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Objectives
By the end of this talk, participants will: Know safe OTC meds for use in pregnancy Correctly choose antibiotics in pregnancy Understand the complexity of prescribing psychiatric medications during pregnancy Learn which types of chronic medications require dose adjustments in pregnancy Understand med options for pain in pregnancy
Up to Date
Drugs in Pregnancy and Lactation (Briggs) Medications in Mothers Milk (Hale)
Do Not Prescribe!
Methotrexate ACE inhibitors Carbamazepine (Tegretol) Valproic acid (Depakote) Isotretinoin (Accutane) Warfarin NSAIDs (Ibuprofen, Indomethacin)
C e a s 1
A healthy 35 yo G1P0 presents for routine pre-natal care. She complains of daily AM nausea, allergic rhinitis and intermittent GERD throughout the day, worse at night. She is also a smoker 1ppd and would like to quit. She is interested in med options for all. What would you recommend?
labelled as contraindicated in pregnancy Not well studies, but widely used without issues Topical treatments are first line
URI symptoms
Benadryl
widely considered safe Dextromethorphan considered safe Guaifenasin associated with neural tube defects Pseudoephedrine possible association c gastroschisis
Try behavioral techniques first? Use intermittent rather than continuous replacement
C e a s 2
A 33 yo G5 P1 (SAB 3) presents at 6 weeks gestation. She has h/o anxiety & insomnia related to recurrent pregnancy loss. She is coping ok right now, but just learned her mother was dx with breast CA. Between pregnancies she has taken Prozac and Klonopin with good effect.
She interested in discussing her options.
Untreated mental illness has significant and measurable effects on maternal & neonatal outcomes All psychotropic meds cross the placenta and are in amniotic fluid and breast milk Only Buspirone, Zolpidem, Buproprion, and Clozapine are pregnancy category B Shared decision making! One medicine only if possible
TM
Cardiac
/cranial/omphalocele with Paxil (also Zoloft) Consider fetal echocardiography for 1st TM Paxil Rate is 1 in 5000/ 8000/ 1000
3rd
TM
Neonatal
Third TM use CLEARLY associated with floppy baby sundrome prolonged severe withdrawal
Lamictal has a growing safety profile Anti-psychotics not well studied maybe safe? Lithium
TM risk of cardiac malformations fetal echo Need to monitor levels closely Neonatal abstinence syndrome
1st
C e a s 3
22 yo G1P0 with h/o frequent UTIs has a positive urine culture at her 1st OB visit. After treating this, you repeat a culture at 12 weeks which is negative. She is seen on L&D with a symptomatic UTI at 24 weeks and admitted with pyelonephritis at 34 weeks.
What are your abx options for these 3 infections?
C e a s 4
27 yo G3 P2 presents for prenatal care at 8 weeks. She has a history of hypothyroidism and epilepsy both well controlled on Synthroid 100mcg qd and Lamictal 100 qd. She is new to the area and has no other specialists established at this time.
What are your recommendations?
C e a s 5
16 yo G1P0 presents at 20 weeks c/o migraine headaches, controlled with Fioricet prior to pregnancy (#30/mo). What can you offer her?
After 5 visits for pain in 2 weeks, you have a heart to heart and refer her to the Suboxone clinic. How do you manage her pain in the third TM & labor?
References
Use of Psychiatric Medications During Pregnancy and Lactation - ACOG Bulletin 92 April 2008 OTC Medications in Pregnancy AFP 2003 Safety of PPIs in Pregnancy Annals 11/09 Managing Antiepileptic Drugs in Pregnancy and Lactation Current Opinion in Neurology 2009
Questions??