This slides deals with the antibiotics that are considered safe and unsafe during pregnancy and least why they are contraindicated

1. Drug handling during pregnancy

2. Outline
• Physiologic changes during pregnancy
• FDA categories
• Anti microbials in pregnancy
– Anti bacterial
– Anti Malarial
– Anti viral
– Anti Fungal
– Anti Helminthes
• Selected teratogenic drugs
• Summary
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3. Introduction
• Pregnancy
– having a developing fetus in the body
– lasts 280 days or 40 weeks from LNMP
– causes complex physiologic changes, including;
o Endocrine
o Renal
o Gastrointestinal
o Skin 3
o Genital
o Cardiovascular
o Hematologic
o Pulmonary

4. Physiologic changes during pregnancy
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5. Pk changes
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• ↓gastric acidity - ↓ BA for weak
acid drugs e.g Ampicilin
• vomiting ↓ ingested drug
• ↑ TBW ↑Vd larger doses of
water soluble drugs
• hypoalbuminemia ↓PBP
↑ free concentration of the drug

6. 6
• CYP3A4 and CYP2D6 activities
• CYP1A2, activity ↓
• RBF ↑ by 25-50% at early gestation
↑renal drug excretion (e.g., β-
lactams, digoxin) ↑
↑

7. 7
•molecular weight
•lipid solubility,
•degree of ionization
•protein binding
•transporters
•P-glycoprotein
• efflux of the drug
• limited metabolic enzymatic
activity
•Decreased GFR
•ion trapping

8. Drug safety in pregnancy
• Is about the effect of drugs on the pregnancy,
fetus or neonate & effects of pregnancy on
drug disposition
• 50 – 100% of maternal drug level might reach
to the fetus
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9. • The Food and Drug Administration (FDA)
created a rating system in 1979 to categorize
the potential risk to the fetus for a given drug.
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10. FDA Pregnancy categories
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11. Antibiotics during pregnancy
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FDA category Antibiotics in the category

12. Effect of drugs on the fetus
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All or none Teratogenicity
Effect also depend on ; dose, frequency and duration of treatment

13. Crucial questions in obstetric Tx
• Who is being treated; the mother, the fetus or
both?
• What dose is appropriate for a pregnant
woman?
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14. Bacterial infections & their Tx in
pregnancy

15. UTI
In Mother
- Predisposed due to different physiological reasons
- short urethra, pregnancy hormones
- hematuria, dysuria, urgency, flank pain, tachypnea,
dehydration.
In Fetus
- miscarriage, IUGR, sepsis, preterm labor,
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16. 16
Uncomplicated
Ciprofloxacin , Norfloxacin ,
Nitrofurantoin,
Cefopodoxime
- Complicated-
-Ampicillin + Gentamicin (IV)
-Cephotaxime,
Recurrent-
- Cotrimoxazole
-Cephalexin,
-Norfloxacin,
nitrofurantoin
Amoxicillin
Cephalexin
Trimetoprim/Sulphamethoxazole

17. C/I
Norfloxacin & Levofloxacin
• Erosion of cartilage & atropathy
Cotrimoxazole
• folic acid deficiency & Kernicterus during first
trimister & term respectively
Nitrofurantoin (at term)
• Can cause hemolytic anemia
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18. 18

19. STDs
STDs in pregnant women range :
A. transmitted across the placenta and infect the infant
prenatally (e.g., syphilis).
B. transmitted during birth and cause neonatal infection
(e.g., Chlamydia, Gonorrhoeae, or HSV)
C. pose a threat for preterm labor (e.g., bacterial vaginosis)
D. Increase risk of vertical HIV transmission (e.g T. vaginalis,
HSV 2) 19

20. Vaginal discharge
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Ciprofloxacin,
or Spectinomycin,
PLUS Doxycycline,
OR Erythromycin,
Spectinomycin + Erythromycin

21. Genital ulcer disease
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•Benzathine penicillin G,
• Doxycycline,
• Ciprofloxacin
• or Erythromycin
Benzathine penicillin G
Erythromycin
Acyclovir Cat B – for vesicular ulcer

22. Congenital Syphilis treatment
• No alternatives for penicillin are acceptable
• desensitization is required for pregnant
women allergic to penicillin
• Jarish-herixhimer reaction
– risk of premature uterine contraction &/or fetal
distress for women taking penicillin
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23. 23
• Metronidazole
500mg P.O., BID for 7 days
- Tinidazole
•Metronidazole
2gm P.O., single dose
• Tinidazole
Metronidazole – not teratogenic in animal & human , therefore Cat B
- concern due to carcinogenic effect in some animal study
- can be used during pregnancy with careful consideration – 1st term
T. vaginalis

24. Anti- TB drugs

25. TB
In Mother
– Weight loss, cough, hemoptysis, chest pain, breathing
difficulty
In Fetus
– preterm delivery, low birth weight, perinatal mortality
– congenital TB is rare
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26. 26
RIFAMPIN(C), ISONIAZID(C), PYRINZAMIDE(C) , ETHAMBUTOL(B)
CYCLOSERINE - C
PARA-AMINOSALCILIC ACID(PAS) - (C)
ETHIONAMIDE(C)
FLUOROQUINOLONES C
CAPREOMYCIN C
MDR TB
STREPTOMYCIN
AMIKACIN, KANAMYCIN
CYCLOSERINE
PARA-AMINOSALCILIC ACID(PAS) - (C)
ETHIONAMIDE(C)
FLUOROQUINOLONES C
CAPREOMYCIN C

27. C/I
• Capreomycin, Ethionamide, PAS
– teratogenic in animals, but no data in humans
• Fluoroquinolones(levo, oflo , moxi)
– Erosion of cartilage & atropathy
STREPTOMYCIN
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Eighth cranial nerve damage

28. • ART should be initiated as soon as TB treatment is
tolerated from 2-8 weeks.
• If patients develop TB after initiation of ART ,
continue ART throughout TB treatment.
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29. Anti- Malarial drugs

30. Malaria
In Mother
• 50% higher incidence of mortality in pregnant than non
pregnant
• Anemia is pronounced, more complication
In Fetus
• Spontaneous abortion, still birth, low birth weight ,
premature labor
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31. 31
Uncomplicated P. Falciparum
•Artemether + Lumefantrine
•Quinine + Doxycycline
Qunine + Clindamycin
Uncomplicated P. Vivax
•Chloroquine Chloroquine
•Primaquine
Complicated P.falciparum&vivax
Artesunate , Quinine + D5W , Artemether ,

32. Other Anti malarial drugs
• Coartem - No sufficient data in pregnancy
• Mefloquine – caution in first trimester
• Primaquine- hemolytic anemia because fetus is
G6PD deficient
• Malarone – alternative for prevention and treatment,
safety during pregnancy not known
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33. Anti- viral drugs

34. HIV
• HIV testing is part of antenatal screening
• transmission – vertical, during delivery & breast
feeding
• 15 -40 % of neonates born to untreated, HIV-infected
mothers get infected.
• maternal viral load one of the major risk factor for
transmission
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35. 35
•TDF+ 3TC + EFV
•ZDV + 3TC +EFV
TDF – cat B, 3TC- Cat C, EFV – Cat D ZDV – Cat C FTC – Cat B

36. First line drugs in HIV & their side effects
• 3TC over FTC -
– because of the propylene glycol in the oral
solution, FTC C/I in pregnancy
• TDF over ZDV -
– Because ZDV causes anemia
– Bone demineralization effect of TDF has not been
confirmed on human fetus
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37. Efavirenz - cat D
• birth defects in 2.8% of offspring with first
trimester exposure
• Ethiopian STG
• Nevirapine Cat B – an option for CD4 count < 250
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38. Other HIV drugs
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39. HBV & HCV
• lowest risk of obstetric complications compared
to other hepatic complications
• Lamivudine,decrease the risk of fetal HBV
infection in women with high HBV viral loads
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40. 40
Lamuvidine
Tenofavir
telbivudine
HBV
HCVRibavirin + INF α
Cat X
No HCV drug has been approved
for use during pregnancy

41. Anti –fungal drugs

42. Vulvovaginal candidiasis
•25% of pregnant women
•not associated with adverse
pregnancy outcomes
•Tx is for relief of symptoms
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43. 43
Nystatin cat B
Clotrimazole cat B
Miconazole, Butoconazole
Terconazole ,Tioconazole : Cat C
•To date no topical antifungal tx was associated with teratognecity
• Griseofluvin- Cat C , its effect on pregnant woman not established
Chronic VVC –Ketoconazole(400mg), Fluconazole(150mg)
Topical

44. systemic fungal infections
• Require larger dose of anti fungals
• Systemic antifungal agents - toxic medications
• use in pregnancy has been limited to life-
threatening fungal infections
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45. 45
•Amphotercin B + Flucytocine
•Fluconazole-Cat D
•Ketoconazole- Cat C
•Itraconazole- Cat C
•Amphotercin B – Cat B
+
Flucytocine – Cat C

46. Side effects
• chronic, high-dose tx in the
first trimester—at doses of
400 to 800 mg daily
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47. Anti- helminthic drugs

48. Hook worm & other helminthes
• may cause anemia, reduced birth weight and
increased perinatal mortality
• Most drugs are Cat- C, however most of them
are OTC
• Lack of information for most of them
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49. 49
•Mebendazole – Cat C
•Albendazole- Cat C
•Ivermectin
•Pyrantel Pamoate- Cat C
Praziquantel Cat B•Diethylcarbamazine
Nematode
Microfilaricidal Cestode & trematode

50. Trypanosomiasis
• Intrauterine transmission can occur
• Abortion, still birth & premature labour
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Leshmaniasis
• L. donovani- fetal loss, severe debility
• Cutaneous – no significant risk for mother or
fetus, treatment delayed till delivery
Treatment same as non pregnant woman
in both infections

51. Selected Drugs With Significant Adverse
Effects on the Fetus
Drug Trimester Effect
ACEI All, Renal damage
TCAs Third Neonatal withdrawal syndrome
Barbiturates All Chronic use: Neonatal dependence
Carbamazepine First Neural tube defects
Cocaine, tamoxifen All Risk of spontaneous abortion
Ethanol All Fetal alcohol syndrome
Iodine All Congenital goiter, hypothyroidism
Lithium First Icreased ICP
Tobacco All Intrauterine growth retardation
Tetracycline All Discoloration of teeth and altered bone growth
Thalidomide & DES First Limb malformation (DES Cancer Risk Icreased)
Warfarin First Alters respiratory tract formation
Second CNS malformation
Third Risk of bleeding – IC hemorrhage

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53. Reference
• Williams Obstetrics, 24th edition, Cunningham,Leveno, Bloom, Y.
Spong, Dashe
• Katzung & Trevor’s Pharmacology: Examination & Board Review,
11th edition, trevor , Katzung , hall
• Drugs in Pregnancy and Lactation, 6th edition: Briggs, Freeman,
Yaffe
• Applied therapeutics : the clinical use of drugs, Mary Anne Koda-
Kimble 9th ed.
• Standard Treatment Guidelines for general hospitals (STG) - third
edition, 2014
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54. Thank you!!!!