Drug use in pregnancy and lactation

2. Drug Use in
Pregnancy and lactation (3)
By
M.D. , Ph.D.
Shahid Beheshti University of Medical Science

3. Drug Use in Pregnancy and lactation (3)
 Fetal Effects of NON Therapeutic Drugs
 Selected Diseases
 Neonatal Therapeutics
 Drug Effects In Lactation

4. Fetal Effects of NON Therapeutic Drugs
 Alcohol
 Caffeine
 Cigarette smoking
 Cocaine
 Marijuana & Heroin

5. Alcohol
 Is contraindicated during pregnancy; no
amount is considered safe.
 Heavy intake causes fetal alcohol syndrome
characterized by multiple congenital defects
and mental retardation.

6. Caffeine
 It is present in coffee, tea, cola drinks, chocolate and
OTC analgesics.
 Ingestion of moderate amounts has caused
spontaneous abortions, preterm births, and low birth
weights.
 High doses may cause cardiac dysrhythmias in the
fetus.
 It is recommend that healthy nonpregnant adults
consume no more than 250 mg of caffeine daily.

7. Amount (gram) Caffeine (mg)
Coffee
Brewed, regular
Instant
Espresso
142–227
142–227
57
40–180
30–120
120
Tea
Brewed, leaf or bag
Instant
Iced
227
227
340
80
50
70
Soft Drinks
Pepsi, Diet Pepsi 340 38
Caffeine Amount In Drinks

8. Cigarette smoking
 Nicotine is contraindicated.
 Effects include increased fetal, neonatal, and
infant mortality; decreased birth weight and
length; and increased complications of
pregnancy.
Placental abruption
spontaneous abortion
preterm delivery

9. Cigarette smoking (Cont,d)
 These effects are due to decreased flow of blood and
oxygen to the placenta.
 Chronic fetal hypoxia from smoking is associated
with mental retardation and other long-term effects
on physical and intellectual development.
 Overall, effects of smoking are dose related:
 Light smoking (<1 pack/day) fetal deaths increase by 20%
 Heavy smoking (≥1 packs/day) increasing deaths by 35%.

10. Cocaine
 May cause maternal vasoconstriction, tachycardia,
hypertension, cardiac dysrhythmias, and seizures.
 It impairs neurologic development, and increase the
risk of spontaneous abortion during the first and
second trimesters.
 In third trimester, cocaine causes increased uterine
contractility which increases the risk of abruptio
placentae.
 They are even more likely to occur with “crack”
cocaine, a highly purified and potent form.

11. Marijuana & Heroin
 Marijuana impairs formation of DNA and
RNA.
 It also may decrease the oxygen supply of
mother and fetus.
 Heroin increases the risks of pregnancy-
induced hypertension, third trimester bleeding
and complications of delivery.

12. Selected Diseases
 AIDS
 UTI (urinary tract infections)
 Asthma
 Diabetes Mellitus
 Hypertension
 Epilepsy

13. AIDS
 HIV infection can be transmitted to the fetus and
neonate, so treatment is needed.
 Oral zidovudine (AZT) monotherapy has been used
for several years, after 14 weeks of gestation.
 During labor, IV AZT is given until delivery.
 After delivery, the infant should be given AZT for 6
weeks, with or without other anti-AIDS drugs.
 Highly active antiretroviral therapy (HAART) is
being used for pregnant women.

14. AIDS (Cont,d)
 HAART is a combination of drugs that may
include:
 A nucleoside reverse transcriptase inhibitor
(zidovudine)
 A non- nucleoside reverse transcriptase inhibitor
(nevirapine)
 A protease inhibitor (ritonavir)
 Women with HIV infection or AIDS should be
encouraged o avoid pregnancy.

15. UTI
 Commonly occur during pregnancy and may include
asymptomatic bacteriuria, cystitis, and pyelonephritis.
 Asymptomatic bacteriuria should be treated in
pregnancy because of its association with cystitis and
pyelonephritis.
 Asymptomatic bacteriuria are also associated with
increased preterm deliveries and low birth weights.
 Hospitalization and an IV cephalosporin may be
needed for pyelonephritis.

16. Asthma
 Asthma is associated with preeclampsia,
perinatal death and congenital malformations.
 Poor asthma control is considered more
detrimental to a fetus than its treatment.
 Good control is essential, drugs include inhaled
β2 agonists & anti inflammatory agents.

17. Diabetes Mellitus
 Poor glycemic control increases the risks of
birth defects.
 For diabetic women who become pregnant,
maintaining normal blood sugar is required for
successful outcomes.
 Oral antidiabetic drugs should be stopped
before conception or as soon as pregnancy is
suspected.

18. Diabetes Mellitus (Cont,d)
 Oral antidiabetic drugs are contraindicated in
pregnancy, mainly because of fetal
hypoglycemia.
 It seems that acarbose, miglitol, and metformin
have little risk for the fetus.
 Insulin is the antidiabetic drug of choice
during pregnancy.
 Human insulin should be used because it is
least likely to cause an allergic response.

19. Diabetes Mellitus (Cont,d)
 Insulin requirements vary during pregnancy so
blood glucose must be monitored closely and
insulin therapy individualized.
 It is especially important that sufficient insulin
is given to prevent maternal acidosis.
 Uncontrolled acidosis is likely to interfere with
neurologic development of the fetus.
 At the same time, careful dietary control and
other treatment measures are necessary.

20. Diabetes Mellitus (Cont,d)
 Insulin requirements usually decrease during
the first trimester and increase after that.
 During labor and delivery, short-acting insulin
and frequent blood glucose tests should be
used.
 During the postpartum period, insulin
requirements increase because of stress,
trauma, infection and surgery.

21. Diabetes Mellitus (Cont,d)
 At the same time, termination of the pregnancy
reverses the diabetogenic hormonal changes
and decreases insulin requirements.
 Short-acting insulin is given, and dosage is
based on frequent measurements of blood
glucose.
 Once the insulin requirement is stabilized, the
client can return to the prepregnancy treatment
program.

22. Hypertension
 Chronic hypertension is hypertension beginning
before conception or up to 20 weeks of
pregnancy.
 It is associated with increased maternal and
fetal risks.
 Nonpharmacologic interventions should be
emphasized.
 If drug therapy is required, methyldopa is the
drug of first choice.

23. Hypertension (Cont,d)
 Diuretics should not be given during
pregnancy.
 They decrease blood volume and may cause
fluid and electrolyte imbalances.
 Some authorities recommend avoiding the
drugs during the first trimester and stopping
them 2 to 3 days before delivery.

24. Epilepsy
 There has been controversy as to whether teratogenic
effects stemmed from epilepsy or drugs.
 A study indicates that the drugs are responsible.
 The rate of birth defects was as follows:
combination therapy 28% > monotherapy 20.6% > no
therapy 8.5%.
 Infants whose mothers took antiepileptics for bipolar
disorder also had higher rates of birth defects.

25. Epilepsy (Cont,d)
 Antiepileptics must be taken during pregnancy
because seizure is harmful to mother and fetus.
 Most pregnancies (95%) result in normal infants.
 Monotherapy with the lowest possible dose is used
and plasma drug levels should be checked monthly.
 Women with epilepsy should take a folic acid
supplement.
 Supplemental vitamin K is needed in the last month
of pregnancy, to prevent bleeding in neonates.

26. Neonatal Therapeutics
 In the neonate, any drug must be used cautiously.
 Drugs are usually given less often because they are
metabolized and excreted slowly.
 At birth, some drugs are administered to prevent
hemorrhagic disease of the newborn and ophthalmia
neonatorum.
 Hemorrhagic disease occurs because the intestinal
tract lacks the bacteria that synthesize vitamin K.

27. Jan. 2007
Neonatal Therapeutics (Cont,d)
 Vitamin K:
 Vitamin K1 (Phytonadione) is found in food
 Vitamin K2 (Menaquinone) is synthesized by
intestinal bacteria
 Vitamin K3 (Menadione) should NEVER be used.
 One dose of phytonadione 0.5 to 1 mg is
injected at delivery.

29. Neonatal Therapeutics (Cont,d)
 Ophthalmia neonatorum is a bacterial
conjunctivitis that may cause blindness.
 It is caused most commonly by C. trachomatis,
a sexually transmitted organism.
 Erythromycin ointment is applied to each eye
at delivery.
 It is effective against both chlamydial and
gonococcal infections.

30. Drug Effects In Lactation
 Most drugs have not been tested in nursing
women and their effect on infant is unknown.
 Maternal drug use during lactation should be
cautious.
 There is some degree of risk with any systemic
medication ingested by the mother.

32. Drug Effects In Lactation (Cont,d)
 The dose reaching the infant is proportional to
the mother’s drug concentration.
 In many instances, the infant may not receive
sufficient drug to produce adverse effects.
 Most OTC and prescription drugs taken only
when needed, are thought to be safe.

33. Drug Effects In Lactation (Cont,d)
 Safe Drugs In Lactation (NOT In Pregnancy):
 Antibacterials (Penicillins And Cephalosporins)
 Anticoagulants (Heparin Or Warfarin)
 Antihypertensives (ACE Inhibitors, Ca2+ Blockers)
 Caffeine (In Moderate Amounts)
 Corticosteroids (Prednisolone or Inhaled Products)
 Decongestants (Nose Drops or Spray)
 Acetaminophen
 Cromolyn

34. Drug Effects In Lactation (Cont,d)
 Safe Drugs In Lactation (NOT In Pregnancy):
 Digoxin
 Famotidine
 Ibuprofen
 Insulin
 Levothyroxine
 Mini-pill OCPs
 Antiepileptics
 Antihistamines
 Benzodiazepines if use is brief

35. Drug Effects In Lactation (Cont,d)
 Drugs to be used with caution in lactation:
 Aspirin (Reye’s syndrome).
 Beta blockers (hypoglycemia)
 Systemic corticosteroids (may suppress growth and
interfere with endogenous corticosteroid production)
 Diuretics
 Cholestyramine (may cause severe constipation in the
infant), & statins
 Methadone
 Metoclopramide
 Theophylline (may cause irritability or disturbed sleep)

36. Drug Effects In Lactation (Cont,d)
 Drugs to be used with caution in lactation:
 Alcohol (within 2 hours of breast-feeding)
 Aluminum-containing antacids
 Amantadine
 Chloramphenicol, metronidazole, nitrofurantoin,
sulfonamides
 Antidepressants (bupropion, tricyclics, and SSRI)
 Antihistamine (clemastine)
 Antipsychotics (older or typical agents)

37. Drug Effects In Lactation (Cont,d)
 Contraindicated drugs in lactation (if they are
required, breast feeding should be stopped):
 All anticancers
 Amiodarone
 Antibacterials (fluoroquinolones, tetracyclines,
trimethoprim [interfere with folic acid metabolism in
the infant])
 Bromocriptine (decreases milk production)
 Doxepin (may cause respiratory depression)

38. Drug Effects In Lactation (Cont,d)
 Contraindicated drugs in lactation (Cont,d)
 Cyclosporine
 Drugs of abuse (including nicotine)
 Ergotamine
 Isotretinoin
 Lithium
 Phenytoin (For epileptics, observe the infant for sedation
and poor suckling)
 Caffeine (may cause irritability in high doses)

40. Thank you
Any question?