Drug use in pregnancy and lactation (3)


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Drug use in pregnancy and lactation (3)

  1. 1. Drug Use inPregnancy and lactation (3) By M.H.Farjoo M.D. , Ph.D. Shahid Beheshti University of Medical Science
  2. 2. 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
  3. 3. Fetal Effects of NON Therapeutic Drugs  Alcohol  Caffeine  Cigarette smoking  Cocaine  Marijuana & HeroinM.H.Farjoo Hamedan Medicine Faculty
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Selected Diseases  AIDS  UTI (urinary tract infections)  Asthma  Diabetes Mellitus  Hypertension  EpilepsyM.H.Farjoo Hamedan Medicine Faculty
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Thank you Any question?