By Kirstie Perrotta, MPH, MotherToBaby California and Lorrie Harris-Sagaribay, MPH, MotherToBaby North Carolina

With schools back in full swing, fall activities underway, and children gathered once again in classrooms and other indoor settings, parents—including those who are pregnant—have renewed questions about COVID-19 and COVID-19 vaccines. MotherToBaby is seeing an increase in questions from pregnant women who want to protect themselves and their families as much as possible. Although more and more women are confident about getting vaccinated against COVID-19 in pregnancy, we continue to get questions about vaccine safety, as well as inquiries about eligibility for the updated boosters. MotherToBaby has teamed up with the Centers for Disease Control and Prevention (CDC) to give you the latest about vaccination for those who are pregnant and for children.

What is the current impact of COVID-19 and pregnancy? 

At this point in the pandemic, we know the importance of taking steps to help prevent a COVID-19 infection in pregnancy. Research has shown that women who are pregnant have a higher chance of becoming very sick, being admitted to intensive care, and needing to be put on a ventilator if they get COVID-19. Some studies have reported a slightly higher chance of death. Researchers have also found increased chances of adverse effects on the pregnancy itself, including preterm delivery, stillbirth, and complications such as preeclampsia.

The good news is, a recent study found that pregnant women who received two doses of an mRNA COVID-19 vaccine had lower rates of stillbirth than those who were unvaccinated. Furthermore, those who also received a booster had lower rates of infection, hospitalization, and pregnancy complications related to COVID-19 than those who received only the two primary doses. This finding is reassuring that staying up to date on the vaccines provides good protection in pregnancy in case of a breakthrough infection.

Why should women who are pregnant and those trying to expand their families consider getting vaccinated against COVID-19?

Vaccination is the best way to protect yourself against getting seriously ill, being hospitalized, and dying from COVID-19. This is true for everyone, but especially for those who are pregnant and others who are at higher risk of complications from COVID-19. Getting vaccinated during pregnancy has the added benefit of passing antibodies to the developing baby, which has been shown to lower the baby’s chances of infection or hospitalization with COVID-19 during the first few months of life.

For those planning a pregnancy, the preconception period is a great time to become up to date on recommended immunizations, including COVID-19 vaccines. This helps ensure that future pregnancies will start out as protected as possible from COVID-19 and other vaccine-preventable illnesses. CDC has helpful information here about vaccines before pregnancy: https://www.cdc.gov/vaccines/pregnancy/vacc-before.html.

What are the long-term effects on the baby when a person gets a COVID-19 vaccine during pregnancy?

It will take time to follow the children of women who were vaccinated in pregnancy to be able to answer this question with data. However, based on what is known about how these and other vaccines work, getting a COVID-19 vaccine during pregnancy is not expected to cause long-term problems for the child. In fact, a pregnancy that stays up to date on the vaccines is more protected and less likely to have complications from COVID-19 that could affect a child’s future growth and development, such as preterm delivery. In addition, studies have demonstrated antibody protection for the infant following vaccination during pregnancy. And, of course, vaccination during pregnancy will continue to protect the parent after delivery while they are caring for their newborn.

Should women who are pregnant get an updated booster?

It is common for vaccines to be updated over time to give better protection against new variants spreading in the community, just as the flu shot is updated every year to provide the best protection against current strains of influenza. The updated COVID-19 booster, which gives added protection against the Omicron variant, is also referred to as bivalent. Women who are pregnant should receive this latest booster for the most up-to-date protection against COVID-19. CDC and the American College of Obstetricians and Gynecologists strongly recommend that pregnant women stay up to date with COVID-19 vaccines, including booster doses.

Like most other people, women who are pregnant are eligible for the updated booster if they have completed a primary COVID-19 vaccine series and it has been at least two months since their last dose (primary or booster). The updated booster can be given in any trimester of pregnancy. Anyone who has had a recent COVID-19 infection can consider delaying the booster by up to 3 months from the time their symptoms started or they tested positive.

Are COVID-19 vaccinations recommended for breastfeeding?

Studies have found that the components of mRNA COVID-19 vaccines are unlikely to enter the breast milk, and no serious side effects have been reported for the breastfed baby. In rare cases, there may be a temporary reduction in milk supply when a person gets an mRNA COVID-19 vaccine, but reassuringly, supply is expected to return to normal within a day or two. In more good news, antibodies against the virus that causes COVID-19 have been found in the breast milk of women who have been vaccinated with mRNA COVID-19 vaccines while breastfeeding. This is a promising finding, although more research is needed to know how much and for how long these antibodies might protect a breastfeeding child against the virus.

CDC, the Academy of Breastfeeding Medicine, and the American Academy of Pediatrics recommend that women who are breastfeeding stay up to date with COVID-19 vaccines, including booster doses.

What resources help pregnant women make informed decisions about protecting themselves and their families against COVID-19?

For questions about COVID-19 vaccines and other exposures during pregnancy and breastfeeding, talk with your healthcare provider or contact a MotherToBaby specialist. You can find MotherToBaby resources on COVID-19 and COVID-19 vaccines at https://mothertobaby.org/pregnancy-breastfeeding-exposures/covid-19/.

For guidance surrounding kids, we’ll turn to Leandris C. Liburd, PhD, MPH, the Associate Director for Minority Health and Health Equity for the Centers for Disease Control and Prevention (CDC).

by Sarah Obican, MD, MotherToBaby President

Though I wish I didn’t remember the day well, I do. I was a maternal fetal medicine fellow in NYC and I was sitting with my two beautiful co-fellows. When I say my co-fellows were beautiful, I mean that inside and out. We were an odd pairing of three musketeers. Young, bright, professional women, training to take care of women with high-risk pregnancies… and all three of us were pregnant. It was completely unplanned and highly unusual for all three of us to conceive, all within a few short weeks of each other. But there we were one day, sitting at our desks, talking about our individual research projects and occasionally interjecting in each other’s conversations with excitement about our future babies. I loved my two colleagues so much, and I was so excited to imagine that we would follow each other’s careers and see our children grow up, all similar in age.

In the middle of this conversation, something made me just get up and say to them “I’ll be right back!” I still don’t know what made me do it. I had a feeling hard to describe, but it made me walk over to our ultrasound unit and ask my sonographer colleague to please do an ultrasound.

I was on the examining table within minutes. But her silence after she put the probe down on my ultrasound gooped-up belly felt like an eternity. Another sonographer came into the room. I knew. That’s when the world went dark.

Now, I am physician and I cannot explain this. For a few moments, quite literally, the bright NYC day, the room, the people in the room, went completely dark. I couldn’t see. I didn’t lose consciousness, but I couldn’t see.  In my career, I sadly had to care for countless women who went through a miscarriage and in that darkness, I wondered if they had experienced the same. A few moments later I was back in the ultrasound room, now with an overcoming wave of sadness which made me wish I was in the numbing darkness again.

The American College of Obstetricians and Gynecologists estimates that 26% of all pregnancies end in a miscarriage and a significant proportion of those are in already clinically recognized pregnancies (when the pregnant woman already knows she is pregnant).

Miscarriage vs. Abortion

The words miscarriage and abortion are often used interchangeably. For example, a missed abortion in the world of obstetrics means that pregnancy stopped naturally and that there is no heartbeat or if early enough in the pregnancy, that there is no continuation of fetal growth or development. These pregnancies can pass naturally with bleeding or can be aided by a physician by giving medication of performing a procedure. During this time, there is a lot in terms of discussion of possible contributing factors including abnormal genetics and counseling on recurrence for the next pregnancy. It’s a tough, sensitive time for patients. I know it from both sides.

Ectopic Pregnancy

Sometimes desired pregnancies present themselves as ectopic pregnancies. An ectopic pregnancy is when an already fertilized egg implants and begins to grow outside of the uterus in an area that cannot adequately support the pregnancy. Most of the ectopic pregnancies (>90%) occur in the fallopian tube, but no matter where the pregnancy implants, it can be life threatening for the pregnant woman. This is because the location in which the ectopic pregnancy has implanted cannot grow, expand and adequately support the pregnancy nutritionally and can result in the structure rupturing and causing internal bleeding. While all miscarriages can feel devastating, an ectopic pregnancy is an emergency that requires immediate treatment by a physician. Depending on the size and development of the ectopic pregnancy and the patient’s symptoms, the ectopic pregnancy can be treated with medication or by surgery. This too gives a great sense of loss for patients because often these pregnancies were highly desired.

It is important to note that being treated for a miscarriage or an ectopic pregnancy either by the use of medications or surgery is not considered a termination. As a high-risk obstetrician, I know that providing great medical care for a miscarriage, an ectopic pregnancy or providing access to desired abortion care is essential for the pregnant woman’s health and safety.

Shedding Light on the Darkness

With my personal journey of years of infertility and in vitro fertilizations, there are not many positives from that sunny day in NYC. However, that personal darkness shed light on all of what my patients in similar situations had to go through. I talk about my history openly, if asked. When appropriate, I share with my patients about my loss and about infertility. I am reminded by my patients that we have to speak more about these human experiences. To normalize them, to not feel alone.  As for the experience of that day, I am thankful for that knowledge and when I have to be the first to tell my patient that she just had a pregnancy loss, I get close to her and I hope that my words, my actions and my demeanor show them what I am thinking inside…. I see you and I’ve got you.

References/Resources

https://www.acog.org/advocacy/abortion-is-essential

https://www.acog.org/advocacy/facts-are-important/understanding-ectopic-pregnancy

https://www.ncbi.nlm.nih.gov/books/NBK532992/#:~:text=The%20American%20College%20of%20Obstetricians%20and%20Gynecologists%20%28ACOG%29,early%20pregnancy%20loss%20occurs%20in%20the%20first%20trimester

It was late on a Tuesday when a chat came in from Dr. Rodriguez. “My patient is taking a medication for epilepsy. She is planning a pregnancy and I’ve seen from some sources she may need to take more folic acid to help prevent birth defects. Does she need to be on a higher dose?” As teratogen information specialists, we receive many inquiries regarding folic acid; and it was understandable why this healthcare provider was confused as the guidance isn’t exactly straightforward.

What is folic acid?

Folic acid is the lab made form of folate. Folate is a B9 vitamin. Folate and folic acid help the body create new cells and can lower the chance of having a child with a class of birth defects called neural tube defects, which are problems with the brain and spinal cord. The neural tube forms very early in pregnancy (around 4 to 6 weeks after the first day of the last menstrual period), so it’s important that any woman who could become pregnant get enough folic acid at least one month BEFORE she gets pregnant. In the United States many of our foods, such as breakfast cereal, bread, pasta, and rice are fortified with folic acid, which meant the vitamin has been added to the food. According to the Centers for Disease Control and Prevention (CDC), folic acid fortification programs have led to a 35% decrease in the rate of neural tube defects! We also get folate, which is the naturally occurring form of Vitamin B9, from foods like dark leafy greens, beans, citrus fruits, and nuts. However, only about 50% of this form is bioavailable (able to be absorbed and used by the body) so additional intake, in the form of a supplement, is recommended by organizations like the CDC and National Institutes of Health (NIH).

How much is needed?

The CDC recommends that all women of reproductive age get at least 400 mcg (0.4 mg) of folic acid each day. Once pregnant, organizations like The NIH and the United States Preventative Services Task Force (USPSTF) recommend that women who are pregnant get 600 to 800 mcg (0.6 to 0.8 mg) of folic acid per day. This amount can usually be met by taking an over-the-counter prenatal vitamin; a higher amount is not recommended for most pregnant women.

Women who have previously had a pregnancy affected by a neural tube defect (NTD) should take a higher dose of folic acid if they are planning to become pregnant again. The CDC and the American College of Obstetricians and Gynecologists (ACOG) recommends 4,000 mcg (4 mg) per day for these individuals. This higher dose should be started at least one month before becoming pregnant and should be continued through the first three months of pregnancy.

So what about Dr. Rodriguez’s patient who was on an anti-epileptic drug (AED) for her seizure disorder? Many, but not all, medications in the AED class are known as “folic acid antagonists.” This means that they can interfere with how the body absorbs and uses this important vitamin. If someone becomes pregnant while taking a folic acid antagonist, they may have lower levels of folic acid in their body and their pregnancy could be at higher risk of neural tube defects. That said, there is no great research that shows that taking extra folic acid would lower the risk of NTDs for women taking folic acid antagonists. So, should a woman taking an AED stick with the 400 mcg per day that is already recommended for everyone, or take more just in case it could be helpful?

Let’s look at the current professional recommendations:

• The American Academy of Neurology and the American Epilepsy Society guidelines state that all women of childbearing age, with or without epilepsy, should be supplemented with at least 400 mcg (0.4 mg) of folic acid per day prior to conception and during pregnancy. They go on to say there is not enough data to know if taking folic acid at doses higher than 400 mcg offer greater protective benefits for women on AEDs.

• The American College of Obstetricians and Gynecologists (ACOG) recommends 4000 mcg (4 mg) of folic acid per day for individuals at increased risk of having a baby with a NTD, which includes women with seizure disorders.

• The Centers for Disease Control and Prevention (CDC) only recommends a higher dose of folic acid for those with a history of a pregnancy affected by a NTD.

• The U.S. Department of Health and Human Services (Office of Women’s Health) recommends talking to your doctor to determine the right dose of folic acid if you are taking a medication for epilepsy.

Clear as mud, right? The current consensus seems to be that there is no consensus. Some groups recommend a higher dose while others do not. In situations like this where there is no clear consensus from the professional groups, it comes down to weighing the risks vs. benefits. The risks include the fact that higher doses of folic acid are not well studied in pregnancy, could mask a B-12 deficiency, and may actually make some medications less effective. The benefits of taking more are theoretical (not proven). A higher dose of folic acid might be protective in preventing birth defects while on a folic acid antagonist, but there is not enough research to know if this is true. Ultimately, much more data will be needed to come up with clear guidelines for women with epilepsy.

Because Dr. Rodriguez’s patient was on carbamazepine, a folic acid antagonist that is associated with a higher chance for neural tube defects, she decided that she would have a thorough discussion of the risk vs. benefits of taking a higher dose of folic acid with her patient before she became pregnant. Dr. Rodriguez was glad she hadn’t missed any overarching recommendations for women who need to take medication to control their seizure disorders during pregnancy. She ended her chat by saying: “It can be a challenge to keep up to date with all the recommendations. I’m so glad to have access to MotherToBaby to be able to ask questions like this.”

MotherToBaby specialists are always happy to review the latest data and professional recommendations with healthcare providers and patients alike. If you have questions about folic acid, epilepsy medication, or any other exposures in pregnancy or lactation, please feel free to get in touch.

Summer is here!  For those of us who are pregnant (and I am currently in my third trimester of pregnancy), the heat and humidity are just a recipe for misery.  But you know who loves heat and humidity?  Yeast.  And summertime is prime time for vaginal yeast infections.         

What is a vaginal yeast infection?

Vaginal yeast infections are caused by an overgrowth of a fungus called Candida.  All women have a balanced mix of fungus (yeast) and bacteria that naturally grow in or around the vagina.  If this natural balance is disrupted, yeast can “overgrow” and cause a yeast infection.  Other names for yeast infection are “vaginal candidiasis,” “vulvovaginal candidiasis,” or “candidal vaginitis.”

Most of the time yeast infections are random, but there are some things that can disrupt this balance and increase the chance for a vaginal yeast infection.  Yeast loves to grow in humid and wet conditions, so simple things like not changing out of a wet bathing suit or sweaty yoga pants for a long time can increase chance for a yeast infection.  Changes in hormones can also increase the chance for a yeast infection.  The change in hormones is the reason why yeast infections also happen more commonly in pregnancy. 

How do I know if I have a yeast infection?

Signs of a yeast infection may include itching, burning and redness around the opening of the vagina, pain or discomfort during urination or sexual intercourse, and white or yellow “cottage cheese like” vaginal discharge.

It is important to know, however, that signs of a yeast infection can be very similar to other vaginal infections or sexually transmitted diseases.  Because of this, if you have the above symptoms during pregnancy do not assume that it is caused by a yeast infection (even if you have had yeast infections before).  Please call and visit your OB or midwife to confirm that it is yeast and not another infection, like bacterial vaginosis or a sexually transmitted disease.  

To confirm that it is a yeast infection your healthcare provider may do a pelvic exam and take a small sample of the vaginal discharge to examine in the office or send to a laboratory before recommending treatments. 

Are yeast infections harmful?

Other than being uncomfortable and sometimes painful, yeast infections do not usually cause complications in pregnancy or for the baby during pregnancy over the background risk.  We know that every pregnancy starts out with a 3-5% chance of having a birth defect and 10-15% chance for miscarriage. This is called the background risk. 

If left untreated, however, a yeast infection could pass to your baby’s mouth during labor and delivery and may cause the baby to have a condition called “thrush”.  Baby may then return the yeast infection back to you if the baby breastfeeds (causing yeast infection on the nipples).  Very rarely a yeast infection in babies can become serious because their immune systems are not yet well-developed.

Yeast infections can also cause body-wide infections and serious complications in pregnant women, especially those who have a weakened immune system because of other health problems. 

How do I treat a yeast infection?

Good news is that yeast infections are usually easy to treat and there are treatments that can be used in pregnancy!  Yeast infections are treated either topically (by placing an antifungal medication into the vagina) or orally (by taking a pill).  

• Oral Medications:  The most common oral antifungal used to treat yeast infections is called fluconazole (Diflucan®) and is typically given once in a single 150mg dose.  It is unlikely that the use of a single low dose of oral fluconazole during pregnancy would greatly increase the chance of birth defects or complications. However, the use of high dose fluconazole for many weeks in the first trimester of pregnancy might be associated with an increase in the chance of birth defects and miscarriage.  Because of this, the Centers for Disease Control and Prevention (CDC) have posted guidelines for treating vaginal yeast infections in pregnancy and these guidelines recommend topical therapies rather than oral medication.  For more details, visit our  Fluconazole (Diflucan®) Fact Sheet.

• Topical Medications: Most common topical therapies include antifungals called azoles and are usually used over a 7-day period.  There are many types of azole medications, but the most common ones used are clotrimazole or miconazole (common trade names include Monistat®, Micatin® and Mitrazole®).  For more details, visit our  Miconazole | Clotrimazole  Fact Sheet.

Some of these topical medications are also available over-the-counter (without a prescription).  You should not use an over-the-counter yeast infection medicine without first talking to your doctor.  Like we talked about before, there are other infections that may mimic a yeast infection and you do not want to be treating the wrong infection!  If you have used an over-the-counter medication and your symptoms do not go away, see your OB or midwife.

Rarely, some individuals may have more complicated yeast infections that last for a long time or come back more than four times a year.  These may have to be treated differently.

Is there anything I can do to prevent a yeast infection?

There are some things that can be done to help lower the chance of an infection developing.  Make sure to talk to your OB or midwife about other ways to lower the chance for yeast infections.

Some of these include:

1. Change out of wet clothes (such as a swimsuit or sweaty leggings) as soon as you can.
2. Use plain warm water to clean the outside of the vaginal area. Avoid using scented tampons and menstrual pads. Avoid hygiene sprays and douching.   
3. Sleep without underwear or in loose fitting pajamas.

Unfortunately, you cannot control the pregnancy hormones, so it is not possible to completely prevent yeast infections!  But the sooner you get it treated, the sooner you can go back to enjoying the regular miseries of being pregnant during the summer!

For more information please see:

Vaginitis | ACOG

Vaginal Candidiasis | Fungal Diseases | CDC

The air we breathe matters and often we do not have control over what is in it. For many, the Spring season brings beautiful flowers and a most welcome warming of temperatures, as well as spending more time outside. It also marks the explosion of pollen, which can irritate both those with allergies and people with asthma. Being outside to engage in outdoor activities also means we are exposed to any air pollution that may be present.

Pregnancy is a sensitive time for both the parent and the developing baby. Preventing issues related to allergies, asthma and air pollution is important for a few reasons. If you do have issues with asthma and it affects your breathing, the amount of oxygen in your blood can drop; this can create problems for baby as you are their source of oxygen while pregnant. The baby may have trouble growing as much as they should or may be born at a low birth weight. This can put the baby at higher risk for several health issues.

There has been increasing research on the possible effects of air pollution on pregnancies. Some studies suggest that higher amounts of pollution in the air are related to babies being born too small or too early. Air pollution also can make asthma symptoms worse. There are some ways to lower the amount of air pollution you are exposed to, and this may be even more important for those that live near highways or high traffic areas, or near landfills. Some clear ideas from the American Pregnancy Association include:

• Buying an air purifier to use in your home
• Checking the air quality before planning outdoor activities to see if it is dangerous for groups sensitive to air pollution or pollen. Simply visit this website and enter your zip code: https://www.airnow.gov/
• Choosing to spend more time indoors when air quality is low
• Buying some plants to have in your home that are known to improve air quality. Some common household plants known to help with this include Peace Lilies, Snake plants, Philodendrons, Spider plants, or Rubber Trees

Other important things to consider are checking in with your healthcare provider about any types of medications you may use to treat your asthma or allergies. Quitting your medications as soon as you become pregnant is often not the best choice for you or baby and managing your symptoms is important for the reasons discussed above. MotherToBaby has a landing page on asthma that includes resources: https://mothertobaby.org/pregnancy-breastfeeding-exposures/asthma/ and one about allergies: https://mothertobaby.org/pregnancy-breastfeeding-exposures/allergies/  These pages have links to fact sheets on many medications that are used to treat symptoms related to both topics. 

As you move through the Spring months into Summer, try to appreciate the seasons while also being aware of how air quality can affect your health. As the saying goes, when you are pregnant you are “breathing for two.” As a reminder, our fact sheets also have breastfeeding information near the bottom of them that you can check out. We also encourage you to remember air quality can affect young children as well – especially ones with asthma.  Finding a healthcare provider you and your family can see routinely to manage asthma related issues is important in order to avoid emergency room visits.

Take a deep breath and remember, whatever your concerns are, experts at MotherToBaby will do our best to give you useful information based on research, or to point you in the right direction if we are unable to help.