PHARM: PREGNANCY AND LACTATION

Lactation Drugs that are OK

-Acetaminon, NSAIDS -Anticoag Warfarin -Sertraline, TCA - Aniepleptic- Carbamazapine, Phytoing, Valp. Acid -Loratadine -PCN, Cephs, Aminos, Macrolides -- Avoid CHlroamphenicol , tetra -Labetalol, Propanolol -PTU, Insulin, Levothyrocin -Prednisolone and Predisone

Fetal alcohol syndrome (FAS)

Anomalies •Cardiac --•Murmur, septal defects •Skeletal --•Growth deficiency --•Small distal phalanges •Central Nervous System --•Microcephaly •Others --•Intrauterine growth retardation, spontaneous abortion, neonatal withdrawal

Introduction

Average of 11 drugs are used during pregnancyMore than 60% of women take more than one medicationWe tend to focus on illicit drugs as a society, use of OTC and legend medications is far more widespreadThe most commonly used medications include: analgesicsantibiotics and antihistaminesanti-emetics and antacidsvitamins and iron supplementation

Dx: Cough and ColdDrug

B -- Loratadine, Chlorpherniramine, Benadryl(but does cross placenta, oyxtocin like?!) C -- Psuedoepedrine(BP, gastroschisi) Graifenesin(Caution 1sTM, and Alcohol products), Dextromethorphin (?? Appears safe, but sedation and resp depression?)

Dx: Psychiatric IllnessDepression

Burproprion- B/C •Consider in concurrent smokers •Lowers seizure threshold ( DONT USE IN SEIZURE D/O or SEVERE N/V) ---•Avoid in preeclampsia & severe N/V

Cardiovascular Changes in Pregnancy

Cardiac Output Increases Stroke Volume Increases Heart Rate Increases Drug Distribution

Weight Gain During Pregnancy

Caution with DOsing dep on size etc

Common Drugs Contraindicated in Breastfeeding.........

Chemo..immune supp and cell division Lithiu,-> Very lipophilic, dont BF - Thioruacils, MMA....PTU OK, Phenodinone anticoag Retioids/Accutane Recreational - ETOH - Cocaine - Heroine/Methadone - Marijuana/ Phenycycldine - Lysergeic Asid LSD

Dx: Psychiatric IllnessDepression

Controversy regarding med use Pt and Family Preferences SSRI-> ZOLOFT prob safest

How much is too much.............. determinants of infant exposure

Drug characteristics •oral bioavailability •poor = minimal absorption •lipid solubility •higher=greater transfer into milk •molecular weight •low molecular weight compounds <200 Daltons diffuse more readily across a concentration gradient

The Bottom Line.....

FETAL DRUG EXPOSURE

Fetal Hydantoin Syndrome(FHS)

Fetal hydantoin Syndrome Craniofacial Broad nasal bridge, wide fontanel, low-set hairline, ocular heperterlorism, cleft lip/palate, epicanthal folds, broad alveolar ridge, short neck, microcephaly, abnormal low-set ears Limbs Small or absent nails, altered palmar crease, dislocated hip, hypoplasia of distal phalanges, digital thumb Other Impaired growth (physical & mental), CHD

Goals of Treatment

Non Severe BP (140/90+). No comorbidities goal= 130-155/80/105. Comorbidities= <140/90 -- Methyldopa, Labetalol, Nifedipine Severe HTN. 160/110+. Goal = <160/110 --- Labetalol, Nifedipine, Hydralzaine...Prob in Hosp. use IV

Renal Changes in Pregnancy

REnal Changes

Thalidomide-Category X

Released in 1956 as a mild sedative to combat nausea in pregnancy. Withdrawn in 1961 discovered human teratogen. Some chemo protocols

Teratology

The study of abnormal fetal developmentTraditionally: limited to gross structural malformationsCurrently: Expanded including more subtle developmental anomalies: Growth retardation, behavioral changes and other functional deficiencies

Allergies

Type I-> Anaphylaxis Type II-> Rash Non Type I PCN-> Can use Cephs! Type I to PCN-> Try not to use Cephs, cross sensitivity

Lactation Drugs

Warfarin is ok

Anticonvulsants

• Congenital malformations in humans caused by anticonvulsants WORST: Pheny and V.A Carbamazapine: Bad but no Cleft or CHD Phenobarbital: Bad, but no neural tube defect

FDA Pregnancy Categories: Category X (Contraindicated)

• Studies in animals or humans have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience, or both, the risk of use to the fetus clearly outweighs any benefit ABSOLUTELY NO USE..Don't even prescribe to female could be pregnany ---Paroxetine(Cadiac effects on fetus), Thalidomide(N/V, sedation effects, still used in Chemo), Acutane /Isotretinoin(acne) (in "I pledge system) Warfarin

Natural and Medicinal Botanicals

•"nutritional supplements" -•Not regulated by FDA -•Virtually no epidemiological studies regarding impact on fetus -•Use only when no other alternative exists -•Even high doses of vitamins maybe an issue

Rx: Pain

•* Associated with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible teratogenicity (ASPIRIN) •†Associated with premature closure of the fetal ductus arteriosus with subsequent persistent pulmonary hypertension of the newborn, fetal nephrotoxicity, and periventricular hemorrhage (NSAIDS)

FDA Pregnancy Categories: Teratogenic Risk of Drugs

•A --- safest •B --- Many that we use fall in this categories •C --- Not sure? •D •X

Importance of FOLIC ACID & Omega-3 Fatty Acids

•ALL women of child bearing potential: folic acid 0.8 mg podaily at least to reduce risk of neural tube defects -•Most MD's recommend 1mg folic acid -•Most RX prenatal vitamins contain 1mg folic acid -•Should be taken prior to conception and through the 1st 4 weeks of gestation to be effective -•Folic acid 4 mg ----•previous pregnancy with NTD ----•3 month prior to and through first trimester •Omega-3 Fatty Acids -•Pregnant women 200 mg of docosahexaenoic acid (DHA) per day -•May be obtained from 1-2 servings of seafood per week or oral supplementation

Mild Analgesics/ Antipyretics (ALL CROSS PLACENTA)

•Acetaminophen (DOC) -Category B -•Use only when necessary -•Reminder: max daily dose = 3 gm(new recommendation 2011) -•Watch out for combination products •NSAIDs (ibuprofen, naproxen) -•Avoid if at all possible!!!! (Esp 3rd Trimester) -•Category B = 1st and 2nd -•Category D = 3rd -----•Patent ductus arteriosus closure! spontaneous abortion, stillbirth, inhibition of labor & prolonged gestation •Aspirinshould never be used (D)!!! D in every trimester, except if Cardiac Defect -•Intracranial bleed if used within 1 week of delivery -•Low dose used only under guidance of MD

AVOID:Known Human Teratogens

•Alcohol, ambisentan, atenolol, bosentan(category X), busulfan, carbamazepine, cocaine, cyclophosphamide, diethylstilbestrol, fluconazole, iodine, isotretinoin (category X), lithium, methotrexate (category X), metronidazole, misoprostol (category X), mycophenolate mofetil, paroxetine, phenytoin, propythiouracil, SSRIs, statins (category X), tamoxifen, tetracyclines, thalidomide(category X), valproate, warfarin PARTICULARLY KNOW CATEGORY X

Fetal alcohol syndrome (FAS)

•An occasional drink? •No level of drinking is known to be SAFE •Don't know ---•period of greatest susceptibility ---•dose-response relationship •Do know -•chronic consumption of 6 ounces/day=high risk -•FAS is not likely with mom's who drink < 1 drink or 2 ounces/day

FDA Pregnancy Categories: Category B

•Animal reproduction studies have not demonstrated fetal risk but there are no controlled studies in women OR •Animal reproduction studies showed adverse effect that was not confirmed in controlled studies in women -- Steroids/Prednisone, PCNs, Cephs, Insulin

FDA Pregnancy Categories: Category C

•Animal studies revealed adverse effects and there are no controlled studies on pregnant women OR •Studies in animals and pregnant women are not available Look at Case reports, RISK vs Benefit --- Fluconazole,

Cough and Cold

•Antihistamines -•B and C -•Avoid in 3rdtrimester -convulsions in premature infants and newborns? •Guaifenesin -•Alcohol!!!in syrup -1sttrimester use -inguinal hernia? -•Use alcohol free products (Naldecon Senior EX)

Dx: Psychiatric Illness

•Anxiety BDZ:Most are category D due to cleft palates, growth retardation, facial development abnormalities •Bipolar Disorder Lithium: (D) cardiac defects, polyhydramnios, fetal diabetes insipidus •Schizophrenia clozapine(B) risperidone(C) olanzapine(C) haloperidol (C) fluphenazine(C)

Isotretinoin (Accutane)Category X

•Approved for use in 1982, Acne •1sttrimester -•risk of fetal malformation = 25%, an additional 25% have mental retardation alone -•Facial asymmetry -•Ear and heart defects •Manufacturer recommends: -•negative pregnancy test prior to initiation -•use of 2reliable methods of contraception

Imm.!!!

•Benefit > risk -•Risk of disease exposure high -•Infection pose risk to mother or fetus -•Vaccine unlikely to cause harm •Live-virus vaccine = contraindicated -•Varicella, MMR, nasal flu vaccine (including H1N1)!!!!!!! -•? Hepatitis A, HPV ------ NOT LIVE, but Little Info

Just the facts.......Where to find them and what do they mean

•Books -•Medications in Mothers' Milk ---•PDA version available -•Clinical Therapy in Breast Feeding Pts. •Pharmaceutical Manufacturers •Primary literature

Asthma-

•Common Illness-> CONTROL! •4-10% •"breathing for two" •Uncontrolled asthma -•Perinatal mortality -•Prematurity -•Low birth weight -•Pre-eclampsia •NHLBI -NAEPP guidelies •ICS associated with metabolic and endocrine defects -- -But it is really important to control asthma, worse that risks to have asthma flare and be intubated No Changes may be best!

Teratology

•Congenital malformation •"...structural abnormalities of prenatal origin that are present at birth and that seriously interfere with viability or physical well being" •Congenital anomalies •birth defects; includes changes in structure, function or conditions •Teratogen •substance, organism or physical agent, or deficiency state present during embryonic life that is capable of causing abnormal development

Immunizations

•Contraindicated -•Measles* -•Mumps* -•Rubella* -•Varicella 800-986-8999 -•BCG -•Nasal flu -•Nasal H1N1 *avoid pregnancy for 30 days after vaccination

FDA Pregnancy Categories: Category A

•Controlled studies in women fail to demonstrate a risk to the fetus and the possibility of fetal harm appears remote Prenatal Vitamins, Synthroid, Folic Acid

Hemorrhoids

•Correct constipation! --•Prenatal MVI with docusate! •Stool softners (docusate) •Sitz bath --•German word sitzen, "sit" in warm water with ½ cup of salt per 3-4 inches of water (~15 mins) •Topical anesthetics or steroids --•Preferred over suppositories --•Only use under supervision of MD --•Tucks medicated pads maybe an option

Breast-Feeding and Contraception

•Delays return of ovulation -marked by amenorrhea •High degree of protection during 1st6 months post-partum •fully feeding •Still can get pregnant •Factors influencing onset of ovulation •Frequency of infant feeding day/night •Formula Supplements

Feto-placental Transfer of Meds

•Drug transfer occurs via diffusion across the placenta (favor movement of lipophilic meds) •Protein bound meds and large molecular weight meds do NOT cross the placenta (heparin & insulin)!! •Elimination of meds from the fetus occurs by diffusion •Meds can accumulate within the fetus due to decreased medication elimination from the fetus kidney (aminoglycosides)

Where to get the facts?

•Drugs in Pregnancy and Lactation ---"BRIGGS"- Commonly referred to --- Really good reference •Medications and Mother's Milk •Micromedex: Teris, Reprotox, Reprotext, Shepard's •http://www.motherisk.org •www.otispregnancy.org(Organization of Teratology Information Services)

Just the facts.......Where to find them and what do they mean

•Drugs in Pregnancy and Lactation •Briggs GG, Freeman RG, Yaffe SJ, eds. Drugs in pregnancy and lactation. 5thedition, Baltimore: Williams & Wilkins; 1998. •WHO Guidelines •Bennett PN, Matheson I, Dukes NMG, et al. eds. Drugs and Human Lactation. Amsterdam: Elsevier;1988. •American Academy of Pediatrics Consensus Statement •American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1994;93:137-50

INFANt EXPOSURE: Maternal Characteristics -determining the mom's serum concentration

•Early Post-partum ---•4-10 days large gaps in alveolar cells ↑ penetration of most drugs into milk •Dose and duration of medication therapy •Maternal drug clearance factors

Diabetes in PregnancyTreatment

•Glyburide dose = 2.5-20 mg per day -•Doses up to 30 mg/day have been required. -•Avoid in patients with sulfa allergy. •Metformin dose = 250 mg once daily -•Titrate weekly to maximum daily dose of 2,500 mg divided two to three times daily --- PROB DOC for women who dont want insulin shots and want oral med - Caution with Renal Fx/Lactic Acidosis risk •Insulin -•T1DM and T2DM: Insulin requirements may increase up to 3 fold during the 3rd trimester -•Insulin during the intrapartum period is usually delivered via a continuous infusion

Treatment NVP

•Goal •Improve quality of life •Prevent dehydration and malnutrition •Nonpharmacological (Dietary/ Lifestyle) •Crackers •Frequent small meals high in protein •Women feel better with carbohydrates, caution though d/t BG spikes-> worsen N/V •Avoid spicy foods or other triggers •Dental rinse vs. brushing

Thromboembolic Disease

•Heparin (DOC) •Low Molecular Weight Heparin (LMWH) -•Administer SC-> Under arm, not belly esp 3rd TM -•Reversal agent heparin-protamine (to some extent) -•LMWH -advantages ---•Heparin induced thrombocytopenia ---•Once daily dose ---•Monitoring Enoxaparin -------•(goal level 4-6 hours post dose 0.5-1 units/ml treatment) ---•Disadvantage -$$$

Dx: Preeclampsia

•Hypertension during pregnancy -•Complicates around 10% of pregnancies -•2ndleading cause of maternal deaths in US

Thromboembolic Disease (Preg. are at higher risk)

•Indication -•Deep vein thrombosis (DVT) -•Prosthetic heart valve -•Clotting factor deficiency •NO WARFARIN!!!!!! X Category --•Fetal malformations, developmental defects •Fetal Warfarin Syndrome --•10-25% risk for affected infants following exposure during the period of 8th-14th week of pregnancy --•Developmental deficiencies, stillbirth, hemorrhage --- Facial deformities, Calcifications on Xrays

Treatment of Preeclampsia

•Indications for delivery in preeclampsia! -•>38 weeks gestation -•Maternal compromise or eclampsia >20 weeks -•Intrauterine growth restriction -•Thrombocytopenia -•Worsening hepatic or renal function -•Severe epigastric pain, n/v •Bed rest •Seizure prophylaxis (Magnesium sulfate, prev. seizures)

INFANT EXPOSURE: Infant Characteristics

•Infant feeding pattern (#,duration,volume) •Percentage of nutrition provided by breast milk •Age of infant and maturity of .. ----•absorption, distribution, metabolism & elimination.....altered pharmacokinetic parameters in the neonate & premature infant

Diabetes in PregnancyTreatment

•Insulin lisproand aspartmay be provide better control than regular insulin •Insulin dosing should be individualized -•Typical starting dose is 0.7-1 units/kg/day •Metformin and glyburide are being utilized with increasing frequency ( if dont want shots..) -•A recent meta-analysis showed that glyburide treatment was inferior to both metformin and insulin -•Metformin plus insulin, when needed, may result in better control

Breast-Feeding and Contraception

•Intrauterine devices (IUD) •Barrier Methods/ Sterilization -----•Do not use diaphragm or cervical cap for 4 wkpost-partum •Progestin only contraceptives recommended ----•Depo-Provera (medroxyprogersterone) •Combined oral contraceptives containing estrogen -•Avoid until 6 months post-partum or until infant weaned due to effects of estrogen decreasing the mothers milk supply -•The baby at 6 weekswill be able to metabolize any hormones that may appear in the milk, can safely be given at 6 weeks

Isotretinoin (Accutane)

•Isotretinoinmust only be dispensed: -•No more than 1 month supply -•Prescribers and patients must enter required information (i.e., pregnancy test results, 2 forms of contraception used, confirmation of patient counseling) in the iPLEDGEsystem for patients to be qualified to receive a prescription. -•Only patients who are registered by prescribers in the iPLEDGEprogram can receive isotretinoin.

Dx: Epilepsy

•Keppraor phenobarbor lamotrigine= DOC (try to treat with monotherapy) •Felbamate/ gabapentin??? FDA -C -usually add on therapy; Common abnormalities: •Orofacialclefts •Skeletal abnormalities •CNS malformations •Cardiac defects •Mental retardation

Just the facts.......Where to find them and what do they mean

•Limitations of the primary literature -•predominantly case reports/small studies -•details of medication use lacking -•measurement of breast milk drug concentrations difficult to reproduce -•lack of standard method of describing degree of infant drug exposure -•intersubject and intrasubject variability to determine infant drug exposure via lactation •Application of literature to specific case is difficult

Metabolism & Elimination of Medications in Pregnancy

•Metabolism: (Liver) •Hepatic metabolism (P450) generally increases due to oestrogenand progesterone (phenytoin) •Some isoenzymesmaybe competitively inhibited by progesterone (theophylline) •Elimination: (Renal) •Renal blood flow increases by 60-80% •GFR increases by 50% •Enhanced elimination of medications (Antibiotics) •Look up doses specific to pregnancy!

Contraindicated Herbals

•Mugwort •Blue cohosh •Tansy •Scotch broom •Goldenseal •Juniper berry •Pennyroyal oil •Rue •Mistletoe •Chaste berry •Balck cohosh •Feverfew (hemmorrhage) *most are uterine stimulants or abortifacients

Where to get the facts?

•NCTIS Pregnancy Exposure Riskline1-800-532-6302Fullerton Genetics Center14 Victoria Rd, Suite 101Asheville, NC 28801Hours: 9:00 AM to 4:00 PM M-FAccepts Calls From: Public and Health Care ProfessionalsImmediate Information for Most Calls? NoCaller's First Contact: genetic counselor

Dx: Hypertension

•NHBPEP Working Group Guidelines •Goal -•Minimize short-term risk of HTN to mother while avoiding compromise to fetus •Chronic Hypertension prior to 20 weeks GA (BP >140/90) •Pregnancy induced hypertension >/= 20 weeks GA (BP >140/90) •AVOID -•ACE -inhibitors (morbidity high 10-20%) (Category D) (Not X-->D) -•AngiotensionII receptor blockers -•Renal failure and death (trimester 2 and 3) •DOC -Labetolo!l or Methyldopa (not as tolerated as labetolol, HIGH FATIGUE) •Goal BP <140/90 •Bedrest-lay on left side

To Nurse or not to Nurse.... in the presence of maternal drug therapy

•Necessity of drug therapy •Literature reports regarding use in lactation •Expected infant exposure with selected agent •Experience in infants & expected pharmacologic effect •Comparison of expected exposure relative to therapeutic dose •Planned dose and duration of use •Impact on milk production •Alternative agents

Isotretinoin (Accutane)

•Only pharmacies registered with and activated in the iPLEDGEprogram can dispense isotretinoin. •Pharmacists must access the iPLEDGEsystem to receive authorization to fill and dispense prescription. •Manufacturers will only ship to iPLEDGE-registered entities (e.g., direct vendor pharmacies, wholesalers). •Wholesalers must register annually in the iPLEDGEprogram. A registered wholesaler may distribute only FDA-approved isotretinoinproduct. •Telephone, fax, and electronic transmission (e.g., e-mail) prescriptions are permitted in the iPLEDGEprogram

The Benefits of Breastfeeding

•Optimal composition for infant nutrition •Lower osmolality •More efficient iron absorption •More efficient protein absorption •Passive immunity via maternal antibodies •Association with fewer infant infections and food allergies •Economic considerations (formulas $$$$) •Development of maternal/infant relationship •Breast milk donation

Absorption of Meds: Pregnancy

•Oral •Gastric emptying & small intestine motility are decreased due to increase progesterone •Gastric pH is increased due to a reduction in H+ secretion and increase in mucus •Nausea and vomiting complications •Inhalation •Enhanced absorption due to increase in cardiac output and tidal volume increase •Intramuscular •Enhanced absorption due to vasodilation

Treatment of Nausea & Vomiting

•Pharmacological •Antihistamines (H1) (First choice options)!!!!! --•Diclegis(Doxylamine& Pyridoxine) : Category A!!! --•Meclizine dimenhydrinate, B diphenhydramine(sedation caution), hydroxyzine •Dopamine antagonist (SECOND choice) --•Phenothiazines(promethazine, metoclopramide/reglan)...More use INPT and failed 1st line •Serotonin (5HT3)-NO longer first choice due to concern for pulmonary hypertension in the neonate --•Ondansetron-ODT (brand $$$-now available generic) •Acetylcholine ?? --•Dicyclomineand scopolamine •Benefit vs. risk of malnutrition and dehydration Antacids can also be used --- Tums good, Ca over Mg products , Histamine 2 receptor Blockers - ines

Anticonvulsants: Goal Proper SiezureControl!

•Phenobarbital (D): Cleft lip -drug or disease? Also withdrawal (barb) and affects vitamin K •Phenytoin- AVOID IF AT ALL POSSIBLE!!!! (D): Fetal HydantoinSyndrome -----(microcephaly, developmental delay, mental retardation, nail hypoplasia), hypocalcemia, clotting factor suppression ----- TITRATE PT OFF •ValproicAcid- AVOID IF AT ALL POSSIBLE (D): Neural tube defects (1-2% chance) -folic acid metabolism? Peirre Robine Syndrome (gen. dz, lungs and kidney damage severe)

FDA Pregnancy Categories: Category D

•Positive evidence of fetal risk, but benefits from use in pregnant women may be acceptable ---LIthium(Cardiac effect in fetus), but may not be worth taking baby off..risk to heart /Epstein ---Seizure Medications ---Chemo Meds

If no studies, what do we do?

•Pregnancy registries •FDA requires drug manufacturers to enroll pregnant women who have taken certain medications •The Organization of Teratology Information Services (OTIS) •Disseminates information about safety of medications during pregnancy and while breastfeeding •National Birth Defects Prevention Study •Funded by the CDC

Diabetes in Pregnancy

•Pregnancy yields a progressive insulin resistance -•Insulin sensitivity may decrease 50% -•Due to increased maternal adipose tissue and hormones produced by the placenta •Insulin doesn't cross the placents, fetus is exposed to mother's hyerpglycemia -•Growth and macrosomia

Nausea and Vomiting

•Presentation -•Affects 50-80% of pregnancies -•7th-12thwk gestation most common -•But can occur throughout pregnancy •Hyperemesis gravidum -•< 1% -•Uncontrollable N/V -•Dehydration / Malnutrition -•TPN

Dx: Epilepsy

•Reducing the risk •patient education •consider drug withdrawal (taper off) •attempt monotherapy •administer folic acid 1-5mg/day for at least 3 months prior •Antenatal management •Antiepileptic Drug Pregnancy Registry •800-233-2334

Dx: Preeclampsia

•Risk factors -•First pregnancy, maternal age(35+), previous history -•Diabetes mellitus, chronic hypertension, obesity -•Connective and vascular tissue disorders -•Nephropathy •Clinical features -•Visual changes, persistent headaches, dizziness -•Epigastric pain, edema -•Thrombocytopenia, increased LFT's -•Decreased renal function * CHECK BP WITH THESE SX

Immunizations

•Safe -•Hepatitis B -•Influenza & H1N1 shot-recommended -•Tetanus/Diptheria -•Meningococcal -•Rabies -•Polio -inactivated -•Pneumococcal??? (questionable if safe)

When the decision is made.....Management of drug effects in the breastfeeding infant

•Safest alternative in a given therapeutic class—minimal exposure profile •Maternal dosing considerations •Avoid sustained release products & agents with long half life •Consider weaning or temporary bottle feeding (have mom continue to pump to keep up milk supply) •Be alert for physical and behavioral changes in the infant •Consider infant concentration measurements

Diabetes in Pregnancy

•Screening all pregnant women at 24-28 weeks -•Administer 50 grams oral glucose solution -•After 1 hour, assess venous glucose concentration -•If exceeds 135-140mg/dl, a 3 hour oral glucose tolerance test (100grams) should be performed •Treatment -•Maintain glycemic control and avoid DKA in patients with T!DM or T2DM (rare in GDM) -•Diet and exercise -•Monitoring glucose at least 3-4 times a day

Dx: Psychiatric IllnessDepression

•TCAs: -Reports of malformed limb with amitriptyline. Most are category C or D •Serotonin reuptake inhibitors (SSRIs): -•Most are category C -•Sertraline is DOC -•Paxil-AVOID! new findings heart defects category D!!!!

Dx: Infection -> Avoid Cs and Ds..

•Tetracyclines (D): skeletal and dental abnormalities, EXCEPT RMSF --- Not even recommended in child under 8 •Aminoglycosides (D): Some have been linked with congenital deafness •Sulfas(Bactrim, septra etc) (C): accentuate hyperbilirubinemia, congenital cardiac defects •Quinolones(-oxocin) (C): animal data showed cartilage malformation, esp Cipro

New pregnancy, lactation drug labeling will replace letter categories!!

•The new requirements start soon... •The first section of the new labeling structure includes information pertaining to pregnancy; including dosing, risks to fetus and registry info. •The second section is on lactation and provides information such as the amount of drug in breast milk, if it can be determined, and the potential effects on the child •The third section pertains to females and males of reproductive potential

Teratology

•The study of abnormal fetal development •Traditionally: •limited to gross structural malformations •Currently: •Expanded including more subtle developmental anomalies: •Growth retardation, behavioral changes and other functional deficiencies

Other "Substances"

•Tobacco -•orofacialclefts associated with inability to detoxify byproducts -•increased risk of SIDS -•exposure reduces birth weight by an average of 300 grams -•decrease in milk production and weight gain of infant -•present in milk in concentrations between 1.5 and 3 times maternal plasma levels •Caffeine -•Avoid with hypertensive patient -•No effect in breastfeeding infants with moderate maternal intake (2 cups per day) •Breast implants -•800,000-1 million women receive silicone implants -•Polymer in coating has alternating silicone and oxygen atoms with methyl groups -has been detected in the milk of women with implants. However, simethiconeis a silicone and is safe

Cough and Cold (High risk during preg)

•Topical decongestants •Nasal saline spray •Humidifiers •Pseudoephedrine! ---•Category C ---•Avoid in 1sttrimester and avoid if pt hypertensive!! ---•? Link to inguinal hernia and club foot? (1st) ----•Problems with mother's milk production while breastfeeding •Oxymetazoline/Afrin (nasal decongestant) ---•Caution = absorbed systemically ---•Rebound nasal congestion

Distribution of Meds: Pregnancy

•Total body water increases therefore Vdof hydrophilic medications increases •Clinical effects maybe compensated by decreases in protein binding •Total plasma concentration of protein bound medications decrease but "free" drug increases (Phenytoin) •Body fat increases which increases Vdof lipophilic medications •Look up doses specific to pregnancy

Heartburn

•Treatment •Frequent small meals •Protein •Avoid po intake 3hr prior to bedtime •Elevate head of bed •Antacids (calcium carbonate (TUMS) pregnant women require 1000mg-1300 mg of elemental calcium per day) •Ranitidine (do NOT use the Zantac ® EFFERdose tablets as they contain benzyl alcholol! (gasping syndrome in neonates)) •Sucralfate?-caution with aluminum content & interferes with fat soluble vitamin absorption (ADEK)

Diabetes in Pregnancy

•Type 1 (T1DM) or Type 2 (T2DM) prior to conception •New onset of gestational diabetes mellitus (GDM) ---•Patients with GDM should be tested for T2DM 6 weeks post delivery •Maternal Complications -•Hypertension and pre-eclampsia -•Cesarean section -•Excessive weight gain -•Risk for future T2DM •Fetal Complications: -•Macrosomia -•Neonatal hypoglycemia -•Hyperbilirubinemia