Phar 491 # Pregnancy

Indication / Medical Problem – _____

Diagnosis
hCG levels (Urine or blood)
serum pregnancy: 1-5mIU/mL
urine pregnancy: 20-50mIU/mL
Progesterone levels
First day of last menstrual cycle
Physical exam
Uterus becomes enlarged and globular
Cervix and uterus soften
Chadwick sign
Darkening of areola
Breast tenderness
Doppler’s confirmation of fetal cardiac activity
Sonographic visualization
Transvaginal ultrasound exam
Determination of gestational age
Date of LMP
Pelvic exam
Uterine size
Fetal measurements on ultrasound
Pelvic exam
Pap smear
Cultures (streptococci and gonococci)
Genital herpes
Warts
Trichomoniasis infection
 Candida infection
Lab tests
CBC
Blood type
Rh factor
Serological tests for syphilis, chlamydia, HIV, Hep B antigen, rubella and
varicella antibody titer
Urinalysis
Glucosuria
Proteinuria
Bacteriuria
Urine culture
Maternal BP, BW and BMI
DM screening
Thyroid test
Toxoplasmosis
Fundal height
Rectovaginal culture for GBS (week 35-37)
Amniotic fluid level
Fetal growth, heart rate and activity

Signs and symptoms

Signs
Higher levels of Estrogen and progesterone
Increased urination
Vomiting
Darkening of areola skin
More prominent veins across breast
Physical exam
Uterus becomes enlarged and globular
Cervix and uterus soften
Chadwick sign
 Doppler’s confirmation of fetal cardiac activity
Sonographic visualization
Transvaginal ultrasound exam
Symptoms
Fatigue
Nausea
Breast tenderness
Food cravings and aversions
Mood changing
Light-headedness
Abdominal bloating
Constipation
Heartburn
Low back pain
Nasal congestion
Uterine cramps (similar to the menses ones)

Risk factors

Desired Outcomes / Goals of Therapy (parameter, value, timeframe)

Ensure ____ remains within the recommended body weight gain during pregnancy
Underweight (BMI<19.8kg/m2)
+12.5-18kg
Normal weight (BMI 19.9-26 kg/m2)
+11.5-16kg
Overweight (BMI 26-29 kg/m2)
+7-11.5kg
Obese (BMI >29 kg/m2)
+6.8kg
Meet the recommended nutritional needs of _____ during her pregnancy
Daily caloric intake
 2nd trimester: +340kcal/day
3rd trimester: +452kcal/day
Protein intake 1.1g/kg/day
Carbohydrates 175g/day
Elemental calcium 1000mg/day
Iron
Non-anemic: 30mg/day
Anemic 30-120mg/day

Drug Therapy Problem(s)

Unnecessary drug therapy (The drug therapy is unnecessary because the patient does
not have a clinical indication at this time)
Needs additional drug therapy (Additional drug therapy is required to treat or prevent
a medical condition)
Ineffective drug [improper selection] (the drug product is not effective at producing
the desired outcome)
Dosage too low (the dose is too low to produce the desired response)
Dosage too high (The dosage is too high resulting in undesirable effects)
ADR (the drug is causing ADR)
Failure to receive drug [noncompliance] (the patient is not able or willing to take the
drug regimen appropriately)
Drug interaction (concurrent drugs interact with each other)
(Patient identifier + sx/disease the patient is experiencing or at risk of experiencing + type of
DRP + relationship or potential relationship to drug therapy + desired course of action)
Patient is at risk of/experiencing Sx an DRP from Relationship to drug therapy and would
benefit from Desired course of action

Therapeutic Alternatives (Pharmacologic and Non-pharmacologic)

Pharmacological (2 examples of each class)
Vitamin D PO
Vitamin C PO
Folic acid/folate PO
Calcium PO
Iron PO
Parenteral opioids
Morphine
Meperidine
Epidural analgesia
Opioid
Fentanyl
Sufentanil
Local anesthetic
Bupivacaine
Ropivacaine
Tocolytics
B2 agonists
Terbutaline
CCB
Nifedipine
Magnesium sulfate
COX inhibitors (NSAIDs)
Indomethacin
Oxytocin receptor antagonists
Atosiban
Glucocorticoids
Betamethasone
Dexamethasone
Antibiotics
Ampicillin
Erythromycin
PG analogs
Carboprost
PGE2 analog
 Dinoprostone
PGE1 analog
Misoprostol
Oxytocin IM or IV
Ergot alkaloids
Ergotamine
Ergonovine
Methylergonovine
Non-pharmacological
Down syndrome screening test
Influenza vaccination
Good food hygiene
Consume fully cooked meats (including eggs)
Avoid unpasteurized dairy products
Thoroughly wash fruits and vegetables before consumption
Wash hands, preparation surfaces, cutting boards, dishes and utensils
with hot, soapy water
GBS screening (week 35-37)
Limit caffeine intake to less than 200mg/day
Recommendation (Pharm, non-pharm)
Date of confinement (due date): 1st day of LMP + 7days  count back 3 months and
add one year
Pharmacological
Down syndrome screening test
Vitamin D 5mcg/600IU (max: 4000IU/day)
Vitamin C 80-85mg daily (max 2000mg/day)
Folic acid/folate:
Before conception  first 2-3 months: 0.4-0.8mg
After 3rd month 0.6mg
High risk of NTD 4mg/day
Calcium 1,000-1,300mg
 Iron:
Non-anemic: 30mg/day
Anemic (1st or 3rd Hgb<11, 2nd <10.4g/dL): 30-120mg/day until
correction
Offer multivitamins if (carrying multiple gestation, heavy smokers,
adolescents, complete vegetarians, substance abusers, women with lactose deficiency)
Labor pain:
Meperidine parenteral OR epidural analgesia
Preventing pre-term labor:
1st 48hrs:
B2 agonist (terbutaline)
Nifedipine
Atosiban
<32 weeks of gestation (DO NOT USE NSAIDs)
Supportive treatment
Glucocorticoids
Antibiotics (if premature membrane rupture & infection)
Initiation of labor:
Dinoprostone (to induce cervical ripening and dilation)  oxytocin
Post-partum hemorrhage
Oxytocin
Ergot alkaloids
PG analogs
Non-pharmacological
Down syndrome screening test
Limit caffeine intake to less than 200mg/day
Good food hygiene
Consume fully cooked meats (including eggs)
Avoid unpasteurized dairy products
Thoroughly wash fruits and vegetables before consumption
 Wash hands, preparation surfaces, cutting boards, dishes and utensils
with hot, soapy water
2nd or 3rd trimester during flu season: Influenza vaccination
35-37 weeks: screen for GBS using rectovaginal culture

Justification of Recommendation
Glucocorticoids stimulate fetal lung maturation, promote production of lung
surfactant, prevents collapse of alveoli
Antibiotics diminishes frequency of neonatal GBS infection
Nifedipine less maternal side effects and improved fetal outcomes
Atosiban less risk to mother and baby
Oxytocin induce and facilitate labor (after cervical ripening)
PGE analogs induce cervical ripening dilation
Landmark trials

Clinical guideline

Monitoring Parameters (parameter, frequency, who)

Follow up every 4 weeks for 7 months and then every 2 weeks until last month
Efficacy
Obstetrician or nurse will record fundal height for _____ every 4 weeks
Obstetrician, nurse or pharmacist will measure ______’s blood pressure
(120/80mmHg) every 4 weeks
Obstetrician, nurse or pharmacist will record ________’s body weight every 4
weeks to ensure she is within the recommended weight gain for her __________
Obstetrician or nurse will perform or order a urinalysis for ______’s protein
(<300mg/24hr) and glucose (0-0.8mmol/L) every 4 weeks
Obstetrician, nurse, pharmacist or nutritionist will ask ______ for her
nutritional intake (daily caloric intake, protein and carbohydrates) and ensure it is sufficient
for her and the baby’s growth every 4 weeks
Obstetrician, nurse, pharmacist or nutritionist will monitor ______ iron levels
(HgB>11g/dL) every 4 weeks
Obstetrician, nurse, pharmacist or nutritionist will monitor ______ folic acid
levels every 4 weeks
 Obstetrician, nurse or pharmacist will monitor ________’s calcium levels
every 4 weeks
Post-week 35
Obstetrician or nurse will perform or order a rectovaginal culture for ______’s
GBS screening every 4 weeks
Obstetrician or nurse will measure fetal growth for _____ every 4 weeks
Obstetrician or nurse will record fetal heart rate for _____ every 4 weeks
Obstetrician or nurse will record fetal heart activity for _____ every 4 weeks
Obstetrician or nurse will record amount of amniotic fluid for _____ every 4
weeks
Safety
Terbutaline:
Obstetrician, nurse or pharmacist will monitor ________’s heart rate to
prevent tachycardia during labor
Obstetrician, nurse or pharmacist will monitor ________’s blood
pressure to prevent hypotension during labor
Obstetrician, nurse or pharmacist will monitor ________for any
gasping, shortness of breath, cold and clammy skin as signs of pulmonary edema during labor
Magnesium sulfate:
Obstetrician, nurse or pharmacist will monitor ________for any
gasping, shortness of breath, cold and clammy skin as signs of pulmonary edema during labor
PGE:
Obstetrician, nurse or pharmacist will monitor ________for signs of
uterine hyperstimulation during labor
Oxytocin:
Obstetrician, nurse or pharmacist will monitor ________for any signs
of water retention during labor
Obstetrician, nurse or pharmacist will monitor ________’s blood
pressure to prevent hypotension during labor
Vitamin D:
Obstetrician, nurse or pharmacist will monitor ________’s calcium
levels every 4 weeks to prevent hypocalcemia (<2.1mmol/L)
Vitamin C:
Obstetrician, nurse or pharmacist will monitor ________’s for signs of
hyperoxaluria every 4 weeks
 Folic acid/folate:
Obstetrician, nurse or pharmacist will ask ________ if she experienced
flushing every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
malaise every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
erythema every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
pruritis every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
skin rash every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
bronchospasm every 4 weeks
Calcium:
Obstetrician, nurse or pharmacist will monitor ________’s calcium
levels every 4 weeks to prevent hypercalcemia (>2.6mmol/L)
Obstetrician, nurse or pharmacist will ask ________ if she experienced
diarrhea every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
nausea or vomiting every 4 weeks
Iron:
Obstetrician, nurse or pharmacist will ask ________ if she experienced
constipation every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
darkening of stools every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
nausea or vomiting every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
stomach cramps every 4 weeks
Obstetrician, nurse or pharmacist will ask ________ if she experienced
heartburn every 4 weeks