Immunizations in Pregnancy

Mamas on Bedrest: My Bout with the Flu

January 19th, 2013

The Flu crept into my home and took up residence for the past week. It started last Thursday when my daughter began complaining of a sore throat. It struck with full force on Saturday when my daughter come home from her Dad’s with a fever, sore throat and lethargy. She seemed to get better on Sunday and we spent the better part of the day getting her science project finished. All seemed well, we seemed to have dodged a bullet, but on Monday, I dropped both kids off at school only to be called back at 10:30 am to pick up my daughter who had a 102 degree fever.

The flu was unrelenting. As I tended to my daughter on Monday and Tuesday, I was caught off guard when my son awoke with a fever on Wednesday.  He was not as ill as my daughter had appeared, but the barking, unrelenting cough was concerning so I took him into the after hours clinic (because of course his symptoms didn’t get worse until after 5 pm!). A nasal culture confirmed flu and he was started on Tamiflu. By the time we left the after hours clinic, my head was throbbing and I had chills. We were all sick.

Tonight, a week later, we are all on the mend. Both of my children are in much better shape than I am, fever free and in pretty much their usual state of exuberance.  I am better, fever free and able to sit up with my head no longer pounding, but I am not quite well after having been the sickest that I have ever been in my life (that I can recall).

My bout with the flu really got me thinking about Mamas on Bedrest. This flu is really severe, and I have to say, it knocked me down in the way that nothing else has that I can recall. I am a strong, healthy person. Mamas on Bedrest, even the healthiest mamas, have compromised immune systems. Pregnancy impacts a woman’s immune system and puts them at risk for numerous opportunistic infections like the flu. So how should Mamas on Bedrest protect themselves (and their babies) in the face of what many are calling a flu epidemic?

The Flu shot. Whether or not to take the flu shot remains a controversial decision. I have to admit that neither my children nor I are able to take the flu shot (my kids are allergic to eggs and I have violent reactions to the shot for unknown reasons!). However, the current medical recommendations are that those at greatest risk (and pregnant women fall into that category) receive the flu shot. As we have previously posted on this blog,  The US Centers for Disease Control and Prevention recommends that every woman who will be pregnant during the flu season get the flu shot. However, many women have fundamental hesitations to taking the flu shot. The only thing that we here at Mamas on Bedrest & Beyond can suggest is that you have a candid talk with your health care provider and learn as much as you can about this year’s flu, the flu vaccine, your personal risk and whether or not taking the flu shot is the best option for you.

Antiviral Medications. My son was prescribed Tamiflu, an antiviral medication prescribed to lessen the duration and severity of the flu. Unfortunately, Tamiflu and many other flu remedies are not indicated in pregnancy, so again, Mamas on Bedrest need to remain vigilant in their flu prevention and to have a very low threshold for seeking medical attention when or if symptoms begin to present.

Alternative/Homeopathic Remedies. These remedies are always controversial. While most alternative and homeopathic remedies are generally non-toxic as compared to their pharmaceutical counterparts, there is typically far less data available regarding efficacy and safety. Again, We cannot recommend or advise Mamas on Bedrest try alternative or homeopathic remedies, we can only say learn as much as you can about any proposed remedies you are considering taking and speak with an experienced, skilled practitioner who can guide you what to take and how to take it.

Finally, the best flu defense is an aggressive offense.  We recommend the following measures for Mamas on Bedrest:

  1. Those who may be infected with the flu should not be around Mamas on Bedrest. Any visitor who has symptoms indicative of flu should not be allowed to visit Mamas on Bedrest.
  2. Infected family members should be kept away from Mamas on Bedrest. Now I know that this can be hard, especially if those affected are your older children or even your spouse. But you mamas are at great risk for developing a severe case of the flu and you and your unborn child are at increased risk for severe complications. As much as possible, have someone else care for sick children and ask your spouse to sleep in another room until they are symptom free.
  3. Increase Rest and Fluid intake.

I don’t want to seem like a Nervous Nelly, but I have to tell you, this flu is serious and I would hate for any mama on bedrest to suffer or for her and her unborn child to be at  risk for severe complications or even death. Mamas, be well, be safe and be healthy!

Mamas on Bedrest: Medications in Pregnancy-Updates on the Latest Research

November 5th, 2012

Whether or not to use medications during pregnancy and which medications are safe to take during pregnancy are always difficult conversations. When a mama has a medical condition, health care providers are always faced with the question,

“Does the risk of using a particular medication outweigh the benefit that the medication will provide to both the mama and baby? Are there potential side effects that are harmful to mama, baby or both?”

These are difficult questions to answer given that there is little research done on the effects of medications during pregnancy due to fear of harm to mama, baby or both. Recently, there have been some published studies indicating that there are some beneficial and safe medications to use during pregnancy and some medications that we may really want to avoid. The FDA has also created a new department to assess risk of medications during pregnancy. All of this breaking news is summarized below.

Probiotics in Pregnancy Reduce Eczema in Pregnancy. In June 2010, research was published in the British Journal of Dermatology that suggests that mamas who take probiotics during the third trimesters and for the first 3 month post partum while breastfeeding showed reduced incidence of eczema in the newborns, but there was no effect on the subsequent development of allergic rhinitis, asthma or atopic dermatitis later on. Because taking probiotics is safe and relatively inexpensive, researchers believe that recommending that pregnant mamas take probiotics during this time period poses no health risk or threat and is most likely beneficial to mamas and infants.

New Recommendations for Tetanus, Diphtheria and Pertussis Vaccination During Pregnancy. Originally posted on October 26, 2012, this post reviews the current guidelines and recommendations for Tdap vaccination during pregnancy.

Link Found Between Vitamin D Levels and Gestational Diabetes. In this blog posted on October 19, 2012, we share the latest data presented at the European Association for the Study of Diabetes (EASD) 48th Annual Meeting suggesting that low Vitamin D levels early on in pregnancy put mamas at greater risk for developing gestational diabetes.

Fish Oil for the Treatment of Post Partum Depression. This Blog post highlights research presented by Dr. Kathleen Kendall-Tackett on La Leche League’s website discussing the role that chronic inflammation plays in post partum depression. She also states that supplementing with fish oil, rich in the Omega 3 Fatty Acids docosaheaenoic acid (DHA) and eicosapentaenoic acid (EPA), fhave been found to be more potent in reducing inflammation and in turn, depression.

Selective Serotonin Reuptake Inhibitors (SSRI’s) for treatment of Depression in Pregnancy. It is a well established fact that depression during pregnancy can lead to serious morbidity and mortality for both mamas and babies. Depression is also more common in women who are experiencing infertility and difficulty conceiving, and until now, SSRI’s were the first line medications prescribed. However, recent data published by Alice Domar, PhD, from Beth Israel Deaconess Medical Center and executive director of the Domar Center for Mind/Body Health at Boston IVF, in Massachusetts shows that treating depression in infertile women with SSRI can have serious deleterious effects for women trying to conceive as well as their babies when they become pregnant.

Publishing in Human Reproduction, Domar states the know evidence.

“SSRI use is associated with possible reduced infertility treatment efficacy as well as higher rates of pregnancy loss, preterm birth, pregnancy complications, neonatal issues and long-term neurobehavioral abnormalities in offspring.

As a result Domar recommends that clinicians consider alternative treatments for depression in women trying to conceive and women who become pregnant using Assisted Reproductive Technologies (ART), namely, Cognitive Behavioral Therapy (CBT).

The Establishment of the Medication Exposure in Pregnancy Risk Evaluation Program. In 2009, the U.S. Food and Drug Administration (FDA) announced the creation of the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). This pilot program is intended to provide a large, ethnically and geographically diverse population with which to address a variety of important and timely issues surrounding the safety of medication use during pregnancy. MEPREP is intended to provide the expertise and data resources to enable studying drug exposures for which there is a signal of potential fetal risk from animal studies, human case reports, or other published literature.

MEPREP is a collaborative effort between The FDA and researchers at the HMO Research Network (HMORN), Kaiser Permanente Northern and Southern California, and Vanderbilt University School of Medicine. It also encompasses the affliated organizations at Kaiser Permanente Northern California, Kaiser Permanente Southern California, Kaiser Permanente Georgia, Kaiser Permanente Northwest, Kaiser Permanente Colorado, Harvard Pilgrim Health Care Institute, Group Health Research Institute, HealthPartners Research Foundation, Lovelace Clinic Foundation, the Meyers Primary Care Institute/Fallon Community Health Plan, and Vanderbilt University School of Medicine.

Data generated comes from the electronic medical records at each institution as well as birth certificate data obtained from the state departments of public health. This extensive data base allows for diverse patient data across a wide demographic of age, racial and ethnicity and geographic area.

It is great to finally see research being done of medication use, efficacy and safety during pregnancy. It is highly likely that as a result of all of this attention and research new, more effective and safer treatments will become available for women with medical illnesses, lessening the risk of complications, poor outcomes and (thankfully) death before,  during and after pregnancy for mamas and babies.

Mamas on Bedrest: New Recommendations for Tetanus, Diphtheria, Pertussis Vaccination During Pregnancy

October 26th, 2012

On October 24, 2012, The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention voted unanimously to recommend that all pregnant women receive a Tetanus, Diphtheria, Pertussis (Tdap) Vaccination during pregnancy. Additionally, ACIP recommends that all women receive a Tdap during each and every pregnancy.

Vaccinations in the United States are controversial. Vaccination during pregnancy is extremely controversial because of the concern of harm to the unborn child. However, ACIP has found that the risk of newborn infants developing pertussis (whooping cough) greatly outweighs any risk of severe adverse reactions to mama or unborn child receiving the Tdap vaccine.

According to Jennifer Liang, MD, from the CDC National Center for Immunization and Respiratory Diseases, who presented the proposed changes during the ACIP meeting in Atlanta, Georgia,

“Although there are no data to address what we really want to know [the potential for severe adverse events associated with repeat vaccinations for pregnant women who have multiple pregnancies in a short time interval], the data from studies in which healthy adults received 2 doses of Tdap are reassuring, and the historical experience with tetanus toxoid vaccine suggests no excess risk of adverse events with multiple doses.”

What is known is that infants that develop pertussis under two months of age have a much higher rate of complications and are at greater risk of death from the disease. It was previously believed that if Mama was up to date with her vaccinations, then baby would be okay. What the ACIP workgroup found is that many women are unsure of their immunization status or they had their Tdap vaccines so long ago (while still within the 10 yr window of “normal” for adults) that transferal of immunity to there babies was minimal if at all. Initially the CDC recommended that women who were unsure of their vaccine status receive Tdap, but now, given current data, they are recommending that all pregnant women receive Tdap during pregnancy between 27 and 36 weeks gestation.

The biggest change to their recommendations is that ACIP recommends that women have Tdap vaccines with all subsequent pregnancies. Based upon a review of published and unpublished studies on the use of Tdap in pregnant women and Tdap safety data from pregnancy registries and the Vaccine Adverse Event Reporting System, the ACIP Pertussis Vaccine Work Group concluded

“A single dose of Tdap at one pregnancy was insufficient to provide protection for subsequent pregnancies and that the benefits of vaccination outweigh the theoretical risks of severe adverse events.”

The work group found that since most women in the US have no more than 2-3 pregnancies, and given the safety and efficacy of Tdap, the additional doses of vaccine (theoretically) pose no threat to Mamas. (I was wondering if multiple doses of Tdap were safe for women who have pregnancies close together, i.e. children born 13 months apart. But given that infants receive multiple doses of a similar vaccination within the first year, this likely poses no immediate threat to mamas.) The working group supports and recommends continued research and study to definitively assess safety of Tdap administration in multiple (and perhaps close) pregnancies.

Other recommendations include vaccinating women in the immediate post partum if immunization status is unknown or if they were not immunized during pregnancy. ACIP also recommends that the childhood immunization schedules be updated so that teenagers that become pregnant receive Tdap according to this new protocol.

With approval of these recommendations by the US Department of Health and Human Services, they will be published in the 2013 edition of Morbidity and Mortality Weekly Report, the guide routinely referred to by health care providers for the latest recommendations to standards of care.

Resources

MedScape OB/GYN and Women’s Health News

The 2011 ACIP Recommendations for Tdap in Pregnancy