PREGNANCY

Question 1

TERATOGENICITY
which drugs are known teratogens?

Answer 1

• ACEi and ARBs
• cytotoxic agents
• sex hormones, progestogens + oestrogens
• lithium salts
• thalidomide
• warfarin

Question 2

TERATOGENICITY
what is the most vulnerable time for exposure?

Answer 2

during 1st trimester

Question 3

PHARMACOKINETICS
which contraceptive options are ineffective with enzyme inducers e.g. carbamazepine?

Answer 3

COCP
POP
progestogen only implant

alternative options = copper IUD, levonorgestrel-releasing IUS or depo injection

Question 4

PHARMACOLOGY

Answer 4

copper IUD,
levonorgestrel-releasing IUS
depo injection

if they want to continue oral contraception they will require at least 50 micrograms of ethinylestradiol either continuously or tri-cycling

Question 5

what are the considerations for safe prescribing in pregnancy?

Answer 5

• is the drug necessary (avoid systemic antibacterials in acne)
• where possible avoid medicines in 1st trimester
• avoid drugs that are known to be harmful
• avoid new medicines due to lack of safety data
• avoid polypharmacy as the risk of harm is increased
• consider adjusting dosage based on maternal physiology and pharmacokinetics (important for drugs with narrow therapeutic range)
• advise against OTC medications

Question 6

ANALGESIA
is paracetamol safe during pregnancy?

Answer 6

• short courses + occasional use is considered safe

Question 7

ANALGESIA
are NSAIDs safe during pregnancy?

Answer 7

they should be avoided in pregnancy
particularly in 3rd trimester (associated with premature closure of ductus arteriosus)

Question 8

ANALGESIA
are opioids safe during pregnancy?

Answer 8

• limited information
• prolonged use during pregnancy = neonatal withdrawal syndrome
• use shortly before delivery = neonatal respiratory depression

Question 9

ANTI-SEIZURE MEDICATIONS
how much is the risk of birth abnormalities increased when taking anti-seizure medications?

Answer 9

2-3 x increased risk (10% risk)

Question 10

ANTI-SEIZURE MEDICATIONS
what are the most common birth abnormalities from anti-seizure medication?

Answer 10

• heart defects
• orofacial clefts
• GU malformations
• neural tube defects

Question 11

ANTI-SEIZURE MEDICATIONS
is sodium valproate used in pregnancy?

Answer 11

• highly teratogenic
• must not be started in patients <55yrs without good reason
• require pregnancy prevention programme

Question 12

ANTI-SEIZURE MEDICATIONS
which anti-seizure medications are safe in pregnancy?

Answer 12

• lamotrigine
• levetiracetam

Question 13

ANTI-SEIZURE MEDICATIONS
which anti-seizure medications are contraindicated in pregnancy?

Answer 13

• carbamazepine
• phenytoin
• phenobarbital
• topiramate
• sodium valproate

Question 14

ANTI-SEIZURE MEDICATIONS
if a patient is on enzyme inducers e.g. carbamazepine and they require emergency contraception which is the best option?

Answer 14

• best = copper IUD
• other option = double normal dose of levonorgestrel (1.5mg to 3mg)

Question 15

can statins be used during pregnancy?

Answer 15

no they should be stopped

Question 16

HTN
what is the management for HTN in pregnancy?

Answer 16

1st line = labetalol
2nd line = nifedipine (if asthmatic)

if neither are suitable
3rd line = methyldopa (must be stopped within 2 days of birth)

Question 17

DIABETES
are oral blood glucose lowering drugs safe in pregnancy?

Answer 17

• metformin = safe + can be continued
• all others (e.g. gliclazide, gliptins, gliflozins) = not safe and should be stopped during pregnancy

Question 18

THYROID DYSFUNCTION
what happens to thyroxine requirements during pregnancy?

Answer 18

requirements increase by 30-50% from very early pregnancy

Question 19

THYROID DYSFUNCTION
how are thyroid levels maintained during pregnancy?

Answer 19

• check TFTs as soon as pregnancy is confirmed
• ensure trimester specific reference ranges are used
• perform TFTs regularly (especially in first 20wks)
• thyroxine requirements remain elevated in breastfeeding

Question 20

VACCINATIONS
is MMR vaccine allowed during pregnancy?

Answer 20

no - it is a live vaccine

Question 21

VACCINATIONS
which vaccinations are recommended during pregnancy?

Answer 21

• influenza
• COVID-19
• pertussis (whooping cough)

Question 22

VACCINATIONS
when is the pertussis (whooping cough) vaccine given during pregancy?

Answer 22

16-32 weeks of pregnancy

Question 23

HYPEREMESIS
What is the community management of hyperemesis gravidarum?

Answer 23

• 1st line antiemetic = promethazine or cyclizine (anti-histamines)
• 2nd line = ondansetron (5-HT3 antagonist) or metoclopramide (dopamine antagonist)

Question 24

ECLAMPSIA
What is the management of eclampsia?

Answer 24

IV magnesium sulfate to prevent + treat seizures –
- Reduces DIC risk as reduced platelet aggregation
- Continue 24h after last seizure or delivery
Treat HTN with labetalol 1st line or nifedipine
Stabilise mum and delivery baby

Question 25

PRE-ECLAMPSIA What should be given to women who are at high or moderate risk of pre-eclampsia and why?

Answer 25

- 75mg aspirin PO OD at 12w until birth - Spiral arteries form around 12w so thought to help them develop

Question 26

PRE-ECLAMPSIA What medical treatment can be given for pre-eclampsia?

Answer 26

Treat HTN with – - PO Labetalol first line (can use IV if severe + inpatient) - PO nifedipine (used if asthmatic) - Hydralazine too - ACEi = CONTRAINDICTAED

Question 27

VTE IN PREGNANCY What is the management of a VTE event? Any contraindications?

Answer 27

- Embolectomy + anticoagulate ASAP with LMWH - Do NOT use warfarin (or DOACs) as can cross placenta + may cause foetal abnormalities (CHD) + intracranial bleeding

Question 28

OBSTETRIC CHOLESTASIS What is the management of obstetric cholestasis?

Answer 28

- Ursodeoxycolic acid first line to improve LFTs + bile acids - Induce labour at 37–38w to reduce stillbirth risk - Vitamin K supplementation - Emollients (calamine lotion to sooth skin) - Antihistamines to help sleep

Question 29

PROM What is the management of PPROM?

Answer 29

- 1st line = IM corticosteroids if foetus <34w - Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d or until labour is established if within 10d - Consider induction at 34w (trade off)

Question 30

POSTNATAL DEPRESSION What is the management of postnatal depression?

Answer 30

- Early identification + close monitoring of those at risk - CBT may help, sertraline + paroxetine if severe as safer in breastfeeding - ?Hospital admission if thoughts of self or baby-harm

Question 31

UTIs IN PREGNANCY what are the treatments?

Answer 31

* Oral antibiotics - Asymptomatic bacteriuria: 3 days - Cystitis 7 days - nitrofurantoin (avoid in 3rd trimester) - amoxicillin (only once sensitivities known) - cefalexin