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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

Bringing Breastfeeding Professionals Access to LactMed for Exposure Information On-the-Go

LactRx by MotherToBaby is a free app providing current information on the use of medications, vaccines, diagnostic agents & drugs of misuse during breastfeeding. The LactRx app provides easy access to the LactMed database, a resource from the National Library of Medicine (NLM). The LactRx app provides access to the LactMed database, which has information on the use of medications, vaccines, diagnostic agents & drugs of abuse during breastfeeding that is updated monthly.

Download the LactRx App

iPhone

Android

History of LactRx App Development

In 2019 the NLM announced that the LactMed app was being discontinued. The announcement prompted a discussion between Phil Anderson, PharmD, FASHP, UC San Diego clinical professor and author of LactMed and Christina Chambers, PhD, MPH, MotherToBaby Past President and Mommy’s Milk: Human Milk Biorepository Program Director, about MotherToBaby sponsoring a new app for LactMed. “This was a hugely popular resource with millions of hits,” said Chambers.  Because of this, she saw it as an opportunity for MotherToBaby to help build and host a new app with all of the LactMed information.

In October of 2021, the idea was brought to the leadership of the Organization of Teratology Information Specialists (OTIS), the professional non-profit that provides the MotherToBaby no-cost service. Development commenced and LactRx was born.

“The NLM made the decision to continue supporting web access to LactMed, and to discontinue support for its app. However, in Dr. Anderson’s experience, the app was a very popular and a user-friendly mode of access to the data,” explained Chambers. “In collaboration with NLM, MotherToBaby was given permission to create the LactRx app and, thus, to expand ease of access to this critical information for providers and the public worldwide.”

LactRx by MotherToBaby was launched in 2022 to bring lactation professionals on-the-go access to exposure information that they can count on. This resource is an extension of MotherToBaby’s free services which includes access to information specialists on breastfeeding and pregnancy exposures by phone, text, email, and live chat.

Additional Information

Information presented in the LactRx app is not intended to be a substitute for professional judgment. Users should consult personal healthcare providers for breastfeeding advice related to their particular situation.

MotherToBaby also works closely with the NLM to contribute bilingual (English/Spanish) evidence-based fact sheets regarding medications, vaccines, diseases, herbal supplements, occupational exposures and more during pregnancy and breastfeeding.

MotherToBaby traditionally provides information on exposures before and during a pregnancy as well as breastfeeding through its no-cost helpline 866-626-6847, texting service 855-999-3525 and website MotherToBaby.org, where the public can live chat or e-mail an expert.

LactRx is sponsored by MotherToBaby, the Leading Resource on Exposures during Pregnancy and Breastfeeding

BRENTWOOD, TN – The non-profit Organization of Teratology Information Specialists (OTIS), through its public-facing service known as MotherToBaby, launches LactRx, a free app providing current information on the use of medications, vaccines, diagnostic agents & drugs of misuse during breastfeeding. The LactRx app provides easy access to the LactMed database, a resource from the National Library of Medicine (NLM).

In 2019 the NLM announced that the LactMed app was being discontinued. The announcement prompted a discussion between Phil Anderson, PharmD, FASHP, UC San Diego clinical professor and author of LactMed and Christina Chambers, PhD, MPH, MotherToBaby Past President and Mommy’s Milk: Human Milk Biorepository Program Director, about MotherToBaby sponsoring a new app for LactMed. “This was a hugely popular resource with millions of hits,” said Chambers.  Because of this, she saw it as an opportunity for MotherToBaby to help build and host a new app with all of the LactMed information.

In October of 2021, the idea was brought to the leadership of the Organization of Teratology Information Specialists (OTIS), the professional non-profit that provides the MotherToBaby no-cost service. Development commenced and LactRx was born.

“The NLM made the decision to continue supporting web access to LactMed, and to discontinue support for its app. However, in Dr. Anderson’s experience, the app was a very popular and a user-friendly mode of access to the data,” explained Chambers. “In collaboration with NLM, MotherToBaby was given permission to create the LactRx app and, thus, to expand ease of access to this critical information for providers and the public worldwide.”

To download LactRx, please click:

iPhone

Android

Information presented in the LactRx app is not intended to be a substitute for professional judgment. Users should consult personal healthcare providers for breastfeeding advice related to their particular situation.

MotherToBaby also works closely with the NLM to contribute bilingual (English/Spanish) evidence-based fact sheets regarding medications, vaccines, diseases, herbal supplements, occupational exposures and more during pregnancy and breastfeeding.

MotherToBaby traditionally provides information on exposures before and during a pregnancy as well as breastfeeding through its no-cost helpline 866-626-6847, texting service 855-999-3525 and website www.MotherToBaby.org, where the public can live chat or e-mail an expert.

More about OTIS and MotherToBaby

The Organization of Teratology Information Specialists (OTIS) is a professional scientific society made up of individuals engaged in assessing and evaluating risks to pregnancy and breastfeeding from environmental exposures. Members include, but are not limited to, specialists in the fields of obstetrics and gynecology, pediatrics, genetics, dysmorphology, perinatal epidemiology, teratology, behavioral teratology, pharmacy, genetic counseling, nursing, midwifery, maternal and child health, public health, and includes experts that provide MotherToBaby services and researchers that conduct MotherToBaby Pregnancy Studies. MotherToBaby is a suggested resource by many federal agencies including the Centers for Disease Control and Prevention (CDC). MotherToBaby is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,000,000 with zero percentage financed with non-governmental sources. The contents of this release are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. To learn more about MotherToBaby and OTIS, please visit www.MotherToBaby.org.  

Media Contact: Nicole Chavez, 619-368-3259, nchavez@mothertobaby.org

Non-Profit’s Expertise Recognized as Leading Resource on Exposures during Pregnancy and Breastfeeding

September 21, 2022

BRENTWOOD, TN – The non-profit Organization of Teratology Information Specialists (OTIS) through its public-facing service, MotherToBaby, are now contributors to the prestigious National Library of Medicine (NLM) where more than 250 of its bilingual (English/Spanish) evidence-based fact sheets can be found on medications, vaccines, diseases, herbal supplements, occupational exposures and more during pregnancy and breastfeeding.

MotherToBaby provides information on exposures before and during a pregnancy as well as breastfeeding traditionally through its no-cost helpline 866-626-6847, texting service 855-999-3525 and website www.MotherToBaby.org, where the public can live chat or e-mail an expert. “This is just one more way we can ensure pregnant people and healthcare providers can have access to reliable, up-to-date, research-based information so they can make better informed decisions during the child-bearing journey or in cases of adoption,” said Christina Chambers, PhD, MPH, MotherToBaby Past President and UC San Diego professor of pediatrics. “Being a part of the NLM is a testament to the reliability of our resources. We are honored to be contributors.”

For more than 200 years, “the National Library of Medicine has been a partner for biological discovery, clinical care decision-making and healthcare choices in everyday living,” according to its website. The NLM includes health information tools and biomedical literature, such as PubMed. The MotherToBaby Fact Sheets through the NLM can be accessed through public and hospital libraries as well as in schools and clinics. It’s also available at the following link: https://www.ncbi.nlm.nih.gov/books/NBK582980/  

More about OTIS and MotherToBaby

The Organization of Teratology Information Specialists (OTIS) is a professional scientific society made up of individuals engaged in assessing and evaluating risks to pregnancy and breastfeeding from environmental exposures. Members include, but are not limited to, specialists in the fields of obstetrics and gynecology, pediatrics, genetics, dysmorphology, perinatal epidemiology, teratology, behavioral teratology, pharmacy, genetic counseling, nursing, midwifery, maternal and child health, public health, and includes experts that provide MotherToBaby services and researchers that conduct MotherToBaby Pregnancy Studies. MotherToBaby is a suggested resource by many federal agencies including the Centers for Disease Control and Prevention (CDC). MotherToBaby is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,000,000 with zero percentage financed with non-governmental sources. The contents of this release are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. To learn more about MotherToBaby and OTIS, please visit www.MotherToBaby.org.  

Media Contact: Nicole Chavez, nchavez@mothertobaby.org, 619-368-3259

Cheese is as old as modern mankind, with clues about its existence reaching all the way back to 8,000 BC when the first sheep and goats were domesticated by our ancestors (www.historyofcheese.com). And since cheese has been around for so long, it is now one of the most popular and beloved foods throughout the world. So, it did not come as a surprise to me that many who are pregnant and breastfeeding ask MotherToBaby about eating cheese all the time! On our texting service alone (855-999-3525), we have received over 400 questions about cheese in the past few years!

Here are some of the recent questions we have received at MotherToBaby:

• “Am I allowed to eat cream cheese on toast?”
• “Is raw milk cheese from the USA OK?”
• “Can I eat goat cheese while breastfeeding?”
• “Is it OK to eat feta cheese during pregnancy?”
• “Can I continue to eat queso cheese on a burrito or nachos while pregnant?”
• “Is unpasteurized cheese OK to eat if it’s been cooked on a pizza?”

When you start researching cheese, you can fall into a rabbit hole on kinds of cheese: hard versus soft, pasteurized or not, Mexican verses Italian? The questions are endless. There are over 1800 different kinds of cheese, divided into 7 categories (www.Funtrivia.com):

1. Fresh Cheeses: Banon, Ricotta, Feta, Cottage cheese, Cream cheese, etc.
2. Natural Rind: Sancerre, Chabichou, Crottin de Chavignol, etc.
3. Soft White Cheese: Camembert, Brie, Chevre Log, etc.
4. Semi-Soft: Edam, Pont L’Eveque, St Nectaire, Tomme de Savoie, Langres, Carre de L’Est, Epoisses, etc.
5. Hard Cheeses: Cheddar, Parmigiano Reggiano, Gruyere, Manchego, etc.
6. Blue Cheeses: Stilton, Roquefort, Gorgonzola, Maytag Blue, Cashel Blue, etc.
7. Flavored Cheeses: Cornish Yarg, Gouda with Cumin, Stilton with Apricots, Devon Garland, etc.

So, what is the bottom line for you if you are pregnant or breastfeeding?

First, check to see if the cheese has been pasteurized or not. Look at the label and you will find that most types of packaged cheese or cheese products sold in America have been pasteurized or heat treated. Pasteurization is defined as a process in which both packaged and non-packaged foods (such as cheese and milk) are treated with moderate heat, usually up to 212 °F, to eliminate pathogens and extend shelf life. If the cheese has gone through pasteurization, then any increased risk for bacteria or other pathogens is very small, and the product isn’t considered to increase risks if eaten during pregnancy and breastfeeding. Of course, keep an eye on the fresh or sell-by date, and keep the product properly refrigerated. Cheese that has not been pasteurized has an increased risk for bacteria such as Listeria. See our fact sheet at Listeria Infection (Listeriosis) – MotherToBaby for more information. If the cheese has not been pasteurized, but has been cooked or heated prior to eating, then there also is little increased risk. Plus, cheese that has been dried, such as parmesan cheese, has a longer shelf life and no known increased risk for bacteria.

One of the most common questions about cheese when pregnant and breastfeeding is about the difference between hard and soft cheese. Hard cheese has been ripened longer and is drier, having a lower water content. Whereas soft cheese is younger or fresher, with a higher moisture content. The higher moisture content in soft cheese can allow for more growth of bacteria. That is why it is a good idea to be sure that soft cheeses are either heated prior to eating or have been pasteurized at the time of production (again, pasteurization is a process to kill bacteria). Most soft cheeses in the U.S. have undergone this process by FDA pasteurization law — so look at the label to be sure and be aware of any possible increased risks if unpasteurized!

Cheese is rich in protein and minerals such as calcium and phosphorus. During pregnancy and while breastfeeding, cheese can be part of your good diet. Some cheese types, such as hard cheese, are higher in fat. So, do watch the fat content if cheese is part of your daily diet! Just follow a few simple rules about checking for pasteurization and being sure the cheese product is heated or has been cooked prior to eating if it was not pasteurized. And then, enjoy eating cheese without worry during pregnancy and breastfeeding! If you have any cheese related questions during pregnancy, or any other exposure questions, be sure to contact MotherToBaby! We will be happy to help you!

Originally Published 5/11/22. Updated 9/30/25.