For medical students in Obstetrics . Safe prescribing during pregnancy and breastfeeding. safe drugs and methods to reduce passage to baby in chronic conditions with polytherapy

1. Drugs in pregnancy and lactation
Mini Sood

2. Objectives
 The learner should be :
 Aware of the hazards of prescribing to women at different stages of
pregnancy
 Know which drugs can be safely given to breast feeding women.

3. Principle
 A broad principle in pregnancy is to avoid all drugs as far as possible –
can be extended to women in reproductive age as well

4. Drugs and the fetus
 First trimester- Teratogenic drugs
 A teratogenic drug is taken by a woman before she realises that she is
pregnant. Sometimes, the risk of using a teratogen is outweighed by the
benefits eg. Warfarin in patient of prosthetic heart valves

5. Effects of drugs on pregnancy
 First trimester
 Teratogenic effects
 Miscarriage
 Second trimester
 Developmental effects (neurol)
 Third trimester
 Preterm or pos-term pregnancy
 Hemorrhage
 Post delivery
 Withdrawal symptoms, prolonged activity in baby

6. Teratogenic drugs in first trimester
 Phenytoin- craniofacial and limb abn
 Carbamazipine- craniofacial and limb abn
 Sodium valproate: neural tube defects
 Ace inhibitors: Abnormalities of the skull
 Alcohol: growth retardation, craniofacial abn
 Stilbesterol: adenocarcinoma of the vagina in females offspring of exposed
mothers

7. Drug category
 Category A: Controlled human studies have
demonstrated no fetal risk
Category B: Animal studies indicate no fetal risk, but
no human studies
OR adverse effects in animals , but not
in well- controlled human studies
Category C: No adequate human or animal studies,
OR adverse fetal effects in animal
studies, but no available human data.
Category D: Evidence of fetal risk, but benefits
outweigh risks.
Category X: Evidence of fetal risk. Risks outweigh
any benefits

8. Safe drugs in pregnancy
 Some Medications Considered Safe for Use During Pregnancy
 Condition Medication
 Asthma Budesonide inhaled or nasal
spray (Pulmicort®,
Rhinocort ®)
 Bladder infection (UTI) Nitrofurantoin (Macrobid®)

-
 Cough Dextromethrophan(Robitussin
DM sugar free
 Constipation Metamucil® , Citrucel®,
Docusate (Colace®, Ducolax

 Milk of magnesia. Polyethyelene glycol (Miralax
 Diabetes Insulin Glyburide
(Micronase®)
 Metformin (Glucophage®)

9. Safe drugs
 Diarrhea Loperamide (Imodium A-D ®)
 Gas (Gas-X ®, Mylicon ®, Phazyme
 Gastroesophageal reflux disease Ranitidine (Zantac®)cimetidine
 Hay fever, sneezing, runny nose, itchy
watery eyes
 Chlorphenramine (Chlor-Trimeton

Diphenhyramine (Benadryl ®)
Headache or fever: Acetaminphen
(APAP,Paracetamol,Panadol,
 Heartburn TUMs
 Hemorrhoids Tucks


10.  High blood pressure Methyldopa (Aldomet®)
 Hyperprolactinemia Bromocriptine (Parlodel®)
Carbergoline (Dostinex®)
 Hypothyroidism Thyroid hormone Levothyroxine
(Synthroid ®, Levoxyl ®)
 Infection Acyclovir (Zovirax ®)
 Azthitromycin (Zithromax ®)
 Cepaholosporins
Cephalexin (Keflex®),
Cefazolin (Ancef ®), cefaclor
(Ceclor®)
 Clindamycin (Cleocin®)
 Erythromycin
 Penicillins
Amoxicillin (Amoxil®),
Amoxicillin Clavulanate
(Augmentin®),

11. Safe drugs
 Insomnia Doxylamine (Unisom Sleep
Tabs®
 Motion sickness Dimenhydrinate
(Dramamine ®)
 Nasal congestion Pseudoephedrine
(Sudafed ®)
Avoid in first trimester
 -. nasal congestion, sneezing,
runny nose, itchy watery eyes Actifed
 Cold and Allergy ® Ingredients: Triprolidine, Pseudoephedrine
-Avoid in first trimester.
• Ginger Pyridoxine 25 mg
Metoclopramide (Reglan ® )

 Preeclampsia Magnesium
sulfate

12. Drugs for long term use
 Drugs and Pregnancy: Should I Continue My Medicines? HIV,
Zidovudine, Nevirapine,(etc)
 Diabetes,
 asthma,
 high blood pressure
 Cardiac disease
 Operated cardiac congenital conditions on anticoagulants
 Chronic renal disease
 Refractory anemia
 Tuberculosis with pregnancy

13. Thalidomide babies

14. Drugs transfer to the fetus
 Placental transfer by
 Active transport
 Passive diffusion
 Facilitated diffusion
 Placental surface area
 Placental metabolism

15. Drug passage into breast milk
 Diffusion from maternal plasma into milk
 Higher concentration in maternal plasma
 Equlibrium established with most drugs between milk and plasma

16. Drug transfer from placenta or into milk
 Molecular weight
 Protein binding
 Lipid solubility
 Ionization
 Chemical structure

17. Fetal drug disposition
 60-80% through fetal liver, and rest through ductus venosus to heart and
brain
 Hepatic metabolism
 Adrenal gland metabolism
 Recirculation through amniotic fluid

18. Calculating drug exposure
 Milk consumption-150ml/kg/d
 Milk concentration
 Relataive infant exposure <10% better(infant dose/maternal dose
mg/kg/d)

19. Neonatal factors
 Volume of mlik consumed
 GIT Transit time
 Higher gastric ph
 Differences in GI Flora
 Higher free drug concentration
 Higher body water
 Lower excretion and metabolism rates

20. Safe drugs during breast feeding
 Penicillins, cephalosporins
 Theophyllines or beta agonists
 Glucocorticoids
 Anticonvulsants
 Tricyclic antidepressants
 Neuroleptics like chlorpromazine
 Antihypertensives like methyl dopa, hydralazine
 Warfarin or heparin

21. Drugs to be avoided
 Aspirin
 Ergotamine
 Sulphonamides, ciprofloxacin, tetracyclines
 Chloramphenicol
 Benzodiazepines
 Lithium
 Antithyroid drugs or iodine
 Sulphonylureas
 Antineoplastic drugs

22. Drugs that inhibit lactation
 Bromocripitine
 Oetrogens and progesterones
 thiazides

23. anti-infectives
 Penicillins
 Cephalosporins
 Antifungals
 Antivirals
 Carbapenems
 Macrolides
 Fluroquinolones
 Aminoglycosides
 Sulfonamides

24. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 A. TrueB. False

25. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. TrueB. False

26. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 A. TrueB. False

27. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 A. TrueB. False

28. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 B. False
 5. A woman who drinks alcohol while pregnant puts her baby at risk
for physical or behavioral problems.
 A. TrueB. False

29. quiz
 1. Most babies of women who smoke weigh the same as babies of
women who don't smoke.
 B. False
 2. Studies have shown babies of women who smoke are twice as
likely as babies of nonsmokers to die of sudden infant death
syndrome (SIDS).
 A. True
 3. Smoking after your baby is born won't harm the child.
 B. False
 4. It's safe to drink alcohol during pregnancy as long as you don't
drink a lot or every day.
 B. False
 5. A woman who drinks alcohol while pregnant puts her baby at risk
for physical or behavioral problems.
 A. True


30. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. TrueB. False

31. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. TrueB. False

32. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. TrueB. False

33. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can have
mental and behavioral problems, low-birth weight and an addiction to the
drug.
 A. TrueB. False

34. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were
pregnant can have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk
becoming infected with hepatitis B or HIV, which can be passed on
to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can
have mental and behavioral problems, low-birth weight and an
addiction to the drug.
 A. True
 10. It's safe for a pregnant woman to take tranquilizers, sleeping pills
or amphetamines.
 A. TrueB. False

35. quiz
 6. Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not safe to take while pregnant.
 A. True
 7. Babies born to women who used narcotics while they were pregnant can
have withdrawal symptoms.
 A. True
 8. Women who inject drugs intravenously while pregnant risk becoming
infected with hepatitis B or HIV, which can be passed on to their babies.
 A. True
 9. Babies born to women who used heroin during pregnancy can have
mental and behavioral problems, low-birth weight and an addiction to the
drug.
 A. True
 10. It's safe for a pregnant woman to take tranquilizers, sleeping pills or
amphetamines.
 B. False

36.  Radioactive drugs used for some diagnostic tests like Gallium-69,
Iodine-125, Iodine-131, or Technetium-99m can be taken if the
woman stops nursing temporarily.
 Bromocriptine (Parlodel): A drug for Parkinson’s disease, it also
decreases a woman’s milk supply.
 Most Chemotherapy Drugs for Cancer: Since they kill cells in the
mother’s body, they may harm the baby as well.
 Ergotamine (for migraine headaches): Causes vomiting, diarrhea,
convulsions in infants.
 Lithium (for manic-depressive illness): Excreted in human milk

37. penicillins
 Category B drugs in pregnancy
 Crosses placenta easily
 Equal concentrations as maternal plasma
 Lactation
 Crosses in low concentration
 Compatible with breast feeding

38. cephalosporins
 Pregnancy category B drug
 Crosses placenta easily
 Some reports of anomalies- cardiac and oral clefts
 Lactation
 Excreated in low concentration in breast milk
 safe

39. carbapenems
 Pregnancy category B/C Drugs
 Cross placenta
 Little human data
 Lactation
 Exc in low concentration
 Unknown effects

40. Fluoroquinolones
 Category c in pregnancy
 Not recommended
 Cartilage damage
 Use safer altern
 Lactation
 Limited human data
 Can be used

41. Aminoglycosides- gentamycin, amikacin, tobramycin
 Pregnancy category C
 Repidly crosses placenta
 Enters amniotic fluid
 Lactation
 safe

42. sulphonamides
 Pregnancy category c
 Crosses placenta rapidly
 Use unsafe in third trimester
 Lactation
 Unsafe in premature

43. Tetracyclines- doxycyclin,mincyclin
 Pregnancy category D
 Problems with teeth, bones and other defects
 Maternal liver toxicity
 Lactation
 unsafe

44. Antivirals acyclovir, famicyclovir, valacyclovir
 Pregnancy category B
 Readily cross placenta
 Safe
Lactation
 Cannot use famiciclovir
 Acyclovir and valacyclovir safe

45. Antiretrovirals
 Generally category B/C
 Maternal benefits outweigh the fetal risks
 Associated with maternal side effects as well
 May or maynot cross the placenta

46. antifungals
 Pregnancy category C/D
 Cross placenta
 Associated with craniofacial effects
 Lactation
 Fluconazole and ketconazole are safe
 Itraconazole and voriconazole not recomm

47. Factors to consider
 Are there alternative treatments?
 Is the disease worse than the therapy?
 Can treatment wait till postpartum?
 What does available literature say?
 Is this drug used in neonates
 Age of neonate
 Duration of therapy
 Pharmacokinetics of the drug
 Maternal risks/benefits

48. Considerations in breastfeeding
 Withhold or delay therapy, if possible
 Use a drug with poor penetration in milk
 Use alternative routes of administration
 Avoid feeding at peak drug concentrations
 Give drug before infants longest sleep
 Pump and dump milk
 Discontinue breast feeding