Medication Considerations in Pregnancy

Sometimes, finding the optimal therapy for a patient can be cumbersome. Many patient-specific factors go into selecting one medication out of many in various classes to treat depression, hypertension, hyperlipidemia, diabetes, and other disease states. One important factor to consider is whether the patient is pregnant or planning to become pregnant, as pregnancy can change medication recommendations drastically.

Pain

Some commonly recommended OTC medications for pain, like ibuprofen, aspirin, and naproxen, aren’t safe during pregnancy. In fact, the use of NSAIDs during pregnancy has been associated with an increased risk of miscarriage.¹ Therefore, acetaminophen is the analgesic to recommend during pregnancy.

Hypertension

In most patient populations, hypertension treatment may include angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), but not in a pregnant individual. Exposure to ACE inhibitors in the first trimester increases the risk of congenital malformations,¹ and medications acting on the renin-angiotensin system can cause serious injuries to the developing fetus and, more severely, death of the fetus. First-line agents for hypertension treatment in pregnancy are labetalol, methyldopa, and nifedipine.^2,3

Depression

Depression treatment in pregnant patients can also be precarious. Many of the selective serotonin reuptake inhibitors (SSRIs) used to manage depression, including fluoxetine, sertraline, escitalopram, and citalopram, are pregnancy category C. Paroxetine products, which are indicated for psychiatric conditions, are pregnancy category D.

The use of SSRIs during pregnancy can be toxic to the fetus, putting it at risk of developing cardiovascular and pulmonary complications. Moreover, antidepressant therapy exposure during pregnancy has been associated with spontaneous abortion. The risk and benefits of using antidepressant therapy must be taken into consideration. Discontinuing antidepressant therapy can be detrimental to patient’s health, causing harm to the fetus.

The American Congress of Obstetricians and Gynecologists recommends SSRI therapy during pregnancy should be individualized to patient-specific factors. Treatment of depression during pregnancy should incorporate the clinical expertise of mental health professionals, obstetricians, pediatricians, and primary health care providers.

Dyslipidemia

In the general population, dyslipidemia treatment will include statins because of the evidence that the use of statins decreases patient lipid profiles. However, statin use in pregnancy is contraindicated because of the inhibition of cholesterol formation, which is important for the developing fetus.

Omega-3 fatty acids can be used safely in pregnancy to help decrease triglycerides. Due to lack of studies regarding use of fibrates in pregnancy, they aren’t recommended in pregnant patients. If a patient happens to become pregnant while taking statins, immediate discontinuation and further evaluation by health care professionals for exposure is recommended.⁴

Many factors go into deciding which therapy is optimal for patients, and even more factors come into play when treating women who are pregnant or planning to become pregnant. Risks and benefits must be weighed when considering the discontinuation of maintenance therapy. Although some treatments may increase the risk of fetal harm, discontinuation of therapy might, in some cases, cause harm to the patient, which could in turn reflect on the fetus. Treatment recommendations may differ dependent on whether the patient is currently pregnant or planning to become pregnant.

References

1. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006;354(23):2443-2451.

2. Medication and drug exposure in pregnancy. EBSCO DynaMed website. ebscohost.com/dynamed. Accessed July 28, 2016.

3. The American College of Obstetricians and Gynecologists. Hypertension in Pregnancy. acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy. Accessed July 28, 2016.

4. Mukherjee M. Dyslipidemia in pregnancy. American College of Cardiology website. 2014. acc.org/latest-in-cardiology/articles/2014/07/18/16/08/dyslipidemia-in-pregnancy. Accessed July 28, 2016.