Pregnancy

• Positive Hcg (human chorionic gonadotropin) confirms pregnancy.
• 1^sttrimester is most susceptible to teratogen due to neuron development.
• At least 600 mcg of folic acid(B9), 27 mg of elemental iron, and 150 mcg of iodine per day (fetal brain development), 1000mg of Ca, 600 IU of vitamin D for most women who are pregnant or planning pregnancy.
• Folic acid: Prevent brain, spinal cord defects; higher amount women at high risk of having a baby with neural tube defects, including those using certain anticonvulsants (carbamazepine, etc.)
• Feel comfortable suggesting an OTC prenatal; Don’t push prenatal with DHA (docosahexaenoic acid). There’s no proof they’ll significantly improve cognitive function in kids.
• Preeclampsia: a condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and proteinuria, Preeclampsia can lead to CV or kidney disease, or progress to eclampsia, which is the occurrence of grand mal seizures during pregnancy that are linked to high BP.

Lactation

• Lactation: A key factor to consider is plasma concentration, drugs with higher plasma concentrations have higher concentrations in the breast milk; adverse effects are more likely to occur in infants less than 2 months old, and are rarely associated with exposure to infants over 6 months.
• Factors that impact drug excretion into breast milk: Drugs with higher protein binding are less likely diffuse into the breast milk (NSAIDs are highly protein bound only found in small amounts in breastfed infants); recommend a shorter half-life drug; bioavailability: drugs with poor oral bioavailability (e.g: gentamicin) won't be absorbed much by infants; pharmacogenomics: codeine is metabolized to morphine. If a mother is an ultra-rapid metabolizer of codeine, both the mom and their breastfed baby will be exposed to more morphine.
• Avoid codeine and tramadol for pain, ↑ risk of sleepiness and breathing problems.
• Avoid breastfeeding if mother has HIV.
• Avoid amphetamine, ergots, lamotrigine/Li/phenobarbital, statins, metronidazole.

 Teratogen

• Drugs with smaller molecular weights or that are more lipophilic are more likely to cross the placenta barrier. 
• Fetal pH is slightly acidic, meds that are weak bases are more likely to cross placenta into fetal circulation. E.g., opioids are lipophilic and crosses the placenta, resulting in ↑ in neural tube defects, respiratory distress, and other birth defects.
• The old lettering category ABCDX has been replaced by "Pregnancy," "Lactation," and "Females and Males of Reproductive Potential,"
• Acne: Isotretinoin, topical retinoids
• Antibiotics: Quinolones, TCN (tendons and bones).
• Anticoagulant: Warfarin.
• Statins, RAAS inhibitors (ACEI, ARB, renin inhibitors).
• Sex hormones: estradiol, progesterone, testosterone, contraceptives.
• Ergots for migraine (ergotamine, dihydroergotamine): reduced blood flow.
• Others: immunosuppressants (methotrexate, hydroxyurea), topiramate/valproic acid: malformation, weight loss drugs, NSAIDs, benzos, etc.

 Nausea vomiting

• Symptoms begin at 4 to 6 weeks gestation, peak at 8 to 12 weeks gestation, subside by the 20th week
• Lifestyle is 1st line: small, frequent meal, avoid spicy/odorous food, frequent naps, avoid stress/long working hour
• OTC: acupressure bands (Sea-Band), ginger, B6 (pyridoxine) with or without doxylamine (Unisom)
• Rx: pyridoxine + doxylamine (Diclegis, Bonjesta)
• Metoclopramide (Reglan): cat B
• 5HT3 antagonist: ondansetron, granisetron (Kytril), dolasetron (Anzemet), all cat B.

Diarrhea

• nondrug measures first: reduce fat and dairy intake.
• Completely avoiding bismuth-containing agents or at least avoiding them AFTER the first half of pregnancy to avoid exposing the baby to salicylates. Loperamide is best avoided during pregnancy, and bismuth subsalicylate is best avoided when breastfeeding. Loperamide may be okay to use in a breastfeeding mom.

Hemorrhoids

• Straining from constipation and pressure on pelvic veins commonly leads to hemorrhoids during pregnancy.
• Suggest topical preparations: minimal systemic absorption
• Avoid vasoconstrictors such as ephedrine, epinephrine, or phenylephrine (Preparation H): may decrease swelling but cause vasoconstriction and may worsen conditions such as hypertension.

Cough/cold/allergy

• Recommend nondrug measures such as plenty of rest and fluids, a humidifier, and honey.
• Decongestants (pseudoephedrine, phenylephrine, oxymetazoline)should be avoided during the first trimester due to the potential risk of malformations.
• nasal decongestants are not risk-free, as they can be absorbed from the nasal mucosa, especially oxymetazoline (Afrin, in breastfeeding is ok).
• it's best to recommend a saline nasal spray for nasal stuffiness during pregnancy and breastfeeding.
• Recommend 1^stgeneration antihistamine (doxylamine), they help allergy symptoms and also have drying effect. Chlorpheniramine is the DOC with the best safety data, avoid brompheniramine (birth defects).
• Antitussives/expectorants such as guaifenesin and dextromethorphan are okay to use in pregnancy, but are not very effective. Some products contain codeine, which is associated with malformations in pregnancy and can cause opioid toxicity.
• Nasal steroid: budesonide or beclomethasone for allergic rhinitis, as they have more safety data.

 GERD

• elevated estrogen and progesterone levels may ↓ esophageal sphincter pressure and ↓gastric motility. 
• 1st line: small, frequent meal, maintain hydration, avoid spicy/odorous food, elevate head of bed
• Antacids are first line drug therapy, consider H2 blockers next, reserve PPI for moderate/severe symptoms.
• Simethicone (Gas-X, Mylicon): for gas

 Constipation

• rising progesterone level can reduce GI motility, prenatal vitamins containing iron can also contribute.
• 1st line: fluid intake, fiber in diet, physical activity.
• Consider bulking agents, such as psyllium. Fiber: Metamucil (psyllium), methylcellulose, Another option is polyethylene glycol (PEG) based osmotic laxatives (Miralax).
• Recommend senna (stool softerner) over bisacodyl (a stimulant laxatives, may work but usually cause more adverse effects such as cramping and diarrhea).
• Avoid lubricants (mineral or castor oil), mineral oil can decrease the absorption of fat soluble vitamins and castor oil has been associated with uterine contractions and diarrhea in infants.

Pain

• APAP is the drug of choice, possible link to ADHD/autism of child.
• Avoid NSAID, which are linked to miscarriage and certain birth defects, and a risk of premature closure of the ductus arteriosus in the third trimester.

Venous thromboembolism

• LMWH is preferred over heparin, compression device can be used.
• Warfarin is teratogenic

Hypertension

• Labetalol, methyldopa, nifedipine.

Hyperthyroidism

• PTU typically used in 1^st trimester, then switch to methimazole for the remaining trimesters. Both drugs carry risk for liver damage.

Asthma

• Maintenance: Inhaled budesonide, available in respules (Pulmicort) or Pulmicort Flexhaler
• Rescue: inhaled albuterol.

Infections

• Generally safe: PCN, cephalosporin, erythromycin/azithromycin (NOT clarithromycin), fosfomycin (Monural)
• UTI: nitrofurantoin or PCN (avoid Bactrim: increase bilirubin & kernicterus)
• Avoid quinolones (cartilage damage) and TCN (bone damage).
• Elevated hormone levels during pregnancy ↑ the risk of vaginal yeast infections.
• Topical azoles (clotrimazole) are first line during pregnancy, treat for at least 7 days. Bacterial vaginosis, anaerobic coverage: clindamycin preferred over metronidazole (avoid in 1st trimester)
• Avoid oral fluconazole, oral tab is linked to miscarriage in first or second trimester.

Vaccine

• Tdap recommended in each pregnancy preferably between 27 and 36 weeks' gestation, regardless of when they last had the shot.

 

Infertility

• The brand names can include part of the words: reproduce, follicle, gonadotropin, ovary etc.

Clomiphene (Clomid, Serophene)

• MOA: Ovulation stimulator that triggers pituitary gland to secrete an ↑ amount of FSH and LH, and acts as a selective estrogen receptor modulator (SERM).
• Warnings: risk of clotting like estrogen and multiple birth.
• 1^stline in women with irregular or absent period.
• SERM acts as estrogen agonist in some tissue and antagonist in other tissues.

Choriogonadotropin (Ovidrel)

• MOA: a gonadotropin analog similar to endogenous hCG (FSH and LH), hormone produced by human placenta. It causes the ovaries to release an egg.
• Specifically, an analogue of LH that binds to the LH/hCG receptors and effect changes in the absence of a LH surge.
• Warning: risk of multiple births.
• Used if poor response to clomiphene.
• Prefilled, inject into stomach, protect from light.

leuprolide (Lupron)

• MOA: a GnRH agonist.
• Initial use causes stimulation of gonadotropic secretion of FSH and LH (fertility) and leads to ↑ estrogen in females and testosterone in males.
• Continuous use suppresses gonadotropins and sex steroids, and ultimately resulting in ↓ levels of testosterone in males and estrogen in females (↓ hormone levels is needed to treat hormone-related conditions such as endometriosis, prostate cancer, etc.).
• Can be used to temporarily shut down hormonal production of ovary, to preserve reproductive ability in women undergoing chemotherapy.

 

Was this page helpful?

Back to top »