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Antidepressants in pregnancy

17.1 Introduction Depression is common among women during pregnancy, and although pregnancy is a time of increased health care utilization, it is likely as many as 66% of women affected during pregnancy are neither identified nor treated [ , ]. In an effort to accurately estimate the number of pregnant women with depressive disorders, Haight et al. (2019) examined US public databases to identify women admitted to…

Cardiovascular medications in pregnancy

16.1 Introduction Cardiovascular disease is the leading cause of death for women in the United States, and similarly in other countries with developed health systems. Heart disease is the leading cause of death worldwide for men and women. While it is common to think of noncongenital heart disease as one of older populations, women of childbearing age can be affected by any noncongenital cardiovascular condition. The…

Diabetes in pregnancy

15.1 Introduction Pregnancy imposes unique metabolic demands to provide sustained and sufficient transfer of nutrients to the growing fetus during fasting periods by ensuring adequate nutrient storage during feeding. Hormones produced by the feto-placental unit play a pivotal role in adjusting metabolic features to benefit both mother and fetus. However, in pregnancies complicated by diabetes mellitus (DM), its metabolic consequences for both mother and fetus can…

Substance abuse in pregnancy

14.1 Introduction Reports of substance abuse during pregnancy are recorded in nursing literature as early as the 1980s with an increase in substance use continuing through to the present [ , ]. Data from the National Survey on Drug Use and Health (NSDUH) [ ] (SAMHSA) revealed a continued increase from an overall estimate of 1 in 10 Americans in 2016 to an estimated 1 in…

Chemotherapy in pregnancy

13.1 Introduction Cancer is the second leading cause of death in women of reproductive age and accounts for 16% of deaths among women between ages 20–44 years [ ]. The incidence is commonly reported as 1 per 1000 pregnancies, but because of challenges in capturing population-based data, the numbers are likely to be underreported. The largest studies report 17 cases of cancer per 100,000 live births,…

Clinical pharmacology of anti-infectives during pregnancy

Serious infections can occur during pregnancy and must be treated to prevent maternal and fetal adverse outcomes. While some anti-infectives have been studied in pregnancy, many agents have inadequate data available to evaluate safety, efficacy, and appropriate dosing, posing a challenge for drug and dose selection. Important safety data have been summarized elsewhere [ , ]. This chapter focuses on pharmacology and pharmacokinetic studies for drugs…

Nausea and vomiting of pregnancy

11.1 Nausea and vomiting of pregnancy One of the most frequently encountered common discomforts related to pregnancy is nausea and vomiting. Nausea and vomiting of pregnancy (NVP) is often most difficult to deal with, often debilitating to patients, relationships, work performance, and severely impacts quality of life (QOL) if untreated or poorly controlled. While likely multifactorial in nature, there is no “magic bullet” or formula which…

The management of asthma during pregnancy

10.1 Introduction Asthma is one of the most common potentially serious medical problems to complicate pregnancy, and may adversely affect both maternal quality of life and perinatal outcomes. Optimal management of asthma during pregnancy (MAP) is thus important for both mother and baby. While the management of asthma in pregnancy relies on guidelines that were based on studies of nonpregnant populations, special considerations regarding the safety…

Anesthetic drugs

9.1 Introduction The challenges of general and regional anesthesia in pregnancy are to optimize maternal physiological function, preserve uteroplacental blood flow and oxygen delivery while avoiding unwanted effects of fetal exposure to drugs. The likelihood of maternal and fetal exposure to anesthetic drugs is not insignificant. Current evidence suggests that between 1% and 2% of pregnant women will undergo a nonobstetric surgical procedure during pregnancy in…

Pharmacogenomics in pregnancy

8.1 Pharmacogenomics If it were not for the great variability among individuals, medicine might as well be a science and not an art. Sir William Osler (1892). While much drug development and many clinical practice guidelines do not directly address variability in drug response, and in many cases assume that the effects of drugs on patients can generally be predicted, the evidence indicates otherwise. Significant numbers…

Conducting randomized controlled pharmaceutical trials in the pregnant population: challenges and solutions

7.1 Introduction The development of a new drug for use in humans classically follows a strict sequence, beginning with in-vitro and animal experiments to identify promising novel molecules, their sites of action, and biological effects. After efficacy and safety in animals is confirmed, three phases of human clinical trials need to be completed prior obtaining approval for use in clinical practice. Phase I studies are conducted…

Treating the placenta: an evolving therapeutic concept

6.1 Introduction Generally, from the perspective of clinical pharmacology, one thinks of the placenta as the route of passage from mother to fetus or the reverse [ ], with or without metabolism. With few exceptions, it is generally not thought of as the target for therapy. However, we believe that as our understanding of placental function grows and as the science and application of obstetric-based clinical…

Fetal drug therapy

Acknowledgments The authors wish to thank Sanaalarab Al-Enazy for her assistance with Fig. 5.1 and Wayne Snodgrass for helpful suggestions. E.R. and M.S.A. are grateful for research support from NIH grants HD083003 and HD047891. 5.1 Introduction The intention of most drugs prescribed during pregnancy is to treat a condition affecting maternal health. Careful attention is placed on the appropriate selection of the medication and its dose that…

Medications and the breastfeeding mother

4.1 Medication use by the breastfeeding mother Mothers may need medication both during and after pregnancy. In both cases, it is important not only to protect the infant but also to provide the mother with necessary drug treatment. The infant may be born having been exposed to maternal medication during gestation. It is important to remember, in addition to drug exposure of the infant during breastfeeding,…

Impact of pregnancy on maternal pharmacokinetics of medications

3.1 Introduction Variability in drug efficacy and safety is multifactorial. Both the pharmacokinetics (how the body handles the drug) and the pharmacodynamics (how the body responds to the drug) play significant roles in drug efficacy and safety. This chapter will discuss the effects of pregnancy on medication pharmacokinetics. The physiologic changes that occur during pregnancy result in marked changes in the pharmacokinetics for some medications. Whether…

Physiologic changes during pregnancy

2.1 Physiologic changes during pregnancy Human pregnancy is characterized by profound anatomic and physiologic changes that affect virtually all systems and organs in the body. Many of these changes begin in early gestation. Understanding of the various physiologic adaptations in pregnancy is vital to the clinician and the pharmacologist as many of these alterations will have a significant impact on pharmacokinetics and pharmacodynamics of different therapeutic…

Answers to Single Best Answer (SBA) questions – part two

Answers Chapter 1 Q1. Answer: c – Puborectalis Laterally, the muscle sheets of the iliococcygeus and ischiococcygeus are oblique The medial fibres of the puborectalis are inserted into the upper part of the perineal body and the succeeding fibres turn medially behind the anorectal flexure, and are inserted into the anococcygeal raphe and the tip of the coccyx. Q2. Answer: b – The isthmus Female sterilization…

Answers to Single Best Answer (SBA) questions – part one

Answers Chapter 2 Q1. Answer: e – When it has been more than 12 months since her last period Explanation: Menopause can only be diagnosed retrospectively, which is 12 months after the last menstrual period. Symptoms of hot flushes, mood swings and vaginal dryness are common when a woman is ‘perimenopausal’. However, these are suggestive of low levels of estrogen and not specifically for being postmenopausal.…

Objective Structured ClinicalExamination (OSCE) Practice Cases

Introduction Objective Structured Clinical Examinations (OSCEs) are commonly used as part of medical school assessments. They allow assessment of clinical performance and important skills which are difficult to assess in written examinations. These include key domains such as clinical skills, communication skills, judgement, leadership and professionalism. In many countries over the past decade, OSCEs have moved away from a rigid ‘checklist’-based scoring system to assessment by…

Single Best Answer (SBA) Questions – Part Two

Introduction This is a selection of single best answer (SBA) questions from across this book. This style of questions is increasingly favoured over the traditional multiple choice questions (MCQs) for examinations. The answers and accompanying explanations can be found in Answers to Single Best Answer (SBA) questions – part two. Questions Chapter 1 Q1 A 48-year-old woman reports symptoms of uterine prolapse and urinary incontinence which…