Topic 3

CLINPH2 Preventive Care

Pharmacotherapy of
Pediatric, Pregnant, and
Geriatric Disorders
Hannah Monica Aquino-Mercado, RPh., CPh.
Review :Maternal Adaptations to Pregnancy
➤ Points to Remember:
➤ Adaptation to pregnancy in humans involves major anatomic,
physiologic and metabolic changes in the mother in order to support
and provide for the nutritional and metabolic needs of the growing
conceptus.
➤ The uterus undergoes hypertrophy and hyperplasia to accommodate
the growing products of conception, reaching a weight of as much as
1100g at term. It likewise undergoes dextrorotation.
➤ The placenta is a complex organ that serves to anchor the developing
fetus to the uterine wall, to provide the exchange of nutrients,
respiratory gases and fetal wastes, and to direct maternal homeostatic
adjustments to meet changing fetal needs by secreting hormones and
other substances into the maternal circulation.
Review :Maternal Adaptations to Pregnancy
➤ Points to Remember:
➤ Breasts undergo hypertrophy and hyperplasia of the glands in
preparation of lactation and also from increase in the bulk of fatty
tissue. The areola progressively darkens, enlarges and forms a
secondary mound.
➤ Cardiovascular changes focus on an increase ain CO and the decrease in
arterial BP resulting from a pronounced decrease in total peripheral
resistance.
➤ There is increased pulmonary ventilation attributable to progesterone
production, as a consequence of increased tidal volume.
Review :Maternal Adaptations to Pregnancy
➤ Points to Remember:
➤ O2 consumption and CO2 production increase steadily in parallel with
increasing fetal mass to reach a level that is about 20% above the non-
pregnant level, but hyperventilation continues until the baby is
delivered.
➤ Renal plasma flow and glomerular filtration rate increase to 40-80%
above normal in humans.
➤ Motility of the GI organs are generally decreased during pregnancy.
➤ The placenta serves as the amain endocrine organ during pregnancy,
being responsible for the production of many hormones to maintain
normal pregnancy.
Review :Maternal Adaptations to Pregnancy
➤ Points to Remember:
➤ Relative insulin resistance developing in the late second trime
serves to shunt the nutrients to fetus after ingestion of meals.
➤ After an initial decrease in the first 8 wks of pregnancy, there is a
steady increase in triacylglycerols, fatty acids, cholesterol,
lipoproteins, and phospholipids. The higher concentration of
estrogen and insulin resistance are thought to be responsible for
the hypertriglyceridemia of pregnany.
Review :Maternal Adaptations to Pregnancy
➤ Points to Remember:
➤ Plasma and red cell volume increase, but the plasma volume
expands by 50%, while the red cell mass increase by only 20-30% .
Consequently, the hematocrit declines from about 45% to about
35%, producing the so called “anemia of pregnancy”.
➤ Musculo-skeletal changes focus on lordosis and joint laxity most
probably attributable to relaxin and progesterone effect.
➤ Common integumentary system changes include
hyperpigmentation, diastases recti and striae.
PRECONCEPTIONAL CARE
➤ It is the provision of biomedical, behavioral and social health interventions to
women and couples before conception occurs.

➤ Goals:
➤ 1. Improve knowledge, attitudes, and behaviors of men and women related to
preconceptional health.
➤ 2. Assure that all women of childbearing age receive preconception care services—
including evidence-based risk screening, health promotion, and interventions—that
will enable them to enter pregnancy in optimal health.
➤ 3. Reduce risks indicated by a previous adverse pregnancy outcome through
interconception interventions to prevent or minimize recurrent adverse outcomes.
➤ 4. Reduce the disparities in adverse pregnancy outcomes.
➤ Importance:
➤ Reducing unintended pregnancy
➤ Prevent birth defects
➤ Prevent LBW and prematurity
➤ Prevent poor pregnancy outcomes and recurrence
➤ Promote healthy behaviors and reduce risk-taking behaviors
➤ Prepares and reinforces parents for parenting
➤ Promote family planning
COUNSELING SESSION
➤ Gynecologists, internists, family practitioners, and pediatricians have
the best opportunity to provide counseling during periodic health
maintenance examinations.
➤ The occasion of a negative pregnancy test is also an excellent time for
education.
➤ Counselors should be knowledgeable regarding relevant medical
diseases, prior surgery, reproductive disorders, or genetic conditions
and must be able to interpret data and recommendations provided by
other specialists.
➤ If the practitioner is uncomfortable providing guidance, the woman or
couple should be referred to an appropriate counselor.
MEDICAL HISTORY (Maternal Assessment)
➤ Diabetes Mellitus
➤ Because maternal and fetal pathology associated with hyperglycemia is
well known, diabetes is the prototype of a condition for which
preconceptional counseling is beneficial.
➤ Many of these complications can be avoided if glucose control is
optimized before conception. The American College of Obstetricians
and Gynecologists has concluded that preconceptional counseling for
women with pregestational diabetes is both beneficial and cost-
effective and should be encouraged.
➤ Glucose is teratogenic at high levels, and rates of congenital fetal
anomalies are directly related to glycemic control in the first trimester.
MEDICAL HISTORY (Maternal Assessment)
➤ HYPERTENSION
➤ Chronic hypertension in pregnancy is associated with higher rates of preterm
birth, placental abruption, intrauterine growth restriction, preeclampsia, and
fetal death. Women with chronic hypertension are at risk of worsening
hypertension and end-organ damage, and 25% of women with hypertension
develop superimposed preeclampsia during pregnancy.
➤ Pregnancy outcome is related to the degree of hypertension. There is no
evidence that treating mild to moderate hypertension in pregnancy improves
perinatal outcomes. Treating severe hypertension (systolic blood pressure of
180 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher)
improves pregnancy outcomes.
➤ Women with long-standing hypertension who are planning pregnancy should
be assessed for retinopathy, renal disease, and ventricular hypertrophy.
MEDICAL HISTORY (Maternal Assessment)
➤ THYROID DISEASE
➤ Hypothyroidism affects 2.5% of women of reproductive age, and even more have
subclinical disease. Hypothyroidism in the first trimester is associated with cognitive
impairment in children. Hypothyroidism (clinical and subclinical) in pregnant women
increases the risk of preterm birth, low birth weight, placental abruption, and fetal
death.5
➤ Women who are adequately treated before pregnancy and those diagnosed and
treated early in pregnancy have no increased risk of perinatal morbidity. It is
essential to monitor women on thyroid replacement therapy and educate them
about its impact on pregnancy. During pregnancy, thyroid replacement dosages
typically need to be increased by four to six weeks' gestation, possibly by 30% or
more.
➤ Hyperthyroidism can result in significant maternal and neonatal morbidity, and
outcomes correlate with disease control. Guidelines recommend achieving
euthyroidism before pregnancy.
MEDICAL HISTORY (Maternal Assessment)
➤ ASTHMA
➤ Women with poorly controlled asthma before pregnancy are more
likely to experience worsening symptoms during pregnancy. Poorly
controlled asthma poses risks to the fetus, such as neonatal
hypoxia, intrauterine growth restriction, preterm birth, low birth
weight, and fetal and neonatal death.
➤ Preconception care should focus on optimizing asthma control
with medications, and identifying and reducing exposure to
allergens. Patients should be counseled on smoking cessation and
avoidance of secondhand smoke exposure.
MEDICAL HISTORY (Maternal Assessment)
➤ THROMBOPHILIA
➤ Women with thrombophilia are more likely to develop venous and
arterial clots during pregnancy and are at risk of preeclampsia.
Effects on the fetus include placental infarction, intrauterine
growth restriction, placental abruption, recurrent miscarriage,
fetal stroke, and fetal death.
➤ Warfarin (Coumadin), an anticoagulant commonly used in the
treatment of thrombophilia, is teratogenic. It is important to
educate women with thrombophilia about the risks of pregnancy
so that they can make informed decisions about conception.
MEDICAL HISTORY
➤ Epilepsy
➤ Women who have epilepsy have an undisputed two- to three- fold
risk of having infants with structural anomalies compared with
unaffected women.
➤ Ideally, seizure control is optimized preconceptionally. Efforts
should attempt to achieve seizure control with monotherapy and
with medications considered less teratogenic. Valproic acid should
be avoided if possible, as this medication has consistently been
associated with a greater risk for major congenital malformations
than other antiepileptic drugs.
MEDICAL HISTORY
➤ Immunizations
➤ Preconception counseling includes assessment of immunity against
common pathogens. Vaccines that contain toxoids—for example,
tetanus, or that consist of killed bacteria or viruses—such as influenza,
pneumococcus, hepatitis B, meningococcus, and rabies—have not been
associated with adverse fetal outcomes and are not contraindicated
preconceptionally or during pregnancy.
➤ Conversely, live-virus vaccines—varicella zoster, measles, mumps,
rubella, polio, chickenpox, and yellow fever—are not recommended
during pregnancy. That said, inadvertent administration of MMR or
varicella vaccines during pregnancy should not generally be considered
indications for pregnancy termination.
MEDICAL HISTORY
➤ GENETIC DISEASES
➤ Family History
➤ The health and reproductive status of each “blood relative” be individually
reviewed for medical illnesses, mental retardation, birth defects,
infertility, and pregnancy loss. Certain racial, ethic, or religious
backgrounds may indicate increased risk for specific recessive disorders.
MEDICAL HISTORY
➤ GENETIC DISEASES
➤ Preconception Health Issues in Men
➤ There are considerations for men as well in the preconceptional period. A man's
family health history is significant when planning pregnancy, as it, along with
maternal family health history, allows for a comprehensive review of genetic
risks.
➤ Men should be screened for STIs and treated appropriately to mitigate
transmission to their partners. Men should not smoke around their partners to
avoid the harmful effects of second-hand smoke. Occupational exposures to
chemicals or toxins may affect spermatogenesis and male fertility; men should
also be careful to avoid exposing their partners to these hazards. Men should be
educated about these risks and about ways to reduce their impact in order to
optimize pregnancy outcomes.
MEDICAL HISTORY
➤ Neural-Tube Defects
➤ The incidence of neural-tube defects is 0.9 per 1000 live births, and they
are second only to cardiac anomalies as the most frequent structural fetal
malformation. It is currently recommended, therefore, that all women
who may become pregnant take 400 to 800 micrograms of folic acid orally
daily before conception and through the first trimester.
MEDICAL HISTORY
➤ Phenylketonuria
➤ Mothers with phenylketonuria who eat an unrestricted diet have
abnormally high blood phenylalanine levels. This amino acid readily
crosses the placenta and can damage developing fetal organs, especially
neural and cardiac tissues. It is therefore recommended that the
phenylalanine concentration be normalized 3 months before conception
and that these levels be maintained throughout pregnancy.
MEDICAL HISTORY
➤ Thalassemias
➤ Individuals of high-risk ancestry be offered carrier screening to allow them
informed decision-making regarding reproduction and prenatal diagnosis.
One method, preimplantation genetic diagnosis, is available for patients at
risk for certain thalassemia syndromes.
➤ Hemolytic anemia
MEDICAL HISTORY
➤ Individuals of Eastern European Jewish Descent
➤ Most individuals of Jewish ancestry in North America are descended from
Ashkenazi Jewish communities and are at increased risk of having
offspring with one of several autosomal recessive disorders such as Tay-
Sachs disease, Gaucher disease, cystic fibrosis, Canavan disease, familial
dysautonomia, mucolipidosis IV, Niemann-Pick disease type A, Fanconi
anemia group C, and Bloom syndrome.
MEDICAL HISTORY
➤ REPRODUCTIVE HISTORY

➤ During preconceptional screening, information should be sought

regarding infertility; abnormal pregnancy outcomes that may
include miscarriage, ectopic pregnancy, and recurrent pregnancy
loss; and obstetrical complications such as preeclampsia, placental
abruption, and preterm delivery. Details involving a prior stillbirth
are especially important.
MEDICAL HISTORY
➤ PARENTAL AGE
➤ Maternal Age
➤ Women at both ends of the reproductive-age spectrum have unique outcomes
to be considered. Adolescents are at increased risk for anemia, preterm delivery,
and preeclampsia compared with women aged 20 to 35 years. The incidence of
STDs is even higher during pregnancy. The older women is more likely to request
preconceptional counseling, either because she has postponed pregnancy and
now wishes to optimize her outcome, or because she has plans to undergo
infertility treatment.
➤ Paternal Age
➤ Although there is an increased incidence of genetic diseases in offspring caused
by new autosomal-dominant mutations in older men, the incidence is still low.
MEDICAL HISTORY
➤ SOCIAL HISTORY
➤ Recreational Drugs and Smoking
➤ Screening for at-risk drinking can be accomplished using a number of
validated tools, like the well-studied TACE questions (American College of
Obstetricians and Gynecologists, 2013). This a series of four questions
concerning tolerance to alcohol, being annoyed by comments about their
drinking, attempts to cut down, and a history of drinking early in the
morning—the eye opener.
MEDICAL HISTORY
➤ Diet
➤ Pica is the craving for and consuming of ice, laundry starch, clay, dirt, or
other nonfood items. It should be discouraged due to its inherent
replacement of healthful food with nutritionally empty products. Many
vegetarian diets are protein deficient but can be corrected by increasing
egg and cheese consumption. Anorexia and bulimia increase maternal
risks of nutritional deficiencies, electrolyte imbalances, cardiac
arrhythmias, and gastrointestinal pathology. Obesity leads to
hypertension, preeclampsia, GDM, labor abnormalities, CS deliver, and
operative complications, and fetal complications.
MEDICAL HISTORY
➤ Exercise
➤ Conditioned pregnant women usually can continue to exercise throughout
gestation. One caveat is that as pregnancy progresses, balance problems
and joint relaxation may predispose to orthopedic injury.

➤ Intimate Partner Violence

➤ Intimate partner violence has been associated with an increased risk for
several pregnancy-related complications, including hypertension, vaginal
bleeding, hyperemesis, preterm delivery, and low-birthweight infants.
PRECONCEPTION PLANNING
Use of Known Teratogens Potential Adverse Pregnancy Outcomes Management of Prevention Options

Antiepileptic drugs Known teratogens; causes craniofacial, cardiac, and limb Use lowest possible dose to maintain control
defects
Folic acid 4mg daily
Fetal hydantoin syndrome

Miscarriage

Isotretinoins Known teratogen; causes CNS, craniofacial, and cardiac Use effective pregnancy prevention
defects
Oral anticoagulants Fetal warfarin syndrome Switch to nonteratogenic anticoagulant (LMWH) before
becoming pregnant
Alcohol Fetal alcohol syndrome Cease alcohol intake before conception
Preterm delivery
Obesity Diabetes, HPN, VTE Weight loss with appropriate nutritional intake before
CS delivery pregnancy
Tobacco Preterm birth Cease tobacco use before conception
Low birth weight
Spontaneous abortion Nonpharmacologic therapies
Increased perinatal mortality
Bupropion
PRENATAL CARE
➤ Kessner Index: system for measuring prenatal care adequacy;
incorporates three items from the birth certificate: 1) length of
gestation 2) timing of the first prenatal visit and 3) number of
visits.

➤ Diagnosis of Pregnancy
➤ Pregnancy is usually identified when a young woman presents with
symptoms and possible a positive home urine pregnancy test result.
Typically, such women receive confirmatory testing of urine or blood for
human chorionic gonadotropin (hCG).
PRENATAL CARE
PRENATAL CARE
➤ Signs and symptoms:
➤ 1. Amenorrhea
➤ 2. Lower reproductive tract changes
➤ 3. Uterine changes
➤ 4. Breast and skin changes
➤ 5. Fetal movement
INITIAL PRENATAL EVALUATION
➤ Prenatal car should be initiated as soon as there is
reasonable likelihood of pregnancy. Major goals are to:
➤ 1) Define the health status of the mother and fetus
➤ 2) estimate the gestational age, and
➤ 3) initiate a plan for continuing obstetrical care.
INITIAL PRENATAL EVALUATION
➤ Definitions:
➤ 1. Nulligravida – a woman who currently is not pregnant nor has ever been
pregnant.
➤ 2. Gravida – a woman who currently is pregnant or has been in the past, irrespective
of the pregnancy outcome. With the establishment of the first pregnancy, she
becomes a primigravida, and with successive pregnancies, multigravida.
➤ 3. Nullipara – a woman who has never completed a pregnancy beyond 20 weeks’
gestation. She may not have been pregnancy or may have had a spontaneous or
elective abortion(s) or an ectopic pregnancy.
➤ 4. Primipara – a woman who has been delivered only once of a fetus or fetuses born
alive or dead with an estimated length of gestation of 20 or more weeks.
➤ 5. Multipara – a woman who has completed two or more pregnancies to 20 weeks’
gestation or more. Parity is determined by the number of pregnancies reaching 20
weeks.
INITIAL PRENATAL EVALUATION
➤ Normal Pregnancy Duration
➤ The mean duration of pregnancy calculated from the first day of
the last normal menstrual period is very close to 280 days or 40
weeks.

➤ Naegele rule – estimating delivery date by adding 7 days to

the date of the first day of the last normal menstrual period
and counting back 3 months. However, a gestational age or
menstrual age calculated in this way assumes pregnancy to
have begun approximately 2 weeks before ovulation, which is
not always the case.
INITIAL PRENATAL EVALUATION
➤ Trimesters
➤ Historically,the first trimester extends
through completion of 14 weeks, the second
through 28 weeks, and the third includes the
29th through 42nd weeks of pregnancy. Most
spontaneous abortions take place during the
first trimester, whereas women with
hypertensive disorders due to pregnancy are
diagnosed during the third trimester.
PREVIOUS AND CURRENT HEALTH STATUS
➤ 1) Psychosocial screening
➤ 2) Cigarette Smoking

➤ 3) Smoking Cessation

➤ 4) Alcohol

➤ 5) Illicit Drugs

➤ 6) Intimate Partner Violence

CLINICAL EVALUATION
➤ Gestational Age Assessment
➤ Precise knowledge of gestational age is one of the most important
aspects of prenatal care because several pregnancy complications
may develop for which optimal treatment will depend on fetal age.
CLINICAL EVALUATION
➤ Laboratory Tests
➤ Initial blood tests:
➤ 1) CBC
➤ 2) Determination of blood type with Rh status
➤ 3) Antibody screen
CLINICAL EVALUATION
➤ Cervical Infections

➤ Chlamydia trachomatis is isolated from the cervix in 2 to 13 percent

of pregnant women. Risk factors include unmarried status, recent
change in sexual partner or multiple concurrent partners, age
younger than 25 years, inner-city residence, history or presence of
other sexually transmitted diseases, and little or no prenatal care.

➤ Neisseria gonorrhea is the gram-negative diplococcal bacteria

responsible for causing gonorrhea.
NUTRITIONAL COUNSELING
➤ Weight Gain Recommendations

➤ The Institute of Medicine and National Research Council (2009)

revised its guidelines for weight gain in pregnancy and continues
to stratify suggested weight gain ranges based on prepregnancy
body mass index (BMI).
NUTRITIONAL COUNSELING
➤ Severe Undernutrition

➤ Evidence of impaired brain development has been obtained in

some animal fetuses whose mothers had been subjected to
intense dietary deprivation. Progeny deprived in mid to late
pregnancy were lighter, shorter, and thinner at birth, and they had
a higher incidence of subsequent diminished glucose tolerance,
hypertension, reactive airway disease, dyslipidemia, and coronary
artery disease.
NUTRITIONAL COUNSELING
➤ Recommended Dietary Allowances

➤ Certain prenatal vitamin-mineral supplements may lead to intakes

well in excess of the recommended allowances. Moreover, the use
of excessive supplements, which often are self-prescribed, has led
to concern regarding nutrient toxicities during pregnancy. Those
with potentially toxic effects include iron, zinc, selenium, and
vitamins A, B6, C and D.
NUTRITIONAL COUNSELING
➤ Exercise

➤ In general, pregnant women do not need to limit exercise,

provided they do not become excessively fatigue or risk injury.
NUTRITIONAL COUNSELING
➤ Common Concerns:

1) Employment 10) Nausea and Vomiting

2) Seafood Consumption 11) Backache
3) Automobile and Air Travel 12) Heartburn
4) Lead Screening 13) Varicosities and Hemorrhoids
5) Coitus 14) Pica and Ptyalism
6) Dental Care 15) Sleeping and Fatigue
7) Immunizations 16) Leukorrhea
8) Biological Warfare and Vaccines 17) Cord Blood Banking
9) Caffeine
Approach to the Patient
➤ A 32-year-old woman with diabetes and hypertension presented for follow-up. She
was interested in gastric bypass surgery. Her blood pressure was 154/89 mm Hg, her BMI
was 41 kg per m2, and her A1C level was 7.9%. She was taking metformin (Glucophage)
and lisinopril (Zestril). She had never been pregnant and was not using contraception.
She would like to have children, but had been unable to conceive for many years and
considered herself infertile.
➤ The patient was encouraged to develop a reproductive life plan, and she and her partner
determined that they wished to delay having children until she was healthier. After discussion of
her contraceptive options, she elected to have an intrauterine device (Mirena) placed. She was
counseled about dietary changes, physical activity, and weight loss, and was referred for
evaluation for gastric bypass surgery. Her medications were titrated to optimize treatment of
diabetes and hypertension, with a goal of discontinuing medications when she lost weight.
➤ One year after surgery, the patient's BMI was 29 kg per m2, and she no longer required
medications for diabetes or hypertension. Her A1C level was 6.5%. She had been taking multiple
vitamins, including folic acid, since her surgery to avoid nutrient deficiencies, and she wished to
have her intrauterine device removed.
Core-Related values and Biblical Reflection:
➤ God-Centered
➤ Excellent
➤ Service-oriented

➤ Psalm 139:13-16 ESV

For you formed my inward parts; you knitted me together in my mother's
womb. I praise you, for I am fearfully and wonderfully made. Wonderful are
your works; my soul knows it very well. My frame was not hidden from you,
when I was being made in secret, intricately woven in the depths of the earth.
Your eyes saw my unformed substance; in your book were written, every one of
them, the days that were formed for me, when as yet there was none of them.