Eduovisual
Pregnancy, Childbirth & Puerperium
Medications in pregnancy and lactation: counseling
— ~90% of pregnant patients take at least one medication; ~70% take a prescription drug
— Only ~10% of FDA-approved drugs have adequate human pregnancy safety data
— Birth defects affect 3% of live births; medications account for <1% but are modifiable
— Preconception visit in any reproductive-age patient on chronic meds (antiepileptics, warfarin, ACEi/ARB, isotretinoin, methotrexate, lithium, statins)
— Positive pregnancy test in a patient on a category D/X-equivalent agent
— Unintended pregnancy with first-trimester exposure already occurred
— Lactating patient resuming chronic therapy postpartum
— Acute illness in pregnancy (UTI, DVT, depression flare, asthma exacerbation) requiring new prescription
— Drug factors: molecular weight, lipid solubility, protein binding, half-life, active metabolites
— Timing: pre-implantation (all-or-none), organogenesis (weeks 3–8, structural defects), fetal period (growth, CNS, functional defects)
— Dose, duration, route; maternal genetics/metabolism
— Background risk of untreated maternal disease (often greater than drug risk — e.g., uncontrolled epilepsy, severe depression, DKA)
— Replaced A/B/C/D/X letter categories with narrative summaries: Pregnancy, Lactation, Females/Males of Reproductive Potential
— Step 3 stems may still reference old categories but expect PLLR-style reasoning
Board pearl: The single most important counseling point is that withholding indicated therapy (e.g., insulin, levothyroxine, antiretrovirals, antiepileptics, heparin for mechanical valve) often poses a greater fetal risk than the drug itself. Frame counseling as risk–benefit, not avoidance. Document shared decision-making in the chart — this is repeatedly tested in Step 3 communication vignettes.
— "28-year-old at 6 weeks gestation on lisinopril for hypertension — what do you do?"
— "Epileptic woman on valproate planning pregnancy — counseling?"
— "Postpartum patient with bipolar disorder wants to breastfeed while on lithium"
— "Pregnant patient with new DVT — anticoagulation choice?"
— "Acne patient of reproductive age starting isotretinoin — requirements?"
— LMP and gestational age — determines window of teratogenic vulnerability
— Complete medication list including OTC, herbals, supplements (e.g., high-dose vitamin A, St. John's wort)
— Substance use: alcohol, tobacco, cannabis, opioids, cocaine, methamphetamine
— Occupational/environmental exposures (solvents, lead, mercury)
— Prior pregnancy outcomes and any prior anomaly
— Family history of congenital anomalies, consanguinity
— Chronic conditions: epilepsy, HTN, DM, depression, thyroid, autoimmune, HIV, mechanical valves
— Confirm indication for each drug (is it still needed?)
— Lowest effective dose, monotherapy when possible
— Switch to safer agent before conception when feasible
— Start folic acid 400 mcg/day (4 mg if on antiepileptics or prior NTD)
— Address adherence: untreated disease drives many adverse outcomes
— Active first-trimester exposure to known teratogen (warfarin, methotrexate, isotretinoin, mycophenolate)
— Pregnancy on REMS-required drug (isotretinoin/iPLEDGE, thalidomide)
— Acute overdose or accidental ingestion
Key distinction: Preconception counseling allows planned medication transitions (e.g., ACEi → labetalol; warfarin → LMWH; valproate → lamotrigine). Once pregnancy is confirmed, the window for primary prevention of organogenesis defects (weeks 3–8) may already be closing — emphasize this in any reproductive-age patient on teratogens. Always offer effective contraception while the patient remains on teratogenic therapy.
— Vitals: BP (chronic HTN identification), HR, BMI
— Thyroid exam, cardiac auscultation (mechanical valves, murmurs)
— Skin: acne severity, signs of autoimmune disease
— Neuro: seizure frequency baseline if epileptic
— Mental status and PHQ-9/GAD-7 if on psychotropics
— Confirm viability and dating: pelvic exam, fundal height, transvaginal US if <12 weeks for crown-rump length
— Fetal heart tones by Doppler from ~10 weeks
— Document fundal height vs gestational age — growth restriction is a concern with many drugs (β-blockers, antiepileptics, SSRIs late, methotrexate survivors)
— Oligohydramnios on exam (fundal-size lag) → consider ACEi/ARB, NSAID exposure
— Maternal hypertension worsening → reassess antihypertensive choice
— Signs of withdrawal in neonate at delivery: SSRI, opioids, benzodiazepines
— Breast exam for engorgement, mastitis, supply
— Infant exam: feeding, weight gain, sedation, jaundice (drugs affecting hepatic metabolism)
— Look for neonatal rash, GI symptoms when mother on new medication
— Preeclampsia → avoid ergots postpartum; methergine contraindicated in HTN
— Postpartum hemorrhage on asthma → avoid carboprost (Hemabate); avoid methergine if HTN
— VTE risk assessment for postpartum anticoagulation
Step 3 management: At every prenatal visit, reconcile medications. Pharmacokinetics shift dramatically in pregnancy — increased GFR (lithium, LMWH, levetiracetam need higher doses), increased volume of distribution, altered CYP activity (CYP3A4 up, CYP1A2 down). Re-dose lamotrigine, levetiracetam, lithium, levothyroxine, LMWH through pregnancy with serum-level monitoring where applicable.
— CBC, type and screen, rubella/varicella immunity, HIV, syphilis, HBsAg, HCV
— TSH if on levothyroxine (target <2.5 first trimester) — increase dose ~30% immediately on confirmed pregnancy
— HbA1c if diabetic — target <6.5% preconception
— Renal panel if on lithium, ACEi, NSAIDs
— LFTs if on valproate, methotrexate, antiretrovirals
— Lithium: levels every 4 weeks until 36 weeks, then weekly; hold 24–48h before delivery; resume immediately postpartum
— Lamotrigine: levels monthly; clearance increases up to 300% — dose often must double
— Levetiracetam, oxcarbazepine: monitor levels; clearance rises
— Digoxin, tacrolimus, cyclosporine: serial levels
— LMWH (therapeutic dosing): anti-Xa 4 hours post-dose, target 0.6–1.0
— Unfractionated heparin: aPTT
— Warfarin (mechanical valve only): INR (rarely used, see chunk 8)
— iPLEDGE for isotretinoin: 2 negative pregnancy tests before initiation, monthly tests, 2 forms contraception, 30-day lockouts
— Mycophenolate REMS: negative pregnancy test before, contraception 4 weeks pre to 6 weeks post
— Detailed anatomy ultrasound at 18–22 weeks for all first-trimester exposures of concern
— Fetal echocardiogram at 20–22 weeks if exposure to lithium, SSRIs (paroxetine), retinoids, antiepileptics
— Serial growth scans if β-blocker, SSRI, antiepileptic use
— MSAFP/quad screen at 15–20 weeks (elevated AFP with valproate/NTD risk)
Board pearl: A pregnant patient newly on levothyroxine needs an immediate 25–30% dose increase at the positive pregnancy test, with TSH rechecked in 4 weeks. Failure to do this is a classic Step 3 wrong-answer trap and a real cause of fetal neurocognitive harm.
— Mandatory after first-trimester exposure to: antiepileptics, lithium, warfarin, ACEi/ARB, SSRIs (paroxetine), methimazole, isotretinoin
— Look for NTDs (valproate, carbamazepine), cardiac defects (lithium → Ebstein anomaly historical risk now considered small ~1/1000–2000; paroxetine → septal defects), facial clefts, limb anomalies, aplasia cutis (methimazole), choanal atresia
— Specific indication after lithium, paroxetine, retinoid, antiepileptic, or pregestational diabetes
— Performed 20–22 weeks
— High-risk teratogen exposure
— Family history concerns
— Offer cell-free DNA screening (10+ weeks) and diagnostic options (CVS 10–13w, amniocentesis 15+w) — but note these detect chromosomal not most drug-induced structural defects
— Free counseling resource; Step 3 may reference as appropriate referral
— OTIS pregnancy studies ongoing for many drugs
— Anti-Ro/La if SSA-positive lupus patient on hydroxychloroquine (continue HCQ — reduces congenital heart block)
— HIV viral load monthly on ART; target undetectable by 36 weeks
— Drug levels as in chunk 4
— Neonatal abstinence scoring (Finnegan) for opioid, SSRI, benzo exposure
— Newborn screen captures hypothyroidism (methimazole exposure)
— Hearing screen (aminoglycoside exposure)
— Echo if antenatal cardiac concern
Key distinction: Anatomy ultrasound detects structural defects (heart, brain, spine, limbs); cell-free DNA detects aneuploidy. They are not interchangeable when counseling about teratogen exposure — order the anatomy scan and, when indicated, fetal echo. A normal cfDNA does not reassure about valproate-induced NTDs or ACEi-induced renal dysgenesis.
— Absolute avoidance (high teratogenic risk, alternatives exist): isotretinoin, thalidomide, methotrexate, mycophenolate, warfarin (1st trim, except mechanical valve), ACEi/ARB (2nd–3rd trim), valproate (when alternatives available), aminopterin
— Avoid if possible: carbamazepine, phenytoin, phenobarbital, lithium (consider continuation if severe bipolar), paroxetine, fluconazole high-dose, tetracyclines, fluoroquinolones, aminoglycosides
— Generally safe / preferred: penicillins, cephalosporins, azithromycin, acetaminophen, labetalol, nifedipine, methyldopa, hydralazine, insulin, levothyroxine, heparin/LMWH, hydroxychloroquine, sulfasalazine (with folate), most SSRIs (sertraline preferred), lamotrigine, levetiracetam
— Step 1: Is the medication necessary? (treat indication adequately?)
— Step 2: Is there a safer alternative with equivalent efficacy?
— Step 3: If switch indicated, do it preconception when possible
— Step 4: If unplanned pregnancy on teratogen, do not abruptly stop life-sustaining therapy (antiepileptics, antipsychotics) without psychiatric/neurologic input — withdrawal seizures or relapse may be worse than continued exposure
— Step 5: Document counseling, refer to MFM/genetics for high-risk exposures
— Background risk (3% birth defects in any pregnancy)
— Disease-specific risk if untreated
— Drug-specific risk with magnitude where known
— Available alternatives
— Plan for monitoring
Step 3 management: When a patient presents at 6 weeks on lisinopril for chronic HTN, the correct action is to stop lisinopril and start labetalol or nifedipine ER today — not at 20 weeks. Although the major fetopathy (renal dysgenesis, oligohydramnios, skull hypoplasia) occurs in 2nd/3rd trimester, switching now prevents that and is the lowest-risk pathway.
— First-line: labetalol, nifedipine ER, methyldopa
— Avoid: ACEi, ARB, direct renin inhibitors (all trimesters), atenolol (IUGR), thiazides (relative)
— Severe-range acute (≥160/110): IV labetalol, IV hydralazine, or PO immediate-release nifedipine
— First-line: insulin (all types; lispro, aspart, NPH, detemir well-studied)
— Metformin and glyburide cross placenta; insulin preferred per ACOG/ADA, though metformin acceptable when insulin declined
— First-line: LMWH (enoxaparin); does not cross placenta
— Mechanical valve: complex — warfarin (especially if dose ≤5 mg) vs dose-adjusted LMWH; specialist decision
— Avoid: DOACs (apixaban, rivaroxaban, dabigatran) — insufficient data
— Preferred SSRIs: sertraline, escitalopram; avoid paroxetine (cardiac defects signal)
— Late third-trimester exposure → neonatal adaptation syndrome, small PPHN risk
— Lithium acceptable with monitoring; lamotrigine often preferred for bipolar depression maintenance; avoid valproate, carbamazepine
— Lamotrigine, levetiracetam preferred; monotherapy at lowest effective dose; folate 4 mg/day; avoid valproate (NTDs, cognitive impairment) and polytherapy when possible
— Safe: penicillins, cephalosporins, azithromycin, clindamycin, nitrofurantoin (avoid term and 1st trim G6PD), metronidazole, erythromycin base
— Avoid: tetracyclines (teeth/bones), fluoroquinolones (cartilage), aminoglycosides (ototoxicity), TMP-SMX (1st trim folate antagonism; 3rd trim kernicterus)
— Doxylamine-pyridoxine first-line for NVP; ondansetron acceptable (small cleft signal, generally safe after 1st trim); famotidine, omeprazole acceptable
— Acetaminophen first-line; avoid NSAIDs after 20 weeks (oligohydramnios, premature ductus closure); avoid chronic opioids
— Albuterol, inhaled budesonide preferred; treat aggressively — hypoxia worse than meds
Board pearl: Sertraline for depression and labetalol for hypertension are the most common "correct answer" choices in pregnancy stems.
— Most drugs enter milk in small amounts (typically <1–2% of maternal dose)
— Relative infant dose (RID) <10% generally considered safe
— Resource: LactMed (NIH) — the standard reference; reasonable to cite
— Factors increasing infant exposure: low molecular weight, low protein binding, lipophilicity, long half-life, active metabolites; prematurity and neonatal age <2 months increase risk
— Acetaminophen, ibuprofen, most penicillins/cephalosporins, azithromycin, metronidazole (single-dose preferable), nitrofurantoin (avoid in G6PD or <1 month), heparin/LMWH, warfarin, insulin, levothyroxine, propranolol, labetalol, nifedipine, enalapril, hydrochlorothiazide (low dose), sertraline, paroxetine (preferred SSRIs in lactation despite pregnancy avoidance), most antiepileptics including lamotrigine and levetiracetam
— Lithium: enters milk; can be used with careful infant monitoring (levels, hydration, TSH) — formerly contraindicated, now case-by-case
— Codeine, tramadol: contraindicated — ultra-rapid CYP2D6 metabolizers → infant respiratory depression/death (FDA boxed warning)
— Fluoxetine: long half-life, active metabolite; sertraline preferred
— Benzodiazepines: short-acting (lorazepam) preferred over diazepam
— Aspirin: avoid high-dose (Reye); low-dose 81 mg OK
— Chemotherapy/cytotoxics, radioactive iodine (I-131), retinoids, amiodarone, ergotamine, chloramphenicol, illicit substances, HIV in resource-rich settings (formula recommended in US)
— Progestin-only methods (POP, implant, IUD, DMPA) preferred and can start immediately postpartum
— Combined estrogen-containing contraceptives: avoid first 21–30 days (VTE risk) and ideally wait 4–6 weeks; may decrease supply in some
CCS pearl: When a postpartum patient on codeine/oxycodone presents with a sleepy, poorly feeding infant, stop the opioid, switch to acetaminophen/ibuprofen, evaluate infant, and consider naloxone if respiratory depression. Do not simply "reassure."
— Physiologic GFR rises 50% by mid-pregnancy; "normal" creatinine in pregnancy is 0.4–0.8 mg/dL — a creatinine of 1.0 is abnormal
— Drugs renally cleared need dose adjustments: LMWH (anti-Xa monitoring), lithium (frequent levels), gabapentin, vancomycin
— ACEi/ARB contraindicated; if proteinuric CKD, use labetalol/nifedipine
— Avoid NSAIDs especially after 20 weeks
— Cholestasis of pregnancy: ursodeoxycholic acid first-line
— Avoid hepatotoxic drugs: methyldopa (rare hepatitis), valproate, methotrexate, high-dose acetaminophen
— Acute fatty liver of pregnancy: delivery is treatment
— Higher baseline rates of HTN, DM, thyroid disease — more chronic meds to reconcile
— Aspirin 81 mg daily from 12 weeks for preeclampsia prevention if any moderate risk factor (age ≥35 + one other = recommended)
— Increased aneuploidy risk → cfDNA screening offered
— Confidentiality with parental involvement varies by state for prenatal care
— Higher rates of preterm birth, anemia — iron, folate, nutritional support
— Screen for IPV, depression
— Tacrolimus, cyclosporine, azathioprine, prednisone — continue (graft loss worse for fetus); avoid mycophenolate, sirolimus (switch preconception)
— Drug levels monthly; tacrolimus often needs higher doses
— Highest-risk obstetric population; multidisciplinary management
— Options: dose-adjusted LMWH with anti-Xa monitoring, UFH, or warfarin (with switch to heparin near delivery)
Step 3 management: A creatinine that fails to drop in early pregnancy in a previously healthy woman should prompt a workup for underlying renal disease and reassessment of all renally cleared and nephrotoxic medications. Treat a "high-normal" creatinine in pregnancy as you would mild CKD in a non-pregnant patient.
— All pregnant women with HIV receive combination ART regardless of CD4/VL; continue if already on (avoid efavirenz only in first 8 weeks per older guidance — current DHHS allows efavirenz throughout)
— Preferred regimens: dolutegravir-based (NTD signal at conception now considered minimal); TDF or TAF + emtricitabine
— Goal: undetectable VL by delivery → vaginal delivery acceptable; if VL >1000 at 34–36w → scheduled cesarean at 38w + IV zidovudine
— Avoid breastfeeding in US
— Methadone or buprenorphine — standard of care; do not detox in pregnancy (relapse, fetal stress)
— Naloxone available; breastfeeding encouraged on methadone/buprenorphine — reduces NAS severity
— Screen with validated tools, integrate with addiction medicine
— Counsel cessation at every visit
— NRT acceptable if behavioral fails; varenicline/bupropion data limited
— No safe level of alcohol; FAS prevention
— Cannabis: avoid; THC enters milk
— Do not abruptly stop antipsychotics or mood stabilizers — relapse risk to mother and fetus
— Lithium continuation often preferred over switch in severe bipolar
— Postpartum psychosis prophylaxis if prior episode
— Hydroxychloroquine: continue in SLE (improves outcomes; reduces neonatal lupus)
— Azathioprine, low-dose prednisone, sulfasalazine, certolizumab: acceptable
— Avoid: methotrexate, mycophenolate, cyclophosphamide, leflunomide
— Switch ≥3 months preconception for methotrexate; cholestyramine washout for leflunomide
— Hypothyroidism: levothyroxine, ↑dose 30% at pregnancy confirmation
— Hyperthyroidism: PTU in 1st trimester, switch to methimazole in 2nd–3rd (PTU hepatotoxicity vs methimazole aplasia cutis/choanal atresia)
Board pearl: Hydroxychloroquine is one of the few medications where stopping causes worse outcomes than continuing in pregnancy — lupus flares, preeclampsia, neonatal heart block. The Step 3 right answer is almost always "continue."
— Warfarin (1st trim): nasal hypoplasia, stippled epiphyses, CNS defects, IUGR
— ACEi/ARB (2nd–3rd trim): renal dysgenesis, oligohydramnios, skull hypoplasia, pulmonary hypoplasia, hypotension
— Valproate: NTDs (1–2%), facial clefts, cardiac defects, cognitive impairment (10 IQ points)
— Carbamazepine: NTDs (0.5–1%), facial dysmorphism
— Phenytoin: fetal hydantoin syndrome (digit/nail hypoplasia, cleft, IUGR)
— Isotretinoin: CNS, cardiac, craniofacial, thymic — ~25% risk
— Methotrexate/aminopterin: cranial, limb, NTD; aminopterin syndrome
— Mycophenolate: ear/facial anomalies, cleft, cardiac
— Thalidomide: phocomelia
— Lithium: Ebstein anomaly (small absolute risk)
— DES (historical): clear cell vaginal adenocarcinoma in daughters
— Methimazole: aplasia cutis, choanal atresia
— Tetracyclines: tooth/bone staining after ~14 weeks
— Aminoglycosides: ototoxicity
— NSAIDs after 20 weeks: oligohydramnios, premature ductus arteriosus closure
— Late-trimester SSRIs: neonatal adaptation syndrome (jitteriness, feeding), small PPHN signal
— Benzodiazepines/opioids late: neonatal withdrawal (NAS)
— β-blockers (atenolol): IUGR, neonatal bradycardia/hypoglycemia
— Magnesium sulfate prolonged: neonatal hypotonia, fetal bone demineralization
— Untreated depression → preterm birth, low birth weight, postpartum depression
— Untreated epilepsy → status epilepticus, trauma
— Untreated HTN → preeclampsia, stroke, placental abruption
Key distinction: Neonatal adaptation syndrome from SSRIs is self-limited (resolves within 2 weeks) and is not a reason to discontinue therapy late in pregnancy — discontinuation risks maternal relapse, which has worse long-term consequences.
— Any first-trimester exposure to a high-risk teratogen (warfarin, methotrexate, mycophenolate, isotretinoin, valproate, lithium, ACEi/ARB)
— Pregestational diabetes, chronic HTN on multiple meds, SLE, transplant patient, mechanical valve, HIV
— Anomaly on screening US
— Polypharmacy with no clear alternatives
— Teratogen exposure, family history of anomaly, prior affected child, advanced maternal age, abnormal screening
— Psychiatry: any major mental illness in pregnancy/postpartum, especially bipolar, psychosis, severe depression with SI
— Neurology: epilepsy in pregnancy
— Cardiology: mechanical valve, peripartum cardiomyopathy, congenital heart disease
— Endocrinology: poorly controlled DM, Graves disease, pituitary disease
— Rheumatology: lupus, RA
— ID: HIV, hepatitis B/C, TB
— Addiction medicine: OUD, SUD
— Acute teratogen overdose/ingestion → poison control + admission for monitoring and antidote (e.g., NAC for acetaminophen — use full standard protocol in pregnancy)
— Severe preeclampsia, eclampsia
— DKA, thyroid storm
— Status epilepticus
— Suicidal ideation with plan
— Acute VTE → therapeutic anticoagulation, often admit
— Postpartum psychosis → psychiatric emergency, admit
— Severe postpartum depression with SI
— Neonatal withdrawal with severe symptoms → NICU
CCS pearl: Acetaminophen overdose in pregnancy → standard N-acetylcysteine protocol, full dose. Untreated maternal hepatotoxicity is the biggest fetal threat. Do not under-dose or delay treatment based on pregnancy status — this is a frequent CCS trap.
— Drug-induced effect
— Underlying maternal disease
— Pregnancy-specific pathology
— Coincidental fetal anomaly (3% background)
— Oligohydramnios at 28 weeks on ACEi: ACEi fetopathy vs ruptured membranes vs placental insufficiency vs fetal renal anomaly → stop ACEi, check membranes, US for renal anatomy
— NTD on anatomy scan with valproate: drug effect likely, but family history, folate deficiency, diabetes also contribute
— Neonatal jitteriness: SSRI adaptation vs hypoglycemia vs hypocalcemia vs sepsis vs NAS
— IUGR: β-blocker (atenolol), smoking, HTN, placental insufficiency, TORCH infection, aneuploidy
— Maternal hypothyroidism worsening: inadequate dose increase vs malabsorption (iron, calcium) vs noncompliance
— Postpartum hemorrhage non-response to oxytocin: uterine atony — choose next agent based on comorbidity (avoid methergine in HTN, carboprost in asthma)
— Valproate > carbamazepine > phenytoin for malformation risk
— Lamotrigine, levetiracetam lowest risk
— Paroxetine has the strongest cardiac signal; sertraline preferred
— Fluoxetine: long half-life, more neonatal effects
— Labetalol/nifedipine/methyldopa OK
— Atenolol → IUGR (avoid)
— ACEi/ARB contraindicated
Key distinction: When a Step 3 stem shows fetal renal/oligohydramnios findings in 2nd–3rd trimester, always suspect ACEi/ARB exposure first; the differential includes posterior urethral valves, bilateral renal agenesis, severe placental insufficiency. Drug history is the cheapest "test."
— Alcohol: FAS — smooth philtrum, thin vermilion border, small palpebral fissures, growth restriction, neurodevelopmental
— Tobacco: IUGR, preterm birth, SIDS
— Cocaine/methamphetamine: placental abruption, IUGR, congenital anomalies
— Lead: neurodevelopmental
— Mercury (methylmercury, fish): CNS
— Ionizing radiation: dose-dependent; <50 mGy considered safe; diagnostic imaging including CT generally below threshold
— TORCH infections: toxoplasmosis, others (syphilis, varicella, parvovirus, Zika), rubella, CMV, HSV
— Maternal hyperthermia: NTDs, especially first trimester
— Poorly controlled diabetes: caudal regression, cardiac, NTDs (HbA1c–dependent)
— Maternal PKU: untreated → microcephaly, MR, cardiac
— US and MRI: safe (avoid gadolinium when possible)
— X-ray, CT: use when indicated — shield abdomen if possible
— Iodinated contrast: acceptable when indicated
— Gadolinium: avoid unless essential
— Nuclear medicine: case-by-case; I-131 contraindicated
— Recommended: Tdap (27–36 wk every pregnancy), influenza (any trimester), RSV (32–36 wk seasonal), COVID-19
— Contraindicated (live vaccines): MMR, varicella, live attenuated influenza, yellow fever (unless high risk)
— Postpartum: catch up on MMR, varicella if non-immune; safe with breastfeeding
Board pearl: A patient at 30 weeks needs Tdap regardless of prior vaccination history — every pregnancy gets one. Influenza vaccine is recommended in any trimester, including the first. These are commonly tested counseling points.
— Resume preconception regimen unless breastfeeding contraindication
— Adjust doses back from pregnancy-elevated levels (lamotrigine, levothyroxine, lithium) within first 1–2 weeks postpartum to avoid toxicity
— Lithium: resume at preconception dose immediately after delivery; check level 24–48h later
— Levothyroxine: return to pre-pregnancy dose; check TSH 6 weeks postpartum
— VTE prophylaxis indicated for many; therapeutic for VTE in pregnancy continued at least 6 weeks postpartum (total ≥3 months from event)
— Warfarin and LMWH both compatible with breastfeeding
— Labetalol, nifedipine, enalapril (acceptable in lactation despite pregnancy ban), HCTZ low-dose acceptable
— Continue postpartum BP monitoring 1–2 weeks (preeclampsia can present postpartum)
— Discuss before discharge
— Progestin-only methods (implant, IUD, POP, DMPA) can start immediately
— Combined hormonal contraceptives: avoid first 21 days, ideally wait 6 weeks if breastfeeding; consider VTE risk
— LARC placement at delivery (immediate postpartum IUD, implant)
— At 1–2 week postpartum visit and 6 weeks
— SSRI of choice if breastfeeding: sertraline or paroxetine (low milk transfer)
— Continue preeclampsia prophylaxis through 36 weeks in next pregnancy if risk factors
— 75-g 2-hour OGTT at 4–12 weeks postpartum
— Lifelong screening every 1–3 years
— A new "preconception" period begins at the postpartum visit
Step 3 management: Schedule the comprehensive postpartum visit by 12 weeks (ACOG: initial contact within 3 weeks, full visit by 12). This visit is the single best opportunity to optimize chronic disease and counsel before a possible next pregnancy.
— Document indication, alternatives, plan to switch teratogens
— Folic acid 400 mcg (4 mg if AED, prior NTD, diabetes)
— Update vaccines (MMR, varicella, Tdap, flu, hep B, HPV)
— Counseling on alcohol/tobacco/substances
— Full medication reconciliation including OTC
— Confirm dating
— Baseline labs
— Update teratogen counseling
— Each prenatal visit: review meds, BP, urine protein, fundal height, FHTs
— Drug levels per chunk 4
— Anatomy scan 18–22 weeks
— GLT 24–28 weeks
— GBS 36–37 weeks
— Aspirin 81 mg continued in those with PEC risk
— Lithium: levels q4w, then q1w from 36w; TSH and renal each trimester
— Lamotrigine: levels monthly; clinical seizure diary
— LMWH (therapeutic): anti-Xa q4–6w
— Levothyroxine: TSH q4w until stable, then q trimester
— HIV: monthly VL
— SSRI: PHQ-9 every visit
— Provide written materials at every counseling point
— Teach back: confirm understanding
— Smoking/alcohol/illicit cessation reinforced each visit
— Avoid OTC NSAIDs after 20 weeks; avoid high-dose vitamin A
— Caffeine <200 mg/day; food safety counseling
— Document risk–benefit discussion, alternatives offered, patient understanding
— Consider written informed consent for high-risk continuations (lithium, AEDs)
CCS pearl: On the CCS, after switching medications in early pregnancy, advance the clock 4 weeks, recheck the indication's control (BP, mood scale, seizure diary), and reorder relevant labs (e.g., TSH after levothyroxine increase, BMP after labetalol). Order an anatomy scan at 18–22 weeks as a downstream step.
— High-risk medication continuation (lithium, AED, immunosuppressant) requires documented risk–benefit discussion
— Capacity must be assessed; pregnancy does not impair autonomy
— Patients may decline recommended therapy; document refusal and continued counseling
— US law/ethics: competent pregnant patient has right to refuse any treatment, including those benefiting fetus
— Coercion and court-ordered cesareans are ethically problematic and rarely upheld
— ACOG position: avoid criminalization of pregnancy behaviors; harm-reduction model
— iPLEDGE (isotretinoin): mandatory monthly negative pregnancy tests, two contraception methods, prescriber/pharmacy/patient registration
— Failure to comply has both safety and legal implications
— Mycophenolate REMS similar
— State variation: some states require reporting positive newborn drug toxicology to CPS
— Substance use disorder treatment in pregnancy should generally not be reported as abuse if engaging in care (federal CARA, state-dependent)
— Counsel patients about state-specific laws
— Most dangerous moments: abrupt drug discontinuation at positive pregnancy test, dose changes around delivery (lithium toxicity postpartum if not down-titrated), handoff from MFM back to primary OB, OB to PCP at 12 weeks postpartum
— Use medication reconciliation at every transition
— Avoid blanket "stop breastfeeding" advice — most drugs compatible; over-restriction harms infant
— Use LactMed/MotherToBaby evidence
— Many decisions are inherently low-evidence
— Disclose uncertainty; document
— Substance use, mental illness disproportionately criminalized in pregnancy in marginalized populations — provide nonjudgmental care
— Insurance coverage for newer agents may limit options; advocate
Step 3 management: A patient on chronic warfarin for a mechanical mitral valve who becomes pregnant — do not unilaterally stop warfarin or switch without cardiology + MFM. The "right" answer is multidisciplinary discussion of warfarin vs LMWH and documented shared decision-making. Unilateral stopping risks fatal valve thrombosis.
— Warfarin → nasal hypoplasia, stippled epiphyses
— ACEi/ARB → renal dysgenesis, oligohydramnios
— Valproate → NTD, 10-pt IQ drop
— Carbamazepine → NTD
— Phenytoin → fetal hydantoin syndrome
— Lithium → Ebstein anomaly (small risk)
— Isotretinoin → multi-organ embryopathy
— Methotrexate → aminopterin syndrome
— Mycophenolate → ear/facial anomalies
— Thalidomide → phocomelia
— DES → clear cell vaginal adenocarcinoma
— Tetracycline → tooth/bone discoloration
— Aminoglycosides → ototoxicity
— Methimazole → aplasia cutis, choanal atresia
— Fluoroquinolones → cartilage damage (theoretical)
— Streptomycin → CN VIII damage
— NSAIDs late → ductus closure, oligohydramnios
— SSRIs late → neonatal adaptation, mild PPHN
— β-blockers (atenolol) → IUGR
— High-dose vitamin A → CNS/cardiac
— Androgens → virilization
— HTN: labetalol, nifedipine, methyldopa
— DM: insulin
— Anticoag: LMWH
— Depression: sertraline
— Bipolar: lithium or lamotrigine
— Epilepsy: lamotrigine or levetiracetam
— Hyperthyroidism: PTU 1st trim, methimazole 2nd–3rd
— Asthma: albuterol, budesonide
— UTI: nitrofurantoin (avoid term), cephalexin, fosfomycin
— Pyelonephritis: ceftriaxone IV
— GBS prophylaxis: penicillin G; if allergic non-anaphylactic → cefazolin; anaphylactic → clindamycin (if susceptible) or vancomycin
— Nausea: doxylamine-pyridoxine
— 400 mcg standard; 4 mg if AED or prior NTD or diabetes
— Start ≥1 month preconception, continue through 12 weeks minimum
— Tdap every pregnancy 27–36 wk; flu any trimester; RSV 32–36 wk
— Live vaccines contraindicated
Board pearl: "Pregnant patient with bipolar disorder on valproate wants to conceive" — the single best step is to switch to lamotrigine preconception with folic acid 4 mg, psychiatry comanagement, and contraception until transition complete.
— 32 yo, +pregnancy test at 7 wks, on lisinopril for HTN. Action?
— Answer: Stop lisinopril, start labetalol (or nifedipine), confirm dating, fetal anatomy scan at 18–22 weeks
— Answer: Switch to lamotrigine, folic acid 4 mg, psychiatry co-management
— Answer: Multidisciplinary (cardiology, MFM); options include dose-adjusted LMWH or warfarin (if low dose) with switch near term
— Started on isotretinoin without iPLEDGE — wrong; correct = iPLEDGE registration, 2 negative tests, 2 contraception methods, monthly tests
— Sleepy infant → stop codeine, switch to non-opioid, evaluate infant for respiratory depression; counsel CYP2D6 ultrarapid metabolizer risk
— Increase levothyroxine ~30% immediately, TSH in 4 weeks
— Patient wants to stop sertraline; answer: continue, risks of untreated depression outweigh; if changing, paroxetine is the one to avoid in pregnancy (but acceptable in lactation)
— Diet/exercise → if uncontrolled → insulin first-line (metformin acceptable alternative per ADA)
— Full NAC protocol; do not delay
— Continue HCQ; add aspirin 81 mg from 12 weeks; folic acid; avoid mycophenolate (switch to azathioprine ≥3 months prior)
— Continue/start ART, target undetectable VL, no breastfeeding in US
— IV labetalol or PO nifedipine; magnesium for severe PEC; postpartum preeclampsia is real
— Therapeutic LMWH, continue ≥6 weeks postpartum and ≥3 months total
— 27–36 weeks every pregnancy regardless of prior
Key distinction: Step 3 stems often test whether you'll continue (HCQ, sertraline, ART, AEDs, lithium when needed) versus stop (ACEi, warfarin, methotrexate, isotretinoin, valproate when alternative exists). Memorize both lists.
The cornerstone of medication counseling in pregnancy and lactation is risk-benefit framing: untreated maternal disease frequently poses greater fetal harm than the drug, so the goal is preconception optimization with the safest effective agent, multidisciplinary monitoring, and documented shared decision-making — not reflexive discontinuation.
— Teratogens with alternatives: ACEi/ARB → labetalol; warfarin → LMWH (most cases); valproate → lamotrigine/levetiracetam; methotrexate/mycophenolate → azathioprine
— Start folic acid 400 mcg (4 mg if AED, prior NTD, diabetes) ≥1 month preconception
— Hydroxychloroquine in SLE, ART in HIV, AEDs in epilepsy, insulin/levothyroxine, immunosuppressants in transplant, SSRIs in moderate-severe depression, lithium in severe bipolar (with monitoring)
— Up-titrate lamotrigine, levothyroxine (~30% at +test), lithium, LMWH; monitor levels; return to pre-pregnancy doses postpartum to avoid toxicity
— Most drugs are compatible (LactMed); contraindicated: codeine/tramadol, amiodarone, radioactive iodine, retinoids, chemo; encourage breastfeeding on methadone/buprenorphine
Board pearl: When in doubt on a Step 3 stem, the right answer almost always involves (1) confirm indication, (2) choose preferred pregnancy-safe agent, (3) document counseling, (4) schedule anatomy scan and appropriate monitoring, (5) plan postpartum reconciliation. Reflex "stop the drug" is usually the distractor.