When Counting Sheep Doesn’t Work: Insomnia and Pregnancy

By Patricia Markland Cole, MPH, MotherToBaby Massachusetts

During my work at MotherToBaby, I have received calls from pregnant woman who want to know what can they safely take to sleep? Usually they are looking at natural remedies like melatonin for information. For some who have been on medications like Ambien before they were pregnant, they now wonder if they can use it because they are having a hard time catching those Zzzz’s. Even though I am not pregnant, I am sure all of us can relate to a night where we wake up and cannot fall back to sleep. We slowly see the time ticking by 10 min, 30 min, 1 hr, 2hrs. It can be so frustrating, especially if you look over at your partner in a state of blissful slumber as you toss back and forth on the bed.

Many women have come to accept a lack of sleep or quality of sleep in pregnancy. In the early part of pregnancy, sleep is interrupted by nausea, vomiting, back pain and an increased need to urinate/pee. In the middle of pregnancy, women are uncomfortable in bed because the baby is moving and kicking, and then there is heartburn, cramps or tingling in the legs.

By the latter part of pregnancy, it is reported that over 97% of pregnant women cannot get a decent night’s sleep. They are waking up and staying awake for longer periods of time. I do recall how surprised I was when I sent an email to one of my colleagues at MothertoBaby in her third trimester of pregnancy, at the crack of dawn her time (I was on the East Coast, she was on the West). I was so surprised when she responded to my email and I knew it was way too early for her to be at the office. When I asked, she stated, she was up and couldn’t sleep and decided to make the most of her time. While many women and clinicians have come to accept this as just a part of pregnancy, the data is starting to show that we need to pay more attention to how pregnant women are sleeping during pregnancy.

What is Insomnia?
Insomnia is one of 3 common sleep disorders during pregnancy. Insomnia includes difficulty falling asleep or staying asleep, waking up very early in the morning, waking up not feeling rested or a combination of these symptoms. Many pregnant women do not view insomnia as a disorder or a problem in their pregnancy, but when it starts to impact how you function during the day especially when it is accompanied with sleepiness, lack of energy, increased irritability, agitation and stress, it should be considered more carefully especially if insomnia starts to occur more regularly and last longer. Having a good night’s rest is important for the well-being of the mother and child.

The concern with persistent insomnia is that it could increase the chance of hypertension and diabetes, which is just as concerning in people who aren’t pregnant too. Another concern is that people who suffer from insomnia have higher levels of substances that increase inflammation in the body (proinflammatory cytokines). These higher levels of cytokines are also seen in women who have experienced preterm birth, postpartum depression and other pregnancy complications. While no association with insomnia and adverse pregnancy effects have been made, researchers have started to take a closer look at the effects of insomnia due to some results. For instance one report observed a higher rate of preterm birth for pregnant women that were sleeping less than 5 hours a night in the latter part of pregnancy. And there were other observations that women who were sleeping less than 5 hours a night in the last month of pregnancy had longer labors and were more likely to have C-sections.

In light of these observations, health care providers are being asked to screen their patients for sleep disorders during pregnancy. The majority of pregnant women consider their insomnia to be mild but in some cases there could be more that is going on like undiagnosed depression or anxiety that can be responsible for the insomnia.

So what’s a tired mom-to-be to do?
Expectant mothers can do their part by being more proactive. It is suggested that expectant moms keep a daily sleep diary which would include your bedtime routine, how long it takes you to fall asleep, if you have difficulty falling back to sleep after waking up, how long you are awake at night and if you feel rested. Talk with your health care provider even if they have not brought it up with you. Sometimes changes in behavior can help, called ‘sleep hygiene’ which involves things like avoiding stimulants (caffeine), not eating late at night, getting exposure to adequate sunlight and using your bed for only sleeping (not watching TV). Other actions that pregnant women can try includes acupuncture, massage, yoga and exercise. In some cases a referral to a sleep specialist may be needed and if all else fails some women may require medications.

Sometimes moms start looking at a natural remedy like melatonin. Melatonin, a hormone that is produced by the pineal gland, is often taken as a supplement to help with sleep. Melatonin is available in two forms, either as a synthetic product or a product that is from animals, usually beef cattle. Most health care professionals recommend avoiding the melatonin from animals due to a very small chance of contamination or viral transmission. Also, melatonin is a supplement and not a medication. That means it’s not regulated by the Food and Drug Administration. Some studies have suggested avoiding use of melatonin during pregnancy due to a concern that the exposure might interfere with mom’s or baby’s sleep cycles.

Others want to know about prescription medications, like Ambien (zolpidem). Ambien has not been shown to increase the risk for birth defects when used in the first trimester of pregnancy. Since Ambien is a sedative hypnotic type of medicine, and has some features similar to benzodiazepines, it is thought that when used near the time of delivery, there may be temporary withdrawal-like symptoms in the baby.

Overall it is important to develop a plan with your health care provider and if a medication is needed, you can call MothertoBaby and we can provide information on medications suggested for use in pregnancy. Remember do not take sleeping lightly during your pregnancy; as one commentator put it, you are “sleeping for two.” You, your baby and even your partner will appreciate your effort.

Patricia Cole, MPH, is the Program Coordinator for MotherToBaby Massachusetts. She obtained her Bachelor’s degree in Biology from Simmons College in Boston and her MPH in Maternal and Child Health from Boston University School of Public Health. She has been the serving the families of New England as a teratogen counselor since 2001 and provides oversight for the day-to-day functions and outreach of the program. She has also provides education to graduate students and other professionals.

MotherToBaby is a service of OTIS, a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about viruses, alcohol, medications, vaccines, diseases, or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or try out MotherToBaby’s new text information service by texting questions to (855) 999-3525. You can also visit MotherToBaby.org to browse a library of fact sheets, email an expert or chat live.

References:
Nodine, PM. (2013). Common Sleep Disorders: Management Strategies and Pregnancy Outcomes. J of Midwifery & Women’s Health. 58:368-377.
Reichner,CA. (2015). Insomnia and sleep deficiency in pregnancy. Obstetric Medicine. 8(4):168-171
Won,CH.(2015). Sleeping for Two: The Great Paradox of Sleep in Pregnancy Commentary. J Clin Sleep Med. 11:645-654.

When Counting Sheep Doesn’t Work: Insomnia and Pregnancy

By Heidi S. Neuburger, MS, MA, Indiana University Audiologist

It was a busy day in the audiology clinic, but my 10AM patient made me pause. I reviewed the medical records for this adorable 2 1/2 year old. His mother, a daycare provider, had contracted cytomegalovirus (CMV) early in her pregnancy. Unfortunately, there is nothing unusual about this. You can get CMV by contact with bodily fluids from a person who carries the virus. If mommy is caring for toddlers, either at home or in her place of work, she is at very high risk for coming into contact with diapers, runny noses, table tops and toys that may be infected with the virus. As many as 38% of toddlers who go to day care may have CMV, and they can pass it to other children, their families, or care givers.

The symptoms of CMV can be mild, or there may not even be any at all. Symptoms can include a little sore throat, fever, swollen glands and fatigue for a few days. But when mommy catches CMV during a pregnancy, there can be serious consequences to the baby in the womb. Congenital CMV infection occurs in 1 out every 100 to 150 babies that are born to mothers with CMV, although only about 1 in 5 of these kids will have long term health problems. (CDC.org)

In this case, the medical record showed that my patient did indeed test positive for the CMV virus at birth. The virus crossed the placenta, from mother to the developing fetus, causing the infection. But to the relief of all, in spite of a positive diagnosis of the presence of the virus in the baby at birth, there did not appear to be symptoms other than a little jaundice, which returned to normal within a couple of weeks. The family breathed a sigh of relief. Yet – here they were. The toddler (now 32 months old) was not talking at all. In fact, he was lagging farther and farther behind his peers developmentally.

After 40 minutes in the sound booth with this little boy I was able to confirm that he had a severe hearing loss in both ears. The fact that he had passed his newborn hearing screen suggested that the hearing loss had been getting worse over time. And a hearing loss of this degree surely had something to do with his delayed language development, and other possible developmental delays.

What can we learn from this challenging outcome? What could have been done?
For October’s National Audiology Awareness and Protect Your Hearing Month, I thought it was particularly timely to focus on the lesson learned from this little boy’s situation. More often than not, when a baby is exposed to CMV in the womb, especially early in the pregnancy, there will not be birth defects. In fact most babies will be born without symptoms or obvious defects. In one study (Naing et al, 2015) 18% of children born positive for CMV were without symptoms at birth, but later had a delayed onset of hearing loss. I would have liked to have seen a heightened level of suspicion that hearing loss may emerge with this child, because of his congenital CMV diagnosis. It may not be possible to stop the onset or worsening of this hearing loss, but repeat testing of his hearing every 4 to 6 months would have gone a long way toward early identification of the hearing loss, and earlier intervention with hearing aids and speech/language therapy.

Hearing loss is just one of the potential effects of CMV infection during pregnancy. To learn more about the broader range of effects, how to test for CMV, and how you can prevent infection, visit the CMV and Pregnancy fact sheet: https://mothertobaby.org/fact-sheets/cytomegalovirus-cmv-pregnancy/. And remember: a MotherToBaby expert is just an email, text message, live chat, or phone call away!

Heidi S. Neuburger, MS, MA, works as an infant laboratory coordinator as part of the technical staff at Indiana University’s Department of Otolaryngology-Head & Neck Surgery. She was program coordinator of MotherToBaby’s Indiana affiliate from 2014 – 2016.

When Counting Sheep Doesn’t Work: Insomnia and Pregnancy

By Lori Wolfe, Certified Genetic Counselor and Teratogen Information Specialist,
MotherToBaby North Texas

Have you ever had a pregnant friend tell you, “it is OK to have just one glass of wine now and then, that’s what my doctor said,” or “my mother drank beer when she was pregnant with me, and I turned out fine.” As a Teratogen Counselor (a birth defects expert), I hear these statements more than you would imagine. You may think it is common knowledge that there is no safe level of alcohol use during pregnancy, and that any use of alcohol while pregnant has the potential to harm the baby. Yet that message is not getting out there to everyone. Studies have long shown that heavy use of alcohol during pregnancy can cause Fetal Alcohol Syndrome, while more recent studies suggest that moderate use (and possibly even light use) can cause long term developmental problems in an exposed child. In fact, Fetal Alcohol Spectrum Disorder is thought to be the leading cause of developmental delays in children. Despite this, studies also show that 1 in 10 to 1 in 13 women continue light drinking of alcohol, even after they know they are pregnant. So I started thinking… Why do some woman continue to drink alcohol during pregnancy?

1. You Didn’t Know You Were Pregnant
Most women find out they’re pregnant when they are 4-6 weeks along – and many may not recognize the signs of pregnancy for quite a few months. So unless you are planning your pregnancy (50% of all pregnancies today are unplanned!), you may indulge in alcoholic beverages before you even know you are pregnant. Thankfully, the majority of women will stop using alcohol once they find out they are pregnant. But unfortunately, the damage could already be done. Harmful exposures (like alcohol) during those first critical weeks of pregnancy have the greatest risk of causing major birth defects. This is why experts at the Centers for Disease Control and Prevention (CDC) recommend that women avoid alcohol not only if they are pregnant or trying to become pregnant, but also if they are sexually active and not using an effective method of birth control.

2. Mixed Messages
It’s not uncommon for pregnant women to receive mixed messages from people they trust about how safe alcohol may be in pregnancy. Even her own doctor may tell her that an occasional glass of alcohol won’t harm her baby. There’s a lot of misinformation out there, even among healthcare providers! It’s important for you and your healthcare provider to keep in mind that the experts at the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (among many others) advise that women avoid alcohol entirely while pregnant, because no amount of alcohol – even light-to-moderate amounts – can be considered safe for a developing baby.

3. It’s A Social Thing
Social pressure from family or friends can be strong. If a woman is used to going out on weekends with her friends and everyone has a glass of wine, she may feel that she needs to drink too, just to fit in. Plus many women feel that the risk of having just a little alcohol during pregnancy is low. These same woman may be doing everything else that they can to remove all other risks to their pregnancy, but they still continue to use alcohol. At MotherToBaby, we understand that the use of alcohol during pregnancy may have perceived benefits to a woman. But we also know that alcohol provides ZERO benefit for a developing baby, and, in fact, can only harm the baby. And because the exact amount of alcohol that could harm a baby is unknown at this point (and does vary woman-to-woman and even pregnancy-to-pregnancy), our philosophy is: WHY TAKE THE RISK?

4. It Helps Me Relax, De-Stress, and Just Deal with Everyday Life
Recently a 35 year old caller told me that she continued to enjoy a half glass of wine every weekend as a treat to herself. “Susan” (not her real name) knew that she was not supposed to drink alcohol, and she even said she got a lot of negative feedback from family and friends, yet she continued to drink throughout her pregnancy. Without realizing it, Susan and other women may be using alcohol to help deal with other unrecognized issues in their lives, such as depression and anxiety, high levels of stress, or little outside support for the pregnancy. At MotherToBaby, it is our job to help women understand how fragile and vulnerable a pregnancy can be to certain exposures; alcohol is one of the dangerous ones. While it may seem a hardship to give up alcohol entirely while pregnant, think about it this way: Pregnancy is only 9 months long (less if you base it on when a woman learns she is pregnant). If a woman is strong enough to survive childbirth, courageous enough to take on the toughest job on earth (parenthood), and resilient enough to survive that job, then abstaining from alcohol for the duration of a pregnancy is nothing. And if it means giving your baby a chance at the best possible start in life, then not drinking alcohol while pregnant is everything.

What Do We Know? There is not a known safe level of alcohol use during pregnancy.
We have known about Fetal Alcohol Syndrome for over 40 years now. Dr. Kenneth Jones, the doctor who first named Fetal Alcohol Syndrome in 1973 states: “When talking about the prenatal effects of alcohol, we usually think exclusively about the dose, the strength, and the timing of alcohol exposure. However, perhaps even more important are factors involving the mother – her genetic background and nutritional status to name just two. Without knowing those genetic and nutritional factors that are critically involved with the way a woman metabolizes alcohol, it is not possible to make any generalizations about a “safe” amount of alcohol during pregnancy.” Studies have shown moderate use, and possibly even light use, of alcohol during pregnancy can cause long term developmental problems in the exposed children. In fact, Fetal Alcohol Spectrum Disorder is thought to be the leading cause of developmental delays in children. Scientists are continuing to study how and why alcohol affects the developing baby, and in future years we will know more about this. But for now we do know there are always risks with drinking alcohol during pregnancy.

Lori Wolfe is a board certified Genetic Counselor and the Director of MotherToBaby’s North Texas affiliate. MotherToBaby aims to educate women about medications and more during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/breastfeeding via MotherToBaby’s toll-free number and by email, Wolfe also teaches at the University of North Texas, provides educational talks regarding pregnancy health in community clinics and high schools, and counsels adoptive parents.

When Counting Sheep Doesn’t Work: Insomnia and Pregnancy

By Bethany Kotlar, MPH, MotherToBaby Georgia

**This information was current as of the time the blog was published. However, information is constantly changing. Please visit Zika Central for the latest information.**

As a teratology information specialist, I counsel women and their families on medications, chemicals, herbal remedies, and illnesses that could harm developing babies. So as the Zika Virus, a viral infection that can cause severe birth defects including microcephaly (a condition where a baby’s head is much smaller than expected, and may indicate a baby’s brain has not developed properly during pregnancy), spread from the Polynesian Islands, to South America, to the Caribbean, I made sure to educate myself on everything we know about the virus, reading article after article and keeping up to date on the Centers for Disease Control and Prevention (CDC’s) recommendations to avoid infection, knowing that eventually I would need this information to counsel a pregnant woman or her family. I never imagined I would use this information to try to prevent becoming infected myself, and that I would fail.

One week in February I opened an email from my in-laws with the subject “30th Birthday Plan.” My husband’s 30th was a few weeks away, and I was excited to see what they had planned. As I read the email detailing a week-long sailing trip in the Caribbean I felt blessed, and honestly a little scared. I rushed to the CDC’s page on Zika to look up whether the islands we were visiting had outbreaks. Sure enough-16 Caribbean islands, including the two we were visiting, had Zika outbreaks. At first I didn’t want to go, which set off an intense inner debate racked with guilt. “How could I say no to a surprise trip for my husband, especially one planned and paid for by my in-laws?” I thought, and in the next second, “But what if I get Zika? I work with pregnant women, I can’t expose them!” Finally, my Dad stepped in. “You’re too adventurous to let Zika scare you away from a vacation.” he said. “Fine,” I thought, “I’ll go, but I’m going to be careful.”

I was careful. Despite the gentle teasing from my in-laws, I insisted on sleeping indoors with the windows closed, even though it was more comfortable outside. I wore bug spray with 30% DEET when I thought mosquitos would be out. I got three or so bites at dinner one night, and three more at the end of our trip. As we headed home I mentally patted myself on the back; “Only six bites,” I thought, “pretty sure I didn’t get Zika!” I was so sure that three days after our trip when I developed a head-to-toe rash I was certain it was an allergic reaction, but after three doses of Benadryl did nothing, I googled Zika-related rashes. Dead ringer. Symptoms of the Zika Virus include rash, joint and muscle pain, red eye, fever, and headache, and boy did I have them. I rushed in to see an infectious disease doctor, who came to the same conclusion. “My money’s on Zika,” he said. Suddenly everyone wanted a piece of me; my blood was sent to the county board of health, Emory’s lab, and a lab in Washington for testing.

A call from the county board of health confirmed what my aching joints hinted at: I tested positive. My first thought was to thank my lucky stars that I have access to safe, reliable birth control. My second was to start worrying about those around me. I had brunch with a pregnant friend before I had symptoms-could I have given her Zika? Thankfully, the answer is no (more on that below)! I was amazed at how a short vacation and six bites could give me Zika. I thought about all the people going to the Caribbean for vacation. How many of them are pregnant or could become pregnant while traveling? Would they wear bug spray? Would they recognize the symptoms? How many are men who could get Zika and then unknowingly transmit it to their sexual partner? How many people are walking around not knowing they were infected? I called my friend and begged her to wear insect repellant for the rest of her pregnancy.

As of July 27, 2016, 1.658 cases of Zika, including 433 pregnant women have been confirmed in the continental United States; 4 cases of local transmission have been reported in Miami-Dade and Broward counties in Florida. There are likely far more cases since most people don’t have symptoms, so never get tested. Zika is mostly spread through mosquito bites, but can also be spread through sex, blood transfusions, or from a mother to baby during pregnancy. We don’t know how long the incubation period (the time between when you get infected and when you see symptoms) is, but it is likely a few days to weeks. For most people the virus stays in the blood for about a week, but some people still have the virus in their bodies for as long as two months. Currently, the only Zika outbreak in the continental United States is in a small area of Dade County, Florida, however,, the mosquitoes that can carry Zika are found in some areas of the US, making a Zika outbreak in the U.S. very possible. You can follow these steps to protect yourself:

1. If you are pregnant or could be pregnant (planning a pregnancy or not using birth control), don’t travel to a country with an active Zika outbreak. You can find a list of current outbreaks here.

2. If your partner has traveled to a country with an active Zika outbreak and you are pregnant, use condoms correctly every time you have sex for the rest of your pregnancy. Why, you might ask? Because Zika can stay in semen longer than in blood, but we don’t know exactly how long it stays there. To be as safe as possible, the CDC recommends using condoms for 6 months.

3. If your partner has traveled to a country with an active Zika outbreak and has symptoms of Zika (rash, fever, headache, joint pain, and conjunctivitis) use condoms correctly whenever you have sex and avoid pregnancy for at least six months. If he does not have symptoms, use condoms and avoid pregnancy for at least two months.

4. If you have traveled to a country with an active Zika outbreak and you are not pregnant, avoid pregnancy for at least two months. The Zika virus can also be transmitted from a woman to her sexual partner. Because of this, use condoms and/or a dental dam when you have sex for two months. Do not share sex toys.

5. If you are currently pregnant, avoid mosquito bites as much as possible by wearing bug spray outdoors (bug spray with at least 30% DEET is preferable; for information on the safety of DEET during pregnancy, see here), wearing long-sleeved shirts and pants, closing windows or using windows with screens, and removing any standing water from around your house. Two things to remember: the mosquitos that spread Zika are daytime biters and like to be indoors, and they can breed in pools as small as a bottle-cap.

If you have questions about the Zika virus or you have been infected or exposed and want free up-to-date information about what this could mean for a current or future pregnancy, you can contact a MotherToBaby expert by phone at (866) 626-6847 or by visiting https://mothertobaby.org//a>.

Bethany Kotlar is a teratology information specialist with MotherToBaby Georgia. She holds a Masters in Public Health specializing in Maternal and Child Health, and is a Certified Childbirth Educator. She enjoys exercising, traveling (and collecting viral illnesses), and Netflix.

MotherToBaby is a service of OTIS, a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about viruses, alcohol, medications, vaccines, diseases, or other exposures, call MotherToBaby toll-FREE at 866-626-6847. You can also visit MotherToBaby.org to browse a library of fact sheets, email an expert or chat live.

When Counting Sheep Doesn’t Work: Insomnia and Pregnancy

By Beth Conover, APRN, CGC, MotherToBaby Nebraska

So…you were really good during your entire pregnancy, giving up every drop of alcohol, quitting smoking tobacco, and, of course, avoiding any drug like marijuana. You were concerned about the development of your baby, and doing everything you could to make a healthy outcome more likely. Good job! But now here you are….you’ve had your baby, you’re giving breastfeeding your best shot…do you still need to be so careful? If you’re wondering this, you’re not alone. It is a top question I get as a health care provider and one of the top questions we get from moms through MotherToBaby’s text information line. I’m a mom myself and after I had my boys, I asked the same things, like “would having a glass of wine when I’m on a date with my husband be the end of the world if I’m breastfeeding?”

Alas, many years later (and many published studies later), I have answers for you.

Let’s start with the facts about breastfeeding. Breastfeeding is good for you and the baby, and you should continue nursing for at least 6 months… and better-yet, a year.

I think of alcohol and tobacco as ‘recreational drugs’ because there is not any medical reason to use them. And while medical use of marijuana is becoming more widespread, for most of us the use of marijuana is not medically necessary. We don’t want rules surrounding the use of alcohol, tobacco, and marijuana to be unnecessarily strict so that they discourage nursing for the optimal amount of time. But we also want nursing moms to know that each of these drugs are passed to breast milk. Fortunately, there are often ways that we can limit the amount that baby gets.

Let’s take a closer look at each one…

Alcohol—alcohol of all kinds (wine, beer, liquor) passes into your milk. Babies don’t like the taste of it, and, if it happens often enough, babies may show developmental delays from exposures to alcohol through breast milk. Fortunately, waiting 2-3 hours after drinking a single alcoholic beverage results in lower amounts in milk. If you have two drinks, wait 4-6 hours…you get the idea. You can pump for comfort and to maintain your milk supply, but be sure to throw away the milk since it likely has alcohol in it. Chronic or heavy users of alcohol probably should not breastfeed.

Tobacco—you know that it is best for your health and that of your baby to avoid smoking tobacco, but if you cannot resist, keep the number of cigarettes as low as possible (preferably less than ½ pack per day) and never smoke around your baby. Nicotine gets into your milk, so try to wait several hours after you smoke before nursing your baby. Second hand smoke increases your baby’s risk for ear and respiratory infections, asthma, and even sudden infant death syndrome. The immunoglobulins in your milk help to lessen those risks, which is why most experts still recommend breastfeeding even if a woman is smoking small amounts of tobacco.

Marijuana – THC, the active ingredient in marijuana, passes into breast milk. Marijuana production is not very well regulated, so there may be other dangerous contaminants. There are not many studies regarding use of marijuana and breastfeeding, but there are concerns that exposure to THC via milk might affect baby’s development. It can also reduce your milk supply. Until more is known, it is recommended that marijuana be avoided in breastfeeding women, and that an effort also be made not to expose the infant to second hand marijuana smoke. If you happen to use marijuana, waiting 1-2 days before resuming nursing will help reduce the amount in milk. Pump and throw away milk in the meantime for comfort and to maintain your milk supply.

Bottom line, by breastfeeding, you’re already taking the first step in providing continued important nutrition for your baby. Way to go! Taking steps to make sure your breastmilk stays as healthy as possible for the entire time you breastfeed will be well worth the effort. Stay strong, live well.

Beth Conover, APRN, CGC, is a genetic counselor and pediatric nurse practitioner. She established the Nebraska Teratogen Information Service in 1986, also known as MotherToBaby Nebraska. She was also a founding board member of the Organization of Teratology Information Specialists (OTIS). In her clinical practice, Beth sees patients in General Genetics Clinic, Prenatal Clinic, and the Fetal Alcohol Syndrome Clinic at the University of Nebraska Medical Center. Beth has provided consultation to the FDA and CDC. Two of her recent publications are, “The Art and Science of Teratogen Risk Communication” and “Safety Concerns Regarding Binge Drinking in Pregnancy: A Review.”