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DRUGS IN PREGNANCY

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     				DRUGS IN PREGNANCY DRUGS IN PREGNANCY Presentation Transcript

    • DRUGS IN PREGNANCY www.doctor.sd
      • INTRODUCTION:
      • ONE SHOULD USE A SMALL ARMAMENTARIUM OF DRUGS THAT HAVE A PROVEN VALUE WITH KNOWN AND RECORDED MINIMAL SIDE EFFECTS.
      • CONSIDER THAT ALL DRUGS MAY AFFECT THE FETUS "EXCEPT HEPARIN & INSULIN".
      • MANY PATIENTS ARE EXPOSED TO ' OVER-THE-COUNTER' MEDICINES DURING THE FIRST TRIMESTER WITH POTENTIAL RISKS.
      • CONSIDER THAT ALL PATIENTS ARE AT RISK OF PREGNANCY DURING THEIR REPRODUCTIVE YEARS.
      • ALWAYS CONSIDER THE RISK OF THERAPY AGAINST THE POTENTIAL FOR NOT TREATING THE DISEASE.
      DRUGS IN PREGNANCY [1] www.doctor.sd
      • PHARMACOKINETICS:
      • A) MATERNAL;
      • 1] DRUG ABSORPTION- - IS AFFECTED BY PHYSIOLOGICAL CHANGES IN PREGNANCY,
      • ALMOST ALL DRUGS CAN CROSS THE PLACENTA,
      • GASTROINTESTINAL TRANSIT IS PROLONGED DUE TO SLOW STOMACH EMPTYING.
      • 2] DRUG DISTRIBUTION- - LIPID SOLUBILITY & PROTEIN BINDING AFFECT THE DISTRIBUTION,
      • PLASMA ALBUMINS FALL DUE TO INCREASED TOTAL BODY WATER & PLASMA VOLUMES.
      • 3] DRUG METABOLISM- - WATER-SOLUBLE DRUGS ARE ELIMINATED UNCHANGED,LIPID-SOLUBLE ARE METABOLIZED BY OXIDATION,OR CONJUGATED IN THE LIVER.
      • 4] DRUG EXCRETION- - IS INCREASED DUE TO THE INCREASED RPF,GFR AND CREATININE CLEARANCE
      [2] www.doctor.sd
      • B) FETAL;
      • DRUG DISTRIBUTION,METABOLISM AND EXCRETIONS OCCUR IN THE FETUS AND PLACENTA,
      • FETAL LIVER AND ADRENAL GLAND METABOLIZES DRUGS BY OXIDATION,OXIDATIVE DEALKYLATION, REDUCTION HYDROXYLATION,HYDROLYSIS AND CONJUGATION.
      • LOW-MOLECULAR-WEIGHT DRUGS DIFFUSE EASILY ACROSS THE PLACENTA,AMINO ACIDS TRANSPORT BY ACTIVE TRANSFER,
      • LIPID SOLUBILITY AND PLASMA PROTEIN BINDING ARE CONTRIBUTORY FACTORS.
      [3] www.doctor.sd
    • BASIC RULES OF PRESCRIBING IN PREGNANCY
      • A) REMEMBER THE OBSTETRIC RULES:
      • 1. FIRST DO NO HARM
      • 2. NEVER BE THE FIRST TO USE THE NEW,NOR THE LAST TO USE THE OLD
      • 3. REMEMBER THAT ALL WOMEN ARE PREGNANT UNTILL PROVED OTHERWISE.
      • B) PRESCRIBING IN PREGNANCY:
      • 1. PRECONCEPTIONALLY; THE PATEINT MAY BE TAKING DRUGS
      • 2. THE PATIENT MAY BE TAKING DRUGS AND FIND SHE IS PREGNANT
      • 3. THE PATIENT WHO IS PREGNANT MAY REQUIRE DRUG TREATMENT.
      [4] www.doctor.sd
    • Fetal therapy Teratogenesis 1/3 trimester 2/3 trimester 3/3 trimester labour puerperium Pre-pregnant Medical disorders of pregnancy Prelabour Induction of labour Analgesics Oxytocics Depression Contraception Breast-feeding Drugs of abuse Antibiotics POTENTIAL RISKS AT DIFFERENT MONTHS OF PREGNANCY [5] www.doctor.sd
      • DIETARY ADVICE:
      • DEFICIENCIES IN PROTEINS,VITAMINS,MINERALS OR TRACE ELEMENTS CAN AFFECT FETAL GROWTH& DEVELOPMENT.
      • THE OPTIMAL WEIGHT GAIN IN PREGNANCY ;FOR THIN WOMEN=12.5 Kg, AND FOR OBESE=5-10 Kg.
      • DIETARY SUPPLEMENTATION:
      • IS AIMED,AMONGST OTHER FACTORS,TO REDUCE CONGENITAL MALFORMATIONS;
      • 1) VITAMINS: DAILY DOSE OF 400 U VIT. D=LOWER THE RISK OF NEONATAL RICKETS,DENTAL ENAMEL DISPLACEMENT.
      • VIT. A = EXCESSIVE DOSE >40 OOO IU,CAN BE HAZARDOUS.
      • FOLIC ACID = DAILY DOSE OF 0.4 mg, WILL REDUCE THE INCIDENCE OF NTD.
      • 2) HAEMATINICS: ORALLY= FERROUS SALTS: SULPHATE , GLUCONATE AND FUMARATE,
      • PARENTERALLY= I.M.,IV. OR AS TOTAL IRON INFUSIONS
      [6] www.doctor.sd
      • PAST OBSTETRIC HISTORY:
      • 1) OVULATION-INDUCING DRUGS;
      • CLOMIPHENE CITRATE -- 2 TO 3X RISK OF STD AND OVARIAN MALIGNANCY,FOLLOWING EXCESSIVE USE >12/12.
      • 2) HORMONES;
      • -DES = PRENATAL EXPOSURE,FOR THREATENED ABORTION, MAY CAUSE ADENOCA OF VAGINA.
      • -PROGESTOGENS = USED IN RECURRENT MISCARRIAGES AND POOR LUTEAL PHASE. NO NEED TO USE THEM NOW.
      • -ORAL CONTRACEPTIVES = SUPPRESS FOLATE AND PYRIDOXINE LEVELS, NO OTHER HARMS.
      • -ANTICOAGULANTS = ASPIRIN(75 Mg)& HEPARIN – ARE USED IN CASES OF RECURRENT ABORTIONS DUE TO SLE OR RAISED APA.
      • -OTHERS = ASPIRIN & NITRIC OXIDE ARE ALSO USED TO IMPROVE UTERINE PERFUSION IN RECURRENT MISCARRIAGES.
      [7] www.doctor.sd
      • C) STD; THE COMMONEST COMMUNICABLE DISEASES GLOBALLY. SCREENING FOR SYPHILIS & AIDS IS IMPORTANT.ABOUT 30% OF THEIR BABIES WILL BE HIV +VE.
      • D) VACCINATION & TRAVEL ; FOR YELLOW FEVER,CHOLERA,POLIOMYEILITIS AND INFLUENZA CAN BE GIVEN ANTENATALLY. RUBELLA VACC. IS ALLOWED ONLY PRE- CONCEPTUALLY OR POSTPARTUM.
      [8] www.doctor.sd
      • SOCIAL HISTORY:
      • A) DRUGS OF ABUSE =THESE PATIENTS ARE ALSO SUBJECT TO STD (HEPATITIS B & HIV). USUALLY SOCIALLY DEPRIVED.
      • 1 ) CIGARETTES – CAUSE IUGR DUE TO NICOTINE ( VASO- CONSTRICTOR) AND ELEVATED CO.
      • 2) ALCOHOL – SHOULD BE RESTRICTED TO ZERO ( FAS !).
      • 3) NARCOTICS – MAY CAUSE; a) IUGR b) INCREASED SB RATE c)NEONATAL ABSTINENCE S. d) SUDDEN INFANT DEATH SYND.
      • 4 ) BENZODIAZEPINES – LEAD TO WITHDRAWAL EFFECTS.
      • 5) COCAINE – THE ONLY DRUG OF ABUSE THAT IS TRULY TERATOGENIC; LOWER BIRTH WEIGHT,PLACENTAL ABRUPTIO, IUFD AND STRUCTURAL ANOMALIES.
      • 6) MARIJUANA – ABSENCE OF MAJOR ADVERSE EFFECTS.
      • 7) CAFFEINE – IN COFFEE,TEA,CHOCOLATE AND ‘OVER-THE-COUNTER’ PREPARATIONS—IT INCREASES MISCRRIAGE & SB RATE.
      • B) DRUG MANAGEMENT = IS AIMED AT ;(1) WITHDRAWAL FROM THE DRUGS,(2) MAINTENANCE OF TOTAL ABSTINENCE.”ZIDOVIDINE” CAN BE USED IN DOSES 300-1200 MG/D, QUITE SAFE.
      [9] www.doctor.sd
      • GENERAL MEDICAL DISORDERS ; A) EPILEPSY = A RISK OF FETAL MALFORMATIONS WHICH IS INCREASED ON TAKING ANTIEPILEPTICS – THESE ARE : 1) MINOR STRUCTURAL WITH NO THREAT TO HEALTH. 2) MAJOR = CLEFT LIP,SPINA BIFIDA AND CHD. ANTIEPILEPTICS : ( a)VALPORATE —SPINA BIFIDA & CRANIAL + FACIAL ANOMALIES.( b) CARBAMAZEPINE – SPINA BIFIDA. ( c) PHENOBARBITONE – CHD & CLEFT PALATE.( d) PHENYTOIN – HYDANTOIN SYNDROME.
      • MANAGEMENT:(1) ADVICE HIGHER DOSES OF COCS. (2) FOLIC ACID(4-5MG) BEFORE CONCEPTION AND UP TO 12/52 PREGNANCY .(3) ADVISE SINGLE DRUG AND LOWEST DOSE. CARBAMAZEPINE IS THE DRUG OF CHOICE .(4) VITAMIN K TO BE GIVEN AT BIRTH TO PROTECT THE INFANT.
      • B) PSYCHIATRIC ILLNESS = like depression (a) Meprobamate or benzodiazepines --- serious neonatal symptoms.Not teratogenic. b ) (Monoamine-oxidase inhibitors– c/i in pregnancy due to anaesthesia .(c) Tricyclic antidepressants--- babies refusal to feed. (d) Lithium salts ;lithium clearance in pregnancy increases.It may affect the fetus causing cyanosis,lethargy,hypotonia,poor suckling and CHD .(e) Phenothiazines can cause Parkinsonism .
      [10] www.doctor.sd
      • C)TRANSPLANTATION : INCLUDING RENAL,LUNG,LIVER,BONE MARROW AND HEART.SURVIVAL RATE = 70-80%.DRUGS USED; 1)ADRENAL STEROIDS – PEPTIC ULCERATION, OSTEOPOROSIS,HYPERTENSION,MATERNAL INFECTION AND POOR TISSUE HEALING. 2)AZATHIOPRINE – HEPATIC TOXICITY,BONE MARROW DEPRESSION,INFECTION AND NEOPLASIA. 3)CYCLOSPORIN – NEPHROTOXICITY,ELEVATED SERUM URIC ACID,LYMPHOMAS AND VIRAL INFECTION. D) HYPERTENSION : MOST DRUGS HAVE A FAVOURABLE BENEFIT. ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ARE CONTRAINDICATED. E)DIABETES MELLITUS : ORAL HYPOGLYCAEMICS ARE CONTRAINDICATED.
      [11] www.doctor.sd
      • INDUSTRIAL HISTORY
      • A)OPERATING THEATRES : VOLATILE GASES MAY CAUSE SPON. ABORTIONS AND CONGENITAL ANOMALIES. SCAVENGER SYSTEMS SHOULD BE INSTALLED. B) LAUNDRIES : ORGANIC SOLVENTS CAN CAUSE ANENCEPHALY OR FETAL DYSMORPHOLOGY. C) COMPUTERS : NO RISK. D) SAUNAS : NO HARM .
      • FAMILY HISTORY GENDER CHOICE : DIETS HIGH IN SODIUM & POTASSIUM AND LOW IN CALCIUM & MAGNESIUM ARE REPORTED TO GIVE AN 80% CHANCE OF A MALE FETUS.
      [12] www.doctor.sd
      • TERATOGENESIS
      • A TERATOGEN: IS AN AGENT THAT CAUSES PHYSICAL AND/OR DEVELOPMENTAL ABNORMALITIES IN THE EMBRYO OR THE FETUS.
      • TIMING OF FETAL LIFE: [ 1 ]PRE-EMBRYONIC PHASE = 1–17 DAY POSTCONCEPTION [ 2 ] EMBRYONIC = 18-55 DAY. [ 3 ]ORGANOGENESIS.
      • TERATOGENIC MECHANISMS : (a) DIRECT EMBRYO TOXICITY. (b) INDIRECT TOXICITY– BY ALTERATION OF METABOLIC FACTORS. (c) GENETIC FACTORS– DETERMINING THE SUSCEPTIBILITY TO TERATOGENESIS (WARFARIN !).
      • CLASSIFICATION: {1} MAJOR TERATOGENS = WITH PROVEN RISKS [THALIDOMIDE,CYTOTOXICS AND RADIOCHEMICALS]. {2} DRUGS WITH SMALL RISKS BUT OCCASIONALLY NEEDED FOR THE HEALTH OF THE WOMAN.
      [13] www.doctor.sd