Drugs & Pregnancy, Contraception

GPA is the abbreviation for a woman’s obstetric history

1. G / gravida =

2. P / para =

3. A or Ab / abortus =

4. Ex: If patient has had 4 pregnancies, 3 births, and 1 miscarriage =

1. # of pregnancies

2. # of births of viable offspring

3. abortions

4. G4, P3, A1

TRIMESTERS

+development

1. 1st trimester =

2. 2nd trimester =

3. 3rd trimester =

1. w1-12 → heart, eye, ear, teeth, genitalia, brain

2. w13-27 → brain, CNS

3. w28 to end → full term

What is the daily recommendation of folic acid?

0.6 mg

DRUG PASSAGE ACROSS PLACENTA

What makes it MORE LIKELY to cross?

1. Lipid solubility →

2. Molecular weight →

3. Protein binding →

4. Degree of ionization →

1. lipophilic

2. smaller

3. lower binding

4. unionized

Drug A can cause eustachian tube defects, but the patient has failed all therapeutic alternatives. When is it safe to give?
A. First trimester
B. Second trimester
C. Third trimester
D. Not worth the risk at any time

C

(eustachian tube in the ear)

OLD FDA PREGNANCY CATEGORIES

1. A

2. B

3. C

4. D

5. X

6. MOST DRUGS ARE CATEGORY ___

1. human studies, NO RISK

2. animal studies no risk/no human studies OR animal studies risk/human studies no risk

3. animal studies risk/no human studies OR no human/animal studies

4. benefit > risk

5. risk > benefit

6. C

NEW PREGNANCY CLASSIFICATION

as of June 30, 2015 → narrative format with 3 sections

1. risk summary

2. clinical considerations

3. data (animal vs human)

COMMON OTC TREATED CONDITIONS

CONSTIPATION → order of rec

1. -

2. -

3. -

4. -

5. -

6. **AVOID …

1. dietary fiber + water

2. bulk forming (psyllium, methylcellulose)

3. stool softener

4. osmotic 

5. stimulant

6. mineral/castor oil

COMMON OTC TREATED CONDITIONS

HEARTBURN → order of rec

1. -

2. -

3. -

4. -

5. **AVOID ..

1. small, freq meals

2. antacids, sucralfate

3. H2RA (famotidine)

4. PPI

5. sodium bicarb, mag trisilicate 

COMMON OTC TREATED CONDITIONS

NAUSEA & VOMITING → order of rec

1. -

2. -

3. -

4. -

5. **AVOID ..

1. small, freq meals

2. pyridoxine (vit B6) ± doxylamine

3. metoclopramide or promethazine

4. ondansetron 

AVOID NSAIDS ______

>/= 20w

________ vaccines are contraindicated in pregnancy →

live → MMR, varicella

Vaccinations to be recommended during pregnancy →

Tdap in 3rd tri, inactivated influenza 

GESTATIONAL DIABETES DIAGNOSIS

1. _____________ is gold standard, performed at 24-28w

A1c less reliable during pregnancy due to increased RBC turnover

2. Can ONLY be diagnosed in ____ or ____ trimester

3. If meet criteria in ___ trimester, is T2DM

1. oral glucose tolerance test OGTT

2. 2nd, 3rd

3. 1st

GESTATIONAL DIABETES TREATMENT

1. Non-pharm →

2. T2DM BG GOALS →

3. GDM BG GOALS →

4. 1ST LINE MEDICATION

5. 2ND LINE MEDICATION

6. Non-preferred/3rd →

1. plate method, 150m/wk exercise

2. 80-130 fasting, <180 2h PP

3. <90 fasting, <120 2h PP

4. insulin

5. metformin

6. glyburide 

HYPERTENSION

1. Treat when BP ______

2. Medications to use →

3. AVOID …

1. >140/90

2. methyldopa > labetalol > nifedipine > thiazides 2nd line

3. ACEi/ARB/renin inhibitors

ECLAMPSIA = preeclampsia + seizures 

Treatment = _______ during and after delivery

IV MgSO4

DYSLIPIDEMIA

1. B/C category

2. C category

TAKE HOME: RISK/BENEFIT ASSESSMENT

only highest risk patients should continue therapy

1. BAS

2. omega-3 FAs 

LACTATION: Relative infant dose (RID) _____ is considered CONTRAINDICATED

(dose received via breast milk relative to mother’s dose)

>/= 10%

BREASTFEEDING OLD CLASSIFICATION SYSTEM

1. Compatible but monitor infant for side effects →

2. Avoid if possible, monitor infant for side effects →

3. Avoid if possible, may inhibit lactation →

4. AVOID →

1. anticonvulsants, opioids

2. doxycycline, chloramphenicol 

3. diuretics, estrogens

4. antineoplastics

LACTATION: STRATEGIES TO MINIMIZE EFFECTS

1. Use ______/_______ absorption

2. _____ half-life

3. Check ______ in infants

4. Dose daily meds ____________

5. Other meds ________

1. topical/poor oral

2. shortest

3. safety

4. before longest sleep interval

5. right after feeding

PROGESTINS

1. ______ cervical mucus

2. Delay ovum, _________

3. Induce __________

4. Block ______ → inhibit ovulation

1. thicken

2. sperm transport

3. endometrial atrophy

4. LH surge

ESTROGENS

1. Suppress ____ release

2. Inhibit _______

3. ________________ (cycle control)

1. FSH

2. ovulation

3. stabilize endometrial lining

PROGESTINS

Drugs + side effect profile

1. 1st generation

2. 2nd generation

3. 3rd generation

4. 4th generation

1. ethynodiol → norethindrone; high androgenic, slight estrogenic

2. norgestrel, levonorgestrel; mod-high androgenic, minimal estrogenic

3. desogestrel → etonogestrel, norgestimate → norelgestromin; little-mod androgenic, no estrogenic

4. dienogest, drospirenone; no est, and, gluco, or mineralocorticoid

1. Androgen effects →

2. Corticoid effects →

1. acne, +weight

2. fluid retention

HORMONAL CONTRACEPTIVES

**Takes _________ to adjust to changes in hormonal levels

2-3m

ESTROGEN ADEs → excess (3)

breast tenderness, +weight, irritability, depression, menorrhagia

1. nausea

2. headaches

3. fluid retention

ESTROGEN ADEs → deficiency (6)

1. breakthrough bleeding early cycle

2. amenorrhea

3. vasomotor sx

4. nervousness

5. -libido

6. vaginal dryness

PROGESTIN ADEs → excess (6)

breast tenderness, +weight, depression

1. +appetite 

2. fatigue

3. +libido

4. alopecia

5. acne/oily skin

6. hirsutism 

PROGESTIN ADEs → deficiency (3)

1. dysmenorrhea

2. breakthrough bleeding late cycle

3. -weight

B

1. COMBINED ESTROGEN+PROGESTIN (CHC) → 3

2. Progestin ONLY → 4

1. COC, patch, ring

2. IUD, inj, implant, POP

COMBINED HORMONAL CONTRACEPTION (CHC)

combined estrogen + progestin

*CONTRAINDICATIONS

1. _______ cancer

2. _____ days postpartum

3. _______ disease

4. ____________

5. ________ related (VTE, smoker, DM + vascular complications, etc)

6. ____________

1. breast

2. <21

3. liver

4. migraine WITH aura

5. vascular

6. dialysis

CHC COUNSELING POINTS

1. _______

2. __________ management

3. No protection against ________

4. _______

5. Warnings for sx of stroke or clot (estrogen) →

1. adherence

2. missed dose

3. STI/STDs

4. ADEs

5. ACHES → abdominal pain, chest pain, headache, eye/speech problems, sev leg pain

Combined ORAL Contraceptives (COCs)

1. Monophasic → _____ amounts of hormones →

1. Multiphasic → _____ amounts of hormones →

2. Multiphasic less _________ and _______

1. consistent → 21 active + 7 placebo

2. varying → biphasic more breakthrough bleeding, triphasic fewer metabolic effects

3. premenstrual sx, dysmenorrhea

TRANSDERMAL PATCH

Xulane, Zafemy, Twirla

1. New patched applied _____ to abdomen, buttocks, upper torso, or upper arm

2. ______ is patch free

3. If off >24h, use back up _____

4. NOT RECOMMENDED _____

5. Return to fertility →

1. weekly

2. week 4

3. x 7d

4. >90kg → Twirla BMI >30

5. 3m

VAGINAL RING

EluRyng, NuvaRing, EnilloRing, Haloette, Annovera

1. ______ continuous use followed by _____ ring-free

2. Effective anywhere in vagina, can be used w vaginal creams, no need to remove during sex, SHOULD NOT BE REMOVED ______

3. Return to fertility →

1. 3w, 1w

2. >2-3h

3. 3m

IUDS ARE CONTRAINDICATED IN … (2)

1. pelvic inflam disease

2. uterine abnormalities 

DEPO-PROVERA INJECTABLE

medroxyprogesterone acetate

1. Available ___ or ___

2. Lasts ______

3. May be given up to _____ late

4. BBW →

5. AEs → 3

6. Return of ovulation →

1. IM, SQ

2. 3m

3. 2w

4. -BMD

5. irregular bleeding, menorrhea, +weight

6. 10m

NEXPLANON IMPLANT

etonogestrel

1. Lasts ____

2. AEs →

3. RECOMMENDS AGAINST USE AT ______

4. Return to fertility

1. 3y

2. irregular bleeding, headache

3. >/= 130% IBW

4. 1m

PROGESTIN-ONLY PILL (POP) ADHERENCE

1. _________ → cannot be taken more than ____ late

2. _________ → cannot be taken more than ____ late

3. If any are taken late, recommended to use back-up contraception for ____

1. norethindrone, norgestrel → 3h

2. drospirenone → 24h

3. 48h

DRUG INTERACTIONS CONTRACEPTIVES

1. _________

2. _________ decrease efficacy

3. _________ induce OC metabolism and decrease efficacy

4. MANAGEMENT →

1. antibiotics

2. antiretrovirals

3. anticonvulsants

4. lower hormone dose, greatest risk w oral (COC/POP)

INITIATING CONTRACEPTION

1. Can start anything within ____ start of menses

2. Use barrier method of abstinence until contraceptive is effective (typically ___)

1. 5d

2. 7d

EMERGENCY CONTRACEPTION

1. ADEs: _______, bloating, menstrual cramps, headache

2. Use within … → Yuzpe (>100 mcg EE, 500 mcg levonorgestrel)

3. → Levonorgestrel (Plan B One-Step, etc)

4. → Ulipristal (Ella)

5. → Paragard (copper) IUD

1. nausea

2. 72h

3. 72h

4. 120h

5. 5d

AR PHARMACIST CONTRACEPTIVE PROTOCOL

1. Must be age ____

2. Can only dispense ____ form

3. Cannot dispense more than a ____ supply until the patient has seen a provider

4. If patient has not been seen by a provider in the last ______, the pharmacist must provide a referral to local provider

5. Must provide patient with an informed ________ and standardized _______

1. 18+

2. oral

3. 6m

4. 6m

5. consent form, fact sheet (Appendix E)