The older you get, the more likely you are to develop various medical conditions—some serious, most not so serious. Medications used to treat those conditions may affect your baby during your pregnancy. We discuss some of those conditions and their treatments in this chapter.
You should be careful with every medication you take during pregnancy. Many people believe if they can buy something without a prescription, it must be safe to use. Or they believe they can use any amount of vitamins, minerals or herbal substances without hesitation.
Beware of this type of thinking! Many substances you use can affect your growing baby. Some effects can be serious. Other effects may be subtle and cause minor birth defects. The effects of others may not be evident for years.
Researchers once believed the placenta acted as a barrier to any agent the mother was exposed to. We now know that isn’t the case. We have discovered most drugs can cross the placenta and could affect the fetus.
Some medications can affect fetal development; they are called teratogens. The study of abnormal fetal development caused by teratogens is called teratology. When a birth defect occurs, we want to know why it happened. This can be frustrating because in many instances we are unable to determine a cause.
The first 13 weeks of development (the first trimester) are the most critical time for a fetus exposed to teratogens. If an embryo is exposed during the first 2 weeks of development, the pregnancy might end in miscarriage. The most critical period of fetal development during the first trimester is between weeks 2 and 8.
The FDA is updating labels on prescription medication to include a fetal-risk summary. This will provide an indication of the possible drug effects on a developing baby. It is also updating labels to include information on the amount of a medication that may be present in breast milk. Included will be information on milk production and ways to reduce exposure for an infant.
Although the first trimester is very important, your baby’s systems continue to grow and to develop throughout your pregnancy. Exposure to some substances can harm a baby even after the first trimester.
The best time to discuss current health concerns is before you become pregnant, but this isn’t always possible. If you discover you’re pregnant and are concerned about the medications you use, talk to your healthcare provider about it as soon as possible.
At your first prenatal visit, discuss all prescription and over-the-counter medicines, herbs, vitamins and minerals you take on a regular basis. You may have to stop taking a particular substance or adjust the dosage.
Never stop taking any medication you use for a chronic health problem without first consulting your healthcare provider! Some medication cannot and should not be stopped during pregnancy.
You’re an important part of your healthcare team, especially during pregnancy. You have to make many decisions about how you will take care of your body during this important time. The suggestions below can help you decide what substances you can use before and during pregnancy.
•Don’t use any unnecessary drugs while trying to conceive.
•Avoid all medications during the first trimester, if possible. If you must take a medication, consult your healthcare provider.
•Talk to your healthcare provider openly and honestly about medications you use. If you have a problem you normally treat with over-the-counter drugs, ask how to treat it during pregnancy.
•If you must use a prescription medication, ask your healthcare provider to prescribe it in its least potent strength.
You may be wondering about taking some medications you may have normally taken before pregnancy. See the chart on the opposite page that addresses different categories of medications. The medications listed on page 222 are considered category-C medications and are believed to be safe to use during pregnancy.
Medication Classification for Pregnancy
Medications a pregnant woman might use have been categorized by the Food and Drug Administration (FDA) to indicate the risk to the fetus if a mother-to-be takes them. If you have questions about any medications you take, ask your healthcare provider which category it fits into.
Category A—Adequate, well-controlled studies in pregnant women have not shown any risk to the fetus. Few medications have been tested to this level. A prenatal vitamin is considered a Category-A medication.
Category B—Animal studies indicate risk to a fetus is probably low, but human studies have not been done. Examples include some antibiotics, such as cefaclor.
Category C—There have been no adequate, well-controlled studies in animals or humans, but it is believed the medication is safe to use during pregnancy. An example is codeine.
Category D—Studies using animals have shown a harmful effect on the fetus, or studies have not been done in humans or animals. There is evidence of risk to the fetus, but it is believed benefits outweigh the risks. One example is phenobarbital.
Category X—There is evidence the medication causes birth defects. Risks outweigh any potential benefits for women. Accutane is a Category X-medication.
Some prescription medications are more common than others; the discussion below includes common substances many women must take during pregnancy. Please note: This information does not take the place of talking with your healthcare provider.
If you use allergy medication, don’t assume it’s safe to take during pregnancy. Some types of allergy medication may not be advised, such as avoiding Sudafed during the first trimester. Many are combinations of several medicines you should be careful about using during pregnancy. Ask your doctor about your medicine, whether prescription or nonprescription, including nasal sprays.
Medications that are OK to use during pregnancy include antihistamines and decongestants. Claritin and Zyrtec are believed to be safe during pregnancy. Ask your doctor which brands are safest for you to use if your allergy problems interfere with your normal lifestyle. Under your doctor’s supervision, you can continue taking allergy shots, but don’t start them during pregnancy.
My healthcare provider has prescribed some medications that I take regularly. I’m not sure if I can take them during pregnancy. Should I stop taking them now or wait to talk about it at my first prenatal visit next week?
Call your healthcare provider’s office and talk to the nurse. Some medications, such as thyroid medicine, are very important during pregnancy. Stopping them could cause problems.
If you’re being treated for depression when you become pregnant, it’s important to continue treatment. Treating depression during pregnancy is as important as treating any other problem.
If you take antidepressants, don’t stop unless advised to do so by your healthcare provider. There is a higher risk in abruptly stopping antidepressants. In addition, studies show that up to 70% of women who take antidepressants during pregnancy relapse into depression if they stop their medication.
Depression can be difficult to manage without using drug therapy. Medication you take is probably necessary for your good health and the good health of your baby. Left untreated, depression can contribute to premature birth, IUGR, low birthweight, stillbirth and low Apgar scores in baby after birth.
Stopping your medication can raise your stress hormones, which increases your risks of complications and problems. The risks to you and your baby may be greater than your risk of taking antidepressants.
There may be a very small increased risk of birth defects with some medications taken during the first trimester. You may benefit by switching to an antidepressant that has been shown to be relatively safe during pregnancy, including fluoxetine (Prozac), citalopram and escitalopram (Lexapro). Pregnancy may affect your body’s ability to metabolize lithium. Talk to your healthcare provider as soon as you confirm your pregnancy.
If you take an SSRI, your dose may need to be increased during the third trimester to maintain your normal mood. There may be a small increased risk of persistent pulmonary hypertension in babies born to women who take SSRI antidepressants after 20 weeks of pregnancy.
There is continued concern about the safety of Paxil during pregnancy. Research suggests exposure to the drug in the first trimester of pregnancy may be associated with an increased risk of heart birth defects. If you’re pregnant, do not stop taking your antidepressant medication without first consulting your healthcare provider.
Today, the average age of menopause is 51. At menopause, you stop ovulating (necessary for conception) and stop having periods. The change is usually gradual, occurring over years, but it may be sudden. If you still have menstrual periods, you can probably still get pregnant.
In the past, women didn’t start taking hormones (hormone-replacement therapy or HRT) until their periods stopped and they were certain of menopause. Today, more women start HRT at younger ages.
If you become pregnant while taking HRT, tell your healthcare provider immediately. There are minor risks associated with pregnancy if you have been taking female hormones.
Incontinence may be more of a problem for women over 35. Do you take medicine to treat an overactive bladder?
The problem of overactive bladder occurs when the brain tells nerves in the bladder there’s a need to urinate even if the bladder isn’t full. Symptoms include going to the bathroom more than 12 times a day, getting up two or more times at night and a sudden, immediate need to go. You may also leak urine.
Medicines to treat the problem work by relaxing muscles. Some commonly prescribed medications include Ditropan, Detrol LA, Sanctura and Enablex. If you take any of these medications, you need to talk to your healthcare provider before pregnancy or as soon as you find out you’re pregnant. He or she can advise you about continued use of your medicine during pregnancy.
You need to continue taking thyroid medication throughout pregnancy. Thyroid hormone is made in the thyroid gland, which is found in the neck. It affects your entire body and is important to your metabolism. Thyroid hormone can affect your ability to get pregnant.
Thyroxin (medication for a low-thyroid or hypothyroid condition) can be taken safely during pregnancy. Propylthiouracil (medication for a high-thyroid or hyperthyroid condition) passes to the baby; you will probably be given the lowest amount possible during pregnancy.
Accutane (isotretinoin) is a common acne treatment. Do not take it if you are pregnant! A woman taking Accutane during the first trimester of pregnancy is at greater risk of miscarriage and birth defects in baby.
Retin-A (tretinoin) is a medication used to relieve minor wrinkling in the facial area. We don’t know its effects on the fetus, so it’s probably best to avoid Retin-A during pregnancy.
Occasionally steroid cream is prescribed for a skin condition. Before using it during pregnancy, discuss it with your healthcare provider. You may be able to use a safer preparation.
Tetracycline, an antibiotic, is often prescribed for skin problems. During pregnancy, avoid all tetracycline! Use of the drug during pregnancy can cause discoloration of your baby’s permanent teeth later in life (one of the reasons tetracyclines should not be prescribed for children under age 8).
Some medications, such as Valium, Librium and Tranxene, are safe to use during pregnancy but should be prescribed only if absolutely necessary. As with any substance, don’t take anything without consulting your healthcare provider.
If you have a headache bad enough to be considered a migraine, call your healthcare provider before you take anything for it. Before pregnancy, you may have been taking Imitrex for migraines; it is given by injection or in pill form. Avoid it during pregnancy; we do not know yet whether it is safe.
Common medications used for blood clots or phlebitis, called anticoagulants, are heparin and Coumadin. Heparin doesn’t cross the placenta, so it is safe to use during pregnancy. It’s administered by injection or I.V. Don’t use Coumadin during pregnancy because it may cause significant problems in the fetus or newborn.
Before you take a medication for a common malady, such as a headache or indigestion, try a nonmedication approach. For example, you might treat a headache with a cold compress or by resting in a dark room. Prevent indigestion by avoiding foods that trigger it, eating smaller meals and eating slowly.
Many asthma medications are OK to use during pregnancy. Inhalers, such as Proventil, are safe. For an asthma attack, your healthcare provider may prescribe prednisone; it is approved for use during pregnancy. Primatene Mist is not recommended.
Medicines to treat anemia can be important during pregnancy and are safe to use. These medications contain iron, which may cause side effects such as constipation, nausea or upset stomach.
Pregnancy is not the time to use any type of diet pill. Avoid prescription diet pills during pregnancy because they have not been proved safe. If you’re taking diet pills when you find out you’re pregnant, stop taking them immediately!
Many people, not just pregnant women, hold the false belief that medications they can buy without a prescription (over-the-counter medicine) are harmless. Nothing could be further from the truth. Carelessness with over-the-counter preparations could harm you and your developing baby.
Use caution when you take any over-the-counter (OTC) medication during pregnancy. Many OTCs contain aspirin, caffeine, alcohol or phenacetin, all of which should be avoided during pregnancy. For example, some OTC antidiarrheal medications contain aspirin. Cough syrups may contain as much as 25% alcohol (that’s 50 proof!).
Use medications that contain ibuprofen with care; brand-name ibuprofen medications include Advil, Motrin and Rufen. Avoid Aleve (naprosyn) and Orudis (ketoprofen) until we know more about their safety during pregnancy. Read package labels, and talk with your healthcare provider or pharmacist before taking anything.
Medical experts believe category-C medications are safe to use during pregnancy. If you use any of these medications, check with your healthcare provider about continuing to use them. He or she will determine whether you should use the medication during pregnancy. Some Category-C medications you may use include acetaminophen, antacids, benzoyl peroxide, beta-adrenergic antagonists, cephalosporins, chlorpromazine, clindamycin, codeine (short term), corticosteroids, cotrimoxazole, cough lozenges, cromolyn, dextromethorphan, dimenhydrinate, diphenhydramine, doxylamine plus pyridoxine, erythromycin, fluoxetine, haloperidol, hydralazine, ipratropium, methyldopa, nitrofurantoin, penicillin, propylthiouracil. rantidine and tricyclic antidepressants.
Avoid cold remedies that contain iodine. It can cause serious thyroid problems in baby. If you regularly take Airborne to prevent colds when you aren’t pregnant, it may be a good idea to skip it during pregnancy. It hasn’t been tested on pregnant women. Be careful with antacids—they can interfere with iron absorption.
You may become constipated at some point during pregnancy and need a laxative. If you find a laxative is necessary for more than 2 or 3 days, contact your healthcare provider. He or she may advise you to make dietary changes to help with the problem.
Some medications for diarrhea are safe during pregnancy. Imodium is OK to use, but most healthcare providers recommend avoiding the pink bismuth-type preparations during pregnancy. If you have bloody diarrhea or diarrhea that lasts longer than a few days, contact your healthcare provider.
Don’t overuse any product during pregnancy. You can get too much of a good thing. Your healthcare provider will not be angry or upset if you call the office with a question about a medication. It’s much easier to answer a question and solve a potential problem about a medication before you take it.
Be cautious about taking vitamin and mineral supplements during pregnancy. Often people don’t think of vitamins and minerals as harmful, but they can be, especially to your developing baby. Use only those vitamins and minerals your healthcare provider recommends you use or prescribes for you.
Safe Over-the-Counter Medications
Some OTC medications considered fairly safe to use while you’re pregnant include:
•acetaminophen (Tylenol)
•antacids (Amphojel, Gelusil, Maalox, milk of magnesia)
•throat lozenges (Sucrets)
•decongestants (chlorpheniramine, Sudafed)
•antidiarrheal preparations (Kaopectate)
•anti-itch preparations (Benadryl)
•some cough medicines (Robitussin)
•hemorrhoid preparations (Anusol, Preparation H)
Many vitamin supplements and “megavitamins” sold in health-food stores contain very high amounts of minerals, vitamins and other substances. Even some foods contain extra vitamins and minerals. Some of these supplements could adversely affect your developing baby.
Avoid any vitamins or minerals other than your prenatal vitamin and iron and/or folic-acid supplements unless prescribed by your healthcare provider specifically for you. Read labels on various foods you eat. Don’t self-medicate with other vitamins or minerals—you don’t need them, and they can be dangerous if taken in excessive amounts.
Prenatal vitamins contain the recommended daily amounts of vitamins and minerals you need during pregnancy. They are prescribed to ensure your health and your baby’s health.
At your first prenatal visit, your healthcare provider will probably give you a prescription for prenatal vitamins. It’s very important for you to take these vitamins for your entire pregnancy.
Each vitamin contains many essential ingredients for the development of your baby and your continued good health, which is why we want you to take them every day until your baby is born. A typical prenatal vitamin contains the following:
•calcium to build baby’s teeth and bones and to help strengthen yours
•copper to help prevent anemia and to aid in bone formation
•folic acid to reduce the risk of neural-tube defects and to aid red blood cell production
•iodine to help control metabolism
•iron to prevent anemia and to help baby’s blood development
•vitamins A, B1 and E for general health
•vitamins B2, B3, B6 for metabolism
•vitamin B12 to promote formation of blood
•vitamin C to aid in your body’s absorption of iron
•vitamin D to strengthen baby’s bones and teeth, and to help your body use phosphorus and calcium
•zinc to help balance fluids in your body and to aid nerve and muscle function
It’s important to know how to take your medicine to get the greatest benefits. Read the label before you take it. Should you take it with food? Before food? After food? No food? A certain number of hours before or after food? When you get up? Before you go to bed? Should you drink extra liquids, avoid milk products or take it in some other special way? Knowing when you should and shouldn’t mix a medication with a food or beverage can increase the benefits of the medicine. Some combinations can be dangerous. Always read directions for taking a medication. If you have questions, discuss them with your pharmacist or healthcare provider.
Sometimes, late in pregnancy, a woman stops taking her prenatal vitamins; she gets tired of taking them or she decides they aren’t necessary. Studies show nearly half of all pregnant women who are prescribed prenatal vitamins don’t take them regularly. The vitamins and iron in prenatal vitamins are essential to the well-being of your baby, so take your prenatal vitamins every day until your baby is born.
Immunizations and vaccinations protect you from diseases. A vaccine is given to provide you with protection against infection and is usually given by injection or taken orally. Each dose of a vaccine contains a very small amount of a weak-ened form of the disease. When you receive a vaccine, your immune system forms antibodies to fight the disease in the future. In most cases, this is enough to keep you from getting a disease. However, in some cases, it doesn’t prevent the disease entirely but greatly reduces severity of the symptoms.
Vaccines come in three forms—live virus, killed (dead) virus and toxoids (chemically altered proteins from bacteria that are harmless). Most vaccines are made from killed viruses; it’s impossible to get the disease after receiving this type of vaccine. With a live-virus vaccine, the virus is so weakened that if your immune system is normal, you probably won’t get sick from it.
Many women of childbearing age in the United States and Canada have been immunized against measles, mumps, rubella, tetanus and diphtheria. A blood test for measles is necessary to determine immunity. The diagnosis of rubella is difficult without a blood test. Physician-diagnosed mumps or a mumps vaccination is necessary evidence of immunity.
During pregnancy, try to decrease your chance of exposure to disease and illness. Avoid visiting areas known to have diseases. Avoid people (usually children) with known illnesses. It’s impossible to avoid all exposure. If you have been exposed, or if exposure is unavoidable, the risk of the disease must be balanced against the potential harmful effects of vaccination.
Can I get a flu shot while I’m pregnant?
Yes, you can. In fact, most healthcare providers recommend a pregnant woman receive a flu shot while she’s pregnant.
A vaccine must be evaluated in terms of its effectiveness and potential for complicating pregnancy. There is little information available on harmful effects on the developing fetus from vaccines. However, we know live-measles vaccine should never be given to a pregnant woman.
The only immunizing agents recommended for use during pregnancy are the Tdap vaccine and the flu vaccine. The Tdap vaccine (tetanus, diphtheria and pertussis) can help you avoid whooping cough. Be sure to get a Tdap booster if it’s been 10 years or more since your last one. In addition, if you work in the garden, with your hands in dirt, you need a booster.
Get a flu shot during pregnancy. If you get the flu during pregnancy, you have a greater chance of complications, such as pneumonia. Experts recommend all women who will be pregnant during flu season get a flu shot. A flu shot can protect you against three strains of influenza. Flu shots can be given safely during all three trimesters. Talk to your healthcare provider about it.
As many as 35% of all pregnant women are at risk of contracting measles, mumps or rubella because they haven’t been vaccinated or they have been vaccinated but their immunity has weakened. However, vaccination for measles, mumps and rubella (MMR) should be administered only when you are practicing birth control. You must continue to use contraception for at least 4 weeks after receiving this immunization.
A pregnant woman should receive primary vaccination against polio only if her risk of exposure to the disease is high. Only inactivated polio vaccine should be used.
If your healthcare provider believes you may be at risk for contracting hepatitis B, it’s safe to take the vaccine during pregnancy. Talk with your healthcare provider if you have concerns.
If you have lung problems, asthma or heart problems, you may want to talk to your healthcare provider about the pneumococcal vaccine to protect you against bacteria that can cause pneumonia, meningitis and ear infections. A plus to taking this vaccine: One study showed antibodies you make after taking the vaccine pass to your baby and can protect him or her from ear infections for up to 6 months!
Pregnancy is a happy time for most women. Occasionally, however, serious problems can occur. Cancer during pregnancy is one serious complication that occurs rarely.
This discussion is included not to scare you but to provide you with information. It may not be a pleasant subject to discuss, especially at this time. However, every woman should have this information at hand. Because many women today wait until they are older to have babies, and cancer strikes more older women, it’s good to have information available so you can discuss the situation with your healthcare provider if you are concerned about it.
Cancer occurs in about one in every 1000 pregnancies. Pregnancy may make it more difficult to diagnose the problem. Tremendous changes affect your body during pregnancy. Some researchers believe cancers influenced by increased hormones may increase in frequency during pregnancy. Increased blood flow may add to the spread of cancer to other parts of the body. Body changes during pregnancy can make it difficult to find or to diagnose an early cancer.
When cancer occurs during pregnancy, it can be very stressful for you and your partner. The healthcare provider must consider how to treat the cancer, but he or she is also concerned about the developing baby. How these issues are handled depends on when cancer is discovered. You, your partner and your healthcare provider must consider many issues before deciding on a course of treatment.
•Must the pregnancy be terminated?
•Can the malignancy affect the developing baby?
•Can therapy be delayed until after the baby is developed or delivered?
•How do medications, chemotherapy or radiation used to treat the cancer affect the fetus?
Cancer during pregnancy must be treated on an individual basis. Anti-cancer drugs stop cell division to help fight the cancer. If taken during the first part of pregnancy, they can affect cell division of the embryo.
Before a woman is treated, a procedure using letrozole and gonadotropin may be used. A woman’s ovaries are stimulated to produce the maximum number of eggs. Eggs are then harvested before chemotherapy or radiation begins.
If you’re now pregnant and have had cancer in the past, tell your healthcare provider as soon as you find out you’re pregnant. He or she may need to make decisions about individualized care for you during pregnancy.
Breast cancer is the type of cancer discovered most often during pregnancy. It is uncommon in women younger than 35. Unfortunately, it may be harder to find breast cancer during pregnancy because of changes in the breasts, including tenderness, increased size and even lumpiness. About 2% of all women who have breast cancer are pregnant when it is diagnosed.
Breast cancer can be treated during pregnancy. Treatment varies, depending on the woman; surgery, chemotherapy, radiation or all three may be required. A physician will determine a course of treatment based on a woman’s particular needs.
Some studies indicate that pregnancy is safe in women with a history of breast cancer if the cancer has been successfully treated. Other studies indicate chemotherapy for breast cancer during pregnancy may also be safe.
A form of breast cancer you should be aware of is inflammatory breast cancer (IBC). Although rare, it can occur during and after pregnancy and may be mistaken for mastitis, which is inflammation of the breast. Symptoms of inflammatory breast cancer include swelling or pain in the breast, redness, nipple discharge and/or swollen lymph nodes above the collarbone or under the arm. You may feel a lump, although one is not always present.
If you experience any of these symptoms, do not panic! Nearly all of the time it will be a breast infection related to breastfeeding. However, if you’re concerned, contact your healthcare provider. A biopsy is used to diagnose the problem.
Quan-Li was a busy executive who never had time for breakfast. She might grab a diet cola and a bag of chips for lunch, and she often ate dinner out with clients. Her plan was to continue this regimen and take a prenatal vitamin during her pregnancy. We had a frank discussion about why her plan wouldn’t work. I explained how her baby relied on her for its nourishment. I advised her that she couldn’t eat that way for the entire pregnancy; she’d feel terrible and might not be able to continue working. With some help, Quan-Li made a commitment to follow a healthful eating plan and to take her prenatal vitamins every night after dinner.
Various cancers of the female organs, including the cervix, the uterus, the vagina, the ovaries, the bladder and the Fallopian tubes, have been reported during pregnancy. Let us reassure you—these cancers are very rare during pregnancy, no matter what your age.
Cervical cancer occurs only once in about 10,000 pregnancies. However, about 1% of the women who have cancer of the cervix are pregnant when the cancer is diagnosed. Cancer of the cervix is extremely curable, especially when discovered early. That’s one reason your Pap smear is important before and during pregnancy.
Bone tumors are rare during pregnancy. However, two types of noncancerous bone tumors can affect pregnancy and delivery. These tumors, endochondromas and benign exostosis, can involve the pelvis; tumors may interfere with labor. The possibility of having a Cesarean delivery is more likely with these tumors.
Other types of cancer, such as Hodgkin’s disease, leukemia or melanoma, are very serious complications of pregnancy. Cancers of the blood occur in one of every 6000 pregnancies. If you are diagnosed with any form of cancer, you and your healthcare provider will discuss ways to treat it.
Treating cancer during pregnancy can be difficult because of the effects various substances and procedures have on mother and fetus. Treatment can cause a variety of problems; a pregnant woman may also experience side effects.
Discuss any questions about cancer treatment during pregnancy with your healthcare provider. He or she can give you the best answers and help reassure you.
Connecting with other women and with couples who have experienced the same situation can be very helpful. One support group, Hope for Two, may be able to help you in many ways. Another group, Pregnant with Cancer, connects new cancer patients with survivors, which can provide you with a great deal of emotional and educational support. Their website is www.pregnantwithcancer.org.