Chapter 21: Drug Use in Pregnancy and Lactation

Question 1

In what trimester is the embryo most susceptible to birth defects caused by teratogens?

Answer 1

1st trimester

Question 2

T/F:

The drug must cross the placenta for the drug to be teratogenic?

Answer 2

True

Drugs must cross the placenta into fetal circulation to be teratogenic

Question 3

What does hCG stand for?

Answer 3

hCG = human chorionic gonadotropin and a (+) lab result indicates pregnancy

Question 4

What are the recommended daily amounts of each of the following for women of child bearing age:

A) Folic Acid
B) Calcium
C) Vitamin D

Answer 4

A) Folic Acid 400-800 mcg daily
B) Calcium 1,000 mg daily
C) Vitamin D 600 IU daily

Prenatal vitamins typically contain 600-800 mcg of folic acid. Folic acid (folate) prevents birth defects of the brain and spinal cord. It should be taken 1 month prior to pregnancy and continued for the first 2-3 months to cover organogenesis.

Question 5

What 2 vaccinations are indicated for pregnant women?

Answer 5

Inactivated influenza vaccine and Tdap

Question 6

When should the Tdap vaccine be administered to a pregnant woman?

Answer 6

Between 27-36 weeks

Question 7

If a pregnant woman has never had a Tdap vaccine or the history is unclear, what vaccine series should the woman receive?

Answer 7

3-dose series of Tdap, then Td, then Td (0, 1 month, 6-12 months)

Question 8

In 2011, thte FDA issued a warning regarding SSRI use during pregnancy and the potential risk for what?

Answer 8

Persistent pulmonary hypertension of the newborn (PPHN)

Question 9

Since 2011, newer data has shown most SSRIs/SNRIs are relatively safe in pregnancy, except which SSRI that has the highest risk of cardiac abnormalities?

Answer 9

Paroxetine (Paxil®)

Question 10

Which of the following medications are considered well-known teratogens? (Select all that apply)

A. Ativan®
B. Bayer® aspirin
C. Ibuprofen
D. Levaquin®
E. Lithobid®

Answer 10

All the medications listed are well-known teratogens including benzodiazepines, all NSAIDs (including ASA), FQs, and lithium.

Question 11

What are 1st line lifestyle modifications to treat morning sickness, nausea, and vomiting in pregnancy?

Answer 11

1. Eat smaller meals
2. Avoid spicy/odorous foods
3. More frequent naps
4. Reduce stress

Question 12

What 1st line drug therapy is recommended by the American College of Obstetricians and Gynecologists to treat morning sickness, N/V?

Answer 12

10-25mg q8h pyridoxine (vitamin B6) +/- doxylamine

Pyridoxine + doxylamine comes as a prescription only medication called Diclegis®, an EC delayed-release tablet that contains 10mg pyridoxine + 10mg doxylamine. Typical starting dose is two tabs po HS.

Oral pyridoxine 10-50mg daily is used with isoniazid to prevent neuropathies, and in higher IV doses to prevent toxicity

Question 13

What lifestyle/drug therapy recommendations can you make to a pregnant woman experiencing heartburn/GERD?

Answer 13

1. eat smaller, more frequent meals
2. avoid food/drink triggers
3. avoid eating within 3 hrs of bedtime
4. elevate head of bed if experiencing while sleeping
5. Calcium antacids (Tums®)

1 tab (500mg) to 4 tabs prn; max 8000mg (16 tabs) daily x 2 weeks

Question 14

Can simethicone be safely recommended for pregnant women with gas?

Answer 14

Yes

Question 15

Advise a pregnant female with constipation.

Answer 15

Eat more dietary fiber, drink more liquid, and increase physical activity. If this fails, take fiber supplement such as psyllium or methylcellulose.

Question 16

What is the DOC for pain in pregnancy?

Answer 16

APAP

Question 17

What is the DOC for cough, cold, allergies (oral) in pregnancy.

Which nasal steroids are considered safest for use for chronic allergy symptoms?

Answer 17

Chlorpheniramine (Chlor-Trimeton®) or diphenhydramine which are both 1st generation antihistamines

Budesonide (Rhinocort®) 2 sprays into each nostril daily
Beclomethasone (Beconase AQ®) 2 sprays into each nostril daily

Using Rhinocort®: prime by shaking and spraying 8x (reprime if not used for 2 days). Blow nose, close other nostril, lean head slightly forward, spray, breath GENTLY inward

Using Beconase AQ®: prime 6x

Question 18

How would you treat a pregnant woman with a UTI? Vaginal fungal infection?

Answer 18

UTI: Cephalexin (Keflex®) 500mg caps Q6H x 7 days

Fungal infection: topical antifungals (creams, suppositories)

Question 19

Which anticoagulant is preferred for VTE in pregnancy?

Answer 19

LMWH

Question 20

DOC for HTN in pregnancy?

Answer 20

labetalol

Question 21

DOC for DM in pregnancy?

Answer 21

insulin

Question 22

DOC for hypothyroidism in pregnancy?

Answer 22

levothyroxine (cat A)

Question 23

DOC for Graves’ disease in pregnancy?

Answer 23

Graves’ disease is a common cause of hyperthyroidism. Two drugs are utilized if pregnant women depending on the trimester:

Propylthiouracil if trying to conceive and in 1st trimester
Methimazole (Tapazole®) during 2nd and 3rd trimester

Typical doses
Propylthiouracil for hyperthyroidism is 50mg PO TID
Methimazole for hyperthyroidism associated with Grave’s disease is 5mg PO TID

Question 24

A pharmacist is consulted regarding acceptable treatment options for a pregnant woman with a chlamydia infection. (Select ALL that apply.)

A Biaxin can be used if the woman has an allergy to beta lactams.
B Amoxil is a preferred agent.
C If Zithromax is used in a high-dose, it will also treat gonorrhea.
D Vibramycin is the preferred agent for chlamydia, in all trimesters.
E Zithromax is a preferred agent.

Answer 24

B, C, and E

Clarithromycin is not a safe macrolide for use in pregnancy. If azithromycin is used at a 2 gram x 1 dose (versus 1 gram x 1 for chlamydia alone), the dose would be adequate to treat both chlamydia and gonorrhea.

Question 25

Julia Bernadino is a 17 year-old female who enters the pharmacy to pick up her birth control pills. The pharmacist would provide a benefit by ensuring that Ms. Bernadino is receiving adequate intake of this B vitamin: ``` A Vitamin B2 B Vitamin B6 C Vitamin B9 D Vitamin B12 E Vitamin E ```

Answer 25

C Vitamin B9 Folic acid, vitamin B9, is in many healthy foods, including fortified cereals (some of which are not healthy), dried beans, leafy green vegetables and orange juice. An OTC multivitamin that contains 400-800 mcg of folic acid can be recommended.

Question 26

A pregnant woman has a bacterial vaginosis infection. Which of the following antibiotics are acceptable treatment options? (Select ALL that apply.) ``` A Clindamycin oral B Azithromycin C Metronidazole oral D Doxycycline E Ciprofloxacin ```

Answer 26

A and C Pregnant women with bacterial vaginosis more often have babies who are born premature or with low birth weight and are therefore treated. Clindamycin and metronidazole are both acceptable options.

Question 27

Which of the following are acceptable treatment options for vaginal trichomoniasis during pregnancy? (Select ALL that apply.) A Metronidazole, oral 2 grams x 1 B Metronidazole, oral 500 mg BID x 7 days C Ceftriaxone, IM D Tinidazole, topical E Clindamycin or metronidazole, topical formulations

Answer 27

A and B Another option is metronidazole, oral 250 mg TID rather than 500 mg BID, either for 7 days duration. If one day course can be used it is preferable, but side effects from the larger dose need to be considered.