By Patricia Olney, MS, CGC, Genetic Counselor & Teratogen Information Specialist, MotherToBaby Georgia

Emily’s call to MotherToBaby came in late at night. Her voicemail message sounded a bit garbled, almost as if she had been crying. I returned her call the next day and heard her anxious voice say, “My psoriasis flared up last week…it’s been several years. I’m really worried because I just found out I’m pregnant.” I replied calmly, “Emily, I’m glad you called MotherToBaby for information. We care about you and your baby!”

How did Emily find me? I’m a pregnancy risk specialist at MotherToBaby, which is a service of the Organization of Teratology Information Specialists (OTIS). MotherToBaby provides FREE, up-to-date, evidence-based information about exposures during pregnancy and breastfeeding. Exposures may include prescription or over-the-counter medications, chemicals in the environment, alcohol, illicit drugs, and viral or maternal illnesses, like psoriasis and psoriatic arthritis. After spending a lot of time searching the Internet for answers to her questions, a frustrated Emily found our website and our toll-free phone number and I was able to provide her with the information she needed.

Psoriasis is a life-long skin disease, but symptoms can come and go. The most common is chronic plaque psoriasis, the type Emily was diagnosed with at the age of 14. Emily described her life since being diagnosed as an emotional rollercoaster. As a teenager, she was self-conscience about how she looked, and often felt depressed. In college she studied by herself and avoided social gatherings. It wasn’t until she met her future husband that she began feeling more in control of her life. He helped her find a specialist in dermatology with experience in treating psoriasis. After trying a variety of treatments, a combination of topical corticosteroids, moisturizers, and medications helped to control her symptoms. Compared with other family members, she described the severity of her psoriasis as mild to moderate. In her late twenties, she had several flare ups which often required medication or UVB phototherapy.

During Emily’s first pregnancy, she told me her psoriasis improved, and she was hoping for the same during her next pregnancy. But the week before calling me, Emily had worked long hours on a project with a tight deadline. She came home late in the evenings, feeling stressed and discouraged. By the end of the week, she noticed the all too familiar red, scaly plaques on her elbows, knees and scalp.

The evening Emily called, she had taken a home pregnancy test. She and her husband planned to have another child, but were surprised how easy it was to conceive. This time, however, she was not prepared to face the possibility of a psoriasis flare up during the first few weeks of pregnancy. I reassured her that she was not alone, and many women face the same uncertainty with pregnancy.

So what can a woman with psoriasis and/or psoriatic arthritis do to prepare for a healthy pregnancy?
Every woman who is planning pregnancy should avoid drinking alcohol and smoking cigarettes, reduce stress, exercise, eat a healthy diet, and take prenatal vitamins with folic acid. In some woman with psoriasis, alcohol, cigarettes or stress may trigger a flare up or aggravate her disease.

Approximately 30% of individuals with psoriasis will develop psoriatic arthritis, characterized by pain and swelling in the joints. Psoriatic arthritis can be a side effect of psoriasis that’s triggered by an interaction of genetic and environmental factors. Medications similar to those that treat psoriasis can improve psoriatic arthritis as well (1).

Women who require medication to treat their psoriasis/psoriatic arthritis should discuss pregnancy planning with their healthcare provider. Some treatments may require a period of time to clear from the body before conception, and certain medications should be avoided during pregnancy.

Will psoriasis and/or psoriatic arthritis go into remission during pregnancy?
This can be hard to predict, and it varies from person to person and even from pregnancy to pregnancy. In approximately two-thirds of pregnant women who have psoriasis, their psoriasis symptoms spontaneously improved during pregnancy due to the increase of estrogen hormones. Others, however, reported that their symptoms got worse during pregnancy. In addition, inflammatory flare-ups can occur 1-2 weeks after delivery (2). If your psoriasis symptoms get worse during your pregnancy or after you deliver, be sure to talk with your doctor. In 2012, the National Psoriasis Foundation published guidelines for treating psoriasis during pregnancy and lactation (3). For example, caution is advised when applying topical steroids to the breast to avoid passing the medication to the baby while nursing.

How can MotherToBaby help?
MotherToBaby counselors are here to help answer any questions or concerns about exposures in pregnancy or while nursing. If you have questions or concerns about psoriasis/psoriatic arthritis – and the medications used to treat these conditions – during pregnancy, call us toll-free at (866) 626-6847. Our service is FREE and confidential. MotherToBaby also conducts research on psoriasis/psoriatic arthritis during pregnancy. This research is observational, meaning participants are not asked to take any medications or to change their daily routine. To learn more about our research program, please contact one of our MotherToBaby Pregnancy Studies experts at (877) 311-8972.

After our call, Emily felt a lot more confident that she was on the right track to having a healthy pregnancy. However, her fear over how a psoriasis flare could affect her pregnancy was quickly followed by questions about how her psoriasis could be safely treated during pregnancy.
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Online resources for individuals with psoriasis/psoriatic arthritis:
National Psoriasis Foundation (http://www.psoriasis.org)
TalkPsoriasis Support Community (http://www.inspire.com/groups/talk-psoriasis/)
Talk Health Partnership (http://www.talkhealthpartnership.com/talkpsoriasis/)
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 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 and to find your nearest affiliate.

References:
(1) Liu J-T, Yeh H-M, Liu S-Y, Chen K-T. Psoriatic arthritis: Epidemiology, diagnosis, and treatment. World Journal of Orthopedics 2014;5(4):537-543.
(2) Babalola, O. and Strober, BE. Management of psoriasis in pregnancy. Dermatologic Therapy 2013;26:285-292.
(3) Hsu S, Papp KA, Lebwohl MG, Bagel J, Blauvelt A, Duffin KC…National Psoriasis Foundation Medical Board. Consensus guidelines for the management of plaque psoriasis. Arch Dermatol. 2012;148(1):95-102.

The runs, the trots, the green apple quickstep. You have heard all the nicknames for it, but even hearing something as cute as “bubble guts” does not make diarrhea any better, especially during pregnancy or breastfeeding.

Just last week, I got a call from someone in a panic: “Leah, it is really bad. I am so uncomfortable. I thought you were supposed to get constipated during pregnancy.”

That caller was not wrong – constipation can be common during pregnancy. Hormones like prostaglandins – which help signal to your intestines that it is time to move things along – tend to slow down during pregnancy. Even still, constipation does not always happen.

Food poisoning, viral illnesses (like COVID-19), and chronic conditions (like IBS or Crohn’s disease) can all cause diarrhea, even during pregnancy or breastfeeding. No matter where it comes from, everyone asks the same question, “How do I make this stop?” Before we answer that question, let us talk about what is really going on when you have diarrhea.

Diarrhea: What is Actually Going On?

What makes diarrhea different from your regular poops? Diarrhea is when you have loose or watery stools (poops). Diarrhea can look brown, but it can sometimes look yellow, mucous-y, or mostly clear. Some other symptoms of diarrhea can include abdominal cramping, feeling the urge “to go,” or gas. Diarrhea can be caused by lots of different things. Sometimes, diarrhea can be caused by food or drinks (such as food poisoning, contaminated water, or allergies to food products like lactose). Diarrhea can also be caused by other conditions (such as viral infections, conditions that affect the GI system, or medications). When you have diarrhea, your body gets rid of water and electrolytes much faster than usual. It is always important (but especially when you have diarrhea) to wash your hands for at least 20 seconds with soap and water after going to the bathroom. This helps prevent the spread of infections.

What Does That Mean if I am Pregnant or Breastfeeding?

One of the main concerns with diarrhea is the risk of dehydration. If you are severely dehydrated during pregnancy, this can increase the risk of some pregnancy-related issues, like oligohydramnios (not enough amniotic fluid). If you are severely dehydrated while breastfeeding, this can lower the amount of breastmilk that you produce. Yellow or dark urine, being unable to urinate, feeling dizzy or faint, and feeling thirsty are some signs of dehydration. Typically, rehydration includes giving yourself more water and more electrolytes to replace the water and electrolytes that you lost from the diarrhea. If you are experiencing dehydration, you should check with your healthcare team about what you can do to rehydrate yourself.

Over-The-Counter Options

Over-the-counter medications might be a helpful way to treat diarrhea, depending on the situation. Let us explore what we know about the common over-the-counter antidiarrheal medications: loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol). For more information on these types of medications, or any others, contact a specialist at MotherToBaby.

Loperamide

Loperamide is a common over-the-counter antidiarrheal. Loperamide works by attaching to certain receptors in your intestines to say, “please don’t move things along so much.” Taking loperamide slows the movement in your intestines, which slows down how often you have a bowel movement.

When you take loperamide as directed, most of the medication stays in your intestines and it is not expected that you would absorb a lot of the loperamide into your bloodstream where it can then reach the baby. Loperamide, however, is not well-studied in pregnancy and it is not known if taking loperamide as directed during pregnancy changes the chance of miscarriage or pregnancy-related issues, like preterm delivery (birth before week 37) or low birth weight (weighing less than 5 pounds, 8 ounces at birth). One study showed that taking loperamide during the first trimester of pregnancy might increase the chance of birth defects and another study did not find an increased chance.

Because there is not a lot of information about using loperamide during pregnancy, you and your healthcare provider may need to decide what’s best for you. Treating diarrhea is important especially to prevent dehydration, but it is also important to consider the limited information we have about this medication in pregnancy.

Loperamide does pass into breastmilk. If you decide to take loperamide while breastfeeding, your infant will get a very small exposure. It is not expected that exposure to loperamide through breastmilk will lead to side effects in the infant.

Bismuth Subsalicylate

Bismuth subsalicylate is another over-the-counter medication that is commonly used for diarrhea.  Some common names for bismuth subsalicylate are Pepto-Bismol, Kaopectate, and BisBacter. Bismuth subsalicylate works by slowing prostaglandins down (which helps to lower inflammation and slow intestinal movements) and encouraging your body to reabsorb water from the intestines (which helps make bowel movements less watery). Bismuth subsalicylate turns into two components in the body: bismuth and salicylate.

Most of the bismuth stays in your intestines and it is not expected that you would absorb a lot of the bismuth into your bloodstream where it can reach the baby.

However, salicylate can be absorbed into your bloodstream. Taking something that has salicylate in it during pregnancy (like bismuth subsalicylate or NSAIDS, like aspirin or ibuprofen), can cause problems with how the baby’s heart works or how baby’s kidneys work which may cause oligohydramnios (not enough amniotic fluid around the baby) and poor lung development. It may also cause bleeding concerns for you.  Because of this, it is generally recommended to avoid any medications that have salicylate in them, especially in the second and third trimester of your pregnancy.

If you take something that has salicylate in it while breastfeeding (like bismuth subsalicylate or NSAIDS, like aspirin or ibuprofen), some salicylate will most likely be present in your breastmilk. There is concern about giving salicylate directly to an infant. Infants tend to metabolize (or process) salicylate slower than adults do. Reye’s syndrome, a rare condition involving brain swelling and liver damage, can happen if an infant is recovering from a viral infection and is exposed directly to salicylate.

For more information on bismuth subsalicylate, check out our “Managing Tummy Troubles During Pregnancy” blog.

The Bottom Line – No Pun Intended

Diarrhea is uncomfortable, exhausting, and when you are pregnant or breastfeeding, often stressful on a whole new level. You should not have to choose between feeling better and worrying about your baby.

Staying hydrated is always a priority, but when symptoms don’t improve, medications might be helpful, depending on your situation. As always, if you notice any changes in your body during pregnancy or in your infant during breastfeeding (like an increase in stools, or a change in color or consistency of stools), you can reach out to a healthcare provider for guidance on what to do next.

And remember, if you ever feel unsure about an exposure, medication, or symptom during pregnancy or breastfeeding, you don’t have to figure it out alone. Evidence-based guidance can bring peace of mind — even on the days your stomach has other plans. Contact a MotherToBaby specialist to talk to someone about your concerns.

Good luck and I hope your tummy feels better soon!

References

https://www.acog.org/womens-health/faqs/problems-of-the-digestive-system

https://www.acog.org/womens-health/faqs/morning-sickness-nausea-and-vomiting-of-pregnancy

By Lauren Kozlowski, MSW, MPH, MotherToBaby Georgia

“I didn’t even know I should ask my OB about that!” It’s a reaction I hear almost daily as a teratogen information specialist (a fancy way of saying I’ve been trained in evaluating and communicating risks of exposures, like medications, during pregnancy). This particular caller’s reaction was like so many women going into their first appointment after finding out they were pregnant – she really didn’t know how to be her own best advocate. I don’t blame her by any stretch. How are women supposed to just know this? What questions should they be asking? Why should they be asking them? I thought, not only did I want to help her, but all of the pregnant women out there, to have a positive, empowering experience once they’ve found their pregnancy care provider team.

The Importance of the HCP Match

Finding the right health care provider (HCP) for you is essential because doctors, physician’s assistants, nurse practitioners, and midwives are people just like you and me. They come with a wide range of personalities and styles of care. Sometimes they will match your own and sometimes they won’t. You want to be sure that the people that you entrust with your health and your baby’s health are going to help you make the right decisions about your care. Plus it is worth thinking about how you can reduce any stress you may have about sitting down with the person who will care for you and be a source of support during your pregnancy. In this blog I’d like to suggest some ways that you can plan for the most successful experience during pregnancy with your HCP. In this case, success means finding a provider who listens to you, makes you feel comfortable and discusses all of your concerns and options openly and respectfully.

Getting the Most Out of Your Appointments

The good news is there are some ways to empower yourself in these situations and be more likely to get what you need! Below I have a list of some ways you can get the most out of appointments with your pregnancy care provider:

1. You should be able to ask your provider anything you’d like to know about their experience and philosophy around pregnancy and child birth. You can even ask to make a non-clinical appointment to sit down with her or him and discuss this if you’d like to.
2. Be prepared for a short visit with the provider at regular appointments throughout your pregnancy. Write down your most important questions and make sure to ask them first.
3. If you’d like to research some topics before your HCP visit, choose your sources wisely. The internet is full of a lot of misinformation, but there are reputable organizations from whom you can get evidence-based information about pregnancy. Just a few examples include the American College of Obstetricians and Gynecologists (ACOG, the professional society for HCPs specializing in women’s health); the Centers for Disease Control and Prevention (CDC); the Food and Drug Administration (FDA); and our own service, MotherToBaby. Pull information from your sources and bring it with you to your appointment to drive your conversation with your HCP.
4. Bring a trusted family member or friend who can bring up anything you forget to – or that can step into the conversation to help make sure you are being heard correctly. This is particularly important at the first visit or when you are worried about something.
5. If you routinely take any medications, bring them up as soon as you find out you are pregnant (and when possible, even before you become pregnant); this will allow you and your HCP to talk about whether there are any alternative medications or therapies better suited for pregnancy and/or breastfeeding. And remember that our specialists at MotherToBaby are available to provide you with up-to-date information on the safety/risk during pregnancy and breastfeeding of any medications you may be taking.
6. If you see a specialist for other medical conditions (such as asthma, diabetes, arthritis, lupus, psoriasis, etc.), tell your OB provider who you are seeing and authorize them to communicate with one another about your care. When you are living with a chronic health condition, connecting your pregnancy care provider with your other health providers is important to ensure your disease is well-managed throughout your pregnancy and when you are breastfeeding.
7. Even if they don’t ask about it, tell your HCP about your use of alcohol, tobacco, or any recreational drugs (like marijuana, heroin, meth, etc.). Some of these substances can affect your pregnancy or your baby’s development, so it’s important for you and your HCP to talk about it even if you are just an occasional user. Recreational drugs are another type of exposure where MotherToBaby experts can provide you with confidential, up-to-date information on the safety/risk of use during pregnancy and breastfeeding. Importantly, talk to your HCP if you need help quitting any of these substances; there are ways to treat substance use disorders during pregnancy. You also have a chance of being screened for substances at birth – meaning they may test both you and your baby at the hospital. Being prepared for this is important so you know what to expect.
8. Ask questions about the hospital at which you will be delivering. Do they have any specific policies or practices you would want to know about in advance? Your HCP will be connected to a specific hospital(s); if you do not want to deliver at that hospital and your insurance allows for other options, you may need to find another prenatal care provider. It is best to ask these questions before you become pregnant or as soon as you start your prenatal care visits.
9. If for any reason you do not feel like your HCP listens to you or is able to create a welcoming, safe environment, change providers! If it’s a requirement of your insurance, get a list of providers in your network. Then ask friends or family if they have someone they’d recommend. You can further whittle down your list by other things that may be important to you, such as a male vs. female provider or office location. Pregnancy is such an important time in a woman’s life, so it’s critical that you are under the care of a health provider that you trust. Depending on where you live and what insurance you have, it may not be possible to find another provider – but if you are able and want to, the sooner you do so in your pregnancy the better. You deserve to feel comfortable and cared for!

A lot of these tips apply to any type of HCP, but pregnancy is a perfect time to flex your self-advocacy muscles and find the provider that is best suited for you. You and baby deserve wonderful and respectful care, and the reality is that sometimes it takes a bit of seeing what’s out there to find the right fit. Finding the right HCP can feel a lot like dating, but don’t be discouraged! If you don’t like the care you are getting, move on to another HCP – with so many exceptional ones out there you can find the best match for you and your pregnancy.

Although not specific to a pregnancy visit, ACOG also offers some tips to help you make the most out of your health care visit: https://www.acog.org/Patients/FAQs/Making-the-Most-of-Your-Health-Care-Visit

If you want to read more about advocating for yourself as a patient, some other resources are below:

Your Best Birth: Providers, Plans and Being Proactive

https://bloomlife.com/wp-content/uploads/2018/11/Best-Birth-Bloomlife-ebook-1.pdf

At the end this includes a great acronym BRAIN (Benefits, Risks, Alternatives, Intuition, Do Nothing) that can be used whenever you are making decisions or have questions about receiving medical care.

A Doctor’s Guide: How To Be A Patient Advocacy Rockstar (For You or a Loved One)

https://www.acsh.org/news/2018/06/21/doctors-guide-how-be-patient-advocacy-rock-star-you-or-loved-one-13106

Health Care Self-Advocacy: Be the Squeaky Wheel

https://www.care2.com/causes/health-care-self-advocacy-be-the-squeaky-wheel.html

The Complete Guide to Becoming Your Own Medical Advocate

https://betterhumans.coach.me/the-complete-guide-to-becoming-your-own-medical-advocate-ddc658a10a57

Lauren Kozlowski, MSW, MPH is serving as the Program Coordinator for MotherToBaby Georgia. She graduated from Boston University with both a Masters of Social Work and a Masters of Public Health. She has experience working with families in both an educational setting, as well as in housing and health, allowing her to recognize the multiple factors contributing to the ability of women and children to thrive. She enjoys living in Atlanta and exploring what the city has to offer.

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.

 

 

BRENTWOOD, TN – MotherToBaby Pregnancy Studies, conducted by the Organization of Teratology Information Specialists (OTIS), has launched a new observational study of mepolizumab (Nucala®) in pregnancy, a new medication for the treatment of severe asthma. This study aims to provide crucial information on the safety of this medication in pregnancy by following asthmatic women during their pregnancy and following their child up to one year of age. Given that untreated asthma can put both the mother and pregnancy at risk, the need for rigorous and ongoing research of new medications and their effects during pregnancy becomes vitally important. This study will expand efforts to better understand safety of asthma medications in pregnancy

Mepolizumab (Nucala®), launched by GlaxoSmithKline (GSK) in November 2015, was the first IL-5 inhibitor approved by the U.S. Food and Drug Administration (FDA) for as an add-on treatment for severe asthma with an eosinophilic phenotype. Similar to inhaled steroids, mepolizumab provides a preventative approach to asthma control; it is thought to act by inhibiting interleukin 5 (IL-5), a group of proteins and signal molecules produced by white blood cells. This may decrease inflammation in the lungs and the number of subsequent severe asthma attacks in persons with eosinophilic asthma. Mepolizumab is administered as an injection under the skin (subcutaneously) once every 4 weeks. It is not intended to treat active asthma symptoms.

“We know that asthma in pregnancy, especially poorly controlled asthma, is associated with higher rates of pregnancy complications, like placental problems, premature delivery, and low birth weight. With this reality, it is especially important that a woman’s asthma be carefully managed prior to and during a pregnancy,” said Christina Chambers, PhD, MPH, MotherToBaby Pregnancy’s Studies lead investigator and world-renowned perinatal epidemiologist at UC San Diego. “Yet medications that are newly approved by the FDA have little to no information about how safe they are for a pregnant woman and her developing baby. Our research aims to fill this critical gap.”

In addition to mepolizumab, MotherToBaby Pregnancy Studies are also enrolling pregnant women who are using other medications for the treatment of their asthma including, but not limited to albuterol, formoterol, salmeterol, and/or inhaled steroids, as well as pregnant women who do not have asthma. These studies are coordinated by the University of California, San Diego, and are in collaboration with the American Academy of Allergy, Asthma & Immunology as part of the Vaccines and Medications in Pregnancy Surveillance System (VAMPSS).

Women who are pregnant and who reside in the U.S. or Canada may be eligible to participate. Participants are not asked to take or alter any medications, do not need to travel, and are not asked to make any changes to their normal routine.

To join or for more information on MotherToBaby Pregnancy Studies, call toll-free 877.311.8972, visit MotherToBaby.org or email MotherToBaby@ucsd.edu.

If you are pregnant or planning a pregnancy and have questions about asthma and the medications used to treat asthma in pregnancy, MotherToBaby Fact Sheets are available in both English and Spanish and can be downloaded for free. MotherToBaby experts are also available to provide free personalized risk assessments via phone, email, text, or live-chat.

More about MotherToBaby

MotherToBaby is the nation’s leading authority and most trusted source of evidence-based information on the safety of medications and other exposures during pregnancy and while breastfeeding.

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) Office of Women’s Health have recognized OTIS and MotherToBaby as a recommended resource for information on exposures during pregnancy and lactation.

 

By Sharon Voyer Lavigne, MS, MotherToBaby CT Teratogen Information Specialist
“I know I should quit, but it’s hard…I’ve cut down, though! I know it’s bad for me, but is it really that bad for my baby anyway?” I had heard these words time and time again as a teratogen information specialist and genetic counselor at MotherToBaby. Let’s call this particular caller “Jenny.” Well, whether Jenny had volunteered this information about her addiction to cigarette smoking or not, I would have asked her anyway. At MotherToBaby Connecticut, we ask all our callers about cigarettes as well as alcohol exposure even if it isn’t the reason they placed the call in the first place. Why? Because most need help quitting without judgment and with the facts about smoking during pregnancy guiding their way to leading a tobacco-free lifestyle. We find that many, if not all, smokers tell us that they have cut down on their use or recently quit once they learned that they were pregnant.

Like Jenny, the general public is well aware that cigarette smoking causes cancer, heart disease as well as other medical conditions. Most have also learned that smoking while pregnant can be dangerous to the baby. However, most women know at least one person, maybe even their own mother, who smoked during pregnancy without any apparent adverse pregnancy outcome. So why should we be concerned? There is much more to this story and with each chapter, I was hoping to let Jenny in on why quitting could change the outcome for her baby…

Chapter 1. Smoking and Fertility
Cigarette smoke contains more than 4,000 toxic chemicals and cancer causing agents, including nicotine, tar, arsenic, lead, carbon monoxide. It is hard to imagine intentionally putting those things into your own body, but imagine the problems they may cause if a developing baby is exposed? These agents can cross the placenta and cause a decrease in the amounts of oxygen and nutrients that reach the baby. There have been reports that suggest smoking prior to pregnancy may make it more difficult to conceive. Discontinuing smoking can reverse this potential fertility road block. Even when men smoke, smoking can adversely affect their chances of getting their partners pregnant.

Chapter 2. Loss of Pregnancy Risk
In the early stages of pregnancy, i.e., the first trimester, smoking cigarettes can increase your chances for an ectopic pregnancy. This condition is when the embryo implants into a fallopian tube and not into the uterus. This is a very serious complication of pregnancy that may require surgery or special medications to stop the growth of the embryo. Another early pregnancy complication related to cigarette smoking in pregnancy is loss or miscarriage. Smoking changes how the blood flows thru the placenta and this change may lead to a loss.

Chapter 3. Potential for Birth Defects
Smoking in pregnancy has been well studied for many decades and there have been reports suggesting an increased risk for birth defects. Oral clefts (cleft lip and or cleft palate) occur when the lip or palate (roof of the mouth) do not fully close during early fetal development. These birth defects of the face are typically surgically corrected here in the United States, but more than one surgery could be necessary and lasting effects may still be visible on the face and in speech development. There have been other reports of other birth defects being more common in moms who smoked in pregnancy, but the level of risk appears small and more information on these is needed to make better risk assessments.

Chapter 4. Pregnancy Complications
Not done yet. Many women are aware of the risks for pregnancy complications with smoking later in pregnancy. Prematurity (born before 37 weeks gestation) and low birth weight are well established risks. Each of these may pose their own secondary risks with complications for the newborn born too small or too soon or both. Placental problems are of concern, including placenta previa (a condition where the placenta covers the cervix and blocks the birth canal) or placental abruption (potentially deadly for mom and baby- this is when the placenta breaks away from the uterine wall causing extensive bleeding). Bleeding alone and stillbirth are pregnancy complications also related to smoking in pregnancy.

Chapter 5. Other Potential Long-Term Effects on Baby
Other complications related to smoking in pregnancy that have been studied are childhood asthma, bronchitis and respiratory infections as well as Sudden Infant Death Syndrome (SIDS). SIDS is difficult to impossible to predict and prevent. Withdrawal symptoms in the newborn such as irritability, increased muscle tone and tremors can be seen in those exposed to smoking late in pregnancy. Usually these symptoms resolve on their own quickly. Behavior problems have also been looked at in children whose mom’s smoked in pregnancy. A higher risk of Attention Deficit Hyperactivity Disorder (ADHD) is currently being studied more carefully.

Chapter 6. Smoking and Breastfeeding
Nicotine can be found in the breast milk, along with many of the other unhealthy chemicals in cigarettes. It is best to avoid smoking if you are nursing your baby. If you cannot stop completely, the benefits to the baby from breastfeeding still outweigh the risks from smoking while nursing. You should not smoke around the baby or let others do this either.

Final Chapter: How Quitting Can Help You Re-Write This Chapter For Baby
Finally, some good news for Jenny and all of those struggling with this crippling addiction… If a woman can stop smoking early in pregnancy, she can reduce the risk for many of the mentioned complications. If quitting isn’t possible than a reduction in the number of cigarettes smoked per day can also make matters better. The less you smoke the lower the chances that you and or your baby will suffer lasting effects in pregnancy. Quitting is best, and it is NEVER TOO LATE to have a positive effect on your baby.

There are many supports for quitting smoking in your community. For advice you can talk to your health care provider, before or during pregnancy. There are medical treatments that can be safe in pregnancy and many quit programs available. Smokers Quit Line at 1-800-784-8699 or online at www.tobacco-cessation.org/PDFs/?NeedHelpBookelt.pdf. Partner and family support is also key, so share your goals with them.

Sharon Voyer Lavigne is a teratogen information specialist, genetic counselor and coordinator of MotherToBaby CT, a non-profit affiliate of the international Organization of Teratology Information Specialists (OTIS). She is based at the University of Connecticut Health Center and is a proud mother of three.

MotherToBaby and OTIS are suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about medications, vaccines, diseases, alcohol, smoking or other exposures, call MotherToBaby toll-FREE at 866-626-6847. You can also visit MotherToBaby.org to browse a library of fact sheets, including one on Cigarette Smoking in Pregnancy/Breastfeeding, and find your nearest affiliate.