This topic includes Introduction, common side effects from maternal medications on infants, guidelines for medication during lactation, effects of various medications on lactation and neonates
This topic includes Introduction, common side effects from maternal medications on infants, guidelines for medication during lactation, effects of various medications on lactation and neonates
PowerPoint presentation of emesis in pregnancy given at resident presentation, obstetrics and gynecology directorate, Komfo Anokye Teaching Hospital
risk factors, symptoms, management of severe vomiting with dehydration and weight loss in pregnancy
hi there .. this poerpoint deal with drugs usage in pregnent women .. th pharmacokinetics .. drug effects on the fetus .. FDA category .. with thanks to my collegues mariam and sherin .. wish to be useful .. enjoy:)
Hypothyroidism is a condition marked by an underactive thyroid gland and may be present during pregnancy. It incidence
0.05% of pregnant women
31% positive for TPO Ab
Associated with Gest Hypertension.
Hyperthyroidism in pregnancy:
Hyperthyroidism is characterized by high level of serum thyroxine and triiodothyronine, low levels of thyroid-stimulating hormones.
Hyperthyroidism during pregnancy usually is caused by an
Autoimmune disorder called Grave’s disease. It incidence :-
- 0.2% of pregnant women
- 95% Grave’s disease
It is a presentation on Thyroid Disorder in Pregnancy 2023
PowerPoint presentation of emesis in pregnancy given at resident presentation, obstetrics and gynecology directorate, Komfo Anokye Teaching Hospital
risk factors, symptoms, management of severe vomiting with dehydration and weight loss in pregnancy
hi there .. this poerpoint deal with drugs usage in pregnent women .. th pharmacokinetics .. drug effects on the fetus .. FDA category .. with thanks to my collegues mariam and sherin .. wish to be useful .. enjoy:)
Hypothyroidism is a condition marked by an underactive thyroid gland and may be present during pregnancy. It incidence
0.05% of pregnant women
31% positive for TPO Ab
Associated with Gest Hypertension.
Hyperthyroidism in pregnancy:
Hyperthyroidism is characterized by high level of serum thyroxine and triiodothyronine, low levels of thyroid-stimulating hormones.
Hyperthyroidism during pregnancy usually is caused by an
Autoimmune disorder called Grave’s disease. It incidence :-
- 0.2% of pregnant women
- 95% Grave’s disease
It is a presentation on Thyroid Disorder in Pregnancy 2023
PHS was invited to present at the local APHON (Association of Pediatric Hematology/Oncology Nurses) meeting in September. PHS IV nurse Jill Wall, RN, BSN, CRNI, presented on the scope of home infusion and all that PHS does to ensure our patients thrive at home.
- Routes of administration
- First pass metabolism, bioavailablilty, drug distribution,
- Drug interactions with proteins, Drug metabolism, elimination, Half-life
Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Neonatal Abstinence Syndrome: Treating Pregnant Women presentation by Dr. Rick McClead, Mona Prasad, Jacqueline Magers and Gail A. Bagwell
Detoxification vs. Maintenance Treatment (methadone or buprenorphine) in Pre...ErikaAGoyer
NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE - Detoxification vs. Maintenance Treatment (methadone or buprenorphine) in Pregnancy:
The participant will be able to: Compare the benefits
and risks of opioid maintenance and opioid
detoxification in pregnancy.
Approach to cardiac murmurs and cardiac examination in childrenVarsha Shah
Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
6 breastfeeding and drugs and acceptable medical reasons for artificial feeding (edited)
1. Lecture 7
Breastfeeding and drugs, and acceptable
medical reasons for artificial feeding
Dr. Varsha Atul Shah
2. Why drugs taken by mother is a
concern?
• Drugs may pass through breast milk to infant maybe harmful
• Most drug levels in the breast milk < 1 - 2% of ingested maternal dosage
• The amount of drug an infant receives from the mother often is negligible.
• The majority of drugs that are given to breastfeeding women do not cause
problems in infants
• Most safety data are on single case reports or small case series
3. Basic questions to determine drug
safety
• Does the drug transfer into breast milk?
• What is the effect on the infant?
• Is the medicine routinely given to infants of this age?
• Is the medication absorbed when given orally?
– If no, it is safe, Heparin
• Can the infant excrete the medication?
5. Pharmocokinetics factors
– Volume of distribution
– Percentage of maternal
protein binding
– Molecular weight
– Water or lipid soluble
– pH
– T max
– T1/2
– Milk-to-plasma ratio
– Active transport
– Relative infant dose
6. Maternal factors
• Mammary epithelium may have drug-
metabolizing capacity
• Milk volume & fat content
• Stage of breast-feeding
7. Infant factors
• Ability to absorb, detoxify & excrete drugs
• High percentage of total body water
• Immature stratum corneum
• Less well developed gastric system
– less acidic environment
– longer gastrointestinal (GI) transit time
– low amounts of some metabolic enzymes in the GI tract, liver, kidney, and
brain to metabolize drugs
.
• Others: genetics, environment, diseases, types of treatment, growth &
development
8. Refer pharmacist
• Evaluate the safety outcome of medication therapy in breast-feeding (BF)
mothers
• Drug info
– name, strength, & dosage form
– Reason drug being prescribed. Essential?
• Maternal info
– Does she feel need to take the drug?
– Physician’s views with regards to BF outcome & taking the drug
– Drug dosage schedule & frequency of BF
• Baby’s info
– Age, gestation, weight, current medication(s)
9. Stepwise approach
• Withhold the drug
• Try nondrug therapies
• Delay therapy
• Choose drugs that pass poorly into milk
• Choose more breast-feeding–compatible dosage forms
• Choose an alternative route of administration
• Avoid nursing at times of peak drug concentrations in milk
• Administer the drug before the infant’s longest sleep period
• Temporarily withhold breast-feeding
• Discontinue nursing
10. Resources for references
• LactMed
• Breastfeeding: A Guide for the Medical Profession 7th ed (Lawrence, 2011 p.
750-903)
• Drugs in Pregnancy and Lactation 7th ed. Briggs, Freeman and Yaffe. (Briggs,
2005)
• Medications and Mothers' Milk. 14th Ed. 2010, Thomas Hale. (Hale, 2010)
11.
12. Infant conditions
• Breast milk or any other milk are contraindicated
• Classic galactosemia
• Maple syrup urine disease
• Phenylketonuria
13. Infant conditions
• Infants for whom breast milk remains the best feeding
option but who may need other food in addition to breast
milk for a limited period
– BW < 1500 g
– < 32 weeks gestational age
– at risk of hypoglycaemia if blood sugar fails to respond to optimal
breastfeeding or breast-milk feeding
14. Maternal conditions that may justify permanent
avoidance of breastfeeding
• HIV infection:
– if replacement feeding is acceptable, feasible,
affordable, sustainable and safe
15. Maternal conditions that may justify temporary
avoidance of breastfeeding
• Severe illness:
– that prevents a mother from caring for her infant, e.g.
sepsis
• HSV-1:
– direct contact between lesions on the mother’s
breasts and the infant’s mouth should be avoided until
all active lesions have resolved
16. Maternal conditions that may justify temporary
avoidance of breastfeeding
• Maternal medication:
– Sedating psychotherapeutics, anti-epileptics, opioids & their
combinations
– Radioactive iodine-131
– Cytotoxic chemotherapy
– Excessive use of topical iodine or iodophors esp on open wounds or
mucous membranes
17. Maternal conditions during which breastfeeding can still
continue, although health problems may be of concern
• Breast abscess:
– BF should continue on the unaffected breast; feeding from the
affected breast can resume once treatment has started
• Hepatitis B:
– Infants should be given hepatitis B vaccine, within the first 48
hours or ASAP thereafter
• Hepatitis C
18. Maternal conditions during which breastfeeding can still
continue, although health problems may be of concern
• Mastitis:
– If BF is very painful, milk must be removed by
expression to prevent progression of the condition
• Tuberculosis:
– Mother & baby should be managed according to
national TB guidelines
19. Maternal conditions during which breastfeeding can still
continue, although health problems may be of concern
• Substance use:
–maternal use of nicotine, alcohol, ecstasy, amphetamines,
cocaine & related stimulants has been demonstrated to
have harmful effects on breastfed babies
–Alcohol, opioids, benzodiazepines & cannabis can cause
sedation
–Mothers should be encouraged not to use these
substances & given opportunities and support to abstain
21. Recreational drug use
• BF should be interrupted for 24 to 48 hours (24 hours for cocaine)
after the last dose
• The T1/2 for each metabolite may prolong the unsafe duration of the
drug
• Even with interrupted BF, infants still may test positive for drugs for
days or weeks. PCP & cocaine may be the most dangerous.
• Social considerations (ability for child care)
22. Mothers on recreational drugs
•Assessment for their dependability
•High-risk mothers discontinue BF
•Low-risk mothers educate about drug
transfer & the hazards
•Inform mothers that baby will test positive
during drug screenings for a long period after
her last drug taking
23. Methadone
• Methadone concentration remains low in
the breast milk - potential infant
exposure is unlikely to have any negative
effect on the developing child
• Even at a maximal allowable pediatric
dose of 270 μg/day, no serious health or
developmental concerns have been
observed
24. Guidelines for Breastfeeding and the Drug-
Dependent Woman
• Must abstain from use of illicit drugs for 90 days before delivery
• Are enrolled, active, and planning to continue in a substance
abuse treatment program
• Have a negative drug screen at delivery
• Have received consistent prenatal care
• Have no other contraindications to breastfeeding
25. Alcohol
• Beer – galactagogue (increase prolactin)
• Conversely, alcohol suppresses oxytocin levels reduces milk
ejection
• Mothers’ alcohol use showed a 23% reduction in the amount of milk
ingested by babies
• BF should be discontinued if mother consumes > 1 drink/hour
26. Alcohol
• Alcohol gives a noticeable odour to breast milk,
which may stimulate sucking initially but decreases
the total milk intake during a feeding
• Spends less time sleeping
• Can cause infant "drunkenness" (deep sleep, deep
respiration, inability to suck, and no reaction to
pain)
27. Alcohol
• Chronic intake of alcohol 50 cans of beer/week causes a
pseudo-Cushing syndrome
• An occasional alcoholic drink not harmful to the infant
• Binge drinking or chronic drinking should be avoided
• Mothers consuming alcohol can resume BF after
moderate alcohol use as soon as the effects of the
alcohol have passed
28. Cigarette Smoking (Nicotine)
• Women who smoke are less likely to initiate breastfeeding
• Decreases milk production
• Significant increase of infantile colic
• At least 19% lower milk fat in smoking mothers
• Women who smoke can & should breastfeed
• Nicotine cessation therapy should be recommended & nicotine replacement
therapy as adjunct therapy
• Nicotine patches with appropriately managed doses were demonstrated to
decrease the absolute infant intake of nicotine & its metabolite
29. Antidepressants
• Psychotherapy should be the first line of treatment
• Medication should be started if psychotherapy is not available, is not
working
• Needed due to the severity of the depression
• All antidepressants are excreted in breast milk
• Serum levels of antidepressants in infants of breastfeeding mothers
have been evaluated
30. Selective serotonin reuptake
inhibitors (SSRIs)
• Sertraline has been recommended due to its lack of side effects in the
infant and unmeasurable drug levels in the infant
• Fluoxetine and its active metabolite (norfluoxetine) have long half lives
• Tricyclic antidepressants, nortriptyline has been the most extensively
studied. Levels are not measurable in infants
• It is recommended to start at 1/2 of the recommended dosage and
increased on a weekly basis with close monitoring
31. OTC products
– Avoid taking if
• little BF information is available
• safer products are available
• combination products with multiple ingredients
• extra-strength forms
• long-acting OTC products especially if an adverse reaction is possible
33. References
1. Technical updates of the guidelines on Integrated Management of Childhood Illness (IMCI). Evidence and
recommendations for further adaptations. Geneva, World Health Organization, 2005.
2. Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva, World
Health Organization, 2007.
3. León-Cava N et al. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington, DC,
Pan American Health Organization, 2002 (http://www.paho.org/English/AD/FCH/BOB-Main.htm, accessed
26 June 2008).
4. Resolution WHA39.28. Infant and Young Child Feeding. In: Thirty-ninth World Health Assembly, Geneva,
5–16 May 1986. Volume 1. Resolutions and records. Final. Geneva, World Health Organization, 1986
(WHA39/1986/ REC/1), Annex 6:122–135.
5. Hypoglycaemia of the newborn: review of the literature. Geneva, World Health Organization, 1997
(WHO/CHD/ 97.1;http://whqlibdoc.who.int/hq/1997/WHO_CHD_97.1.pdf, accessed 24 June 2008)
6. HIV and infant feeding: update based on the technical consultation held on behalf of the Inter-agency Task
Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants, Geneva, 25–27
October 2006. Geneva, World Health Organization, 2007
http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf,accessed 23 June 2008).
7. Breastfeeding and maternal medication: recommendations for drugs in the Eleventh WHO Model List of
Essential Drugs. Geneva, World Health Organization, 2003.
8. Medications and breast- feeding: Current concepts. Frank J. Nice and Amy C. Luo. J Am Pharm Assoc.
2012;52:86–94.
9. Acceptable medical reasons for use of breast-milk substitutes. WHO/NMH/NHD/09.01
WHO/FCH/CAH/09.01
34. References
10. Mastitis: causes and management. Geneva, World Health Organization, 2000 (WHO/FCH/CAH/00.13;
http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.13.pdf, accessed 24 June 2008).
11. Hepatitis B and breastfeeding. Geneva, World Health Organization, 1996 (Update No. 22).
12. Breastfeeding and Maternal tuberculosis. Geneva, World Health Organization, 1998 (Update No. 23).
13. Background papers to the national clinical guidelines for the management of drug use during pregnancy,
birth and the early development years of the newborn. Commissioned by the Ministerial Council on Drug
Strategy under the Cost Shared Funding Model. NSW Department of Health, North Sydney, Australia,
2006 (http://www.health.nsw.gov.au/pubs/2006/bkg_pregnancy.html, accessed 24 June 2008).
14. Medications and breast- feeding: Current concepts. Frank J. Nice and Amy C. Luo. J Am Pharm Assoc.
2012;52:86–94.
[“If no, it is safe, Heparin” – sorry what does this phrase mean?]
Drugs with high Vd may enter different compartments of the body, therefore resulting in a lower concentration in the blood. These drugs may take a longer time to clear from the body than drugs with lower Vd. However, drugs may have different elimination half-lives in the plasma and peripheral compartments; thus, drugs with a high Vd may produce lower milk levels.
PB shows the extent to which a drug is bound to the plasma albumin and other proteins. Therefore, drugs that have high PB would generally reduce the infant’s exposure to the medication.
Beta-adrenergic blocking drug atenolol has low PB of 6% to 16% and therefore would be more extensively excreted into breast milk.
Drugs with higher MWs less likely to pass into breast milk. Heparin, interferons, and insulin, for example, are compounds with large MWs and are unlikely to contribute to toxic drug concentrations in breast milk.
Drug molecules that are water soluble are less likely to concentrate in the breast milk.
By avoiding feeding the infant at the time the drug reaches its maximum concentration in the plasma (Cmax), the mother can decrease the likelihood of exposing her infant to the drug.
After five half- lives, approximately 97% of drug is eliminated from breast
If M/P is less than 1, it is usually safe to breast- feed.
Relative infant dose. The relative infant dose (RID) is calculated by dividing the theoretical infant weight–adjusted dose supplied via breast milk by the maternal weight–adjusted dose. When RID is less than 10% of maternal dose, the medication is considered generally safe for breast-feeding.
Milk volume is usually greatest in the early morning, while the fat content of milk is usually highest in the late morning. Because a larger volume of milk in the breast during the early morning is likely, taking drugs at that time would result in a higher drug concentration in the breast milk.
Mothers are advised to breast-feed first, then take their medication, thereby decreasing the likelihood of any overexposure to the infant. Similarly, it would be optimal for mothers to take drugs that are less lipid-soluble in the late morning because
Different stages of breast-feeding can affect the amount transfer of lipid-soluble drugs into breast milk.
Colostrum
0 to 3 days; thicker, higher in protein & antibodies, and acts as a laxative.
Transitional milk
4 to 7 days , high levels of fat & lactose. Helps in regain weight loss
Mature milk
7 to 10 days
Consisting largely of water
Foremilk contains more water, vitamins, and protein.
Hindmilk contains higher levels of fat and aids in the weight gain of infants.
High percentage of total body water, and thus higher doses (per kg body weight) of water-soluble drugs are required because a higher percentage of their body weight is water.
Immature stratum corneum that can increase exposure to applied topical medications.
less acidic (more alkaline) environment that can alter the rate and amount of drug absorption and metabolization
their gastrointestinal (GI) transit time also is prolonged because of slower motility
The low amounts of some metabolic enzymes in the GI tract, liver, kidney, and brain also play a role in an infant’s ability to metabolize drugs.
Sometimes, their clearance of drugs (e.g., theophyline, phenytoin) is higher than in adults.
In most cases, it’s best for the mother to breast-feed just before taking a dose of a drug and/or at least 2 hours after taking a dose. Short-acting drugs taken on an every-3-to-6-hour schedule usually reach peak plasma and milk levels in approximately 1 to 2 hours.
LactMed: A peer reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed.
Classic galactosemia: galactose-free formula
Maple syrup urine disease:special formula free of leucine,isoleucine and valine
Phenylketonuria: phenylalanine-free formula
(some breastfeeding is possible, under careful monitoring).
Sedating psychotherapeutic drugs, anti-epileptic drugs & opioids & their combinations
may cause side effects e.g. drowsiness, respiratory depression, are better avoided if a safer alternative is available
Radioactive iodine-131
better avoided given that safer alternatives are available - a mother can resume BF about 2/12 after receiving this substance
Excessive use of topical iodine or iodophors esp on open wounds or mucous membranes:
can result in thyroid suppression & electrolyte abnormalities in the breastfed infant and should be avoided
Low-risk mothers should be given the details of drug transfer into the breast milk & the hazards of the drug to their babies.
Research has shown that the methadone concentration remains low in the breast milk such that the potential infant exposure is unlikely to have any negative effect on the developing child.