WOMEN’S HEALTH - PREGNANCY

KRISTEN PARKER, PHARMD

PGY1 PHARMACY RESIDENT – ESKENAZI HEALTH

[email protected]
ABOUT ME
OUTLINE

 Fetal development timeline

 Prenatal care
 Medication use in pregnancy
 Treatment recommendations for common pregnancy disease states and pregnancy complaints
OBJECTIVES

 Recognize appropriate prenatal diet and supplement recommendations for women

 Provide vaccination recommendations for pregnant women
 Use information in a package insert to evaluate if a drug is safe for use in pregnancy
 Construct an appropriate treatment regimen for common pregnancy-related complaints
 Select an appropriate treatment for pregnancy complications
FETAL DEVELOPMENT
FETAL DEVELOPMENT - FIRST TRIMESTER

Week 4
• Heartbeat begins to beat Week 8
• Arm bud appear Week 6 • External ears begin to
• Liver, pancreas, • Lungs begin to form form
gallbladder and spleen • Fingers and toes start to • Face begins to look
begin to form form human

Week 5 Week 7
• Eyes start to form • Hair follicles start to
• Leg buds appear form
• Blood circulates • Visible elbows and toes
• Facial features begin to
form

Weeks 3-8 are essential to fetal development and are key times to avoid drugs when possible
FETAL DEVELOPMENT – SECOND/THIRD TRIMESTER

Week 9-15 Weeks 27-38

• Reproductive organs form • Increase in body fat
• Teeth begin to form • Bones complete development
• Brain activity is detectable • Brain is continuously active

Weeks 16-26
• Rapid brain development
• Alveoli in lungs form
• Internal eyes and ears form
• Muscles develop
• Eyebrows, eyelashes and nails form
QUESTION BREAK

 During which trimester of pregnancy is medication use most concerning?

A. First trimester
B. Second trimester
C. Third trimester
PRENATAL CARE
WEIGHT GAIN DURING PREGNANCY
PRENATAL DIET

Increase Limit
• 300-400 extra calories per • Artificial sweeteners
day • Dairy
• Raw eggs
• Unwashed fruits and
vegetables
• Herbal teas
• Undercooked meats
• Caffeine

ACOG. 2020.
WHAT DOES 200 MG OF CAFFEINE LOOK LIKE?

5-Hour Energy 200 mg

Starbucks medium roast (tall) 155 mg
Keurig Green Mountain (K-cup) 120 mg
Red Bull 76 mg
Nespresso (pod) 50-60 mg
Diet Coke (can) 46 mg
Tea 20-40 mg

Examine.com
PRENATAL SUPPLEMENTS

Omega-3-
Folate Iron Calcium
fatty acids
Supplementation
Adequate folate
Iron deficiency tied can decrease Helps with
decreases neural
to low birth weight maternal bone loss, production of
tube defects by
and preterm birth HTN and prostaglandins
>50%
preeclampsia

0.4 mg daily
or 12 oz of seafood per
27-30 mg daily* 1000-1300 mg daily
4 mg daily if high week*
risk

ACOG. 2020.
PATIENT CASE

 LP is 26 year old female who comes up to the pharmacy counter holding multiple vitamin bottles and asks which
one is best to use in pregnancy. What would you tell her?
 Look for a prenatal vitamin that included folic acid, iron, calcium and omega-3-fatty acids
 Refer her to an OB for proper prenatal care
SUBSTANCE USE IN PREGNANCY
ALCOHOL

Placental
Miscarriage
abruption

 American Academy of Pediatrics recommends NO

alcohol consumption
Preterm
birth

Fetal
alcohol Stillbirth
syndrome

CDC 2020.
FETAL ALCOHOL SYNDROME

 Small head size

 Poor coordination
 Low body weight
 Hyperactive behavior
 Poor memory
 Difficulty in school
 Learning disabilities
 Speech and language delays
Janet F. Williams et al. Pediatrics 2015;136:e1395-e1406

CDC 2020.
TOBACCO AND MARIJUANA

Tobacco Marijuana
 Potential risks include preterm birth, low birth  Potential risks include low birth weight, brain
weight, birth defects, sudden infant death syndrome development disruption, decreased attention span,
 Plan with women to allow for a tobacco –free period behavioral problems, and marijuana use in the child
by the age of 14
prior to conception
 FDA-approved cessation aids have not been studied
in pregnancy

CDC 2020.
OPIOIDS

 Use during pregnancy has been linked with preterm birth, stillbirth, maternal mortality, feeding problems,
breathing problems and neonatal abstinence syndrome (NAS)
 Clinicians should weight the benefits and risks or initiating or continuing opioids in a pregnant patient
 Patients with substance use disorder can be referred to a medication assisted treatment center
 Both methadone and buprenorphine have been used

Obstet Gynecol 2017.

VACCINATION RECOMMENDATIONS
VACCINATION RECOMMENDATIONS

All pregnant women Pregnant women with risk factors

 Influenza- by the end of October  PPSV23
 Tdap – 27-36 weeks  HepA
 HepB
 MenACWY

CDC 2020.
VACCINES TO AVOID DURING PREGNANCY

 HPV
 Shingrix
 Live vaccines
 MMR
 Live influenza
 Varicella
 Zostavax

CDC 2020.
PATIENT CASE

 After recommending a prenatal vitamin for LP, she also states she wants to get caught up on her vaccinations in
order to be the healthiest mom she can be for her baby. She received a flu vaccine two years ago, has not received
the HPV vaccine and has no other risk factors. What vaccinations would you recommend for her during
pregnancy?
 Inactivated flu vaccine by the end of October
 Tdap at 27-36 weeks
 HPV vaccine after pregnancy
MEDICATION USE IN PREGNANCY
PHARMACOKINETIC CHANGES
Absorption

• Decreased rate of absorption

• Increased extent of absorption due to slower GI motility

Distribution

• Increased volume of distribution for hydrophilic drugs

• Decreased protein binding to albumin

Metabolism

• Altered phase 1 and phase 2 metabolism enzymes

• CYP2C19 activity reduced
• CYP3A4 activity increased

Excretion

• Increased renal and hepatic blood flow

• Increased CrCl

Semin Perinatol. 2015.

PACKAGE INSERTS

21 CFR §201.56.
PREGNANCY CATEGORIES

8.1 Pregnancy + Labor and 8.3 Females and Males of

8.2 Lactation
Delivery Reproductive Potential
• Pregnancy Exposure • Presence in human milk • Pregnancy testing
Registry contact • Effects on child recommendations or
information • Effects on milk requirements
• Fetal and maternal risk production • Contraception
summary • Counseling information recommendations or
• Dose adjustment • Exposure minimization requirements
recommendations strategies • Human and/or animal
• Fetal and maternal • Monitoring reaction data on infertility risks
adverse reactions • Human and animal data
• Human and animal Data

21 CFR §201.56.
ACTIVITY

 Look up the package insert for Gilenya (fingolimod)

 How would you use this drug in a patient who is pregnant or trying to get pregnant?
 How would you use this drug in a patient who is breastfeeding?
 How would you counsel a female of reproductive potential who is starting this drug?
HOW WOULD YOU USE THIS DRUG IN A PATIENT WHO IS
PREGNANT OR TRYING TO GET PREGNANT?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
HOW WOULD YOU USE THIS DRUG IN A PATIENT WHO IS
BREASTFEEDING?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
HOW WOULD YOU COUNSEL A FEMALE OF REPRODUCTIVE
POTENTIAL WHO IS STARTING THIS DRUG?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
TREATMENT RECOMMENDATIONS DURING
PREGNANCY
NAUSEA AND VOMITING OF PREGNANCY

 Risk Factors
 Common in early pregnancy
 History of motion sickness, migraines, GERD or
 Early treatment may prevent more serious nausea/vomiting with prior pregnancy
complications  High fat diet
 Treatment approaches include dietary and lifestyle  Younger age at conception
changes and/or medications depending on severity
 Family history of nausea and vomiting in pregnancy

Obtet Gynecol 2018; 131:15-30.

DIETARY AND LIFESTYLE CHANGES

 Start prenatal vitamins 3 months prior to conception

 Avoid triggers (foods, smells, motion)
 Eat small, frequent, low-fat meals
 Eat a light snack like crackers before getting out of bed
 Drink chilled beverages
 Eat ginger
 Acupressure bands
 Behavioral methods
 Counseling
 Hypnosis
 Acupuncture

Obtet Gynecol 2018; 131:15-30.

Image from Sea-Banc.com
NAUSEA

Dietary and
Pyridoxine Pyridoxine +
lifestyle
(Vitamin B6) Doxylamine
changes

Am Fam Physician 2018. 98(9):595-602

PYRIDOXINE + DOXYLAMINE COMBO PRODUCT

NDClist.com
VOMITING

Meclizine
Dietary and lifestyle Pyridoxine +
Dimenhydrinate
changes Doxylamine
Diphenhydramine

Metoclopramide
Promethazine
Methylprednisolone Ondansetron
Prochlorperazine
Droperidol

Am Fam Physician 2018. 98(9):595-602

HEARTBURN

Non-pharmacologic Pharmacologic
 Eat small, frequent meals  H2 blockers

 Avoid smoking, caffeine, peppermint and chocolate  Cimetidine

 Famotidine
 Raise head of bed
 Ranitidine
 Drink fluids between meals
 Proton pump inhibitors
 Chew gum  Pantoprazole
 Avoid eating or drinking close to bedtime  Omeprazole

 Non-salicylate antacids
 Sucralfate
 Metoclopramide
Am Fam Physician 2018. 98(9):595-602
CONSTIPATION

Non-pharmacologic Pharmacologic
 Dietary changes  Osmotic laxatives
 Polyethylene glycol
 Increased fiber
 Lactulose
 Increased fluids
 Bulk forming laxatives
 Avoid constipating foods  Psyllium

 Regular exercise  Stimulant laxative

 Bisacodyl
 Limit stress
 Senna

 Stool softener
 Docusate

Am Fam Physician 2018. 98(9):595-602

PAIN, FEVER, AND HEADACHE

 Pain
 Chronic pain should be adequately treated

 Fever
 See OB if unresolved in 24-36 hours

 Headache
 See OB if it is persistent or occurs after 20 weeks

Am Fam Physician 2018. 98(9):595-602

PAIN, FEVER, AND HEADACHE

Non-pharmacologic recommendations Pharmacologic recommendations

 Cool compress  Acetaminophen = drug of choice
 Avoid triggers  It does appear to cross the placenta but in studies with
over 10,000 infants, there were no increased risk of
 Manage stress malformations in newborns exposed to acetaminophen
 Practice relaxation techniques in the first trimester

 Eat regularly  NSAIDS

 Avoid use after 32 weeks
 Get adequate sleep

Am Fam Physician 2018. 98(9):595-602

US Pharm. 2006. 3:33-47.
COUGH AND COLD

• Nasal decongestant spray

Congestion • Pseudoephedrine in 2nd/3rd trimester

• Chlorpheniramine
Rhinorrhea • Diphenhydramine

• Chlorpheniramine
Sleeplessness • Diphenhydramine

Am Fam Physician 2018. 98(9):595-602

US Pharm. 2006. 3:33-47.
URINARY TRACT INFECTIONS

Non-pharmacologic recommendations
 Occur in about 10% of pregnant women  Hydration
 Increase the risk of preterm labor, transient renal  Proper wiping (front to back)
failure, hematologic abnormalities, ARDS, sepsis  Void before and after sex
and shock
 Avoid scented feminine products
 Wear cotton underwear
 Avoid tight fitting clothes

Am Fam Physician 2018. 98(9):595-602

PHARMACOLOGIC RECOMMENDATIONS FOR UTIS IN
PREGNANCY

First generation cephalosporins

Nitrofurantoin (avoid at term)
Penicillins
Erythromycins

Fluoroquinolones
Tetracyclines
Sulfamethoxazole/Trimethoprim*

Am Fam Physician 2018. 98(9):595-602

PATIENT CASE

 LP returns to your pharmacy in a month and complains of “morning sickness”. She states she has tried to avoid
foods that make it worse, has been eating small frequent meals and even tried Vitamin B6 but nothing has helped.
She asks what medication she could take to help with her nausea?
 Pyridoxine + doxylamine
 Recommend she buys it OTC as it is cheaper
CHRONIC DISEASE STATE MANAGEMENT
DEPRESSION

 Between 14 and 23% of pregnant women will experience a depressive disorder while pregnant
 Maternal depression is linked to increased rates of adverse outcomes
 Preterm birth
 Low birth weight
 Fetal growth restriction
 Postnatal complications

Obstet Gynecol. 2009;114(3):703-713.

DEPRESSION SCREENING IN PREGNANCY

 Edinburgh Depression Scale

 Score of 10 or greater is indicative
of possible depression
 Maximum score is 30

British Journal of Psychiatry 1987; 150:782-

786.
N Engl J Med 2002; 347:194-199
DEPRESSION

Consider agent
Previous or current
continuation ±
antidepressant use
CBT
EPDS score ≥ 10
No history of
Consider CBT ±
depression
Screen all sertraline
treatment
pregnant women

Monitor, reassess
EPDS score < 10
next visit
EPILEPSY

 If possible, avoid valproate and polytherapy of antiepileptic drugs

 Avoidance of phenytoin and phenobarbital during pregnancy may be considered to prevent reduced cognitive
outcomes
 There is insufficient evidence to determine if lamotrigine or other specific AEDs increase the risk of fetal
malformations

Neurology 2009; 79:133-141 .

DIABETES MANAGEMENT

 Fetal risks
 Maternal risks
 Miscarriage
 Cesarean delivery
 Stillbirth
 Preeclampsia
 Birth injury
 Kidney disease
 Neonatal hypoglycemia
 Retinopathy
 Hyperbilirubinemia
 Cardiac and neural tube defects

Diabetes Care. 2020.

DIABETES MANAGEMENT

 Increase self-monitoring of blood glucose (SMBG) to 4 times daily

 More stringent goals
 Fasting <95
 2-hour Postprandial <120

 Preferred pharmacologic treatment

 Insulin

Diabetes Care. 2020.

HYPERTENSION MANAGEMENT

Recommended agents
Labetalol ACE Inhibitors
Amlodipine ARBs
Nifedepine
HCTZ
Hydralazine

Avoid use
Methyldopa

Drugs. 2014;74(3):283-296.
PREGNANCY COMPLICATIONS
GESTATIONAL DIABETES – RISK FACTORS

Immediate
Overweight Previous
family with Pre-diabetes
(BMI ≥25) GDM
T2DM

Polycystic
Non-white Age > 25
Ovary
Race years
Syndrome

Diabetes Care. 2020.

GESTATIONAL DIABETES – FETAL RISKS

Higher Rates of:

Longer hospital stay Hypoglycemia

NICU admission Perinatal distress Macrosomia

Diabetes
Diabetes Care.
Care. 2020.
2020.
GESTATIONAL DIABETES – DIAGNOSIS

One Step Test

• Fast for 8 hours prior
• Consume 75g of glucose
• Obtain BG at 1 and 2 hours after glucose dose

Two Step Test

• Consumer 50g of glucose while non-fasting
• If BG >130-140 proceed to second test
• Consume 100g glucose then obtain BG at 1, 2 and 3 hours after glucose dose

Diabetes Care. 2020.

GESTATIONAL DIABETES - TREATMENTS

Lifestyle Injectable Oral

Modifications Medication Medications
• Diet • Basal • Metformin
• Exercise insulin • Glyburide
• Regular • Bolus
SMBG insulin

Diabetes
Diabetes Care.
Care. 2020.
2020.
THROMBOEMBOLISM

 DVTs can happen during any trimester, PEs are more common postpartum
 Non-pharmacologic options
 Inferior vena cava (IVC) filter
 Thrombectomy
 Compression stockings (prophylaxis)

 Pharmacologic treatments – treat for at least 6 months

 Low-molecular weight heparin
 Unfractionated heparin
 Apixaban

Curr Treat Options Cardiovasc Med. 2018 Jul 23;20(8):69.  

ANTICOAGULATION MANAGEMENT AROUND DELIVERY

Pre-delivery
Restarting anticoagulation
- Stop LMWH 24 hours prior
to induction of c-section - C-section: 6-12 hours
- Stop oral agents 24-48 hours - Epidural: 12 hours after
before induction of c-section removal
- Hold UFH and monitor aPTT - Uncomplicated vaginal
around delivery delivery: 4-6 hours
PREECLAMPSIA

 Occurs on its own or on top of chronic hypertension

 Categorized by hypertension (>140/90) and proteinuria (>300mg/24h)
 Risk factors include previous preeclampsia, ethnicity, increased maternal BMI before pregnancy, multiple gestations and
underlying medical conditions
 Fetal risks include premature delivery, growth retardation, and death
 Severe symptoms
 Headache, blurry vision
 End organ damage

Drugs. 2014;74(3):283-296.
 MILD PREECLAMPSIA MANAGEMENT

 BP twice weekly
 Weekly labs (CBC, platelets, LFTs, uric acid, creatinine)
 Proteinuria screening
 Fetal non-stress test twice weekly
 Amniotic fluid measurement 1-2 times per week
 Ultrasound for fetal growth every 3-4 weeks

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 SEVERE PREECLAMPSIA MANAGEMENT

Hypertension management Seizure prophylaxis

 Hydralazine (IV or IM)  Magnesium sulfate 4-6 g IV bolus over 15-20 minutes then 2 g/hr

 Labetalol (IV)  Monitoring

 Reflexes
 Nifedepine (PO)
 Mental status
 Nitroprusside (IV)  Respiratory status
 Urine output
 Magnesium levels

 Alternatives
 Phenytoin
 Benzodiazepines

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 MAGNESIUM MONITORING

Serum Magnesium (mg/dl) Effect

5-9 Therapeutic
>9 Loss of deep tendon reflexes
>12 Respiratory paralysis
>30 Cardiac arrest

Antidote for magnesium toxicity = Calcium Gluconate 1 g (IM or IV)

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 HELLP SYNDROME

 Hemolysis, elevated liver enzymes, and low platelet count

 Symptoms are non-specific
 Epigastric pain
 Nausea
 Vomiting

 Diagnosis via lab abnormalities

 Treatment
 Platelets
 Corticosteroids

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 ECLAMPSIA

 Seizure causes by elevated blood pressure during pregnancy

 Seizure usually lasts 60-90 seconds
 Treatment
 Immediate delivery
 Magnesium sulfate to prevent additional seizures

Am Fam Physician. 2016 Jan 15;93(2):121-127.
GROUP B STREP

 Test women at 35-36 weeks to determine need for antibiotics during labor
 Prophylaxis is used during labor in patients who are colonizers to reduce incidence of early onset neonatal sepsis
 Recommended agents:
 First line
 Penicillin G 5 million units IV once then 2.5-3 million units IV q4hours
 Ampicillin 2 g IV once then 1g IV q4hours

 PCN allergy (mild)

 Cefazolin 2g IV once then 1g IV q8hours

 PCN allergy (severe/anaphylaxis)

 Clindamycin 900 mg IV q8hours
 Vancomycin 1g IV q12hours

Am Fam Physician. 2011 May 1;83(9):1106-1110.
PREMATURE MEMBRANE RUPTURE

Treatment
 Risk factors  Corticosteroids
 Betamethasone 12 mg Q24H x 2 days
 Lack of prenatal care
 Dexamethasone 6 mg Q24H x 2 days
 Cigarette smoking during pregnancy
 Antibiotics
 Previous preterm birth  Ampicillin 2 g IV + erythromycin 250 mg Q6H x 48 hours followed

 STDs by amoxicillin 250 mg + erythromycin 333 mg Q8H x 5 days

 Group B strep prophylaxis for carriers or patients who have not yet
 Occurs before the onset of labor (<37 weeks) been tested

 Water breaks but no contractions  Tocolytics

 Magnesium sulfate

Am Fam Physician. 2006 Feb 15;73(4):659-664.
 PRETERM LABOR

Prevention
 Labor before 37 weeks of gestation  Minimize controllable risk factors
 Risk factors  Progesterone
 Non-Hispanic black race  200 mg vaginal suppository if no history or preterm birth
 <6 months between pregnancies with prior pregnancies

 Low pre-pregnancy weight  250 mg IM weekly (week16-36) if history of preterm birth

with prior pregnancy
 Chronic medical conditions (diabetes, HTN, thyroid disorders)
 Prior preterm delivery
 Substance use during pregnancy
 Bacterial vaginosis

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 PRETERM LABOR

 Magnesium sulfate 4-6 g IV bolus then 1 g/h x 12 hours

 Corticosteroids
 Betamethasone 12 mg Q24H x 2 days
 Dexamethasone 6 mg Q12H x 4 days

 Group B strep prophylaxis

 Tocolytics
 Nifedepine
 Indomethacin
 Terbutaline
 Magnesium

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 TOCOLYTICS

Fetal or
Agent Maternal Side Effects Newborn Contraindications Dose
Adverse Effects
Nifedipine Dizziness, flushing, No known Hypotension, preload 10 mg po q 20 min x
(calcium hypotension.  Suppression effects dependent cardiac 3 doses, then 20 mg
channel of heart rate, contractility, pathology (aortic po q 4-6 hours
blocker) and LV pressure when insufficiency)
used with Mg SO4. 
Elevation of LFTs

Indomethacin Nausea, reflex, gastritis, Constriction of Peptic ulcer disease, 50-100 mg PO or PR,
(NSAID) emesis PDA, renal failure, platelet then 25 mg-50 mg q 6
oligohydramnios dysfxn hours
, necrotizing
enterocolitis

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 TOCOLYTICS

Fetal or Newborn
Agent Maternal Side Effects Contraindications Dose
Adverse Effects
Terbutiline, Tachycardia, hypotension, Fetal tachycardia Maternal tachycardia 0.25 mg subcut
(beta-adrenergic tremor, palpitations, every 15-30
receptor agonist) dyspnea, chest pain, minutes
pulmonary edema,
hypokalemia,
hyperglycemia
Magnesium sulfate Flushing, diaphoresis, Neonatal depression Myasthenia gravis 4-6 g IV loading
nausea, loss of DTRs, dose, 2 gram/hr
respiratory depression, IV
suppresses heart rate and
contractility,
neuromuscular blockade

Am Fam Physician. 2017 Mar 15;95(6):366-372.
QUESTION BREAK

 LP is now at 30 weeks gestation and presents to the ED, she is having contractions and thinks she is in labor. The
OB resident confirms she is in preterm labor and asks for your help with medications recommendations. LP has no
known drug allergies and is group B strep negative.
 Tocolytic
 Nifedepine 10 mg PO q20 min for 3 doses then 20 mg PO q4-6 hours

 Magnesium sulfate 4-6 g IV bolus then 1 g/h x 12 hours

 Corticosteroids
 Betamethasone 12 mg Q24H x 2 days
 Dexamethasone 6 mg Q12H x 4 days
MEDICATION USE IN PREGNANCY RESOURCES

 CDC
 https://www.cdc.gov/pregnancy/meds/treatingfortwo/treatment-guidelines.html

 March of Dimes
 https://www.marchofdimes.org/pregnancy/prescription-drugs-over-the-counter-drugs-supplements-and-herbal-products.aspx

 MotherToBaby
 https://mothertobaby.org/
KEY TAKEAWAYS

 Refer back to the objectives to get an idea of topics you will be tested on
 Focus on indications for the drugs/supplements we discussed
 Do not focus on dosing
RESIDENT EVALUATION

https://butler.qualtrics.com/jfe/form/SV_b7NdVRSFqPrMQq9
WOMEN’S HEALTH - PREGNANCY
KRISTEN PARKER, PHARMD

PGY1 PHARMACY RESIDENT – ESKENAZI HEALTH

[email protected]