1. DIABETES & PREGNANCY

15. Drugs to Avoid in Pregnancy In a surveillance study of lovastatin exposures during pregnancy, normal outcomes were 85% congenital anomalies 4.0% spontaneous abortions 8.0% and fetal deaths/ stillbirths 1.0% (9) Possible teratogen Do not use in pregnancy Variable Decreases synthesis of cholesterol in the liver HMG-CoA reductase inhibitors In one case-controlled study, 3 of 14 newborn exposed to aspirin within 1 week of delivery had minor hemorrhaging compared with 1 of 17 controls(10). In two retrospective studies, mothers of 1,291 malformed infants were foiund to have consumed aspirin during pregnancy more frequently than mothers of normal infants (11:12) Maternal and newborn hemorrhage, increased perinatal mortality, intrauterine growth retardation, and teratogenic effects Do not use in pregnancy 81-325 mg/d Cyclo-oxygenase inhibitor Aspirin Screen for angiotensin receptor blocker use in pregestational diabetic patients and stop before conception Fetal teratogen Do not use in pregnancy Variable 25-100mg/d Blocks angiotensin II receptor sites Angiotensin receptor blocker Screen for ACE inhibitor use in pregestational diabetic patients and stop before conception Fetal teratogen Do not use in pregnancy Variable 5-40 mg/d Blocks the conversion of angiotensin I to angiotensin II ACE inhibitor Notes Side Effects Benefits Dosage Mechanism of action Agent

19. Insulin in Diabetes and Pregnancy May Use with or without the shorter – acting insulin Hypoglycemia, Hypokalemia injection –site reactions, lipodystophy Intermediate acting As needed Protein hormone that regulates glucose metabolism Insulin neutral protamine Hagedorn Must use multiple injection per day for tight control Hypoglycemia, Hypokalemia injection –site reactions, lipodystophy Short-acting As needed Protein homone that regulates glucose metabolism Insulin regular Patient satisfaction in one study favored insulin Aspart with long acting insulin over regular insulin Hypoglycemia, Hypokalemia, Injection-Site reactions, liodystrophy Reduced Postprondial hyperglycemia Short onset of action, rapid acting, reduces postprandial hyperglycemia As needed Protein hormone that regulates glucose metabolism Insulin Aspart NOVORAPID Lispro Notes Side Effects Benefits Dosage Mechanism of Action Agent

20. Insulin in Diabetes and Pregnancy In small observational study, women with polycystic ovarian disease taking metformin before conception and throughout pregnancy had a 10-fold reduction in the development of gestational diabetes (41) Inadequately controlled blood glucose levels, lactic acidosis, diarrhea, nausea, and vomiting May decrease the incidence of gestational diabetes among women with polycystic ovarian syndrome 500-2,000 mg/d Increases insulin sensitivity Metformin Notes Ideally begun before conception Side Effects Nausea, abdominal pain, rash, anorexia Benefits Reduces fetal neural tube defects Dosage 400ug/d to 1.0 mg/d Mechanism of Action itamin supplementation Agent Glargine to be avoided in pregnancy Folic Acid