Use of Glaucoma Medications During Pregnancy or by Breastfeeding Mothers
Often, IOP decreases during pregnancy, both in healthy subjects and in patients with glaucoma. However, glaucoma patients who are pregnant frequently continue to require ocular hypotensive medical therapy throughout the pregnancy. As mentioned previously, topical ocular hypotensive medications are systemically absorbed; they subsequently cross the placenta and enter the fetal circulation or can be secreted into breast milk. Unfortunately, there is little definitive information concerning the safety of glaucoma medication use in pregnant women or breastfeeding mothers.
The decision as to whether to continue ocular hypotensive therapy during pregnancy, and what agents to use, should be made in collaboration with the patient and her obstetrician. Ideally, these plans should be formulated and implemented prior to conception, if possible. The theoretical risk of teratogenicity and other adverse outcomes necessitates an assessment of the potential benefits of treatment and a careful evaluation of the treatment regimen.
With all topical ocular hypotensive medications, pregnant and breastfeeding patients should be advised to perform nasolacrimal occlusion during eyedrop instillation. In general, it is prudent to minimize the use of medications in pregnant women whenever possible. The lowest effective dose should be given. The clinician may want to consider laser trabeculoplasty or other surgical intervention in cases in which the benefits outweigh the potential risks. Antifibrotic agents, however, should be avoided since there is evidence of human fetal risk based on adverse reaction data.
Mathew S, Harris A, Ridenour CM, et al. Management of glaucoma in pregnancy. J Glaucoma. 2019;28(10):937–944.
Pellegrino M, D’Oria L, De Luca C, et al. Glaucoma drug therapy in pregnancy: literature review and Teratology Information Service (TIS) case series. Curr Drug Saf. 2018;13(1):3–11.
Previously listed in Pregnancy Category C (a classification system that has been abandoned by the FDA; Category C included drugs for which animal studies showed an adverse effect on the fetus but there were no adequate studies in humans), PGF2α analogues have been shown to be embryocidal in rodent studies when administered at extremely high doses (15–97 times the human dose). Travoprost is teratogenic in rats at intravenous doses that correspond to exposure levels up to 250 times the human exposure at the maximum recommended human ocular dose. PGF2α exerts abortifacient activity by increasing uterine contractility and may induce labor, albeit at much higher doses than those used in topical therapy. It is unlikely that topically administered prostaglandin analogues place the fetus at significant risk during pregnancy.
β-Blockers (formerly listed in Pregnancy Category C) are often used for the treatment of systemic hypertension during pregnancy. There have been reports of growth retardation, arrhythmia, bradycardia, and lethargy affecting the fetus or newborn exposed to systemically or topically administered β-adrenergic antagonists. These agents are concentrated in breast milk and are relatively contraindicated in breastfeeding mothers because of their potential adverse effects on infants.
Previously listed in Pregnancy Category B (Category B included drugs for which animal studies failed to demonstrate a risk to the fetus, but there were no adequate and well-controlled studies in pregnant women), brimonidine is a preferred agent for use during pregnancy. Because brimonidine has been linked to apnea in infants, its use should be discontinued in pregnant women prior to delivery to minimize the risk of this complication in the newborn. Brimonidine should also be avoided in breastfeeding mothers. For more information about brimonidine use in infants and children, see Chapter 11.
Carbonic anhydrase inhibitors
The CAIs (Pregnancy Category C) are teratogenic in rodents, and there are case reports of forelimb deformities in infants whose mothers were on systemic CAIs during pregnancy. Systemic CAIs should be avoided for the treatment of glaucoma in pregnant women. It may be preferable to also avoid the use of topical CAIs in pregnant women if possible, particularly during the first trimester.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.