Slides for medical students dealing with pregnant and postpartum women. Safe drugs for common conditions. Presentation with interactive quiz. 48 slides

1. Drugs in pregnancy and lactation
Mini Sood

2. Objectives
 The learner should be :
 Aware of the hazards of prescribing to women at different stages of
pregnancy
 Know which drugs can be safely given to breast feeding women.

3. Principle
 A broad principle in pregnancy is to avoid all drugs as far as possible –
can be extended to women in reproductive age as well

4. Drugs and the fetus
 First trimester- Teratogenic drugs
 A teratogenic drug is taken by a woman before she realises that she is
pregnant. Sometimes, the risk of using a teratogen is outweighed by the
benefits eg. Warfarin in patient of prosthetic heart valves

5. Effects of drugs on pregnancy
 First trimester
 Teratogenic effects
 Miscarriage
 Second trimester
 Developmental effects (neurol)
 Third trimester
 Preterm or pos-term pregnancy
 Hemorrhage
 Post delivery
 Withdrawal symptoms, prolonged activity in baby

6. Teratogenic drugs in first trimester
 Phenytoin- craniofacial and limb abn
 Carbamazipine- craniofacial and limb abn
 Sodium valproate: neural tube defects
 Ace inhibitors: Abnormalities of the skull
 Alcohol: growth retardation, craniofacial abn
 Stilbesterol: adenocarcinoma of the vagina in females offspring of exposed
mothers

7. Drug category
 Category A: Controlled human studies have
demonstrated no fetal risk
Category B: Animal studies indicate no fetal risk, but
no human studies
OR adverse effects in animals , but not
in well- controlled human studies
Category C: No adequate human or animal studies,
OR adverse fetal effects in animal
studies, but no available human data.
Category D: Evidence of fetal risk, but benefits
outweigh risks.
Category X: Evidence of fetal risk. Risks outweigh
any benefits

8. Safe drugs in pregnancy
 Some Medications Considered Safe for Use During Pregnancy
 Condition Medication
 Asthma Budesonide inhaled or nasal
spray (Pulmicort®,
Rhinocort ®)
 Bladder infection (UTI) Nitrofurantoin (Macrobid®)

-
 Cough Dextromethrophan(Robitussin
DM sugar free
 Constipation Metamucil® , Citrucel®,
Docusate (Colace®, Ducolax

 Milk of magnesia. Polyethyelene glycol (Miralax
 Diabetes Insulin Glyburide
(Micronase®)
 Metformin (Glucophage®)

9. Safe drugs
 Diarrhea Loperamide (Imodium A-D ®)
 Gas (Gas-X ®, Mylicon ®, Phazyme
 Gastroesophageal reflux disease Ranitidine (Zantac®)cimetidine
 Hay fever, sneezing, runny nose, itchy
watery eyes
 Chlorphenramine (Chlor-Trimeton

Diphenhyramine (Benadryl ®)
Headache or fever: Acetaminphen
(APAP,Paracetamol,Panadol,
 Heartburn TUMs
 Hemorrhoids Tucks


10.  High blood pressure Methyldopa (Aldomet®)
 Hyperprolactinemia Bromocriptine (Parlodel®)
Carbergoline (Dostinex®)
 Hypothyroidism Thyroid hormone Levothyroxine
(Synthroid ®, Levoxyl ®)
 Infection Acyclovir (Zovirax ®)
 Azthitromycin (Zithromax ®)
 Cepaholosporins
Cephalexin (Keflex®),
Cefazolin (Ancef ®), cefaclor
(Ceclor®)
 Clindamycin (Cleocin®)
 Erythromycin
 Penicillins
Amoxicillin (Amoxil®),
Amoxicillin Clavulanate
(Augmentin®),

11. Safe drugs
 Insomnia Doxylamine (Unisom Sleep
Tabs®
 Motion sickness Dimenhydrinate
(Dramamine ®)
 Nasal congestion Pseudoephedrine
(Sudafed ®)
Avoid in first trimester
 -. nasal congestion, sneezing,
runny nose, itchy watery eyes Actifed
 Cold and Allergy ® Ingredients: Triprolidine, Pseudoephedrine
-Avoid in first trimester.
• Ginger Pyridoxine 25 mg
Metoclopramide (Reglan ® )

 Preeclampsia Magnesium
sulfate

12. Drugs for long term use
 Drugs and Pregnancy: Should I Continue My Medicines? HIV,
Zidovudine, Nevirapine,(etc)
 Diabetes,
 asthma,
 high blood pressure
 Cardiac disease
 Operated cardiac congenital conditions on anticoagulants
 Chronic renal disease
 Refractory anemia
 Tuberculosis with pregnancy

13. Thalidomide babies

14. Drugs transfer to the fetus
 Placental transfer by
 Active transport
 Passive diffusion
 Facilitated diffusion
 Placental surface area
 Placental metabolism

15. Drug passage into breast milk
 Diffusion from maternal plasma into milk
 Higher concentration in maternal plasma
 Equlibrium established with most drugs between milk and plasma

16. Drug transfer from placenta or into milk
 Molecular weight
 Protein binding
 Lipid solubility
 Ionization
 Chemical structure

17. Fetal drug disposition
 60-80% through fetal liver, and rest through ductus venosus to heart and
brain
 Hepatic metabolism
 Adrenal gland metabolism
 Recirculation through amniotic fluid

18. Calculating drug exposure
 Milk consumption-150ml/kg/d
 Milk concentration
 Relataive infant exposure <10% better(infant dose/maternal dose
mg/kg/d)

19. Neonatal factors
 Volume of mlik consumed
 GIT Transit time
 Higher gastric ph
 Differences in GI Flora
 Higher free drug concentration
 Higher body water
 Lower excretion and metabolism rates

20. Safe drugs during breast feeding
 Penicillins, cephalosporins
 Theophyllines or beta agonists
 Glucocorticoids
 Anticonvulsants
 Tricyclic antidepressants
 Neuroleptics like chlorpromazine
 Antihypertensives like methyl dopa, hydralazine
 Warfarin or heparin

21. Drugs to be avoided
 Aspirin
 Ergotamine
 Sulphonamides, ciprofloxacin, tetracyclines
 Chloramphenicol
 Benzodiazepines
 Lithium
 Antithyroid drugs or iodine
 Sulphonylureas
 Antineoplastic drugs

22. Drugs that inhibit lactation
 Bromocripitine
 Oetrogens and progesterones
 thiazides

23. anti-infectives
 Penicillins
 Cephalosporins
 Antifungals
 Antivirals
 Carbapenems
 Macrolides
 Fluroquinolones
 Aminoglycosides
 Sulfonamides

24. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 A. TrueB. False

25. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. TrueB. False

26. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 A. TrueB. False

27. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 A. TrueB. False

28. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 B. False
 5. A woman who drinks alcohol while pregnant puts her baby at risk
for physical or behavioral problems.
 A. TrueB. False

29. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 B. False
 5. A woman who drinks alcohol while pregnant puts her baby at risk
for physical or behavioral problems.
 A. True


30. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. TrueB. False

31. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. TrueB. False

32. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. TrueB. False

33. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can have
mental and behavioral problems, low-birth weight and an addiction to the
drug.
 A. TrueB. False

34. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were
pregnant can have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk
becoming infected with hepatitis B or HIV, which can be passed on
to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can
have mental and behavioral problems, low-birth weight and an
addiction to the drug.
 A. True
 10. It's safe for a pregnant woman to take tranquilizers, sleeping pills
or amphetamines.
 A. TrueB. False

35. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can have
mental and behavioral problems, low-birth weight and an addiction to the
drug.
 A. True
 10. It's safe for a pregnant woman to take tranquilizers, sleeping pills or
amphetamines.
 B. False

36.  Radioactive drugs used for some diagnostic tests like Gallium-69,
Iodine-125, Iodine-131, or Technetium-99m can be taken if the
woman stops nursing temporarily.
 Bromocriptine (Parlodel): A drug for Parkinson’s disease, it also
decreases a woman’s milk supply.
 Most Chemotherapy Drugs for Cancer: Since they kill cells in the
mother’s body, they may harm the baby as well.
 Ergotamine (for migraine headaches): Causes vomiting, diarrhea,
convulsions in infants.
 Lithium (for manic-depressive illness): Excreted in human milk

37. penicillins
 Category B drugs in pregnancy
 Crosses placenta easily
 Equal concentrations as maternal plasma
 Lactation
 Crosses in low concentration
 Compatible with breast feeding

38. cephalosporins
 Pregnancy category B drug
 Crosses placenta easily
 Some reports of anomalies- cardiac and oral clefts
 Lactation
 Excreated in low concentration in breast milk
 safe

39. carbapenems
 Pregnancy category B/C Drugs
 Cross placenta
 Little human data
 Lactation
 Exc in low concentration
 Unknown effects

40. Fluoroquinolones
 Category c in pregnancy
 Not recommended
 Cartilage damage
 Use safer altern
 Lactation
 Limited human data
 Can be used

41. Aminoglycosides- gentamycin, amikacin, tobramycin
 Pregnancy category C
 Repidly crosses placenta
 Enters amniotic fluid
 Lactation
 safe

42. sulphonamides
 Pregnancy category c
 Crosses placenta rapidly
 Use unsafe in third trimester
 Lactation
 Unsafe in premature

43. Tetracyclines- doxycyclin,mincyclin
 Pregnancy category D
 Problems with teeth, bones and other defects
 Maternal liver toxicity
 Lactation
 unsafe

44. Antivirals acyclovir, famicyclovir, valacyclovir
 Pregnancy category B
 Readily cross placenta
 Safe
Lactation
 Cannot use famiciclovir
 Acyclovir and valacyclovir safe

45. Antiretrovirals
 Generally category B/C
 Maternal benefits outweigh the fetal risks
 Associated with maternal side effects as well
 May or maynot cross the placenta

46. antifungals
 Pregnancy category C/D
 Cross placenta
 Associated with craniofacial effects
 Lactation
 Fluconazole and ketconazole are safe
 Itraconazole and voriconazole not recomm

47. Factors to consider
 Are there alternative treatments?
 Is the disease worse than the therapy?
 Can treatment wait till postpartum?
 What does available literature say?
 Is this drug used in neonates
 Age of neonate
 Duration of therapy
 Pharmacokinetics of the drug
 Maternal risks/benefits

48. Considerations in breastfeeding
 Withhold or delay therapy, if possible
 Use a drug with poor penetration in milk
 Use alternative routes of administration
 Avoid feeding at peak drug concentrations
 Give drug before infants longest sleep
 Pump and dump milk
 Discontinue breast feeding