Ch. 48 Drug use in Pregnancy & Lactation

What confirms pregnancy?

high levels of human chorionic gonadotropin (hCG) in the urine or blood

Which trimester are teratogens the most dangerous?

First trimester

• when most organ development occurs

Guidelines for pregnancy

ACOG

Folate deficiency during pregnancy can cause:

Neural tube defects

Folate (B9) is found in what foods?

- Cereals

- Dried beans

- Green leafy vegetables

- Orange Juice

How much calcium & vitamin D do pregnant women between 19-50 y/o require?

Calcium: 1000 mg/day

Vitamin D: 600 IU/day

Traditional Pregnancy Categories

A - No risk of use

B - No risk in animals

C - Harm in animals

D - Harm in human fetus

X - Contraindicated

New Pregnancy Categories

8.1 - Risk to fetus

8.2 - Lactation risk

8.3 - Male or Female reproduction

2 vaccines recommended for pregnant women

- Inactivated Influenza

- Tdap

Teratogenic Medications

- Isotretinoin, retinoids

- FQs, Tetracyclines, AGs, Leflunomide

- Warfarin

- Statins, Lomitapide

- ACEs, ARBs, Aliskiren, Entresto

- Hormones (estrogen, testosterone, SERMS)

- Migraine meds (DHE, ergotamine)

- Paroxetine

- Valproic acid, Phenobarbital, Phenytoin, Carbamazepine

- Topiramate

- Lithium

- Hydroxyurea

- Methotrexate

- NSAIDs

- Misoprostol

- Amiodarone, Dronedarone

- Atenolol

- BZDs

What is Preeclampsia?

Elevated blood pressure with evidence of organ damage (proteinuria)

Eclampsia

High blood pressure during pregnancy that results in seizure, coma, or death

What is the only known cure for preeclampsia?

Delivery of fetus

To prevent Preeclampsia, ACOG & ADA recommend adding ________________ at the end of the first trimester for women at risk.

LD aspirin

Risk factors for Preeclampsia

- T1D or T2D

- Renal disease

- Chronic HTN

- Hx of Preeclampsia

Managing Pregnancy Conditions

Morning sickness/NV

- Lifestyle first: smaller meals, avoid spicy or odorous foods, etc.

- Pyridoxine (Vitamin B6) ± doxylamine

Ginger is “possibly effective”

Managing Pregnancy Conditions

GERD/Heartburn

- Lifestyle: smaller more frequent meals, avoid eating 3H before sleep, elevate head of bed

- Calcium carbonate (Tums)

Managing Pregnancy Conditions

Flatulence

Simethicone

Managing Pregnancy Conditions

Constipation

- Lifestyle: More fluids and fiber

- Bulk-forming laxatives (psyllium, calcium polycarbophil)

- Docusate or PEG (Prevention or treatment)

Managing Pregnancy Conditions

Cough/Cold/Allergies

- First line: Cromolyn

- Second line: 1st gen antihistamines (chlorpheniramine (drug of choice))

- Intranasal steroids are fine if needed for chronic allergies (budesonide is preferred, beclomethasone)

Managing Pregnancy Conditions

Pain

- Lifestyle: hot/cold packs, massage, PT, etc.

- APAP

Managing Pregnancy Conditions

Asthma

- Maintenance: Budesonide preferred, but all are inhaled steroids are acceptable

- Rescue: ICS-formoterol or inhaled albuterol

Managing Pregnancy Conditions

Iron-deficient anemia

- Supplemental iron

Managing Pregnancy Conditions

HTN

- Labetalol

- Methyldopa

- Nifedipine

Managing Pregnancy Conditions

Diabetes

- Insulin (preferred)

- Metformin & glyburide may also be used

Managing Pregnancy Conditions

Vaginal fungal infection

- Topical antifungals (not fluconazole)

Managing Pregnancy Conditions

UTI

- Cephalexin

- Amoxicillin

- Bactrim or Nitrofurantoin (avoid in first trimester and last 2 weeks)

Must treat bacteriuria, even if asymptomatic

Managing Pregnancy Conditions

Anticoagulation (VTE)

LMWH > UFH

- Prophylaxis: pneumatic compression devices ± LMWH

Managing Pregnancy Conditions

Anticoagulation (Mechanical valve)

LMWH (warfarin is teratogenic)

Managing Pregnancy Conditions

Hypothyroidism

increase levothyroxine dose by 30-50%

Managing Pregnancy Conditions

Hyperthyroidism

1st trimester: PTU

2nd/3rd: Methimazole

* Both have high risk for liver damage

The American Academy of Pediatrics (AAP) recommends that babies be exclusively breastfed for the first _______ months of life (as long as mutually desired).

6 months

Babies receiving breast milk partially or exclusively should receive

10 mcg (400 IU) of vitamin D supplementation daily

Human milk contains little __________, so breastfed babies require 1 mg/kg daily during months 4-6. (infants have a store for first 4 months of life)

iron

Should a woman with HIV breastfeed?

No, can be transmitted through breast milk

Codeine and tramadol can be used by breastfeeding mothers (True/False)

False

• Risk of excessive sleepiness, breathing difficulty and/or death in the infant

Meds to avoid during lactation

- Amphetamines

- Amiodarone

- Ergotamines

- Lithium

- Metronidazole

- Phenobarbital

- Statins