Pregnancy, Breastfeeding, and Drugs: Don't Overestimate Risk!

Pregnant women on medication are naturally concerned about possible teratogenicity, but these fears are frequently overblown and should be balanced against the need to treat chronic conditions in the mother.

When pregnant women have chronic conditions, pharmacists and other health care providers often need to discuss chronic medications with their patients who are concerned about possible tetratogenicity. HIV infection, asthma, epilepsy, and inflammatory bowel disease are just a few conditions that must be medicated throughout gestation. Disease exacerbations can influence pregnancy outcomes negatively. Yet pregnant women tend to overestimate medication-associated risks during pregnancy. Often, their information sources are “coffee klatch-based” and they hold many misconceptions. In their minds, all medication use creates a chance of major congenital malformation.

Several recent articles direct the health care provider’s attention to the perinatal period. They raise questions, summarize concerns, and offer suggestions about medication use while women are pregnant or breastfeeding.

Doreen Matsui’s review of pregnant women’s adherence to medication is a comprehensive review of adherence in general—its many types, incidence, and influencing factors—and adherence in pregnant women specifically. Pregnancy itself is one additional factor that can influence adherence. She documents that 39% of pregnant women who need medication are nonadherent, often citing their concern about potential teratogenicity as a barrier.

She suggests several measures to improve adherence. All health care providers need to address pregnant women’s fears in advance and reinforce the message throughout pregnancy. Stressing the importance of adherence to prospective mothers and their babies is an important first step. Providing evidence-based information and helping the patient understand it is essential. Directing patients to consult with a drug information service that specializes in the perinatal period can also help.

Breastfeeding

According to Frank J. Nice, author of Nonprescription Drugs for the Breastfeeding Mother, 2nd Edition (www.nicebreastfeeding.com), “More than one million mothers yearly in the United States do not breastfeed because they are given insufficient or incorrect information on medication use by their pharmacists and health care providers.”

The January 2012 issue of the Journal of the American Pharmacists Association has an exceptional review of medications and breastfeeding. Nice and coauthor Luo indicate that many health care professionals—including pharmacists—advise breastfeeding mothers against taking medication, and some mothers forgo breastfeeding, choosing to continue their medication rather than breastfeed. This is unnecessary in many cases.

These authors describe the many circumstances in which taking medication while breastfeeding is perfectly acceptable. They explain the pharmacokinetics of drug partition into breast milk. Additionally, they provide 2 lists for practicing pharmacists. The first provides questions pharmacists can use to assess the individual mother and her specific prescription or OTC medications. The second describes options if medication is contraindicated. They also discuss galactagogues—drugs and herbals used to increase milk supply—and direct readers to reliable websites for breastfeeding information.

Algorithms

Researchers have also published a decision-making algorithm for managing pregnancy in the inflammatory bowel disease patient this month. This algorithm promotes continued pharmacotherapy throughout pregnancy and during lactation, and includes coverage of biologic agents. And, a new review of the use of antiepileptic drugs (AED) during pregnancy is also available. This review covers necessary preconception counseling; the need for folate supplementation before and after conception; and approaches to selecting the most effective AED while minimizing risks. They advise avoiding polytherapy and valproate, if possible.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.