Pregnancy and Breastfeeding

Folic acid can be taken when trying for a baby and up to 12 weeks of pregnancy to reduce the risk of what?

Birth defects - e.g. spina bifida

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It is important not to take vitamin _ or retinol supplements while pregnant.

A

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It is recommended to take 10mcg daily of which vitamin?

Vitamin D

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Most medicines taken during pregnancy cross the ________ and reach the baby.

Placenta

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Name 2 reliable sources of information regarding medicines in pregnancy?

BUMPS website
(Best Use Medicines in Pregnancy)
&
UKTIS
(UK Teratology Information Service)

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How many weeks is the 1st trimester?

12 weeks

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During the 1st trimester of pregnancy, drugs can produce congenital malformations (___________).

Teratogenesis

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Risk of congenital malformations are highest between which weeks?

Week 3-11

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You could use the mnemonic TERATO to remember teratogenic drugs. Name them using this.

T - Thalidomide
E - Epilepsy
R - Retinoid (Vitamin A)
A - ACE inhibitors/ARBs
T - Third element (Lithium)
O - Oral contraceptives

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What weeks are considered 2nd trimester of pregnancy?

Weeks 13-26

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What weeks are considered 3rd trimester of pregnancy?

Weeks 27-40+

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During the 2nd and 3rd trimesters, drugs can affect growth or functional development of the foetus or have _____ effects on fetal tissues.

Toxic

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When should drugs be prescribed during pregnancy?

When the benefits to the mother outweighs the risk to the foetus

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Why does miscarriage occur?

It is a protective mechanism that occurs if there any complications during pregnancy

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Absence of drug information regarding pregnancy means that it is safe to take in pregnancy.
T/F?

False - Further research into the drug using other resources is required

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If possible, all drugs should be avoided during 1st trimester of pregnancy.
T/F?

True

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Are ACE inhibitors safe to use in pregnancy?

No

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What is usually given instead of ACE inhibitors for hypertension in pregnancy?

Labetalol (beta-blocker)

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What medication and at what dose should be given to pregnant women with hypertension from 12 weeks til birth to reduce risk of pre-eclampsia?

Aspirin 75-150mg daily

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In what way do anti-hypertensives have an effect on the foetus?

Restrict blood flow to the placenta

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Which trimesters are ACE inhibitors contraindicated?

2nd and 3rd

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How do you describe hypertension that was present before or during the first 20 weeks of pregnancy?

Chronic hypertension

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What is gestational hypertension?

Hypertension developed in a pregnant women who is 20+ weeks pregnant.

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When does this hypertension become 'pre-eclampsia'?

If after 20 weeks and there is multi-organ involvement

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What is a main symptom of pre-eclampsia other than new-onset hypertension?

Proteinuria

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When should a pregnant woman with hypertension be offered anti-hypertensive medication?

If BP is >140/90mmHg

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What is the target BP for a pregnant woman?

135/85mmHg

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What is the 2nd line treatment for hypertension in pregnancy?

Calcium Channel Blocker (CCB)

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Which other antihypertensive may be used but is becoming less commonly used nowadays?

Methyldopa

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Diuretics are safe in pregnancy.
T/F?

False - Should not be used in pregnancy

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How often should a pregnant women's BP be checked?

Twice a week

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Should a pregnant women be sold OTC Paramol tablets?

No

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What would you recommend for pain in a pregnant woman?

Paracetamol

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Why are NSAIDs not recommended for use in pregnancy, and contraindicated in 3rd trimester?

Can reduce renal blood flow
Increase risk of ductus arteriosis (DA) constriction

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What is the ductus arteriosis?

Connects the pulmonary artery to the aorta in the heart of foetus

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If referring a patient to the GP who has pain in which paracetamol has not helped, what is important to tell them to manage their expectations?

That they may not provide stronger painkillers and may refer to physiotherapist

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Lifestyle advice would be 1st line option for pregnant women with dyspepsia. This includes:

Eat smaller meals more frequently
Avoid trigger foods (chocolate, spicy food, caffeine)
Maintain regular physical activity
Try sleep on left side
Raise head of bed up a little

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If these do not work, what would be 2nd line?

Antacid such as peptac

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How often would you recommend they take an antacid?

on a when required basis

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If an antacid does not work then what is 3rd line option?

PPI/H2RA

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Famotidine is preferred over omeprazole in pregnancy.
T/F?

False - omeprazole preferred as it is not known to cause any harmful effects to baby

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At how many weeks should nausea and vomiting in pregnancy resolve?

16-20 weeks

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What are some self-care measures that may help with nausea and vomiting in pregnancy?

Eat plain biscuits in the morning
Drink little amounts often
Avoid triggers (such as odours, heat and noise)
Ginger (fresh, tea, capsules)
Small protein rich meals, low in carbs and fat

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Which drug treatment are 1st line for pregnant women?

Cyclizine/promethazine (antihistamines)
Prochlorperazine/chlorpromazine (Phenothiazines)
Doxylamine with pyridoxine (Xonvea)

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Which one of these treatments are the only licensed one for this indication?

Doxylamine with pyridoxine (Xonvea)

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Which anti-emetics are used 2nd line?

Ondansetron
Domperidone
Metoclopramide

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Which one of these has an increased risk of a cleft palate when used in 1st trimester of pregnancy?

Ondansetron

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What advice would you give to a pregnant woman who is experiencing constipation?

Adequate fluids
Increase fibre
Exercise

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Which type of laxative should be offered first line in pregnant women?

Bulk-forming such as ispaghula husk (Fybogel)

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What is 2nd line?

Osmotic laxative such as lactulose

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What is important to advise pregnant women regarding varicose veins?

They are common in pregnancy
They are not harmful to you or baby
They often improve after pregnancy

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Haemorrhoids are common in pregnancy. What is the main cause of haemorrhoids?

Constipation/straining

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Anusol HC ointment can be used in pregnancy as it is a topical preparation and is not absorbed into the bloodstream.
T/F?

False - It can be absorbed into bloodstream and toxicity to foetus has been found in animal studies so should avoid

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Can you give oral histamines to a pregnant woman OTC?

No - they are not licensed in pregnancy

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This is because they are teratogenic.
T/F?

False

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Methadone patients who fall pregnant need to be taken off the ORT programme as this is unsafe for the baby.
T/F?

False - Methadone is safe in pregnancy

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Can a patient reduce their methadone dose if they want to reduce the opioid exposure to the foetus?

Yes if they want to but they don't have to

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Why may it be better for a patient to stay on their usual dose of methadone throughout pregnancy?

Reducing dose may increase risk of relapse which would have worse outcomes

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When could a patient start reducing their ORT dose?

2nd trimester

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All patients using drugs including those on ORT should be referred to which service?

Special Needs In Pregnancy (SNIP)
service

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What would you do if a pregnant patient was sick 5 minutes after taking their methadone?

Give another dose then call their addiction worker to get a new Rx to cover this dose

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What is Neonatal Abstinence Syndrome (NAS)?

When the baby experiences withdrawal after birth as it is no longer exposed to the substance that it was previously in the womb.

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What is given to the baby to control their symptoms and wean off of the substance?

Morphine liquid (Oramorph)

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Name a few of the symptoms of NAS.

High pitched cry
Tremor
Seizures
Rapid breathing
Fever/sweats

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Would it be appropriate to switch the patient from methadone to buprenorphine due its reduced risk of NAS?

If the patient is stable on methadone then should not switch to buprenorphine as it can increase risk of withdrawal in foetus

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Which epilepsy medication is not suitable for women and girls of childbearing age due to its teratogenicity?

Sodium Valproate (Epilim)

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Carbamazepine is associated with congenital malformations.
T/F?

True

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Which 2 anti-epileptic drugs are less risky in pregnancy?

Lamotrigine
Levetiracetam

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What should the patient be enrolled in if they are on teratogenic drugs such as sodium valproate?

Pregnancy Prevention Programme (PPP)

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For depression in pregnancy, sertraline is the drug of choice as it is not associated with any adverse effects and is 100% safe.
T/F?

False - Can be prescribed as there is no definitive risk of malformations

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However, there is a small increased risk of congenital _____ defects when used in early pregnancy.

heart

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Codeine is not contraindicated in pregnancy but can be used when breastfeeding.
T/F?

False - other way about

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Mother taking codeine towards end of pregnancy can increase risk of what syndrome after the birth of the baby?

Neonatal Abstinence Syndrome

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Why is codeine contraindicated in breastfeeding?

Due to risk of opioid toxicity in infant as it is excreted in breast milk

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The risk in breastfeeding mothers taking codeine is that a higher quantity of morphine metabolite may be produced and excreted in breast milk when taking a normal dose of codeine. Why would this happen in some patients?

If they are an ultra rapid-metaboliser

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Which similar drug can be used in breastfeeding because it is not affected by ultra rapid metabolism?

Dihydrocodeine

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Tramadol is contraindicated in breastfeeding women.
T/F?

False - it can be used but baby should be closely monitored

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Warfarin is more suitable in breastfeeding than DOACs.
T/F?

True

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Why is there not as much evidence of drugs in pregnancy and breastfeeding?

Ethical issues with clinical trials etc.

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Ibuprofen and _________ are the preferred NSAID in breastfeeding due to their shorter half-lives.

Diclofenac

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If a patient on ORT throughout pregnancy wishes to breastfeed, is this safe for the baby?

It is actually encouraged as it can reduce the length and intensity of NAS

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Warfarin is not recommended in pregnancy but is safe in breastfeeding.
T/F?

True

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Which class of antibiotics should be avoided in pregnancy and breastfeeding due to risk of effects to skeletal development and discolouration of teeth?

Tetracyclines

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Which drug can impact on the sucking reflex of the baby while breastfeeding?

Phenobarbital

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Bromocriptine may have an impact on what during breastfeeding?

production of milk

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water-soluble drugs are more likely to pass through into breast milk.
T/F?

False - lipid-soluble more likely to pass into breastmilk

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Drugs can potentially be more toxic to babies that were _________ or born with ________ due to damage to the liver.

Premature
Jaundice

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Why are insulin and heparin not excreted into breastmilk?

Because they have high molecular weights

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Does breastmilk contain vitamin D?

No

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If baby is breast fed with no formula top ups, how much vitamin D should they be supplemented with daily?

8.5-10mcg

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When does a child not need a vitamin D supplement and why?

If taking >500ml formula milk daily as this is fortified with vitamin D

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Aspirin is suitable in breastfeeding women because it is not excreted in breast milk.
T/F?

False - It is excreted in breast milk and can increase risk of Reye's syndrome

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Which antibiotic may cause an unpleasant taste in milk, possibly causing rejection by the infant?

Metronidazole

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Diazepam should be avoided in breastfeeding.
T/F?

True

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What could you recommend in mother who has sore/cracked ******* from breastfeeding?

Rub some of the milk on them as this has healing properties which may relieve soreness

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These are more at risk of becoming infected and developing thrush. What is an effective OTC treatment for this?

Miconazole 2% cream

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How should a breastfeeding mother use this?

Apply after feeds and clean ******* before next feed

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Thrush usually only affects one ******.
T/F?

False - both ******* due to transmission of infection from one to the other

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What can be given for oral thrush in a baby?

Miconazole oral gel (Daktarin oral gel)

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What age is this licensed for use?

4 months and older

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What is the condition called where there is inflammation of the breast tissue which sometimes involves infection?

Mastitis

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Why are breastfeeding women more likely to get mastitis?

As it may be caused by a build up of milk

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What antibiotic is first line in a woman with mastitis that is infected?

Flucloxacillin

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What is 2nd line if the patient is allergic to penicillin?

Erythromycin/clarithromycin

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What is the most common organism associated with infective mastitis?

Staphylococcus Aureus

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What is non-pharmacological advise for managing mastitis?

Use a warm compress on breast or take a warm bathe to relieve pain and help milk to flow

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It is advised to avoid chloramphenicol when pregnant/breastfeeding especially in the 3rd trimester due to the risk of which condition in the baby?

Grey baby syndrome

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Pregnancy and Breastfeeding

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