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OB12 Obstetrics
Counselling of the Pregnant Woman Toronto Notes 2019
• airtravelisacceptableinsecondtrimester;airlinecutofffortravelis36-38wkgestationdependingon the airline, to avoid giving birth on the plane
• sexualintercourse:maycontinue,exceptinpatientsatriskfor:abortion,pretermlabour,orplacenta previa; breast stimulation may induce uterine activity and is discouraged in high-risk patients near term
• smoking:assist/encouragetoreduceorquitsmoking
■ increased risk of decreased birth weight, placenta previa/abruption, spontaneous abortion, preterm
labour, stillbirth
• alcohol: no amount of alcohol is safe in pregnancy; encourage abstinence from alcohol during
pregnancy; alcohol increases incidence of abortion, stillbirth, and congenital anomalies ■ fetal alcohol syndrome (see Pediatrics, P24)
• cocaine:microcephaly,growthretardation,prematurity,abruptioplacentae
• marijuana:smokingassociatedwithlowbirthweightinfants.Increasedriskofpretermdeliveryif
concomitantly smoking tobacco.
• biopsychosocialconsiderations:discussbirthplan,offercommunitymaternalresources
Medications
• mostdrugscrosstheplacentatosomeextent
• veryfewdrugsareteratogenic,butveryfewdrugshaveprovensafetyinpregnancy • useanydrugwithcautionandonlyifnecessary
• analgesics:acetaminophenpreferabletoASAoribuprofen
Table 7. Documented Adverse Effects, Weigh Benefits vs. Risks, and Consider Medication Change
Weight Gain in Pregnancy
BMI
<18.5 18.5-24.9 >25 - 29.9 >30
Total Gain
28-40 lb 25-35 lb 15-25 lb 11-20 lb
Weekly Gain inT2&T3 1-1.3 lb/wk
1 lb/wk 0.5-0.7 lb/wk 0.4-0.6 lb/wk
Drug Resources During Pregnancy and Breastfeeding
• Motherisk at the Hospital for Sick Children
in Toronto: www.motherisk.org
• Hale T. Medications and mothers’ milk,
11th ed. Pharmasoft Publishing, 2004
• Lactmed: https://toxnet.nlm.nih.gov/
newtoxnet/lactmed.htm
Contraindicated Medication ACE Inhibitor Carbamazepine Chloramphenicol
Lithium Misoprostol
NSAIDs Phenytoin
Retinoids (e.g. Accutane®) Sulpha drugs
Tetracycline
Valproate
Warfarin
Adverse Effect
Fetal renal defects, IUGR, oligohydramnios
ONTD in 1-2%
Grey baby syndrome (fetal circulatory collapse 2° to toxic accumulation) Ebstein’s cardiac anomaly, goiter, hyponatremia
Mobius syndrome (congenital facial paralysis with or without limb defects), spontaneous abortion, preterm labour
Premature closure of the ductus arteriosus after 30 weeks GA (prior to that, Indomethacin used for Tocolysis)
Fetal hydantoin syndrome in 5-10% (IUGR, mental retardation, facial dysmorphogenesis, congenital anomalies)
CNS, craniofacial, cardiac, and thymic anomalies
Anti-folate properties, therefore theoretical risk in T1; risk of kernicterus in T3 Stains infant’s teeth, may affect long bone development
Congenital malformation (including ONTD) up to 9%
Increased incidence of spontaneous abortion, stillbirth, prematurity, IUGR, fetal warfarin syndrome (nasal hypoplasia, epiphyseal stippling, optic atrophy, mental retardation, intracranial hemorrhage)
Immunizations
Intrapartum
• administrationisdependentontheriskofinfectionvs.riskofimmunizationcomplications
• safe:tetanustoxoid,diphtheria,influenza,hepatitisB,pertussis
• avoidlivevaccines(riskofplacentalandfetalinfection):polio,measles/mumps/rubella,varicella • contraindicated:oraltyphoid
• thePublicHealthAgencyofCanadarecommends:
■ all pregnant women receive the influenza vaccine
■ all pregnant women should be given Tdap every pregnancy irrespective of immunization history
ideally between 27-32 weeks but can be given at 13-26 weeks if high risk of preterm labour. If Tdap was given in T1 (ie prior to pregnancy recognition) it does not need to be repeated
Postpartum
• rubellavaccineforallnon-immunemothers.Ifthey'vehadanadultboosterandremainnon-immune, they should not be revaccinated, pregnancy should be deferred for at least one month following vaccination
• hepatitisBvaccineshouldbegiventoinfantwithin12hofbirthifmaternalstatusunknownorpositive – follow-up doses at 1 and 6 mos
• anyvaccinerequired/recommendedisgenerallysafepostpartum