNLESS the patient has heparin-induced thrombocytopenia?
1) Fondaparinux (synthetic pentasaccharide)
2) Injectable direct thrombin inhibitors (lepirudin, bivalirudin)
Should you give oral agents Dabigatran, Rivaroxaban, or Apixapan for a VTE during pregnancy?
No
What is Dabigatran?
A direct thrombin inhibitor
What is Rivaroxaban?
Direct factor Xa inhibitor
What is Apixaban?
Direct factor Xa inhibitor
Why shouldn’t warfarin be given during pregnancy?
1) Nasal hypoplasia
2) Stippled epiphysis (chondodysplasia punctata)
3) Limb hypoplasia
4) Eye abnormalities (risk period 6-12 weeks of gestation)
5) CNS anomalies are associated with exposure during 2nd and 3rd trimesters.
High risk women for VTE with prosthetic heart valves should be given:
1) LMWH twice daily (or UFH every 12 hours) during pregnancy.
AND
2) Low-dose aspirin of 75-100mg/day.
Unfractionated heparin should be monitored by:
aPTT
Low molecular weight heparin should be monitored by:
Anti-Xa level
What are the organisms responsible for UTIs in pregnancy?
1) E. Coli
2) Gram (-) rods (Proteus, Klebsiella)
3) Group B Streptococcus
The presence of Group B Streptococcus (GBS) in urine indicates:
Heavy colonization of the genitourinary tract = increases the risk for GBS infection in the newborn.
Treatment of asymptomatic bacteriuria and cystitis is necessary to prevent:
Pyelonephritis
The most commonly used antibiotics to treat asymptomatic bacteriuria and cystitis are:
1) β-lactam antibiotics:
a) Amoxacillin
b) Cephalosporins
2) Nitrofurantoin
Nitrofurantoin is not active against:
Proteus species
Nitrofurantoin should not be used after week __ in patients with G6PD deficiency. Why?
37; because of the risk of hemolytic anemia in the newborn.
What is Co-trimoxazole?
Sulfa-containing drugs
Sulfa-containing drugs can contribute to the development of newborn ___, and should be avoided during:
Kernicterus; the last week of gestation
Trimethoprim is a:
Folate antagonist
Trimethoprim is contraindicated during the first trimester because:
Association with cardiovascular
malformations
Fluoroquinolones are containdicated because of:
Association with impaired cartilage development
Tetracyclines are containdicated because of:
Association with deciduous teeth discoloration if given after 5 months of gestation
___ is the standard of care for pregnant women with pyelonephritis.
Hospitalization
Pyelonephritis in pregnancy treatment?
1) Parenteral administration of 2nd and 3rd generation cephalosporins (cefuroxime and ceftriaxone)
2) Ampicillin + Gentamicin
3) Ampicillin-sulbactam
The total duration of therapy for acute pyelonephritis in pregnancy is:
10-14 days
Nitrofurantoin should be avoided in pyelonephritis because:
It does not achieve therapeutic levels outside urine
Bacterial vaginosis in pregnancy treatment?
Recommended: Metronidazole
Alternative: Clindamycin
Chlamydia in pregnancy treatment?
Recommended: Azithromycin
Alternative: Erythromycin
Genital herpes in pregnancy treatment?
Acyclovir or valacyclovir
Gonorrhea in pregnancy treatment?
Recommended: Ceftriaxone , treat chlamydial infection concurrently
Alternative: Azithromycin
Trichomoniasis in pregnancy treatment?
Metronidazole
Which drug against protozoa should be avoided during pregnancy?
Tinidazole
Risks of medications use to the fetus are ___(more/less) than risks of untreated asthma.
Less
Bronchial asthma treatment in pregnancy?
Step 1: Short-acting β2-agonists (SABA) [Albuterol] + Inhalational corticosteroids [Budesonide]
Step 2: Long-acting β2-agonists (LABA) [Salmetrol] + Inhalational corticosteroids [Budesonide]
Does seizure frequency change for most pregnant women with epilepsy?
No
Seizures may become more frequent in pregnant woman because of changes in:
1) Maternal hormones
2) Sleep deprivation
3) Medication adherence problems because of fear of teratogenic risk
4) Changes of free serum concentration of antiepileptic drugs
Why might there be changes in free serum concentration of antiepileptic drugs in pregnant woman with epilepsy?
1) Increased maternal volume of distribution
2) Decreased protein binding from hypoalbuminemia
3) Increased hepatic drug metabolism
4) Increased renal drug clearance
The risks of uncontrolled seizures to the infant
are __(greater/less) than those associated with antiseizure drugs.
Greater
Major malformations are 2-3 times more likely to occur in children born to women taking:
Antiseizure drugs
Which antiseizure drugs are probably the safest during pregnancy?
1) Carbamazepine
2) Lamotrigine
3) Levetiracetam
Which antiseizure drugs carry lower risk than valproic acid (VPA)?
1) Gabapentin
2) Oxcarbazepine
3) Zonisamide
Which antiseizure drugs carry Significant risk?
1) Valproic acid
2) Topiramate
3) Phenobarbital
Major malformations with valproic acid are:
Dose-related
Valproic acid during pregnancy can cause:
1) Neural tube defects (spina bifida)
2) Facial clefts
3) Cognitive teratogenicity
All women taking antiepileptic drugs should receive: (!!)
Folic acid supplementation (4-5 mg daily) starting before pregnancy and continuing through the first trimester, and preferably throughout pregnancy.
When to avoid or postpone pregnancy?
1) Uncontrolled epilepsy
2) Drug-resistant epilepsy
3) Polytherapy
4) High dose ASDs
5) Non-adherence
6) Poor general health
Chronic hypertension of pregnancy is defined as:
1) Hypertension occurring before 20 weeks of gestation
2) Use of antihypertensive medications before pregnancy
3) Persistence of hypertension beyond 12 weeks postpartum
Severe chronic hypertension of pregnancy is:
≥160/≥110 mmHg
When treating chronic hypertension in pregnant women you should be careful:
NOT to compromise utero-placental blood flow. (Lower BP over a period of hours).
If there is no end organ damage, antihypertensive drugs may not be used to treat:
Non-severe hypertension (<160/<105 mmHg).
ACEis, ARBs, renin inhibitors, and mineralocorticoid receptor antagonists should be avoided in pregnancy because:
Teratogenicity and toxicity to fetus
What is Aliskiren?
Renin inhibitor
Atenolol should be avoided in pregnancy because:
Associated with fetal growth restrictions
Hypothyroidism in pregnancy should be treated with:
Levothyroxine (larger dose due to increased requirement)
Hypothyroidism should be monitored by:
TSH level
Hyperthyroidism in pregnancy should be treated with:
Thionamides:
a) Propylthiouracil (PTU) FIRST TRIMESTER
b) Methimazole REST
Iodine 131 (I131) is contraindicated in pregnancy because of:
The risk of damage of fetal thyroid
Preterm labor occurs between:
20-37 weeks of gestation
What is a leading cause of infant morbidity and
mortality?
Preterm labor
What are Tocolytics?
Drugs that slow or stop the contractions of a woman’s uterus during pregnancy
What are the purposes of tocolytic therapy?
1) Postpone delivery to allow for maximal effect of antenatal corticosteroid therapy
2) Allow for transportation of the mother to a facility equipped to deal with high-risk deliveries
3) Prolongation of pregnancy when there are underlying, self limiting conditions that can cause labor (pyelonephritis, abdominal surgery).
Tocolytics are not used beyond:
34 weeks of gestation
Tocolytic agents include:
1) β-agonists
2) Magnesium
3) Calcium channel blocker
4) Prostaglandin inhibitors (NSAIDs)
Tocolytic agents prolong pregnancy by __ days.
2-7
Tocolytic agents do not reduce overall rates of:
1) Respiratory distress syndrome
2) Neonatal death
3) Preterm delivery
What are terbutaline and ritodrine?
β2-agonists
IV magnesium sulfate has a ____ role:
Neuroprotective; it decreases the occurrence of cerebral palsy
Maternal adverse effect of IV magnesium sulfate?
Pulmonary edema
What is Nifedipine?
Calcium channel blocker
One significant adverse reaction of Nifedipine as a tocolytic is:
Hypotension with consequent effect on utero-placental blood flow
NSAIDs (Indomethacin) as a tocolytic are associated with:
Increased rate of closure of the ductus arteriosus when used after 32 weeks of gestation, for more than 48 hours.
Which corticosteroids can be used for fetal lung maturation?
1) Betamethasone
2) Dexamethasone
Both for 2 days between 24-34 weeks of gestation
Group B Streptococcus (GBS) infection in pregnancy treatment?
1) Penicillin G
2) Ampicillin
3) Cefazolin (if penicillin allergy, but no risk of anaphylaxis)
4) Clindamycin or Erythromycin (if penicillin allergy with high risk)
5) Vancomycin (If resistant to #4)
Concerns with induction of labor (cervical ripening) are:
1) Ineffective labor
2) Hyperstimulation that may adversely affect the fetus
Which drugs can be used for cervical ripening?
1) Prostaglandin E2 analogs (Dinoprostone)
2) Prostaglandin E1 analog (Misoprostol)
3) Oxytocin (for induction)
Prostaglandin E1 analog (Misoprostol) is containdicated in women with previous
___ because of its association with:
Uterine scar; uterine rupture
The first phase of labor starts from:
Onset of labor - Complete cervical dilation.
In the first phase of labor, women perceive __ pain because of:
Visceral; uterine contractions
The second phase of labor is the period between:
Complete cervical dilation - Delivery
In the second phase of labor, women perceive __ pain because of:
Visceral; Perineal stretching
Pharmacologic approach to labor pain management:
1) Parenteral opioids
2) Epidural analgesia
3) Nitrous oxide (NO)
