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.

Did you know that 70% of pregnant women take at least one prescribed medication? And that 90% take any medication during pregnancy? How do you know if it is safe for a pregnant woman to take these medicines?

MotherToBaby Teratogen Information Specialists (TIS) are experts at answering questions about any possible increased risk of taking an over-the-counter (OTC) or prescribed medication, as well as any other exposures! A teratogen is something that can increase the risk for birth defects to the developing baby, and other problems such as a smaller baby or early delivery, when exposure occurs during pregnancy. Special intensive training is required to become a TIS, before we are able to answer the questions of healthcare providers, pregnant and lactating women, their relatives and partners, prospective adoptive parents, and the public. We get calls from people of all ages, teens up to older adults, even prospective grandparents. Teratogen specialists learn how to investigate the question, summarize the data, and then communicate it in a way that is easily understood. Every contact is a little different because each scenario is different, but that makes each day endlessly fascinating for those at MotherToBaby who respond to your inquires.

This work is different than the work of other healthcare providers such as a genetic counselor, midwife or obstetrician – we don’t generally delve into family history, and we don’t make direct recommendations. We try to be reassuring as we give you the most up-to-date exposure information. We consider the potential effects of taking AND not taking a medication, herbal supplement, or OTC drug. There are important considerations when someone is planning a pregnancy, facing a newly discovered pregnancy or an unanticipated pregnancy, dealing with worsening mental or physical health conditions, or with the sudden diagnosis of a birth defect or pregnancy loss.

We answer questions from prospective adoptive parents who may only have 36 hours to decide if they will accept a baby whose biological mom used heroin, methamphetamine or alcohol in pregnancy. We listen to pregnant callers worried about the substantial alcohol they drank or the marijuana they used before getting a positive pregnancy test. We also answer questions from people worried about Zika virus exposure on their honeymoons. And common questions these days involve the COVID-19 virus and the COVID vaccines and booster shoots given at any time in pregnancy or while breastfeeding.                                                  

Teratogen specialists also get calls about the potential consequences of pain medications for those who are pregnant and facing surgery such as a pre-op visit for a herniated disc – and are in excruciating pain. We have numerous conversations with lactating women who were advised to “pump and dump” after dental work or general anesthesia, or CT scans and we are able to discuss why this dated practice is usually unnecessary. Some women call repeatedly due to anxiety or simply because our TIS team has reliable expertise. We also answer breastfeeding questions about COVID-19 and the vaccines, prescriptions and OTC medications, or how much of a drug gets into breastmilk.  And we get questions from pregnant and postpartum individuals who are trying to avoid using inhalers or taking their anxiety/nausea/ADHD medications. We share the research and reassure them that some health conditions need to be treated with medications because it’s best for mom and baby. Some conversations are more sensitive – such as women with a history of multiple miscarriages, IVF, or other high-risk pregnancies who are trying to make only the best choices in a high-stakes stressful time. Sometimes there are tears, and that’s OK.

Often, we talk about the benefits to the individual of taking/using the medication or other product, versus any possible risks to the pregnancy or the baby. We tell them to consider the long view, that as a parent, you will be making “risk vs. benefit” decisions for nearly the next two decades for the child growing inside you. So, it’s important for you to make a choice now that gives you a good quality of life, and also to consider every aspect of the consequences for you both mentally and physically. In addition, it is in the important input of your partner and your healthcare providers.

It is a privilege to be part of the lives of all those who come to MotherToBaby for information. We are sensitive to different cultures, backgrounds, sexual orientation, and gender identification. We have 12 affiliate offices in the US and one in Canada. We provide information by phone, text, email, and live chat, and because we work across three times zones, we can respond quickly!

Affiliate offices are based in universities, academic medical centers, or health departments. Our multi-disciplinary team of Teratogen Information Specialists includes genetic counselors, nurses, doctors, and others with a master’s degree or Master of Public Health specifically. We also provide services in Spanish. We meet at least annually for training plus more often within our own institutions to discuss new publications and developments in the field.

Please spread the word. We welcome your inquiries!

Carrie called MotherToBaby on a Monday morning. She sounded anxious. “I just got home from a pretty wild bachelorette party held last week in New Orleans. I started feeling nauseous on the plane and I have thrown up twice this morning. I couldn’t eat breakfast. I’m really tired and my breasts hurt a little. I’m worried I might be pregnant.” Carrie was wondering if we could help her figure out if she was pregnant or not. Although MotherToBaby mainly answers questions about medications and other exposures during pregnancy and breastfeeding, the “am I pregnant” question is one we hear often.

This call reminded me of another one that I received several weeks prior – Anya called to say that she was two days late for her period, but she hadn’t been able to take a pregnancy test just yet. She was taking birth control pills and had missed one day but took two pills the next day, just like her doctor had told her to do if that happened. She was hoping she wasn’t pregnant, but she was worried that taking the birth control pills may have increased the chance for a birth defect in her baby if she was pregnant.

January is National Birth Defects Awareness Month, and a great time for those planning a pregnancy to review their own risk for having a child with a birth defect. Over half of all pregnancies in this country are unplanned. Talk with one of our specialists. Together with MotherToBaby, you can consider your own risk in a thorough discussion. Also see this link to the CDC page on birth defects prevention.

Back to our callers’ situations. There are many signs of early pregnancy and they may be different from person to person. Yet there can be other reasons a person might have any of these symptoms, which is why it’s important to perform a pregnancy test. The following symptoms could be side effects from hormonal contraception OR early signs of illness OR your period is about to start OR actually signs of pregnancy. These include light vaginal bleeding or spotting, mild uterine cramping, sore or swollen breasts, feeling tired, feeling bloated, feeling moody, urinating more often than usual, food aversions, nausea or vomiting, constipation, stuffy or runny nose. Even a missed period might not mean you are pregnant.  

If you think you may be pregnant, the best way to know for sure is to take a pregnancy test. Home pregnancy tests, sold at grocery stores, pharmacies and drugstores, are about 90% accurate on the day you are supposed to have your period. If you wait just one more week, the tests are reported to be about 97-99% accurate. Taking a test sooner than the day your period is supposed to start can lead to false negative results. How? Pregnancy tests measure a hormone called human chorionic gonadotropin (hCG) in your urine and your body only makes this hormone if you’re pregnant. Your body makes more hCG as time passes though, and your test could be negative if there isn’t enough hCG to measure in your urine yet. Home urine pregnancy tests are just as accurate as the urine tests at the doctor’s office when they are used correctly and at the right time in your menstrual cycle. Before you begin, make sure to check the expiration date on the outside of the box. Carefully read the instructions. If you still aren’t sure about the result, visit a clinic to be tested again.

While a woman waits until the day she can take a pregnancy test, meaning until she knows for certain whether or not she is pregnant, it’s important to avoid alcohol, smoking, and drugs. All of these substances can be harmful to a pregnancy and to a developing baby. MotherToBaby is an excellent resource for discussing these exposures during pregnancy, plus for any medications you might be taking. This conversation can be useful in making decisions with your doctor about continuing or stopping a medication. In some cases, it may actually be better to continue taking certain medicines, for both your own health and the baby’s well-being. Don’t stop your medications until you speak with your doctor or pharmacist.

If your period has not started within a week after a negative result, you should take another pregnancy test. If it’s still negative, make an appointment with your healthcare professional to determine what may be going on. You might be stressed, be exercising too much, getting sick or experiencing hormonal imbalances. All of these should be discussed with a doctor. If you are not pregnant, it’s also an excellent time to discuss short-term birth control or long-acting reversible contraception (LARC) like IUDs or birth control implants. No contraceptive method is 100% effective, and I’ve spoken with people who became pregnant even with LARC, but the chance of an unplanned pregnancy is far less with correct use of contraception with every sexual act. It’s also a good idea to start tracking your periods to learn more about your body and to know when to expect your period. Check out your app store for free apps like: Flo, Clue Period & Cycle Tracker, or Ovia Fertility & Cycle Tracker.

If your home pregnancy test is positive, make an appointment with your healthcare provider. The sooner your pregnancy is confirmed, the sooner you can begin prenatal care. Either before or when you suspect a pregnancy, begin taking a daily prenatal vitamin with at least 400mcg of folic acid. These help support the baby’s growth and development and are an important supplement to a good nutritious diet. Check to see if you are up to date on all recommended vaccines. Get some exercise, plenty of sleep, and pay attention to your mental health. See our healthy pregnancy blog post for more details. MotherToBaby is here to help with any questions you have throughout pregnancy and while breastfeeding.