Chapter 18.

Immunization Issues for Pregnant Women Ideally, women of childbearing age should be immunized before becoming pregnant to protect their babies against serious diseases. For instance, rubella causes serious damage to the unborn fetus and is preventable by rubella vaccine. Varicella (chickenpox) can cause birth defects in the fetus and fatal pneumonia in the mother; it is preventable by varicella vaccine. Teta.n.u.s in the newborn, often fatal, is prevented if the mother has been immunized, as is the case with many other vaccine-preventable diseases.

Although many medications, including some vaccines, are avoided during pregnancy because of potential harm to the mother or fetus, some vaccines are actually recommended for pregnant women. Certain immunizations during pregnancy will enhance the mother's health and others will protect the child by means of the mother's antibodies that remain in the child for the first 36 months of life.

While certain drugs may harm the developing fetus, the risk of a developing fetus being harmed by vaccination of the mother during pregnancy remains only theoretical. Currently, no evidence exists of risk from vaccinating pregnant women with any inactivated viral or bacterial vaccine or toxoid. Live attenuated vaccines, including MMR [measles, mumps, and rubella] and varicella, are of greater theoretical concern, so it is recommended that women avoid pregnancy as a "Immunization Issues: Vaccines for Pregnant Women," 2007 National Network for Immunization Information (www.immunizationinfo.org). Reprinted with permission.

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Pregnancy and Birth Sourcebook, Third Edition precautionary measure for at least 28 days after administration of these vaccines. This 28-day rule is used even though there is no evidence in prior studies of damage to the fetus when the pregnant mother received one of these vaccines.

Pregnant women and health care providers should always consider the risks and benefits of the vaccine as well as the risks of the disease before administering or receiving the vaccine. Immunization before conception is always preferred to immunization during pregnancy to prevent disease in the child. After delivery, women susceptible to rubella or varicella should be immunized with MMR or varicella vaccine before discharge from the hospital.

Breast-feeding does not interfere with the response to the vaccines recommended for adults. Although rubella vaccine virus has been found in human milk, this and other vaccines provided to the mother during pregnancy or immediately postpartum have not been shown to interfere with the immune response of children to the vaccine. Also, no child has developed illness from a vaccine administered to their mother. Human milk contains antibodies and other factors that may help protect infants against many infectious diseases.

The Centers for Disease Control and Prevention (CDC) has published a recommended adult immunization schedule [http://www.cdc .gov/vaccines/recs/schedules/adult-schedule.htm], including for pregnant women.

Vaccines Recommended for All Pregnant Women Influenza: Pregnant women who become infected with influenza viruses are at increased risk of hospitalization, serious medical complications, and adverse pregnancy outcomes. Immunization of the pregnant woman with inactivated influenza virus vaccine is effective at reducing febrile respiratory infections in pregnant woman. Immuniz-ing the mother during pregnancy also protects her newborn because she pa.s.ses immune antibodies across the placenta (influenza antibodies are actually higher in umbilical cord blood than in the mother's blood). Infants with influenza virus infection account for many hospitalizations and are predisposed to bacterial respiratory infections. Pregnant women who become infected with influenza viruses are at increased risk of hospitalization, serious medical complications, and adverse pregnancy outcomes. Immunization of the pregnant woman with inactivated influenza virus vaccine is effective at reducing febrile respiratory infections in pregnant woman. Immuniz-ing the mother during pregnancy also protects her newborn because she pa.s.ses immune antibodies across the placenta (influenza antibodies are actually higher in umbilical cord blood than in the mother's blood). Infants with influenza virus infection account for many hospitalizations and are predisposed to bacterial respiratory infections.

Childhood deaths a.s.sociated with influenza virus infection occur most frequently in infants less than 6 months of age. Unfortunately, during the first 6 months of life, there are no vaccines or anti-influenza virus drugs available. For these reasons, pregnant women should receive inactivated influenza virus vaccine and those who will be helping to care for the newborn should be vaccinated as well. Studies of 160 Immunization Issues for Pregnant Women influenza vaccination of more than 2,000 pregnant women have demonstrated no adverse effects to the fetus from the vaccine. However, the nasal influenza vaccine should not be given to pregnant women because it is a live virus vaccine.

Teta.n.u.s: Teta.n.u.s in newborn infants-once common throughout the Americas-is prevented if the mother has been immunized. This is because an immune mother pa.s.ses antibodies to the baby across the placenta. The mother is immune if she has been immunized before becoming pregnant or during pregnancy. An expectant mother whose teta.n.u.s immunization status is uncertain or whose last immunization was more than 10 years ago should be immunized against teta.n.u.s. This is usually given combined with diphtheria toxoid vaccine (a product called Td). Recently a new Td vaccine that also contains vaccine for pertussis has been licensed for adults (Tdap) including for use for women in the child-bearing age group. Pregnancy is not a contraindication to Tdap immunization. However, at this time, CDC recommends that pregnant women who received the last teta.n.u.s toxoid-containing vaccine less than 10 years ago receive Tdap in the post-partum period according to the routine vaccination recommendations. If the last dose of teta.n.u.s toxoid-containing vaccine was more than 10 years before, they prefer that she be immunized with Td during the second and third trimester instead of Tdap. Teta.n.u.s in newborn infants-once common throughout the Americas-is prevented if the mother has been immunized. This is because an immune mother pa.s.ses antibodies to the baby across the placenta. The mother is immune if she has been immunized before becoming pregnant or during pregnancy. An expectant mother whose teta.n.u.s immunization status is uncertain or whose last immunization was more than 10 years ago should be immunized against teta.n.u.s. This is usually given combined with diphtheria toxoid vaccine (a product called Td). Recently a new Td vaccine that also contains vaccine for pertussis has been licensed for adults (Tdap) including for use for women in the child-bearing age group. Pregnancy is not a contraindication to Tdap immunization. However, at this time, CDC recommends that pregnant women who received the last teta.n.u.s toxoid-containing vaccine less than 10 years ago receive Tdap in the post-partum period according to the routine vaccination recommendations. If the last dose of teta.n.u.s toxoid-containing vaccine was more than 10 years before, they prefer that she be immunized with Td during the second and third trimester instead of Tdap.

Vaccines That Pregnant Women Should Not Receive Generally, live-attenuated vaccines are contraindicated for pregnant women because of the theoretical risk of transmission of the vaccine virus to the fetus. The following live, attenuated vaccines should not be administered during pregnancy except in unusual circ.u.mstances: * influenza live virus vaccine (nasal spray) * oral poliovirus vaccine (no longer distributed in the United States) * measles-containing vaccines * mumps-containing vaccines * rubella-containing vaccines * smallpox (vaccinia) vaccine * typhoid vaccine (Ty21a) 161.

Pregnancy and Birth Sourcebook, Third Edition * varicella (chickenpox) live virus vaccine * yellow fever vaccine Varicella: Varicella (or, chickenpox) vaccine is universally recommended for all children and nonpregnant adults who are susceptible, but it is not given to pregnant women. Pregnant women who develop chickenpox (varicella) are at increased risk of having severe illness and a small proportion of their newborns may be born with congenital varicella syndrome. Susceptible women who are exposed to varicella (or shingles, which is caused by the same virus) should receive varicella-zoster immune globulin (VariZIG) within 96 hours, which may prevent or modify infection. Antiviral drugs usually are reserved for pregnant women with severe chickenpox illness. Infants born to mothers who had chickenpox within 5 days of delivery are also given VariZIG within 48 hours of delivery to prevent them from having serious illness. Vaccination with varicella live virus vaccine during pregnancy is not recommended, although inadvertent vaccinations have not been a.s.sociated with adverse outcomes. A pregnant household member is not a contraindication for varicella immunization of a child within that household, however. Varicella (or, chickenpox) vaccine is universally recommended for all children and nonpregnant adults who are susceptible, but it is not given to pregnant women. Pregnant women who develop chickenpox (varicella) are at increased risk of having severe illness and a small proportion of their newborns may be born with congenital varicella syndrome. Susceptible women who are exposed to varicella (or shingles, which is caused by the same virus) should receive varicella-zoster immune globulin (VariZIG) within 96 hours, which may prevent or modify infection. Antiviral drugs usually are reserved for pregnant women with severe chickenpox illness. Infants born to mothers who had chickenpox within 5 days of delivery are also given VariZIG within 48 hours of delivery to prevent them from having serious illness. Vaccination with varicella live virus vaccine during pregnancy is not recommended, although inadvertent vaccinations have not been a.s.sociated with adverse outcomes. A pregnant household member is not a contraindication for varicella immunization of a child within that household, however.

The varicella vaccine virus rarely spreads from a vaccinated person who develops rash to susceptible persons within households. The risk for a susceptible pregnant woman and her fetus should be very low after this type of exposure. However, the pregnant woman who believes that she is susceptible to chickenpox and who has a household exposure to someone who develops rash after varicella immunization should inform her physician.

Ideally, women should be immune to chickenpox before pregnancy, either from vaccine or chickenpox. At the completion of pregnancy, susceptible women should receive the first dose of chickenpox vaccine before discharge from the healthcare facility. A second dose should be administered four to eight weeks later.

Measles, mumps, and rubella: Measles, mumps, and rubella live virus vaccines-usually given together as MMR-should not be administered during pregnancy. However, because measles increases the risk for spontaneous abortion or premature delivery, pregnant susceptible women are given immune globulin within six days of exposure. The mumps virus has not been a.s.sociated with problems during pregnancy. Wild rubella virus infection in early pregnancy has a high risk of causing congenital rubella syndrome (CRS) in fetuses. This is a devastating disease that is preventable by the use of vaccine prior 162 Measles, mumps, and rubella live virus vaccines-usually given together as MMR-should not be administered during pregnancy. However, because measles increases the risk for spontaneous abortion or premature delivery, pregnant susceptible women are given immune globulin within six days of exposure. The mumps virus has not been a.s.sociated with problems during pregnancy. Wild rubella virus infection in early pregnancy has a high risk of causing congenital rubella syndrome (CRS) in fetuses. This is a devastating disease that is preventable by the use of vaccine prior 162 Immunization Issues for Pregnant Women to pregnancy. Pregnant women are screened early in pregnancy to be certain that they are immune. If susceptible and exposed, the pregnant woman and her physician together will need to consider her options. The rubella-susceptible woman should be immunized with MMR in the immediate post-partum period. However, CDC has followed the outcomes of inadvertent rubella vaccination of pregnant women and no cases of CRS have been detected.

Transmission of MMR vaccine viruses within households has not been demonstrated (except rubella virus from nursing mothers to their infants). Thus, susceptible children should be immunized whether or not there is a pregnant household contact.

Yellow fever: Live attenuated yellow fever vaccine is not known to cause developmental malformations. It is only administered to pregnant women if travel to an endemic area where she is going to be at risk of exposure to yellow fever is unavoidable. Live attenuated yellow fever vaccine is not known to cause developmental malformations. It is only administered to pregnant women if travel to an endemic area where she is going to be at risk of exposure to yellow fever is unavoidable.

Typhoid fever: Neither the live attenuated Ty21a nor the Vi polysaccharide typhoid fever vaccines have been tested in pregnant or breastfeeding women. Some experts might consider the polysaccharide vaccine for pregnant or lactating women if travel to an endemic area is unavoidable and she is likely to be at risk of exposure to Sal-monella typhi (the cause of typhoid fever). Neither the live attenuated Ty21a nor the Vi polysaccharide typhoid fever vaccines have been tested in pregnant or breastfeeding women. Some experts might consider the polysaccharide vaccine for pregnant or lactating women if travel to an endemic area is unavoidable and she is likely to be at risk of exposure to Sal-monella typhi (the cause of typhoid fever).

Vaccines for Some Pregnant Women The following vaccines should be considered for pregnant women who are at risk for acquiring or being exposed to these diseases. Because spontaneous abortion occurs more commonly in the first trimester of pregnancy, some obstetricians prefer to avoid administering vaccines during this time, if possible, to avoid any temporal a.s.sociations that might occur. Specific recommendations for travel by pregnant women (and others) can be obtained at www.cdc.gov/travel.

Hepat.i.tis B virus: Hepat.i.tis B (HBV) infection during pregnancy can result in severe disease for both the mother, the fetus, and ultimately for the neonate. Immunization is recommended universally in the United States for everyone under the age of 18 years and those older than that who have increased risk of exposure. Pregnancy is not a contraindication for HBV immunization and vaccine should be given to persons with occupational or lifestyle risks, special patients risk groups (such as those undergoing hemodialysis), those who have another s.e.xually transmitted disease, household and s.e.xual contacts of 163 Hepat.i.tis B (HBV) infection during pregnancy can result in severe disease for both the mother, the fetus, and ultimately for the neonate. Immunization is recommended universally in the United States for everyone under the age of 18 years and those older than that who have increased risk of exposure. Pregnancy is not a contraindication for HBV immunization and vaccine should be given to persons with occupational or lifestyle risks, special patients risk groups (such as those undergoing hemodialysis), those who have another s.e.xually transmitted disease, household and s.e.xual contacts of 163 Pregnancy and Birth Sourcebook, Third Edition HBV carriers, prison inmates, and for international travelers to endemic areas. All pregnant women should have early prenatal screening for immunity and, if susceptible and if they have a risk factor, should be immunized.

All pregnant women should be screened for active hepat.i.tis B virus infection because most women who are infected do not know it and, if they have hepat.i.tis B infection, the newborn infant will need to receive a birth dose of hepat.i.tis B vaccine and hepat.i.tis B immune globulin-giving both within hours of birth reduces the likelihood that the child will become infected with hepat.i.tis B virus and, if infected, reduces the chances that the baby will be chronically infected.

Pneumococcal infection: Pneumococcal polysaccharide vaccine (PPV23) is indicated for specific medical conditions (such as asplenia Pneumococcal polysaccharide vaccine (PPV23) is indicated for specific medical conditions (such as asplenia [absence of the spleen], metabolic, renal, cardiac, and pulmonary diseases, and immunosuppression). Pregnant women with those conditions should also receive the vaccine, preferably prior to pregnancy-but it can be given to a pregnant woman if she has not previously been immunized.

Rabies exposure: The risk of rabies far exceeds the theoretical risk from the vaccine if the expectant mother has been exposed to the disease. The risk of rabies far exceeds the theoretical risk from the vaccine if the expectant mother has been exposed to the disease.

Meningococcal infection: Studies of pregnant women immunized with meningococcal polysaccharide vaccine and their newborns have not demonstrated any adverse effects. This means that that vaccine would likely be safe for a pregnant woman at high risk for meningococcal infection. Because the new meningococcal conjugate vaccine (MCV4) is the preferred vaccine for people 1155 years of age, many experts would prefer to give MCV4 in this setting, although there are no data on the safety of MCV4 during pregnancy. Studies of pregnant women immunized with meningococcal polysaccharide vaccine and their newborns have not demonstrated any adverse effects. This means that that vaccine would likely be safe for a pregnant woman at high risk for meningococcal infection. Because the new meningococcal conjugate vaccine (MCV4) is the preferred vaccine for people 1155 years of age, many experts would prefer to give MCV4 in this setting, although there are no data on the safety of MCV4 during pregnancy.

Hepat.i.tis A: Pregnant women are at risk of acquiring hepat.i.tis A virus infection if there is someone infected in the household, if they have occupational exposure, or if traveling to areas where hepat.i.tis A is endemic. Although formal studies of hepat.i.tis A vaccine in pregnant women have not been performed, the vaccine is produced from inactivated virus so the theoretical risk for the fetus should be low. Pregnant women are at risk of acquiring hepat.i.tis A virus infection if there is someone infected in the household, if they have occupational exposure, or if traveling to areas where hepat.i.tis A is endemic. Although formal studies of hepat.i.tis A vaccine in pregnant women have not been performed, the vaccine is produced from inactivated virus so the theoretical risk for the fetus should be low.

The vaccine has been used in pregnant women without adverse events having been reported. Because international travel is now the most frequent source of exposure for Americans to hepat.i.tis A, vaccination 164 Immunization Issues for Pregnant Women prior to travel to endemic areas is particularly important. For pregnant women who have been exposed to hepat.i.tis A virus, testing for susceptibility may be warranted but should not delay the administration of immune globulin (gamma globulin).

Polio: Wild-type polioviruses have been eliminated in the United States and thus there is not usually an indication for immunization of the pregnant woman except for those women traveling to endemic areas. If polio vaccine is indicated, only the inactivated vaccine should be given to a pregnant woman and not the oral live virus vaccine. Wild-type polioviruses have been eliminated in the United States and thus there is not usually an indication for immunization of the pregnant woman except for those women traveling to endemic areas. If polio vaccine is indicated, only the inactivated vaccine should be given to a pregnant woman and not the oral live virus vaccine.

Anthrax: Women vaccinated against anthrax earlier in life have had no problems with their pregnancies or babies. No studies have been published regarding use of anthrax vaccine among pregnant women, although an ongoing study by the Naval Health Research Center and the National Center for Birth Defects and Developmental Disabilities suggest that children born to women who were immunized with anthrax vaccine in the first trimester of pregnancy could have an increased risk of birth defects. The Advisory Committee for Immunization Practices recommends that pregnant women not be vaccinated against anthrax. However, in the circ.u.mstances of an exposure to aerosolized anthrax (such as might occur in a bioterror attack), the theoretical risks of the vaccine would likely be far less than the risk of disease; pregnant women should be vaccinated against anthrax only if the potential benefits of vaccination outweigh the potential risks to the fetus. Women vaccinated against anthrax earlier in life have had no problems with their pregnancies or babies. No studies have been published regarding use of anthrax vaccine among pregnant women, although an ongoing study by the Naval Health Research Center and the National Center for Birth Defects and Developmental Disabilities suggest that children born to women who were immunized with anthrax vaccine in the first trimester of pregnancy could have an increased risk of birth defects. The Advisory Committee for Immunization Practices recommends that pregnant women not be vaccinated against anthrax. However, in the circ.u.mstances of an exposure to aerosolized anthrax (such as might occur in a bioterror attack), the theoretical risks of the vaccine would likely be far less than the risk of disease; pregnant women should be vaccinated against anthrax only if the potential benefits of vaccination outweigh the potential risks to the fetus.

Human papillomavirus: Although the initial clinical trials of human papillomavirus (HPV) vaccine specifically excluded pregnant women, 1,244 pregnancies occurred in the vaccine group and 1,272 Although the initial clinical trials of human papillomavirus (HPV) vaccine specifically excluded pregnant women, 1,244 pregnancies occurred in the vaccine group and 1,272 occurred among the women who received placebo. There were no differences in the rates of miscarriage, late pregnancy fetal deaths, or birth defects among their babies. Infants of 500 women who were breast feeding when they received vaccine had no more adverse events than did those who got placebo and none of the events was considered related to vaccine. The FDA [U.S. Food and Drug Administration]

has established a registry to record the outcomes of pregnancy among women who are inadvertently given HPV vaccine while pregnant.

References Gall, SA 2003. Maternal Immunization. Obstetrics and Gynecology Clinics of North America, Obstetrics and Gynecology Clinics of North America, 30(4):632636. 30(4):632636.

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Pregnancy and Birth Sourcebook, Third Edition CDC (2008). Guiding principles for development of ACIP recommendations for vaccination during pregnancy and breast- feeding. MMWR MMWR 57(21): 580. 57(21): 580.

CDC (2009). Recommended adult immunization schedule- United States, 2009. MMWR MMWR 57(53):Q14. 57(53):Q14.

Zaman K, Roy E, Arifeen SE, et al. 2008. Effectiveness of maternal influenza immunization in mothers and infants. N Engl N Engl J Med J Med 359: 155564. 359: 155564.

CDC. 2008. Summary of ACIP recommendations for preven- tion of pertussis, teta.n.u.s and diphtheria among pregnant and postpartum women and their infants. MMWR MMWR 57(04):489. 57(04):489.

CDC (2008). Prevention and control of influenza: Recommen- dations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR, MMWR, 57 (RR-07), 160. 57 (RR-07), 160.

AAP, Committee on Infectious Diseases (2006). Varicella- Zoster Infections. In: LK Pickering (Ed.), Red Book: Report of Red Book: Report of the Committee on Infectious Diseases the Committee on Infectious Diseases (27th ed., pp. 71125). (27th ed., pp. 71125).

Elk Grove Village, IL.

AAP, Committee on Infectious Diseases (2006). Rubella. In: LK Pickering (Ed.), Red Book: Report of the Committee on Infectious Diseases Red Book: Report of the Committee on Infectious Diseases (27th ed., pp. 5749). Elk Grove Village, IL. (27th ed., pp. 5749). Elk Grove Village, IL.

American College of Obstetricians and Gynecologists (2003).

Immunization during Pregnancy. ACOG Committee Opinion 282.

CDC (2006). General recommendations on immunization: recommendations of the Advisory Committee on Immuniza- tion Practices (ACIP). MMWR MMWR 55(RR15);148. 55(RR15);148.

CDC (2002). Notice to Readers: Status of U.S. Department of Defense Preliminary Evaluation of the a.s.sociation of Anthrax Vaccination and Congenital Anomalies. MMWR MMWR February 15, 2002 / 51(06);127. February 15, 2002 / 51(06);127.

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Chapter 19.

Taking Medicines during Pregnancy Chapter Contents.Section 19.1-Is It Safe to Use Medicines during Pregnancy? ........................................................... 168 Section 19.2-Aspirin and Pregnancy ....................................... 173 167.

Pregnancy and Birth Sourcebook, Third Edition Section 19.1 Is It Safe to Use Medicines during Pregnancy?

Excerpted from "Pregnancy and Medicines: Frequently Asked Questions," by the Office of Women's Health (www.4women.gov), part of the U.S. Department of Health and Human Services, May 1, 2007.

Is it safe to use medicine while I am pregnant?

There is no clear-cut answer to this question. Before you start or stop any medicine, it is always best to speak with the doctor who is caring for you while you are pregnant. Read on to learn about deciding to use medicine while pregnant.

How should I decide whether to use a medicine while I am pregnant?

When deciding whether to use a medicine in pregnancy, you and your doctor need to talk about the medicine's benefits and risks.

* Benefits: Benefits: What are the good things the medicine can do for me and my growing baby (fetus)? What are the good things the medicine can do for me and my growing baby (fetus)?

* Risks: Risks: What are the ways the medicine might harm me or my growing baby (fetus)? What are the ways the medicine might harm me or my growing baby (fetus)?

There may be times during pregnancy when using medicine is a choice. Some of the medicine choices you and your doctor make while you are pregnant may differ from the choices you make when you are not pregnant. For example, if you get a cold, you may decide to "live with" your stuffy nose instead of using the "stuffy nose" medicine you use when you are not pregnant.

Other times, using medicine is not a choice-it is needed. Some women need to use medicines while they are pregnant. Sometimes, women need medicine for a few days or a couple of weeks to treat a problem like a bladder infection or strep throat. Other women need to use medicine every day to control long-term health problems like asthma, diabetes, depression, or seizures. Also, some women have a 168 Taking Medicines during Pregnancy pregnancy problem that needs medicine treatment. These problems include severe nausea and vomiting, earlier pregnancy losses, or preterm labor.

How do prescription and over-the-counter (OTC) medicine labels help my doctor choose the right medicine for me when I am pregnant?

Doctors use information from many sources when they choose medicine for a patient, including medicine labels. To help doctors, the U.S.

Food and Drug Administration (FDA) created pregnancy letter categories to help explain what is known about using medicine during pregnancy. This system a.s.signs letter categories to all prescription medicines. The letter category is listed in the label of a prescription medicine. The label states whether studies were done in pregnant women or pregnant animals and if so, what happened. Over-the-counter (OTC) medicines do not have a pregnancy letter category. Some OTC medicines were prescription medicines first and used to have a letter category. Talk to your doctor and follow the instructions on the label before taking OTC medicines.

The FDA chooses a medicine's letter category based on what is known about the medicine when used in pregnant women and animals.

The FDA is working hard to gather more knowledge about using medicine during pregnancy. The FDA is also trying to make medicine labels more helpful to doctors. Medicine label information for prescription medicines is now changing, and the pregnancy part of the label will change over the next few years.

OTC medicines: All OTC medicines have a Drug Facts label. The Drug Facts label is arranged the same way on all OTC medicines. This makes information about using the medicine easier to find. One section of the Drug Facts label is for pregnant women. With OTC medicines, the label usually tells a pregnant woman to speak with her doctor before using the medicine. Some OTC medicines are known to cause certain problems in pregnancy. The labels for these medicines give pregnant women facts about why and when they should not use the medicine. Here are some examples: All OTC medicines have a Drug Facts label. The Drug Facts label is arranged the same way on all OTC medicines. This makes information about using the medicine easier to find. One section of the Drug Facts label is for pregnant women. With OTC medicines, the label usually tells a pregnant woman to speak with her doctor before using the medicine. Some OTC medicines are known to cause certain problems in pregnancy. The labels for these medicines give pregnant women facts about why and when they should not use the medicine. Here are some examples: * Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin (acetylsalicy-late), can cause serious blood flow problems in the baby if used 169 Pregnancy and Birth Sourcebook, Third Edition Table 19.1. Definition of Medicine Categories: Prescription Medicines Definition of Medicine Categories: Prescription Medicines Pregnancy Category Definition Examples of Drugs A.

In human studies, pregnant women Folic acid; used the medicine and their babies did Levothyroxine (thyroid not have any problems related to using hormone medicine) the medicine.

B.

In humans, there are no good studies.

Some antibiotics like But in animal studies, pregnant animals amoxicillin; Zofran received the medicine, and the babies (ondansetron) for did not show any problems related to the nausea; Glucophage medicine.

(metformin) for dia- Or in animal studies, pregnant animals betes; some insulin received the medicine, and some babies used to treat diabe- had problems. But in human studies, tes such as regular pregnant women used the medicine and and NPH [neutral their babies did not have any problems protamine Hagedorn]

related to using the medicine.

insulin C.

In humans, there are no good studies.

Diflucan (fluconazole) In animals, pregnant animals treated with for yeast infections; the medicine had some babies with prob- Ventolin (albuterol) lems. However, sometimes the medicine for asthma; Zoloft may still help the human mothers and (sertraline) and babies more than it might harm.

Prozac (fluoxetine) Or no animal studies have been done, for depression and there are no good studies in preg- nant women.

D.

Studies in humans and other reports Paxil (paroxetine) show that when pregnant women use for depression; the medicine, some babies are born with Lithium for bipolar dis- problems related to the medicine. How- order; Dilantin ever, in some serious situations, the (phenytoin) for epilep- medicine may still help the mother and tic seizures; some the baby more than it might harm.

cancer chemotherapy X.

Studies or reports in humans or animals Accutane show that mothers using the medicine (isotretinoin) for cystic during pregnancy may have babies with acne; Thalomid (tha- problems related to the medicine. There lidomide) for a type of are no situations where the medicine can skin disease help the mother or baby enough to make the risk of problems worth it. These medi- cines should never be used by pregnant women.

170.

Taking Medicines during Pregnancy during the last third of pregnancy (after 28 weeks). Also, aspirin may increase the chance for bleeding problems in the mother and the baby during pregnancy or at delivery.

* The labels for nicotine therapy drugs, like the nicotine patch and lozenge, remind women that smoking can harm an unborn child. While the medicine is thought to be safer than smoking, the risks of the medicine are not fully known. Pregnant smokers are told to try quitting without the medicine first.

What if I'm thinking about getting pregnant?

If you are not pregnant yet, you can help your chances for having a healthy baby by planning ahead. Schedule a pre-pregnancy checkup.

At this visit, you can talk to your doctor about the medicines, vitamins, and herbs you use. It is very important that you keep treating your health problems while you are pregnant. Your doctor can tell you if you need to switch your medicine. Ask about vitamins for women who are trying to get pregnant. All women who can get pregnant should take a daily vitamin with folic acid (a B vitamin) to prevent birth defects of the brain and spinal cord. You should begin taking these vitamins before you become pregnant or if you could become pregnant. It is also a good idea to discuss caffeine, alcohol, and smoking with your doctor at this time.

Is it safe to use medicine while I am trying to become preg- nant?

It is hard to know exactly when you will get pregnant. Once you do get pregnant, you may not know you are pregnant for 10 to 14 days or longer. Before you start trying to get pregnant, it is wise to schedule a meeting with your doctor to discuss medicines that you use daily or every now and then. Sometimes, medicines should be changed, and sometimes they can be stopped before a woman gets pregnant. Each woman is different. So you should discuss your medicines with your doctor rather than making medicine changes on your own.

What if I get sick and need to use medicine while I am pregnant?

Whether or not you should use medicine during pregnancy is a serious question to discuss with your doctor. Some health problems need treatment. Not using a medicine that you need could harm you 171 Pregnancy and Birth Sourcebook, Third Edition and your baby. For example, a urinary tract infection (UTI) that is not treated may become a kidney infection. Kidney infections can cause preterm labor and low birth weight. An antibiotic is needed to get rid of a UTI. Ask your doctor whether the benefits of taking a certain medicine outweigh the risks for you and your baby.

I have a health problem. Should I stop using my medicine while I am pregnant?

If you are pregnant or thinking about becoming pregnant, you should talk to your doctor about your medicines. Do not stop or change them on your own. This includes medicines for depression, asthma, diabetes, seizures (epilepsy), and other health problems. Not using medicine that you need may be more harmful to you and your baby than using the medicine.

For women living with HIV [human immunodeficiency virus], the Centers for Disease Control and Prevention (CDC) recommends using zidovudine (AZT) during pregnancy. Studies show that HIV positive women who use AZT during pregnancy greatly lower the risk of pa.s.sing HIV to their babies. If a diabetic woman does not use her medicine during pregnancy, she raises her risk for miscarriage, stillbirth, and some birth defects. If asthma and high blood pressure are not controlled during pregnancy, problems with the fetus may result.

Are vitamins safe for me while I am pregnant?

Regular multivitamins and prenatal vitamins are safe to take during pregnancy and can be helpful. Women who are pregnant or trying to get pregnant should take a daily multivitamin or prenatal vitamin that contains at least 400 micrograms (mcg) of folic acid. It is best to start taking these vitamins before you become pregnant or if you could become pregnant. Folic acid reduces the chance of a baby having a neural tube defect, like spina bifida, where the spine or brain does not form the right way. Iron can help prevent a low blood count (anemia). It's important to take the vitamin dose prescribed by your doctor. Too many vitamins can harm your baby. For example, very high levels of vitamin A have been linked with severe birth defects.

Are herbal remedies, "natural" products, or dietary supplements safe for me while I am pregnant?

Except for some vitamins, little is known about using dietary supplements while pregnant. Some herbal remedy labels claim they 172 Taking Medicines during Pregnancy will help with pregnancy. But, most often there are no good studies to show if these claims are true or if the herb can cause harm to or your baby. Talk with your doctor before using any herbal product or dietary supplement. These products may contain things that could harm you or your growing baby during your pregnancy.