I just returned from New York, so I am in “a talk about air travel” frame of mind.  (The reason for the trip was a board meeting for Save The Children. They are doing some amazing work to help children, mothers and families in Haiti as well as the USA and developing countries around the world….please go on their website http://www.savethechildren.org for more information.)

As usual, I felt that the flight was interminably long, the air was dry and the food….well, I won’t discuss it here, I already did a segment about microbes on the plane. But what I haven’t addressed in the past is whether it is safe for pregnant women to fly.  ACOG (the American College of Obstetricians and Gynecologists) issued a new committee opinion in October 2009. Here is a brief summary…

If there is a complication in pregnancy, it will usually occur in the first or last trimester (bleeding and miscarriage initially, premature labor and delivery the last trimester). Most commercial airlines allow pregnant women to fly up to 36 weeks. Some may be more restrictive when it comes to international flights. (I know my daughter was told she could not fly on El AL after 32 weeks and she had to bring a letter from her obstetrician to show that she was less than that on her last flight).

Air travel is certainly not recommended during pregnancy for women who have medical problems (especially cardiac) or obstetrical problems. (The latter would include bleeding, a possible impending miscarriage, pre-eclampsia, a history or risk of premature labor, a pregnancy complicated by hypertension, diabetes or failure of normal growth of the fetus). The airlines and your doctor do not want you to go into labor on a long flight, begin to hemorrhage, or rupture your membranes (even if you are the at-that time-Alaskan governor!)

All travelers should avoid dehydration and immobilization for long periods of time; we all know about the risk of deep vein thrombosis… this is even more of an issue if you are pregnant. So wear support stockings, drink plenty of water (my advice is a 6 ounces for every hour of flight), move your lower extremities (well, if you drink enough you’ll have to make frequent trips to the bathroom!), avoid restrictive clothing (no tights) and don’t consume gas-producing drinks (carbonated sodas) or foods before flying.

And remember, there is no way to predict sudden turbulence. So keep that seat belt fastened below your hipbones while seated.

Now, let’s consider radiation exposure which increases at high altitudes. The current recommendation is not to be exposed to more than 1mSv over the course of a 40-week pregnancy. Even the longest intercontinental flights will expose passengers to no more than 15% of this limit. (So round trip should be 30%.) For the “average” pregnant flier, this should not be a problem. But if you are a frequent flier or are a part of the air crew, you should check with your employer and the Federal Aviation Administration.

Final recommendation by ACOG: “In the absence of a reasonable expectation for obstetrical or medical complications, occasional air travel is safe for pregnant women.”

And I would like to add… especially if you don’t have to fly coach!

We have all heard about the importance of breast feeding….for the baby. But less attention has been paid to what lactation can do for a Mom’s future risk of cardiovascular disease. So here are some breast-to-heart facts: Breast feeding increases caloric expenditure by approximately 480 calories a day, which of course means that pregnancy weight is more easily lost postpartum. Lactation improves glucose tolerance. (This means that when you do consume sugar or anything converted to glucose, your insulin levels won’t instantly surge; as you know surging insulin is not good, it can cause fat storage and increased “bad” triglycerides). Breast feeding also helps general fat metabolism and will lower the C-reactive protein profile. (C-reactive protein is a marker for inflammation and is correlated with the inflammatory process that increases development of plaque and cardiovascular disease). There are also a number of studies that have shown a long term benefit for lactation on midlife metabolic syndrome (high blood pressure, high triglycerides and obesity) and cardiovascular disease.

A new study published in the January Journal of Obstetrics and Gynecology gave additional credence to the “breast feeding is good for a Mom’s heart” theory. (Of course it’s good for emotional heart aspects, but that’s not what this article is about). In 1996 and 1997, The Study of Women’s Health Across the Nation (aptly acronymed SWAN) was established. Women between the ages of 42 and 52 were followed in seven sites. Two hundred and ninety seven of these women who reported at least one live birth on enrollment were enrolled in this aspect of the study; 121 women consistently breast fed all their children for at least 3 months, 84 inconsistently did so and 92 did not. Special electronic beam tomography scans were done on all the women to measure the amount of calcification in their coronary arteries and aorta. (Note calcification of these areas indicates the presence of atherosclerotic plaque and its presence has been show to increase the risk of heart attack or stroke.)

Those women who did not breast feed were more likely to be African American, more likely to smoke, consume fatty food, and ingest more calories. They were also less likely to be college graduates than the women who breast fed. But before we say voila, maybe these factors were more important than whether they breast fed, note that the statisticians adjusted for all of these factors. And they still found that mothers who had not breast fed were 3.82 more like to have aortic calcification and 2.78 more likely to have coronary artery calcification than those who had.

Bottom line: The decision to breast feed has implications not just for the health of the baby, but also for the heart of the Mom. Breast feeding may help her stay healthy longer and allow her to care for and cherish her children. Let’s make sure we, our daughters and any friends who plan to have a baby are aware of this!

Exposes about food contamination have been the subject of socially and nutritionally minded authors for hundreds of years. In 1906 Upton Sinclair wrote the book “The Jungle” which detailed the horrible conditions in Chicago’s meat packing houses. (Remember he wrote about workers who fell into rendering tanks and were ground along with animal parts!) Although conditions for the workers (but not necessarily the cows) have vastly improved, contamination of meat products (usually from bacteria) as well as vegetables and fruit are still common, especially as food sources go global. (Do you know where your strawberries come from? What about your fish?) And when a particular pathogen enters the food chain and causes sickness or death to the consumer, it enters so many widely distributed products that identifying its final “resting place” (other than the GI system of the unfortunate person who ate it) requires extraordinary food surveillance. The CDC estimates that 5,000 Americans die from 76 million cases of food-borne illness in the United Stated every year. The most susceptible are the very young, the very old, the immunocompromised, pregnant women and their fetuses.

Pregnancy can diminish immune resistance and an unfettered infection can cause miscarriage as well as fetal malformations, disability, illness and death to the newborn. Hence food safety and safe food choices are especially important in pregnancy. Here are some of the food-borne pathogens and the foods that may contain them that merit special attention…

Listeria monocytogenes

This bacterium is usually killed by pasteurization and cooking. It can, however be airborne and contaminate treated foods. And to make matters worse it can grow inside a refrigerator!

Foods likely to be contaminated: Unpasteurized milk products, refrigerated and ready-to-eat- products (dairy, meats, poultry and seafood and deli products). The prevalence of Listeria in these foods is estimated to be nearly 2%. Food packaged in the store is less safe than that packaged by the original manufacturer.

Symptoms: Typically mild…low grade gastroenteritis, or flu like symptoms. More serious infection (called listeriosis) causes vomiting, abdominal pain, diarrhea with fever and in some cases meningitis and overwhelming infection (septicemia). Pregnant women are 20 times more likely to develop listeriosis than all other individuals, indeed one third of all cases occur during pregnancy. And even if the initial symptoms are mild, the bacteria may cross the placenta and infect the fetus.

The FDA and CDC have issued guidelines for safe eating in pregnancy in order to avoid listeria infection. These include:

* Avoid cross-contamination with fluid from hot dog packages.
* Keep raw meets separated from vegetables, cooked food and ready-to-eat foods.
* Eat perishable foods as soon as possible.
* Throw out expired food.
* Wipe spills immediately and clean the refrigerator regularly with hot water, liquid detergent and then rinse.
* Eat lower risk food and avoid unpasteurized milk or any foods from raw milk!
* Don’t eat hot dogs, luncheon meats or deli meats unless reheated or steamed. Don’t eat refrigerated pates or meat spreads. (OK if canned)
* Don’t eat refrigerated smoked seafood unless it’s in a cooked dish. These are often labeled “nova-style”, “smoked”, “kippered” or “jerky”. (So there goes that bagel, cream cheese and lox…I guess the bagel and cream cheese can stay as long as the latter is pasteurized!)

Toxoplasma gondii:

This is a parasite which can cross the placenta and cause surviving children to have long-term problems (specifically serious eye and brain damage). Most pregnant women have no symptoms when infected. The fetus is at risk if the mother is exposed just before or during her pregnancy, but is unlikely to become infected if the mother has had the infection in the past. (This can be checked with a special antibody test; however, the test is not routinely done in the US because there are no established effective treatments.)

Food Sources: Contaminated meat, especially wild game (if undercooked or raw), unpasteurized milk, unwashed fruits and vegetables, contaminated water.

Other Sources: Cats are hosts to this parasite and become infected if they are kept outdoors, hunt and/or eat raw meet. They excrete the toxoplasmosis as cysts or eggs in their feces. The chance of infection from a cat is low if it is kept indoors, doesn’t hunt or eat raw meat. (Cat food manufacturers know this.)

Here are the CDC guidelines to prevent Toxoplasmosis infection:

* Freeze meat for several days before cooking
* Cook meats to at least 160 degrees (or higher to kill other pathogens). Note meats that are smoked, cured in brine, or dried may still be infectious.
* Keep children’s sandboxes covered.
* Wear gloves when gardening or handling sand in sand boxes.
* Peel and thoroughly wash fruits and vegetables before eating.
* Keep your cat indoors; don’t feed it raw or undercooked meats or unpasteurized milk
* If possible have someone else change the litter box, if not, wash your hands and disinfect the litter box daily with near boiling water for 5 minutes.
* Don’t get a new cat while pregnant or handle stray cats, especially kittens.
* Don’t drink unpasteurized milk, including goat’s milk.
* Don’t drink water from the environment unless it’s boiled. (I guess they mean water from rivers and streams…. This seems like a good idea in general.)
* Control rodents (I won’t comment on this one).
* If you butcher wild game or venison, bury the organs so that feral cats can’t eat them and spread infection. (I guess this applies to very few of us, oh, but wait…there’s Sarah Palin!)

Raw Fish:

This is where raw sushi and sashimi get boycotted by pregnant women. Raw fish can harbor parasites such as roundworms, tapeworms and flatworms as well as bacteria and viruses. And don’t forget, ceviche (fish prepared in acid and not really cooked) is included in the raw category. If you do dine in a Japanese restaurant during pregnancy order the vegetable or cooked sushi, although some purists might worry that these are prepared with the same utensils as the raw stuff. Maybe you should just get the teriyaki or the noodle soup…

Sprouts:

Just when you thought that you could and should consume healthy vegetables such as sprouts (alfalfa, clover and radishes), I have disappointing news. It turns out that sprouts have been found to contain E.coli and Salmonella. (A 2007 survey of retail foods in the US found a bad strain of E.coli in 1.5% of alfalfa sprouts compared to 0.17% of ground beef that they sampled!). Sprouts are produced under warm, moist conditions which encourage the growth of bacteria. They become internalized in the seed during sprouting. So washing doesn’t remove the bacteria! The only safe way to eat sprouts during pregnancy is to cook them.

Eggs:

So many chickens live in crowded squalor, infecting one another and their eggs with salmonella. The current estimates are that 1/20,000 eggs contain this bacteria. We are not talking abstention here….just cook the egg until the whites and yolks are firm. If you are making Cesar salad or a food that requires raw egg, use pasteurized egg. And always wash you hands after handling eggs.

Peanuts:

Strictly speaking, this legume should not be part of a discussion of contaminated foods. But peanut allergy is such a concern, I have included it in this article.

Should a pregnant woman avoid eating peanuts in order to diminish the risk of peanut allergy in her child? We used to tell pregnant women that this was a forbidden nut. But statistics subsequent to this admonition have shown that it doesn’t seem to make a difference and peanut allergy in children has increased. Indeed a 2008 study showed that sensitization does not appear to occur from intra uterine exposure. According to the American Academy of Pediatrics there is a lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of peanut (and other) allergies in infants. So if you have some peanut butter, don’t feel guilty.

Water:

Municipal water is generally very safe in the US. (Although I probably should modify this statement… there was a recent article in the New York Times that exposed water contamination that was not reported nor efficiently dealt with by the EPA….mostly in smaller communities.). Most bottled water does not contain fluoride which will benefit the future teeth of the developing fetus. And if water is sold in certain types of plastic containers it can become contaminated with potentially harmful chemicals.

I have not dealt with “the fish or no fish” debate (other than the raw kind) nor have I begun to discuss organic versus non organic, processed food, fats or caloric intake. I’ll leave all that for another article (or more). But I hope that the above gives you (if you are pregnant) or someone you care about (i.e. daughters, relatives and friends) a sense of which foods and food preparations are potentially harmful to a pregnant women and her baby. When it comes to contamination and infection, she is eating for two.

My daughter is pregnant and she, like many pregnant women, has been offered the possibility of private umbilical cord blood banking. She might ask my opinion.

I get offers to put oodles of information and brochures in my waiting room for expectant parents (I don’t, since I no longer deliver babies). Absent information directly proffered by obstetricians, women are targeted by private cord banking companies through direct to pregnant –consumer advertising in prenatal magazines, web sited and the peer pressure established among pregnant women and their families as they traverse the studies, tests and tribulations of their gestation. So when that final push for a healthy baby is made by the Mom (or by the obstetrician if she has a C Section), should there be one more painless procedure performed? Should cord blood with its special stem cells be removed and sent for private storage for the next 20 years just in case it can be used as “biologic insurance” against a future disease of the child or a sibling?

A recent review that addressed cost-effectiveness of this procedure was published in the Journal of Obstetrics and Gynecology. They cited a survey by the American Society for Blood and Bone Marrow Transplantation of private umbilical cord blood banks; of approximately 460,000 private banked cord blood units, only 99 had been shipped for transplantation. Another survey of 93 pediatric specialists who perform the transplantations in the United States and Canada reported that only 49 transplants had been done in the donor child or its siblings; moreover in 36 of the instances, there was a known disease in a sibling and the blood had been collected preemptively.
There are several problems that may cause this minimal use: Some of the samples were contaminated by bacteria, others were improperly labeled. The literature indicates that 25% to 56% of cord blood specimens could not be used either because the stem cell count within the blood was too small or because of problems with the blood’s storage. Then there is the issue of whether the transplantation will help the disorder for which it is given. Currently the estimate of probability of future need for cord blood for treatment of the donor child is 1 in 2,500 or 0.04%. (It is currently used for bone marrow failure which can cause aplastic anemia or for blood malignancies such as leukemia as well as certain metabolic disorders.) However, if the donor child does develop leukemia there is concern about transplanting his or her own stem cells since they may have the propensity to become malignant. This would not be a problem if a sibling needs the stem cells obtained from the cord blood of a presumably healthy donor child. Hence the probability of using umbilical cord blood for a sibling is a little greater, but still rare, 1 in 1,425 or 0.07%.

The cost of private umbilical cord banking and storage for 20 years is high and according to Web sites ranges from $3,620 and $4,170.

The final assessment in what the statisticians call “base case analysis” (sorry but you might as well learn some new terms) is that private umbilical cord blood banking results in a lifetime gain of 0.0026 years. And if the cost is $3,620 (compared to $0 if not done) this amounts to an additional expenditure of $1,374,246 per life year saved.

The only way it might be “cost effective” (a term we will hear more and more as we strive to reduce the cost of health care) is if the likelihood of a child needing its own stem cell transplant was greater than 1 in 110 or of the likelihood of a sibling needing a stem cell transplant rose to 1 in 43…and/or the cost of umbilical cord blood banking was reduced to $262 (or less than 7% of what it is now).

The American College of Obstetricians and Gynecologists and The American Association of Pediatrics have already made statements recommending against private cord blood banking unless there is a family member with a known diagnosis that could be treated by umbilical cord blood. Despite this many patients still want to “play it safe” probably because they don’t understand the statistics and overestimate the probability of the need for its use. (And the data may not be appropriately explained.) Let’s also acknowledge the medical magic implied in the term “stem cells”. If we can get them for our progeny, it can’t be unnecessary or too expensive.  Obstetricians are placed in a difficult position and often have to accommodate their patient’s request. Dissuading is harder than accommodating.

The cost benefit for use of umbilical cord blood transplants would greatly benefit from a program of public cord banking. But alas this is not available in most areas of the United States.

Bottom line (and I’ll try to convince my daughter)…private umbilical cord blood banking is cost effective only for families with rare blood diseases in which a child has a very high risk of requiring a stem cell transplant. The for-profit private cord banking facilities are unlikely to stress these facts.

We could ask our kids (rarely works), speak to the school administrators (they are probably the last to know),  read Seventeen and Cosmo or just look with despair at the promiscuous styles offered to and requested by young girls (and boys).

In my perusal of journals, I found a fascinating study which addresses this question. It comes from the National Youth Risk Behavior Survey conducted from 1999 though 2007. (Remember it takes a year or two to collect, analyze and publish information of this sort, hence it did not include ‘08 and ‘09.) Researches analyzed data from this survey to determine age at first intercourse in 66,882 black, Latino and Latina, white and Asian students in grades 9 though 12. According to the students’ anonymous self reports, the probability for “coital debut” by their 17th birthday (I’m assuming they meant vaginal intercourse, the use of euphemisms in medical reportage is astounding!) was: 82% for black males, 74% for black females, 69% for Latinos, 59% for Latinas, 53% for white males, 58% for white females, 33% for Asian males and 28% for Asian females

Now before we take this report and approach our children or grandchildren with queries as to whether they fall into the above listed statistics (“did you or didn’t you?”), I should point out that the survey was based on self-reported data. Girls are more likely to underreport sexual activity, whereas boys tend to over report. The survey did not stratify the groups by parental income or educational level, nor did it differentiate between public or private school attendance. And the study did not include youths who had dropped out of school (who would, most likely, skew early coital debut to higher probability).

I realize that parents don’t always like to look at gross statistics when it comes to their own progeny. But this large study does show us that a majority of teens self report that they were sexually active before the age of 17. It’s way better than rumors… and should help parents decide when to make sure that their daughters have access to appropriate contraception. (This may have the appearance of a plug for Planned Parenthood and I should disclose that in the past I was on the board of the LA chapter of this organization). We know that timing is important for HPV vaccination. The best results will be achieved if the vaccine is given before a girl becomes sexually active. Hence most pediatricians now discuss this with parents at a time when they are not quite ready to consider that their “little girl” will engage in sexual activity. But they will… Finally this survey emphasizes what we already know; all young teens should be taught about STD’s and the need for protection before they have that first, often too early, sexual encounter.

So there I was giving a lecture “somewhere” other than California. The organizers took me to dinner in a “fancy” French restaurant. The private dining room was booked for a wedding reception and as the bride arrived with her attendants I could not help but notice two young women who were visibly pregnant… and smoking. To make matters worse one held a nearly empty bottle of beer. I so wanted to go up to these women and suggest that they were increasing their risk of preterm labor, diminishing their progeny’s physical and mental growth and ultimately risking fetal and/or neonatal death, but of course, did not.

I strongly advise women to quit cigarette smoking before they conceive (or before they start to smoke, whichever comes first) for their own health. But if it’s too late, I should have a method to offer them on how to quit while they are pregnant. Although I have never been a smoker, I understand from many friends and family how difficult it can be. “Cold Turkey” describes my lack of cooking skills at Thanksgiving and is also the preferable way to quit while pregnant, but may just be too difficult.

Thank goodness, the data from a study of 100,000 pregnant women in Denmark and their offspring has shown a reasonable substitute, nicotine replacement therapy (NRT). Despite the fact that women who used nicotine replacement therapy were more likely to be over the age of 35 and drink two or more alcoholic drinks per week during pregnancy, they were NOT at increased risk of stillbirth compared to women that neither smoked nor used NRT. The women who continued to smoke throughout their pregnancy had a significantly increased rate of stillbirth as well as the risk of having a child with oral cleft, malformations of the circulatory system and/or digestive system. Those who stopped but used NRT were at reduced risk.

The important fact is that although NRT does contain nicotine, it doesn’t have the other 2999 chemicals that are present in cigarette smoke (yuck!). The American College of Obstetrics and Gynecology has stated in an official opinion that although, quitting cold turkey is best, women who cannot quit smoking without assistance may use NRT during pregnancy. They recommend that NRT products that provide intermittent nicotine — such as gum or lozenges– be tried before resorting to products that provide a constant dose (the nicotine patch)

Perhaps I should have offered one of these products to those pregnant and smoking women that were in the restaurant.

Most of us need our coffee. It is the most commonly ingested pharmacologically active substance in the U.S.A. and, not to be too become too national, I should point out ….in the world! We cosume caffeine in our coffee, tea (black and green), soft drinks, chocolate (although white chocolate, which is mostly sugar and butter is exempt), coffee flavored food, over-the counter medications such as Excedrin, Anacin and Midol as well as prescription meds for pain such as Fiorinol and Darvon Compound to name a few. Our average daily consumption is 280 mgs which is the equivalent of two and a half cups of brewed caffeinated coffee a day.

And we are so addicted. This very time honored substance (yes, it was much sought after and cultivated before the creation of Starbuck’s) is similar in its affect on our brains to amphetamines, nicotine, ephedrine and even cocaine. At high doses (200 to 800mgs) it stimulates neurotransmitters that activate the award system in our brains. And if we suddenly withdraw, the symptoms may be most unpleasant: headache, fatigue, irritability, depressed mood and problems with concentration. (I can attest to all these, I tried to stop in order to deal with heartburn…I won’t go into the results, but perhaps my husband will.)

So what should women do who want to get pregnant….or have been pregnant and now want to analyze whether their caffeine consumption caused their progeny to be born prematurely, grow up too fast, act out or not get into an Ivy League School. (For the sake of full disclosure….mine did not; and yes I drank coffee.)
Here’s where I bring in study results. Medical therapies and advice should be based on evidence based, randomized investigations….and the best and brightest are chosen by the Cochrane Review. They scan biographies and/or published studies and often correspond with the investigators. They look for randomized and at least quasi controlled trials. They did this when they investigated the effect of caffeine and/or supplementary caffeine versus restricted caffeine intake or placebo on pregnancy outcome. Only one study out of 80 met their standards! Caffeinated instant coffee (which has about 95 mgs of caffeine per cup) was compared with decaffeinated instant coffee (3 mgs a cup). Reducing the caffeine intake of the regular coffee drinkers from 3 cups a day to one or less did not affect birth weight or length of gestation. The conclusion was that “there was insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birth weight or other pregnancy outcomes”.

More investigations will probably be forthcoming (some may be sponsored by caffeine and pharmaceutical industries) … but many won’t be appropriately controlled. So let me go on the line (or in a cup) right now and give the reassurance many of us would like. Coffee, cola drinks or chocolate are not harmful in pregnancy. I would suggest, however that you limit all the above to no more than the equivalent of 3 cups of coffee. That should be enough to reward those neurotransmitters in our brains. And, while addressing cravings …alcohol (and of course smoking) in pregnancy is and will always be a no no.

Most of us can point to depressing episodes in our lives….woes befall all of us: the economy, personal loss, worries about errant spouses, children (remember, we are only as happy as our most unhappy child) and aging parents. And I haven’t even begun to list the enormity of the global energy problems, international conflicts and consequences of disease. (If I keep going, I’m bound to find something that depresses you!) There is, of course, a difference between having to deal with either personal or large scale social issues that lead to sadness and worry and the occurrence of true clinical depression. The best way to define the latter, without going into treatises put out by the American Psychiatric Association, is that nothing gives you pleasure; nor can you function in your everyday mode of life. If you feel that you are in a dark tunnel with no light at the other end, day after day; you are clinically depressed. And a huge number of us are… up to 25% of women develop clinical depression at some point in their lives (more then twice the prevalence of clinical depression in men, which may be a reflection of our genetic capacity for concern and sensitivity).

Clinical depression peaks in our reproductive years. Nine percent of women will have an episode during or within 3 months of pregnancy. The consequences can be harmful to both mother and child. There are entire medical journals dealing with “the safest way” to deliver a baby, the pros and cons of Cesarean vs. natural delivery, the concerns about vacuums, forceps, routine episiotomy, not to mention tables to ascertain desired weight gain, concerns about preterm deliveries and of course tests to ensure the genetic integrity of our offspring. But few Ob Gyns are trained to either recognize or treat clinical depression in pregnancy. When asked by a patient whether it is safe to start or continue antidepressant medication during pregnancy….we hem and haw. Here is what I now tell my patients:

Women are more apt to develop depression during pregnancy if they:

• Have a history of depression at any time including a previous pregnancy or postpartum.
• Have been diagnosed with clinical depression in the past.
• Have a family history of depression, especially during pregnancy or postpartum.
• Have other psychiatric illnesses (panic disorder, obsessive-compulsive disorder, bipolar disorder, substance abuse).
• Marital instability…this cover a lot of issues, I translate it as a non supportive, or worse yet, abusive spouse.
• Unplanned pregnancies …unfortunately as many as 50% of pregnancies are not planned).

Depression can harm a pregnancy:

Studies have shown that women who are depressed during pregnancy have twice the risk of cesarean section, premature delivery and neonatal intensive care admissions of the newborn as well as four times the risk of delivering a low birth weight infant when compared to women who were not depressed. Depression and severe stress can cause changes in the hormonal environment in which the fetus is developing (This includes steroids such as cortisol, maternal brain hormones, estrogen, progesterone, insulin and growth hormones to name a few). The theory is that this “upset” hormonal milieu can impact fetal growth and fetal programming so that the infants, especially those born at lower than expected birth weights to women who were significantly depressed or stressed during their pregnancy are at future increased risk for schizophrenia, cardiovascular disease, type 2 diabetes osteoporosis and depression.

Treatment: Is it Safe in Pregnancy?

All psychiatric medications cross the placenta. If a pregnant woman is mildly or even moderately depressed (a brief definition: she has no thoughts of suicide, has not needed medication for depression in the past and is able to continue her usual functions) then traditional psychotherapy may be all she needs to successfully deal with her depression. (And we have all become more familiar with therapy sessions after watching Gabriel Byrne). But if her depression is moderate to severe and medication has helped in the past, her best option would be pharmacologic….i.e. antidepressant medication. And the current recommendation is to use the drug that previously worked. Clinical depression is a medical disorder that, like diabetes or hypertension can adversely affect the outcome of pregnancy…not treating it will create a greater risk for a woman and her unborn child than treating it. There has been a reluctance to include pregnant women in many pharmaceutical studies conducted in the past, but as the need to address depression in all women becomes apparent, antidepressants are now being investigated for use during pregnancy.

SSRI’s (Selective Serotonin Reuptake Inhibitors)
There are many….each with a slight change in chemistry, indication and side effects. Medications in this category include Zoloft, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, and Serazone. As I write this, more are being introduced. Multiple studies have shown there is a very low absolute risk of congenital anomalies when these medications are used during pregnancy. But the pharmaceutical companies and prescribing physicians must include appropriate reports of adverse effects….sort of like the list of everything that can go wrong at the end of those direct-to- consumer ads you see on television (usually stated in a hurried, breathless manner by a male voice) or read in the patient information provided with the prescriptions.

So here are some: There have been studies that describe an increased risk of abdominal and skull defects with first trimester use of SSRI’s and a rare cardiac defect with Paxil. (Although a Canadian study contradicted the latter.) There has been no evidence of fetal malformations due to use of Prozac in pregnancy…this is indeed the most studied (and oldest) SSRI.

There maybe a sight increase in miscarriage rates among women who take antidepressants compared to nondepressed women: 12.5% v. 8.7%. (It’s difficult to establish if this is due to the meds or their underlying depression). There are also reports that third trimester exposure to SSRI’s can cause tremor, breathing, sleeping and feeding problems in newborns, but this is usually mild and disappears after 2 weeks. The long term good news is that these medications appear to have no effect on exposed children’s IQ, language development or temperament.

Benzodiazepines (such as Valium, Xanex, Dalmane, Ativan, Klonipen. Restoril)
There have been studies that may have shown an increase in cleft palate in infants exposed to benzodiazepines but other studies have not… quite frankly the literature is not definitive.

Lithium
This is considered relatively safe during pregnancy: but it may increase an exposed infant’s risk of a rare cardiac valve problem. The recommendation is to stop lithium 24 hours before delivery.

To Summarize: If you are on a medication for depression that works, especially an SSRI and you conceive….keep taking it. If you stop, chances are you will have a relapse and this can harm you and your pregnancy. Know that you may need higher doses as the pregnancy develops. (There are a lot of changes in the metabolism and dilution of any medication as you and your pregnancy grow.) After 4 to 6 weeks you and your doctor may decide you need to increase the dose every 2 to 3 weeks until your symptoms are in remission.

Every time the media reports on a new adverse effect from an antidepressant….remember that bad news makes news. If you suffer from clinical depression before or during pregnancy, treatment can make a very positive difference in your pregnancy outcome and the future health of your child.