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Transcript
2015-02-06
January 13, 2015
Common
Medications in
Pregnancy
Dr. Suzi Leggatt
Overview
❖
Resources
❖
Hypertension
❖
Thyroid
❖
Allergy, Asthma, Eczema
❖
Antibiotics
❖
Depression
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2015-02-06
Resources
❖
VGH Pharmacist
❖
Motherisk (1 877 439 2744)
❖
Briggs et. al. - Drugs in Pregnancy and Lactation (most
current is 10th ed.)
❖
Up to Date
Drug Risk Categorization
❖
Category A - controlled human studies show no risk
(vitamins)
❖
Category B - no evidence of risk in studies (Tylenol,
Gravol, Diclectin)
❖
Category C - risk cannot be ruled out (MOST DRUGS)
❖
Category D - positive evidence of risk (Colchicine,
Methotrexate, Spironolactone, Tetracycline, Warfarin)
❖
Category X - contraindicated in pregnancy (Accutane)
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2015-02-06
Drugs to Avoid in Women Planning
Pregnancy
❖
Anti-neoplastic agents - including MTX, check with
Rheumatology re: biologics
❖
Retinoids (Accutane, ?topicals)
❖
ACEIs and ARBs (definite fetal renal consequence in
2nd/3rd trimesters)
❖
Caution re: epileptic meds (esp. Valproate) - PLAN!
❖
NO LIVE VACCINES!
For Preconception Hypertension
❖
Labetolol 50 - 200 mg bid - tid
❖
Aldomet (methyldopa) 250-500 mg up to qid
❖
Adalat XL (nifedipine) 20-90 mg OD
❖
Doses weaned postnatally for women with pregnancy
induced hypertension or preeclampsia
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2015-02-06
Thyroid Disease in Pregnancy
❖
Hypothyroidism - usually levothyroxine (Synthroid,
Eltroxin) (T4), liothyronine (Cytomel) (T3) ok, small
numbers studied
❖
Hyperthyroidism - Propylthiouracil*, Methimazole,
Carbimazole - planning and a specialist ideal ahead of
pregnancy
Allergy, Asthma, Eczema
❖
may use loratidine, cetirizine, chlorpheniramine
❖
topicals NS ok (cromylyn, steroids, ?decongestants)
❖
inhaled CS, and bronchodilators (long and short acting) ok
❖
PO prednisone on as need basis
❖
montelukast - likely ok, not well studied
❖
topical steroids ok, lower potency and less, maximize
emollients. Avoid newer agents (Elidel, Protopic), safety
unknown.
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2015-02-06
Common Antibiotics in
Pregnancy
❖
NO TETRACYCLINES!
❖
Fluoroquinolones - jury is still out
❖
Clarithromycin, avoid if able (Class C)
❖
Azithromycin, and erythromycin (except estolate salt) ok
❖
Penicillin, cephalosporin ok
❖
Clindamycin ok
❖
Trimethoprim - not 1st trimester
❖
Sulfamethoxazole - ok, not close to term (jaundice)
❖
Nitrofurantoin - ok, not close to term (hemolytic anemia)
❖
Metronidazole - ok, probably best to avoid in the 1st
trimester
❖
Gentamycin - when needed
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2015-02-06
Depression and Pregnancy
❖
Common!
❖
Not all women need meds
❖
If meds warranted, counsel appropriately
❖
Consider stability and plan
❖
Perinatal Mental Health team at VGH
❖
Public Health Nurses
❖
Traci McGee - Postpartum Support Program
Why Would We Treat?
❖
Severity, recurrance, risk factors
❖
Effect on mom’s health & pregnancy - increased risk
PPD, harm to her or fetus. Depression = independent
risk factor for higher rate operative delivery
❖
Effect on fetus - low birth weight, prematurity
❖
Effect on infant - increased irritability, and decreased
motor tone and reflexes, need to bond to parent, breast
feeding less likely.
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Are We Concerned re: SSRIs?
❖
2005 GlaxoSmithKline advisory raised question of Paxil
and congenital cardiovascular defects (particularly VSD),
with 1st trimester exposure, retrospective, unpublished
data
❖
major malformation 4%
❖
cardiovascular malformations 2%
❖
Background risk cardiovascular malformations ~1%, all
malformations 2-3%
❖
Motherrisk’s statement is ‘to date, no selective
serotonin reuptake inhibitor has been found to be
associated with increased risk of congenital
malformations, including cardiovascular anomalies’
❖
UptoDate: Paroxetine may be associated with a
small absolute increase in congenital heart defects,
but results across multiple studies are inconsistent
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2015-02-06
❖
All SSRIs can be used prenatally, and
postnatally - preference to sertraline and
citalopram
❖
Less data with SNRIs (venlafaxine, bupropion), but
considered safe
❖
lorazepam, clonazepam ok, usually used with psychiatric
input
❖
Seroquel, lamotrigine, risperidone - limited data
SSRI Effect in Childhood?
❖
SSRI exposure does not appear to affect postnatal
growth of infants
❖
SSRIs/SNRIs - little to no long-term effect on
infant/childhood intelligence, language and behaviour.
Long-term effects difficult to dissect from effect of
maternal depression itself.
❖
SSRI exposure - small to non-existent risk of autism
spectrum disorders
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2015-02-06
Pharmacotherapy in the pregnant woman has to be
balanced against the known risks of untreated
depression including missing prenatal appointments,
poor diet, increased circulating stress hormones,
possible substance abuse, attempts to self-abort and
suicidal behaviour.
Preconception Lifestyle Planning
❖
Smoking
❖
Obesity
❖
Pre-gestation Type 2 DM
❖
Alcohol and other drug use
❖
Preconception Folic Acid supplementation (1-2 mg/d)
❖
HARM REDUCTION POTENTIAL HERE!!
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