common dematological sysetimic medications and pregnancy

1. By : M . Fotoh Hussein.
Dermatology & venereology resident

4. _Oral retinoids
Acitretin and Isotretinoin
glucocorticoids
Antihistaminics
Antibiotics
Antiviral drug
antifungal drugs
antimalarial drugs
immunosuppressants
methotrexate cyclosporine and azathioprine
Dapsone

9. Glucocorticoids
Systemic corticosteroids in moderate doses
are considered safe in pregnant women
with persistent itching or autoimmune
disease. But individual drugs are in
different FDA categories e.g. prednisone
(class B), prednisolone (class B),
dexamethasone (class C),
betamethasone (C) class

10. According to many authors, prednisone is preferred during pregnancy
because its penetration through the placenta is limited by enzymes,
while dexamethasone almost completely passes through. Children of
mothers treated with corticosteroids during pregnancy should be
additionally monitored for adrenal insufficiency due to iatrogenic
hormone suppression. Prednisone may also cause premature birth,
premature amniotic rupture, intrauterine growth restriction (IUGR), as
well as diabetes, hypertension, pre-eclampsia and eclampsia. Many
clinicians recommend reducing the dose to 7.5 mg/day in long-term
treatment and avoiding doses higher than 20 mg/day [29]. Prednisone
is metabolized into prednisolone. Studies have shown that a small
amount of the metabolite is transferred to breast milk [30]. For women
treated with doses of 10–80 mg of prednisone, relative blood levels in
children was 0.02% to 0.074% (0.002–0.059 mg), which is less than 10%
of infantile endogenous cortisol levels [31]

11. Previous studies have shown no adverse
reactions in breast-fed infants, however mothers
were treated with low doses of corticosteroids (5–
10 mg/day) [32, 33]. In order to minimize
exposure and avoid peak serum concentration
occurring within the 1st h after drug ingestion, it
is recommended that the mother should wait 4 h
before breastfeeding. During that time, drug
concentration in the milk falls to the level in
maternal plasma [34]. The pediatrician society
believe that corticosteroids are safe for
breastfeeding women [2].

13. First-generation antihistamines are considered as safe during pregnancy
They include diphenhydramine, cyproheptadine,
promethazine, chlorpheniramine,
tripelennamine and hydroxyzine. The
FDA categorizes first-generation antihistamine drugs based on the risk of
fetal defects Drugs such
as diphenhydramine and chlorpheniramine are class B [5, 6]. Promethazine
and hydroxyzine belong to class C drugs due to lack of well-controlled
studies on humans [1]. First-generation antihistamines are well known of
their sedative properties as a result of their applicability to cross the blood-
brain barrier

14. Cetirizine and loratadine are the only non-sedative
antihistamines with B category. There were reports
of an increased risk of hypospadias in children of
mothers using loratadine, but further studies did
not confirm this [1, 11–13]. For years loratadine
and cetirizine have been preferred as first-line
drugs used during the second and third trimester
[11]. Caution must be taken and high doses of
antihistamines should not be administered before
delivery. Those drugs can cause an oxytocin effect,
stimulating uterine contractions what can lead to
premature birth.

15. First-generation antihistamines FDA categories
Chlorpheniramine B
Cyproheptadine B
Diphenhydramine B
Hydroxyzine C
Promethazine C
Tripelennamine B
Table1
First-generation antihistamines categories according to FDA
Second-generation antihistamines FDA categories
Cetirizine B
Fexofenadine C
Loratadine B
Levocetirizine B
Desloratadine C
Table2
Second-generation antihistamines categories according to FDA

17. Penicillins, cephalosporins, macrolides and clindamycin are considered as safe
during pregnancy.
Metronidazole can be safely administered only in the second and third
trimester.
All above drugs are class B medications according to the FDA

21. Due to a great number of reports documenting safety of aciclovir,
it is considered as the drug of choice during pregnancy. This drug
is classified as class B
Valacyclovir
This drug is a prodrug that is convert rapidly to acyclovir
(acyclovir)
Famciclovir has been assigned to pregnancy category B.
Animal studies failed to reveal evidence of
teratogenicity. There are no controlled data in human
pregnancy. Famciclovir should only be given during
pregnancy when need has been clearly established.

23. Fluconazole is embryo–fetotoxic and teratogenic in rodents and
rabbits. Total fluconazole dose >300 mg should be considered teratogenic
and remains contraindicated throughout pregnancy, with FDA designation
D. A single low dose (≤300 mg total dose) of fluconazole does not increase
the risk of congenital disorders and may be considered in the absence of a
topical alternative after the first trimester.
Itraconazoleis embryotoxic and teratogenic in rodents. Clinical
studies have not detected any increased risk during pregnancy, especially
during the first trimester, and the FDA labels itraconazole category C. Given
the risk conveyed by the azole family in humans, the drug should still be
avoided during pregnancy, especially during the first trimester. The
manufacturer therefore recommends that effective contraception should be
continued throughout treatment and for 2 months thereafter
Amphotericin B is classified as category B by the FDA. It is
considered as the safest antifungal drug in pregnancy and is a major tool in the
fungal armamentarium in this setting. Liposomal amphotericin B should also be
considered safe in pregnancy. Data regarding other lipidic derivatives remain
scarce and they should be used only in case of unavailability of other polyenes.

24. Terbinafineis classified as category B by the FDA. It was not shown to
be toxic in animal pregnancies, but human data are not available, hence
hampering its systemic use in pregnancy. In contrast, topical terbinafine, which
has limited absorption ability, can be prescribed
Griseofulvinis classified as category C by the FDA. It is
carcinogenic, embryotoxic and teratogenic in rodents. Human data are too
limited to allow its use in pregnancy, especially in the first trimester.

26. Our findings support preliminary evidence for the safety of HCQ therapy
during pregnancy. This treatment probably should be maintained throughout
pregnancy in patients with systemic lupus erythematosus
Arthritis Rheum. 2003 Nov;48(11):3207-11.
Safety of hydroxychloroquine in pregnant patients with connective tissue
diseases: a study of one hundred thirty-three cases compared with a
control group.
Costedoat-Chalumeau N1, Amoura Z, Duhaut P, Huong DL, Sebbough
D, Wechsler B, Vauthier D, Denjoy I, Lupoglazoff JM, Piette JC.

34. Dapsone has been assigned to pregnancy
category C. There are no animal data or
controlled data in human pregnancies.
Experience with dapsone during all
trimesters of human pregnancy has not
indicated an increased risk of fetal
abnormalities. Dapsone should only be
given during pregnancy when benefit
outweighs risk