Dispelling myths: Safe medication use in pregnancy and breastfeeding

By Julia Giannini and Certina Ho

Rachel is a 29-year-old lawyer who is actively trying to conceive her first child. She is both excited and nervous and has begun asking her family and friends advice on planning for pregnancy. She is wondering whether she should wait to begin taking prenatal vitamins until she is pregnant, as she does not want to take supplements unnecessarily.

 

Myth #1: Prenatal vitamins should not be taken until pregnancy is confirmed, and not all women require them.

It is recommended that, if possible, women begin prenatal vitamin supplementation three months prior to conception. Most standard prenatal multivitamins contain folic acid, iron, and calcium. Talk to your doctor about your potential risks for fetal neural tube defects, to determine the correct dose of folic acid required. Every woman should be taking folic acid supplement prior to and during pregnancy.

 

Rachel has been taking Escitalopram for depression for the past five years. Her depression was well controlled, and she is now stable on her medication. She was told by a friend that since many medications are unsafe to the developing fetus, women should stop taking medications when they become pregnant. Rachel is extremely worried about this.

 

Myth #2: All medications should be stopped throughout pregnancy.

Not all medications are contraindicated in pregnancy and may be continued under safe and effective medication management. However, it is always important to talk to your doctor and consider individual patient factors, determining the benefits (of taking, continuing, or starting medication(s)) versus the risks (of not treating or managing your medical condition(s) during pregnancy). Pregnancy consists of three trimesters, where different stages of fetal development are taking place. Some medications should be avoided during the first trimester (e.g., decongestants). Other medications increase the chance of birth defects and should be avoided in the second and third trimesters (e.g., ACE Inhibitors that are used to lower blood pressure). Finally, some medications are absolutely contraindicated (e.g., isotretinoin, an acne medication, should not be taken during pregnancy or by women who may become pregnant, as it will very likely cause birth defects). [Readers can learn more about medication use during pregnancy at MyHealth.Alberta.ca https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=uf9707]

 

Myth #3: Psychiatric medications, as a class, are harmful to a developing fetus.

In the case of Rachel, she is stable on an antidepressant prior to becoming pregnant. No concrete evidence has been found to support an increased baseline risk of congenital anomalies with most of the first-line antidepressants, including her medication, Escitalopram. If a patient is on a medication at the time of pregnancy and the condition is under control, the recommendation is to continue treatment during and after pregnancy, to prevent relapse of the condition. One notable exception is Paroxetine, which may increase the risk of cardiac malformations in the first trimester. On the other hand, untreated depression can come with its own risks, such as early pregnancy loss, low birth weight, post-partum depression, and even suicidal ideation. The bottom line is that many psychiatric medications may be used safely during pregnancy, provided that the benefits outweigh the associated risks.

 

Rachel is now two-month pregnant and struggling with “morning sickness”. She is confused why her nausea occurs throughout the day, and not just in the morning. She would like to use medications to help her feel better. However, she heard from her sister that they aren’t very effective, and the morning sickness will usually pass after the first trimester, so it’s best to avoid additional medications.

 

Myth #4: Nausea and vomiting in pregnancy occur only in the morning, and women usually see relief after the first trimester.

The term “morning sickness” is misleading, as nausea and vomiting often occur at all times of the day. Severity normally peaks at 11-13 weeks of gestation, and while many women experience relief after the first trimester, some continue to experience it throughout the remainder of pregnancy. Although evidence surrounding anti-nausea medications is conflicting, they are a reasonable and safe options, usually taken 4-6 hours before symptoms onset. If non-pharmacological management is preferred, oral ginger and acupressure options are also available. [Readers can learn more about nausea and vomiting of pregnancy at UpToDate.com https://www.uptodate.com/contents/nausea-and-vomiting-of-pregnancy-beyond-the-basics]

 

It is now seven months later, and Rachel has delivered a healthy baby. She has decided to exclusively breastfeed for the first six months. She believes that, similarly to pregnancy, medication use during breastfeeding should be avoided, since it can pass into breast milk and affect the baby.

 

Myth #5: Medications avoided in pregnancy are generally also avoided in breastfeeding.

Not all medications that are unsafe in pregnancy are also unsafe during breastfeeding. Conversely, there are some medications that are safe in pregnancy, but generally avoided in breastfeeding. It is important to talk to your doctor about the benefits versus risks of medication use during breastfeeding, considering whether significant amounts of the drug are found in breast milk, and how the medication may affect the infant. It is also necessary to consider the maternal risks of not treating or managing medical condition(s) during breastfeeding.

Below is a list of other resources pertaining to safe medication use in pregnancy and breastfeeding:

Julia Giannini is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.