pregnancy and breastfeeding Flashcards
(20 cards)
explain what should be explained and considered in a patient who is planning to become pregnancy on anti-epileptic drug treatment
a woman who has seizures realistically cannot stop taking their antiepileptics during their pregnancy.
A decision to stop taking AED whilst pregnant should be based on AED withdrawal principles in any one person who has epilepsy. The trial should occur at least 6 months prior to planned conception to ensure seizures are not going to reoccur.
A women must be informed that the risk of congenital malformation may increase 2-3-fold for her child, however, she has better than 90% chance of bringing a child without major defects into the world.
Changing the treatment of a women with well controlled epilepsy in cases of medication with potential teratogenic risk may be a risk for inducing seizures. In the absence of alternative medication, phenytoin and carbamazepine may be continued when pregnancy is planned.
what are preferred AED in pregnancy and what should be avoided ?
1st line is lamotrigine or levetiracetam as they have the least cardiovascular effects and teratogenicity associated. carbamazepine and lamotrigine at low doses least risk of congenital malformations
AVOID:
- Carbamazepine is teratogenic in human beings. Monotherapy was found to increase the malformation rate about a two-fold
- sodium valproate associated with neural tube defects, left cleft and hypospadias
- phenobarbital and phenytoin with cardiac malformations
- phenytoin and carbamazepine with cleft palate in the fetus.
what is targeted blood pressure in pregnant women and what are severe complications associated with hyper-tension during pregnancy ?
Blood pressure of 140/90 mmHg is the threshold for hypertension in pregnancy.
Treatment should only be initiated at levels higher than 160/110 mmHg, because below that there are no advantage in treatment for the outcome of mother and child.
Complications of severe hypertension in pregnant women may include intracerebral bleeding, cardiac problems, and placental dysfunction. Placental detachment, prematurity, intrauterine growth restriction, and perinatal death are problems that may occur due to placental dysfunction.
what are first lien treatment for hypertension during pregnancy ?
1st trimester beta blockers such as labetalol, metoprolol, propranolol. pharmacological effects such as decreased heart rate, hypoglycemia, and respiratory problems, particularly in premature neonates, when treatment with β-blockers continues until birth
2nd ot 3rd trimester:
Nifedipine or verapamil, the best-studied calcium antagonists during pregnancy, are the preferred first-line drugs for the treatment of hypertension or cardiac arrhythmias in the second and third trimesters. In the first trimester, calcium antagonists are considered to be second-line therapy. If exposure with another calcium blocker has occurred during the first trimester, a detailed ultrasound diagnosis is advisable. Overall, exposure to a calcium antagonist during pregnancy is not an indication for either invasive diagnostic procedures or termination of pregnancy.
Oral labetalol† as first-line treatment to keep:
diastolic blood pressure between 80–100mmHg
systolic blood pressure less than 150mmHg
Measure twice a week. Stop ACE/ARB hydrochlorothiazide
what antihypertensives is contraindicated in pregnancy ?
ace inhibitors or ARB or hydrochlorothiazide. In humans, use of drugs that act on the renin angiotensin system during the second and third trimesters increases fetal and neonatal morbidity and death
what is preferred treatment for diabetes in pregnancy ?
1st lien - diet and exercise
type 1 diabetes: insulin can be used as they are too large of molecules to pass through the membranes. If there is excellent glycemic control on insulin lispro, it is not compulsory to change to regular insulin if the patient is pregnant. Long-acting insulin analogs should be avoided during pregnancy.
type 2 diabetes
1. diet and exercise: if target not met within 1-2 weeks then infer 2/3
2. metformin and exercise/ diet if diet and target is not met within 1-2 weeks
3. insulin with to without metformin and diet/excercise if FBG is above 7mmol
what is preferred treatment fro rheumatoid arthritis ?
Sulfasalazine is the DMARD of first choice during pregnancy. Azathioprine, cyclosporine, hydroxychloroquine/chloroquine, as well as gold compounds and D-penicillamine are reserve treatment options. If penicillamine is used for an illness outside the group of rheumatic conditions(e.g. Wilson’s disease), the lowest possible dosage should be selected.
Women of childbearing potential should be started on leflunomide only when pregnancy tests are negative and safe contraception is in use. Leflunomide should be discontinued when pregnancy is planned.
Cyclophosphamide, methotrexate and biologics are contraindicated during pregnancy. NSAIDs may be given until week 30, and prednisone/prednisolone throughout pregnancy.
Treatment with the drugs not recommended here does not necessitate a termination of pregnancy or any invasive diagnostic procedures, even when low-dose methotrexate has been used. However, detailed fetal ultrasound should be considered after treatment with any of these drugs.
what is the preferred choice of antidepressant for depression in the 1st trimester ?
- ssris such as sertraline are safer for mother and child with suicidal ideation
The older TCAs, such as amitriptyline, clomipramine, desipramine, imipramine, and nortriptyline, belong to the group of drugs of choice in the treatment of depression during pregnancy. Monitoring of maternal serum levels is recommended, and if necessary the daily dose. Tricyclics are considered lower risk than newer antidepressants during pregnancy but have a higher fatal toxicity index than SSRIS
avoid paroxetine as associated with minor cardiovascular malformations
why should tetracyclines be avoided during pregnancy ?
Tetracyclines cross the placenta, and they bind strongly to calcium ions. From the sixteenth week of pregnancy, tetracyclines are strongly bound in this way in developing tooth and bone structures, causing brown discoloration of deciduous teeth and inhibition of bone growth
why should warfarin be avoided in pregnancy ?
Problems associated with perinatal administration of warfarin have included central nervous system defects, spontaneous abortion, stillbirth, prematurity, hemorrhage, and ocular defects when given anytime during pregnancy, and a fetal warfarin syndrome when given during the first trimester. Warfarin is considered contraindicated during pregnancy.
why should thalidomide be avoided in pregnancy ?
Thalidomide causes different types of musculoskeletal defects, including the well-known phocomelia. Anomalies of the thumb, central nervous system anomalies, impairment of major organ systems and anomalies of neurological development were reported
Thalidomide is absolutely contraindicated in pregnancy, because it is the most powerful known human teratogen.
Susie, 34, is 32 weeks pregnant. She comes to your pharmacy to look for advice.
She has hay fever symptoms of itchy eyes, sneezing and a runny nose. What could you prescribe?
sodium cromoglicate and corticosteroid nasal spray
can use loratadine or cetirizine as well
avoid chlorphenamine and promethazine de do increased sensitivity in newborn - itchy eyes, seeing and irritability
What are the recommendations for the use of NSAIDs and the Flu vaccine in pregnancy?
no live vaccines should be used and
Administration of NSAIDs during the latter part of pregnancy may cause premature closure of the fetal ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and delay labor and delivery. There are no adequate and well controlled studies of diclofenac or other NSAIDs in pregnant women. The use of drugs known to inhibit cyclooxygenase/prostaglandin synthesis may impair female fertility
Describe some of the ways that drugs can produce unwanted effects whilst breast-feeding
Nearly all drugs pass into the milk at some extent, except heparin and insulin because they are too large of molecules to pass into the membranes. Milk is slightly more acidic allowing for weakly basic drugs to transfer more readily into the breast milk and become trapped to secondary ionisation. Potential harm to the infant may be inferred from the amount of drug or inactive metabolite of the drug delivered to the infant; the efficacy of absorption, distribution, metabolism and excretion of the drug by the infant; and the nature of the effect of the drug on the infant.
Some infants such as those born prematurely or who have jaundice are at slightly higher risk of toxicity
Some drugs such as phenobarbital affect their sucking reflex whilst others such as bromocriptine affect their lactation
Vitamin D in breast feeding infants
all women who are breastfeeding should take a daily supplement of 10mcg vitamin D.
infants and young children should take vitamin D in the form of drops if they are
- Aged 6 month to 5 years (unless they are taking more than 500ml of formula a day and this is fortified as vitamin D)
- Aged under 6 months and breastfeeding and their mother did not take vitamin D supplements throughout pregnancy
Antibiotics in breast feeding
- Antibiotics such as penicillin’s, cephalosporins and macrolides are considered to be compatible with breastfeeding however there are theoretical risk to affect the infant bowel flora and allergic sensitisation
- Safety of metronidazole is controversial due to possibility of high transfer into breast milk
- Top tips: either withholding breastfeeding during treatment (continue to lactase and expel milk but discard to allow natural lactation routine), maximising the amount of time between taking the dose and breastfeeding child to allow medicating to reduce its effects, alternating breast and bottle feeding
- Transfer of tetracyclines is low but avoided due to risk of inhibiting bone growth or causing dental staining.
- Fluroquinolones should also be avoided as they have been reported to cause arthropathies in immature animals
- Sulphonamides such as sulphamethoazole are unlikely or be problematic but avoid avoided in infants with hyperbilirubinemia or glucose-6-phosphate dehydrogenase deficiency.
diazepam in breastfeeding
- Diazepam is a drug with a long half-life and may accumulate in the body with prolonged exposure – may be associated with lethargy, poor suckling and reduced weight gain
- If given a single dose eg for sedation then there is no need to wait to resume breastfeeding although with a newborn or preterm infant, a cautious approach would be to wait a period of 6 to 8 hours before resuming nursing
carbamazepine in breastfeeding
Carbamazepine, phenytoin and sodium valproate are generally considered to be compatible with breastfeeding although the infant should be observed for evidence of central nervous system depression
Carbamazepine has relatively high levels in breastmilk and breastfed infants have serum levels that are measurable, but usually below the anticonvulsant therapeutic range. Most infants have had no adverse reactions, but sedation, poor sucking, withdrawal reactions and 3 cases of hepatic dysfunction have been reported
atenolol in breast feeding
avoid atenolol in favour of antihypertensives that have lower infant exposure eg metoprolol or verapamil
Because of atenolol’s relatively extensive excretion into breastmilk and its extensive renal excretion, other agents may be preferred while nursing a newborn or preterm infant or with high maternal dosages. Timing breastfeeding with respect to the time of the atenolol dose appears to be of little benefit in reducing infant atenolol exposure because the time of the peak is unpredictable
What problems affecting mum or baby may arise whilst breastfeeding?
What advise could you recommend as a community pharmacist?
Cracked nipples
Apply expressed breast milk
Use of emollients (safe for baby when suckling ) e.g. camomile nipple creams
Breast engorgement
Feed baby with no restrictions on frequency or length of feeds
Self management such as simple analgesia (paracetamol) for pain relief , massage breasts after feeds, minimal expressing of milk to relive full breasts (induces oversupply)
Use of heat packs or warm shower before feeding / expressing milk which stimulates milk let down, use of clod pack after feeding / expressing to relieve pain and oedema
Wear well fitting bra and clothing that does not restrict the breasts
Blocked ducts –
advise on feeding from the affected breast frequently
Use heat packs or warm shower for symptom relief
Wear well fitting bra and clothing so as not to restrict the breasts
Gentle massage of the breast, while the baby is feeding, to help relive the obstruction
If white spot on nipple , bath and rub the area with a warm damp towel
Advise on signs of mastitis – pain, fever and / or general malaise, tender red swollen and hard area on breast
If persistent breast mass , get checked in case of alternative diagnosis
Mastitis
Symptoms as before
May mimic breast cancer or breast abscess
Non infectious vs infectious – hard to distinguish but suspect infection if looks infected, purulent discharge, influenza like symptoms and pyrexia lasting > 24hrs, considerable breast discomfort
If lactating – symptoms worsening despite milk removal, positive breast milk culture – not routinely done in primary care
Thrush
Pain in both nipples or breasts after feeds, after previously having had no pain after feeding – sore to severe and lasts for up to one hour after every feed
Unlikely to be thrush if : always have pain after breast feeding , only affects one nipple or breast , have a fever, warm red patch on one of breasts
Could lead to oral thrush in baby
Can carry on breast feeding while treating for thrush
Use of antifungal gel or liquid for oral thrush in babies
In breast feeding women – use of cream applied sparingly around nipple after feeds (tablets may be required)
Should improve within 2-3 days
Lack of suckling
Check out baby – may have tongue tie
May be attachment issues
