Marijuana & Pregnancy – Is it Safe?

By Sonia Alvarado, Senior Teratogen Information Specialist, MotherToBaby CA

Marijuana has been in the news a lot lately and for marijuana users who have had to smoke in illegally, it appears societal attitudes about pot smoking may be changing.  Twenty states have laws legalizing some form of marijuana use. Two states, Colorado and Washington, have legalized its recreational use. In an interview, the NFL Commissioner seemed to leave open the possibility that medicinal use could be considered for NFL players if there was scientific evidence that it was helpful to treat injuries and pain. Even President Obama has said that he doesn’t believe marijuana is any more dangerous than alcohol. Marijuana is currently listed as a Schedule I drug. Other Schedule I drugs include heroin, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (ecstasy).

 

What The Research Shows Us

According to studies, pregnant women who use illicit substances are more likely to use marijuana compared to other drugs. This is often due to the belief that marijuana is less harmful to the developing embryo and fetus, compared to other drugs such as cocaine or heroin.

Marijuana is Cannabis. The delta-9-tetrahydrocannabinol (THC) in the Cannabis plant produces the psychoactive effect or “high.” Marijuana can be smoked in a joint, inhaled through a bong or vaporizer, eaten in food and teas/beverages, used in tinctures, and topical balms.  Smoking and ingestion exposes the user to THC, producing the high. When smoked in a joint, the user is exposed to carbon monoxide from the burning of the leaf as well as tar, which can stay behind in the lungs.

Marijuana use during pregnancy has been studied since the 1960’s. Like all studies, there are weaknesses that have been pointed out. For example, asking women about past drug use may not be the most accurate way to make a connection between the dose of the drug and the adverse effects because the women may have forgotten. Also asking women to volunteer information about drug use, which they may fear disclosing even in a confidential setting, may make it difficult to know how frequently pregnant women use drugs overall. Still, a number of experts have reviewed hundreds of reports in humans and animals. At least to this point, the studies do not support an association between marijuana smoking and birth defects. One large study of 12,825 interviews done after delivery, did not find a statistical association between marijuana use and birth defects.

However, the studies also show that marijuana is not risk free. Studies have reported associations between marijuana smoking and growth restriction and lower birth weight, particularly in women who keep smoking through delivery or late in pregnancy. An Australian study of almost 420,000 live births reported a higher risk for neonatal intensive care admission for newborns exposed prenatally to pot. Also, there are reports of abnormal responses or behaviors in the newborn period and this suggests a toxicity or withdrawal. The symptoms include exaggerated and prolonged startle reflexes (sleep cycle disturbances with high-pitched crying.) In a Brazilian study, exposed newborns were “more irritable and less responsive to calming, cried more during the examination, and exhibited more jitteriness and startles than the non-exposed neonates.” Pregnant women who smoke daily and/or through delivery, have a higher risk for complications in their pregnancy compared to women who quit in the first trimester.

Researchers have attempted to assess the long-term effects of prenatal marijuana exposure. Studies of 3, 10 and 14-year old prenatally exposed children suggest that the prenatal exposure to high doses of marijuana may make it harder for children to learn and may affect their emotions (increased aggression) and increase depression symptoms. Studies are needed to assess which prenatally exposed children are most at risk. Its important to note that the children in these studies often have had prenatal exposure to other drugs as well, struggles with poverty and other life challenges, making it difficult to know that the findings are due to a single drug exposure.

 

So Where Does Marijuana Rank Compared To Other Drugs?

Alcohol: Specific to use during pregnancy, marijuana is not alcohol. Alcohol is still the drug with the highest risk and the widest range of birth defects, including physical, mental and behavioral. Alcohol is a drug with the highest use throughout the world, easy legal access, and social acceptance.

Cocaine: Cocaine, by comparison, is associated with a small risk for birth defects, and a higher risk for admission to newborn intensive care for withdrawal and toxicity. Additionally, cocaine is associated with prenatal growth retardation, lower birth weight, shorter length, and smaller head circumference. Studies suggest the effects on height extend into childhood.

Heroin: Heroin has not been associated with an increased risk for birth defects, however, is associated with a higher risk for withdrawal and admission to newborn intensive care and sudden infant death syndrome.

 

Bottomline: Snuff Out Smoking It

Clearly, marijuana use in pregnancy is not preferable, nor less risky, compared to most other drugs when a side-by-side comparison is made. Changing societal attitudes doesn’t change the fact that the developing embryo (and fetus) is dependent on the mother for oxygen, nutrients and a balance of hormones, chemicals and other substances to grow normally. Disrupting the normal fetal environment, through the introduction of marijuana or other recreational drugs, puts the pregnancy at risk in the short-term and possibly the long term as well.

 

Sonia Alvarado is a bilingual (Spanish/English) Senior Teratogen Information Specialist with MotherToBaby California, a non-profit that aims to educate women about medications and more during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/breastfeeding via MotherToBaby’s toll-free hotline, email and private chat counseling service, she’s provided educational talks regarding pregnancy health in community clinics and high schools over the past decade.

 

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 beauty products, medications or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or visit MotherToBaby.org to browse a library of fact sheets and find your nearest affiliate.
photo credit: MendezEnrique via photopin cc
 

 

Pregnant with Disabilities: Multiple Sclerosis

By Neda Ebrahimi , Teratogen Information Specialist, Motherisk

As a counselor with Motherisk, the Canadian partner of MotherToBaby and a service of the Organization of Teratology Information Specialists (OTIS), I hear many stories from women about pregnancy. Some of those stories strike cords with me. Their urgency and desire to make the healthiest decisions possible for their future children is both understandable and admirable. In honor of National Multiple Sclerosis Awareness Month, I give you Nina’s story.

 

Nina’s Story

“I’m 31 years old, and I was diagnosed with Relapsing Remitting Multiple Sclerosis (RRMS), when I was only 22. My first relapse was scary. I was writing my finals, and 2 days before my last final, I lost sight completely in one eye, and my legs felt so week and wobbly that I couldn’t stand even for a second. After going to the hospital and receiving several courses of steroids over 10 days, I started to improve but it took 2 months for my symptoms to fully resolve. And then, everything went back to normal, as if nothing had ever happened. I received my diagnosis several months after, and it felt like a death sentence. I had 2 more relapses before my doctor put me on disease modifying drug (DMD), and I started with Infterferon-B1a. Over the last 8 years, I only experienced 5 more relapses. The last relapse I had was only a few months ago; I lost sight in my left eye, and numbness that ran from my face to my toes on just the right side of my body. I have always been able to work full-time except when I’m experiencing a relapse, for which I’ve had to take a month off. I am a dentist, so not surprisingly I can’t carry out my job when I’m experiencing numbness in my hand. I met John 5 years ago at the MS clinic I used to visit. He was a nurse there. We fell in love, and despite of my illness he proposed to me last year, and we talked about having a family, with two children, hopefully one boy and one girl, and living happily ever after. It didn’t initially worry me that one day I may want children. John is crazy about kids, and I feel my maternal instincts kick in every time I hold a baby. Since we got married, my anxiety has been increasing proportionally to my yearning for having a child.  I know my MS can’t be cured, at least not now, I know it can get worst over time, and eventually I may need support to carry out even simple tasks. Or Maybe I won’t, and I would be one of the few who never enter the progressive state. I don’t know if I’ll be able to care for a baby and meet his or her demands. What will happen after my pregnancy? I really don’t want to experience another relapse after I deliver. How am I going to manage my illness, and what will happen if I need to came off my DMD when I’m pregnant or breastfeeding? There are so many questions, and I don’t know who to turn to.”

Nina is not alone in her thirst for answers. MS is an autoimmune neurological disease with very different presentation. No two MS patients are exactly the same and symptoms can vary from just the occasional mild tingling in the finger tips to more severe symptoms that render the patient unable to walk or stand for several weeks. With Relapsing Remitting MS accounting for 85% of all MS cases, most patients will undergo a remissive state after an attack, and will resume their daily life with little or no hindrance. Some patients will continue to have modest symptoms during the remissive state which they learn to adapt to and manage by different medications and or lifestyle changes.  As there are no current cures for MS, many MS patients live for decades with this disease, and must find the means to maintain a high quality of life as the disease progresses, which can be challenging in the later stages of the disease.

MS impacts many more women than men with a 3:1 ratio in North America.  As the disease onset occurs during the reproductive ages, many women with MS face the dilemma of pregnancy at some point during their lives. Young women, like Nina, with MS planning pregnancies, have many questions. Because the disease presentation and progression varies from person to person, there is no exact answer and treatment and management must be tailored to the specific person’s need. However, I’d like to address some of the most common questions to help all of the “Ninas” out there:

1. “Would the disease adversely impact the pregnancy and my developing baby”?

Up until the late 1950s, women with MS were advised to terminate their pregnancies. With our advancement in the field, we know that this is almost never necessary. Many women with MS continue to have healthy babies, and research shows that there is no increased risk for having a baby with a structural malformation or developmental delay and many deliver healthy babies with no major complications. Although there is a trend toward lighter weight babies, the birth weight percentile remains in the normal range for most. Another observation has been the higher rate of miscarriage in the MS population with mixed results from different studies. The reason for this is not well understood, but the majority of miscarriages are in early pregnancy. While miscarriage rates in the general population are around 10-15%, in women with MS the rates are closer to 20%-30%. With successful conception, the chance of delivering a healthy baby at term is high, and women with MS should be assured that their disease is unlikely to cause harm to the developing baby.

2. “Would my baby also have MS”?

There is a complex interplay between genetics and environment leading to MS. While the risk of getting MS in the general population is 0.3%, having a parent with MS will increase this risk by almost 15 times. So children of women with MS may have a 3% to 6% chance of developing MS later in life, but the environmental and lifestyle factors may play the ultimate role in disease manifestation. Hence despite the genetic contribution, the risk for your baby developing MS remains small and can potentially be modified.

 3. “If I stop my DMD when planning, what are the risks of having a relapse while I try to conceive?”

Depending on how long it takes to conceive, the drug free period prior to pregnancy may be a risky period for experiencing a relapse. While some women conceive after just one cycle, many will conceive after several months of actively trying to become pregnant. It will take 1 to 3 months (depending on the drug) to fully clear the system, and during this time, some may experience disease activity. If prior to starting the DMD you had very active disease, there is a risk that you’ll experience a relapse when you stop the medication, especially if it takes more than 3 months for you to conceive. The decision to continue DMDs is highly individualized and is determined on a case-by-case basis.  You and your neurologist will determine the best mode of action.

4. Would having a pregnancy make my MS progress faster?

Pregnancy has not been shown to speed the disease process. In fact, pregnancy is a state of remission for many women with MS, and a time for optimal wellbeing. It is well established that relapse rates reduce by 70% by the third trimester of pregnancy compared to the year prior to pregnancy. However after delivery the relapse rate increases, with 60% of women experiencing a relapse in the first 3 to 6 months postpartum. While the risk is increased in the postpartum period, the course of MS tends to return to its baseline, and no worse than what it was in the year prior to pregnancy. Some studies have found a protective effect with pregnancy, with a delay in the long-term disease progression; however, more studies are needed to confirm this finding.

5.      Would I be able to continue my DMD through the pregnancy?

Although many women with MS go through remission in the pregnancy, some will continue to experience disease activity especially in the first two trimesters. The decision to continue DMDs is dependent on several factors, including the type of medication, disease activity in the year prior to pregnancy, and the type of control achieved with the given DMD. The use of glatiramer, Interferon Beta 1a/1b, in pregnancy have not been associated with an increased risk for malformations and if you achieved great control with these drugs, and are at a high risk of relapsing, your physician may consider continuing your therapy through the pregnancy. The newer drugs, especially the oral DMDs, have not been well studied, therefore it is recommended that you discuss with your neurologist the best plan for the course of your pregnancy. There are ongoing research studies looking at the outcome of pregnancies following exposure to these medications. MotherToBaby and its affiliates are engaged in such studies. For study information or for the most up-to-date information about newer medications used to treat MS during pregnancy, call from anywhere in North America toll-FREE 866-626-6847.

6. What if I have a relapse during pregnancy?

While relapses during pregnancy are uncommon, they may happen, and can be quite severe for some women. Steroids are usually used to treat those relapses, although some success has been shown with IVIg therapy as well. A woman that experiences a severe debilitating relapse during her pregnancy, may require the standard steroid therapy, while a woman that experiences a mild flare-up may choose, in collaboration with her physician, to abstain from treatment. Systemic steroid use in the first trimester has been associated with a very small risk for cleft lip and palate, and use in the second half of pregnancy may increase the risk for having a smaller baby and for delivering prematurely (before 37 weeks gestation). However, it is recommended that you speak with your health care provider before you stop or change any medication. The benefits of taking a steroid and treating your condition should be weighed against these small possible risks. For more information, check out this fact sheet online: http://www.mothertobaby.org/files/Prednisone_6_13_1.pdf or call anywhere in North America toll-FREE 866-626-6847.

7. Should I breastfeed or start my DMD right after delivery?

The postpartum period is a period with a high risk of experiencing relapses. Data on whether breastfeeding has protective effect has conflicting results. Some studies suggest a protective effect, possibly due to the delay of menses returning, while others show no impact. Information on safety of DMDs in the breastfeeding period are scarce, however given the large molecule size of glatiramer acetate, and Interferons, it is unlikely any will transfer into milk. If they do, they are likely not to be absorbed from the baby’s gastrointestinal tract. There is no information regarding other DMD usages during lactation. The benefits of breastfeeding baby are numerous, but, ultimately, your functionality and ability to care for your child take priority. The decision to breastfeed or not may depend on your ability to breastfeed, especially since the demands of a newborn and the hormonal changes in the postpartum period can be very taxing on your energy levels and if you experience chronic fatigue due to your condition.  Thus, if a woman (while consulting her physician) decides to breastfeed she may do so. However, if she needs to restart her DMD, currently she may be advised to stop breastfeeding.


Bottom line: While having MS poses physical and emotional challenges, it does not jeopardize a woman’s capacity to mother. With careful planning and close collaboration with your doctors and healthcare providers, and especially with some support from family and friends, you will be able to have successful pregnancies, healthy children, and out of control teenagers, just like any other woman. So if becoming a mother is something you have always wanted and looked forward to, having MS is more of a bump in the road rather than a life sentence, and with some maneuvering you can achieve your dreams. Happy parenthood!                                                           

 


Neda Ebrahimi is a research associate and counselor at the Canadian Motherisk program, a non-profit MotherToBaby/OTIS affiliate that aims to educate the public about medications and more during pregnancy and breastfeeding. The Motherisk program is also a center for teaching and clinical research in the area of exposures in pregnancy and breastfeeding. Neda is pursuing her PhD in the field of Multiple Sclerosis in Pregnancy. To learn more about her work and about her study, email her at neda.ebrahimi@sickkids.ca or call 416-813-7654 ext. 204928. You can also call the Motherisk Helpline at 1-877-439-2744 and ask to be referred to the MS study.

 

MotherToBaby and its affiliates are services 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 MS, medications or other exposures during pregnancy or breastfeeding, call toll-FREE 866-626-6847 or visit www.MotherToBaby.org.

Real Complications, Real Voices: Hyperemesis Gravidarum

In this seriesGiving Birth with Confidence addresses well known and lesser known pregnancy and birth complications by sharing practical information and voices from real women who have experienced them. While most birth complications happen infrequently, they do happen. If you or someone you know is pregnant, it’s important to be aware of the signs and symptoms of complications. We encourage you to join in the conversation in the comments section. The following information is not meant to replace diagnosis or information from your care provider.

 

Hyperemesis Gravidarum

Morning sickness is a well known form of ongoing mild nausea that affects the majority of pregnant women at some point during their pregnancy (generally in the first trimester). Hyperemesis gravidarum (HG) — an extreme form of morning sickness — is not as common but affects approximately 60,000 women annually in the United States. Unlike morning sickness, women with hyperemesis gravidarum experience significant health risks and disruption to their daily life. HG usually resolves by 21 weeks, but may last throughout pregnancy for a small number of women.

The biggest obstacle in diagnosing and dealing with HG is the misconceptions that surround it. Many brush it off as the more mild morning sickness and may lead a mother to believe she is exaggerating and should just “deal with it.” Continual vomiting  and unrelenting nausea is not a simple case of morning sickness. If any of the following symptoms describe your experience, seek professional help as soon as possible.

Warning Signs 

  • Nausea that does not let up combined with severe vomiting

Symptoms 

From the Hyperemesis Research & Education Foundation at www.helpher.org:

  • Anemia (low red blood cells)
  • Body odor (from rapid fat loss & ketosis)
  • Confusion
  • Decreased urination
  • Dehydration
  • Dry, “furry” tongue
  • Excessive salivation
  • Extreme fatigue
  • Fainting or dizziness
  • Food aversions
  • Gall bladder dysfunction
  • Headache
  • Hypersensitive gag reflex
  • Increased sense of smell
  • Intolerance to motion/noise/light
  • Jaundice
  • Ketosis
  • Liver enzyme elevation
  • Loss of skin elasticity
  • Low blood pressure
  • Overactive thyroid or parathyroid
  • Pale, waxy, dry skin
  • Rapid heart rate
  • Rapid weight loss of 5% or more (from pre-pregnancy weight)
  • Secondary anxiety/depression
  • Vitamin/electrolyte deficiency
  • Vomiting of mucus, bile or blood

Diagnosis 

Your care provider can diagnose HG by measuring the amount of weight loss — it’s usually associated with a greater than 5% pre-pregnancy body weight loss — as well as by checking your urine for ketones (chemicals produced when the body burns fat or energy for fuel), and assessing your overall condition. Alternative, more natural remedies include bed rest, acupressure, acupuncture, herbs, hypnosis, and regular chiropractic care.

Treatment

The earlier a mother is treated for HG, the easier it is to manage and prevent more serious risks and complications. Depending on the severity, HG is treated with medications to reduce nausea and vomiting, IV fluids to treat dehydration, and nutritional therapy via vitamin supplements, intravenous nutrition, or tube feeding.

Risks

Most risks and complications resulting from HG occur from untreated or prolonged symptoms. Risks include:

  • Gall bladder disease
  • TMJ  disorders
  • Depression
  • Anxiety
  • Difficulty maintaining healthy weight
  • Diabetes
  • Motion sickness
  • Cavities
  • Preterm labor
  • Pre-eclampsia
  • Potential future health risks to an infant whose mother was malnourished (caused by HG)

Cause

The cause of hyperemesis gravidarum is yet unknown, though there are many theories all centering around the hormonal changes changes that occur during pregnancy.

Prevention

There are no known ways to prevent hyperemesis gravidarum.

More Resources

For more extensive resources and research on hyperemesis gravidarum, visit the Hyperemesis Research & Education Foundation at www.helpher.org.

Real Voices of Mothers who Experienced Hyperemesis Gravidarum

Shana was diagnosed with HG in her first pregnancy (in addition to a second trimester diagnosis of gestational diabetes). Initially, she thought it was just typical morning sickness, but realized it could be something more after talking to other moms and her doctor. She recalls:

I did not have a glowing, happy pregnancy. Now that I have my beautiful son, it’s hard for me to look back and accurately remember how miserable I was, but I have a pregnancy journal that does a pretty good job of jogging my memory.

Though I desperately wanted to eat well, just getting near food would set me off and my husband would come home from work to find me sobbing because all I had managed to eat that day was five Saltine crackers and I was afraid I was hurting our baby by not getting enough nourishment.

No one talks about HG and if it hadn’t been for that one acquaintance, I would have never known that what I was going through was not the usual course of morning sickness. I was also lucky enough to receive a the book Managing Morning Sickness from my husband’s aunt, who works as a nurse on a high risk maternity ward. From that book I learned that HG can be way, way worse than how I had it and that some women can be hospitalized for months. I also learned about other triggers, like flashing lights and motions, which explains the vomiting bout I experienced after stupidly watching the movie Twister with my husband one night!

I still feel like my body is not good at being pregnant, like I am somehow missing that magical happy pregnancy capability that I see other women have. It made me doubt in my body’s abilities. I also often felt afraid.

Holly experienced a severe case of HG in her fourth pregnancy, after having three prior pregnancies without it. Because of the diagnosis and complications from the illness, it was also her first out-of-home birth. Holly details her experience:

The first time I threw up when pregnant with my fourth baby, I was excited. We desperately wanted another baby and my quick counting let me know the timing was right. Testing later that day provided a strong, early positive.

By a few weeks later I was spending all day vomiting and all my efforts to stay hydrated were failing. I knew things had to change when I called the midwife in tears from my bathroom floor, too sick to move, too dehydrated to vomit more and yet still gagging, and I heard a suggestion for more protein and small sips of water. I ended up going to the ER for IV fluids — the first of many ER trips for my pregnancy.

After switching to an OB for care, I began taking antiemetics, antibiotics for a UTI exacerbated by chronic dehydration, steroids, and receiving home nursing care to get fluids and medications administered at home. I continued getting liters of fluids and vitamins at home, as well as iv medications. Despite this, I was still sick.

I was terrified of dying. I was petrified of falling on the stairs, either by myself or while carrying my young toddler. I began to scoot down them on my bottom, like a small child. I told my two older children what to do if I fell and didn’t get up, or if they found me sleeping and couldn’t rouse me. We practiced reciting our names and addresses in case they needed to call 911 while my husband was at work. I was lucky and had a very supportive husband, circle of friends, and medical team. My church brought over meals and members came to sit and visit with me. My home health nurses were professional and caring.

By my third trimester I was having strong early contractions and added more medication to try to stay pregnant. I was terrified of having gone through so much and losing my baby. When I finally was full term I delivered my baby in the hospital. My labor was relatively short but I was nauseated the whole time. My baby was born healthy and strong — he is the easiest of my children so far and deeply treasured. And my nausea ended as soon as I had him.

For all the support  I received I also received a lot of criticism. Perhaps it was my attitude. Perhaps I needed more chiropractic care, or acupuncture, or seabands. Was I eating organic? As horrible as I felt physically, the guilt I felt when people told me there was something else I should have or could have been doing other then taking medications and endangering my baby was horrible. It was terrifying to take medications after having had natural pregnancies and home births. I wish I’d had a way to articulate to people that I tried. I didn’t fail. My doctor was amazing and my body and baby are amazing. Hyperemesis gravidarum, is not.

HG appeared for Kathy in both of her pregnancies, approximately 5 years apart. Without the assistance of medication (her doctor did not prescribe any), she discovered tricks to cope with the nausea and vomiting.

After two months of eating less than a full meal per day my weight was dropping. I started out at about 112 lbs and dropped to 100 and change. It was demoralizing as much as physically diminishing. I distinctly recall curling up on the floor of the shower, crying as the water washed over me, feeling like a failure because I couldn’t nourish my baby. That was a particularly low point. Assurance from my OB that the baby would get what he needed, one way or another, was not that helpful. I couldn’t even keep a prenatal vitamin down. The one trick that sometimes helped was to suck on a hard candy before a meal, as the introduction of some sugar to my system seemed to ease the process. Too much food at once was only asking for trouble.

In my second pregnancy, symptoms came on at about the same time but had a distinct pattern: one day of feeling miserably ill, followed by a slighter better day, then a third day where I could keep more food down. This three-day cycle repeated for weeks. In the process, I made a discovery that was very helpful. Despite all the suggestions to nibble on something bland before rising, my best bet, in terms of keeping food down later, was to empty my stomach of the excess acid right away. Because I was running out of foods I could eat and then throw up (it’s hard to down some oatmeal knowing it’s meant to come right back up), I hit upon water. I kept a glassful on my nightstand, and when I awoke I’d take a big gulp, run for the bathroom, and be done with it. I continued to have a mix of good days and bad, but by emptying out the acid first I seemed to have better luck keeping food down. I still lost a fair amount of weight with that pregnancy, close to 10% of my weight like before, but the symptoms were relieved and I felt like I had more control. That was huge.

In both pregnancies, I delivered healthy babies, my son weighing in at 8 lbs 8 oz and my daughter just four ounces less. My son was eight days overdue, but otherwise the pregnancy and delivery went fine once the HG passed.

 

Don’t Let the Bugs Bite! — Tips for Bug Bite Prevention & Treatment During Pregnancy

 By Chris Colón, MS, LCGC, MotherToBaby Teratogen Information Specialist

For many people, summer is an enjoyable time of year. The weather is warmer, more outdoor activities are available, and there are often more chances to spend time with family and friends. Summer is also a time of year that many people experience something less fun: bites and stings. Depending on your location and what you’re doing, the chance of bites or stings may be much higher in the summer. Even though many bites and stings are not thought to cause medical problems, women that are pregnant or breastfeeding may be concerned about getting and treating bites and stings. Below are some common bites and stings that people can be exposed to this time of year. This information should not take the place of medical care and advice from your health care provider.

 

Bug bites and stings, such as those from most mosquitoes, ticks, biting flies, ants, spiders, bees, wasps, hornets, and yellow jackets can cause reactions. For most people, these reactions are usually mild, and have symptoms such as pain, redness, and swelling, which are uncomfortable but not harmful. Some people can have an allergic reaction to certain bites and stings, making those more important to treat quickly. Without medical attention, allergic reactions can cause serious symptoms, like trouble breathing or swallowing, swelling of the face, mouth or throat, and feeling dizzy or lightheaded. If you experience any of these symptoms after a bite or sting, contact a health care provider right away.

 

Mosquitos and West Nile Virus (WNV)

There are also some bites that can spread diseases. Rarely, mosquitos infected with West Nile Virus (WNV) can pass it to humans. Most people infected with WNV will have no symptoms at all or very mild symptoms. A few people with WNV will develop more serious symptoms, like fever, headache, tiredness, body aches, swollen glands and/or a skin rash on the chest or stomach. There are no specific treatments for WNV, and symptoms often go away on their own. More severe cases may need a lot of medical care or even a stay in the hospital. There is very little information about WNV during pregnancy.  There have been reports of over 70 women who had WNV during pregnancy. Only one of these babies was born with medical problems, and it is hard to know if those problems were caused by WNV.  More research is needed before we can know how WNV during pregnancy may affect a developing baby. If you think you have developed WNV, contact your healthcare provider, and be sure to let them know if you are pregnant, planning pregnancy, or breastfeeding.

 

Ticks and Lyme disease

Most tick bites do not carry disease or cause health problems. However, sometimes ticks carry diseases. This includes Lyme disease, an infection that is caused by Borrelia burgdorferi bacterium. Symptoms of Lyme disease are headache, stiff neck, fever, muscle or joint pain and swelling, and a red rash that may look like a “bull’s-eye.” It’s important to treat Lyme disease to avoid more health problems, especially if you are pregnant or breastfeeding. It is usually treated with antibiotics. When correctly treated, Lyme disease has not been shown to increase risks to a pregnancy. If you think you have developed Lyme disease, contact your healthcare provider to talk about your treatment options. Be sure to tell your healthcare provider if you are pregnant, planning pregnancy, or breastfeeding.

 

Creatures with Venom

Some creatures, like scorpions, snakes, and spiders can have a substance that may be toxic to humans, called venom. Bites and stings from these kinds of creatures are usually not life threatening, and may not need medical treatment. However, some types of venom can be more toxic, especially to young children and older adults.  Although it is not very common, bites and stings from creatures that have venom can cause problems in pregnancy such as miscarriage, birth before 37 weeks of pregnancy, the placenta detaching from the uterus before labor (called placental abruption), and stillbirth. Depending on the type of creature and the venom they have, these bites and stings may require medical treatment. If you are stung by a scorpion, snake, spider or other creature that has venom during pregnancy or breastfeeding, contact your healthcare provider. If your symptoms are severe or spread, you should seek medical attention and information from your provider, a local care center or poison control center as soon as possible.

 

Treating Bites and Stings

If you have a bite or sting and are experiencing only mild symptoms, you can usually treat it yourself. If you need to, remove the stinger or tick carefully without squeezing it. Wash the area with soap and water, and then apply an antiseptic to kill germs. You can use a hydrocortisone cream or calamine lotion and cover the area with a dry, sterile bandage. If there is swelling, use an ice pack or cold compress. Many people take an over-the-counter medicine to treat itching, swelling, and hives, such as an antihistamine. Some also take a pain reliever for mild pain. However, it is suggested that you contact your healthcare provider before starting or stopping any medications (even over-the-counter ones) during pregnancy or breastfeeding.

 

Preventing Bites and Stings

There are ways to limit your exposure to bites and stings. If you can, avoid places and conditions where you are more likely to get bitten or stung, like wooded and brushy areas with high grass, brush, and leaves. If you are going to be outdoors where and when bugs, snakes and scorpions may be present, wear long sleeves and pants if possible. Avoid wearing sandals or walking barefoot in grass. When eating outdoors, try to keep food covered at all times. Avoid wearing sweet-smelling perfumes, hair sprays, colognes and deodorants, as well as bright-colored clothing. Keep window and door screens in good repair to shield against bugs.

 

Using bug repellent can reduce and prevent bug bites. Many common brands contain DEET (N,N-ethyl-m-toluamide or m-DET) as the active ingredient, and come in the form of a lotion, spray, or oil that is put onto skin or clothing. DEET use is the most effective protection against malaria, Lyme disease, dengue fever, yellow fever, and the West Nile Virus. Because illness caused by any of these diseases during pregnancy can be harmful to a developing baby, it’s important to protect yourself. When used as directed on the package label, DEET has not been shown to cause an increased risk of problems with pregnancy or breastfeeding.

 

In general, although bites and stings can be annoying, they most often do not lead to serious health problems. Most can be treated without needing medical attention. In rare cases, some bites and stings can lead to allergic reactions or the spread of disease. However, when treated properly, these complications are thought to have low risks, if any, to pregnancy or breastfeeding. So go out there and enjoy the summer – and remember to use bug repellent!

 

MotherToBaby has facts sheets on West Nile Virus and DEET in pregnancy and breastfeeding, which can be found at MotherToBaby.org. For more information on medications and exposures during pregnancy and breastfeeding, call MotherToBaby toll-free at (866) 626-6847. MotherToBaby is a service of the Organization of Teratology Information Specialists (OTIS). MotherToBaby and OTIS are suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC). 

 

Chris Colón is a licensed genetic counselor based in San Diego, California. She works as a Teratogen Information Specialist for MotherToBaby and is co-chair of the organization’s Education Committee.

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Stretch Marks: What the Research Shows Us

By Sonia Alvarado, Senior Teratogen Information Specialist, MotherToBaby CA

Celebrity pregnancies get lots of media attention and are quick to share their own thoughts on what they eat, how they deal with pregnancy weight and unwanted effects like stretch marks.

Stretch marks (SM) and pregnancy are almost synonymous. Reports suggest that 50-90% of pregnant women get stretch marks. However, you might be slightly comforted by the fact that that SM are not limited to pregnancy. In fact, men and women, boys and girls can get stretch marks and it can start as early as puberty! Basically, in healthy people, pregnancy, getting breast implants, bodybuilding, and general weight gain can result in SM. Certain illnesses and medication use are also associated with SM.

“Striae distensae,” the medical name for stretch marks, are easily recognized. SM appear as lines or streaks on the arms, stomach, thighs, hips, breasts, upper arms, lower back and shoulders. While SM don’t generally cause intense pain, they can be mildly painful and can also include itchiness (resist scratching!) and dryness. SM start off pink and change color to brown, purple, and eventually fade to a silvery color. While we know what SM look like, experts aren’t completely sure what causes them other than probably genes, changes in skin, hormones, collagen and in some cases, underlying illness.

So maybe you have SM. Or concerned you may get them. Wondering if there are lotions that can help prevent them. Search no further! We have the skinny on this subject. Read on.

 

Treatment for Existing Stretch Marks

Save your money! If you have existing SM, currently, there is no over-the-counter cosmetic product that cures or gets rid of SM.  Topical oils, vitamins (including E, A) and lotions don’t penetrate into the skin sufficiently to increase collagen production and repair the skin.

Spend your money – if you can/care to. In-office procedures, such as glycolic acid peels with retinoids, as well as laser treatments, have been shown in studies to improve the appearance of SM and measurably improve collagen and elastin. The downside is that these interventions are expensive and may not be appropriate for every woman. Do your homework and find an experienced and recommended dermatologist. You will want to ask if the laser treatment is appropriate for your skin color, how many similar patients the doctor has treated, and the range of outcomes. If you are pregnant, you’ll want to talk to your doctor before considering any treatments on existing SM. Studies that have looked at the absorption into the bloodstream of topical retinoids during pregnancy have been somewhat reassuring. However, because retinoids are in a class of drugs that have been associated with birth defects when used systemically, it’s unlikely that care providers will approve their use during pregnancy.

Prevention of Stretch Marks

A Cochrane review published in 2012 by Brennan et al, looked at published studies on topical preparations for the purpose of preventing SM. The authors evaluated research on topical agents for the purpose of preventing SM published through the Cochrane Pregnancy and Childbirth Group in the U.K. They included randomized trials that included exposed pregnant women and non-exposed pregnant women  (not exposed to the study drug/chemical) or no treatment group.  The authors reviewed six trials that included 800 women and found no statistically significant difference between developing SM and not developing SM if you used the studied products, nor differences in the severity of the SM if you used the studied products/did not use the studied products. They called for larger studies and better quality studies. The products evaluated included those with vitamin E, hyaluronic acid and others.

A Turkish study published in May 2012, in the Journal of Clinical Nursing, included three groups: pregnant women who applied bitter almond oil with a 15 minute massage, pregnant women who applied bitter almond oil with no instruction to massage, and a non-exposed group. The study found that the exposed bitter almond oil group with massage had a lower chance of developing SM. This was a small study, with only 47 women in the exposed/massage group (48 in the exposed/no massage group). Additional and larger studies are needed.

Another small study published in 2012 in the International Journal of Cosmetic Science suggested that a combination moisturizer containing hydroxyprolisilane C, rosehip oil, Centella asiatica triterpenes and vitamin E might be beneficial over other moisturizers and reduce the number of SM that can occur during pregnancy.

Based on the available research, including our limited understanding of the underlying factors (genetics, others) that play a role in the development of SM, it isn’t advised to spend a lot of money on lotions or creams to prevent stretch marks. However, research may suggest that massaging lotions or creams into the skin could help reduce the appearance or occurrence of SM. I’m not aware of studies that have looked specifically at the act of massaging lotions or creams daily, for a specific time, in the areas at risk for SM, but in several studies and reports that suggested some benefit, it appears that massage (or working the lotion into the skin) appeared to be a technique that was widely used for the exposed group vs. the non-exposed group. While I’m not suggesting it would work, it doesn’t hurt and might decrease the dryness and itchiness that accompanies and sometimes precedes SM. 

 

Sonia Alvarado is a bilingual (Spanish/English) Senior Teratogen Information Specialist with MotherToBaby CA, formerly known as the CTIS Pregnancy Health Information Line, a non-profit that aims to educate women about medications and more during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/breastfeeding via MotherToBaby’s toll-free hotline, email and private chat counseling service, she’s provided educational talks regarding pregnancy health in community clinics and high schools over the past decade.

 

MotherToBaby CA is a service of the 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 beauty products, medications or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or visit MotherToBaby.org to browse a library of fact sheets and find your nearest affiliate.

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How to Soothe Common Pregnancy Discomforts: Heartburn

In this new series on Giving Birth with Confidence, we’re going to cover some of the most common discomforts that can happen during pregnancy and share tried-and-true ways to help soothe or eliminate them. Pregnancy can be an amazing time in a woman’s life, but it can also be challenging. The reality is that some women’s bodies accept and cope well with pregnancy and some don’t. In any case, having extra tools in your coping toolbox can go along way toward increasing your quality of life during the 4o-ish weeks of pregnancy.

Five Ways to Extinguish the Fire of Heartburn During Pregnancy

By Hillari Dowdle, freelance writer for FitPregnancy

It was heartburn that got me in the end. I could take the swelling, the back pain, the constant trips to the bathroom, the itchy skin, the fatigue, the sweating, the sleeplessness and even the psychological shock of seeing the scale tip 200 pounds. But the constant, searing pain of heartburn made the miracle of pregnancy seem more like a curse—by the middle of my third trimester, my mantra had changed from Please, let him be healthy! to Just get him OUT!

That fiery sensation known as heartburn happens when the lower esophageal sphincter (LES), a muscle responsible for keeping stomach contents in their place, begins to relax or leak. this allows stomach acids to flow upward into the esophagus, explains Suzanne Trupin, M.D., CEO of Women’s Health Practice of Champaign, Ill. Pregnant women are prime candidates for two reasons: First, the hormone relaxin—busy limbering up your joints and connective tissue for an easier birth—slows your digestion, meaning food stays in your stomach longer and triggers more acid production. Second, your growing baby exerts pressure on both the stomach and the LES, increasing the chance that acids will be pushed up into the esophagus.

So what’s an expectant mother to do? Follow these five tips to relieve the pain:

1. Eat less, more often
Overeating exacerbates heartburn, says rachel Brandeis, M.S., a registered dietitian in Atlanta who specializes in prenatal nutrition. “When you’re pregnant, there’s less room for your stomach to expand,” she explains. Maintaining a sensible diet will not only stave off heartburn in the short term, but throughout your pregnancy as well, because gaining more than the recommended weight puts more pressure on your abdomen, which can trigger the condition. Instead of three meals a day, aim for six mini-meals (See “Mini-Size Me” below) of no more than 1 1⁄2 cups of food each, Brandeis recommends. Smaller meals are easier for your body to digest.

2. Eliminate trigger foods
Identify the foods that intensify your heartburn and banish them from your diet. While there are no universally “banned” foods, common heartburn triggers include acidic foods, such as citrus fruits and tomatoes, greasy or fried foods, spicy foods, chocolate, coffee, carbonated beverages, and alcohol (which, as you well know, you should eliminate anyway!).

3. Focus on fluids
“Liquid-y foods are less likely to cause problems than solids, since they move through the stomach more quickly,” Brandeis says. Soups, smoothies, yogurt, milkshakes, protein shakes and puddings are good choices. Look for liquids that offer plenty of protein, such as milk and drinkable yogurt, and aim to make solids a little less so: “chew solid foods slowly and extremely well, until they’re almost liquefied,” Brandeis adds.

4. Sleep smart
To avoid nighttime heartburn, don’t eat anything for at least three hours before bedtime. Elevate the head of your bed by placing books under the legs, and if you’re not already sleeping on your left side, start now; stomach acids will have to travel uphill to reach the esophagus—no easy feat!

5. Time for Tums
It’s fine to find relief in a bottle of tums or rolaids or other calcium- containing antacids. However, “too much calcium can block iron absorption, so don’t take tums at the same time you take your prenatal vitamin,” Brandeis advises. By the time I gave birth, I estimate I’d ingested my own considerable body weight in tums. This overuse created calcium overload, which may have exacerbated my anemia. If you’re taking antacids 10 times a day (or more—as I was), talk to your doctor: she may want to check for ulcers or a hiatal hernia (where part of the stomach protrudes into the chest cavity), or prescribe medication.

Also, avoid antacids that list aluminum (such as aluminum hydroxide or aluminum carbonate) as an ingredient; it can cause constipation and can even be toxic in large doses. Remedies containing aspirin (such as alka-seltzer) should also be avoided during pregnancy; look for salicylate or acetylsalicylic acid in ingredients lists. You don’t want an antacid containing sodium bicarbonate (baking soda) or sodium citrate, either. Both are high in sodium, which causes water retention.

Mini-Size Me

Here’s a sample of what a day’s worth of small, healthful meals looks like:

1 cup of oatmeal with milk and 1 apple

1 cup of yogurt with fruit

1 ⁄2 peanut butter and jelly sandwich and 1 cup of vegetable soup

1 handful of whole-grain crackers and 1 ounce of your favorite hard cheese

2 ounces of chicken, 1 ⁄2 cup of mashed sweet potatoes and 1⁄2 cup of cottage cheese with fruit

Find eight more small snacks that are easy to make, packed with pregnancy nutrients and delicious at fitpregnancy.com/snackideas.

 

Did you experience heartburn during pregnancy? What helped you get rid of it? Share in the comments — women want to know!

 

Reading Beyond the Headlines: A Closer Look at the Study on Antidepressants During Pregnancy

A recent study regarding the use of antidepressants has been gaining a lot of media attention. The actual study, The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has been described by media with a fair amount of fear-based headlines. Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRIs), is an important topic of research,  as care providers from many fields address the prevalence and negative effects of depression and other mood disorders in pregnancy.

 

Understandably, pregnant women and their families may be greatly alarmed by these dramatic press releases, and in some cases may consider suddenly discontinuing their medication, without realizing the significant risks that accompany suddenly stopping medication. What do the experts say?

 

I asked the study’s lead researcher, Alice Domar, MD what advice she would offer a pregnant woman who is currently on one of the SSRI medications listed in the study to do, and she kindly offered this response:

 

I would never recommend the sudden discontinuation of an SSRI during pregnancy. There are significant side effects associated with the abrupt cessation of antidepressants and we don’t know the impact on the developing fetus. The three main points we were trying to make with the paper were: 1) there are risks associated with taking SSRIs during pregnancy, 2) there are no clear benefits, and 3) each patient needs to have a discussion with her physician about her individual risk/benefit ratio.  There is a huge difference between a woman who is suicidal, who in all likelihood should remain on medication, versus women with mild or moderate symptoms who would benefit from a different approach, such as cognitive behavioral therapy, or physical exercise, both of which are very effective in the treatment of depressive symptoms.” –Alice Domar, MD (personal email communication, 11/2/12)

 

Another of the study’s researchers, Dr. Adam Urato, offered this follow-up:

“Your question is a good one (What would you advise a pregnant woman who is currently on one of the SSRI medications listed in the study to do?) and it is one I deal with several times each week as an Maternal-Fetal Medicine specialist.  I agree with Dr. Domar’s comments.  Sudden discontinuation of the SSRIs is not recommended.  They should be tapered for those who plan to discontinue them. The patient and their pregnancy health care provider (and their mental health provider) need to be aware of the scientific evidence regarding these drugs.  That evidence shows significant risk of pregnancy complications (like miscarriage and preterm birth) and no evidence of benefit for moms and babies.  In non-pregnant populations, alternatives like cognitive behavioral therapy and exercise appear to be as effective as the SSRI antidepressants and without the side effects and pregnancy risks.” (Personal email communication, 11/2/12)

 

Reaching out to experts in the field provided roundtable perspective. Christina Chambers, MPH, PhD, California Teratogen Information Specialist (CTIS) and director of the Pregnancy Health Information Line, had these thoughts:

“I agree with the authors’ comments. Caution is warranted, treatment makes sense when benefits are clear, and women with less severe illness might consider alternative approaches if they work, abrupt discontinuation without doctor’s advice is not a good idea, and care needs to be taken to address the issue of complications for mother and baby of untreated or poorly treated maternal depression. If a woman has questions, she should consult her doctor. She can also call the Organization of Teratology Information Specialists (OTIS) at 866-626-6847 to speak to an expert in this field.” (Personal email communication, 11/2/12)

 

Lucy Puryear, MD, immediate past president of Postpartum Support International (PSI) and Medical Director of The Women’s Place: Center for Reproductive Psychiatry offered:

“For women with mild to moderate depression psychotherapy and alternative treatments are absolutely the first choice. But for women with moderate to severe depression that is impairing functioning, antidepressants must be an option. Antidepressants do work in this population and save lives. Our challenge is to continue to look for the safest and most effective treatments for women during this vulnerable period.” (Personal email communication, 11/2/12)

 

PSI’s Executive Director Wendy N. Davis, PhD, agreed,

“We are most concerned that women will be unduly frightened by articles that discuss risks of antidepressants but do not discuss positive experiences or research studies that show little statistical relationship between SSRI use and pregnancy outcome. We want to connect women with reliable resources and experts in perinatal psychiatry so they can make thoughtful decisions about treatment options for depression and anxiety during pregnancy.”

 

A word about the science….

One of the pre-eminent researchers in the field, Adrienne Einarson of The Motherisk Program, shared some important criticisms of this study:

Here are my main problems with this publication:

1) It is said to be a review on treatment for infertility patients, however, one-third of the paper is about the lack of efficacy of antidepressants in general.
2) To say there is no evidence for effectiveness in pregnancy is true, but that is simply because there are no RCTs (randomized control studies), not because this has been proven.
3) All of the studies that were picked were ones that found negative effects, with no mention of how marginal the statistical significance really was.
4) The paragraph that is the most concerning is the one starting with “There is compelling evidence that SSRI use prior to and during pregnancy can pose significant risks to the pregnancy and to the short- and long-term health of the baby…” Of course there is compelling evidence when you choose your studies to fit your hypothesis.

This was a biased review, not a systematic one as reviews should be. In fact, there was not a single study referenced in this paper that did not find any harmful effects when there are many that have been published. (Personal email communication, 11/4/12)

 

When I was pregnant with my daughter, I had a sinus infection. I went to a general practitioner for treatment and shared that I was on an SSRI. You would have thought I told her I was shooting heroine every hour on the hour while tossing back jello shots and chain smoking! If I hadn’t had the science from my research treatment team at the UCLA Women’s Life Center, I could have easily been scared into stopping my medication. Instead I pulled out a collection of evidence-based research I carried in my purse and left it with her.

 

Unfortunately, for a woman who is pregnant and has depression, trying to decipher headlines and the seemingly constant stream of warnings might be overwhelming. Not to mention the stigma that accompanies depression and motherhood. Most don’t realize that to be that mom means you have to be constantly armed with proof that you are not harming your child. This is where having Adrienne Einarson’s insights can help you navigate the science, and advocate for your health and well-being.

 

Take Home Message:

If you are currently pregnant and taking an SSRI, do not abruptly stop taking your medication until you talk health care provider about risks and benefits for your individual care. If you feel you may be experiencing depression or anxiety and are pregnant, you deserve help with your symptoms. Not getting help has been proven to have negative effects on a developing fetus and increases the risk of pre-term birth, lower birth weight, and postpartum depression. Discuss your symptoms with your care provider immediately. I highly recommend using the resources available at OTIS (866) 626-6847 to address your concerns and questions.

 

____________________

Walker would like to thank Alice Domar MD; Adam Urato, MD; Christina Chamber, PhD, MPH; Lucy Puryear, MD; Wendy Davis, PhD; and Adrienne Einarson for their contributions.

 

Reference

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

 

Other Resources:

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

In the News: Asthma Medication During Pregnancy

According to a new study from the Netherlands reported by Reuters Health, more than one-third of pregnant women on asthma medications stop taking them during the first few months of pregnancy. These findings are alarming because asthma, when untreated and uncontrolled, can have negative affects on a developing fetus. Last year, we provided a blog post discussing the importance of keeping asthma controlled during pregnancy:

“It is important for pregnant women to remember that they are their babies’only source of oxygen. If a mom’s asthma is not controlled, both she and her baby are getting less oxygen. Although babies do not take their first breath until they are born, in utero they receive all their oxygen from the placenta (the blood connection between mom and baby). …untreated asthma is considered to be riskier than asthma controlled with medications in pregnancy.”

Regarding the safety of asthma medication, Reuters reports:

“Both the Global Initiative for Asthma (GINA) and the U.S. National Asthma Education and Prevention Program recommend that women continue taking asthma medications throughout pregnancy, because the risks of exacerbated asthma are greater than the risks of the medication.”

Further, GINA advises “there is not much evidence showing that asthma medications are harmful to the fetus.” In the article on our blog, OTIS teratogen information specialist Nadia Mohamedi talks about the low risks from certain asthma medications:

“The majority of women can control their asthma by taking an inhaled medication like albuterol or an inhaled corticosteroid. Inhaled medications act directly on the air passageways to decrease inflammation and open them up for breath. Because inhaled medications are not meant to be absorbed and distributed throughout the body like a pill you swallow is, very little of inhaled medications are absorbed into your blood and able to go to your developing baby. Thus, inhaled medications are usually considered to be of a low risk to the baby.”

Have you/are you experiencing pregnancy with asthma? Chime in — let us know your thoughts on the study and how your experience has been.

Breakouts and Babies: How Acne Medications Can Affect Pregnancy

By Chris Colón, MS, OTIS Education Committee Member

 

As many women can tell you, pregnancy brings a lot of changes: not only in your life, but in your body. Women can experience morning sickness, swelling in the hands and feet, and (of course) weight gain. Because of the changes in hormones, women can also notice a difference in their skin, from the “pregnancy glow” to acne breakouts. Typically, women would use whatever treatment works best for them to fight acne. But in pregnancy, everything a woman does can affect her baby, so it’s important to know what medications are safe to use during this special time.  Listed below are some common medications used to treat acne and the possible effects to pregnancy:

 

Isotretinoin (Accutane, Amnesteem®, Claravis, and Sotret) is taken by mouth to treat very serious cases of acne, and is usually only prescribed when other treatments have not worked. Isotretinoin is an artificial form of Vitamin A that is only available by prescription.  Studies have shown that taking even one pill of isotretinoin during pregnancy can cause birth defects in up to 35% of exposed pregnancies. Because this is considered to be a high risk, isotretinoin must be taken under the careful supervision of a doctor.

 

Women of reproductive age that decide to take isotretinoin are enrolled by their doctor into the iPLEDGE* program, which includes counseling about the risks associated with the drug in an unintended pregnancy. Women at risk for pregnancy must use two forms of effective birth control prior to starting the drug. Pregnancy tests are also done prior to taking isotretinoin. Women who are not considered at risk for pregnancy are not required to use birth control while taking isotretinoin. These include:

 

  • Those who have stopped having periods for 12 months in a row (menopause; confirmed by a doctor)
  • Those who have had both ovaries or uterus taken out by surgery
  • Those whose ovaries do not work and cannot get pregnant (confirmed by a doctor)
  • Those who commit to not having any sexual contact with a male at any time for
    at least 1 month before, during, and 1 month after the last dose

 

If a woman gets pregnant while taking isotretinoin, she should stop taking the medicine immediately and call her doctor right away. In general, it is recommended that women of child-bearing age avoid isotretinoin and other Vitamin A-based medicines, such as Acitretin (sold as Soriatane) and high dose Vitamin A (more than 20,000 IU per day).**

 

Tretinoin (Atralin, Avita, Retin-A, Renova, Tretin-X) is acne treatment called a retinoid, and is related to Vitamin A. It is a topical medication (applied to the skin) and is available by prescription. Although tretinoin is related to Vitamin A (like isotretinoin), it is not thought to be as harmful to pregnancy. Tretinoin contains a much lower dose of the active medication, which means that when applied to the skin, the amount absorbed through the skin would be very small. One expert suggested that the amount that is absorbed is equivalent to 1/7 of the Vitamin A found in one prenatal vitamin. This means that less tretinoin makes it into the mother’s blood and to the baby. If more tretinoin is used, the risk may theoretically be increased, so it is important to use this medication as directed. Because acne is considered to be a cosmetic problem, and due to the possible risks, it is usually recommended not to use this medication during pregnancy.

 

Tetracycline, doxycycline and minocycline are antibiotics used to treat acne and other conditions. These antibiotics are available by prescription and usually taken by mouth. Studies have not found an increased risk for birth defects when these antibiotics are used in the first trimester. However, use after 16 weeks is associated with discoloring of the teeth (permanent) and may temporarily slow down the growth of small bones.

 

So how are breakouts safely treated during pregnancy? Over-the-counter medications that contain benzoyl peroxide are considered safe for pregnant women to use. Skin treatments that contain salicylic acids, azelaic acids, and glycolic acids are thought to be unlikely to cause any risk to a pregnancy, because they are absorbed in small amounts through the skin. Before taking ANY medications or treatments during pregnancy, it is important to talk to a health care provider first.

 

Even women not planning on becoming pregnant aren’t out of the woods yet – almost half (about 50%) of all pregnancies are unplanned. Women who are sexually active should consider talking to their doctor about the effects medications can have on a pregnancy (planned or unplanned).

 

Have questions about exposures before, during, or after pregnancy? Contact the Organization of Teratology Information Specialists (OTIS) at 866-626-6847 or visit our website at otispregnancy.org.

 

*For more information on the iPLEDGE Program, visit www.ipledgeprogram.com

 

**Isotretinoin (Accutane) and Pregnancy. Retrieved from http://www.otispregnancy.org/files/isotretinoin.pdf

 

Chris Colón, MS, is a genetic counselor and a member of the OTIS Education Committee. OTIS is a North American non-profit dedicated to providing accurate evidence-based information about exposures during pregnancy and breastfeeding.

 

Skincare Products & Mercury: Understanding Labels to Protect Your Baby

By Sonia Alvarado, CTIS Pregnancy Health Information Line Counselor

What do you know about the safety of the cosmetics you use on your face and body every day? I’m not talking just about foundation and lipstick, but face cream, body lotion, stretch mark cream, skin lighteners, shampoo, and conditioner? Do you read — or understand – the labels on all of the products that you buy? What about the skincare products that you get as gifts?

 

On March 6, the FDA issued a press release alerting consumers and retailers about mercury poisoning/toxicity in women and in some cases, the entire family, as a result of exposure through skin lightening creams that were sold in the U.S. but manufactured outside of the country. A search of the medical literature found reports of mercury toxicity related to creams/lotions manufactured in Mexico and China, although the FDA site reports that these products have also been sold illegally in the United States in shops found in Latino, Asian, African or Middle Eastern neighborhoods. Online shops have no borders, so the possibility of purchasing a tainted product may be higher.

 

Mercury is divided into three types – elemental, inorganic, and organic. Organic is the kind that you find polluting streams and fish (methyl mercury).

 

Inorganic mercury is the type found primarily in batteries. It’s also been reported in some disinfectants, health/homeopathic remedies, and skin and acne creams and lighteners (illegally). Inorganic mercury can be labeled as mercuric chloride, mercuric acetate, and mercuric sulfide. In the case of lotions containing inorganic mercury, not only is the user exposed, but the entire household may be at risk as the lotion is exposed to air, becomes a vapor, and members inhale or ingest it.

 

Exposure to inorganic and organic mercury is a concern for the entire family, including pregnant women. It’s important to understand, however, that each type of mercury has potential risks depending on the route of exposure and the dose. Some forms are more readily available (absorbed into the body) if inhaled and some more available in the body if ingested.

 

Mercury crosses the placenta. High levels in the mom would be expected to produce high levels in the developing embryo or fetus. High levels of exposure in pregnancy have been associated with miscarriage. Studies of high levels of methyl mercury exposure (the kind typically found in fish) have been associated with neurologic disorders in the exposed infants/children (see http://www.otispregnancy.org/files/methylmercury.pdf). Studies of methyl mercury in pregnancy or children are more common than studies of inorganic mercury related to exposure from cosmetics or imported homeopathic remedies, which leaves a gap in our awareness and ability to treat individuals who have been exposed. This also means that it is difficult to know the levels that may be more or less harmful to the developing pregnancy.

 

Symptoms of mercury toxicity in the early stages include nausea, vomiting, and diarrhea. Symptoms of high acute exposure or chronic long-term exposure include kidney problems, gastroenteritis, metallic taste in the mouth, hypotension and shock, rashes, and excessive sweating, as well as others.

 

The FDA advisory reminds us of the importance of reading labels and understanding the potential risks with using hygiene products or cosmetics products (or supplements, herbal remedies, etc.) that are foreign-made. Per the FDA:

  • Check the label of any skin lightening, anti-aging or other skin product you use. If you see the words “mercurous chloride,” “calomel,” “mercuric,” “mercurio,” or “mercury,” stop using the product immediately.
  • If there is no label or no ingredients are listed, do not use the product. Federal law requires that ingredients be listed on the label of any cosmetic or drug.
  • Don’t use products labeled in languages other than English unless English labeling is also provided.
  • If you suspect you have been using a product with mercury, stop using it immediately. Thoroughly wash your hands and any other parts of your body that have come in contact with the product. Contact your health care professional or a medical care clinic for advice.
  • If you have questions, call your health care professional or the Poison Center at 1-800-222-1222; it is open 24 hours a day.
  • Before throwing out a product that may contain mercury, seal it in a plastic bag or leak-proof container. Check with your local environmental, health or solid waste agency for disposal instructions. Some communities have special collections or other options for disposing of household hazardous waste.

Cosmetic products in the U.S.are, unfortunately, not regulated by the FDA. Furthermore, while companies are required to properly label products, the FDA does not pre-approve cosmetic product labeling either. It is illegal to sell misbranded cosmetics in the U.S., but, again, the FDA does not regulate or approve “cosmetic” products.

 

Cosmetics are commonly used during pregnancy and typically a low concern to the pregnancy due to expected low absorption into the bloodstream and therefore low exposure to the pregnancy but it can’t hurt to be cautious and take a second look at the products we are using especially in light of this recent FDA warning.

For more detailed information on cosmetics, please visit the FDA website: http://www.fda.gov/Cosmetics/default.htm

References:

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm294849.htm

http://www.epa.gov/teach/chem_summ/mercury_inorg_summary.pdf

Mercury exposure among household users and nonusers of skin-lightening creams produced in Mexico – California and Virginia, 2010.

Centers for Disease Control and Prevention (CDC).

MMWR Morb Mortal Wkly Rep. 2012 Jan 20;61(2):33-6.

Sonia Alvarado is a bilingual (Spanish/English) Teratogen Information Specialist with the California Teratogen Information Service (CTIS) Pregnancy Health Information Line, a statewide service that aims to educate women about exposures during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/lactation via CTIS’ toll-free hotline and email service, she’s provided educational talks regarding pregnancy health in community clinics and high schools over the past decade. In addition, Sonia contributes to the service’s website, develops training materials for new CTIS staff, and is the supervising Teratogen Information Specialist trainer. Sonia attended San Diego State University and has worked in Tuberculosis Control for San Diego County’s Public Health Department. Sonia’s work has also been published through several tuberculosis studies. In her spare time, she loves to volunteer with the March of Dimes as an expert speaker on themes related to pregnancy.

 

CTIS Pregnancy Health Information Line is part of the Organization of Teratology Information Specialists (OTIS), a non-profit with affiliates across North America. California women with questions or concerns about pregnancy exposures can be directed to (800) 532-3749 or by visiting CTISPregnancy.org. Outside of California, please call OTIS counselors at (866) 626-OTIS (6847).