Chapter 48. Drug Use in Pregnancy & Lactation

How much folate should be consumed in adults vs pregnancy?

• adults = 400 mcg/day

• pregnancy = 600 mcg DFE/day

How much calcium and vitamin D do pregnant women ages 19-50 years old require to ensure bone health?

• Calcium = 1000 mg/day

• Vitamin D = 600 IU/day

Previous Pregnancy Categories & Interpretation

A - Controlled studies in animals and women show no risk in 1st trimester

B - animal studies show no fetal risk (none in ppl)

C - Animal studies show harm (none in ppl) -> use only if benefit outweighs risk

D - Positive evidence of risk to human fetus; b vs r still

X - use in pregnancy contraindicated

Updated pregnancy sections in package inserts

• 8.1 Pregnancy - describes risk of adverse developmental outcomes; encourage to join pregnacy registries

• 8.2 Lactation - Whether drug/metabolites are present in milk

• 8.3 Females & Males of Repro Potential - Effects on fertility; requirements for pregnancy testing and contraception

Which organization determines which specific drugs are hazardous teratogens?

NIOSH

Key Drugs Causing Teratogenicity

Acne

• Isotretinoin, topical retinoids

Antibiotics

• Quinolones

• Tetracyclines

Anticoagulants

• Warfarin

Dyslipidemia, HF, HTN

• Statins

• RAAS inhibitors (ACE, ARBs, aliskiren, Entresto)

Hormones

• Most (estradiol, progesterone incl. megestrol)

• Raloxifene

• Duavee

• Testosterone

• Contraceptives

Migraine

• Dihydroergotamine, ergotamine

Others

• Hydroxyurea

• Lithium

• Ribavirin

• Thalidomide

• Topiramate

• Misoprostol

• Methotrexate

• NSAIDs

• Paroxetine

• Wt loss drugs

• Valproic acid/Divalproex

What is a popular reference for prescribing information in pregnancy?

Briggs' Drugs in Pregnancy and Lactation

What immunizations are indicated during pregnancy?

inactivated flu vaccine; single dose of Tdap each pregnancy

Management of morning sickness, vomiting, nausea

• Lifestyle first

• Drug interventions first-line: Pyridoxine (vitamin B6) +/- doxylamine

• Ginger is "possibly effective"

GERD/Heartburn Management

• Lifestyle first (smaller, frequent meals; avoid foods, etc.)

• Antacids such as Tums

Flatulence mgmt

Simethicone

Constipation Management

• Lifestyle first

• Fiber (psyllium, calcium polycarbophil) if lifestyle fails

Cough, Cold, & Allergies Management

• First line: Cromolyn

• Second line: Chlorpheniramine (DOC); 1st generation antihistamine

• Avoid liquid formulations that contain alcohol

• Chronic allergy: budesonide (any nasal steroid is OK)

Pain Management

• Acetaminophen first line

• Avoid NSAIDs, including aspirin

Asthma management

• Maintenance: Budesonide pref. (all ICS are ok)

- Respules are used in nebulizer

• Rescue: ICS-formoterol or albuterol

Hypertension Management

Labetalol, nifedipine ER, Methyldopa

*ACE, ARBs, aliskiren, Entresto contraindicated

Diabetes management

• Insulin preferred if not controlled w lifestyle

• Low-dose aspirin for Type 1 and 2 diabetics (and GDM)

Infection management

Generally considered safe:

• Penicillins (incl. ampicillin and amoxicillin)

• Cephalosporins

• Erythromycin and azithromycin

• Topical antifungals -> use for vaginal fungal infections

How should UTI be treated in pregnancy?

• Cephalexin

• Amoxicillin

• Alternatives: SMX/TMP, nitrofurantoin last line and not during 1st trimester/last 2 weeks of pregnancy

*MUST treat bacteriuria, even if asymptomatic

Managing Toxoplasmosis

• Test prior to pregnancy with IgG test

• Avoid unpasteurized dairy and cat feces

Anticoagulation Management

• LMWH preferred over UFH

• Prophylaxis: pneumatic compression devices +/- LMWH

• Warfarin teratogenic

• Oral factor Xa inhibitors and DTIs have not been adequately studied in pregnancy and are not recommended

Hypothyroidism management

Levothyroxine - will require a 30-50% dose increase during pregnancy

Hyperthyroidism management

• 1st trimester = PTU

• 2nd and 3rd = MMI

*both have a high risk for liver damage

What supplement should babies receiving any breast milk have?

• 400 IU of vitamin D supplementation daily

• After 4 months of age = Iron supplementation (1mg/kg daily)

What resource can be used to check for drug safety during breastfeeding?

LactMed (or Brigg's)

When is breastfeeding NOT recommended?

If a mother has a documented HIV infection

Which medications for pain should be avoided during breastfeeding?

Tramadol and codeine (d/t risk of excessive sleepiness, breathing difficulty, and/or death in infant) -> opioids affect infant

*esp. in CYP2D6 ultra-rapid metabolizer mothers

What medications should be avoided completely during lactation?

amphetamines, amiodarone, ergotamines, lithium, metronidazole, phenobarbital, and statins

As Always, Every Loving Mom Plays Safe