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40 Cards in this Set

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Characteristics of Absorption in Pregnancy
1.
2.
3.
4.
1. Decreased GI motility
2. Decreased gastric acid secretion
3. Nausea and vomiting
4. Increased skin absorption
Blood volume increase __-__% during pregnancy
30-50%
Adipose tissue percentage (increases/decreases) during pregnancy.
Increases
How does nausea and vomiting during pregnancy affect protein stores?
Protein stores can be decreased
How do increased progesterone levels in pregnancy affect metabolism?
They cause hepatic enzyme induction
How does increased blood volume in pregnancy affect renal elimination?
Increased blood volume leads to increased renal blood flow and increased GFR.
How can substances be transferred across the placenta?
1.
2.
3.
4.
5.
1. Simple diffusion (most drugs)
2. Facilitated diffusion (glucose)
3. Active transport (vitamins, amino acids)
4. Pinocytosis (immune antibodies)
5. Breaks between cells (erythrocytes)
What factors influence drug transfer across the placenta?
1.
2.
3.
4.
5.
6.
1. Molecular weight
- <600 (most drugs) easy
- >1,000 (ex: heparin); difficult
2. Lipid solubility (lipid soluble transfers easily)
3. Ionization
-drugs ionized at physiologic pH cross slowly (quatemary amines)
-weak acids and bases with pKa 4.3-8.5 transfer rapidly
4. Protein binding
-free, unbound drugs cross the placenta
5. Uterine and umbilical blood flow
-maternal blood pressure, cord compression, drug therapy
6. Maternal diseases
-PIH, diabetes, erythroblastosis change the permeability of the placenta
What are some examples of the benefits of placental transfer of drugs?
1. PCN administered to a pregnant woman with syphilis will cross the placenta and is highly concentrated in fetal blood

2. Zidovudine can prevent vertical transmission of HIV from mother to child
What is a teratogen?
A substance (drug or environmental agent) that leads to birth of a malformed baby

Usual manifestations of teratogenesis are restricted growth, death of the fetus, carcinogenesis, and defects in organ structure or function
Common teratogenic effects of medications:
1. Spontaneous abortion
2. Developmental defects
3. Malformations
4. Intrauterine growth retardation
5. Mental retardation
6. Carcinogenesis
7. Mutagenesis
What are congenital malformations?
Structural abnormalities of prenatal origin that are present at birth and seriously interfere with viability or physical well-being
What is a congenital anomaly ("birth defect")?
Malformation or functional defect (mental or physical growth retardation, CNS depression, deafness, etc)
What are the causes of malformations?
1. Monogenic
2. Chromosomal
3. Multifactorial
4. Environmental
5. Uknown
Most commonly used drugs during pregnancy:
analgesics, antimicrobials, antiemetics
True or False: The placenta is NOT a barrier.
TRUE - almost all drugs will cross the placenta; concentration may range from 0-100% of mother's level
What effect does drug/substance exposure have on an embryo at the time of conception and implantation (first 2 weeks)?
"all-or-none effect" - embryo will either die without realization of pregnancy or cells will regenerate and the embryo will not be damaged.
When is the classic teratogenic period?
31-70 days from last menstrual period (critical 6 weeks)
-first trimester; period of organogenesis (physical abnormalities)

(exposure > 70 days from LMP may result in functional or behavioral defects)
FDA pregnancy risk categories apply to drugs marketed after:
December 1983
True or False: FDA pregnancy risk categories are easy to interpret.
FALSE: statements are often ambiguous and difficult to interpret. The FDA may develop a more meaningful, evidence-based, narrative system for classification.
What drug prescribed during the 50-60's caused severe limb defects (phocomelia) and other organ dysgenesis (heart, kidney, etc) and was a precursor to the Kefauver Harris Amendment?
Thalidomide
What should always be considered in selecting drugs for pregnant women?
maternal morbidity and mortality; treat each case on an individual basis
True or False: If a woman smokes during her pregnancy, there is always a risk to the fetus even if she stops.
FALSE: If a woman stop smoking by the end of her first trimester, she is not more likely to have a low birth weight baby than a woman who never smoked.
ACE Inhibitors

FDA Risk:

Avoid:

Complications:
FDA Risk: C/D

Avoid: in second and third trimesters

Complications: structural changes like decreased ossification of skull and possible renal tubular dysgenesis
Other complications: oligohydramnios, craniofacial deformity, limb contractures, pulmonary hypoplasia, fetal hypotension, renal failure, anuria, death (fetal/neonatal)
Aspirin

FDA Risk:

Complications
(may be beneficial in low doses (81mg), avoid chronic or high doses, few associations of congenital malformations with occasional use)

FDA Risk: C/D if full dose in 3rd tri

Complications: Near term - may prolong gestation and labor
Increased risk of bleeding in the newborn (especially intracranial hemorrhage in preemie or low-birth weight infants)
Closure of ductus arteriosus may occur if used in high doses in 3rd tri
NSAIDS

FDA risk:

Effects:
FDA risk: D if in the 3rd tri near delivery

Effects: decrease uterine contractions
-little evidence linking these drugs with congenital malformations in the 1st tri
-3rd tri use may result in closure of the ductus arteriosus result in persistent pulmonary HTN, may also inhibit labor and prolong pregnancy
Retinoids - Accutane

FDA Risk:

Effects:

Recommendations
FDA Risk: X

Effects: critical period of exposure 4-7 weeks after LMP
-defects including cardiovascular and nervous systems and craniofacial abnormalities have been reported

Recommendations: 2 negative pregnancy tests before starting therapy and 2 reliable methods of contraceptive during therapy and for a month after last dose
True or False: Epilepsy is a contraindication for pregnancy.
FALSE: >90% of women with epilepsy have normal pregnancies
Preconception management measures when taking anticonvulsants:
-interactions with AED and hormonal contraceptives (recent studies show that malformations are most likely due to AED therapy)
-folic acid supplementation may decrease the risk of malformation in some women (neural tube defects)
True or False: It is probably best to continue treatment with current drug if seizures controlled and woman becomes pregnant.
TRUE
True or False: Valproic acid may be associated with higher teratogenicity than other AEDs.
TRUE: higher umbilical concentrations than maternal concentrations (perhaps because of increased placental transfer)
What is the most studied drug in the anticonvulsant class?
Phenytoin (catergory D) causing Fetal Hydantoin Syndrome (FHS)
What is FHS?
Generally associated with a variety of craniofacial defects as well as hypoplasia of the distal phalanges and small or absent fingernails.
May be due to decreased levels of epoxide hydrolase, an enzyme which increases the clearance of some potentially toxic metabolites (epoxides)
What 2 anticonvulsants are associated with malformations seen in FHS, neural tube defects, growth and mental retardation, impaired physical-mental development, congenial heart defects, and cleft lip and palates?
Carbamazepine (Category D) and Valproic Acid (Category D)
Warfarin

Category:

Effects:

Avoid:
Category: X/D

Effects: Fetal warfarin syndrome (FWS) - critical period of exposure seems to be 6th-9th week of gestation; characterized by nasal hypoplasia, depressed bridge of the nose and poorly calcified axial skeleton and proximal femur
Other features: low birth weight, congenital heart disease, deafness, optic atrophy, micropthalmia, shortened fingers, etc

Avoid: 2nd and 3rd trimesters - use may produce various CNS abnormalities resulting in blindness, deafness, hydrocephalus, seizures, spasticity, etc
Other problems: spontaneous abortion, stillbirth, prematurity and hemorrhage
True or False: Low molecular weight heparin has a molecular weight > 3500 and does not cross the placenta.
TRUE: Data suggests LMWH does not increase the risk of adverse birth outcomes.

(Lovenox safe for use in pregnancy)
What are some examples of safe OTC meds to use in pregnancy?
1. Diphenhydramine, chlorpheniramine
2. Acetaminophen
3. Pseudoephedrine
4. Guaifenesin, dextromethorphan
5. Docusate, senna, MOM
6. Loperamide
7. Calcium carbonate
What are the 2 questions to consider when determining risks vs. benefits in taking OTC meds in pregnancy?
1. What would happen if this condition were not treated?

2. Would the patient get well without treatment?
What are some considerations when counseling in pregnancy?
1. Careful not to make recommendations that cannot be supported by at least some scientific data
2. Try to provide the patient with as much detail as possible
3. Make time for your patient and give yourself time to prepare/obtain information
What characteristics should be considered in improving communication with patients?
1. The willingness of the pharmacist to answer questions
2. Tone of voice
3. Interest shown in the matter at hand
4. Confidence in which questions are answered
5. Terminology used