The holiday season was in full swing when Katie found out she was pregnant. She called me and wanted to know if she could continue to take Zoloft (or sertraline), the medication she was prescribed to treat her depression. The idea of coming off of the medication scared Katie, just as much as the idea of taking something that could affect her baby did. Katie also had been feeling a bit more exhausted and down than usual, possibly due to both her pregnancy and to a case of the holiday blues. ‘Tis may be the season to be jolly – but it is also a time when emotions (and stress levels) can run high.

Reasons for the Holiday Blues

Some of the most common reasons that people feel extra stress during the holidays include money, family, traveling, over-committing to attending events, and for some, the inability to spend time with their loved ones. Being pregnant can add another layer of anxiety to an already hectic time. Though the season is always presented as a time filled with joy, it can certainly take a toll on people’s mental health. It is important to note that when depression is left untreated during pregnancy, there may be increased risks for miscarriage, preeclampsia, preterm delivery, low birth weight, and a number of other harmful effects on mom and baby. See our fact sheet on depression and pregnancy. It’s also important during pregnancy to not stop (or start) taking any medications without first talking with your health provider. Whether or not a woman continues to take a medication throughout her pregnancy will depend on the benefits of taking the medication versus any possible risks associated with the medication. For that reason, I suggested to Katie that she should speak with her healthcare provider about whether or not continuing to take sertraline is in her best interest given her particular health history and pregnancy.

Mental Health & SSRIs

I then reviewed with Katie everything that we know about sertraline use during pregnancy. Sertraline has been one of our most viewed fact sheets on MotherToBaby.org in recent months, and is in a class of medications called SSRI’s, or selective serotonin reuptake inhibitors. A small number of studies have found associations between sertraline use during pregnancy and particular birth defects, such as heart defects. However, the majority of the studies looking at over 10,000 pregnant women, have found that women taking sertraline during pregnancy are not more likely to have a baby with a birth defect than women not taking the medication. Overall, the available information does not suggest that sertraline increases the chance for birth defects above the 3-5% background risk that is there for every pregnancy. We have a wonderful fact sheet on this medication that you can view here. We also have a mental health web page where you can see links to fact sheets on other SSRI’s and commonly prescribed medications for people dealing with depression and anxiety, as well as Baby Blogs on related topics. All of our fact sheets also address breastfeeding, so if you are in the postpartum period please also take a look or reach out to us with questions.

If you’re feeling blue this holiday season, remember that it is just as important to take care of yourself as it is to care for those around you. The holidays can also be a wonderful time of year to take stock of what it is in life that you’re thankful for. If you do find that you are feeling down or depressed and have been feeling this way for quite some time, seeing your healthcare provider may be a good step to take. If you are pregnant and dealing with feelings of sadness and depression, do not assume you cannot take a medication to help with your symptoms. If you are pregnant and already taking a medication for depression, don’t stop taking it without talking to your healthcare provider. Always check with your health care provider before starting or stopping any medication.

The experts at MotherToBaby are always here to offer the latest information on medications in order to help you and your healthcare provider make the best care plan possible for you and baby. If you’re feeling blue, make sure to reach out to a friend or family member that can remind you you’re not alone, and that you are cared for. To all women and their families, here’s to a healthy, happy holiday season!

If you have listened to the news lately, you have probably heard of the outbreak of lung injuries and related deaths associated with e-cigarettes and vaping products. Breaking news by health experts have reported that tetrahydrocannabinol (THC) was present in most of the samples of the products and lung tissue collected from the injured individuals, but Vitamin E acetate was present in all of the samples that have been tested to date. While this is a major breakthrough, the experts are not ready to draw any conclusion as of yet, for it is possible that there are other ingredients involved. Here at MotherToBaby we strive to prepare for the questions that may arise from hot topics such as this for the women and providers we serve. Therefore, this seems as good a time as any to ask, “What do we know about vaping and pregnancy?” For the purpose of this blog, I’m going to focus on nicotine vaping.

What are ENDS?

Electronic nicotine delivery systems (ENDS) describe a variety of products that includes vaporizers, vape pens, hookah pens, tank systems, mods and electronic cigarettes (e-cigarettes). Although ENDS were originally developed as an alternative way to inhale tobacco products (like nicotine), the devices are now also used to vape other substances, like cannabis. Each of these devices work by heating a liquid to produce an aerosol that a person inhales into their lungs producing a mist (vape). The liquid in ENDS can contain: nicotine, tetrahydrocannabinol (THC), cannabidiol (CBD) oils, propylene glycol and glycerol.

Are ENDS a safer alternative than cigarette smoking in pregnancy?

ENDS products came on the market in the U.S. in 2007, and their popularity quickly grew. One of the reasons they grew in popularity was due to the belief that they were a safer alternative to cigarettes, and could help smokers quit or reduce the amount of cigarettes they smoke. Cigarettes contain nicotine and many other agents as well as carbon monoxide. Cigarette smoking during pregnancy has been associated with an increased chance of miscarriage, cleft lip or palate, premature birth (before 37 weeks) and SIDS (sudden infant death syndrome). Smoking has also been associated with an increase chance of infertility, ectopic pregnancy (a pregnancy that occurs outside of the uterus) and complications with the placenta (i.e., placental abruption and placenta previa). The issues with cigarette smoking are not only limited to pregnancy but continue after the birth of the child as well. Smoking has been associated with a higher chance for asthma, childhood obesity and behavioral problems.

While pregnancy is a big motivation for women to quit smoking, many struggle and look for a solution during pregnancy. Complicating the issue is the fact that many nicotine replacement therapies have not been well studied, and their effectiveness in helping smokers to quit has been questioned. Therefore, there is a hesitancy to use them. Also, medications to help stop smoking, like bupropion (Wellbutrin) and varenicline (Chantix), while not considered to pose a significant chance of birth defects, have limited data regarding their use in pregnancy. Recently the Food and Drug Administration (FDA) added warnings to the label regarding an increased chance of psychiatric effects including suicidal thoughts. This does not mean these medications should not be used by pregnant women who medically need them, but it shows how complex the issue of choosing an appropriate medication can be when you need to weigh the risks versus benefits. This leads pregnant women to find an alternative that might solve their problem and for some, ENDS seemed like the solution when they came on the market.

The effects of inhaling the substances contained in ENDS are not known, especially when it comes to pregnancy. One study has shown that users of e-cigarettes can obtain a substantial amount of nicotine from e-cigarettes that is comparable to regular cigarettes, and we do know that nicotine can cross the placenta. Animal data shows that exposure to the chemicals found in e-cigarettes can cause various effects on offspring that include impact to the immune system, lung and heart function, and neuro-development (related to the function of brains and nerves); unfortunately, so far there is no data to suggest what the impact in human pregnancy might be. In addition, while ENDS products may reduce exposure to many of the toxins in cigarettes, there is still exposure to nicotine and other toxic chemicals, which can pose an increased chance of harm to pregnancies. Also, some ENDS products that have stated they were free of nicotine have been tested and were actually found to contain nicotine.

There is no evidence to support ENDS as an effective way to stop smoking.

A recent review of the use of ENDS products among non-pregnant patients found no strong evidence that they help in the effort to quit smoking. Regardless of the lung injuries that are currently in the news, health experts recommend that pregnant women avoid all ENDS use. Instead, any pregnant woman who is struggling to quit smoking should talk with their health care provider to discuss a plan that is suitable to them and contact resources such as the National Quitline Network (1-800-QUIT NOW). Quitting is best for you and your child so go ahead and clear the air. Trust me; your baby will thank you.

References:

Whittington J. et al. 2018. The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature. Obstetrical and Gynecological Survey. 73(9): 544-549

Committee on Underserved Women et al. 2017. Smoking Cessation During Pregnancy. 130(4): e200-e204.

Kuehn B. 2019. Vaping and Pregnancy. JAMA. 321(14)

Steenhuysen J. “UPDATE 1-U.S. CDC reports ‘breakthrough’ in vaping lung injury probe as cases top 2,000.” Reuters: Yahoo finance. 8 November 2019. Web 11 November 2019.

A couple of weeks ago, a friend of mine who is in her second trimester of pregnancy, called me in a panic. Due to her recent medical history, it was recommended that she get an MRI in addition to her yearly mammogram as a way to screen for breast cancer. She, like many women who have the same question, was relieved and grateful to get this information. She then asked, “do women get diagnosed with cancer in pregnancy? Can they be treated?”

What We Know about Cancer in Pregnancy

Yes, cancer occurs in about one in a thousand pregnancies every year. The most commonly diagnosed cancers in pregnancy are breast, cervical, Hodgkin’s disease, malignant melanoma, and leukemias. It can be tricky to diagnose cancer during pregnancy because common cancer symptoms such as fatigue, changes in the breasts, bloating, headaches, rectal bleeding, blotchy skin, and achy joints can also be symptoms of pregnancy.

Diagnosis

Cancer can be diagnosed in different ways, including physical exams, biopsies, blood tests, ultrasounds and pap smears – all of which are used in pregnancy. But what about other tests?

• X-rays can be used to diagnose cancer during pregnancy. The level of radiation used during an x-ray is too low to cause any known harm to the developing baby. When possible, women can use a lead shield that covers the abdomen during x-rays.
• Computed tomography (CT or CAT) scans of the head or chest do not directly expose the developing baby to radiation. CT scans of the abdomen or pelvis can be done in pregnancy if absolutely necessary.
• Magnetic resonance imaging (MRI) does not use radiation and can be used in pregnancy.

Once diagnosed, the next thing to consider are various treatment options. Cancer can be successfully treated during pregnancy, but there are some important things to think about such as the size and location of the tumor, if the cancer has spread to other body parts, how far along you are in the pregnancy, and any other health conditions you may have.

• Many medications used for cancer treatment (chemotherapeutic agents) are usually not given in the first trimester of pregnancy, because that’s when a lot of the baby’s development is happening. However, it’s possible to use them in the second or third trimesters. This can vary based on many factors, including the medication itself.
• Surgical procedures (including using anesthesia) can usually be done during pregnancy.
• For treatments such as radiation, hormone therapy, and targeted therapies, it’s often suggested to wait until after the baby is born.
• Depending on the exact treatments and medications, breastfeeding may or may not be recommended.

Thankfully, my friend’s MRI is normal at this time. She was reminded to watch for any changes in her breasts and keeping an eye on any symptoms. Remember, whether you are pregnant or not, it’s always best to report any concerns to your healthcare provider as soon as possible. This way you can be properly evaluated, and treated if necessary, because most of the time a healthier mom leads to a healthier baby.

We have all heard that breastfeeding is the best way to feed your baby because you can bond with your child and give them the best nutrients and immunity for lifelong health. Besides that, breastfeeding helps moms stay healthy by getting you back to pre-pregnancy weight faster, preventing breast and ovarian cancer, and ensuring heart health. However, sometimes putting baby on the breast is easier said than done – not all moms can breastfeed in the traditional sense of holding your baby to the breast at all times. Moms may not be available if they need to return to work, care for other children, or if their baby stays in the hospital or Neonatal Intensive Care Unit (NICU) after birth.

Enter breast pumps.

Breast pumps have been used for centuries to help moms extract breastmilk to be given later to their baby. There are different pumps to choose from, including manual, battery powered and electric pumps. The best pump for getting milk out are double-electric hospital-grade pumps.

The type of pump you use also matters in terms of potential contamination (i.e., when foreign material can pass into the milk). What matters the most is whether a pump uses an “open” or “closed” system. A “closed” system breast pump has a physical barrier between the parts that touch your breastmilk (flanges, bottles, valves), and the tubing and pump motor (called the “backflow protector”). This keeps your milk sectioned off from the body of the pump. The parts that can easily be cleaned and sterilized are separate from the parts that cannot be cleaned and sterilized, like the interior of the pump motor. This is why hospital grade breast pumps are safe for multiple users – because they have this barrier.

“Open” system breast pumps do not have barriers between the parts that touch your breastmilk and the tubing and pump motor. Because of this, moisture from pumping can enter the tubing and motor. Since mold flourishes in dark, moist places, the open system has a greater risk for mold growth. This means that impossible-to-clean places like the interior of a breast pump motor are very inviting to mold. The most common places to find mold in a breast pump are the tubing, the areas and valves that connect bottles to flanges, and the insides of pumps which have been stored for a long time in a moist basement.

How can I keep mold out of my breast pump and breastmilk?

All breast pump parts that come in contact with breastmilk should be cleaned and fully dried after each use. This includes flanges, bottles, valves and breast shields. You can eliminate possible contaminants by washing them with liquid dishwashing soap and warm water. Rinse each piece thoroughly with hot water for 10-15 seconds. Place the pieces neatly on a clean paper towel or on a clean drying rack and allow them to air dry. A dishwasher with a drying cycle can also be used. Avoid using cloth towels to dry your pump parts because they can carry germs and bacteria that are harmful to your breastmilk and your baby.

It is not necessary to clean breast pump tubing unless it comes in contact with breast milk. If you wash your tubing, make sure you hang it to air dry before attaching it to your breast pump. If small water drops (condensation) appear in the tubing after you have pumped, attach the tubes to the pump before you attach your flanges/bottles and turn the pump on for a few minutes until the tubing is dry.

What if I find mold in my breast milk?

At MotherToBaby UR Medicine, we have developed an algorithm (set of rules) to help people manage breastmilk that is potentially contaminated. It is meant to be used in hospitals for sick children, but can be useful for you and your health care provider. Most full-term, healthy, and older infants do not need the precautions outlined below. If you find foreign material in your breastmilk or pump parts, contact your baby’s pediatrician to get advice on what to do.

If your baby is sick or premature, consider sharing the information below with your baby’s provider if you find mold in your breastmilk or pump parts. It is meant to be followed in order from step 1, which includes discarding any milk with foreign material in it (like mold.) Step 2 can help to determine when any other expressed milk may have been affected. For instance, if you know you washed your pump 4 days ago and found the material today, any milk you pumped in the past 4 days could have been contaminated. Contaminated milk could be frozen, which is likely to kill most bacteria and many fungi, or it could be pasteurized using home pasteurization (Step 3). You also need to think about what should be fed to your baby in the meantime: do you have older, stored milk? Do you need donor milk? If you need to use formula, should it be “hypoallergenic?” (Step 4). These are good conversations to have with your baby’s doctor. If you don’t have enough breastmilk, some communities will have breastfeeding medicine specialty providers or lactation consultants who can help mothers with milk supply concerns. You can search for these providers online by clicking here.

Algorithm for decision-making when pump parts are found to contain foreign material (potential bacteria or fungus). The box at the lower right reminds providers which babies are at lowest risk from drinking milk that has any foreign material in it.

Last, we want to leave you with words of encouragement because we know breastfeeding isn’t easy. It’s downright hard for most. Having that said, please know that resources like MotherToBaby are here for you and just by reading this blog, you’re taking steps to ensure your milk is pumped and stored safely. You’re doing a great job and we can be certain your baby appreciates all you do.

Rogelio Perez D’Gregorio, MD, MS is an Assistant Director of MotherToBaby UR Medicine and Assistant Professor of Obstetrics and Gynecology at the University of Rochester.

Other blog contributions were made by:

Casey Rosen-Carole, MD, MPH, MSEd, FABM, IBCLC is Medical Director of Lactation Services and Programs, Assistant Professor of Pediatrics and OBGYN, and a Consultant for the Lactation Study Center and MotherToBaby URMedicine

Ruth A Lawrence, MD, DD (Hon) FABM, FAAP is Distinguished Alumna Professor Pediatrics and Obstetrics/Gynecology, Northumberland Trust Chair in Pediatrics, UR School of Medicine and Dentistry. Co-Director of the Finger Lakes Children’s Environmental Health Center.

REFERENCES:

Ameda. Is there mold in your breast pump equipment?

Centers or Disease Control and Prevention. Facts about Stachybotrys chartarum and Other Molds.

Eglash A, Liliana Simon L, et al. (2017). ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants, Revised 2017. Breastfeed Med.;12(7):390-395.

FDA. U.S. Food and Drugs Administration. Breast pumps.

Hygela Health. Closed System Breast Pumps vs. Open System Breast Pumps.

Jennai L. Moms ABC. How to clean breast pup tubing mold.

La Leche League International. Pumping Milk.

Labiner-Wolfe J, Sara B. Fein SB, Katherine R. Shealy KR, et al. (2008). Prevalence of Breast Milk Expression and Associated Factors. Pediatrics 2008;122:S63–S68.

Magoha H, Kimanya M, De Meulenaer B, et al. (2014). Association between aflatoxin M1 exposure through breast milk and growth impairment in infants from Northern Tanzania. World Mycotoxin Journal. 7(3):277-284.

Spectra. Mould in your Breast Pump Tubing?

Stöppler MC. What is mold?

Walker M. (2012). Pumps and pumping protocols. Clinics in Human Lactation 10. Hale Publishing L.P.

By Nevena Krstić, Genetic Counselor, MotherToBaby Florida

When I was 17 weeks pregnant, my husband and I got in a car accident. The guy going in the opposite direction swerved into our lane and hit our car head on. Airbags deployed. The car was totaled.

Moments after the impact happened, I remember looking over at my husband to see that he was ok, unbuckling my seat belt which had left burn marks all over my pregnant belly, getting out of the car, and lying down on the sidewalk. And, as the adrenaline slowly went down, the immense fear overtook my whole body. I was alive, but what will happen to the baby?

The doctors scheduled me for an ultrasound. I was so nervous to get the ultrasound; the anxiety was almost unbearable. Ultrasounds are supposed to be fun, right? They always look so fun on TV. The couples are either joyously smiling or shedding happy tears as the doctor shows them images of their baby. Most of the time it is when they find out if they are having a boy or a girl. That is how I imagined my ultrasounds too. I was looking forward to the experience I imagined. I was not looking forward to the experience I was facing. I was dreading my ultrasound.

Thankfully the baby was alive and appeared to be developing as expected. The accident did not appear to have harmed the baby directly. However, it did cause a small tear in my placenta causing it to bleed. The tear was small, but if it got bigger it could cause real problems including miscarriage. And the doctors had no way of predicting what would happen or when. All they could offer me was more ultrasounds.

What is the Purpose of an Ultrasound?

Ultrasounds are medical tests. They are mainly used as either a routine scan at around 18-22 weeks of pregnancy to look at the baby’s developing body or the anatomy. This scan is therefore often referred to as the “anatomy scan.” Ultrasounds are also used to look at the baby when there is a suspected problem or if there is a specific concern, such as bleeding during pregnancy, elevated risk on some routine blood testing, use of medication, or, as in my case, car accidents.

What Can Ultrasound Tell Me about My Baby?

Doctors are able to find out a lot of medical information during ultrasound. Ultrasound, also called sonogram, is a type of medical imaging that uses high-frequency sound waves to produce images which help doctors examine the baby’s anatomy from head to toe, including images of the baby’s brain, heart, spine, kidneys, and other organs.

Most women who have this ultrasound done will have a normal anatomy scan and are reassured that their baby is developing as expected. For some women, however, the ultrasound will show a change in the baby’s size, the shape, size, or function of one of his/her organs, the amount of amniotic fluid around the baby, or changes to the placenta itself. A baby may be diagnosed with a specific birth defect (like a heart defect or a spine defect) on an anatomy scan. Some of these birth defects can be very serious. We know that every pregnancy has a 3-5% chance of having a birth defect. The ultrasound may also show a finding that may raise concern for another pregnancy complication, and more ultrasounds or testing may be recommended.

Ultrasound, however, is not perfect. Ultrasound is good at ruling out problems, but is not perfect at finding every birth defect before baby is born. Therefore, a normal anatomy ultrasound does not guarantee that the baby won’t have a birth defect or a complication. Sometimes the ultrasound may raise concern that there is a birth defect or complication when there really is not one seen on follow-up tests or after birth. There is no test that can be done before baby is born that can guarantee a perfectly healthy baby.

Are Ultrasounds Safe?

Typically, women will have two ultrasounds in pregnancy, one in the first trimester to confirm the pregnancy, and one anatomy scan in the second trimester. Some women, however, may need to have ultrasounds more often, especially if there are complications in pregnancy.

For me, in order to track the bleeding in my placenta and the growth of my baby, the doctors did one ultrasound every month of pregnancy… And every month I would walk into the ultrasound room filled with angst and anticipation of bad news. Thankfully bad news never came, the placental tear did not get bigger, and baby continued to grow. And by the last couple of ultrasounds, dare I say, I even looked forward to seeing my baby’s squished little face. But it did make me wonder if exposing my baby to so many ultrasounds was safe?

All things considered, ultrasounds are generally ok. However, just like with every medical procedure, ultrasounds should only be performed if medically necessary and recommended by the doctor to avoid exposing baby to heat produced by the sound waves of ultrasound. Therefore, while moms-to-be may be tempted to get that 3D or 4D ultrasound, or buy your own fetal home monitor (and believe me I was), it may be best to avoid these additional ultrasounds and stick to the ones recommended by the doctor.

I went on to deliver a healthy baby girl, who is now a mobile little one-year-old. I thank my lucky stars for her every day. But in my pregnancy with her I realized a very important thing that I want to share. Ultrasounds can be fun and joyous events. For most pregnant moms they will be fun. They will reassure them that their babies are healthy and developing and may confirm for them the sex of the baby. Having that said, we should not take for granted that ultrasounds are very powerful medical tests that have the ability to tell moms a lot more information about the health of their baby. So supporting anxious moms as they enter their ultrasound appointments is key.

Nevena Krstić is a certified genetic counselor based in Tampa, Florida. She currently works for MotherToBaby Florida, which is housed at the University of South Florida Health in the Department of Obstetrics and Gynecology.

About MotherToBaby 

MotherToBaby is a service of the Organization of Teratology Information Specialists (OTIS), suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about exposures during pregnancy and breastfeeding, please call MotherToBaby toll-FREE at 866-626-6847 or try out MotherToBaby’s new text information service by texting questions to (855) 999-3525. You can also visit MotherToBaby.org to browse a library of fact sheets about dozens of viruses, medications, vaccines, alcohol, diseases, or other exposures during pregnancy and breastfeeding or connect with all of our resources by downloading the new MotherToBaby free app, available on Android and iOS markets. Also, make sure to subscribe to The MotherToBaby Podcast available on iTunes, Google Play Music, Spotify and podcatchers everywhere.