Originally published in The Ottawa Citizen August 19, 2003
Original Title: Medication safety during pregnancy

Moms-to-be should speak to their pharmacist and doctor about prescription medications and any other drugs they might be taking’ What medications are safe to use during pregnancy? Should I stop my prescription medications? How can I treat my heartburn? Can I drink coffee?”

Health care providers need accurate information to answer these questions. Some women have medical conditions that require ongoing treatment. If they stop, they could increase the potential risk to their baby and themselves.

Minor health problems might require medical therapy, and pregnant women may use over-the-counter medications (OTCs) to treat them.

There is understandable angst and concern about medication use during pregnancy. One or two per cent of birth defects are due to drug exposure during that time. Ninety five per cent of defects are due to random chance or genetics.

It is unethical to subject pregnant women to clinical trials to establish the safety of a particular medication. The risk to the fetus and mother outweigh any potential benefit of the research — a lesson learned from the use of thalidomide.

In 1975, the U.S. Food and Drug Administration defined pregnancy risk factors for all drugs, and Motherisk (www.motherisk.org) provides a similar service to the public and health care providers.

In June, the Centre for Addiction and Mental Health (CAMH) released a booklet called Is it Safe for My Baby? It offers assessment of risk and recommendations for the use of medication, alcohol, tobacco and other drugs during pregnancy and breastfeeding.

This excellent guide reviews the safety of more than 200 substances when pregnant or breastfeeding. It includes a host of information covering over-the-counter and prescription medications, illegal drugs, herbal preparations, cosmetics, household chemicals, solvents, paints and cleaners.

The booklet’s release comes at a time when some prescription-only medications are now reclassified as OTC medications.

Pregnancy is not a static situation. Certain medications might be safe in the last trimester but not in the first. The reverse is also true. Let us look at some common concerns during pregnancy: pain, heartburn, nausea, constipation, caffeine, tobacco, marijuana and herbal remedies.

Tylenol (acetaminophen) is present in many OTC cold and flu medications. There is no known link between it and birth defects. ASA-containing products such as Aspirin and non-steroidal anti-inflammatory (NSAID) medications seem to be safe in the first two trimesters of pregnancy but only in low doses. However, greater doses might cause bleeding in the newborn, decreased birth weight and prolonged pregnancy.

Therefore, ASA and NSAIDs should not be used in the last trimester (28 to 40 weeks).

Infrequent use of Tylenol with codeine or other prescription narcotics is safe, but daily use can increase the risk of miscarriage, premature delivery and complications during delivery. If possible, stick with acetaminophen alone to treat pain.

Heartburn can worsen as the size of the uterus increases. Increasing pressure within the abdominal cavity can cause stomach acid to splash up into the esophagus. Antacids such as Tums, Maalox, Rolaids and Gaviscon are generally safe to use throughout pregnancy. If these options fail, the use of Zantac or Pepcid would be the next safe step.

For nausea, Diclectin (pyridoxine/doxylamine) is the only medication approved by the Society of Obstetricians and Gynecologists of Canada for use during pregnancy. The society does not recommend Gravol (dimenhydrinate) for routine use, but it is used in its intravenous form for severe vomiting and dehydration (hyperemesis gravidarum).

Fibre laxatives such as Metamucil or Prodiem and stool softeners Soflax and Colace are safe to use. The stimulant laxatives such as Ex-Lax, cascara and castor oil might cause uterine contractions and should be a last resort.

Caffeine in excess of 300 milligrams per day (three regular cups of coffee) can increase the risk of miscarriage and low birth weight babies. Caffeine consumption in a combination of other products such as 500 millilitre energy drinks (50 to 125 milligrams), a 45-gram chocolate bar (50 milligrams), 355-millilitre colas (30 to 90 milligrams) and a cup of tea (20 to 90 milligrams) can easily exceed the maximum allowable daily limit.

The harm from tobacco is dose-dependent. The more you smoke, the greater the miscarriage risk, premature delivery and low birth weight babies. It is the carcinogenic compounds and other chemicals rather than the nicotine that increase the health risk to the fetus.

Cannabis (marijuana) poses the same risk to the fetus as tobacco with an extra caveat: Newborns might have more sleep disturbances and other cognitive difficulties.

While some clinical data exists for some herbal remedies, the effect of others remains unknown. Ginkgo biloba can cause bleeding, dong quai (ephedra) and feverfew can induce premature labour.

Discuss your concerns with your doctor or pharmacist before taking medication and review all your prescription medications during your pregnancy.

The information booklet is available from CAMH for $2.50 (1-800-661-1111 or by contacting marketing@camh.net).

Related articles:

1. Safety of medication use during pregnancy
2. It’s vital to know how drugs interact
3. Patient Safety in Canada 2007

Originally published in The Ottawa Citizen August 7, 2001

Some women can sail through pregnancy with nary a problem while others can have a difficult time. The basis for treating these conditions rests entirely upon individual circumstances. If these problems interfere with ones ability to function consult with your doctor. Ask about the available treatment options. It is important to have options and to be comfortable with the decision one makes when opting for a particular treatment.

Heartburn is a common problem occurring any time during pregnancy. It is caused by fetal growth. The enlarging uterus exerts pressure on the stomach forcing acid into the esophagus potentially causing ulcers within it. It tends to be more painful at night when acid production is greatest.

When the pain becomes more than just an irritant, there are several solutions. Frequent small meals can help absorb some of the acid. An antacid like TUMS can alleviate minor heartburn. It also provides much needed calcium. In moderate to severe cases, Zantac (Ranitidine) is used. Both medications are safe to use during pregnancy.

Nausea and vomiting tends to be most severe in the first 12 weeks of pregnancy. It can markedly reduce one’s food and water intake. In severe cases, the patient is hospitalized because of weight loss and dehydration. The only SOGC (Society of Obstetricians and Gynecologists of Canada) approved medication for the treatment of nausea in pregnancy is Diclectin.

The effect of one’s work environment at home or office should not be understated. Many pregnant women intend to work for as long as possible. However for some their physical stamina wanes. Back and hip pain makes it difficult to sit or stand for extended periods of time. Fatigue catches up to them earlier in the day. Left unchecked these problems can lead to exhaustion and for some, depression. I strongly suggest that patients pay close attention to what their body tells them. It is important to maximize one’s emotional and physical strength for delivery and the post-partum period.

When, where and how deliveries occur is another area of interest for many. One commonly hears that subsequent deliveries are always faster than the first. Not necessarily. Complications can slow labour. These include big shoulders, a large or poorly positioned head and ineffective contractions.

Complications can be unexpected. Last month, Ms. P. had a perfect delivery. However her placenta, usually delivered within five to 30 minutes after the baby, became stuck within the uterus. It prevented the uterus from contracting. Within 30 minutes about a litre of blood was lost. An adult has a blood volume of about 5 litres. Medication and manual removal of the placenta controlled the bleeding. Appropriate pain relief was used before its removal. Had she been at home, she may have bled to death before being able to reach the hospital.

Last month I attended another “normal” labour and delivery. Once the baby was delivered, he would not breathe. There were no warning signs that this would happen. He did not respond to normal stimulation. He was floppy and blue. You have four minutes before he suffers brain damage.

The neonatal team arrives within 30 seconds. They insert a tube into his airway to suction out secretions and to help him breathe. Silence envelops the room as time slows down. Everyone waits for the child to cry. The parent’s faces are frozen in fear. Within two minutes the baby starts to whimper, then cry. His skin turns pink and he moves his arms. A collective sigh, the mother and father cry. If he was born at home, he would have died.

I relate these events to you not to be a scaremonger. Labour and delivery can be unpredictable. We have one of the lowest infant and maternal mortality rates in the world. Modern obstetrical care has led parents to expect normal outcomes as a matter of fact. This is a fantastic turnaround in expectations. Seventy-five to 100 years ago, one hoped that some of their babies survived childbirth. Mr. B., a volunteer fireman and the father of Ms. P. commenting on her delivery stated, “Well, I would sooner fight a fire with a fire truck than use a bucket.” Indeed. The availability of rapid obstetric and neonatal backup that a hospital can offer is invaluable.

Home births carry an increased risk of morbidity and mortality if complications arise. Granted most home births are uncomplicated and indeed it is a more intimate and comfortable place to give birth. The degree of acceptable risk is an individual choice. But it is impossible to predict which of these normal deliveries will go wrong. Most times, you beat the odds practicing low-risk obstetrics. But the potential risk to the health of the mother and child is not to be gambled. The birth of one’s child is indeed a joyous occasion. One to two days in hospital to maximize the health and safety of the mother and child is a small inconvenience for the next 18 years raising a healthy child.

Related articles:

1. Safety with medication vital during pregnancy
2. Post partum depression
3. The choices we make