How to make good choices for you and your baby.
When Lyle Kenny was pregnant with her second child, she suffered constant migraines. Her OB was sympathetic but said Kenny couldn't take the medication she usually took for relief. Visits to an acupuncturist, osteopath, and chiropractor made no difference. So she was sent to a neurologist who had no experience treating pregnant women. He said there was nothing he could do.
"I was incapacitated," says Kenny, 35, a mom of two boys in Brooklyn. "I couldn't take care of my son. I couldn't function, and I felt like nobody was dealing with it." After Kenny ended up in the ER three times, her OB finally let her take the painkiller Percocet, which brought a little relief. For the rest of her pregnancy Kenny reached for the bottle when she "absolutely had to," but was "really freaked out about what was going to happen to the baby."
She is far from alone.
"The decision of whether or not to use medications affects pretty much every pregnant patient, whether it's Tylenol for a headache or medication for a more serious condition such as a seizure disorder," says Chad Klauser, M.D., assistant clinical professor of obstetrics and gynecology at the Mt. Sinai School of Medicine in Manhattan.
According to the Centers for Disease Control and Prevention (CDC), 90 percent of women take medication at some point in their pregnancy and 70 percent take prescription medication. And yet women facing these decisions are often given conflicting information on medication safety from their primary care providers, their OBs, and the Internet.
That kind of ambiguity makes the decision to take medication in pregnancy very scary. I should know. I developed unexplained pain around my heart one week into my first pregnancy. For five months it was misdiagnosed as various things, including heartburn, and I took several medications to alleviate it, worrying what the effect on my child would be. Nothing worked. The pain became so bad that I ended up in the ER twice and was finally hospitalized. Along the way, I was subjected to X-rays, CT scans, and nuclear radiation -- all the things the books tell you to stay away from during pregnancy.
When the problem was finally diagnosed as benign inflammation in the sac around my heart, I had to manage it with ibuprofen and then steroids for the remainder of my pregnancy. I felt incredibly scared and guilty for doing so. I was worried that the radiation I had been exposed to had harmed my developing baby, and that the steroids I was taking would damage her immune system. I had to undergo monthly ultrasounds to make sure my daughter was growing properly and that my amniotic fluid levels were adequate (both of these can be affected by steroid use in pregnancy).
My daughter was born healthy, but the stress of worrying about her safety and my health hit me like a ton of bricks six months after delivery. I developed debilitating postpartum anxiety and eventually needed medication to control it.
Kenny, too, lived through her pregnancy in fear. Because of the medications she took and the inconsistent information she was given, Kenny says she was "scared to death there would be something wrong with the baby. It was bad," she says. "I don't think I will ever get pregnant again."
Why doctors can be confused
Medicating pregnant women can be more art than science. Drug companies rarely test pharmaceuticals on pregnant women in the controlled clinical trials that doctors depend upon when making treatment choices. To help physicians advise their patients on taking medications during pregnancy, the Food and Drug Administration (FDA) devised a rating system in the 1970s to indicate the likelihood of a medication causing harm to a developing baby. Drugs receive a rating of A, B, C, D, or X, depending on whether they have been studied in pregnancy and whether laboratory or animal studies indicate there could be a risk. An A rating is generally considered safest and X very dangerous. But the majority of medications are categorized as category C, which means there is a lack of adequate scientific data in humans to indicate whether they could cause harm.
"The category system looks very simple," says Sandra Kweder, M.D., deputy director of the office of new drugs at the FDA Center for Drug Evaluation and Research. "Unfortunately, the reality of prescribing in pregnancy doesn't come down to being quite so simple. As someone who has taken care of a lot of pregnant women, [I can say] it is not a smart thing to just rely on that," Dr. Kweder says. The FDA is in the process of changing drug pregnancy labeling, but the new system will take several more years to implement and women are looking for answers now.
Unfortunately, many of them turn to an unreliable source: the Internet. A recent CDC survey of 25 websites that offered lists of "safe medications in pregnancy" found significant inconsistencies between them. Twenty-two medications deemed safe by one site were considered unsafe by one or more of the others. Only three sites listed the references they used to make their determinations, and only half recommended making the decision with a health-care provider, which is what all experts in the field recommend women do before choosing to take any drug.
No medication does not mean no risk
In the face of such uncertainty it might seem safest to avoid medication altogether. But that can bring its own set of (sometimes greater) risks.
"There is this thought that because you are going to get pregnant, you have to stop every medication," says Siobhan Dolan, M.D., professor of obstetrics and gynecology and women's health at the Albert Einstein College of Medicine in New York City and author of Healthy Mom, Healthy Baby.
"Take depression. The old notion was that medication posed risks, and taking no medication did not pose risks. But that's not true. A depressed mother poses risks to the fetus, not to mention that the mothers' well-being needs to be considered in the equation." Mental health professionals in reproductive medicine agree that there are several antidepressants that carry only a small risk of harm to developing fetus and that, in women for whom depression is a serious medical concern, not treating it carries a higher risk than the medication.
Ultimately, when women need medication for significant health issues (mental or otherwise) during pregnancy, "it's all about weighing the risks and benefits for moms and babies and getting to the safest medication," says Dr. Dolan.
Even though the research is limited, doctors are able to make informed choices about medications based upon the results of laboratory and animal studies as well as the accumulated experiences of women who have taken medication in pregnancy.
"There are very few instances where we have to recommend medications that have a largely unknown or a known adverse effect on pregnancies," says Dr. Klauser, who treats women with complex medical conditions at his maternal fetal medicine practice in New York City.
When Dr. Klauser talks with a patient about taking a medication, he says he tries to help her understand the risks that come with medicating balanced against the potential effects on her and her baby if she leaves an acute condition untreated. Dr. Dolan agrees: "We don't want women to have to feel so afraid. We're trying to move away from 'this is so scary and bad' to weighing the risks and benefits and making a good decision."
That will be a welcome shift for women who need medication to take care of their health during pregnancy. I understand the fear Kenny feels about getting pregnant again. That's exactly how I felt after my first difficult pregnancy. But after seeing that my daughter was growing up happy and healthy, I changed my mind.
Before we started trying for number two, my husband and I sat down with each of my doctors (including my psychiatrist) to talk through the medications I might have to take (including the possibility of Zoloft for anxiety) and how we would use them safely.
As luck would have it, I remained healthy throughout my second pregnancy. But I was reassured to know that I had made a plan with doctors I trusted about how I could take care of myself if and when I needed to.
10 Tips for Making Good Medication Choices in Pregnancy
Plan ahead when possible. If you're on medication for a chronic condition (mental or physical), meet with your OB or specialist before trying to conceive to discuss what is known about the medication you are taking and whether there are safer choices you can switch to.
Don't decide on your own. If you discover you are pregnant while taking a medication critical to your health (mental or physical), speak to your provider before deciding to stop it.
Talk with your doctor. Even if you're not on medication, ask your provider what drugs (such as pain relievers and cold medicines) she is comfortable with your taking. "Most OBs can provide you a list of safe medications that their practice came up with through the use of guidelines," says Dr. Klauser. Of course, if you don't have a true medical need for a medication, it's best to avoid exposing your developing baby to it.
Find good medical care. If you have a chronic condition (such as asthma, epilepsy, high blood pressure, depression, or diabetes) ask your specialist or OB if he has experience treating pregnant women, and, if not, if he can recommend a colleague who does. Look for a provider who works in consultation with other specialists such as a maternal-fetal medicine expert.
Limit your sources of information. If you want to do additional research, ask your provider what websites she recommends. Dr. Dolan likes MothertoBaby, a website and hotline (866-626-6847) with up-to-date information on many medications. She says genetic counselors can be another good resource. They have access to detailed databases with the latest information on medication effectiveness and safety.
Choose fewer medications when possible. "We always attempt to use the [lowest] number of medications possible," says Dr. Klauser. Let every physician you encounter know the medications you are taking. The more you use, the greater the likelihood for an interaction that might be harmful to you or your developing baby.
But don't assume less is better. One mistake even doctors make, says Dr. Kweder, is to lower the medication dose to reduce any potential risk. "They think they are doing the right thing, but if it doesn't work because you gave too little, you're getting the risk for no benefit." In fact, says Kweder, many medications require a higher dosage in pregnancy, because they are metabolized or cleared more rapidly by the liver or the kidney, which may function differently during pregnancy. The new FDA rating system will address dosing as well as safety.
Count over-the-counter meds. OTC medications can present the same risks as prescription medication. And because many of them combine several ingredients, they have the potential to present a greater risk. Before taking any medication, talk with your provider.
Don't equate natural with safe. "Some herbal combinations and supplements have components that can stimulate uterine activity and can be potentially quite dangerous for a pregnancy," says Dr. Klauser.
Ask out about extra testing. If a medication is known to increase the risk of a problem in pregnancy, your doctor can do extra ultrasounds or other tests to look for early signs that you should discontinue it. Ask your provider if she recommends additional monitoring.
Kate Rope is the coauthor of The Complete Guide to Medications During Pregnancy and Breastfeeding.
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