By Lynn Martinez, Teratogen Information Specialist, MotherToBaby Utah

“O.K., so I can’t look at pizza the same way. Saltine crackers seem to be my go-to snack for sustenance and don’t even SAY the word ‘curry!’ Oh no, I said it… Please excuse me while I hurl,” said Nicole, 34, who’s pregnant with her second child.

For many of the moms I counseled as a teratogen information specialist with the international non-profit, MotherToBaby, this is part of the reality of becoming a mom – nausea and vomiting of pregnancy (NVP). Yes, it’s a real diagnosis. “Please help me! Can I take something to help this nausea?” is usually the caller’s desperate question following her description of how she’d rather swim with sharks than accidentally catching a whiff of chicken tikka masala.

Nausea and vomiting of pregnancy (NVP) affects most pregnant women, whether it’s their first pregnancy or a subsequent one. For nearly a third it can be serious enough to disrupt their usual lives and routines. In the past, it has too often been discounted, but now more health care providers are willing to take it seriously and treat their patients. One of the drugs I get asked about more and more often recently is ondansetron, or Zofran, as it’s more commonly known.

Ondansetron is FDA-approved for use with nausea and vomiting in non-pregnant patients, but has been found to be effective for and used increasingly to treat NVP. Early studies demonstrated no increased fetal risk with its use. Two later studies found very small associations with oral clefting (cleft lip and or palate). Oral clefting defects are very common, so associations with exposures are more likely to be coincidental. These studies have not conclusively shown ondansetron to cause clefting or any other defect. More recent research continues to be reassuring. Therefore, it is unlikely the drug needs to be avoided during pregnancy

Other drugs to treat NVP have also been shown not to be a problem for the baby. The combination of doxylamine and vitamin B6 has been used for many years and is effective for many women. This combination is now available in the newly-marketed Diclegis. Ginger, whether in its raw form or in tablets, also works well for some expectant moms.

“So there are options?” exclaimed Nicole. “Thank goodness! Is it appropriate to ask my older child to work with daddy to get me some medication for nausea this Mother’s Day – instead of flowers?” she giggled.

For some women the nausea and vomiting subside greatly after the first trimester, but for those who need extra support with some treatment, encourage the moms-to-be in your life to consult their health care providers for options. And, whatever you do, do not, I REPEAT, do NOT show up with a potpourri basket for mom coupled with freshly-made Panang curry this Mother’s Day.

Lynn Martinez is a retired Teratogen Information Specialist. Lynn has traveled around the Utah educating doctors, nurse midwives, pharmacists and others over the past three decades.

Rachel called us the morning she woke up and found a bat hanging out in her closet.  As far as she could tell, she had not been bitten.  She was 10 weeks pregnant and wondered what her next steps should be. Her husband also did not detect any bites. He kindly relocated the bat to the outside of their home, but now they were both exposed to potential rabies infection. She was about to leave for work, and her husband had already left for a busy day at the office.

Rachel had been down this road before in high school with a similar event in her childhood home. At that time, her whole family went to their local emergency department and were treated with a rabies vaccine series, or post exposure prophylaxis, to prevent them from becoming ill with rabies.  At that time, she remembered being told that she would never need to go through the series again.  She was calling us today because her OB provider referred her to MotherToBaby Connecticut for clarification. 

In researching this comment about never needing to be treated again, I decided I needed some assistance from our local Poison Control. They confirmed that yes, she did need to be seen and re-treated in an emergency department of her choice. They also put me in contact with our State of CT Epidemiologist for further consultation. Our epidemiologist reiterated the need to be treated again because of this exposure. Rachel’s pregnancy was not a reason to avoid treatment.

In such circumstances, the benefits outweigh the potential chances for adverse pregnancy outcome from the preventative vaccine series. Rachel’s husband would need the vaccine, as well.

The Centers for Disease Control and Prevention (CDC) has a nice online review that I shared with Rachel that confirmed the need for her to receive treatment with the rabies vaccine. It also confirms the benefits of treatment in pregnancy outweighs the chances for any adverse pregnancy outcomes.

Rabies

• Because of the potential consequences of inadequately managed rabies exposure, pregnancy is not considered a contraindication to postexposure prophylaxis. Certain studies have indicated no increased incidence of abortion, premature births, or fetal abnormalities associated with rabies vaccination. If the risk of exposure to rabies is substantial, pre-exposure prophylaxis also might be indicated during pregnancy. Rabies exposure or the diagnosis of rabies in the mother should not be regarded as reasons to terminate the pregnancy. 

Treatment for rabies exposures include the actual rabies vaccine as well as the Human Rabies Immune Globulin (HRIG). The HRIG is a medication given at the time of exposure to provide the patient with immediate protection from the rabies virus. It is only ever given once. That means Rachel will not need HRIG again.

Instead, she will just need two injections of the rabies vaccine (there are up to five shots given after a first exposure). The vaccine helps your body build its own immunity to protect you against the rabies virus.

Because this was her husband’s first exposure, he will need the full treatment including the HRIG and up to five injections of the rabies vaccine.

How urgently did Rachel and her husband need to be treated? The epidemiologist said sooner rather than later, recommending they visit an emergency department within the day of exposure.

Though Rachel was not excited about having to get vaccinated again, she was relieved to learn exactly what she needed to do for the health of her baby, her husband, and herself.

We were grateful for the collaboration with our local Poison Control, state epidemiologist and the CDC documents.  The best possible reproductive data was provided for this couple to make the best reproductive decisions for themselves. With the help of MotherToBaby and our collaborators, this was one less bat-tle they had to face alone.

Arizona is HOT, especially in the summer. I knew this when I moved to Tucson almost a decade ago. Since then, I have had two pregnancies while living in Arizona. I was lucky not to have to spend the last weeks of pregnancy and first weeks with my newborn in the summer heat.

Of course, Arizona is not the only place experiencing hot weather. 2023 was the planet’s warmest year on record, according to the National Oceanic and Atmospheric Administration. Temperature records have already been broken in 2024, and extreme heat is becoming more commonplace. It is important to understand how extreme heat can affect health in the general population, and for us at MotherToBaby, how high temperatures can specifically affect people who are pregnant. For more insight on this issue, we turned to Dr. Christina Han with our partner, the Society for Maternal-Fetal Medicine.

What is extreme heat?

Extreme heat has been defined as “a period of high heat and humidity with temperatures above 90 degrees for at least two to three days.” (Ready.gov). According to Dr. Han, ”extreme heat can lead to health issues for anyone, including heat rash, sunburn, heat cramps, heat exhaustion or heat stroke. These environmental changes also increase the rates of violence and exposure to pollution.  Some groups of people are more likely to be affected by extreme heat, including people who are pregnant.”

What is hyperthermia?

Hyperthermia is a rise in body temperature that happens when the body absorbs more heat than it releases. One of the most common causes of hyperthermia is heat stroke. Fever, extreme exercise, or use of hot tubs or saunas can also increase the chance of hyperthermia.

Being pregnant during extreme heat can increase the chance of developing heat stroke, heat exhaustion, or other heat-related illness. In extreme heat, the body has to work harder to keep cool for two. When the body is unable to cool itself properly, there can be an increased chance of hyperthermia.

What are the concerns with extreme heat and pregnancy?

Studies have reported a small increased chance for neural tube defects (NTDs) in babies of people who had high fevers lasting 24 hours or longer  before the 6th week of pregnancy.  A few studies have reported a small increased chance for other birth defects when fever or hyperthermia happen in early pregnancy, especially if the fever is untreated. Other studies have not found a higher chance for birth defects when a person experiences hyperthermia early in pregnancy.

People who are pregnant also need to drink more water to avoid dehydration. Chronic dehydration can affect pregnancy outcomes. One study suggests that chronic dehydration can affect newborn weight, length, and head and chest circumference. Some studies have reported associations between high temperatures during pregnancy and a higher chance of preterm birth, low birth weight, and stillbirth.

What are some signs of heat-related illness?

Heat stroke: Body temperature of 103°F or higher; hot, red, dry, or damp skin; headache; confusion, dizziness; nausea; passing out.

Heat exhaustion: Heavy sweating; cold, pale, and clammy skin; nausea/vomiting; dizziness, headache, muscle cramps; tiredness/weakness; passing out.

Heat-related illnesses can sometimes be an emergency. Anyone who thinks they are having a medical emergency should seek care right away. For more information on when to seek medical help, visit the Centers for Disease Control and Prevention (CDC) page here: https://www.cdc.gov/niosh/topics/heatstress/heatrelillness.html.

Dr. Han also shared some general tips for dealing with extreme heat during pregnancy:

• Stay cool as much as possible, both indoors and outdoors
• Avoid peak sun hours if you must be outside
• Avoid or minimize strenuous activities
• Wear appropriate clothing such as hats and loose lightweight clothing
• Avoid alcohol and limit caffeine
• Wear sunscreen
• Use caution when engaging in strenuous activities; be sure to take breaks, drink water, and get plenty of rest.
• Check the local news for heat warnings and health/safety tips

Find more information from CDC on preventing heat-related illness here: https://www.cdc.gov/extreme-heat/prevention/index.html.

Dr. Han’s final tip: Don’t forget to talk with your provider! “Your healthcare provider can help you find resources and ways to protect yourself and your family. Managing exposure to extreme heat is important for everyone’s health, including those who are pregnant.”

MotherToBaby specialists are also available to talk with you about exposures before or during pregnancy. Best of luck staying cool out there!

For breastfeeding people living in rural areas, it is often difficult to find appropriate breastfeeding and lactation resources as they can be few and far between. According to the Centers for Disease Control and Prevention (CDC), infants in rural areas are less likely to ever breastfeed than infants living in urban areas.

Emma, a new mother to a baby boy, lives in a rural area where the nearest town with a healthcare facility is over an hour away. Even by phone, it was difficult to reach her provider’s office. She was determined to provide the best for her son, including breastfeeding; however, she was concerned about managing her post-partum anxiety and depression. She wasn’t sure where to find out if her medications were something she could take while breastfeeding – which made her more anxious! Emma faced some common challenges living in a rural area:

• Travel Barriers – Emma struggled with general breastfeeding and medications concerns, all while managing the demands of a newborn; traveling long distances for an appointment was not only exhausting, but also not ideal.

• Limited Local Support – Emma’s town had no specialized breastfeeding support services. The nearest support group was a two-hour drive away, making it difficult for Emma to access help when she needed it most.

• Limited Resources – Finding reliable information about breastfeeding was another challenge. Emma felt isolated and unsure where to turn for accurate information.

One day, while searching for answers online and discovering mixed information about the medications she wanted to start, Emma discovered MotherToBaby. Intrigued by our expert support that was available remotely and promptly, she explored our fact sheets, blogs, and podcasts that cover a range of breastfeeding topics. After reviewing our website, she was delighted to see our live chat service!

During our conversation, we addressed Emma’s concerns about breastfeeding while on her medications to treat her post-partum anxiety and depression. We were also able to discuss the recommendations for vaccines while breastfeeding (like the updated COVID-19 and influenza vaccines. We also answered her questions about cold medications, referring her to our specialized blog. She was very relieved to connect with someone so quickly and receive accurate information on the spot.

The flexibility of MotherToBaby’s online services was also a game-changer for Emma. She was now able to access information at times that suited her schedule, as she also could use our text, email, or phone service. This was particularly important for Emma, since her days were unpredictable and often included late-night feedings and other unexpected moments!

MotherToBaby referred Emma to online lactation resources and support groups. Engaging with other breastfeeding parents and experts on an online platform can provide her with emotional support and encouragement. Sharing experiences and hearing from others who faced similar challenges can also help Emma feel less alone and more empowered in her breastfeeding journey. Engaging with the online community and support can provide Emma with a sense of connection and support that was missing in her rural area, which can help her more easily navigate the ups and downs of breastfeeding.

Mental health support was also very important to Emma because she lacked this in her daily life. Resources like Post-Partum Support International (PSI) and the National Maternal Mental Health Hotline are now tools Emma has to support her along the way.

With evidence-based information about her medications and referrals to the appropriate resources, Emma felt much more reassured about treating her anxiety and depression while breastfeeding. She felt more knowledgeable and prepared to continue taking care of herself and her newborn. The convenience of online support and education alleviated much of the stress she had been feeling. She could now focus more on bonding with her baby, knowing she can turn to MotherToBaby should she have more questions or concerns about medications or exposures while breastfeeding.

References:

https://www.ruralhealthinfo.org/toolkits/maternal-health/2/breastfeeding

https://www.cdc.gov/breastfeeding/data/facts.html

One of the most common Zika-related questions we get at MotherToBaby is, “What is the risk of Zika if I travel to Country X?” Or, a variation of the same: “We just got back from Country X. Do we really need to wait 3 months before we try to get pregnant?”

Back when the Zika epidemic was sweeping the western hemisphere, answering these travel-related questions was fairly straightforward. It was easier to know where there was a risk for Zika infection as governments and public health organizations around the world collaborated to identify and report cases. Since then, the number of reported Zika cases has fallen dramatically, but sporadic, low-level transmission continues to happen in some areas. Systems for detecting and reporting cases vary widely from country to country now, making it difficult to know the exact level of risk in any given area.

So, what’s a traveler to do?

First and foremost, all travelers should avoid mosquito bites to help prevent not only Zika, but also other diseases spread by mosquitoes. Preventing bites is important for everyone, especially those who are pregnant or planning a pregnancy and their partners. The best way to prevent mosquito bites while traveling is to use an Environmental Protection Agency (EPA)-registered insect repellent with one of the following active ingredients:

• DEET
• Picaridin (also known as KBR 3023 and icaridin)
• IR3535
• Oil of lemon eucalyptus (OLE)
• Para-menthane-diol (PMD)
• 2-undecanone

Other ways to help prevent bites during travel include wearing loose-fitting, long-sleeved shirts and pants, and sleeping in areas free of mosquitoes (such as accommodations with window and door screens or air conditioning, or sleeping under a mosquito net).  

Second, consider your destination.

Check for active Zika Travel Health Notices from the Centers for Disease Control and Prevention (CDC). Travel Health Notices indicate areas with known current transmission of Zika.

After checking for Zika Travel Health Notices, visit the CDC interactive Zika map. The map uses different shades of blue to broadly classify Zika risk in countries and territories around the world:

• Dark blue areas have reported Zika transmission in the past and there could be current sporadic or low-level transmission in some areas. As in any area, there could be delays in detecting and reporting any new outbreaks.
• Medium blue areas have the kind of mosquitoes that most commonly spread Zika, but they have not reported Zika cases in the past.
• Light blue areas are not known to have the kind of mosquitoes that most commonly spread Zika, and they have not reported Zika cases in the past.

Third, learn the recommendations.

Learn the recommendations related to pregnancy based on your destination (summarized below). Depending on where you’re thinking of going, CDC might advise that you avoid travel, take steps to prevent passing the virus to a partner through sex (sexual transmission), and/or delay pregnancy if you or your partner are planning to become pregnant. Preventing sexual transmission of Zika means using condoms or dental dams, not sharing sex toys, or not having sex for 2 months after travel (for biological females) or 3 months after travel (for biological males). If delaying pregnancy after travel, follow these same timeframes (2 months after travel for biological females and 3 months after travel for biological male partners).

Recommendations for areas with a Zika Travel Health Notice:

• If you are pregnant, avoid travel to these areas.
• If your partner is pregnant and you must travel to these areas, prevent mosquito bites and sexual transmission during and after travel according to the guidelines and timeframes above.
• If you or your partner are planning a pregnancy and you choose to travel to these areas, prevent mosquito bites, prevent sexual transmission, and delay pregnancy after travel according to the guidelines and timeframes above.

Recommendations for areas with current or past transmission (dark blue on the map):

• If you or your partner are pregnant and you choose to travel to these areas, be sure to prevent mosquito bites. If you are concerned about Zika, prevent sexual transmission during and after travel according to the guidelines and timeframes above.
• If you or your partner are planning a pregnancy, be sure to prevent mosquito bites. If you are concerned about Zika, prevent sexual transmission during and after travel and consider delaying pregnancy according to the guidelines and timeframes above.

For travel to all other areas with mosquitoes, take steps to prevent bites.

Lastly, talk to your healthcare provider.

Talk to your healthcare provider about any questions or concerns. They can help you consider the nature of your travel, your ability to prevent mosquito bites and sexual transmission, the risks associated with a potential Zika infection, your pregnancy plans, and any other factors specific to you, your partner, and your circumstances. 

MotherToBaby specialists are also available to talk with you about Zika or other travel-related exposures before or during pregnancy. Safe and happy travels!