Pha 416 - Drug Use In Pregnancy

Front 1

Define gravidity

Back 1

Number times a woman experiences pregnancy
- Multiple birth is one pregnancy

Front 2

Define Parity

Back 2

Number of a woman’s pregnancies which exceed 20 weeks gestation

Front 3

Define G4P2113

Back 3

G= number of pregnancies
P=
Full term deliveries
Preterm deliveries
Abortions
Living children

Front 4

Effect of progesterone in the GI tract:

Back 4

decreases GI motility.

Front 5

Physiological changes in response to pregnancy:

Back 5

↑ Cardiac output
↑ Renal perfusion and function
↑ Blood volume (by 50%)
↓ GI motility
↑ Weight gain

Front 6

Increased physiological demands due to pregnancy:

Back 6

Calories - additional 300/day
Protein - additional 10 gm/day
Calcium - 1200 mg/day
Folic acid - 400 mcg/day
Iron - additional 30 mg/day from 2nd trimester on

Front 7

How pregnancy affects the half life of renally eliminated drugs?

Back 7

Half life become shorter

Front 8

What type of drugs acquire a larger apparent Vd during pregnancy?

Back 8

Lipophobic drugs (hydrophilic)

Front 9

How pregnancy affects the extent and rate of absorption of oral administrated drugs?

Back 9

Potentially decreases them.

Front 10

Effects of smoking on the fetus?

Back 10

Low birth weight
Premature birth
Increase risk of respiratory issues

Front 11

What immunizations should be kept up to date during pregnancy?

Back 11

Rubella
Hep B
Influenza
Varicella
Tdap

Front 12

Which weeks during pregnancy present the greatest risk for dramatic structural malformations?

Back 12

Second through eighth week
(organogenesis period)

Front 13

What are the risks of drug use during the 2nd and 3rd trimester of pregnancy?

Back 13

Effects on growth, neurologic developments, mental development, and reproduction

Front 14

What are the factors affecting drug placental transfer?

Back 14

Low protein binding
High lipophilicity
Low molecular weight (< 600)
Unionized state

Front 15

What drugs are important human teratogens especially during the first trimester?

Back 15

Phenytoin
Lithium
Misoprostol
Retinoids (systemically)
Thalidomide

Front 16

What drugs are important human teratogens especially during the 3rd trimester?

Back 16

ACE inhibitors
Carbamazepine
Valproic Acid
Tetracyclines (for 2nd and 3rd)

Front 17

What abnormality can be produced by the used of ACE-I during pregnancy?

Back 17

Renal failure / agenesis

Front 18

What abnormality can be produced by the used of Carbamazepine and Valproic Acid during pregnancy?

Back 18

Neural tube defects

Front 19

What abnormality can be produced by the used of Phenytoin during pregnancy?

Back 19

Fetal hydantoin syndrome

Front 20

What abnormality can be produced by the used of Lithium during pregnancy?

Back 20

Ebstein's anomaly

Front 21

What drug is an important teratogen throughout pregnancy and what abnormality it produces?

Back 21

Alcohol
Fetal alcohol syndrome

Front 22

What abnormality can be produced by the used of tetracyclines during pregnancy?

Back 22

Discoloration of teeth

Front 23

Potential abnormalities due to the use of warfarin during pregnancy include:

Back 23

Fetal warfarin syndrome
(critical period 6-9 weeks)

Front 24

What are some suspected teratogens?

Back 24

Benzodiazepines
Estrogens
Progestogens
Quinolones

Front 25

Important drugs with Non-teratogenic AE:

Back 25

Antithyroid drugs
Aminoglycosides
Aspirin
Barbiturates
Benzodiazepines
Beta-Blockers
Caffeine
Chloramphenicol
Cocaine
Diuretics
Isoniazid
Narcotic analgesics
Nicotine
NSAIDs
Oral hypoglycemic agents
PTU (propylthiouracil)
Sulfonamides

Front 26

Agents Considered Safe to use during pregnancy:

Back 26

Acetaminophen
Cephalosporins
Corticosteroids
Docusate sodium
Erythromycin
Multiple vitamins
Narcotic analgesics
Penicillins
Phenothiazines
Thyroid hormones
Tricyclic antidepressants

Front 27

What are some references to obtain info of drugs used during pregnancy?

Back 27

Primary literature
Drugs in Pregnancy and Lactation
- Briggs
www.motherisk.org
www.toxnet.nlm.nih.gov
www.reprotox.org

Front 28

How to treat morning sickness during pregnancy:

Back 28

- Use Nonpharmacologic Treatment

First options:
- Doxylamine (antihistamine)
- Meclizine
- Vit. B6 and B12

Secondary options:
Promethazine
Metoclopramide
Ondansetron

Front 29

How to treat constipation during pregnancy:

Back 29

It could be a side effect of iron and calcium supplementation.

Treatment:
Fluids
Physical exercise
High fiber foods
Bulk-forming laxatives
Stool softeners
Milk of magnesia

Front 30

What therapies are contraindicated to treat constipation during pregnancy?

Back 30

NO enemas or strong stimulant laxatives

Front 31

Treatment of GERD during pregnancy:

Back 31

Ranitidine (Zantac®)
Metoclopramide (Reglan®) for severe
PPIs

Front 32

Treatment of Epilepsy during pregnancy:

Back 32

ALL anticonvulsants are considered teratogenic

Uncontrolled epilepsy poses greater threat to the fetus than drug therapy

Single drug therapy when possible

Folic acid supplementation 0.4 – 5 mg daily
Vitamin K 10 mg PO daily in the last month

Front 33

What medications have to be screened for neural tube defects when use to treat epilepsy during pregnancy?

Back 33

Carbamazepine (Tegretol®)
Divalproex sodium (Depacon®)
Valproic acid (Depakote®)

Front 34

Risk for gestational DM:

Back 34

>30 years of age
Obese
Previous history
positive family history
Racial background

Front 35

During what weeks should a pregnant patient be screened for gestational DM?

Back 35

Screening between the 24-28th week of gestation

Tight glycemic control is key

Front 36

How to treat DM during pregnancy:

Back 36

Tight glucose control with drug therapy if unable to control blood glucose on diet alone

Initiate therapy for
- FBS > 90 – 99
- 1 hr post prandial > 140
- 2 hr post prandial of >120 – 127

Goal: maintain
FBS 80 - 110 and
2 hr post prandial of <155

Front 37

When glyburide can be considered for the treatment of DM in a pregnant patient?

Back 37

After the 11 week of gestatio

Front 38

What is the risk for using metformin during pregnancy?

Back 38

Risk of premature birth

Front 39

For how long and for what should a neonate from a diabetic patient be closely monitor?

Back 39

Monitor neonate closely first 24 hrs for hypoglycemia

Front 40

What is the preferred agent to prevent thromboembolism in pregnant woman?

Back 40

LMWH

2nd: low dose ASA and heparin

DO NOT USE WARFARIN

Front 41

Treatment of bacterial vaginosis on a pregnant woman:

Back 41

Metronidazole
- 500 mg po BID X 7 days
- 250 mg po TID X 7 days
Clindamycin 300 mg po BID X 7 days

Do not use vaginal preparations

Front 42

What drug is a good option to treat high blood pressure in a pregnant woman?

Back 42

Nifedipine

Avoid ACE-I and ARBs

Front 43

Drugs that can be used to treat headache during pregnancy?

Back 43

Non-pharmacologic tx
APAP, codeine, narcotics

Sumatriptan - probably OK

Front 44

How is pregnancy- induce hypertension defined?

Back 44

Elevation of blood pressure after the 20th week in excess of 140 systolic and/or 90 diastolic

Elevation of 30 mm Hg systolic or 15 mm HG diastolic above the baseline

Front 45

What are the common signs of pre-eclampsia?

Back 45

High blood pressure
Protein in the urine
Pitting edema

others:
blurred vision
abdominal pain
elevated liver enzymes

Front 46

What is the difference between pre-eclampsia and eclampsia?

Back 46

Eclampsia is defined as pre-eclampsia with seizures

Front 47

Pre-eclampsia prophylaxis:

Back 47

ASA 50 – 150 mg daily
Calcium supplementation

Front 48

Drug of choice to treat high blood pressure during pre-eclampsia:

Back 48

methyldopa (Aldomet®)
(hardly used)

Front 49

Alternative drugs to treat pre-eclampsia:

Back 49

hydralazine (Apresoline®), labetalol
nifedipine

Front 50

Drugs contraindicated in the treatment of pre-eclampsia:

Back 50

ACE-I
Diuretics

Front 51

Treatment for mild to moderate pre-eclampsia:

Back 51

Bed rest

Front 52

Treatment for moderate to severe pre-eclampsia:

Back 52

- Hospitalization

- Magnesium sulfate 2 - 4 gm IV bolus, followed by 1-3 gm IV/hr until delivery

Front 53

What is the optimal magnesium serum concentration during the treatment of pre-eclampsia?

Back 53

maintain serum concentration @ 4-7 mEq/L (fairly high)

Front 54

What complications can be seen at magnesium concentrations of more than 13mEq/L and 15mEq/L?

Back 54

Respiratory depression >13 mEq/L
Cardiac arrest > 15 mEq/L

Front 55

How to reverse magnesium toxicity?

Back 55

with calcium gluconate

Front 56

What is the mechanism of action of magnesium to treat pre-eclampsia?

Back 56

Magnesium helps with PIH because it relaxes smooth muscle raising the seizure threshold

Front 57

When to delivery a baby during pre-eclampsia?

Back 57

Use Hydralazine and labetalol IV to control blood pressure

Delivery if no response within 24-48 hrs

Front 58

How to treat seizures during eclampsia?

Back 58

Treat with magnesium sulfate 5 – 6 gm IV bolus

Front 59

What are some possible pre-eclampsia Complications?

Back 59

Seizures
DIC (Disseminated Intravascular Coagulopathy)
HELLP syndrome:
- Hemolysis
- Elevation of Liver enzymes
- Low Platelets

Front 60

Definition of premature labor:

Back 60

Contractions with cervical changes prior to 37th week

Front 61

Goal in the treatment of premature labor:

Back 61

to postpone delivery 24 – 48 hours

Front 62

Premature labor treatment:

Back 62

Bed rest
Fluids
Antibiotics for Group B Strep Prophylaxis
Corticosteroids (for less than 34wks of gestation)

Front 63

What antibiotics are preferred in the prophylaxis of Group B strep during premature labor?

Back 63

Pen G
Ampicillin

Ancef (if pen allergy w/o hives)
Clindamycin (high resistant)
Vancomycin

Front 64

What are the corticosteroids of choice during premature labor?

Back 64

Betamethasone

Dexamethasone

Front 65

What is the role of corticosteroids during premature labor?

Back 65

Corticosteroids stimulate baby’s lungs to make surfactant

Front 66

What tocolytic should be used for women with contractions but NO cervical changes during premature labor?

Back 66

Terbutaline (beta-2 agonists)
(limit use to inpatient and for less than 72 hrs)

No commonly used outpatient or if contractions present due to SE

Front 67

What tocolytic should be used for women with contractions AND cervical changes during premature labor?

Back 67

Magnesium sulfate

Front 68

What tocolytic can be used orally for the outpatient treatment of premature labor?

Back 68

NSAIDs: indomethacin and katerolac

CCB: Nifedipine (preferred)

Front 69

What is the SE of magnesium when used during premature labor?

Back 69

pulmonary edema

Front 70

What is a possible SE of NSAIDs when used during premature labor?

Back 70

premature constriction of ductus arteriosus

Front 71

Miscarriage and PTL is associated with low levels of ...

Back 71

Progesterone

Front 72

What are some indications for labor induction:

Back 72

Post-term pregnancy (> 40wks)

Maternal medical problem

Suspected fetal compromise

Fetal demise

Premature/prolonged rupture of membranes

Chorioamnionitis: infection of the membranes that surround the baby and hold water in.

Front 73

Desired physiological effects to induce labor:

Back 73

Cervical ripening

Contraction stimulation

Front 74

Drugs used for cervical ripening during post term induction:

Back 74

Prostaglandin E2

Misoprostol

Front 75

Drugs used for contraction stimulation during post term induction:

Back 75

Oxytocin (Pitocin®)
- IV titrated to frequency and strength of contraction

Front 76

Herbal agents for labor induction:

Back 76

Laminaria
Evening primrose oil
Black haw
Black and blue cohosh
Red raspberry leaves

Front 77

What narcotic analgesics should be used during labor and delivery?

Back 77

Fentanyl (preferred)

Morphine

Front 78

SE of narcotics used for analgesia during labor and delivery:

Back 78

Fetus: CNS and respiratory depression and skeletal muscle flaccidity (floppy baby syndrome)

Mom: rigors and N/V

Front 79

How is fentanyl usually administrated during labor and delivery?

Back 79

- Usually combined with bupivacaine

- Administered via continuous infusion into the epidural space

Front 80

How to reverse narcotic overdose or hypersensitivity?

Back 80

Nalaxone

Front 81

How to reverse Heparin overdose or hypersensitivity?

Back 81

Protamine

Front 82

How to reverse Oxytocin overdose or hypersensitivity?

Back 82

Magnesium sulfate

Front 83

Which laxatives are contraindicated in pregnancy?

Back 83

castor oil and mineral oil