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Pregnancy (PK changes (Absorption (Increased gastric pH, Delayed gastric…
Pregnancy
PK changes
Absorption
Increased gastric pH
Delayed gastric emptying/vomiting
Metabolism
Increased hepatic perfusion & increased GFR
Increased progesterone/estrogen (alter enzymes)
Distribution
Increased body fat/water --> increased Vd
Decreased albumin --> decreased protein binding
Elimination
Placental transfer
Lipophilic
< 500 Da
no charge
Low protein binding
Cardiac Output increases
Drug Selection
Factors to consider
Acute vs. chronic illness
Stage/trimester of pregnancy
Route of administration
Dose
Duration of therapy
Sources of evidence
Animal studies
FDA risk categories
Case reports & voluntary reporting
Length of time on market
Limitation: pregnant women not included in clinical trials
Principles of selection
Duration of therapy
Lowest effective dose
Adequate safety data
Anemia
Iron deficiency
Oral iron 150-200 mg in 2-3 divided doses
B12 deficiency
Oral vitamin B12 (Cobalamin) 1-2 mg QD for 1-2 weeks
Folate deficiency
Oral folate 1mg QD for 4 months
Supplements/vaccines :
influenza, Tdap
Call CDC info line for help!
folic acid 0.4-0.9mg/day (reduce risk of NTD)
Pregnancy influenced issues
Acute
GI
GERD
Nonpharm & Lifestyle
Small meals
GERD lifestyle changes
First-line
Antacids
H2RAs
Ranitidine
Cimetidine
Second line
PPIs
Avoid
Sodium bicarbonate & magnesium trisilicate
Nausea/vomiting
Nonpharm
Small, frequent meals
Avoid spicy/fatty foods
Acupressure on wrist
Ginger
Peaks weeks 8-12; resolves week 16
First-line
Pyridoxine +/- doxylamine
Avoid
Ondansetron
Due to cleft lip/palate
Second line
Metoclopramide
Can have issues with sedation & EPS
Hyperemesis gravidarum
Corticosteroids
Avoid in first trimester
Constipation
Nonpharm
Exercise
Increase fiber & fluids
First-line
Stool softener, i.e. docusate
Bulf-forming, i.e. Metamucil
Osmotic laxative, i.e. lactulose
Avoid
Mineral oil
Castor oil
Chronic
Diabetes
Nonpharm
Diet modifications
Exercise
Monitor blood glucose
First-line
Human insulin
Second line
Metformin
Glyburide
Hypertension
Nonpharm
Stress reduction
Exercise
Prevention of preeclampsia
Aspirin
Pharm
Labetalol
Avoid
ACEIs/ARBs
Methyldopa
Nifedipine
VTE
First-line
LMWH >> warfarin & heparin
Alternative; argatroban
Avoid
DOACs
Fondaparinux
Duration
Provoked
At least 3 months
PLUS 6 weeks postpartum
Physiology
Duration: 280 days - three trimesters
UTI
Pharm
Beta-lactams
Cephalosporin
Avoid
Sulfa during last week of gestation
fluoroquinolones
Tetracyclines
Macrobid during first semester