By Mara Gaudette, MS, CGC, Teratogen Information Specialist, MotherToBaby

My friend Jocelyn, newly (and unexpectedly!) pregnant called in a bit of a panic. Her cardiologist was switching her high blood pressure medication now that she was pregnant.  Jocelyn was still waiting for her asthma doctor to call her back but she figured her asthma treatment plan was another of the many changes she needed to make to accommodate the pregnancy. “Does anything stay the same?” she asked.

Jocelyn was relieved to learn that at least in the case of asthma, the answer is, often, YES! The general thought is that the medications working to treat asthma in a non-pregnant woman are the same ones that should be continued during pregnancy. This is because the main concern is with asthma itself and making sure the developing baby is getting a good supply of oxygen. Improving asthma control is thought to be best for both mom and baby.

Jocelyn had been taking an inhaled corticosteroid for the past five years-ever since she otherwise needed to use her fast-acting rescue inhaler almost daily. Fortunately, for Jocelyn, if a daily preventative is needed, an inhaled corticosteroid like Pulmicort® that she was already taking is a preferred treatment. Why? Well, for one thing, it often works well to stop symptoms. Secondly, because it is inhaled, less of the medication should be able to reach a pregnancy compared to most oral medications. For the same reasons, albuterol for relief of immediate asthma symptoms is also considered a preferred treatment during pregnancy. But, had Jackie been on other types of inhalers when she identified her pregnancy, and they were working well for her, they probably would not need to be changed either.

Maternal asthma that is not well controlled is associated with higher rates of pregnancy complications, such as decreased growth of the baby and preterm delivery (birth before week 37). Therefore, it is important that asthma management during pregnancy continues to include the medications that best control an individual’s asthma symptoms. “Ok,” Jocelyn said. “I will keep going with my inhalers and bug the doctor’s office again to get back to me to confirm.”

Thankfully, the next call I got from Jocelyn wasn’t so panic-stricken. “It sounds like my doctor wants me to continue my asthma inhalers.” With a calmer tone to her voice since our first conversation, she added, “although I would never be a guinea pig, it would be nice if I could help other pregnant women with asthma so they wouldn’t have to go through the scare I just went through.” I told her we can never have too much information when it comes to asthma and treatments during pregnancy and let her know that at MotherToBaby we are still enrolling pregnant women with asthma, pregnant women taking asthma medicines, and even pregnant women without asthma. There is no cost and you are not asked to take any medication… so guinea pigs need not apply! Just call 877-311-8972 or volunteer for a study through our website. 

“Oh, what about my allergy medicine?” Jocelyn remembered to ask. “When I don’t take Zyrtec®, my asthma flares, and my allergies have been crazy this spring.” I let her know that antihistamines in general have relatively reassuring pregnancy profiles, but it is always good to check on the specific medication.  Pregnancy studies with cetirizine, the medication found in Zyrtec®, have found no increase in birth defects. You can check the product label to make sure cetirizine is the only medication in your product since brand name products can make different formulations. As with any medication in pregnancy, check in with your healthcare provider and follow their dosing recommendations.

More detailed medication information can be found in the following fact sheets:

https://mothertobaby.org/fact-sheets/albuterol-pregnancy/

https://mothertobaby.org/fact-sheets/asthma-and-pregnancy/

https://mothertobaby.org/fact-sheets/cetirizine/

https://mothertobaby.org/fact-sheets/inhaled-corticosteroids-icss-pregnancy/

Bottomline, breathe in, breathe out, and enjoy your pregnancy as best as possible!

Mara Gaudette is a genetic counselor and received her Masters Degree from Northwestern University. Drawn to the satisfaction of providing immediate
reassurance to worried women, she began educating the public about teratogens at MotherToBaby’s Illinois affiliate more than a decade ago. Today, she counsels for MotherToBaby California via phone and live chat.

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, alcohol, diseases, vaccines, or other exposures during pregnancy or breastfeeding, call MotherToBaby toll-FREE at 866-626-6847 or visit MotherToBaby.org to browse a library of fact sheets and find your nearest affiliate.

“I can’t get rid of it fast enough!” Caroline was 5 months pregnant and at her wits end when she contacted MotherToBaby. “My migraine is so bad that I can barely get out of bed, but I feel like there’s nothing I can do about it since I’m pregnant. I don’t want to harm the baby!” We often get questions like Caroline’s from women planning a pregnancy or already pregnant who would like information on the prevention and treatment of migraine headaches, so I start by asking Caroline what she would have used if she weren’t pregnant. Caroline told me that she would have taken ibuprofen and or sumatriptan.

Migraine preventions and treatments fall into three basic categories:

1. Over the counter remedies such as aspirin or other NSAIDs, or acetaminophen with or without caffeine.
2. Prescription medications such as opioids, various anticonvulsants, triptans, tricyclic antidepressants and beta blockers.
3. Alternative therapies such as Botox or other nerve block injections, massage therapy, acupuncture, high doses of magnesium, or essential oils.

Most women have tried more than one therapy that has failed before they find one or a combination of products that will work for them. Migraines can be very debilitating, so the thought of having to go without a prevention or treatment that works can be very anxiety producing. Yes, it is true that some women find that their migraines disappear during pregnancy, but in others, they become more frequent. Having a plan for prevention and treatment, just in case, is necessary. We can help with the development of that plan by providing migraine sufferers with evidence-based information about the safety of various treatments during pregnancy (and also while breastfeeding!). Below is a brief summary of many common migraine medications and treatments, but we encourage you to visit our Fact Sheets or contact our experts for more detailed information.

Over the Counter Remedies

Typically, non-steroidal anti-inflammatory medications like aspirin, naproxen and ibuprofen are not recommended in pregnancy.

Acetaminophen alone does not always provide relief for a migraine, but its use should not be of great concern depending on how much or how often it is needed.

Caffeine can sometimes be added to enhance the relief of a migraine in some individuals. Typically, such doses of caffeine are not expected to create an increased chance for adverse pregnancy outcome.  For further guidance on caffeine, see our fact sheet.

Other over the counter remedies that fall into the herbal or supplement categories are also not recommended since they are not well regulated or studied for safety. See our fact sheet on herbal supplements.

Prescription Medications

Many women find that over-the-counter products are not helpful enough and turn to healthcare providers for prescription medication relief. Prevention of the headache in the first place is key for some. 

Beta blockers have been around a long time and used daily for migraine prevention in some individuals. Studies do not suggest that their use in pregnancy is high risk. See our Fact Sheets on metoprolol and propranolol for additional information.

The tricyclic antidepressants, such as amitriptyline and nortriptyline, are older drugs that have been successful in some at the prevention of migraine headaches when used daily. They too have not been found to be high risk products when used in pregnancy.

Other medications such as certain anticonvulsants have been used to prevent or reduce the severity or frequency of migraines. However, these medications have more complex concerns when used in pregnancy. The chance for complications in pregnancy must be individually and carefully weighed against the benefits of keeping migraines in check.

The “triptan” products were designed specifically to treat migraine headaches and include sumatriptan, rizatriptan, frovatriptan and naratriptan. As the “triptan” medication that has been around the longest time, sumatriptan has relatively reassuring data on use during pregnancy.

Opioids are used to treat the extreme pain caused by migraines. While they are not typically found to cause a significant increased chance for birth defects, regular use can create problems later in pregnancy or after birth. In some cases, their use may cause rebound headaches and therefore create more need for treatment.

Alternative Therapies

Migraines can be really difficult to prevent or treat, and some women turn to alternative therapies. Botox, bupivacaine, or lidocaine injections have been used as nerve blockers to treat migraines.  However, it may not be best to try these out for the first time during a pregnancy.

Some non-pharmaceutical options include massage therapy and acupuncture. Your healthcare provider may be able to refer you to someone who has experience implementing these treatments with pregnant women.

Essential oils are used topically or in a diffuser. Be careful not to ingest any. If you are nursing or have an infant, be sure not to leave oils on your body where they might accidently ingest them.

We have had questions about the use of high doses of magnesium to curb migraines. We cannot recommend this option and suggest that you seek out the advice of your healthcare provider to determine if such treatment would be helpful or wise. 

The Takeaway

I gave Caroline a summary of what is known about her usual migraine treatments, and suggested she have a conversation with her healthcare provider to discuss a safer alternative to ibuprofen and whether her provider would suggest any other changes to her treatment plan. The bottom-line is the benefits of some treatments may outweigh the risks of not treating migraines. A healthy mama from toe to head (especially a pain-free head) is best for baby too.

Your Partner in Health for Pregnant and Lactating Patients with Cardiovascular Disease

MotherToBaby supports cardiologists and lipidologists in managing cardiovascular disease during pregnancy and while breastfeeding. We understand the challenges that you face when deciding on treatment courses when your patient is pregnant or breastfeeding. Care of people who are pregnant and/or lactating with serious conditions like hypertension, hypercholesterolemia, or ASCVD is further complicated by the physiological changes of pregnancy that may alter treatment needs throughout the course of pregnancy. Our resources will help you weigh the risks and benefits to both your patient who is pregnant and their baby as you determine a treatment plan that maximizes disease management and minimizes maternal and fetal/infant risk.

We are also dedicated to furthering the information and understanding of medication safety in pregnancy through our observational MotherToBaby Pregnancy Studies, and we are proud to lead more than half of all Food and Drug Administration (FDA)-mandated pregnancy registries conducted in the U.S. MotherToBaby Pregnancy Studies are rigorously designed cohort studies that aim to provide critically needed product safety information – and your patient referrals make all the difference. If you have cardiac or lipid patients with comorbid conditions like COVID-19, asthma, rheumatoid arthritis, or Crohn’s disease, please consider referring them to our research studies. With your referral, you are helping us generate data that will lead to improved product safety information in pregnancy, thereby providing patients and health providers with the evidence they need to make more informed treatment decisions.

Heart disease and stroke are the leading cause of pregnancy-related death before, during, and up to a year after delivery.

— Centers for Disease Control and Prevention (CDC)

Explore how we can help you and your pregnant and breastfeeding patients by providing no-cost exposure risk assessments, patient education materials, and more.

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Download our LactRx app for on-the-go access to the Library of Medicine’s LactMed database for current information on cardiology and lipidology medications as well as other drugs and vaccinations to which breastfeeding mothers may be exposed.

Partners

• The FH Foundation
• The Foundation of the National Lipid Association (NLA)
• PCNA
• Society for Maternal-Fetal Medicine   
• Society for Birth Defects Research & Prevention
• Patient Education Genius
• MyHealthTeams
• PatientsLikeMe
• The Mighty

By Pat Olney, MS, CGC, Pregnancy Risk Specialist, MotherToBaby Georgia

One day in early June I received a frantic call from a woman who had first called Georgia’s Poison Control Center worried about the agent used to treat her varicose veins. She thought that she did the right thing by postponing her treatment until after she gave birth, but now was concerned about breastfeeding her newborn. The medical director at poison control, who is one of our advisory board members, gave her the correct information: “Call Pat Olney at MotherToBaby!”

The caller’s vascular surgeon advised her to pump her breast milk over the next 24-48 hours, and discard it; otherwise known as pump and dump. The first thing she did before calling poison control was surf the Internet for answers. She began feeling guilty about having had the procedure. She lamented, “Why didn’t I wait until after my baby was done nursing!”

First, I needed to learn a little bit about varicose veins. Varicose veins are more common in women than men, and women may first develop varicose veins during pregnancy. Pregnancy puts an added burden on the veins as the amount of blood flowing through the veins increases. Veins in the legs are already working against gravity, and pressure from the increased blood volume can cause veins to swell and bulge near the surface of the skin. They tend to get worse with each subsequent pregnancy, as women get older, or if a woman is overweight. Varicose veins can be very painful. Typically, the problem tends to improve after delivery. For our caller, the pain and discomfort continued and she decided to seek treatment.

The agent used for her varicose vein treatment was sodium tetradecyl sulfate (STS). I consulted my brand new 2014 edition of Dr. Thomas Hale’s manual of lactational pharmacology, “Medications & Mother’s Milk.” Dr. Hale’s book is used all over the world, and he is recognized as an expert in this highly specialized field. STS, a sclerosing agent, is injected into the affected vein. Dr. Hale describes this agent: “…an anionic surfactant which causes local inflammation, and thrombus formation, thereby occluding and eventually obliterating the affected vein.” He goes on to say “severe reactions such as anaphylactic shock, pulmonary embolism have been reported, although rare.”

Sounds terrible, doesn’t it? I said to myself…no wonder this woman called poison control!

Dr. Hale developed the following lactation risk categories:
L1 Compatible: drug has been taken by a large number of breastfeeding women without any observed increase in adverse effects in the infant; controlled studies fail to demonstrate a risk to the infant, or the product is not orally bioavailable in an infant

L2 Probably compatible: drug has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant, and/or the evidence of a demonstrated risk is remote

L3 Probably compatible: there are no controlled studies in breastfeeding women; however, the risk of untoward effects to breastfed infant is possible, or controlled studies show only minimal non-threatening adverse effects; drugs should be given only if potential benefit justifies potential risk to infant; new medications that have no published data are automatically categorized in this category, regardless of how safe they may be

L4 Possibly hazardous: positive evidence of risk to breastfed infant or to breast milk production; benefits of use may be acceptable despite the risk to infant; e.g. if the drug is needed in a life-threatening situation or a serious disease for which safer drugs cannot be used or are ineffective

L5 Hazardous: studies in breastfeeding mothers have demonstrated significant and documented risk to the infant based on human experience, or is a medication that has a high risk of causing significant damage to infant; drug is contraindicated in women breastfeeding an infant

Did the vascular surgeon give our caller the correct information?

Sodium tetradecyl sulfate falls into lactation category L3. There are no studies done in nursing women, and there is no data on its transfer into human milk. Dr. Hale goes on and states, “This product could be hazardous if introduced in the infant through breast milk. Therefore, extreme caution is recommended with its use in a lactating mother.”

Since there are no published studies, and no data, our caller was given the correct advice: pump and dump. Fortunately, her baby was already taking an occasional bottle, so she thought the baby would easily switch back to breastfeeding.

Sometimes the advice given to lactating mothers is not so straightforward. As summarized in a clinical report published by the American Academy of Pediatrics (AAP), “Many breastfeeding women are wrongly advised to stop taking necessary medications or to discontinue nursing because of potential harmful effects on their infants. Not all drugs are present in clinically significant amounts in human milk or pose a risk to the infant. Certain classes of drugs can be problematic, either because of accumulation in breast milk or due to their effects on the nursing infant or mother.”

When counseling a woman who has chosen to give her baby the best start in life, it’s important to get the facts, even if evidence-based information is lacking.

Questions? For your FREE personalized risk assessment, call MotherToBaby toll-FREE (866) 626-6847. MotherToBaby is a service of the international non-profit Organization of Teratology Information Specialists (OTIS), a society that supports and contributes to worldwide initiatives for teratology education and research. MotherToBaby affiliates and OTIS are suggested resources by many agencies, including the Centers for Disease Control and Prevention (CDC), and are dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding. Learn more at MotherToBaby.org.

 

Patricia Olney, MS, is a certified genetic counselor and pregnancy risk specialist at MotherToBaby Georgia, Emory University. She received her masters degree at the University of California, Berkeley and has practiced genetic counseling for more than 25 years. MotherToBaby GA is funded by the Georgia Department of Behavioral Health and Developmental Disabilities.

Reference:
The American Academy of Pediatrics (AAP) August 2013 “The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics.”

By Beth Conover, APRN, CGC MotherToBaby Nebraska, UNMC

“There are so many risks to the baby if I go for dental work, right?” “What about x-rays?” “I don’t like going to the dentist anyway, so I’ll probably just wait until my baby is born. That should be fine, right?” Worries, excuses, we’ve heard it all at MotherToBaby when it comes to dental procedures during pregnancy. We often receive questions from women wondering whether dental care is safe. In short, the answer is….yes! What better time to talk about the reasons why it’s ok than during June – typically the month the American Dental Association dubs as “Oral Health Month.”

Routine dental care is low risk, and most emergency procedures can be done as well.
Good oral health improves your overall health, and increases your chances of a good pregnancy outcome. However, when you are scheduling a dental appointment and are pregnant (or trying to get pregnant), let the office know so that they can be prepared to make decisions about which procedures are safe for your baby. In some cases, you or your dentist may want to wait until after delivery for elective (non-necessary) procedures.

Here are some commonly asked questions we get from pregnant women:

• When I brush my teeth, my gums have started to bleed. Is this normal? What should I do?

Bleeding gums is a common problem during pregnancy. Pregnant women have hormonal changes that can increase their chances of getting gum problems such as gingivitis (puffy and tender red gums that bleed easily). Your dentist will want to monitor this so that it does not progress to a more serious gum disease. Periodontal disease is a bacterial infection of the gums and jaw bones that support the teeth, and can increase your chances of having a smaller baby, delivering early, and having other pregnancy complications. Dentists recommend that you floss daily, and get your teeth cleaned on a regular basis during pregnancy (consider having it done more frequently, if you are having pregnancy gingivitis).

• It seems like pregnancy is causing me to get more cavities in my teeth…am I right?

Pregnancy can contribute to women having more cavities. This is in part due to changes in diet such as frequent snacks including sugary foods. To prevent cavities, eat a healthy diet and brush your teeth after eating sweets. In addition, if you have morning sickness, the acid from your stomach can affect your tooth enamel and make cavities more likely. Rinse your mouth with water or mouthwash after morning sickness episodes. If your toothpaste is making your morning sickness worse, ask your dentist for the name of a bland-tasting toothpaste.

• What if I need to get a cavity filled or a tooth pulled? Can I have a local anesthetic?

Agents like lidocaine which are injected into your gums are low risk for your baby. In one study, researchers compared pregnant women who received lidocaine injections as part of dental treatment with women who did not, and found no significant increase in risk for miscarriage, prematurity, or birth defects. If you need a pain medication, your dentist will take into account where you are in your pregnancy so as to make a choice that is safest for your baby.

• Are dental x-rays safe in pregnancy?

You may choose to have routine X-rays done prior to pregnancy, or to delay them until after you deliver – talk to your dentist about the best options for you. However, if you have a dental emergency and need to have them done, don’t hesitate. Advances in technology have made dental X-rays safer, and they do not involve as much radiation or may not involve radiation at all. Your dental office will cover your neck and abdomen with a lead apron, which lessens the exposure to your baby even more.

• What else can I do to ensure dental health?

Schedule a visit to your dentist before you are pregnant. Get teeth cleaned, gums examined, and any dental issues addressed prior to pregnancy.

Brush your teeth at least twice a day and floss once a day. This helps reduce plaque, the sticky film that covers your teeth and can make gums inflamed and increase your risk for periodontal disease.

I hope I’ve given you a few good tips to chew on – Your teeth and baby will thank you. Have a healthy pregnancy!

Beth Conover, APRN, CGC, is a genetic counselor and pediatric nurse practitioner. She established the Nebraska Teratogen Information Service in 1986, also known as MotherToBaby Nebraska. She was also a founding board member of the Organization of Teratology Information Specialists (OTIS). In her clinical practice, Beth sees patients in Pharmacogenetics Clinic and Genetics Clinic at the University of Nebraska Medical Center. Beth has provided consultation to the FDA and CDC.

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.