Prescribing medications safely during pregnancy

A large body of information about medications prescribed during pregnancy is readily available to internists and patients either on-line or through books and medical journals. Much of the evidence about many prescribed drugs is either anecdotal or presented with sufficient warnings about its use during pregnancy. This article discusses specific medications to set the risks and benefits into a more proper perspective, thereby alleviating certain fears and, when necessary, improving compliance.     

Exposure to alcohol-containing medications during pregnancy

QUESTION: A pregnant patient consulted her physician after discovering that a diphenhydramine preparation (Benadryl elixir) she used for allergy symptoms during the first trimester of her pregnancy contained 15% alcohol. Should she be concerned about fetal alcohol spectrum disorder in her baby? ANSWER: Most ethanol-containing medical preparations are safe during pregnancy. Adult doses of some elixirs with high ethanol concentrations might produce blood levels similar to those achieved by drinking 1 alcoholic beverage. Caution is advisable when prescribing ethanol-containing elixirs to pregnant women, as is informing them about the alcohol content.     

Exposure to attention deficit hyperactivity disorder medications during pregnancy

QUESTION: An 18-year-old patient of mine, currently under treatment for attention deficit hyperactivity disorder (ADHD) with methylphenidate, just found out that she is pregnant. What are the risks for the baby when the mother uses ADHD medications during pregnancy? ANSWER: Available evidence for amphetamines suggests no increased risk of malformations with use of therapeutic doses, and inadvertent exposure during pregnancy is unlikely to be harmful. Human data for methylphenidate and atomoxetine treatment in pregnancy are very limited. Documented cases do not suggest teratogenicity, but we cannot rule out this risk with the information available.     

Over-the-counter medications in pregnancy

Pregnant women commonly use over-the-counter medications. Although most over-the-counter drugs have an excellent safety profile, some have unproven safety or are known to adversely affect the fetus. The safety profile of some medications may change according to the gestational age of the fetus. Because an estimated 10 percent or more of birth defects result from maternal drug exposure, the U.S. Food and Drug Administration has assigned a risk category to each drug. Many drugs have not been evaluated in controlled trials and probably will not be because of ethical considerations. Of the commonly used over-the-counter medications, acetaminophen, chlorpheniramine, kaolin and pectin preparations, and most antacids have a good safety record. Other drugs, such as histamine H2-receptor blockers, pseudoephedrine, and atropine/diphenoxylate should be used with caution. If use of smoking cessation products is desired, the intermediate-release preparations minimize the amount of nicotine while maintaining efficacy. With all over-the-counter medications used during pregnancy, the benefit of the drug should outweigh the risk to the fetus.     

Benefits and risks of elimination diets.

Elimination diets have been used for the prevention or treatment of allergic disease with the diet of the pregnant or breastfeeding mother or the child, or both, being modulated as deemed appropriate. Evidence from studies published so far suggests that dietary restrictions are in fact effective only in the treatment of specific food allergies, not in allergy prevention. An elimination diet of a child or a breastfeeding mother entails a risk to normal nutrition and growth of the child. Although studies are lacking, dietary restrictions during lactation may well be harmful also to the mother's health. Substitution of nutritionally important foods and professional guidance are necessary for the successful treatment of food allergies.     

A practical guide to the use of psychotropic medications during pregnancy and lactation

The use of psychotropic medications during the perinatal period is often met with fear and discomfort on the part of both clinicians and patients. There is a great deal of misinformation about the risks of medication use during pregnancy and lactation. The risk of untreated or undertreated mental illness during this time is an important consideration when making treatment recommendations. This paper serves as a practical guide for clinicians who may be treating patients with psychotropic medication during the perinatal period. A heuristic tool for making treatment decisions will be introduced, and coverage of specific psychiatric disorders and medication classes will be provided.     

Benefits and risks of IgA in immunoglobulin preparations

The case of Immunoglobulin A (IgA) in transfusion medicine is unsettled: on one hand IgA is an important component of adaptive immunity and its deficiency may cause disease, on the other its presence in blood products might induce, in rare instances, allergy-like symptoms if not anaphylaxis.The practice with i.v. immunoglobulins currently changes as up to 10% concentrated preparations are given at fast rates hence even trace amounts of IgA contained in these IgG preparations can cause unexpected (side-) effects. Fortunately, the spectrum of sensitive IgA assays, along with anti-IgA screening assays now permits laboratories to narrow down IgA-dependent transfusion reactions to the real cases, in which IgA was the decisive trigger of anaphylaxis, proven or not by the presence of anti-IgA of the IgG or even IgE class. Tolerance to allogenic IgA has recently been reported. The known association of HLA with IgA deficiency (IgAD) has now been completed with an association to the nonsynonymous variant in IFHI1, allowing physicians to more precisely spot recipients at risk for an IgA-dependent transfusion reaction. Our review, along with our own experience here in Switzerland, allows us to conclude that IgA is a beneficial antibody rather than an allergen to be placed at the end of the list of non-infectious transfusion complications such as TRALI, febrile non-hemolytic reactions, purpura or volume overload.     

Emergencies caused by side effects of psychiatric medications

Psychiatric medications cause side effects in several organ systems that need emergency evaluation and treatment. Serious cardiovascular side effects include postural hypotension, cardiac conduction blockade, and SA mode dysfunction; serious neurological side effects include extrapyramidal reactions, seizures, delirium, catatonia, pseudotumor cerebri, ataxia, and glaucoma; serious genitourinary side effects include urinary retention, nephrotic syndrome, and priapism, and the serious hematological side effect of agranulocytosis. Also potentially fatal syndromes secondary to psychiatric drugs are the neuroleptic malignant syndrome, hyperandrenergic crisis, the serotonin syndrome, and lithium toxicity. Individual psychiatric drug classes most notorious for causing side effects with high morbidity and mortality are low potency neuroleptics, clozapine, tertiary tricyclics, monoamine oxidase inhibitors, and lithium.