Humira is an immunosuppressant and can lower the ability of your immune system to fight bacterial, viral, or fungal infections or make an infection worse.  Humira has not been studied during pregnancy or breastfeeding. Animal studies revealed no fetal harm or malformations with IV administration of this drug.

Be sure to talk with your healthcare provider regarding the use of Humira during pregnancy and breastfeeding.

HUMIRA is a prescription medicine used to reduce the signs and symptoms of:

• Moderate to severe rheumatoid arthritis (RA) in adults. HUMIRA can be used alone, with methotrexate, or with certain other medicines. HUMIRA may prevent further damage to your bones and joints and may help your ability to perform daily activities.
• Moderate to severe polyarticular juvenile idiopathic arthritis (JIA) in children 2 years of age and older. HUMIRA can be used alone, with methotrexate, or with certain other medicines.
• Psoriatic arthritis (PsA) in adults. HUMIRA can be used alone or with certain other medicines. HUMIRA may prevent further damage to your bones and joints and may help your ability to perform daily activities.
• Ankylosing spondylitis (AS) in adults.
• Moderate to severe Crohn’s disease (CD) and to achieve and maintain clinical remission in adults who have not responded well to certain other medications. HUMIRA is also used to reduce signs and symptoms and to achieve clinical remission in these adults who have lost response to or are unable to tolerate infliximab.
• Moderate to severe Crohn’s disease (CD) and to achieve and maintain clinical remission in children 6 years of age and older when certain other treatments have not worked well enough.
• Moderate to severe hidradenitis suppurativa (HS) in people 12 years and older.
• In adults, to help get moderate to severe ulcerative colitis (UC) under control (induce remission) and keep it under control (sustain remission) when certain other medicines have not worked well enough. It is not known if HUMIRA is effective in people who stopped responding to or could not tolerate anti-TNF medicines.
• To treat moderate to severe chronic plaque psoriasis (Ps) in adults who are ready for systemic therapy or phototherapy, and are under the care of a doctor who will decide if other systemic therapies are less appropriate.
• To treat non-infectious intermediate (middle part of the eye), posterior (back of the eye), and panuveitis (all parts of the eye) (UV) in adults and children 2 years of age and older.

Humira and Pregnancy

Therapeutic Effect: Reduces swelling, tenderness, inflammation of joints; prevents or slows progressive destruction of joints in rheumatoid arthritis (RA).
Pregnancy Safety Rating:  Category B, caution in nursing.
Pregnancy Recommendation: Limited Human Data – Probably Compatible

Humira’s Side Effects:

The use of adalimumab during pregnancy carries a variety of possible side effects. It is important to note that any medication can cause side effects.
Possible side effects include:

• Frequent (20%): Pruritus, injection site erythema, pain, swelling.

• Occasional (12%-9%): Headache, nausea, sinusitis, rash.

• Rare (7%-5%): Hypertension, abdominal or back pain.

Pregnancy/Lactation Considerations: It is unknown if this medication is distributed in breast milk.

Adalimumab Pregnancy Summaries:

The following summaries are cited directly from the sources of Briggs, Freeman, & Yaffe and the Reprotox Toxicology Center.
Briggs, Freeman, & Yaffe:
No developmental toxicity attributable to adalimumab has been observed in a limited number of cases, and the animal data suggest low risk. However, limited human pregnancy experience prevents a more complete assessment of embryo-fetal risk.

Theoretically, tumor necrosis factor-alpha (TNF) antagonists could interfere with implantation and ovulation, but this has not been shown clinically (1). The maternal benefits from treatment with adalimumab appear to far outweigh the unknown embryo-fetal risks (2, 3).

It is not known if the antibody can cross the placenta early in gestation when most adalimumab exposures have occurred. If it is similar to immunoglobulin G (IgG), clinically significant amounts would cross only late in gestation and thus would present no direct risk to the embryo-fetus during early development.

Because of the long elimination half-life, use before conception may result in inadvertent exposure of an unplanned pregnancy.  If adalimumab is used in pregnancy for treatment of rheumatoid arthritis, health care professionals are encouraged to call the toll-free number (877-0311-8972) for information about patient enrollment in the Organization of Teratology Information Specialists (OTIS) Rheumatoid Arthritis study and Pregnancy Registry.

Reprotox Toxicology Center:
Preclinical studies in mice and monkeys did not show adverse effects of adalimumab or a comparable antibody on embryo development.
Adalimumab is an antibody that binds to TNF-alpha and interferes with its interaction with cell surface receptors. This product is marketed as Humira for the treatment of rheumatoid arthritis and Crohn’s disease.

According to information submitted to the FDA, no adverse effects were noted in the offspring of monkeys treated with up to 100 mg/kg each week. This dose is at least 266 times the recommended human dose based on plasma concentrations.

When a comparable antibody to mouse TNF alpha was administered to pregnant mice, there were no adverse effects on fetal survival or morphologic development (8). There were no adverse effects on immune function in the offspring except an inconsistent decrease in splenic cell expansion in females but not males (9). This observation may not be clinically important.

Recommendations

The American Pregnancy Association recommends consulting your obstetric healthcare provider and any prescribing physician before starting or stopping medications.

If you are pregnant and have questions related to medication use during pregnancy, the Reprotox Toxicology Center is the most comprehensive and user-friendly resource on medication use during pregnancy.

The American Pregnancy Association does not prescribe medication nor do we serve as a consult for medication use during pregnancy.  It is imperative that you discuss the use of any medication during pregnancy with your health care provider.

The purpose of this document is to provide you with information to support discussions with your health care provider.

Sources:

Humira Safety Information

Adalimumab Pregnancy and Breastfeeding Warnings: Drugs.com

Hodgson, Barbara and Kizior, Robert, Saunders Nursing Drug Handbook 2015, Elsevier, St. Louis, MO. ISBN: 978-1-4377-2334-2.
Briggs, Gerald, Freeman, Roger and Yaffe, Sumner, Drugs in Pregnancy and Lactation, 9^th Ed., Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA. ISBN: 978-1-60831-708-0, 2011.

Physicians’ Desk Reference (PDR), PDR Network, LLC, Montvale, NJ 07645 ISBN: 978-1-56363-780-3

Reproductive Toxicology Center, https://www.reprotox.org, agent #2687

The post Humira During Pregnancy appeared first on American Pregnancy Association.

When should I start taking folic acid?

You should start taking folic acid prior to getting pregnant even if you are not trying to conceive. Neural tube defects usually develop in the first 28 days of pregnancy, often before a woman even knows that she is pregnant.

If you find you are pregnant and have not been taking folic acid, you should start now to help prevent any neural defects in the first three months of pregnancy.

The absence of this important nutrient increases the possibility of a neural tube defect (a defect in the development of the spinal cord).

• Spina bifida is a condition in which the spinal cord is exposed. If the vertebrae (bones of the spinal column) surrounding the spinal cord do not close properly during the first 28 days after fertilization, the cord or spinal fluid bulge through, usually in the lower back.
• Anencephaly is the severe underdevelopment of the brain.

What foods contain folic acid?

Approximately half of all pregnancies are unplanned, so the U.S. Food and Drug Administration has taken steps to fortify certain foods so that all women of childbearing age receive a daily dose of folic acid.

The following foods can help you obtain your recommended amount:

• Leafy green vegetables, such as spinach
• Citrus fruits, such as orange juice
• Beans, peas and nuts
• Enriched bread, cereals and other grain products
• Rice
• Pasta

A daily vitamin with folic acid may be suggested by your health care provider since the foods listed above may not contain enough folic acid to meet the daily requirement.

How do I know if I am at risk of having a baby with neural defects, and how can I prevent this from happening?

Women who are at greatest risk are those that have had a previous pregnancy that involved a neural defect. Women who are not eating a balanced diet that includes folic acid are also at risk.
The best way to prevent neural defects is to take the recommended 600 – 800 micrograms (0.6 – 0.8 milligrams) of folic acid daily for one month before conception and during the first three months of pregnancy. The daily amount should not exceed 1000 micrograms (1.0 milligrams).

Multivitamins that include folic acid should only be used as a supplement under the supervision of your health care provider.

How are neural tube defects diagnosed?

Neural tube defects are detected through an alpha-fetoprotein test (AFP). AFP is a blood test administered at 16-18 weeks gestation.  The test measures alpha-fetoprotein, a substance produced by the fetus and secreted into the amniotic fluid.
AFP is also found in the mother’s blood. The level of AFP in the mother’s blood peaks at about 30-32 weeks.  Abnormally high amounts of AFP may indicate that a baby has a neural tube defect.

What are other reasons for an elevated AFP?

An elevated AFP could mean the mother is carrying twins or that there is a problem with the placenta. Women with diabetes or liver disease may also have an elevated AFP level.

However, an elevated AFP could also mean that there are birth defects present such as severe kidney disease, liver disease, esophageal or intestinal blockage, Down Syndrome, urinary obstruction, or osteogenesis imperfecta (fragility of the baby’s bones).

If I have an elevated AFP, what additional tests are available?

• A second AFP test
• Ultrasound
• Amniocentesis

Want to Know More?

• Pregnancy Nutrition
• Natural Sources of Vitamin B6 During Pregnancy
• Role of Vitamin B in Pregnancy
• Vitamin D and Pregnancy

The post Folic Acid in Pregnancy appeared first on American Pregnancy Association.

Cymbalta and Pregnancy

Since depression is diagnosed more commonly in women and pregnancy triggers or worsens depression, it is no wonder that concern for the health and wellness of the baby comes to mind. Depression is challenging for anyone to manage and it often interferes with healthy practices like eating well-balanced meals and exercising. Both of these are important for both you and your baby. So, if you are dealing with depression, it is important to talk to your health care provider about Duloxetine during pregnancy as an option for managing your care.

Brand name: Cymbalta
Manufacturer: Eli Lilly

Therapeutic Effect:

Cymbalta is indicated for:

• The treatment of a major depressive disorder.
• The treatment of generalized anxiety disorder. Generalized Anxiety Disorder is defined by the DSM-IV as excessive anxiety and worry, present more days than not, for at least 6 months.
• The management of neuropathic pain associated with diabetic peripheral neuropathy.
• The management of fibromyalgia.

Pregnancy Safety Rating: Category: C
Pregnancy Recommendation: Human data suggest risk in the 3rd trimester

Duloxetine Side Effects:

• Frequent (20%-11%): Nausea, dry mouth, constipation, insomnia.
• Occasional (9%-5%): Dizziness, fatigue, diarrhea, drowsiness, anorexia, diaphoresis, vomiting.
• Rare (4%-2%): Blurred vision, erectile dysfunction, delayed or failed ejaculation, anorgasmia, anxiety, decreased libido, hot flashes.

Lifespan Considerations

May produce neonatal adverse reactions (constant crying, feeding difficulty, hyperreflexia, irritability). Unknown if distributed in breast milk. Breastfeeding not recommended.

Pregnancy Summaries

Briggs, Freeman, & Yaffe – Duloxetine causes developmental toxicity in animals (growth restriction in rats and rabbits; behavior deficits and death in rats) at doses

Want to Know More?

• Medication and Pregnancy
• Depression During Pregnancy

Sources:

1. Hodgson, Barbara and Kizior, Robert, Saunders Nursing Drug Handbook 2012, Elsevier, St. Louis, MO. ISBN: 978-1-4377-2334-2.
2. Briggs, Gerald, Freeman, Roger and Yaffe, Sumner, Drugs in Pregnancy and Lactation, 9th Ed., Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA. ISBN: 978-1-60831-708-0, 2011.
3. Physicians’ Desk Reference (PDR), PDR Network, LLC, Montvale, NJ 07645 ISBN: 978-1-56363-780-3
4. Reproductive Toxicology Center, https://www.reprotox.org, agent # 3983

The post Duloxetine During Pregnancy appeared first on American Pregnancy Association.

Which Iron-rich foods are best for pregnancy?

Meat & Eggs

• Beef
• Liver (not recommended)
• Oysters (cooked)
• Clams
• Shrimp
• Chicken
• Turkey
• Ham
• Veal
• Lamb
• Pork
• Eggs

Vegetables

• Spinach, cooked
• Collards
• Chard
• Kale
• Tomatoes, canned, stewed
• Green Peas
• Broccoli
• Sweet potatoes
• Green beans
• Dandelion greens
• Beet greens

Fruit

• Strawberries
• Raisins
• Watermelon
• Prunes
• Figs
• Dried peaches
• Dried apricots

Beans/Legumes/Nuts

• Beans (white beans, kidney beans, and chickpeas/garbanzo beans)
• Lentils
• Dried peas
• Cashews
• Pistachios
• Pumpkin/squash seeds

Breads / Cereals / Starches

• Whole wheat bread
• Baked potato
• Oat cereal
• Bran cereal
• Cornmeal
• Enriched pasta
• Enriched rice

Other foods

• Dark Chocolate (best for last)

Iron Absorption

Not all sources of iron are equal in the amount of iron available to be absorbed by the body. There are two types of iron—heme iron and non-heme iron. Heme iron is found in meat, poultry, and fish, while non-heme iron is found in both plant foods (vegetables, beans, fortified grains) and meat.

Heme iron, however, is much more readily absorbed by the body. The body can absorb up to 30 percent of heme iron, while it can only absorb 2-10% of non-heme iron.

While meat may improve your iron levels more readily, it is important to eat a variety of sources of iron, including plant sources.
For this reason, when eating foods containing non-heme iron, it is best to pair them with foods containing vitamin C, which can aid iron absorption.

Some foods rich in vitamin C include guava, bell peppers, kiwis, oranges, grapefruit, strawberries, Brussels sprouts, cantaloupe, and papaya.
Also, eating heme sources of iron (meat) at the same meal as non-heme sources of iron (plants) can increase the absorption of non-heme iron.
More Helpful Articles:

• How to Treat Iron Deficiency Naturally During Pregnancy
• Anemia During Pregnancy
• Nutrients and Vitamins for Pregnancy

Compiled using information from the following sources:

1. Centers for Disease Control and Prevention. (2011). Iron and iron deficiency.

2. The American National Red Cross. (n.d.). Iron-rich foods.

https://www.redcrossblood.org/learn-about-blood/health-and-wellness/iron-rich-foods

3. The Office of Dietary Supplements. (2015). Iron.

https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

4. U.S. Department of Health and Human Services, National Institutes of Health, & National Heart, Lung, and Blood Institute. (2011). Your guide to anemia.

5. Centers for Disease Control and Prevention. (2011). Iron and iron deficiency.

6. The American National Red Cross. (n.d.). Iron-rich foods.

https://www.redcrossblood.org/learn-about-blood/health-and-wellness/iron-rich-foods

7. The Office of Dietary Supplements. (2015). Iron.

https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

The post Iron-rich Foods for Pregnancy appeared first on American Pregnancy Association.

A normal balanced diet contains enough folic acid. However, a lack of folic acid will cause anemia and sometimes other symptoms. Pregnancy causes reserves of folic acid in your body to be used by the growing baby. You are at risk of becoming low in folic acid during the later stages of pregnancy, particularly if you do not eat well during pregnancy.

What are the symptoms of folic acid deficiency?

Symptoms due to anemia are caused by the reduced amount of oxygen in the body include tiredness, having little energy (lethargy), feeling faint and becoming easily breathless.

Less common symptoms include headaches, heartbeats suddenly becoming noticeable (palpitations), altered taste and ringing in your ears (tinnitus). You may look pale and have numbness in your hands and feet.

Where to find natural forms of folate and folic acid

Folate is naturally found in foods such as vegetables, fruits, and grains, whereas folic acid is the synthetic form of folate and is added to supplements and fortified foods. It is best to get nutrients, such as folate, from unfortified foods.
The daily recommended intake of folic acid for pregnant women is 400 – 800 micrograms per day (0.4 – 0.8 milligrams), while the recommended upper limit is no more than 1000 micrograms (1.0 milligrams) of folic acid per day.

 Foods That Contain Folic Acid

Below is a list of some foods containing folate or folic acid:

Vegetables

• Edamame
• Okra
• Spinach
• Artichoke
• Turnip greens
• Broccoli
• Asparagus
• Brussel sprouts
• Romaine or mesclun lettuce
• Escarole or endive
• Beets
• Potato with skin

Fruit

• Avocado
• Papaya
• Orange juice

Legumes

• Beans (cranberry, roman, mung, adzuki, pinto, navy, black, white, kidney, great northern)
• Lentils
• Peas (black-eyed, chickpeas, pigeon)
• Sunflower seeds
• Peanuts

Meat

• Liver

Fortified foods

• Pasta (enriched)
• Bagel (enriched)
• Bread (enriched)

Want to Know More?

• Pregnancy Nutrition
• Diet During Pregnancy
• Nutrients and Vitamins for Pregnancy

Compiled using information from the following sources:

1. Dieticians of Canada. (2014, February 25). Food sources of folate.

2. Harvard School of Public Health Nutrition Source. (n.d). Keep the multi, skip the heavily fortified foods

3. The Spina Bifida & Hydrocephalus Association of Ontario. (n.d). Food sources.

The post Where to Get Folic Acid Naturally During Pregnancy appeared first on American Pregnancy Association.

Pregnant and lactating women need 1000 mg of calcium per day; pregnant and lactating teens need 1300 mg of calcium per day. This leads many to ask, where can you get Calcium naturally?

Where to Get Calcium Naturally During Pregnancy

Below is a list of some foods where you can get calcium naturally:

Fruit/Vegetables

• Collard greens
• Broccoli rabe
• Cress
• Kale
• Green soybeans
• Bok choy
• Rhubarb
• Figs (dried)
• Broccoli
• Oranges

Dairy

• Ricotta cheese
• Yogurt
• Milk
• Mozzarella cheese
• Cheddar cheese
• American cheese
• Feta cheese
• Cottage cheese
• Frozen yogurt
• Ice cream
• Parmesan cheese

Fish

• Sardines
• Salmon
• Shrimp

Beans

• White beans
• Chickpeas
• Red beans

Fortified foods

• Rice milk, almond milk, or soy milk (fortified)
• Orange juice (fortified)
• Oatmeal (fortified)
• Cereal (fortified)

Other foods

• Wakame

Want to Know More:

• Vitamin D and Pregnancy
• Nutrients and Vitamins for Pregnancy
• Prenatal Vitamin Ingredients

Compiled using information from the following sources:

1. International Osteoporosis Foundation. (n.d.). Calcium content of common foods.

2. March of Dimes Foundation. (2009). Eating and nutrition.

3. Office of Dietary Supplements. (2013, November 21). Calcium.

https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/#h7

34 The National Osteoporosis Foundation. (n.d.). A guide to calcium-rich foods.

The post Calcium in Pregnancy appeared first on American Pregnancy Association.

How to Get Probiotics Naturally

Yogurt: The most commonly used food source for acquiring probiotics naturally is yogurt. Live yogurt and live yogurt drinks are two viable options.

Kefir: Similar to yogurt is the fermented dairy product called kefir. Kefir involves a combination of fermented kefir grains and goat’s milk. This is considerably less common than regular live-cultured yogurt.

Chocolate: Expecting mothers will be excited to learn that probiotics can often be found in high-quality dark chocolates. The levels of probiotics are often significantly higher.

Algae: Taking to the sea and leveraging microalgae, such as blue-green algae, chlorella, and spirulina, provides consumers with both Lactobacillus and Bifidobacteria.

Miso: For the Asian food connoisseur, Miso soup is another source for getting probiotics naturally. Miso is made from fermented barley, beans, rice, or rye. It is the fermentation process that brings in the probiotics.

Pickles: We have all heard of the expecting mother craving pickles and ice cream. The good news is that pickles are another source of probiotics.

Tea: Kombucha Tea is a fermented tea that is high in probiotics, providing expecting mothers with an opportunity to drink their probiotic. The good news is the caffeine levels in these teas are lower than regular teas, although there is still some caffeine.

Milk: It is also possible to get probiotics from fermented and some unfermented milk.
When you look over the list, it is easy to see why live cultural yogurt is the most commonly used food source for getting probiotics naturally.

Want to Know More?

• Pregnancy Nutrition
• Diet During Pregnancy
• Nutrition During Breastfeeding

Compiled using information from the following sources:

1. Dugoua, Jean-Jacques et al., “Probiotic Safety in Pregnancy: A Systematic Review and Meta-analysis of Randomized Controlled Trials of Lactobacillus, Bifidobacterium, and Saccharomyces spp, Journal of Obstetrics and Gynecology Canada, 2009; 31(6).

2. Delias, Jackie, Bozzo, Pina, and Einarson, Adrienne, “Are probiotics safe for use during pregnancy and lactation? National Library of Medicine, National Institute of Health.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056676/

3.Group, Edward, “Probiotic Foods,” Global Health Center

The post Getting Probiotics Naturally During Pregnancy appeared first on American Pregnancy Association.

Albuterol While Pregnancy

• Brand names: Albuterol, AccuNeb, Combivent, Combivent Respimat, Duoneb, ProAir HFA, Proventil HFA, Ventolin HFA, VoSpire ER, Xopenex HFA

• Manufacturer:  Bausch & Lomb, Dey, Mutual, Mylan, Boehringer Ingelheim, Merck, GlaxoSmithKline, Dava, Sunovion, Teva

Therapeutic Effect: Reduces airway resistance and relieves bronchospasm.
Pregnancy Safety Rating: Category C; do not use while nursing.
Pregnancy Recommendation: Compatible

Albuterol’s Side Effects:

Below are some side effects that may be experienced when using albuterol during pregnancy

• Frequent: Nausea (15%); restlessness, nervousness, tremors (20%); dizziness (less than 7%); headache (27%); blood pressure changes, including hypertension (5%-3%); throat dryness and irritation, pharyngitis (less than 6%); heartburn, transient wheezing (less than 5%).

• Occasional (3%-2%): Asthenia, insomnia, altered taste. Inhalation: Dry, irritated mouth or throat; bronchial irritation, cough.

• Rare: Diarrhea, dry mouth, drowsiness, flushing, anorexia, diaphoresis.

Pregnancy/Lactation Considerations: This medication appears to cross the placenta. It is unknown if albuterol is distributed in breast milk, and it may hinder uterine contractibility.

Albuterol Pregnancy Summaries:

The following summaries are cited directly from the sources of Briggs, Freeman, & Yaffe and the Reprotox Toxicology Center.
Briggs, Freeman, & Yaffe – Albuterol (salbutamol) has not caused structural anomalies, but there is evidence of an association with functional and neurobehavioral toxicity with prolonged use. Similar to other β-mimetics, the drug can cause maternal and fetal tachycardia and hyperglycemia.
Nevertheless, the drug should not be withheld because of pregnancy, but excessive use should be avoided. If albuterol is used in pregnancy for the treatment of asthma, health care professionals are encouraged to call the toll-free number (877-311-8972) for information about patient enrollment in an Organization of Teratology Information Specialists (OTIS) study.
Reprotox Toxicology Center – Albuterol can interfere with embryo development in mice but not rats or rabbits. Two epidemiology studies have suggested an increase in specific birth defects associated with albuterol use in early pregnancy, but the defects were different in the two studies, and the findings may have been due to chance.
Albuterol (salbutamol; Proventil; Ventolin; Airet; Volmax) is a beta-sympathomimetic used in the treatment of asthma. This agent has also been used to inhibit preterm labor. Based on available safety studies, a 2004 NIH report on the treatment of asthma during pregnancy recommended albuterol (#1015) as the preferred beta-agonist (34).
The R-enantiomer is called levalbuterol and is marketed as Xopenex for the treatment of asthma. In preliminary reports, various teratogenic effects, including cleft palate, were found when albuterol was administered to pregnant mice, but similar effects were not found in rats or rabbits (1,25).
No abnormalities were found in the offspring of three women who received albuterol continuously beginning early in the second trimester (2-4).
In a study on 259 pregnant asthmatics who used inhaled beta sympathomimetics, 180 of whom used these agents during the first trimester, there was no increase in congenital anomalies or adverse perinatal outcome attributable to the therapy (5).
Most of these women used metaproterenol (#1132), although isoetharine (#2062), epinephrine (#1083), isoproterenol (#1888), and albuterol were also used. The Swedish Medical Birth Registry reported an association between albuterol use during pregnancy and cardiac defects in the offspring with an adjusted relative risk of 1.38 (95% confidence interval 1.12-1.70) (35).
A large number of comparisons in this study raise the possibility that the albuterol-related finding was a chance association. The National Birth Defects Prevention Study presented a case-control study of facial clefts that showed an association with early pregnancy used of albuterol (36).
The odds ratio for isolated cleft lip was 1.79 (95% CI 1.07-2.99) based on 18 exposed cases and the odds ratio for isolated cleft palate was 1.65 (95% CI 1.06-2.58) based on 25 exposed cases. There was no significant association between albuterol use and cleft lip with cleft palate.
The authors indicated that their findings may have been due to the medication, underlying asthma, or to chance.
There is an experience with the use of albuterol as a tocolytic agent in late pregnancy (6-15,26,37). Typically, albuterol will increase maternal cyclic-AMP, glycogenolysis, lipolysis, and insulin levels, but will decrease serum potassium levels (7,12-14).
Effects on the circulatory system include an increase in heart rate and a drop in blood pressure (7,8,10). Although these effects are more prominent in the mother, the fetus may show similar responses (28). By contrast, inhaled albuterol at recommended doses did not appear to affect maternal blood pressure, heart rate, or Doppler flow velocity studies of the uterine and fetal central circulation (23).
The placental transfer of albuterol has been demonstrated in an in vitro system using perfused term human placentas (16). In contrast to the available reports on intravenously administered albuterol, some clinical studies have found no significant increase in the length of gestation associated with the chronic oral administration of albuterol (15,17).
However, a more recent study by Thai clinicians, using a higher dose (32 mg/day) than the older studies (20 mg/day (15,17,32,33), reported oral albuterol did prolong gestation in a population of 132 pregnancies (31).
Tachycardia was detected in 86% of the mothers, and neonatal complications, including respiratory distress, were observed in more than 20% of the neonates (31). One newborn exposed in utero to albuterol had a significant elevation of growth hormone levels (18).
Long term adverse effects in the offspring, including alterations in growth, have not been noted with beta-sympathomimetics as a group (19-22). One small study identified an increased incidence of prenatal exposure to beta-sympathomimetics (ritodrine (#1548) or albuterol) among premature infants with retinopathy (24).
The authors of this study, reported in a letter-to-the-editor, suggested that these agents reduce retinal perfusion and predispose eye tissues to damage by other factors.
Administration of albuterol to the mother in the second and third trimesters of pregnancy has been used successfully to treat fetal heart block (27,29,30). We did not locate reports on the use of albuterol during lactation.

Next Steps:

The American Pregnancy Association recommends consulting your obstetric healthcare provider and any prescribing physician before starting or stopping medications.
If you are pregnant and have questions related to medication use during pregnancy, the Reprotox Toxicology Center is the most comprehensive and user-friendly resource on medication use during pregnancy.  You can subscribe for only $17.00 per month– Subscribe Now.
The American Pregnancy Association does not prescribe medication, nor do we serve as a consult for medication use during pregnancy.  It is imperative that you discuss the use of any medication during pregnancy with your health care provider.
The purpose of this document is to provide you with information to support discussions with your health care provider.
Sources:
Hodgson, Barbara and Kizior, Robert, Saunders Nursing Drug Handbook 2015, Elsevier, St. Louis, MO. ISBN: 978-1-4377-2334-2.
Briggs, Gerald, Freeman, Roger and Yaffe, Sumner, Drugs in Pregnancy and Lactation, 9th Ed., Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA. ISBN: 978-1-60831-708-0, 2011.
Physicians’ Desk Reference (PDR), PDR Network, LLC, Montvale, NJ 07645 ISBN: 978-1-56363-780-3
Reproductive Toxicology Center, https://www.reprotox.org, agent #2687

The post Albuterol During Pregnancy appeared first on American Pregnancy Association.

Taking Medication During Pregnancy

Please know that many women take prescription medication during pregnancy for necessary reasons like diabetes, seizures, depression, anxiety, and other medical conditions. Some pregnant women take medications to help with common discomforts of pregnancy such as heartburn, morning sickness, or headaches.
Pregnancy can affect the effectiveness of your medication. When you are pregnant, your blood volume increases, and your heart and kidneys both work harder. This means that medications have the potential to pass through your body more quickly than usual. This may mean that you have to take more medicine or take it differently.
In most cases, there are different types of medications to address a particular problem. Your health care provider may switch the type of medication you are on to take care of your medical needs while lessening any risk to your developing baby.

Medication Risk Factor Classifications

Each medication has a risk factor classification associated with potential risk factors during pregnancy. These ratings, along with an evaluation of the risks and benefits of using a particular medication in your situation, will help you and your health care provider determines what steps to take.

Pregnancy categories:

• Category A:  Controlled studies show no risk or find no evidence of harm.

• Category B:  Animal studies show no risks, but there are no controlled studies in pregnant women.

• Category C:  Animal studies have shown risk to the fetus, there are no controlled studies in women, or studies in women and animals are not available.

• Category D:  There is positive evidence of potential fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (i.e. life-threatening condition to mother).

• Category X:  Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk. The drug is contraindicated in women who are or may become pregnant.

Category C is the confusing category. A medication gets this classification if there is insufficient data on its use during pregnancy. It could be safe or probably safe, or it could be potentially harmful.

Alternatives to Medication During Pregnancy

Your doctor has the best in mind for both you and your developing baby. She might look to change the course of treatment by incorporating other methodologies such as acupuncture, herbal medications, or behavioral techniques. Of course, this depends on what medical conditions you are dealing with.
You or your health care provider can explore the Natural Medicines Database to find out information about herbs and their use during pregnancy.

Recommendations

You should never start or stop taking medication while pregnant without first consulting your health care provider. Here are some steps to help make sure you and your developing baby are properly cared for.

• Always consult your doctor: This is your first and most important step.
• Read the Label: Look for warnings or pregnancy indications. You should also look for potential allergic reactions as well as expiration dates.
• Be aware of side effects: Consult your health care provider or the pharmacist about potential side effects. Some medications cause side effects like sleepiness, headaches, or vomiting which may be enhanced because of pregnancy hormones.
• Organize your medications: Be careful to not mix up your medications to avoid overdosing.
  
• Do not skip medications: Take as prescribed by your health care provider
• Do not share medications!
• Ask Questions: It is appropriate to ask questions about medication safety for you and your developing baby. Ask about the medication name, generic alternatives, benefits and risks, and problems to watch for.
• Keep Records: It is always beneficial to keep a record of medications taken whether pregnant or not. This becomes even more important if you are expecting.
• Check Pregnancy Medication Registries: The FDA has a new pregnancy and medication registry that you may find helpful.

The post Medication and Pregnancy appeared first on American Pregnancy Association.

Quetiapine and Pregnancy

• Brand name: Seroquel

• Manufacturer: AstraZeneca

Therapeutic Effect: Seroquel is used to treat schizophrenia and manic episodes associated with bipolar I disorder.
Pregnancy Safety Rating: Category C
Pregnancy Recommendation: There is limited human data. Animal data suggest risk.

Side Effects:

• Frequent: (19-10%) Headache, dizziness, drowsiness.

• Occasional: (9%-3%) Constipation, orthostatic hypotension, dyspepsia (heartburn, indigestion, epigastric pain), tachycardia, rash, rhinitis, dry mouth, asthenia (loss of strength, energy), abdominal pain.

• Rare: (2%) Back pain, weight gain, fever.

Pregnancy/Lactation Considerations: It is unknown if quetiapine is distributed in breast milk. It is not recommended for breastfeeding mothers.

Pregnancy Summaries:

The following summaries are cited directly from the sources of Briggs, Freeman, & Yaffe, the Physicians’ Desk Reference, and the Reprotox Toxicology Center.

Briggs, Freeman, & Yaffe – Quetiapine is a potent atypical antipsychotic that may cause clinically significant improvements in the symptoms experienced by a schizophrenic patient. In certain situations, this improvement may result in an increased opportunity for conception and subsequent pregnancy.

Quetiapine was not teratogenic in two animal species, but only low doses have been evaluated. Administration of higher doses was prevented because of significant maternal, embryo, and fetal toxicity.
The human pregnancy experience is too limited for an assessment of the embryo-fetal risk. However, because of the very limited human pregnancy experience with atypical antipsychotics, the American College of Obstetricians and Gynecologists does not recommend the routine use of these agents in pregnancy, but a risk-benefit assessment may indicate that such use is appropriate(1).

However, because quetiapine is indicated for severe debilitating mental disease, the benefits to the mother appear to outweigh the unknown risk (2).

A 1996 review on the management of psychiatric illness concluded that patients with histories of chronic psychosis or severe bipolar illness represent a high-risk group (for both the mother and the fetus) and should be maintained on pharmacologic therapy before and during pregnancy(3). Folic acid (4mg/day) has been recommended for women taking atypical antipsychotics because they may have a higher risk of neural tube defects due to inadequate folate intake and obesity(4).

Physicians’ Desk Reference – There are no adequate and well-controlled studies in pregnant women and quetiapine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. For further information, please refer to the Physicians’ Desk Reference or contact your Healthcare Provider.

Reprotox Toxicology Center – Based on experimental animal studies, quetiapine is not expected to increase the risk of congenital anomalies. Quetiapine in a small series of cases did not increase the risk of birth defects.
If you are pregnant and have questions related to medication use during pregnancy, this is Reprotox Toxicology Center is the most comprehensive resource on medication use during pregnancy.

Next Steps:

The American Pregnancy Association does not prescribe medication, nor do we serve as a consult for medication use during pregnancy.  It is imperative that you discuss the use of any medication during pregnancy with your health care provider.
The purpose of this document is to provide you with information to support discussions with your health care provider.

Sources:

Hodgson, Barbara, and Kizior, Robert, Saunders Nursing Drug Handbook 2012, Elsevier, St. Louis, MO. ISBN: 978-1-4377-2334-2.
Briggs, Gerald, Freeman, Roger and Yaffe, Sumner, Drugs in Pregnancy and Lactation, 9th Ed., Wolters Kluwer/Lippincott Williams & 3. Wilkins, Philadelphia, PA. ISBN: 978-1-60831-708-0, 2011.
Physicians’ Desk Reference (PDR), PDR Network, LLC, Montvale, NJ 07645 ISBN: 978-1-56363-780-3
Reproductive Toxicology Center, https://www.reprotox.org, agent # 4099

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