Lecture 7 Pregnency Clinical Pharmacy 1

LECTURE 6
Care for special patients populations: pregnancy and

lactation
BY
DR/ ASMAA AHMED HAMED
THE RISK OF BIRTH DEFECTS IS USUALLY HIGHER DURING
ORGANOGENESIS.
Teratogens Health professionals should know which medications have teratogenic risk. A
teratogen is an exogenous agent that can modify normal embryonic or fetal development.
Teratogenicity can manifest as structural anomalies, functional deficit, cancer, growth
restriction, neurologic impairment, or death (spontaneous abortion, stillbirth)
SOURCES OF INFORMATION ON THE USE OF DRUGS
• During Pregnancy and Lactation Health-care professionals should be able to compare the
main sources of drug information relevant to pregnancy and lactation. Some specialized
information sources provide data on the use of medications during pregnancy and lactation
(Table 48–4).
• All patients capable of childbearing should be counseled on the appropriate dose of folic
acid to prevent congenital anomalies. The American College of Obstetricians and
Gynecologists (ACOG) and the US Preventive Services Task Force recommend that all
patients capable of pregnancy take 0.4 to 0.8 mg of folic acid daily, beginning 1 month
before pregnancy and through the first 2 to 3 months, to prevent NTD.
MEDICATION AND LACTATION
• According to the latest policy statement from the American Academy of Pediatrics (AAP), mothers
should breast-feed exclusively for 6 months and continue for 1 year if possible.
Drug Transfer Into Breast Milk
• To study drug effects, breast-fed infant’s serum drug levels could be measured to evaluate
safety; however, these data are often unavailable. In most instances, the approximate quantity of
drug ingested by the breast-fed infant is estimated using published measured drug concentrations in
breast milk. With these data, the percentage of pediatric dose or, if a pediatric dose is not available,
the relative infant dose (percentage of weight-adjusted maternal dose) can be calculated, assuming
an average of 150 mL/kg/day of milk ingested by a breast-fed infant.
CONDITIONS PREVALENT IN PREGNANCY AND LACTATION
• When possible, treat conditions occurring during pregnancy with nonpharmacologic

treatments instead of drug therapy. Evaluate the need for treatment, including benefits
and risks, and possibility of delaying treatment after pregnancy or breast-feeding. For
chronic diseases, please refer to the relevant chapters.
1. Iron-Deficiency Anemia
• Anemia during pregnancy is defined as a hemoglobin level less than 11 g/dL (110 g/L;
6.83 mmol/L). Maternal symptoms include fatigue, palpitations, and decreased exercise
tolerance and resistance infections. Fetal risks are prematurity, low birth weight, and
perinatal death. All pregnant patients should be screened for anemia, and those with iron
deficiency should be treated with oral iron preparations in addition to prenatal vitamins. Iron
supplementation decreases the prevalence of maternal anemia at delivery and reduces
transfusion requirements. It is unclear whether supplementing nonanemic pregnant patients
will improve perinatal outcomes but it reduces maternal fatigue.
2. Nausea and Vomiting of Pregnancy (NVP)
• Early treatment with pyridoxine (vitamin B6) or a combination of pyridoxine and
doxylamine is recommended to prevent progression to more severe NVP such as
hyperemesis gravidarum. When insufficient, diphenhydramine, prochlorperazine,
promethazine, ondansetron, or metoclopramide can be prescribed.
3. Pain
• Maximize nonpharmacological measures. Acetaminophen is the safest analgesic during
pregnancy.
4. Urinary Tract Infections
• Treatment options include β-lactams, nitrofurantoin, and fosfomycin (Table 48–7).
Trimethoprim-sulfamethoxazole should be avoided during organogenesis (congenital
malformations) and near term (theoretical risk of kernicterus).
5. Preterm Labor
• Preterm birth is defined as a delivery before 37 completed weeks (< 259 days). Preterm
birth, especially before 32 weeks of pregnancy, is the major cause of short- and long-term
neonatal mortality and morbidity. In case of a premature delivery threat, depending on the
GA, the following should be started, antenatal corticosteroids for fetal pulmonary maturation,
an antibiotic to lower the risk of neonatal group B streptococcal disease, and magnesium
sulfate for fetal neuroprotection. Tocolytics can be administered in preterm labor and
antibiotics in preterm premature rupture of membranes (PPROM) to prolong pregnancy.
A. Antenatal Corticosteroids
• Administration of antenatal corticosteroids to the mother to accelerate the maturation of the fetal lungs
decreases incidence and severity of neonatal respiratory distress syndrome, intraventricular hemorrhage,
necrotizing enterocolitis, and death. Provide a single course of antenatal corticosteroids (betamethasone or
dexamethasone) to patients between 24 and 33 weeks of gestation at risk of delivery within 7 days.
B. Tocolytic Agents
• Tocolytics are used when preterm labor occurs before 33 weeks to delay delivery to complete a course of
corticosteroids and allow transfer of the mother to a center with neonatal intensive care facilities. Tocolytics
include magnesium sulfate, β-mimetics (terbutaline), prostaglandin inhibitors (indomethacin), oxytocin receptor
blockers (atosiban, not available in the United States), and calcium channel blockers (nifedipine)
C. Neuroprotection
• Magnesium sulfate given to patients at risk of delivery before 32 weeks gestation decreases the
incidence of subsequent neurologic morbidities like cerebral palsy
D. Antibiotics for PPROM
• In the presence of PPROM, 2 days of parenteral ampicillin/erythromycin followed by 5 days of
oral amoxicillin and erythromycin are associated with a delay of delivery and reduction in maternal
and neonatal morbidity (Table 48–7). Patients with PPROM should receive adequate intrapartum
Group B Streptococcus (GBS) prophylaxis for the first 48 hours to prevent neonatal infection (refer
to section on “GBS infection”).
E. Progesterone
• Progesterone is used to reduce the risk of preterm birth in patients with singleton gestation and
a prior spontaneous singleton preterm delivery and should be initiated between 16 and 24 weeks
of gestation.
6. Group B Streptococcus Infection
• All patients with unknown status should be treated if labor or PPROM occur before 37 weeks. IV
penicillin G or ampicillin is preferred treatment. If penicillin-allergic, cefazolin (for nonanaphylactic
penicillin reaction) or clindamycin (for anaphylactic penicillin reaction) can be used.
7. Induction of Labor
• Pharmacological methods include prostaglandin E1 (eg, vaginal misoprostol) and E2 (eg, vaginal
or cervical dinoprostone). Oxytocin is the most frequently used pharmacological method of labor
induction.
8. Postpartum Hemorrhage
• Oxytocin and carbetocin (long-acting analog of oxytocin) can prevent excessive blood loss
associated with delivery and caesarian section
9. Hypertension
• Treat severe hypertension (systolic above 160 mm Hg or diastolic above 110 mm Hg)
promptly to avoid target-organ damage. It is recommended to maintain blood
pressure levels between 120 to 160 and 80 to 110 mm Hg for pregnant patients with
non severe hypertension. In nonpreeclamptic hypertension, maintaining blood
pressure control benefits the mother without harming the fetus. Labetalol and
extended release nifedipine are first-line treatments . Angiotensin-converting enzyme
inhibitors (ACEi), angiotensin II receptor antagonists, renin inhibitors, or
mineralocorticoid receptor antagonists are not recommended.
10. Preexisting Diabetes Mellitus
• Patients with preexisting DM should be screened for diabetic nephropathy and
retinopathy. Type 1 DM (T1DM) are tested for gestational hypothyroidism and anti-
TPOAbs Thyroid peroxidase . Low-dose aspirin is indicated to reduce preeclampsia risks for
patients with type 1 and type 2 diabetes and should be initiated as early as 12 weeks
gestation and continued until delivery.
11. Anticoagulation
• Thromboembolic risk increases during pregnancy and up to 12 weeks postpartum.
Anticoagulation with low-molecular-weight heparins or unfractionated heparin may
be required antepartum and/or postpartum for some patients, even when not
anticoagulated before pregnancy. Dosage is specific to the underlying condition.

Lecture 7 Pregnency Clinical Pharmacy 1

Uploaded by

Copyright:

Available Formats

Lecture 7 Pregnency Clinical Pharmacy 1

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lecture 7 Pregnency Clinical Pharmacy 1

Uploaded by

Copyright:

Available Formats

LECTURE 6

Care for special patients populations: pregnancy and

• When possible, treat conditions occurring during pregnancy with nonpharmacologic

You might also like