WOMEN’S HEALTH - PREGNANCY

KRISTEN PARKER, PHARMD

PGY1 PHARMACY RESIDENT – ESKENAZI HEALTH

KRISTEN.PARKER@ESKENAZIHEALTH.EDU
ABOUT ME
OBJECTIVES

 Recognize appropriate prenatal diet and supplement recommendations for women

 Provide vaccination recommendations for pregnant women
 Use information in a package insert to evaluate if a drug is safe for use in pregnancy
 Construct an appropriate treatment regimen for common pregnancy-related complaints
 Select an appropriate treatment for pregnancy complications
OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
FETAL DEVELOPMENT - FIRST TRIMESTER

Week 4
• Heartbeat begins to beat Week 8
• Arm bud appear Week 6 • External ears begin to
• Liver, pancreas, • Lungs begin to form form
gallbladder and spleen • Fingers and toes start to • Face begins to look
begin to form form human

Week 5 Week 7
• Eyes start to form • Hair follicles start to
• Leg buds appear form
• Blood circulates • Visible elbows and toes
• Facial features begin to
form

Weeks 3-8 are essential to fetal development and are key times to avoid drugs when possible
FETAL DEVELOPMENT – SECOND/THIRD TRIMESTER

Week 9-15 Weeks 27-38

• Reproductive organs form • Increase in body fat
• Teeth begin to form • Bones complete development
• Brain activity is detectable • Brain is continuously active

Weeks 16-26
• Rapid brain development
• Alveoli in lungs form
• Internal eyes and ears form
• Muscles develop
• Eyebrows, eyelashes and nails form
OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
WEIGHT GAIN DURING PREGNANCY
PRENATAL DIET

Increase Limit
• 300-400 extra calories per • Artificial sweeteners
day • Dairy
• Raw eggs
• Unwashed fruits and
vegetables
• Herbal teas
• Undercooked meats
• Caffeine

ACOG. 2020.
WHAT DOES 200 MG OF CAFFEINE LOOK LIKE?

5-Hour Energy 200 mg

Starbucks medium roast (tall) 155 mg
Keurig Green Mountain (K-cup) 120 mg
Red Bull 76 mg
Nespresso (pod) 50-60 mg
Diet Coke (can) 46 mg
Tea 20-40 mg

Examine.com
PRENATAL SUPPLEMENTS

Help with Help prevent Help prevent

fetal fetal maternal
development complications complications

ACOG. 2020.
PRENATAL SUPPLEMENTS

Omega-3-
Folate Iron Calcium
fatty acids
Supplementation
Adequate folate
Iron deficiency tied can decrease Helps with
decreases neural
to low birth weight maternal bone loss, production of
tube defects by
and preterm birth HTN and prostaglandins
>50%
preeclampsia

0.4 mg daily
or 12 oz of seafood per
27-30 mg daily* 1000-1300 mg daily
4 mg daily if high week*
risk

ACOG. 2020.
PATIENT CASE

 LP is 26 year old female who comes up to the pharmacy counter

holding multiple vitamin bottles and asks which one is best to
use in pregnancy.
What would you tell her?
What ingredients should she be looking for?
 Look for a prenatal vitamin that included folic acid, iron, calcium
and omega-3-fatty acids
 Refer her to an OB for proper prenatal care
VACCINATION RECOMMENDATIONS

All Pregnant Women

• Influenza- by the end of October

• Tdap – 27-36 weeks

Pregnant Women with Risk Factors

• PPSV23
• HepA
• HepB
• MenACWY

CDC 2020.
VACCINES TO AVOID DURING PREGNANCY

HPV

Live vaccines
• MMR
• Live influenza
• Varicella
• Zostavax
CDC 2020.
COVID-19 VACCINE IN PREGNANCY

The American College of

Obstetricians and
Gynecologists (ACOG)
recommends that COVID-19
vaccines should not be
withheld from pregnant or
lactating individuals.
PATIENT CASE

 After recommending a prenatal vitamin for LP, she also states she
wants to get caught up on her vaccinations in order to be the
healthiest mom she can be for her baby. She received a flu
vaccine two years ago, has not received the HPV vaccine and has
no other risk factors.
What vaccinations would you recommend for her during pregnancy?
 Inactivated flu vaccine by the end of October
 Tdap at 27-36 weeks
 HPV vaccine after pregnancy
ALCOHOL

Placental
Miscarriage
abruption

 American Academy of Pediatrics recommends NO

alcohol consumption
Preterm
birth

Fetal
alcohol Stillbirth
syndrome

CDC 2020.
FETAL ALCOHOL SYNDROME

 Small head size

 Poor coordination
 Low body weight
 Hyperactive behavior
 Poor memory
 Difficulty in school
 Learning disabilities
 Speech and language delays
Janet F. Williams et al. Pediatrics 2015;136:e1395-e1406

CDC 2020.
TOBACCO AND MARIJUANA

Tobacco
 Potential risks include preterm birth, low birth
weight, birth defects, sudden infant death syndrome
 Plan with women to allow for a tobacco –free period
prior to conception
 FDA-approved cessation aids have not been studied
in pregnancy
Marijuana
 Potential risks include low birth weight, brain
development disruption, decreased attention span,
behavioral problems, and marijuana use in the child
by the age of 14

CDC 2020.
OPIOIDS

 Use during pregnancy has been linked with preterm birth, stillbirth, maternal mortality, feeding problems,
breathing problems and neonatal abstinence syndrome (NAS)
 Clinicians should weight the benefits and risks or initiating or continuing opioids in a pregnant patient
 Patients with substance use disorder can be referred to a medication assisted treatment center
 Both methadone and buprenorphine have been used

Obstet Gynecol 2017.

OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
PHARMACOKINETIC CHANGES

Absorption Distribution Metabolism Excretion

• Decreased rate • Increased • Altered phase 1 • Increased renal
of absorption volume of and phase 2 and hepatic
• Increased distribution for metabolism blood flow
extent of hydrophilic enzymes • Increased CrCl
absorption due drugs • CYP2C19
to slower GI • Decreased activity
motility protein binding reduced
to albumin • CYP3A4
activity
increased
Semin Perinatol. 2015.
PACKAGE INSERTS

21 CFR §201.56.
ACTIVITY

 Look up the package insert for Gilenya (fingolimod)

 How would you use this drug in a patient who is pregnant or trying to get pregnant?
 How would you use this drug in a patient who is breastfeeding?
 How would you counsel a patient who is capable of becoming pregnant who is starting this drug?
HOW WOULD YOU USE THIS DRUG IN A PATIENT WHO IS
PREGNANT OR TRYING TO GET PREGNANT?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
HOW WOULD YOU USE THIS DRUG IN A PATIENT WHO IS
BREASTFEEDING?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
HOW WOULD YOU COUNSEL A PATIENT WHO IS CAPABLE OF
BECOMING PREGNANT WHO IS STARTING THIS DRUG?

Gilenya [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation.; 2019
OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
OVERALL PRINCIPLE

Utilize drug resources and patient

specific information to determine the
safest treatment option during pregnancy
DIABETES MANAGEMENT

Fetal risks Maternal risks

• Miscarriage • Cesarean delivery
• Stillbirth • Preeclampsia
• Birth injury • Kidney disease
• Neonatal hypoglycemia • Retinopathy
• Hyperbilirubinemia
• Cardiac and neural tube
defects

Diabetes Care. 2020.

DIABETES MANAGEMENT

Increase self- More stringent goals Preferred

monitoring of blood • Fasting <95 pharmacologic
glucose (SMBG) to • 2-hour Postprandial treatment
4 times daily <120 • Insulin

Diabetes Care. 2020.

HYPERTENSION MANAGEMENT

Recommended agents
Labetalol ACE Inhibitors
Amlodipine ARBs
Nifedepine
HCTZ
Hydralazine

Avoid use
Methyldopa

Drugs. 2014;74(3):283-296.
OUTLINE

Disease state
Fetal Treatment of
Medication use management
development Prenatal care pregnancy
in pregnancy during
timeline complications
pregnancy
NAUSEA AND VOMITING OF PREGNANCY
NAUSEA AND VOMITING OF PREGNANCY

 Risk Factors
 Common in early pregnancy
 History of motion sickness, migraines, GERD or
 Early treatment may prevent more serious nausea/vomiting with prior pregnancy
complications  High fat diet
 Treatment approaches include dietary and lifestyle  Younger age at conception
changes and/or medications depending on severity
 Family history of nausea and vomiting in pregnancy

Obtet Gynecol 2018; 131:15-30.

DIETARY AND LIFESTYLE CHANGES

 Start prenatal vitamins 3 months prior to conception

 Avoid triggers (foods, smells, motion)
 Eat small, frequent, low-fat meals
 Eat a light snack like crackers before getting out of bed
 Drink chilled beverages
 Eat ginger
 Acupressure bands
 Behavioral methods
 Counseling
 Hypnosis
 Acupuncture

Obtet Gynecol 2018; 131:15-30.

Image from Sea-Banc.com
NAUSEA

Dietary and
Pyridoxine Pyridoxine +
lifestyle
(Vitamin B6) Doxylamine
changes

Am Fam Physician 2018. 98(9):595-602

PYRIDOXINE + DOXYLAMINE COMBO PRODUCT

NDClist.com
VOMITING

Meclizine
Dietary and lifestyle Pyridoxine +
Dimenhydrinate
changes Doxylamine
Diphenhydramine

Metoclopramide
Promethazine
Methylprednisolone Ondansetron
Prochlorperazine
Droperidol

Am Fam Physician 2018. 98(9):595-602

PATIENT CASE

 LP returns to your pharmacy in a month and complains of

“morning sickness”. She states she has tried to avoid foods that
make it worse, has been eating small frequent meals and even
tried Vitamin B6 but nothing has helped. She asks what
medication she could take to help with her nausea.
 Pyridoxine + doxylamine
 Recommend she buys it OTC as it is cheaper
HEARTBURN

Non-pharmacologic Pharmacologic
 Eat small, frequent meals  Histamine 2 blockers

 Avoid smoking, caffeine, peppermint and chocolate  Cimetidine

 Famotidine
 Raise head of bed
 Ranitidine
 Drink fluids between meals
 Proton pump inhibitors
 Chew gum  Pantoprazole
 Avoid eating or drinking close to bedtime  Omeprazole

 Non-salicylate antacids
 Sucralfate
 Metoclopramide
Am Fam Physician 2018. 98(9):595-602
CONSTIPATION

Non-pharmacologic Pharmacologic
 Dietary changes  Osmotic laxatives
 Polyethylene glycol
 Increased fiber
 Lactulose
 Increased fluids
 Bulk forming laxatives
 Avoid constipating foods  Psyllium

 Regular exercise  Stimulant laxative

 Bisacodyl
 Limit stress
 Senna

 Stool softener
 Docusate

Am Fam Physician 2018. 98(9):595-602

PAIN, FEVER, AND HEADACHE

• Chronic pain should be adequately treated

Pain • Risks and benefits of opioid use should be weighed

• See OB if unresolved in 24-36 hours

Fever

• See OB if it is persistent or
Headache • See OB if it occurs after 20 weeks gestation

Am Fam Physician 2018. 98(9):595-602

PAIN, FEVER, AND HEADACHE

Non-pharmacologic recommendations Pharmacologic recommendations

 Cool compress  Acetaminophen = drug of choice
 Avoid triggers  It does appear to cross the placenta but in studies with
over 10,000 infants, there were no increased risk of
 Manage stress malformations in newborns exposed to acetaminophen
 Practice relaxation techniques in the first trimester

 Eat regularly  NSAIDS

 Avoid use after 32 weeks
 Get adequate sleep

Am Fam Physician 2018. 98(9):595-602

US Pharm. 2006. 3:33-47.
COUGH AND COLD

• Nasal decongestant spray

Congestion • Pseudoephedrine in 2nd/3rd trimester

• Chlorpheniramine
Rhinorrhea • Diphenhydramine

• Chlorpheniramine
Sleeplessness • Diphenhydramine

Am Fam Physician 2018. 98(9):595-602

US Pharm. 2006. 3:33-47.
URINARY TRACT INFECTIONS
 Occur in about 10% of pregnant women
 Increase the risk of preterm labor, transient renal
failure, hematologic abnormalities, ARDS, sepsis
and shock
 Pregnant women should be treated for bacteriuria
even if they are asymptomatic
Am Fam Physician 2018. 98(9):595-602
Non-pharmacologic recommendations
 Hydration
 Proper wiping (front to back)
 Void before and after sex
 Avoid scented feminine products
 Wear cotton underwear
 Avoid tight fitting clothes
PHARMACOLOGIC RECOMMENDATIONS FOR UTIS IN
PREGNANCY

First Line Options Avoid

• First generation cephalosporins • Fluoroquinolones
• Cephalexin • Ciprofloxacin
• Nitrofurantoin (avoid at term) • Levofloxacin
• Penicillins • Tetracyclines
• Amoxicillin • Doxycycline
• Ampicillin • Minocycline
• Piperacillin • Sulfamethoxazole/Trimethopri
m

Am Fam Physician 2018. 98(9):595-602

DEPRESSION

 Between 14 and 23% of pregnant women will experience a depressive disorder while pregnant
 Maternal depression is linked to increased rates of adverse outcomes
 Preterm birth
 Low birth weight
 Fetal growth restriction
 Postnatal complications

Obstet Gynecol. 2009;114(3):703-713.

DEPRESSION SCREENING IN PREGNANCY

 Edinburgh Depression Scale

 Score of 10 or greater is indicative
of possible depression
 Maximum score is 30

British Journal of Psychiatry 1987; 150:782-

786.
N Engl J Med 2002; 347:194-199
DEPRESSION MANAGEMENT

Consider agent
Previous or current
continuation ±
antidepressant use
CBT
EPDS score ≥ 10
No history of Consider CBT ±
depression pharmacologic
Screen all treatment therapy
pregnant women

Monitor, reassess
EPDS score < 10
next visit
GESTATIONAL DIABETES – RISK FACTORS

Immediate
Overweight Previous
family with Pre-diabetes
(BMI ≥25) GDM
T2DM

Polycystic
Non-white Age > 25
Ovary
Race years
Syndrome

Diabetes Care. 2020.

GESTATIONAL DIABETES - TREATMENTS

Preferred
Lifestyle
Pharmacologic
Modifications
Options
• Diet • Insulin
• Exercise • Metformin
• Regular SMBG

Diabetes
Diabetes Care.
Care. 2020.
2020.
THROMBOEMBOLISM

 Pregnant women are more prone to blood clots

 Deep vein thrombosis (DVTs) can happen during any
trimester
 Non-pharmacologic options
 Inferior vena cava (IVC) filter
 Thrombectomy
 Compression stockings (prophylaxis)

 Pharmacologic treatments – treat for at least 6

months

Curr Treat Options Cardiovasc Med. 2018 Jul 23;20(8):69.  

PREECLAMPSIA

 Categorized by hypertension (>140/90) and proteinuria (>300mg/24h)

 Risk factors include previous preeclampsia, ethnicity, increased maternal BMI before pregnancy, multiple gestations and
underlying medical conditions
 Fetal risks include premature delivery, growth retardation, and death

Drugs. 2014;74(3):283-296.
 MILD PREECLAMPSIA MANAGEMENT

• BP twice weekly
• Weekly labs (CBC, platelets, LFTs, uric acid,
creatinine)
Monitor • Proteinuria screening
closely • Fetal non-stress test twice weekly
• Amniotic fluid measurement 1-2 times per week
• Ultrasound for fetal growth every 3-4 weeks

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 SEVERE PREECLAMPSIA MANAGEMENT

Hypertension management Seizure prophylaxis

 Hydralazine (IV or IM)  Magnesium sulfate 4-6 g IV bolus

 Labetalol (IV)  Monitoring

 Reflexes
 Nifedepine (PO)
 Mental status
 Nitroprusside (IV)  Respiratory status
 Urine output
 Magnesium levels

 Alternatives
 Phenytoin
 Benzodiazepines

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 ECLAMPSIA

Seizure caused by elevated blood pressure during pregnancy

Seizure usually lasts 60-90 seconds

Treatment
• Immediate delivery
• Magnesium sulfate to prevent additional seizures

Am Fam Physician. 2016 Jan 15;93(2):121-127.
 HELLP SYNDROME

 Hemolysis, elevated liver enzymes, and low platelet

count
 Symptoms are non-specific Treatment
 Epigastric pain
• Platelets
 Nausea
• Corticosteroids
 Vomiting

 Diagnosis via lab abnormalities

Am Fam Physician. 2016 Jan 15;93(2):121-127.
GROUP B STREP

 Test women at 35-36 weeks to determine need for antibiotics during labor
 Prophylaxis is used during labor in patients who are colonizers to reduce incidence of early onset neonatal sepsis
 Recommended agents:

Penicillin allergy Penicillin allergy

First line
(mild) (severe)
• Penicillin G • Cefazolin • Clindamycin
• Ampicillin • Vancomycin

Am Fam Physician. 2011 May 1;83(9):1106-1110.
PREMATURE MEMBRANE RUPTURE

Definition • Water breaks but no contractions

• Occurs before the onset of labor (<37 weeks)

Risk •
•
Lack of prenatal care
Cigarette smoking during pregnancy

factors
• Previous preterm birth
• STDs

Am Fam Physician. 2006 Feb 15;73(4):659-664.
PREMATURE MEMBRANE RUPTURE – TREATMENT

Purpose Examples
Corticosteroids Reduce the risk of respiratory distress • Betamethasone
syndrome • Dexamethasone
Antibiotics Reduce postpartum endometriosis, • Ampicillin + erythromycin
choriamnionitis, neonatal sepsis,
neonatal pneumonia and intraventricular
hemorrhage
Tocolytics Suppress premature labor • Nifedipine
• Indomethacin
• Terbutaline
• Magnesium
Magnesium sulfate Fetal neural protection

Am Fam Physician. 2006 Feb 15;73(4):659-664.
 PRETERM LABOR

Prevention
 Labor before 37 weeks of gestation  Minimize controllable risk factors
 Risk factors  Progesterone
 Non-Hispanic black race  200 mg vaginal suppository if no history or preterm birth
 <6 months between pregnancies with prior pregnancies

 Low pre-pregnancy weight  250 mg IM weekly (week16-36) if history of preterm birth

with prior pregnancy
 Chronic medical conditions (diabetes, HTN, thyroid disorders)
 Prior preterm delivery
 Substance use during pregnancy
 Bacterial vaginosis

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 PRETERM LABOR – TREATMENT

Purpose Examples
Corticosteroids Reduce the risk of respiratory distress • Betamethasone
syndrome • Dexamethasone
Antibiotics Group B strep prophylaxis • Penicillin G
(if indicated) • Cefazolin
• Vancomycin
Tocolytics Suppress premature labor • Nifedipine
• Indomethacin
• Terbutaline
• Magnesium
Magnesium sulfate Fetal neural protection

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 TOCOLYTICS

Fetal or
Agent Maternal Side Effects Newborn Contraindications Dose
Adverse Effects
Nifedipine Dizziness, flushing, No known Hypotension, preload 10 mg po q 20 min x
(calcium hypotension.  Suppression effects dependent cardiac 3 doses, then 20 mg
channel of heart rate, contractility, pathology (aortic po q 4-6 hours
blocker) and LV pressure when insufficiency)
used with Mg SO4. 
Elevation of LFTs

Indomethacin Nausea, reflex, gastritis, Constriction of Peptic ulcer disease, 50-100 mg PO or PR,
(NSAID) emesis PDA, renal failure, platelet then 25 mg-50 mg q 6
oligohydramnios dysfxn hours
, necrotizing
enterocolitis

Am Fam Physician. 2017 Mar 15;95(6):366-372.
 TOCOLYTICS

Fetal or Newborn
Agent Maternal Side Effects Contraindications Dose
Adverse Effects
Terbutiline, Tachycardia, hypotension, Fetal tachycardia Maternal tachycardia 0.25 mg subcut
(beta-adrenergic tremor, palpitations, every 15-30
receptor agonist) dyspnea, chest pain, minutes
pulmonary edema,
hypokalemia,
hyperglycemia
Magnesium sulfate Flushing, diaphoresis, Neonatal depression Myasthenia gravis 4-6 g IV loading
nausea, loss of DTRs, dose, 2 gram/hr
respiratory depression, IV
suppresses heart rate and
contractility,
neuromuscular blockade

Am Fam Physician. 2017 Mar 15;95(6):366-372.
QUESTION BREAK

 LP is now at 30 weeks gestation and presents to the ED, she is having contractions and thinks she is in labor. The
OB resident confirms she is in preterm labor and asks for your help with medications recommendations. LP has no
known drug allergies and is group B strep negative.
 Tocolytic
 Nifedepine

 Magnesium sulfate
 Corticosteroids
 Betamethasone
 Dexamethasone
MEDICATION USE IN PREGNANCY RESOURCES

 CDC
 https://www.cdc.gov/pregnancy/meds/treatingfortwo/treatment-guidelines.html

 March of Dimes
 https://www.marchofdimes.org/pregnancy/prescription-drugs-over-the-counter-drugs-supplements-and-herbal-products.aspx

 MotherToBaby
 https://mothertobaby.org/
KEY TAKEAWAYS

 Refer back to the objectives to get an idea of topics you will be tested on
 Focus on aligning pregnancy complications with their treatments
 Understand how to navigate resources such as package inserts to find information of safe medication use in
pregnancy
 Recognize specific drug classes that were highlighted as to be avoided in pregnancy
 Do not focus on dosing
RESIDENT EVALUATION

https://butler.qualtrics.com/jfe/form/SV_4YsfjSCIv4ZGR5Y
WOMEN’S HEALTH - PREGNANCY
KRISTEN PARKER, PHARMD

PGY1 PHARMACY RESIDENT – ESKENAZI HEALTH

KRISTEN.PARKER@ESKENAZIHEALTH.EDU