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SOURCE

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Source: Ward KE. Pregnancy and lactation: therapeutic considerations. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146066717. Accessed May 17, 2017.

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DEFINITION

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  • Therapeutic issues affecting both mother and child, including time from birth through lactation.

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PATHOPHYSIOLOGY

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  • Medications enter breast milk via passive diffusion of nonionized and non-protein-bound medication.

  • Drugs with high molecular weights, lower lipid solubility, and higher protein binding less likely to cross into breast milk or transfer more slowly.

  • The higher the serum concentration of drug in mother’s serum, the higher the concentration in breast milk.

  • Drugs with longer half-lives maintain higher levels in breast milk.

  • Timing and frequency of feedings and amount of milk ingested by infant important considerations.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Postpartum issues.

    • Drug use during lactation.

    • Relactation.

      • The process of increasing the breast milk supply for women whose milk has not “come in,” who have inadequate milk production despite appropriate breastfeeding frequency or pumping, or who have weaned or never breastfed after delivery.

    • Mastitis.

      • Inflammation of the breast that occurs in 3–20% in lactating women.

    • Postpartum depression.

      • Mood disorders in the postpartum period may include post-partum blues, postpartum depression, and postpartum psychosis.

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DIAGNOSIS

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  • Refer to individual disorders for diagnostic considerations.

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DESIRED OUTCOMES

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  • Ensure both maternal and newborn health during months after birth.

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TREATMENT: GENERAL APPROACH

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  • Principles for selecting medications during pregnancy:

    • Select drugs that have been used safely.

    • Eliminate nonessential medication and discourage self-medication.

    • Avoid medications known to be harmful.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • For postpartum depression, recommend:

    • Emotional support from family and friends.

    • Education about condition.

    • Psychotherapy.

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TREATMENT: PHARMACOLOGIC THERAPY

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  • Drug use during lactation.

    • To reduce risk to infant from drugs transferred through breast milk, select medications:

      • Considered safe for infant.

      • With shorter half-lives.

      • More protein bound, with lower bioavailability and lower lipid solubility.

  • Relactation.

    • Metoclopramide 10 mg 3 times daily for 7–14 days recommended pharmacologic therapy. Use only if nondrug therapy ineffective.

  • Mastitis.

    • Usually caused by penicillin-resistant Staphylococcus aureus; Escherichia coli and Streptococcus are also implicated.

    • Treat mother with dicloxacillin, oxacillin, or cephalexin for 10–14 days.

    • Recommend:

      • Bedrest.

      • Analgesia with ibuprofen.

      • Application of heat.

      • Frequent evacuation of breast milk.

  • Postpartum depression.

    • Sertraline, paroxetine, fluoxetine, and nortriptylineare most studied in the post-partum period.

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MONITORING

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  • Refer to monitoring for individual medical disorders.

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ADDITIONAL RESOURCES

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  • Logdson BA. Drug use during lactation. J Am Pharm Assoc (Wash). 1997;NS37(4):407–418. [PMID 9519651]

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Date Written: May 17, 2017

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Contributor: Lauren ...

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