G & R Exam 3
Category C pregnancy risk
Risk in animals; little human data; most drugs are here. Only give if benefit >risk -lantus, fluoxetine, albuterol
Category X pregnancy risk
Risks involved in drug use clearly outweigh potential benefits, NEVER use by pregnant women -warfarin, statins
what are the drugs of choice for treatment of depression in a breastfeeding mother?
SSRIs -sertraline is preferred -NO FLUOXETINE Can also utilize TCAs -amitriptyline is preferred -NO DOXEPIN
Folic acid and pregnancy
Supplemental folic acid in early pregnancy reduces neural tube defects. -400-800mcg daily -max benefit 1 month prior thru 3 months of pregnancy
Vaccines in pregnancy
- cannot have live vaccines (varicella, HPV, MMR) - can have flu vaccine (injection only, no flumist) - Tdap each pregnancy between 27-36 weeks
what year were traditional medicaid programs now required to cover family planning services and supplies?
1972
Mastitis
inflammation of the breast; most commonly occurs in women who are breastfeeding from the bacteria staph aureus. -fever, redness, breast tenderness, flu like symptoms
decongestant ok to use in pregnacy
phenylephrine, no adverse events reported to baby, does not appear to affect milk production
somatic premenstrual symptoms
physical -bloating, cramping -weight gain -breast tenderness -HA
Parity
number of births
which classes of hypertensive medications are CONTRAINDICATED during pregnancy?
-ACEI -ARBs
Some known human teratogens
-ACEI/ARBs -Androgens -anticonvulsants -lithium -tetracyclines -isotretinoin
OTC Medications in pregnancy
-ASA not recommended -Pepto Bismol (bismuth subsalicylate) -NSAIDs just avoid if possible, no in 1st trimester, caution in 2nd
Preeclampsia Risk factors
-Age- teen or over 40 -Previous preeclampsia -obesity -multiple gestation -chronic hypertension -nulliparity -tobacco use
What are four recommendations for preventative care services under the ACA?
-HRSA bright futures -ACIP (vaccines that should be covered) -U.S preventative task force (grade A or B) -contraception and contraceptive services
transporters in the syncytiotrophoblast on fetal side
-MRP
Transporters in the syncytiotrophoblast on maternal side
-NET -SERT -P-gp (drug resistance) -MRP2 (drug resistance)
signs and symptoms of endometriosis
-Pelvic pain -Infertility -Dysuria (painful urination) -Dysmenorrhea -Dyschezia (painful defecation)
Preeclampsia signs and symptoms
-Sudden weight gain (2kg in 1 week) -edema -decrease urine output -Blurred vision and seeing spots -low platelets -elevated liver enzymes -hemolysis
psychoactive drugs to use with caution in breastfeeding mom
-citalopram -diazepam -fluoxetine -lamotrigine -lithium -mirtazapine -venlafaxine sometimes it is better to continue meds if mom is well controlled with monitoring of baby
factors affecting the amount of drug received by the infant in breast milk
-colostrum vs mature milk -infants ability to absorb, detoxify, and excrete the drug
what can decrease lactation?
-alcohol -bromocriptine/cabergoline -oral contraceptives containing estrogen -sudafed
medications contraindicated in lactation
-amphetamines -antineoplastics -illicit substances -radioactive substances, including iodine -immunosuppressants -lithium -misoprostol
Amenorrhea treatment
-based on underlying cause and must be determined on an individual basis -hormonal therapy may be needed -decrease exercise and encourage weight gain Hyperprolactinemia -cabergoline twice weekly -bromocriptine 2.5mg TID
PCOS pathophysiology
-excessive LH -> no ovulation -> causes excess androgen -defect in insulin -> hyperinsulinemia, insulin resistance -> increases androgens
PCOS signs and symptoms
-hirsutism -absence of ovulation & menstruation -DM -acanthosis nigricans -weight gain/obesity
causes of menhorrhagia
-hypothryoidism -uterine fibroids -anticoag drugs
PK affect of longer gastrointestinal transit time (3rd trimester)
-increased fraction absorbed -overlap with previous dose? longer absorption rate
Breastfeeding contraindications according to AAP
-infant with galactosemia (inability to process breast milk) Has a mother who is: -HIV positive -has T cell lymphoma virus -active, untreated TB, H1N1, or varicella -using illicit drugs
What plans MUST offer preventative care without cost sharing under ACA?
-large employer plans -small employer plans -individual plans
benefits of breastfeeding for mother
-lose weight faster -decreased risk of cancers -less postpartum bleeding -reduced osteoporosis risk
Gastroesophageal Reflux disease in pregnancy treatment
1st line -Antacids or sulcralfate 2nd Line -H2 receptor blocker (famotidine) Avoid sodium bicarb and stop agents after pregnancy or before if symptoms resolve.
Lactations (8.2) formally Nursing mothers must include what three things in the summary?
-presence of drug in human milk -effects of drug on breast fed child -effects of drug on milk production
Mastitis treatment
1) ABX (usually cephalosporins such as cefazolin/Ancef) 2) warm compresses 3) empty breast completely to prevent further engorgement and problems 5) massage affected area to promote full release 6.) tylenol or ibuprofen (no opioids, if absolutely necessary, morphine is best option) **don't STOP breastfeeding from affected side;
PMS (premenstrual syndrome) diagnosis
1-4 symptoms of physical or mood, must be present in 2 cycles symptoms must impair functioning
endometriosis treatment
1. CHC (preferred) 2. NSAIDs (dont normally work well for pain) 3. GnRH analogs (Lupron, Leuprolide, second line options, max of 6-24 months depending on product due to bone loss)
Dysmenorrhea treatment
1. Heat 2. NSAIDS (first line pharm option) 3. Oral combo contraceptives (first line pharm option) 4. Exercise 5. Tylenol (second line pharm) 6. progestin only (second line pharm)
PCOS treatment
1. Weight reduction 2. Oral contraceptives (hirsutism) (yaz) 3. Clomiphene citrate (infertility) 4. Insulin synthesizers (metformin)
what things should you avoid when trying to minimize the effects of drugs on infants through breastfeeding?
1.) avoid long acting formulations with active metabolites -barbituates, benzos, fluoxetine 2) avoid nursing at times of peak drug conc (tmax) -try to take medication right after feeding or before a prolonged sleep perioid
Iron deficiency anemia treatment in pregnancy
30-60 mg elemental iron (325 mg ferrous sulfate) -PLUS FOLIC ACID -watch for GI side effects, can cause constipation
How long does the American Academy of Pediatrics recommended a mother breastfeed?
6 months, encouraged until 12 months
federal medical assistance percentage for family planning services under traditional medicaid
90%
at what percentage do protein bound meds have a very low transference?
>90%
ectopic pregnancy
A pregnancy outside of the womb, usually in a fallopian tube -methotrexate may be taken to avoid surgery -one dose IM may repeat in 5-7 days if HcG levels has not declined by 25% -heavy bleeding, cramping, N/V, diarrhea
Which of the following estradiol dosage forms has lowest VTE risk? A. Patch B. Tablet C. Injection D. All are equal
A. Patch
Which lab value is expected to increase with testosterone therapy? A. Hemoglobin B. Estradiol C. K+ D. TSH
A. hemoglobin
For women with PCOS who are not attempting to conceive, what is the best medical maintenance therapy to treat menstrual disorders? A.Metformin B.CHC's C.Progestin D.Leuprolide E.Clomiphene
B. CHCs
When should you monitor testosterone level in a patient using injectable testosterone? A. Peak B. Mid-cycle C. Trough D. Timing does not matter
B. Mid-cycle
For the past 4 months, several days before each period, a 22 year old female has been experiencing headaches, breast pain, increased appetite and food cravings, abdominal bloating and swelling, cramps and changes in bowel habits, severely depressed mood, anxiety and emotional lability, This constellation of symptoms greatly interferes with her daily life. Her physical and psychological symptoms resolve completely after menstruation ceases. CBC, TSH, are within normal limits. Which of the following is the most likely diagnosis? What would be first line treatment for the patient in previous question? A. Premenstrual syndrome B. Premenstrual dysphoric disorder C. Hypothyroidism D. Iron deficiency anemia
B. Premenstrual dysphoric disorder -fluoxetine or sertraline
How should testosterone be injected? A. Intramuscular (IM) B. Subcutaneous (SQ) C. Both IM and SQ are appropriate
C. Both IM and SQ are appropriate
Which of the following effects of masculinizing therapy is NOT reversible? A. Increased skin oiliness B. Cessation of menses C. Deepened voice D. Vaginal Dryness
C. Deepened Voice
Which of the following feminizing treatments can help regrow scalp hair in transwomen? A. 17-beta estradiol B. spironolactone C. finasteride D. medroxyprogesterone
C. finasteride
A 40 year old G5P5 patient returns to discuss her heavy menstrual bleeding. She has regular periods but they are heavy and cause significant disruption to her life. Lab evaluation has been unremarkable including normal TSH and prolactin. She has no PMH aside from hypertension controlled with losartan. Her husband had a vasectomy and she does not desire further childbearing. Which of the following is the most appropriate treatment of her abnormal uterine bleeding? A.Vaginal hysterectomy B.Combined estrogen-progestin oral contraceptives C.Levonorgestrel IUD D.Laparoscopic hysterectomy
C. levonorgestrel IUD
A 31 year old nulliparous female presents for evaluation of infertility. She reports unprotected intercourse with her husband for the past 2 years without conception. Her partner has fathered a child in a previous relationship. She describes irregular menses every 3-4 months. Her physical exam is notable for a BMI of 36, mild hirsutism around her chin and upper lip, and acanthosis nigricans around her neck. Which of the following is the first treatment recommendation that you would make for her? A.Metformin B.Clomid C.Lifestyle changes D.Gastric bypass E.Insulin
C. lifestyle changes
A 68 year old presents for evaluation of bilateral vulvar burning and irritation that has been going on for the past 2 years. She denies gynecologic problems in the past including abnormal vaginal bleeding and discharge. She has seen multiple providers in the past who have recommended loose fitting clothing and good hygiene. In the past she has tried topical steroids and fungal cream with no relief. On physical exam there are no abnormal lesions on the vulva. What is the most likely diagnosis? A.Contact dermatitis B.Vulvar atrophy C.Vulvodynia D.Herperatic neuralgia E.Chronic fungal infection
C. vulvodynia
Enzyme variation in hepatic metabolism during pregnancy
CYP1A2 -increase in 2nd and 3rd trimesters (more in third) CYP2D6 -increase in 2nd and 3rd trimesters (more in third) CYP3A4 -increase in 2nd trimester only
contraception and breastfeeding
Estrogen containing products may suppress lactation and quality of milk produced -Prefer progestin-only pills (Micronor) consider non hormonal opitons -If must use hormonal product, use after 6+ weeks postpartum
Risk factors for the development of endometriosis include all of the following except: A.Menarche before age 11 B.Heavy, prolonged cycles C.Nulliparity D.Lactation E.Shortened ovulatory menstrual cycles
D. Lactation
Which of the following physical changes are least affected by feminizing hormones? A. Decreased oiliness of the skin B. Breast growth C. Decreased muscle mass D. Thinning and slowed growth of facial hair
D. thinning and slowed growth of facial hair
A 27 year old female is diagnosed with endometriosis. She is placed on a medication and develops acne, weight gain, hirsutism, and edema. Lab results are significant for abnormal liver function tests. Which drug was she most likely prescribed?
Danazol (androgenic side effects)
Anovulatory bleeding
Dysfunctional uterine bleeding due to absence of ovulation -adolescent anovulatory bleeding is normal for up to 5 years due to immature hypothalamus-pituitary-ovarian axis
An obese 41 year old multiparous female with diabetes and hypertension has completed her family and presents asking about preventing future pregnancies. She smokes about a ½ pack per day. She has a history of abnormal uterine bleeding and reports a family history of endometrial cancer in her mother. Which of the following would be a particularly useful method of contraception? A.Total hysterectomy B.Endometrial ablation C.CHC's D.Copper-IUD E.Levonorgestrel IUD
E. Levonogestrel IUD
A 29 year old with endometriosis diagnosed by laparoscopy 2 years ago presents complaining of chronic pelvic pain. She was prescribed CHC's however she stopped taking them 6 months ago as she no longer needed contraception. What are your options for managing her pain at this point? A.Repeat laparoscopy with excision of lesions B.GnRH agonist with addback therapy for 1 year C.Norethindrone acetate D.Danazol E.All of the above
E. all of the above
What is the most common cause of abnormal uterine bleeding in the 13-18 year old age range? A.Hypothyroidism B.Uterine fibroids C.Imperforate hymen D.Platelet dysfunction E.Dysregulation/immaturity of the hypothalamic-pituitary-ovarian axis
E. dysregulation/immaturity of the hypothalamic-pituitary-ovarian axis
A 17 year old gymnast presents for the evaluation of primary amenorrhea. She has been training at an Olympic development center. She regularly pushes herself to the point of exhaustion. She has normal secondary sexual characteristics and external female genitalia. She has a negative pregnancy test. Which of the following would NOT be found in this patient? A.Low FSH B.Very low LH C.Very low estradiol D.Normal prolactin E.Elevated TSH
E. elevated TSH -it would probably be low due to being underweight
A 21 year old female is in the office for a follow up of her dysmenorrhea. She states that because ibuprofen has only slightly improved her pain, she would like something else. She is currently in a monogamous relationship and would like contraceptive protection as well. Her vital signs today include: Ht: 63 inches Wt: 99kg BP: 118/68 mmHg HR: 72 beats/min What is the best recommendation?
Ethinyl estradiol 35mcg and ethynodiol diacetate 1mg (Demulin 1/35) Take one tablet every day for 11 weeks; then repeat after a 1 week hormone free interval this is best option as it has a long duration = less periods throughout the year.
heavy menstrual bleeding treatment
First line -NSAIDS (if contraception not desired) -hormonal IUD (amenorrhea may occur) Second line -oral contraceptives -trane acid (do not use with hormonal contraception) -surgery, only real cure
since fetal kidney is immature, what does that mean for the GFR?
GFR is reduced about 25% of that of an adult
A 34 year old nulliparous patient presents complaining of worsening dysmenorrhea for the last 8 months. She describes her pain and beginning 3 days prior to the onset of menses and peaks on the second day of bleeding. She also reports severe pain with defecation during menses. Her PCP started her on CHC's that she has been taking compliantly for the past 4 months. She has no PMH or surgical history. Physical exam is notable for a BMI of 40 kg/m2. Which is the next best option for this patient?
Gonadotropin-releasing hormone therapy (second line treatment of endometriosis)
What is endometriosis?
Growth of endometrial tissue outside of uterus -most common type of secondary dysmenorrhea
PMDD treatment
Intermittent SSRI and SNRI during luteal phase -sertraline, fluoxetine avoid paroxetine -venlafaxine -clomiphene (TCA)
Thyroid disorder in pregnancy
Hypothyroidism -levothyroxine is ok with monitoring -dose may increase by 50 % during pregnancy -ok to increase dose at confirmation of pregnancy by 30% or increase 25-50mcg daily
traditional medicaid
Low income (mandatory serves + additional the state chooses) -children -pregnant women -parents -elderly -disabled
Category B pregnancy risk
No controlled studies have been conducted in humans; animal studies show no risk to the fetus -benadryl, famotidine, ondansetron
GDM in pregnancy treatment
Non Pharm -lifestyle change -sugar level monitoring Pharm -insulin -glyburide (only time it is ok to use in pregnancy) -metformin oral agents do not control levels as well as insulin
Constipation in pregnancy treatments
Non pharm - high fiber foods, fluids exercise 1st line (pharm) -fiber supplements, stool softeners 2nd line short term -peg, senna, bisacodyl NO CASTOR OIL
N/V in pregnancy treatment
Non pharm -frequent, small meals -bland foods high in protein -chilled, tart beverages -avoid fatty/spicy foods, foods with odor, empty stomach Pharm -b6 (pyridoxine) alone or with doxylamine -metoclopramide -ondansetron (cate B) well tolerated, watch qtc intervals
GERD in Pregnancy Treatment
Non pharm -small, frequent meals -avoid food before bed -elevate head Pharm -tums -famotidine omeprazole is category C but if patient is unable to continue daily activities due to GERD may think about using.
Organeogenesis
Occurs primarily during 4-10 weeks of prenatal development. -highest risk of birth defects at this stage
female sexual dysfunction treatment
Ospemifene (osphena) -SERM but has increased risk or endometrial cancer and increased VTE risk
induction of labor, what is used?
Oxytocin (Pitocin)
what is the difference between premenstrual symptoms and premenstrual syndrome (PMS)
PMS adversely effects work and social life
Category D pregnancy risk
Positive evidence of human fetal risk. Use only if no other choice -high dose fluconazole, lithium, tetracycline
benefits of breastfeeding for baby
Possible protection against: -allergies/asthma, SIDS, resistance to lymphoma, diabetes Reduced incidence of: -constipation, diarrhea, respiratory/ear infections, UTIs, eczema
Preeclampsia prevention and treatment
Prevention -low dose ASA after 12 weeks gestation Treatment -1st line hypertensive therapy: IV labetolol or hydralazine -2nd line: oral SR nifedipine
Pregnancy and Lactation Labeling Rule (PLLR)
Provides a framework for clearly communicating information on the benefits and risks of using a drug during pregnancy and lactation to help facilitate prescribing decisions
mood disorder treatment in pregnancy
TCAs -desipramine, nortriptyline SSRIs -sertraline, citalopram, escitalopram are ok to use -fluoxetine is maybe ok, shows some sign of harm -paroxetine is a no go Typical Antipsychotics -chlorpromazine, haloperidol, perphenazine have no significant teratogenic effects Atypical antipsychotics -olanzapine, clozapine, quetiapine avoid benzos
Asthma treatment in pregnancy
Using asthma meds (inhalation products) during pregnancy is safer than letting asthma get worse -beta agonist (albuterol preferred, can continue LABA if needed) -corticosteriods, avoid in 1st trimester, budesonide preferred
Postpartum Hemorrhage (PPH)
a loss of 500 ml or more after birth -methylergonovine -15-methyl PGF
Drugs at steady state in mom will be what in fetus?
about 50-100% less than maternal levels
PK affect of reduced albumin concentration
altered protein binding for drugs highly bound to albumin -end result is more free drug competition for binding sites with increased concentrations of estrogen and progesterone -end result is more free drug
what beta blocker do you avoid for chronic hypertension during pregnancy?
atenolol (category D)
Gestational hypertension (GH)
begins after the 20th week of pregnancy, no proteinuria -has elevated blood pressure 140/90 mmHg or greater Treatment begins >150/100 with goal of 130-150/80-100
preterm birth
birth of an infant less than 37 weeks after conception with cervical changes -betamethasone IM x 2 doses or dexamethasone IM x 4 doses may be administered to mothers delivering preterm birth
A 16 year old non sexually active female presents with midline, crampy lower abdominal pain, which radiates to her legs and back, and occurs during the first 2-3 days of menses. She denies pain during the rest of her monthly cycle. She is diagnosed with primary dysmenorrhea. She is prescribed ibuprofen, which improves her pain, but does not eradicate it. Which is the next best step in therapy?
can either switch NSAID or try CHC as she is not wanting to become pregnant. Could also try them together in combonation
polycystic ovary syndrome (PCOS)
condition where both ovaries have many cysts due to a hormone imbalance
Neural Tube Defects (NTDs)
congenital malformation of brain and/or spinal column due to failure of neural tube to close during embryonic development -spina bifida and anencephaly
Category A pregnancy risk
controlled studies in humans show no risk to the fetus -folic acid, minerals, doxylamine, levothyroxine
decreased renal blood flow in the 3rd trimester results in________________.
decreased elimination
group B strep testing in pregnancy
done between 35-37 wks -penicillin/ampicllin given at time of admission in labor if vaginal birth -if C-section no antibiotics are given
Ion trapping in breast milk
drug becomes trapped in breast milk due to low pH of milk
CYP1A2 in pregnancy and medications
drugs that utilize this enzyme will need dose reductions to prevent toxicity due to decrease in enzyme -theophylline, clozapine
UGT1A4 in pregnancy and medications
enzyme is increased in pregnancy, decreases drug concentration in plasma. monitoring and dose adjustments may be neccessary -lamotrigine
menhorrhagia
excessive bleeding
True or False: Smoking is a contraindication to using estrogen in transwomen
false
True or False: a patient with a history of VTE can NOT use estradiol
false
True or False: the effects of GnRH analogues are irreversible
false
_______ soluble substances cross the placenta easier than _______ soluble substances.
fat, water
what is ion trapping?
fetal plasma pH<maternal -base drugs are more ionized on fetus side, less cross placenta back to maternal side which can cause accumulation in fetus
What trimester is most critical for drug exposure?
first trimester
Syncytiotrophoblast
fused multinucleated cell -continuous, prevents WBC from crossing over
weak acids HA
hold H+ so no charge (unionized) -if pH is greater than pKa most of the drug will be ionized form (A-)
preferred hypertensives for lactation
hydralazine, methyldopa avoid atenolol and acebutolol
Preeclampsia: what is it?
hypertension, edema, and proteinuria during pregnancy
if pKa is 2 units away in either direction for a weak base, what percent of the drug is unionized
if -2 % unionized is 1 if +2 % unionized is 99
Albumin decrease effect on pharmacokinetics during pregnancy
increase volume of distribution
PK affect of increase weight and body fat in pregnancy
increased partitioning/storage of fat soluble drugs
what happens at week 20 gestation that completes the barrier between amniotic fluid and fetus?
keratinized skin forms
Epilepsy in pregnancy
known to cause birth defects -lamotrigine, carbamazepine however if well controlled on meds before pregnancy probably safer to continue. antiepileptics decrease folate levels -increase folic acid to 4 mg D monitor serum levels -increase in volume distribution, decrease in protein binding, increase in clearance
What percent of birth defects are caused by medications?
less than 1%
VTE prevention and treatment in pregnancy
low molecular weight heparin (LMWH) -weight based -enoxaparin warfarin is contraindicated
Female Sexual Dysfunction
low sexual desire, sexual arousal disorder, orgasmic disorder, sexual pain disorder
Sodium Multivitamin Transporter
maternal to fetal transfer of biotin and panthotethate -carbamazepine, primodine
organic cation transporters (OCTs) (active transport)
maternal to fetal transfer or carnitine -methamphetamine, verapamil, quinidine
Nausea and vomiting effects on Pharmacokinetics during pregnancy
may decrease absorption
PK affect of increased plasma volume in pregnancy
may increase Vd, resulting in lower conc in plasma -higher loading dose may be needed for hydrophillic drugs
GI motility decreasing has what effect on pharmacokinetics during pregnancy
may increase drug absorption
what medication is a galactagogues that helps increase prolactin levels for lactation?
metoclopramide -10-15 mg TID for a limited duration
affective premenstrual symptoms
mood/behavior -anger/irritability -food cravings -anxiety -change in libido
cost sharing amounts for pregnant women under traditional medicaid
no cost sharing permitted
Cost sharing amount for family planning services under traditional medicaid
no cost sharing permitted for these services
secondary amenorrhea
no menses for 6 months or 3 cycles
"Exemption" as it deals with contraceptive coverage
no requirement to cover the 17 methods of contraception without cost sharing. -religious employers classified as houses or worship (churches)
"Accommodation" as it pertains to contraceptive coverage
no role of contraception coverage for religious employer, coverage is offered by insurance company at no charge -religious affiliated employers (hospitals, universities, institutions) -closely held for profit corporate employers with religious objections
are pregnant women eligible for medicaid under the AMA expansion?
no, only under traditional medicaid
PMS treatment
non pharm options -decrease caffeine/sodium -yoga or other exercise Pharm options -NSAIDs for pain -spironolactone -vit b, calcium, magnesium avoid herbal remedies
_____________ drugs cross the placenta easier than __________ drugs.
non-ionized, ionized
ACA Medicaid expansion
non-medicare-eligible individuals under 65 with incomes up to 133% of FPL (services will differ from that of traditional medicaid)
Gravidity
number of pregnancies
dysmenorrhea definition and what causes it?
painful menstruation -increase release of prostaglandins (inflammation mediators)
Folic acid for women of high risk
previously affected pregnancy -4 mg d in months surrounding conception taking anticonvulsants -4 mg d through entire pregnancy do NOT take multiple doses of multivite -tk 1 multivite d and folic acid 1 mg TIF
maternal to fetal drug transfer
primarily diffusional exchange -LMW readily diffuse -lipophillic, uncharged
What is the most significant transference property of drugs into breast milk?
protein binding
Tocylytics
stop contractions, no clear first line, prolongs pregnancy but 2-7 days -nifedipine (calcium channel blocker) -Indomethacin, rectal dose followed by oral (NSAID) -Terbutaline, IV, SQ, PO (beta 2 agonist)
Primary amenorrhea
the failure to begin menstruating by age 16 with secondary development OR absence of menses at age 14 without secondary developement
endocytic activity
transfer of immunglobulins (MVB multivesicular bodies)
anovulatory bleeding treatment
treat underlying causes -pcos, hyperprolactemia CHC minipills, IUD
Body fat increase effect on pharmacokinetics during pregnancy
volume of distribution of LIPID soluble drugs will be increased
________ ________ drugs tend to concentrate more in breast milk. Why?
weakly basic -pH of milk is weakly acidic (6.8-7) opposites attract
weak bases BH+
will hold charge (ionized) -if pH is greater than pKa most of the drug will be unionized (B)
if a mother has mastitis, is the milk ok for the baby to consume?
yes