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