By Beth Kiernan, MPH, Interviewer & Teratogen Information Specialist, MotherToBaby

“I just found out I’m pregnant, and while I am glad, I’m also pretty overwhelmed,” lamented Marian, a never-pregnant, newly-married woman who had struggled with Crohn’s disease since her teenage years but was finally in semi-remission. “I’m not sure I’m comfortable taking my medications now, even though my doctors say they are fine. I can’t even sleep! I am worried I’m harming my baby. I wonder if there will be long-term effects. I don’t even know if it’s OK to breastfeed and still take my medications, but I’ve had a terrible time in the past when my insurance changed and I didn’t have access to these drugs.”

“Your concerns are the concerns of every pregnant woman who takes medication for a chronic health condition,” I told her gently. “This is the hallmark of motherhood, when a mother puts her baby’s concerns above her own. However, in your case, you’ll need to carefully consider the risks vs. the benefits of taking or not taking your medication. The goal is to keep your Crohn’s disease from flaring so as to ensure as healthy a pregnancy as possible. Let me share some information with you. Once you have that knowledge, you will feel empowered, and you’ll be able to sleep soundly knowing that you are making the best choices for both yourself and your baby.”

How did Marian find me? I am a counselor at MotherToBaby Pregnancy Studies, conducted by the Organization of Teratology Information Specialists. Here at MotherToBaby, we help pregnant women, their partners, and their doctors by providing up-to-date information about exposures in pregnancy. What do we mean by “exposures”? Exposures could include prescription medications, over the counter medications, herbal supplements, caffeine, alcohol, fever, hair dye…you name it, and the question has probably been asked and answered to the best of our ability by someone in our global network of counseling services.

Half of all pregnant women in the U.S. take at least one prescription medication in pregnancy.¹ For many of these women, taking their medication isn’t a choice; it’s vital to their health and well-being. I’m talking about women who take medications to control seizures, to treat psychiatric illness, to treat pain, to treat asthma, or to delay the progression of diseases such as Multiple Sclerosis or Rheumatoid Arthritis. Depending on the severity of your Inflammatory Bowel Disease (IBD), you may fall into this category too. It may be that NOT treating your Crohn’s or Colitis will worsen your symptoms, and could lead to a situation where both you and your baby would be threatened. Lengthy hospitalization, severe pain, blood loss, surgery – all may outweigh the risk of taking the very medication that could prevent these grim developments.

And while many women plan ahead to get pregnant, consult with their doctors, consider their medication use in advance, and start or stop medications in anticipation of conception, over 50% of pregnancies in the U.S. are unplanned.² However pregnancy happens for you, it’s important to learn about your medications and what others who take them have experienced with regard to pregnancy. Some medications were approved long ago by the Food and Drug Administration and we have years of good data on their use in pregnancy. Others, particularly newer biologics used to treat autoimmune diseases like IBD, may only have been on the market for a few years at the time you inquire, so there may not be a lot of information available about the use of the drug in pregnancy – which means you will need to weigh the risks of taking or not taking the medication to both you and your baby. Your doctor can help you assess those risks, and so can information specialists like me at MotherToBaby.

It will also be important to ask whether or not there could be any impact of your IBD medications to a breastfeeding baby. Undoubtedly, breastfeeding is far more beneficial to a baby than using commercial formula, but inquiring about actual infant experience with a mother’s medication use will be valuable information for you and your baby. The American Academy of Pediatrics, and your pediatrician, can tell you if there are concerns for your newborn.

If you’ve given yourself the luxury of time by planning your pregnancy, speak with your gastroenterologist and your obstetrician or family doctor about your medications and your plans for a future pregnancy. Gather a team of experienced physicians who will support you in your choices, and avail yourself of their advice to ensure you will be healthy when the time comes to begin trying to get pregnant. Studies show that conceiving when your disease is in remission decreases your risk of having pregnancy complications and ongoing IBD flares.³ Also, now is a good time to begin taking a multivitamin or prenatal vitamin with folic acid to ensure the best start for your baby.

What if you aren’t planning pregnancy this year? Then use this article as a starting point for considering the future. If you are of reproductive age, every sexual encounter presents the chance of becoming pregnant. It’s important to know what you might face in terms of medication risks were you to unexpectedly become pregnant. Ask your prescribing doctor or the pharmacist about the research on your medication in pregnancy, or call MotherToBaby at our toll-free number 877-311-8972 and ask to speak with a counselor.

Beth Kiernan is a Teratogen Information Specialist with MotherToBaby Pregnancy Studies, a non-profit that conducts observational research about exposures in pregnancy and provides information to healthcare providers and the general public on medications and more during pregnancy and breastfeeding. She is based at the University of California, San Diego, and is the married mother of four children ages 12 to 23 years.

MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about medications, vaccines, diseases, or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or call the Pregnancy Studies team directly at 877-311-8972. You can also visit MotherToBaby.org to browse a library of fact sheets, including one on IBD in Pregnancy, and find your nearest affiliate.

References:
1. Mitchell, AA et. al. (2011). Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Ob GYN; 205(1): 51.e1–51.e8.

2. Finer LB and Zolna MR. (2011). Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception; 84(5):478–485.

3. Abhyankar et. al. (2013). Meta-analysis: the impact of disease activity at conception on disease activity during pregnancy in patients with inflammatory bowel disease.
Aliment Pharmacol Ther. 38(5):460-6.

By Jennifer Namazy, MD,
Allergist & Immunologist, MotherToBaby Pregnancy Studies Asthma Study Consultant

My first patient of the day was an urgent visit for a woman with shortness of breath. Her name was Heather and she had found out she was pregnant about two months ago. She was thrilled since she had been trying to have a baby for about two years. Once she found out she was pregnant she did three things: she shared the wonderful news with family, she began plans on her new nursery and she stopped all of her asthma medications. She is in her 30s and prior to her pregnancy had been on no medications other than those needed to control the asthma she has had since she was a toddler. These medications include an inhaled corticosteroid, a long acting bronchodilator and rescue medicine in the form of a short acting bronchodilator. She felt that since she was lucky to have become pregnant, she did not want to harm the tiny baby now growing inside her – thus her decision to stop taking her asthma medications. So while she started plans on bringing this baby into the world, the inflammation in her lungs began to go unchecked. At first, she noticed that when she would go to the gym it was harder for her to catch her breath. Then she noticed she was waking up at night feeling like an elephant was sitting on her chest. She attributed the symptoms to being “out of shape” and “anxiety” about the new baby. Finally, while she was having lunch with some friends, someone told a funny story, and her laugh quickly became a wheezy cough. That’s when she ended up in my office.

Asthma is one of the most common serious medical problems to complicate pregnancy. We know that asthma can get better, get worse or stay the same during pregnancy. Uncontrolled asthma may cause problems for both mom and baby. Having flares of asthma during pregnancy can lead to low oxygen levels in mom which translates to low oxygen levels for baby. This may lead to problems with baby’s growth.

As we embark on May’s National Asthma and Allergy Awareness Month, I thought it’d be a perfect time to go over some critical reminders if you have asthma and find out you’re pregnant. Here are some things you should do to keep you and your baby healthy:

Don’t stop your asthma medications – Managing asthma during pregnancy is not different than before you were pregnant. The majority of commonly used medications such as those used by Heather that are described above, which include inhaled corticosteroids, are generally safe. If you have questions about the safety of the medications you are taking, call your doctor or contact MotherToBaby.

Keep those appointments – Since asthma can change during pregnancy, it is important to visit with your doctor on a monthly basis to assess your asthma. Waiting until you have symptoms can often be too late. Lung function testing can detect small changes in airway blockage that can then be treated right away.

Join an Asthma and Pregnancy study – Fewer than 10% of all medications have enough information to determine their safety for use in pregnancy. You can help change that by joining a pregnancy study! These studies provide more safety information on commonly used medications during pregnancy, and they do not require you to change your medications. To learn more, visit MotherToBaby’s Asthma and Pregnancy Study page.

Don’t forget your allergies – While having bad allergies during pregnancy has not been shown to have an effect on the baby, it can affect your sleep and general quality of life. Avoiding those triggers, such as: dust, pet dander, pollens, etc. and using allergy medications when needed, can make for a less stuffy, and more pleasant, pregnancy.

Dr. Jennifer Namazy is an allergist and immunologist, specializing in treating asthma and other respiratory conditions in children, adults and pregnant women. She practices at Scripps Clinic Medical Group in La Jolla, CA. She currently serves as an expert consultant for MotherToBaby’s asthma in pregnancy studies.

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.

Tanya called in on a Monday morning. “I’m getting married in a few months and we want to start trying to get pregnant right away. What should I be doing now to have the best chance of a healthy baby?”

Preconception health and pregnancy planning present a terrific opportunity to assess a wide range of factors that can give your baby the best start. This blog will outline the things to consider, as I relayed to Tanya:

Your Personal Health

Are you generally healthy? If you already get headaches or have acid reflux, know that pregnancy can make these more frequent. Ask your doctor if the way you treat these common conditions should change once you are pregnant. Ask about your current exercise routine and if you need to alter it during pregnancy. Get checked for sexually transmitted infections because some may not show symptoms. Also discuss your medications – some should be stopped before you start trying to conceive, such as Valproic acid, leflunomide (e.g. Arava®), teriflunomide (Aubagio®), methotrexate, and isotretinoin (e.g. Accutane®) to name just a few. For others, you’ll want to weigh the risks vs. the benefits with your health provider before you conceive. Talk with your doctors now to make a plan.

Caffeine

Do you drink caffeinated coffee, tea, or soda? What about energy drinks, protein powders, or Kombucha? MotherToBaby’s fact sheet on caffeine may put your mind at ease and encourage you to think about all your beverage options.

Body Weight

Is your weight a concern? One of the best things you can do before conception is to get to a healthy weight. Women who are overweight or obese have increased risks for miscarriage, birth defects, gestational diabetes, high blood pressure and preeclampsia, and unplanned cesarean birth. Now is a good time to meet with a nutritionist or go on a sensible diet to get to a healthy weight in anticipation of pregnancy. Once you are pregnant, continue to watch what you eat but don’t try to lose weight. Weight gain is inevitable during pregnancy but guidelines from the American College of Obstetricians and Gynecologists (or ACOG, the leading professional society for OB/GYNs) advise women to gain anywhere from 11-40 pounds, depending on your pre-pregnancy weight. It’s a myth that you need to “eat for two,” so don’t set yourself up for postpartum weight gain by eating more than you should. After delivery of an average 7-8 lb. baby, you may lose 2 lbs. in amniotic fluid, 1.5 lbs. of placenta, 5-7 lbs. in blood volume, and 2 lbs. as the uterus returns to its normal size. That could still leave you with 10 pounds of excess weight, or more if you gained more weight during the pregnancy. Some women never take off those extra pounds, and their weight creeps up with successive pregnancies and age, which can lead to pregnancy complications and chronic health problems later on. See our exercise fact sheet for more information.

Chronic Health Conditions

Do you have chronic health conditions like diabetes, high blood pressure, migraines, asthma, high cholesterol, heart conditions, varicose veins, or anemia? Do you have an autoimmune disease like Crohn’s or ulcerative colitis, lupus, rheumatoid arthritis, ankylosing spondylitis, multiple sclerosis, psoriasis or psoriatic arthritis? Meet with your obstetrician for a “preconception” appointment to discuss how a pregnancy might impact your health, and how your health might affect a future pregnancy. Your specialist can provide an important opinion too. A maternal-fetal medicine specialist (MFM) is a doctor who specializes in high-risk pregnancies, and consulting with a MFM once you are pregnant could help you learn how to optimize your and your baby’s health.

Mental Health

What about your mental health? If you have a history of anxiety or depression, ADHD or other conditions, ask your psychiatrist and OB about treatment, and don’t make changes before you do. Many medications can be continued during pregnancy and while breastfeeding. In fact, mental health is incredibly important – for example, when a woman doesn’t treat her mood disorder or inadequately treats it, some studies suggest risks for miscarriage, premature birth, low birth weight, and preeclampsia. Talk therapy is vitally important too. And if you struggle with mental health concerns during the pregnancy, you are at risk for postpartum depression. Let’s face it – pregnancy and caring for a new baby is stressful, so now is the time to marshal your helpers – friends, relatives, therapists and doctors – to ensure you have enough support. Your obstetrician should ask about mental health but if not, speak up. Your doctor can be your ally here, helping you get treatment and addressing concerns related to pregnancy and postpartum mental health. And MotherToBaby can give you an overview of the research related to any prescriptions you might choose to take.

Dental Health

Have you seen a dentist lately? Oral health can impact a pregnancy, meaning that if you have swollen or bleeding gums, a toothache or an infection, it can increase risks to the pregnancy. If you need to have a dental x-ray, take antibiotics, or have local anesthesia for a dental procedure, these are generally acceptable during pregnancy, but best to complete before you get pregnant. Contact MotherToBaby for more details.

Your Workplace

Where do you work? MotherToBaby can give you information to minimize exposures in a veterinarian office, dry cleaners, salon, laboratory/hospital, imaging center, pest control service, or other business. Your occupational safety department can recommend personal protective equipment (PPE) and tell you about ventilation that may be in place to ensure workplace safety. Safety data sheets (SDS) give an overview of chemicals used in industry and are available online or at work.

Food Safety

Read up on food safety and learn how to minimize your exposure to foods that have commonly been associated with foodborne illness such as E. coli or listeria. Get in the habit of washing your fresh fruits and vegetables well. Check out other blogs on our website too.

Vitamins and Supplements

Have you started taking a prenatal vitamin? Are you getting enough folic acid? ACOG recommends that women take at least 400 mcg of folic acid before getting pregnant and at least 600-800 mcg/day once they are pregnant. This can help prevent birth defects of the brain and spinal cord. Call MotherToBaby if you want to learn the recommended daily intake for specific vitamins or minerals. In general, taking more than what is recommended is not advisable – we haven’t studied how mega-doses of vitamins may impact a pregnancy. Other supplements beyond taking a prenatal vitamin are not advisable either – the Food & Drug Administration (FDA) doesn’t supervise their manufacturing plants and past surveys have shown some supplements actually contain contaminants. Furthermore, we’ve seen instances where the label didn’t match the contents of the bottle and could cause ill effects. Pregnant and breastfeeding women should avoid herbal supplements unless specifically recommended by your doctor.

Alcohol, Cannabis, and Tobacco

Do you smoke cigarettes? Do you use cannabis for medicinal or recreational purposes? Do you drink alcohol? Recent research has demonstrated that marijuana use very early in pregnancy causes changes in brain development, which could result in behavioral or learning challenges we see later in the child’s life. Cigarettes increase risks for pregnancy loss, among other things. And alcohol is known to cause a variety of birth defects known as fetal alcohol spectrum disorder (FASD). We don’t believe that there is a “safe” amount of alcohol which when consumed doesn’t cause issues for a developing child. Now is the time to quit smoking, drinking, and using cannabis – your baby will be heathier for it. MotherToBaby can provide resources, or check with your doctor.

Vaccinations

Are you up to date on all your vaccines? Did you get a flu shot this past season? You don’t want a vaccine-preventable illness to have an impact on your pregnancy. Flu infection can increase risks for more severe symptoms, longer-lasting illness, pregnancy loss and premature delivery, which can have a lifelong impact on your baby. Flu vaccine helps prevent infection. Another benefit to vaccinating during pregnancy? Studies show the protection extends to your baby, and gives them a little extra immunity from birth until they can receive vaccines. Also good to know: some vaccines can be given and are recommended during pregnancy, like a flu shot or TDAP, but others are best given before you conceive to avoid a small risk of spreading the illness to the fetus (e.g. the measles, mumps, and rubella (MMR) vaccine, as well as the Varicella (chicken pox) vaccine) – so try to get these done at least a month before trying to conceive. Check your medical records to see the last time you received any of these vaccinations. If you don’t know if you were previously vaccinated, your doctor can draw blood to check if you have immunity.

Your Pets

Do you have a cat? There is some concern in pregnancy about an infection called toxoplasmosis, which is caused by a parasite that can be found in cat feces. Read our blog for more info on what you can do to prevent this infection if you have a fur baby at home.

Other Illnesses

Do your upcoming travel plans involve travel to a warm tropical place? Check out our Zika fact sheet to learn more before you book nonrefundable tickets. In general, women will want to wait to try to conceive for eight weeks from the time of your return home; the wait time is three months if your male partner travels with you. COVID-19 is also spreading around the globe and our fact sheet can give you the latest information on whether and how it could affect a pregnancy.

Finally, your obstetrician or primary care doctor would be glad to see you for a Preconception consultation. Make an appointment to discuss your personal history and health. It’s a great way to get you and your baby off to the best start.

*May is Maternal Mental Health Awareness Month*

By Elizabeth Salas, MPH, Teratology Information Specialist, MotherToBaby California

If you are feeling anxious during your pregnancy, you’re not alone. It seems every year there are more articles and news stories on the latest health hazards. Whether you read it online or in a medical journal, hear it on the news or from friends and family, there’s no shortage of information on health concerns. This seems especially true during pregnancy.

 Having Questions Vs. Having Anxiety

 It’s normal to have questions and concerns during pregnancy. Every woman has them. Every woman also deserves to have her questions answered and concerns addressed. Beyond having questions about what’s safe to eat, products to use, or medications to take, pregnant women must balance their normal activities and responsibilities with scheduling prenatal appointments and preparing for their baby’s arrival. With so much to think about, it’s not unusual for pregnant women to feel a little bit anxious. So what’s the difference between having questions and having anxiety? How much anxiety is too much during pregnancy?

The month of May is Maternal Mental Health Awareness Month, and a great time to tackle these questions, raise awareness, and talk about mental health.

What Are Anxiety Disorders?

 While stressful events in our lives can cause anxiety that is mild and temporary, anxiety disorders are different in that the fear and anxiety can be excessive and/or persistent over time and can interfere with a person’s ability to function in their daily life. It is estimated that 13-18% of American adults or up to 40 million people each year experience an anxiety disorder.^{1, 6} Anxiety disorders include generalized anxiety disorder (GAD), panic disorder, post-traumatic stress disorder (PTSD), social phobia, and other phobias. These conditions can cause individuals to experience a great deal of worry or fearfulness. Anxiety disorders can cause physical symptoms such as difficulty sleeping, fatigue, headaches, muscle aches, irritability, lightheadedness, dizziness, trembling, hot flashes, feeling out of breath, and nausea among other symptoms.⁶

 Anxiety Disorders And Pregnancy

While more attention has been given to the study of anxiety disorders during pregnancy in the last decade, information is limited. Screening tools for anxiety disorders during pregnancy, such as those used to screen for depression during pregnancy and postpartum, have not been well studied and are not used regularly in obstetric clinics.² Without screening being part of routine prenatal care, it is up to pregnant women to express their concerns about anxiety to their healthcare providers. It also means that some women might not get the help they need.

Anxiety disorders during pregnancy are estimated to affect from 4%-39% of women.³ While some studies suggest that pregnant women are more likely to have anxiety disorders than non-pregnant women, other studies found that pregnant women are just as likely than non-pregnant women to have an anxiety disorder.⁴ How many women develop anxiety disorders during pregnancy is not well understood. A woman with a preexisting anxiety disorder may find that her condition is worse during pregnancy, but for others symptoms may stay the same. While gaps in our knowledge remain about anxiety disorders in pregnancy, the importance of maternal mental health is receiving more attention.⁵

What If I’m Having Problems With Anxiety?

Whether starting a new job, dealing with financial stressors, or struggling with a relationship or health complications, we have all experienced anxiety at some point in our lives. If your anxiety is affecting you more than usual or if you’re concerned you may be experiencing an anxiety disorder, talk to your healthcare provider right away. Your provider will ask about your symptoms and may give you a screening questionnaire to fill out. If you are having symptoms they will talk to you about your options and may refer you to a mental health provider. Depending on a woman’s diagnosis and the severity of her condition, she and her providers may decide to treat her condition with talk therapy, behavior modification, medications, or a combination of these. Many pregnant women take medications for anxiety during pregnancy and delivery healthy full-term babies.

Since anxiety disorders can cause significant physical symptoms and stress in a person’s life, these conditions require attention and treatment just like any other medical condition during pregnancy. Every woman and every pregnancy is different. Working together with your provider to keep you healthy during pregnancy isn’t just important for your health; it’s important for the health of your developing baby too.

WHERE CAN I GET MORE INFORMATION?

California Maternal Mental Health Collaborative

 To learn more about maternal mental health disorders, access a self-quiz, and obtain a list of resources that can help, visit the California Maternal Mental Health Collaborative website.

http://www.2020mom.org/mmh-disorders/

http://www.2020mom.org/get-help/

 National Institute of Mental Health

 To learn more about anxiety disorders, check the National Institute of Mental Health website and their Anxiety Disorders information booklet.

http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml?rf=53414

http://www.nimh.nih.gov/health/publications/anxiety-disorders/nimhanxiety_34436.pdf

 MotherToBaby

At MotherToBaby, we answer questions about exposures during pregnancy and breastfeeding. We receive questions on everything from hair dye to medications used to treat anxiety and depression and much more. Our service is free, confidential, and provides information that is evidence-based. Most importantly, our service is available to you and your healthcare providers. To speak to a MotherToBaby expert, you can call toll free at (866) 626-6847 or visit us online.  https://mothertobaby.org/

  

Elizabeth Salas is the Lead Teratology Information Specialist for MotherToBaby California, a non-profit that provides information to healthcare providers and the general public about medications and more during pregnancy and breastfeeding. She is based at the University of California, San Diego, and is passionate about the work MotherToBaby is doing to promote healthy moms, healthy pregnancies and healthy babies.

 MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about medications, vaccines, diseases, or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or call the Pregnancy Studies team directly at 877-311-8972. You can also visit MotherToBaby.org to browse a library of fact sheets, as well as visit our website for MotherToBaby Pregnancy Studies, www.PregnancyStudies.org.

References:

1. Combs H, Markman J. Anxiety disorders in primary care. Med Clin North Am. 2014 Sep; 98 (5):1007-23. doi: 10.1016/j.mcna.2014.06.003. Epub 2014 Jul 11. PubMed PMID: 25134870.
2. Evans K, Spiby H, Morrell CJ. A psychometric systematic review of self-report instruments to identify anxiety in pregnancy. J Adv Nurs. 2015 Mar 26. doi: 10.1111/jan.12649. PubMed PMID: 25818179.
3. Goodman JH, Chenausky KL, Freeman MP. Anxiety disorders during pregnancy: a systematic review. J Clin Psychiatry. 2014 Oct;75(10):e1153-84. doi: 10.4088/JCP.14r09035. PubMed PMID: 25373126.
4. Howard LM, Molyneaux E, Dennis CL, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. Lancet. 2014 Nov 15;384(9956):1775-88. doi: 10.1016/S0140-6736(14)61276-9. Epub 2014 Nov 14. PubMed PMID: 25455248.
5. Howard LM, Piot P, Stein A. No health without perinatal mental health. Lancet. 2014 Nov 15;384(9956):1723-4. doi: 10.1016/S0140-6736(14)62040-7. Epub 2014 Nov 14. PubMed PMID: 25455235.
6. National Institute of Mental Health. 2009. Anxiety Disorders. NIH Publication No. 09 3879. Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml

By Lorrie Harris-Sagaribay, MPH, Teratogen Information Specialist and
Coordinator, MotherToBaby North Carolina

Back in the early 1970s, pregnant women and their health care providers didn’t talk about alcohol and drugs in pregnancy. Birth defects caused by alcohol? Unheard of! Then, along came two pediatric specialists at the University of Washington who changed everything: Drs. David W. Smith and Kenneth Lyons Jones noticed that a group of babies who had been exposed to high amounts of alcohol during pregnancy were all born with a similar pattern of unusual facial features and developmental delay. Their astute observations, along with further research and collaboration, led them to coin the term Fetal Alcohol Syndrome (FAS) in 1973.

The discovery that alcohol was a teratogen (an exposure that can cause birth defects) fueled the research on other exposures and opened up a world of questions. What about other drugs? What about medications? In order to share findings from the limited but ongoing research, Dr. Jones established the first teratogen information service in 1979, housed in a small apartment in San Diego and run by a dedicated staff of three. This service was the beginning of what would later become MotherToBaby.

Fast forward to June 2017, when experts from MotherToBaby and other teratogen information services around the world gathered in Denver, Colorado for the 30th Annual Meeting of the Organization of Teratology Information Specialists (OTIS). There, dozens of experts presented the latest research on exposures during pregnancy. Speakers summarized what we’ve learned, pointed out what we still don’t know, and suggested priorities for future research. Here are a few highlights from the meeting:

Prescription Opioids
At one time, opiates were peddled as remedies for fatigue, menstrual cramps, and even teething in children (search Mrs. Winslow’s Soothing Syrup as an example). Now, more than a century later, we are in the middle of an epidemic of substance use disorders from opioid pain relievers. And according to a 2014 study, more than 14% of pregnant women in the U.S. are prescribed opioids at least once during pregnancy for reasons such as back pain and migraines. Pregnant women who develop opioid use disorders (either before or during the pregnancy) are encouraged to undergo maintenance therapy such as methadone treatment, which is less risky to the baby and more likely to result in successful recovery than sudden withdrawal would be.

Infants with ongoing exposure to opioids during pregnancy can experience withdrawal symptoms at birth, commonly called neonatal abstinence syndrome (NAS). Like Fetal Alcohol Syndrome, NAS was first described in the literature in the 1970s, by Dr. Loretta Finnegan. The syndrome has gotten renewed attention during the current opioid epidemic as providers and researchers consider the best ways to prevent and manage NAS. Studies have shown that hospitalized infants with NAS have better outcomes–less severe symptoms, less need for medication, and shorter hospital stays–when they are breastfed, even if the mothers are still on opioid maintenance therapy. But some health care providers hesitate to encourage breastfeeding in these cases out of concern about baby’s ongoing exposure to the mother’s medication through the milk. Continued funding can help address these concerns by developing consistent standards of care for infants with NAS. If you are using opioids for any reason, be sure to talk to your health care provider as soon as you find out you are pregnant. Together, you can work on a plan for the best possible care for you and baby during and after the pregnancy.

Cocaine
To study the effects of cocaine in pregnancy, researchers have followed a group of young adults, now in their early 20s, since they were born. About half the group was exposed to cocaine before birth. Early on, the researchers observed that those with cocaine exposure had challenges with attention and remembering what they saw when compared to the children who had not been exposed to cocaine. In older years, exposed children had more difficulty with language skills, more behavior problems at school and at home, reported more substance use and risk-taking behavior, and had more difficulty with everyday skills such as staying organized, thinking ahead, and controlling their own behavior. Some dropped out of school. Interestingly, having a positive home environment seemed to help with some, but not all, of these challenges. For example, children in foster or adoptive homes had better language and reasoning skills than children who still lived with their birth mothers who used cocaine, but there was no difference in their behaviors. As the study continues, researchers hope to learn more about how prenatal cocaine exposure affects these individuals into adulthood.

E-cigarettes
E-cigarettes are marketed and often seen as a “safer” option to cigarettes. In fact, the most common users are current and former cigarette smokers who are using e-cigarettes to replace or reduce the number of cigarettes they smoke. In a study of over 1,300 pregnant women, those using e-cigarettes reported doing so because they felt they were less harmful than cigarettes, or to help with smoking cessation. They also preferred the sweeter flavors, and thought they were even less harmful than the tobacco-flavored liquids.

E-cigarettes don’t expose users to the combustion by-products of traditional cigarettes, but even those labeled “nicotine-free” do contain nicotine, and vaporization creates its own potentially harmful by-products. Since e-cigarettes are liquid-filled and can be smoked longer, it’s more difficult to monitor actual exposure to nicotine than it is with traditional cigarettes. Plus, because e-cigarettes are not regulated by the FDA, there is no way of knowing exactly what they contain and what your pregnancy is exposed to when you use them.

Past studies have observed that prenatal exposure to nicotine affects baby’s brain development and increases the chance of later behavior problems and depression in adolescence. It even predicts baby’s own cigarette use in his/her teen years. And recent studies have shown that those adolescents who use cigarettes are more likely to also use e-cigarettes as teens and adults than their peers who don’t use cigarettes. We will learn more about the possible long-term effects of prenatal e-cigarette use as the first generation of children who were exposed to them in pregnancy gets older.

Marijuana
Marijuana is the most common “illicit” drug used in pregnancy. Some health care providers in Colorado, where marijuana is now legal, are seeing more pregnant women who believe that using it is not harmful and might even be beneficial. For example, pregnant women in one survey reported using marijuana to help manage depression or anxiety, help with pain, or ease nausea and vomiting, among other reasons. Without crucial data about exactly how marijuana might be harmful to a pregnancy, some health care providers are hesitant to talk to women about it, even if they know they are using it in pregnancy.

There is little doubt that marijuana can be harmful in pregnancy: THC crosses the placenta and, even in very early pregnancy, can affect the cells that form the baby’s brain. But studies on its effects on overall brain development and pregnancy outcomes have had mixed results so far, and they face challenges such as co-exposures (women using other substances along with marijuana) and, in some cases, relying on self-reporting to know how much of the drug a pregnancy is exposed to (this can skew the data if users do not accurately reveal how much and how often they use.) As researchers forge ahead to provide better answers, the best advice is still to avoid marijuana altogether in pregnancy.

Alcohol
Since those early years, we have discovered that the facial features and developmental delay often seen with FAS are not the only possible effects of prenatal exposure to alcohol. In some children, subtle changes to the brain might not be noticed until the child is older and begins to struggle with learning and behavior problems that can follow them into adulthood. This range of possible effects has been more recently named Fetal Alcohol Spectrum Disorder (FASD). According to Dr. Jones, FASD affects about 2% of babies born in the U.S. each year–more common than autism–despite the fact that it is 100% preventable.

Looking ahead.
The decades ahead require not only continued research, but also increased awareness of what we already know. To that end, each September we observe FASD Awareness Month. MotherToBaby is happy to answer your questions about alcohol and other exposures in pregnancy—in fact, check out our brief YouTube video here. Together, we can continue the work towards the best possible outcomes for future generations.

Lorrie Harris-Sagaribay, MPH is the Coordinator of MotherToBaby North Carolina and a bilingual Teratogen Information Specialist. After working with midwives as a community health educator with the Peace Corps in Honduras, she earned her Master of Public Health at the University of North Carolina at Chapel Hill. She has worked in the field of maternal and child health for over 25 years.

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.

References:

Bateman BT et al. Patterns of Opioid Utilization in Pregnancy in a Large Cohort of Commercial Insurance Beneficiaries in the United States. Anesthes 2014;120(5):1216-1224.

McQueen K and Murphy-Oikonen J. Neonatal Abstinence Syndrome. N Engl J Med 2016; 375:2468-2479.

Presented at the (joint) Annual Meetings of OTIS (Organization of Teratogen Information Specialists), DNTS (Developmental Neurotoxicology Society), RSA (Research Society on Alcoholism) and the Teratology Society in Denver, Colorado on June 25-27, 2017:

• From the FAS to OTIS – A Long Strange Trip. Buzz Chernoff, California Environmental Protection Agency (Retired).
• The Opioid Epidemic and Impact of Prenatal Exposure on Child Development. Lynn Singer, Case Western Reserve University.
• Project Newborn: What We Have Learned from 20 Years of Research on Prenatal Cocaine Exposure. Sonia Minnes, Case Western Reserve University.
• Epigenetic Changes Induced by Prenatal Nicotine and Cocaine Exposure. Pradeep Bhide, Florida State University.
• Effects of Prenatal Nicotine Exposure on Adolescent Dopamine Systems. Frances Leslie, University of California at Irvine School of Medicine.
• Electronic Cigarette Use in Pregnancy: Patient and Provider Perspectives. Katrina Mark, University of Maryland School of Medicine.
• Pathways from Prenatal Tobacco Exposure to Electronic Cigarette Use. Natacha M. DeGenna, University of Pittsburgh School of Medicine.
• Perceptions and Use of Electronic Cigarettes during Pregnancy: Implications for Infant Outcomes. Laura Stroud, Brown Medical School.
• Pathways from Prenatal Exposures to Tobacco and Cannabis to Adult Electronic Cigarette Use. Natacha De Genna, University of Pittsburgh Medical School.
• Counseling Women about Prenatal Marijuana Use: Weeding through the Data. Torri D. Metz, University of Colorado-Denver.
• Introduction: Marijuana and Child Development Symposium. Diana Dow-Edwards, SUNY/Downstate Medical Center.