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l Zidovudine (ZDV) short course 2 страница
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RUBEOLA VIRUS
Epidemiology
Rubeola (measles) is highly contagious. Its incubation period is 10–14 days. Since the advent of the measles vaccine, rates have fallen by 99%. Rubeola is extremely rare in pregnancy because of low susceptibility in adults.
Clinical Manifestations
The prodrome, which consists of fever, cough, conjunctivitis, and coryza, lasts 1–2 days; Koplik spots (pinpoint gray-white spots surrounded by erythema) appear on the second or third day; a rash emerges on the fourth day. Patients remain contagious from the onset of symptoms until 2–4 days after the appearance of the maculopapular and characteristic semiconfluent rash. Measles may be complicated by pneumonia, encephalitis, or otitis media. Pneumonia occurs in 3. 5–50. 0% of adults who contract measles, and superinfection may occur. Superinfection should be suspected in patients who demonstrate clinical deterioration, an elevated WBC with a leftward shift, and a chest radiograph with evidence of multilobar infiltrates. Encephalitis occurs in 1: 1000 cases of measles and may result in permanent neurologic impairment and a mortality rate of 15–33%. Another rare but serious sequela is subacute sclerosing panencephalitis, which occurs in 0. 5–2: 1000 cases. It typically develops 7 years after measles infection and is most common in children who contract measles before the age of 2. Subacute sclerosing panencephalitis usually has a fatal outcome.
Maternal infection. Higher rates of mortality have been observed in pregnant women with measles, primarily due to pulmonary complications. A small increase in spontaneous abortion and preterm labor also has been noted.
Fetal infection. No definitive evidence of a teratogenic influence exists. Infants born to infected mothers are at risk of neonatal infection resulting from transplacental viral transmission.
Diagnosis
Maternal infection. Clinical diagnosis is considered to be reliable. When the patient's presentation is atypical, laboratory confirmation of the diagnosis by serologic studies may be required. A pregnant woman with measles should be evaluated for preterm labor, volume depletion, hypoxemia, and secondary bacterial pneumonitis.
Fetal infection. Ultrasonographic evaluation of the fetus is sufficient; microcephaly, growth restriction, and oligohydramnios should be sought.
Management
Susceptible (nonimmune) women should receive a vaccine postpartum and should be advised to use contraception for 3 months after vaccination, because the vaccine is of the live, attenuated viral variety. Susceptible pregnant women who are exposed to measles should receive immune globulin, 0. 25 mg/kg IM. Measles is not a contraindication for breast feeding. No specific therapy is available for measles other than supportive measures and close observation for the development of complications. Infants delivered to mothers who develop measles within 7–10 days of delivery should receive IM immune globulin (0. 25 mg/kg) as well.
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MYCOPLASMA AND UREAPLASMA
Epidemiology
Mycoplasma species are common inhabitants of genital mucous membranes. Colonization rates are higher among patients from lower socioeconomic groups. Women who do not use barrier methods of contraception are more likely to be colonized. The rate of colonization increases with number of sexual partners.
Clinical Manifestations
Maternal infection. Mycoplasma hominis and Ureaplasma urealyticum are commonly identified in women with bacterial vaginosis. The exact impact of these organisms on human reproduction has yet to be clarified. They have been implicated in infertility, habitual abortion, and low birth weight. An association between chorioamnionitis and mycoplasmal infection has been reported.
Fetal infection. Studies have failed to demonstrate an association between adverse pregnancy outcomes and maternal mycoplasmal infection. In neonates with meningitis, however, Mycoplasma species were most frequently isolated from cerebrospinal fluid.
Diagnosis is confirmed by cervical culture.
Management
Mycoplasma hominis infections respond to treatment with clindamycin. Infection with Ureaplasma species usually responds to tetracyclines and to erythromycin, which are the appropriate antibiotics to use in pregnancy. No immunizations for these infections exist.
TOXOPLASMA
Epidemiology
The incidence of acute toxoplasmosis infection in pregnancy has been estimated to be 0. 2–1. 0%. Congenital toxoplasmosis occurs in 1–8: 1000 live births. Transmission occurs primarily via ingestion of undercooked or raw meat containing cysts, ingestion of food or water contaminated by the feces of an infected cat, or handling of material contaminated by the feces of an infected cat.
Clinical Manifestations
Maternal infection. Specific symptoms signaling acute toxoplasmosis infection are uncommon in pregnant women. A mononucleosis-like syndrome, including fatigue, malaise, cervical lymphadenopathy, and atypical lymphocytosis, may occur. Placental infection and subsequent fetal infection occur during the spreading phase of the parasitemia. The overall risk of fetal infection is estimated to be 30–40%, and the rate of transmission increases with gestational age.
Fetal infection. During the first trimester, the rate of transmission is approximately 15%. The rate of second trimester transmission is approximately 30% and of third trimester transmission, 60%. Fetal morbidity and mortality rates are higher after early transmission. Infected neonates often have evidence of disease, including low birth weight, hepatosplenomegaly, icterus, and anemia. Sequelae such as vision loss and psychomotor and mental retardation are common. Hearing loss is demonstrated in 10–30% and developmental delay in 20–75%. Chorioretinitis often develops.
Diagnosis. Screening for toxoplasmosis is not routine in the Ukraine. Because most women with acute toxoplasmosis are asymptomatic, the diagnosis is not suspected until an affected infant is born. For women who do present with symptoms of acute toxoplasmosis, both IgM and IgG titers should be measured as soon as possible.
A negative IgM finding rules out acute or recent infection, unless the serum has been tested so early that an immune response has not yet been mounted. A positive test finding is more difficult to interpret because IgM may be elevated for more than 1 year after infection.
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Serologic tests generally used include the Sabin-Feldman dye test, the indirect fluorescent antibody test, and ELISA.
Management
For women who elect to continue their pregnancies after a diagnosis of toxoplasmosis, therapy must be initiated immediately and continued in the infant for a year or more to decrease the risk of development of sequelae. Medical therapy is believed to decrease the risk of development of permanent sequelae by 50%.
Spiramycin reduces the incidence of fetal infection but not necessarily the severity of fetal infection. It is recommended for the treatment of acute maternal infections diagnosed before the third trimester and should then be continued for the duration of the pregnancy. If amniotic fluid PCR results for Toxoplasma are negative, spiramycin is used as a single agent; if results are positive, pyrimethamine and sulfadiazine should be added. Spiramycin dosing is 500 mg PO five times daily, or 3g/day in divided doses.
Pyrimethamine and sulfadiazine. These two agents act synergistically against Toxoplasma gondii. The dosing is pyrimethamine, 25 mg PO daily, or sulfadiazine, 1 g PO four times daily, for 28 days. Folinic acid, 6 g IM or PO, is administered three times per week to prevent toxicity. During the first trimester, pyrimethamine is not recommended due to a risk of teratogenicity. Sulfadiazine is omitted from the regimen at term.
HERPES SIMPLEX VIRUS (HSV)
Epidemiology
Type 1 herpes simplex virus (HSV) is responsible for most nongenital herpetic infections and infrequently involves the genital tract. Type 2 HSV is usually recovered from the genital tract. Approximately 1: 7500 live-born infants contracts HSV perinatally. Whether pregnancy alters the rate of recurrence or frequency of cervical shedding of virus is disputed. Surveys indicate that the incidence of asymptomatic shedding in pregnancy is 10% after the first episode and 0. 5% after a recurrent episode.
Primary maternal infection with HSV results from direct contact, generally sexual, with mucous membranes or intact skin infected with the virus.
Fetal infection with HSV can occur via three routes. In utero transplacental transmission and ascending infection from the cervix both occur. The most common route, however, is direct contact with infectious maternal genital lesions during delivery.
Clinical Manifestations
Maternal infection. Primary infections are often severe but may be mild or even asymptomatic. Vesicles appear 2–10 days after exposure on the cervix, vagina, or vulva. Swelling, erythema, and pain are common, as is lymphadenopathy near the affected region. The lesions generally persist 1–3 weeks, with concomitant viral shedding. Reactivation occurs in 50% of patients within 6 months of the initial outbreak and subsequently at irregular intervals. Recurrent outbreaks are generally milder, with viral shedding for less than 1 week. In pregnancy, primary outbreaks are not associated with spontaneous abortion but may increase the incidence of preterm labor in late pregnancy.
Fetal infection is usually the result of a primary maternal infection. Congenital infections resulting from a recurrent maternal infection are rare, accounting for less than 1% of fetal infections. The transplacental passage of maternal IgG antibody is believed to account for the low rate of transmission. Overall, congenital infections are very rare. Few are asymptomatic. The majority ultimately produce disseminated or CNS disease. Localized infection is usually associated with a good outcome, but infants with disseminated infection have a mortality rate of 60%, even with treatment. At least half of infants surviving disseminated infection develop serious neurologic and ophthalmic sequelae.
Diagnosis
When HSV is suspected, a swab specimen may be obtained from the lesion or vesicle and sent for tissue culture. Seven to 10 days must be allowed for isolation of the virus via tissue culture, because 6 days may be required for low numbers of infective particles to produce the characteristic cytopathic changes in vitro. Tissue culture has 95% sensitivity and very high specificity. The use of HSV-specific ELISA allows preliminary diagnosis within 24–48 hours of culturing. Serology is of limited value in diagnosis because a single antibody titer is not predictive of the presence or absence of genital shedding of the virus. To reduce the likelihood of a false-negative result, the patient should point out the location of any lesions, as well as sites of prior outbreaks. A sample from the endocervical canal and exfoliated cells from all suspicious areas should be obtained. Smears of scrapings from the bases of vesicles may be stained using Tzanck or Papanicolaou techniques, which reveal multinucleated giant cells that implicate HSV infection. CMV cervical infection, however, is difficult to differentiate from HSV infection by smears.
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Management
Patients with a history of genital herpes should undergo a careful perineal examination at the time of delivery. Active genital HSV in patients in labor or with ruptured membranes is an indication for cesarian section, regardless of the duration of rupture. There is evidence that HSV recurrences in the regions of the buttocks, thighs, and anus are associated with low rates of cervical virus shedding, so that vaginal delivery is allowed. Vaginal delivery is indicated if there are no signs or symptoms of HSV. Acyclovir may be used to treat HSV infection in pregnancy; however, valacyclovir hydrochloride (Valtrex) has been shown to be more effective and is more easily tolerated due to a twice-daily dosing schedule. Third trimester suppression with valacyclovir, 500 mg PO daily, should be considered in women with frequent outbreaks during their pregnancies.
Self Test
1. Perinatal transmission rates of HIV make up:
A. from 14% to 33% in industrialized nations
B. 45% in industrialized nations
C. 10- 15%
D. 50-67%
2. Avoidance of labor may also:
A. decrease the risk of vertical transmission of HIV
B. increase the risk of transmission
3. CMV symptoms include all the following except for:
A. low-grade fever
B. malaise
C. arthralgias
D. pharyngitis with lymphadenopathy
E. high temperature
4. The major route of transmission of varicella zoster virus is:
A. respiratory
B. direct contact with vesicular or pustular lesions
5. Fetal infection after maternal viremia of rubella leads to:
A. a multiple organ system involvement
B. a state of acute infection
6. The rate of transmission of toxoplazma
A. increases during pregnancy
B. decreases during pregnancy
C. is stable during pregnancy
7. Clinical features of neonates infected with toxoplasma are the following, except for:
A. low birth weight
B. hepatosplenomegaly
C. icterus
D. anemia
E. high temperature
8. Which of the following drugs should be used for treatment of toxoplasma in pregnant?
A. spiramycin
B. sumsmed
C. abacavir
D. corticosteroids
9. Congenital toxoplasmosis occurs in:
A. 1–8: 1000 live births
B. 20: 1000 live births
C. 30-40: 1000 live births
D. 40: 1000 live births
10. Active genital HSV in patients in labor is an indication for:
A. cesarian section
B. natural way of delivery
C. vacuum delivery
D. forceps delivery
E. embryotomy
Appendixes
Appendix 1. The list of obligatory practical skills
External obstetrical examination of pregnant women at antenatal clinic (obstetric grips by Leopold-Levitsky)
Speculum examination of obstetrical patients
Evaluatoin of the fetal status (fetal heart sound, probable mass). To determine estimated body weight of the fetus
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Examination of maternal pelvis and evaluation of its functional characteristics
Taking smears from the vagina, cervix of the uterus, urethra
Microscopic examination of the contents of the vagina to determine the quantity of amniotic fluid. Evaluation of the results
Taking smears from the vagina for colpocytological examination. Evaluation of the results
Vaginal and bimanual examination of pregnant women
Evaluation of the results of biophysical profile, cardiotocography (CTG)
Filling the history of childbirth
The first toilet of a newborn
Measures to be taken to resuscitate a newborn with asphyxia
Amniotomy
Manual protection of the perineum in delivery of fetus
Episiotomy, perineotomy
Operations for suturing of ruptures of perineum (of I and II degree), vaginal walls and the cervix of the uterus
Taking out staples and stitches
Assistance in rendering aid in extraction of the fetus by podalic end
Assistance in cesarean section
Assistance in vacuum extraction of the fetus
Operation of the manual control of the uterine cavity, manual removal of the afterbirth
Appendix 2. Drugs in obstetric practice
Maternal and Fetal Drug Responses
Maternal and fetal drug responses are influenced by two factors during pregnancy. First, pregnancy-induced changes in maternal physiology can cause alterations in the absorption, distribution, and elimination of drugs in the mother. Second, the placental–fetal unit affects the amount of drug entering the fetal circulation, the fraction of drug metabolized by the placenta, and the distribution and elimination of the drug by the fetus.
Teratology
Birth defects are generally considered to be structural defects of the newborn. These may be divided into three categories: (1) malformations that are structural defects caused by intrinsic problems in embryologic differentiation or development; (2) disruptions that occur when normal fetal development has been disrupted, such as a limb amputation as a result of amniotic bands; and (3) deformations of a normally differentiated part, such as Potter's facies. During the time between conception and implantation, the embryo is relatively insensitive to teratogenic effects. This time is associated with an “all or none” response in which the embryo either survives unharmed or dies. The conceptus is most susceptible to major organ malformations during the period of embryogenesis, from 4 to 12 weeks after the onset of the last menstrual period. After organogenesis, a teratogen can affect the growth of organs, the size of organs, or their function. Toward the end of pregnancy, drugs may directly affect the fetus and newborn, causing complications at the time of delivery or with postnatal care.
Drug Therapy during Pregnancy
Safety. Fetal safety is a major concern in guiding the selection of drugs prescribed during pregnancy. Effective drugs that have been in use for a long time are thus preferred over newer preparations. Exposure should be decreased by using the smallest effective dose for the shortest duration possible. No drug should be prescribed during pregnancy without a clear need.
Analgesics
Acetaminophen (Tylenol)
Discription: Acetaminophen is an analgesic and antipyretic drug of choice at any time during pregnancy. Large population-based studies have shown no increase in congenital malformation with the use of acetaminophen or paracetamol.
Indications: Used to relieve mild to moderate pain and has minimal antiinflammatory effects.
Dosage: 325–1000 mg PO every 4–6 hours not to exceed 4, 000 mg/day.
Side Effects: Overdoses of acetaminophen can cause severe, even fatal, hepatic dysfunction. Allergies to this drug can also occur.
Precautions: Use with caution in presence of alcoholism or liver disease. Daily use of alcohol, especially when combined with phenobarbital, may enhance acetaminophen's hepatotoxicity. It may produce a slight increase in prothrombin time in patients receiving oral anticoagulants, but the clinical significance of this effect is not clear.
Tramadol (Ultram)
Description: Analgesic, with additional inhibition of norepinephrine and serotonin reuptake.
Indications: Mild to moderate pain, adjunct in severe pain. It is useful in cases when opioids cannot be used.
Dosage: PO 50–100 mg every 4–6 hours as needed. Start at low dose to minimize side effects (not to exceed 400 mg/day).
Side Effects: Dizziness, vertigo, headache, constipation, nausea and vomiting, dyspepsia, pruritus, and sedation.
Precautions: Seizure disorder, peptic ulcer disease, and psychotic disorders.
Lidocaine (Xylocaine) Patch, Ointment, Oral Gel, Infusion, Eutectic Mixture
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Description: Local anesthetic, antiarrhythmic.
Indications: Itching and pain of various disorders [postherpetic neuralgia (PHN), peripheral diabetic neuropathy (PDN), burns]; irritation and inflammation in the mouth and throat; as an infusion, this is a diagnostic test for neuropathic pain. In obstetric practice may be used for local and peridural anesthesia.
Side Effects: Stinging, burning, redness, tenderness, swelling, or rash.
Precautions: Heart disease, serious illness, infections, or allergies.
Nonsteroidal Antiinflammatory Drugs
Nonsteroidal antiinflammatory drugs (NSAIDs) (e. g., ibuprofen, indomethacin, naproxen, sulindac, diclofenac) have been predominantly studied in their role as tocolytic agents. These drugs are reversible inhibitors of prostaglandin synthetase and inhibit premature uterine contractions. Fetal exposure to NSAIDs has been associated with premature closure of the ductus, resulting in pulmonary hypertension. A reduction in amniotic fluid is also associated with the use of these drugs. Experience with most NSAIDs in humans is limited, and it must be suspected that all agents that inhibit prostaglandin synthesis can cause adverse effects during pregnancy. Therefore, the potential toxicity of NSAIDs is the basis for the recommendation that they be used judiciously and not in the third trimester.
The most common are: Choline Salicylate, Magnesium Salicylate (anhydrous), Salicylic Acid, Salsalate, Sodium Salicylate. Salicylates (synthetic derivatives of salicylic acid) are nonsteroidal antiinflammatory agents (NSAIAs); the pharmacologic actions (e. g., analgesia, anti-inflammatory effects) of salicylates appear to result principally from the salicylate moiety.
Aspirin (Acetylsalicylic Acid)
Description: Aspirin is the drug most frequently taken during pregnancy. It readily crosses the placenta. Some case-controlled studies have reported associations between aspirin use in pregnancy and congenital malformations.
Indications: Aspirin is used extensively in the treatment of mild to moderate pain, fever, and inflammatory diseases. Aspirin is also used in the prevention of arterial and possibly venous thrombosis. Aspirin, however, should be used with extreme caution in pregnancy. The use of high-dose aspirin in the second half of pregnancy is more controversial. Pregnant women treated with more than 3 g per day for rheumatoid arthritis during the second half of pregnancy were found to have prolonged gestation and labor. High-dose aspirin given near to delivery has been demonstrated to cause bleeding tendencies and central nervous system (CNS) hemorrhage in the newborn, particularly in premature infants. The near-term use of aspirin may cause constriction or closure of the fetal ductus arteriosus due to the inhibition of prostaglandin synthetase.
Dosage: PO 0. 25- 0. 5 g every 4–6 hours after meal.
Side Effects: Allergic reaction, anemia, stomach mucosal ulceration.
Precautions: gastric ulcer, duodenal ulcer, anemia, intolerance.
Indomethacin
Description: Indomethacin is a protypical nonsteroidal antiinflammatory agent (NSAIA) that also exhibits analgesic and antipyretic activity.
Indications: Indomethacin is used orally or rectally for antiinflammatory and analgesic effects in the symptomatic treatment of active stages of moderate to severe rheumatoid arthritis (including acute flares of chronic disease), osteoarthritis, and ankylosing spondylitis. Indomethacin may cause serious adverse effects and should not be used as a simple analgesic or antipyretic. In obstetric practice indometacin may be used for treatment of threatened abortion in late terms of pregnancy due to its tocolitic effect.
Dosage: PO 25 mg every 4–6 hours as needed, course dose 200-400 mg.
Side Effects: Dizziness, headache, gastric indigestion, etc.
Precautions: Heart disease, thyrotoxicosis, glaucoma, bronchial asthma, ulcer of stomach, indomethacin intolerance.
Opiates
Promedol
Description: active analgetic, the action is almost the same as morphine.
Indications: it is used in labor for pain relief, but not later than 2 hours before delivery.
Dosage: Subcutaneous introduction: 1-2 ml of 1-2% solution, IV use 1 ml of 1% solution. For PO use 0. 025 -0. 05 g.
Side Effects: nausea, vomiting, constipation, respiratory depression.
Precautions: respiratory failure, extreme emaciation.
Morphine, meperidine, and oxycodone are recommended as safe analgesic agents during pregnancy without any teratogenic effects. However, the use of any opiate can produce respiratory and CNS depression in the newborn. Thus, in Ukraine promedol is the only drug from this group which is used in pregnancy.
Antiemetic drugs
Metoclopramide (Reglan, Cerucal)
Description: Dopamine antagonist, antiemetic, peristaltic stimulant.
Indications: Nausea and emesis. It is also used in obstetrical practice for management of pregnants with toxemia.
Dosage: Oral, IM, IV, 10 mg up to four times daily.
Side Effects: Restlessness, drowsiness, anxiety, headache, extrapyramidal symptoms.
Precautions: Contraindicated in obstructive GI pathology, neuroleptic syndrome. Caution in presence of seizure disorder and depression.
Thiethylperazine Maleate (Torecan)
Description: Phenothiazine derivate, antiemetic agent.
Indications: Nausea and emesis, gestosis of early term of pregnancy.
Dosage: Oral, IM, IV, 6. 5 mg 1-2 times a day. The highest daily dose is 13 mg.
Precautions: Contraindicated in obstructive GI pathology, neuroleptic syndrome. Caution in presence of seizure disorder and depression.
See also Droperidol, Benadryl, Haloperidol, Promethazine, Hydroxyzine (Atarax, Vistaril).
Antihistamine Drugs
Antihistamines (histamine H1-receptor antagonists) competitively inhibit most of the pharmacologic actions of histamine: Atarax, Benadryl, Dimedrol, Hydroxyzin, Vistaril, Clemastine (Tavegil), Zaditen (Ketotiphen), Diprazinum (Phenergan, Pipolphen, Allergan), Suprastin (Allergan S, Chloropiramine, Sinopen).
Antihistamines, which inhibit the effects of histamine at H1 receptors, have been classified as first generation (i. e., relatively sedating) or second generation (i. e., relatively nonsedating).
Hydroxyzine (Atarax, Vistaril)
Description: Antihistamine, antiemetic, sedative–hypnotic.
Indications: Itching, emesis, anxiety.
Dosage: For PO and IM use 25–100 mg every 6 hours. Adjust dose to patient response.
Side Effects: Drowsiness, dry mouth, dizziness, discomfort at site of injection.
Precautions: Epilepsy, prostatic hypertrophy, glaucoma, hepatic disease.
Promethazine (Pipolphen, Phenergan, Allergan)
Description: Phenothiazine, dopamine antagonist, antipsychotic, antiemetic, sedative, antihistamine.
Indications: Nausea and vomiting.
Dosage: Can be used PO, IV, or IM for antiemesis, 12. 5 to 25 mg every 4 hours, not to exceed 100 mg/day.
Side Effects: Shares the side effects of antihistamines, anticholinergic effects (dry mouth, blurring vision), phenothiazines (extrapyramidal symptoms), leukopenia, obstructive jaundice.
Precautions: Caution with cardiovascular or hepatic disease, and in the presence of other CNS depressants.
Diphenhydramine (Dimedrol, Benadryl, Allergan B)
Description: Antihistamine, antiemetic, sedative–hypnotic.
Indications: Nausea, vomiting, and itching.
Dosage: For PO, use 25–50 mg every 4–6 hours. For IV/IM, use 10–50 mg every 4–6 hours (not to exceed 400 mg/day).
Side Effects: Antihistaminic effect such as drowsiness, sedation, dry mouth, vertigo, urinary retention.
Precautions: Caution in patients with seizure, increased intraocular pressure.
Suprastin (Allergan S, Chloropiramine, Sinopen)
Description: Antihistamine drug.
Indications: allergic dermatosis and urticaria, allergic rhinitis, Quincke's edema, initial stage of bronchial asthma, etc.
Dosage: For PO, use 0. 025g every 8 hours. For IV/IM, use 1–2 ml of 2% solution every 6-8 hours.
Side Effects: sleepiness, general weakness.
Clemastine Fumarate (Tavegil)
Description: it is an ethanolamine-derivative, second generation antihistamine.
Indications: Allergic rhinitis, allergic urticaria and angioedema, common cold.
Dosage: For PO, use 0. 001g every 12 hours, highest dose - 0. 004g/d. For IV/IM, use 1–2 ml of 0. 1% solution (1-2 mg) every 8-12 hours.
Cautions: Clemastine fumarate shares the toxic potentials of other antihistamines, and the usual precautions of antihistamine therapy should be observed. There are no adequate and controlled studies to date using clemastine fumarate in pregnant women, and the drug should be used during pregnancy only when clearly needed. Clemastine is distributed into milk. Drowsiness, irritability, refusal to feed, and high-pitched cry occurred in one breast-fed infant (10 weeks of age) of a woman who received 2. 68 mg of clemastine fumarate daily for 3 days. Because of the potential for serious adverse reactions to clemastine in nursing infants, a decision should be made whether to discontinue nursing or the drug, taking into account the importance of the drug to the woman.
Antianemia Drugs
Description: Ferrous fumarate, ferrous gluconate, ferrous sulfate, carbonyl iron, and polysaccharide-iron complex are iron preparations that are commercially available for oral administration in the prevention and treatment of iron deficiency.
Indications: Iron preparations are used for prevention and treatment of iron deficiency.
Dosage and Administration: Oral iron preparations should be taken between meals (e. g., 2 hours before or 1 hour after a meal) for maximum absorption but may be taken with or after meals, if necessary, to minimize adverse GI effects. The recommended dietary allowance of iron for pregnant women is 27 mg daily. The recommended dietary allowance of iron for lactating women is 10 or 9 mg of iron daily.
Side Effects: Usual oral therapeutic dosages of iron preparations produce constipation, diarrhea, dark stools, nausea, and/or epigastric pain.
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