Download - 5 Prescribing in Preg.(5th May) 2003
![Page 1: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/1.jpg)
PRESCRIBING IN PREGNANCY
Dr Vasudha Belgaumkar
Associate ProfessorDept. of DermatologyBJGMC Pune
![Page 2: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/2.jpg)
Common Concerns ? •Contraceptive failure d/t drug
interactions
•Possible interference with conception
•Potential risk of spontaneous abortion
•Potential risk to mother/fetus
![Page 3: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/3.jpg)
FDA Pregnancy Drug Risk Categories
X Contraindicated in pregnancyD Positive evidence for risk to fetusC Risk cannot be r/o.Human studies lackingB No risk to human fetusA Controlled studies – no fetal riskN No category assigned
![Page 4: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/4.jpg)
Sources for InformationWHOTERISUSP-DIReproductive toxicology serviceAAP (lactation)Briggs GG et al
![Page 5: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/5.jpg)
Before Conception
Contraceptive failure
Interference with conception
![Page 6: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/6.jpg)
Contraceptive Failure
Azathioprine-------------- IUDNSAID---------------------IUDGriseofulvin---------------OCPRifampicin------------------OCPTetracycline----------------OCPSulphonamides-------------OCP
![Page 7: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/7.jpg)
Interference with Conception
Cyclophosphamide
Methotrexate
![Page 8: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/8.jpg)
Gestation (2- 2.5 wks)DRUG
![Page 9: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/9.jpg)
Gestation (3- 8 wks)
Differentiated Cells
Congenital Anomalies
Normal Embryo
DRUG
![Page 10: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/10.jpg)
Second TrimesterMaturation of
organ systems
Prolonged exposure to medication
e.g. Fetal hypothyroidism (iodides)
Teeth d’coloration (tetracycline)
Fetal drug metabolism slowerthan maternal
![Page 11: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/11.jpg)
Third Trimester (Near delivery)
Nonteratogenic conditions
Sulphonamides (risk in premature
infants)
NSAIDSPersistent fetal circulationOligohydramnios
![Page 12: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/12.jpg)
Absolutely Contraindicated Drugs
Category XRetinoidsEstrogensFinasterideFluorouracilMethotrexateStanozololThalidomide
![Page 13: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/13.jpg)
Category DAzathioprineAspirinBleomycinColchicineCyclophosphami
deTetracyclinePotassium iodide
![Page 14: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/14.jpg)
Category N
Griseofulvin
Spironolactone
![Page 15: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/15.jpg)
SAFETY OF DRUGS IN PREGNANCY
![Page 16: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/16.jpg)
Itching in Pregnancy
P.U.P.P.P.
Papular Dermatitis
Progesterone Induced Folliculitis
Atopic Eruption of Pregnancy
Cholestatic Pruritus
Herpes gestationis(Pemphigoid gestationis)
![Page 17: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/17.jpg)
AntihistaminesChlorpheniramine (B)Cyproheptadine (B)Diphenhydramine (B)Cetrizine (B), Hydroxyzine (N)
(except 1st trimester)Loratidine (B)Fexofenadine (C )Leukotriene inhibitors – Montelukast
(Cat B)
![Page 18: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/18.jpg)
Antibacterials
TOPICAL SYSTEMICBacitracin PenicillinsMupirocin CephalosporinsPolymyxin B ErythromycinSulphonamides AzithromycinSulphur/ResorcinolRetapamulin
![Page 19: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/19.jpg)
ANTIBIOTIC CATEGORYFluroquinolones CSulphonamides CTetracyclines DFucidic acid/ Na-fusidate
C
![Page 20: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/20.jpg)
TOPICAL ANTIFUNGALS
Category DrugB Clotrimazole, Naftifin,
Nystatin, Oxiconazole, Terbinafin
C Miconazole, Ketoconazole, Sulconazole, Butoconazole, Se-sulphide
C SertaconazoleC EberconazoleC LulliconazoleC Amorolfine
![Page 21: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/21.jpg)
Systemic Antifungals
Category
Drug
B Nystatin, Terbinafine
C Fluconazole, Itraconazole, Ketaconazole
D VoriconazoleN Griseofulvin
![Page 22: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/22.jpg)
AntiviralsAcyclovir,Valacyclovir,Famcyclovi
r =B
Cidofovir = C
Ganciclovir = C
Foscarnet = C
![Page 23: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/23.jpg)
Acne/ Rosacea
![Page 24: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/24.jpg)
Topical
Category
Drug
BClindamycin, Erythromycin, Azithromycin, Azelaic acid, Metronidazole
C Benzoyl peroxide, Adapalene, Tretinoin
X Tazarotene
![Page 25: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/25.jpg)
Systemic
Category
Drug
B Erythromycin, Azithromycin
C SulphonamidesD TetracyclineX Isotretinoin
![Page 26: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/26.jpg)
Systemic RetinoidsSpontaneous abortions
Stillbirths
Malformations – Cranial, Cardiovascular, CNS defects
![Page 27: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/27.jpg)
“iPledge” RequirementsCompulsory registration of
Prescribers/Patients/Pharmacists
Information recorded Confirmation of pt counseling Contraception methods utilized Pregnancy test result
Female of childbearing potential: “non menopausal female who has not had a hysterectomy, bilateral oophorectomy or medically documented ovarian failure”
![Page 28: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/28.jpg)
Telogen effluvium : Post partum hair shedding
Minoxidil (Cat.C):N/R in pregnancy/lact.
![Page 29: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/29.jpg)
Antiscabetics & Pediculocides
Category
Drug
B Permethrin, Malathion, Lindane, Sulphur
C Crotamiton, Ivermectin
![Page 30: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/30.jpg)
Genital Herpes (HSV) In Pregnancy
Acyclovir/ Famciclovir/ Valacyclovir
![Page 31: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/31.jpg)
Molluscum Contagiosum
Cryotherapy, TCA, Surgical Excision
![Page 32: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/32.jpg)
• Cryotherapy• TCA• Surgical Excision
HPV Infections
![Page 33: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/33.jpg)
• Podophyllin- X
• Podophyllotoxin- C
• Imiquimod- C
HPV Infections (cont)
![Page 34: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/34.jpg)
Syphilis
Benzathine Penicillin is T/t of Choice
![Page 35: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/35.jpg)
HIV in Pregnancy
Efavirenz, Delavirdine - C/I d/t teratogenicity
Other ART drugs considered safe
![Page 36: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/36.jpg)
Herpes gestationis : Pemphigoid GestationisBullous Pemphigoid of Pregnancy
![Page 37: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/37.jpg)
Impetigo Herpetiformis
![Page 38: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/38.jpg)
Systemic CorticosteroidsPreg Cat C “Therapeutic doses of cortisone during
pregnancy are unlikely to pose substantial teratogenic risk but data insufficient”
Animals studies- cleft lip/palate, placental insufficiency, spontaneous abortion, stillbirth, IUGR
Fetal HPA axis suppression near deliveryDoses > 10mg/d throughout preg a/w LBW,
hypertension & cardiovascular mortalityPrednisolone inactivated by placenta- DOC
![Page 39: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/39.jpg)
Topical Steroids
Preg Cat ‘C’Use over limited period - not a/w
adverse effectsLarge amounts used over extensive
areas - risk of LBWFluorinated steroids should be
avoided
![Page 40: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/40.jpg)
BiologicalsEtanercept, Infliximab, Adalimumab- Cat
‘B’
ImmunomodulatorsTacrolimus, Pimecrolimus, Cyclosporin,
MMF, Imiquimod - Cat ‘C’Interferons – Cat ‘C’
Vit. D AnaloguesPreg. Cat ‘C’
![Page 41: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/41.jpg)
Leprosy in PregnancyDapsone
Cat ‘C’ 3rd Trimester- Neonatal hemolysis
and methemoglobinemia Folic acid 5mg/d
Rifampicin
Cat ‘C’ 1st Trimester- very high doses : teratogenic in
animals 3rd Trimester- increased risk of neonatal bleeding
Clofazimine Cat ‘C’ Brownish discoloration
![Page 42: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/42.jpg)
Fluroquinolones & Minocycline - C/I
Clarithromycin- Safe
![Page 43: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/43.jpg)
Lepra Rections
Systemic steroids
NSAIDS - Paracetamol, Ibuprofen (avoid preconception & 3rd trimester), Aspirin
Chloroquine/HCQS- Cat ‘C’
Colchicine- Cat ‘C’
Thalidomide - Cat ‘X’
![Page 44: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/44.jpg)
Phototherapy & Photo-chemotherapy
PUVA- NR
NBUVB- Safe
![Page 45: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/45.jpg)
Local anaestheticsLidocaine – B
Prilocaine – B
![Page 46: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/46.jpg)
SUMMARY
![Page 47: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/47.jpg)
![Page 48: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/48.jpg)
Drugs in Pregnancy
![Page 49: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/49.jpg)
Drugs in Pregnancy
![Page 50: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/50.jpg)
LACTATIONControversies among various
sourcesBest sources: AAP and WHOSafe in pregnancy but not during
lactation: Eg: 1st gen.antihistaminicsSafe in lactation but not during
pregnancy: Eg: Topical Retinoids
![Page 51: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/51.jpg)
FDA Lactation Drug Risk Categories
Discontinue “ A decision should be made
whether to discontinue the drug taking into account importance of drug to mother”
Caution “ Advised if drug is absorbed &
excreted into human breast milk & does not have known adverse reactions or tumorigenic potential”
![Page 52: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/52.jpg)
Adverse Effects in InfantsOccur during first 6 mths of life
Sedation – 1st gen. antihistamines
Neurotoxic effects
Diarrhoea
Teratogenic drugs (Cat. D & X) contraindicated
![Page 53: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/53.jpg)
Safe Drugs during Lactation1. Analgesics – Paracetamol2. Antibacterials – Bacitracin, Penicillins Macrolides, Cephalosporins, 3. Antifungals: Topical- Ciclopirox, Clotrimazole, Miconazole,Oxiconazole, Terbinafine (except on nipple) Systemic- Terbinafine, Fluconazole (single
dose)4. Antivirals – Acyclovir,
Famcyclovir,Valacyclovir
![Page 54: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/54.jpg)
Safe Drugs during Lactation (cont)
5.Antiscabetics – Crotamiton, Permethrin & Lindane (controversial)
6. Antihistaminics – Loratidine, Fexofenadine
7. Corticosteroids: Oral- use Prednisolone, avoid nursing
x 4h Topical- avoid use over nipple/areola
8. Antiacne – Adapalene, BP, Tretinoin, Azelaic acid9. Calcipotriene
![Page 55: 5 Prescribing in Preg.(5th May) 2003](https://reader033.vdocuments.us/reader033/viewer/2022051519/5695cf611a28ab9b028dd6ef/html5/thumbnails/55.jpg)
THANK YOU