Depression

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: All stressed out with nowhere to go

April 15th, 2010

Mamas on bed rest are at increased risk of going into preterm labor!

Now any woman on bed rest reading this is probably ready to click off. Why am I stating the obvious? Because the answer to my original statement is not what you think. Women who are prescribed bed rest receive the prescription because they have incompetent cervices, pre-eclampsia, gestational diabetes, vaginal bleeding, placental issues, poor fetal growth or some other obstetrical complication. These complications increase a pregnant woman’s risk of going into preterm labor and increase the health risks to both mother and baby.

But consider this: in addition to being at increased risk of going into preterm labor due to an obstetrical complication, women who are on prescribed bed rest-either in the hospital or at home as an outpatient-have an additional increased risk of going into preterm labor due to being on bed rest. The fact of the matter is despite its intention, being on prescribed bed rest is stressful, and it’s this stress that compounds the risk of going into preterm labor.

The Physiologic Effects of Stress

Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist who studies the effects of chronic stress and depression on health. Her websites UppityScienceChick.com and BreastfeedingMadeSimple.com have a combination of evidenced based science linking chronic stress and depression as well as very “people-friendly” information on the ameliorating effects of breastfeeding on depression in new mothers.

In the normal stress response, the brain releases chemicals from the hypothalamic-pituitary axis (HPA) which stimulates the adrenal glands to produce adrenaline for “flight/fight” and cortisol to aid in repair from disease or injury. At the same time, the immune system releases chemicals called cytokines that start a cascade of events designed to slow, halt and reverse  inflammation associated with illness or injury.

According to Kendall-Tackett and her colleagues in this emerging field of psychoneuroimmunology, in people under chronic stress, these usually protective mechanisms go haywire. The normal stress reaction is that the brain perceives danger or stress and sends messages to the adrenal glands and immune system to prepare for defense. Once the stress or danger is removed, the HPA gets the message that there is no longer any danger and stops sending out messages to the adrenal glands and the immune systems. The systems reset themselves and stop producing and secreting the protective hormones and chemicals.

In a person under continuous stress, the HPA continuously sends out “stress” messages. The adrenal glands continuously produce and secrete adrenaline and cortisol in response  and as a result  too much adrenaline and cortisol are produced. A similar response occurs in the immune system. Cytokines are produced and released in excess by the immune system in response to the perceived “threat”. The result is a state of chronic inflammation.

Psychoneuroimmunology and Mamas on Bedrest

So what does all this science mean for Mamas on Bedrest? Well, the normal physiology of pregnancy results in elevated levels of cytokines, the chemicals released by the immune system in response to stress, in the third trimester. Accordingly, women in the third trimester of pregnancy are at increased risk of developing depression. Since cytokines remain elevated into the post partum period, this inflammatory response persists and increases the risk of developing post partum depression.

Women on prescribed bed rest are stressed simply by being placed on prescribed bed rest. Add to that stress the time they may spend worrying about their health, the health of their babies, their families, their jobs, their finances, etc… and you can see that they are under additional stress. Their HPA’s are firing like gangbusters telling the adrenals glands and immune system to prepare for battle. Adrenal hormones are present in excess. Cytokines are produced and put out by the immune system in excess. Hence, a woman on bed rest who is stressed is in a heightened state of inflammation. She’s all stressed out with nowhere to go.

But what does this mean for her pregnancy? Researchers have shown that cytokines act on the cervix causing an inflammatory response. This inflammation causes cervical “ripening”, i.e. the cervix to shorten and thin and prepare for delivery of the baby. Hormones secreted from the adrenal glands trigger partuition. If this inflammatory response occurs before 37 weeks of pregnancy, in addition to be at risk for preterm labor due to obstetrical complications, mama is also at risk of preterm labor due to the stress response on her cervix. If she’s already on bed rest for an incompetent cervix this is a “double whammy.” But in combination with other known obstetrical complications, this can become a very serious problem.

But there is good news

When women on bed rest are able to keep their stress levels low, they are able to reduce their inflammatory responses and lower their risks of preterm labor. The psychoneuroimmunologists have also found that DHA, an Omega 3 fatty acid found in fish oils helps lower the inflammatory response. While no one is telling mamas on bed rest to go out and to start taking fish oil (you have to be very careful with supplements during pregnancy. Always consult with your OB or midwife and/or a nutritionist prior to taking any supplements during pregnancy!) this information relates directly to our discussion on eating a healthy, well balanced, whole foods diet.

There is so much more to this story and we will continue the discussion in the subsequent post.

Please share your thoughts on this blog post in the comments section below. Also, please share this vital information with friends and loved ones.

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