Pregnancy and Lactation

Pregnancy & Lactation #5 ELLIE TABAR, PHARMD FEB 11,2025 PHAR 840/IPC IMMUNOLOGIC CONDITIONS AND SPECIAL POPULATIONS -Typlaal pregnanay 36-Youaals *confirm pregnency Human chorionic gonadotropin hormone (HCG) from unhe orbloed Pregnancy Backgrееn the mornus! -Best time to touke the test candy momig be H06 concentration Pregnancy lasts 36-40 weeks, divided into three trimesters. eminmat toins organs dael! hCG confirms pregnancy. The first trimester is when the embryo is most susceptible to teratogens. Teratogenic drugs should be discontinued before pregnancy. warfarin Accafh Toboca Alcohol valpornc add ◆ Pharmacokinetic changes require dose adjustments, e.g., levothyroxine for hypothyroidism. Tobacco Use in Pregnancy • Smoking during pregnancy increases risks of miscarriage, stillbirth, preterm birth, and low birth weight. • Infants exposed to tobacco smoke are at higher risk for SIDS, asthma, and respiratory issues. • USPSTF recommends behavioral counseling as the primary intervention. • Nicotine replacement therapy (NRT) use in pregnancy is approached with caution due to insufficient evidence es • Avoiding secondhand smoke exposure is critical for maternal and fetal health. • Quitting smoking during pregnancy significantly improves health outcomes for both mother and baby. 2/5/2025 5 Alcohol Use in Pregnancy • No Safe Amount: ACOG and other health organizations state no amount of alcohol is safe during pregnancy. • Fetal Alcohol Spectrum Disorders (FASDs):Alcohol use can cause birth defects and developmental disabilities. underdevelopingtangs go • Premature Birth: Drinking increases the risk of preterm birth and low birth weight. • Birth Defects: Alcohol exposure raises the risk of congenital abnormalities. Alcohol passing • Complete Abstinence Recommended: To protect the baby’s health, pregnant placengtal Blokenormal individuals should avoid alcohol entirely. developmatof 2/5/2025 byby 6 environmenttoxins A so Tabaso Common Teratogens If wecan'tswitchtothesafest • Teratogenic drugs should be discontinuedas in pregnancy. • About half of pregnancies are unplanned. • Medications with teratogenic risks are highlighted in drug labels. FDAcategory • Always review pregnancy risk factors when evaluating medications. 2/5/2025 7 tdemondofneutfent me Vitamin and Mineral Supplementation Brianspiralor Bapprotectptfronneunettubdefed Befrpregnenay • Women of childbearing age should take 400 mcg/day of folic acid. • Pregnancy increases folate requirements to 600 mcg/day. • Calcium and Vitamin D are crucial for fetal skeletal development. weeks effectonfirstfew progenay otters's • Pregnant women (19-50 years) need 1,000 mg/day of calcium and 600 IU/day of Vitamin D. • Prenatal vitamins are available OTC and by prescription. Did 2/5/2025 omega Helpwlayeondindadopmat 8 Drug Treatment in Pregnancy • Lifestyle modifications are preferred for treatment. • If ineffective, choose medications carefully. • Vaccinations in pregnancy follow specific guidelines. forBothMOM DAD livevaccine 2/5/2025 oHarmbabgemeningitist 10 song takethe testafter21 Pregnancy Tests • Urine Tests: Detect hCG in urine, commonly used at home, about 99% accurate. dayofmissing • Blood Tests: Conducted in a medical setting, detect hCG earlier and measure levels precisely. • Home Tests: Best used after a missed period for accurate results. • Clinical Confirmation: Blood tests and ultrasounds confirm pregnancy in medical settings. Best Time to Test: or Ruleoutoctopicprogeny • After a missed period for the most accurate results. Testing too early may lead to a false negative. • If Period is Irregular: Wait at least 21 days after unprotected sex before testing. • Use the first morning urine for higher hCG concentration, improving accuracy. • Retesting: If the initial test is negative but pregnancy is suspected, retest a few days later. 2/5/2025 11 congeption or spermand Egg fertilize most critical and Pregnancy TerminologyTetrgent • Trimesters: First Trimester: Weeks 1–13 • Second Trimester: Weeks 13–27 • Third Trimester: Weeks 28–40 Imf • Gestational Age: Time measured from the first day of the last menstrual period. • Full-Term Pregnancy: Typically lasts around 40 weeks. • Preterm Birth: Birth before 37 weeks. Inducethebaby weIf placentapassUIweek itstart • Post-term Pregnancy: Pregnancy lasting beyond 42 weeks. Theorganandnutrientsfrom placentadegrees Soit'sgoingto to age 2/5/2025 harmthebabyThatswhyinducing12 2/5/2025 13 Placental Drug Transfer: How Drugs Reach the Baby Drugs travel from mother’s blood → placenta → baby’s blood (via umbilical vein). • Some drugs are partially broken down in the fetal liver, while others circulate freely. • The placenta does not block all drugs—many can reach the baby and affect development. • Repeated drug doses = more exposure to the baby because the drug keeps recirculating. 2/5/2025 15 Placental Drug Exposure Risks Drugs can impact the placenta and fetus in different ways: 1. Direct Fetal Effects: Drugs cross the placenta and enter the baby’s bloodstream, affecting fetal development. Example: Opioids can cause neonatal withdrawal syndrome. 2. Placental Damage: Some drugs harm the placenta, reducing its ability to supply oxygen and nutrients. Example: Cocaine can cause placental abruption (separation from the uterus), leading to miscarriage. 3. Restricted Blood Flow (Vasoconstriction): Some drugs narrow blood vessels, reducing oxygen and nutrients to the fetus. Example: Nicotine and methamphetamines can cause low birth weight. 4. Teratogenic Effects (Birth Defects): Some drugs disrupt fetal development, especially in the first trimester when organs are forming. Example: Isotretinoin (Accutane) can cause severe birth defects. 5. Altered Fetal Metabolism: The fetal liver is immature, so it cannot break down drugs efficiently. Drugs stay longer in the fetal system, increasing toxicity risks. 6. Long-Term Developmental Effects: Some drugs may not cause immediate birth defects but can lead to learning disabilities, behavioral issues, or chronic diseases later in life, Example: Alcohol (Fetal Alcohol Syndrome) causes cognitive and growth problems. im 2/5/2025 16 pregeneycauses all theproblems CNIconsti Managing Nausea and Vomiting in Pregnancy Non-Pharmacological Management • Eat small • frequent meals • Avoid triggers like strong smells • Separate solids and liquids when eating • Use ginger or acupressure for relief. 2/5/2025 17 Managing Nausea and Vomiting in Pregnancy Pharmacological Management First-line: Vitamin B6 (Pyridoxine)(cat A) Second-Line Treatment: Doxylamine (cat B) Combination Therapy: (cat A) • Diclegis (Category A): Delayed-release 10 mg doxylamine + 10 mg pyridoxine • Bonjesta ER: 20 mg doxylamine + 20 mg pyridoxine 2/5/2025 18 Managing Nausea and Vomiting in Pregnancy Alternatives: (cat B) Notthesafest Antihistamines :OTC Benadryl (Diphenhydramine) or Dramamine (Dimenhydrinate) Phenothiazines: Promethazine (Phenergan) , Prochlorperazine (Compazine) , Chlorpromazine (Thorazine) 5-HT3 Receptor Antagonists: Ondansetron (Zofran), Dolasetron (Anzemet), Granisetron (Kytril) Severe Cases (Hyperemesis Gravidarum) : Diagnosed with severe dehydration, weight loss, or electrolyte imbalance. • Treatment: IV fluids, antiemetics, or hospitalization if needed 2/5/2025 19 Thereasonbehindit i Hormonechanges motility suturesisgewing no Constipation Management During Pregnancy Avoids ✔ Affects ~40% of pregnant women MS ✔ May contribute to hemorrhoid development Funting 8alassidey Management: walking sodium ✅ First-line: High dietary fiber, fluid intake, and moderate physical activity ✅ Second-line: Bulk-forming agents (e.g., Psyllium) and stool softeners ✅ Osmotic laxatives (e.g., Milk of Magnesia) may be used occasionally ✅ Stimulant laxatives (e.g., Senna, Bisacodyl) should be used only short-term ⚠ Caution: - Magnesium & sodium salts may cause electrolyte imbalance - Stimulant laxatives can lead to dependency - Avoid mineral oil (impairs fat-soluble vitamin absorption) 2/5/2025 Be ofdyhydzation electrolyte leadto salt mineral oil Absourbugter imbona psylliamar makeitbiggeran easiertopass 20 hormonalchanges pressureand a and Heartburn Relief During Pregnancy GERD Firstline good • Lifestyle Modifications( eg, Eat Small, Frequent Meals, Avoid Trigger Foods, Stay Upright After Eating, Elevate the Head During Sleep) Pharmacological Management: Foyt 1. Antacids: Calcium-based antacids (e.g., Tums) are generally safe and can provide quick relief. • Avoid antacids containing sodium bicarbonate or magnesium trisilicate. BID or Beoftheegtroytaiddone refamotidire 2. H2 Receptor Antagonists 3. Proton Pump Inhibitors (PPIs) I lonelimitedsource 201med omeppo 2/5/2025 21 Lf uoutolerateheadach painiHighBp asmoreofthe badSE Headache & Pain Management During Pregnancy ✔ Most common types: Tension headaches & migraines ✔ Migraine improvement is likely during pregnancy (~50% of cases) Management: ✅ Non-Pharmacologic: Stress management, relaxation, hot/cold packs ✅ First-line: Acetaminophen (DOC for pregnancy, Category C) ✅ Second-line: Caffeine in limited amounts, Magnesium supplements the B2 ✅ Preventative: Riboflavin, Coenzyme Q10, Pyridoxine (Vitamin B6) ✅ Propranolol at the lowest effective dose (if needed) ⚠ Caution: gtd a - NSAIDs: Category C in 1st & 2nd trimester, Category D in 3rd trimester (>30 weeks) - Triptans: Contraindicated in the 3rd trimester - Avoid opioids when possible due to dependency risks 2/5/2025 caffeinegoodfor migrinebutlimited Bsitcausepreturne BirthIlownegatel 22 Asthma Management During Pregnancy ✔ Asthma is a common chronic condition in pregnancy ✔ Poorly controlled asthma increases risks: preeclampsia, preterm labor, fetal growth restriction, stillbirth Management Goals: ✅ Maintain asthma control with the lowest effective dose ✅ Inhaled corticosteroids (ICS) are preferred for long-term control - Budesonide is the preferred ICS (Category B, safest for pregnancy) ontorta mopgarHFA ✅ Short-acting beta-agonists (SABAs) for acute symptoms (e.g., Albuterol) ✅ Monitor lung function regularly and adjust therapy as needed ⚠ Caution: everywhere me - Avoid systemic corticosteroids unless necessary due to fetal risks - Poor asthma control poses a higher risk than controlled medication use 2/5/2025 23 Cold, Cough & Rhinitis Management During Pregnancy ✔ Common due to immune and hormonal changes during pregnancy Management: ✅ First-line (DOC for allergic rhinitis): Chlorpheniramine (Category B) ✅ Alternative antihistamines: Loratadine or Cetirizine (Category B, less sedating) ✅ First-line for congestion: Saline Nasal Spray (Category A) – Safe & effective ✅ Intranasal corticosteroids (ICS): Budesonide (Preferred, Category B) ✅ First-line for cough: Honey, throat lozenges, hydration ✅ Dextromethorphan (Category C) – Can be used if necessary for short-term relief ✅ Acetaminophen for fever or pain (Category C, safest option) ⚠ Caution: vascular issues orcause - Avoid pseudoephedrine in the first trimester (risk of birth defects) rebated - Limit intranasal decongestants (Afrin, Neo-Synephrine) to short-term use - Avoid NSAIDs (Category C in 1st/2nd trimester, Category D in 3rd trimester) at - Avoid codeine-containing cough syrups due to risk of fetal harm 2/5/2025 24 Tetrogdinentours pregnancycontraindil UTI Management During Pregnancy WIFIO ✔ UTIs are common in pregnancy and require prompt treatment to prevent complications uinolonsfl my Management: t ✅ First-line antibiotics: Cephalexin (Keflex), Amoxicillin, Augmentin (Category B) ✅ Nitrofurantoin (Macrobid) – **Avoid near-term (38-42 weeks)** due to risk of hemolytic anemia Iftikhar ✅ Fosfomycin – Safe alternative for uncomplicated UTI ✅ For pyelonephritis: Ceftriaxone IV or Ampicillin + Gentamicin ⚠ Caution: GBcotsepsis - **Avoid fluoroquinolones (e.g., Ciprofloxacin, Levofloxacin)** – Risk of fetal cartilage toxicity (Category C) Brosindonge pp Bactrim (Trimethoprim-Sulfamethoxazole) in the first trimester and near-term** – Risk of neural tube defects & kernicterus - **Avoid a locking He - **Untreated UTI can lead to preterm labor and low birth weight** 🔹 Always perform a urine culture before and after treatment to confirm eradication. FA 2/5/2025 be folicacidprevent neuraltubedefeats 25 compsia avayhighBP prog to med Hospital mad Hypertension Management During Pregnancy • ✔ Hypertension in pregnancy includes chronic HTN, gestational HTN, and preeclampsia • Management: ontrain• GB indication yqtauserftscton.fi Tontra ✅ First-line (DOC): Labetalol (Beta-blocker, Category C) – Preferred option contra • ✅ Alternative: Nifedipine (Extended-release, Category C) – Safe & effective capzaa • ✅ Methyldopa (Category B) – Historically used but less effective • ⚠ Caution: y Don'teadaourkidnaytodeetop • - **Avoid ACE inhibitors (e.g., Lisinopril, Enalapril) & ARBs (e.g., Losartan) – Teratogenic (Category D/X)** • - **Avoid Atenolol – Risk of fetal growth restriction** • - **Monitor for preeclampsia signs (e.g., proteinuria, severe HTN, edema)** • 🔹 Severe HTN (≥160/110 mmHg) requires urgent treatment to prevent maternal and fetal complications. • 🔹 Delivery may be indicated if preeclampsia is worsening despite treatment 2/5/2025 26 Preeclampsia: Understanding the Condition ✔ Preeclampsia is a serious pregnancy-related condition that develops after 20 weeks of gestation. It is characterized by high blood pressure, protein in the urine, and potential organ damage. What Happens in Preeclampsia? • During normal pregnancy, blood vessels in the placenta expand to allow better blood flow to the baby. • In preeclampsia, these blood vessels do not widen properly, leading to reduced blood flow to the placenta. • This causes poor oxygen and nutrient supply, leading to placental stress and the release of harmful substances into the mother’s bloodstream. • These substances trigger widespread blood vessel constriction and inflammation, resulting in high blood pressure and organ damage. 2/5/2025 27 EXIT Preeclampsia: Understanding the Condition Symptoms of Preeclampsia PSS ✅ High blood pressure (≥140/90 mmHg) after 20 weeks ✅ Protein in the urine (sign of kidney stress) ✅ Swelling in hands, face, and legs ✅ Severe headache, vision changes, or upper right abdominal pain Why is Preeclampsia Dangerous? • Can restrict baby’s growth due to poor blood flow. • Increases risk of preterm birth, placental abruption, and stillbirth. • In severe cases, it can cause seizures (eclampsia), stroke, liver or kidney failure in the mother. 2/5/2025 28 Mg orRego Preeclampsia: Understanding the Condition How is it Managed? ✅ Blood pressure control with safe medications like Labetalol, Nifedipine, or Methyldopa. ✅ Magnesium sulfate is given if seizures are a risk. ✅ Close monitoring of the baby and mother for signs of worsening disease. ✅ The only cure is delivery of the baby and placenta, often earlier than the due date if symptoms are severe. 💡 Early detection and proper management help protect both mother and baby from serious complications. NMg 2/5/2025 ERasthma arythia proedarifa seizures 29 largebabyifpoint payattentiontoPB Diabetes Management During Pregnancy ✔ Includes pregestational diabetes (Type 1 & 2) and gestational diabetes (GDM) Management: ✅ First-line (DOC): **Insulin** – Preferred for blood sugar control (Does not cross placenta) ✅ Alternative: **Metformin & Glyburide** – May be used if insulin is not an option ✅ Lifestyle modifications: Diet, exercise, and glucose monitoring Glycemic Targets (ADA 2024 Guidelines): ✔ Fasting glucose: **≤95 mg/dL** ✔ 1-hour postprandial: **≤140 mg/dL** ✔ 2-hour postprandial: **≤120 mg/dL** 2/5/2025 30 Diabetes Management During Pregnancy ⚠ Caution: - **Avoid oral sulfonylureas (except Glyburide) due to neonatal hypoglycemia risk** - **Avoid SGLT2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors during pregnancy** - **Poor glycemic control increases risk of fetal macrosomia, preeclampsia, and stillbirth** 🔹 Screening for gestational diabetes (GDM) occurs at **24-28 weeks gestation** using the **1-hour glucose challenge test (GCT)**. 🔹 If GDM is diagnosed, postpartum glucose screening is needed to assess for Type 2 diabetes risk. 2/5/2025 31 Routine Vaccination During Pregnancy ✔ Vaccination during pregnancy protects both mother and baby from preventable diseases. ✅ Recommended Vaccines: • Influenza (Inactivated) – Safe in any trimester; prevents severe flu complications. • Tdap (Tetanus, Diphtheria, Pertussis) – Given at 27-36 weeks to protect newborns from pertussis. • COVID-19 Vaccine – Recommended to reduce severe illness risk. ⚠ Contraindicated Vaccines (Avoid Live Vaccines): • MMR (Measles, Mumps, Rubella) • Varicella (Chickenpox) • Live Influenza Vaccine (FluMist) • HPV Vaccine (Defer until postpartum) 2/5/2025 32 Routine Vaccination During Pregnancy 🔹 Additional Vaccines (Based on Risk Factors): • Hepatitis B – Recommended for unvaccinated or at-risk mothers. • RSV Vaccine – Consider between 32-36 weeks during RSV season for newborn protection. • Hepatitis A, Pneumococcal, and Meningococcal vaccines – Given only if indicated by risk factors. 💉 Maternal immunization is crucial for protecting newborns during early infancy. 2/5/2025 33 Thyroid Management During Pregnancy • ✔ Thyroid disorders in pregnancy can affect both maternal and fetal health. Proper management is essential. ✅ Hypothyroidism Management (Underactive Thyroid) • First-line (DOC): Levothyroxine (Category A) – Safest and most effective treatment. • Dose adjustments: Increase levothyroxine dose by 30-50% as early as the first trimester. • Monitor: TSH levels every 4-6 weeks during pregnancy to maintain levels within trimester-specific ranges. ⚠ Caution: • Untreated hypothyroidism increases the risk of miscarriage, preeclampsia, preterm birth, and developmental issues. • Avoid overtreatment to prevent fetal hyperthyroidism. • Take levothyroxine on an empty stomach, separate from prenatal vitamins (iron/calcium interfere with absorption). 2/5/2025 34 Thyroid Management During Pregnancy ✅ Hyperthyroidism Management (Overactive Thyroid) • Mild cases: Often require no treatment; just close monitoring. • Moderate to severe cases: • First trimester: Propylthiouracil (PTU) – Preferred (Category D but safer early in pregnancy). • After first trimester: Switch to Methimazole (MMI) – Lower risk of liver toxicity than PTU. ⚠ Caution: • Avoid high doses of anti-thyroid medications to prevent fetal hypothyroidism and goiter. • Untreated severe hyperthyroidism (e.g., Graves’ disease) increases risk of miscarriage, preterm birth, and fetal heart failure. • Beta-blockers (e.g., Propranolol) may be used short-term for symptom control (tachycardia, tremors). 2/5/2025 35 Thyroid Management During Pregnancy • Beta-blockers (e.g., Propranolol) may be used short-term for symptom control (tachycardia, tremors). 🔹 Postpartum Considerations • Postpartum thyroiditis can occur and mimic hyperthyroidism initially, then progress to hypothyroidism. • Monitor TSH and symptoms postpartum, especially in those with a history of thyroid disorders. 💡 Key Takeaways: ✔ Levothyroxine is the DOC for hypothyroidism; adjust doses early. ✔ PTU is preferred in the first trimester for hyperthyroidism; switch to MMI later. ✔ Monitor thyroid function closely throughout pregnancy. 2/5/2025 36 need The NOTin The etat 2/5/2025 37 2/5/2025 38 Exclusively breastfeed for the first 6 months. • Introduce solid foods at 6 months while continuing breastfeeding. • Continue breastfeeding for at least 1 year, and up to 2 years or beyond, if desired. 2/5/2025 39 Definition: • Lactation: Production and secretion of milk from mammary glands post-delivery. Purpose: • Provides essential nutrients and immune protection to the newborn. 2/5/2025 40 Hormonal Regulation • Components: • Alveoli: Milk-producing sacs lined with secretory cells. • Ducts: Channels transporting milk from alveoli to the nipple. • Myoepithelial Cells: Surround alveoli; contract to expel milk. 2/5/2025 41 Hormonal Regulation Prolactin: • Stimulates milk production. • Levels increase during pregnancy; milk secretion inhibited until after birth. Oxytocin: • Triggers milk ejection (let-down reflex) in response to infant suckling. Let-Down Reflex - Mechanism: • Infant suckling stimulates nerve endings in the nipple. • Signals sent to the hypothalamus prompt oxytocin release. • Oxytocin causes myoepithelial cells to contract, expelling milk into ducts. 2/5/2025 42 Lactational Amenorrhea Method (LAM) • Exclusive breastfeeding can naturally suppress ovulation, serving as a temporary contraceptive method. Criteria for Effectiveness: • Baby is less than 6 months old. • Mother is exclusively breastfeeding. • Menstrual periods have not resumed. • Over 98% effective when all criteria are met. 2/5/2025 43 What is Relactation? •Relactation is the process of increasing or resuming breast milk production. •It helps mothers who have stopped breastfeeding or struggle with low milk supply. 2/5/2025 44 no Relactation enoughty momcan'tproduce Non-Pharmacological Methods •Frequent Breastfeeding: Nursing signals the body to produce more milk. Ideally, feed every 1-2 hours. •Frequent Breast Pumping: If direct breastfeeding isn't possible, pump every 2-3 hours. Helps mimic baby's feeding pattern. Pharmacological Methods •Metoclopramide 10 mg TID (Three Times Daily) for 7-14 Days •Increases prolactin levels to stimulate milk production. •Used short-term due to potential side effects (fatigue, mood changes, risk of depression). 2/5/2025 45 Drug Transfer into Breast Milk • Most medications are safe during breastfeeding, but each case must be evaluated. Low Risk (Generally Safe): •Drugs with low oral bioavailability (poorly absorbed by the infant). Stayinbody • Short half-life medications (cleared quickly from the mother’s body). shorter • Drugs with extensive protein binding (less drug enters milk). High Risk (Use with Caution or Avoid): •Cytotoxic drugs, radioactive substances, or high-dose opioids. •Long half-life medications(may accumulate in infant). •Drugs affecting CNS function(sedatives, antipsychotics, etc.). 2/5/2025 46 AAP Recommendations for Safe Medication Use •Use the lowest effective dose for the shortest duration. •Monitor infant for side effects (drowsiness, feeding difficulties, irritability). •Time breastfeeding to minimize infant exposure (e.g., nurse before taking medication). Single-Dose Medications: • Prefer medications that can be taken once daily. • Schedule just before the infant’s longest sleep interval. Multiple Daily Doses: •Take immediately after breastfeeding to maximize the gap before the next feeding. 2/5/2025 47