Drug use in pregnancy and lactation (3)
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Drug use in pregnancy and lactation (3)

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Drug use in pregnancy and lactation (3) Drug use in pregnancy and lactation (3) Presentation Transcript

  • Drug Use inPregnancy and lactation (3) By M.H.Farjoo M.D. , Ph.D. Shahid Beheshti University of Medical Science
  • Drug Use in Pregnancy and lactation (3)  Fetal Effects of NON Therapeutic Drugs  Selected Diseases  Neonatal Therapeutics  Drug Effects In LactationM.H.Farjoo Hamedan Medicine Faculty
  • Fetal Effects of NON Therapeutic Drugs  Alcohol  Caffeine  Cigarette smoking  Cocaine  Marijuana & HeroinM.H.Farjoo Hamedan Medicine Faculty
  • Alcohol  Is contraindicated during pregnancy; no amount is considered safe.  Heavy intake causes fetal alcohol syndrome characterized by multiple congenital defects and mental retardation.M.H.Farjoo Hamedan Medicine Faculty
  • Caffeine  It is present in coffee, tea, cola drinks, chocolate and OTC analgesics.  Ingestion of moderate amounts has caused spontaneous abortions, preterm births, and low birth weights.  High doses may cause cardiac dysrhythmias in the fetus.  It is recommend that healthy nonpregnant adults consume no more than 250 mg of caffeine daily.M.H.Farjoo Hamedan Medicine Faculty
  • Caffeine Amount In Drinks Amount (gram) Caffeine (mg)CoffeeBrewed, regular 142–227 40–180Instant 142–227 30–120Espresso 57 120TeaBrewed, leaf or bag 227 80Instant 227 50Iced 340 70Soft DrinksPepsi, Diet Pepsi 340 38
  • Cigarette smoking  Nicotine is contraindicated.  Effects include increased fetal, neonatal, and infant mortality; decreased birth weight and length; and increased complications of pregnancy. Placental abruption spontaneous abortion preterm deliveryM.H.Farjoo Hamedan Medicine Faculty
  • Cigarette smoking (Cont,d)  These effects are due to decreased flow of blood and oxygen to the placenta.  Chronic fetal hypoxia from smoking is associated with mental retardation and other long-term effects on physical and intellectual development.  Overall, effects of smoking are dose related:  Light smoking (<1 pack/day) fetal deaths increase by 20%  Heavy smoking (≥1 packs/day) increasing deaths by 35%.M.H.Farjoo Hamedan Medicine Faculty
  • Cocaine  May cause maternal vasoconstriction, tachycardia, hypertension, cardiac dysrhythmias, and seizures.  It impairs neurologic development, and increase the risk of spontaneous abortion during the first and second trimesters.  In third trimester, cocaine causes increased uterine contractility which increases the risk of abruptio placentae.  They are even more likely to occur with “crack” cocaine, a highly purified and potent form.M.H.Farjoo Hamedan Medicine Faculty
  • Marijuana & Heroin  Marijuana impairs formation of DNA and RNA.  It also may decrease the oxygen supply of mother and fetus.  Heroin increases the risks of pregnancy- induced hypertension, third trimester bleeding and complications of delivery.M.H.Farjoo Hamedan Medicine Faculty
  • Selected Diseases  AIDS  UTI (urinary tract infections)  Asthma  Diabetes Mellitus  Hypertension  EpilepsyM.H.Farjoo Hamedan Medicine Faculty
  • AIDS  HIV infection can be transmitted to the fetus and neonate, so treatment is needed.  Oral zidovudine (AZT) monotherapy has been used for several years, after 14 weeks of gestation.  During labor, IV AZT is given until delivery.  After delivery, the infant should be given AZT for 6 weeks, with or without other anti-AIDS drugs.  Highly active antiretroviral therapy (HAART) is being used for pregnant women.M.H.Farjoo Hamedan Medicine Faculty
  • AIDS (Cont,d)  HAART is a combination of drugs that may include:  A nucleoside reverse transcriptase inhibitor (zidovudine)  A non- nucleoside reverse transcriptase inhibitor (nevirapine)  A protease inhibitor (ritonavir)  Women with HIV infection or AIDS should be encouraged o avoid pregnancy.M.H.Farjoo Hamedan Medicine Faculty
  • UTI  Commonly occur during pregnancy and may include asymptomatic bacteriuria, cystitis, and pyelonephritis.  Asymptomatic bacteriuria should be treated in pregnancy because of its association with cystitis and pyelonephritis.  Asymptomatic bacteriuria are also associated with increased preterm deliveries and low birth weights.  Hospitalization and an IV cephalosporin may be needed for pyelonephritis.M.H.Farjoo Hamedan Medicine Faculty
  • Asthma  Asthma is associated with preeclampsia, perinatal death and congenital malformations.  Poor asthma control is considered more detrimental to a fetus than its treatment.  Good control is essential, drugs include inhaled β2 agonists & anti inflammatory agents.M.H.Farjoo Hamedan Medicine Faculty
  • Diabetes Mellitus  Poor glycemic control increases the risks of birth defects.  For diabetic women who become pregnant, maintaining normal blood sugar is required for successful outcomes.  Oral antidiabetic drugs should be stopped before conception or as soon as pregnancy is suspected.M.H.Farjoo Hamedan Medicine Faculty
  • Diabetes Mellitus (Cont,d)  Oral antidiabetic drugs are contraindicated in pregnancy, mainly because of fetal hypoglycemia.  It seems that acarbose, miglitol, and metformin have little risk for the fetus.  Insulin is the antidiabetic drug of choice during pregnancy.  Human insulin should be used because it is least likely to cause an allergic response.M.H.Farjoo Hamedan Medicine Faculty
  • Diabetes Mellitus (Cont,d)  Insulin requirements vary during pregnancy so blood glucose must be monitored closely and insulin therapy individualized.  It is especially important that sufficient insulin is given to prevent maternal acidosis.  Uncontrolled acidosis is likely to interfere with neurologic development of the fetus.  At the same time, careful dietary control and other treatment measures are necessary.M.H.Farjoo Hamedan Medicine Faculty
  • Diabetes Mellitus (Cont,d)  Insulin requirements usually decrease during the first trimester and increase after that.  During labor and delivery, short-acting insulin and frequent blood glucose tests should be used.  During the postpartum period, insulin requirements increase because of stress, trauma, infection and surgery.M.H.Farjoo Hamedan Medicine Faculty
  • Diabetes Mellitus (Cont,d)  At the same time, termination of the pregnancy reverses the diabetogenic hormonal changes and decreases insulin requirements.  Short-acting insulin is given, and dosage is based on frequent measurements of blood glucose.  Once the insulin requirement is stabilized, the client can return to the prepregnancy treatment program.M.H.Farjoo Hamedan Medicine Faculty
  • Hypertension  Chronic hypertension is hypertension beginning before conception or up to 20 weeks of pregnancy.  It is associated with increased maternal and fetal risks.  Nonpharmacologic interventions should be emphasized.  If drug therapy is required, methyldopa is the drug of first choice.M.H.Farjoo Hamedan Medicine Faculty
  • Hypertension (Cont,d)  Alternatives include beta blockers, clonidine, hydralazine, nifedipine, and prazosin.  With beta blockers, fetal and neonatal bradycardia, hypotension, hypoglycemia, and respiratory depression is reported.  Some authorities recommend avoiding the drugs during the first trimester and stopping them 2 to 3 days before delivery.M.H.Farjoo Hamedan Medicine Faculty
  • Hypertension (Cont,d)  Opinions seem divided on the use of ACE inhibitors.  Some sources say the drugs are contraindicated others say they can be used during the first trimester.  The same occur with angiotensin II receptor blockers (ARBs), because they also act on the renin angiotensin system.  Diuretics should not be given during pregnancy.  They decrease blood volume and may cause fluid and electrolyte imbalances.M.H.Farjoo Hamedan Medicine Faculty
  • Epilepsy  There has been controversy as to whether teratogenic effects stemmed from epilepsy or drugs.  A study indicates that the drugs are responsible.  The rate of birth defects was as follows: combination therapy 28% > monotherapy 20.6% > no therapy 8.5%.  Infants whose mothers took antiepileptics for bipolar disorder also had higher rates of birth defects.M.H.Farjoo Hamedan Medicine Faculty
  • Epilepsy (Cont,d)  Antiepileptics must be taken during pregnancy because seizure is harmful to mother and fetus.  Most pregnancies (95%) result in normal infants.  Monotherapy with the lowest possible dose is used and plasma drug levels should be checked monthly.  Women with epilepsy should take a folic acid supplement.  Supplemental vitamin K is needed in the last month of pregnancy, to prevent bleeding in neonates.M.H.Farjoo Hamedan Medicine Faculty
  • Neonatal Therapeutics  In the neonate, any drug must be used cautiously.  Drugs are usually given less often because they are metabolized and excreted slowly.  At birth, some drugs are administered to prevent hemorrhagic disease of the newborn and ophthalmia neonatorum.  Hemorrhagic disease occurs because the intestinal tract lacks the bacteria that synthesize vitamin K.M.H.Farjoo Hamedan Medicine Faculty
  • Neonatal Therapeutics (Cont,d) Vitamin K:  Vitamin K1 (Phytonadione) is found in food  Vitamin K2 (Menaquinone) is synthesized by intestinal bacteria  Vitamin K3 (Menadione) should NEVER be used. One dose of phytonadione 0.5 to 1 mg is injected at delivery. Jan. 2007
  • Neonatal Therapeutics (Cont,d)  Ophthalmia neonatorum is a bacterial conjunctivitis that may cause blindness.  It is caused most commonly by C. trachomatis, a sexually transmitted organism.  Erythromycin ointment is applied to each eye at delivery.  It is effective against both chlamydial and gonococcal infections.M.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation  Most drugs have not been tested in nursing women and their effect on infant is unknown.  Maternal drug use during lactation should be cautious.  There is some degree of risk with any systemic medication ingested by the mother.M.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  The dose reaching the infant is proportional to the mother’s drug concentration.  In many instances, the infant may not receive sufficient drug to produce adverse effects.  Most OTC and prescription drugs taken only when needed, are thought to be safe.M.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Safe Drugs In Lactation (NOT In Pregnancy):  Antibacterials (Penicillins And Cephalosporins)  Anticoagulants (Heparin Or Warfarin)  Antihypertensives (ACE Inhibitors, Ca2+ Blockers)  Caffeine (In Moderate Amounts)  Corticosteroids (Prednisolone or Inhaled Products)  Decongestants (Nose Drops or Spray)  Acetaminophen  CromolynM.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Safe Drugs In Lactation (NOT In Pregnancy):  Digoxin  Famotidine  Ibuprofen  Insulin  Levothyroxine  Mini-pill OCPs  Antiepileptics  AntihistaminesM.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Drugs to be used with caution in lactation:  Aspirin  Beta blockers (acebutolol, atenolol)  Corticosteroids (systemic drugs may suppress growth and interfere with endogenous corticosteroid production)  Diuretics  Dyslipidemics (cholestyramine [may cause severe constipation in the infant],statins)  Methadone  Metoclopramide  TheophyllineM.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Drugs to be used with caution in lactation:  Alcohol (within 2 hours of breast-feeding)  Aluminum-containing antacids  Amantadine  Antianxiety agents (benzodiazepines)  Antibacterials (chloramphenicol, metronidazole, nitrofurantoin, sulfonamides)  Antidepressants (bupropion, tricyclics, and selective serotonin receptor inhibitors)  Antihistamine (clemastine)  Antipsychotics (older or typical agents)M.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Contraindicated drugs in lactation (if they are required, breast feeding should be stopped):  Amiodarone  Antibacterials (fluoroquinolones, tetracyclines, trimethoprim [interfere with folic acid metabolism in the infant])  Antineoplastics  Bromocriptine (decreases milk production)M.H.Farjoo Hamedan Medicine Faculty
  • Drug Effects In Lactation (Cont,d)  Contraindicated drugs in lactation (Cont,d)  Cyclosporine  Drugs of abuse (amphetamines, cocaine, heroin, marijuana, phencyclidine, nicotine)  Ergotamine  Isotretinoin  Lithium  Phenytoin  Caffeine (large amounts)M.H.Farjoo Hamedan Medicine Faculty
  • Thank you Any question?