This sheet is about exposure to tocilizumab in pregnancy and while breastfeeding. This information is based on published research studies. It should not take the place of medical care and advice from your healthcare provider. 

What is tocilizumab? 

Tocilizumab is a prescription medication that has been used to treat rheumatoid arthritis (RA), giant cell arteritis in adults, and juvenile idiopathic arthritis (JIA) in children. It has also been used to treat symptoms of severe COVID-19 in hospitalized patients. The brand name for tocilizumab is Actemra®.  

MotherToBaby has a fact sheet on rheumatoid arthritis here: https://mothertobaby.org/fact-sheets/rheumatoid-arthritis/.  

Sometimes when women find out they are pregnant, they think about changing how they take their medication, or stopping their medication altogether. However, it is important to talk with your healthcare providers before making any changes to how you take your medication. Your healthcare providers can talk with you about the benefits of treating your condition and the risks of untreated illness during pregnancy. 

I take tocilizumab. Can it make it harder for me to get pregnant?  

It is not known if tocilizumab can make it harder to get pregnant. 

Does taking tocilizumab increase the chance of miscarriage?  

Miscarriage is common and can occur in any pregnancy for many different reasons. It is not known if taking tocilizumab can increase the chance of miscarriage. Some studies have suggested that taking tocilizumab might increase the chance of miscarriage, while other studies have not. In the studies that reported an increased chance of miscarriage, other factors that are known to increase the chance of miscarriage such as age, use of multiple medications, and symptoms of the health condition being treated were reported as well. Because miscarriage can happen for many reasons, it is hard to know whether a medication, the condition being treated, or other factors such as age or health are the cause.  

Does taking tocilizumab increase the chance of birth defects?  

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. We look at research studies to try to understand if an exposure, like tocilizumab, might increase the chance of birth defects in a pregnancy. 

Tocilizumab use during pregnancy is not expected to increase the chance of birth defects. Tocilizumab is not expected to cross the placenta and reach the pregnancy in large amounts during the first trimester, which is the time when a birth defect is most likely to happen. For more information on periods of development, see the MotherToBaby fact sheet on critical periods of development here: https://mothertobaby.org/fact-sheets/critical-periods-development/.  

Does taking tocilizumab in pregnancy increase the chance of other pregnancy related problems? 

Tocilizumab might cross the placenta in higher amounts in the second and third trimesters of pregnancy. Some studies have shown an increased chance of pregnancy complications including preterm delivery (birth before week 37) and low birth weight (weighing less than 5 pounds, 8 ounces [2500 grams] at birth) when tocilizumab is used throughout pregnancy to treat conditions such as RA. However, since poorly controlled RA can also increase the chance for preterm delivery, low birth weight, babies born smaller than expected, and other pregnancy complications, it is not known if these findings are due to tocilizumab or to the medical condition being treated.  

Published reports of tocilizumab use to treat severe COVID-19 during the second or third trimesters of pregnancy have not identified an increased chance of pregnancy problems or problems for newborns related to the medication. The pregnancy-related problems reported in these cases, such as preterm delivery, c-section, or admission to the neonatal intensive care nursery (NICU) were believed to be because of the severe COVID-19 infection or other underlying medical conditions or complications.  

Does taking tocilizumab in pregnancy affect future behavior or learning for the child?  

There have been limited studies done to see if tocilizumab can increase the chance of behavior or learning issues for the child. In a study that looked at infants who were exposed to tocilizumab for a short time during the second or third trimesters of the pregnancy, there were no reported changes in their development up to 6 months or 1 year of age.  

Can my child receive live vaccines if I take tocilizumab during pregnancy? 

Since tocilizumab might suppress the immune system of adults taking it, there is a theoretical (not proven) concern that the same thing could happen to the baby if they are exposed during pregnancy. If someone has a weakened immune system, they might be more likely to develop an infection from a live vaccine.  

Live vaccines contain a small amount of live virus. In the United States, rotavirus is the only live vaccine routinely given in the first year of life. Most babies can get inactivated vaccines in the first year of life. Inactivated vaccines do not contain live virus, so they cannot cause the disease they protect against. Talk to your child’s healthcare provider about your exposure to tocilizumab during pregnancy. They can talk with you about the vaccines your child should receive and the best time for your child to receive them. 

Breastfeeding while taking tocilizumab: 

Tocilizumab passes into breast milk in small amounts, but it is expected to be destroyed in a breastfed child’s stomach before it can be absorbed into the child’s body. No adverse effects have been reported in infants exposed to tocilizumab through breast milk. Experts consider tocilizumab acceptable for use in breastfeeding. If you suspect the baby has any symptoms, contact the child’s healthcare provider. Be sure to talk to your healthcare provider about all your breastfeeding questions.  

If a man takes tocilizumab, could it affect his fertility or increase the chance of birth defects? 

Limited studies have been done to see if tocilizumab could affect male fertility (ability to make healthy sperm). There was no increase in birth defects in a report that included 8 infants born to males who used tocilizumab. In general, exposures that men have are unlikely to increase risks to a pregnancy. For more information, please see the MotherToBaby fact sheet Paternal Exposures at https://mothertobaby.org/fact-sheets/paternal-exposures-pregnancy/.  

Please click here for references.  

This sheet is about stress in pregnancy and while breastfeeding. This information is based on available published literature. It should not take the place of medical care and advice from your healthcare provider.

What is stress?

Stress is the way the body reacts to something that is unusual, dangerous, unknown, or disturbing. Stress can come from any event or thought. When under stress, the body undergoes physical, chemical, and emotional changes. Almost anything can cause stress, and everyone experiences it at some point in their life. Stress can make people feel frustrated, overwhelmed, angry, or nervous. Everyone deals with stress in their own way. A very stressful situation for one person may not be all that stressful for another. Because we all have different reactions to stress, it is hard to study how stress may affect pregnancy or breastfeeding.

What are some of the symptoms of stress?

• Physical symptoms: Chest pain, fast heart rate, breathing problems, headaches, vision problems, teeth grinding, dizziness, fatigue, stomach problems, changes in eating partners, and muscle aches.
• Mental symptoms: Confusion, memory loss, nightmares, problems focusing, having a hard time making decisions, and changes in sleeping patterns.
• Emotional symptoms: Feelings of anxiety, guilt, grief, fear, irritability, worry, frustration, loneliness, or being overwhelmed. May include periods of anger or crying.
• Social symptoms: Staying away from friends and family, eating too much or too little, drinking too much alcohol, and using drugs.

Does stress affect health?

In small amounts, stress can be positive and healthy. However, being under a lot of stress over time might affect health and well-being. Stress can increase a person’s chance of developing conditions like high blood pressure or depression. Stress might also cause existing medical problems to worsen. For example, if someone has diabetes and is under stress, it may be hard for them to keep their blood sugar levels under control.

If you are having symptoms of stress, talk with your healthcare provider. It is important to get help from a mental health professional, counselors, or other qualified healthcare provider before your stress level becomes out of control. They can help you find the resources and assistance needed to cope with stress.

Do medications used to treat potential health effects of stress, like high blood pressure, ulcers, or depression, increase risks to my pregnancy?

Many medications can be used during pregnancy. In fact, it may be more harmful to a pregnancy if some conditions are not treated or well-controlled. Contact MotherToBaby to talk with a specialist about specific medication(s) during pregnancy and breastfeeding.

Can stress make it harder for me to get pregnant?

Studies that suggest stress might make it harder to get pregnant. However, these studies have limitations and are not able to give clear guidelines on how different amounts of stress or the length of time a woman is experiencing stress may affect their ability to get pregnant. If you are struggling getting pregnant and this is causing you stress, be sure to talk with your healthcare provider.

I just found out that I am pregnant. What are some ways to lower my stress level?

• Don’t be afraid to ask for help.
• Talk about your feelings with people you trust including friends, family, and/or healthcare/mental health professionals.
• Follow good health habits: avoid smoking, drinking alcohol, or taking non-prescription drug; take your prescribed medication as directed; eat a healthy diet; drink plenty of water; rest; and follow an exercise plan approved by your healthcare provider.
• Try to have fun and do things that you enjoy.
• Consider practicing mindfulness or doing meditation.

Does stress increase the chance of miscarriage?

Miscarriage is common and can occur in any pregnancy for many different reasons. It is unknown if stress on its own increases the chance of miscarriage. While studies suggest a lot of stress during pregnancy could increase the chance of miscarriage, it is hard to know if the increased chance is from stress alone or if it is due to other factors.

Does stress increase the chance of birth defects?

Every pregnancy starts with a 3-5% chance of having a birth defect. This is called the background risk. It is hard to measure stress and to study its effects on pregnancy. However, it is unlikely that stress alone will increase the chance of birth defects.

Does stress in pregnancy increase the chance of other pregnancy-related problems?

Some studies suggest that stress can contribute to preterm delivery (birth before week 37) or low birth weight (weighing less than 5 pounds, 8 ounces [2500 grams] at birth). However, because everyone experiences and responds to stressful situations in their own way, there is no clear information on if stress alone increases the chance of these complications.

Does stress in pregnancy affect future behavior or learning for the child?

Some studies have linked stress during pregnancy to an increased chance of the child(ren) developing mental health and behavioral problems later in life. However, there is not enough information to know if it is only stress or other factors that can increase the chance for these issues.

Breastfeeding and stress:

Stress may cause problems with breastfeeding. For some women, breastfeeding itself can feel overwhelming and stressful. It can be helpful for a woman who is breastfeeding to have support while nursing. This can include a breastfeeding support group, a lactation specialist, and/or friends or family members who can give help and support. If you are having trouble breastfeeding, please contact your healthcare provider or your baby’s pediatrician. Be sure to talk to your healthcare provider about all your breastfeeding questions.

If a man is stressed, could it affect fertility or increase the chance of birth defects?

Some studies have suggested that stress can affect a man’s fertility (ability to get a woman pregnant). In general, exposures that men have are unlikely to increase the risks to a pregnancy. For more information, please see the MotherToBaby fact sheet Paternal Exposures at https://mothertobaby.org/fact-sheets/paternal-exposures-pregnancy/.

Please click here for references.

This sheet is about having Gaucher disease in pregnancy or while breastfeeding. This information is based on published research studies. It should not take the place of medical care and advice from your healthcare provider. 

What is Gaucher disease?  

Gaucher disease is a genetic condition that causes low levels of an enzyme, called glucocerebrosidase, that helps break down certain fatty substances in the body. When this enzyme is low, these fats build up in parts of the body, such as the liver, spleen, lungs, bone marrow, and sometimes the brain. Over time, this buildup can cause these organs to get larger and not work as well. 

Common symptoms of Gaucher disease include thinning of the bone (osteopenia), bone pain/fractures, enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), lack of healthy red blood cells (anemia), fatigue (low energy), low blood platelet levels (thrombocytopenia), and easy bruising and bleeding.  

Symptoms can range from mild to severe and depend on the type of Gaucher disease a person has. The 3 major types of Gaucher disease are called Type 1, Type 2, and Type 3; and there are 2 subtypes.  

I have Gaucher disease. What should I talk about with my healthcare team before I get pregnant?  

It is important to talk to your healthcare team (including your obstetrician, anesthesiologist, hematologist, and Gaucher disease specialist) about plans for treating your condition before and during pregnancy, during delivery, and after delivery. If possible, talk with your healthcare team before getting pregnant. If your pregnancy is unplanned, contact your healthcare providers as soon as you find out you are pregnant.  

Things to talk about with your healthcare team include: 

• Ways to monitor your pregnancy and your Gaucher disease symptoms. 

• Any medications or vitamins you should take during pregnancy. People with Gaucher disease might not have enough vitamins and nutrients, such as Vitamin D or calcium.  

• Getting your bones checked. Pregnancy can increase the chance for severe bone pain (bone crisis).  

• Getting any necessary vaccines before and during pregnancy, especially if you have had your spleen removed. Many vaccines can be given in pregnancy. For more information, please see the MotherToBaby fact sheet on vaccines at https://mothertobaby.org/fact-sheets/vaccines-pregnancy/. 

• Any other questions or concerns you have. 

I have Gaucher disease. Can it make it harder for me to get pregnant?  

Gaucher disease is not expected to make it harder to get pregnant.  

Does having Gaucher disease increase the chance for miscarriage?  

Miscarriage is common and can happen in any pregnancy. Some studies show that Gaucher disease might increase the chance of miscarriage, especially in women with more severe symptoms or who are not receiving treatment. Other studies suggest that miscarriage rates are similar to women without Gaucher disease.  

Does having Gaucher disease increase the chance of birth defects?  

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. We look at research studies to try to understand if an exposure, like having Gaucher disease, might increase the chance of birth defects in a pregnancy. Gaucher disease is not expected to increase the chance of birth defects.  

Would having Gaucher disease increase the chance of other pregnancy-related problems? 

Studies have shown mixed results about pregnancy-related problems in women with Gaucher disease. Some studies have found a higher chance of preterm delivery (birth before week 37) and low birth weight (weighing less than 5 pounds, 8 ounces [2500 grams] at birth). Other pregnancy complications, such as high blood pressure and gestational diabetes, have been reported but are not common. 

Some women who have Gaucher disease start to have new symptoms during pregnancy. In addition, symptoms of Gaucher disease, such as anemia, thrombocytopenia, enlarged spleen or liver, and bone problems can worsen during pregnancy. Having severe thrombocytopenia increases the chance of bleeding around the time of delivery.  

This bleeding risk can affect decisions about anesthesia for delivery. It is important to talk with your healthcare team about your plans for delivery, including the use of anesthesia.  

Does Gaucher disease in pregnancy affect future behavior or learning for the child?    

Studies have not been done to see if Gaucher disease can cause behavior or learning issues for the child. 

Breastfeeding while I have Gaucher disease: 

Gaucher disease does not appear to affect the ability to breastfeed. However, breastfeeding for more than 6 months may not be recommended for some women with Gaucher disease who have low bone density. This is because most women will lose 3% to 7% of their bone density while breastfeeding. Although the lost bone is usually regained after breastfeeding stops, this loss might be too much for someone who already has low bone density. Be sure to talk to your healthcare provider about all your breastfeeding questions. 

If a man has Gaucher disease, can it affect his fertility or increase the chance of birth defects? 

Studies have not been done to see if Gaucher disease could affect male fertility (ability to make healthy sperm) or increase the chance of birth defects above the background risk. In general, exposures that men have are unlikely to increase risks to a pregnancy.  For more information, please see the MotherToBaby fact sheet Paternal Exposures at https://mothertobaby.org/fact-sheets/paternal-exposures-pregnancy/. 

Please click here for references.

This sheet is about exposure to certolizumab pegol in pregnancy and while breastfeeding. This information is based on available published literature. It should not take the place of medical care and advice from your healthcare provider.

What is certolizumab pegol?

Certolizumab pegol is a medication that has been used to treat some autoimmune conditions. It is called a tumor necrosis factor (TNF) inhibitor because it binds and blocks TNF, a substance in the body that causes inflammation in the joints, spine, and skin. Certolizumab pegol is sold under the brand name Cimzia^®.

MotherToBaby has fact sheets on some autoimmune conditions, such as:

• Rheumatoid arthritis (https://mothertobaby.org/fact-sheets/rheumatoid-arthritis/),
• Psoriasis and Psoriatic Arthritis (https://mothertobaby.org/fact-sheets/psoriasis-and-pregnancy/),
• Ankylosing spondylitis (https://mothertobaby.org/fact-sheets/ankylosing-spondylitis/),
• Inflammatory Bowel Disease (https://mothertobaby.org/fact-sheets/inflammatory-bowel-disease-pregnancy/).

Sometimes when women find out they are pregnant, they think about changing how they take their medication, or stopping their medication altogether. However, it is important to talk with your healthcare providers before making any changes to how you take this medication. Your healthcare providers can talk with you about the benefits of treating your condition and the risks of untreated illness during pregnancy.

I take certolizumab pegol. Can it make it harder for me to get pregnant?

There are no human studies looking at whether taking certolizumab pegol could make it harder for a woman to get pregnant. Animal studies did not find an effect on fertility (ability to get pregnant).

Does taking certolizumab pegol increase the chance of miscarriage?

Miscarriage is common and can occur in any pregnancy for many different reasons. Studies have not found a higher rate of miscarriage with the use of certolizumab pegol in pregnancy.

Does taking certolizumab pegol increase the chance of birth defects?

Every pregnancy starts out with a 3-5% chance of having a birth defect. This is called the background risk. There is published data on over 2,000 pregnancies with exposure to certolizumab pegol. A higher chance of birth defects has not been reported.

Does taking certolizumab pegol in pregnancy increase the chance of other pregnancy-related problems?

Severe autoimmune disease symptoms (“flares”) have been associated with a higher chance for pregnancy complications, such as preterm delivery (birth before week 37) or low birth weight (weighing less than 5 pounds, 8 ounces [2500 grams] at birth). In a small review of 14 pregnancies with exposure to certolizumab pegol, all infants were born full term, only 1 infant had low birth weight, and no infant infections were reported in the first 6 months after delivery.

It is unlikely that the developing baby will be exposed to very much of this medication in pregnancy. Studies that measured drug levels in blood of pregnant women, and in the umbilical cord blood and infant blood found little to no transfer of certolizumab pegol across the placenta to the developing baby. (The placenta is a temporary organ that develops during pregnancy and works as the blood connection between the pregnant woman and the baby). Certolizumab pegol was not found in the cord blood of 13 out of 14 babies. It was only found in very small amounts in the cord blood of 1 baby.

Does taking certolizumab pegol in pregnancy affect future behavior or learning for the child?

Studies have not been done to see if certolizumab pegol can increase the chance of behavior or learning issues for the child. A study that included certolizumab pegol along with other biologic medications found no differences in developmental milestones in the infants’ first year of life.

Can my baby receive live vaccines before one year of age if I take certolizumab pegol later in pregnancy?

Babies exposed to biologics in pregnancy appear to have the same response to vaccines as babies not exposed to these medications and build antibodies as expected. Most vaccines given to infants less than one year of age are noninfectious. Noninfectious (non-live) vaccines can be given to a baby even if certolizumab pegol is taken during pregnancy. Live vaccines usually contain a weakened form of the virus or bacteria that it vaccinates against. Live vaccines pose a very small chance a person could get the infection from the vaccine. Live vaccines are usually not given to people using TNF inhibitors. Research has reported that infants exposed to certolizumab pegol in pregnancy were not found to be at a higher risk of serious infections than infants not exposed to these medications. Vaccines protect babies from getting common infections that can sometimes cause serious or even life-threatening illness. In the United States, the rotavirus vaccine is the only live vaccine given to infants less than one year of age. Rotavirus is one of the leading causes of vomiting and severe diarrhea in children. Your pediatrician or healthcare provider can further discuss the risks and benefits of live vaccines with you.

Breastfeeding while taking certolizumab pegol:

Certolizumab pegol is a very large protein and not very much of the medication is expected to pass into breast milk. A report that measured certolizumab pegol levels in the breastmilk of 17 women found very low or undetectable levels. Certolizumab pegol is also not well absorbed when swallowed, so any medication that gets into breast milk would be less likely to enter the baby’s blood system. Be sure to talk to your healthcare provider about all your breastfeeding questions.

If a man takes certolizumab pegol, could it affect his fertility or increase the chance of birth defects?

Studies have not been done to see if certolizumab pegol could affect a man’s fertility (ability to get a woman pregnant) or increase the chance of birth defects. In general, exposures that fathers or sperm donors have are unlikely to increase risks to a pregnancy. For more information, please see the MotherToBaby fact sheet Paternal Exposures at https://mothertobaby.org/fact-sheets/paternal-exposures-pregnancy/

Please click here for references.

MotherToBaby is currently conducting a study looking at certolizumab pegol and other medications used to treat autoimmune disease in pregnancy. If you are interested in taking part in this study, please call 1-877-311-8972 or sign up at https://mothertobaby.org/join-study/.

This sheet is about exposure to atomoxetine in pregnancy and while breastfeeding. This information is based on published research studies. It should not take the place of medical care and advice from your healthcare provider. 

What is atomoxetine?

Atomoxetine is a mediation that has been approved to treat attention deficit hyperactivity disorder (ADHD). It belongs to a class of medications known as norepinephrine reuptake inhibitors (NRIs). A brand name for atomoxetine is Strattera®. 

Sometimes when people find out they are pregnant, they think about changing how they take their medication, or stopping their medication altogether. However, it is important to talk with your healthcare providers before making any changes to how you take your medication. Your healthcare providers can talk with you about the benefits of treating your condition and the risks of untreated illness during pregnancy. 

I take atomoxetine, and I was told that I am a poor/slow metabolizer. What does that mean for my pregnancy?

Some people’s bodies metabolize (process) atomoxetine slower than others. People who are slow metabolizers might have higher levels of the medication in their blood. It is not known if this could affect a pregnancy differently than people who metabolize the medication more quickly. 

I take atomoxetine. Can it make it harder for me to get pregnant?

Studies have not been done in humans to see if atomoxetine could make it harder to get pregnant. Animal studies did not show a change in fertility (ability to get pregnant).  

Does taking atomoxetine increase the chance of miscarriage?  

Miscarriage is common and can occur in any pregnancy for many different reasons. Studies have not been done to see if atomoxetine could increase the chance of miscarriage. 

Does taking atomoxetine increase the chance of birth defects?

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. We look at research studies to try to understand if an exposure, like atomoxetine, might increase the chance of birth defects in a pregnancy. 

Atomoxetine has not been well studied for use during pregnancy. Four human studies have not suggested an increased  chance of birth defects. Most of these studies used a prescription database to see who had a prescription for atomoxetine during their pregnancy. Prescription-based studies cannot tell us if the person who filled the prescription took the medication during their pregnancy. 

When looking at doses typically used by humans, animal studies did not suggest an increased chance of birth defects. With levels higher than those used with human treatment, there is some question of a higher chance for birth defects. It is not known if this information would apply to humans, especially those who are considered poor metabolizers.  

Does taking atomoxetine in pregnancy increase the chance of other pregnancy-related problems?

It is not known if atomoxetine can increase the chance of other pregnancy-related problems such as low birth weight (weighing less than 5 pounds, 8 ounces [2500 grams] at birth). One study of 453 people who filled a prescription for atomoxetine during the first 20 weeks of pregnancy showed no increased chance of placental abruption (when the placenta pulls away from the wall of the uterus before labor starts), being small for gestational age, preterm delivery (birth before week 37), or preeclampsia (high blood pressure and problems with organs, such as the kidneys), that can lead to seizures (called eclampsia). Prescription-based studies cannot tell us if the person who filled the prescription took the medication during their pregnancy. 

Does taking atomoxetine in pregnancy affect future behavior or learning for the child?  

Studies have not been done to see if atomoxetine can increase the chance of behavior or learning issues for the child. 

Breastfeeding while taking atomoxetine:  

There are no studies on the use of atomoxetine while breastfeeding. If you suspect the baby has any symptoms (such as being too sleepy), contact the child’s healthcare provider. Be sure to talk to your healthcare providers about all your breastfeeding questions.   

If a man takes atomoxetine, could it affect fertility or increase the chance of birth defects?

Studies have not been done to see if atomoxetine could affect men’s fertility (ability to get partner pregnant) or increase the chance of birth defects. In general, exposures that fathers or sperm donors have are unlikely to increase the risks to a pregnancy. For more information, please see the MotherToBaby fact sheet Paternal Exposures at https://mothertobaby.org/fact-sheets/paternal-exposures-pregnancy/.  

Please click here to view references.

There is a pregnancy registry for women who take medications for ADHD, called The National Pregnancy Registry for ADHD Medications. For more information please visit their website: https://womensmentalhealth.org/adhd-medications/