Drugs in Pregnancy and Lactation Materials

DRUGS IN PREGNANCY AND LACTATION: DO NOT LET DOWN YOUR PATIENTS

ASHLEY WALSH, PharmD

Ashley Walsh is a graduate of the University of Connecticut, School of Pharmacy, with a BS in Pharmacy Studies and a Bachelor of Science in Molecular and Cell Biology.

Topic Overview

Nine in ten women report taking at least one medication during pregnancy. A great need exists to provide medication safety information to all women of childbearing potential. Prenatal care should start well before conception. Still, for most, prenatal care begins once they realize they are pregnant (or later), leaving a gap in care from conception to the first consultation with a healthcare provider. Identifying pregnancy and lactation status is a major barrier to intervention by pharmacy staff. In addition, women of childbearing potential may have chronic conditions requiring prescription medication. Understanding medication safety is important to improve maternal and infant health. Patient education prevents unnecessary premature infant weaning and non- adherence to medications. Although some medications are known teratogens, information about safety in pregnancy and lactation is lacking. Trusted information resources help determine appropriate medications.

Accreditation Statement

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-24-123-H01-P

Pharmacy Technician  0669-0000-24-124-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: September 5, 2024 Expiration Date: September 5, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians

How to Earn Credit: From September 5, 2024, through September 5, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Recognize common pregnancy-related ailments and medication safety resources

Describe the effects of medication use during pregnancy and lactation

List safe and effective over-the-counter medications for patients who are pregnant or lactating

Identify methods to determine pregnancy or breastfeeding status

Disclosures

The following individuals were involved in developing this activity: Ashley Walsh, PharmD, Jeannette Y. Wick, RPh, MBA, FASCP, and Pamela Sardo, PharmD, BS. Pamela Sardo, Jeannette Y. Wick, and Ashley Walsh have no conflicts of interest or financial relationships regarding the subject matter discussed. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

Drugs in Pregnancy and Lactation: Do Not Let Your Patients Down Introduction

According to the Centers for Disease Control and Prevention, childbearing is a common experience among women in the United States. Nine in ten women report taking at least one medication during pregnancy. A great need exists to provide medication safety information to all women of childbearing potential. Pharmacies can expand their services and contribute towards providing care for pregnant or breastfeeding women in the community. Pharmacists can assist with ensuring medication safety for those of reproductive potential.

Women of Childbearing Potential

In the United States (US), an estimated 50% of all women experience at least one birth by age 25, and 85% have given birth by age 44.1 Since 1996, healthcare practitioners have focused on improving pregnancy outcomes by improving and promoting preconception care (PC). 1,2 The Select Panel on Preconception Care (SPPC) defines PC as “a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management.” Unfortunately, there is limited evidence determining effective methods to deliver this and improve PC.1

The American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) describe pre- pregnancy care goals to reduce the risk of adverse health effects for the woman, fetus, and neonate. In furtherance of these goals, they recommend healthcare providers collaborate with the woman to address modifiable risk factors, optimize health, and provide education about healthy pregnancy.3

ACOG and ASRM also recommend reviewing all medications during pregnancy counseling, including nutritional supplements and herbal products, that could affect reproduction and pregnancy.3 Despite available recommendations, millions of women and couples lack PC.1 All patients, planning and not planning a pregnancy, can benefit from PC. Reserving PC only for women planning a pregnancy risks the first prenatal visit being too late to prevent certain outcomes for the mother or infant.4 A simple recommendation for patients to take folic acid supplementation prevents neural tube defects when taken before conception and throughout the first trimester.5 Also, healthcare providers should screen male partners for androgen use, which is associated with reversible (with cessation) azoospermia (no sperm in ejaculate) and infertility in males.3

Healthcare providers should assess and address prenatal risks for “every woman, every time.”4 One Key Question is an initiative backed by ACOG and ASRM, providing a framework for healthcare providers to routinely ask: “Would you like to become pregnant in the next year?”3,6 Furthermore, any patient encounter is an opportunity to counsel about wellness, possibly improving obstetric and reproductive outcomes should they choose to reproduce.3 Pharmacists may consider adapting screening tools to provide or refer preconception care.4

Resources for Preconception Care: Screening tools, examples, and guidance are available from the Preconception Health and Healthcare Initiative at the following link: https://beforeandbeyond.org/resources/screening-tools/

The American Academy of Pediatrics, World Health Organization, and Institute of Medicine concur that mothers should breastfeed exclusively for the first 6 months and continue for 1 year or longer (as mutually desired by mother and infant).8,9,10 Breastfeeding decreases infants’ mortality risk due to

diarrhea or other infections. During illness, breastmilk is crucial, supplying energy and nutrients.10 Breast milk reduces child mortality in those who are malnourished.10 In addition to infants’ benefits, breastfeeding contributes to the health of mothers by reducing ovarian and breast cancer risk.10

Barriers to Care

Pharmacists serve as a medication resource to patients and prescribers.11 Pharmacists can provide drug information regarding toxicity during pregnancy and lactation.4 Unfortunately, recommendations regarding medications are inconsistent among scientific resources and, at times, may be conflicting.12 Since pharmacists feel their formal education lacked adequate training on maternal medication use, unnecessary disruption to breastfeeding is recommended.12

Younger women and women with learning disabilities may fail to recognize pregnancy. Patients may overlook or misinterpret early signs and symptoms. Furthermore, patients may misinterpret symptoms or attribute them to other causes. Age, health, or contraception may lower patients’ perceived likelihood of pregnancy. Patients may not understand the risk for pregnancy while using contraception. Patients may not experience any pregnancy symptoms. Others may not be self-aware enough to recognize symptoms or are in denial. Regardless, misinterpretation and delaying care may cause adverse pregnancy outcomes.13

Patients may feel afraid, depressed, or ambivalent, resulting from a confirmed pregnancy. These emotions can lead to avoidant and delaying coping strategies. Female teenagers and women misusing substances may feel judged. This can result in feelings of anxiety, leading to pregnancy secrecy and ongoing concealment.13 Delayed decision-making or perceived obligation to terminate pregnancy may also contribute to postponing care.13

Identifying pregnant or lactating women is difficult and often a sensitive topic.12 Methods to determine status include scanning patient profiles for prenatal vitamins, physician communication, patient self-disclosure, and signature waivers (patient signs a waiver declaring pregnancy status).12

Discomfort while breastfeeding in public has been associated with shortened lactation duration. Reports are available on social media depicting people shaming those who are breastfeeding or telling them they cannot breastfeed in a public place. This may cause women to avoid public breastfeeding and avoid breastfeeding in front of individuals who make them feel uncomfortable. Patients need more support to avoid social isolation and continue lactation as desired.14

Takeaway:

How would you identify pregnant or lactating patients in the pharmacy setting?

Medication Safety

Researchers have designated only a few medications as safe and effective in pregnancy, which limits prescribers' options.11 Medication decisions are personal and complex.15 With prescriber recommendation, medications might be necessary when the potential benefits for the patient outweigh the risks to the infant or fetus. Table 1 lists select drugs and their risks in pregnancy and lactation.16-27 Patients who are pregnant should take the lowest effective doses of the safest medications whenever medically reasonable.

Pharmacy staff can discuss medication information patients read on the internet regarding safety in pregnancy.28 Certain websites may inaccurately claim a medication is safe or unsafe in pregnancy. Patients cannot trust a product’s safety merely because it says “natural.”28

Balancing risks to the infant against the potential benefits of maternal treatment and the risk of untreated disease is challenging.29 Resources are available to guide decision-making about medication risks for a pregnant or lactating patient.4,29

Pharmacists should begin evaluating medication use in pregnancy and lactation by searching primary literature. PubMed, Ovid, ProQuest, Embase, and Web of Science are available for access to information.29 Pharmacists can also gather information using REPROTOX (a database). This source provides a summary of available primary literature and details medications’ impact during pregnancy and lactation.29

More details about medications used during lactation are available through LactMed, a peer-reviewed free database (found at www.ncbi.nlm.nih.gov/books/NBK501922). LactMed provides information about drug levels in breast milk and infant blood, drug effects on milk supply, and lactation success. It also suggests alternate therapy to harmful medications.29

Medication safety on the drug label is another source of information.29 In 2014, the Federal Drug Administration (FDA) finalized the Pregnancy and Lactation Labeling Rule to improve pregnancy and breastfeeding-related information presentation. Previously, prescribing information categorized medications by letter (A, B, C, D, and X). These letters designated drugs ranging from no evidence of risk demonstrated to studies showing clear evidence of fetal risk.29,30 Since June 2015, over 2200 prescription medications have updated labeling format.15 New labels have abandoned the letter-based system and replaced it with three categories: pregnancy, lactation, and females and males of reproductive potential.29,30 Pharmacists should refer

patients for a maternal-fetal medicine consultation or genetic counseling to explore the risk-benefit profile of medications with known risks or newer medications with limited safety data.29

Takeaway:

How will you balance acquiring the necessary information about drug safety with a workload?

Adverse Pregnancy Outcomes

Adverse pregnancy outcomes that may be caused by medications include the following:1,17,18

Birth defects

Infant death

Low birth weight

Miscarriage

Neonatal abstinence syndrome (also called NAS)

Preterm birth

Stillbirth

Sudden unexpected infant death (also called SUID)

Specificity of the medication, dose, stage of embryonic development, genotype of the mother and fetus, drug interactions, and other environmental or morphological factors affect medications’ teratogenicity.11 Pharmacists recognize teratogenic drugs and can provide recommendations for alternate therapies.4

Pharmacists should review and discuss each medication’s pregnancy safety with patients seeking counseling. Specifically, pharmacists need to identify potentially teratogenic medications and review risks in detail. Patients

taking teratogenic medications need to understand reliable contraception’s importance. Healthcare providers should collaborate with patients desiring pregnancy who are taking teratogenic medications to adjust medications before contraception discontinuation. Providers need to guide transitioning to safer medications.3 Table 2 provides a list of medications associated with adverse pregnancy outcomes and recommendations for effective PC.1,33,34,35

Table 2

Adverse Pregnancy Outcomes and Effective Preconception Care1,33-35

Anti-epileptics

Some are teratogenic; consider lower doses of the current

regimen

Medication (Preconception Risk)

Recommendations to Reduce Adverse Outcomes in Pregnancy

Isotretinoins Avoid, can result in miscarriages or birth defects

Levothyroxine Increase doses for proper neurologic development of the fetus

Oral anticoagulants Avoid exposure during early pregnancy, change to nonteratogenic medication

Pregnancy Registries and Research Studies

The 21st Century Cures Act established a Task Force for the National Institutes of Health called Pregnant Women and Lactating Women (PRGLAC). They advised the Secretary of Health and Human Services regarding gaps in knowledge and research on safe and effective therapies for pregnant and lactating women, finishing their work in 2021.36 The recommendations’ underlying theme was to include pregnant and lactating women in clinical research by removing them as an example of a vulnerable population.37 PRGLAC also recommended removing regulatory barriers to research in

pregnant women and optimizing registries with a user-friendly website for listings.37

Patients can volunteer to enroll in a pregnancy exposure registry to help healthcare providers and other pregnant patients. Registries collect information to learn more about prescription medication (and vaccination) safety.28 Pregnancy exposure registries may include patients who have not taken a researched medication. Registries also collect information about newborns after birth.38

Patient Resource:

Patients can find a list of pregnancy exposure registries at the FDA’s List of Pregnancy Exposure Registries: https://www.fda.gov/consumers/pregnancy-exposure-registries/list- pregnancy-exposure-registries

Pharmacy staff should encourage patients to report problems with their medications. FDA MedWatch gathers information about unexpected side effects or adverse events, product quality problems, preventable product use or medication errors, and therapeutic failures. Options for reporting problems include calling a 1-800 number to request a form by mail or completing it online.28

Research studies collect information about medication safety during pregnancy. Patients who choose to join a study will continue their current medications and will not change any part of their health routine.39

Takeaway:

Patients can submit their interest in joining a study at MotherToBaby, a service of the non-profit Organization of Teratology Information Specialists (OTIS), at the following link:25 https://mothertobaby.org/join-a-study- form/ or by calling (877) 311-8972.

Question:

Who would you encourage to join a pregnancy exposure registry or research study?

Chronic Conditions Requiring Medication

Women who have chronic conditions will often continue to need treatment while pregnant and lactating. Such patients have limited therapy options. Pharmacists are available to manage chronic conditions and recommend alternatives.4 Examples of health conditions managed during pregnancy include the following:39

Asthma

Depression

Epilepsy

Heart disease

Infectious diseases

Pain

Thyroid disorders

Pregnant patients experience anatomical, physiological, and hemodynamic changes.11 Additionally, hormonal mediated and immune response changes may affect medication pharmacokinetics and

pharmacodynamics. Studies focused on pharmacology and specific conditions during pregnancy with associated physiological changes are lacking. Providers need evidence-based guidelines to optimize treatment during each trimester.11

Ideally, pharmacists should counsel patients with diabetes mellitus about disease control before pregnancy. Uncontrolled diabetes increases the fetal rate of congenital anomalies.5 Counseling includes discussion about optimal weight management, glucose monitoring, regular exercise, alcohol and tobacco cessation, and available social support.5 Providers should screen women for thyroid disease and initiate appropriate therapy.5 Prior to pregnancy, patients with epilepsy should consider anticonvulsant discontinuation or consider an alternative treatment.5

Potentially, asthma may worsen with pregnancy. Medication management and counseling patients to avoid triggers are important to control asthma.5 Before becoming pregnant, patients with hypertension should consider changing their regimen to avoid adverse fetal effects. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.5

Pregnancy-related Ailments Nausea and Vomiting

A common condition associated with pregnancy is nausea and vomiting. Although nausea and vomiting present no harm to the fetus, it can affect the patient’s ability to work or participate in everyday activities. Safe treatment options are available to improve symptoms and prevent them from worsening.40

Non-pharmacological interventions include eating dry toast or crackers before getting out of bed in the morning, eating five or six small meals daily to avoid an empty stomach, and eating frequent bites of nuts or fruits.40

Patients for whom these changes are unsuccessful may consider medication. Initially, patients should try vitamin B6 (available OTC) for nausea and vomiting in pregnancy. If symptoms remain after trying vitamin B6, patients can add doxylamine (OTC sleep aid) to their treatment. Alternatively, a prescription medication combining vitamin B6 and doxylamine is available and is safe and effective without fetal harm.40 Lastly, patients who failed other treatment options can take antiemetics.40

Although some antiemetics are safe during pregnancy, safety information is conflicting or limited.40 The European Medicines Authority recommends avoiding ondansetron in the first trimester based on findings from large epidemiological studies showing a small increased risk of oral clefts.41,42 Conversely, a meta-analysis found no significant association observed with major congenital malformations.43 The decision to take any medication during pregnancy is based on whether the benefits outweigh the potential risks.40

Patients commonly choose OTC antihistamines, like diphenhydramine, during pregnancy to treat nausea, vomiting, and relieve allergy symptoms (e.g., itchy or runny nose, sneezing, water eyes). The National Birth Defects Prevention Study studied 54 antihistamines and looked at more birth defect phenotypes than previously reported. The study has found no association between birth defects and antihistamine use.44 Meclizine is another antinauseant option. Patients can take meclizine 25 mg orally every four to six hours as needed. Although the results of human studies regarding the association between meclizine and fetal facial clefts are mixed, three large trials found no association with teratogenicity.45,46,47 Another safe antiemetic agent is promethazine, when administered orally or rectally, 12.5 to 25 mg every four hours.48

Constipation

Factors responsible for causing constipation in pregnancy are as follows:49

Hormonal changes (progesterone)

Inadequate hydration

Insufficient fiber intake

Lack of physical activity

Medications (e.g., iron, calcium)

Stress

Unbalanced diet

Patients can adjust their nutrition intake and aim for 25 to 30 grams of fiber by consuming 4 to 5 cups of fresh fruits and vegetables daily.49 Patients struggling to reach their daily fiber goals may consider taking fiber supplements, like psyllium or methylcellulose (bulk-forming laxative).49,50 Additionally, staying hydrated by drinking plenty of water is helpful. Patients should engage in moderate exercise for 150 minutes per week.49

Beyond lifestyle changes to modifiable factors, there are medications patients can safely use during pregnancy for constipation. Prescription and OTC medications are available treatment choices.49

OTC medications may introduce small risks.50 Medications indicated for constipation include osmotic and stool softener laxatives, lubricants, and stimulants. The intestine absorbs osmotic laxatives minimally, so exposure to the developing infant is expectantly low.50 Laxatives cause food to move through the intestines quicker and may reduce the amount of nutrients absorbed, possibly causing nutrient deficiency.50 Magnesium hydroxide and polyethylene glycol are available OTC, and sodium bisphosphate and lactulose are prescriptions.50 Fetal exposure to docusate sodium (a stool softener) is small since very little medication reaches the patient’s bloodstream. According to available information, docusate sodium is unlikely to increase the chance of birth defects when used as directed.51 Other OTC medications—stimulants (e.g., senna, bisacodyl, and castor oil) and lubricants (e.g., mineral oil)—may cause severe stomach cramps, and patients should use them with caution.50 Patients should be aware that castor oil may cause bowel and uterine cramping. Toward the end of pregnancy, patients need to discuss using castor

oil with their providers because it may begin labor. This is not a concern earlier in pregnancy when the cervix is not ready for labor.50

Prucalopride is a prescription used to treat chronic idiopathic constipation (happening for at least 6 months) with ongoing pregnancy exposure monitoring.52,53 This medication has a pregnancy exposure registry; however, available case reports are insufficient to identify any drug-associated risks of miscarriage, major birth defects, or adverse maternal or fetal outcomes. Thus, patients may want to save this option as a last resort if possible.52 Notably, patients taking prucalopride excrete this medication in breast milk. Data on the effects on the infant or milk supply is lacking.52

Pain

Back pain is a common problem in pregnancy.54 Stretching abdominal muscles, hormone changes, and the growing uterus contribute to back pain. Patients should wear supportive clothing, like an abdominal support garment, and low-heeled shoes with good arch support (e.g., athletic or walking shoes).54 Pharmacists should refer patients experiencing severe back pain or ongoing pain for more than two weeks to their obstetrician-gynecologist to rule out other causes of pain.54

Pharmacy staff can assist patients who are pregnant with back pain in choosing a suitable pain reliever. Technicians can alert the pharmacist that a patient needs an OTC recommendation. Pharmacists should advise patients who are pregnant to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) during their last trimester (after 28 weeks) since they can cause serious infant blood flow problems. Taking aspirin may cause bleeding problems in the mother or infant during pregnancy or delivery.55

ACOG has always identified acetaminophen as one of the only safe pain relievers during pregnancy. Studies have shown unclear evidence proving a direct relationship between acetaminophen during any trimester and fetal developmental issues.56,57 However, pharmacists should recommend

acetaminophen with caution. Recent experimental and epidemiological research suggests prenatal exposure to acetaminophen may alter development and increase the risk of neurodevelopmental, reproductive, and urogenital disorders. A consensus statement published in the journal Nature Reviews Endocrinology recommends minimizing use whenever possible.58

Drugs in Breast Milk

Infants’ medication exposure and associated risks continue after birth during breastfeeding.11 Primarily, pharmacists’ roles in medication management are to prevent or lower the risk of adverse effects in infants through transferred medication in breast milk.12 Since few large clinical trials enroll breastfeeding women, pharmacists often have limited data to work with, like case-control studies or animal studies .11

Through passive diffusion, medications pass from maternal plasma into maternal milk.59 More drug penetrates milk during the first week postpartum.11 Drug-specific factors affect the amount of drug entering the mother’s milk supply. Table 3 lists those factors.11

Patients may manage or treat minor ailments with OTC medications and rely on their pharmacy for recommendations. Pharmacists should not make any recommendations regarding medication use without evidence demonstrating safety in breast milk. Safety is important; however, overcautious recommendations may compromise breastfeeding women’s health by leaving conditions untreated.60 Pharmacists’ hesitancy to offer recommendations may result in premature infant weaning or medication non- adherence.61 “When in doubt, don’t breastfeed” is a misconception regarding medication use while breastfeeding. Often referred to as “pump and dump,” women pump to collect breastmilk and then discard it to prevent infant drug exposure. In most situations, this is an unnecessary practice. Brief disruptions in breastfeeding results in substantial negative effects on the infant and the mother’s milk supply.12

Partnering with patients and engaging them in shared decision-making is important in reproductive healthcare. Patients are more likely to participate in their care when healthcare providers include them in the conversation about their treatment options. Shared decision-making involves multiple stakeholder perspectives (e.g., patient, provider, nurse midwife, lactation consultant, pharmacist). Patients’ decisions are sensitive to their concerns, needs, and preferences. They are also lifestyle-dependent. Personalized patient care improves patient experience.62

Lactation-related Ailments

Circumnavigating the involvement of a healthcare professional, patients may self-diagnose and purchase OTC medications. Commonly sought information includes directions for use, efficacy, and methods to minimize transfer into breast milk.63

Women who are breastfeeding may be concerned about insufficient milk production, leading to inadequate infant nutrition.61 They are highly susceptible to developing health problems, including breast redness and engorgement.61 The La Leche League recommends nursing or expressing milk

at least every 2 hours, using ice (20 minutes on, then 20 minutes off), and taking a hot shower to help engorgement.64 Pharmacists can also recommend medication for the pain. LactMed recommends acetaminophen or ibuprofen for analgesia since the amount of drug in milk is much less than the doses given to infants.20,65

Women who are breastfeeding may also be concerned about contraception options and medication transfer to their breastfed infant.60 LactMed reports progesterone is unharmful to milk production or nursing duration. The amount of progesterone ingested by the infant (through breastmilk) is small and not expected to cause adverse effects.66

Learning More

Patients can access trusted resources when learning about medication safety in pregnancy or lactation. Pharmacy staff should remind patients to consider their source of information before making any choices. Pharmacies can suggest websites from Table 4 to steer patients in the right direction.28,39,67,68,69,70

Summary

Patients who are pregnant or lactating are concerned with their health and their infant’s health. Pharmacists can assist patients in choosing safe medications and balance their need for therapy with any risks. Trusted resources are available to research medication safety and guide recommendations for treatment.

Course Test

Which is true about treating constipation in pregnancy?

Prucalopride is a first-line treatment choice

Castor oil is safe for use during any trimester

Laxatives carry no risk of nutrient deficiency

Psyllium is a supplement that increases fiber

What is TRUE about treating common pregnancy-related ailments?

Avoiding medication is always the safest option

Non-pharmacological options offer the most relief

Acetaminophen use is generally safe in the first trimester

All OTC medications are safe in the third trimester

Which option below is most likely to identify a pregnant patient?

Scan the patient’s medication profile for prenatal vitamins

Identify pregnancy based on physical appearance

Suspect every woman of childbearing age is pregnant

Ask every woman if she is currently pregnant

Where can a pharmacist direct patients to find trustworthy information about medication safety during lactation?

Primary literature

MotherToBaby

Exposure registries

Research studies

Which of the following medications require increasing doses for proper neurological development of the fetus?

warfarin

folic acid

levothyroxine

methylcellulose

Which statement is TRUE about safely taking medication during pregnancy?

NSAIDs are safe after 28 weeks gestation

Isotretinoin is safe during all trimesters

Folic acid is unsafe before the second trimester

Acetaminophen is generally safe during all trimesters

A patient says she is 5 weeks pregnant. She asks to fill her prescription for warfarin, but it has zero refills. You should

call the provider who wrote the warfarin prescription and suggest an alternative.

call the patient’s OBGYN to alert them the patient is pregnant and taking medication.

inform the patient that you will request refills with the prescription.

inform the patient that she needs a referral for genetic counseling.

A pharmacist will most likely get evidence-based information about medication safety for pregnant patients from

medication labels.

ProQuest.

LactMed.

Google.

What ailments are common in pregnancy?

Seasonal allergies

Constipation and pain

Asthma attacks

Arthritis and diarrhea

Which statement is correct regarding medication use in breastfeeding patients?

Patients can “pump and dump” without any adverse results

Ibuprofen is generally safe since the amount in milk is less than the amount given to infants

Acetaminophen is unsafe since the amount in milk is more than the amount given to infants

Progesterone causes adverse reactions in the mother and infant

References

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Stanhope KK, Kramer MR. Association Between Recommended Preconception Health Behaviors and Screenings and Improvements in Cardiometabolic Outcomes of Pregnancy. Prev Chronic Dis. 2021;18:E06. Published 2021 Jan 21. doi:10.5888/pcd18.200481

ACOG Committee Opinion No. 762: Prepregnancy Counseling. Obstet Gynecol. 2019;133(1):e78-e89. doi:10.1097/AOG.0000000000003013

DiPietro Mager NA. Fulfilling an Unmet Need: Roles for Clinical Pharmacists in Preconception Care. Pharmacotherapy. 2016;36(2):141-

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Jack BW, Atrash H, Coonrod DV, Moos MK, O'Donnell J, Johnson K. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S266- S279. doi:10.1016/j.ajog.2008.07.067

Power to Decide. One key question online. Powertodecide.org. Updated 2024. Accessed April 14, 2024. https://powertodecide.org/what-we- do/information/resource-library/one-key-question-online

Preconception Health and Healthcare Initiative. Preconception clinical toolkit. Beforeandbeyond.org. Published 2014. Accessed May 1, 2024. https://beforeandbeyond.org/toolkit/desires-pregnancy/at-your- fingertips/

McGuire S. Institute of Medicine (IOM) Early Childhood Obesity Prevention Policies. Washington, DC: The National Academies Press; 2011. Adv Nutr. 2012;3(1):56-57. doi:10.3945/an.111.001347

Meek JY, Noble L; Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988

World Health Organization (WHO). Infant and young child feeding. Who.int. Published December 20, 2023. Accessed April 23, 2024. https://www.who.int/news-room/fact-sheets/detail/infant-and-young- child-feeding

Griffin BL, Stone RH, El-Ibiary SY, et al. Guide for Drug Selection During Pregnancy and Lactation: What Pharmacists Need to Know for Current Practice. Ann Pharmacother. 2018;52(8):810-818. doi:10.1177/1060028018764447

Byerley EM, Perryman DC, Dykhuizen SN, Haak JR, Grindeland CJ, Muzzy Williamson JD. Breastfeeding and the Pharmacist's Role in

Maternal Medication Management: Identifying Barriers and the Need for Continuing Education. J Pediatr Pharmacol Ther. 2022;27(2):102-108. doi:10.5863/1551-6776-27.2.108

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Leeming D, Marshall J, Hinsliff S. Self-conscious emotions and breastfeeding support: A focused synthesis of UK qualitative research. Matern Child Nutr. 2022;18(1):e13270. doi:10.1111/mcn.13270

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DISCLAIMER

The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.

Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course, or course material.

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