Cases: Drugs in Cases: Drugs in PregnancyPregnancy

Max Brinsmead PhD FRANZCOGMax Brinsmead PhD FRANZCOGFebruary 2015February 2015

Jenny Q - The ProblemJenny Q - The Problem

You discover that your 22-year old You discover that your 22-year old patient who has missed two patient who has missed two menstrual periods whilst taking menstrual periods whilst taking Loette is about 12 weeks pregnant…Loette is about 12 weeks pregnant…

She asks if her ingestion of The Pill She asks if her ingestion of The Pill will affect her babywill affect her baby

Jenny Q - The ProblemJenny Q - The Problem

Loette contains ethinyloestradiol 30 ug and Loette contains ethinyloestradiol 30 ug and levonorgestrel 150 uglevonorgestrel 150 ug

It is a category B3 for ingestion during It is a category B3 for ingestion during pregnancypregnancy

A related oestrogen, stilboestrol, is category A related oestrogen, stilboestrol, is category D and known to cause malformationsD and known to cause malformations

Levonorgestrel is a progestin with some Levonorgestrel is a progestin with some androgenic potential and causes androgenic potential and causes masculinisation of the female fetus when masculinisation of the female fetus when given to pregnant animalsgiven to pregnant animals

Jenny Q – what we didJenny Q – what we did

Jenny was counselled:Jenny was counselled:

That there is no good evidence from large That there is no good evidence from large studies in women that oestrogens and studies in women that oestrogens and progestins in contraceptive doses are progestins in contraceptive doses are teratogenicteratogenic

About the overall risks of fetal About the overall risks of fetal malformations (2-4%)malformations (2-4%)

An ultrasound scan at 18 weeks revealed An ultrasound scan at 18 weeks revealed normal fetal anatomynormal fetal anatomy

Jenny Q - the outcomeJenny Q - the outcome

Jenny delivered a male infant at 38 Jenny delivered a male infant at 38 weeks gestation with a minor degree weeks gestation with a minor degree of hypospadiasof hypospadias

Samantha J - The ProblemSamantha J - The Problem

A 16-year old girl, who is just A 16-year old girl, who is just confirmed to be about 6 weeks confirmed to be about 6 weeks pregnant, reports that she is taking pregnant, reports that she is taking Doxycycline daily for acneDoxycycline daily for acne

Her mother is very worried and asks Her mother is very worried and asks if the pregnancy should be if the pregnancy should be terminatedterminated

Samantha J - The ProblemSamantha J - The Problem

Doxycycline (a tetracycline) is Doxycycline (a tetracycline) is Category D for pregnancyCategory D for pregnancy

It causes inhibition of bone growth It causes inhibition of bone growth and dysplasia and discolouration of and dysplasia and discolouration of teethteeth

Samantha J – what we didSamantha J – what we did

The family (including the boyfriend) was The family (including the boyfriend) was counselled about the non teratogenicity of counselled about the non teratogenicity of tetracyclines in the first trimester (up to tetracyclines in the first trimester (up to 18 weeks gestation)18 weeks gestation)

Options for the pregnancy and the Options for the pregnancy and the potential baby were explored with the potential baby were explored with the assistance of a social workerassistance of a social worker

Samantha J - the outcomeSamantha J - the outcome

Samantha and her boyfriend elected Samantha and her boyfriend elected to continue the pregnancyto continue the pregnancy

A normal female infant was delivered A normal female infant was delivered at termat term

A very proud grandmother was A very proud grandmother was present at the birthpresent at the birth

Julie M - The ProblemJulie M - The Problem

This 34-year old mother of two (and wife This 34-year old mother of two (and wife of a laboratory immunologist) is planning of a laboratory immunologist) is planning an African holiday. She is 18 weeks an African holiday. She is 18 weeks pregnant and asks about malarial pregnant and asks about malarial prophylaxis.prophylaxis.

One of the places they plan to visit is the One of the places they plan to visit is the Victoria Falls which is an area of Victoria Falls which is an area of chloroquine-resistant Plasmodium chloroquine-resistant Plasmodium falciparum.falciparum.

Julie M - The ProblemJulie M - The Problem

All drugs required for the treatment All drugs required for the treatment of malaria are potentially teratogenic of malaria are potentially teratogenic (Category D or B2/3)(Category D or B2/3)

Especially those required for the Especially those required for the treatment of chloroquine-resistant treatment of chloroquine-resistant malariamalaria

Julie M – what we didJulie M – what we did The couple were counselled that:The couple were counselled that:

Malaria poses a significant hazard to the Malaria poses a significant hazard to the pregnant womanpregnant woman

She should consider not going to Victoria She should consider not going to Victoria FallsFalls

They should all take appropriate They should all take appropriate precautions against mosquito bitesprecautions against mosquito bites

She should take Chloroquin in prophylactic She should take Chloroquin in prophylactic doses as this is not teratogenic (Category doses as this is not teratogenic (Category A for malarial prophylaxis)A for malarial prophylaxis)

Julie M - the outcomeJulie M - the outcome

A healthy female infant was born at A healthy female infant was born at term after their return term after their return

But was readmitted to hospital at 7 But was readmitted to hospital at 7 weeks of age with “cyanotic spells”weeks of age with “cyanotic spells”

Heather B - The ProblemHeather B - The Problem

This 24-year old nullipara consults This 24-year old nullipara consults you before attempting pregnancy you before attempting pregnancy about her anticonvulsant medication.about her anticonvulsant medication.

She was diagnosed as epileptic at She was diagnosed as epileptic at the age of 13 years and is taking the age of 13 years and is taking Dilantin 100 mg BD and Epilim 200 Dilantin 100 mg BD and Epilim 200 mg TDSmg TDS

Heather B – the issuesHeather B – the issues All anticonvulsants are teratogenicAll anticonvulsants are teratogenic

First confirm the diagnosis and the First confirm the diagnosis and the continuing need for therapycontinuing need for therapy

Single agent therapy is preferredSingle agent therapy is preferred

Choose an anticonvulsant with the lowest Choose an anticonvulsant with the lowest teratogenicityteratogenicity

And one with an option for prenatal And one with an option for prenatal diagnosis e.g. Epilim and spina bifidadiagnosis e.g. Epilim and spina bifida

The role of Folic acid prophylaxisThe role of Folic acid prophylaxis

Tiffany S - The ProblemTiffany S - The Problem

This 24-year old nullipara presents at This 24-year old nullipara presents at 6 weeks amenorrhoea with a positive 6 weeks amenorrhoea with a positive pregnancy testpregnancy test

She is very worried because she was She is very worried because she was drinking alcohol very heavily at the drinking alcohol very heavily at the time of conception and in the 2 time of conception and in the 2 weeks afterwardsweeks afterwards

Tiffany S – What we didTiffany S – What we did

She was counselled that alcohol has She was counselled that alcohol has its principal effects on the developing its principal effects on the developing brainbrain

And will cause either miscarriage or And will cause either miscarriage or have no effect at this gestationhave no effect at this gestation

A PV scan was reassuringA PV scan was reassuring She is advised to discontinue all She is advised to discontinue all

alcohol for the remainder of the alcohol for the remainder of the pregnancy and lactation periodpregnancy and lactation period

Tiffany S – Other IssuesTiffany S – Other Issues

Tiffany was wearing button-down Tiffany was wearing button-down sleeves and asked to have her BP sleeves and asked to have her BP check through this garmentcheck through this garment

She subsequently disclosed to a She subsequently disclosed to a midwife that she was a regular midwife that she was a regular heroin userheroin user

Tiffany S - The ProblemTiffany S - The Problem

Heroin use in pregnancy is not Heroin use in pregnancy is not teratogenic but is associated with an teratogenic but is associated with an increased risk of miscarriage, increased risk of miscarriage, stillbirth, prematurity, neonatal death stillbirth, prematurity, neonatal death and IUGRand IUGR

However, it is the lifestyle (incl However, it is the lifestyle (incl smoking) that is the issuesmoking) that is the issue

And good outcomes can occur with And good outcomes can occur with good antenatal care of heroin usersgood antenatal care of heroin users

Tiffany S – What we didTiffany S – What we did

Tiffany (and her partner) were fast-tracked Tiffany (and her partner) were fast-tracked to a Methadone programto a Methadone program

Her daily dose of Methadone was gradually Her daily dose of Methadone was gradually reduced but she was unable to go below reduced but she was unable to go below 20 ml per day20 ml per day

She was provided with close, supportive, She was provided with close, supportive, multidisciplinary AN caremultidisciplinary AN care

She was unable to stop smokingShe was unable to stop smoking Her partner was less successful on Her partner was less successful on

Methadone and she eventually separated Methadone and she eventually separated and turned to her parents for supportand turned to her parents for support

Tiffany S - The OutcomeTiffany S - The Outcome

Delivery of a 2.6 Kg baby occurred at Delivery of a 2.6 Kg baby occurred at 37 weeks37 weeks

The baby suffered neonatal narcotic The baby suffered neonatal narcotic abstinence syndrome requiring short abstinence syndrome requiring short term treatment with herointerm treatment with heroin

Breast-feeding was encouraged & Breast-feeding was encouraged & eventually successfuleventually successful

Tiffany enjoyed motherhood and Tiffany enjoyed motherhood and came off all drugs over 6 monthscame off all drugs over 6 months

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