Med. Therapy4

Sara Qaradeh
Contraception
1
Definition
• Contraception is
the prevention of pregnancy

by
- inhibiting sperm from reaching a mature
ovum
or
- preventing a fertilized ovum from implanting
in the endometrium.
2
The Menstrual Cycle
• The median length of the menstrual cycle is 28 days

(range 21 to 40).
• The first day of menses is day 1 which marks the

beginning of the follicular phase.
• Ovulation usually occur on day 14 of the menstrual

cycle.
• After ovulation, the luteal phase last until the

beginning of the next cycle.
3
The Menstrual Cycle
• The hypothalamus secrets gonadotropin-

releasing hormone (GnRH)
which stimulates
the anterior pituitary
to secrete
Gonadotropins (follicle stimulating hormone
(FSH), and luteinizing hormone (LH).)
4
The Menstrual Cycle
• In the follicular phase
FSH levels increase

- cause recruitment of a small group of follicles
for continued growth.
- Between days 5 and 7, one of these becomes the
dominant follicle, which later ruptures to release the
oocyte.
- The dominant follicle
- develops increasing amounts of estradiol and
inhibin
- providing a negative feedback on the
secretion of GnRH and FSH.
5
The Menstrual Cycle
• The dominant follicle continues to grow and
synthesizes estradiol, progesterone, and androgen.
• Estradiol
- stops the menstrual flow from the previous cycle
- thickens the endometrial lining
- produces thin, watery cervical mucus.
• FSH regulates aromatase enzymes that induce

conversion of androgens to estrogens in the follicle.
6
The Menstrual Cycle
• The pituitary releases
a midcycle LH surge
- that stimulates the final stages
of follicular maturation and ovulation.
• Ovulation occurs
- 24 to 36 hours after the estradiol peak and
- 10 to 16 hours after the LH peak.
7
The Menstrual Cycle
• The LH surge is the most clinically useful
predictor of approaching ovulation.
• Conception is most successful

- when intercourse takes place from 2 days
before ovulation to the day of ovulation.
• After ovulation, the remaining luteinized follicles

become the corpus luteum,
- which synthesizes androgen, estrogen, and
progesterone
8
The Menstrual Cycle
• If pregnancy occurs:
- human chorionic gonadotropin (hCG)
- prevents regression of the corpus luteum

- stimulates continued production of
estrogen and progesterone.
• If pregnancy does not occur:
- the corpus luteum degenerates, progesterone

declines, and menstruation occurs.
9
10
11
12
Treatment
Goal of Treatment:
• the prevention of pregnancy following sexual

intercourse.
13
Nonpharmacologic therapy
• The abstinence (rhythm) method is associated

with relatively high pregnancy rates.
14
Barrier Techniques
Diaphragms
• Effective because they are barriers and

because of the spermicide placed in
the diaphragm before insertion.
• It should be inserted up to 6 hours

before intercourse and must be left in
place for at least 6 hours after.
• It should not be left in place for more

than 24 hours because of the risk of
toxic shock syndrome (TSS). 15
Barrier Techniques
Cervical cap
• Can be inserted 6 hours prior

to intercourse
• Should not remain in place

for longer than 48 hours to
reduce the risk of TSS.
16
Barrier Techniques
• With use of diaphragms or cervical caps

- a condom should also be used to protect
against sexually transmitted diseases (STDs)
including human immunodeficiency virus
(HIV).
17
Barrier Techniques
Condoms
• Most condoms made in the United States

are latex, which is impermeable to viruses
• ~5% are made from lamb intestine, which

is not impermeable to viruses.
• Mineral oil–based vaginal drug

formulations (eg, Cleocin vaginal cream,
Premarin vaginal cream,) can decrease the
barrier strength of latex.
18
Barrier Techniques
Condoms
• Condoms with spermicides are not

recommended,
as
- they provide no additional protection
against pregnancy or STDs
- may increase vulnerability to HIV.
19
Barrier Techniques
The female condom (Reality)
• Covers the labia, as well

as the cervix.
• However, the pregnancy

rate is higher than with
male condoms.
20
Pharmacologic therapy
Spermicides
• Most spermicides contain nonoxynol-9
- a surfactant that destroys sperm cell walls

and blocks entry into the cervical os.
- They offer no protection against STDs
- when used more than twice daily,

nonoxynol-9 may increase the transmission of
HIV.
21
Spermicide-Implanted Barrier Techniques
• The vaginal contraceptive sponge (Today)

contains nonoxynol-9 and provides protection for
24 hours.
• After intercourse, the sponge must be left in

place for at least 6 hours before removal.
• It should not be left in place for more than 24 to

30 hours to reduce the risk of TSS.
22
Hormonal Contraception
• Hormonal contraceptives contain either
- a combination of synthetic estrogen and

synthetic progestin
Or
- a progestin alone.
23
• Progestins
- Thicken cervical mucus
- Delay sperm transport
- Induce endometrial atrophy.
- Block the LH surge and thus inhibit ovulation.
• Estrogens
- Suppress FSH release (which may contribute to
blocking the LH surge)
- Stabilize the endometrial lining and provide cycle
control.
24
• Mestranol must be converted to ethinyl

estradiol (EE) in the liver to be active.
• It is approximately 50% less potent than EE.
25
• Progestins
- vary in their progestational activity
- differ with respect to inherent

- estrogenic,
- antiestrogenic
- androgenic effects.
26
• Their estrogenic and antiestrogenic properties occur
because progestins are metabolized to estrogenic
substances.
• Androgenic activity depends on

- the presence of sex hormone (testosterone) binding
globulin
And - the androgen-to-progesterone activity ratio.
If sex hormone binding globulin decreases, free

testosterone levels increase, and androgenic side effects
are more prominent.
27
Considerations with Use of
Combined Hormonal Contraceptives (CHC)
Before prescribing a CHC.
• Obtain
- Medical history
- Blood pressure measurement
• Discuss
- the risks
- benefits
- adverse effects with the patient
28
Noncontraceptive benefits of OCs include
• Decreased menstrual cramps and ovulatory pain.
• Decreased menstrual blood loss.
• Improved menstrual regularity.
• Decreased iron deficiency anemia.
• Reduced risk of ovarian and endometrial cancer; and

reduced risk of ovarian cysts, ectopic pregnancy, pelvic
inflammatory disease, endometriosis, uterine fibroids,
and benign breast disease. 29
• The main safety concern about CHCs is their

lack of protection against STDs.
30
Women over 35 Years of Age
• CHCs containing less than 50 mcg EE may be considered in

healthy, nonsmoking women > 35 years.
• CHCs are not recommended for women older than 35 years

with migraine, uncontrolled hypertension, smoking or
diabetes with vascular disease.
• Studies have not demonstrated an increased risk of

cardiovascular disease with low dose CHCs in healthy,
nonobese women.
31
Smoking Women
• Women > 35 years who smoke and take OCs

- have an increased risk of MI
- therefore, clinicians should prescribe CHCs with caution, if at
all, in these patients.
• Smoking 15 or more cigarettes per day by women over 35 years

- is a contraindication to the use of CHCs
- the risks generally outweigh the benefits even in those who
smoke fewer than 15 cigarettes per day.
• Progestin-only contraceptive methods should be considered in this

group. 32
Hypertension
• CHCs, regardless of estrogen dose, can cause small increases

in blood pressure (6–8 mm Hg).
• In women with hypertension, OCs have been associated with

an increased risk of myocardial infarction (MI) and stroke.
• Use of low-dose CHCs is acceptable in women younger than

35 years with well-controlled and monitored hypertension.
33
Hypertension
• Systolic blood pressure greater than or equal to 160 mm Hg

or diastolic blood pressure greater than or equal to 100 mm
Hg
- is a contraindication to use of CHCs.
• Women with a systolic blood pressure of 140 to 159 or a

diastolic blood pressure of 90 to 99 mm Hg
- should also avoid CHC, as the risks generally outweigh
the benefits.
34
Diabetes
• Except for some levonorgestrel-containing products,

- formulations containing low doses of progestins do not
significantly alter insulin, glucose, or glucagon release after a
glucose load in healthy women or in those with a history of
gestational diabetes.
• Women younger than 35 years with diabetes but no vascular

disease who do not smoke
- can safely use CHCs
• Diabetic women with vascular disease or diabetics of more than 20

years’ duration
- should not use CHCs.
35
Dyslipidemia
• Generally, synthetic progestins decrease HDL and increase LDL.
• Estrogens decrease LDL but increase HDL and may moderately

increase triglycerides.
• Most low-dose CHCs (with the possible exception of levonorgestrel

pills, which may reduce HDL levels in some patients) have no
significant impact on HDL, LDL, triglycerides, or total cholesterol.
• The mechanism for the increased cardiovascular disease in CHC

users is believed to be thromboembolic and thrombotic changes,
not atherosclerosis.
36
Dyslipidemia
• Women with controlled dyslipidemia

- can use low-dose CHCs
- with monitoring of fasting lipid profiles.
• Women with uncontrolled dyslipidemia (LDL > 160 mg/dL,

HDL < 35 mg/dL, triglycerides > 250 mg/dL) and additional risk
factors (e.g., coronary artery disease, diabetes, hypertension,
smoking, or a positive family history)
- should use an alternative method of contraception.
37
Thromboembolism
• Estrogens have a dose-related effect in the

development of venous thromboembolism (VTE) and
pulmonary embolism
- especially in women with underlying

hypercoagulable states
Or - who have acquired conditions (e.g., obesity,

pregnancy, immobility, trauma, surgery, and certain
malignancies) that predispose them to coagulation
abnormalities. 38
Thromboembolism
• OCs containing the newer progestins (eg, drospirenone,

desogestrel, norgestimate)
- carry a slightly increased risk of thrombosis compared to
other progestins.
• The transdermal patch and vaginal ring

- provide continuous higher exposure to estrogen and have
an increased thromboembolic risk.
• The risk of VTE in women using OCs is three times the risk in
nonusers.
- However, this risk is less than the risk of thromboembolic
events during pregnancy.
39
Thromboembolism
• For women at increased risk of thromboembolism

(older than 35 years, obesity, smoking, personal or
family history of venous thrombosis, prolonged
immobilization)
- consider low-dose oral estrogen contraceptives

containing older progestins or progestin-only methods.
40
Migraine Headache
• Women with migraines may experience a decreased or increased

frequency of migraines when using CHCs.
• CHCs may be considered for

- healthy, nonsmoking women with migraines without aura.
• Women of any age who have migraine with aura and women over 35
years with any type of migraine
- should not use CHCs.
• Women who develop migraines (with or without aura) while receiving

CHCs
- should immediately discontinue their use and consider a progestin
only option.
41
Breast Cancer
• There is a small increase in the relative risk of having

breast cancer
- while combined OCs are taken and for up to 10
years following discontinuation.
• Cancers diagnosed in women who used combined

OCs were less advanced than cancers diagnosed in
women who had not used OCs.
42
Breast Cancer
• The choice to use CHCs should not be influenced

by the presence of benign breast disease or a
family history of breast cancer with either BRCA1
or BRCA2 mutation.
• Women with a current or past history of breast

cancer should not use CHCs. 43
Systemic Lupus Erythematosus
• OCs with less than 50 mcg EE

- do not increase the risk of flare among women with
stable SLE and without antiphospholipid/anticardiolipin
antibodies.
• CHCs should be avoided in women

- with SLE and antiphospholipid antibodies or
vascular complications.
- Progestin-only contraceptives can be used in these
women.
44
Obesity
• OCs have lower efficacy in obese women, and low-dose OCs

may be especially problematic.
• Obese women are at increased risk for VTE.
• The transdermal contraceptive patches should not be used

- as a first choice in women weighing greater than 90 kg
(198 lb).
• Progestin-only contraception may be better for obese women

over 35 years.
45
General Considerations for Oral Contraceptives
• With perfect use

- their efficacy is more than 99%
But
• With typical use

- up to 8% of women may experience
unintended pregnancy.
46
• Monophasic OCs
- contain a constant amount of estrogen and

progestin for 21 days, followed by 7 days of placebo.
• Biphasic and triphasic pills
- contain variable amounts of estrogen and

progestin for 21 days and are followed by a 7-day
placebo phase.
47
• Extended-cycle pills and continuous

combination regimens
- may offer some side effect and
convenience benefits.
- One particular extended-cycle OC

increases the number of hormone-containing
pills from 21 to 84 days, followed by a 7-day
placebo phase, resulting in four menstrual
cycles per year.
48
• The progestin-only “minipills”
- Tend to be less effective than combination OCs.
- They are associated with irregular and unpredictable

menstrual bleeding.
- They must be taken every day of the menstrual cycle at

approximately the same time of day to maintain
contraceptive efficacy.
- They are associated with more ectopic pregnancies than

other hormonal contraceptives.
49
• In the first-day start method

- women take the first pill on the first day of the next
menstrual cycle.
• In the Sunday start method

- the first pill is taken on the first Sunday after starting
the menstrual cycle.
- Women should use a second contraceptive method
for 7 to 30 days after OC initiation.
• The World Health Organization’s Selected Practice

Recommendations for Contraceptive Use can be used for
guidance when instructing women what to do if a pill is
missed. 50
Choice of an Oral Contraceptive
• In women without coexisting medical conditions,
- an OC containing 35 mcg or less of EE and less
than 0.5 mg of norethindrone is recommended.
• Adolescents, underweight women (<50 kg [110 lb]),

women older than 35 years, and those who are
perimenopausal may
- have fewer side effects with OCs containing 20 to
25 mcg of EE.
- However, these low-estrogen OCs are associated
with more breakthrough bleeding and an increased risk
of contraceptive failure if doses are missed.
51
Managing Side Effects
• Many symptoms occurring in the first cycle of OC use
- (eg, breakthrough bleeding, nausea, and bloating)
- improve by the third cycle of use.
• Instruct women to immediately discontinue CHCs if they

experience warning signs referred to by the mnemonic
ACHES
- abdominal pain - chest pain
- headaches - eye problems
- severe leg pain.
52
Drug Interactions
• Tell women to use an alternative method of

contraception if there is a possibility of a drug
interaction compromising OC efficacy.
53
Drug Interactions
Rifampin
• Reduces the efficacy of OCs.
• Advise women to use an additional nonhormonal

contraceptive agent during and for at least 7 to
28 days after the course of rifampin therapy.
54
Drug Interactions
Antibiotics
• Tell women about the small risk of interaction

with other antibiotics, and that additional
nonhormonal contraceptives can be considered if
desired.
• If there is breakthrough bleeding in women

taking concomitant antibiotics and OCs, an
alternate method of contraception should be
used during the time of concomitant use.
55
Drug Interactions
Phenobarbital, carbamazepine, and phenytoin
• Potentially reduce the efficacy of Ocs
• And many anticonvulsants are known teratogens.
• Intrauterine devices (IUDs), injectable

medroxyprogesterone, or nonhormonal options
may be considered for women taking these
drugs.
56
Drug Interactions
• Combined OCs may decrease the efficacy of

lamotrigine and increase the risk of seizures.
• Certain antiretroviral therapies may decrease

the efficacy of OCs.
57
Discontinuation of the oral contraceptive,
return of fertility
• In several large cohort and case-control studies,
infants conceived in the first month after an OC was
discontinued had no greater chance of miscarriage
or a birth defect than those born in the general
population.
• There is no evidence that use of OCs, transdermal

patches, or vaginal rings decreases subsequent
fertility.
58
59
60
Emergency Contraception (EC)
• Progestin-only and progesterone receptor modulator

products are approved by the FDA and
recommended as first-line EC options.
• They will not disrupt the fertilized egg if implantation

has already occurred.
• Use of higher doses of CHCs is another option for EC

(Yuzpe method), but this option is not widely used
and may cause more side effects.. 61
• The progestin-only formulation containing one 1.5 mg
tablet of levonorgestrel (Next Choice OneDose; Plan B
One Step) is approved for EC in the United States.
• The levonorgestrel-containing formulation is the regimen

of choice.
• These one-dose options

- to be given within 72 hours (3 days) of unprotected
intercourse
- but the sooner it is taken, the greater the efficacy.
- There is some evidence that it may be effective for
up to 5 days after unprotected intercourse, but in this
situation ulipristal (Ella) “selective progesterone receptor
modulator” or a copper IUD may be a better option. 62
• Levonorgestrel-containing EC products are now

available without a prescription in the United States.
• Ulpristal
- a selective progesterone receptor modulator
- available by prescription as a single dose of 30
mg taken within 120 hours of unprotected
intercourse.
- It is considered noninferior to levonorgestrel
containing ECs.
63
• Nausea and vomiting occur significantly less

often with progestin-only and progesterone
receptor modulator EC compared to the Yuzpe
method.
• Backup nonhormonal contraceptive methods

should be used after EC for at least 7 days.
64
Transdermal Contraceptives
• A combination contraceptive is available as a transdermal

patch (Ortho Evra)
• May have improved adherence compared with OCs.
• It is as effective as CHCs in women weighing less than 90 kg

(198 lb)
- so the patch is not recommended as a first-line option

in women weighting more than 90 kg.
65
Transdermal Contraceptives
• The patch should be applied to the abdomen, buttocks, upper

torso, or upper arm
• Applied at the beginning of the menstrual cycle and replaced

every week for 3 weeks. The fourth week is patch-free.
• Women using the patch are exposed to ~60% more estrogen

than if they were taking an OC containing 35 mcg of EE
- possibly leading to increased thromboembolic risk, and
the approved labeling for the patch includes a warning in this
regard.
66
Vaginal Rings
• NuvaRing releases ~15 mcg/day of EE and 120
mcg/day of etonogestrel over a 3-week period.
• On first use, the ring should be inserted on or

prior to the fifth day of the cycle, remain in place
for 3 weeks, then be removed.
• One week should lapse before the new ring is

inserted on the same day of the week as it was
for the last cycle.
• A second form of contraception should be used

- for the first 7 days of ring use
or - if the ring has been expelled for more than
3 hours. 67
Long-acting Injectable
and Implantable Contraceptives
• Women who particularly benefit from progestin-only

methods, including minipills, are those:
- who are breast-feeding
- intolerant of estrogens
- those with concomitant medical conditions in
which estrogen is not recommended.
• Injectable and implantable contraceptives are also

beneficial for women with adherence issues.
• Contraceptive failure rates with long-acting progestin

contraception are lower than with CHC. 68
Injectable Progestins
• Depot medroxyprogesterone acetate (DMPA) 150 mg
- is administered by deep intramuscular injection in the
gluteal or deltoid muscle
- within 5 days of onset of menstrual bleeding
- and the dose should be repeated every 12 weeks.
• Another formulation contains 104 mg of DMPA (Depo-

SubQ Provera 104)
- which is injected subcutaneously into the thigh or
abdomen.
69
• Exclude pregnancy in women
- more than 1 week late for repeat injection of the

intramuscular formulation
or - 2 weeks late for repeat injection of the subcutaneous
formulation.
• Return of fertility may be delayed after discontinuation.
70
• DMPA can be given
- immediately postpartum in women who are not breast-
feeding
- but in women, who are breast-feeding, delay
administration for 6 weeks.
• The median time to conception from the first omitted dose is 10

months.
• The most frequent adverse effect of DMPA is

- menstrual irregularity, which decreases after the first
year.
- Breast tenderness, weight gain, and depression occur less
frequently.
71
• DMPA is associated with a reduction in bone mineral density

(BMD), but there are no clear data that demonstrate the
effects of DMPA on fracture risk.
• Loss of BMD seems to be greater with increasing duration of

use, and effects on BMD may not be completely reversible
upon discontinuation.
• DMPA should not be continued beyond 2 years unless other

contraceptive methods are inadequate.
72
73
Subdermal Progestin Implants
• Nexplanon, an etonogestrel implant
which is radiopaque, is a 4 cm implant,
containing 68 mg of etonogestrel that
is placed under the skin of the upper
arm.
• It releases 60 mcg daily for the first

month, decreasing gradually to 30
mcg/day at the end of the 3 years of
recommended use.
• Efficacy exceeds 99%, but it may be

less in women more than 130% of their
ideal body weight.
74
Subdermal Progestin Implants
• The major adverse effect is irregular menstrual

bleeding.
• Other side effects are headache, vaginitis,

weight gain, acne, and breast and abdominal
pain.
• It does not appear to decrease BMD.
• Fertility returns within 30 days of removal.

75
Intrauterine Devices
• The contraceptive activity
occurs before implantation.
• Endometrial suppression is
caused by progestin-releasing
IUDs.
• Efficacy rates are greater than

99%.
• The risk of pelvic inflammatory

disease among users is low.
76
Intrauterine Devices
• ParaGard (copper) can be left in place for 10 years.
- Disadvantages of ParaGard are increased

menstrual blood flow and dysmenorrhea.
• Mirena, Liletta, and Skyla release levonorgestrel.
- They must be replaced after 5 years (Mirena)

and 3 years (Skyla and Liletta).
- They cause a reduction in menstrual blood
loss.
77
Evaluation of Therapeutic Outcomes
• Monitor blood pressure annually in all CHC users.
• Monitor glucose levels closely when CHCs are started or stopped in

women with a history of glucose intolerance or diabetes mellitus.
• For all contraceptive users do annual cytologic screening (more

often if they are at risk for STDs), pelvic and breast examination,
and well woman consultation.
• Also, regularly evaluate for problems that may relate to the CHCs
(eg, breakthrough bleeding, amenorrhea, weight gain, and acne).
These screenings do not have to occur before prescribing hormonal
contraceptives.
78
Evaluation of Therapeutic Outcomes
• Annually monitor women using Nexplanon for menstrual cycle
disturbances, weight gain, local inflammation or infection at the
implant site, acne, breast tenderness, headaches, and hair loss.
• Evaluate women using DMPA every 3 months for weight gain,

menstrual cycle disturbances, and fractures.
• Monitor women with IUDs at 1 to 3 month intervals for proper

positioning of the IUD, changes in menstrual bleeding patterns,
upper genital tract infection, and protection against STDs.
• Clinicians should monitor and when indicated screen for HIV and
STDs. Counsel all women about healthy sexual practices, including
the use of condoms to prevent transmission of STDs when
necessary.
79
80
81
Pregnancy and Lactation:
Therapeutic Considerations
1
Resources on the use of drugs in
pregnancy and lactation include:
• The Food and Drug Administration (FDA)

categorization system (A, B, C,
D, and X)
• The primary literature
• Tertiary compendia
• Textbooks
• Computerized databases
- (eg, www.motherisk.org
www.toxnet.nlm.nih.gov
2
Physiologic and pharmacokinetic factors
• The duration of pregnancy is approximately

280 days
- (measured from the first day of the last
menstrual period to birth).
• Pregnancy is divided into three periods of 3

calendar months (ie, trimesters).
3
• Drug absorption during pregnancy may be

altered by
- delayed gastric emptying
- vomiting.
• An increased gastric pH may affect absorption

of weak acids and bases.
4
• Hepatic perfusion increases.
• Higher estrogen and progesterone levels may

alter liver enzyme activity and increase
elimination of some drugs but cause
accumulation of others.
5
• Maternal plasma volume and cardiac output

increase .
• Glomerular filtration increase by 30% to 50% or

higher during pregnancy
- lowering the plasma concentration of
renally cleared drugs.
• Body fat increases

- volume of distribution of fat-soluble drugs
may increase.
6
• Plasma albumin concentrations decrease
- volume of distribution of highly protein

bound drugs may increase.
- However, there may be little change in

serum concentration, as these unbound drugs
are more rapidly cleared by the liver and
kidneys.
7
• The placenta is the organ of exchange between

the mother and fetus for drugs.
• Drugs with molecular weights
- less than 500 Da transfer readily
- from 600 to 1000 Da cross more slowly
- greater than 1000 Da (eg, insulin and

heparin) do not cross in significant amounts.
8
• Lipophilic drugs (eg, opiates and antibiotics)

cross more easily than do water-soluble drugs.
• Free drugs pass easily:

- However, certain protein-bound drugs
may achieve higher plasma concentrations in
the fetus than in the mother.
9
Drug selection during pregnancy
• The incidence of congenital malformation is
approximately
- 3% to 5%
- 1% of all birth defects are caused by medication
exposure.
• Adverse effects on the fetus depend on:

- drug dosage
- route of administration
- concomitant exposure to other agents
- stage of pregnancy when the exposure occurred.
10
• Fetal exposure to a teratogen in the first 2 weeks after
conception
- may have an “all or nothing” effect (ie, could
destroy the embryo or have no ill effect).
• Exposure during organogenesis (18–60 days

postconception)
- may cause structural anomalies
- methotrexate, cyclophosphamide,
diethylstilbestrol, lithium, retinoids, thalidomide, some
antiepileptic drugs [AEDs], and coumarin derivatives).
11
• Exposure after 60 days post conception may
result in
- growth retardation, central nervous

system (CNS) or other abnormalities, or death.
- NSAIDs and tetracycline derivatives are

more likely to exhibit effects in the second or
third trimester.
12
• Principles for drug use during pregnancy include
(1) selecting drugs that have been used safely for a long
time.
(2) prescribing doses at the lower end of the dosing

range.
(3) eliminating nonessential medication and discouraging

self-medication.
(4) avoiding medications known to be harmful.

13
Classification of drugs used in pregnancy
United States FDA Pharmaceutical Pregnancy Categories
Adequate and well-controlled human studies

have failed to demonstrate a risk to the fetus in
Pregnancy
the first trimester of pregnancy (and there is no
Category A
evidence of risk in later trimesters).
Animal reproduction studies have failed to

demonstrate a risk to the fetus and there are no
adequate and well-controlled studies in pregnant
Pregnancy
women OR Animal studies have shown an
Category B
adverse effect, but adequate and well-controlled
studies in pregnant women have failed to
demonstrate a risk to the fetus in any trimester.14
Animal reproduction studies have shown an

adverse effect on the fetus and there are no
Pregnancy adequate and well-controlled studies in humans,
Category C but potential benefits may warrant use of the
drug in pregnant women despite potential risks.
There is positive evidence of human fetal risk

based on adverse reaction data from
Pregnancy investigational or marketing experience or
Category D studies in humans, but potential benefits may
warrant use of the drug in pregnant women
despite potential risks. 15
Studies in animals or humans have demonstrated

fetal abnormalities and/or there is positive
evidence of human fetal risk based on adverse
Pregnancy reaction data from investigational or marketing
Category X experience, and the risks involved in use of the
drug in pregnant women clearly outweigh
potential benefits.
Pregnancy
FDA has not classified this drug.
Category N
16
Preconception planning
• Folic acid supplementation
- between 0.4 and 0.9 mg daily is recommended
throughout the reproductive years
- to reduce the risk for neural tube defects in offspring.
• Women of child bearing age (at high risk)
- Those who take certain seizure (AED) medicationsm
(especially valproic acid)
or
- who have had a previously affected pregnancy (who
have previously delivered a child with
a neural tube defect)
- should take 0.4 - 5mg/day. 17

Preconception planning
• Reduction in the use of alcohol, tobacco, and other
substances prior to pregnancy improves outcomes.
• For smoking cessation, behavioral interventions are

preferred.
• Use of nicotine replacement therapy during pregnancy is

controversial; if used:
- Intermittent delivery formulations (eg, gum) are
preferred over patches.
- If patches are used, 16-hour patches are preferred

over 24-hour patches.
18
Pregnancy-influenced issues
Constipation
• Constipation commonly occurs during pregnancy
• Institute education, physical exercise, and increased intake of

dietary fiber and fluid.
• If additional therapy is warranted, give

-Supplemental fiber and / or stool softner.
- lactulose, sorbitol
- magnesium and sodium salts
- Polyethylene glycol
can be used intermittently short term.
• Senna and bisacodyl can be used occasionally.
• Avoid castor oil and mineral oil.
19
GERD
• Lifestyle and dietary modifications:
- Small, frequent meals
- Alcohol, tobacco, and caffeine avoidance
- Food avoidance 3 hours before bedtime
- Elevation of the head of the bed.
• If necessary, initiate
- Aluminum, calcium, or magnesium antacids

- sucralfate
- Ranitidine or Cimetidine .
- Proton pump inhibitors are options if response to histamine 2
(H2)–receptor blockers is inadequate.
• Avoid sodium bicarbonate and magnesium trisilicate. 20

Hemorrhoids
• High intake of dietary fiber, adequate oral fluid intake, and
use of sitz baths.
• If response is inadequate:
- Laxatives and stool softeners.
- Topical anesthetics
- Skin protectants (petrolatum, zinc oxide, cocoa
butter)
- Astringents (calamine, zinc oxide)
may help irritation and pain.
• Topical hydrocortisone may reduce inflammation and

pruritus. 21
Nausea and vomiting
• Nonpharmacologic treatments
- Eating small, frequent meals
- Avoiding fatty and spicy foods
- Acupressure.
• Pharmacotherapy
- Antihistamines (eg, doxylamine)
- Pyridoxine
(pyridoxine alone or in combination with doxylamine
to be first line treatment)
- Dopamine antagonists (eg, metoclopramide, phenothiazine).
(May cause sedation and extrapyramidal effects).
- Ondansetron
(May cause oral cleft).
• Ginger is considered safe and effective.

22
Nausea and vomiting
• Hyperemesis gravidarum
- severe nausea and vomiting causing weight loss >5% of

prepregnancy weight, dehydration, and ketonuria.
- Corticosteroids have been effective:

- Dexamethasone and prednisolone.
- but the risk of oral clefts is increased.

- They should not be used during the first
trimester
23
Gestational diabetes mellitus
• First-line therapy:
- Dietary modification and caloric restrictions for obese women.
- Exercise
- Daily self-monitoring of blood glucose is required.
• If nutritional intervention fails to achieve

- fasting plasma glucose levels of < than 95mg/dL
- 1-hour postprandial level of < 140 mg/dL.
- 2-hour postprandial levels of < 120 mg/dL
--- therapy with

- recombinant human insulin should be instituted (DOC).
- glyburide may be considered an alternative.

- Metformin may also be considered
but long-term safety data are limited
24
Gestational diabetes mellitus
• The American College of Obstetricians and

Gynecologists (ACOG) support
either
insulin, glyburide, or metformin for first-line
therapy.
25
Hypertension
• Gestational hypertension
- hypertension without proteinuria developing after 20 weeks’
gestation
• Chronic hypertension
- Preexisting hypertension or developing before 20 weeks’
gestation.
• Chronic hypertension
- with superimposed preeclampsia.
• Preeclampsia
- hypertension with proteinuria.
• Eclampsia: a medical emergency, is preeclampsia with seizures. 26

Hypertension
• Hypertension in pregnancy is either

- systolic blood pressure above 140mm Hg
or
- diastolic blood pressure above 90 mm Hg
based on two or more measurements at least

4 hours apart. 27
Hypertension
• For women at risk for preeclampsia
- low-dose aspirin (60–81 mg/day)
- beginning late in the first trimester reduces the risk
for preeclampsia by 17%.
• Aspirin reduces the risk of preterm birth by 8% and fetal

and neonatal death by 14%.
• Calcium, 1 to 2 g/day, decreases the relative risk of

hypertension by 35% and preeclampsia by 55%.
• Calcium, 1 g/day, is appropriate for all pregnant women.

28
Hypertension
• Magnesium sulfate is used
- to decrease the risk of progression of

preeclampsia to eclampsia by almost 60%.
- to treat eclamptic seizures.
• Avoid diazepam and phenytoin. 29

Thyroid abnormalities
• Gestational transient thyrotoxicosis
- usually resolves by 20 weeks’ gestation.
- antithyroid medication is usually not needed.
• Pregnant women with overt hyperthyroidism:

- should be treated with methimazole or
propylthiouracil.
• Pregnant women with overt hypothyroidism:

- should receive thyroid replacement therapy (ie,
levothyroxine).
30
Venous thromboembolism
• For treatment of acute thromboembolism during
pregnancy
- low-molecular-weight heparin is preferred over
unfractionated heparin.
• Continue treatment throughout pregnancy and for 6 weeks

after delivery.
• Duration of therapy should not be less than 3 months.
• Avoid warfarin
- because it may cause fetal bleeding, nose hypoplasia,
stippled epiphyses, or CNS anomalies.
31
Venous thromboembolism
• For women at intermediate or high risk for
recurrent VTE:
- provide antepartum prophylaxis with LMWH
plus 6-week postpartum prophylaxis with
LMWH or warfarin.
• For women with prosthetic heart valves,

thrombophilias, and those at very high risk for
VTE:
- consult current guidelines.
32
Acute care issues in pregnancy
Headache
• For tension and migraine headaches during
pregnancy
First-line therapies are nonpharmacologic,

including:
- relaxation
- stress management
- biofeedback.
33
Headache
Tension headache
• Acetaminophen or ibuprofen can be used if necessary.
• All NSAIDs are contraindicated in the third trimester

- because of the potential for closure of the ductus
arteriosus.
• Avoid aspirin in the third trimester:

- as it may also cause closure of the ductus arteriosus,
maternal and fetal bleeding, and decreased uterine
contractility.
• Opioids are rarely used. 34

Headache
Migraine headache
• Acetaminophen and ibuprofen can be used.
• Opioids have been used

- they can contribute to nausea
- long-term use can cause neonatal withdrawal.
• For nonresponsive migraines, sumatriptan can be used.
• Ergotamine and dihydroergotamine are contraindicated.
• For migraine-associated nausea:

- promethazine, prochlorperazine, and metoclopramide can be
used.
35
Headache
Migraine headache
• For pregnant women with severe headaches

(usually migraine) not responsive to other
treatments:
- Propranolol, at the lowest effective dose,
can be used as preventive treatment.
• Alternatives include amitriptyline or

nortriptyline, 10 to 25 mg daily.
36
Urinary tract infection
• The principal infecting organism is
- Escherichia coli.
• But
- Proteus mirabilis, Klebsiella pneumoniae, and group B
Streptococcus
cause some infections.
• Untreated bacteriuria may result in

- pyelonephritis
- preterm labor
- hypertension.
- anemia.
- transient renal failure
- low birth weight.
37
• Treatment of asymptomatic bacteriuria is

necessary
- to reduce the risk of pyelonephritis and
premature delivery.
• Treatment for 7 to 14 days is common.
• Repeat urine cultures are recommended

monthly for the remainder of gestation.
38
• The most commonly used antibiotics for asymptomatic
bacteriuria and cystitis are:
the β-lactams (penicillins and cephalosporins
“Cephalexin”) and nitrofurantoin
• E. coli resistance to ampicillin and amoxicillin

- is problematic.
• Nitrofurantoin
- is not active against Proteus
- should not be used after week 37 due to concern for
hemolytic anemia in the newborn. 39
• Sulfa-containing drugs
- may increase the risk for kernicterus in the newborn
- should be avoided during the last weeks of gestation.
• Folate antagonists, such as trimethoprim

- relatively contraindicated during the first trimester because
of their association with cardiovascular malformations.
• Regionally, increased rates of E. coli resistance to trimethoprim-

sulfa limit its use
• Fluoroquinolones and tetracyclines

- are contraindicated
40
• Inpatient therapy for pyelonephritis has included
parenteral administration:
- of second- or third generation cephalosporins
- ampicillin plus gentamicin
Or - ampicillin-sulbactam.
• Switching to oral antibiotics can occur after the woman

is afebrile for 48 hours, but avoid nitrofurantoin.
• The total duration of antibiotic therapy for

pyelonephritis is 10 to 14 days.
41
Sexually transmitted diseases
Chlamydia trachomatis
• Complications of Chlamydia trachomatis include:

- pelvic inflammatory disease, ectopic
pregnancy, and infertility.
• Chlamydia infection can be

- transmitted at birth to the neonate
- cause conjunctivitis and a subacute, afebrile
pneumonia.
42
Syphilis
• Benzathine Penicillin G is the drug of choice for all

stages of syphilis except neurosyphilis, which is
treated with Aqueous Penicillin G.
• Penicillin is effective for preventing transmission

to the fetus and treating the already infected
fetus.
43
Neisseria gonorrhoeae
• Is a risk factor for pelvic inflammatory disease and preterm
delivery.
• Symptoms in the neonate (eg, rhinitis, vaginitis, urethritis,
ophthalmia neonatorum, and sepsis)
- usually start within 2 to 5 days of birth
- Blindness can occur.
• Oral cephalosporins have been removed as a preferred
treatment option for Gonorrhea because of antimicrobial
resistance.
• Coinfection with Chlamydia is common, so usually
treatment of Gonorrhea includes treatment for Chlamydia.44
Herpes
• The overriding concern with genital herpes is

transmission of the virus to the neonate during birth.
• Maternal use of acyclovir during the first trimester is

not associated with an increased risk of birth defects.
• Valacyclovir is an alternative.
45
Bacterial vaginosis
• Caused by anaerobic bacteria, mycoplasmas,

and Gardnerella vaginalis.
• It is a risk factor for premature rupture of

membranes, preterm labor, preterm birth,
intraamniotic infection, and postpartum
endometritis.
46
Trichomoniasis
• Associated with an increased risk of

premature rupture of membranes, premature
delivery, and low birth weight.
• Treatment may prevent respiratory or genital

infection in the neonate
47
48
49
50
51
Chronic illnesses in pregnancy
Asthma
• The risks of medication use to the fetus are

lower than the risks of untreated asthma.
• Diagnosis and staging of asthma during

pregnancy
- is the same as in nonpregnant women
- but more frequent follow-up is necessary

52
Asthma
• Step 1:
- all pregnant patients with asthma should have access
to a short-acting inhaled β2-agonist (albuterol is the
preferred agent).
• For persistent asthma (step 2 or higher)
- low, medium, or high doses of controller

corticosteroids are foundational.
- Budesonide is preferred, but corticosteroids used

before pregnancy can be continued.
• Long-acting β2-agonists are safe.

53
Asthma
• Cromolyn, leukotriene receptor antagonists,

and theophylline
- are considered alternative agents

- but they are not preferred.
• For patients with the most severe disease,

- systemic corticosteroids are recommended
54
Allergic rhinitis
• First-line medications
- intranasal corticosteroids
- nasal cromolyn
-first-generation antihistamines (eg, chlorpheniramine

and hydroxyzine).
• Intranasal corticosteroids
- the most effective treatment and have a low risk for

systemic effect.
- Beclomethasone and budesonide have been used
most. 55
Allergic rhinitis
• Loratadine and cetirizine
- do not appear to increase fetal risk
- but they have not been extensively studied.
• Use of an external nasal dilator, short-term

topical oxymetazoline, or inhaled corticosteroids:
- may be preferred over oral decongestants,

especially during early pregnancy.
56
Diabetes
• Glycemic control can change dramatically during pregnancy
- frequent adjustments may be needed.
- Self-monitored blood glucose should occur before
and after meals, and sometimes between 2 and 4 am.
• Patients with type 1 diabetes may continue human insulin.
• Evidence supports insulin detemir as the first-line long-

acting insulin analogue.
• Glyburide and metformin are considered first line for GDM,

so they may be potential treatment alternatives for type 2
diabetes during pregnancy.
57
Epilepsy
• Major malformations are two to three times

more likely in children born to women taking
AEDs than to those who do not
• The risks of untreated epilepsy to the fetus are

considered to be greater than those
associated with the AEDs.
58
Epilepsy
• Major malformations with valproic acid therapy are
dose related and range from 6% to 9%.
• When possible, avoid valproic acid during pregnancy

- to minimize the risk of neural tube defects, facial
clefts, and cognitive teratogenicity.
• Phenobarbital should also be avoided.

- cardiac malformations.
If either is used during pregnancy, the lowest effective

dose should be used. 59
Epilepsy
• Drug therapy should be:
- optimized prior to conception
- AED monotherapy is recommended when possible.
- Rates of major malformations associated with

monotherapy of other AEDs are 2.9% to 3.6%.
- Polytherapy is associated with higher rates.
• If drug withdrawal is planned, it should be fully completed

prior to conception (at least 6 months prior to conception)
60
Epilepsy
• All women taking AEDs should take

- folic acid, 4 to 5 mg daily
- starting before pregnancy and continuing
through at least the first trimester and
preferably through the entire pregnancy.
• All neonates receive vitamin K at delivery.

61
Epilepsy
• Carbamazepine and lamotrigine

- may be the safest AEDs for use in
pregnancy.
• Phenytoin, lamotrigine, and carbamazepine

- may cause cleft palate.
62
Human Immunodeficiency Virus Infection
• In women newly diagnosed with HIV, or who have not

previously received antiretroviral therapy (ART):
- ART should be initiated as soon as pregnancy is

determined, since risk of perinatal transmission is
lower with earlier viral suppression.
- ART therapy is selected from those recommended

for nonpregnant adults (with consideration given to the
teratogenic profiles of each drug)
63
• Women already taking ART therapy:

- should continue their regimen provided that
viral suppression below the level of detection is
documented.
• For ART-naïve women:

- use of a three-drug combination regimen is
recommended.
The clinical guidelines provided at

https://aidsinfo.nih.gov are the most current. 64
• Pregnant women with HIV RNA levels above 1000 copies/mL (1000 ×
103/L) approaching delivery should:
- have cesarean section at 38 weeks gestation to reduce the risk of
perinatal HIV transmission.
• If HIV RNA levels are at or below that level

- Cesarean section is not recommended.
• If maternal viral load is greater than that level or unknown:

- IV zidovudine should be initiated with a 1-hour load (2 mg/kg)
followed by a continuous infusion (1 mg/kg/h) for 2 hours (cesarean) or
until vaginal delivery.
• Women with a viral load at or below 1000 copies/mL (1000 × 103/L) near
delivery :
- do not require zidovudine IV, but should continue their ART.
65
Hypertension
• Chronic hypertension in pregnancy is defined as:
- Hypertension occurring before 20 weeks of gestation
- the use of antihypertensive medications before
pregnancy
or
- the persistence of hypertension beyond 12 weeks
postpartum defines
• It is classified as
- mild/nonsevere: (sBP 140–159 mm Hg or dBP 90–109
mm Hg).
- severe: (sBP 160 mm Hg or higher or dBP 110 mm Hg
or higher).
66
Hypertension
• Chronic HTN can cause:

- maternal complications
- fetal growth restriction
- hospital admission.
67
Hypertension
Nonsevere hypertension (sBP 140–159 mm Hg or dBP 90–109 mm Hg).
• Treatment of nonsevere HTN reduces risks of severe HTN by 50%
but does not substantially affect fetal outcomes.
• According to ACOG, drug therapy is recommended for pregnant

women with persistent chronic HTN with a blood pressure of
160/105 mm Hg and above.
• When antihypertensive therapy is used, maintenance of sBP

between 120 and 160 mm Hg and dBP between 80 and 105 mm Hg
is recommended.
• If there is no evidence of end organ damage, and sBP is below 160

mm Hg and dBP is below 105 mm Hg, drug therapy is not
suggested.
68
Hypertension
• Severe hypertensionc (systolic blood pressure

[sBP] = >160 mm Hg or diastolic blood
pressure [dBP] ≥ 110 mm Hg)
• Severe HTN in pregnancy requires treatment:

- and lowering of BP should occur over a
period of hours to prevent compromise of
uteroplacental blood flow.
69
Hypertension
Severe hypertension
• Recommended agents are:
- parenteral labetalol and hydralazine, but hydralazine
is associated with more maternal and fetal adverse effects.
- Oral nifedipine may also be used.
- Limited evidence supports the use of magnesium

sulfate, except when it is being used concomitantly for
preeclampsia.
• Nitroprusside, diazoxide, and nitroglycerin should be

reserved for refractory HTN in an appropriately monitored
environment. 70
Hypertension
Nonsevere hypertension (sBP 140–159 mm Hg or dBP 90–109 mm Hg).
• Drugs commonly used:

- methyldopa
- labetalol
- calcium channel blockers.
- β-Antagonists except atenolol.
• ACE inhibitors, angiotensin receptor antagonists, and renin

inhibitors are contraindicated throughout pregnancy.
• Thiazide diuretics can be used in women who were treated with

them before pregnancy
71
Depression
• In general, monotherapy is preferred over
polytherapy even if higher doses are required.
• If antidepressants are used, the lowest possible

dose should be used for the shortest possible
time to minimize adverse fetal and maternal
pregnancy outcomes.
• In one study, pregnant women who stopped

taking antidepressants were more likely to
relapse than women who completed treatment.
72
Depression
• The selective serotonin reuptake inhibitors (SSRIs) are
not considered major teratogens with the exception of
paroxetine.
• Initiation of paroxetine:
- for women who intend to become pregnant, or
- are in their first trimester of pregnancy,
should be considered only after other treatment

options have been evaluated because of the risk for
cardiovascular malformations in the fetus.
73
Depression
• The serotonin/norepinephrine reuptake inhibitors (SNRIs) are less
well defined.
• Use of SSRIs and SNRIs in the latter part of pregnancy is associated

with:
- persistent pulmonary HTN of the newborn
- prenatal antidepressant exposure syndrome

ie, - cardiac, respiratory, neurologic, gastrointestinal,
- metabolic complications from drug toxicity
- withdrawal of drug therapy.
• Tricyclic antidepressants are not considered major teratogens but

have been associated with neonatal withdrawal syndrome when
used late in pregnancy. 74
Thyroid disorders
For hypothyroidism
• Initiate levothyroxine 0.1 mg/day.
• Women receiving thyroid replacement therapy

before pregnancy may require increased dosage
during pregnancy.
• Monitor thyroid-stimulating hormone (TSH) levels

every 4 to 6 weeks during pregnancy to allow for
dose titration according to TSH levels.
75
Thyroid disorders
Hyperthyroidism therapy
• Hyperthyroidism therapy includes the thioamides

(eg, methimazole, propylthiouracil [PTU]).
• The goal of therapy is to attain free thyroxine

concentrations near the upper limit of normal.
76
Labor and delivery
preterm labor
Preterm labor
• is labor that occurs between 20 and 37 weeks of

gestation
- when changes in cervical dilations and/or
effacement (cervical ripening) happen along with
regular uterine contractions
or
- when the initial presentation includes regular
contractions and cervical dilation of at least 2 cm.
77
Labor and delivery
preterm labor
Tocolytic Therapy
• Goals:
- to postpone delivery long enough to allow for
- maximum effect of antenatal steroids

- transportation of the mother to a facility
equipped to deal with high-risk deliveries
- prolong pregnancy when there are underlying
self-limited conditions that can cause labor.
78
Labor and delivery
preterm labor
Tocolytic Therapy
• Tocolytics can be started when there are regular uterine

contractions with cervical change.
• They are not generally used beyond 34 weeks of gestation
• Do not use them in cases of:

- intrauterine fetal demise
- a lethal fetal anomaly
- intrauterine infection
- fetal distress
- severe preeclampsia
- vaginal bleeding
- maternal hemodynamic instability.
79
Labor and delivery
preterm labor
Tocolytic Therapy
• β-agonists (terbutaline and ritodrine)
• Magnesium sulfate
• NSAIDs
• Calcium channel blockers.
• Prostaglandin inhibitors and calcium channel blockers may

be preferable, based on delaying delivery and improving
neonatal outcomes.
80
Labor and delivery
preterm labor
Tocolytic Therapy
• β-Agonists have a higher risk for maternal side effects.
• A common dose of terbutaline is 250 mcg subcutaneously

- which may be repeated in 15 to 30 minutes for
inadequate response.
- with a maximum of 500 mcg given in a 4-hour period.
• An FDA black box warning cautions:

- against oral dosing
or - prolonged parenteral use (beyond 48–72 hours)
because of maternal cardiotoxicity and death.
81
Labor and delivery
preterm labor
Tocolytic Therapy
• Magnesium sulfate
• A Cochrane review does not support the

effectiveness of magnesium sulfate for tocolysis.
• However, it can be used IV during preterm labor

to decrease the occurrence of moderate to
severe cerebral palsy. 82
Labor and delivery
preterm labor
Tocolytic Therapy
• Nifedipine is associated with fewer side effects than magnesium or β-

agonists.
• Nifedipine decreases risk of delivery within 7 days compared to β-agonist
• Nifedipine loading doses range between 10 and 40 mg, with subsequent

dosing of 10 to 20 mg every 4 to 6 hours, with dose adjustment based on
patterns of preterm contractions.
• Five to 10 mg nifedipine may be administered sublingually every 15 to 20

minutes for three doses.
- Once stabilized, 10 to 20 mg may be administered orally every 4 to
6 hours for preterm contractions.
• It can cause hypotension and a change in uteroplacental blood flow.

83
Labor and delivery
preterm labor
Tocolytic Therapy
• Indomethacin, 50 to 100 mg orally or rectally,

followed by 25 to 50 mg orally every 6 hours
has been used.
• Premature constriction of the ductus

arteriosus has been reported.
84
Labor and delivery
preterm labor
Antenatal Glucocorticoids
• A Cochrane review shows the benefit of Antenatal Glucocorticoids
- For fetal lung maturation
- to prevent respiratory distress syndrome,
intraventricular hemorrhage, and death in infants delivered
prematurely.
• Betamethasone, 12 mg IM every 24 hours for two doses.
• Dexamethasone, 6 mg IM every 12 hours for four doses.
to pregnant women between 24 and 34 weeks’ gestation who

are at risk for preterm delivery within the next 7 days.
• Benefits from antenatal glucocorticoid administration are believed

to begin within 24 hours.
85
Labor and delivery
Group B Streptococcus infection
• Prenatal screening (vaginal/rectal cultures) for group B
Streptococcus colonization of all pregnant women at 35
to 37 weeks’ gestation is recommended.
• If
- cultures are positive
- woman had a previous infant with invasive group
B Streptococcus disease
- the woman had group B Streptococcus bacteriuria
antibiotics are given.
86
Labor and delivery
Group B Streptococcus infection
• Penicillin G, 5 million units IV, followed by 2.5 million units IV every 4
hours until delivery.
Alternatives
• Ampicillin, 2 g IV, followed by 1 g IV every 4 hours
• Cefazolin, 2 g IV, followed by 1 g every 8 hours.
• Clindamycin, 900 mg IV every 8 hours.
• Erythromycin, 500 mg IV every 6 hours.
• In penicillin-allergic women in whom sensitivity testing shows resistance

to clindamycin and erythromycin
- vancomycin, 1 g IV every 12 hours until delivery, can be used.
87
Labor and delivery
Cervical ripening and labor induction
• Prostaglandin E2 analogues (eg, dinoprostone [Prepidil gel
and Cervidil vaginal insert]) are commonly used for cervical
ripening.
• Fetal heart rate monitoring is required (especially with

when CervidilR (insert) is used, and for 15 minutes after its
removal.
• Misoprostol, a prostaglandin E1 analogue, is effective and

inexpensive
- but it has been associated with uterine rupture.
• Oxytocin is the most commonly used agent for labor

induction after cervical ripening. 88
Labor and delivery
Labor analgesia
• The IV or IM administration of narcotics is commonly
used for pain associated with labor.
• Epidural analgesia involves

- administering an opioid and/or an anesthetic (eg,
fentanyl and/or bupivacaine) through a catheter into
the epidural space to provide pain relief.
• Compared with epidural analgesia, parenteral opioids

are associated with
- lower rates of oxytocin augmentation, shorter
stages of labor, and fewer instrumental deliveries.
89
Labor and delivery
Labor analgesia
• Epidural analgesia is associated with
- longer stages of labor
- more instrumental deliveries
- more maternal fever
compared to parenteral narcotic analgesia.
• Patient controlled epidural analgesia results in a lower total dose of

local anesthetic
• Complications of epidural analgesia include hypotension, nausea,

vomiting, itching, and urinary retention.
• Other options for labor analgesia include spinal analgesia and nerve
blocks.
90
Drug use during lactation
• Medications enter breast milk via passive diffusion of nonionized and
non–protein bound medication.
• Drugs with
- high molecular weights
- lower lipid solubility
- higher protein binding
are less likely to cross into breast milk, or they transfer more slowly or in
smaller amounts.
• The higher the maternal serum concentration of drug, the higher the
concentration will be in breast milk.
• Drugs with longer half-lives are more likely to maintain higher levels in
breast milk.
• The timing and frequency of feedings and the amount of milk ingested by
the infant are also important.
91
Drug use during lactation
Strategies for reducing infant risk from drugs
transferred into breast milk include:
• Selecting medications for the mother that

would be considered safe for use in the infant.
• Choosing medications with shorter half-lives,

higher protein binding, lower bioavailability,
and lower lipid solubility.
92
Relactation
• For relactation use
- metoclopramide, 10 mg three times daily
for 7 to 14 days
only if nondrug therapy is ineffective.
93

Med. Therapy4

Uploaded by

Copyright:

Available Formats

You might also like

Med. Therapy4

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Med. Therapy4

Uploaded by

Copyright:

Available Formats

Sara Qaradeh

the prevention of pregnancy

• The median length of the menstrual cycle is 28 days

• The first day of menses is day 1 which marks the

• Ovulation usually occur on day 14 of the menstrual

• After ovulation, the luteal phase last until the

• The hypothalamus secrets gonadotropin-

FSH levels increase

• FSH regulates aromatase enzymes that induce

• Conception is most successful

• After ovulation, the remaining luteinized follicles

- human chorionic gonadotropin (hCG)

- prevents regression of the corpus luteum

• If pregnancy does not occur:

- the corpus luteum degenerates, progesterone

• the prevention of pregnancy following sexual

• The abstinence (rhythm) method is associated

• Effective because they are barriers and

• It should be inserted up to 6 hours

• It should not be left in place for more

• Can be inserted 6 hours prior

• Should not remain in place

• With use of diaphragms or cervical caps

• Most condoms made in the United States

• ~5% are made from lamb intestine, which

• Mineral oil–based vaginal drug

• Condoms with spermicides are not

• Covers the labia, as well

• However, the pregnancy

• Most spermicides contain nonoxynol-9

- a surfactant that destroys sperm cell walls

- They offer no protection against STDs

- when used more than twice daily,

• The vaginal contraceptive sponge (Today)

• After intercourse, the sponge must be left in

• It should not be left in place for more than 24 to

• Hormonal contraceptives contain either

- a combination of synthetic estrogen and

• Mestranol must be converted to ethinyl

• It is approximately 50% less potent than EE.

- differ with respect to inherent

• Androgenic activity depends on

If sex hormone binding globulin decreases, free

• Decreased menstrual blood loss.

• Improved menstrual regularity.

• Decreased iron deficiency anemia.

• Reduced risk of ovarian and endometrial cancer; and

• The main safety concern about CHCs is their

• CHCs containing less than 50 mcg EE may be considered in

• CHCs are not recommended for women older than 35 years

• Studies have not demonstrated an increased risk of

• Women > 35 years who smoke and take OCs

• Smoking 15 or more cigarettes per day by women over 35 years

• Progestin-only contraceptive methods should be considered in this

• CHCs, regardless of estrogen dose, can cause small increases

• In women with hypertension, OCs have been associated with

• Use of low-dose CHCs is acceptable in women younger than

• Systolic blood pressure greater than or equal to 160 mm Hg