Download - Pregnancy Physiology & Conditions
Pregnancy Physiology & Conditions
Dr Hadi Esmaily PharmD.
Pregnancy CheckβhCG & αhCGTypesAccuracyFalse negative:
1. Done before the first day of a missed period
2. Urine is not at room temperature3. Ectopic pregnancy4. History of ovarian cysts (PCOs)5. Menotropins or chorionic gonadotropin
TerminologyParity: Number of deliveries after 20
weeks' gestationGravida: Number of pregnanciesExample: a Pregnant woman who
has previously delivered one set of twins & had 1 abortions is described as a gravida 3, para 1 (G3, P1)
Perinatal period: 20th week of gestation -28th day after birth
Terminology Cont.Gestational age: the time from the
start of the last menstrual cycleAbortion: a delivery before 20 weeks'
gestationPreterm birth A fetus delivered
between 20-37 weeks' gestationTerm infant: A fetus delivered
between 37-42 weeks' gestationPostmaturity birth: A fetus delivered
after 42 weeks' gestation
Pregnancy PhysiologyConception begins after
fertilization of an ovumAfter 5-6 days, blastocyst
adheres to the endometriumIt secretes hCG, maintains the
corpus luteum so that menstruation is prevented & pregnancy can continue
Pregnancy Physiology8-10 days after conception, hCG
can be measuredPlacenta serves as a strong
barrier but a few cells are able to cross
Date of Confinementseveral methods:
1. LMp2. Pelvic Examination3. Uterine Size4. Fetal parameters by ultrasound
Add 7 days to the first day of the LMp, subtract 3 m & add 1 y (Naegele rule)
Vitamins & Minerals Supplementation
Nutritional status should be assessed preconceptionally with the goal of optimizing maternal, fetal, & infant health
Iron Iron requirements ↑ because:
1. Maternal blood volume expansion
2. Fetal needs3. Placenta cord needs4. Blood loss at the time of
delivery5. Some women may already have
inadequate body stores of iron before pregnancy
Iron supplementation is necessaryA pregnant woman needs
about 18 to 21 mg iron/day(15-50% ↑Absorption)
Anemia in PregnancyAnemia in Pregnancy:
◦1st & 3rd Trimester: Hb<11◦Second Trimester: Hb<10.5
The classic morphologic changes outside of pregnancy, are not prominent in pregnant women.
Women with iron deficiency needs 60-120 mg iron daily
Folic AcidThe RDA of Folic Acid in
pregnancy is 0.6 mg (0.4-0.8)women who receive folic acid
daily during the first trimester are less likely to have a child with neural tube defects (Spina Bifida & Anencephaly)
CalciumCa is needed for adequate
mineralization of skeleton & teeth, esp. in the 3rd trim. as teeth formed
The RDA in pregnancy◦1,000 mg/day for women >19 y ◦1,300 mg/day for women <19 y
Pregnancy-Induced Pharmacokinetic ChangesPhysiologic changes can alter the
absorption, distribution, metabolism, & elimination of drugs.
Factors influence pharmacokinetics of drugs:1. Maternal physiologic changes 2. The effects of the placental-fetal
compartment
Nausea & Vomiting50-80% during 5-12 weeks of
gestation~ 91% of cases will resolve by 20
wManagement:
1. Non Pharmacologic2. Pharmacologic
Non Pharmacologic ManagementSmaller frequent meals consisting
of a low-fat, bland, & dry diet (e.g., bananas, crackers, rice, toast)
Avoid spicy & highly aromatic foodsTake prenatal vitamins with iron at
night High protein mealsRest Avoidance of the sensory stimuli
Pharmacologic ManagementModerate-Severe N/V that
nonpharmacologic fails or threatens metabolic or nutritional status
H1 receptor blockers & Pyridoxine (B6)(Diphenhydramine, Hydroxyzine,
Dimenhydrinate)Phenothiazines or Metoclopramide if
antihistamines fail
Dosing of Pharmacologic Management
Medications Used for Nausea & Vomiting during Pregnancy
Drug Dose Pregnancy CategoryPyridoxine 10–25 mg PO three to four times
dailyA
Diphenydramine 25–50 mg PO, IV, IM every 4–6 hrs B
Hydroxyzine 25–50 mg PO every 6–8 hrs CPromethazine 12.5–25 mg PO, PRN every 6 hrs C
Metoclopramide 5–10 mg PO, IM, IV every 8 hrs B
Ondansetron 4–8 mg PO, IV every 8 hrs B
Ginger (Zingiber Officinale)Randomized trials and
controlled studies suggest that powdered ginger is more effective than placebo, and equivalent to vitamin B6
↑ Adverse effects on pregnancy outcome has not been reported, but larger studies are needed
Reflux EsophagitisReflux esophagitis/heartburn is affecting
2/3 of womenEnlarging uterus ↑Intra-abdominal
pressure, & estrogen/progesterone relax the esophageal sphincter
Management:1. Lifestyle Modification2. Calcium Carbonate3. Aluminum Antacids4. H2 Blockers5. PPIs
Urinary Tract InfectionsIt is one of the most common
complications of pregnancy Changes leads to bacteriuria
1. Enlarged uterus (compress the ureters)
2. ↑Progesterone → Relaxation of ureteral muscle
3. Urine alkalization4. Glucosuria
Asymptomatic Bacteriuria Versus
Acute Cystitis>105 CFU of bacteria, obtained by 2
consecutive clean-catch samples If in the absence of any urinary
symptomsAsymptomatic Bacteriuria
If with frequency, urgency, dysuria, and hematuria without fever
Acute Cystitis
Urinary Tract Infections Cont.If ASBs are left untreated lead to
pyelonephritis, low-birth-weight infants, and premature delivery
Most common pathogens:1. E. coli2. Klebsiella pneumonia3. Proteus mirabilis,4. Enterobarter species
Urinary Tract Infections Cont.
Common Antibacterials:1. Penicillins2. Cephalosporins3. Nitrofurantoin
Pyelonephritis in Pregnancy1-2%Leads to sepsisParental Antibiotics:
◦Cefazolin 2 g IV every 8 hours◦Gentamycin (targeted peak of 8 mcg/mL and
trough less than 1 mcg/mL)Continued for at least 48 hours after
becoming afebrileThen Continue orally cephalexin 500 mg
PO four times daily for a total of 10-14 days of antibiotic therapy (PO+IV)
Diabetes MellitusPregestational DiabetesGestational Diabetes Mellitus (GDM)Goal:
1. FPG: <90 mg/dL2. Premeal <100 mg/dL3. l-hour postprandial: 100-120 mg/dL4. Hb-Alc levels in the normal range (4.5-
5) Insulin Versus Oral Hypoglycemics
HTNHypertension in pregnancy:
1. Systolic BP>140 mm Hg 2. Diastolic BP>90 mm Hg
Management:1. Methyldopa2. Labetalol3. Nifedipine
Prevention of RhD Alloimmunization
Blood group incompatibility between a pregnant woman and her fetus
Leads to alloimmunization of the mother and hemolytic anemia in the fetus
An Rh D-negative mother becomes immunized after exposure to fetal erythrocytes that carry the D antigen
As little as 0.1 mL of blood can immunize a human
The severity of HDN depends on the concentration of maternal antibodies
Prevention of RhD Alloimmunization
RhoGAM® (300 mcg IM)Antepartum Prophylaxis
◦Giving RhD Ig IM at 28 weeks' gestation
Postpartum Prophylaxis◦A second dose of RhD Ig should be
repeated within 72h of delivery
Drugs In Pregnancy and lactation Briggs
PregnancyCase ReportsLactationClinical
Management
Drugs in Pregnancy
A: SafeB: Human Studies Show No RiskC: The Risk Can Not Be Ruled OutD: Positive Evidence Of RiskX: Contraindicated
Drugs Suspected/Proven to be Human TeratogenAlcoholACEIs, ARBAminopterinAndrogensBexaroteneBosentanCarbamazepineChloramphenicolCocaineCorticosteroids
CyclophosphamideDanazolDiethylstilbestrol
(DES)EfavirenzEtretinateIsotretinoinLeflunomideLithium
MethimazoleMethotrexateMisoprostolMycophenolateParoxetinePenicillaminePhenobarbitalPhenytoinRadioactive iodineRibavirin
StatinsStreptomycinTamoxifenTetracyclineThalidomideTretinoinValproateWarfarin
Drugs Suspected/Proven to be Human Teratogen
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