Patient Care and Monitoring

1. Provide prenatal counseling regarding lifestyle modifications (healthy diet, exercise, avoidance of tobacco, alcohol, and illicit or unnecessary drugs) and medication use during pregnancy. When possible, attain good control of maternal conditions prior to conception. Identify patients at risk of psychosocial problems. Immunize as needed.

2. Perform routine screening at first appointment during pregnancy

• Hematocrit or hemoglobin levels

• Urinalysis and urine culture

• Determination of blood group and Rhesus type

• Determination of immunity to rubella virus

• Syphilis and sexually transmitted diseases

• Cervical cytology (if needed)

• Hepatitis B surface antigen

• HIV antibody testing

3. Recommend appropriate folic acid and multivitamins prior to conception.

4. After pregnancy is achieved, encourage lifestyle modifications, routine pregnancy monitoring and care, and medication adherence.

5. When possible, treat pregnancy conditions with nonpharmacologic treatments instead of using drug therapy.

6. When considering pharmacologic treatment, evaluate the following:

• Evaluate the need for treatment, including benefits and risks. Avoid treatments that do not show evidence of benefit or that can be delayed until after pregnancy of breast-feeding.

• Are the symptoms related to benign conditions of pregnancy? (e.g., palpitations); how bothersome are the symptoms? (e.g., nausea and vomiting); in case of chronic treatment, does it need to be continued during pregnancy? (e.g., dys-lipidemia); is the condition interfering with other pathologies? (e.g., nausea and diabetes); could starting/continuing/stopping the treatment pose a risk for the fetus/neonate?

• Is an effective treatment available?

• What are the maternal side effects of the drug?

• Which is the best drug when used alone?

• Which is the drug with the best safety data in pregnancy/lactation?

7. Encourage breast-feeding. If maternal drug therapy is required during breastfeeding, try to choose short-acting agents with the longest history of safe use in lactation, and administer immediately after feedings.

• Avoid treatments that show no evidence of benefit or that can be delayed until after breast-feeding.

• If possible, select drugs that are used in neonates or children and that are well tolerated.

• When possible, select drugs that yield low percentages of pediatric or relative infant doses (preferably less than 10%).

• Consider infant age when analyzing safety of a drug during breast-feeding. Premature or very young children will be more sensitive to drug effects than older children.

• Avoid drugs that can hinder breast milk production.

8. Monitor infants for birth defects and/or unusual reactions that may be due to maternal drug use. Report suspected drug-related reactions to the FDA or pharmaceutical companies.

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