Cases: Drugs in Pregnancy

1. Cases: Drugs in Pregnancy Max Brinsmead PhD FRANZCOG March 2014

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… • 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 It is a category B3 for ingestion during pregnancy 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

4. Jenny Q – what we did • Jenny was counselled: • 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%) • 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

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 • 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 and cause discolouration of a baby’s 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) • Options for the pregnancy and the potential baby were explored with the assistance of a social worker

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

10. 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. • 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 • 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

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

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

14. Heather B - The Problem • 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

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

16. Tiffany S - The Problem • 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

17. Tiffany S – What we did • 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 • A PV scan was reassuring • She is advised to discontinue all alcohol for the remainder of the pregnancy and lactation period

18. Tiffany S – Other Issues • 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

19. 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 • However, it is the lifestyle (incl smoking) that is the issue • And good outcomes can occur with good antenatal care of heroin users

20. Tiffany S – What we did • 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 • She was provided with close, supportive, multidisciplinary AN care • She was unable to stop smoking • Her partner was less successful on Methadone and she eventually separated and turned to her parents for support

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