Pregnancy, Labor, Delivery- Higgins

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 s

  • 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

Definition of teratogen:

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

Difference btwn 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

What are the most common pregnancy-influenced GI issues?

• n/v

• constipation

• acid reflux

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

• RFs:

  • 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’s the one step and two step method for screening and diagnosis of gestational diabetes mellitus (GDM)?

• one step method

  • 75-gram oral glucose tolerance test (OGTT)

  • draw plasma glucose at fasting, 1 and 2 hrs after admin

  • GDM diagnosis when 1 or more of the following met:

    • fasting: 92 mg/dl

    • 1hr: 180 mg/dl

    • 2hr: 153 mg/dl

• two step method

  • step 1

    • 50-gram oral glucose tolerance test (OGTT) in a non-fasting state

    • draw plasma glucose 1 hr after admin

    • if plasma glucose ≥140 mg/dL then move to step 2

  • step 2

    • 100-gram OGTT with fasting 1-,2-, and 3-hr levels

    • GDM diagnosis when 2 or more of the following met:

      • fasting: 95 mg/dl

      • 1hr: 180 mg/dl

      • 2hr: 155 mg/dl

      • 3hr: 140 mg/dl

What is the first line tx for GDM?

• dietary and exercise changes

• at least 4 times daily

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

WHAT IS 1st LINE?

• BASAL INSULIN w/ bolus if needed

• alternatives: metformin, glyburide

How is preeclampsia diagnosed?

• elevated blood pressure + proteinuria

• if no proteinuria:

  • new onset of thrombocytopenia + serum creatine >1.1 mg/dl

    OR

  • doubling of creatinine + elevated LFTs + pulmonary edema

    OR

  • new onset HA

Preeclampsia risk factors:

idk how important

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:

  • preeclampsia

  • eclampsia

  • stroke

  • labor induction

  • placental abruption

• fetus:

  • intrauterine growth restriction

  • preterm delivery

  • low birth weight

  • still birth

• chronic HTN:

  • death

  • pulmonary edema

  • renal insufficiency/failure

  • myocardial infarction

  • cesarean delivery

  • postpartum hemorrhage

  • GDM

  • congenital anomalies

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 are preferred if there is a urgent need?

• preferred: labetalol and nifedipine XR

• urgent need: IV labetalol, IM hydralazine, or nifedipine IR

  • 2nd line: nicardipine or esmolol infusion

______________ 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?

What should be administered before placental delivery to reduce blood loss?

• blood loss >1000ml or blood loss with s/sx of hypovolemia

• oxytocin should be administered

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 min continuous infusion

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

37

RFs for preterm labor?

idk how imp

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

• allow for max effect of antenatal corticosteroid and Mg admin

• allow for transport of pregnant pt. to high-risk hospital

What drugs can be used for tocolytic therapy?

• b adrenergic receptor agonist (terbutaline)

• CCBs (nifedipine)

• NSAIDs (indomethacin)

• Mg for fetal neuroprotection

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

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

IV ampicillin q4 hrs until delivery

Prelabor rupture of membranes (PROM) before 34 weeks prophylactic antibiotics should be initiated to prolong pregnancy, reduce infection in patient and neonate and reduce major morbidities and mortality.

What abx should be given for PROM pts.?

• 7 day course of:

  • IV ampicillin + erythromucin for 2 days followed by oral amoxicillin + erthromycin for 5 days

• amoxillin-clavulanate not rec

The ACOG recommends antenatal corticosteroids for fetal lung maturation in what pts.?

What are the most common antenatal corticosteroid regimens?

• rec for 24-34 weeks gestation and at high risk for preterm delivery

• most common regimens:

  • betamethasone IM, 2 doses 24 hrs apart

  • dexamethasone, 4 doses 12 hrs apart

HIGGINS REVIEW:

1. PK changes in pregnancy- ADME

2. Resources for drug information in pregnancy

3. Which medications are teratogens and what can you do to reduce risk

4. Preterm labor medication considerations

5. Focus on what needs to be given to protect baby

6. Treatment of pregnancy complications

7. Focus on nonpharmacologic and first line pharmacologic management

1. most imp PK changes:

   • plasma volume, cardiac output, and eGFR increase 30-50%

   • body fat increases= increase Vd

   • plasma albumin decreases

   • hepatic perfusion increases

   • absorption: n/v, delayed gastric emptying, and increase in gastric pH

   • increased levels of estrogen/progesterone= affect the liver enzyme activity

2. resources:

   • FDA and package inserts

   • fact sheets

   • Brigg’s drugs in pregnancy and lactation

   • FDA pregnancy registry

3. key medications that are teratogens

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

   • NSAIDs and tetracyclines—> 2nd and 3rd trimester

   • antiseizure meds—> no VALPROIC ACID

4. preterm labor medication considerations

   • tocolytic therapy

     • b-adrenergic receptor agonists (terbutaline)

     • CCBs

     • NSAIDs

   • Mg (for neuroprotection)

   • abx

     • EBS—> IV ampicillin q4hrs

     • PROM—> 7 day regimen

   • antenatal corticosteroids

     • betamethasone IM, 2 doses 24 hrs apart

     • dexamethasone, 4 doses 12 hrs apart

5. what needs to be given to protect baby

   • in general: folic acid supplements, multivitamins with Ca and Fe

   • vaccines: Tdap, inactivated influenza

6. tx of pregnancy complications

   • GDM

     • 1st line: diet and exercise

     • pharm tx: INSULIN

       • alt: metformin or glyburide

   • preeclampsia

     • labetalol and nifedipine XR preferred

     • if urgent need: IV labetalol, IM hydralazine, IR nifedipine —> 1st line

     • must also give Mg

   • postpartum hemorrhage

     • oxytocin

   • postpartum depression

     • initial tx: nonpharm

     • pharm tx: sertraline, paroxetine, fluoxetine, nortriptyline

     • brexanolone

PRACTICE:

JC is a 25-year-old Black female who is pregnant with her first child. She is currently 28 weeks gestational age and begins to have contractions and bleeding. Which of the following medications can be used to attempt to postpone delivery?

a. Terbutaline

b. Magnesium

c. Dexamethasone

d. Ampicillin

a.