Chapter 99: Pregnancy and Lactation

Update Summary

June 26, 2023

The following sections were updated:

• Addition of new guidelines from ACOG and the Society for Maternal-Fetal Medicine in section “Management of Hypertension”

• Confirmation of new guidelines in section “Epilepsy”

• New ACOG guidelines regarding SSRI and mood stabilizer use in the section “Mental Health Conditions”

• Addition of information regarding FDA approval of brexanolone in the section “Mental Health Conditions”

KEY CONCEPTS

• Complex physiology surrounds the process of fertilization and pregnancy progression.

• Medication characteristics and physiologic changes modify pharmacokinetics during pregnancy, including changes in absorption, protein binding, distribution, and elimination, requiring individualized pharmacotherapy selection and dosing.

• Although medication-induced teratogenicity is a serious concern during pregnancy, most medications can be used during pregnancy. Healthcare providers need to evaluate the risk of the medication with the risk of the untreated condition. Informed selection of pharmacotherapy is essential.

• Healthcare practitioners must know where to find and how to evaluate evidence related to medications used during pregnancy and lactation.

• Acute pregnancy issues, such as nausea and vomiting, can be treated with nonpharmacologic treatment or carefully selected pharmacotherapy.

• Some acute and chronic illnesses pose additional risks during pregnancy, requiring treatment with appropriately selected and monitored pharmacotherapies to minimize risk to the fetus and pregnant individual.

• Management of the pregnant individuals during the peripartum period not only can encompass uncomplicated pregnancies/deliveries, but can also include a wide variety of potential complications that require the use of evidence-based treatments to maximize positive outcomes.

• Understanding the physiology of lactation and pharmacokinetic factors affecting medication distribution, metabolism, and elimination can assist the clinician in selecting appropriate medications during lactation.

BEYOND THE BOOK

Search the Food and Drug Administration (FDA) Website (https://tinyurl.com/2ujhjm) for “Pregnancy and Lactation Labeling Rule.” Choose one link to review and then summarize the key points about the new pregnancy and lactation labeling requirements. How do they differ from pregnancy categories? Do pregnancy categories still exist? This activity is useful to enhance understanding about what type of pregnancy and lactation information to expect in medication product labeling.

Patient Care Process for the Management of Gestational Diabetes

Collect

• Patient characteristics (eg, age, race, gender identity, biological sex, pregnancy status)

• Characteristics of the pregnancy (eg, gestational age, gravidity and parity, weight gain to date)

• Characteristics of previous pregnancy(ies) (eg, prior gestational diabetes, birth weight of previous children, unexplained fetal demise)

• Patient history (past medical, family, social habits, physical activity habits, and dietary discretion)

• Current medications (including complementary or alternative therapies) and adherence to medication schedules

• Social and cultural issues: preferences, values, and beliefs; health ...