Considerations in Pregnancy + drug use in pregnancy and lactation

Question 1

what CV characteristics are increased in pregnancy?

Answer 1

blood volume
cardiac output by 8wks

Question 2

what are some possible causes to increased lower limb venous pressure with pregnancy

Answer 2

enlarging uterus impedes inferior vena cava pressure + placenta acts as AV shunt

Question 3

3rd trimester may see ___________ episodes from gravid uterus impeding flow in ____________

Answer 3

supine hypotensive
inferior vena cava

Question 4

what CV characteristics are decreased in pregnancy?

Answer 4

BP in first trimester
systemic peripheral vascular resistance

Question 5

what respiratory characteristics are increased in pregnancy?

Answer 5

oxygen consumption
sensitivity of medullary respiratory center to CO2
minute ventilation (tidal volume and resp rate)

Question 6

what resp characteristics are decreased in pregnancy?

Answer 6

residual volume

Question 7

in pregnancy, there may be compensatory respiratory ________
1. acidosis
2. alkalosis

Answer 7

alkalosis

Question 8

why does the medullary respiratory center become more sensitive to CO2 in pregnancy?

Answer 8

effects of progesterone

Question 9

how much iron supplementation is recommended during last half of pregnancy?

Answer 9

50-60mg

Question 10

absorption of iron
1. increases
2. decreases
in pregnancy

Answer 10

increases by 15%

Question 11

pregnancy sees an increase in clotting factors due to

Answer 11

increased estrogen

Question 12

why is there an increased risk of thrombosis peripartum

Answer 12

Virchow’s triad: venous stasis (rest), hypercoagulability (E), endothelial damage (from delivery)

Question 13

in pregnancy, the smooth muscle of the GIT ____________, resulting in _____________
1. relaxes, faster gastric emptying
2. relaxes, slower gastric emptying
3. increases tone, faster gastric emptying
4. increases tone, slower gastric emptying

Answer 13

2

Question 14

delayed gastric emptying in pregnancy results in

Answer 14

upper GI sx like heartburn/ GERD
N/V

Question 15

what are some renal adaptations seen in pregnancy

Answer 15

increased blood flow and GFR
increased activity of the RASS system (from E)
increased glucosuria

Question 16

in pregnancy, is glucosuria present in nondiabetics?

Answer 16

yes- GFR increases but ability to absorb glucose remains teh same
may not be a good indicator of glucose control in diabetics

Question 17

a T1DM pregnant patient is having glucosuria, this
1. indicates a loss of blood glucose control
2. indicates diabetic ketoacidosis
3. may be present at normal blood glucose levels
4. is a good indicator of diabetes in pregnancy

Answer 17

3

Question 18

PK changes in pregnancy includes

Answer 18

increased Vd adn CL
decreased GI motility = slower absorption time = later peak
decreased protein binding (albumin)

Question 19

Maternal and fetal drug response during pregnancy are influenced by 2 factors

Answer 19

Pregnancy induced physiologic changes
Placental fetal unit

Question 20

rank the following teratogens on incidence of congenital manifestations
unknown, genetic, medication exposure, environment

Answer 20

unknown > genetic > environment > med exposure

Question 21

list 3 factors that can influence teratogenicity

Answer 21

The embryonic stage at exposure
Genotypes of the mother a fetus
The extent to which the drug crosses the placenta
Type of agent: dose, duration of exposure
Simultaneous exposure to other drugs/ environmental agents

Question 22

placental drug transfer can occur by

Answer 22

simple diffusion, differential diffusion, active transport, and pinocytosis

Question 23

placental drug transfer is influenced by

Answer 23

MW, protein binding, lipid solubility, degree of ionization, placental blood flow, placental metabolism, thickness of placental membrane

Question 24

list 3 reasons why it is difficult to determine the safety of drugs in pregnancy

Answer 24

most RCTs exclude pregnant women
oevrall risk of most teratogens is low = needs large number of exposures
most data currently from case reports that is not generalizable to all women
small sample sizes
contribution of maternal disease unknown
recall bias in retrospective studies
unbalanced reporting

Question 25

what are pregnancy registrise

Answer 25

post marketing data, voluntary, recorded prospectively what meds mother was taking, if there are any effects on baby

Question 26

what 4 drugs can affect brain development

Answer 26

isotretinoin, phenytoin, carbamazepine, valproic acid

Question 27

lsit the 9 proven teratogens

Answer 27

thalidomide DES alcohol cocaine androgens isotretinoin warfarin methotrexate valproic acid

Question 28

Alcohol use during pregnancy is associated with a range of complications called

Answer 28

FASD

Question 29

FASD 1. results in lifelong physical, behavioural, intellectual effects 2. is completely preventable by avoiding alcohol in pregnancy 3. severity depends on amount of alcohol drank, timing of drinking 4. all of the above

Answer 29

4

Question 30

when is the fetus most vulnerable to alcohol

Answer 30

days 19-21

Question 31

what is the most severe subtype of FASD

Answer 31

FAS- physical + brain damage + neurodevelopmental effects

Question 32

what % of FAS have the classical characteristics

Answer 32

10%

Question 33

what are some classical sx of FAS

Answer 33

low nose bridge, short nose/ flat midface, smooth philtrum, thin upper lip, small jaw, microcephaly, epicanthal folds, short palpebral fissures, minor ear abnormalities, height/ weight <10th percentile

Question 34

neurodevelopmental effects, no physical evidence

Answer 34

ARND

Question 35

many birth defects (ex- cardiac, skeletal, renal, etc) from alcohol

Answer 35

ARBD (alcohol related birth defects)

Question 36

what is pFAS

Answer 36

(partial fetal alcohol syndrome): partial physical effects and neurodevelopmental effects

Question 37

neonatal adaptation sx usually resolves in

Answer 37

~2wks

Question 38

common drugs precipitating neonatal withdrawal includes

Answer 38

drugs of abuse, psychotropic drugs, antidepressants (SSRIs)

Question 39

Some drugs can cause withdrawal sx in the neonate (if taken during the ________________)

Answer 39

last trimester around the time of delivery

Question 40

cannabis in pregnancy may affect ________, ____________, ___________ consequences

Answer 40

May affect fetal growth (inconsistent evidence), neurodevelopment, learning and behavioral consequences

Question 41

evidence of cannabis in pregnancy mostly comes from 1. smoking 2. edibles 3. sprays

Answer 41

1

Question 42

general guidelines for ITC use with pregnancy (4)

Answer 42

Try nonpharm first Try to avoid meds during first trimester Use noncombination, short acting agents Choose topical over oral meds

Question 43

passage of medication into milk is primarily from

Answer 43

passive diffusion

Question 44

drug transfers into human milk more easily if it is

Answer 44

Highly lipid soluble Low in protein binding Low in MW (<500d) Nonionized (pKa important) High conc in mother

Question 45

general rules for taking meds in breastfeeding

Answer 45

Choose drug with less secretion into milk Avoid nursing at times of peak drug conc Take med before infant’s longest sleep period If ST tx, consider temp holding BF

Question 46

medication levels tend to peak in breastmilk ____ after oral dose

Answer 46

1-3hrs

Question 47

Relative infant dose

Answer 47

Relative infant dose = infant’s dose via milk (mg/kg/d)/ mother’s dose (mg/kg/d)

Question 48

what is L1 in Hale's medication

Answer 48

safest

Question 49

if the RID is < ____, it is generally safe to use

Answer 49

10%

Question 50

RID of most meds are ___

Answer 50

<1%

Question 51

what % of THC exposed to the mother reaches the baby?

Answer 51

0.8-2.5%