Use in Pregnancy

Clinical Particulars (therapeutic indications, administration, contraindications, special warnings and precautions, interaction with other drugs, use in pregnancy or lactation, effects on driving, undesirable effects, overdose)... 

IV rt-PA has been safely given in patients with cervical arterial dissection There are four reports of IV rt-PA use in pregnancy, with one case complicated by intrauterine hematoma,rt-PA should be used in this setting only after careful assessment of the risks and benefits. There is insufficient data to determine the benefit of rt-PA in the pediatric population, with no randomized trials. 

TABLE 44-2. Sources of Information for Drug Use in Pregnancy and Lactation... 

Other agents that appear to be safe for use in pregnancy include the proton pump inhibitors, sucralfate, and meto-clopromide (Table 44-5). The proton pump inhibitor with the largest body of human safety data during pregnancy is omeprazole.24... 

Treat conditions during pregnancy that pose a risk to the fetus or neonate. Choose therapy as recommended by guidelines or those with the longest history of safe use in pregnancy. 

O All symptomatic adults and children over the age of 8 years should be treated with metronidazole 250 mg three times daily for 7 days, or tinidazole 2 gas a single dose, or nitazoxanide 500 mg twice daily for 3 days.3 The pediatric dose of metronidazole is 15 mg/kg per day three times daily far 7 days. Alternative drugs include furazolidone 100 mg four times daily or paromomycin 25 to 30 mg/kg per day in divided doses daily for 7 days. Paromomycin may be used in pregnancy instead of metronidazole. Pediatric patients can also be treated with suspensions of either furazolidone 8 mg/kg per day in four divided doses far 7 days, or nitazoxanide (Alina) 100 to 200 mg every 12 hours for 3 days. 

Pregnancy Agents contraindicated in pregnancy include podofilox, fluorouracil, and podophyllin. Imiquimod is not approved for use in pregnancy, although it has been considered after signed consent has been obtained. Bichloroacetic and trichloroacetic acid have been used without problems. Ablative therapy is also a viable option. 

ARBs appear to have the lowest incidence of side effects compared with other antihypertensive agents. Because they do not affect bradykinin, they do not cause a dry cough like ACE inhibitors. Like ACE inhibitors, they may cause renal insufficiency, hyperkalemia, and orthostatic hypotension. Angioedema is less likely to occur than with ACE inhibitors, but crossreactivity has been reported. ARBs should not be used in pregnancy. 

Chronic hypertension is defined as elevated BP that was noted before pregnancy began. Methyldopa is considered the drug of choice because of experience with its use. /3-Blockers, labetalol, and CCBs are also reasonable alternatives. ACE inhibitors and ARBs are known teratogens and are absolutely contraindicated. The direct renin inhibitor aliskiren also should not be used in pregnancy. 

Although the vaccine has not been associated with congenital rubella syndrome, its use in pregnancy is contraindicated. Women should be counseled not to become pregnant for 4 weeks after vaccination. 

The FDA approved label is the official description of a drug product and includes what the drug is used for who should take its adverse events (side effects) instructions for use in pregnancy, children, and other populations and safety information for the patient. Labels are often found inside drug product packaging. 

Retinol is contraindicated for use in pregnancy because of its teratogenic effect. 

Mitchell AA, Rosenberg L, Shapiro S, et al. Birth defects related to Bendectin use in pregnancy. JAMA 1981 245 2311-14. 

Pregnancy When used in pregnancy during the second and third trimesters, ACE Is can cause injury and even death to the developing fetus. When pregnancy is detected, discontinue the ACEI as soon as possible. 

Potentially alarming idiosyncratic reactions may occur with therapeutic doses. Pregnancy Category C. Use in pregnancy only if potential benefits justify potential risk to the fetus. 

As with ACE inhibitors, renin inhibitors should not be used in pregnancy, specifically the second and third trimesters, during which they will interfere with fetal kidney development. 

Evidence from three randomized controlled trials suggests that the optimal duration of treatment for the titration regimen is 12-18 months, and for the block-replace regimen is 6-12 months. However, people frequently relapse when treatment is stopped. People most likely to achieve remission are those with mild disease and small goitres. This approach is sometimes more convenient for the patient, with greater stability of thyroid function, though it cannot be used in pregnancy. 

Iodides should not be used alone since the normal gland will escape from iodide blockade in 2-8 weeks. Chronic use in pregnancy is not recommended because it crosses placenta and cause fetal goitre. Iodide treatment results in high intrathyroidal iodide content that can delay the onset of thioamide therapy or delay the use for radioactive iodine therapy for weeks if not months. Adverse effects include Hodism which is rare and reversible. The clinical symptoms are acneiform rash, sialadenitis, mucous membrane ulceration, conjuctivitis, rhinor-rhoea, metallic taste and rarely anaphylactoid reaction. 

There is little difference in clinical response among the various tetracyclines The selection of an agent, therefore, is based on tolerance, ease of administration, and cost. The restriction of their use in pregnancy and in patients under the age of 8 years apphes to all preparations. 

Krischnamurty, S., and S. Joshi. Gender differences and low birth weight with maternal smokeless tobacco use in pregnancy. J Trop Pediatr 1993 39(4) 253-254. 

Lee, M.J. (1998) Marihuana and tobacco use in pregnancy. Obstet Gynecol Clini North Am 25 65-83. 

Cates, C. (1999) Benzodiazepine use in pregnancy and major malformations or oral clefts pooled results are sensitive to zero transformation used. BM] 319 918-9. 

Dolovich, L., Addis, A., Vaillancourt, J.M.R., Power, J.D.B., Koren, G., and Einarson, T.R. (1998) Benzodiazepine use in pregnancy and malformations ot oral clefts meta-analysis of cohott and case-control studies. BMJ 317 839—843. 

Key to FDA use in pregnancy ratings. Physicians Desk Reference, 49th ed. (1995) Montvale, NJ Medical Economics Data Production Co., p. 2797. 

---