Pregnancy, Labor, Delivery (Andrews)

The # of times a woman has been pregnant is called _________.

idk how imp

gravidity

The # of pregnancies exceeding 20 weeks gestation is called ___________.

idk how imp

parity

Early symptoms and signs of pregnancy?

• early symptoms

  • fatigue

  • increased urination

  • n/V

    • “morning sickness”

• signs:

  • missed period

  • change in cervical mucus

  • bluish discoloration of vaginal mucosa

  • increased skin pigmentation

  • breast changes

In pregnant women:

• what should be supplemented in pregnancy to prevent neural tube defects?

• multivitamin with ______+_______ should be given.

• minimize consumption of what stimulant?

• what intake should be limited due to mercury content?

• can you drink alcohol?

• folic acid 0.4mg PO daily

• multivitamin with calcium and iron

• minimize caffeine consumption

• limit seafood intake (12 oz)

• don’t drink alcohol

What vaccines should be given during pregnancy? which shouldn’t?

• give inactivated influenza vaccine

• give Tdap vaccine ~27-36 weeks gestation

• NO LIVE vaccines

What PK changes occur during pregnancy?

• Absorption

• Distribution

• Metabolism

• Excretion

• Absorption

  • decrease GI motility and gastric acid secretion

  • altered bioavailability due to n/v

  • increased skin absorption

• Distribution

  • blood volume increases 30-50%

  • increased TBW

  • body fat increases

  • albumin conc decreases

• Metabolism

  • hepatic perfusion increases

  • hepatic metabolism altered (CYP implications)

• Excretion

  • renal blood flow increases 25-50%

  • GFR increases by 50%

    • renally excreted drugs should be adjusted up

  • lower SCr concentrations

What must be considered with medication use in pregnancy

• Maternal benefit

• Maternal adverse effects

• Fetal risk

• Developmental timing of exposure

• Risks of untreated disease

Definition of teratogen:

substance (drug or environmental agent) that has the potential to produce abnormal development in the fetus

Is the placenta an absolute barrier

• Placenta is not an absolute barrier

  • Most substances cross by diffusion

Difference between Congenital vs Congenital malformation vs Congenital anomaly:

idk how important

• congenital → any condition existing at birth, regardless of cause

• congenital malformation → structural defect in an organ or body part arising during fetal development

• congenital anomaly → broader term for any deviation from normal development, including structural, functional, or metabolic abnormalities (includes malformations)

What medications are associated with teratogenic effects during organogenesis?

• chemo drugs, sex hormones, lithium, retinoids, thalidomide, warfarin, antiseizure medications

• NSAIDs and tetracyclines → effects in 2nd and 3rd trimester

How does drug exposure effect each period of pregnancy?

• first 4 weeks of gestation

• embryonic period

• 2nd/3rd trimester

I do NOT think important!!!!!!!!

• first 4 weeks of gestation = all-or-none phenomenon

• embryonic period = structural anomalies

• 2nd/3rd trimester = growth restriction, CNS abnormalities, impaired organ fxn, fetal demise

What antiseizure medication should be avoided during pregnancy?

valproic acid

What resources are available to assess medication safety in pregnant individuals?

• FDA

• package inserts

• fact sheets

• Brigg’s Drugs in pregnancy and lactation

• can volunteer to sign up for a pregnancy exposure registry

FDA Pregnancy Lactation Labeling Rule (PLLR)

• Old A, B, C, D, X categories are replaced by

  • Pregnancy

  • Lactation

  • Females and Males of Reproductive Potential

What are the most common pregnancy-influenced GI issues?

• n/v

• constipation

• acid reflux (GERD)

• Hemorrhoids

Gestational diabetes mellitus (GDM) is

• diagnosed when?

• what happens to carbohydrate tolerance? b-cells? insulin resistance?

• RFs? idk how important

• diagnosed between 24-28 weeks

• carbohydrate intolerance, pancreatic b cell dysfunction, insulin resistance

• Risk Factors:

  • history of GDM

  • high-risk race

  • BMI ≥ 25 kg/m2

  • TGs >250 mg/dL

  • indications of insulin resistance

  • history of diabetes

  • physical inactivity

  • Polycystic ovary syndrome

  • A1c >5.7%

  • previous birth of an infant weight ≥4 kg

  • HTN

  • HDL <35 mg/dL

What is the first line tx for GDM?

• diet and exercise

• Blood glucose monitoring

What pharmacotherapy can be used for GDM pts. if diet and exercise fail?

WHAT IS 1st LINE?

• Insulin is preferred

• alternatives: metformin, glyburide

How is preeclampsia diagnosed?

• New-onset HTN after 20 weeks + proteinuria OR signs of end-organ dysfunction

• May also occur postpartum

Preeclampsia may progress rapidly to what? Main symptom?

Eclampsia → seizures!!

What are the complications of uncontrolled HTN?

• pregnant individuals:

• fetus:

• chronic HTN:

IDK HOW IMPORTANT

• pregnant individuals:

  • stroke

  • Renal failure

  • Pulmonary edema

  • maternal death

  • placental abruption

• fetus:

  • intrauterine growth restriction

  • preterm delivery

  • still birth

treatment of preeclampsia with pharmacotherapy is recommended when blood pressure is ≥______ mmHg.

160/110 mmHg

What antihypertensives are preferred for tx of preeclampsia?

What antihypertensives should be avoided?

• preferred

  • Labetalol

  • Nifedipine

  • Hydralazine

• avoided

  • ACEi/ARBs

  • Renin inhibitors

  • Mineralocorticoid receptor antagonists

______________ is recommended with severe hypertension with preeclampsia to prevent progression to eclampsia and treat eclamptic seizures.

magnesium

HELLP syndrome is an acronym for what?

• H = hemolysis

• EL = elevated liver enzymes

• LP = low platelet count

Postpartum hemorrhage is losing how much blood?

First line treatment

• blood loss >1000ml OR blood loss with signs of hypovolemia

• oxytocin

Initial tx for postpartum depression?

Pharm tx?

What drug has a specific indication for postpartum?

• initial: psychotherapy, CBT, group/family therapy

• pharm tx: sertraline, paroxteine, fluoxetine, nortriptyline

  • Brexanolone is FDA approved for tx of postpartum

What is the BBW for Brexanolone?

Admin?

• REMs program

• BBW → excessive sedation and sudden loss of consciousness

• IV admin as 60 HOURS continuous infusion

Preterm labor is uterine contractions before ____ weeks gestation with changes in cervical dilation and/or effacement.

37

Risk Factors for preterm labor?

idk how imp

• Previous preterm delivery

• h/o cervical surgery

• short cervical length

• infections

• vaginal bleeding

• UTIs

• Periodontal disease

• Low pregnancy weight

• smoking

• SUD

• shorten interval between pregnancies

Tocolytic therapy is used to postpone delivery long enough to do what?

• allow for max effect of antenatal corticosteroid and Mg admin

  • Antenatal corticosteroids to work (Betamethasone or Dexamethasone)

  • Mg for neuroprotection

• allow for transport of pregnant pt. to appropriate care center

What drugs can be used for tocolytic therapy?

• Nifedipine

• Indomethacin

• Terbutaline

• Mg (for fetal neuroprotection, not primary tocolysis)

10-30% of pregnant individuals are colonized with Group B Strep (GBS) which leads to pregnancy risks.

Screening?

What abx are given until delivery for pts. with GBS?

• Universal screening at 36-38 weeks gestation

• IV ampicillin q4 hrs until delivery

What are benefits of Prelabor rupture of membranes (PROM) before 34 weeks

• Prolong pregnancy

• Reduce infection

• Improve neonatal outcomes

Summary

• Pregnancy

• Complications

• Labor & Delivery

Pregnancy

• Causes major PK and physio changes

• Med use requires careful risk-benefit assessment

Complications

• GDM, Preeclampsia/Eclampsia, HELLP, Postpartum hemorrhage, Postpartum depression

Labor & Delivery

• Tocolytics delay labor

• Steroids and antibiotics improve neonatal outcomes