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REPRODUCTION & GYNAECOLOGY > Prescribing in Pregnancy > Flashcards

Prescribing in Pregnancy Flashcards

1
Q

All of the organs in a foetus have pretty much formed by what week of pregnancy?

A

week 11

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2
Q

When do women who are pregnant usually get their first scan?

A

12 weeks

detailed scan occurs at 20 weeks

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3
Q

What drug previously used as an anti-emetic for morning sickness is now known to have caused in utero deaths and also congenital defects?

A

Thalidomide

  • caused mainly limb defects
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4
Q

What evidence do we have for drugs that ARE used in pregnancy?

A
  • randomised clinical trials
  • Anecdotal reports
  • Circumstantial evidence of safe use
  • Retrospective series where exposure has occurred
  • Data extrapolated from animal studies
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5
Q

What do doctors prescribe to try and prevent pregnancy complications?

A
  • Consider non-drug alternatives
    e.g.
    Physiotherapy instead of NSAIDs
    CBT instead of antidepressants
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6
Q

If benefits outweigh risks to the mother, does a doctor usually prescribe in pregnancy?

A

Yes BUT a lot of drugs are unlicensed for pregnancy use so they are prescribing “off license”

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7
Q

Most women are reluctant to take drugs during pregnancy and most doctors are reluctant to prescribe drugs to pregnant women. TRUE/FALSE?

A

TRUE

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8
Q

If a drug is prescribed to a pregnant woman, how should the dosage and course be adapted?

A

Minimum effective dose for the shortest amount of time

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9
Q

What percentage of women DO take some form of drug during their pregnancy, and what type of drugs are most commonly taken?

A

Painkillers ~12%
Antibiotics ~11%
Antacids ~8%
(Also folic acid and iron)

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10
Q

What medications over the counter should not be taken by women who are pregnant?

A

NSAIDs
St John’s wort
Other herbal preparations

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11
Q

What type of drugs are known to cross the placenta?

A
  • Almost all drugs cross placenta
  • Especially small, lipid-soluble drugs (Cross quickly)
  • Large molecular weight drugs DON’T CROSS (Heparin)
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12
Q

What are the main principles of pharmacokinetics and how does pregnancy affect these?

A

Absorption
- morning sickness affects this

Distribution

  • Increased plasma vol. and fat stores for volume distribution
  • Decreased protein binding => increased free drug

Metabolism

  • Increased liver metabolism of some drugs
    e. g. Phenytoin

Elimination
- Elimination of renally excreted drugs increases

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13
Q

It is thought pregnant women might be slightly more sensitive to some drugs during pregnancy. GIve an example of this?

A

BP reduces in second trimester of pregnancy

=> more sensitive to anti-hypertensives in 2nd trimester

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14
Q

What pre-conception counselling would ideally be given before patients get pregnant?

A
  • Stop smoking and drinking alcohol
  • Folic acid 400mcg daily for 3 months prior and first 3 months of pregnancy
  • Counselling on their chronic conditions
    e. g. Epilepsy, diabetes, hypertension
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15
Q

The period with the greatest risk of teratogenicity is during what weeks in the 1st semester of pregnancy?

A

Period of greatest teratogenic risk
4th -11th week
=> Avoid drugs if at all possible during this period

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16
Q

What drugs are teratogenic and what effects do they cause?

A

ACE inhibitors/ARB = Renal hypoplasia
Antiepileptics = Cardiac, facial, limb, neural tube defects
Lithium = Cardiovascular defects
Retinoids = Ear, cardio, skeletal defects
Warfarin = Limb and facial defects

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17
Q

What is the aim of the valproate pregnancy prevention programme?

A

Scheme where women of childbearing age have to sign to say they have been educated on the risks of using valproate if they were to get pregnant

18
Q

How can some drugs affect the baby around term or at the time of labour?

A
  • Affects progress of labour
  • Adaptation of foetal circulation (Premature closure of ductus arteriosus)
  • Suppression of foetal systems (Opiates – resp. depression)
  • Bleeding (Warfarin)
19
Q

How can drugs that the mother was on during pregnancy affect the baby even AFTER it is born?

A
  • Withdrawal syndrome (opiates, SSRI)

- Sedation

20
Q

What previous drug used for preventing miscarriage has been shown to have very late effects on babies born to these mothers?

A

Diethylstilbestrol

  • children develop vaginal or urogenital adenocarcinoma in teenage years
21
Q

Compliance in pregnancy is poor. TRUE/FALSE?

A

TRUE

  • women avoid taking their asthma inhalers
  • 20% of women discontinue antiepileptic medication
22
Q

Women who receive no epilepsy treatment during pregnancy are still more likely to have a child born with congenital defects than those without epilepsy. TRUE/FALSE?

A

TRUE

=> untreated epilepsy in pregnancy can cause the mother to have seizures which may cause complications to the child

23
Q

Why do seizures amongst females with epilepsy increase when they are pregnant?

A
  • Non-compliance to meds in pregnancy
  • Changes in plasma concentrations of drugs
    (Due to vomiting from morning sickness OR Increased clearance)
24
Q

What drug regime is normally preferred for pregnant patients with epilepsy and what drugs are commonly avoided?

A
  • Monotherapy preferred (as opposed to multiple agents)
  • Avoid valproate, phenytoin
  • ALSO GIVE Folic acid 5mg daily
25
Q

What percentage of women taking AED’s have children born with congenital malformations?

A

96% = No MAJOR congenital malformations (heart defects etc)

=>Benefits of treatment outweigh risks in most cases

26
Q

How is diabetes commonly managed in pregnant women?

A
  • insulin requirements change during pregnancy
    => many women put on insulin injections
  • Sulphonylureas removed as not safe
  • Poor control increases risk of congenital malformations and intra-uterine death
27
Q

If hypertension needs treated in pregnancy, what agents can be used for this?

A

Labetalol
Methyldopa
(Nifedipine MR - “off license”)

28
Q

What anti-hypertensives should be avoided in pregnancy?

A
  • Avoid ACE inhibitors / ARB

- Beta blockers may inhibit foetal growth in late pregnancy

29
Q

What common acute problems do patients often need medication for during pregnancy?

A
  • N+V = Cyclizine (safest)
  • UTI (local guidelines) => Nitrofurantoin, (3rd trimester = trimethoprim)
  • Pain => Paracetamol
  • Heartburn = Antacids
30
Q

How should VTE be prevented in pregnancy?

A

ALL women - pregnant/ labour/ puerperium

  • be encouraged to mobilise
  • be adequately hydrated

Those with 2 significant risk factors (BMI, smoking, age etc)
=> thromboprophylaxis with LMWH at delivery and up to 7 days post-partum

31
Q

Why is LMWH used for thromboprophylaxis in pregnancy and not warfarin?

A

Warfarin in early pregnancy
= Teratogenic

Warfarin in late pregnancy
= Risk of haemorrhage during delivery

32
Q

What drugs can enter the breast milk if a baby is breastfeeding?

A

Most drugs enter breast milk, especially:
- Small molecules
- Fat soluble (lipophilic) drugs
BUT very few enter in sufficient quantities to cause a problem

33
Q

Why can the length of a feed cause potentially more problems?

A

Foremilk – protein rich
Hindmilk – higher fat content
Longer feeds => higher amounts of fat soluble drugs in milk that baby receives

34
Q

Why may drugs from breastmilk accumulate in a newborn?

A

immature metabolism

35
Q

What drugs cause issues if transferred through breastmilk?

A 
Phenobarbitone – suckling difficulties
Amiodarone – neonatal hypothyroidism
Cytotoxics – bone marrow suppression
Benzodiazepines – drowsiness
Bromocriptine – suppresses lactation
36
Q

Where can extra information of prescribing in pregnancy be found?

A

BNF:

  • Guidance on Prescribing chapter at front
  • Specific prescribing information listed under each drug

UK Teratology Information Service

UKDrugs in Lactation Advisory service

37
Q

When should you consider starting pregnancy specific anti-hypertensives if a patients BP is high before conceiving?

A
  • Can wait until after BP dip in 2nd trimester

OR can start before pregnant

38
Q

How is a DVT or PE treated during pregnancy?

A

LMWH injections that the patient can self administer

  • if PE then patient may need to stay in hospital until more stable
39
Q

What type of antibiotics can cause grey teeth staining of the baby if taken during pregnancy?

A

Tetracyclines (e.g. doxycycline)

40
Q

What “drug” if taken during pregnancy can cause multiple facial changes including a flattened face and nose?

A

Alcohol

=> Foetal Alcohol Syndrome

41
Q

What old anti-epileptic was known to cause cleft-lip and palate if taken during pregnancy?

A

Phenytoin

42
Q

What teratogenic side effects are common with taking sodium valproate during pregnancy?

A

Spina Bifida
Anencephaly
(NEURAL TUBE defects)

REPRODUCTION & GYNAECOLOGY (58 decks)

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