What to Expect When Youre Not Expecting A Pregnant Patient Dr. - PowerPoint PPT Presentation

What to Expect When You’re Not Expecting A Pregnant Patient Dr. Vanessa Paquette, BSc(Pharm), ACPR, PharmD Clinical Pharmacy Specialist – Maternal Fetal Medicine Children’s and Women’s Health Center of BC

Presenter Disclosure I have no current or past relationships with commercial entities I have received a speaker’s fee from CSHP for this learning activity

Commercial Support Disclosure This learning activity has received no financial or in-kind support from any commercial or other organization

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Learning Objectives • By the end of this presentation, the participant will be able to: – Describe the physiological changes that occur during pregnancy – Interpret laboratory values in pregnant patients – Describe the utility of sepsis prognostic scores in pregnancy – Describe the pharmacokinetic changes that occur during pregnancy – Apply the pharmacokinetic changes in pregnancy to drug dosing – Treat a pregnant patient with influenza

Maternal Health Maternal death rates rose in Canada, US over 20 years. Thomas Reuters, 2014 May 6. Available from: https://www.cbc.ca/news/health/maternal-death-rates-rose-in-canada-u-s-over-20-years-1.2633940

Public Health Agency of Canada. Perinatal Health Indicators for Canada 2013: a Report of the Canadian Perinatal Surveillance System. Ottawa, 2013.

Public Health Agency of Canada. Perinatal Health Indicators for Canada 2013: a Report of the Canadian Perinatal Surveillance System. Ottawa, 2013

Public Health Agency of Canada. Perinatal Health Indicators for Canada 2013: a Report of the Canadian Perinatal Surveillance System. Ottawa, 2013

Maternal Health • Maternal morbidity and mortality is preventable • Canada is working towards a national surveillance system to reduce maternal morbidity and mortality • Non-obstetric causes of death are emerging in Canada and across the developed world as significant contributors • Pharmacists are an essential health care provider in the goal to improve maternal health J Obstet Gynaecol Can 2017;39(11):1028 – 1037

Pharmacist Involvement in Maternal Health • Epilepsy management and drug therapy monitoring • Acute psychosis and chronic mental health conditions • Treatment of substance use disorders • Management of hypertensive disorders (pre existing and pregnancy related) • Asthma management • Hyperemesis gravidarum • Diabetes management (pre existing and gestational diabetes) Ann Pharmacother 2012; 46: 297-300 J Pharm Technol 2016; 32(5): 191-195

Pharmacist Involvement in Maternal Health • Pharmacokinetic-based dosing of digoxin for fetal arrhythmias • Anticoagulant dosing and monitoring • Treatment of acute infections including STIs • Treatment of HIV-positive mothers and their infants • Nutritional management (folic acid requirements, anemia) • Preventative health including immunizations and smoking cessation • Contraception counseling • Drug information in pregnancy and lactation Ann Pharmacother 2012; 46: 297-300 J Pharm Technol 2016; 32(5): 191-195

Quiz Question: Obstetric Terminology • G4 T1 P3 A1 L4 (PPD 4 SVD 39+2) A) 4 pregnancies, 1 singleton at > 37 weeks gestational age (wga), 3 singletons < 37 wga, 1 abortion, 4 living children B) 4 pregnancies, 1 singleton at > 35 wga, 3 singletons < 35 wga, 1 abortion, 4 living children C) 4 pregnancies, 1 set of twins at > 37 wga, 3 singletons < 37 wga, 1 abortion, 4 living children D) 4 pregnancies, 1 singleton at > 37 wga, 1 singleton < 37 wga, 1 set of twins < 37 wga, 1 abortion, 4 living children

Case 27 year old female, G2A1, 24 wga Admitted to CTU for sepsis, source ?pneumonia HPI - Onset of fever, chills, sore throat, nasal congestion, body ache x 2 days, new onset productive cough and SOB x 1 days  ER - Febrile, tachycardic, tachypnic, SOB, 02 sat 96%, 2L NP - Fluid, NP swab, sputum culture, pip/tazo + vanco, OB consult, fetal monitoring, OB U/S - Chest X ray ordered but sent back from radiology with the comment “need to explain risks in pregnancy before imaging can be done” PMH - NKDA - MRSA pneumonia 3 years ago, MRSA colonized - Hx opioid use disorder (smoked heroin, no IVDU), last use 1 year ago, stable on buprenorphine/naloxone 24 mg SL daily - Major depressive disorder, stable on escitalopram 20 mg po daily - Smokes ½ pack per day - Therapeutic abortion (TA) 2 years ago - Takes a prenatal vitamin daily - Has not received the flu vaccine (pharmacy did not have a thimerisol free product so it was recommended she not get it)

Case Social Unemployed, lives in low income housing on the downtown eastside with her partner, pregnancy unplanned but wanted, good prenatal care Review of Temp 38.8, HR 110, BP 98/69, RR 20, 02 sat 96% RA systems CNS: A/O x 3, chills, feels tired and unwell Resp: cough, yellow-green sputum, feels SOB, crackles bilaterally, right worse than left, upper lobes clear Cardio: no chest pain, no murmurs GI: mildly nauseated GU: no cramping, no PV bleeding, normal u/o Ext: no peripheral edema Imaging ?CXR OB U/S normal growth, normal amniotic fluid volume Micro Blood cultures pending Urine culture negative Sputum culture 4+ WBC, 3+ GPC Influenza B +ve

Case Labs Lactate 1.5 (ER 2.2 ) CBC WBC 19.3 (ER 12.6), Hgb 98, Neutrophils 16.5 (ER 9.2) Lytes Within normal limits (WNL) Liver WNL Renal Scr 70 (ER 85) TDM Vancomycin level ordered for pre 4 th dose Current medication Piperacillin/tazobactam 3.375 g IV Q6h Vancomycin 1 g IV q12h Buprenorphine/naloxone 24 mg SL daily Escitalopram 20 mg po daily Dalteparin 5000 sc daily Prenatal vitamin 1 tab po daily Acetaminophen 325 – 650 mg po q4-6 h PRN

Issue #1 • There are significant physiology changes during pregnancy, so how does that impact my assessment and monitoring of my patient’s condition? Sepsis as an example https://stock.adobe.com/ca/images/question-mark-pregnant-belly-pregnancy-woman-problem-thinking/102770035

Sepsis in Pregnancy • Third leading cause of maternal death worldwide (increasing in incidence in developed countries) • Accounts for 5% off all maternal death in developed countries • Substandard care often identified as a contributor to mortality, usually related to lack of recognition of sepsis • The signs and symptoms of sepsis in pregnant women may be less distinctive than in the non-pregnant population and are not necessarily present in all cases • Disease progression may be much more rapid than in the non-pregnant state • Literature and guidelines on the definition/diagnosis and management of sepsis do not included pregnant patients (screening and monitoring/prognostic tools not validated in pregnant population) Int J Obstet Anesth 2018; https://doi.org/10.1016/j.ijoa.2018.04.010 Reproductive Health 2017; 14:67 DOI 10.1186/s12978-017-0321-6

Green Top Guideline No. 64a. London: RCOG; 2012.

Defining Sepsis In Pregnancy Global maternal and neonatal sepsis initiative. World Health Organization. Maternal sepsis [infographic]. Available from;: URL: http://srhr.org/sepsis/wp- content/uploads/2017/08/WHO_Infographic-Maternal-sepsis-overview-EN-A4-WEB.pdf Int J Obstet Anesth 2018; https://doi.org/10.1016/j.ijoa.2018.04.010 Reproductive Health 2017; 14:67 DOI 10.1186/s12978-017-0321-6

Physiological Changes in Pregnancy Changes in almost every organ system! CV ↑ cardiac output ↑ heart rate ↓ peripheral vascular resistance ↓ arterial pressure Heme ↑ plasma volume ↑ red cell volume ↑ white blood cells anemia Resp ↑ tidal volume ↑ minute-ventilation ↓ residual volume ↓ PaCO2, physiologic dyspnea Renal ↑ renal plasma flow ↑ glomerular filtration rate ureteropelvic dilation ↑ total body water Breathe 2015: 11: 297-301. Cardiovasc J Afr 2016; 27: 89 -94 Front Pharmacol. 2014; 5: 65.

Physiological Changes in Pregnancy GI delayed gastric emptying prolonged small bowel transit time diaphragm elevation Coag ↑ factors VII, VIII, IX, X, XII, Von Willebrand and fibrinogen ↓ protein S ↓ fibrinolytic activity BP Decreased by 5 – 10 mmHg (returns to pre pregnancy values closer to term) HR Increased by 10 – 20 bpm (approaches 90 – 100 bpm at rest during third trimester) RR Can be increased Temp No change 02 sat Target > 96% Breathe 2015: 11: 297-301. Cardiovasc J Afr 2016; 27: 89 -94 Front Pharmacol. 2014; 5: 65.

Laboratory Values in Pregnancy • Reported lab values will NOT reflect reference ranges for pregnant women! HgB 105 – 140 g/L (anemia < 105 – 110 g/L) WBC 6 – 16 10 9 /L Scr Decrease 30% (20 – 30 umol/L) 30 – 70/80/90 umol/L Albumin Decrease 15 – 20% (change from 33 – 43 g/L to 23 – 33 g/L over course of pregnancy) D dimer Mean > 1 mg/L by third trimester (> 2000 ug FEU/L) Alk Phos Increases by 100% (can increase to well over 200 U/L in third trimester) TSH 0.1 – 4 mU/L pH 7.4 – 7.45 PO2 100 – 104 mmHg PCO2 27 – 32 mmHg Serum bicarb 18-22 mEq/L BJOG 2008;115: 874 – 881. Obstet Gynecol 2009; 114: 1326 - 31

Sepsis Calculators in Pregnancy • SIRS (temp > 38 or < 36, HR > 90, RR > 20 or PaC02 < 32, WBC > 12 or < 4) – Pregnancy will not affect temperature – Pregnancy may affect HR – Pregnancy may affect RR and PaCO2 – Pregnancy may affect WBC Obstetric patients may meet criteria for SIRS simply as a result of normal maternal physiology Obstet Gynecol 2014;124:535 – 41

Am J Obstet Gynecol 2010;203:573.e1-5.