M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
Clinical Pharmacy 2 Lab Group 1
Lesson 1: Hormonal Replacement Therapy
CASE PRESENTATION ON HRT
Synthroid 75 mcg po once daily
●
NKDA
All
ROS
Chief Complaint
●
●
●
“I have been having hot flashes for the past few
months, and I just can’t take it anymore.”
(+) hot flashes, occasional night sweats and insomnia,
vaginal dryness. (–) for weight gain, constipation.
LMP 12 months ago.
Physical Examination
HPI
●
Emma Peterson is a 50-year-old woman who reports
experiencing two to three hot flashes per day,
occasionally associated with insomnia. She also
states she is awakened from sleep about two to three
times per week needing to change her bed clothes
and linens. Her symptoms began about 3 months
ago, and over that time, they have worsened to the
point where they have become very bothersome. She
states that her mother was prescribed a pill for this,
but she is hesitant to take the same thing because
she heard on the news and from friends that the
medication may not be safe. She also does not want
to “get her period back,” if possible. Successfully
treated for depression in the past, she is currently
controlled on paroxetine therapy. She currently
exercises three times a week and tries to follow a
low-cholesterol diet.
Gen
WDWN female in NAD
●
BP 128/86, P 78, RR 15, T 36.4°C; Wt 76.2 kg, Ht
5'6''
VS
Skin
●
●
●
●
WNL
Neck/Lymph Nodes
Supple, no bruits, no adenopathy, no thyromegaly
Lungs/Thorax
●
Depression
GERD
HTN
Hypothyroidism
Warm, dry, no lesions
HEENT
PMH
●
●
●
●
●
●
CTA bilaterally
Breasts
●
Supple; no masses
●
RRR, normal S1 and S2; no MRG
●
Soft, NT/ND, (+) BS; no masses
CV
FH
●
Mother died of stroke at age 67; father died of lung
cancer at age 62. Patient has one brother, 52, and
one sister, 48, who are alive and well, but both with
HTN.
Abd
Genit/Rect
SH
●
Married, mother of two healthy daughters, ages 21
and 25. She is an RN in a neighboring physician’s
office. She walks on her treadmill three times a week
and is trying to follow a dietitian-designed
lowcholesterol diet. She does not smoke and
occasionally drinks a glass of red wine with dinner.
●
Pelvic exam normal except (+) mucosal atrophy; stool
guaiac (–)
●
(–) CCE; pulses intact
Ext
Meds
●
●
●
Hydrochlorothiazide 25 mg po once daily
Omeprazole 20 mg po once daily
Paroxetine 20 mg po once daily
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
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M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
Lab Results
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Na 136 mEq/L
Hgb 12.7 g/dL
Ca 9.3 mg/dL
K 3.9 mEq/L
Hct 39.3%
AST 32 IU/L
Cl 104 mEq/L
WBC 6.5 °x 103/mm3
ALT 30 IU/L
CO2 25 mEq/L
Plt 208 °x 103/mm3
TSH 2.46 mIU/L
BUN 10 mg/dL
FSH 87.8 mIU/mL
Random Glu 98 mg/dL
SCr 0.7 mg/dL
UPT (–)
Fasting Lipid Profile: T. chol 190 mg/dL ; HDL 50 mg/dL; LDL
132 mg/dL; Trig 180 mg/dL
2.
Medical treatment for menopause simply focuses on
relieving its manifestations and managing chronic conditions
that may occur with aging. Estrogen hormone replacement
therapy is the most common and effective treatment for the
relief of the signs and symptoms of menopause, especially hot
flashes, which the patient is specifically concerned about.
Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this
patient?
The Mayo Clinic suggests different ways to manage
signs and symptoms associated with menopause.
●
●
Neuro
●
Normal sensory and motor levels
●
Other
●
PAP smear and mammogram: Normal
Assessment
●
50-year-old, symptomatic postmenopausal woman
considering HRT versus other treatment options
QUESTIONS
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.
●
Omeprazole interacts with Levothyroxine (Synthroid)
by increasing gastric pH, lowering the levels of
Levothyroxine. Hence, symptoms of hypothyroidism
are not addressed.
1.b. What information (signs, symptoms, laboratory
values) indicates the presence or severity of this patient’s
problems as she begins menopause?
●
●
●
●
●
●
●
The patient is in her menopausal age (50 years old)
Frequent hot flashes
Occasional night sweats and insomnia
Vaginal dryness
LMP was 12 months ago
Mucosal atrophy was observed
Elevated FSH (87.8 mIU/mL)
Desired Outcome
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
What are the goals of therapy for this
patient’s menopausal symptoms?
●
To cool hot flashes, it is recommended to know what
triggers the flashes so it can be avoided. Aside from
these, it is recommended to always have a glass of
water and to dress in layers.
OTC water-based or silicone-based lubricant can also
be used to decrease vaginal discomfort. It is best to
avoid glycerin-containing lubricant to avoid burning or
irritation. Staying sexually active can also help
increase blood flow in vagina.
It is important to practice getting enough sleep
regularly, eating a balanced diet, exercising regularly,
and avoiding smoking.
Some alternative medicines include:
○ Plant estrogens like isoflavones (soybeans,
lentils, chickpeas, other legumes) and
lignans (flaxseed, whole grains, and some
fruits and vegetables). Although these
should be consumed carefully since this can
interfere with the patient’s high blood
pressure.
○ Bioidentical
hormones
(plant-sourced
hormones)
○ Black cohosh
○ Yoga
○ Acupuncture
○ Hypnosis
3.b. What are the benefits and risks of HRT for this
patient?
HRT can help reduce the symptoms of menopause that the
patient is currently experiencing. In addition, it slightly reduces
that patient’s risk of bowel cancer, prevents cardiovascular
disease, and protects the patient in developing osteoporosis.
However, there are increased risk of developing breast cancer,
blood clot, and or gallbladder/gallstone problems for patients
undergoing HRT.
3.c. What pharmacotherapeutic hormonal therapies are
available for the treatment of menopause?
The pharmacotherapeutic hormonal therapies available for the
treatment of menopause includes Estrogen therapy and
Estrogen Progesterone/Progestin Hormone Therapy (EPT).
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M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
●
●
Estrogen therapy - Estrogen is taken alone
○ may be prescribed as a tablet, spray, cream,
vaginal ring, gel or spray.
EPT - Also called combination therapy, this form of HT
combines doses of estrogen and progesterone
●
●
●
3.d. What nonhormonal alternatives may be used to
manage menopausal symptoms?
Clonidine - might provide some relief from hot flashes.
Gabapentin - helps reduce hot flashes and useful for
women who can't use estrogen therapy.
Low-dose antidepressants - helps in the management
of hot flashes and may be useful for women who can't
take estrogen for health reasons or for women who
need an antidepressant for a mood disorder.
To manage menopause non hormonal alternatives can be used
like:
Optimal Plan
4.
What drug, dosage form, dose, schedule, and duration are best for this patient?
DRUG
INDICATION
DOSE
FREQUENCY
ROUTE
TREATMENT
DURATION
PRICE
Premarin
Moderate to severe
vasomotor symptoms of
menopause
0.3 mg
once daily
PO
daily regimen or cyclic
regimen (25 days on, 5
days off)
Php 39.25 per
tab
Hydrochlorot
hiazide
Hypertension
25 mg
once daily
PO
Maintenance
Php 6.25 per tab
Omeprazole
GERD
20 mg
once daily
PO
Maintenance
Php 27.50 per
cap
Paroxetine
Depression
20 mg
once daily
PO
Tapered once symptoms
improve
Php 34.80 per
tab
Synthroid
Hypothyroidism
75 mcg
once daily
PO
Maintenance
Php 11.25 per
tab
Reference
https://reference.medscape.com/drug/premarin-estrogens-conjugated-342771
Outcome Evaluation
5. What clinical and laboratory parameters are necessary
to evaluate the therapy for achievement of the desired
therapeutic outcome and to detect or prevent adverse
effects?
●
●
●
●
Pelvic exam - examines the organs of the female
reproductive system; detects swelling and other
abnormalities
Mammogram - detects early sign of breast cancer
Estrogen test - helps monitor HTR for menopause
Blood fats, sugar levels, liver function - help monitor
for any unwanted effects of HRT
6.
What information should be provided to the
patient to enhance adherence to the
medication, ensure successful therapy, and
minimize adverse effects?
The information that should be provided to the patient in order
to enhance adherence, ensure successful therapy and
minimize adverse effects would be the importance of
medication regimen compliance as well as the consequences
of non-adherence to the patient’s health and safety. The patient
must be advised not to abruptly stop the use of HRT unless
otherwise told by her physician.
■ CLINICAL COURSE
Reference:
https://www.rxlist.com/premarin-drug.htm
https://www.medsafe.govt.nz/consumers/cmi/p/premarin.pdf
https://medlineplus.gov/lab-tests/estrogen-levels-test/
The patient returns to her physician after taking HRT for 1
year. She reports that her hot flashes, night sweats, and
occasional insomnia have significantly decreased and
would like to know if she should continue taking the HRT
regimen and if so, for how long.
Patient Education
The patient should continue taking the HRT regimen. The
lowest effective dose should be taken for the shortest amount
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
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M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
of time. Research has supported an acceptable HRT of 2-5
years. On the other hand, long-term use depends on the
individual decision between the patient and the doctor, in
consideration to the annual assessment.
■ FOLLOW-UP QUESTIONS
1. What is the optimal dose and length of time for a patient
to continue on HRT?
There is no predetermined period of time for which one should
use HRT; it is a decision between a patient and a doctor (The
Menopause Charity, 2022). But as much as possible, HRT
should be used at the lowest possible dose and for the shortest
period of time. Generally, treatment should be initiated with
Premarin 0.3 mg. Subsequent adjustments to the dose and
duration of treatment should be based upon the individual
patient response and reassessment done annually by the
healthcare provider (Pfizer, 2023).
Reference:
https://www.breastcancer.org/research-news/20100708
https://www.themenopausecharity.org/2022/04/19/starting-or-c
ontinuing-hrt-many-years-after-your-menopause/
https://www.pfizermedicalinformation.com/en-us/premarin/dosa
ge-admin
2. How should HRT be discontinued after successful
treatment? Would your recommendation for HRT change if
the patient had been complaining of genital symptoms
only? Why or why not?
Sudden discontinuation of HRT after successful treatment is
not recommended. Gradually decreasing HRT dose should be
done to prevent recurrence of symptoms. If the patient had
only complained genital symptoms, HRT would still be
recommended. Physical examination revealed mucosal
atrophy which indicates vaginal dryness. Wilson (2018)
suggested that HRT should be used to address and relieve this
symptom as it can cause inflammation of the vaginal wall.
Reference:
https://www.nhs.uk/conditions/hormone-replacement-therapy-h
rt/#
https://www.medicalnewstoday.com/articles/189406#quick_fact
s
HRT, patients with a history of breast cancer are likely to
develop new or recurrent breast cancer. In general, doctors do
not recommend HRT if a woman was previously treated for
breast cancer. A 2021 analysis found that women who took
systemic HRT with a history of breast cancer had a 46% higher
risk of recurrence. Current recommendations say that women
with a history of breast cancer should not take any type of
systemic HRT (Breastcancer.org, 2023). Therefore, HRT would
not be recommended for the patient.
Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780586/
https://pubmed.ncbi.nlm.nih.gov/19095500/#
https://www.cancer.org/cancer/breast-cancer/living-as-a-breast
-cancer-survivor/menopausal-hormone-therapy-after-breast-ca
ncer.html#
https://www.breastcancer.org/risk/risk-factors/using-hormone-r
eplacement-therapy
4. What is the use of black cohosh in menopausal women?
Black cohosh helps relieve menstrual cramps and menopausal
symptoms. Further studies have mentioned that it improves
physical and psychological menopausal symptoms, including
anxiety, hot flashes, night sweats, and vaginal dryness.
Although its safety and effectiveness were poorly evaluated,
this dietary supplement is still recommended by some doctors
for short-term use (less than 6 months) for the relief of hot
flashes.
Reference:
https://www.mountsinai.org/health-library/herb/black-cohosh#
■ SELF-STUDY ASSIGNMENTS
1.
Research non-hormonal therapies that have
been studied for the relief of menopausal
symptoms and compare the scientific
evidence of their efficacy to traditional
hormonal medications.
·
The non-hormonal therapy used for menopause
symptoms include Paroxetine, Clonidine, and
Gabapentin among others. Compared to
hormonal therapies that are primarily used and
are first line treatment for menopause symptoms,
non-hormonal therapies are less effective but are
still useful alternatives.
2.
Review the results of the Women’s Health
Initiative (WHI) study and provide a summary
of the findings regarding HRT and
cardiovascular risk and breast cancer risk.
3. Would your recommendation for HRT change if this
patient were to have had significant risk factors for CHD or
a personal history of breast cancer? Why or why not?
HRT increases the risk of heart disease in healthy
postmenopausal women. Analyses showed that women who
started HRT less than 10 years after menopause remained at
increased risk of heart disease on average for about six years.
Overall risks of long-term use of hormone therapy outweigh the
benefits (Women's Health Initiative, 2010). HRT is not
recommended for patients with risk factors for CHD.
There is a known link between estrogen levels and breast
cancer growth. A clinical trial has shown that with the use of
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
The study sponsored by National Heart, Lung, and Blood
Institute (NHLBI) called the Women’s Health Initiative (WHI),
was a long-term study to assess how some diseases affect
post-menopausal women. It was found that post-menopausal
4
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
women who takes hormone therapy had an increased risk for
cardiovascular diseases and breast cancer.
●
https://www.womenshealth.gov/30-achiev
ements
References:
● https://www.health.harvard.edu/womenshealth/nonhormonal-treatments-for-meno
pause
Subjective
Objective
Demographics
●
Emma Peterson
●
50-year old female.
Medication list
●
Hydrochlorothiazide
25 mg po once
daily
●
Omeprazole 20 mg
po once daily
●
Paroxetine 20 mg
once daily
●
Synthroid 75 mcg
po once daily
Chief complaint
●
Hot flashes associated with
insomnia
●
Her sleep is disrupted 2-3
times per week.
●
The patient does not want to
get her period back
PMH
●
●
●
●
Depression
GERD
Hypertension
Hypothyroidism
●
●
Mother died of stroke at 67
Father died of lung cancer at
62
Brother is 52 y/o and has
hypertension
Sister is 48 y/o and has
hypertension
Vital signs
●
●
●
●
●
●
●
SH
●
●
●
●
Married
Have 2 healthy daughters
ages 21 and 25
She is a registered nurse
She exercises thrice a week
and follows a low-cholesterol
diet
Allergy
●
No known drug allergy
(NKDA)
Review of systems
●
●
●
(+) hot flashes, occasional
night sweats, insomnia, and
vaginal dryness.
(–) weight gain, constipation.
Last Menstrual Period- 12
months ago.
Lab results
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
50-year-old,
symptomatic
postmenopausal
woman
considering
HRT
versus
other
treatment options
Drug interaction
BP= 128/86
RR= 15 bpm
PR= 78 bpm
T= 36.4C
Wt= 76.2kg
Ht= 5’6”
FH
●
Assessment
Na 136 mEq/L
Hgb 12.7 g/dL
Ca 9.3 mg/dL
K 3.9 mEq/L
Hct 39.3%
AST 32 IU/L
Cl 104 mEq/L
WBC 6.5 °x
103/mm3
ALT 30 IU/L
CO2 25 mEq/L
Plt 208 °x 103/mm3
TSH 2.46 mIU/L
BUN 10 mg/dL
FSH 87.8 mIU/mL
Random Glu 98
mg/dL
SCr 0.7 mg/dL
UPT (–)
●
The Omeprazole being
taken by the patient
interacts with the
prescribed
Levothyroxine by
increasing gastric pH
and decreasing the
levels of Levothyroxine
which will make the
hypothyroidism
treatment ineffective.
Plan
Pharmacologic Treatment
●
Hormone replacement therapy (HRT)
may be used to manage the signs
and symptoms of menopause,
especially the hot flashes that are
bothering the patient.
●
The patient may take Premarin
tablets at 300 mcg-1.25mg daily as
prescribed by a physician.
●
Non hormonal alternatives may also
be used such as Clonidine,
Gabapentin and low-dose
antidepressants for the patient’s
condition.
Non-Pharmacologic Treatment
●
Use of OTC water-based or
silicone-based lubricant to reduce
vaginal discomfort
●
Sexual activity may also help by
increasing blood flow in vagina
●
Ensure enough rest and sleep as
well as a healthy and balanced diet
●
Yoga and exercise
●
Acupuncture and hypnosis
●
Black cohosh and plant-sourced
hormones
Medical Examination/Follow Up
●
Physical examination including pelvic
and breast should be done
●
Periodic check-ups are
recommended
Fasting lipid profile:
●
●
●
●
T. chol 190 mg/dL ;
HDL 50 mg/dL;
LDL 132 mg/dL;
Trig 180 mg/dL
Physical
●
Well-developed,
well- nourished
(WDWN) and no
abnormality
detected (NAD)
HEENT
●
Within normal limits
(WNL)
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
5
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
Lymph nodes
●
Supple, no bruits,
no adenopathy, no
thyromegaly
CTA bilaterally
Breasts
●
Supple; no masses
●
Regular
rate&rhythm (RRR),
normal S1 and S2,
no murmur, rubs, or
gallops (MRG)
CV
Abdomen
●
Soft, NT/ND (non
tender/non
distended), (+)
Bowel sound (BS);
no masses
Genit/ Rect
●
Pelvic exam normal
except (+) mucosal
atrophy; (–) stool
guaiac
Extremities
(–)Cyanosis, Clubbing, Edema
(CCE); pulses intact
Neuro
●
Normal sensory
and motor levels
●
Normal PAP smear
and mammogram
Other
References:
https://www.mayoclinic.org/diseases-conditions/menopause/diagnosis-treatment/drc-20353401
https://www.drugs.com/medical-answers/after-taking-levothyroxine-omeprazole-3562259/#
https://www.medicines.org.uk/emc/product/2900/smpc#
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
6
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
Lesson 2: Contraception
The group assigned for this activity should prepare a case
presentation (following either a SOAP/FARM format) in a
power point presentation. All members should actively
collaborate with the team and shall present this in our virtual
meet. Make sure all the information and questions have
references that are properly cited. Attach the PDF file copy of
your report on the quiz question.
Meds
●
●
All
●
ROS
●
M3L2 WHILE TASK
Chief Complaint
● “My fiancé and I are getting married soon, and we’re
not ready for kids just yet.”
HPI
●
Madeline Macy is a 24-year-old graduate student who
presents to the Family Medicine Clinic for
contraceptive counseling. She and her fiancé, Fritz,
are planning to be married in approximately 3 months.
Madeline states that she and Fritz have been in a
monogamous sexual relationship for the past 2 years,
and that their primary method of contraception has
been via the inconsistent use of male condoms. She
is here today to be evaluated for the use of hormonal
contraceptives. The patient states she began menses
at age 14, with irregular cycles of 25–36 days in
length. Her last menses was 2 weeks ago. The
patient states she has heard about contraceptive
options that “keep you from having a period,” and she
wants to know more about those options, and if they
would be okay for her to try.
NKDA (No known drug allergy)
Menstrual periods are the most irregular during
exam times. Migraine headaches are not
accompanied by aura or focal neurologic symptoms,
and have been well controlled on prophylactic
medication. (Patient states she has not had a
migraine for more than 6 months; however, prior to
being placed on propranolol for migraine prophylaxis,
she
reported
experiencing
menstrual-related
headaches in addition to frequent migraines.)
Physical Examination
Gen
●
WDWN (well developed, well nourished) female in
NAD (No abnormality detected)
●
BP 116/74, PR 66, RR 14, T 37°C; Wt 56 kg, Ht 5'6''
VS
Skin
●
Mild facial acne
HEENT
●
PMH
●
Propranolol LA 160 mg po once daily for migraine
prophylaxis
Naproxen 220 mg, one to two tablets po Q 8 h PRN
menstrual cramps
Migraine headaches without aura or focal neurologic
symptoms; well controlled for the past 6 months on
prophylactic therapy
PERRLA (pupils equal, round, and reactive to light
and accommodation); EOMI (extra-ocular motion
intact); TMs (tympanic membrane) intact; oral mucosa
clear
Neck/Lymph Nodes
● Supple without lymphadenopathy or thyromegaly
FH
●
●
●
●
Mother, age 52, has HTN and osteoporosis.
Grandmother died from complications of breast
cancer, which was diagnosed at age 60.
Father, age 53, has osteoarthritis, hypothyroidism,
and hyperlipidemia.
Grandfather died at age 74 of MI.
Lungs
●
CTA (Clear to Auscultation), no wheezing
CV
●
NSR (Normal sinus rhythm); no MRG (Murmur,
gallops or rubs)
SH
●
Currently lives in a house on campus, which she rents
with three other graduate students. Once she and
Fritz are married, they plan to rent an apartment
together until she finishes graduate school. She
admits to occasional social use of tobacco and
alcohol (“a few drinks and a couple of cigarettes at
parties on the weekends”). Otherwise, she denies
regular smoking or alcohol use during the week, and
she denies illicit drug abuse.
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
Breast
● Equal in size without nodularity or masses, nontender
Abd
●
Soft, NT (Non tender), no masses or organomegaly
Genit/Rect
● Normal vaginal exam w/o tenderness or masses
7
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
MS/Ext
● Normal ROM (Range of motion); normal muscle
strength
●
●
Neuro
●
Labs
●
NHS website. (2021, November 18). Complications.
nhs.uk.
https://www.nhs.uk/conditions/migraine/complications/
Shearman RP. Oral contraceptives. Aust Fam
Physician. 1984 Sep;13(9):685-91. PMID: 6508652.
A & O (alert and oriented) x 3
Negative Pap smear and UPT (Urine pregnancy test)
Assessment
● Young, generally healthy, sexually active female with
a history of migraine headache disorder that has been
well controlled with prophylactic medication is
requesting hormonal contraceptives for birth control.
1.c. What medical problems are relative contraindications
to hormonal contraceptive use, and do any of these apply
to this patient?
●
Smoking and her irregular spontaneous menstruation
are the medical problems that are relatively
contraindicated to hormonal contraceptive use that
apply to the patient.
Problem Identification
Reference:
● Shearman RP. Oral contraceptives. Aust Fam
Physician. 1984 Sep;13(9):685-91. PMID: 6508652.
1.a. Create a list of the patient’s potential drug therapy
problems.
1.d. What other information should be obtained before
creating a pharmacotherapeutic plan?
●
●
Prescribing combined pills and contraceptive patches
are not usually recommended if the patient is taking
propranolol or other medicines for high blood
pressure.
Naproxen interacts with drospirenone-containing birth
control pills. Health problems, especially heart
problems, are observed with concurrent use of these
drugs due to induced hyperkalemia.
Reference:
● The Pill | Penn State Student Affairs. (n.d.).
https://studentaffairs.psu.edu/health-wellness/medical
-services/health-information-resources/pill
● NHS website. (2022, September 1). Propranolol.
nhs.uk. https://www.nhs.uk/medicines/propranolol/
1.b.
What
medical
problems
are
absolute
contraindications to hormonal contraceptive use, and do
any of those conditions apply to this patient?
●
●
The medical problems that are absolutely
contraindicated to hormonal contraceptive use that
apply to the patient are active migraine and potentially
having breast cancer since the patient has a family
history of having one.
With her family history of cardiovascular disease and
hyperlipidemia, she is also not advised to take
combined contraceptive pills.
Reference:
● Judge CP, Zhao X, Sileanu FE, Mor MK, Borrero S.
Medical contraindications to estrogen and
contraceptive use among women veterans. Am J
Obstet Gynecol. 2018 Feb;218(2):234.e1-234.e9. doi:
10.1016/j.ajog.2017.10.020. Epub 2017 Oct 27.
PMID: 29111146; PMCID: PMC5807130.
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
●
●
●
Specifically, when do they plan to have a child?
Is the patient taking supplements or vitamins?
Does the patient undergo STD screening?
1.
What are the goals of pharmacotherapy in this
case?
● To
prevent pregnancy following sexual
intercourse.
● To ascertain the best option of contraception
for the patient that will not put her at risk of
developing other pressing diseases such as
breast cancer and cardiovascular disease
among others.
2.
What pharmacotherapeutic alternatives are
available for prevention of pregnancy in this
patient?
Therapeutic Alternative
● Opting for progestin-only pills rather than
combined hormonal oral contraceptives.
● Use of progestin implants or Depo
medroxyprogesterone
acetate
(DMPA)
injectables instead of peroral pills.
● Utilizing intrauterine devices (IUD) to deliver
the progestin levonorgestrel.
Non-Therapeutic Alternative
● Hormone-free
contraception
through
ParaGard IUD which utilizes copper to
prevent pregnancies.
● Natural family planning
○ Body temperature
○ Cervical mucus
○ Calendar (Most successful when
intercourse takes place from 2 days
before ovulation to the day of
ovulation)
8
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
●
Withdrawal Method
Reference:
● Barhum, L. (2022, November 8). What to know about
non-hormonal birth control.
https://www.medicalnewstoday.com/articles/320213
● https://americanheadachesociety.org/wp-content/uplo
ads/2021/01/AHS-First-Contact-Hormones-Contrcepti
ve-Options.pdf
3.
What contraceptive method, dose, and schedule
are best for this patient?
● The contraceptive method that is the best for
the patient is by using progestin-only
“minipills” to prevent unwanted pregnancy.
One tablet is to be taken daily for 28
consecutive days. Each subsequent pack
is started immediately after finishing the
previous pack. The interval between two pills
should be 24 hours. It is best to take the
medication after evening meals or before
going to sleep. Patients may continue taking
the pill as long as they want to avoid
pregnancy. The patient has an option to
choose between:
○ Cerazette (Desogestrel) 75 mcg
■ Tablet-taking has to start
on day 1 of the woman's
natural cycle (day 1 is the
first day of her menstrual
bleeding).
■ Starting on days 2-5 is
allowed, but during the first
cycle a barrier method is
recommended for the first
7 days of tablet-taking.
○ Exluton (Lynestrenol) 500 mcg
■ Tablet-taking has to start
on day 1 of the woman's
natural cycle (day 1 is the
first day of her menstrual
bleeding).
■ Starting on days 2-5 is
allowed, but during the first
cycle a barrier method is
recommended in addition
for the first 7 days of
tablet-taking.
○ Daphne (Lynestrenol) 500 mcg
■ Tablet-taking has to start
on day 1 of the woman's
natural cycle (day 1 is the
first day of her menstrual
bleeding).
■ Start any day as long as
the patient is not pregnant
but use a back-up method
such as condom for the
next seven days as a
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
precaution
pregnancy.
to
avoid
Reference:
● Cerazette Full Prescribing Information, Dosage &
Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/cerazette
?type=full
● Exluton Full Prescribing Information, Dosage & Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/exluton?ty
pe=full
● Daphne Full Prescribing Information, Dosage & Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/daphne?t
ype=full
Outcome Evaluation
1.
What clinical and laboratory parameters are
necessary to evaluate the therapy for efficacy and
adverse effects?
● Prior to Prescribing: Blood pressure, BMI,
Lipid levels, Liver enzymes, Bimanual
examination and cervical inspection, Clinical
breast examination, Glucose levels test,
Hemoglobin, and Thrombogenic mutations.
● Monitor blood pressure during the course of
use to ensure that it is maintained within
normal range.
Reference: Progestin-only Pills. (2017, February 1). Centers
for
Disease
Control
and
Prevention.
https://www.cdc.gov/reproductivehealth/contraception/mmwr/sp
r/progestin.html.
1.
What information should be provided to the
patient to enhance adherence, ensure successful
therapy, and minimize adverse effects?
● Tell the patient not to skip on taking the pill
even if there is a brief pause from sexual
activity. Regularity in taking the pill is very
important because contraceptive efficacy is
reduced if a pill is delayed for 3 hours.
○ If the user is less than 3 hours late
in taking any tablet, the missed
tablet should be taken as soon as it
is remembered and the next tablet
should be taken at the usual time to
avoid
premature
withdrawal
bleeding.
○ If she is more than 3 hours late, she
should follow the same advice but
also additionally use a barrier
method for the next 7 days of
tablet-taking.
○ If tablets were missed in the very
first week of use and intercourse
took place in the week before the
tablets were missed, the possibility
9
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
of
a pregnancy should be
considered.
Patients should only stop taking the pill after
finishing a pack; otherwise bleeding may
start.
The patient should also stop smoking to
prevent or reduce breakthrough bleeding.
Drinking alcohol should also be ceased since
it precipitates vomiting. Vomiting and
persistent severe diarrhea can interfere with
the absorption of the pill.
●
Reference:
● Cerazette Full Prescribing Information, Dosage &
Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/cerazette
?type=full
● Exluton Full Prescribing Information, Dosage & Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/exluton?ty
pe=full
● Daphne Full Prescribing Information, Dosage & Side
Effects
|
MIMS
Philippines.
(n.d.).
https://www.mims.com/philippines/drug/info/daphne?t
ype=full
●
●
●
■ CLINICAL COURSE
Madeline returns to the clinic in 2 months complaining of
worsening acne and breakthrough bleeding.
■ FOLLOW-UP QUESTIONS
1.
What medical conditions can be the cause of
breakthrough bleeding? If breakthrough bleeding
is not caused by an underlying medical condition,
how can it be managed?
● Breakthrough bleeding is a prevalent side
effect of “minipill” or the progestin-only pills.
This is usually common during the first
months of starting with oral contraceptives
and the bleeding may go away on its own.
When compared to combined birth control
pills, the sudden bleedings are also more
unpredictable in the progestin-only type. In
order to manage this problem, it is advised
for the patient to take the medication at the
same time everyday. If the patient is more
than 3 hours late taking the progestin-only
pill, take the missed dose right away and use
a backup method of contraception (such as a
condom) for the next 2 days. Another factor
is smoking which is linked to higher rates of
menstrual irregularities and breakthrough
bleeding. Therefore, it is also suggested for
her to cease smoking.
Reference:
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
●
2.
Santos-Longhurst, A. (2021, October 13).
What You Need to Know About
Breakthrough Bleeding on Birth Control.
Healthline.
https://www.healthline.com/health/womens-h
ealth/breakthrough-bleeding-on-the-pill
Salvaggio HL, Zaenglein AL. Examining the
use of oral contraceptives in the
management of acne. Int J Womens Health.
2010 Aug 9;2:69-76. doi:
10.2147/ijwh.s5915. PMID: 21072299;
PMCID: PMC2971728.
familydoctor.org editorial staff. (2020, July 6).
Progestin-Only Birth Control Pills.
familydoctor.org.
https://familydoctor.org/progestin-only-birth-c
ontrol-pills/
What recommendations can be made to address
this patient’s complaint of worsening acne?
● Increase in acne could also be attributed to
her use of progestin-containing pills. Unlike
combined oral contraceptives that decreases
androgen levels, these “minipills” cause
fluctuations or rise in these male hormones
leading to increased sebum production and
acne. To address this complaint, the
following products could be recommended to
reduce hormonal acne: benzoyl peroxide
(topical acne treatment), Tretinoin (topical
retinoid), and salicylic acid (chemical
exfoliant). Other tips to manage acne are to
cleanse your face twice daily with a gentle
cleanser, use moisturizer, and go for
non-comedogenic
products
to
avoid
pore-clogging.
Lastly,
the
help
of
dermatology experts is highly suggested.
Reference:
● Dunn, J. (2022, August 12). How Do Birth Control
Pills
Help
with
Acne.
Scripps.
https://www.scripps.org/news_items/7002-how-do-birt
h-control-pills-help-with-acne#:~:text=Birth%20control
%20pills%20that%20contain,%E2%80%9D)%20can
%20make%20acne%20worse.
● Sanghvi, S. (2021, December 20). Contraceptive pill
and
acne.
Lloyds
Pharmacy.
https://onlinedoctor.lloydspharmacy.com/uk/contracep
tion/the-pill-and-acne#:~:text=The%20progestogen%2
Donly%20pill%2C%20or,oily%20skin%2C%20resultin
g%20in%20acne.
● Curology team. (2022, August 16). Fact vs. fiction:
Does
progesterone
cause
acne.
Curology.
https://curology.com/blog/fact-vs-fiction-does-progeste
rone-cause-acne/.
■ SELF-STUDY ASSIGNMENTS
Compare the costs of each method of birth control and
prepare a report that contains your conclusions as to
10
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
which method provides the best efficacy at the most
reasonable cost.
●
●
●
●
Cerazette (Desogestrel) 75 mcg
○ 620.00 pesos per box
Exluton (Lynestrenol) 500 mcg
○ 189.25 pesos per box
Daphne (Lynestrenol) 500 mcg
○ 147.50 pesos per box
ParaGard IUD
○ Anywhere from 10,000 to 15,000 pesos on
average
The three mini pills above provide the same efficacy,
but in terms of money and flexibility, Daphne (Lynestrenol)
500 mcg was the most reasonable cost and the medication
that can easily be terminated in terms of contraception. Since
the couple still plans to have kids in the future, ParaGard IUD
is the least recommended contraception because it is costly
and its effect could last up to 10 years.
Reference:
● Watsons Philippines.com
● Quesada, F. A. (2022, February 2). IUD Available in
the Philippines: Is It Right For You? Learn More Here.
Hello Doctor.
https://hellodoctor.com.ph/sexual-wellness/contracepti
on/iud-philippines/
Subjective
Objective
Assessment
Plan
Demographics
●
Madeline Macy
●
24-year old female
Vital Signs
●
Weight= 56 kg
●
Height= 5’6”
●
Blood Pressure= 116/74
mmHg
●
Respiratory Rate= 14 bpm
●
Pulse Rate= 66 bpm
●
Temperature= 37C
Young, generally healthy, sexually
active female with a history of migraine
headache disorder that has been well
controlled with prophylactic medication
is requesting hormonal contraceptives
for birth control.
Non-Pharmacologic Treatment
●
Hormone-free contraception
through ParaGard IUD
which utilizes copper to
prevent pregnancies.
●
Natural family planning
●
Body temperature
○
Cervical mucus
○
Calendar
Intercourse
takes place from
2 days before
ovulation to the
day of ovulation
●
Withdrawal Method
Chief Complaint
●
Does not want to have kids
Past Medical History
●
Migraine headaches without
aura or focal neurologic
symptoms; well controlled
for the past 6 months on
prophylactic therapy
Allergy
●
NKDA
Medication List
●
Propranolol LA 160 mg po
once daily
●
Naproxen 220 mg, one to
two tablets po Q8h PRN
Skin
●
Family History
●
Mother, age 52, has HTN
and osteoporosis.
●
Grandmother died from
complications of breast
cancer, which was
diagnosed at age 60.
●
Father, age 53, has
osteoarthritis,
hypothyroidism, and
hyperlipidemia.
●
Grandfather died at age 74
of MI.
Social History
●
Engaged
●
A graduate student
●
Smokes and drinks alcohol
occasionally
●
She denies illicit drug abuse
Review of Systems
●
Irregular period
●
Migraine headaches are not
accompanied by aura or
focal neurologic symptoms
●
Menstrual-related
headaches prior to
propanolol treatment
Mild facial Acne
Physical
●
WDWN
●
NAD
HEENT
●
PERRLA
●
EOMI
●
TMs intact
●
Oral mucosa clear
Neck/Lymph Nodes
●
Supple without
lymphadenopathy or
thyromegaly
Lungs
●
CTA, no wheezing
Cardio Vascular
●
NSR ; no MRG
Breast
●
Equal in size without
nodularity or masses,
nontender
Abdomen
●
Soft, NT (non tender); no
masses, no acromegaly
Genit/ Rect
●
Normal vaginal exam w/o
tenderness or masses
Musculoskeletal & Extremities
●
Normal ROM
●
Normal muscle strength
Neuro
●
Alert and Oriented x 3
Laboratory data
●
(-) Pap smear and Urine
pregnancy test
Pharmacologic Treatment
●
Opting for progestin-only
pills rather than combined
hormonal oral
contraceptives.
○
Daphne
(Lynestrenol)
500 mcg
○
1 tablet is to be
taken daily
Q24h for 28
consecutive
days.
○
Preferably, take
it after evening
meals or before
going to sleep.
○
Other
alternatives:
Exluton 500 mcg
& Cerazette 75
mcg
●
Use of progestin implants or
Depo medroxyprogesterone
acetate (DMPA) injectables
instead of peroral pills.
●
Utilizing intrauterine devices
(IUD) to deliver the
progestin levonorgestrel.
Lesson 3: Pregnancy and Lactation
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
11
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
M3.L 3. While Task Pregnancy & Lactation
Selective Serotonin Reuptake Inhibitor (SSRI)
at 20 mg per day.
The group assigned will Create a power point or AVP
presentation on the 4 cases for pregnancy and lactation use
FARM/SOAP format in presenting the case. Answer the
questions found after each case make sure all group members
present and participate during case presentation.
Assessme
nt
Question 1
Case 1:
Plan
A 2 day old full term infant has excessive shrill crying , jittery
and feeding poorly. The medical team cannot find any cause
for these effects. The mother, Maria, is worried that they maybe
due to paroxetine exposure via breast milk and wonders
whether St. Johns Wort would be as safer alternative. Maria
has been taking 20 mg paroxetine daily throughout her
pregnancy and this has been continued after delivery.
1. What is the most likely drug related explanation?
● Paroxetine is an antidepressant in the Selective
Serotonin Reuptake Inhibitor class, under pregnancy
category D. Paroxetine exposure can explain the
symptoms experienced by the 2-day-old infant since
the mother has been taking the medication through
her pregnancy. Infants exposed to Paroxetine,
especially during the first trimester of pregnancy, have
an increased risk of congenital malformations,
particularly cardiovascular malformations.
2. Is it safe for the mother to continue to take paroxetine
while breastfeeding?
● Generally, it is safe to take Paroxetine because it is
one of the most preferred antidepressants for
breastfeeding mothers. But with exposure to
Paroxetine during pregnancy, the infant has a higher
risk of experiencing occasional mild side effects like
insomnia, restlessness, and increased crying.
3. Is St John's Wort a reasonable alternative?
● St. John’s Wort is also effective in managing
depression however, it is not recommended to be
taken by pregnant or breastfeeding women. Hypericin
and hyperforin are detected in the breastmilk. Toxicity
is also observed in infants with long-term exposure to
St. John’s Wort.
References:
https://www.ncbi.nlm.nih.gov/books/NBK501190/
Subjective
The patient has been taking 20mg of
Paroxetine daily throughout her pregnancy
and it was continued after delivery. Her 2 day
old infant has been experiencing excessive
crying, jittering and poor feeding behavior
which the mother suspects was due to
Paroxetine exposure during her breastfeeding.
Objective
The patient is currently taking Paroxetine, a
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
During pregnancy, women are at higher risk of
being depressed. Paroxetine is taken by the
mother to address her depression. After birth,
symptoms of Paroxetine withdrawal syndrome
are observed in the infant.
●
●
●
●
The pharmacotherapeutic goal for
Maria is to manage her condition
without jeopardizing the safety of her
newborn and herself.
The patient should be advised to
consult with her physician to address
the withdrawal symptoms being
experienced by her 2-day-old
newborn.
The withdrawal symptoms,
specifically the poor eating habit
must be monitored and addressed
because it could lead to poor
nutrition which is not good for the
baby.
The mother is advised to take
intervals between feeding and taking
Paroxetine.
Question 2
Case 2:
A 30 year old epileptic woman is currently taking 1500mg
valproic acid daily. She wishes to conceive but is concerned
about the possibility of birth defects due to valproate exposure
in pregnancy. Her Seizure has been difficult to control with
alternative anticonvulsants.
1. What are the risks associated with valproate treatment
during pregnancy?
● Children born from mothers who have taken valproic
acid during pregnancy have an increased risk of
developing decreased communication, social and
cognitive skills, developmental delay, and memory
impairment. Taking valproic acid during pregnancy
increases the risk of birth defects – congenital
malformations (neural tube defects and malformations
in the body). Hypoglycemia is also observed in
neonates, while some infants have hepatic failure.
Women taking valproic acid during pregnancy are
also at risk of developing hepatic failure and clotting
abnormalities which can cause hemorrhagic
complications to the neonate, leading to death.
2. How can these risk be minimized?
● The risks associated with Valproate treatment during
pregnancy may be minimized by taking folic acid
supplementation during the first trimester and tapering
off the dose of the Valproic acid since it is not safe to
abruptly stop taking this medication once started.
Polytherapy of antiepileptic drugs should also be
considered. Increased congenital malformations were
12
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
observed in the monotherapy of antiepileptic drugs
than with antiepileptic drugs polytherapy.
neonatal fluconazole dosage. It means that the dose to the
breastfed infant is estimated to be less than the dose that
would be given directly to the infant to treat an infection.
Subjective
Objective
Assessme
nt
Plan
The patient is a 30-year-old woman who was
diagnosed with epilepsy she is planning to
conceive but is concerned about the risks
associated with the drug she is taking during
pregnancy. She is having difficulty controlling
her seizures with alternative anticonvulsants.
Therefore, the infant would not be exposed to this amount with
The patient is currently taking 1500mg of
Valproic acid daily.
fluconazole is often used.
The patient is currently taking Valproic acid for
her epilepsy and she is planning to conceive a
baby. Valproate is not recommended during
pregnancy because it increases the risk of the
child developing birth defects and
developmental delays. The patient is having a
hard time controlling her seizures using
alternative anticonvulsants.
concern for a breastfeeding mother since only small amounts
●
●
●
●
The pharmacotherapeutic goal for
the patient is to effectively manage
her seizures and find a way to safely
conceive a child while undergoing
epilepsy treatment.
In order to reduce the risks of taking
Valproate during pregnancy, the
patient may be prescribed with folic
acid and the dosage of the Valproic
acid should be gradually reduced if
possible because stopping it abruptly
is not safe
The patient will still continue on
taking the prescribed Valproic acid
for her seizures since there are no
other suitable alternatives for her
condition.
Continuous monitoring and follow-up
check-ups must be conducted
regularly.
each feeding. In addition, a study has found that fluconazole is
often prescribed for breastfeeding mothers to treat breast
candidiasis, especially with recurrent or persistent infections. It
was also stated that when other treatments fail, treatment with
Similarly, miconazole cream 2% should not be a
of the product pass into the breastmilk.However, the mother
must be advised to remove all topical products before feeding.
Reference
https://www.ncbi.nlm.nih.gov/books/NBK582846/#:~:text=Ther
e%20are%20currently%20no%20studies,expected%20to%20b
e%20a%20concern.
2. What other therapeutic measures must be taken?
Since the mother is complaining of bilateral nipple
pain during and after breastfeeding, this is a sign of thrush or
yeast infection in the breast. In this case, the infant might
develop thrush in the mouth. Although the mother was given
fluconazole, the amount of fluconazole transferred through
breast milk is not enough to treat the breastfed infant. If the
infant does have an infection, medical treatment will be
needed.
Subjective
4 weeks after delivery, a breastfeeding mother
complains about bilateral nipple pain before
and after feeding, which she has been feeding
for the past 4 days. She was prescribed with
miconazole cream 2% to be applied to the
nipple after feeding. Alongside, she was given
fluconazole 200 mg for a presumed candidal
infection. She expressed concern that the
medication might affect the infant.
Objective
The patient was given miconazole cream 2%
to be applied to her nipples. She was also
asked to take fluconazole 200 mg dailly for 14
days.
Assessme
nt
The mother expressed her concern that the
medication might have effects on the infant.
Although both prescribed medications do not
have significant effects on the baby.
Plan
The mother should continue taking the
prescribed medications. Although her
symptoms suggest a sign of thrush or yeast
infection, the mother is advised to temporarily
stop breastfeeding the infant in order to
prevent the transfer of infection to the infant’s
mouth. The patient is also advised to monitor
Question 3
Case 3:
A breastfeeding mother returned to see her midwife 4 weeks
after delivery of a full term healthy infant. She is complaining of
bilateral nipple pain during and after breast feeding, a problem
that was constant for the past 4 days. She was advised to use
miconazole cream 2% to the nipples after each feed. This
provided initial relief but symptoms returned after a few days.
She was given a course of fluconazole 200 mg daily for 14
days for a presumed candidal infection but expressed concern
that the medication affect the infant.
1. Is the regimen safe to use during lactation?
Fluconazole 200 mg daily for 14 days in breastfeeding
mothers is considered acceptable. Even though fluconazole
can enter breast milk, it is still acceptable because the amount
of fluconazole excreted into the breast milk is less than the
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
13
M3. Pharmacotherapy for Obstetrics & Gynecologic Disorder
the child for signs of infection or even signs of
reactions.
Assessment
Smoking causes damage to the fetus in the
lungs and brain, and increased the risk of
developing a cleft lip. Nicotine from smoke
can also be transferred to the baby causing
an increased risk of sudden infant death
syndrome (SIDS). Abrupt quitting of
smoking can cause withdrawal, especially
for the smoker. The mother should
consider NRT.
Plan
The mother should consider NRT. Nicotine
replacement therapy is available in
patches, gum, inhalator, nasal spray,
mouth spray, oral spray, lozenges (except
licorice flavor), and micro tabs. This is safer
than smoking because it is believed to
produce lesser chemicals. The mother is
advised to take oral forms of NRT first and
when pregnancy-related nausea and
vomiting are experienced, patches can be
used. Although, the effects of NRTs differ
for every patient. It is important to choose
to use only licensed NRT.
Question 4
Case 4:
A mother who wishes to give up smoking seeks advice on the
safety of nicotine replacement therapy while breastfeeding.
She is currently in the latter stages of pregnancy but does not
wish to use these products until after delivery and has not been
successful in significantly reducing her smoking without aids?
1. What are the likely effect of smoking in breastfeeding?
Smoking while breastfeeding can allow harmful
chemicals to pass from the mother to the infant through breast
milk. According to the Centers for Disease Control and
Prevention, “maternal smoking is a risk factor for sudden infant
death syndrome (SIDS), as well as lower respiratory illnesses,
ear infections, and impaired lung function in infants.” The
presence of nicotine also lowers the serum prolactin level,
decreasing the maternal milk supply.
2. Can NRT be used safely while breastfeeding?
Nicotine replacement therapy is safe while
breastfeeding. It increases chances of quitting smoking.
Although there has not been much research on NRT, it is said
that the amount of nicotine excreted into the breast milk from
nicotine therapy is less dangerous for the baby than smoke
inhalation from smoking tobacco products. Studies have
mentioned that:
●
●
Reference
https://www.nhs.uk/pregnancy/keeping-well/stop-smoking/#:~:t
ext=Nicotine%20replacement%20therapy,Champix%20or%20
Zyban%20during%20pregnancy.
https://www.publichealth.hscni.net/sites/default/files/Smoking%
20Pregnancy%20A5_Leaflet_02_16.pdf
Nicotine absorption from NRT is SLOWER
than from smoking.
Increase in blood level of nicotine from NRT
is also SLOWER.
In addition to this, nicotine replacement therapy prevents or
lessens withdrawal symptoms because it only supplies enough
blood nicotine levels (Mohrbacher, 2020).
3. If Yes, which products are preferred?
There are numerous nicotine replacement therapies that the
patient can use. However, it is more preferred that the patient
first use a short-acting oral form of NRT like gum, lozenge or
inhaler. In addition, the patient is advised not to use nicotine
patches first as they provide a constant delivery of nicotine into
the body.
Subjective
A pregnant mother smokes and now wants
to quit smoking so she is looking into
nicotine replacement therapy.
Objective
NA
Group 1 BSP3B [Angeles, Bagsit, Ballena, Bambalan, Bautista, Cabal]
14