Drugs-in-Pregnanhhhhhhhhhhhhhhhhhhhhhhhhhhcy.ppt

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1. Drugs in pregnancy and
breastfeeding
Roisin McCabe
Clinical pharmacist
Princess Royal Maternity hospital

2. Learning outcomes
•General prescribing principles in pregnancy
•Pharmacokinetics in pregnancy
•Common conditions in pregnancy
•Common conditions in breastfeeding
•Common clinical conditions
•Chronic conditions and pregnancy
•Resources

3. General Prescribing principles in pregnancy
•No drugs 100% safe in pregnancy
•Risk vs benefit
•Control of underlying diseases such as arthritis,
asthma, epilepsy, IBD improves neonatal outcomes
•Limited data available for many drugs
•Older generic drugs usually have more data
available
•Minimise drug exposure- monotherapy were possible
•Highest risk for baby is during organogenesis
however drugs can cause harm at any gestation

4. Altered pharmacokinetics in pregnancy
•Increased volume of distribution
•Increased renal and liver clearance
•Reduced gastric emptying
•Reduced protein binding
•Nausea and vomiting
•Increase in gastric pH

5. Common conditions in
pregnancy

6. Nausea and vomiting
•Non drug therapies: wristbands, ginger, plain biscuits
•First line: prochlorperazine or cyclizine
•Second line: metoclopramide, domperidone
•Avoid ondansetron in first trimester (small risk of orofacial and
cardiac anomalies)
Pain
•Could be pregnancy or non-pregnancy related pain
•Non drug treatment: TENs, heat/ cold packs, physio etc
•First line: paracetamol
•Second line: short term dihydrocodeine
•NSAIDs: not recommended in pregnancy esp 3
rd
trimester.
Okay for use when breastfeeding

7. Heartburn
•Lifestyle advice: small meals, extra pillow, avoid
trigger foods
•First line: peptac (available on pharmacy first)
•Second line: omeprazole, antacids
Constipation
•Very common in pregnancy, advise to increase
fluid/ fibre intake, temporarily stop iron
•First line: lactulose/ bulk forming agents
•Avoid stimulant laxatives in 3
rd
trimester
•Important to prevent constipation post natally
whilst on opiates

8. Haemorrhoids
•Topical preparations are fine to use in pregnancy
and breastfeeding
•Use steroid free preparations first line (theoretical
risk in 1
st
trimester)
•May require addition of lidocaine gel
Thrush
•Single dose clotrimazole pessary (without
applicator) first line
•Not licensed OTC but could be supplied by IP
•Avoid oral treatment
•Lifestyle advice

9. General prescribing principles in
breast feeding
•Does it pass into breast milk?
•What percentage of drug is in breast milk?
•Is it a drug that would be used in babies?
•Is it readily absorbed from GI tract?

10. Common conditions in breastfeeding
Mastitis
•Usually affects one breast
•Often a swollen area/ hard lump
•Systemic symptoms: temperature, flu-like feeling
•Oral flucloxacillin 1g QDS for 5 days
•Clarithromycin 500mg BD for 5 days in pen allergic
•Women should be advised to continue breastfeeding/ expressing
•Warm bath/ shower and massage can help
Thrush
•Sharp pain in breast which continues after every feed (in women who were
previously pain free)
•Usually affects both breasts
•Miconazole cream (remove before breast feeding)
•Oral nystatin for baby and miconazole cream to nappy area twice daily
•Avoid miconazole gel in under 4 months

11. Common clinical conditions

12. Cough/ cold
•avoid OTC cold preparations in pregnancy
•Avoid oral decongestants e.g phenylephrine
•Avoid cough suppressants
•Steam inhalation/ saline nasal spray
•Simple analgesia (paracetamol only
antenatally)
•Short term oxymetazoline nasal spray may
be used if above options not effective

13. Hay fever
•Non drug therapy: pollen avoidance, barrier
ointment
•Steroid nasal spray safe for use in
pregnancy
•Sodium cromoglycate eye drops safe to use
in pregnancy
•loratadine, cetirizine and chlorphenamine
safe for use in pregnancy and breastfeeding
•Avoid decongestants

14. Mouth ulcers
•OTC products safe to use in pregnancy
•Can be sign of iron/ b12 or folate
deficiency
Oral thrush
•Miconazole gel safe in pregnancy

15. Skin
Atopic eczema/ contact dermatitis
•steroid cream safe in pregnancy (not licensed?)
Fungal infections
•topical clotrimazole and miconazole safe in pregnancy
Itch
•itch in the absence of a rash could be sign of obstetric
cholestasis
•usually affects limbs and trunk, particularly hands and feet
•Usually worse at night
•usually occurs during 3
rd
trimester
•OTC emollients/ menthol creams may be given to women
with confirmed OC

16. Threadworms
•First line: hygiene measures e.g. washing linen,
frequent hand washing etc
•Need to be continue hygiene measures for at least 6
weeks
•Mebendazole can be given in 2
nd
and 3
rd
trimester if
required
Head lice
•First line: wet combing
•Second line: physical insecticides e.g. dimeticone
•Malathion products generally thought to be safe in
pregnancy but usually last line

17. Scabies
•Topical malathion first line in pregnancy
and breastfeeding
•Permethrin also generally thought to be
safe in pregnancy and breastfeeding
•Remove from the nipples before feeds
and reapply after feeds

18. Infections
UTI
•Refer in pregnancy as sample needed
•Can treat breastfeeding women as per PGD
•Trimethoprim 200mg BD for 3 days
•Nitrofurantoin: avoid in younger infants (<8 days)
Skin infections
•Flucloxlacillin considered safe in pregnancy and
breastfeeding
•Pregnant and breastfeeding women excluded from PGD but
could give if IP

19. Chronic conditions and
pregnancy

20. Asthma
•Pregnancy does not normally have an effect
on asthma
•Continue current inhalers
•Montelukast: no evidence of increased risk
of congenital malformations or adverse
effects in pregnancy, should be continued in
pregnancy if clinically indicated
•Treatment with oral steroids were clinically
indicated
•Note breathlessness is common in
pregnancy

21. Hypertension
•Increased risk of pre-eclampsia, pre-term delivery, low
birthweight
•First line anti-hypertensives: labetalol
•Second line: nifedipine
•3
rd
line: methyldopa- should be avoided post natally
•Aim bp less than 135/85mmHg
•Ace inhibitors/ ARBs should not be routinely used in
pregnancy as teratogenic. Women should be switched
to alternative as above
•Low dose aspirin should be given to women with a
history of chronic hypertension

22. Diabetes
•Increased risk of miscarriage, pre-eclampsia,
congenital abnormalities and neonatal complications
so tight diabetic control is important
•Glucose handling is significantly altered during
pregnancy. Insulin resistance also increases
throughout pregnancy
•IDDM will likely require increased insulin doses during
pregnancy
•Oral hypoglycaemic agents other then metformin are
not recommended in pregnancy
•Diabetic nephropathy may worsen during pregnancy
•Following birth insulin requirements will fall rapidly
•Oral hypoglycaemic drugs other than metformin
should be avoided in breastfeeding

23. Epilepsy
•Pregnancy does not usually affect seizure control
•Lamotrigine and levetiracetam are generally the
safest options in pregnancy
•Risk of having a baby born with a physical birth
abnormality
General population 2 to 3 out of 100 babies
Carbamazepine 4 to 5 out of 100 babies
Phenobarbital 6 to 7 out of 100 babies
Phenytoin about 6 out of 100 babies
Topiramate 4 to 5 out of 100 babies
Valproate about 10 out of 100 babies
•Women with epilepsy should take folic acid 5mg for
12 weeks prior to conception

24. Resources
•BUMPS-
bumps - best use of medicine in pregnancy (medic
inesinpregnancy.org)
•Briggs: Drugs in Pregnancy and Lactation: A
Reference Guide to Fetal and Neonatal Risk
•Drugs During Pregnancy and Lactation :
Treatment Options and Risk Assessment
•UKTIS-uktis.org
•Lactmed
•Specialist Pharmacy Service
•NHSGGC Obstetric guidelines
•RCOG