Week 3 pregnancy & lactation (everything) Flashcards
1
Q
***Physiological changes of pregnancy may alter drug disposition and effect through:
A
Indirect and Direct effects
2
Q
**example of a DIRECT physiological change
A
Direct Effects - ex. Placental transfer
3
Q
*** Even after delivery drugs may affect
A
breastfeeding
4
Q
*** example of a INDIRECT physiological change
A
Indirect Effects - Changes in placental and uterine function
5
Q
Pregnant women in U.S. average 4.2 medications (study from 2006-2008)
97% take at least
A
1 medication
30.5% of the 97% take at least 5 medications
6
Q
Most common medications taken during pregnancy
A
Antiemetics
Antibiotics
Analgesics
7
Q
*most common medications taken during pregnancy; at least 10% taking drugs with long term effects on CNS
A
Antidepressants
Anticonvulsants
Antipsychotics
8
Q
**concerns of medications during pregnancy:
A
Teratogenicity Effects ( not only congenital abnormalities but non-birth development such as puberty) **
9
Q
Teratogenicity Effects of medications results
examples
A
Fetal Loss
Congenital Malformation
Fetal Growth Restriction
Preterm Labor
10
Q
Genetic difference responsible for
A
some variations in genetic response
11
Q
Pregnancy does not obviously modify
A
pharmacogenetic
12
Q
Obstetric conditions are related to
A
complex genetic factors
13
Q
**Metabolism of codeine to morphine greatly affected by
A
polymorphisms ( means “many form” and it occurs when we have many classes that are related to each other by inheritance) **
14
Q
* exam Recently recognized mothers who are ultra-rapid metabolizers of codeine may transfer morphine
A
through breast milk to cause neonatal CNS depression and even death
15
Q
Major physiologic changes during pregnancy alter drug disposition
A
Absorption and Uptake
16
Q
physiologic changes in pregnancy alter Oral absorption and bioavailability
A
not usually affected by pregnancy
17
Q
physiologic changes in pregnancy alter Intestinal motility
A
decreases
18
Q
physiologic changes in pregnancy on gastric emptying
A
Gastric emptying only delayed during labor or administration of opioids
19
Q
physiologic changes in pregnancy on FRC
A
Reduced FRC (functional residual capacity)
20
Q
physiologic changes in pregnancy on minute ventilation:
A
Increased minute ventilation
21
Q
increased minute ventilation increases pulmonary uptake of:
A
increases pulmonary uptake of inhalation anesthetic agents
22
Q
renal blood flow increases what percent
A
60-80%
23
Q
GFR increases what percent
A
50%
24
Q
If a drug is excreted unchanged by the kidneys - how do we adjust the dose
A
increase the dose
due to increased GFR - renal BF increases 60-80%
25
if a drug is metabolized by the liver - what must we do to the dose
increase or decrease depending on metabolic pathway involved
26
bioavailability- the fraction of an administered drug that reaches systemic circulation- how is this changed in pregnancy
not usually changed significantly
27
physiologic changes of pregnancy will affect individual drugs depending on what?
their physicochemical characteristics (physical and chemical) and metabolic pathways
28
**exam during pregnancy what three drugs do you increase metabolism of?
phenytoin
morphine
midazolam
29
**exam - during pregnancy what two drugs do you decreases metabolism of
caffeine
| theophylline.
30
**exam- name the drug used for mild analgesic and antipyretic during pregnancy.
does it have a teratogenic risk associated with this drug?
There is no know teratogenic risk associated with the use of ACETAMINOPHEN
31
**exam-
| what analgesic drug do we avoid in the third trimester?
Aspirin
32
**exam-
why do we avoid aspirin in the third trimester of pregnancy?
name 3 injuries that occur
Renal injury
Oligohydramnios
Intrauterine constriction of the ductus arteriosus
33
**exam
| what do we know about opioids and their teratogenic risk
NO teratogenic risk!
34
**exam-
tramadol has analgesic effects from weak opioid activity and inhibition of serotonin and norepinephrine uptake- when do we avoid it and why>
early pregnancy- associated with high number of spontaneous abortions
avoid during first trimester
35
Describe Ebsteins anomaly-
is a rare heart defect in which the tricuspid valve — the valve between the upper right chamber (right atrium) and the lower right chamber (right ventricle) of the heart — isn't formed properly.
36
**exam- lithium therapy has a small increased risk for what two condition
cardiac defects- especially ebsteins anomaly
37
**exam what specific diuretic should be avoided
spironolactone
38
**which antihypertensive drugs are safe during pregnancy
methyldopa
labetalol
calcium entry blocking agents
hydralazine
39
**which respiratory drug is not recommended? I checked it was withdrawn with US market!
Zileuton
40
**name the preferred short acting beta 2 receptor agonist
albuterol
41
**name the preferred long acting beta 2 adrenergic agonist
salmeterol
42
**pregnant women have 5 times the normal risk for what condition
venous thromboembolism and thrombosis and is a significant cause of maternal death
43
**do heparins cross the placenta
NO
44
**what is the preferred anticoagulant to give mothers
low molecular weight heparin
preferred over
unfractionated heparin
easy to administer and does not require monitoring
45
**LMWH is less likely to cause what condition
HIT- heparin induced thrombocytopenia
46
why isn't rivaroxaban and dagibatran recommended
it crosses the placenta
47
**what does the american college of obstetricians and gynecologists recommend for the initial drug for nausea
B6-pyridoxine
with or w/o doxylamine
48
**what medication has been used for refractory vomiting during pregnancy
ondansetron (5-hydroxytryptamine receptor antagonist)
49
**there is debate over which anti-diabetic should be first line drug choice. what medications are considered safe (3)
insulin
metformin
glyburide
50
**what anti-infective drug is considered safe but some recommend avoiding during first trimester
metronidazole
51
**what is the first line anti infective drug used pregnant women
penicillins and cephalosporins
52
**where should pregnant women avoid traveling
malaria endemic areas
53
**if a pregant women travels to malaria endemic area what meds can be used
chloroquine
mefloquine
54
**what are the effects of caffeine
no evidence of teratogenic affects in humans
55
**what are the effects of cannabis
no effects- but dont take it because of the adverse effects of smoking
56
**what are the risks of nicotine replacement- e cigarettes and vaping
unknown
57
**HIGHLY teratogenic drug
thalidomide, ribavirin, isotretinoin, acitretin, valproate
58
highly teratogenic drugs additional recommendations
So high risk of teratogenic- use two forms of BC
59
do anticonvulsants cross the placenta
yes- all of them
60
do the offspring of anti epileptic patients has a propensity to develop epilopsy
yes
61
fetal anticonvulsant syndrome refers to
the board orofacial, cardiovascular and digital malformations
62
fetal hydantoin syndrome
craniofacial abnormalities, and limb abnormalities
63
fetal carbamazepine associated with
spinal bifidia
64
fetal barbital syndrome associated with
decreased intellectual and cognitive development of neonates
65
fetal valproate syndrome
epicentral folds, shallow orbits, hypertelorism low ears flat nasal bridge
66
total body water increases
8%
67
intravascular volume increases what percent
Intravascular volume increases by 40% thus,
68
what type of drugs have increase volume of distribution
hydrophilic drugs- neuromuscular blockers
69
*** what drug has the highest teratogenic risk?
valproate
followed by:
Phenytoin
Phenobarbitone
Topiramate
70
anesthetic drugs do they go to the breast milk
no
71
ketamine give or avoid
avoid- do not give postoperative infusion of drugs
72
what diabetic drug should be used with caution while breast feeding
metformin- use with caution
73
sulfonamides are they safe while breast feeding
no
74
amiodarone while breastfeeding can cause what complications
iodine release- thyroid dysfunction.
75
phenobarbital and diazepam
can accumulate in the baby coming from breast milk.
76
intravascular volume increases by what %?
40%
77
*** due to the increased intravascular volume during pregnancy, hydrophilic drugs (such as NMB) have an increased:
volume of distribution ***
78
** body fat increases during pregnancy. given large vol of distribution what does this also impact?
lipophilic drug protein binding **
79
plasma albumin concentration is reduced about 70% -- what does this mean?
less protein binding locations
- increased concentrations of free drugs
80
increased concentrations of free drug (not pr bound) is offset by
increased clearance (GFR)
81
*** Total (free bound) concentration of a drug will decrease and we may need to
reset therapeutic target range lower to compensate **
82
*** these two drugs require monitoring and modification of dose b/c of changes in pr-binding:
Theophylline ***
| Phenytoin
83
first trimester exposure to diazepam increase the R/O
```
cleft lip (with or w/o cleft palate)
neural tube defects
intestinal atresia
limb defects
```
84
perinatal use of diazepam has been associated with:
hypotonia
hypothermia
resp. depression
85
overall, it appears risks are small but benzo's should only be used in the first trimester if the perceived benefit offsets the possible
teratogenic risks
86
*** what drug has the highest teratogenic risk?
valproate
followed by:
Phenytoin
Phenobarbitone
Topiramate
87
the most common serious neurologic problem during pregnancy
epilepsy
88
this type of antidepressant does not appear to be associated w/ congenital abnormalities or neurodevelopmental problems
tricyclics
89
this type of antidepressant should be avoided in pregnancy
maoi's
90
this type of antidepressant cross the placenta to varying degrees
SSRIs
91
As a class, SSRI's increase the rate of :
cardiac malformations and risk complications
92
antipsychotic drugs are generally not associated w/:
increased congenital malformations
93
***is labetalol safe in pregnancy?
typical dose?
yes
5-10mg
94
*** ACE and ARBs' safe in pregnancy?
should not be given
```
-can result in:
fetal RF and oligohydramnios
fetal limb contractures
craniofacial deformities
pulmonary hypoplasia
```
95
*** Amiodarone safe or not during pregnancy?
safe - most often the agent used
96
-maternal asthma is common in pregnancy.
have B2 adrenergic receptor agonist and corticosteroids been associated with congenital malformations?
no!
97
montelukast and zafirlukast
are considered safe
98
zileuton is
not recommended
99
theophylline and aminophylline have no
adverse fetal effects
100
rivaroxaban and the thrombin inhibitor dabigatran (pradaxa)
are not recommended
they cross the placenta
101
pregnancy is a hypercoagulable state b/c of relative increases in many:
coag factors and increased venous stasis
102
pregnant women have 5x the normal risk for
VTE ---> significant cause of maternal death
103
***postoperative infusions of what drug is best to be avoided due to limited safety data
ketamine**
depression clinics - not for PD
104
** LMWH is preferred over:
unfractionated heparin b/c it is easy to administer** and does not req monitoring **
105
phenobarbital and diazepam in infants are considered safe... but what should we be aware of
in infants elimination could be slower and they could accumulate
106
the shorter half life of UFH means that it is easier to
reverse
107
warfarin is a vitamin K antagonist that can cause an:
embryopathy, especially in 1st trimester
108
fondaparinux and argatroban (direct thrombin inhibitors) appear to be
safe in pregnancy
109
** short therm us of aminoglycosides is acceptable but what should be avoided b/c of risk for congenital deafness after 1st trimester?
streptomycin
110
sulphonamides and nitrofurantoin are safe but avoid
sulfamethoxazole during the first trimester
111
Tetracyclines should not be administered after what week of pregnancy? Why?
5th week
-teeth darkening
112
these drugs are so high risk that two forms of Birth Control are recommended when taking:
```
Thalidomide
Ribavirin
Isotretinoin
Acitretin
Valproate
```
TRIAV
113
only a few types of drugs are strongly contraindicated during breastfeeding, these are:
cytotoxic and immunosuppressive drugs
114
drugs may also affect lactation and some are used therapeutically for
this purpose
| to improve/reduce lactation
115
drugs that increase the secretion of ____ can stimulate milk production.
prolactin
116
Transfer of drugs to breast milk occurs mainly by
passive diffusion
117
the rate of passive transfer into breast milk depends on what elements:
1. lipid solubility
2. molecular wt
3. degree of ionization
4. protein binding
118
Amount of drug in breast milk is a variable fraction of the
maternal concentration
119
what is it that we generally have no concern regarding transfer of in breast milk?
anesthetic drugs
120
postoperative infusions of what drug is best to be avoided due to limited safety data
ketamine
121
_____ do not transfer well to breast milk
LA's
122
phenobarbital and diazepam in infants are considered safe... but what should we be aware of
in infants elimination could be slower and they could accumulate
123
** Iodine released during its metabolism may cause
thyroid dysfunction **
124
** this antidiabetic should be used with CAUTION while nursing preterm infants and neonates
metformin
125
** during breastfeeding, sulfonamides should be avoided due to:
displacement of bilirubin from binding sites
