Medications in pregnancy

Mamas on Bedrest: Decongestants and Birth Defects

January 31st, 2014

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Hello Mamas!  With cold and flu season upon us, I wanted to take a moment and go over important information about taking medications for symptoms.

Being sick while you are pregnant is a bear because you are very limited in what you can take. So many medications are not good for your baby’s development that most healthcare providers advise mamas not to take anything. A recent article in the American Journal of Epidemiology noted that the use some nasal and oral decongestants during the first trimester can cause birth defects. In this study, Dr. Wai-Ping Yau at the Sloan Epidemiology Center in Boston looked at data from a birth defects study conducted from January 1993-January 2010. Studying 12,734 infants with birth defects and 7606 control infants (infants without birth defects) the researchers looked at those who had birth defects and then contacted the mothers regarding the use of medications during pregnancy.

Pseudophedrine has long been used by mamas during pregnancy and has been touted as being safe. However, there has been some question of suspected limb shortening when used in the first trimester. These researchers wanted to know if pseudophedrine and other decongestants did in fact cause any sort of birth defects and if so, what types. Dr. Yau and his colleagues found that phenylephrine use was associated with endocardial (heart) cushion defect (4 exposed cases), phenylpropanolamine was associated with ear defects ( 4 exposed cases), and phenylpropanolamine was associated with pyloric stenosis (narrowing and hardening of the passage from the stomach to the small intestine) (6 exposed cases). They also found elevated risks of 2 malformations with the use of intranasal decongestants (nasal sprays): pyloric stenosis and tracheo-esophageal fistula. In addition, renal collecting system anomalies potentially could be associated with second-trimester exposure to oxymetazoline.

The authors reiterated the fact that the numbers of infants affected were very small, for each products used birth defects occurred in less than 10/1000 births. Yet they suggested that further studies be done to make a definitive cause/effect statement for the medications. They also made specific note that most of the associations were the result of mamas using medications during the first trimester, so they suggested that health care providers reiterate to their patients the importance of not using any medications during that critical developmental time.

What is a mama to do if she becomes ill while pregnant? Well, after looking at this study, if she is in the first trimester, it looks as if she is going to have to tough it out. Since such a large amount of fetal development occurs in the first 12-16 weeks, refraining from the use of any medication during that time-except in cases of absolute necessity-appears to be the best course of action. How would mama know if treating her illness is an absolute necessity? She must consult with her health care provider.

Sometimes when mama is ill, the risk treating her illness is outweighed by the potential harm to her baby if she does not receive treatment. Case in point, when I was pregnant with my son, my asthma flared. I hadn’t had an asthma attack in year! But the change in my immune system with the pregnancy triggered something and there I was wheezing. I called my OB and was told to use my rescue inhaler and immediately scheduled to see a pulmonologist the next day. The pulmonologist started me on daily inhaled corticosteroids for the remainder of my pregnancy (about 4 months). His rationale was that if I was not getting enough oxygen neither was my baby. It was more important to keep my airways clear by eliminating inflammation and sensitivity with the inhaled steroid than for me to have low oxygen levels and potentially subject my baby to the same.

If you have questions about what medications (or even herbal/”natural” medicinal preparations) are safe to take if you are sick, please call and talk to your health care provider before you take anything. As Dr. Yau and his colleagues noted in the aforementioned study,

“It is not known whether any of the oral decongestants (pseudoephedrine, phenylephrine, and phenylpropanolamine) cross the placenta to exert any direct effect on the fetus.”

With that being the case, Mamas, if you become ill and feel that you need to take something for your symptoms (including home remedies!!), Please consult with your health care provider first!

 

References:

Wai-Ping Yau, Allen A. Mitchell, Kueiyu Joshua Lin, Martha M. Werler, Sonia Hernández-Díaz. Use of Decongestants During Pregnancy and the Risk of Birth Defects American Journal of Epidemiology. 2013;178(2):198-208.

MedScape OB/GYN Women’s Health

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: Use Medications in Pregnancy with Caution and Supervision

March 16th, 2011

Asthma Flare During Pregnancy

When I was pregnant with my son my asthma flared up. I hadn’t had an attack in years but there I was, about 5 1/2 months pregnant and suddenly I couldn’t breathe. I had a Proventil (albuterol) inhaler, but I was reluctant to take it. I called my OB service (of course this happened on the weekend) and her nurse called me back and instructed me to use the inhaler. They also referred me to a pulmonologist to make sure that my asthma was controlled throughout the remainder of my pregnancy.

The pulmonologist was a really wonderful man and took a long time with me assessing my medical history and my current asthma situation. He prescribed Pulmicort, an inhaled steroid, to be taken twice daily for the remainder of my pregnancy. Evidently I had developed some sort of inflammatory response in my respiratory system. It wasn’t clear if it was due to the pregnancy hormones or some sort of viral illness, but I was inflammed none the less. I was very hesitant to take the steroid inhaler. But the pulmonologist reassured me that it was safe during pregnancy and would not cause any adverse complications with my baby. Furthermore, he reminded me that if I wasn’t breathing well, I would not be getting enough oxygen. If I wasn’t getting enough oxygen for my body, then I certainly couldn’t give adequate oxygen to my baby. I was sold.

A pregnant woman’s body undergoes so many changes that often she develops illnesses and ailments that she’s never had before-and may well never have again-but which can be quite problematic during pregnancy. Treating illness during pregnancy can be a real challenge because many medications have not been adequately tested in pregnant women and their exact effects on the pregnant woman and her baby are unknown. However there are many situations, my asthma being one such case, where treating the ailment outweighs the potential harm of the medication. At the very least, the untreated condition is as hazardous to the mother and baby as the treatment. So what should a pregnant woman do if she becomes ill or if she is on regular medication for a chronic condition? Let’s address the chronic condition first.

Chronic Conditions and Pregnancy

Many women with chronic medical conditions such as asthma, epilepsy, colitis, depression and others may take medication regularly to manage symptoms and keep flares or attacks at bay. However, many of the medications used to treat these conditions may be harmful to a developing fetus. Very little pharmaceutical testing is done on pregnant women due to the potential harm to both mother and baby. So if a woman has a chronic medical condition and is contemplating pregnancy-or has already become pregnant, her is what she should do:

  • Notify her obstetrician or midwife immediately that she is on medication for a chronic condition
  • If she has a specialist who is monitoring her chronic condition, notify them immediately of her pregnancy
  • DO NOT STOP YOUR MEDICATION! This could have serious medical effects for you and your baby. Consult with the provider who prescribed your medication and discuss whether or not to continue the medication, to change medications, or to taper off the medication entirely. Medication changes should always be supervised.
  • Notify your providers of any and all medications that you are taking, especially if you have to change medications due to your pregnancy, so that you can avoid potential interactions and side effects.

Transient illnesses and Pregnancy

Pregnancy depresses a woman’s immune system, leaving her susceptible to many viruses and illnesses she would otherwise be able to easily fend off. So many women contract colds, allergies and other maladies and can’t seem to shake them. When this occurs, check with your OB or midwife to determine which over the counter (OTC) medications are safe for you to take.

A word of caution: Don’t assume that “natural” or “herbal” preparations are safe to take during pregnancy. So many people assume that if something is “natural” it is not harmful. Nothing could be further from the truth! Many pharmaceuticals are actually derived from herbs or plants. Penicillin for example, was originally derived from mold yet is a potent antibiotic. Herbs and “natural” preparations work because plants have bioactivity, i.e. they are able to change your biology.  This is how all medications work-they act on your body to either suppress a symptom or to enhance your body so that it can fight whatever is ailing it. However, because a woman’s body changes so much during pregnancy, what is normally harmless (at least to her) may in fact be harmful (if not to her, potentially to her baby). Always check with your OB or midwife before taking any medication while you are pregnant.

There is no doubt about it, pregnancy is wonderful and yet hard on a woman’s body. But with proper daily care and professional expertise as needed, most pregnant women cruise peacefully through pregnancy and have healthy babies.

Photo:  I was about 6 months pregnant with my son in this photo. My then 3 yo daughter is trying to move me.