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Cheryl K. Seymour, MD MDFMR December 2009

By the end of this talk, participants will: Know safe OTC meds for use in pregnancy Correctly choose antibiotics in pregnancy Understand the complexity of prescribing psychiatric medications during pregnancy Learn which types of chronic medications require dose adjustments in pregnancy Understand med options for pain in pregnancy

Please look things up!

Up to Date
Drugs in Pregnancy and Lactation (Briggs) Medications in Mothers Milk (Hale)

LactMed online search

FDA Drug Categories

Do Not Prescribe!
Methotrexate ACE inhibitors Carbamazepine (Tegretol) Valproic acid (Depakote) Isotretinoin (Accutane) Warfarin NSAIDs (Ibuprofen, Indomethacin)

Managing common symptoms

C e a s 1

A healthy 35 yo G1P0 presents for routine pre-natal care. She complains of daily AM nausea, allergic rhinitis and intermittent GERD throughout the day, worse at night. She is also a smoker 1ppd and would like to quit. She is interested in med options for all. What would you recommend?

Common symptoms of pregnancy

Allergic rhinitis

labelled as contraindicated in pregnancy Not well studies, but widely used without issues Topical treatments are first line

URI symptoms

widely considered safe Dextromethorphan considered safe Guaifenasin associated with neural tube defects Pseudoephedrine possible association c gastroschisis

Common symptoms of pregnancy

GERD Antacids & H2 blockers considered generally safe Some recommend avoiding prolonged use of aluminum or calcium (Maalox) PPIs are also considered safe (meta-analysis 2009) Nausea Ginger, B6 then Diphenhydramine Promethazine the safest dopamine agonist Prednisone after 10 weeks (palate formation)

An interesting clinical dilemma

Smoking cessation Nicotine is FDA pregnancy category D Causes IUGR, premature birth, SAB, SIDS, etc. etc. Smoking has nicotine + 3000 other chemicals

Try behavioral techniques first? Use intermittent rather than continuous replacement

Depression, anxiety & insomnia

C e a s 2

A 33 yo G5 P1 (SAB 3) presents at 6 weeks gestation. She has h/o anxiety & insomnia related to recurrent pregnancy loss. She is coping ok right now, but just learned her mother was dx with breast CA. Between pregnancies she has taken Prozac and Klonopin with good effect.
She interested in discussing her options.

Depression, anxiety & insomnia

Untreated mental illness has significant and measurable effects on maternal & neonatal outcomes All psychotropic meds cross the placenta and are in amniotic fluid and breast milk Only Buspirone, Zolpidem, Buproprion, and Clozapine are pregnancy category B Shared decision making! One medicine only if possible

Depression, anxiety & insomnia

SSRIs -- In general, data is poor or conflicting



/cranial/omphalocele with Paxil (also Zoloft) Consider fetal echocardiography for 1st TM Paxil Rate is 1 in 5000/ 8000/ 1000



withdrawal symptoms, transient Unconfirmed risk of persistent pulm HTN

Atypicals less well studied, but no concerns at this time

Depression, anxiety & insomnia


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

A detour to bipolar & epilepsy

Lamictal has a growing safety profile Anti-psychotics not well studied maybe safe? Lithium
TM risk of cardiac malformations fetal echo Need to monitor levels closely Neonatal abstinence syndrome

Valproate (Depakote) and Carbamazepine (Tegretol) should be avoided

Antibiotics throughout pregnancy

C e a s 3

22 yo G1P0 with h/o frequent UTIs has a positive urine culture at her 1st OB visit. After treating this, you repeat a culture at 12 weeks which is negative. She is seen on L&D with a symptomatic UTI at 24 weeks and admitted with pyelonephritis at 34 weeks.
What are your abx options for these 3 infections?

Antibiotics throughout pregnancy

Generally considered safe:
Penicillin / Ampicillin / Amoxicillin Nitrofurantoin Cephalosporins

Clindamycin / Azithromycin / Erythromycin

Antibiotics throughout pregnancy

Tetracycline NEVER PRESCRIBE Congenital defects, teeth discoloration

Cipro maybe OK but not usually needed ? Mskel fetal abnormalities not well studied Second line for gonorrhea and TB

Bactrim generally avoided esp in 1st TM Trimethoprim is a folic acid antagonist!

Antibiotics throughout pregnancy

UTIs / Asymptomatic bacteruria Nitrofurantoin Cefpodoxime Augmentin Always culture and check another to assure clearance! Recurrent UTI or bacteruria Post coital or daily Nitrofurantoin or Cephalexin Pyelonephritis Ceftriaxone or Amp/Gent Continuous prophylaxis until delivery!

Another detour treating BV

Metronidazole orally and topically is safe If symptomatic tx oral or topical If asymptomatic and no PMH of preterm birth, there is no evidence of benefit to treatment WHY

If asymptomatic AND PMH pre-term birth unclear

screening do so at 1st TM and use Clinda! Metro associated with pre-term birth in this cohort

A changing volume of distribution

C e a s 4

27 yo G3 P2 presents for prenatal care at 8 weeks. She has a history of hypothyroidism and epilepsy both well controlled on Synthroid 100mcg qd and Lamictal 100 qd. She is new to the area and has no other specialists established at this time.
What are your recommendations?

A changing volume of distribution

Pre-existing Hypothyroidism Thyroid hormone need increases as early as 5 wks Can increase by as much as 50% Consider increasing the dose empirically as soon as pregnancy is diagnosed
2 extra pills per week = 30% increase

Follow TSH throughout pregnancy

Why? Volume of distribution, TBG increase, fetal
need, placental deiodenase, PNV block absorption

A changing volume of distribution

Epilepsy Lamictal clearance is enhanced and rate of clearance increases as pregnancy progresses Serum levels are > 50% less than prepregnancy Monitor levels often and use pre-pregnancy therapeutic level as a target Best option is to plan pregnancy and consider med choices and levels in advance

Pain, pain, pain!

C e a s 5

16 yo G1P0 presents at 20 weeks c/o migraine headaches, controlled with Fioricet prior to pregnancy (#30/mo). What can you offer her?
After 5 visits for pain in 2 weeks, you have a heart to heart and refer her to the Suboxone clinic. How do you manage her pain in the third TM & labor?

Pain, pain, pain!

Migraine Headaches Benadryl, Tylenol, Promethazine can be used prn Propranolol prophylaxis is also safe Fioricet contains caffeine possible SAB risk Ergots contraindicated and Triptans avoided Remember many migraines are not Narcotics have the potential for addiction & abuse & neonatal withdrawal syndromes

Pain, pain, pain! - Suboxone

Its not Suboxone! Its Subutex! Buprenorphine only means no antagonist Is a partial agonist, slow to dissociate, low activity What you need to know on L&D Do treat mothers pain! Local may work better Dont give baby Naloxone for resp depression Infants do need to be monitored for NAS


Medications in Pregnancy and Lactation

Parts 1 & 2 Green Journal ACOG Jan & Feb 2009

Use of Psychiatric Medications During Pregnancy and Lactation - ACOG Bulletin 92 April 2008 OTC Medications in Pregnancy AFP 2003 Safety of PPIs in Pregnancy Annals 11/09 Managing Antiepileptic Drugs in Pregnancy and Lactation Current Opinion in Neurology 2009