Medications in pregnancy

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: Psychotherapy or SSRI’s for Prenatal Depression

October 3rd, 2012

More and more attention is being given to perinatal mood disorders, and finally to prenatal depression. Until very recently, many clinicians didn’t believe that expectant mamas got depressed! The consensus seemed to be,

“She’s pregnant, right? Of course she’s happy!”

What research data is now showing is that regardless of whether the pregnancy is planned or not, or regardless of whether the mother wants the baby or not,  many women-across all ages, races and backgrounds-experience prenatal depression.

In September 2012, 2 new articles were published discussing treatment of prenatal depression. Alison K Shea, MD, PhD and colleagues at the University of Toronto, in Ontario, Canada examined the effectiveness and risk of Selective Seratonin Reuptake Inhibitors (SSRI’s like Paxil, Prozac, etc..) as treatment for depression in pregnant women. Their study looked at key factors that influence maternal and fetal drug exposure during pregnancy and the potential but still unknown long-term developmental consequences of prenatal exposure to antidepressants.

Sherryl H Goodman, PhD at Emory University in Atlanta, Georgia and and  Sona Dimidjian, PhD at the University of Colorado in Boulder examined and identified how psychosocial treatment of depression during pregnancy may be enhanced by taking a developmental psychopathology perspective.  Dr. Goodman and Dr. Dimidjian point out that psychopathology occurs on a continuum.

“The developmental psychopathology emphasis on disorders occurring on a continuum of severity is highly relevant to intervention considerations for antenatal depression,” they write, “especially when considering pharmacological as opposed to nonpharmacological treatment for more severe vs less severe depression.”

This is a really interesting contrast. The Canadian researchers are proposing that we focus more on the action of drugs and make sure that risks and side effects are minimized while also making sure that the drugs are metabolized safely and working in safe and effective doses.  They are not considering any sort of psychotherapy at all-at least not stated in their publications.

The American researchers are at the polar opposite end of the pendulum stating that while medication has a place in treating depression, in pregnant women, looking at how psychological disorders manifest-at different times and in different intensities in a person’s life depending on circumstances-one may be able to pre-emptively abort depressive episodes or at the very least minimize their severity. In pregnancy especially, women with prior depression are at increased risk of developing perinatal depression, so identifying those women with a history of depression early and taking a proactive approach to their mental health (i.e. taking steps to avoid developing a full blown depression in the first place) may in fact be a more effective treatment in the long run. (It certainly has fewer systemic side effects!)

What we do know is that depression is no good for mamas or babies.

I am more and more encouraged to see research being focused on perinatal mood disorders. Depression in mamas, whether pregnant, newly post partum or well into motherhood is a known risk factor for maternal morbidity and mortality, but also for impaired development in the fetuses, infants and children. When a pregnant mama is not feeling well emotionally, she doesn’t take optimum care of herself and hence doesn’t take optimum care of her baby. In these cases, we can see intrauterine growth retardation or failure to thrive. In extreme cases, we may see fetal demise. Depressed new mamas my avoid their babies and as a result feeding is impaired, the baby may not grow as expected for age and/or may experience behavioral/developmental. Children of depressed mamas often exhibit behavioral problems, learning difficulties and in extreme cases abuse. Clearly, treating depression is essential for the health and well being of mamas and their children.

And while I can appreciate the need to be aware of the dosing and pharmacologic activity of antidepressants in pregnant women, I have to agree with the researchers from Emory and U. Colorado; failing to look at psychosocial issues such as socioeconomic status, marital relationship and social support when evaluating a mama for depression is overlooking the potential causes of depression. If a pregnant woman is in a difficult marriage, simply giving her an antidepressant without taking into consideration the issues of her marriage and getting appropriate counseling is not really adequately treating her depression. If a pregnant mama is not safe at home or doesn’t have a home, an antidepressant is woefully inadequate at addressing her needs. Only with careful consideration of a pregnant mama’s entire history-including her psychosocial history-can adequate treatment for depression be rendered. In many cases, both medication and psychotherapy will be needed.

When it comes to depression in and around pregnancy, I am a firm believer that all options need to be presented and utilized for treatment. Because of a pregnant mama’s physical condition and the risk of toxicity to the baby,  medication may not be the best option. For other pregnant mamas, psychotherapy alone may prove inadequate. But if we continue to explore and make available all treatment options, I think we’ll be well on our way to effectively treating depression in mamas at all stages of their reproductive lives.

Resources

Managing Depression in Pregnancy: The Debate Continues. Medscape OB/GYN and Women’s Health

“Fetal Serotonin Reuptake Inhibitor Antidepressant Exposure: Maternal and Fetal Factors”  Alison K Shea, MD, PhD; Tim F Oberlander, MD, FRCPC; Dan Rurak, PhD.  Canadian Journal of Psychiatry. 2012;57(9):523–529.

“The Developmental Psychopathology of Perinatal Depression: Implications for Psychosocial Treatment Development and Delivery in Pregnancy” Sherryl H Goodman, PhD; Sona Dimidjian, PhD.  Canadian Journal of Psychiatry. 2012;57(9):530–536.

Mamas on Bedrest: Speak Up!!

July 16th, 2012

Mamas on Bedrest, Mama Mindy Spoke up!

Several months ago, actually over a year ago, I wrote a guest blog for Science and Sensibility, the blog for Lamaze International. It was a discussion on the FDA warning on the use of Terbutaline for the prevention of preterm labor. It was a heated discussion to say the least. Many of the providers commenting felt that I had been too harsh in saying that it was inappropriate to prescribe a drug with potentially severe side effects, especially without giving complete disclosure to patients, mamas, of these side effects.  But I think the power of this discussion came from the comments from mamas. It was fantastic (in my opinion) to see mamas sharing their experiences.

Recently I got a ping of another mama commenting on the blog. Here is Mama Mindy’s experience with Terbutaline during her pregnancy, preterm labor and bed rest experience:

I know i am waaaaay late on this article but for other women who may come across it i just want to share my experience:


I had cramping(contractions) from about 9 weeks till i delivered at 31 weeks after pprom.  I was first given terb at 23 weeks.  5 shots, no dilation, contractions started immediately upon leaving the hospital again.  I was sent back that afternoon, given terb every 3 hours for about 24 hours straight along with constant iv fluids and some other med for contrax. Wasnt even told what it was, it was just injected in my iv.  I was given a cerclage for cervical incompetence…..which is funny because i understood that cervical incompetence was characterized by dilation absent contractions…anyway.  the cerclage seemed to cause even greater uterine irritability.  Literally every week from 23 to 31 weeks i was back in l and d and every time i was given 3 to 5 shots of terb and eventually procardia and indomethacin combined.  I was also given torodol in my iv and had to freak out on the nurse and make her call the dr to find out what the hell they were injecting into me!!! 

So in total i probably recieved between 30 and 40 shots of terb along with torodol, procardia, indo, and one or two drugs i never even knew the name of.  At 29 weeks the peri ordered a terb pump for me.  I flat out refused it.  My ob said he understood my reasoning but recommended it anyway.  The on call dr laughed in my face and refused to let me leave the hospital without it.  I had to sign an ama form.  The peri told me my insurance wouldn’t cover it anyway but then marked me as a noncompliant patient!!  The only person who was reasonable was a nurse who discussed the terb pump in depth with me and agreed that i shouldn’t be a candidate for it.  I had side effcts completely ignored and was treated like i was a monster.  No one wanted to discuss risks or efficacy, it was their way or the highway.  Not only did i have to deal with this from the hospital but now my refusal of the terb pump is even being used against me in a custody case…even after the fda warning.  This is all just nuts to me and women need to start educating themselves and their drs if need be.

As many of you know, one of the greatest motivators for me in creating Mamas on Bedrest & Beyond is to advocate for women’s health and maternity care for all women. Additionally, I want to provide a place where women, mamas, can share information and resources to make wise health care choices. I am absolutely thrilled that mamas are speaking up and at times, gaining the knowledge and resources that they need to make wise health care choices.

Read through the thread on Science and Sensibility’s blog and read mamas’ stories. We really have the right and the power to effect change-not only for ourselves, but for other mamas.

Mamas on Bedrest, Speak Up!