• Prevent Neural Tube Defects!  --> give folic acid 400 mcg PO daily > 3 months
• Smoking cessation/alcohol and other substance abstinence
• Chronic disorder management
• Vaccinations

• 2-8 weeks after fertilization
• Most body structures are formed during this time

• Early eyes
• Limb buds of arms/legs

• Nose/lips
• Brain is developed into 5 components
• Lumen of spinal cord is continuous with brain vesicles allowing free CSF flow

• Major organs
• Hands/feet are seen
• Testosterone produced by testes

Indications

• Family history
• Siblings with severe birth defects
• Women with > 2 miscarriages
• Women age > 34 yrs

Methods

• Chorionic villus sampling during 10-12 wks gestation
• Amniocentesis during 15-20 wks gestation

• FDA-Approved: Mifepristone 600 mg PO followed ~48 hrs later by misoprostol 400 mcg PO
• Preferred: Mifepristone 200 mg PO followed by misoprostol 800 mcg vaginally

• Infection
• Bleeding

• Reduced GI motility
• Increased gastric pH
• N/V

• Increase in TBW
• Decreased albumin binding capacity
• Increased Vd

• Decreased biliary excretion
• Increased maternal plasma volume and cardiac output
• Increased renal blood flow, GFR

• Maternal dosage
• Route of administration
• Maternal PK
• Maternal plasma protein binding
• Drug characteristics

• No fetal risk shown in controlled human studies

• No human data available
• Animal studies show no fetal risk OR animal studies show a risk but human studies do not show fetal risk

AKA "Data Free Zone"

• No controlled studies on fetal risk available for humans or animals OR fetal risk shown in controlled animal studies but no human data available
• Benefit of drug use must clearly justify potential fetal risk in this category

• Studies show fetal risk in humans
• Use of drug may be acceptable even with risks, such as in life-threatening illness or where safer drugs are ineffective

• Risk to fetus clearly outweighs any benefits from these drugs

> 18,000 - 25,000 IU/day

X

Nonpharm

• Physical exercise
• Increase dietary fiber, increase fluid intake

Pharm

• 1st line -- fiber supplements, docusate
• 2nd line -- bisacodyl, lactulose, sorbitol
• 3rd line -- senna

AVOID

• mineral oil, caster oil
• Decreases fat soluble vitamins (Vit K) which increase risk for hemorrhaging

• Elevated hCG, estrogen/progesterone, prostaglandin E2, thyroid hormones
• H. pylori seropositivity
• Abnormal peristalsis
• Psychosocial factors

Nonpharm

• Small/frequent meals
• Caffeine avoidance
• Food avoidance 3 hrs before HS
• Elevation of head of bed

Pharm

• 1st -- Ca2+ antacids
• Al3+ and Mg2+ also OK
• 2nd -- H2RAs and sucralfate (cat. B)
• 3rd -- PPIs, Reglan
• AVOID: Na Bicarb, Mg trisilicate

Nonpharm

• Increase dietary fiber
• Increase fluid intake
• Sitz bath

Pharm

• Skin protectants
• AVOID: topical anesthetics, steroids

Nonpharm

• Rest
• Decrease stress
• Ice-paks
• Massage
• Reassurance

Pharm

• APAP is safest

AVOID: Triptans, Ergotamine

Saline>Topical Decongestants>Oral Decongestants

Sudafed OK for short period

Budesonide and beclomethasone preferred as nasal spray

Treat with antihistamines

Chlorpheniramine most studied and widely used

Can use Claritin and Zyrtec (cat B)

Water is preferred

Guaifenesin/DM are category B

Codeine is Cat B

Use if you have to, but usually nothing will work because cough is due to pressure exerted by the fetus

Screen with urine culture at 1st prenatal visit and during 3rd trimester

Pharm

• Macrobid (Nitrofurantoin) x 7-10 days
• Cephalexin as an alternative x 7-10 days
• IV Cephalosporin if pyelonephritis x 2 weeks
• Schedule repeat urine culture to confirm cure

AVOID: Bactrim, Tetracyclines, Fluoroquinolones

• Use PCN even if allergy because it crosses placenta
• Desensitize if allergic

ERY (macrolide)

Baby will get conjunctivitis

Nonpharm

• Activity restriction (bed rest)
• Psychosocial therapy
• Biofeedback

Severe if SBP > 160 mmHg or DBP > 110 mmHg or:

• Proteinuria
• Oliguria
• Visual disturbances
• Pulmonary edema/cyanosis
• Epigastric pain
• Elevated LFTs
• Thrombocytopenia
• Fetal growth restriction

• ASA
• Calcium supplementation

• Delivery if term
• DBP > 110 mmHg: IV hydralazine/Labetolol. PO Nifedipine
• Mg for seizure prevention

Seizures

• Magnesium Sulfate:  Bolus 4g IV x 1, may give IM if necessary; Maintenance drip 2-4 g/hr IV; may continue 12-24 hr post delivery once normal BP/adequate diuresis
• Phenytoin
• Delivery post seizure

Methyldopa

Labetolol

Others: prazosin, nifedipine, isradipine, clonidine, diuretics

ACEI

ARB

Atenolol

• Obesity
• History of GDM
• Glycosuria
• FH of DM

• Threshold of 140 mg/dl has 10% less sensitivity than a threshold of 130 mg/dl but fewer false-positive results
• Either threshold is acceptable

Fasting: 80-110 mg/dl

2hr Postprandial: < 155 mg/dl

• SMBG daily
• MNT followed by insulin/metformin
• Moderate caloric restriction
• If estimated fetal weight > 4500g, cesarean delivery may be considered

• Propylthiouracil (PTU)
• Methimazole

• Thyroid Replacement Therapy
• Requirements increase 25-50% during pregnancy

• Antiepilepsy Drug monotherapy is recommended
• May withdraw AED prior to conception
• Vitamin K 10 mg PO daily during last month if on enzyme-inducing AED

• History of thromboembolism or hypercoagulable conditions
• Prosthetic heart valve
• Previous operative vaginal delivery or cesarean section
• Obesity/smoking
• Family history of thrombosis

• Compression stockings
• Low Molecular Weight Heparin preferred
• Unfractionated heparin alternative
• AVOID: Warfarin during pregnancy -- it may be substituted post-partum and continued for at least 6 weeks

• Rh factor is an inherited protein found on the surface of red blood cells
• If mother is Rh-Negative, there is incompatibility between the blood of a mother and her baby
• Mother produces antibodies and may cause destruction of fetal red blood cells

Rho(D) Immune Globulin

• Give at 28 weeks gestation, unless the father is also known to be Rh-negative
• Give within 72 hrs after the delivery of an Rh-positive newborn
• Give after a 1st trimester pregnancy loss
• Give after invasive procedures, such as chronic villus sampling, amniocentesis, or fetal blood sampling

Cervical changes and uterine contractions before 37 weeks gestation

• Previous preterm delivery
• Multiple gestation
• Infections
• Poverty
• Non-Caucasian race
• Maternal smoking/alcohol/drug use
• Uterine functional causes
• Fetal causes (congenital anomalies and growth retardation)

• Used as early as 20 weeks gestation has shown reduction in preterm delivery

Labor Inhibitors

Used to postpone delivery for:

• administration of antenatal corticosteroids
• Transportation of mother to facility equipped for high-risk deliveries

Antenatal corticosteroids use helps produce surfactant in the lungs of the baby -- takes 24 hrs to get doses in

• Intrauterine infection
• Fetal distress
• Severe preeclampsia
• Vaginal bleeding
• Maternal hemodynamic instability

• Ca2+ Channel Blockers (Nifedepine)
• Beta-Adrenergic Agents (Terbutaline)
• Magnesium IV
• NSAIDs (Indomethacin)

• Hyperkalemia
• Arrhythmias
• Hyperglycemia
• Hypotension
• Pulmonary edema

• Shown to be ineffective as a tocolytic and increased mortality in infants
• Causes "floppy baby" in infants

• Maternal Side Effects RARE
• pulmonary edema
• hypotension
• muscle paralysis
• tetany
• cardiac arrest
• respiratory depression

• Used for fetal lung maturation --> prevents respiratory distress syndrome, intravascular hemorrhage, death of premature infants
• Indicated in women 24-34 weeks gestation at risk for preterm labor in next 7 days

Dosing

• Betamethasone 12 mg IM q24hr x2
• Dexamethasone 6 mg IM q12hr x 4

• PCN G 5M units x 1, 2.5-3 M units until delivery
• Ampicillin 2 g IV x 1, 1 g q4hr until delivery

If Penicillin Allergy:

• No anaphylaxis -- cefazolin 2 g IV x1, 1 g q8hr until delivery
• Anaphylaxis -- Clindamycin 900 mg IV q8h until delivery
• Anaphylaxis (Clindamycin resistant or sensitivities unknown) -- Vancomycin

• Prolongation of 1st and 2nd stages of labor
• Hypotension
• N/V
• Itching
• Urinary retention

• Metoclopramide
• Antipsychotics
• Domperidone
• Oxytocin
• Alcohol

• Nicotine
• Estrogen
• Bromocriptine
• Diethylstilbestrol
• Dinoprostone
• Metergoline
• Pyridoxine
• MAOI

• Amphetamines
• Lithium
• Antineoplastics
• Bromocriptine
• Ergotamine
• Nicotine
• Drugs of abuse (cocaine)

• Alcohol in moderation
• Analgesics
• Anticonvulsants
• Antibiotics
• Caffeine in moderation
• Laxatives
• Insulin

high doses

C