Sa aking mga Minamahal ( alam niyo kung sino kayo),
Pwede ba akong maging mahangin kahit sandali? Konting yabang lang po. Ang di matuwa di kayo required magbasa ng blog ko. Tsupi!
Ibabalita ko lang po that to date I have recently published 3 journal articles in international peer reviewed journals. Sa world of academe kasi this is an important achievement. To publish one paper internationally is hard enough but 3 in one year is really a feat. There is such a term in universities --- PUBLISH OR PERISH. As a professor, to publish original research articles is a must to be retained in the university and to be promoted.Yun lang po. Salamat sa tulong ng lahat ng tao to make these endeavors successful. Who I am right now I owe to a lot of people - my teachers since elementary grade, my UP professors (mentors), my students , my friends, my colleagues and my family. And before I forget, thank you to all my detractors and critics as well.
1. The Role Of Adjuvant Surgery In The Management Of Gestational Trophoblastic Neoplasia (GTN) J Reprod Med 2008; 53: 513-518
2. Sexual Dysfunction As A Complication Of Treatment Of Gestational Trophoblastic Neoplasia (GTN) J Reprod Med 2008; 53: 595-599
3. Efficacy of Methotrexate as Primary Single Agent Therapy for Nonmetastatic and Low risk Metastatic GTN at UP-PGH. Cancer Therapy 2008; 6: 611-616
Thursday, September 11, 2008
DRUGS, MEDICATIONS AND IMMUNIZATIONS DURING PREGNANCY
Outline
I. Introduction
II. Pharmacokinetics in Pregnancy
III. Feto-placental Pharmacokinetics
IV. Principles of Teratogenesis
V. Mechanisms of Teratogenesis
VI. FDA Pregnancy Categories
VII. Representative Human Developmental Toxicants
VIII. Guidelines For Prescribing And Counseling In Pregnancy
IX. Immunization during Pregnancy
X. References
INTRODUCTION
Pharmacotherapeutic decisions in pregnancy take into consideration numerous factors. The ideal drug for treatment in pregnancy is efficacious for the maternal indication, is minimally transported through the placenta and, in the event of transplacental passage, exerts minimal effect on the fetus. Often neglected but of similar importance are drug characteristics that influence tolerability and adherence to dosage and dosing schedule, more so when the drug therapy in question exacerbates conditions common to pregnancy such as emesis, gastrointestinal changes either in the form of diarrhea or constipation, glucose intolerance and hypertension.
PHARMACOKINETICS IN PREGNANCY
Fig 1. Physiologic changes in pregnancy
Physiologic changes in pregnancy significantly affect pharmacokinetics in the pregnant patient (figure 1). These changes include:
1. Cardiovascular changes- increased cardiac output (40%) and increased plasma volume (50%) and total blood volume (40%)
2. Gastrointestinal changes - decreased gut motility, increased gastric pH and nausea and vomiting
3. Respiratory changes - hyperventilation, increased tidal volume, and increased pulmonary blood volume
4. Volume changes -dramatic increases in maternal aqueous and fatty tissue spaces (greatest at 10-30 weeks) and the increase in total body water (mostly extracellular: 40% maternal, 60% feto-placental)
5. Metabolic changes- relative decrease in serum albumin concentration (25%) and elevated levels of steroid hormones competing for protein binding sites, elevated levels of serum progesterone, elevated levels of serum estrogen
6. Renal changes - increase renal blood flow (50%) and the consequent increase in glomerular filtration (50%) 1
Table I. Physiologic changes in pregnancy and their impact on pharmacokinetics of selected agents , ,
PHYSIOLOGIC CHANGES IN PREGNANCY EFFECTS ON PHARMACOKINETICS KEY EXAMPLES
Decreased gut motility, increased gastric pH and nausea and vomiting Variable bioavailability of oral preparations Most oral preparations
Hyperventilation, increased tidal volume, and increased pulmonary blood volume Increased alveolar uptake of inhaled drugs Inhaled anesthetics
Increased cardiac output, and increased plasma volume and total blood volume Increased volume of distribution
Increases in maternal aqueous and fatty tissue spaces (greatest at 10-30 weeks) and the increase in total body water Further increase in the volume of distribution
Relative decrease in serum albumin concentration and elevated levels of steroid hormones competing for protein binding sites Increased free drug fractions of protein-bound drugs Diazepam, phenytoin, sodium valproate (especially in the 3rd trimester)
Elevated levels of serum progesterone Increased cytochrome metabolism of some drugs Phenytoin, carbamazepine, sodium valproate
Elevated levels of serum estrogen Decreased cytochrome oxidase metabolism of some drugs Theophylline and caffeine
Increase renal blood flow and the consequent increase in glomerular filtration Increased renal excretion and creatinine clearance Lithium, Digoxin
Ampicillin (doubled)
The net effect of these changes lead to an expected decreased steady state drug concentration in pregnancy if a normal dose is administered, i.e. a higher dose will be needed to achieve therapeutic levels, although drug-specific exceptions will occur.
Although the changes in pharmacokinetics in the pregnant patient appear to be very important in theory, these changes are often not significant clinically. Notable exceptions are drugs that are exclusively eliminated via the renal route, such as lithium and digoxin. The increase in renal excretion leads to a significant decrease in serum concentrations, and, considering their narrow therapeutic range, may necessitate serum concentration monitoring. Also noteworthy are antiepileptics (carbamazepine, valproic acid and phenytoin) which experience a decrease in effective serum concentrations secondary to increased hepatic and renal elimination, increase in plasma volume, and decreased protein binding. 3, These drugs, however, are more the exception than the rule, because the changes mentioned above are often offset in most conditions.
Thus, very often it is the effects on the developing fetus that are taken into greater consideration in therapeutic decisions in pregnancy rather than maternal factors.
FETO-PLACENTAL PHARMACOKINETICS
Drugs that eventually reach the fetus are (almost) always administered to the mother. For a drug to exert its effects on the fetus, transplacental transport must take place. After maternal administration, drugs first pass through the placenta before reaching the fetal serum. From the fetal serum, drugs are then transferred transplacentally to the mother and are eventually excreted.
Raised areas on the basal surface of the placenta, termed as maternal lobes or cotyledons, are intimately related with several fetal cotyledons, allowing maternal circulation to be virtually superimposed onto the fetus. For materials to pass from mother to fetus, however, solutes must pass through the syncytiotrophoblast, either directly through its cytoplasm, or, less commonly, via a network of specific transporters. The transport of molecules from maternal to fetal circulation thus involves the passage between 3 functional compartments: maternal blood, the tropohoblastic cytoplasm, and finally fetal circulation (figure 2).
The great majority of substances depend on simple diffusion to pass through these compartments. The rate of transport between mother and fetus, then, is dictated by the molecular weight, degree of ionization, protein-binding and finally relative concentrations across these compartments. 2,3,4
Fig 2. Major pathways and interrelations of pharmacokinetics in maternal, placental and fetal units. Size of arrows indicates relative importance of effect. (Re-drawn from an original by Garland M. Pharmacology of drug transfer across the placenta. Obstet Gynecol Clin Nth Am. 1998 25(1) 21-42 )
Several key factors involved in drug transfer across the placenta are:
1. The physicochemical properties of drugs, i.e. lipid solubility, degree of ionization, molecular size and protein binding characteristics. Drugs that are highly lipid soluble, non-ionized, of low molecular weight (<200 daltons) and minimally protein-bound easily cross the placental barrier
2. The transfer of flow-limited drugs are affected by placental blood flow and maternal serum drug concentrations (greater maternal serum concentrations create a greater concentration gradient causing increased placental transport)
3. Compounds that alter blood flow also alter maternal drug disposition and consequently affect placental transfer
4. Placental metabolism (i.e. dealkylation, hydroxylation and demethylation) also influence drug transport through the placenta, although these effects are relatively minor compared to metabolism via the maternal and fetal liver
5. Fetal metabolism may also play a part, but these effects may change during pregnancy 5
.
Fetal pharmacokinetics also plays a role in determining the net effect of drugs on the fetus (i.e. teratogenicity):
1. Maternal blood flow through the placenta gradually increases during gestation (from 50mL/min at 10 weeks of pregnancy to a peak of 600mL/min at 38 weeks AOG), thereby increasing the fetal drug exposure as pregnancy progresses.
2. The protein binding capacity of fetal plasma is significantly lower than that of maternal circulation (fetal plasma albumin concentration may be 15% greater than maternal, but this is offset by the lower levels (37%) of alpha1-acid glycoprotein and the lower affinity for binding of fetal plasma proteins) leading to a greater free fraction for drugs that enter the fetal circulation (especially basic drugs such as propranolol and lidocaine and drugs with poor affinity to fetal proteins such as ampicillin and benzylpenicillin) and consequently, a greater risk for toxicity.
3. The fetal plasma and amniotic fluid are slightly more acidic than maternal blood, favoring the ionization and subsequent ion-trapping of basic drugs in the fetal compartment after transplacental passage. This apparent accumulation in the fetal plasma further predisposes to toxicity.
4. The fetal liver also expresses drug-metabolizing enzymes such as cytochrome oxidases, but the metabolizing capacity is much less than that of the mother. Drugs that pass through the placenta may thereby undergo first-pass metabolism through the fetal liver before reaching systemic circulation, though this effect is modulated by the ductus venosus shunt and may vary by 30-70%.
5. The fetal kidney is immature and glomerular filtration is markedly reduced. Glomerular filtration rate increases with gestational age, but peaks to only 2-4mL/min at term, primarily because the fetal kidney receives only 3% of cardiac output, compared to 25% in the adult. Cation secretion (e.g. cimetidine) is efficient, but the renal excretion of anionic drugs (e.g. penicillin) is very low.
6. Fetal urine enters amniotic fluid, which may be subsequently swallowed by the fetus, and renally excreted drugs and metabolites may subsequently be reabsorbed.2,3,
In general, drugs that exist as large, highly protein bound and/or ionized molecules in maternal plasma and are poorly absorbed into the maternal bloodstream rarely cross the placental membrane and are usually confined to the maternal circulation in therapeutic doses, thus exhibiting minimal effects to the fetus.
Because of decreased protein binding, ion-trapping and poor metabolism and excretion, drugs that do pass to the fetal circulation exhibit a greater potential for toxicity than they do for the mother.
PRINCIPLES OF TERATOGENESIS
By far the greatest concern for both patient and physician in drug therapy during pregnancy are the possible teratogenic effects of drugs on the fetus. Teratogens (from the Greek teratos meaning “monster”) refer to any agent that acts during the embryonic or fetal period and produces a permanent alteration in form or function. These alterations include birth defects, or visible deformities that are congenital in origin, but may occur as metabolic derangements that may be more subtle at birth.
Environmental factors (e.g. maternal conditions, infectious agents, mechanical problems, chemicals, drugs, radiation, hyperthermia, etc.) account for about 10% of all abnormal outcomes in pregnancy. Evaluation of the teratogenic effect of agents depends on the following criteria: 1) proven exposure to agent at critical times in prenatal development, 2) consistent epidemiologic evidence, 3) clearly characterized clinical effects (i.e. syndromes), 4) frequency of clinical syndromes reflecting actual frequency of exposure in the population and 5) the ability of the agent to cross the placenta or sufficiently alter maternal or fetal metabolism to cause significant effects. Other useful but non-essential criteria for evaluating teratogenicity are experimental animal models that mimic the human malformation at clinically comparable exposures and that the mechanisms of teratogenesis are understood and/or results are biologically plausible.1,3, , 7
The timing of exposure to a suspected teratogen plays a crucial role in its effect on fetal development (figure 3). Periods of susceptibility in embryogenesis are characterized by rapid cell division and differentiation.
Fig 3. Sequence of events in normal embryogenesis. (Figure taken from Human Pharmacology: Molecular to Clinical, 2nd ed.)
Fig 4. Outcomes associated with exposure at different stages of reproduction
During the preimplantation or the so called “all or none” period (<15 days from fertilization to implantation), the zygote undergoes rapid cleavage and organization into an outer and inner cell mass (blastocyst formation). Development during this stage can be considered “all or none”, that is, injurious stimuli are either sufficient enough to cause the death of the embryo, or compensation by the uninjured cells are enough to continue normal development (figure 4).
The embryonic period (from the 2nd to the 8th weeks AOG) is the most crucial stage in teratogenesis. Fetal susceptibility to teratogens is greatest at this stage, and is central to the pathogenesis of most structural malformations
The fetal period (from 9 weeks up to term) is characterized by the maturation of fetal organs important to functional development. The fetus remains vulnerable to insult, and exposure to teratogens may still result to defects in function and minor anomalies. An example is the pulmonary hypoplasia caused by any agent that causes a reduction in amniotic fluid volume from 20-25 weeks.
MECHANISMS OF TERATOGENESIS
Some proposed mechanisms of teratogenicity include:
1. Cell death beyond recuperative capacity of the embryo/fetus
2. Mitotic delay; increase in the length of the cell cycle
3. Retarded differentiation
4. Physical constraint and vascular insufficiency
5. Interference with histogenesis by cell depletion, necrosis, calcification, etc
6. Inhibited cell migration and cell communication 6
Other agents have more established physiologic and genetic mechanisms. For example, agents may disrupt the metabolism of folic acid. Folic acid plays an important role in the synthesis of DNA and RNA bases. Drugs that either prevent the absorption of folate or acts as antagonists (e.g. anti-seizure medications: valproic acid, phenobarbital, carbamazepine and phenytoin) predispose to a variety of congenital malformations, the most common of which are neural tube defects.4, 6
Other drugs exert their effects by the production of oxygen free radicals and other oxidative intermediates. Free radicals are often rendered innocuous by cytoplasmic epoxide hydroxylase. This enzyme system, however, is immature in the fetus, leading to the accumulation of these free radicals in fetal tissues, and subsequent carcinogenic and mutagenic effects. Specific examples include phenobarbital, phenytoin and carbamazepine, which are metabolized by hepatic microsomes into epozides and arene oxides.6
The maternal condition itself may play a role in fetal malformations, and provide a synergistic effect with the drug in question. Alcoholism in pregnant women, for instance, is often associated with concomitant use of other recreational drugs and smoking, as well as nutritional deficiencies. Fetuses born to alcoholic mothers, thus, exhibit greater tendencies for congenital defects than would otherwise be explained by exposure to alcohol alone. Likewise, epileptic mothers, even without therapy, carry a greater risk for congenital malformations.
Genetic factors of the fetus also contribute to the teratogenic mechanism of toxins. Previous mutations that alter the functions of certain enzymes, especially those crucial to the removal of toxic agents, may increase the susceptibility of a particular teratogen (e.g. risk of malformation after exposure to phenytoin is increased in fetuses with low activities of epoxide hydroxylase). This interplay of both environmental and genetic factors probably account for most anomalies that are “multifactorial” in origin.1,6,8
Other agents act by the direct alteration of key genetic sequences in embryogenesis. A key example is a group of genetic sequences that direct the future position of numerous structures in the body. These homeobox genes are arranged in a fixed order along the length of the chromosome. This position, in turn corresponds to a particular body region: the 3’ end corresponds to the caudal region, and the 5’ end directs the development of the caudad region. Agents that predispose to a particular homeobox gene (e.g. valproic acid exhibits a predilection to the 5’ end) thus preferentially cause malformations to the corresponding body region (caudally in the case of valproic acid). 4,6,8,9
Finally, paternal factors can also exert effects on malformations on the fetus. Agents that cause germline mutations and genetic maldevelopment of sperm cells can destine the fetus to become malformed even before implantation takes place. Also, drugs or agents taken by the paternal spouse can gain access to the developing fetus during sexual intercourse in pregnancy.4,6,7, 8, 9
The great majority of agents, however, have poorly understood mechanisms of teratogenesis. The difficulties in analyzing the mechanisms of teratogenicity include the following:
1. Normal development is an extremely complex process that even now is not completely understood.
2. Environmental toxicants include a wide range of chemical, physical and biological agents that initiate a wide variety of mechanisms, and exposure to specific toxicants are rarely encountered alone in the clinical setting.
3. Some toxicants may affect only a fraction of individuals in the population, while sparing others from their teratogenic effects.
4. A mechanistic understanding of developmental toxicity involves understanding at several levels of biologic organization 1,2,3,9
FDA PREGNANCY CATEGORIES
As a guide to physicians, the Food and Drug Administration utilizes a lettered classification system with regards to their safety for use in pregnancy. The FDA recommendations are based on the best available clinical evidence, and assigns lettered categories to drugs from “A”, or drugs that have been categorically demonstrated to have no teratogenic effects in humans, to “D” and “X”, or drugs that have been directly linked to congenital malformations in humans. The “X” classification is used for drugs that are absolutely contraindicated in pregnancy, while “D” is usually applied to drugs that are positively teratogenic, but for which no other useful alternatives are presently available.
Table II. Drug FDA categories
FDA Category Interpretation Examples
A Controlled studies in humans show no risk. Adequate, well-controlled studies in pregnant women have failed to demonstrate risk to the fetus. Multivitamins or prenatal supplements
B No evidence of risk in humans. Either animal findings show risk, but human findings do not; or, if no adequate human studies have been done, animal findings are negative. Penicillins
C Risk cannot be ruled out. Human studies are lacking, and animal studies are either positive for fetal risk, or lacking as well. However, potential benefits may justify the potential risk.
D Positive evidence of risk. Investigational or post-marketing data show risk to the fetus. Nevertheless, potential benefits may outweigh the potential risk. Carbamazepine, phenytoin
X Contraindicated in pregnancy. Studies in animals or hmans, investigational or post-marketing reports have shown fetal risk which clearly outweighs any possible benefit to the patient. Isotretinoin, Thalidomide, Diethylsilbestrol
The next table (Table 3) lists drugs that are proven human teratogens. Most drugs in this list are either Category D or X, but some are listed as Category C. When viewing this list, it is important to note that some medications may commonly cause malformations, while others rarely cause them, even when a positive relationship does exist. Also, because drugs are only used when a disease already exists, it is often hard to show whether the birth defects are caused by the agent itself and not the clinical condition. Careful clinical judgment is then necessary to weigh the possible risk and benefits from the use of a particular agent.
Table III. Human Teratogens 7,8,10
• ACE inhibitors (eg, captopril, enalapril) - D • Acetohydroxamic acid (AHA) - X
• Aminocaproic acid - D • Androgens (eg, Danazol) - X
• Angiotensin II receptor antagonists (eg, losartan, valsartan) - D • Antineoplastics (alkylating agents) - D
• Antineoplastics (antimetabolites) - X o 5-Fluorouracil
o Methotrexate o Methylaminopterin
o Cytarabine o Busulfan
o Chlorambucil o Azathioprine
o Cyclophosphamide o Mechlorethamine
o Cisplatin o Bleomycin
• Aminoglycosides (eg, gentamicin, streptomycin) - D • Aspirin - D
• Atenolol - D • Benzodiazepines - D and X
• Flurazepam (X) o Temazepam (X)
o Triazolam (X) • Bromides - D
• Carbamazepine - D • Colchicine – D
• Corticosteroids - C • Danazol - X
• Diethylstilbestrol - Not on market • Ergotamine - X
• Finasteride - X • Fluconazole - C
• Folic acid antagonists o Phenytoin - D
o Methotrexate – X • Lithium - D
• Methimazole - D • Methylene blue - C
• Mifepristone, RU-486 - D • Minoxidil - C
• Misoprostol - X • Mysoline - D
• Penicillamine - D • Phenobarbital or methylphenobarbital - D
• Potassium iodine and medications that effect iodine levels (diatrizoate) - D • Progestins - X (except megestrol and norethindrone - D)
• Raloxifene (Evista) - X • Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
• Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X • Tamoxifen – D
• Tetracycline - D • Thalidomide - X
• Valproic acid - D • Warfarin - X
REPRESENTATIVE HUMAN DEVELOPMENTAL TOXICANTS
The deleterious effects of medications vary depending on the critical periods of development when exposed to said agents. Different organs have different critical periods, although the period from gestation day 15 to day 60 is critical for many organs. The brain and skeleton are always sensitive, from the beginning of the third week to the end of pregnancy and the neonatal period. The heart is most sensitive during the third and fourth weeks of gestation while the external genitalia are most sensitive during the eighth and ninth weeks.1,2,3,4,6,810
One must also consider that genetic mutations and medications may cause similar abnormalities and syndromes. Axial malformations in mice can result from mutations in certain HOX genes or exposure to retinoids in cases of treatment of dermatologic disorders in unsuspected pregnant women. Maternal ingestion of warfarin can result in defective bone mineralization, telebrachydactyly, and facial dysmorphism with nasal hypoplasia. Human X-linked dominant chondrodysplasia punctata (CDPX2), or Happle syndrome, is associated with mutations in the human emopamil-binding protein, a delta-delta-sterol isomerase involved in cholesterol biosynthesis. Happle syndrome is a genetic disease of bone and cartilage whose phenotype is quite similar to the dysmorphism caused by warfarin ingestion. 10
The following table (table 4) lists some representative human developmental and their associated clinical syndromes:
Table IV. Representative human teratogens.
AGENT USE ADVERSE EFFECTS
13-cis retinoic acid Tx of cystic acne Craniofacial, CVS and mental deficits
Aminopterin Folate antagonist Abortion, CNS, craniofacial, growth defects
ACE inhibitors Antihypertensive Skull defects and kidney hemorrhage
Cigarette smoke Stimulant Growth retardation, facial defect
DES Synthetic estrogen Reproductive tract defects and vaginal cancer
Diphenylhydantoin Anticonvulsant Craniofacial, mental defects, fetal loss, growth retardation
Etretinate Psoriasis Limb, ear, cardiac, thymic defects
Lead Environmental contaminant Abortion, growth retardation, CNS defects
Penicillamine Chelator Connective tissue defects
Polychlorinated biphenyls Environmental contaminant Growth retardation, hyperpigmentation, neurobehavioral deficits
Thalidomide Antiemetic Reduction defects in limb and ears
Valproic acid Anticonvulsant Neural tube closure defects
Lithium Bipolar disorders Cardiac defects
GUIDELINES FOR PRECRIBING AND COUNSELING IN PREGNANCY
As a rule of thumb, drug intake in the pregnant patient is generally avoided, especially in the first trimester, when the fetus exhibits the greatest risk for congenital malformations. It is important to consider, then, whether non-pharmacologic treatments are available and equally as effective for the condition (i.e. pain management).
When drug therapy is absolutely necessary, preference must be given to drugs that have a proven safety profile (Category A and B), as opposed to newer agents for which data is lacking or equivocal. Monotherapy is preferred and in instances where drug combinations is the treatment of choice, agents must be introduced one at a time. Exposure of the fetus to the agent must be kept to a minimum: lowest possible dose and shortest possible effective treatment duration. When other routes are available, systemic administration should be avoided (inhalational and topical versus oral and intravenous). And most importantly, the benefits of the use of any drug should clearly outweigh any risks posed to both the fetus and mother.
But because most exposure to drugs in pregnant women occurs even before the pregnancy is known, the physician will often find himself in the position of counseling the patient of the teratogenic risk after exposure. Obstetricians, general practitioners, pediatricians and geneticists as well as other health professionals such as pharmacists, midwives and nurses are frequently asked by concerned pregnant women about the risk of drug intake, other medicinal products and exposure to other substances for the unborn child. In providing such counsel to patients, the physician must always make sure that he has the most current, best evidence about the drug in question. It must always be emphasized that a baseline 3% risk for congenital malformations exists for all pregnancies even without any known exposure to any agent. 1,2,3,7,9,10
It should also be emphasized that except for some important exceptions, most commonly prescribed and over-the-counter medications are relatively safe in pregnancy, and even for those with proven teratogenic potential, the issue of relative risk (an increase in probability versus an all-or-none phenomenon) should always be explained. Also, equal emphasis should be put on the possible risks for malformations associated with the condition for which the drug therapy was indicated (e.g. epileptics have a baseline 5% risk for malformations as opposed to 3% in uncomplicated pregnancies).2,3,7 ,11,12 And lastly, the dilemma of weighing risk versus benefit should also be touched, because some conditions (e.g. fever) carry a greater risk of producing malformations than any theoretical risk associated with the drug therapy in question (e.g. paracetamol).
Table 5 lists some common conditions in pregnancy and the important agents to consider for each:
Table V. Common conditions in pregnancy and associated drugs and interventions. Letters in parentheses indicate FDA categories. , , , ,11,12
CONDITION DRUGS/INTERVENTION
Bacterial Infections Penicillins (B) - preferred agents and probably the safest antimicrobial in pregnancy
Eryhtromycin (B) - for penicillin allergic patients
Use with caution: Cephalosporins (B), Chloramphenicol (B), Metronidazole (C)
Tuberculosis Rifampicin, Isoniazid, Ethambutol - have shown no increased risk for congenital malformation; use with caution
Colds, Coughs Always aim for symptomatic relief with fluids and rest.
Antihistamines with relative safety: Chlorpheniramine (B), Triprolidine (C), and Diphenhydramine (C) (more rapid onset of rebound congestion in pregnancy; use for no longer than 2-4 days)
Pseudoepehdrine (C) - generally considered safe in pregnancy
Cough Suppressants: Guaifenesin (C) or Dextromethorphan (C) (avoid preparations with alcohol and iodine)
Nausea and Vomiting Should always be treated conservatively when effective (rest, small, frequent meals, and acupressure)
Pyridoxine - Vit B6 (A); Pyridoxine in combination with Doxylamine (B); or Emetrol - first-line
Use with caution: Promethazine (C), Metaclopramide (C)
Pain Relief Paracetamol (B) - pain reliever and antipyretic of choice
Ibuprofen (B), Naproxen (B), Aspirin (D) - use with caution
For Severe Pain: Narcotics (Codeine, Demerol, Morphine) may be considered, but addictive potential for both mother and fetus should be recognized (risk for respiratory depression)
Local Anesthetics (Xylocaine) may be used safely, but combinations with Epinephrine are generally avoided
Diarrhea Kaolin and Pectin (B) - anti-diarrheal of choice, not absorbed systemically
Loperamide (B) - most probably safe
Asthma Treatment is the same as with the non-pregnant patient
Theophylline (B), Salbutamol via aerosol (B), Steroids (B) and Leukotrienes (B) are all safe in pregnancy
Epilepsy Always emphasize the increase in risk for malformations (5% in epileptics vs 3% in others) with or without therapy. Avoid drug combinations whenever possible and use therapeutic drug monitoring when necessary
Therapy is ideally maximized before pregnancy and one may consider slowly withdrawing therapy if patient has been seizure free for 2-3 years.
There is absolutely no justification for shifting from a drug with teratogenic risk (e.g. carbamazepine) to one about which even less is known.
Phenobarbital (D) - no increased frequency in minor or major birth defects
Carbamazepine (D) - traditionally the drug of choice in pregnancy, but present data on its teratogenic potential is unclear
Phenytoin (D) - teratogenic potential influenced by genetics (epoxide hydroxylase levels)
Valproic Acid (D) - 1-2% risk of spina bifida, also associated with minor cranio-facial abnormalities
Hypertension Methyldopa (C) - most widely used, unparalleled safety record in pregnancy
Beta-blockers (except Atenolol (D)) - not teratogenic, but may cause growth restriction
Hydralazine - no adverse fetal effects, used for the 2nd-3rd trimesters
Sodium Nitroprusside - readily crosses placenta and in theory, may cause accumulation of cyanide in the fetus; no adequate clinical data
Hyperthyroidism Propylthiouracil - used more often than carbamazepine. Is less lipid-soluble and more protein-bound, thus transported less well to the fetus and breastmilk.
IMMUNIZATION IN PREGNANCY
Vaccination in pregnancy, similar to drug use, is a special scenario in that both the effects on the mother and fetus must be considered together in its administration. Vaccines that generate an immune response in the maternal serum may also become protective to the fetus when maternal antibodies pass through the placenta. This phenomenon, however, may be detrimental when a sufficient amount of maternal antibodies are transmitted as to interfere with the development of natural antibodies in the fetus. Maternal reactions to vaccination, such as fever and hypersensitivity may also adversely affect fetal support and development.
These risks, however, are primarily theoretical. At present, there is no available clinical evidence that vaccination either with inactivated bacteria or viruses or toxoids carries any risk to the fetus. Live vaccines, however, carry a greater theoretical risk of causing fetal disease and are generally avoided in pregnancy. Altogether, the benefits of vaccination in pregnancy generally outweigh the risks of fetal disease, especially when the risk of developing the disease is relatively high (post-exposure prophylaxis) and when the vaccine is unlikely to cause any harm.
Live-viruses (measles, mumps, rubella) are generally contraindicated in pregnancy because of the probable risk of vertical transmission. When a live-virus vaccine is inadvertently given to a pregnant woman, or when a vaccinated woman subsequently becomes pregnant within 4 weeks of the vaccine, counseling about the possible effects on the fetus is indicated. Regardless of whether a live attenuated or killed vaccine is administered, risk versus benefit assessment is still the rule of thumb.1,13,14
Table 6 summarizes the relative safety of common vaccines in pregnancy:
Table VI. Vaccination in pregnancy
VACCINE SAFE IN PREGNANCY? COMMENTS
Tetanus-Diphtheria (Td) Yes Pregnant patients should receive Tetanus toxoid as a booster if there has been no prior administration within the last 10 years. Previously unvaccinated patients should receive a complete series of 3 vaccinations. The preferred schedule is after the second trimester, with each dose given 4 weeks apart. This is the only vaccine routinely indicated for all susceptible pregnant patients
Hepatitis A Not established Because vaccine is a killed vaccine, theoretical risk is low, but safety in pregnancy has not been determined. May be indicated for high risk patients.
Hepatitis B Yes Pregnancy is not a contraindication, and patients at high risk (e.g. >1 sex partner in the last 6 months, concurrent STD, IV drug use, or an HBsAg-positive partner) should be vaccinated. Current vaccines are noninfectious and no data has shown detrimental effects to the fetus.
Human Papillomavirus (HPV) Not recommended Vaccine has been related to some adverse outcomes in pregnancy, but data is limited.
Influenza (Inactivated) Yes Recommended during influenza season, as pregnant patients who become infected are at increased risk for severe complications. No adverse fetal outcomes reported.
Measles, Mumps and Rubella No Risk to fetus of live vaccines cannot be excluded and should not be administered in pregnant patients. Vaccinated women should be advised not to become pregnant for 28 days after administration.
All Rubella containing vaccines are contraindicated because of the risk of developing Congenital rubella syndrome (CRS) in the fetus. But to date, no documented cases of post-vaccination CRS have been reported.
Pneumococcal Not established Safety in pregnancy has not been evaluated, although no adverse effects have been reported.
Polio (IPV) Yes, but avoided No adverse effects reported, but generally avoided due to theoretical risks. High risk patients, however, may be considered for vaccination
Tetanus-Diphtheria- Pertussis (DPT) Yes Pregnancy is not a contraindication to DPT. Maternal Pertussis antibodies may be protective to the infant in early life, and so many practitioners prefer this vaccine over Tetanus toxoid alone.
Varicella No Because effects on the fetus are unknown, Varicella should be avoided entirely in pregnancy. But because of its lower virulence, the risk of transmission (if any) should even be lower than the wild type. VZIG should be strongly considered, however, for pregnant patients exposed to varicella.
BCG Not recommended No harmful effects reported
Typhoid Not established No available data
Rabies Yes, as post-exposure prophylaxis Because the consequences of rabies far outweigh the risk of vaccination, pregnancy is not a contraindication for post-exposure prophylaxis
I. Introduction
II. Pharmacokinetics in Pregnancy
III. Feto-placental Pharmacokinetics
IV. Principles of Teratogenesis
V. Mechanisms of Teratogenesis
VI. FDA Pregnancy Categories
VII. Representative Human Developmental Toxicants
VIII. Guidelines For Prescribing And Counseling In Pregnancy
IX. Immunization during Pregnancy
X. References
INTRODUCTION
Pharmacotherapeutic decisions in pregnancy take into consideration numerous factors. The ideal drug for treatment in pregnancy is efficacious for the maternal indication, is minimally transported through the placenta and, in the event of transplacental passage, exerts minimal effect on the fetus. Often neglected but of similar importance are drug characteristics that influence tolerability and adherence to dosage and dosing schedule, more so when the drug therapy in question exacerbates conditions common to pregnancy such as emesis, gastrointestinal changes either in the form of diarrhea or constipation, glucose intolerance and hypertension.
PHARMACOKINETICS IN PREGNANCY
Fig 1. Physiologic changes in pregnancy
Physiologic changes in pregnancy significantly affect pharmacokinetics in the pregnant patient (figure 1). These changes include:
1. Cardiovascular changes- increased cardiac output (40%) and increased plasma volume (50%) and total blood volume (40%)
2. Gastrointestinal changes - decreased gut motility, increased gastric pH and nausea and vomiting
3. Respiratory changes - hyperventilation, increased tidal volume, and increased pulmonary blood volume
4. Volume changes -dramatic increases in maternal aqueous and fatty tissue spaces (greatest at 10-30 weeks) and the increase in total body water (mostly extracellular: 40% maternal, 60% feto-placental)
5. Metabolic changes- relative decrease in serum albumin concentration (25%) and elevated levels of steroid hormones competing for protein binding sites, elevated levels of serum progesterone, elevated levels of serum estrogen
6. Renal changes - increase renal blood flow (50%) and the consequent increase in glomerular filtration (50%) 1
Table I. Physiologic changes in pregnancy and their impact on pharmacokinetics of selected agents , ,
PHYSIOLOGIC CHANGES IN PREGNANCY EFFECTS ON PHARMACOKINETICS KEY EXAMPLES
Decreased gut motility, increased gastric pH and nausea and vomiting Variable bioavailability of oral preparations Most oral preparations
Hyperventilation, increased tidal volume, and increased pulmonary blood volume Increased alveolar uptake of inhaled drugs Inhaled anesthetics
Increased cardiac output, and increased plasma volume and total blood volume Increased volume of distribution
Increases in maternal aqueous and fatty tissue spaces (greatest at 10-30 weeks) and the increase in total body water Further increase in the volume of distribution
Relative decrease in serum albumin concentration and elevated levels of steroid hormones competing for protein binding sites Increased free drug fractions of protein-bound drugs Diazepam, phenytoin, sodium valproate (especially in the 3rd trimester)
Elevated levels of serum progesterone Increased cytochrome metabolism of some drugs Phenytoin, carbamazepine, sodium valproate
Elevated levels of serum estrogen Decreased cytochrome oxidase metabolism of some drugs Theophylline and caffeine
Increase renal blood flow and the consequent increase in glomerular filtration Increased renal excretion and creatinine clearance Lithium, Digoxin
Ampicillin (doubled)
The net effect of these changes lead to an expected decreased steady state drug concentration in pregnancy if a normal dose is administered, i.e. a higher dose will be needed to achieve therapeutic levels, although drug-specific exceptions will occur.
Although the changes in pharmacokinetics in the pregnant patient appear to be very important in theory, these changes are often not significant clinically. Notable exceptions are drugs that are exclusively eliminated via the renal route, such as lithium and digoxin. The increase in renal excretion leads to a significant decrease in serum concentrations, and, considering their narrow therapeutic range, may necessitate serum concentration monitoring. Also noteworthy are antiepileptics (carbamazepine, valproic acid and phenytoin) which experience a decrease in effective serum concentrations secondary to increased hepatic and renal elimination, increase in plasma volume, and decreased protein binding. 3, These drugs, however, are more the exception than the rule, because the changes mentioned above are often offset in most conditions.
Thus, very often it is the effects on the developing fetus that are taken into greater consideration in therapeutic decisions in pregnancy rather than maternal factors.
FETO-PLACENTAL PHARMACOKINETICS
Drugs that eventually reach the fetus are (almost) always administered to the mother. For a drug to exert its effects on the fetus, transplacental transport must take place. After maternal administration, drugs first pass through the placenta before reaching the fetal serum. From the fetal serum, drugs are then transferred transplacentally to the mother and are eventually excreted.
Raised areas on the basal surface of the placenta, termed as maternal lobes or cotyledons, are intimately related with several fetal cotyledons, allowing maternal circulation to be virtually superimposed onto the fetus. For materials to pass from mother to fetus, however, solutes must pass through the syncytiotrophoblast, either directly through its cytoplasm, or, less commonly, via a network of specific transporters. The transport of molecules from maternal to fetal circulation thus involves the passage between 3 functional compartments: maternal blood, the tropohoblastic cytoplasm, and finally fetal circulation (figure 2).
The great majority of substances depend on simple diffusion to pass through these compartments. The rate of transport between mother and fetus, then, is dictated by the molecular weight, degree of ionization, protein-binding and finally relative concentrations across these compartments. 2,3,4
Fig 2. Major pathways and interrelations of pharmacokinetics in maternal, placental and fetal units. Size of arrows indicates relative importance of effect. (Re-drawn from an original by Garland M. Pharmacology of drug transfer across the placenta. Obstet Gynecol Clin Nth Am. 1998 25(1) 21-42 )
Several key factors involved in drug transfer across the placenta are:
1. The physicochemical properties of drugs, i.e. lipid solubility, degree of ionization, molecular size and protein binding characteristics. Drugs that are highly lipid soluble, non-ionized, of low molecular weight (<200 daltons) and minimally protein-bound easily cross the placental barrier
2. The transfer of flow-limited drugs are affected by placental blood flow and maternal serum drug concentrations (greater maternal serum concentrations create a greater concentration gradient causing increased placental transport)
3. Compounds that alter blood flow also alter maternal drug disposition and consequently affect placental transfer
4. Placental metabolism (i.e. dealkylation, hydroxylation and demethylation) also influence drug transport through the placenta, although these effects are relatively minor compared to metabolism via the maternal and fetal liver
5. Fetal metabolism may also play a part, but these effects may change during pregnancy 5
.
Fetal pharmacokinetics also plays a role in determining the net effect of drugs on the fetus (i.e. teratogenicity):
1. Maternal blood flow through the placenta gradually increases during gestation (from 50mL/min at 10 weeks of pregnancy to a peak of 600mL/min at 38 weeks AOG), thereby increasing the fetal drug exposure as pregnancy progresses.
2. The protein binding capacity of fetal plasma is significantly lower than that of maternal circulation (fetal plasma albumin concentration may be 15% greater than maternal, but this is offset by the lower levels (37%) of alpha1-acid glycoprotein and the lower affinity for binding of fetal plasma proteins) leading to a greater free fraction for drugs that enter the fetal circulation (especially basic drugs such as propranolol and lidocaine and drugs with poor affinity to fetal proteins such as ampicillin and benzylpenicillin) and consequently, a greater risk for toxicity.
3. The fetal plasma and amniotic fluid are slightly more acidic than maternal blood, favoring the ionization and subsequent ion-trapping of basic drugs in the fetal compartment after transplacental passage. This apparent accumulation in the fetal plasma further predisposes to toxicity.
4. The fetal liver also expresses drug-metabolizing enzymes such as cytochrome oxidases, but the metabolizing capacity is much less than that of the mother. Drugs that pass through the placenta may thereby undergo first-pass metabolism through the fetal liver before reaching systemic circulation, though this effect is modulated by the ductus venosus shunt and may vary by 30-70%.
5. The fetal kidney is immature and glomerular filtration is markedly reduced. Glomerular filtration rate increases with gestational age, but peaks to only 2-4mL/min at term, primarily because the fetal kidney receives only 3% of cardiac output, compared to 25% in the adult. Cation secretion (e.g. cimetidine) is efficient, but the renal excretion of anionic drugs (e.g. penicillin) is very low.
6. Fetal urine enters amniotic fluid, which may be subsequently swallowed by the fetus, and renally excreted drugs and metabolites may subsequently be reabsorbed.2,3,
In general, drugs that exist as large, highly protein bound and/or ionized molecules in maternal plasma and are poorly absorbed into the maternal bloodstream rarely cross the placental membrane and are usually confined to the maternal circulation in therapeutic doses, thus exhibiting minimal effects to the fetus.
Because of decreased protein binding, ion-trapping and poor metabolism and excretion, drugs that do pass to the fetal circulation exhibit a greater potential for toxicity than they do for the mother.
PRINCIPLES OF TERATOGENESIS
By far the greatest concern for both patient and physician in drug therapy during pregnancy are the possible teratogenic effects of drugs on the fetus. Teratogens (from the Greek teratos meaning “monster”) refer to any agent that acts during the embryonic or fetal period and produces a permanent alteration in form or function. These alterations include birth defects, or visible deformities that are congenital in origin, but may occur as metabolic derangements that may be more subtle at birth.
Environmental factors (e.g. maternal conditions, infectious agents, mechanical problems, chemicals, drugs, radiation, hyperthermia, etc.) account for about 10% of all abnormal outcomes in pregnancy. Evaluation of the teratogenic effect of agents depends on the following criteria: 1) proven exposure to agent at critical times in prenatal development, 2) consistent epidemiologic evidence, 3) clearly characterized clinical effects (i.e. syndromes), 4) frequency of clinical syndromes reflecting actual frequency of exposure in the population and 5) the ability of the agent to cross the placenta or sufficiently alter maternal or fetal metabolism to cause significant effects. Other useful but non-essential criteria for evaluating teratogenicity are experimental animal models that mimic the human malformation at clinically comparable exposures and that the mechanisms of teratogenesis are understood and/or results are biologically plausible.1,3, , 7
The timing of exposure to a suspected teratogen plays a crucial role in its effect on fetal development (figure 3). Periods of susceptibility in embryogenesis are characterized by rapid cell division and differentiation.
Fig 3. Sequence of events in normal embryogenesis. (Figure taken from Human Pharmacology: Molecular to Clinical, 2nd ed.)
Fig 4. Outcomes associated with exposure at different stages of reproduction
During the preimplantation or the so called “all or none” period (<15 days from fertilization to implantation), the zygote undergoes rapid cleavage and organization into an outer and inner cell mass (blastocyst formation). Development during this stage can be considered “all or none”, that is, injurious stimuli are either sufficient enough to cause the death of the embryo, or compensation by the uninjured cells are enough to continue normal development (figure 4).
The embryonic period (from the 2nd to the 8th weeks AOG) is the most crucial stage in teratogenesis. Fetal susceptibility to teratogens is greatest at this stage, and is central to the pathogenesis of most structural malformations
The fetal period (from 9 weeks up to term) is characterized by the maturation of fetal organs important to functional development. The fetus remains vulnerable to insult, and exposure to teratogens may still result to defects in function and minor anomalies. An example is the pulmonary hypoplasia caused by any agent that causes a reduction in amniotic fluid volume from 20-25 weeks.
MECHANISMS OF TERATOGENESIS
Some proposed mechanisms of teratogenicity include:
1. Cell death beyond recuperative capacity of the embryo/fetus
2. Mitotic delay; increase in the length of the cell cycle
3. Retarded differentiation
4. Physical constraint and vascular insufficiency
5. Interference with histogenesis by cell depletion, necrosis, calcification, etc
6. Inhibited cell migration and cell communication 6
Other agents have more established physiologic and genetic mechanisms. For example, agents may disrupt the metabolism of folic acid. Folic acid plays an important role in the synthesis of DNA and RNA bases. Drugs that either prevent the absorption of folate or acts as antagonists (e.g. anti-seizure medications: valproic acid, phenobarbital, carbamazepine and phenytoin) predispose to a variety of congenital malformations, the most common of which are neural tube defects.4, 6
Other drugs exert their effects by the production of oxygen free radicals and other oxidative intermediates. Free radicals are often rendered innocuous by cytoplasmic epoxide hydroxylase. This enzyme system, however, is immature in the fetus, leading to the accumulation of these free radicals in fetal tissues, and subsequent carcinogenic and mutagenic effects. Specific examples include phenobarbital, phenytoin and carbamazepine, which are metabolized by hepatic microsomes into epozides and arene oxides.6
The maternal condition itself may play a role in fetal malformations, and provide a synergistic effect with the drug in question. Alcoholism in pregnant women, for instance, is often associated with concomitant use of other recreational drugs and smoking, as well as nutritional deficiencies. Fetuses born to alcoholic mothers, thus, exhibit greater tendencies for congenital defects than would otherwise be explained by exposure to alcohol alone. Likewise, epileptic mothers, even without therapy, carry a greater risk for congenital malformations.
Genetic factors of the fetus also contribute to the teratogenic mechanism of toxins. Previous mutations that alter the functions of certain enzymes, especially those crucial to the removal of toxic agents, may increase the susceptibility of a particular teratogen (e.g. risk of malformation after exposure to phenytoin is increased in fetuses with low activities of epoxide hydroxylase). This interplay of both environmental and genetic factors probably account for most anomalies that are “multifactorial” in origin.1,6,8
Other agents act by the direct alteration of key genetic sequences in embryogenesis. A key example is a group of genetic sequences that direct the future position of numerous structures in the body. These homeobox genes are arranged in a fixed order along the length of the chromosome. This position, in turn corresponds to a particular body region: the 3’ end corresponds to the caudal region, and the 5’ end directs the development of the caudad region. Agents that predispose to a particular homeobox gene (e.g. valproic acid exhibits a predilection to the 5’ end) thus preferentially cause malformations to the corresponding body region (caudally in the case of valproic acid). 4,6,8,9
Finally, paternal factors can also exert effects on malformations on the fetus. Agents that cause germline mutations and genetic maldevelopment of sperm cells can destine the fetus to become malformed even before implantation takes place. Also, drugs or agents taken by the paternal spouse can gain access to the developing fetus during sexual intercourse in pregnancy.4,6,7, 8, 9
The great majority of agents, however, have poorly understood mechanisms of teratogenesis. The difficulties in analyzing the mechanisms of teratogenicity include the following:
1. Normal development is an extremely complex process that even now is not completely understood.
2. Environmental toxicants include a wide range of chemical, physical and biological agents that initiate a wide variety of mechanisms, and exposure to specific toxicants are rarely encountered alone in the clinical setting.
3. Some toxicants may affect only a fraction of individuals in the population, while sparing others from their teratogenic effects.
4. A mechanistic understanding of developmental toxicity involves understanding at several levels of biologic organization 1,2,3,9
FDA PREGNANCY CATEGORIES
As a guide to physicians, the Food and Drug Administration utilizes a lettered classification system with regards to their safety for use in pregnancy. The FDA recommendations are based on the best available clinical evidence, and assigns lettered categories to drugs from “A”, or drugs that have been categorically demonstrated to have no teratogenic effects in humans, to “D” and “X”, or drugs that have been directly linked to congenital malformations in humans. The “X” classification is used for drugs that are absolutely contraindicated in pregnancy, while “D” is usually applied to drugs that are positively teratogenic, but for which no other useful alternatives are presently available.
Table II. Drug FDA categories
FDA Category Interpretation Examples
A Controlled studies in humans show no risk. Adequate, well-controlled studies in pregnant women have failed to demonstrate risk to the fetus. Multivitamins or prenatal supplements
B No evidence of risk in humans. Either animal findings show risk, but human findings do not; or, if no adequate human studies have been done, animal findings are negative. Penicillins
C Risk cannot be ruled out. Human studies are lacking, and animal studies are either positive for fetal risk, or lacking as well. However, potential benefits may justify the potential risk.
D Positive evidence of risk. Investigational or post-marketing data show risk to the fetus. Nevertheless, potential benefits may outweigh the potential risk. Carbamazepine, phenytoin
X Contraindicated in pregnancy. Studies in animals or hmans, investigational or post-marketing reports have shown fetal risk which clearly outweighs any possible benefit to the patient. Isotretinoin, Thalidomide, Diethylsilbestrol
The next table (Table 3) lists drugs that are proven human teratogens. Most drugs in this list are either Category D or X, but some are listed as Category C. When viewing this list, it is important to note that some medications may commonly cause malformations, while others rarely cause them, even when a positive relationship does exist. Also, because drugs are only used when a disease already exists, it is often hard to show whether the birth defects are caused by the agent itself and not the clinical condition. Careful clinical judgment is then necessary to weigh the possible risk and benefits from the use of a particular agent.
Table III. Human Teratogens 7,8,10
• ACE inhibitors (eg, captopril, enalapril) - D • Acetohydroxamic acid (AHA) - X
• Aminocaproic acid - D • Androgens (eg, Danazol) - X
• Angiotensin II receptor antagonists (eg, losartan, valsartan) - D • Antineoplastics (alkylating agents) - D
• Antineoplastics (antimetabolites) - X o 5-Fluorouracil
o Methotrexate o Methylaminopterin
o Cytarabine o Busulfan
o Chlorambucil o Azathioprine
o Cyclophosphamide o Mechlorethamine
o Cisplatin o Bleomycin
• Aminoglycosides (eg, gentamicin, streptomycin) - D • Aspirin - D
• Atenolol - D • Benzodiazepines - D and X
• Flurazepam (X) o Temazepam (X)
o Triazolam (X) • Bromides - D
• Carbamazepine - D • Colchicine – D
• Corticosteroids - C • Danazol - X
• Diethylstilbestrol - Not on market • Ergotamine - X
• Finasteride - X • Fluconazole - C
• Folic acid antagonists o Phenytoin - D
o Methotrexate – X • Lithium - D
• Methimazole - D • Methylene blue - C
• Mifepristone, RU-486 - D • Minoxidil - C
• Misoprostol - X • Mysoline - D
• Penicillamine - D • Phenobarbital or methylphenobarbital - D
• Potassium iodine and medications that effect iodine levels (diatrizoate) - D • Progestins - X (except megestrol and norethindrone - D)
• Raloxifene (Evista) - X • Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
• Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X • Tamoxifen – D
• Tetracycline - D • Thalidomide - X
• Valproic acid - D • Warfarin - X
REPRESENTATIVE HUMAN DEVELOPMENTAL TOXICANTS
The deleterious effects of medications vary depending on the critical periods of development when exposed to said agents. Different organs have different critical periods, although the period from gestation day 15 to day 60 is critical for many organs. The brain and skeleton are always sensitive, from the beginning of the third week to the end of pregnancy and the neonatal period. The heart is most sensitive during the third and fourth weeks of gestation while the external genitalia are most sensitive during the eighth and ninth weeks.1,2,3,4,6,810
One must also consider that genetic mutations and medications may cause similar abnormalities and syndromes. Axial malformations in mice can result from mutations in certain HOX genes or exposure to retinoids in cases of treatment of dermatologic disorders in unsuspected pregnant women. Maternal ingestion of warfarin can result in defective bone mineralization, telebrachydactyly, and facial dysmorphism with nasal hypoplasia. Human X-linked dominant chondrodysplasia punctata (CDPX2), or Happle syndrome, is associated with mutations in the human emopamil-binding protein, a delta-delta-sterol isomerase involved in cholesterol biosynthesis. Happle syndrome is a genetic disease of bone and cartilage whose phenotype is quite similar to the dysmorphism caused by warfarin ingestion. 10
The following table (table 4) lists some representative human developmental and their associated clinical syndromes:
Table IV. Representative human teratogens.
AGENT USE ADVERSE EFFECTS
13-cis retinoic acid Tx of cystic acne Craniofacial, CVS and mental deficits
Aminopterin Folate antagonist Abortion, CNS, craniofacial, growth defects
ACE inhibitors Antihypertensive Skull defects and kidney hemorrhage
Cigarette smoke Stimulant Growth retardation, facial defect
DES Synthetic estrogen Reproductive tract defects and vaginal cancer
Diphenylhydantoin Anticonvulsant Craniofacial, mental defects, fetal loss, growth retardation
Etretinate Psoriasis Limb, ear, cardiac, thymic defects
Lead Environmental contaminant Abortion, growth retardation, CNS defects
Penicillamine Chelator Connective tissue defects
Polychlorinated biphenyls Environmental contaminant Growth retardation, hyperpigmentation, neurobehavioral deficits
Thalidomide Antiemetic Reduction defects in limb and ears
Valproic acid Anticonvulsant Neural tube closure defects
Lithium Bipolar disorders Cardiac defects
GUIDELINES FOR PRECRIBING AND COUNSELING IN PREGNANCY
As a rule of thumb, drug intake in the pregnant patient is generally avoided, especially in the first trimester, when the fetus exhibits the greatest risk for congenital malformations. It is important to consider, then, whether non-pharmacologic treatments are available and equally as effective for the condition (i.e. pain management).
When drug therapy is absolutely necessary, preference must be given to drugs that have a proven safety profile (Category A and B), as opposed to newer agents for which data is lacking or equivocal. Monotherapy is preferred and in instances where drug combinations is the treatment of choice, agents must be introduced one at a time. Exposure of the fetus to the agent must be kept to a minimum: lowest possible dose and shortest possible effective treatment duration. When other routes are available, systemic administration should be avoided (inhalational and topical versus oral and intravenous). And most importantly, the benefits of the use of any drug should clearly outweigh any risks posed to both the fetus and mother.
But because most exposure to drugs in pregnant women occurs even before the pregnancy is known, the physician will often find himself in the position of counseling the patient of the teratogenic risk after exposure. Obstetricians, general practitioners, pediatricians and geneticists as well as other health professionals such as pharmacists, midwives and nurses are frequently asked by concerned pregnant women about the risk of drug intake, other medicinal products and exposure to other substances for the unborn child. In providing such counsel to patients, the physician must always make sure that he has the most current, best evidence about the drug in question. It must always be emphasized that a baseline 3% risk for congenital malformations exists for all pregnancies even without any known exposure to any agent. 1,2,3,7,9,10
It should also be emphasized that except for some important exceptions, most commonly prescribed and over-the-counter medications are relatively safe in pregnancy, and even for those with proven teratogenic potential, the issue of relative risk (an increase in probability versus an all-or-none phenomenon) should always be explained. Also, equal emphasis should be put on the possible risks for malformations associated with the condition for which the drug therapy was indicated (e.g. epileptics have a baseline 5% risk for malformations as opposed to 3% in uncomplicated pregnancies).2,3,7 ,11,12 And lastly, the dilemma of weighing risk versus benefit should also be touched, because some conditions (e.g. fever) carry a greater risk of producing malformations than any theoretical risk associated with the drug therapy in question (e.g. paracetamol).
Table 5 lists some common conditions in pregnancy and the important agents to consider for each:
Table V. Common conditions in pregnancy and associated drugs and interventions. Letters in parentheses indicate FDA categories. , , , ,11,12
CONDITION DRUGS/INTERVENTION
Bacterial Infections Penicillins (B) - preferred agents and probably the safest antimicrobial in pregnancy
Eryhtromycin (B) - for penicillin allergic patients
Use with caution: Cephalosporins (B), Chloramphenicol (B), Metronidazole (C)
Tuberculosis Rifampicin, Isoniazid, Ethambutol - have shown no increased risk for congenital malformation; use with caution
Colds, Coughs Always aim for symptomatic relief with fluids and rest.
Antihistamines with relative safety: Chlorpheniramine (B), Triprolidine (C), and Diphenhydramine (C) (more rapid onset of rebound congestion in pregnancy; use for no longer than 2-4 days)
Pseudoepehdrine (C) - generally considered safe in pregnancy
Cough Suppressants: Guaifenesin (C) or Dextromethorphan (C) (avoid preparations with alcohol and iodine)
Nausea and Vomiting Should always be treated conservatively when effective (rest, small, frequent meals, and acupressure)
Pyridoxine - Vit B6 (A); Pyridoxine in combination with Doxylamine (B); or Emetrol - first-line
Use with caution: Promethazine (C), Metaclopramide (C)
Pain Relief Paracetamol (B) - pain reliever and antipyretic of choice
Ibuprofen (B), Naproxen (B), Aspirin (D) - use with caution
For Severe Pain: Narcotics (Codeine, Demerol, Morphine) may be considered, but addictive potential for both mother and fetus should be recognized (risk for respiratory depression)
Local Anesthetics (Xylocaine) may be used safely, but combinations with Epinephrine are generally avoided
Diarrhea Kaolin and Pectin (B) - anti-diarrheal of choice, not absorbed systemically
Loperamide (B) - most probably safe
Asthma Treatment is the same as with the non-pregnant patient
Theophylline (B), Salbutamol via aerosol (B), Steroids (B) and Leukotrienes (B) are all safe in pregnancy
Epilepsy Always emphasize the increase in risk for malformations (5% in epileptics vs 3% in others) with or without therapy. Avoid drug combinations whenever possible and use therapeutic drug monitoring when necessary
Therapy is ideally maximized before pregnancy and one may consider slowly withdrawing therapy if patient has been seizure free for 2-3 years.
There is absolutely no justification for shifting from a drug with teratogenic risk (e.g. carbamazepine) to one about which even less is known.
Phenobarbital (D) - no increased frequency in minor or major birth defects
Carbamazepine (D) - traditionally the drug of choice in pregnancy, but present data on its teratogenic potential is unclear
Phenytoin (D) - teratogenic potential influenced by genetics (epoxide hydroxylase levels)
Valproic Acid (D) - 1-2% risk of spina bifida, also associated with minor cranio-facial abnormalities
Hypertension Methyldopa (C) - most widely used, unparalleled safety record in pregnancy
Beta-blockers (except Atenolol (D)) - not teratogenic, but may cause growth restriction
Hydralazine - no adverse fetal effects, used for the 2nd-3rd trimesters
Sodium Nitroprusside - readily crosses placenta and in theory, may cause accumulation of cyanide in the fetus; no adequate clinical data
Hyperthyroidism Propylthiouracil - used more often than carbamazepine. Is less lipid-soluble and more protein-bound, thus transported less well to the fetus and breastmilk.
IMMUNIZATION IN PREGNANCY
Vaccination in pregnancy, similar to drug use, is a special scenario in that both the effects on the mother and fetus must be considered together in its administration. Vaccines that generate an immune response in the maternal serum may also become protective to the fetus when maternal antibodies pass through the placenta. This phenomenon, however, may be detrimental when a sufficient amount of maternal antibodies are transmitted as to interfere with the development of natural antibodies in the fetus. Maternal reactions to vaccination, such as fever and hypersensitivity may also adversely affect fetal support and development.
These risks, however, are primarily theoretical. At present, there is no available clinical evidence that vaccination either with inactivated bacteria or viruses or toxoids carries any risk to the fetus. Live vaccines, however, carry a greater theoretical risk of causing fetal disease and are generally avoided in pregnancy. Altogether, the benefits of vaccination in pregnancy generally outweigh the risks of fetal disease, especially when the risk of developing the disease is relatively high (post-exposure prophylaxis) and when the vaccine is unlikely to cause any harm.
Live-viruses (measles, mumps, rubella) are generally contraindicated in pregnancy because of the probable risk of vertical transmission. When a live-virus vaccine is inadvertently given to a pregnant woman, or when a vaccinated woman subsequently becomes pregnant within 4 weeks of the vaccine, counseling about the possible effects on the fetus is indicated. Regardless of whether a live attenuated or killed vaccine is administered, risk versus benefit assessment is still the rule of thumb.1,13,14
Table 6 summarizes the relative safety of common vaccines in pregnancy:
Table VI. Vaccination in pregnancy
VACCINE SAFE IN PREGNANCY? COMMENTS
Tetanus-Diphtheria (Td) Yes Pregnant patients should receive Tetanus toxoid as a booster if there has been no prior administration within the last 10 years. Previously unvaccinated patients should receive a complete series of 3 vaccinations. The preferred schedule is after the second trimester, with each dose given 4 weeks apart. This is the only vaccine routinely indicated for all susceptible pregnant patients
Hepatitis A Not established Because vaccine is a killed vaccine, theoretical risk is low, but safety in pregnancy has not been determined. May be indicated for high risk patients.
Hepatitis B Yes Pregnancy is not a contraindication, and patients at high risk (e.g. >1 sex partner in the last 6 months, concurrent STD, IV drug use, or an HBsAg-positive partner) should be vaccinated. Current vaccines are noninfectious and no data has shown detrimental effects to the fetus.
Human Papillomavirus (HPV) Not recommended Vaccine has been related to some adverse outcomes in pregnancy, but data is limited.
Influenza (Inactivated) Yes Recommended during influenza season, as pregnant patients who become infected are at increased risk for severe complications. No adverse fetal outcomes reported.
Measles, Mumps and Rubella No Risk to fetus of live vaccines cannot be excluded and should not be administered in pregnant patients. Vaccinated women should be advised not to become pregnant for 28 days after administration.
All Rubella containing vaccines are contraindicated because of the risk of developing Congenital rubella syndrome (CRS) in the fetus. But to date, no documented cases of post-vaccination CRS have been reported.
Pneumococcal Not established Safety in pregnancy has not been evaluated, although no adverse effects have been reported.
Polio (IPV) Yes, but avoided No adverse effects reported, but generally avoided due to theoretical risks. High risk patients, however, may be considered for vaccination
Tetanus-Diphtheria- Pertussis (DPT) Yes Pregnancy is not a contraindication to DPT. Maternal Pertussis antibodies may be protective to the infant in early life, and so many practitioners prefer this vaccine over Tetanus toxoid alone.
Varicella No Because effects on the fetus are unknown, Varicella should be avoided entirely in pregnancy. But because of its lower virulence, the risk of transmission (if any) should even be lower than the wild type. VZIG should be strongly considered, however, for pregnant patients exposed to varicella.
BCG Not recommended No harmful effects reported
Typhoid Not established No available data
Rabies Yes, as post-exposure prophylaxis Because the consequences of rabies far outweigh the risk of vaccination, pregnancy is not a contraindication for post-exposure prophylaxis
Sunday, September 7, 2008
Isang Awit
I
Di ko naman hinanap
Di ko naman ginusto
Ngunit sadyang ang tadhana
Ay lubhang mapagbiro
II
Nagkita, nawalay
Nagkita na muli
Sa una’y walang tama
Ng yumao’y tumindi
KORO:
Di ko na kaya
Sa yo ay mawalay
Bawat pintig
Bawat hininga
Sa yo ay aking alay
III
Mga taon na ang nagdaan
Ang sidhi’y di nagbago
Sulyap mo’y dulot pa rin
Tibok nitong aking puso
IV.
Bawat hibla ng hininga
Bawat galaw ng aking laman
Habang ako ay nabubuhay
Ito’y sayo lamang
Di ko naman hinanap
Di ko naman ginusto
Ngunit sadyang ang tadhana
Ay lubhang mapagbiro
II
Nagkita, nawalay
Nagkita na muli
Sa una’y walang tama
Ng yumao’y tumindi
KORO:
Di ko na kaya
Sa yo ay mawalay
Bawat pintig
Bawat hininga
Sa yo ay aking alay
III
Mga taon na ang nagdaan
Ang sidhi’y di nagbago
Sulyap mo’y dulot pa rin
Tibok nitong aking puso
IV.
Bawat hibla ng hininga
Bawat galaw ng aking laman
Habang ako ay nabubuhay
Ito’y sayo lamang
Thursday, August 28, 2008
SEXUAL DYSFUNCTION
Sexual Dysfunction
The number of patients attending a doctor with acknowledged sexual dysfunction will
depend on the cultural background of the patients and the perceived attitude of the
doctor. Many patients present with gynecological symptoms even when their problems
are psychosocial or psychosexual. If the doctor is not aware of this, patients may be
inappropriately managed.
• Not all doctors have the time or ability to deal with sexual problems in depth but
a sympathetic approach will help to resolve many problems. In other more complex
cases, referral to a psychosexual counselor will be appropriate.
• Psychosexual therapy requires good rapport between the therapist and the patient
or couple and this may take time to achieve. Such therapy can be very time
consuming and progress may be slow.
• An understanding of both male and female sexual function and dysfunction is
necessary when providing counseling to the patient or to the couple.
• The gynecologist must be aware of the concerns regarding sexual function of a
patient who is advised to undergo surgical treatment - particularly vaginal surgery.
Adequate explanation must be given to the patient who may not express her
concerns directly.
Male sexual dysfunction
Normal male coital function requires arousal through mental, visual or tactile stimulation, erection (a parasympathetic function), penetration, ejaculation (a sympathetic function) and resolution.
Low sex drive and failure of arousal
• Congenitally diminished testicular function (as in Klinefelter's syndrome). Treatment with testosterone is likely to be beneficial if circulating levels are low.
• Psychiatric problems such as anxiety, depression and stress.
• Psychosocial and psychosexual problems due to marital disharmony or to latent or
overt homosexuality. Counseling may be beneficial.
• Medications such as sedatives, tranquillizers and hypotensive drugs can reduce sex
drive.
Impotence
• Congenital neurological problems such as spina bifida.
• Acquired neurological problems due to traumatic spinal tract damage or to a tumor.
Psychiatric problems are commonly related to anxiety, depression or stress, or may
follow an industrial or road traffic accident which leads to compensation orientated
sexual dysfunction.
• Psychosocial and psychosexual maladjustment or malorientation.
• Medical disorders, e.g. diabetes, hyperprolactinaemia, myxedema or liver failure.
• Drugs such as alcohol and psychotropic, anticholinergic and hypotensive medications. It is important to warn patients that sexual dysfunction is a possible side-effect of certain drugs.
• Psychoemotional problems following vasectomy.
• Disorders of the urogenital tract such as infection or Peyronie's disease. In Peyronie's disease a fibrous plaque develops between the fascia and the tunica albuginea of the corpora cavernosa causing angulation of the penis and pain on erection.
Management
• Appropriate counseling and treatment of medical problems or alteration of drug
therapy.
• In a few patients surgical implantation of a penile prosthesis may be helpful.
Ejaculatory problems
• Congenital abnormalities such as hypospadias or phimosis.
• May be due to drugs which affect neurological control.
• Premature ejaculation is a common problem which can sometimes be treated effectively by squeezing the glans penis gently when the desire to ejaculate is felt, until
the desire disappears. This process is repeated up to five times before ejaculation
is allowed to occur. Treatment with clomipramine (25-75 mg a day) may also be
helpful.
• Ejaculatory incompetence may occur with anxiety and stress.
• Retrograde ejaculation can occur, particularly after prostatectomy. Ejaculation with
a full bladder may overcome the problem.
Female sexual dysfunction
Normal female sexual arousal occurs more through mental and tactile stimulation than
by visual stimulation. During arousal lubricating secretions are produced. Intercourse
can be pleasurable in the absence of orgasm which does not occur in all women.
Local problems
• An imperforate hymen or vaginal atresia will prevent penetration.
• Superficial or deep dyspareunia may lead to apareunia.
Dyspareunia may be due to failure of arousal.
• Superficial dyspareunia may be due to infection such as candidiasis or trichomoniasis, or to atrophic vaginitis, or may occur following surgery such as an episiotomy or posterior repair.
• Deep dyspareunia may be due to pelvic inflammatory disease or endometriosis.
General problems
• Libido may be reduced by general debilitation or by oestrogen lack as in hypogonado- trophic hypogonadism, gonadal failure or hyperprolactinaemia.
• Drugs do not affect sexual function in women as much as in men, but libido may
be reduced by oral contraception, phenothiazines and drugs of addiction in some
women.
• Psychiatric problems such as anxiety, depression and psychosis commonly cause
sexual dysfunction and require appropriate management and treatment.
• Psychosexual problems are a common cause and common result of marital dishar-
mony. Management includes counseling of both partners often over a period of
weeks or months.
History
• Obtaining a good history from a patient with sexual dysfunction is an art.
• A sympathetic unhurried, uncritical approach is essential.
Examination
• Thorough general and pelvic examination to exclude organic problems.
• The woman's response to pelvic examination may be a helpful indicator of the
nature of the problem.
Management
• Depends on the problem.
• Local and general medical problems should be treated appropriately.
• Referral to a psychosexual counselor or psychiatrist may be required.
The number of patients attending a doctor with acknowledged sexual dysfunction will
depend on the cultural background of the patients and the perceived attitude of the
doctor. Many patients present with gynecological symptoms even when their problems
are psychosocial or psychosexual. If the doctor is not aware of this, patients may be
inappropriately managed.
• Not all doctors have the time or ability to deal with sexual problems in depth but
a sympathetic approach will help to resolve many problems. In other more complex
cases, referral to a psychosexual counselor will be appropriate.
• Psychosexual therapy requires good rapport between the therapist and the patient
or couple and this may take time to achieve. Such therapy can be very time
consuming and progress may be slow.
• An understanding of both male and female sexual function and dysfunction is
necessary when providing counseling to the patient or to the couple.
• The gynecologist must be aware of the concerns regarding sexual function of a
patient who is advised to undergo surgical treatment - particularly vaginal surgery.
Adequate explanation must be given to the patient who may not express her
concerns directly.
Male sexual dysfunction
Normal male coital function requires arousal through mental, visual or tactile stimulation, erection (a parasympathetic function), penetration, ejaculation (a sympathetic function) and resolution.
Low sex drive and failure of arousal
• Congenitally diminished testicular function (as in Klinefelter's syndrome). Treatment with testosterone is likely to be beneficial if circulating levels are low.
• Psychiatric problems such as anxiety, depression and stress.
• Psychosocial and psychosexual problems due to marital disharmony or to latent or
overt homosexuality. Counseling may be beneficial.
• Medications such as sedatives, tranquillizers and hypotensive drugs can reduce sex
drive.
Impotence
• Congenital neurological problems such as spina bifida.
• Acquired neurological problems due to traumatic spinal tract damage or to a tumor.
Psychiatric problems are commonly related to anxiety, depression or stress, or may
follow an industrial or road traffic accident which leads to compensation orientated
sexual dysfunction.
• Psychosocial and psychosexual maladjustment or malorientation.
• Medical disorders, e.g. diabetes, hyperprolactinaemia, myxedema or liver failure.
• Drugs such as alcohol and psychotropic, anticholinergic and hypotensive medications. It is important to warn patients that sexual dysfunction is a possible side-effect of certain drugs.
• Psychoemotional problems following vasectomy.
• Disorders of the urogenital tract such as infection or Peyronie's disease. In Peyronie's disease a fibrous plaque develops between the fascia and the tunica albuginea of the corpora cavernosa causing angulation of the penis and pain on erection.
Management
• Appropriate counseling and treatment of medical problems or alteration of drug
therapy.
• In a few patients surgical implantation of a penile prosthesis may be helpful.
Ejaculatory problems
• Congenital abnormalities such as hypospadias or phimosis.
• May be due to drugs which affect neurological control.
• Premature ejaculation is a common problem which can sometimes be treated effectively by squeezing the glans penis gently when the desire to ejaculate is felt, until
the desire disappears. This process is repeated up to five times before ejaculation
is allowed to occur. Treatment with clomipramine (25-75 mg a day) may also be
helpful.
• Ejaculatory incompetence may occur with anxiety and stress.
• Retrograde ejaculation can occur, particularly after prostatectomy. Ejaculation with
a full bladder may overcome the problem.
Female sexual dysfunction
Normal female sexual arousal occurs more through mental and tactile stimulation than
by visual stimulation. During arousal lubricating secretions are produced. Intercourse
can be pleasurable in the absence of orgasm which does not occur in all women.
Local problems
• An imperforate hymen or vaginal atresia will prevent penetration.
• Superficial or deep dyspareunia may lead to apareunia.
Dyspareunia may be due to failure of arousal.
• Superficial dyspareunia may be due to infection such as candidiasis or trichomoniasis, or to atrophic vaginitis, or may occur following surgery such as an episiotomy or posterior repair.
• Deep dyspareunia may be due to pelvic inflammatory disease or endometriosis.
General problems
• Libido may be reduced by general debilitation or by oestrogen lack as in hypogonado- trophic hypogonadism, gonadal failure or hyperprolactinaemia.
• Drugs do not affect sexual function in women as much as in men, but libido may
be reduced by oral contraception, phenothiazines and drugs of addiction in some
women.
• Psychiatric problems such as anxiety, depression and psychosis commonly cause
sexual dysfunction and require appropriate management and treatment.
• Psychosexual problems are a common cause and common result of marital dishar-
mony. Management includes counseling of both partners often over a period of
weeks or months.
History
• Obtaining a good history from a patient with sexual dysfunction is an art.
• A sympathetic unhurried, uncritical approach is essential.
Examination
• Thorough general and pelvic examination to exclude organic problems.
• The woman's response to pelvic examination may be a helpful indicator of the
nature of the problem.
Management
• Depends on the problem.
• Local and general medical problems should be treated appropriately.
• Referral to a psychosexual counselor or psychiatrist may be required.
Wednesday, August 27, 2008
Saying NO
Perhaps, the best strategy that I have learned in the past year to manage my time and my life is learning how to say “NO”. Saying no is not bad when used in appropriate circumstances. There are times when we must say no. No to others, sometimes no to ourselves and definitely no to our children. I used to have a difficult time saying no to others, thus depleting myself of what rightfully belongs to me: my time, possessions and self-worth.
Why did I have trouble saying “NO” for the longest time?
I believe my foremost reason is the fear of rejection; I was so afraid of what others will say or even think and how others will view me. Another reason is probably the mistaken notion that I can do the task and fit it in my schedule no matter what. What am I a super woman for? Another reason is not wanting to hurt other people and hating the feeling that I have been mean when I say no to others.
What made me change and what helped me learn this crucial skill?
Perhaps, going through several earth-shattering and life-threatening personal emotional crisis (midlife???) has helped me truly look deep inside myself and reflect on what is important to me. Learning to say no helps us learn to be kind to ourselves. It also teaches people around us, even those we really love and truly important to us (such as our family), to respect personal/individual boundaries. I also realized that anyone who depends on someone else’s approval for his/her own happiness is doomed to a life of misery. And surely, I don’t want to be miserable for the rest of my life. I hate hurting other people’s feelings but I have forgotten that my feelings are quite important too. There is no greater sin than not loving myself.
So, yes. I have learned how to say NO. And it feels soooo good!!!!
Why did I have trouble saying “NO” for the longest time?
I believe my foremost reason is the fear of rejection; I was so afraid of what others will say or even think and how others will view me. Another reason is probably the mistaken notion that I can do the task and fit it in my schedule no matter what. What am I a super woman for? Another reason is not wanting to hurt other people and hating the feeling that I have been mean when I say no to others.
What made me change and what helped me learn this crucial skill?
Perhaps, going through several earth-shattering and life-threatening personal emotional crisis (midlife???) has helped me truly look deep inside myself and reflect on what is important to me. Learning to say no helps us learn to be kind to ourselves. It also teaches people around us, even those we really love and truly important to us (such as our family), to respect personal/individual boundaries. I also realized that anyone who depends on someone else’s approval for his/her own happiness is doomed to a life of misery. And surely, I don’t want to be miserable for the rest of my life. I hate hurting other people’s feelings but I have forgotten that my feelings are quite important too. There is no greater sin than not loving myself.
So, yes. I have learned how to say NO. And it feels soooo good!!!!
Saturday, August 23, 2008
TEAM BUILDING
Room 706-707 Don Santiago Building
Taft Avenue, Manila 1000
(632) 523-8271 loc 48
Program Title: GO TEAM… MY TEAM! A seminar workshop on team building
I. Overview
A Rhythms facilitated team building workshop is an effective, time efficient yet enjoyable way to bring about organizational integration and performance improvement.
We do away with ineffective gimmicky team building activities and the ‘paralysis through analysis’ profiling of individual personality types. Instead paraticipants attending our team building workshop, will critically focus on how their organization operates, what it does, why it does it, where things are done, how they are done, who does what, and to what effect.
Using a variety of innovative and fun techniques, delegates will quickly grasp the ‘big picture’ then step-by-step, drill down to where improvements can be made.
Participants will find the workshop challenging, exciting, thought provoking and rewarding. Ultimately they will leave the workshop with ideas for improvement and an enthusiastic fresh perspective on:
• The world of work
• Their roles
• Their business process including inputs and outputs
• How and why things are measured, plus the effect on people and the effectiveness of such measurement
• Group interactions
• Team-work
• The goals of the organization and most importantly
• Areas for individual, inter-groups and organizational performance improvement
II. Goal and Aim
Our team building workshop has a simple, doable and achievable goal and aim.
• Our goal is to achieve improvement in the way all members of the team/organization (whether management or rank and file) view and do their jobs. This brings about the productivity improvement benefit that all organizations desire.
• Our aim is to inspire action that improves the way the organization operates and the way staff interact.
III. Key Features
• Uses an 'open systems' model of your organization
Your organization is a complex system, irrespective of its function and size. During the team building process we use a simple open systems model of your organization to explore structural relationships, develop organizational awareness and show cause and effect relationships, in order to bring about the performance improvements you are looking for.
• The team building workshop is scaleable
This means you can concentrate on a group, or a number of groups. Using the open systems approach to model effective team building, you can include representatives from either management and/or employees. It's a simple matter of identifying where you wish to bring about change (improvement), apply the open systems model, diagnose it, then explore the results using the various team building exercises and activities devised to specifically explore, analyze then improve productivity.
• Customization of the team building workshop to your organization
Customization is key to successful performance improvement outcomes. The pre-workshop delivery phase requires modeling of your organization, the use powerful trending techniques on key performance indicators (can be internal and or external indicators,) the identification of 'special interest groups' (SIGs) to be role played, the guest speakers, to deliver short sharp 'buzz sessions' and so on.
IV. Benefits
• Demonstrably better, more relevant and practical team building methodology that is easy to organize and deliver
• Content is relevant, interesting, challenging and rewarding, it taps into real world workplace experiences of employees, no contrived irrelevant team building exercises, activities and simulations.
• Universal relevance to any organization. Anyone in any organization can contribute, the more diverse the backgrounds the better potential for true team building.
• Makes use of the people with the experience at all levels and utilizes this diversity of interests and experiences to shape solutions and improvements.
• Valuable information, based on the sensitivities of all involved will flow out of the workshop. Look out for many areas for performance improvement to be offered up - from all hierarchical levels represented in the workshop.
• Identifies the challenges faced by the organization, internally and externally.
• Gains consensus through role playing special interest groups (SIGs) (the 'Executive' group, the 'Customers' group, the (other) 'Stakeholders' group, the 'Employees' group etc.
• Encourages self-criticism.
• Helps develop group and individual opinions by testing ideas, then transforming them.
• Can identify future leaders or provide a training ground for future leaders.
• Can identify hidden talent and talents within the group.
• Develops trust, responsibility and loyalty.
• Often produces solutions to previously insoluble problems.
• No irrelevant and ineffective gimmicks.
• Adaptable to needs and vocabularies of any group of employees.
• Easy to target key result areas, where performance is below what is required.
o Old technology, old procedures, old policies, old methods, or
o New technologies, new procedures, new policies, new methods
V. Sample Program of Activities:
NOTE: This represents a sample team building day/activity for 15 to 25 participants.
This is only an outline --- threaded throughout the day are personal time, group shares, fun, and surprises.
Activities may not necessarily be given in this order and may be tailored according to specific needs of the organization
Course No. Hot and Cold… warm up and ice breakers
Introduction of Workshop, participants, facilitators and speakers
Course No: Barangay Ginebra… Team and teamwork
Activities and games to define your organization: its functions, strengths, weakness and the role you play
Course No: My Coach (eg Coach Jawo) … Top 10 Ways to Motivate & Success Coach Your TEAM"
Different leadership styles and creative problem solving, sparking employee/colleague motivation
Course No: "IBA ako… ibahin mo ako…”
Activities to build relationships, trust and appreciate individual differences
Course No: Gaya-gaya, Puto maya : Don't do as I do. Do as I say.
Activities to build, improve and maintain effective communication skills
Course No: Ang Aking Paglalakbay
Activities for personal insight and growth, stress management, anger management (bellydance, yoga, relaxation techniques)
Course No: Go Team… My team!
Team building program finale: appreciating our strengths and weaknesses, and taking our team to the next level
***** please inquire re package and individual module Rates
Team Building Programs Include:
Handouts & manuals, activity equipments, e-mail follow-up consultations up to 6 months, & fun and effective power-packed day/s!
Improve your team’s communication skills, initiate creative problem solving, and build trust for a cohesive team with good leadership!
VI. Workshop Delivery
We are situated at Room 706 Don Santiago Building Taft Avenue, Manila and will deliver the workshop, ourselves or use a partner organization or any part of Manila or province by arrangement.
A. Duration
There are a range of options in respect of duration. 1, 2 or 3 day workshops, or
A project based approach, with an initial workshop following on from which ad hoc debriefing / progress workshops to coordinate activities flowing from 1. above, such as site visits to other locations, progressing various improvement activities and so on.
B. Location
We will deliver the workshop:
-in our wellness center
- On your premises, if you have suitable facilities available. Essentially you provide your in-house facilities, book our accommodation and we deliver.
- On suitable premises in a location near to you, with suitable facilities. Essentially you book our and (optionally) your accommodation, we travel and deliver.
- Other areas: Essentially you book our and your accommodation, we travel and deliver.
C. Methodology
The essential facilities we use are: White board, Flip charts and board and overhead slide projection facility, games and outdoor activities
We are goal driven and in order to do this we need to know from the onset what it is your organization seeks to do better. In order to achieve change in your group we need to know the answer to the following question.
What is it you seek from our team building workshop?
This may appear a trite question, but we are surprised by the number of people unable to give an answer to the question.
Consider:
Transfer of knowledge or sharing of knowledge and information...To practice problem solving...To develop skills...To change attitudes...To examine a problem...Etc.
D. Cost
Workshop cost is usually computed on a per head/day basis excluding meals, transportation and accommodation
Cost is also dependent on the number of participants, duration of workshop and specific needs of organization
Rates are negotiable and discounts can be given.
OUR STRESS MANAGEMENT COURSES ARE ALSO AVAILABLE AS CUSTOMISED…
1-to-1 Life Skills Coaching/Relationship Coaching/Spiritual counseling - Private groups – Organization or Corporate in-house Seminars or Workshops
For further inquiries you may contact:
Dr. Faye Cagayan (632) 523-8271 loc 48
Email: cagayanmsfs@druginfo.ph http://www.docfaye.multiply.com/
Taft Avenue, Manila 1000
(632) 523-8271 loc 48
Program Title: GO TEAM… MY TEAM! A seminar workshop on team building
I. Overview
A Rhythms facilitated team building workshop is an effective, time efficient yet enjoyable way to bring about organizational integration and performance improvement.
We do away with ineffective gimmicky team building activities and the ‘paralysis through analysis’ profiling of individual personality types. Instead paraticipants attending our team building workshop, will critically focus on how their organization operates, what it does, why it does it, where things are done, how they are done, who does what, and to what effect.
Using a variety of innovative and fun techniques, delegates will quickly grasp the ‘big picture’ then step-by-step, drill down to where improvements can be made.
Participants will find the workshop challenging, exciting, thought provoking and rewarding. Ultimately they will leave the workshop with ideas for improvement and an enthusiastic fresh perspective on:
• The world of work
• Their roles
• Their business process including inputs and outputs
• How and why things are measured, plus the effect on people and the effectiveness of such measurement
• Group interactions
• Team-work
• The goals of the organization and most importantly
• Areas for individual, inter-groups and organizational performance improvement
II. Goal and Aim
Our team building workshop has a simple, doable and achievable goal and aim.
• Our goal is to achieve improvement in the way all members of the team/organization (whether management or rank and file) view and do their jobs. This brings about the productivity improvement benefit that all organizations desire.
• Our aim is to inspire action that improves the way the organization operates and the way staff interact.
III. Key Features
• Uses an 'open systems' model of your organization
Your organization is a complex system, irrespective of its function and size. During the team building process we use a simple open systems model of your organization to explore structural relationships, develop organizational awareness and show cause and effect relationships, in order to bring about the performance improvements you are looking for.
• The team building workshop is scaleable
This means you can concentrate on a group, or a number of groups. Using the open systems approach to model effective team building, you can include representatives from either management and/or employees. It's a simple matter of identifying where you wish to bring about change (improvement), apply the open systems model, diagnose it, then explore the results using the various team building exercises and activities devised to specifically explore, analyze then improve productivity.
• Customization of the team building workshop to your organization
Customization is key to successful performance improvement outcomes. The pre-workshop delivery phase requires modeling of your organization, the use powerful trending techniques on key performance indicators (can be internal and or external indicators,) the identification of 'special interest groups' (SIGs) to be role played, the guest speakers, to deliver short sharp 'buzz sessions' and so on.
IV. Benefits
• Demonstrably better, more relevant and practical team building methodology that is easy to organize and deliver
• Content is relevant, interesting, challenging and rewarding, it taps into real world workplace experiences of employees, no contrived irrelevant team building exercises, activities and simulations.
• Universal relevance to any organization. Anyone in any organization can contribute, the more diverse the backgrounds the better potential for true team building.
• Makes use of the people with the experience at all levels and utilizes this diversity of interests and experiences to shape solutions and improvements.
• Valuable information, based on the sensitivities of all involved will flow out of the workshop. Look out for many areas for performance improvement to be offered up - from all hierarchical levels represented in the workshop.
• Identifies the challenges faced by the organization, internally and externally.
• Gains consensus through role playing special interest groups (SIGs) (the 'Executive' group, the 'Customers' group, the (other) 'Stakeholders' group, the 'Employees' group etc.
• Encourages self-criticism.
• Helps develop group and individual opinions by testing ideas, then transforming them.
• Can identify future leaders or provide a training ground for future leaders.
• Can identify hidden talent and talents within the group.
• Develops trust, responsibility and loyalty.
• Often produces solutions to previously insoluble problems.
• No irrelevant and ineffective gimmicks.
• Adaptable to needs and vocabularies of any group of employees.
• Easy to target key result areas, where performance is below what is required.
o Old technology, old procedures, old policies, old methods, or
o New technologies, new procedures, new policies, new methods
V. Sample Program of Activities:
NOTE: This represents a sample team building day/activity for 15 to 25 participants.
This is only an outline --- threaded throughout the day are personal time, group shares, fun, and surprises.
Activities may not necessarily be given in this order and may be tailored according to specific needs of the organization
Course No. Hot and Cold… warm up and ice breakers
Introduction of Workshop, participants, facilitators and speakers
Course No: Barangay Ginebra… Team and teamwork
Activities and games to define your organization: its functions, strengths, weakness and the role you play
Course No: My Coach (eg Coach Jawo) … Top 10 Ways to Motivate & Success Coach Your TEAM"
Different leadership styles and creative problem solving, sparking employee/colleague motivation
Course No: "IBA ako… ibahin mo ako…”
Activities to build relationships, trust and appreciate individual differences
Course No: Gaya-gaya, Puto maya : Don't do as I do. Do as I say.
Activities to build, improve and maintain effective communication skills
Course No: Ang Aking Paglalakbay
Activities for personal insight and growth, stress management, anger management (bellydance, yoga, relaxation techniques)
Course No: Go Team… My team!
Team building program finale: appreciating our strengths and weaknesses, and taking our team to the next level
***** please inquire re package and individual module Rates
Team Building Programs Include:
Handouts & manuals, activity equipments, e-mail follow-up consultations up to 6 months, & fun and effective power-packed day/s!
Improve your team’s communication skills, initiate creative problem solving, and build trust for a cohesive team with good leadership!
VI. Workshop Delivery
We are situated at Room 706 Don Santiago Building Taft Avenue, Manila and will deliver the workshop, ourselves or use a partner organization or any part of Manila or province by arrangement.
A. Duration
There are a range of options in respect of duration. 1, 2 or 3 day workshops, or
A project based approach, with an initial workshop following on from which ad hoc debriefing / progress workshops to coordinate activities flowing from 1. above, such as site visits to other locations, progressing various improvement activities and so on.
B. Location
We will deliver the workshop:
-in our wellness center
- On your premises, if you have suitable facilities available. Essentially you provide your in-house facilities, book our accommodation and we deliver.
- On suitable premises in a location near to you, with suitable facilities. Essentially you book our and (optionally) your accommodation, we travel and deliver.
- Other areas: Essentially you book our and your accommodation, we travel and deliver.
C. Methodology
The essential facilities we use are: White board, Flip charts and board and overhead slide projection facility, games and outdoor activities
We are goal driven and in order to do this we need to know from the onset what it is your organization seeks to do better. In order to achieve change in your group we need to know the answer to the following question.
What is it you seek from our team building workshop?
This may appear a trite question, but we are surprised by the number of people unable to give an answer to the question.
Consider:
Transfer of knowledge or sharing of knowledge and information...To practice problem solving...To develop skills...To change attitudes...To examine a problem...Etc.
D. Cost
Workshop cost is usually computed on a per head/day basis excluding meals, transportation and accommodation
Cost is also dependent on the number of participants, duration of workshop and specific needs of organization
Rates are negotiable and discounts can be given.
OUR STRESS MANAGEMENT COURSES ARE ALSO AVAILABLE AS CUSTOMISED…
1-to-1 Life Skills Coaching/Relationship Coaching/Spiritual counseling - Private groups – Organization or Corporate in-house Seminars or Workshops
For further inquiries you may contact:
Dr. Faye Cagayan (632) 523-8271 loc 48
Email: cagayanmsfs@druginfo.ph http://www.docfaye.multiply.com/
Tuesday, August 19, 2008
Preparing for Childbirth
FAQs About Your Pregnancy
Welcome dear mothers to this new phase of your life!
It is always a joy to know we are accomplishing God's purpose for us as women. And as stewards of this new life within us, there are some things you, my dear mom to be, should know...
What is prenatal care?
This is the standard of care that you, a mom-to-be should be receiving from me or other health care providers (obstetrician, family physician, midwife, traditional birth attendants/hilot/kumadrona).
Is prenatal care important? What is its purpose?
Yes! Prenatal care is very, very important. It ensures that you and your baby will be as healthy as possible by following some simple guidelines and checking in regularly with me, your obstetrician.
What happens during prenatal visits?
I will be asking you about your medical history as well as your partner’s and family’s. I will also ask how you have been feeling and changes that are occurring in you. Your weight and your vital signs (cardiac rate, pulse rate, breathing) will be taken especially your blood pressure every visit.
On your first visit, I will do a general physical examination with breast, abdominal and pelvic exam to check the size and shape of your uterus and a Pap smear to check for infections and abnormal masses of the cervix (the opening of the uterus). Subsequent visits may not be as intensive but will still require attention to your personal physical, emotional and psychological details
Urine and blood tests will be requested on the first visit and again later as needed. Urine tests are done to check for infections, high sugar levels (which can be a sign of diabetes) and high protein levels (which can put you at risk for preeclampsia, a type of high blood pressure in pregnancy). Blood tests are done to check for low iron levels (anemia) and infections as well as other bleeding problems.
An ultrasound may be requested to help me accurately date your pregnancy - when your baby is due or to check on your baby's growth and position in your uterus. An ultrasound uses sound waves to create an image of your baby on a video screen. This examination in general does not cause abnormalities in your baby.
Other tests may be needed/requested if you or your baby are at risk for any problems.
What is my usual schedule for prenatal visits?
If you are age 18 to 35 and healthy you will probably have a "low-risk" pregnancy. If so, our scheduled check up will be
* once a month for the first 28 weeks (seven months)
* every two or three weeks from the 28th to the 36th week (eighth month)
* weekly from the 36th week until delivery (ninth month)
If you have a "high-risk" pregnancy, you will need to see me more often.
What conditions are considered high risk?
Pregnant women experiencing these complications are advised not to travel, exercise or have sex, etc. Some of these complications include:
* Cervical problems, such as 'incompetent cervix'
* Vaginal bleeding
* Multiple foetuses
* If you are aged 35 years or over and pregnant for the first time
* Gestational diabetes, past or present
* High blood pressure, past or present
* Pre-eclampsia, past or present
* Abnormalities of the placenta, past or present
* Prior miscarriage
* Prior ectopic pregnancy
* Signs of premature labor
Are there foods I should avoid?
It is quite important to eat a balanced diet for you and baby. There are a few foods that you should be more careful about eating while you are pregnant. Meat, eggs and fish that are not fully cooked could put you at risk for an infection. Wash all fruit and vegetables. Keep cutting boards, dishes and utensils clean. General hygiene such as hand washing is still the rule of the day. Eat 3 to 4 servings of dairy foods each day. This will give you enough calcium for you and your baby. Do not drink unpasteurized milk or eat unpasteurized milk products. Soft cheeses such as Brie, feta, Camembert and Mexican queso fresco may have bacteria that can cause infections.
It would be nice if you refrain from caffeinated and carbonated drinks but If you drink coffee or other drinks with caffeine, do not have more than 1 cup each day.
It is okay to use artificial sweeteners such as aspartame (some brand names: Equal, NutraSweet) and sucralose (brand name: Splenda) while you are pregnant, but you should try to take them in moderation. If you have a genetic disease called phenylketonuria, or PKU, you shouldn't use aspartame at all.
What vitamins should I take?
It is best that you have started taking folic acid before you get pregnant to prevent neural tube defects (problems in your bay’s brain or spinal cord). You should take 400 mcg (0.4 mg) of folic acid every day for the first 12-16 weeks of your pregnancy. Any prenatal vitamin supplement will do but an additional iron and calcium supplement is necessary especially if you are not able to eat a balanced diet.
How much weight gain is considered normal during pregnancy?
About 25 to 30 pounds. If you don't weigh enough when you get pregnant, you may need to gain more. If you're very heavy when you get pregnant, you may need to gain only 15 to 18 pounds.
Pregnancy isn't the time to start dieting just so to prevent having a cesarean section due to a big baby! It's best to gain about 2 to 3 pounds during the first 12 weeks and about 1 pound a week after that.
Is it okay to take medications?
Check with me before taking any medicine, including over the counter drugs like aspirin and other pain relievers, cough medications and decongestants. Even medicine you can buy without a prescription can cause birth defects, especially if it's taken during the first 3 months of pregnancy. Medications are not necessarily bad. There will be drugs that you may need to take otherwise the illness that you have, if not treated with drugs, may cause problems in the baby. Rest assured that drugs that you will be prescribed will be those considered safe in pregnancy as shown by medical evidence.
Can I still work while pregnant?
Of course!! In general, if your pregnancy is uncomplicated, you can continue working. However, this depends also if you have any problems with your pregnancy, what kind of work you do and if you're exposed to anything at work that could harm your baby. For instance, lifting heavy objects or standing for long periods can be hard on you. Radiation, lead and other heavy metals, such as copper and mercury, could be damaging to the baby. Working in front of a computer screen is not thought to cause harm to an unborn baby.
What exercises can I do?
Exercising during pregnancy makes labor and delivery easier. Walking and swimming are great aerobic choices. I would recommend sayuntis- a belly dance routine I specifically designed for you, my expectant mom, as a low impact and fun exercise to prepare you for childbirth.
Unless you have problems in your pregnancy, you can probably do whatever exercise you did before you got pregnant. You may feel better if you're active. Try to get at least 30 minutes of exercise each day. Talk to me first about any special conditions that you may have.
If you didn't exercise before pregnancy, start slowly. Don't overdo exercise. If you can't talk easily while exercising, you are straining yourself and working too hard. Don't get overheated. Drink plenty of water so that you don't get dehydrated. It's best to avoid anything that could cause you to fall or hurt yourself.
What conditions will prevent me from exercising?
There are some conditions that make exercise contraindicated in pregnancy like having premature labor contractions, preeclampsia, bleeding conditions in pregnancy such as placenta previa. Other medical conditions such as heart disease, thyroid problems and diabetes may pose a problem. It would be best to consult first so we can discuss what exercise or physical activity regimen is best suited for you.
Can I travel?
Generally speaking, yes. The safest time for a pregnant woman to travel is during her second trimester, provided she isn't experiencing any complications. If you are pregnant and considering travel, you must consult with me, especially if your pregnancy is high-risk. Take into consideration the standard of medical care at your chosen destination, just in case you need help. Consider also immunizations when the place you are going to is endemic for certain diseases. Check with airlines regarding maximum age of gestation where travel is allowed- it’s usually up to 28-30 weeks AOG.
Is it okay to have sex?
Yes, unless I believe you're at risk for problems such as presence of infections, bleeding and premature contractions. Don't be surprised if you're less--or more--interested in sex. (most probably less interested) You need to find or try different positions, such as lying on your side or being on top as you get bigger. If you have oral sex, tell your partner not to blow air into your vagina. This could force air inside you, which could cause an air embolism.
What discomforts will I feel and what can I do to feel better?
Here are the most common discomforts and some advice on how you can feel better.
Morning sickness. This may happen anytime during the day (or night). Try eating frequent, small meals, (every 2 hours) and avoid greasy foods. Keep crackers by your bed to eat before getting up. Avoid scents that trigger a nauseous reaction.
Inform me if morning sickness is so severe that it causes you to lose weight, look dehydrated and feel weak.
Tiredness. Sometimes tiredness in pregnancy is caused by anemia, so have your complete blood count done. Get enough rest. Take a daytime nap if possible.
Leg cramps. Gently stretch the calf of your leg by curling your toes upward, toward your knee. Drink milk and take calcium supplements. Exercise!
Constipation. Drink plenty of fluids. Eat foods with lots of fiber, such as raisins and bran cereal. Don't take laxatives without consulting first. Stool softeners may be safer than laxatives.
Hemorrhoids. Don't strain during bowel movements. Try to avoid becoming constipated. Clean yourself well after a bowel movement (wet wipes may be less irritating than toilet paper). Take several warm soaks ( hot sitz baths) a day.
Frequent urination. You may need to urinate more often as your baby grows because he or she will put pressure on your bladder. This can't be helped. Report to me if urinating becomes difficult and painful and comes in trickles.
Varicose veins. Avoid clothing that fits tightly around your legs or waist. Rest and put your feet up as much as you can. Move around if you must stand for long periods. You may need to use support hose.
Moodiness. Your hormones are on a roller coaster ride during pregnancy. Plus, your life is undergoing a big change. Don't be too hard on yourself. If you feel very sad or think about suicide, talk to me ASAP. Exercise and dance!
Heartburn. Eat frequent, small meals often. Avoid spicy or greasy foods. Don't lie down right after eating. If this occurs frequently, consult me.
Infections/vaginal itchiness/discharge. The amount of discharge from the vagina increases during pregnancy. Yeast infections, which can also cause discharge, are more common during pregnancy. It's a good idea to consult before taking any medication.
Bleeding gums. Brush and floss regularly, and see your dentist for cleanings. Don't put off dental visits because you're pregnant, but be sure to tell your dentist you're pregnant.
Stuffy nose. This is also related to changes in the levels of the female hormone estrogen. You may also have nosebleeds.
Edema (retaining fluid). Rest with your legs up. Lie on your left side while sleeping so blood flows from your legs back to your heart better. Don't use diuretics (water pills). If you're thinking about cutting down on salt to reduce swelling, talk with me first. Your body needs enough salt to maintain the balance of fluid and cutting back on salt may not be the best way to manage your swelling.
Skin changes
Stretch marks appear as red marks on your skin. Lotion can help keep your skin moist and may help reduce the itchiness of dry skin. Stretch marks really can't be prevented and may be genetic but they often fade after pregnancy.
Other skin changes may include darkening of the skin on your face and around your nipples, and a dark line below your belly button. Staying out of the sun or using a sunscreen may help lessen these marks. They'll probably fade after pregnancy.
Call me …
Most pregnancies proceed without any problem. But problems can happen unexpectedly. If you have any of these warning signs, please call me :
* sudden weight gain of more than two pounds within one day
* swelling of the face, ankles, legs, or feet
* severe or repeated headaches that last more than two or three hours and are not relieved with the medication I have recommended
* fainting
* blurred vision, flashes of light, or spots before your eyes
* pain or burning with urination
* marked increase in thirst
* greatly increased or decreased urination
* unusual smelling vaginal discharge
* light vaginal bleeding or spotting
Go to the hospital immediately if you have any of these very dangerous warning signs:
Signs Of Premature Labor
Pregnancy takes about 40 weeks. If contractions cause the cervix to open earlier than normal — between the 20th and 37th week — labor may be premature. This may result in the birth of a premature baby. Babies born before the 37th week may have trouble breathing, eating, and keeping warm. The signs of premature labor include one or more of these
* uterine contractions every 10 minutes or shorter
* repeating or constant menstrual-like cramps in the lower abdomen
* abdominal cramps with or without diarrhea
* pelvic pressure that feels like the fetus is pushing down on your vagina and your hips or pelvis is splitting
* increase or change in vaginal discharge
* sudden gush of watery fluids from the vagina (water breaking)
* feeling like the fetus is "balling up"
Signs Of Other Serious Problems
* heavy bleeding from the vagina
* constant severe lower abdominal pain or cramps on one or both sides
* dimness or blurring of vision that lasts two or three hours
* dizziness and/or double vision
* severe or continued vomiting
* chills and/or fever of 101°F or more
* fever of 101°F or more with pain or burning during urination
* sudden severe swelling or puffiness of the face, hands, legs, ankles, or feet, especially if you have a headache or vision change
* after six months of pregnancy, you notice a significant decrease in the movement of the fetus
* after six months of pregnancy, you think the fetus hasn't moved in eight hours or more
You may not like it but if you want to stay healthy for yourself and your baby throughout pregnancy there are...
Definite Don'ts in Pregnancy
* Don't smoke. Smoking raises your risk for miscarriage, premature birth, low birth weight and many other problems.
* Don't use recreational drugs. Cocaine, heroin, marijuana, metamphetamine or shabu, ecstasy, etc increase your risk of miscarriage, preeclampsia, premature birth and congenital/ developmental defects. And your baby could be born addicted to the drug you've been taking.
* Don't drink alcohol. Drinking alcohol during pregnancy is the major cause of preventable birth defects, including mental slowness.
* Don't clean your cat's litter box, or eat raw or undercooked red meat. You could get toxoplasmosis, a disease that can cause birth defects.
* Don't sit in the sauna or hot tub. This raises your risk of miscarriage and birth defects.
* Don't douche. Douching could force air into the vagina, which can cause an air embolism.
* Don’t feel sad or ugly or unloved. This may be one of the most tiring and confusing moments of your life due to changes in hormones, physique, etc yet this is also a time to appreciate God’s most precious gift. Remember that there are a lot of people around you who cares for you and your baby… including ME!!!
Please remember that it takes teamwork to have a healthy pregnancy and a healthy baby.
Women who get early and regular prenatal care have healthier pregnancies and healthier babies. It is important that you as well as your partner and I communicate well and work together. It is your responsibility to try to stay as healthy as you can and learn what is normal and what is not. Watch out for changes in your body that may be warning signs.
It is my duty on the other hand to help you understand your pregnancy, identify problems before they become serious, and to provide care when you need it.
Remember, the things you tell me are confidential.
That means that I can’t tell anyone else what you say without your permission. So don’t be afraid to talk to me about issues that might be uncomfortable or embarrassing. It’s OK to tell me if you smoke, drink alcohol or take any drugs, or about your sexual activities (past and present) or if your partner hurts or scares you. I need to know all about you and your lifestyle so that I can give you and your baby the best care. Consider me as part of your family - an ate or tita.
By the way, my dear mom to be, be sure to have a dental checkup early in pregnancy to help your mouth remain healthy. You may even want to see your dentist more often than usual.
With love,
Doc Faye
Welcome dear mothers to this new phase of your life!
It is always a joy to know we are accomplishing God's purpose for us as women. And as stewards of this new life within us, there are some things you, my dear mom to be, should know...
What is prenatal care?
This is the standard of care that you, a mom-to-be should be receiving from me or other health care providers (obstetrician, family physician, midwife, traditional birth attendants/hilot/kumadrona).
Is prenatal care important? What is its purpose?
Yes! Prenatal care is very, very important. It ensures that you and your baby will be as healthy as possible by following some simple guidelines and checking in regularly with me, your obstetrician.
What happens during prenatal visits?
I will be asking you about your medical history as well as your partner’s and family’s. I will also ask how you have been feeling and changes that are occurring in you. Your weight and your vital signs (cardiac rate, pulse rate, breathing) will be taken especially your blood pressure every visit.
On your first visit, I will do a general physical examination with breast, abdominal and pelvic exam to check the size and shape of your uterus and a Pap smear to check for infections and abnormal masses of the cervix (the opening of the uterus). Subsequent visits may not be as intensive but will still require attention to your personal physical, emotional and psychological details
Urine and blood tests will be requested on the first visit and again later as needed. Urine tests are done to check for infections, high sugar levels (which can be a sign of diabetes) and high protein levels (which can put you at risk for preeclampsia, a type of high blood pressure in pregnancy). Blood tests are done to check for low iron levels (anemia) and infections as well as other bleeding problems.
An ultrasound may be requested to help me accurately date your pregnancy - when your baby is due or to check on your baby's growth and position in your uterus. An ultrasound uses sound waves to create an image of your baby on a video screen. This examination in general does not cause abnormalities in your baby.
Other tests may be needed/requested if you or your baby are at risk for any problems.
What is my usual schedule for prenatal visits?
If you are age 18 to 35 and healthy you will probably have a "low-risk" pregnancy. If so, our scheduled check up will be
* once a month for the first 28 weeks (seven months)
* every two or three weeks from the 28th to the 36th week (eighth month)
* weekly from the 36th week until delivery (ninth month)
If you have a "high-risk" pregnancy, you will need to see me more often.
What conditions are considered high risk?
Pregnant women experiencing these complications are advised not to travel, exercise or have sex, etc. Some of these complications include:
* Cervical problems, such as 'incompetent cervix'
* Vaginal bleeding
* Multiple foetuses
* If you are aged 35 years or over and pregnant for the first time
* Gestational diabetes, past or present
* High blood pressure, past or present
* Pre-eclampsia, past or present
* Abnormalities of the placenta, past or present
* Prior miscarriage
* Prior ectopic pregnancy
* Signs of premature labor
Are there foods I should avoid?
It is quite important to eat a balanced diet for you and baby. There are a few foods that you should be more careful about eating while you are pregnant. Meat, eggs and fish that are not fully cooked could put you at risk for an infection. Wash all fruit and vegetables. Keep cutting boards, dishes and utensils clean. General hygiene such as hand washing is still the rule of the day. Eat 3 to 4 servings of dairy foods each day. This will give you enough calcium for you and your baby. Do not drink unpasteurized milk or eat unpasteurized milk products. Soft cheeses such as Brie, feta, Camembert and Mexican queso fresco may have bacteria that can cause infections.
It would be nice if you refrain from caffeinated and carbonated drinks but If you drink coffee or other drinks with caffeine, do not have more than 1 cup each day.
It is okay to use artificial sweeteners such as aspartame (some brand names: Equal, NutraSweet) and sucralose (brand name: Splenda) while you are pregnant, but you should try to take them in moderation. If you have a genetic disease called phenylketonuria, or PKU, you shouldn't use aspartame at all.
What vitamins should I take?
It is best that you have started taking folic acid before you get pregnant to prevent neural tube defects (problems in your bay’s brain or spinal cord). You should take 400 mcg (0.4 mg) of folic acid every day for the first 12-16 weeks of your pregnancy. Any prenatal vitamin supplement will do but an additional iron and calcium supplement is necessary especially if you are not able to eat a balanced diet.
How much weight gain is considered normal during pregnancy?
About 25 to 30 pounds. If you don't weigh enough when you get pregnant, you may need to gain more. If you're very heavy when you get pregnant, you may need to gain only 15 to 18 pounds.
Pregnancy isn't the time to start dieting just so to prevent having a cesarean section due to a big baby! It's best to gain about 2 to 3 pounds during the first 12 weeks and about 1 pound a week after that.
Is it okay to take medications?
Check with me before taking any medicine, including over the counter drugs like aspirin and other pain relievers, cough medications and decongestants. Even medicine you can buy without a prescription can cause birth defects, especially if it's taken during the first 3 months of pregnancy. Medications are not necessarily bad. There will be drugs that you may need to take otherwise the illness that you have, if not treated with drugs, may cause problems in the baby. Rest assured that drugs that you will be prescribed will be those considered safe in pregnancy as shown by medical evidence.
Can I still work while pregnant?
Of course!! In general, if your pregnancy is uncomplicated, you can continue working. However, this depends also if you have any problems with your pregnancy, what kind of work you do and if you're exposed to anything at work that could harm your baby. For instance, lifting heavy objects or standing for long periods can be hard on you. Radiation, lead and other heavy metals, such as copper and mercury, could be damaging to the baby. Working in front of a computer screen is not thought to cause harm to an unborn baby.
What exercises can I do?
Exercising during pregnancy makes labor and delivery easier. Walking and swimming are great aerobic choices. I would recommend sayuntis- a belly dance routine I specifically designed for you, my expectant mom, as a low impact and fun exercise to prepare you for childbirth.
Unless you have problems in your pregnancy, you can probably do whatever exercise you did before you got pregnant. You may feel better if you're active. Try to get at least 30 minutes of exercise each day. Talk to me first about any special conditions that you may have.
If you didn't exercise before pregnancy, start slowly. Don't overdo exercise. If you can't talk easily while exercising, you are straining yourself and working too hard. Don't get overheated. Drink plenty of water so that you don't get dehydrated. It's best to avoid anything that could cause you to fall or hurt yourself.
What conditions will prevent me from exercising?
There are some conditions that make exercise contraindicated in pregnancy like having premature labor contractions, preeclampsia, bleeding conditions in pregnancy such as placenta previa. Other medical conditions such as heart disease, thyroid problems and diabetes may pose a problem. It would be best to consult first so we can discuss what exercise or physical activity regimen is best suited for you.
Can I travel?
Generally speaking, yes. The safest time for a pregnant woman to travel is during her second trimester, provided she isn't experiencing any complications. If you are pregnant and considering travel, you must consult with me, especially if your pregnancy is high-risk. Take into consideration the standard of medical care at your chosen destination, just in case you need help. Consider also immunizations when the place you are going to is endemic for certain diseases. Check with airlines regarding maximum age of gestation where travel is allowed- it’s usually up to 28-30 weeks AOG.
Is it okay to have sex?
Yes, unless I believe you're at risk for problems such as presence of infections, bleeding and premature contractions. Don't be surprised if you're less--or more--interested in sex. (most probably less interested) You need to find or try different positions, such as lying on your side or being on top as you get bigger. If you have oral sex, tell your partner not to blow air into your vagina. This could force air inside you, which could cause an air embolism.
What discomforts will I feel and what can I do to feel better?
Here are the most common discomforts and some advice on how you can feel better.
Morning sickness. This may happen anytime during the day (or night). Try eating frequent, small meals, (every 2 hours) and avoid greasy foods. Keep crackers by your bed to eat before getting up. Avoid scents that trigger a nauseous reaction.
Inform me if morning sickness is so severe that it causes you to lose weight, look dehydrated and feel weak.
Tiredness. Sometimes tiredness in pregnancy is caused by anemia, so have your complete blood count done. Get enough rest. Take a daytime nap if possible.
Leg cramps. Gently stretch the calf of your leg by curling your toes upward, toward your knee. Drink milk and take calcium supplements. Exercise!
Constipation. Drink plenty of fluids. Eat foods with lots of fiber, such as raisins and bran cereal. Don't take laxatives without consulting first. Stool softeners may be safer than laxatives.
Hemorrhoids. Don't strain during bowel movements. Try to avoid becoming constipated. Clean yourself well after a bowel movement (wet wipes may be less irritating than toilet paper). Take several warm soaks ( hot sitz baths) a day.
Frequent urination. You may need to urinate more often as your baby grows because he or she will put pressure on your bladder. This can't be helped. Report to me if urinating becomes difficult and painful and comes in trickles.
Varicose veins. Avoid clothing that fits tightly around your legs or waist. Rest and put your feet up as much as you can. Move around if you must stand for long periods. You may need to use support hose.
Moodiness. Your hormones are on a roller coaster ride during pregnancy. Plus, your life is undergoing a big change. Don't be too hard on yourself. If you feel very sad or think about suicide, talk to me ASAP. Exercise and dance!
Heartburn. Eat frequent, small meals often. Avoid spicy or greasy foods. Don't lie down right after eating. If this occurs frequently, consult me.
Infections/vaginal itchiness/discharge. The amount of discharge from the vagina increases during pregnancy. Yeast infections, which can also cause discharge, are more common during pregnancy. It's a good idea to consult before taking any medication.
Bleeding gums. Brush and floss regularly, and see your dentist for cleanings. Don't put off dental visits because you're pregnant, but be sure to tell your dentist you're pregnant.
Stuffy nose. This is also related to changes in the levels of the female hormone estrogen. You may also have nosebleeds.
Edema (retaining fluid). Rest with your legs up. Lie on your left side while sleeping so blood flows from your legs back to your heart better. Don't use diuretics (water pills). If you're thinking about cutting down on salt to reduce swelling, talk with me first. Your body needs enough salt to maintain the balance of fluid and cutting back on salt may not be the best way to manage your swelling.
Skin changes
Stretch marks appear as red marks on your skin. Lotion can help keep your skin moist and may help reduce the itchiness of dry skin. Stretch marks really can't be prevented and may be genetic but they often fade after pregnancy.
Other skin changes may include darkening of the skin on your face and around your nipples, and a dark line below your belly button. Staying out of the sun or using a sunscreen may help lessen these marks. They'll probably fade after pregnancy.
Call me …
Most pregnancies proceed without any problem. But problems can happen unexpectedly. If you have any of these warning signs, please call me :
* sudden weight gain of more than two pounds within one day
* swelling of the face, ankles, legs, or feet
* severe or repeated headaches that last more than two or three hours and are not relieved with the medication I have recommended
* fainting
* blurred vision, flashes of light, or spots before your eyes
* pain or burning with urination
* marked increase in thirst
* greatly increased or decreased urination
* unusual smelling vaginal discharge
* light vaginal bleeding or spotting
Go to the hospital immediately if you have any of these very dangerous warning signs:
Signs Of Premature Labor
Pregnancy takes about 40 weeks. If contractions cause the cervix to open earlier than normal — between the 20th and 37th week — labor may be premature. This may result in the birth of a premature baby. Babies born before the 37th week may have trouble breathing, eating, and keeping warm. The signs of premature labor include one or more of these
* uterine contractions every 10 minutes or shorter
* repeating or constant menstrual-like cramps in the lower abdomen
* abdominal cramps with or without diarrhea
* pelvic pressure that feels like the fetus is pushing down on your vagina and your hips or pelvis is splitting
* increase or change in vaginal discharge
* sudden gush of watery fluids from the vagina (water breaking)
* feeling like the fetus is "balling up"
Signs Of Other Serious Problems
* heavy bleeding from the vagina
* constant severe lower abdominal pain or cramps on one or both sides
* dimness or blurring of vision that lasts two or three hours
* dizziness and/or double vision
* severe or continued vomiting
* chills and/or fever of 101°F or more
* fever of 101°F or more with pain or burning during urination
* sudden severe swelling or puffiness of the face, hands, legs, ankles, or feet, especially if you have a headache or vision change
* after six months of pregnancy, you notice a significant decrease in the movement of the fetus
* after six months of pregnancy, you think the fetus hasn't moved in eight hours or more
You may not like it but if you want to stay healthy for yourself and your baby throughout pregnancy there are...
Definite Don'ts in Pregnancy
* Don't smoke. Smoking raises your risk for miscarriage, premature birth, low birth weight and many other problems.
* Don't use recreational drugs. Cocaine, heroin, marijuana, metamphetamine or shabu, ecstasy, etc increase your risk of miscarriage, preeclampsia, premature birth and congenital/ developmental defects. And your baby could be born addicted to the drug you've been taking.
* Don't drink alcohol. Drinking alcohol during pregnancy is the major cause of preventable birth defects, including mental slowness.
* Don't clean your cat's litter box, or eat raw or undercooked red meat. You could get toxoplasmosis, a disease that can cause birth defects.
* Don't sit in the sauna or hot tub. This raises your risk of miscarriage and birth defects.
* Don't douche. Douching could force air into the vagina, which can cause an air embolism.
* Don’t feel sad or ugly or unloved. This may be one of the most tiring and confusing moments of your life due to changes in hormones, physique, etc yet this is also a time to appreciate God’s most precious gift. Remember that there are a lot of people around you who cares for you and your baby… including ME!!!
Please remember that it takes teamwork to have a healthy pregnancy and a healthy baby.
Women who get early and regular prenatal care have healthier pregnancies and healthier babies. It is important that you as well as your partner and I communicate well and work together. It is your responsibility to try to stay as healthy as you can and learn what is normal and what is not. Watch out for changes in your body that may be warning signs.
It is my duty on the other hand to help you understand your pregnancy, identify problems before they become serious, and to provide care when you need it.
Remember, the things you tell me are confidential.
That means that I can’t tell anyone else what you say without your permission. So don’t be afraid to talk to me about issues that might be uncomfortable or embarrassing. It’s OK to tell me if you smoke, drink alcohol or take any drugs, or about your sexual activities (past and present) or if your partner hurts or scares you. I need to know all about you and your lifestyle so that I can give you and your baby the best care. Consider me as part of your family - an ate or tita.
By the way, my dear mom to be, be sure to have a dental checkup early in pregnancy to help your mouth remain healthy. You may even want to see your dentist more often than usual.
With love,
Doc Faye
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