You may have heard that the Centers for Disease Control and Prevention (CDC) recently recommended a new vaccine for use in the third trimester of pregnancy. Known as Abrysvo^TM, the vaccine helps protect newborns against severe cases of respiratory syncytial virus (RSV). RSV is the leading cause of infant hospitalization in the United States, with anywhere from 58,000-80,000 hospitalizations occurring each year among children younger than 5. Even more upsetting is that 100-300 children under age 5 die from RSV every year. With these statistics in mind, this new RSV vaccine is exciting news for infants and their families.

Ava, 24 weeks along with her first pregnancy, contacted the MotherToBaby live chat service early one morning with some questions about the new RSV vaccine. First, she wanted to understand how vaccinating a pregnant woman could provide protection for a baby. As a Teratogen Information Specialist, I was happy to answer this question for Ava. I started by explaining that when a person gets vaccinated, their body makes antibodies. These antibodies protect the body against the actual infection if a person is exposed to the virus or bacteria later in life. During pregnancy, the antibodies that a pregnant woman makes after being vaccinated can cross the placenta and pass to the developing baby, providing the newborn with some protection against the infection during the first few months of life.

I went on to explain that although the RSV vaccine is new, the idea of getting a vaccine during pregnancy to protect the baby (called “passive immunity”) has been around for some time. The Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough), has been recommended for use in pregnancy since 2011. Whooping cough is another infection that can be very serious for newborns, so having protection from birth as a result of maternal vaccination is ideal. The flu shot and COVID-19 vaccine can also pass antibodies to the developing baby during pregnancy. This is great news since newborns can’t get their own flu or COVID-19 shots until 6 months of age and need to rely on passive immunity in the meantime.

Next, Ava had a question about when she should get the RSV vaccine. She had plans to get her flu shot and Tdap vaccine at her next prenatal visit at 28 weeks. She wanted to know if she could get the RSV vaccine at the same time. Although these three vaccines (along with the updated COVID-19 vaccine) can all be given on the same day, the RSV vaccine should be given during a specific timeframe in order to pass as many antibodies as possible to the baby. Experts recommend that the RSV shot be given between 32 and 36 weeks of pregnancy. This allows enough time for RSV antibodies to pass to the baby before delivery.

With this recommendation in mind, Ava decided that her prenatal appointment at 32 weeks would be the perfect time to get the RSV vaccine. She had seen firsthand just how serious RSV can be when her 1-month-old niece was hospitalized with RSV last winter, so she didn’t want to take any chances with forgetting to get the RSV vaccine during her pregnancy.

Before we ended the chat, I mentioned to Ava that there is also a shot called nirsevimab (Beyfortus^TM) that can be given directly to babies under 8 months of age. Also known as a monoclonal antibody, this shot is another way to protect infants against severe RSV disease. Most babies do not need nirsevimab if their mom received the RSV vaccine during pregnancy. I suggested Ava talk with her healthcare provider about the pros and cons of both options.

Although having to remember to get another vaccine in pregnancy can feel like just one more thing a pregnant woman needs to add to their never-ending to do list, the decision to vaccinate can prevent serious complications from RSV, and possibly even save the baby’s life. Here at MotherToBaby we are happy to go over the current recommendations for vaccines in pregnancy and answer any questions that you may have. Don’t hesitate to call, chat, text, or email with any questions about the RSV vaccine or other exposures during pregnancy. You can also check out our newest fact sheet about this vaccine here https://mothertobaby.org/fact-sheets/respiratory-syncytial-virus-rsv-vaccine-abrysvo/.  

References:

Centers for Disease Control and Prevention. 2023. RSV Vaccination for Pregnant Women. Available at: https://www.cdc.gov/vaccines/vpd/rsv/public/pregnancy.html

Centers for Disease Control and Prevention. 2023. RSV Surveillance & Research. Available at: https://www.cdc.gov/rsv/research/index.html

Let’s be honest, we live in an era of perfection. Perfect hair, perfect nails, perfect teeth, perfect everything! Nowadays, it seems like almost all the celebrities, and influencers, have some type of work done on their teeth, and it looks great! Makes you want to try it out for yourself. However, these options might not be affordable or available to everyone. I know I wouldn’t be able to get those treatments for myself. So, I have settled for teeth whitening products used at home. Because yes, I too want pearly white teeth!

Now, does it matter if I am pregnant or  breastfeeding? Which ones are okay to use, the strips, the toothpastes, and/or the blue light therapy? So many options to choose from, right? Before we talk about each of those ingredients, it’s important to point out that every pregnancy starts out with a small chance (3-5%) of having a baby with a birth defect, we call this the background risk. Now that we have defined the background risk, when we talk about any possible increased risk for birth defects, we refer to the increased risk above that background risk. Now, let’s break it down and take a look at some of these products and their ingredients.

1. Whitening strips

Most teeth whitening products contain various ingredients that are not well studied in pregnancy or lactation. Without good research it’s difficult to know whether the ingredients can cause a problem for the developing baby or breastfed infant. However, when the product is used as directed on the teeth (not swallowed) it is unlikely that a significant amount would enter the pregnant woman’s system or the breast milk. Let’s take a closer look at some of those common ingredients:

• Carbamide peroxide breaks down into urea and hydrogen peroxide when in contact with organic compounds in living tissues.

  • Urea is a chemical formed from protein breakdown and is often used in lotions to improve hydration. Urea is also found naturally in the body and is also part of breast milk. Since the body can excrete large amounts of urea, exposure to small or moderate amounts of urea is not expected to increase the chance of birth defects or cause any adverse effects to the breastfed infant.
  • Hydrogen peroxide is added to cosmetics and personal care products as an antimicrobial ingredient to inhibit the growth of microorganisms. It also oxidizes stains on the teeth to whiten them. When in contact with your teeth, hydrogen peroxide will break down as a molecule of water and oxygen gas. Because of this, it is not likely to pose any significant chance for birth defects or problems while breastfeeding.

You may also find,

• Sodium Hydroxide. This ingredient is commonly found in industry and home-based products, such as soaps. It is toxic to tissues, and it is not meant to ingest or breathe. When used in dental preparations, they alter the acidity of the mouth for better protection of the teeth. There are no human studies done on sodium hydroxide in pregnancy or breastfeeding. However, due to potential maternal alkalosis (increase in the pH of the body), careful use should be advised in when an individual has kidney problems during pregnancy or while breastfeeding.
• Glycerin is colorless, odorless, and a sweet glycerol (sugar alcohol), used as a lubrication agent in multiple cosmetic products such as toothpaste, shaving cream, and soaps. Glycerin crosses the placenta in small amounts but there are no studies in humans looking at glycerin. However, since data in animals did not show any increase in birth defects, it is not likely that glycerin in tooth whitening would put a pregnancy or breastfed infant at increased chance for problems.
• Menthol is widely used in a variety of products in the cosmetic world as a flavoring and fragrance agent. There are no studies in humans on use of menthol in pregnancy or breastfeeding. However, animal data did not show any increase in birth defects. Therefore, when used in small amounts, it is unlikely to pose any increased chances for birth defects or any other problems during pregnancy or while breastfeeding your baby.
• Carbomer is commonly used as thickening agents and emulsifiers for pharmaceuticals and many other products. Carbomer is added to teeth whitening strips as a thickener and usually found in small amounts in some products. Because of the large molecular size of carbomer and the small amount used in these products, it would be unlikely to cause problems during pregnancy or enter the breast milk in amounts that are of concern for a breastfeeding baby.

2. Whitening toothpastes

Majority of these toothpastes contain:

• Sodium Monofluorophosphate (MFP), a sodium salt commonly used to increase the amount of fluoride incorporated into the enamel which can help prevent cavities. No research has been done during pregnancy; it is unknown if it causes problems for the baby. Sodium Monofluorophosphate can potentially cause adverse effects if ingested, its use should be monitored closely during pregnancy and while breastfeeding your baby.
• Sodium fluoride is a colorless or white powder that dissolves in liquid. Sodium fluoride is mostly used for prevention of dental cavities, to polish the teeth, and reduce oral odor. Sodium fluoride can be found in drinking water. Ingestion of these ingredients in excessive amounts during pregnancy could lead to impaired development of the baby’s teeth. Sodium fluoride gets into the breastmilk in small amounts, and it is not expected to cause adverse effects to the breast-fed infant.

3. Blue (LED) Light Therapy

This therapy is often used to treat acne and sun damage. This therapy will only work in areas where the light reaches, and it usually needs a combination of photosynthesizing drugs to activate the ingredients and help whiten the teeth. This blue (LED) light therapy is used with gels or strips containing some of the ingredients above. Some may contain ingredients we have not reviewed above. There is limited research on the use of blue light therapy during pregnancy or breastfeeding and the risk of birth defects or other pregnancy problems are unknown. However, the light itself is not expected to increase the risk of birth defects or pose any adverse effects to the breastfed infant.

4. Other ingredients commonly used:

• Herbals are not regulated by the Food and Drug Administration (FDA). Therefore, we are never sure what is in the product, and there is not enough information to evaluate possible risk to a developing baby or breastfed infant. For more information about herbals and supplements during pregnancy or breastfeeding, please refer to our fact sheet at: https://mothertobaby.org/fact-sheets/herbal-products-pregnancy/.
• Alcohol should be avoided completely during pregnancy. It has been established that there is no known amount or type of alcohol that is okay to consume during pregnancy. However, using a teeth whitener with alcohol is not expected to result in a significant amount getting in your bloodstream or the breast milk since the product is applied topically. Do not swallow or drink any of these products and use as directed on the package. If desired, you can select an alcohol-free product. To read more about alcohol during pregnancy and while breastfeeding, please refer to our Fact Sheet at: https://mothertobaby.org/fact-sheets/alcohol-pregnancy/ .

If you are interested in learning more about other products and their individual ingredients, make sure to contact the experts at MotherToBaby.

And remember, it is important to feel good in your own skin but, if you are leaning towards getting your teeth whitened, here are some tips to think about before buying any product. 

1. Look for non-alcohol based products.
2. Use the product as directed, do not swallow it, and do not exceed the time listed on the package.
3. Contact the experts at MotherToBaby.org with your questions.

By: Kirstie Perrotta, MPH and Becky Spencer, PhD, APRN, PMHNP-BC, IBCLC, PMH-C, FILCA

Shannon was newly pregnant and had been referred to MotherToBaby by her doctor. She was taking 50 mg of sertraline per day for general anxiety and her doctor thought that she may need to wean off the medication now that she was 5 weeks pregnant. Shannon had been taking the medication for 3 years and was feeling great on her current dose, so she had some concerns about this plan. On the MotherToBaby website’s live chat service, Shannon was connected with me, a teratogen information specialist, where she asked “Do I really need to stop my anxiety medication, or could I just continue on a lower dose?”

I started by addressing the importance of weighing the risks vs. benefits of taking any mental health medication during pregnancy. Sertraline is very well studied and has not been associated with a risk for birth defects, but does have the potential to cause neonatal adaptation syndrome or withdrawal approximately 10-30% of the time and persistent pulmonary hypertension in less than 1% of exposed infants. On the other hand, we know that untreated anxiety can also cause problems for the pregnancy, including an increased risk for preterm delivery. For many patients, the benefits of staying on a medication like sertraline outweigh the potential risks, but each case is unique and ultimately the patient needs to decide what they are most comfortable with.

Getting to Shannon’s next question about dose, I shared that although many pregnant women feel they need to decrease their dose once they get a positive pregnancy test, the opposite is in fact true. During pregnancy, there are many changes that occur including weight gain, increased blood volume and enlargement of the kidneys. On the outside, things won’t look much different, but research shows these changes happen soon after conception. This means that medication doses that previously worked well to control a condition become “diluted,” in a sense, and may not be as effective. In some cases, women need to actually increase their dose to continue to control the disease.

To learn more about how bodily changes during pregnancy impact medication dosing, we turn to Becky Spencer, PhD, APRN, PMHNP-BC, IBCLC, PMH-C, a psychiatric nurse practitioner who specializes in perinatal mental health at Texas Women’s University with some more questions about this fascinating phenomenon.

Q. Can you tell us a little more about what is happening in the body during pregnancy and why medications become less effective?

Becky Spencer: You are correct, Kirstie, that pregnancy has a significant impact on drug absorption, which is how a drug is transported into the bloodstream, drug distribution, which is the disbursement of a drug as it moves through the blood and tissues of the body, and drug metabolism, which is the process by which the body breaks down and eliminates drugs or other substances. During pregnancy, especially later in pregnancy, drug absorption from the stomach into the bloodstream is decreased due to slower gastric emptying and slower movement of the bowel and colon, so it can take longer for a medication to be absorbed and get to work.

A pregnant woman’s blood volume almost doubles during pregnancy which impacts drug distribution. With the dilution effect there is a lower concentration of medication in the blood plasma which results in less medication reaching the target tissues. Most drugs are metabolized in the liver or kidneys. During pregnancy, the increased blood flow to the kidneys results in an increased glomerular filtration rate (GFR), which means that medications are cleared from the bloodstream quicker, meaning the drug stays in the body less time. Similarly, hormone levels increase during pregnancy which increases the activity of various metabolic enzymes in the liver that metabolize drugs. When the liver metabolizes a drug more quickly there is less drug that reaches the target tissues.

What these changes mean for pregnant women who take medication for mood and anxiety disorders is that the dose of medication that they were taking before pregnancy may have a decreased effect during pregnancy, because the biological changes effectively decrease the amount of medication reaching the target tissues, in this case, the brain. Pregnant women may have an increase in mood and anxiety symptoms that they interpret as a worsening condition when, in fact, the decrease in circulating medication is the cause for an increase in symptoms.

Q. In your practice, how often do you see women increasing their mood medication dose? Does the dose need to be increased substantially?

Becky Spencer: That is a great question. The answer is that it depends on the type of medication, the specific condition (depression, anxiety, obsessive compulsive disorder, bipolar, etc.), and the severity of symptoms. Psychiatric providers typically increase medication dosages in gradual amounts until the patient has symptom relief or desired therapeutic effect. If a patient is experiencing a partial response to a medication (some improvement in mood and anxiety symptoms) best practice is to increase the dose of that medication before considering adding an additional medication.

Another question that I hear is whether or not dosages of medication should be based on achieving a specific blood plasma concentration level. The short answer is, for most medications, no. We don’t routinely check blood plasma concentrations of most antidepressants because valid and reliable therapeutic plasma concentration ranges do not exist. Some mood stabilizing medications like valproate or lithium do require blood plasma monitoring both during pregnancy and outside of pregnancy. Euthymia, or stable mood, is the goal of medication dose adjustments for mood and anxiety disorders during pregnancy.

Q. What about after delivery? Does the dose need to be decreased right away?

Becky Spencer: It depends on the type of medication, and, to some extent, the symptoms that the patient is experiencing. The postpartum period is a vulnerable time for mood and anxiety disorders for several reasons including the significant hormonal shift that occurs after birth, lack of sleep, role adjustment to caring for a baby, and for some new parents, lack of necessary social and emotional support. Decreasing antidepressants too quickly after birth could exacerbate mood and anxiety symptoms during that very vulnerable time. The decision to decrease dosages of any medication prescribed for mood and anxiety disorders should be a collaborative decision between the patient and the provider. If decreasing mediation dose is desirable, it should occur gradually and any change in mood and anxiety symptoms should be reported to the provider. The one exception to this rule is for patients taking lithium. If lithium dosages were increased during pregnancy, they must be decreased to pre-pregnancy dosages after delivery.

Q. Shannon is asking about sertraline, an anti-anxiety medication, but are there other drugs that women need to also increase their dose of during pregnancy?

Becky Spencer: Any medications used to treat mood and anxiety disorders, including antidepressants, mood stabilizers, antipsychotics, and anti-anxiety medications, may need dose increases during pregnancy. The most important point is for pregnant women to monitor their mood and anxiety symptoms and report them to their provider. The decision to increase doses of medication should always be a collaborative decision between the patient and the healthcare prescriber.

Q. How should patients approach this conversation with their healthcare provider?

Becky Spencer: The decision to take any medication during pregnancy must be based on a discussion between healthcare providers and patients that takes into consideration the available research on the risks of specific medications AND the risks of untreated or undertreated mental conditions for both the pregnant woman and the baby. The risks of not treating mood and anxiety disorders during pregnancy are well documented and significant. Untreated or undertreated mood and anxiety disorders during pregnancy are associated with hypertension, preterm delivery, low birth weight, and long-term negative impacts on motor and cognitive development of the baby. Mental health conditions are the leading cause of maternal mortality in the United States. Effective treatment for mood and anxiety disorders in the perinatal period will literally save lives.

My top three tips for having a discussion with healthcare providers about medications for mood and anxiety disorders in the perinatal period include:

• Make an appointment with a psychiatric provider who specializes in perinatal mood and anxiety disorders or reproductive psychiatry. The provider directory on the Postpartum Support International website is a great place to find specialists in your state, and many provide telehealth services.

• If your obstetric provider is hesitant to treat your mood and anxiety symptoms, recommend that they make an appointment to speak with a psychiatric provider who specializes in treatment of perinatal mood and anxiety disorders during pregnancy at the Postpartum Support International Psychiatric Consult Line. This free service is staffed by perinatal psychiatrists who are available to share their skills and expertise and provide guidance to fellow medical professionals on prescribing medications during pregnancy and lactation.

• MotherToBaby Fact Sheets are an excellent resource and a great way to start a conversation with your provider about specific medications for mental health during pregnancy and lactation. I recommend that pregnant and lactating women who are taking medications for mood and anxiety disorders access and print out the MotherToBaby Fact Sheets for the medications that they are taking or are interested in learning more about, read them, jot down questions, and take them to their obstetric and/or psychiatric providers to start the conversation. Remember that you are your own best advocate for you and your baby’s health.

Thanks so much for sharing your insight, Becky. It’s always great to learn more about this topic.

Ultimately, Shannon decided to stick with her current dose for the first few weeks of pregnancy and make an appointment with her psychiatrist to discuss increasing her dose in a few weeks. In the meantime, she was planning to monitor her mood to make sure the anxiety remained well controlled.

If you have questions about mental health medications, dose, or any other exposures in pregnancy or lactation, please feel free to reach out to a MotherToBaby specialist via phone, chat, text, or email for more information. Additionally, you can visit our Mental Health Resource Hub to access fact sheets, blogs, and podcasts on mental health conditions and the medications used to treat them during pregnancy and breastfeeding.

References:

• Cook, N., Ayers, S., & Horsch, A. (2018). Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. Journal of Affective Disorders, 225, 18–31. doi:10.1016/j.jad.2017.07.045
• Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms Are Not OK: COVID-19 and Maternal Mental Health. Frontiers in Global Women’s Health, 1. doi:10.3389/fgwh.2020.00001
• Deligiannidis, K. M., Byatt, N., & Freeman, M. P. (2014). Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. Journal of Clinical Psychopharmacology, 34(2), 244-255. doi: 10.1097/JCP.0000000000000087
• Grigoriadis, S., Graves, L., Peer, M., Mamisashvili, L., Tomlinson, G., Vigod, S. N.… Richter, M. (2018). Maternal Anxiety During Pregnancy and the Association with Adverse Perinatal Outcomes. The Journal of Clinical Psychiatry, 79(5). doi:10.4088/jcp.17r12011
• Hussein W, Lafayette RA. Renal function in normal and disordered pregnancy. Curr Opin Nephrol Hypertens. 2014 Jan;23(1):46-53. doi: 10.1097/01.mnh.0000436545.94132.52. PMID: 24247824; PMCID: PMC4117802.
• Hutner, L. A., Catapano, L. A., Nagle-Yang, S. M., Williams, K. E., & Osborne, L. M. (Eds.). (2021). Textbook of women’s reproductive mental health. American Psychiatric Pub.
• Prakash, C., & Nagle-Yang, S. (2019). Postpartum psychosis: Protecting mother and infant. Current Psychiatry, 18(4), 12-21.
• Rusner, M., Berg, M., & Begley, C. (2016). Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes. BMC Pregnancy and Childbirth, 16(1). doi:10.1186/s12884-016-1127-1
• Sachdeva P, Patel BG, Patel BK. Drug use in pregnancy; a point to ponder! Indian J Pharm Sci. 2009 Jan;71(1):1-7. doi: 10.4103/0250-474X.51941. PMID: 20177448; PMCID: PMC2810038.
• Shay, M., MacKinnon, A. L., Metcalfe, A., Giesbrecht, G., Campbell, T., Nerenberg, K. … Tomfohr-Madsen, L. (2020). Depressed mood and anxiety as risk factors for hypertensive disorders of pregnancy: a systematic review and meta-analysis. Psychological Medicine, 50(13), 2128–2140. doi:10.1017/s0033291720003062
• Slomian, J., Honvo, G., Emonts, P., Reginster, J.-Y., & Bruyère, O. (2019).
• Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women’s Health, 15, 174550651984404. doi:10.1177/1745506519844044
• Trost, S. L., Beauregard, J. L., Chandra, G., Njie, F., Berry, J., Harvey, A., Goodman, D. (2023). Pregnancy-Related Deaths: Maternal Mortality Review Committees in 36 states, 2017–19. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html

“I’m supposed to get dermal fillers tomorrow, is it still safe for me to get this procedure!?” Erin had booked this appointment with their dermatologist weeks ago, and while Erin was so excited today to learn that they were pregnant, they weren’t sure if the fillers were still a good idea. Hopeful for smoother skin and less noticeable wrinkles, they called us for guidance. Erin isn’t alone in having questions – MotherToBaby information specialists are often asked about getting cosmetic procedures during pregnancy or while breastfeeding.

Some cosmetic procedures require surgery; these are a type of plastic surgery. Examples include liposuction, breast augmentation, and rhinoplasty (nose). These types of cosmetic surgeries are best avoided while pregnant. But what about less invasive procedures? Let’s look at some commonly asked about treatments:

Botox

Botox is an injectable form of botulinum toxin. When used cosmetically, Botox is typically injected in the face or neck to help smooth out wrinkles or fine lines in the skin by temporarily paralyzing or relaxing the muscles. Botox is expected to stay in the area where it is administered and not enter the bloodstream. Because of this, it is unlikely to enter breast milk or to cross the placenta where it could reach a developing baby. However, it is important to note that Botox hasn’t been studied specifically for use during pregnancy or breastfeeding. There is also a risk for infection at the injection site, and the possibility that the toxin could spread beyond the area where it was administered. Read more about Botox here: https://mothertobaby.org/baby-blog/botox-baby-what-we-know-about-the-risks-during-pregnancy-breastfeeding/

Semi-Permanent Makeup & Microblading

Semi-permanent makeup is achieved by tattooing areas of the face to highlight natural features and typically lasts for a few years before fading. This might include eye liner, lips, or eyebrows. Microblading is another form of tattooing used on the eyebrows. When it comes to the ink used in semi-permanent makeup, it isn’t clear how much of the pigment in the ink is able to enter the blood stream, cross the placenta, or how much is able to reach the baby. For folks who are breastfeeding, it also isn’t clear how much of the pigment might pass into breast milk. This makes it difficult to know if the pigment itself might cause a risk. We do know that with any tattoo, there is a possibility of infection if the equipment is not sterilized properly. There can be a risk for Hepatitis B, Hepatitis C, HIV, and other infections like staph. There is also a possibility of infection during the healing process. If you do choose to get semi-permanent makeup while pregnant or breastfeeding, be sure to go somewhere that is practicing good hygiene. Also be sure to contact your healthcare provider if the tattooed area seems like it isn’t healing correctly.

Teeth Whitening

Many people are also interested in brightening up their pearly whites. Some common teeth whitening products include whitening strips, whitening toothpastes, at home Blue (LED) Light Therapy, and professional whitening procedures administered by a dental hygienist or dentist. For the most part, these products are not expected to increase risks to a pregnancy or a breastfeeding baby. For more details about specific ingredients in teeth whitening products see: https://mothertobaby.org/baby-blog/whitening-teeth-during-pregnancy-or-breastfeeding-lets-bite-into-the-subject/

Chemical Peels

There are a few different types of cosmetic chemical peels that are used to address uneven skin tones, wrinkles, acne scarring, or sun damage by applying a product on the skin (topically) that then removes part of the upper layers of the skin. This usually involves a type of acid – it might be a combination of hyaluronic acid, glycolic acid, trichloroacetic acid, salicylic acid, or lactic acid and other ingredients. Light chemical peels involve the outer layer of skin (epidermis). Deep chemical peels can penetrate a bit further into the layers of your skin. Because the chemicals in each peel can vary, it can be a good idea to ask ahead of time for an ingredient list. A MotherToBaby specialist can talk with you about the active ingredients in the specific chemical peel you are considering. Read more about your skin & skin care here: https://mothertobaby.org/baby-blog/whats-the-skinny-on-skin-care

Lip Fillers & Dermal Fillers

Lip and dermal (or face) fillers are injected substances that are used to fill in lines and wrinkles or add volume to areas in the face or lips. There are currently four types of fillers that are approved by the Federal Drug Administration (FDA). Hyaluronic acid fillers are the most common. Hyaluronic acid, along with Calcium hydroxylapatite and Polylactic acid fillers are considered temporary – these will eventually be broken down and absorbed by the body. Polymethylmethacrylate is not absorbed by the body – this filler is made up of small round plastic beads suspended in collagen. So what do we know about the use of fillers during pregnancy or breastfeeding? The answer is not much. There is limited research on these substances when administered during pregnancy or while breastfeeding, so it may be best to pause any injections until a later date. There is also a potential risk for infection at the injection site. The FDA advises anyone interested in fillers to get them from a licensed healthcare provider and to discuss the risks and benefits with them before the procedure.           

So, what did Erin do about their appointment for dermal fillers?

When it comes to cosmetic procedures while pregnant or breastfeeding, it is important to consider what is known about a procedure and weigh any potential risks. In Erin’s case, they decided it would be best to wait to reschedule their next dermal filler appointment until after their child was born. They ended our call by telling me, “I think it will give me more peace of mind to cancel my appointment and wait until after my pregnancy now that I know there isn’t much research. I’ll talk to my dermatologist about other skin care options in the meantime.” 

Do you have a question about a cosmetic procedure during pregnancy or breastfeeding?

Speak with a MotherToBaby specialist via phone, text, chat, or email.

• My fear and anxiety over my soon-to-arrive first child is overwhelming on a daily basis…I’m angry some days, sad some days, and panicked other days.
• My anxiety and depression levels has been higher than normal
• I’m scared when I go anywhere or see anyone, even when I’m maintaining social distancing.
• We planned on having an amazing support team and the rug was pulled from under us.
• I realize this is uncharted territory, but I have not felt supported as a first-time mother.¹

These were the sentiments of pregnant individuals going through the pandemic.  It was an unprecedented event and as MotherToBaby Specialists we were challenged with dealing with the anxiety of expectant parents as they tried to get reliable information and deal with their fears, anxiety, and frustrations. Fortunately, as time went on, the infection did not appear to increase the chance of birth defects but now there is a question of the emotional toil it put on pregnant women.

Post-traumatic stress disorder (PTSD) is a condition of persistent mental and emotional stress that occurs after suffering a stressful or extremely traumatic event. Unlike post-traumatic stress that lessens over time, the symptoms of PTSD do not fade. Symptoms of PTSD fall into the following four categories and can vary in severity:

1. Intrusion: may include intrusive thoughts or distressing memories, flashbacks, nightmares
2. Avoidance: may include avoiding thinking or talking about the event or their feelings; avoiding things that remind them of the event (people, places, activities).
3. Negative changes in thinking or mood: may include lack of memory on details about the event; negative thoughts and feelings about themselves or others; feeling numb or detached from others; loss of interest in activities.
4. Changes in physical and emotional reactions (arousal): may include being irritable and having angry outbursts; self-destructive behavior; having problems concentrating or sleeping.

In general, PTSD occurs more often in women than in men and in the pregnant population more than non-pregnant individuals.  According to some studies, 3% to 19% of pregnant women experience PTSD.² When it comes to psychiatric disorders during pregnancy, PTSD after childbirth or postpartum PTSD is considered the third most common mental health disorder after depression and nicotine dependence.³

If left untreated or poorly treated, PTSD can have long lasting effects not only for the pregnant woman but also in her relationships with other people, especially family, and interfere in bonding with their child and breastfeeding that can have long-lasting impact on the child.   Pregnant women with untreated PTSD have a higher chance of experiencing negative birth outcomes including gestational diabetes (diabetes that develops during pregnancy), preeclampsia (severe high blood pressure), low birthweight (weight at birth of < 2500 grams,5.5 pounds), and preterm birth (before 37 weeks pregnancy).  Also, quite alarming, PTSD is closely linked to attempting or committing suicide and substance abuse, two leading causes of maternal death in the United States.³

We know that the pandemic was a stressful situation for the entire country and especially pregnant women, but what were the long-term effects, particularly in regard to PTSD.  In general, risk factors for postpartum PTSD include, but are not limited to, the fear of childbirth, prenatal health concerns (preeclampsia, birth defects), the lack of emotional/social support, depression and anxiety. During the pandemic the primary concern was the risk of infection for themselves and for their child before birth and after.  Also, birth plans had to be changed due to hospital restrictions. They did not have the social support that they expected or planned with their doulas, partners, family or friends.  The lack of social support was not only an issue during childbirth but remained after birth due to stay-at-home orders.  Furthermore, expectant parents may have had to face other problems amplified by the pandemic like unemployment and the loss of a loved one. The sense of security and community was greatly affected during the pandemic and then expectant parents had to navigate a new world while just becoming parents, as expressed by pregnant women above.  All of these factors can create a traumatic experience of childbirth and raise the chance for PTSD.

There have been multiple studies investigating the effects of the COVID-19 pandemic during pregnancy. While studies may have differed in their approach to review this topic, the results generally showed that giving birth during the pandemic had many effects on the pregnant population and that PTSD was quite common. Also, rates of PTSD were higher among Black and Latinx pregnant women than whites and lower socio-economic status (i.e., less educational and income).  

Recommendations:

There is a call for PTSD to be screened during pregnancy and after to make sure that no one falls through the cracks. It is suggested that providers who had patients deliver in the early part of the pandemic, follow-up with them to make sure they are coping well.  Not everyone who experiences PTSD will need counseling, but pregnant women should know about their options.

“Trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood, and untreated cause of human suffering,” said Peter Levine, PhD, trauma specialist. For pregnant individuals, if your symptoms are interfering with your quality of life, please speak with your healthcare professional so that you can get the assistance that you need. As MotherToBaby information specialists we can connect you  to the resources that can promote your health and well-being. We provide information about medications used to treat PTSD as well as exposure to anxiety, depression, and stress on pregnancy and breastfeeding. We are just one important resource that new and expecting parents can rely on for confidential information. Contact us today or visit our Resource Hub on Mental Health during pregnancy and breastfeeding.

There are resources available to help you.

Postpartum Support International: https://www.postpartum.net/learn-more/postpartum-post-traumatic-stress-disorder/

National Maternal Mental Health Hotline: 1-833-943-5746 (1-833-9-HELP4MOMS)

https://mchb.hrsa.gov/national-maternal-mental-health-hotline

References:

1. Kinser PA, Jallo N, Amstadter AB, et al. 2021. Depression, Anxiety, Resilience, and Coping: The Experience of Pregnant and New Mothers During the First Few Months of the COVID-19 Pandemic. J Womens Health (Larchmt). May;30(5):654-664. 
2. Padin AC, Stevens NR, Che ML, et al. 2022. Screening for PTSD during pregnancy: a missed opportunity. BMC Pregnancy Childbirth. Jun 14;22(1):487.
3. Khsim IEF, Rodríguez MM, et al. 2022. Risk Factors for Post-Traumatic Stress Disorder after Childbirth: A Systematic Review. Diagnostics (Basel). Oct 26;12(11):2598.
4. Sharpe, Rachel. “100+ PTSD Quotes to Help Survivors Cope with Trauma”. Declutter the Mind, 27 February 2021. https://declutterthemind.com/blog/ptsd-quotes/. Accessed 22 April 2023
5. Shuman CJ, Morgan ME, et al. 2022. Associations Among Postpartum Posttraumatic Stress Disorder Symptoms and COVID-19 Pandemic-Related Stressors. J Midwifery Womens Health. Sep;67(5):626-634.
6. Benzakour L, Gayet-Ageron A, et al. 2022. Traumatic Childbirth and Birth-Related Post-Traumatic Stress Disorder in the Time of the COVID-19 Pandemic: A Prospective Cohort Study. Int J Environ Res Public Health. Oct 31;19(21):14246.