W13 Pregnancy and Lactation (GW)

Question 1

General Info about pregnancy:

Answer 1

• ‘Normal’ pregnancy is ~ 40 weeks.
  -Baby fully grown and ready for birth from 37 weeks.
  -Pre-term baby = born before 37 weeks
• Women can breastfeed for as long as they like / can
  -Usually recommend to exclusively breast-feed for first 6 months, then mix of breast-feeding and solid food from 6 months.
  -Some sources advise to keep going until baby is at least 2 years old – some may stop way before that, some may continue way after, so never assume & always check!
• May see following terms in medical notes:
  -Gravida = Number of pregnancies (including current- twins still count as 1)
  -Para = Number of viable births after 20 weeks’ gestation
  These will be written in the notes as GXPX, e.g.G2P1 = second pregnancy, 1 child
  -Numbers may not match – e.g. if miscarriage, abortion, stillbirth

Question 2

Medicines in Pregnancy and Lactation:
When is the greatest harm from drugs?
What can be affected in the second trimester?

Answer 2

Drugs can have harmful effects on embryo or foetus at any time during pregnancy.
If mum is breast-feeding, should query safety of drug in breastfeeding.

• First trimester – greatest risk of harm from drugs (esp wk 3-11)
  -Drugs may cause congenital malformations or lead to teratogenicity.
• Second and third trimester
  -Drugs may affect growth or functional development on foetus.
• Term
  -Drugs given shortly before or during labour can affect labour or the neonate.
• Lactation
  -Some drugs pass through into breast milk and can affect the baby.

Question 3

How to know what’s safe?! (3)

Answer 3

1. Good history taking
   How far along with the pregnancy? How many weeks?
   Was the baby born at term and was fit and well? Were they premature and needed SCBU admission?
2. Who’s asking and why are they asking?
   Response will be different if speaking to mum/family or another HCP.
   Are they thinking about giving a drug to the mum?
   Have they already given the drug and are having a panic?
   The answer to this will change your approach to the query.
3. Use the right resource
   BNF or SPC will always be first port of call, but usually says ‘manufacturer advises avoid’ – what then?
   Use specialist resources or medicines information lines.

Question 4

General Considerations in Pregnancy

Answer 4

• If the drug is teratogenic, avoid.
  -Teratogen = Agent that causes risk of malformation to embryo.
  -May also lead to loss of embryo = not acceptable.
• Patients with chronic conditions should be referred ASAP to specialist when considering/actually pregnant to ensure medication regimens are safe.
• Balance risk to mother’s health V risk to baby’s health.
  -Queries are often ‘grey’

Question 5

General Considerations in Lactation

Answer 5

• Ideally, always want mum to breast feed due to the benefits to the baby.
  -Nutrition, passive immunisation, lower risk of developing asthma, T1DM etc
• Drugs should therefore not be a reason to prevent breast feeding.
• Very little information out there on safety of drugs in lactation.
• No info does not mean guaranteed safety.

If little info available, consider:
* Amount of drug/metabolite likely to reach baby (e.g. big molecules unlikely to reach milk)
* Pharmacokinetics: Efficiency of drug absorption, distribution and elimination by baby (e.g. premature baby V term baby)
* Pharmacodynamics: Likely effect of drug on baby (sedation? Poor wt gain?)

Question 6

Resources for queries re lactation? (6)

Answer 6

1. BNF
2. Summary of Product Characteristics (SPC)
3. Drugs in Pregnancy and Lactation (via medicines complete)
4. SPS website- Safety in breastfeeding – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice
5. BUMPS – Best Use of Medicines in Pregnancy
6. UKTIS – UK Teratology Information Service

Take care if using paper resources – may get outdated quickly.

If still not sure, DON’T GUESS – refer to Medicines Information service for health board / trust or national organisation (e.g. UKTIS)

Question 7

Nitrofurantoin and Trimethoprim:

Answer 7

Nitrofurantoin: Avoid at term- may produce neonatal haemolytic
Trimethoprim- avoid in 1st term

Question 8

Conditions / Complications in Pregnancy
1. Hyperemesis Gravidarum

Answer 8

• Nausea and vomiting in pregnancy is common (morning sickness)
  -Starts week 4 – 7
  -Peaks week 9 – 16
  -Resolves by week 16 – 20
• Hyperemesis gravidarum is the severe end of the symptom spectrum:
  -Prolonged, persistent and severe n + v
  -Associated with weight loss (5% of pre-pregnancy weight), dehydration and electrolyte imbalance
• Risk factors: first pregnancy, twins, PMH or FHx of HG, obesity
• Maternal complications: vitamin deficiency, weight loss, GORD, VTE, psychological impact, AKI.
• Foetal complications: preterm delivery, low birth weight

Question 9

Management of HG (for info)

Answer 9

1. Oral antiemetics
   First line: Cyclizine and prochlorperazine
   Second line: metoclopramide and ondansetron
2. If still vomiting, needs admission to hospital
   IV antiemetics (usually cyclizine and ondansetron)
   IV fluids if dehydrated
   Thiamine PO or IV if prolonged vomiting to avoid vitamin B deficiency and potentially Wernicke’s encephalopathy
   Thromboprophylaxis whilst an in-patient
   If sickness refractory, offer corticosteroids (IV hydrocortisone then switch to PO prednisolone, wean to a stop when able)

Question 10

Ondansetron note?

Answer 10

(very) small risk of oral clefts following use in the first 12 weeks of pregnancy
- counsel mum
- make an informed decision

Question 11

Complications of pregnancy
2. Gestational Hypertension

Answer 11

• Managed in secondary care
• Risk factors: Nulliparity, aged 40+, PMH or FHx pre-eclampsia, twins, obesity, pre-existing vascular or kidney disease.
• Complications: Can lead to pre-eclampsia and eclampsia.
  Will monitor BP and check for proteinuria at least weekly.
• Target BP: 135/85 mmHg
• Management: Labetalol or Nifedipine or Methyldopa
• First line usually labetalol
  -Titrate doses to get a response
  -Beta blocker
  -Can affect baby – likely to see hypoglycaemia when born.
• Duration: Will need throughout pregnancy, then reviewed after birth

Question 12

Complications of pregnancy
3. Pre-eclampsia and eclampsia
Symptoms?
Treatment?
Risks?
Management?

Answer 12

• Pre-eclampsia= -New-onset hypertension (>140/90 mmHg) + -Proteinuria +
  -Maternal organ dysfunction (renal/liver/neuro/haem)
• Symptoms: Severe headache, blurry vision, severe pain below ribs, vomiting, swelling of face/hands/feet
• Risk factors: PMH gestational hypertension, CKD, autoimmune disease (e.g. SLE), T1 or T2DM, obese, aged 40+, twins.
• If at risk, will be given aspirin 150mg OD until birth (unlicensed).
• If starts to exhibit symptoms, at risk of developing into eclampsia, where mother will have tonic-clonic seizures
  Risk to mum: Aspiration, hypoxia, cerebral oedema, death
• Risk to baby: Oxygen starvation, low birth weight, pre-term delivery, death
• Management: Anticonvulsants (IV magnesium sulphate), antihypertensives, deliver the baby (emergency Caesarean)
• Note: Can occur at any time during pregnancy or in period post-partum – vigilant and monitor BP

Question 13

Complications of pregnancy
4. DVT and PE

Answer 13

• Development of VTE during pregnancy is reportable to the Welsh Government – considered unacceptable.
• Risk of severe morbidity and death.
  Every woman needs VTE scoring antenatally, each time they’re admitted to hospital and postnatally.
• Thresholds decided locally.
• If scoring high antenatally:
  -LMWH SC OD throughout pregnancy and 6 weeks postnatally.
  -Dose based on booking weight.
• If scoring high as inpatient:
  -LMWH SC OD as in-patient only.
• If scoring high postnatally:
  -LMWH SC OD for 10 days after birth.
  -Dose based on booking weight

RCOG Green-top guide on VTE is excellent

(guideline is for info, no need to memorise)

Question 14

Complications of pregnancy

Question 15

Complications of pregnancy
5. Obstetric Cholestasis
What is it?
Symptoms?
Causes?
Risks?
Management?

Answer 15

• Also called intrahepatic cholestasis of pregnancy.
• Symptoms: Pruritis, elevated bile acid levels, jaundice.
• Causes: Unknown – mix of hormones, genes and environment.
• Onset: Most common during 3rd trimester. Resolves post-birth.
• Risk: Small increased risk of stillbirth, pre-term birth, psychological issues in mum (coping with itch, lack of sleep).
• Management:
  -No evidence that anything really works.
  -Often prescribed topical emollients and chlorphenamine to soothe itch.
  -Ursodeoxycholic acid traditionally used to reduce bile acid levels – no longer recommended by RCOG but still seen in practice.
  -NB antihistamines unlikely to help with itch, as it’s not driven by histamine – may still be used to induce sleep.
  -Monitor bile acid levels – if start to creep too high, will induce labour to resolve issue.

Question 16

Complications of pregnancy
6. Gestational Diabetes
Risk factors?
Complications?
Diagnosis?
Monitoring?
Management?

Answer 16

• Diabetes that occurs during pregnancy, with woman usually reverting to normal after birth.
  -But more likely to develop T2DM in later life.
• Risk factors: Obese, previous big baby, PMH or FHx of gestational diabetes.
• Complications: Heavy birth weight baby, neonatal hypoglycaemia, premature delivery, RDS in infant, hypertension, pre-eclampsia.
• Diagnosis: Done via 75g, 2-hour Oral Glucose Tolerance Test.
• Monitoring: HbA1c not routinely monitored; just monitor blood glucose. Closely monitored throughout pregnancy in secondary care.
• Management:
  1. Diet and exercise
  2. Modified-release metformin
  3. Insulin

Question 17

Complications of pregnancy
7. Managing existing health conditions
What are the 4 main conditions that should be considered?

Answer 17

• Should be under the care of a consultant throughout pregnancy (i.e. not midwife-led birth) and a specialist in the condition.
• Condition must be optimally managed to prevent harm to mum and baby
• Main conditions to consider:
  Hypothyroidism
  -TSH and T3 / T4 levels change throughout pregnancy.
  -Levothyroxine dose may need to  by 40-50% during pregnancy before returning to normal post-birth.
  Type 1 diabetes
  -Insulin requirements may change throughout pregnancy.
  -Planned birth, as need to switch to sliding scale during labour.
  Epilepsy
  -Must have antiepileptics reviewed to ensure safe for pregnancy.
  -Challenging to manage – AED clearance dramatically changes in 3rd trimester (key example: lamotrigine)
  Mental health conditions
  -Will have medication reviewed by perinatal mental health team to ensure safe for pregnancy. Often tricker to manage for lactation.
  -Commonly see sertraline used – considered safe.

Question 18

Drugs in Lactation
Codeine can it be used in P & BF?

Answer 18

• Safe if used PRN in pregnancy
• Frequently used as labour pains start
• Must NOT be used in breastfeeding
  -Is present in milk
  -Do not know if baby is a fast or slow metaboliser of codeine.
  -If accumulates, risk of respiratory depression in baby.
  -Would just give mum Oramorph®

Question 19

Lactation:
1. NAS Scoring
What is Neonatal abstinence syndrome?
Symptoms of NAS ?
Management?

Answer 19

• If mum has used drug throughout pregnancy, baby will be born dependant on that drug.
• After birth, will not have drug in same quantities (even if breastfeeding), therefore will go into drug withdrawal.
  -Neonatal Abstinence Syndrome
• Symptoms: Tremors, irritability, d + v, fever, high-pitched crying
• Will monitor baby for up to 5 days post-birth and score the symptoms. If a threshold is reached, will start treatment.
• Commonly seen for babies exposed to heroin, methadone and buprenorphine. Will sometimes score if on certain AEDs or SSRIs.
• Management:
  -Depends on the causative agent.
  -Usually either morphine 100mcg/mL oral solution (special) or phenobarbital oral solution

Question 20

Lactation:
2. Mastitis
What is it?
Symptoms?
Management?

Answer 20

• Common condition in breastfeeding women where the breast tissue becomes infected.
• Symptoms: Painful breast, fever, malaise, red/tender swelling on breast.
• Management:
  -Self-help: warm compress on breast / warm path to relieve pain and help milk flow. Not to wear a bra. Rest.
  -Pain: simple analgesia
  -If nipple appears infected: Try to send milk sample. Usually use PO flucloxacillin for 2 weeks (alternative if allergy, e.g. clarithromycin).
  -If thrush suspected: Daktarin cream after feed on nipple, Nystatin or Daktarin oral gel to baby after feed.
  -Continue to breast feed if possible

Question 21

What are the common condition seen in pregnancy and their management?

Answer 21

Hypermesis Gravidarum
Gestational Hypertension
Gestational Diabetes
Pre-eclampsia and eclampsia
DVT and PE
Obstetric Cholestasis
Managing existing health conditions (hypothyroidism, T1DM, Epilepsy, MH conditions)

Question 22

What are the common conditions seen in BF and their management?

Answer 22

1. NAS- neonatal abstinence syndrome
2. Mastitis