handling calls about medicines during pregnancy & breast feeding caroline riddle & alison...

Handling calls about medicines during pregnancy & breast feeding

Caroline Riddle & Alison Alvey

South West Medicines Information Service

Handling calls about medicines during pregnancy & breastfeeding

Timetable

9.30 Introduction & learning outcomes

Medicines during pregnancyWorkshop 1

11.00 Tea break

Medicines when breast feedingWorkshop 2

12.30 Review of learning outcomes and close


Learning Outcomes

By the end of this session participants will be able to:

Provide general advice on the use of medicines during pregnancy and breast feeding.

List the resources available to assist with these types of enquiries.

Gather necessary background information to be able to clarify the question.


Types of Enquiries

Which is the most appropriate medicine for a particular condition in pregnancy or breast feeding? e.g. choice of antihistamine in pregnancy? e.g. choice of analgesic in breast feeding?

Assessing the risk of a medicine when exposure during pregnancy or breast feeding has already occurred? e.g. risks of exposure from a course of antibiotics when lady

had not realised she was pregnant? e.g. possible effects in breast fed baby from the mum’s

analgesic use?


Medicines during pregnancy

Increased public awareness and concern since the thalidomide tragedy.

Background rate of 2-3% for major congenital malformations. Over 75% of these are of unknown aetiology.

Virtually all medicines cross the placenta and reach the foetus in measurable concentrations.

Medicines do not need to cross the placenta to affect the foetus.

Many pregnancies are unplanned and medicines will have been taken inadvertently

Medicines can not always be avoided, especially in the treatment of long-term conditions.


Teratogen

Any agent which given in pregnancy that directly or indirectly causes structural or functional abnormalities in the foetus or child after birth.

Cocaine CNS, intestinal & kidney damage

Anticonvulsants (carbamazepine, valproate, phenytoin)

Facial defects, mental retardation

Retinoids Cranio-facial, CVS & CNS defects

NSAIDs Closure of ductus arteriosis

Warfarin Foetal warfarin syndrome


Identification Of Teratogens

Many possible causes for a birth defect (genetic, physiological, nutrition, medicines, pollutants).

Extremely difficult to determine whether or not a particular agent is a teratogen.

Clinical trials of medicines in pregnant women is usually unethical.

Difficult to extrapolate findings in animal studies to a human pregnancy.

Risk of teratogenecity may increase if the number of different medicines is increased.


Timing Of Exposure

1st Trimester (1- 12 weeks post LMP) Up to 2 weeks, “all or nothing” effect Weeks 3-8, major organ systems being formed

2nd Trimester (4th – 6th month) Cerebellum & urogential system still forming Growth and functional development

3rd Trimester (6th – 9th month) Specific effects e.g. NSAIDs (pulmonary hypertension) B-

blockers (hypoglycaemia) Near Term/During labour Adverse effects on labour or on neonate after delivery.


Potential Adverse Effects

Spontaneous abortions Intra-uterine growth retardation Prematurity Stillbirths Obstetric complications Neonatal side effects

Withdrawal reactions Drug side effects in neonate


General Advice for Medicines in Pregnancy

Consider non-drug treatments.

Only prescribe medicines if absolutely necessary.

Avoid all medicines in the 1st trimester if possible.

Assess benefit/risk ratio for both mother & infant.

Avoid new medicines as usually more experience with well-established ones.

Use the lowest effective dose for as short a time as possible.

Avoid polypharmacy


Essential questions to ask

Is lady pregnant or planning to become pregnant? Her age? Has she already taken the medicine(s)? Has this been prescribed or self-treating? Medicine(s), indication, dose, frequency, route &

duration of exposure? Number of weeks pregnant at time of exposure? How is pregnancy progressing? Any previous pregnancies & outcomes?


Information sources

eBNF (Appendix 4 -pregnancy) www.medicinescomplete.com

NHSD Medicines Q&As – can be used as a sole resource. Access through NHSD intranet

Electronic Medicines Compendium (eMC) www.medicines.org.uk

Toxbase www.spib.axl.co.uk


Limitations of Information sources

eBNF – Appendix 4: Not all medicines are listed If a medicine is not listed cannot assume it is safe Medicine may be listed under class rather than individual

medicine name Not very detailed information Manufacturer’s information is often quoted (often very cautious) Info not usually suitable to read out to caller – may alarm them

unnecessarily

NHSD Q&As: Only a limited number available



eMC: Statements often based on legal concerns rather than evidence Advice normally very cautious Where no information available usually advise to avoid

Toxbase: Some monographs not been updated Requires evaluation/interpretation


When to refer

If there is no information or information is unclear or conflicting

Medicine has been taken but info sources say to avoid in pregnancy.

If pregnant lady has taken a known teratogen If pregnant lady is on medicines to control long term

conditions. Will need to discuss treatment plan with her Dr.

Many pregnancy enquiries will require referral to GP/midwife or onto UKMI.


Workshop: Medicines during Pregnancy


Tea Break


Timetable

9.30 Introduction & learning outcomes

Medicines during pregnancyWorkshop 1

11.00 Tea break

Medicines when breastfeedingWorkshop 2

12.30 Review of learning outcomes and close


Medicines when breastfeeding

Distinct from medicines use in pregnancy Most medicines are unlicensed for use in breast-

feeding Information is sparse on the effects, so often prefer

older medicines that have more data


Advice on infant feeding

Breast milk is the best form of nutrition for infants.

Exclusive breastfeeding for the first 6 months.

Breastfeeding (and/or formula milk) with appropriate solid food after 6 months, ideally for up to 1 year.

Mothers unable (or choose not) to breastfeed should be helped to optimise infant feeding.


How much of the medicine reaches the baby?

Depends on:

Plasma concentration of medicine in the mother.

Characteristics of the medicine.

Amount of medicine passed into breast milk.

Amount of milk taken by baby per feed (approx 150mL/kg).


General advice

Avoid unnecessary use of medicines.

Assess risk / benefit for mother and baby.

Higher risk for premature babies.

Check if medicine licensed for babies.

Avoid long-acting medicines

Avoid black-triangle medicines.

Try to time feed to avoid when drug levels in milk are highest.

Monitor baby for adverse effects.


Essential questions to ask

Has mum already taken the medicine(s) or is she wanting to take?

Medicine(s), indication, dose, frequency, route & duration of exposure?

Has this been prescribed or self-treating?

Have any other medicines been considered or tried?

What age is the baby? Full term & healthy?

How often is baby feeding? – Totally breast fed or bottle too?


Information sources

eBNF (Appendix 5 – Breast feeding)

Electronic Medicines Compendium (eMC)

NHSD Medicines Q&As

UKMi Central www.ukmicentral.nhs.uk



eBNF – Appendix 5 Not all medicines are listed If a medicine is not listed cannot assume it is safe Not very detailed information Good place to start

eMC Statements often based on legal concerns rather than evidence Where no information available usually advise to avoid When it is known that the medicine appears in breast milk, but

no further details are available, caution is usually advised

NHSD Q&As Only a limited number available


Information sources – UKMi central

Web site of the MI services that jointly provide the UK Drugs in Lactation Advisory Service

Provides brief guidance for a number of drug groups such as anti-asthma agents & NSAIDs

Includes preferred agents for use in lactation & monitoring advice

A quick reference guide lists meds by pharmacological group

Each medicine or group is then classified according to risk


Guide to Assessing Risk

Medicines unsuitable for BF mothers - to be avoided

Use with caution and monitor baby

Medicines which appear safe - may be given

1UKMi Drugs in Lactation Advisory Service

1


When to refer

If there is no information or information is unclear or conflicting.

Medicine has been taken but info sources say to avoid in breast feeding.

Mother is taking multiple medicines

Baby was born pre-term and/or has medical conditions.

Many breast feeding enquiries may need to be referred on to GP/midwife etc.


Quiz & Workshop 7: Medicines when Breastfeeding


Learning Outcomes

By the end of this session participants will be able to:

Provide general advice on the use of medicines during pregnancy and breast feeding

List the resources available to assist with these types of enquiries

Gather necessary background information to be able to clarify the question

handling calls about medicines during pregnancy & breast feeding caroline riddle & alison...

Documents

use of medicines

pregnancy workshop

human pregnancy

tea break medicines

clinical trials of medicines

number of different

breast feeding

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