Taking medication while pregnant: what to consider

For me, spring means allergy season: constant sneezing, itchy eyes, the works.  Basically, my sinuses go into full freak-out mode and decide that protecting me from some as-yet-unidentified pollen is more important than actually functioning.

Fortunately, medications exist that can calm down my widely overactive immune response.

However, I’m pregnant, and our culture is filled with messages about how the smallest dose of anything is dangerous and scary and really you just shouldn’t risk it.  And most meds aren’t well-studied during pregnancy, so it can be hard to figure out what’s worth worrying about.

So what’s an expectant mother to do?

1.  Talk to your doctor.

Or your nurse practitioner.  Pharmacists can also be helpful, although I’ve found their advice tends to be more generic.

When it comes to anything concerning pregnancy, this is the #1 rule: talk to a medical professional.  Call up your OB/GYN’s office, or bring it up during an appointment, or whatever is applicable for your situation.

My OB/GYN helpfully provides all her prenatal patients with a one-page list of common medications that are considered safe to take as directed during pregnancy.  Happily for me and my allergies, diphenhydramine (Benadryl) and loratadine (regular Claritin) are on her approved list.

Relatedly, you should also talk to a doctor before abruptly stopping medication during pregnancy.  Even if the drug in question is widely considered dangerous to fetal development, you might be risking worse effects by doing a sudden withdrawal instead of a controlled taper.

2.  Be skeptical of online information.

This is a universally true rule for life, but it is especially true when it comes to medical information.  Health info on the web has always been questionable, and it seems to have gotten worse in recent years with the proliferation of “healthy living” websites.

Pregnancy-related Google queries are particularly unreliable.  Most of the results you’ll get for something like “is it safe to take Benadryl while pregnant?” are mommy forums where other women have asked the same thing—and gotten a bunch of responses from women who also don’t know the answer.

I understand the desire to scour the internet, hoping that someone somewhere knows something that can give you a definitive yes or no on medication safety.  I’ll be honest, I’ve done some serious Googling on this stuff myself.  But with a lot of drugs, we just don’t have that much data about safety during pregnancy, and you’re far better off going with someone who’s qualified to interpret the data that do exist.

If you must ask the internet, go directly to a reliable source.  I’ve found these resources to be valuable:

  • The medication fact sheets at MotherToBaby, which are put together by experts in teratology (the study of birth defects).
  • The InfantRisk Forums, part of the InfantRisk Center at the Texas Tech University Health Sciences Center.  Forum questions about medication safety are answered by administrators, who are qualified medical professionals.  The InfantRisk Center also has an app, although I haven’t tried it myself.
  • The Massachusetts General Hospital Center for Women’s Mental Health has a ton of info about mental health and psychiatric medications during pregnancy, although you sometimes have to dig around a bit in their archives.

3.  Consider the risks of not taking medication.

The discourse around taking medication while pregnant (or indeed, doing anything while pregnant) revolves around minimizing risk.  There is a general tendency for people to focus on the risk of doing something, as in, “if there’s even the tiniest risk of taking this medication, I won’t do it.”  But what about the risks of not doing?

For example, imagine you’re pregnant and thinking about taking some acetaminophen (Tylenol).  Tylenol is on my OB/GYN’s “OK to take” list, and is broadly considered safe for pregnancy at appropriate doses.  But maybe you saw that study recently about there being a possible association between Tylenol during pregnancy and children’s later behavior problems, and you’re nervous.  You’re worried that you might be taking an unnecessary risk.

What are the risks of not taking that Tylenol?  It depends on your situation.

If you’re just a little sore, maybe you stretched a muscle the wrong way, or you’ve got a bit of a tension headache, there’s probably not much risk to skipping the Tylenol.

But if you’re running a fever, there are documented risks to not taking a fever-reducer like Tylenol: high fevers, particularly during the first trimester, are associated with birth defects.

If you’re in serious pain—let’s say it’s not something directly dangerous, just really uncomfortable—the risks are somewhere in the middle.  Pain stresses your body, making it pump out cortisol and other stress hormones.  Pain might make it hard for you to sleep, or to otherwise care for yourself.  We don’t know that much about how stress affects developing babies.  I wouldn’t want to imply that it has dire effects, because everyone deals with some amount of stress during pregnancy, but lessening the stress on your body is probably a good thing.

(This last one is where allergy medication falls for me: the risk of not taking it is that I will feel like absolute crap.)

With other medications, especially those that haven’t been well-studied, the risk calculation is even more complicated and specific to individual situations.  I am currently taking the antidepressant escitalopram (Lexapro), after a great deal of thought and consultation with a psychiatrist who specializes in pregnant and postpartum women.  I’m aware of what we know and don’t know about the risks of taking Lexapro during pregnancy.  I’m also aware of the risks of untreated depression in pregnant women in general, and the risks of untreated depression in me in particular.

4.  Understand how drugs are classified during pregnancy.

Whenever someone asks a med question on a mommy forum, there’s always that one person who shows up to announce that the drug in question is Category B and therefore obviously dangerous and clearly the rest of you are dolts for even considering otherwise.

That person is a pompous twit, and also wrong.

For a number of years, the U.S. Food and Drug Administration (FDA) sorted medications into five pregnancy categories, A, B, C, D, and X.  Other countries use different systems, often based on similar principles.  As of mid-2015, the FDA officially stopped using the five-category system, but it’s still widely in common use for discussing drug risks, and it’s useful to know what the categories mean.  (It’s also not clear to me that the new labeling rules, which supposedly provide more information, are actually in use yet.)

Here’s what the categories mean:

Category A:  There have been controlled human studies showing no risk to taking this drug in the first trimester, and there is no evidence of risk in other trimesters.

Very few meds are in Category A.  It’s actually pretty hard to find examples.  Folic acid (you know, the stuff in your prenatal vitamin that helps spinal development) is Category A.  Many thyroid replacement hormones are Category A.

Category B:  There have not been controlled human studies, but the existing evidence (including animal studies) indicates there are no serious risks.

Pretty much everything that’s basically fine is in Category B.  The meds on my OB/GYN’s “OK to take” list are Category B.  Tylenol is Category B, as are some antibiotics, some allergy medications, and a variety of other things.

There is, I think, a tendency for laypeople to assume that drugs end up in Category B because they’re inherently not as safe as drugs in Category A, and that isn’t true.  A lot of meds end up stuck in Category B because it’s really, really difficult—not to mention frequently ethically problematic—to run controlled trials, the kind where you assign people to treatment and non-treatment (control) groups in advance, in pregnant women.  You can ask women about their med usage and compare outcomes, as they did in the Tylenol study mentioned above, but a lot more confounding factors can creep in that way.

(Somewhat weirdly, Category B does include drugs that have had controlled human studies with good outcomes—if there are also animal studies that show possible risk.  As always, talk to your doctor for details on your particular drug.)

Category C:  There are limited data in humans, and maybe some animal data showing risk.

There are a bunch of different combinations of data (or lack thereof) that can put something in Category C.  There’s “we don’t have formal studies on this, but women have been taking it for a while and it doesn’t seem to cause anything dramatically bad.”  There’s “we can poison animals with really high doses of this, but we don’t have human data.”  There’s “we’ve seen this cause withdrawal symptoms in newborns but it doesn’t seem to have any long-term effects on their development.”  In short, Category C meds are not known to be safe, but they are also not known to be unsafe.

General pregnancy references often lump Category C meds in the “don’t take this” group, but what they mean is “don’t take this without consulting your doctor about your own personal situation.”  Any source that tries to tell you Category C drugs are absolutely unsafe should be treated with great suspicion.

Examples of Category C medications include my Lexapro and several other antidepressants, some types of antibiotics, and the antiviral Tamiflu.

Category D:  Human data show that this drug can have negative effects on developing babies, but the benefits might still outweigh the risks in certain situations.

If you’re dealing with a serious health situation—epilepsy, cancer, etc.—and less risky drugs are not available or appropriate, a doctor may consider giving you something from Category D.

Interesting fact: the common painkiller ibuprofen (Advil) is in Category D in the third trimester.

Category X:  Human data show that this drug is dangerous and should not be taken during pregnancy.

Category X includes things like thalidomide (infamously prescribed for morning sickness in the late 1950s), methotrexate (used, among other things, to treat ectopic pregnancies), and isotretinoin (the prescription acne medication Accutane).

5.  Don’t panic.

And carry a towel.  (Because if I can’t make Hitchhiker’s Guide to the Galaxy jokes on my own blog, where can I?)

Do I worry, sometimes, that taking Lexapro and allergy medications and the occasional Tylenol will hurt my growing baby?  Yes.  But I’ve talked about my worries with my doctors, and I trust them, and I trust myself.

Be thoughtful and be cautious—but take care of yourself.

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The blessing of Tylenol

Little Boy woke in the night with a mid-level fever, moaning and crying and generally unhappy.  I gave him an age-appropriate dose of Tylenol, then sat back in the rocking chair to soothe his wee self.  As we snuggled, his hot head pressing against my shoulder, I felt a surge of gratitude for that basic drug, and for all of modern medicine.  I don’t have to sit through the night, listening to his cries of discomfort and praying for the fever to break.  I can make him comfortable and loved and relaxed and give him the sleep his body needs.

What’s your favorite part of modern medicine?