Pregnancy and Lactation

5 Stages of Pregnancy

Fertilization (fallopian tube) Day 0 (sperm attach to outer receptor, egg unresponsive, combine to zygote)

Day 3: uterus, cell division

Day6: implantation in uterus, blastocyst

Day 10: under endometrium, embryo here (body structure formation)

Day 56 to term: fetal period maturation

Gravidity and parity definition

Gravidty: # of pregnancies

Parity: # of fetuses delivered after 20 weeks gestation

Term, premature, aborted/ectopic pregnancies, living childnre.

Gestational age, due date calculation, trimesters time frames

Gest: age of embryo starting with first day of LAST menstural period (2 weeks prior to fertilization)

Due date: +7 days to first day of last menstrual period then-3 months

Tris: 0-13, 14-26, 27-40

Pregnancy effect on monther

More plsama, Vd, cardiac output, weight and higher pH

lower albumin, BP, gi motility

Cyp3a4, 2d6, 2c9 increased, 1a2 2c19 decreased.

Pregnancy and Fetus 3 things made (fluid, cord, pl)

Amniotic fluid: protect and nutrient, and lets fetus move

Umbilical cord: exchange maternal and fetal blood

Placenta: maternal and fetal tissue: barrier between mother and fetus, lets gas exchange, waste removal and med transfer, is passive diffusion of meds

Med properties 4 for placenta transfer, and 4 non med properties (weight, phil, ion, bind)

Non med: conc, pH, blood, enzymes?)

Low molecular weight (<600), Lipophilic, non ionized in maternal blood, low protein binding

Non med properties: fetal-maternal conc gradient, maternal blood pH less acidic, blood flwo in favor of fetus, have drug metab enzymes in placenta.

Teratogen definition

Substance with potential to alter tissue development of organogenesis (vuleranble week 2-8 weeks post -conception)

Increased risk: time of exposure, develompent stage, matneral dose< frequency and pk

Class A, B, C, D, X

A: No risk at all

B: animal studies showed safe, but no good RCT to show safe

C: Animal show bad but not RCTs

D: Positive evidnece of risk, but benefit >risk

X: Too dangerous

Limitations of classes and PLLR?

Category B>C is just not true and doesn't address lactation

Pregnancy and lactation rule: Gotta provide specfic information

For preg: dosing+potential risk to fetus, have registry

Lact: Amount of med in breast milk and potential effects

DSM5 and ACOG for pregnancy depression

DSM: Major depression during pregnancy or in first 4 weeks after delivery, (mostly during pregnancy)

ACOG: MDD during or in 1st 12 months after delivery,

PHQ2 vs PHQ9

2 required DSM 5, 9 is all DSM criteria needed for MDD

Psychotherapy for MDD and Antidepressants MOA

Psycho: target MDD symptoms (1st line for mild-moderate)

Antidepressants: target defiency, but sus for pregnancy (elevated CV malformation, and also scary for gestational SSRI and spontaneous abortion)

3 drugs to use for preg MDD and what class ok?

Citalopram, escitalopram or sertraline: 1st line for severe, 2nd line for mild-moderate

SSRI are a class not known to affect reproduction

Risk assessment limited by agent doe

MDD drug ADEs, stop bad wh, 3rd trimester issue

If abrupt stop, can lead to withdrawal syndrome especially for those with shorter duration

If adult: have flu like symptoms

In fetus exposed in 3rd trimester: have poor neontal adaptation (is like addicted)

Resolves in 2-14 days though, and resolves with supportive care

Anxiety disorder definition

Chronic, excess perception of danger, can be debilitating.

Use a standardized validated tool when they pregnant to check for it

Antidepressants and benzos for anxiety?

Antidepresasnts: Same agents as depression, similar level of safety and efficacy

Benzos have unclear effect on neurodevelopment, so no recommendation

Anxiety treatment for 1-3 trimester?

Avoid benzos in 1st trimester

In 3rd trimester can cuase infat sedation and withdrawal, floppy infant synedrome, lethargic

iPledge REMs for isotretinoin

Severe recalcitrant for nodular acne:

Dispense max 30 days, and females must use 2 forms of contraception prior, during and 1 month after therapy

2 negative tests before prescribing.

MNT and carb controlled meal plan?

Medical nutrition therapy for gestational diabetes:

Carb controlled meal plan: limit carbs to 33-40% of calories, use complex

40% fat and 20% protein for rest, and gotta exercise

Pharm treatment for diabetes when and what drug?

Only give if can't achieve glycemic control with MNT and exercise

Use insulin as preferred agent, but not regular just cause such long onset and peak of action

Metformin use in GDM, risk? Lactation, and CI???

Pregnancy Cat B, but only during 2nd and 3rd trimester study (no 1st)

Lactation: compatible yuge

CI:

Lactic acidosis BBW, and Scr>1.4 for F and >1.5 for M

Stop metformin if have hypoxemia risk

Glyburide and glipizide for diabetes?

Stim insulin secretion

Manufacturer dependent for pregnancy category for glyburide, glipizde is just C

Discont 2 week prior to expected delivery date for buride and 1 month for zide

Lactatino is probably compatible

Labetalol, nifedipine, methyldopa, thiazide categories, and ACEI/ARBs..? For chronic HTN

All are B or C, but ACEI and ARBS ARE A BIG NO

Thiazides are 2nd line

Labetalol, hydralazine, nifedipine for Eclampsia?

LABETALOL is 1st line, p good, but CI with heart issues

Hydralazine: HIgher and more dosing needed, also more fetal distress buh

Nifedipine: can have reflex tachycardia

Algo for Chronic vs gestational HTN

If

If >20 weeks gestation w/o protineuria then just gestational HTN, but if have protein then preeclamspai and with seizures is eclampsia

Treat severe acute episodes with labetalol, hydralazine or nifedipine,

Only use HTN meds if >160SBP and >110 DBP

Pain relief what meds? 2 class

Acetaminophen IS DRUG OF CHOICE REMEMBER

NSAIDS are sus, avoid if can, if can't use ibuprofen or naproxen if not in 3rd trimester

Cough+Cold what drugs? 1 Drug of choice, and decongestant what drug

Chlorpheniramine is drug of choice, benadryl at high dose leads to oxytocin effects so bad

Sudafed as decongestant of choice, mucinex and delsym is sus.

Emesis 4 drugs to give and diarrhea what do (1 drug of choice)?

Emsis; B6, antihistamines, ondasetron, metoclopramide

Diarhrea, DO NOT RECOMMEND SELF TREATMNET IF HAVE INFECTION: use Pectin as agent of choice, and loperamide maybe

Acid reflux drug of choice? What other 2 safe ish?

Antacid is agent of choice, but high dose aluminmum and mag sulfate is tocolytic

H2RA also safe

PPIs are eh safe

Breast milk benefits

Is whey+casein, with some good immune benefits, ph=7.2

Mother:decrease post partum bleeding, depression, t2dm , t2dm and cancer, quicker recovery also

Infant: protect against ilness, less death

Breastfeeding CIs

VIruses, Active TB, illicit drug use

Amphetamines, chemotherapy STATINS

Important to have vaccines ESPECIALLY TDAP

However no HPV, measles, mumps, rubella and varicella vaccines.

6 Med transfer to milk properties (F, MW, pKa, Bind, phil, t1/2)

High F

Low MW (<200 daltons)

high pKa >7.2

Lipophilic

Low protien binding

Long t1/2

Meds can diffuse out of breastk milk back into serum

M:P ratio

<1 minimal transfer to milk

1-5 can be sequestered in milk

>5 likely sequestered in milkd

Theoretical infant dose: estimates max dose infaant can get: C(milk) daily infant milk intake

mesds and breast milk (pain, immunization, depression)

Pain: short term use of nsaid good but no narcotics

No small pox or yellow fever immunization

Antidperssants are in breast milk but not CI, just some developmental issues

If mild depression then CBT and IPT first, (Citalo, escitalo and sertraline are 2nd line options as drugs)