Pharmacists’ Role in Improving Outcomes During Maternal and Neonatal Emergencies

In an interview conducted with Pharmacy Times, Morgan King, PharmD, BCPPS, clinical pharmacy specialist at Cleveland Clinic Health System, discussed the leading causes of preventable maternal and neonatal mortality and the critical role pharmacists can play in addressing care gaps. King highlighted key insights from her ASHP Midyear presentation, emphasizing how pregnancy-related physiologic changes significantly alter medication dosing and response. She explained that although emergency treatment should not be delayed, pharmacists must understand pregnancy-specific pharmacokinetic considerations to ensure safe and effective therapy. Overall, King underscored the importance of pharmacist expertise in selecting optimal treatments for obstetric and neonatal emergencies.

Pharmacy Times: What are the leading causes of preventable maternal and neonatal mortality, and how can pharmacists help address these gaps in care?

Morgan King, PharmD, BCPPS: The leading causes of preventable maternal mortality generally are things like preeclampsia and eclampsia, postpartum hemorrhage, sepsis, and other cardiac conditions such as stroke, arrhythmias, and cardiomyopathy. As far as the neonate goes—and the way that this Midyear presentation is really tailored—it is more about when the baby comes out. If the baby is premature, oftentimes prematurity is going to be the cause of mortality. A lot of the neonatal emergencies that we're going to see are really respiratory driven, so it's really just providing respiratory support.

Pharmacy Times: How do pregnancy-related physiologic changes and the neonate’s transition after birth impact drug pharmacokinetics and pharmacodynamics during obstetric or neonatal emergencies?

King: There are a lot of physiological changes that occur in pregnancy from the first trimester, second trimester, third trimester, and then even postpartum. There is an increased plasma volume, which causes an increased volume of distribution. There are hormonal changes that occur that affect drug absorption and metabolism. There are varying levels of CYP enzymes, which are used for drug metabolism, and those change throughout pregnancy. All of these different changes affect how we dose medications. In general, when moms are pregnant, they often require higher doses as they move through pregnancy.

With regard to emergencies, if it's really a true emergency, you're still going to give the drug how you're going to give the drug. Where these changes come into play is knowing that Mom might need a higher dose of medication—for example, a higher dose of antibiotics—because she's going to clear it faster. If she's septic and on vasopressors while still pregnant, the concern is that you can cause uterine constriction, which cuts off blood supply to the baby, so you're trying to balance that. I think just having a general idea of what these changes are and knowing that doses may differ in pregnancy allows you to give optimal drug therapy to the mom.

Pharmacy Times: When managing emergencies such as preeclampsia, eclampsia, or sepsis, what key strategies should pharmacists prioritize when evaluating a case?

King: If it's a true emergency, we're going to treat Mom how we're going to treat Mom. A lot of the medications that we use in pregnancy and in these types of emergencies are similar to medications that you're going to use in a nonpregnant person. There are some caveats. For example, preeclampsia is high blood pressure in pregnancy. We have our preferred drugs, so we typically use IV labetalol or IV hydralazine if there is a hypertensive emergency, whereas there are other drugs you can use in nonpregnant patients. I think having an idea of what the preferred treatment options are in pregnancy helps us know which medications are preferred if that mom comes into your emergency room.