Prescribing for the pregnant patient Mehta, Niharika; Chen, Kenneth; Powrie, Raymond O
Cleveland Clinic journal of medicine,
06/2014, Letnik:
81, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Prescribing in pregnancy can be challenging for providers facing insufficient information about drug safety, overestimation of the risk of medications by both the patient and the care provider, and ...increasing litigation costs. This article provides key concepts to consider when prescribing for a pregnant patient and offers practical advice for choosing the safest possible drug treatments.
Mrs F is a 30-year-old woman with a history of chronic hypertension and possible preeclampsia during her first pregnancy. She is currently trying to conceive and wants to know how her hypertension ...will affect a future pregnancy and how it should best be managed, both now and during a pregnancy. The management of chronic hypertension before, during, and after a pregnancy is discussed with an emphasis on the goals of treatment and safety of medications during pregnancy and with breastfeeding. Preeclampsia is the most common complication of chronic hypertension in pregnancy and is a particular worry for Mrs F because she may have had it with her prior pregnancy. The current understanding of the pathogenesis of this enigmatic illness is therefore also reviewed, along with its implications for long-term maternal health.
Abstract Introduction Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States. Cesarean delivery is a known risk factor. This study was to determine the ...incidence of deep vein thrombosis (DVT) post cesarean delivery. Materials and Methods This was a prospective cohort study where two patients having undergone cesarean delivery each day were randomly selected. A lower extremity compression ultrasound was performed prior to hospital discharge. If no DVT was detected, participants were asked to return for a second ultrasound two weeks postpartum. Participants were also telephone-interviewed at three months for reported VTE. Results Of the 194 patients who consented to study participation, only one participant developed DVT after cesarean delivery, giving an overall incidence of 0.5% (95% CI, 0.1 to 2.8%). There were no DVT identified on the second ultrasound nor VTE reported 3 months postpartum. Conclusions We found the DVT rate after cesarean delivery to be 0.5%.
Prescribing anticoagulants to pregnant women can be difficult and stressful. Fortunately, low-molecular-weight heparins (LMWHs)
and unfractionated heparin are quite safe and efficacious when properly ...selected, dosed, and monitored. Maternal and fetal
concerns must be considered at all times, with a careful assessment of the risks and benefits of anticoagulant therapy in
each patient. Further research should help to clarify who should receive thromboprophylaxis, how to prevent adverse pregnancy
outcomes in women with various thrombophilias, and how best to treat pregnant women who have a prosthetic heart valve.
KEY POINTS Pregnancy is a hypercoagulable state. Thrombotic risk in an individual pregnancy depends on many maternal and situational
factors.
KEY POINTS When indicated, careful anticoagulation can proceed with minimal risk to the mother and fetus.
KEY POINTS Heparins, especially LMWHs, are the main anticoagulants used in pregnancy. Dosing depends on the clinical indications and
on the agent selected.
KEY POINTS If anticoagulation is absolutely necessary and LMWH is contraindicated, a newer, alternative anticoagulant should be considered.
KEY POINTS Warfarin should not be used in pregnancy in any but the highest-risk situations.
Abstract Objective To evaluate the association between intrahepatic cholestasis of pregnancy (ICP) and gestational diabetes mellitus (GDM). Study design A retrospective case-control study of ...pregnancy outcomes in 57,724 women managed at a university teaching hospital in Rhode Island, USA, in whom universal screening for GDM had been performed and who were assessed for the incidence of ICP. Pregnancies complicated by ICP or GDM between February 2005 and June 2011 were identified from the electronic patient records using appropriate ICD codes. A total of 125 cases were required to detect a difference in the incidence of GDM in ICP at 5% significance with 80% power. Demographic and clinical outcome data (including maternal age, ethnic group, BMI, and infant weight and gender) were also collected. Results Of the 57,724 pregnancies, 143 were complicated by ICP (0.25%) and 4880 by GDM (8.5%). Nineteen ICP cases had GDM. The incidence of GDM in ICP was 13.6% (19/140, OR 1.68 CI 1.04–2.72). Where gestational ages were available ( n = 105), of those screened for GDM prior to developing ICP, 13.4% (11/82, OR 1.64 CI 0.88–3.06) had a confirmed diagnosis, rising to 30% (7/23, OR 4.69 CI 1.98–11.1) in cases that were screened following the onset of cholestasis. Simple linear regression analysis of adjusted birth weight centiles in ICP revealed a significant linear trend of increasing centiles with gestational age ( p = 0.005). Conclusions These data support the hypothesis that the incidence of GDM is higher in women predisposed to developing ICP. It is likely that this susceptibility increases further following the onset of cholestasis.
Quantification of changes in glucose and lipid concentrations in women with intrahepatic cholestasis of pregnancy (ICP) and uncomplicated pregnancy and study of their influence on fetal growth.
A ...prospective study comparing metabolic outcomes in cholestastic and uncomplicated singleton pregnancies was undertaken at two university hospitals in the U.K. and U.S. from 2011-2014. A total of 26 women with ICP and 27 control pregnancies with no prior history of gestational diabetes mellitus were recruited from outpatient antenatal services and followed until delivery. Alterations in glucose, incretins, cholesterol, and triglycerides were studied using a continuous glucose monitoring (CGM) system and/or a standard glucose tolerance test (GTT) in conjunction with GLP-1 and a fasting lipid profile. Fetal growth was quantified using adjusted birth centiles.
Maternal blood glucose concentrations were significantly increased in ICP during ambulatory CGM (P < 0.005) and following a GTT (P < 0.005). ICP is characterized by increased fasting triglycerides (P < 0.005) and reduced HDL cholesterol (P < 0.005), similar to changes observed in metabolic syndrome. The offspring of mothers with ICP had significantly larger customized birth weight centiles, adjusted for ethnicity, sex, and gestational age (P < 0.005).
ICP is associated with impaired glucose tolerance, dyslipidemia, and increased fetal growth. These findings may have implications regarding the future health of affected offspring.
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