1. Cases: Drugs in Pregnancy Max Brinsmead PhD FRANZCOG February 2015

2. Jenny Q - The Problem You discover that your 22-year old patient who has missed two menstrual periods whilst taking Loette is about 12 weeks pregnant… You discover that your 22-year old patient who has missed two menstrual periods whilst taking Loette is about 12 weeks pregnant… She asks if her ingestion of The Pill will affect her baby She asks if her ingestion of The Pill will affect her baby

3. Jenny Q - The Problem Loette contains ethinyloestradiol 30 ug and levonorgestrel 150 ug Loette contains ethinyloestradiol 30 ug and levonorgestrel 150 ug It is a category B3 for ingestion during pregnancy It is a category B3 for ingestion during pregnancy A related oestrogen, stilboestrol, is category D and known to cause malformations A related oestrogen, stilboestrol, is category D and known to cause malformations Levonorgestrel is a progestin with some androgenic potential and causes masculinisation of the female fetus when given to pregnant animals Levonorgestrel is a progestin with some androgenic potential and causes masculinisation of the female fetus when given to pregnant animals

4. Jenny Q – what we did Jenny was counselled: Jenny was counselled: That there is no good evidence from large studies in women that oestrogens and progestins in contraceptive doses are teratogenic That there is no good evidence from large studies in women that oestrogens and progestins in contraceptive doses are teratogenic About the overall risks of fetal malformations (2-4%) About the overall risks of fetal malformations (2-4%) An ultrasound scan at 18 weeks revealed normal fetal anatomy An ultrasound scan at 18 weeks revealed normal fetal anatomy

5. Jenny Q - the outcome Jenny delivered a male infant at 38 weeks gestation with a minor degree of hypospadias Jenny delivered a male infant at 38 weeks gestation with a minor degree of hypospadias

6. Samantha J - The Problem A 16-year old girl, who is just confirmed to be about 6 weeks pregnant, reports that she is taking Doxycycline daily for acne A 16-year old girl, who is just confirmed to be about 6 weeks pregnant, reports that she is taking Doxycycline daily for acne Her mother is very worried and asks if the pregnancy should be terminated Her mother is very worried and asks if the pregnancy should be terminated

7. Samantha J - The Problem Doxycycline (a tetracycline) is Category D for pregnancy Doxycycline (a tetracycline) is Category D for pregnancy It causes inhibition of bone growth and dysplasia and discolouration of teeth It causes inhibition of bone growth and dysplasia and discolouration of teeth

8. Samantha J – what we did The family (including the boyfriend) was counselled about the non teratogenicity of tetracyclines in the first trimester (up to 18 weeks gestation) The family (including the boyfriend) was counselled about the non teratogenicity of tetracyclines in the first trimester (up to 18 weeks gestation) Options for the pregnancy and the potential baby were explored with the assistance of a social worker Options for the pregnancy and the potential baby were explored with the assistance of a social worker

9. Samantha J - the outcome Samantha J - the outcome Samantha and her boyfriend elected to continue the pregnancy Samantha and her boyfriend elected to continue the pregnancy A normal female infant was delivered at term A normal female infant was delivered at term A very proud grandmother was present at the birth A very proud grandmother was present at the birth

10. Julie M - The Problem Julie M - The Problem This 34-year old mother of two (and wife of a laboratory immunologist) is planning an African holiday. She is 18 weeks pregnant and asks about malarial prophylaxis. This 34-year old mother of two (and wife of a laboratory immunologist) is planning an African holiday. She is 18 weeks pregnant and asks about malarial prophylaxis. One of the places they plan to visit is the Victoria Falls which is an area of chloroquine-resistant Plasmodium falciparum. One of the places they plan to visit is the Victoria Falls which is an area of chloroquine-resistant Plasmodium falciparum.

11. Julie M - The Problem Julie M - The Problem All drugs required for the treatment of malaria are potentially teratogenic (Category D or B2/3) All drugs required for the treatment of malaria are potentially teratogenic (Category D or B2/3) Especially those required for the treatment of chloroquine-resistant malaria Especially those required for the treatment of chloroquine-resistant malaria

12. Julie M – what we did Julie M – what we did The couple were counselled that: The couple were counselled that: Malaria poses a significant hazard to the pregnant woman Malaria poses a significant hazard to the pregnant woman She should consider not going to Victoria Falls She should consider not going to Victoria Falls They should all take appropriate precautions against mosquito bites They should all take appropriate precautions against mosquito bites She should take Chloroquin in prophylactic doses as this is not teratogenic (Category A for malarial prophylaxis) She should take Chloroquin in prophylactic doses as this is not teratogenic (Category A for malarial prophylaxis)

13. Julie M - the outcome A healthy female infant was born at term after their return A healthy female infant was born at term after their return But was readmitted to hospital at 7 weeks of age with “cyanotic spells” But was readmitted to hospital at 7 weeks of age with “cyanotic spells”

14. Heather B - The Problem Heather B - The Problem This 24-year old nullipara consults you before attempting pregnancy about her anticonvulsant medication. This 24-year old nullipara consults you before attempting pregnancy about her anticonvulsant medication. She was diagnosed as epileptic at the age of 13 years and is taking Dilantin 100 mg BD and Epilim 200 mg TDS She was diagnosed as epileptic at the age of 13 years and is taking Dilantin 100 mg BD and Epilim 200 mg TDS

15. Heather B – the issues Heather B – the issues All anticonvulsants are teratogenic All anticonvulsants are teratogenic First confirm the diagnosis and the continuing need for therapy First confirm the diagnosis and the continuing need for therapy Single agent therapy is preferred Single agent therapy is preferred Choose an anticonvulsant with the lowest teratogenicity Choose an anticonvulsant with the lowest teratogenicity And one with an option for prenatal diagnosis e.g. Epilim and spina bifida And one with an option for prenatal diagnosis e.g. Epilim and spina bifida The role of Folic acid prophylaxis The role of Folic acid prophylaxis

16. Tiffany S - The Problem Tiffany S - The Problem This 24-year old nullipara presents at 6 weeks amenorrhoea with a positive pregnancy test This 24-year old nullipara presents at 6 weeks amenorrhoea with a positive pregnancy test She is very worried because she was drinking alcohol very heavily at the time of conception and in the 2 weeks afterwards She is very worried because she was drinking alcohol very heavily at the time of conception and in the 2 weeks afterwards

17. Tiffany S – What we did Tiffany S – What we did She was counselled that alcohol has its principal effects on the developing brain She was counselled that alcohol has its principal effects on the developing brain And will cause either miscarriage or have no effect at this gestation And will cause either miscarriage or have no effect at this gestation A PV scan was reassuring A PV scan was reassuring She is advised to discontinue all alcohol for the remainder of the pregnancy and lactation period She is advised to discontinue all alcohol for the remainder of the pregnancy and lactation period

18. Tiffany S – Other Issues Tiffany S – Other Issues Tiffany was wearing button-down sleeves and asked to have her BP check through this garment Tiffany was wearing button-down sleeves and asked to have her BP check through this garment She subsequently disclosed to a midwife that she was a regular heroin user She subsequently disclosed to a midwife that she was a regular heroin user

19. Tiffany S - The Problem Tiffany S - The Problem Heroin use in pregnancy is not teratogenic but is associated with an increased risk of miscarriage, stillbirth, prematurity, neonatal death and IUGR Heroin use in pregnancy is not teratogenic but is associated with an increased risk of miscarriage, stillbirth, prematurity, neonatal death and IUGR However, it is the lifestyle (incl smoking) that is the issue However, it is the lifestyle (incl smoking) that is the issue And good outcomes can occur with good antenatal care of heroin users And good outcomes can occur with good antenatal care of heroin users

20. Tiffany S – What we did Tiffany S – What we did Tiffany (and her partner) were fast- tracked to a Methadone program Tiffany (and her partner) were fast- tracked to a Methadone program Her daily dose of Methadone was gradually reduced but she was unable to go below 20 ml per day Her daily dose of Methadone was gradually reduced but she was unable to go below 20 ml per day She was provided with close, supportive, multidisciplinary AN care She was provided with close, supportive, multidisciplinary AN care She was unable to stop smoking She was unable to stop smoking Her partner was less successful on Methadone and she eventually separated and turned to her parents for support Her partner was less successful on Methadone and she eventually separated and turned to her parents for support

21. Tiffany S - The Outcome Tiffany S - The Outcome Delivery of a 2.6 Kg baby occurred at 37 weeks Delivery of a 2.6 Kg baby occurred at 37 weeks The baby suffered neonatal narcotic abstinence syndrome requiring short term treatment with heroin The baby suffered neonatal narcotic abstinence syndrome requiring short term treatment with heroin Breast-feeding was encouraged & eventually successful Breast-feeding was encouraged & eventually successful Tiffany enjoyed motherhood and came off all drugs over 6 months Tiffany enjoyed motherhood and came off all drugs over 6 months

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