NAPLEX: Male & Female Health - Drug Use in Pregnancy & Lactation

gravida

# of times person has been pregnant

para

# of times a patient has given birth

vitamin and mineral supplementation in pregnancy

folate

- adults with childbearing potential

- pregnancy

Adults recommended: 400 mcg DFE/day

Pregnancy: 600 mcg DFE/day

vitamin and mineral supplementation in pregnancy

calcium and vitamin D

Pregnant women 19-50 y/o:

- Ca: 1000 mg/day

- Vitamin D: 15 mcg/day (600 IU/day)

vitamin and mineral supplementation in pregnancy

iron

Pregnant women: 27 mg/day

FDA pregnancy category A interpretation

animal and human studies show no risk

FDA pregnancy category B interpretation

animal studies show no risk

FDA pregnancy category C interpretation

studies in humans and animals are not available

FDA pregnancy category D interpretation

positive evidence of fetal risk

FDA pregnancy category X interpretation

use in pregnancy is CI

common teratogens

acne

Isotretinoin

Topical retinoids

common teratogens

antibiotics

Quinolones

Tetracyclines

common teratogens

anticoagulants

warfarin

common teratogens

dyslipidemia, HF, HTN

Statins

RAAS inhibitors

common teratogens

hormones

Estradiol

Progesterone (megestrol)

Raloxifene

Duavee

Testosterone

Contraceptives

common teratogens

migraine

DHE 45

Ergotamine

common teratogens

Hydroxyurea

Lithium

Methotrexate

Misoprostol

NSAIDs

Paroxetine

Ribavirin

Thalidomide

Topiramate

Weight loss drugs

Valproic acid / Divalproex

Amiodarone

Droneadarone

Aminioglycosides

Atenolol

Benzodiazepines

Dutasteride

Finasteride

Fluconazole

Voriconazole

Griseofulvin

ERAs (bosentan)

Leflunomide

Lenalidomide

Lomitapide

Methimazole propylthiouracil

Mycophenolate

Radioactive iodine

Carbamazepine

Phenobarbital

Phenytoin

immunization recommendations in pregnancy

Avoid all live vaccines

Recommend

- Tdap during each pregnancy ideally between weeks 27 and 36

- COVID-19 during any trimester

- RSV vaccine (Abrysvo) if pt will be between weeks 32 and 36 during Sept to January

preeclampsia

elevated BP + evidence of organ damage most often to kidneys (ex: proteinuria) or liver

when does preeclampsia typically occur

20 wks after gestation

preeclampsia prevention

add daily low dose aspirin at the end of first trimester for pregnant women at risk (DM, renal disease, hx preeclampsia, chronic HTN)

morning sickness, nausea, vomiting management

lifestyle first - eat smaller more frequent meals, drink water, avoid triggers

if lifestyle fails recommend pyridoxine (vitamin B6) +/- doxylamine (unisom)

ginger is possibly effective

GERD/heartburn management

lifestyle first

if lifestyle fails recommend antacids

can consider H2RA or PPI as add on therapy

flatulence management

Simethicone (Gas-X, Mylicon)

constipation management

lifestyle first: inc fluid intake, dietary fiber, physical activity

if lifestyle fails: fiber (psyllium, calcium polycarbophil, methylcellulose)

can consider docusate, polyethylene glycol

cough, cold allergy management

1st line: cromolyn

2nd line: 1st gen antihistamines (chlorpheniramine, diphenhydramine)

Non sedating 2nd gen agents (loratadine, cetirizine) now recommended by obstetricians

If nasal steroids are needed for chronic allergy sx all intranasal steroids are safe - budesonide (Rhinocort) and beclamethasone (Beconase) are considered safest

Avoid oral decongestants (pseudophedrine) during 1st trimester

Avoid liquid formulations that contain alcohol

Dextromethorphan and mucolytic guaifenesin have limited safety data

pain management

Non drug options (hot/cold packs, light massage, physical therapy)

1st line = APAP

Avoid NSAIDs including ASA (except low dose for preeclampsia prevention) especially at 20 wks gestation or later

Opioids should only be used if no alternatives

asthma management

Maintenance: budesonide is preferred (respules for baby)

- All inhaled corticosteroids (ICS) are considered safe

- Long acting beta agonists can be continued with ICS if needed

Rescue: ICS-formoterol or albuterol

iron deficiency anemia management

Supplemental iron

Prenatal vitamins with iron

take on an empty stomach - may worsen nausea + constipation

HTN management

Labetalol

Nifedipine ER

Methyldopa

Hydralazine

ACEi, ARB, aliskiren, entresto CI in pregnancy

Low dose ASA is recommended for preeclampsia prevention in pt w chronic HTN

DM management

Insulin is preferred if not controlled with lifestyle

Metformin and glyburide sometimes used

Low dose ASA is recommended for preeclampsia in both T1 and T2DM

infection management

which antibiotics are generally considered safe to use

Penicillins

Cephalosporins

Eryomycin

Azithromycin

infection management

vaginal fungal infections

topical antifungals (creams, suppositories) x7 days

infection management

UTI

Cephalexin 500 mg PO q6h x7 days

Amoxicillin 500 mg PO q8h x7 days

Alt: nitrofurantoin, bactrim, fosfomycin

Nitrofurantoin and bactrim = last line during 1st trimester + avoid during last 2 wks of pregnancy

infection management

toxoplasmosis

Test prior to pregnancy with IgG test

Avoid dirty food and water, unpasteurized dairy products, cat feces

infection management

abx to NOT use

quinolones (d/t cartilage damage), tetracyclines (d/t teeth discoloration)

infection management

vaginal fungal infections - agents to AVOID

fluconazole

VTE management

Treatment: LMWH preferred over UFH d/t ease of administration

PPX: pneumatic compression devices +/- LMWH (preferred over UFH)

anticoagulation w mechanical valve

If regularly on warfarin - convert to LMWH during pregnancy

Can switch back to warfarin after 13th week of pregnancy then back to LMWH close to delivery

risk of developing VTE is _____ (increased/decreased) during pregnancy and first 6 wks postpartum

increased

anticoagulation monitoring

peak anti Xa levels drawn 4 hrs post dose (LMWH) or aPTT (UFH)

hypothyroidism management

Levothyroxine will require 30-50% dose increase during pregnancy

hyperthyroidism management

prefer to normalize mother's thyroid fxn prior to pregnancy

mild cases do not require treatment

if meds needed:

- 1st trimester: PTU

- 2nd/3rd trimester: methimazole

PTU and methimazole have high risk for _____ damage

liver damage

AAP recommends babies be exclusively breastfed for ______ and breastfeed with complementary foods for at least ______ if possible

exclusively breastfeed: first 6 mo of life

breastfeed w complementary food for at leat first 2 yrs

iron supplementation for new borns

most have adequate iron store for first 4 mo of life

can consider iron supp (1 mg/kg daily) after 4 mo until infant can obtain adequate iron from eating iron rich food (usually ~6 mo old)

properties of drugs that can typically get into breast milk

Non ionized

Have small molecular birth weight

Low volume of distribution

High lipid solubility

pain management in breastfeeding mothers

avoid codeine, tramadol

breastfeeding and HIV infection

Breastfeeding is not recommended for women with documented HIV infection

meds that should be avoided in lactation

Chemotherapy

Illicit drugs

Radioactive compounds used for treatment/diagnostic studies (iodine)

Amphetamines

Amiodarone

Ergotamines

Lithium

Metronidazole

Phenobarbital

Statins

infections that are bad in pregnancy

toxoplasmosis

rubella

cmv infection

zika virus

drug resources for lactation / pregnant patients

lactmed

briggs

hales

metronidazole in breastfeeding women

avoid metronidazole

or milk should be pumped an discarded for 12-24 hrs after a single dose