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DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition

Chapter 99: Pregnancy and Lactation

SELF­ASSESSMENT QUESTION­ANSWERS
1. B . Drugs with a high molecular weight do not substantially cross the placenta. Drugs with low protein binding, lipophilicity, and those that are weak
bases all contribute to passage of drug to the placenta. See “Transplacental Medication Transfer” section for additional information.

2. B . The American College of Obstetricians and Gynecologists (ACOG) recommends that at least 0.4 mg of folic acid should start 1 month prior to
conception and continue throughout at least the first trimester to reduce the risks of neural tube defects. See “Preconception Planning” section for
additional information.

3. B . According to ACOG, the preferred therapy for diabetes management in pregnancy is insulin. Additionally, the patient has uncontrolled A1c, so
achieving control prior to the pregnancy and help further reduce the risks in pregnancy. Neither liraglutide nor canagliflozin are recommended
therapies in pregnancy and have limited to no data in pregnancy. See “Glucose Management” section for additional information.

4. B . Both docusate and psyllium are recommended agents for constipation in pregnancy. Since the patient is also experiencing straining and has
adequate dietary fiber intake, adding the stool softener can help improve symptoms. See “Constipation” section for additional information.

5. B . ACOG recommends starting low dose aspirin between 12 and 28 weeks (ideally 12­16 weeks) in patients who have 1 high­risk factor or 2
moderate­risk factors for preeclampsia. This patient has a high­risk factor of history of preeclampsia. See “Complications of Hypertension” section
for additional information.

6. C . According to ACOG, low­molecular­weight heparin like enoxaparin is the recommended therapy for treatment of acute thromboembolism
during pregnancy. Fondaparinux should be avoided unless the patient has a severe heparin allergy. Warfarin is avoided because of its risk of
teratogenicity. Due to the limited data with direct oral anticoagulants, these agents are not recommended for use in pregnancy. See
“Thromboembolic Disorders” section for additional information.

7. B . An H2 receptor antagonist, like famotidine, is the preferred therapies to prevent against heartburn/GERD symptoms during pregnancy. See
“Gastroesophageal Reflux Disease” section for additional information.

8. D . Medication change to avoid the use of valproic acid and phenobarbital is suggested before conception is attempted because of known
teratogenic risks and the availability of less teratogenic medications. Antiseizure medication monotherapy is recommended with regimen
optimization occurring before conception. See “Epilepsy” section for additional information.

9. A . Sumatriptan is the least likely to cross the placenta. Ibuprofen should not be used during pregnancy, especially after 20 weeks gestation.
Magnesium and propranolol are both used for prophylaxis of migraines. See “Headache” section for additional information

10. D . According to recommended step therapy, step 2 adds a low­dose inhaled corticosteroid as the preferred step therapy. Continuing only albuterol
for the duration of the pregnancy is inappropriate as the patient’s asthma is uncontrolled. Adding a low dose steroid plus salmeterol would be
indicated for step 3 of asthma treatment. Adding an oral steroid would not be recommended as controller therapy as inhaled therapies are
preferred as well as the risks associated with long term oral steroid use. See “Allergic Rhinitis and Asthma” section for additional information.

11. B . One of the purposes of tocolysis is to postpone delivery long enough to allow for the maximal effect of antenatal corticosteroid administration.
Tocolysis duration should be limited to 1 week and should not be initiated beyond 34 weeks. So, this patient would require tocolysis with
nifedipine and antenatal steroids for lung maturity. Indomethacin use after 32 weeks is not recommended due to the risks to the fetus. See
“Preterm Labor” section for additional information.
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12. B . Since the patient QUESTION­ANSWERS,
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13. D . Metformin and glyburide have both been used as alternatives in patients who decline insulin therapy. However, glyburide appears inferior to
 preferred as well as the risks associated with long term oral steroid use. See “Allergic Rhinitis and Asthma” section for additional information.
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11. B . One of the purposes of tocolysis is to postpone delivery long enough to allow for the maximal effect of antenatal corticosteroid administration.
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Tocolysis duration should be limited to 1 week and should not be initiated beyond 34 weeks. So, this patient would require tocolysis with
nifedipine and antenatal steroids for lung maturity. Indomethacin use after 32 weeks is not recommended due to the risks to the fetus. See
“Preterm Labor” section for additional information.

12. B . Since the patient has late latent syphilis, penicillin is the preferred treatment. This patient should undergo desensitization with penicillin to
receive three doses of penicillin to treat the infection. See Table 99­5 in “Sexually Transmitted Infections” section for additional information.

13. D . Metformin and glyburide have both been used as alternatives in patients who decline insulin therapy. However, glyburide appears inferior to
insulin in preventing neonatal morbidity (eg, higher NICU admission, respiratory distress, birth trauma, excessive fetal growth). See “Glucose
Management” section for additional information.

14. B . Both labetalol and nifedipine are preferred agents to manage hypertension in pregnancy according to ACOG; however, this patient has asthma
so nifedipine would be preferred. Labetalol is an alpha­1 and nonselective beta blocker, so it has the potential to constrict the beta receptors in the
lungs to worse asthma control. See “Treatment of Hypertension” section for additional information.

15. E. High lipid solubility contributes to greater likelihood of transfer to breast milk. Drugs with a short half­life, that have low bioavailability, or are
highly protein bound are less likely to pass into breast milk. See “Medication Use During Lactation” section for additional information.

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SELF­ASSESSMENT QUESTION­ANSWERS, Alicia B. Forinash; Kylie Barnes Page 2 / 2
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