1. INTRODUCTION http://www.youtube.com/watch?v=h WWsfrfq69A http://www.youtube.com/watch?v=h WWsfrfq69A http://www.youtube.com/watch?v=h WWsfrfq69A http://www.youtube.com/watch?v=h WWsfrfq69A

2. DRUG THERAPY DURING PREGNANCY Developed By D. Ann Currie, R.N.,M.S.N. 2012

3. PHYSIOLOGICAL CHANGES DURING PREGNANCY AND THEIR IMPACT ON DRUG THERAPY PHYSIOLOGICAL CHANGES DURING PREGNANCY AND THEIR IMPACT ON DRUG THERAPY EVERY SYSTEM IN THE BODY IS EFFECTED BY PREGNANCY EVERY SYSTEM IN THE BODY IS EFFECTED BY PREGNANCY PHARMACOKENETICS OF DRUGS IS EFFECTED BY PREGNANCY PHARMACOKENETICS OF DRUGS IS EFFECTED BY PREGNANCY

4. PHARMACOKENETICS OF DRUGS DURING PREGNANCY ABSORPTION- DECREASED GI MOTILITY CAUSES INCREASED DRUG ABSORPTION. ABSORPTION- DECREASED GI MOTILITY CAUSES INCREASED DRUG ABSORPTION. DISTURBUTION- PROTIEN BINDING IS DECREASED CAUSES INCREASED FREE DRUG TO BE AVAILABLE. DISTURBUTION- PROTIEN BINDING IS DECREASED CAUSES INCREASED FREE DRUG TO BE AVAILABLE. METABOLISM-INCREASED HEPATIC METABOLISM OCCURS FOR SOME DRUGS METABOLISM-INCREASED HEPATIC METABOLISM OCCURS FOR SOME DRUGS

5. PHARMACOKENETICS EXCRETION- IN THE 3RD TRIMESTER INCREASED RENAL BLOOD FLOW & GFR CAUSES SOME DRUGS TO CLEAR THE BODY FASTER. EXCRETION- IN THE 3RD TRIMESTER INCREASED RENAL BLOOD FLOW & GFR CAUSES SOME DRUGS TO CLEAR THE BODY FASTER.

6. DRUG THERAPY IN THE CHILDBEARING CLIENT REQUIRES SPECIAL CONSIDERATIONS REQUIRES SPECIAL CONSIDERATIONS IS CHALLENGING TO PROVIDE EFFECTIVE TX WHILE AVOIDING HARM TO EMBRYO,FETUS OR NEONATE IS CHALLENGING TO PROVIDE EFFECTIVE TX WHILE AVOIDING HARM TO EMBRYO,FETUS OR NEONATE CENTERED ON BENEFIT/RISK RATIO CENTERED ON BENEFIT/RISK RATIO EFFECTS OF DRUGS NOT ALWAYS KNOWN EFFECTS OF DRUGS NOT ALWAYS KNOWN

7. ANY DRUG TAKEN BY THE PREGNANT OR BREASTFEEDING CLIENT HAS THE POTENTIAL TO REACH THE FETUS BY WAY OF MATERNAL CIRCULATION OR NEONATE BY WAY OF BREASTMILK

8. EFFECTS OF DRUGS ON THE EMBRYO, FETUS, OR NEONATE MAY VARY--- MAY VARY--- NO EFFECT. NO EFFECT. LITTLE LITTLE SERIOUS- FETAL TOXICITY SERIOUS- FETAL TOXICITY SPONTANEOUS ABORTION SPONTANEOUS ABORTION DEATH DEATH FETAL MALFUNCTION FETAL MALFUNCTION FETAL MALFORMATIONS. FETAL MALFORMATIONS.

9. DRUG THERAPY DURING PREGNACY CENTERED ON BENEFIT/RISK RATIO CENTERED ON BENEFIT/RISK RATIO EFFECTS OF SOME MEDICATION ARE KNOWN EFFECTS OF SOME MEDICATION ARE KNOWN UNKNOWN- NEW MEDICATIONS, DIFFERENT COMBINATIONS, DEFICIENCY IN MATERNAL METABOLISM UNKNOWN- NEW MEDICATIONS, DIFFERENT COMBINATIONS, DEFICIENCY IN MATERNAL METABOLISM NO DRUG IS ABSOLUTELY SAFE. NO DRUG IS ABSOLUTELY SAFE.

10. RECENT STUDIES 75% OF PREGNANT CLIENTS USE 3- 10 DIFFERENT DRUGS(PRESCRIPTION OR OTC’S) OTHER THAN VITAMINS/MINERAL SUPPLEMENTS DURING THEIR PREGNANCY. 75% OF PREGNANT CLIENTS USE 3- 10 DIFFERENT DRUGS(PRESCRIPTION OR OTC’S) OTHER THAN VITAMINS/MINERAL SUPPLEMENTS DURING THEIR PREGNANCY. OTC’S WERE USED 4 TIMES THAT OF PRESCRIPTION DRUGS. OTC’S WERE USED 4 TIMES THAT OF PRESCRIPTION DRUGS.

11. TYPES OF DRUGS USED IN THE STUDY BY PREGNANT CLIENTS DIETARY SUPPLEMENTS DIETARY SUPPLEMENTS ANTIEMETICS ANTIEMETICS ANTACIDS ANTACIDS TRANQUILIZERS TRANQUILIZERS HYPNOTICS HYPNOTICS ANTIBIOBIOTICS ANTIBIOBIOTICS ANTIHISTAMINES ANTIHISTAMINES ANALGESICS ANALGESICS DIURETICS DIURETICS ETOH ETOH CNS DEPRESSANTS CNS DEPRESSANTS CNS STIMULANTS CNS STIMULANTS

12. DRUG LEVELS IN THE FETUS REACHED 50- 100% OF THE MATERNAL BLOOD LEVELS

13. SELF TREATMENT WITH DRUGS DURING PREGNANCY SELF TX OF MINOR ILLNESSES OR DISCOMFORTS SHOULD BE DISCOURAGED SELF TX OF MINOR ILLNESSES OR DISCOMFORTS SHOULD BE DISCOURAGED *SELFTREATMENT OF ANY ILLNESSES SHOULD BE DISCOURAGED *SELFTREATMENT OF ANY ILLNESSES SHOULD BE DISCOURAGED WOMEN SHOULD BE INSTRUCTED TO KEEP A COMPLETE RECORD OF ALL MEDICATIONS TAKEN. WOMEN SHOULD BE INSTRUCTED TO KEEP A COMPLETE RECORD OF ALL MEDICATIONS TAKEN.

14. THE CHALLENGE OF PROVIDING EFFECTIVE CARE/TX FOR THE CHILDBEARING CLIENT AVOID HARM TO EMBRYO, FETUS, NEONATE. AVOID HARM TO EMBRYO, FETUS, NEONATE. DILEMMA UNFORTUNATELY THE RISK OF MOST DRUGS HAVE NOT BEEN ESTABLISHED. DILEMMA UNFORTUNATELY THE RISK OF MOST DRUGS HAVE NOT BEEN ESTABLISHED. DESPITE NOT KNOWING DRUG THERAPY DURING PREGNANCY DESPITE NOT KNOWING DRUG THERAPY DURING PREGNANCY

15. CANNOT OR SHOULD NOT BE AVOIDED BECAUSE THE HEALTH OF THE FETUS DEPENDS ON THE HEALTH OF THE MOTHER. CANNOT OR SHOULD NOT BE AVOIDED BECAUSE THE HEALTH OF THE FETUS DEPENDS ON THE HEALTH OF THE MOTHER. FOR EXAMPLE: SEIZURES,DM, MG, SLE,OR INFECTIONS. FOR EXAMPLE: SEIZURES,DM, MG, SLE,OR INFECTIONS.

16. BIRTH DEFECTS INCIDENCE OF MAJOR STRUCTURAL DEFECTS(ABNORMALITIES) IS ABOUT 6% OF ALL PREGNANCIES. INCIDENCE OF MAJOR STRUCTURAL DEFECTS(ABNORMALITIES) IS ABOUT 6% OF ALL PREGNANCIES. 3% ARE CAUSED BY DRUGS OR ENVIRONMENTAL FACTORS/EXPOSURE 3% ARE CAUSED BY DRUGS OR ENVIRONMENTAL FACTORS/EXPOSURE 3% HAVE A UNKNOWN CAUSES 3% HAVE A UNKNOWN CAUSES

17. BIRTH DEFECTS 1/2 OF THE BIRTH DEFECTS ARE OBVIOUS AT BIRTH. 1/2 OF THE BIRTH DEFECTS ARE OBVIOUS AT BIRTH. 1/2 OF THE BIRTH DEFECTS AREN’T DISCOVERED UNTIL LATER IN LIFE OR DISCOVERED DURING AN AUTOPSY 1/2 OF THE BIRTH DEFECTS AREN’T DISCOVERED UNTIL LATER IN LIFE OR DISCOVERED DURING AN AUTOPSY INCIDENCE OF MINOR STRUCTURAL ABNORMALIES IS NOT KNOWN. INCIDENCE OF MINOR STRUCTURAL ABNORMALIES IS NOT KNOWN.

18. BIRTH DEFECTS INCIDENCE OF FUNCTIONAL ABNORMALITIES IS NOT KNOWN- GROWTH RESTRICTIONS, MENTAL RETARDATION, AND LEARNING DISABLITIES INCIDENCE OF FUNCTIONAL ABNORMALITIES IS NOT KNOWN- GROWTH RESTRICTIONS, MENTAL RETARDATION, AND LEARNING DISABLITIES SOME ABNORMALITIES HAVE MULTIPLE CAUSES-GENETIC FACTORS, ENVIRONMENTAL FACTORS, CHEMICALS OR DRUGS. SOME ABNORMALITIES HAVE MULTIPLE CAUSES-GENETIC FACTORS, ENVIRONMENTAL FACTORS, CHEMICALS OR DRUGS.

19. TERATOGENIC TERATOGENESIS TERAS-”MONSTER” TERAS-”MONSTER” GENSIS-”PRODUCING” GENSIS-”PRODUCING” BIRTH DEFECTS/DISTORTION OF GROSS ANATOMY. BIRTH DEFECTS/DISTORTION OF GROSS ANATOMY. EXAMPLES- CLEFT LIP/PALATE, CLUBFOOT, NEURAL TUBAL DEFECTS, MISSING OR MALFORMED LIMBS/FINGERS. EXAMPLES- CLEFT LIP/PALATE, CLUBFOOT, NEURAL TUBAL DEFECTS, MISSING OR MALFORMED LIMBS/FINGERS.

20. Birth Defects

21. TERATOGENIC ALSO-BEHAVORIAL AND/ OR BIOCHEMICAL ABNORMALITIES. ALSO-BEHAVORIAL AND/ OR BIOCHEMICAL ABNORMALITIES. TERATOGENESIS MAYBE DIRECT-IE- MALFORMATIONS OF STRUCTURES TERATOGENESIS MAYBE DIRECT-IE- MALFORMATIONS OF STRUCTURES OR INDIRECT-SUCH AS INTERFERING WITH O2 OR NUTRIENTS. OR INDIRECT-SUCH AS INTERFERING WITH O2 OR NUTRIENTS.

22. TERATOGENIC EXAMPLE OF KNOWN TERATOGENIC AGENTS: EXAMPLE OF KNOWN TERATOGENIC AGENTS: ONE TIME EXPOSURE IS THALIDOMIDE-CAUSES MISSING LIMBS. ONE TIME EXPOSURE IS THALIDOMIDE-CAUSES MISSING LIMBS. CONT. OR PROLONG EXPOSURE IS ETOH-CAUSES FAS. CONT. OR PROLONG EXPOSURE IS ETOH-CAUSES FAS. SEE HANDOUT FOR OTHER AGENTS. SEE HANDOUT FOR OTHER AGENTS.

23. Fetal Alcohol Syndrome- FAS

24. FETAL EFFECTS FROM DRUGS DEPEND ON SEVERAL FACTORS TIME- WHEN DRUG IS TAKEN IN PREGNANCY. TIME- WHEN DRUG IS TAKEN IN PREGNANCY. PREIMPLANTATION/PRESOMITE PERIOD-CONCEPTION TO 2 WEEK PREIMPLANTATION/PRESOMITE PERIOD-CONCEPTION TO 2 WEEK HIGH DOSE- MAYBE LETHAL/DEATH/ABORTIONS. HIGH DOSE- MAYBE LETHAL/DEATH/ABORTIONS. LOW DOSE-MAYBE NOTHING. LOW DOSE-MAYBE NOTHING.

25. EMBRYONIC PERIOD-3-8 WEEKS *FIRST TRIMESTER* EMBRYONIC PERIOD-3-8 WEEKS *FIRST TRIMESTER* GROSS MALFORMATIONS GROSS MALFORMATIONS FETAL PERIOD-9-40 WEEKS(TERM) FETAL PERIOD-9-40 WEEKS(TERM) FUNCTION PROBLEMS RATHER THAN GROSS ANATOMY- *LEARNING DEFICITS &/OR BEHAVORIAL ABNORMALIES FUNCTION PROBLEMS RATHER THAN GROSS ANATOMY- *LEARNING DEFICITS &/OR BEHAVORIAL ABNORMALIES

26. Slides of pregnancy http://www.medicinenet.com/fetal_de velopment_pictures_slideshow/article. htm http://www.medicinenet.com/fetal_de velopment_pictures_slideshow/article. htm http://www.medicinenet.com/fetal_de velopment_pictures_slideshow/article. htm http://www.medicinenet.com/fetal_de velopment_pictures_slideshow/article. htm

28. WHY IS IDENTIFICATION OF TERATOGENIC AGENTS SOMETIMES DIFFICULT TO IDENTIFY?

29. INCIDENCE OF CONGENITAL ANOMALIES IS GENERALLY LOW. INCIDENCE OF CONGENITAL ANOMALIES IS GENERALLY LOW. ANIMAL TESTS MAY NOT BE RELIABLE ANIMAL TESTS MAY NOT BE RELIABLE PROLONGED OR INCREASED EXPOSURE MAYBE REQUIRED. PROLONGED OR INCREASED EXPOSURE MAYBE REQUIRED. EFFECTS MAYBE DELAYED OR NOT RECONIZED. EFFECTS MAYBE DELAYED OR NOT RECONIZED. BEHAVIORAL EFFECTS ARE DIFFICULT TO DOCUMENT. BEHAVIORAL EFFECTS ARE DIFFICULT TO DOCUMENT. CONTOLLED EXPERIMENTS CANNOT BE DONE ON HUMANS. CONTOLLED EXPERIMENTS CANNOT BE DONE ON HUMANS.

30. DOCUMENTATION IS INCOMPLETE DOCUMENTATION IS INCOMPLETE ONLY IN A LIMITED NUMBER OF DRUGS IS THE TERATOGENIC EFFECTS KNOWN OR PROVEN. ONLY IN A LIMITED NUMBER OF DRUGS IS THE TERATOGENIC EFFECTS KNOWN OR PROVEN. LACK OF PROOF OF TERATOGENICITY DOES NOT MEAN A DRUG IS SAFE IN PREGNANCY LACK OF PROOF OF TERATOGENICITY DOES NOT MEAN A DRUG IS SAFE IN PREGNANCY MAY MEAN THERE IS A LACK OF RESEARCH OR INFORMATION. MAY MEAN THERE IS A LACK OF RESEARCH OR INFORMATION.

31. PROVING A DRUG IS A TERATOGEN 3 CITERIA MUST BR MET: 3 CITERIA MUST BR MET: 1. DRUG MUST CAUSE A CHARACTERISTIC SET OF MALFORMATIONS. 1. DRUG MUST CAUSE A CHARACTERISTIC SET OF MALFORMATIONS. 2. IT MUST ACT ONLY DURNIG A SPECIFIC WINDOW OF VULNERABILITY-3-8 WEEKS OF GESTATION 2. IT MUST ACT ONLY DURNIG A SPECIFIC WINDOW OF VULNERABILITY-3-8 WEEKS OF GESTATION

32. 3.THE INCIDENCE OF MALFORMATIONS SHOULD INCREASE WITH INCREASED DOSAGE & DURATION OF EXPOSURE. 3.THE INCIDENCE OF MALFORMATIONS SHOULD INCREASE WITH INCREASED DOSAGE & DURATION OF EXPOSURE.

33. PLACENTAL DRUG TRANSFER THE PLACENTA IS NOT A COMPLETE BARRIER. THE PLACENTA IS NOT A COMPLETE BARRIER. SOME DRUGS ARE STOPPED. SOME DRUGS ARE STOPPED. SOME DRUGS(IN FACT MOST) ARE NOT. SOME DRUGS(IN FACT MOST) ARE NOT. WAYS DRUGS ARE TRANSFER ACROSS- SIMPLE DIFFUSION-ACTIVE TRANSPORT. WAYS DRUGS ARE TRANSFER ACROSS- SIMPLE DIFFUSION-ACTIVE TRANSPORT.

34. TRANSFER DEPENDS ON SEVERAL FACTORS CHEMICAL PROPERTY OF THE DRUG CHEMICAL PROPERTY OF THE DRUG MOLECULAR WEIGHT. MOLECULAR WEIGHT. PROTEIN BINDING CAPABILITIES. PROTEIN BINDING CAPABILITIES. CHEMICAL CONFIQURATION. CHEMICAL CONFIQURATION. LIPID SOLUBILITY.* LIPID SOLUBILITY.* PERIOD OF TIME DRUG REMAINS IN MATERNAL BLOODSTREAM PERIOD OF TIME DRUG REMAINS IN MATERNAL BLOODSTREAM HALFLIFE OF THE DRUG. HALFLIFE OF THE DRUG.

35. TRANSFER DEPENDS ON SEVERAL FACTORS CONT. CONT. AMOUNT OF THE DRUG. AMOUNT OF THE DRUG. PATHOLOGICAL PROCESSES OF THE PLACENTA. PATHOLOGICAL PROCESSES OF THE PLACENTA. WHEN IN THE PREGNANCY- INCREASED BLOOD FLOW TO THE PLACENTA IN LAST PART OF PREGNANCY. WHEN IN THE PREGNANCY- INCREASED BLOOD FLOW TO THE PLACENTA IN LAST PART OF PREGNANCY.

36. MOST DRUGS TRANSFER AND ARE AT 50-100% THAT OF THE MATERNAL LEVELS * SOME DRUG LEVELS ARE MORE THAN THE MATERNAL LEVELS

37. DRUGS THAT TRANSFER EASILY ARE LIPID SOLUBLE. DRUGS THAT TRANSFER EASILY ARE LIPID SOLUBLE. DRUGS THAT ARE DIFFICULT/HARD TO TRANSFER ARE IONIZED DRUGS- HIGHLY POLAR-OR PROTEIN BOUND. DRUGS THAT ARE DIFFICULT/HARD TO TRANSFER ARE IONIZED DRUGS- HIGHLY POLAR-OR PROTEIN BOUND.

38. HOW IS DATA COLLECTED ON DRUGS WHICH CAUSE PROBLEMS IN PREGNANCIES? NO HUMAN EXPERIMENTATION NO HUMAN EXPERIMENTATION SYSTEMATIC COLLECTION AND ANALYZING OF DATA ON DRUGS TAKEN BY PREGNANT CLIENTS. SYSTEMATIC COLLECTION AND ANALYZING OF DATA ON DRUGS TAKEN BY PREGNANT CLIENTS. REPORTING OF INFORMATION BY HEALTH PROFESSIONALS. REPORTING OF INFORMATION BY HEALTH PROFESSIONALS. SEE FORM. SEE FORM.

39. THE NURSE’S ROLE AND RESPONSIBILITY IN DRUG THERAPY IN THE CHILDBEARING CLIENT KNOWLEDGE (CURRENT &ACCURATE INFORMATION)- KNOWLEDGE (CURRENT &ACCURATE INFORMATION)- PREGNANCY PREGNANCY MEDICAL CONDITIONS MEDICAL CONDITIONS MEDICAL TREATMENTS MEDICAL TREATMENTS DRUGS AND CLIENT DRUGS AND CLIENT

41. EDUCATION OF PREGNANT/PREPREGNAN T CLIENTS PROVIDE ACCURATE INFORMATION WITH RATIONALES PROVIDE ACCURATE INFORMATION WITH RATIONALES INFORMATION SOULD BE CURRENT AND BASED ON EVIDENCE. INFORMATION SOULD BE CURRENT AND BASED ON EVIDENCE. * ESTABLISH ENVIRONMENT CONDUCIVE TO EXCHANCE OF INFORMATION*- TRUST. * ESTABLISH ENVIRONMENT CONDUCIVE TO EXCHANCE OF INFORMATION*- TRUST. POTENTIAL HARM/RISKS. POTENTIAL HARM/RISKS.

42. EDUCATION BENEFITS BENEFITS COMMON SUBSTANCES & OTC DRUGS TO AVOID IN PREGNANCY- ASA,ETOH,INCREASED DOSES OF MULTVITAMINS,CAFFIENE,CIGARETTE SMOKING,ETC. COMMON SUBSTANCES & OTC DRUGS TO AVOID IN PREGNANCY- ASA,ETOH,INCREASED DOSES OF MULTVITAMINS,CAFFIENE,CIGARETTE SMOKING,ETC. AVOID SELF TX-OTC’S, DRUGS FORM MEXICO. AVOID SELF TX-OTC’S, DRUGS FORM MEXICO.

43. ADVOCATE FOR CLIENTS AND GENERAL PUBLIC. ADVOCATE FOR CLIENTS AND GENERAL PUBLIC. * SUPPORT* * SUPPORT* ASSIST WITH COPING IF CLIENT HAS TAKEN A TERATOGENIC AGENT..WITH GUILT OR FEAR…ASSOCIATED WITH DRUGS TAKEN IN PREGNANCY. ASSIST WITH COPING IF CLIENT HAS TAKEN A TERATOGENIC AGENT..WITH GUILT OR FEAR…ASSOCIATED WITH DRUGS TAKEN IN PREGNANCY.

44. PREGNANT CLIENT’S BILL OF RIGHTS “RIGHT TO KNOW”

45. QUESTIONS QUESTIONS

46. Thank you Thank you http://www.youtube.com/watch?v=YIkoSP qjaU4

47. For individual drugs see handout.