Quad therapy

[Barbara]

After two failed IVF cycles, my dr has recommended me to have quad therapy using evorel patches; cyclogest pessaries; clexane injections; prednisolone tablets and if the treatment is successful then aspirin too. What do you know about this treatment and what interaction does these drugs have on breastfeeding my Toddler or early pregnancy if it works.

[Sandra]

Barbara,


Breastfeeding:

Evorel (estrogen) is rated an L3-limited data-probably compatible. Estrogen transfer into human milk is low and clinical effects in the infant are unlikely. Estrogens may suppress milk synthesis. Infantile feminization is unlikely at normal dosages.

Cyclogest (progesterone) is rated an L3-limited data-probably compatible. The direct effect of progesterone therapy on the nursing infant is generally unknown, but it is believed minimal to none as natural progesterone is poorly bioavailable to the infant via milk. Cases of gynecomastia in infants have been reported but are extremely rare. Some women are sensitive to the effects of progesterone and could experience a reduction in milk synthesis.

Clexane (enoxaparin)is rated L2-limited data-probably compatible. Because it is a peptide fragment of heparin, its molecular weight is large (2000-8000 daltons). The size alone would largely preclude its entry into human milk at levels clinically relevant. Due to minimal oral bioavailability, any present in milk would not be orally absorbed by the infant. Monitor the infant for rare-bruising on the skin, blood in urine, vomit or stool and petechia

Aspirin is rated an L2 limited data-probably compatible. The amount transferred into breast milk is 2.5-10.8% of your dose. Aspirin is certainly implicated in Reye syndrome, but most often in older children (not infants) who have a viral illness such as flu or chickenpox. Even when present at small plasma levels in these children, it was implicated in Reye syndrome. However, the amount in breast milk is incredibly low even following large therapeutic doses. Aspirin is almost completely gone in 2 hours after an oral dose. A brief wait of 2-3 hours after administration would virtually eliminate all aspirin transfer to milk. If the infant has a known viral illness we recommend skipping aspirin dose, or waiting longer to breastfeed about 24 hours. Monitor the infant for rare-bruising on the skin, blood in urine or stool, and petechia.


Pregnancy:

Evorel (estrogen) is rated P5 - Major risk likely to exceed benefits. Oral contraceptive use should be discontinued until pregnancy is ruled out. Estrogenic agents exposure during pregnancy in 614 mothers have been associated with increase frequency of eye and ear abnormalities, cardiovascular anomalies, and Down's syndrome.

Cyclogest (progesterone) is rated P2 - Benefits are likely to exceed risk. Progesterone does not increase the risk of non-genital birth defects. A report of hypospadias has been associated with progestin exposure during pregnancy.

Clexane (enoxaparin) is rated P2 - Benefits are likely to exceed risk. Major congenital anomalies in live births occurred at rates (2.5%) similar to background rates. All pregnancies have a background risk of birth defect, loss, or other adverse outcome regardless of drug exposure (1-3%). Enoxaparin does not cross the placenta, and is not expected to result in fetal exposure to the drug. Human data from a retrospective cohort study, which included 693 live births, suggest that enoxaparin does not increase the risk of major developmental abnormalities.

Aspirin is rated P3 - Unknown, risk to the fetus cannot be ruled out. Aspirin therapy during pregnancy does have inherent risks that appear to be dose related but does not appear to increase the risk of congenital malformations. Aspirin therapy should only be used during pregnancy if the benefit to the mother outweighs the risk to the fetus and using only the lowest effective dose possible especially in the first and third trimesters.


I hope this helps.If you have any other questions please call the InfantRisk Center at 806-352-2519. Thanks,

Sandra Lovato R.N.
InfantRisk Center

[Barbara]

Hi thanks for your help, you don't mention the Prednisolone steroid and their affect on breast milk and early pregnancy. Many thanks.

[Sandra]

Barbara,

Prednisone is rated an L2-limited data-probably compatible. The amount passed into breast milk is 1.8-5.3% of your dose. [COLOR=#333333][FONT=lucida grande]Small amounts of prenisone-prednisolone are transferred to the breast milk, although it is probably safe in breastfeeding. There is concern of growth impairment in breastfed infants with high-dose prolonged steroid therapy. In small doses, most steroids are certainly not contraindicated in nursing mothers. If high doses greater than 40mg are needed wait 4 hours to breastfeed. [/FONT][/COLOR]We have had some calls of reduced milk supply when moms are on high doses of prednisone, just continue to nurse and pump every 2 hours to try and keep supply up. Monitor infants growth and development.

Prednisone in pregnancy is a P3-unknown-risk to fetus cannot be ruled out. [COLOR=#333333][FONT=lucida grande]Although prednisone may slightly increase the risk of oral clefts ( approx. 1 % above baseline) and premature birth, disease flares may place the fetus at a higher risk of complications. Therefore, prednisone should not be used during pregnancy unless the benefit to the mother outweighs the risk to the fetus. Rare cases of congenital cataracts have also been reported when oral prednisone was given throughout gestation. Neonates must be screened for adrenal insufficiency at birth when oral steroids are used throughout gestation.

Sandra Lovato R.N.
InfantRisk Center[/FONT][/COLOR]

[Barbara]

Thanks. I'm interested to get your opinion on this type of treatment as I wish to carry on feeding my little boy who is 2 this month.

Many thanks.

[Sandra]

Barbara,

We would say this is probably ok since your infant is older and not getting much milk, and the amount passed into breast milk is small, but it may reduce your milk supply. We suggest low dose prednisone if used long term. Monitor the infant for all of the previously listed side effects. We provide you with the data we have and the ultimate decision is between you and your Dr.

Sandra Lovato R.N.
InfantRisk Center
806-352-2519