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FOUNDATION OVERVIEW

Drug use in pregnancy requires special considerations since medications have the potential to affect the developing fetus. In addition, pregnancy alters pharmacokinetic parameters of some medications, resulting in a need for dosage adjustment. Drug regimens for management of acute and chronic disorders in pregnancy should be tailored to optimize the health of the mother while minimizing risk to the fetus. After delivery, measures should be taken to minimize drug exposure to the breastfeeding infant. Pharmacists can play a key role in maximizing the safe and effective use of medications during pregnancy and lactation.

PRECONCEPTION CARE

Preconception care should be discussed with all women of childbearing age. The goal of preconception care is to minimize poor pregnancy, fetal/infant and maternal outcomes. Elements of preconception care include supplementation, dietary considerations, immunizations, and optimization of control of chronic diseases.

Vitamin and Mineral Supplementation

Folic acid deficiency is a major cause of neural tubal defects (NTDs), and adequate intake of folic acid can reduce the incidence of NTDs by 50% to 70%. Women of childbearing age should be advised to take a multivitamin (MVI) with 400 mcg of folic acid daily. During pregnancy, the recommended intake increases to 600 mcg. Higher doses (4-5 mg daily) are required for women with an increased risk of delivering a child with NTDs (eg, women taking antiepileptic medications). Initiation of supplementation should be at least 1 month before conception and continue throughout the first trimester.

Multivitamins offer additional benefit in meeting calcium (1000-1300 mg) and iron requirements. Calcium is important for bone health for the mother and fetus, and may reduce the risk of pre-eclampsia. Additional calcium supplementation with calcium carbonate or citrate may be needed if MVI and dietary intake is insufficient. The Center for Disease Control (CDC) recommends supplementation with 27 mg/d of elemental iron to support the increased demands of pregnancy.

Dietary Considerations

Caffeine consumption may increase risk of miscarriage and low birth weight. Low to moderate amounts of caffeine (<200 mg/d) appear to be safe. Seafood contains long-chain omega-3 polyunsaturated fatty acids and mercury. Fatty acids are beneficial to the central nervous system, but mercury can lead to birth defects. It is recommended to limit intake to 12 ounces of seafood per week with lower mercury content. Alcohol consumption may adversely affect fertility, contribute to complications during pregnancy, and cause fetal alcohol syndrome (physical, behavioral, and cognitive abnormalities) in infants. No level of alcohol consumption is considered safe during pregnancy.

Immunizations

Ideally, immunizations should be up-to-date before conception. Inactivated vaccines are safe during pregnancy and live vaccines (eg, varicella, measles, mumps, rubella [MMR]) should be avoided due to a theoretical risk of transmission to the fetus. Influenza is associated with high morbidity and mortality, and all pregnant women or women likely to become pregnant ...

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