Medications in pregnancy

Mamas on Bedrest: “Pre-Partum Depression: What is it and what you need to know”

March 4th, 2013

depressed woman“Pre-Partum Depression: What is it and what you need to know”

This was the promo title for the segment on The Rikki Lake Show. As I was cleaning out my DVR this weekend I came across this show and watched.  Rikki had a young woman who was sharing that she felt overwhelmed about being pregnant with her second child at age 25. She was afraid that she wouldn’t have the energy to take care of both children, and she was particularly afraid that she wouldn’t love her younger child as much as her oldest daughter.  Another woman related that she was depressed about being pregnant because she had just gotten back to her pre-pregnancy weight and physical condition after her first pregnancy. An expert was present assuring the women know that what they were feeling was normal and how to deal with the feelings.  She discussed the difference between the “pre-partum blues vs. pre-partum depression”, and there were other support professionals there offering advice and tips.

Many people are unaware of the fact that many women suffer with depression during their pregnancies. According to the American Pregnancy Association, the American Congress of Obstetricians and Gynecologists (ACOG) estimates that depression during pregnancy occurs in 14-23% of pregnant women. Everyone agrees that depression in pregnancy can be a challenge to treat. One tries as much as possible to keep pregnant women off of medications. The expert on the show clearly stated that since depression is a major medical condition and can have negative effects on mama, the pregnancy and the baby, if medication is needed, it is prescribed. However, early identification and early intervention in the form of cognitive behavioral (talk) therapy and social support are the first lines of treatment in pregnant women with mood disorders.

The signs and symptoms of depression during pregnancy: (symptoms must persist for two weeks or more)

  • Persistent sadness
  • Difficulty concentrating
  • Sleeping too little or too much
  • Loss of interest in activities that you usually enjoy
  • Recurring thoughts of death, suicide, or hopelessness
  • Anxiety
  • Feelings of guilt or worthlessness
  • Change in eating habits (most notably weight loss)

As always, I approach issues in pregnancy with the lens of high risk pregnancy and Mamas on Bedrest, and again I was dismayed to see that Mamas on Bedrest were left out of this discussion. While I have not been able to find definitive numbers on rates of pre-partum depression in Mamas on Bedrest, Judith Maloni, PhD published extensively on the topic. In her publication, Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth, Maloni states in this journal article,

“In the presence of pregnancy complications, perinatal stress emanates, not only from having a high-risk pregnancy, but also from the increased threat to health, hospitalization, and obstetric treatments that are frequently physically and psychologically invasive and demanding and serve as a reminder of the precarious nature of the pregnancy…Exposure to chronic environmental stressors as well as anxiety, separation, and concerns for self and family contribute to behavioral stress response…The experiences of vigilant waiting for an important

future maternal or infant health outcome over which women have no control and of isolation likely compound maternal stress. Isolation has been identified as one of the major contributors to increased allostatic (emotional/behavioral stress) load.”

Treatment for Mamas on Bedrest who may be suffering with pre-partum depressive symptoms is no different than treatment for mamas not on bed rest. However, it is the isolation and lack of social contact that increases the likelihood that depression or depressive symptoms will be missed in Mamas on Bedrest. I posted the common signs and symptoms of pre-partum depression above and implore you, if any of these symptoms speaks to you or you have experienced them for 2 weeks or more, consult with your health care provider or at the very least, tell a trusted individual so that they can help you get help. One of the important nuggets the expert on the Rikki Lake show added is that most obstetricians are not skilled in treating depression of any sort. They are surgeons. So while it is important that you discuss your symptoms and situation with your obstetrician or midwife, if you are truly depressed (having symptoms for 2 weeks or more), ask for a referral to a mental health professional. They are more skilled at diagnosing and treating mood disorders and can offer suggestions on alternative forms of therapy besides medication.

Finally, the American Pregnancy Association also lists the following “alternative therapies” for the treatment of depressive symptoms in pregnant women.
  • Exercise–Exercise naturally increases serotonin levels and decreases cortisol levels. (Purchase our DVD Bedrest Fitness for and exercise program specifically for Mamas on Bedrest!!)
  • Get adequate rest–Lack of sleep greatly affects the body and mind’s ability to handle stress and day to day challenges. Work on establishing a routine sleep schedule that has you going to sleep and getting up at the same time.
  • Diet and Nutrition–Many foods have been linked to mood changes, the ability to handle stress and mental clarity. Diets high in caffeine, sugar, processed carbohydrates, artificial additives and low protein can all lead to issues regarding your mental and physical health. Make a conscious decision to start fueling your body with the foods that can help you feel better.
  • Acupuncture-New studies report acupuncture to be a viable option in treating depression in pregnant women. (Be sure to consult with an acupuncturist skilled in treating pregnant women!)
  • Omega-3 fatty acids–For years its been know that omega-3 can help with a number of health issues, but the newest studies are showing that taking a daily supplement of omega-3/ fish oils can decrease symptoms of depression. Pregnant women would want to make sure to take a mercury free version of fish oil and check with their care provider or nutritionist on a recommended amount. (send e-mail to info@mamasonbedrest.com for information on pharmaceutical grade fish oils and the recommended dosages in pregnancy)
  • Herbal remedies—There are a number of herbal and vitamin supplements known to affect moods and the hormone serotonin. Talk with your health care provider and nutritionist/ herbalist about the options of using St John’s Wort, SAM-e, 5-HTP, magnesium, vitamin B6 and flower remedies. Many of these can not be used in conjunction with antidepressants and should be evaluated on the dosage for pregnant women.

Unfortunately, pre-partum depression is a reality, and there is an increased risk of occurrence in Mamas on Bedrest due to the isolation and lack of social contact. If you are feeling sad, blue or truly feel depressed, please tell your health care provider or other trusted individual. If you don’t know who to tell, you can always send an e-mail to info@mamasonbedrest.com and we’ll help you get the support that you need.

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: An Update on Pre-Eclampsia

November 26th, 2012

Pre-Eclampsia is one of the leading reasons that mamas are prescribed bed rest. Overall, hypertensive disorders (high blood pressure) during pregnancy account for 11% of pregnancy related deaths during pregnancy according to the US Centers for Disease Control and Prevention. Clearly, early recognition and treatment of pre-eclampsia are essential for the health and well being of both mamas and babies. Here, we give a review of pre-eclampsia and some of the latest information and treatments available.

Overview

Definition-Pre-Eclampsia is defined as blood pressure > 140/90 mmHg on at least 2 occasions 6 hours apart and protein in the urine (>300mg in a 24 hr period). Pre-Eclampsia is also associated with facial and extremity swelling and in severe cases, kidney failure and grand mal seizures.

Presentation-Pre-Clampsia typically presents after 20 weeks gestation and is often asymptomatic at diagnosis. It can occur in the new first time mother as well as in a “veteran” mama. It presents in singleton pregnancies as well as in multiple gestations. There is no particular presentation or no particular type of mama who will develop pre-eclampsia. What is known is that women with pre-existing conditions such as high blood pressure, cardiovascular disease, diabetes, kidney disease, or clotting/blood disorders are at increased risk of developing pre-eclampsia. Pre-eclampsia is also more common in women with multiple gestations (Twins or more) and older mamas. The wild card is obesity. Some studies have shown that mamas who enter pregnancy overweight or obese increase their risks of developing pre-eclampsia. Other studies have not been conclusive. Currently obesity is not considered an absolute risk factor for pre-eclampsia, but given its negative effects on other aspects of mama’s health and hence baby’s health, obese mamas should be watched closely.

Pre-Eclampsia is classified as mild or severe and treatment is guided depending on the severity. Mild pre-eclampsia is defined as hypertension (BP >140/90 mmHg) on two occasions at least 6 hours apart, but without evidence of end-organ damage (kidney disease inparticular). Severe pre-eclampsia may include an array of signs and symptoms and significant laboratory findings. At least one of the following signs or symptoms must be present with the indicators of pre-eclampsia for the condition to be regarded as severe. Severe Pre-Eclampsia is a medical emergency and must be treated immediately, typically by immediate delivery of the infant so as to save the life of both mama and infant.

Symptoms of Severe Pre-Eclampsia

Neurological: blurred vision, severe headache, altered mental status, stroke, seizures

Liver Damage: Right Upper Quadrant abdominal pain, elevated liver enzymes indicating liver damage (Precursors to HELLP Syndrome, Hemolysis, Elevated liver enzyme levels, low platelet count)

Kidney: Protein in the urine, decreased urine output, dark urine

Pulmonary Edema: Fluid in the lungs

Fetal: Intrauterine Growth Retardation

Blood Disorders: Increase in blood clotting, Low platelet count

Treatment of Pre-eclampsia

As previously stated, severe pre-eclampsia and pre-eclampsia that has progressed to organ damage or HELLP Syndrome is a medical emergency and must be treated aggressively in the hospital setting. Mild pre-eclampsia can be treated with bed rest and medication with close watch for development of symptoms indicating progression to a more severe form.

Medications

Magnesium Sulfate-Magnesium sulfate is considered first-line treatment for the prevention of primary and recurrent eclamptic seizures. It is also utilized for prophylactic treatment in all patients with severe preeclampsia.

Anti-Hypertensive (high Blood Pressure)Medications – Medications known to decrease blood pressure but found to be safe in pregnancy are Hydralazine, Labetalol, Nifedipine, Nicardipine and Sodium Nitroprusside.

Aspirin Therapy – Low dose aspirin therapy is controversial in the treatment of pre-eclampsia. While an individual study was unable to prove benefit for using low dose aspirin therapy as a preventive for pre-eclampsia, a meta-analysis of several studies found that using low dose aspirin starting before 16 weeks of gestation and continuing throughout pregnancy. Currently, low dose aspirin therapy is not recommended as a preventive treatment for pre-eclampsia. Physicians and researchers are still trying to determine which women are at greatest risk for developing pre-eclampsia and which women will benefit from low dose aspirin therapy.

References:

Pre-Eclampsia Revisited. Tammy D. Hart, BS, PharmD, Martha B. Harris, BS, PharmD. November 20, 2012.

US Pharmacist. 2012;37(9):48-53. © 2012  Jobson Publishing

Aspirin in the prevention of pre-eclampsia in high risk women: a randomised placebo controlled PREDO trial and a meta analysis of randomised trials. Villa, P., Kajantie, E., Räikkönen, K., Pesonen, A.-K., Hämäläinen, E., Vainio, M., Taipale, P., Laivuori, H. and on behalf of the PREDO Study group (2012).  BJOG: An International Journal of Obstetrics & Gynaecology. doi: 10.1111/j.1471-0528.2012.03493.x