a b c d e a b c d e f g h i j k l m n o p q r s t u v Pregnancy Lactation Wednesday March 18 2015 8 00 PM Pregnancy 1 Define pregnancy related terminology Grava number of times a woman is pregnant Para number of pregnancies greater than 20 weeks gestation Term pregnancy after 37 weeks of pregnancy Premature baby born before 37 weeks of pregnancy Ex G3P2103 i ii G 3 pregnancies P 2 full term births 1 premature birth 0 abortions 3 living children 2 Identify medications teratogens that are harmful during pregnancy and explain why 5 alpha reductase inhibitors Finasteride Category X May cause altered development of male sex organs ACEI ARBs Category D Could cause fetal renal damage esp in 2nd or 3rd timester Alcohol Could cause fetal alcohol syndrome FAS mental and growth retardation Anticonvulsants phenytoin topiramate valproic acid category D may cause fetal hydantoin syndrome skill and facial abnormalities NTDs cleft palate atrial defect Anti neoplastics Category D Inhibit rapidly dividing cells Angdrogens and estrogens Category X genital tract abnormalities Aspirin Category D Bleeding Cocaine Vasoconstrictor reducing blood flow to fetus preterm delivery miscarriage Diethylstilbestrol DES Category X vaginal and cervical cancer in female offspring genital abnormalities in male offspring Lithium Category D cardiac malformations Ebstein s anomaly Live vaccines theoretical risk of transmitting virus to fetus Methimazole Category D induce a goiter and cretinism stunts physical and mental growth Methotrexate Category X skeletal malformations Misoprostol Category X abortifactant NSAIDs Category D 3rd trimester premature closing of ductus arteriosus jaundice brain damage fetus and bleeding in mother during delivery Paroxetine Category D congenital heart defects particularly ventricular septal defects Statins Category X evidence lacking Tetracyclines Category D stained teeth diminished long bone growth Thalidomide Category X deafness severe limb malformation focamelia babies seal limbs Tobacco low birth weight preterm delivery sudden infant death syndrome SIDS sudden abortion cleft lip palate Vitamin A Category X Isotretinoin accutane craniofacial dysmorphisms cleft palate thymic aplasia and NTDs or excessive vitamin A intake 18 000 IU day facial abnormalities NTDs Warfarin Category X fetal warfarin syndrome CNS anomalies blindness deafness mental retardation 3 Given a patient case discuss various ways to prevent birth defects a Folic acid B9 supplementation i ii iii iv Best 1 month prior to conception 400mcg day for ALL women of child bearing age 600 mcg day for pregnant women 2nd and 3rd trimester 4 mg day for women with either of the following 1 2 3 Has a NTD Had a child with a NTD Has Type 1 DM Test 2 Page 1 3 4 Has Type 1 DM Taking anti convulsant medication b c Abstain from alcohol Smoking cessation i ii Cognitive behavioral therapy is the best Pharm tx available Bupropion Nicotine replacement therapy iii Benefits for baby 1 2 1 2 3 1 2 3 1 2 3 4 1 2 3 4 5 Increased oxygen flow to baby Decreased risk of predisposing baby to bronchitis and asthma Decreased risk of having a low birth weight baby or giving birth preterm iv Benefits for mom Increased energy and ability to breath Decreased risk of developing heart disease having a stroke lung cancer or chronic lung disease COPD More money to spend d Avoid limit caffeine intake i ii iii Caffeine can increase BP increase HR and is a diuretic which predisposes females to dehydration Crosses into the placenta and has been linked to miscarriages Intake should be limited to one 12oz Cup per day containing 200 mg caffeine rec 150 300mg day e Vaccination i ii Live vaccines should be given a month or more before pregnancy During pregnancy 1 Flu shot and Tdap ideally between 27 and 36 weeks of pregnancy iii After pregnancy 1 2 Tdap after delivery if not given during pregnancy MMR and or varicella vaccine prior to leaving the hospital if not already immune 4 Recommend appropriate treatment options non pharm or pharm for common pregnancy related problems a Morning Sickness Non pharm i Slowly rising from bed Eating small snacks before getting up Ginger up to 1g day Eating multiple small meals throughout the day ii Pharm tx Pyridoxine B6 10 25 mg 3 4x day No more than 100mg day Doxylamine 12 5 25 mg 3 4x day Metoclopramide Prochlorperazine Diclegis pyridoxine and doxylamine a b c Day 1 2 2 tabs PO QHS Day 3 1 tab QAM and 2 tabs QHS If sx persist further 1 tab QAM 1 tab mid afternoon and 2 tab QHS MAX 4 tab day b Hyperemesis Gravidarum severe persistent N V i May result in dehydration electrolyte metabolic disturbances nutritional deficiency hospitalization and IV fluids c Allergies i Non pharm ii Pharm 1 Avoid allergen humidifier nasal saline clear fluids Test 2 Page 2 1 2 3 4 5 1 2 3 4 1 2 3 1 2 3 1 2 3 4 1 2 3 4 1 2 3 1 2 3 4 ii Pharm AVOID decongestants in the 1st trimester Mast cell stabilizer Cromolyn intranasal Category B Intranasal corticosteroids Budesonide Beclomethasone Fluticasone Mometasone Triamcinolone 1st gen antihistamines Chlorpheniramine DOC Diphenhydramine Doxlyamine 2nd gen antihistamines Cetirizine loratadine desloratadine fexofenadine crosses placenta avoid d Constipation i Possible causes Iron in prenatal vitamins Increase in progesterone in the 2nd trimester reduces GI motility which increases water absorption from stools resulting in hard stool Decreased activity levels Compression of the intestines by the baby a Associated with more AE such as cramping and diarrhea ii Non pharm iii Pharm tx Increase dietary fiber 25 30gm day Increase fluid intake 10 12 cups day Exercise Bulk forming laxatives Stool softeners Stimulant laxatives senna or bisacodyl Osmotic laxatives miralax Avoid castor oil and mineral oil 4 5 Back Pain e i Prevention ii Non pharm tx iii Pharm tx Wear low heeled shoes Maintain good posture Sleep on side with pillow between knees Squat down to pick something up Heat ice pad Massage chiropracter Exercise yoga walking water aerobids Elevate feet when sitting Acetaminophen Avoid aspirin and NSAIDs in 3rd trimester NSAIDs OK in 1st and 2nd trimester f Indigestion heartburn i Non pharm Multiple small meals snacks No food prior to bed Raise head of bed Traffic light diet a Red i ii iii iv OJ cranberry grapefruit lemons Tomatoes raw onions Ice cream sour cream Chocolate brownies coffee tea ii Pharm tx 1 Ca Mg Al containing antacids for mild sx Test 2 Page 3 Ca Mg Al containing antacids for mild sx H2RA ranitidine