indications & contra indication of various medicines with pro & cons in various stages of the pregnancy

1. DR. YOGESH PATEL
MBBS, DGO
DIPLOMA IN LAPAROSCOPY (D. MAS)
FELLOWSHIP IN LAPAROSCOPY (F. MAS)
FELLOWSHIP IN INFERTILITY (F. ART)
PG DIPLOMA IN ULTRASONOGRAPHY (D. USG)
EMERGENCY MEDICINE SPECIALIST
FORMER CONSULTANT AIIMS NEW DELHI
MEMBER OF THE WORLD ASSOCIATION OF LAPROSCOPIC SURGEONS

3. • A TERATOGEN is an agent that can produce
a permanent alteration of structure or
function in an organism exposed during
embyronic or fetal life.
• The word ‘teratogen’ is derived from a
greek word ‘teratos’ meaning monster.
• Three charecteristics of teratogens are
- Dose specificity
- Organ specificity
- Species specificity.

4. HADEGEN is an agent interferes with
normal maturation and function of an
organ.
TROPHOGEN is an agent that alters
growth.
HADEGEN and TROPHOGEN generally
affects processes occurring after
organogenesis and even after birth.

5. GENERAL PRINCIPLES OF
TERATOLOGY
Teratogenic effects depend on interplay of
4 major factors:
Period of embryonic development at which
organogenesis is disturbed
The agent causing the derangement
The dose of the agent
Genetic constitution of the developing fetus

6. PRINCIPLE MECHANISMS OF
TERATOGENESIS
Teratogens act by disturbing specific
physiological processes, which leads to -
 Cell death,
 Altered tissue growth or
 Abnormal cellular differentiation.
 Mutations, genetic or chromosomal, before or
after conception.

7. 1. DISRUPTION OF FOLIC ACID METABOLISM
Drugs like hydantoin, carbamazepine, valproic acid
and phenobarbital impair folate absorption can lead
to decreased periconceptional folate levels causing
birth defects like oral clefts, cardiac defects and
urinary tract abnormalities.
2. MUTAGENESIS-. Mutation in gene for methylene
tetrahydrofolate reductase causing Neural tube
defects.
Genetic polymorphism of gene for TGF-1 causing
cleft palate.

8. 3. PATERNAL EXPOSURES-Mechanism
involved are;
Induction of a gene mutation or
chromosomal abnormality in sperm.
Paternal germ cell exposure to drugs or
environmental agents may alter gene
expression.
 Drug in seminal fluid can directly affect
the fetus.

9. 4. HOMEO BOX GENES
 Homeobox genes are essential for
establishing positional identity of various
structures along the body axis from
branchial area to coccyx.
 Retionic acid is a potent teratogen that
can activate these genes prematurely ,
resulting in chaotic gene expression at
sensitive stage of development causing
abnormalities in hind brain and
limbbuds.

10. WILSON’S 6 PRINCIPLES
OF TERATOGENICITY
1.Suspectibility to teratogenicity depend
on the genotype of the conceptus and the
manner in which this interacts with
adverse environmental factors.
2.Teratogeneic agents act in specific ways
on developing cells and tissues to initiate
sequence of abnormal development

11. 3.Suspectibility to teratogenicity varies with
developmental stages at the time of
exposure to an adverse influence.
-There are critical periods of suspectibility to
agents and organ systems affected by these
agents.
4.Manifestations of deviant development
increase in frequency and degree as dosage
increases from the No Observable Adverse
Effect Level (NOAEL) to a dose producing
100% Lethality (LD100)

12. 5. The access of adverse influences on
developing tissues depend on the nature of
the influence. Several factors affect the
ability of a teratogen to contact with
developing concepts such as
 the nature of agent
its effective route
 degree of maternal exposure
 rate of placental transfer
 systemic absorption
 composition of the maternal and fetal
genotypes.

13. 6.There are 4 manifestations of
deviant development
1. death,
2. malformation,
3. growth retardation and
4. functional development

14. DEVELOPMENTAL PERIOD
Developmental period is divided in to 3
stages:
PREIMPLANTAION PERIOD-It is the 2
weeks from fertilization to implantation.The
zygote undergoes cleavage, and an insult
damaging a large no of cells usually causes
death of the embryo or can produce dose
dependent diminution of body length and
size.
.

15. EMBRYONIC PERIOD
It is from the second through the eightth
week.it encompasses organogenesis and
is the most crucial with regard to
structural malformations.
FETAL PERIOD Maturation and
functional development continue after 8
weeks and during this period certain
organs remain vulnerable

17. Multifactorial
42%
Unknown
37% Chromosomal
3%
Monogenic
8%
Teratogens
10%
Baird et al. AJHG 42:677, 1988
Birth Defects in Childhood

18. HORMONES AND
TERATOGENICITY
 Exposure to exogenous sex hormones before 7
completed weeks generally has no effect on
external structures.
 Between 7 and 12 weeks, however, female
genital tissue is responsive to exogenous
androgens and exposure can result in full
masculinization.
 The tissue continues to exhibit some response
until 20 weeks, with exposure causing partial
masculinization or genital ambiguity

19. The most commonly reported abnormalities
include a hypoplastic, T-shaped uterine
cavity; cervical collars, hoods, septa, and
coxcombs; and "withered" fallopian tubes .
Drugs causing female virilization are
testosterone,danazol,and androgenic steroids.
Antenatal exposure to medroxyprogesterone
acetate given as an intramuscular depot
contraceptive causes virilization of female
fetus and feminisation of male fetus.

20. Drugs in Pregnancy
 Use only drugs which are extensively used
in past
 Do not use new or untried drug
 Use smallest effective dose
 No drug is safe beyond all doubts in early
pregnancy

21.  FDA PREGNANCY CATEGORIES
 The FDA-assigned pregnancy categories as used in the Drug
Formularyare as follows
Category A
 Adequate and well-controlled studies have failed to
demonstrate a risk to the fetus in the first trimester of
pregnancy (and there is no evidence of risk in later trimesters).

22.  Category B
 Animal reproduction studies have failed to
demonstrate a risk to the fetus and there are no
adequate and well-controlled studies in pregnant
woman

23.  Category C
 Animal reproduction studies have shown an adverse effect
on the fetus and there are no adequate and well-
controlled studies in humans, but potential benefits may
warrant use of the drug in pregnant women despite
potential risk.

24.  Category D
 There is positive evidence of human fetal risk based on
adverse reaction data from investigational or marketing
experience or studies in humans, but potential benefits
may warrant use of the drug in pregnant women despite
potential risk

25.  Category X
 Studies in animals or humans have demonstrated fetal
abnormalities and/or there is positive evidence of human
fetal risk based on adverse reaction data from
investigational or marketing experience, and the risks
involved in use of the drug in pregnant women clearly
outweigh potential benefits

26. * Tetracyclines * Quinolones
* ACE-Inhibitors * ARB s
* Warfarin
* Statin * Alcohol
* Valproic Acid * Phenytoin
* Lithium Salts * Vitamin - A
Avoid by All Means (Category D)

27. COMMONLY USED DRUGS IN
PREGNANCY
 ANTI EMETIC DRUDS
 GASTROINTESTINAL DRUGS
 VITAMINS
 ANALGESICS AND ANTI INFLAMATORY
 ANTIHISTAMINICS
 ANTITUSIVES
 ANTIMICROBIALS
 ANTIFUNGALS
 ANTHELMINTICS

28.  DRUGS IN UTI
 DRUGS IN MALARIA
 DRUGS IN TYPHOID
 DRUGS IN HIV
 DRUGS IN TB

29. Anti-emetic Drugs in Pregnancy
Doxylamine (Doxinate- Doxylamine + Pyridoxine)
SAFE - More than 30 million women took Bendectin from
1956 to 1983. At least 25 epidemiological studies and 2 meta-
analyses have been performed regarding its use during
pregnancy, making it the world’s most studied drug in
pregnancy. Also one of the most talked about Litogen
Promethazine , Chlorpromazine, Diphenhydramine,
Dimenhydrinate and Cyclizine are safe but better
avoided near term
Ondansetron and Metoclopramide should be used
with caution, particularly during the first trimester

30. GASTROINTESTINAL DRUGS
DRUGS FDA
PREGNANCY
CATEGORY
NATURE OF EFFECT
ANTACID
MAGNESIUM
HYDROCHLORIDE
B The safety of antacid use during the 1st
trimester of pregnancy has not been
established. 2nd and 3rd trimester use
appears to be without adverse effects.
ALLUMINIUM
HYDROCHLORIDE
C
SUCRALFATE B Sucralfate is poorly absorbed and no
adverse effects to the fetus have been
reported.

32. Folic Acid Supplementation in Pregnancy
Prevents Neural tube defects
* Neural tube defects develop in the first 28 days
after conception.
* "Once you know you're pregnant it's too late to do
anything about [them],"
* Half of all pregnancies are unplanned.The incidence of
neural tube defects might be  45%
• Vitamin B12 deficiency also implicated in neural tube
defect.Hence it is recommended to supplement 50 mcg
of Vit B12 with 400mcg of FA daily.

33.  Another compound which requires mention is DHA
(Docosa Hexaenoic Acid-Omega 3 Fatty Acid).
 It helps in development of brain,nervous system and
eyes.
 It is usually recommended in the dose of 200 mg/day
in 1st and 2nd TM.

34. VITAMINS IN PREGNANCY
DRUG FDA
PREGNANCY
CLASS
NATURE OF EFFECT
FAT SOLUBLE
VITAMINS
VITAMIN A C SYNTHETIC VIT A LIKE
RETINOL,RETINYLE ESTER AVOIDED
DURING PREGNANCY AS ANIMAL
SRUDIES SHOWS ANOMALIES OF
HEAD AND LIMB DEFORFMITIES.B-
CAROTINE IS SAFE.
VITAMIN D C UPTO 400 IU /DAY SAFE.HIGHER
DOSES HAS TERATOGENIC
POTENTIAL
VITAMIN E D AVOIDED IN PREGNANCY,USE ASSO
WITH STILLBIRTH & LBW
VITAMIN K B SAFE IN PREGNANCY

35. WATER SOLUBLE VITAMINSDRUG FDA
PREGNANCY
CLASS
NATURE OF EFFECT
THIAMINE (B1) B Safe in all trimester
RIBOFLAVINE (B2) B Safe in all trimester
NIACINE (B3) C Animal studies shows fatal
hepatic toxicity, avoided in
pregnancy
PYRIDOXINE (B6) B Safe in all trimester
CYNO COBALAMINE
(B12)
B Safe in all trimester
VITAMIN C B
C (AT HIGHER
DOSES)
Safe but higher doses associated
with preterm birth

36. Analgesics & Anti-inflammatory Drugs in Pregnancy
Drugs/Wks. 0-12 12-24 24-Term Comments
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Paracetamol S S S hepatic/renal tox.
Aspirin C C N closure of D.A.in
utero
NSAID S C N ---do---
“ - Ketorolac N N N
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.
NSAID USE NEAR TERM CAN CAUSE DELAYED ONSET OF
LABOUR
* S = Safe C = Cautious use N = Not to use

37. In humans, an  incidence of oligohydramnios
has been observed in women who consumed
significantamounts of aspirin, non-selective COX inhibitors
or selective COX 2 inhibitors during the third trimester
of pregnancy.aspirin use in 1st trimester associated with
Gastorchisis.
COX 2 inhibitors have been found to be nephrotoxic
particularly during nephrogenesis (during last part
of pregnancy and early neonatal period)-
NSAIDs In Pregnancy : COX 2 Inhibitors

38. NSAID USE IN PREGNANCY
 EFFECT ON MOTHER
Prolongation of pregnancy
prolongation of labour
increased blood loss before and after birth
anaemia
EFFECT ON NEONATES
Increased intracranial haemorrhage
Persistent pulmonary hypertension
premature closure of ductus arteorus

39. Antihistaminics In Pregnancy
 First-generation (e.g. chlorpheniramine) and second-generation
(e.g. cetirizine) antihistamines have not been incriminated as
human teratogens.
 No controlled trials with loratadine and fexofenadine in human
pregnancy
* H1 blockers do not increase the teratogenic risk in humans and
may, in fact, be associated with a protective effect. By preventing
vomiting, antihistamines may ensure better metabolic conditions
to the fetus and thus may reduce some.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

41. Antibiotic Category Antibiotic Category
Ampicillin B Tetracyclines D
Amoxycillin B Quinolones D
Cephalosporines B
Azithromycin B
Clarithromycin C
Clindamycin B Aminoglycosides
Amikacin C
Gentamycin C
Strepto./Kana C*
Antibiotics In Pregnancy

42. ANTI MICROBIAL DRUGSDRUG CATEGORY NATURE OF EFFECT
PENICILLINS B SAFE DURING PREGNANCY
CEPHALOSPORINS B SAFE DURING PREGNANCY 2ND
GENERATION
CEPHALEXINE,CEPHACHLOR
AVOIDED IN 1ST TRIMESTER
ERYTHROMYCINE B ERYTHROMYCINE ESTOLATE
CAN CAUSE HEPATO TOXICITY IN
WOMEN,NO HARM TO FETUS
AMINOGLYCOSIDES C CONGENITAL HEARING
LOSS,DEAFNESS IN FETUS
CHLORAMPHENICOL C BLOOD DYSCARIASIS,APLASTIC
ANAEMIA,NEAR TERM GRAY
BABY SYNDROM

43. DRUG FDA PREG
CATEGORY
NATURE OF EFFECT
TETRACYCLINES D
B (TOPICAL)
STAINING OF THE TEETH .
RETADATION OF GROWING
SKELETAL SYSTEM.
FLUOROQUINOLONES
CIPROFLOXACIN
NORFLOXACIN
OFLOXACIN
LEVOFLOXACIN
C NOT USED IN PREGNANCY.WERE
SHOWN TO CAUSE EROSION OF
CARTILAGE, ARTHOPATHIES IN
FETUSES
SULFONAMIDES B
D (NEAR
TERM)
EVIDENCE ASSOCIATED WITH
SULFONAMIDE USE NEAR TERM
CAUSE
HYPERBILLIRUBINAENIA,HEMOL
YTIC ANAEMIA(IN G6PD DEFF)
KERNICTERUS IN NEONATES

44. DRUG FDA PREGNANCY
CATEGORY
NATURE OF EFFECT
METRONIDAZOLE B
C (IN 1ST TRIMESTER)
CONTRAINDICATED IN
1ST TRIMESTER,
2ND & 3RD TRIMESTER
ACCEPTABLE IF
ALTERNATE THERAPIES
FAILED

45. DRUG CATEGORY ADVERSE EFFECT
PIPERACILLIN B SIMILAR TO
PENICILLINS
VANCOMYCIN C SAFETY NOT PROVED
RECOMODED IF
INDICATED
LINEZOLID C SAFETY NOT PROVED

46. Antifungal Drugs In Pregnancy
 Imidazoles - safe as topical therapy for fungal skin
infections . Nystatin is minimally absorbed and is
effective for vaginal therapy
 Amphotericin B - no reports of teratogenesis
 Fluconazole - exhibits dose-dependent teratogenic
effects; safe at lower doses (150 mg/day). Several reports
suggest fluconazole use associated with skull
abnormality, cleft lip & palate,humero radial fusion.
 Ketoconazole, flu cytosine, and griseofulvin -
teratogenic and/or embryotoxic in animals

47. U.T.I.IN PREGNANCY
DRUG 1ST
TRIMESTER
2ND TRIMESTER 3RD TRIMESTER
NITROFURANTOI
N
SAFE SAFE SAFE
AMOXYCILLIN SAFE SAFE SAFE
CEPHALEXIN AVOID SAFE SAFE
FLUROQUINOLO
NES
AVOID USE IF BENEFITS
OUTWEIGHTS RISK
USE IF BENEFITS
OUTWEIGHTS
RISK
ASYMPTOMATIC BACTIUREA ,ACUTE CYSTITIS ARE COMMON DURING
PREGNANCY.DRUG OF CHOICE ARE AMOXYCILLIN AND NITRO FURANT
OIN . ACCORDING TO DRUG SENSITIVITY CEPHALOSPORINES CAN BE USED

48. Treatment of malaria in
pregnancy
ACT should be given for treatment of P. falciparum
malaria in second and third trimester of pregnancy
QUININE is NOT recommended in the first
trimester.
P. vivax malaria can be treated with chloroquine.

49. CHLOROQUINE DOSES
 PROPHYLAXIS: Drug of choice is chloroquine

51. TYPHOID IN PREGNANCY
DRUG 1ST TRIMESTER 2ND & THIRD
TRIMESTER
CEFIXIME SAFE SAFE
CEFTRIAXONE SAFE SAFE
AZITHROMYCIN SAFE SAFE
CIPROFLOXACIN CONTRAINDICATED USE IF BENEFITS
OUTWEIGHTS THE
RISK

52. Pregnancy , HIV & ART
Use of combination ART during pregnancy both to safeguard
maternal health and to reduce the risk of vertical transmission of
HIV-1 infection is advocated .
1ST TRIMESTER: ZIDOVUDINE +LAMIVUDINE+TENOFOVIR
2ND & 3RD TRIMESTER +
.
ZIDOVUDINE+LAMIVUDINE+EFAVIRENZ or
NEVIRAPINE
NEVIRAPINE: recommended for prevention of parents to child
transmission
Single dose nevirapine is safe

53. TUBERCULOSIS IN PREGNANCY
DRUG CATEGORY SAFETY IN
PREGNANCY
RIFAMPICIN B SAFE IN PREGNANCY
ISONIAZIDE B SAFE IN PREGNANCY
PYRAZENAMIDE C SAFETY NOT PROVED
ETHAMBUTOL C SAFETY NOT PROVED
STREPTOMYCIN X CONTRAINDICATED
DUE TO FETAL
OTOTOXICITY,NEPHRO
TOXICITY& NURO
MUSCULAR BLOCKADE
AS TUBERCULOSIS IS RAMPANT IN DEVELOPING COUNTRY LIKE INDIA
ONCE DIAGNOSED TRETMENT DURING PREGNANCY SHOULD BE CONTINUED

54. ANTICANCER DRUGS
 Practically all cytotoxic drugs given to pregnant
women profoundly damage the developing foetus,
abortion foetal death and teratogens
 cyclophosphamide ,methotrexate,5-
fluorourouracil,azathioprine,
paclitaxel,etopocide,actinomycin –d
 Practically all comes under category x

55. Substance abuse
 HEROIN ,COCAIN,MARIJUANA ,NICOTINE ARE ALL
AFFECT PREGNANCY AND FOETUS ADVERLY.
 FOETAL ALCOHOL SYNDROME :INTRAUTERINE
AND POSTNATAL GROWTH RETADATION,LOW
IQ,MICRO CEPHALY,FACIAL ABNORMALITY
,IMMUNOLOGICAL IMPAIRMENT
 HEAVY DRINKING ASSOCIATED WITH ABORTION

56. Advances in Medicine and Technology have led
many patients with chronic medical illness to get
pregnant and carry their pregnancy successfully to
viability where need to continue their medication in
pregnancy is imperative.

57. Thyroid Disorders in Pregnancy
Hyperthyroidism and Pregnancy
 Thioamide group drugs and surgery (in few cases) are
available modalities of treatment pregnancy.
 Propylthiouracil is drug of choice during 1st trimester . PTU
is better than Methimazole as it crosses the placenta less
readily and partially inhibits the conversion of T4 to T3.And
also methimazole has a slightly higher risk of birth defects
(though very small).
 Latest guidelines recommend switching to Methimazole for
second and third trimester.
 Pre-op. preparation with iodides is contraindicated for fear
of neonatal goiter and hypothyroidism.
 Radio active Iodine is contraindicated in pregnancy for both
treatment and diagnosis.

58. Hypothyroidism and Pregnancy
 Levothyroxine is the drug of choice ,and no use of other
thyroid preparation such as T3 or natural dessicated thyroid
drugs is recommended.
 LevoThyroxine is given in dose of 100 mcg/day,in newly
diagnosed case.
Pre-existing Hypothyroidism
 Thyroid hormone need increases as early as 5 wks.
 By 4 to 6 weeks, dose usually needs to be increased by as
much as 50%.
 It is preferable to overtreat rather than undertreat thyroxine
deficiency. There is no risk to fetus as placenta metabolises
most of thyroxine.
 Once well controlled , the TSH should be done in each
trimester.

59. Hypothyroidism and Pregnancy
 The recommended TSH level in pregnancy in-
 First Trimester - 0.1 to 2.5 mIU/L
 Second Trimester - 0.2 to 3.0 mIU/L
Third Trimester - 0.3 to 3.0 mIU/L
 In the patients with post partum hyperthyroidism, first
choice is Methimazole 20-30 mg/day
 Recommendations are to take the drug after breast feeding.
 Infants should be screened periodically for TFT as per
guidelines.

60. Thyroid disorders and pregnancy
Group Effects Category
Liothyronine,
thyroxine
Hormonal drug - A
Propylthiouracil,
Methimazole
Anti-Thyroid drug Congenital goitre
by inhibiting
thyroxine
synthesis in the
fetus.
C

61. Epilepsy and Pregnancy
 The 2012 guidelines of NICE caution for the use of Na
Valproate.
 These guidelines offer little advise on which Anti-Epileptic
Drug (AED) is safe in pregnancy.
 BNF emphasizes continuation of therapy in pregnancy stating
that “RISK of HARM to mother and fetus from a uncontrolled
epilepsy outweighs that of continued AED therapy”.
 Best option is to plan pregnancy.
 All epileptic women of child bearing potential should receive
folate supplements.
 AEDs should be continued during pregnancy and
monotherapy should be used if possible at the lowest effective
dose as risk of abnormality is greater with polytherapy.

62. Epilepsy and Pregnancy
 Current evidence suggests that women taking valproate in
the 1st trimester run at the highest risk of congenital
anomalies –a dose related effect.
 Phenytoin and Phenobarbitol has to be avoided in
pregnancy.
 Lamotrigine has been found to be associated with lower
congenital anomalies in recent studies ,though is not FDA
approved as a ‘safe’ drug and further evidences are awaited.
 To date no anti-epileptic drug has proven safe in pregnancy
in terms of teratogenesis.Treatment must be
individualized for all patients.

63. Epilepsy and Pregnancy
ANTI-
CONVULSANT
DRUGS
Group Effects Category
Lamotrigine 4
fold- MT,10 -PT ,
Topiramate-2%
Phenyltriazine
Newer Drug
Increased risk
Cleft Palate
C
Clonazepam Benzodiazepine hypotonia,
respiratory
depression and
hypothermia in
the newborn
C
Levetiracetam Newer drug Theoretical risk of
skeletal
abnormalities and
impaired growth
C

64. Epilepsy and Anticonvulsant drugs
DRUGS Group Effects Categor
y
Carbamazepine
1-2 %
Iminostilbene Fetal Hydatoin Syndrome,spina
bifida,coagulation defect
D
Phenytoin sodium
5-11 %
Hydatoin Fetal Hydatoin
Syndrome,carniofacial
anomalies,finger nail
hypoplasia,cardiac
defects,clefts,coagulation defect
D
Methylphenobarbi
tone,
phenobarbitone
10-20%
Barbiturate Clefts ,cardiac
abnormalities,urinary tract
malformations,coagulation
defect
D
Sodium valproate
(valproic acid)
1-2% MT
9-12% PT
Aliphatic
carboxylic acid
Neural tube defects,clefts,
skeletal
abnormalities,developmental
delay
D

65. Epilepsy and Anticonvulsant drugs -
Considerations
 Fetal Hydatoin Syndrome
Upper Facial Features include upturned nose,mild
mid facial hypoplasia,long upper lip with thin
vermilion border;lower distal digital hypoplasia.
 For Pts. On Carbamazepine & Valproate
 Alfa Feto Protein (AFP) level - at 14 - 16 Wks.
Anomaly scan USG - at 16 - 20 Wks.
 Amniocentesis for AFP & Acetylcholinesterase
levels

66. Diabetes And Pregnancy
 Traditionally Insulin therapy has been considered the gold
standard for management of diabetes because of its
efficacy in achieving tight glucose control and the fact that
it does not cross the placenta and have effects on the fetus.
 Since Gestational Diabetes Melitus is characterised by
insulin resistance and decreased insulin secretion
,treatment with oral hypoglycemic agents target these
defects and are of particular interest.
 1st Generation Sulphonylurea and Biguanide all are
teratogenic.
 However ,evidence to support this is weak.

67. Diabetes And Pregnancy
 The currently available data indicate that the use of both
metformin and sulphonylurea ,show no increase in risk of
neonatal hypoglycemia and other neonatal morbidities.
Metformin -
 A Biguanide compound, which crosses the placenta.
 Use of Metformin in the 1st trimester did not show any increase in
risk of congenital anomalies or neonatal deaths.However ,they
have showed increase in Spontaneous Preterm Birth .
 Clinical experience and evidence so far support the safety and
efficacy of metformin use in pregnancy with respect to immediate
pregnancy outcomes.
Glyburide-
 2nd Generation Sulphonylurea when used antenatally was not
detected in cord serum of any infant.
 Various studies recommend the safety of drug antenatally.
Whether OHA should be prescribed initially or one should be
started with addition of other remains avenue for research.

68. Anti-diabetic DrugsAnti-diabetic
Drugs
Group Effects Category
Insulin Hormonal drug - A
Acarbose, miglitol Alpha Glucosidase
inhibitor.
- B
Glyburide 2nd generation
Sulphonylurea
- B
Chlorpropamide,
glibenclamide,
gliclazide,
glimepiride,
glipizide,
tolazamide,
tolbutamide
Sulphonylurea Neonatal
hypoglycaemia.
C
Metformin Biguanide - C

69. Asthma and Pregnancy
 According to a study, asthma prevalence ranges
from 4-8 %.
 Albuterol and Budesonide are the preferred
drug as more data is available.
 Short acting ß agonist inhaler - safe
 Inhaled Beclomethasone & Budesonide – safe
 Long acting ß agonist inhaler - not studied
 Other inhaled steroids not tested

70. Asthma and Pregnancy
 Oral Prednisolone is metabolised by placenta and only
10% reaches to fetus,and hence is safe,but has  maternal
complications.
 Emergency Rx - regular dose of ß agonist inhaler at 15 - 20
minutes for 3 to 4 doses with
corticosteroid.
Add Ipratropium Inhalation.
 Labor and Delivery-
Stress dose steroid-i.v. 100mg hydrocortisone 8 hrly till
24hr post delivery is recommended.

71. Asthma and Pregnancy-
Recommendations
For Mild intermittent asthma –Inhaled Beta –
agonists
Moderate persistent-Low dose inhaled corticosteroid
and long acting beta agonists or medium dose inhaled
steroids and long acting beta agonists
Alternatively,Low dose (or medium) inhaled
corticosteroids and either theophylline or leukotrine
antagonists.
Severe persistent-High dose inhaled steroid and long
acting Beta agonist and oral steroids.
Alternatively,High dose inhaled steroid ,theophylline
and oral steroids.

72. Asthma and Pregnancy
Drugs Group Category
Ephedrine, fenoterol,
isoprenaline, orciprenaline,
rimiterol,
Salbutamol (albuterol),
terbutaline
Sympathomimetics-Bronchodilators A
Theophylline,Aminophylline Methylxanthines-Bronchodilators A
Sodium cromoglycate Mast cell stabilizer A
Ipratropium bromide Anti-cholinergic-Bronchodilator B
Montelukast, Zafirlukast Leukotriene Antagonist B
Nedocromil Mast cell Stabilizer B
Eformoterol, salmeterol Sympathomimetic-Bronchodilator B
Beclomethasone,
budesonide, fluticasone,
salmeterol
Inhalatinal Corticosteroids and
Bronchodilators
B

73. Steroids and Pregnancy
 Systemic steroids in daily doses in 1st trimester (Category
D),(Category C-2nd and 3rdtrimester)
 Hydrocortisone,prednisone,and other corticosteroids
when given in 1st TRIMESTER in a meta-analysis
demonstrated an increase in incidence of facial
clefts,and have a increased risk of hypertension
,obesity,gestational diabetes in mother with daily doses.
 Beclomethasone, flunisolide, fluticasone,
triamcinolone(B),Budesonide(A) –inhalational and
intranasal agents are safe.
 Topical Agents- Fluocortolone, halcinonide,
triamcinolone (A),Methylprednisolone aceponate (C)
Mometasone (B) – safe.

74. Steroids and Pregnancy
 Recent reports contradicts that intravenous
dexamethasone modifies the clinical course of HELLP
Syndrome.
 Rescue course of steroid for lung maturation before 34
weeks improves neonatal outcome without any risk .
 Repeated rescue doses has been associated with SGA,
and low birth weight babies and decrease in head
circumference and are not recommended.
 Betamethasone and Dexamethasone -
Dexamethasone is short acting and is associated with
increased risk of PVL ,IVH and ROP.

75. Anti-Hypertensive Drugs and
Pregnancy
 Anti-hypertensive drugs are not known teratogens
in 1st trimester of pregnancy,and are not known to
cause IUGR hence there is no need to be changed
urgently .
 First choice of drug is Methyl-Dopa(A), even for
essential hypertension and pre –eclampsia.
 Second-line drugs are nifedepine (Cat C) and
labetalol(Category C).

76. Anti-Hypertensive Drugs and
Pregnancy
 Diuretics-Thiazides group causes neonatal
thrombocytopenia,bleeding ,electrolyte disturbance
when given at time of delivery.
 Frusemide decrease uteroplacental blood flow and are
reserved for heart failure and are not used as
antihypertensives or in simple edema.
 Also there is increased PGE2 synthesis and hence
increased incidence of PDA closure in preterm
newborns.There are no acute effects with its
administration

77. Anti-Hypertensive Drugs and
Pregnancy
ACE Inhibitor Fetopathy
 Candesartan cilexetil, eprosartan, irbesartan, losartan, valsartan-
Angiotensin 2 receptor antagonist
 Captopril, cilazapril, enalapril, fosinopril, lisinopril, perindopril,
quinapril, ramipril, trandolapril –Angiotensin Converting Enzyme
Inhibitors.
 Most of recommendations are that if exposure to ACE inhibitors
occurs during 1st trimester ,it has to be stopped latest by 2nd trimester.
 ACE inhibitors in First Trimester-Exposure caused 8% had major
congenital anomaly-predominantly cardio vascular and central
nervous system malformations,i.e. 2.7 times higher than observed.
 Renal ischemia ,renal tubular dysgenesis, and
anuria,Oligohydroamnios-limb contractures, and prevents normal
lung development in 2nd and 3rd trimester.
 And exposure to it in 1st trimester do not form a indication for
termination of pregnancy.

78. Cardio-Vascular Drugs-Anti-Hypertensive Drugs
Anti-
Hypertensive
Drugs
Group Effects Category
Guanethidine,
Methyldopa
Central
Sympatholytics
- A
Prazosin,
Terazosin,
Doxazosin
Alpha Blocker - B
Clonidine, Central
Sympatholytic
- B
Spironolactone Diuretic
K+ Sparing
Feminization of
Male Fetus
B
Acetazolamide DIURETICS
CA inhibitor
- B
Amlodipine,
diltiazem,nifedipin
e,verapamil
Calcium Channel
Blocker
Fetal Hypoxia if
maternal
hypotension
C

79. Cardio-Vascular Drugs-Anti-Hypertensive Drugs
Anti-Hypertensive
Drugs
Group Effects Category
Labetalol Alpha+Beta Blocker C
Hydralazine,Minoxidil Arteriolar
vasodilator
- C
Sodium nitroprusside Arteriolar and
venous Vasodilator
- C
Amiloride, triamterene Potassium sparing
diuretics
electrolyte
disturbances in the
fetus
C
Candesartan cilexetil,
eprosartan, irbesartan,
losartan, valsartan
ANGIOTENSIN II
RECEPTOR
ANTAGONISTS
(ARAS)
ACE Inhibitor
Fetopathy
D
Captopril, cilazapril,
enalapril, fosinopril,
lisinopril, perindopril,
quinapril, ramipril,
trandolapril D
ANGIOTENSIN
CONVERTING
ENZYME (ACE)
INHIBITORS
D

80. Valvular Heart Disease
 Diuretic Therapy and Beta-blocker are given .
 In new onset AF i.v. Verapamil or electro cardioversion
is performed.
 For chronic AF ,Digoxin (Category-A) ,CCB or Beta
blocker is given.
 Therapeutic anticoagulation is recommended in case
of persistent fibrillation.
 Endocarditis prophylaxis is recommended.

81. Cardio-Vascular Drugs-Anti-Arrythmic Drugs
 Bradyarrythmias-Permanent artificial pacemakers are well
tolerated.
 Tacharrythmias-Adenosine(safe in pregnancy owing to
rapid onset of action and short half life.) followed by Ca –
Channel or beta blocking agents.
Even Electrical cardioversion is not contraindicated in
pregnancy.
 Atrial flutter and fibrillation –mostly associated with
thyrotoxicosis or MS.
Digoxin is the drug of choice.It crosses the placenta and
has been used to treat fetal SVT.Dose monitoring and
increment is required as gestation increases . Heparin has
to be given in chronic cases.
 Ventricular Tachycardia-Beta -Blocker therapy is
recommended in pregnancy.

82. Cardio-Vascular Drugs-Anti-Arrythmic Drugs
Anti-Arrythmic
Drugs
Group Effects Category
Lignocaine Membrane
stabilizing agent
- A
Mexiletine,
Flecainide
Membrane
stabilizing agent
- B
Adenosine,
disopyramide,
procainamide
Adenosine
receptor Blocker
- B
Quinidine Membranes
stabilizing agent
High doses cause
fetal damage
C
Amiodarone Agents widening
AP
abnormal thyroid
function
and bradycardia in
the fetus
C
Bretylium tosylate Agents widening
AP
fetal hypoxia
associated with
maternal
hypotension.
C

83. ANTICOAGULANT AGENTS
 Used in pregnancy for patients with mechanical valves and
thromboprophylaxis in high risk women.
 Warfarin-Category D freely crosses the placental barrier
and can cause significant teratogenic effects on fetus.
 Exposure to Warfarin between 6th to 9th week of gestation
causes Warfarin Embryopathy and may be low in patients
who take 5mg or less per day,i.e. effect is dose dependent .
 Warfarin Embryopathy (DiSala Syn)- Nasal and midface
hypoplasia and stippled vertebral and femoral
epiphyses,hypertelorism ,chondrodysplasia
punctata,microcephaly.
 It occurs due to 1st trimester exposure

84. ANTICOAGULANT AGENTS
 LMWH and UFH are high molecular weight heparin and
donot cross the placenta.
 In cases of Mechanical Valve Prophylaxis-
 LMWH or UFH are given till 12 week of gestation with
warfarin substitution from 13 week until close to delivery
around at 36 weeks when LMWH or UFH is resumed.
 LMWH is associated with lower risk of osteoporosis and
HIT compared to UFH.
 Heparin is stopped as soon as the labour pains start or
before 4 hours of cesarean sections and is again started 6
hours of completion of labour.UFH can be reversed with
protamine sulphate.

85. ANTICOAGULANT AGENTS
 The same recommendation is for thromboprophylaxis
in pregnancy in high risk groups.
 However ,warfarin is not used and only heparin is used
throughout pregnancy.Warfarin is associated with
increased feto maternal bleeding and higher rates of
intra cerebral haemorrhage in neonate.
 In post partum period ,Warfarin is resumed after 7
days.

86. Anti-Depressant and Anxiolytic
Drugs
• Antidepressants in Pregnancy
Fluoxetine Category B Amitryptiline Category C
Sertraline Category B Doxepin Category C
Citalopram Category B Imipramine Category C
Lithium Category D
• Anxiolytic,Sedative & Hypnotic Drugs In
PregnancyBenzodiazepine Drugs e.g.
Diazepam / Alprazolam - Category D
Buspirone - Category B
Zolpidem - Category B

87. Anti-Depressant Drugs And
Considerations in Pregnancy
SSRIs –
In general, data is poor or conflicting
 1st TM
 Cardiac /cranial/omphalocele with Paroxetine
 Consider fetal echocardiography for 1st TM Paroxetine
 Rate is 1 in 5000/ 8000/ 1000
 3rd TM
 Neonatal withdrawal symptoms, transient.
 Unconfirmed risk of persistent pulmonary HTN.

88. Anti-Depressant Drugs And
Considerations in Pregnancy
Benzodiazepenes-
 Third TM use CLEARLY associated with “floppy baby
sundrome” – prolonged severe withdrawal
 No long term studies of infant neurobehavior
 Question of oral cleft with early exposure
 Should be tapered, not stopped abruptly

89. Bipolar Disease
 Lamotrigine has a growing safety profile
 Anti-psychotics not well studied – maybe safe?
 Lithium
 1st TM risk of cardiac malformations and Ebstein’s
anomaly– fetal echo
 Need to monitor levels closely
 Neonatal abstinence syndrome

90. Antirheumatic drug therapy in
pregnancy
 Paracetamol is safest drug amongst the drug used in
Rheumatic diseases.
 Aspirin and Indomethacin are not safe in 3rd TM but
can be contd. as discussed earlier if pt. is stabilised on
these drugs .
 Disease Modifying Anti-Rheumatic Drugs like
Sulphasalazine-Category B .
 Cytotoxic drugs should be discontinued 2-3 months
before pregnancy.

91. The benefits of
immunization to the
pregnant woman and her
neonate usually outweigh
the theoretic risks of
adverse effects.

92. The administration of vaccines
during pregnancy poses a
number of concerns about the
risk of transmitting a virus to a
developing fetus.
This risk is primarily theoretic.

93. MATERNAL BENEFITS
The objective of vaccination during
pregnancy is to protect the mother and,
potentially, the fetus and newborn.
Pregnant women respond adequately
to vaccines even though pregnancy is
an immunologically altered state.

94. BENEFITS OF IMMUNIZATION IN PREGNANCY
FOR THE FETUS/INFANTS
Maternal vaccination protects the
mother from a vaccine-preventable
disease that she could transmit to her
fetus or infant.
Maternal antibodies typically have a
half-life of 3 to 4 weeks in the
newborn, and progressively decrease
during the first 6 to 12 months of life.

95. SAFETY OF IMMUNIZATION IN PREGNANCY FOR
THE FETUS/INFANT
There are no published data indicating
that inactivated vaccines are
teratogenic or embryotoxic, or have
specific adverse pregnancy outcomes.

96. MATERNAL SAFETY
 Reactions following vaccination are usually
limited to the injection site.
 No increase in anaphylactic reactions or
events that might induce preterm labour has
been observed.
 National Advisory Committee on
Immunization (NACI) has concluded that
there is no safety reason to avoid the use of
vaccines for pregnant women.

97. BIOLOGIC PRODUCTS DURING
PREGNANCY
There is no known risk to the fetus or
pregnant woman from administration of
immune globulin for passive immunization
and should be administered to pregnant
women as required.

98. Live, Attenuated Vaccines
 They elicit strong cellular and antibody responses and often confer
lifelong immunity with only one or two doses.
Measles , Mumps , Rubella , Poliomyelitis , Yellow fever , Varicella ,
Smallpox
Inactivated Vaccines
 Inactivated vaccines by killing the disease-causing microbe with
chemicals, heat and stimulate a weaker immune system response than
do live vaccines.
Influenza , Rabies , Hepatitis B , Hepatitis A
Toxoid Vaccines
 Immune system receives a vaccine containing a harmless toxoid, and
the immune system produces antibodies that lock onto and block the
toxin.
Tetanus , Diphtheria

99.  Live virus vaccines are therefore
generally contraindicated in
pregnancy
 It can be given to non-pregnant
women with the advice to avoid
pregnancy for at least 28 days
following immunization.

100. CENTER FOR DISEASE
PREVENTION AND CONTROL
If a live-virus vaccine is
inadvertently given to a pregnant
woman, or if a woman becomes
pregnant within four weeks after
vaccination,
she should be counseled about
potential effects on the fetus.

101. GENERALLY SAFE DURING
PREGNANCY INCLUDE
 Diphtheria,
 Tetanus,
 Influenza,
 Hepatitis B.
Other vaccines, such as:
 Meningococcal
 Rabies,
may be considered

102. BECAUSE OF THE THEORETIC RISK OF
FETAL TRANSMISSION
Vaccines that are contraindicated in pregnancy
include
1. Measles, Mumps, and Rubella;
2. Varicella;
3. B C G

104. TETANUS
 Tetanus infection can cause production of a
neurotoxin, leading to tetanic muscle contractions.
 Tetanus toxoid is routinely recommended for
susceptible pregnant women.
 Routine tetanus vaccine are recommended in second
trimester and second dose after one month & only one
dose is recommended if woman was previously
vaccinated in last 2 year

105. TETANUS,DIPTHERIA & PERTUSIS VACCINE
 No evidence to prove that Tetanus and diptheria toxoids are
teratogenic
 Optimal timing for Tdap administration is between 27 and 36 weeks of
gestation although Tdap may be given at any time during pregnancy
 Previously vaccinated pregnant women who have not received a Td
vaccination within the past 10 years should receive a booster dose.
 If Tdap is not administered during pregnancy, Tdap should be
administered immediately postpartum.

106. HEPATITIS A VACCINNE
 It is an inactivated vaccine and used in pregnancy only as
post exposure prophylaxis
 Hepatitis A virus vaccines should use with hepatitis A
immune globulin in one dose 0.02ml/kg intramuscular
 Administration of immune globulin is strongly
recommended which is considered safe during pregnancy
and is more than 85 % effective in preventing acute
hepatitis

107. HEPATITIS B VACCINE
Risk factors for a pregnant woman include:
1. Having multiple sexual partners,
2. Using or abusing intravenous drugs,
3. Having occupational exposure,
4. Contact of acutely infected persons or persons with a
chronic carrier state.

108. HEPATITIS B VACCINE
 It contains noninfectious hepatitis B surface antigen particles and it
cause no risk to the fetus.
 Neither pregnancy nor lactation is a contraindication to vaccination
 Routine dose schedule are at 0,1 & 6 month
 Hepatitis B immune globulin has been assigned to pregnancy category
C by the FDA.
 Hepatitis B immune globulin should only be given during pregnancy if
clearly needed. Its use is recommended for post exposure prophylaxis
during pregnancy

109. RABIES VACCINE
 Pregnancy is not considered a contraindication to postexposure
prophylaxis.
 Rabies exposure or the diagnosis of rabies in the mother should
not be regarded as reasons to terminate the pregnancy.
 Passive immunization by administration of human rabies
immune globulin (HRIG), 20 IU per kg of HRIG is given at the
wound site for high-risk bites .
 Routine dose schedule is at 0 , 3 , 7 , 21 days

110. HUMAN PAPILLOMA VIRUS ( HPV ) VACCINE
 HPV vaccine is not recommended for use in pregnancy
because efficacy and safety of HPV vaccination in
pregnancy are limited
 If a woman is found to be pregnant after initiating the
vaccination series, completion of the series should be
delayed until after pregnancy.
 If a vaccine dose has been administered during
pregnancy, there is no indication for any intervention.

111. UNIVALENT VARICELLA VACCINE
&
MEASLES-MUMPSMRUBELLA VACCINE
 Varicella vaccine and MMR are live attenuated vaccine and contraindicated in
pregnancy because there is theoretical risk to the fetus
 But in outweigh outbreaks, vaccination may be considered.
 Inadvertent immunization with MMR vaccine is not a reason for pregnancy
termination.
 Vaccination of women during the postpartum period, especially for Rubella and
varicella, should be encouraged
 Passive immunization in varicella is administration of varicella zoster immune
globulin (VZIG). This agent is administered intramuscularly in a dose of one vial per
10 kg of . Ideally, VZIG should be administered within 96 hours of exposure.

112. OTHER LIVE ATTENUATED
VACCINES
 Live attenuated oral typhoid vaccine is contraindicated in
pregnancy
 Live oral polio vaccine (OPV) should not be administered to
pregnant women; .
 BCG vaccine should not be given during pregnancy

113.  Whether live or inactivated vaccines are used, vaccination
of pregnant women should be considered on the basis of
the risk of the vaccination vs the benefits of protection in a
particular circumstance.
 Preconception immunization of pregnant women to prevent
disease in the offspring is preferred to vaccination of pregnant
women.

114. IMMUNIZATION OF
BREASTFEEDING WOMEN
 In general, routinely recommended vaccines may be
safely administered to breastfeeding women.
 No vaccines are contraindicated during breastfeeding
 Inactivated vaccine is preferred if the breastfeeding
woman has a chronic health condition.

115. Although many medications are
safe to use during breastfeeding,
most drugs will get into lactation to
some degree and may even affect
lactation.

116. DRUGS THAT ARE
CONTRAINDICATED IN LACTATING
MOTHER
Drugs Effect
 Amiodarone Neonatal Hypothyrodism
 Aspirin Reys Syndrome
 Barbiturates Drowsiness
 Benzodipines Lethary
 Carbimazole Hypothyroidism
 OCP,s Reduce lactation
 Cytoxic drugs Immune supression/Neutropenia
 Ephedrine Irritability
 Tetracycline's Tooth discolouration
 Chloroquine Retinal damage

117. DRUGS THAT SUPPRESS THE
LACTATION
 Bromocryptine
 Estradiol valerate
 Testosterone enanthate
 Pyridoxine
 Levadopa
 Ergocryptine
 Monoamine oxidase inhibitors
 Cabergoline

118. RELATIVE CONTRAINDICATED
DRUGS TO LACTATING MOTHER
 Isoniazide
 Suifonamide
 Dapsone
 Nitrofurantoin
 Antithyroid drugs

120. RADIATIONS IN PREGNANCY
 The accepted cumulative dose of
ionizing radiation during pregnancy
is 5 rad, and no single diagnostic
study exceeds this maximum.
 The most sensitive time period for
central nervous system teratogenesis
is between 10 and 17 weeks of
gestation.

121.  Ionizing radiation (x-ray) is
composed of high-energy photons
that are capable of damaging DNA
and generating caustic free
radicals.
 A patient's dose of photons is
measured in the gray (Gy) and the
rem, or in the older and more
commonly recognized unit, the
rad

122. ESTIAMTED FETAL EXPOSURE FOR
VARIOUS DIAGNOSTIC IMAGING
METHODS
EXAMINATION TYPE
[Pts FILMS]
ESTIMATED FETAL
DOSE PER
EXAMINTION [Rad]
No. EXAMINATIONS
REQUIRED FOR
CUMULATIVE DOSE
CHEST 0.00001 71421
DENTAL 0.0001 50000
UPPER LOWER
EXTREMITY
0.001 5000
CERVICAL 0.002 2500
SKULL 0.004 1250

123. DIFFERENT RADIOLOGICAL
INVESTIGATION
Examination
Typical effective dose (mSv)
to the whole body
Typical absorbed dose (m Gv)
to the organ in question
Chest X-ray 0.02 0.01–0.15
Head CT 1–2 56
Chest CT 5–7 13
Abdomen CT 8 14
Chest, abdomen and pelvis CT 9.9 12
Barium enema 15 15
Cardiac CT angiogram 9–12 40–100
CT colonography 6–11
Neonatal abdominal CT 2O 20
Screening mammography 0.4 3

124. EFEECTS OF RADIATION
1. RADIATION-INDUCED TERATOGENESIS
The fetal malformations most commonly
caused by high-dose radiation are central
nervous system (CNS) changes, especially
microcephaly and mental retardation

125. 2. RADIATION INDUCED MALIGNANCY
Exposure to as little as 1 or 2 rad
has also been associated with a
slight increase in childhood
malignancies, especially leukemia.
For example, the background rate of
leukemia in children is about 3.6
per 10,000. Exposure to one or two
rad increases this rate to 5 per
10,000

126. 3.RADIATION-INDUCED GENE MUTATION
Radiation can cause germ-line
mutations, potentially affecting future
generations.
The dosage required to double this
baseline mutation rate is between 50 and
100 rad, far in excess of the radiation
doses occurring in common radiographic
studies.

127. MRI IN PREGNANCY
Most studies evaluating MRI safety during
pregnancy show no ill-effects.
Its is good practice to avoid MRI during
pregnancy, particularly during elective
studies or during first trimester, but MRI
remain preferable to any studies using
ionizing radiation.
No significant risk of acoustic injury to the
foetus during prenatal MRI.

128. ABORTION COUNSELLING
“Exposure to x-ray during pregnancy is
not an indication for therapeutic
abortion.”

129. CONCLUSION
A pregnant woman who is ill and requires
radiographic imaging faces potential risks
from her disease to her own health as well as
that of her developing infant's.
 These risks almost always outweigh the
minor hazards posed by low-dose radiation
exposure. Physicians should not hesitate to
order a study if an appropriate work-up of
the mother requires a specific test to guide
diagnosis and treatment.

130. However, nonurgent x-rays should be
avoided in weeks 10 to 17, the period of
greatest CNS sensitivity.
 When diagnostic imaging is acutely
needed, ultrasonography may represent an
alternative to ionizing radiation and is
considered safe throughout pregnancy.
 Patient counseling before radiation
exposure will help alleviate anxiety and
misunderstandings. Proper communication
may also reduce unnecessary litigation in
the event of an unexpected outcome.