Teratogen Information Specialist and MotherToBaby New York director, Mark Roth, joins genetic counselor and host Chris Stallman to talk about exposures a father may have and whether they might affect the health of a pregnancy.
Our experts continue the conversation about Zika Virus and why we’re still talking about it well after its initial outbreak. We answer questions about men and Zika, planning a pregnancy and Zika, and much more. Lorrie Harris-Sagaribay, MPH, a bilingual teratogen information specialist at MotherToBaby North Carolina and Kirstie Perrotta, MPH, a teratogen information specialist at MotherToBaby California join host Chris Stallman, a certified genetic counselor, teratogen information specialist and mother of four, to answer the public’s questions.
Rebecca J. Schmidt, PhD, a molecular epidemiologist at UC Davis, joins host Chris Stallman, CGC, to talk about research surrounding wildfires, pollution and the effects on pregnancy. Dr. Schmidt also gives some information on a DIY project to reduce pollutants in your own home.
Resources Mentioned in this Episode:
How to build a Corsi-Rosenthal Box: https://www.youtube.com/watch?v=hIuH-2naozI
“Keeping Your Cool When Fire Season Heats Up,” MotherToBaby Blog
By: Kirstie Perrotta, MPH and Becky Spencer, PhD, APRN, PMHNP-BC, IBCLC, PMH-C, FILCA
Shannon was newly pregnant and had been referred to MotherToBaby by her doctor. She was taking 50 mg of sertraline per day for general anxiety and her doctor thought that she may need to wean off the medication now that she was 5 weeks pregnant. Shannon had been taking the medication for 3 years and was feeling great on her current dose, so she had some concerns about this plan. On the MotherToBaby website’s live chat service, Shannon was connected with me, a teratogen information specialist, where she asked “Do I really need to stop my anxiety medication, or could I just continue on a lower dose?”
I started by addressing the importance of weighing the risks vs. benefits of taking any mental health medication during pregnancy. Sertraline is very well studied and has not been associated with a risk for birth defects, but does have the potential to cause neonatal adaptation syndrome or withdrawal approximately 10-30% of the time and persistent pulmonary hypertension in less than 1% of exposed infants. On the other hand, we know that untreated anxiety can also cause problems for the pregnancy, including an increased risk for preterm delivery. For many patients, the benefits of staying on a medication like sertraline outweigh the potential risks, but each case is unique and ultimately the patient needs to decide what they are most comfortable with.
Getting to Shannon’s next question about dose, I shared that although many pregnant women feel they need to decrease their dose once they get a positive pregnancy test, the opposite is in fact true. During pregnancy, there are many changes that occur including weight gain, increased blood volume and enlargement of the kidneys. On the outside, things won’t look much different, but research shows these changes happen soon after conception. This means that medication doses that previously worked well to control a condition become “diluted,” in a sense, and may not be as effective. In some cases, women need to actually increase their dose to continue to control the disease.
To learn more about how bodily changes during pregnancy impact medication dosing, we turn to Becky Spencer, PhD, APRN, PMHNP-BC, IBCLC, PMH-C, a psychiatric nurse practitioner who specializes in perinatal mental health at Texas Women’s University with some more questions about this fascinating phenomenon.
Q. Can you tell us a little more about what is happening in the body during pregnancy and why medications become less effective?
Becky Spencer: You are correct, Kirstie, that pregnancy has a significant impact on drug absorption, which is how a drug is transported into the bloodstream, drug distribution, which is the disbursement of a drug as it moves through the blood and tissues of the body, and drug metabolism, which is the process by which the body breaks down and eliminates drugs or other substances. During pregnancy, especially later in pregnancy, drug absorption from the stomach into the bloodstream is decreased due to slower gastric emptying and slower movement of the bowel and colon, so it can take longer for a medication to be absorbed and get to work.
A pregnant woman’s blood volume almost doubles during pregnancy which impacts drug distribution. With the dilution effect there is a lower concentration of medication in the blood plasma which results in less medication reaching the target tissues. Most drugs are metabolized in the liver or kidneys. During pregnancy, the increased blood flow to the kidneys results in an increased glomerular filtration rate (GFR), which means that medications are cleared from the bloodstream quicker, meaning the drug stays in the body less time. Similarly, hormone levels increase during pregnancy which increases the activity of various metabolic enzymes in the liver that metabolize drugs. When the liver metabolizes a drug more quickly there is less drug that reaches the target tissues.
What these changes mean for pregnant women who take medication for mood and anxiety disorders is that the dose of medication that they were taking before pregnancy may have a decreased effect during pregnancy, because the biological changes effectively decrease the amount of medication reaching the target tissues, in this case, the brain. Pregnant women may have an increase in mood and anxiety symptoms that they interpret as a worsening condition when, in fact, the decrease in circulating medication is the cause for an increase in symptoms.
Q. In your practice, how often do you see women increasing their mood medication dose? Does the dose need to be increased substantially?
Becky Spencer: That is a great question. The answer is that it depends on the type of medication, the specific condition (depression, anxiety, obsessive compulsive disorder, bipolar, etc.), and the severity of symptoms. Psychiatric providers typically increase medication dosages in gradual amounts until the patient has symptom relief or desired therapeutic effect. If a patient is experiencing a partial response to a medication (some improvement in mood and anxiety symptoms) best practice is to increase the dose of that medication before considering adding an additional medication.
Another question that I hear is whether or not dosages of medication should be based on achieving a specific blood plasma concentration level. The short answer is, for most medications, no. We don’t routinely check blood plasma concentrations of most antidepressants because valid and reliable therapeutic plasma concentration ranges do not exist. Some mood stabilizing medications like valproate or lithium do require blood plasma monitoring both during pregnancy and outside of pregnancy. Euthymia, or stable mood, is the goal of medication dose adjustments for mood and anxiety disorders during pregnancy.
Q. What about after delivery? Does the dose need to be decreased right away?
Becky Spencer: It depends on the type of medication, and, to some extent, the symptoms that the patient is experiencing. The postpartum period is a vulnerable time for mood and anxiety disorders for several reasons including the significant hormonal shift that occurs after birth, lack of sleep, role adjustment to caring for a baby, and for some new parents, lack of necessary social and emotional support. Decreasing antidepressants too quickly after birth could exacerbate mood and anxiety symptoms during that very vulnerable time. The decision to decrease dosages of any medication prescribed for mood and anxiety disorders should be a collaborative decision between the patient and the provider. If decreasing mediation dose is desirable, it should occur gradually and any change in mood and anxiety symptoms should be reported to the provider. The one exception to this rule is for patients taking lithium. If lithium dosages were increased during pregnancy, they must be decreased to pre-pregnancy dosages after delivery.
Q. Shannon is asking about sertraline, an anti-anxiety medication, but are there other drugs that women need to also increase their dose of during pregnancy?
Becky Spencer: Any medications used to treat mood and anxiety disorders, including antidepressants, mood stabilizers, antipsychotics, and anti-anxiety medications, may need dose increases during pregnancy. The most important point is for pregnant women to monitor their mood and anxiety symptoms and report them to their provider. The decision to increase doses of medication should always be a collaborative decision between the patient and the healthcare prescriber.
Q. How should patients approach this conversation with their healthcare provider?
Becky Spencer: The decision to take any medication during pregnancy must be based on a discussion between healthcare providers and patients that takes into consideration the available research on the risks of specific medications AND the risks of untreated or undertreated mental conditions for both the pregnant woman and the baby. The risks of not treating mood and anxiety disorders during pregnancy are well documented and significant. Untreated or undertreated mood and anxiety disorders during pregnancy are associated with hypertension, preterm delivery, low birth weight, and long-term negative impacts on motor and cognitive development of the baby. Mental health conditions are the leading cause of maternal mortality in the United States. Effective treatment for mood and anxiety disorders in the perinatal period will literally save lives.
My top three tips for having a discussion with healthcare providers about medications for mood and anxiety disorders in the perinatal period include:
Thanks so much for sharing your insight, Becky. It’s always great to learn more about this topic.
Ultimately, Shannon decided to stick with her current dose for the first few weeks of pregnancy and make an appointment with her psychiatrist to discuss increasing her dose in a few weeks. In the meantime, she was planning to monitor her mood to make sure the anxiety remained well controlled.
If you have questions about mental health medications, dose, or any other exposures in pregnancy or lactation, please feel free to reach out to a MotherToBaby specialist via phone, chat, text, or email for more information. Additionally, you can visit our Mental Health Resource Hub to access fact sheets, blogs, and podcasts on mental health conditions and the medications used to treat them during pregnancy and breastfeeding.
References:
This interactive tool shows when the baby’s body parts could be most sensitive to exposures, and is best displayed on a desktop. Please click on each part of the chart below to learn more about the different terms and colors included. If you need help interpreting this chart or have additional questions about an exposure of concern, please contact a MotherToBaby specialist.
Calculate based on:
Enter Last Menstrual Period (LMP) Start
Date:
(For example, the date(s) you drank
alcohol or took a medication)
Click to use today’s date
Click RESET to
erase the dates and start over
The first day of the last menstrual period is typically used to date a
pregnancy.
The estimated date of conception is about two weeks after the LMP.
This
is the point in the cycle when the egg and sperm meet to create a zygote
(the first cell that contains the instructions needed to grow into a baby).
Today X
When a person is pregnant, a missed period happens about four weeks after the
LMP. This is usually the earliest point at which a pregnancy can be
confirmed.
The estimated due date is when the baby is expected to be born.
Most periods occur every 28 days and last anywhere from 2-7 days.
The all or none theory is that exposures in the first two weeks after
conception will either have an all (miscarriage) or none (no risk) effect.
Once a body part has formed, birth defects are unlikely to occur. However,
problems can sometimes happen after a body part has formed correctly. As the
structures continue to grow and develop during the latter part of a
pregnancy, medications, infections, genetics, health conditions, trauma,
prematurity, and other issues can cause problems with how the body part
works. Intellectual disability and hearing loss are examples of functional
problems.
Before an organ starts to form, many complex changes are happening in
the embryo to prepare for development. There is limited information
about what is happening during this stage of pregnancy. This makes
it difficult to know how early exposures could affect future
development.
The neural tube is a structure that forms early in pregnancy. Once it closes,
the neural tube develops into the central nervous system (brain and spinal
cord), which is crucial for controlling our body’s functions, senses, and
movements. Examples of birth defects that can occur when the neural tube
does not form correctly during pregnancy are spina bifida (incomplete
closure of part of the spine) and anencephaly (missing front part of the
brain).
The lungs are a pair of organs in the chest responsible for helping with
breathing. The lungs take in oxygen from the air you breathe and send it
into your blood, which your body needs to work. The lungs also get rid of
carbon dioxide, a waste gas your body doesn’t need, by pushing it out when
you exhale. During pregnancy, the lungs are filled with fluid, but once the
baby is born, they start breathing air. An example of a birth defect that
can occur when the lungs do not form correctly during pregnancy is pulmonary
sequestration (extra lung tissue).
The kidneys are two bean-shaped organs that remove waste products from the
blood and produce urine. The kidneys break down drugs, help regulate blood
pressure, balance electrolytes, and stimulate the production of red blood
cells. An example of a birth defect that can occur when the kidneys do not
form correctly during pregnancy is renal agenesis (missing kidney).
The heart is a strong, muscular organ located slightly to the left of the
center of the chest. The heart works like a pump to send blood with oxygen
throughout the body. The heart has four chambers: two upper chambers called
atria and two lower chambers called ventricles. Blood enters the heart
through the atria and is pumped out through the ventricles. The right side
of the heart pumps blood to the lungs to pick up oxygen, and the left side
pumps the oxygen-rich blood to the rest of the body. Examples of birth
defects that can occur when the heart does not form correctly during
pregnancy are ventricular septal defect (hole in the heart) and Ebstein’s
anomaly (problem with the heart valve).
Eyes are the organs in your body that allow you to see. Light enters through
the cornea and pupil, passes through the lens, and reaches the retina, which
sends signals to your brain to create vision. An example of a birth defect
that can occur when the eyes do not form correctly during pregnancy is
anopthalmia/micropthalmia (small or missing eyes).
The arms are the two upper limbs of the body consisting of the upper arm,
forearm, and hands. People use their arms to perform a variety of activities
including lifting, pushing, pulling, throwing, climbing, and writing. An
example of a birth defect that can occur when the arms do not form correctly
during pregnancy is a limb reduction defect (missing or short arms).
The legs are the two lower limbs of the body consisting of the upper leg,
knee, lower leg, ankle, and foot. The legs support the body’s weight and
help with a range of movements including walking, jumping, sitting, and
standing. An example of a birth defect that can occur when the legs do not
form correctly during pregnancy is a limb reduction defect (missing or short
legs).
The brain is a complex organ that controls many body functions. The brain
receives, processes, and interprets information related to thoughts,
decisions, memories, emotions, speech, touch, motor skills, vision,
breathing, temperature, and hunger. An example of a birth defect that can
occur when the brain does not form correctly during pregnancy is
microcephaly (smaller than normal head and brain).
The ears are located on the sides of our head and are the parts of our body
that let us hear sounds. Each ear has three main parts: the outer ear, the
middle ear, and the inner ear. The outer ear is the part we can see, and it
helps to catch sounds and send them into the ear canal. The middle ear has
tiny bones that pass sound vibrations to the inner ear, where the sound is
turned into signals that our brain can understand. Ears also help us keep
our balance. An example of a birth defect that can occur when the ears do
not form correctly during pregnancy is anotia/microtia (missing or malformed
ears).
The abdominal wall includes the skin and muscles that cover the belly and
help protect the internal organs in this stomach area. Examples of birth
defects that can occur when the abdominal wall does not form correctly
during pregnancy are gastroschisis (when the intestines stick out of a hole
in the belly) and omphalocele (intestines develop outside of the body).
The axial skeleton is the part of the skeleton that forms the main framework
of your body. It includes the bones of your head, neck, and trunk. This
means it consists of the skull, the spine, and the rib cage. The axial
skeleton supports and protects the brain, spinal cord, and organs in the
chest. It also provides a place for muscles to attach, which helps you move
and maintain your posture. An example of a birth defect that can occur when
the axial skeleton does not form correctly during pregnancy is
craniosynostosis (bones in the skull join together too early).
The lips are soft, movable parts of the mouth that help us speak, eat, and
show emotions. They help protect the teeth and mouth. An example of a birth
defect that can occur when the lips do not form correctly during pregnancy
is cleft lip (opening in the upper lip).
The palate is the roof of the mouth. It is a structure made up of bone and
soft tissue that separates your mouth from your nasal cavity (where you
breathe through your nose). The palate helps you eat and speak by guiding
food and air where they need to go. An example of a birth defect that can
occur when the palate does not form correctly during pregnancy is cleft
palate (opening in the roof of the mouth).
Teeth are hard, white structures in our mouths that help us chew and digest
food. They are made mostly of a material called enamel, which is the hardest
substance in our bodies. An example of a birth defect that can occur when
the teeth do not form correctly during pregnancy is hyperdontia (extra
teeth).
The external genitalia include the organs that are located outside of the
body, like the clitoris or penis. These organs can have more than one
function. For example, the penis helps removes urine from the body and
release sperm. Examples of birth defects that can occur when the external
genitalia do not form correctly during pregnancy are hypospadias (opening of
the penis is on the underside instead of the tip) and clitoromegaly (larger
than expected clitoris).
Miscarriage is defined as a pregnancy loss before 20 weeks.
Miscarriage is common and can occur in any pregnancy for many
different reasons. In the US, about 1 in every 7 pregnancies results
in miscarriage.
Stillbirth is defined as a pregnancy loss after 20 weeks. In the US,
about 1 in every 175 pregnancies results in a stillbirth.
Preterm Birth: Preterm birth is when a baby is born before 37 weeks of
pregnancy. Babies born preterm are more likely to experience health
problems. In the US, about 1 in every 10 babies is born preterm.
A term birth is when a baby is fully developed and ready to be born. Any
delivery from 37 weeks of pregnancy up to 42 weeks is considered term.
Babies born at term are less likely to experience health problems. In the
US, about 9 out of every 10 babies is born to term.
During the all or none period, exposures are thought to either have
an all (miscarriage) or none (no risk) effect.
There is a “critical period” during pregnancy when the risk of birth
defects is highest. During this time, various factors such as
exposures, genetics, and health conditions can influence the
development of one or more body parts. Birth defects can range from
mild to severe, potentially requiring surgery or leading to lifelong
disabilities.
Please note days and weeks of pregnancy are an estimate
only (timing depends on each pregnant person’s menstrual cycle, ovulation, and
implantation; which can vary). Additionally, information on when birth defects can
occur is based on sparse data and subject to limitations. The information presented
above is an estimate only, and some variation is expected.
Birth defects can happen in any pregnancy for different reasons. Out of all babies born each year, about 3 out of 100 (3%) will have a birth defect. Pregnancy problems (like miscarriage) can also happen in any pregnancy. Sometimes, exposures like medications, drugs, alcohol, and infections can increase the chance for birth defects or pregnancy complications. However, for an exposure to cause a problem, it generally has to happen during the “critical period” when a body part is forming. The dose, frequency, and the way the exposure enters the body (swallowed, breathed in, put on the skin, etc.) can also play a role. We look at research studies to try to understand if a certain exposure might increase the chance of birth defects or other problems in a pregnancy. Learn more by reading our Critical Periods of Development Fact Sheet.
This chart shows when different parts of a baby’s body form during pregnancy and when birth defects or pregnancy complications might happen. By entering the first day of your last menstrual period (LMP), the calculator can estimate how far along you are today. It can also tell you if an exposure happened during a critical time in your baby’s development.
Exposures are not a common cause of birth defects. Genetics, age of the parents, health conditions in the pregnant person, and a combination of these factors can also play a role in fetal development. Additionally, even when an exposure of concern takes place during the critical period, not every baby will be affected by a birth defect. Once a body part has formed, exposures are less likely to cause birth defects. However, as the baby continues to grow and develop in the second and third trimesters, some exposures can cause problems with how the body part works. Problems with the baby’s growth or early (preterm) delivery might also happen as the pregnancy continues.
Research on early development is limited. The chart gives a general idea of when an exposure could cause a birth defect, but individual differences are expected. Our team can help you understand the timing of your pregnancy and review any exposures you have had. For a personalized assessment, contact MotherToBaby by phone, chat, text, or email.
Our MotherToBaby Fact Sheets offer the most current information on exposures in pregnancy and breastfeeding.
Explore our ongoing pregnancy studies by health condition or medication to find the right one for you.
Call, text, chat, or email for a free personalized risk assessment on exposures in pregnancy and breastfeeding.
| Episode 32: Paternal Exposures during Pregnancy June 30, 2021 |
page {PAGENO} of {PAGETOTAL} |