Question

Case 1: A 32 year-old patient calls the clinic because her pregnancy test is positive. This pregnancy is unexpected. Her first sign that she might have been pregnant was intense nausea in the morning, which she initially thought was her GERD and ulcer disease flaring up, but then she began vomiting after meals, and developed breast tenderness, and she knew this was something unusual.

She wants you to suggest something for relief. She has a cabinet full of meds she has taken in the past when she had aggravation of her ulcer disease.

Q1: What might the nurse recommend that the patient take for relief?

Q2: Are there medications used to treat GERD/peptic ulcers that pose a risk to pregnancy?

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Case 2: A 24 year-old patient has just learned that she is pregnant. She suffers from frontal lobe epilepsy for which she is taking phenytoin-ER, 200 mg, PO, twice daily. She had approximately a seizure per month in childhood until the right medication and right dose were found. She tried many, and phenytoin was not the first choice, but was the only one that seemed to work.

She is panicked because she knows she had been cautioned in the past that epilepsy medications can cause birth defects.

She had been using the birth control patch and is actually quite shocked that she is pregnant.

Q1: Are this patient’s concerns about her anti-epileptic medication justified, and is it important for her to stop the phenytoin immediately?

Q2: What next steps would the nurse recommend to this worried patient?

Q3: Are there some important interactions between medications used for birth control and anti-epileptic medications?

Answer 1

Answer: Case 1

1) The nurse might recommend the patient,try eating smaller,more frequent meals and dry foods,such as crackers.Drink plenty of fluids to stay hydrated. Avoid eating late at night,elevation of the head of the bed and avoiding foods and medications causing heart burn and nausea.If symptoms becomes severe may require hospitalization.

2) Only the histamine2- receptor antagonists (H2RA) except nizatidine are the most commonly used and safest medications for the pregnant woman with heart burn, not responding to lifestyle modification and non-absorbable medication.All three drugs(cimetidine,ranitidine,and famotidine) are FDA approved category B drugs for pregnancy.

Answer: Case 2

1)The patient concern about the drug phenytoin is justifiable.This drug should not be used during pregnancy unless the benefit outweighs the risk to the fetus.If this drug is used during pregnancy,or if the patient becomes pregnant while taking the drug should be informed of the potential harm to the fetus and to stop immediately.

2) The nurse should advise to consult the physician to change the drugs.There are new anti- seizure medications,lamotrigine and levetiracetam are the most widely used due to their known safety during pregnancy.

3)Antiepileptic drugs known to induce the hepatic cytochrome P450(CYP450) isoenzyme cause decreased sexhormone levels in women taking oral contraceptives,raising the potential for decreased effectiveness of oral contraceptives and increased risk of unplanned pregnancy.