If you’ve been to a doctor’s office while planning or during a pregnancy, chances are quite good folic acid (to prevent neural tube defects), DHA (to promote baby’s brain development) and iron (for prevention of anemia) have been recommended.  These relatively universal recommendations have been shown to help promote health pregnancies, and safety of these supplements have been well established.  Unfortunately, as nutritional supplements are regulated by the FDA, there is a lot of misleading information or simply limited information about most nutritional supplements.  While some of these supplements may be beneficial, others may in fact be harmful in pregnancy, even some of the “natural” ones.  Here’s a short list of some of the more commonly asked about supplements and what information is available for them.

1. Tabacum – an herbal product used for nausea/vomiting in pregnancy.  Unfortunately, this tobacco-based supplement contains nicotine and should definitely be avoided in pregnancy as it can cause harm to a baby’s brain and lungs.
2. Melatonin – this supplement has actually garnered a lot of interest in pregnancy studies, and there are some ongoing studies to assess whether it may reduce risk of preeclampsia and growth restriction in pregnancy.  However, at this time, safety data in pregnancy is relatively limited, and since Unisom with doxylamine has an extensive safety profile (and can help with nausea in pregnancy), doxylamine is would typically be advised rather than melatnonin until further safety testing can be done.
3. Kombucha – often used as a source of probiotics, this fermented food can contain alcohol as a part of the fermentation process, so kombucha should be avoided as alcohol intake in pregnancy can be associated with birth defects and intellectual/behavioral disorders.
4. CBD – although many people may be aware of the potential for marijuana and THC use in pregnancy to affect a baby’s brain development and increase the risk for a smaller or preterm baby, it may be less well-known that CBD use in pregnancy should also be avoided.  In addition to potential for liver toxicity, there is also concern for negative effects on the developing male reproductive system.
5. Astragalus – used to boost immunity, energy or even milk production postpartum, it can cause irregular heartbeat, dizziness and may be passed along to the fetus during pregnancy and lactation, so it should be avoided during and after pregnancy.
6. Red raspberry leaf- taken as a tea to reduce labor pain, nausea and miscarriage while increasing milk production, it appears to be relatively safe, although it hasn’t been proven to be effective for treating any of the above claims.
7. Nux vomica – this herbal treatment for nausea should undoubtedly be avoided in pregnancy as it contains strychnine, which can be harmful to both mom and baby.  In fact, the primary use of strychnine today is as rat poison.
8. Vitamin A – one of the trickier supplements in pregnancy.  Very low levels can potentially be associated with growth restriction, hearing loss for baby, insulin resistance for the baby later in life, and some birth defects such as microcephaly or kidney defects.  Too much is also bad – increased risk of miscarriage and heart/nervous system defects.  A typical prenatal vitamin often helps walk the line between too much/too little, although supplementing with more than 5000 IU per day should be avoided during pregnancy, and intake should not exceed more than 25000 IU per week.

Supplement use in pregnancy can be complicated, and the limited or misleading information available can make the decision of whether or not to take them very confusing.  Unfortunately, your provider may have little to add to the conversation as most of these products don’t have controlled studies available to quote, and they aren’t regulated by the FDA.  Generally, it often makes sense to err on the side of caution as even if the supplements may not have inherent risk, these products are not infrequently contaminated by other products that may not be safe in pregnancy.  The bottom line is that all supplements used in pregnancy should be reviewed with your provider so that you can make the best possible decisions regarding supplement use in your pregnancy.

​Dr. Nick

“I have ADHD and take Adderall.  I just found out I’m pregnant.  Now what?”

ADHD, or attention-deficit/hyperactivity disorder has become one of the most commonly diagnosed neurodevelopmental disorders of childhood, and the number of people on medication for ADHD has increased dramatically.  According to the CDC, 6.1 million (9.4%) of children between the ages of 2 through 17 have been diagnosed with ADHD.  Two thirds of these children are taking medication.  4% of adults have been diagnosed with ADHD and this number has increased steadily over the last couple of years.  Currently the number of women with ADHD on medications is small.  About 1 in 100 women took ADHD medication during pregnancy.  This number will likely increase dramatically as so many more adults carry the diagnosis. 

Medications taken for ADHD include the following: Adderall, Concerta, Vyvanse, Ritalin, Focalin, Dexedrine, Metadate to name a few.  These medications are stimulants and can be short acting, intermediate or long acting.  The side effects of these medications include loss of appetite, weight loss, sleep problems, tics, heart palpitations, or worsening of anxiety or depression. 

Is my baby at higher risk of birth defects if I take medication for ADHD?  The answer to this is, unfortunately, yes.  ADHD medication in early pregnancy may be related to the following birth defects: gastroschisis (a condition where the baby’s intestine develop outside the baby’s body), omphalocele (a condition where the intestine of other abdominal organs are outside of the body), and transverse limb deficiency (where all or part of an arm/hand or leg/foot don’t develop).  A study performed by the CDC found that women who took ADHD medicine during early pregnancy were at a higher risk of having a baby with certain birth defects compared to women who did not take ADHD medication. Since the overall risk of birth defects is very low, data from this study was based on small numbers and so the literature on ADHD medication during pregnancy is very limited. 

In addition to this, there is an increased risk of low birth weight, prematurity, preeclampsia and increased morbidity because of increased placental vasoconstriction (when the blood vessels contract and don’t deliver blood effectively).  There can also be symptoms neonatal withdrawal. 

So, what should I do?  Unfortunately, we don’t have a great reservoir of information on the topic because the data is limited.  The data is even further limited to determining long term behavioral and learning effects to children who were exposed to stimulants in utero.  For these reasons, we encourage women with mild to moderate ADHD symptoms to consider discontinuing medication and switch to behavioral therapy while pregnant or even before conceiving if possible. 

For patients with severe ADHD, this decision would likely be made on a case by case basis in conjunction with their psychiatrist.  If you are pregnant or trying to conceive and currently taking medication for ADHD, please have a detailed discussion with your provider prior to continuing (or discontinuing) the medication while pregnant or attempting pregnancy.
 
Dr. Pam

I get this question a lot from my patients during their postpartum visit.  “So, I just had a baby and would like for my kids to be close in age- when is the best time to have my next baby?”
In the medical literature, this is called “birth spacing” and there have been lots of studies that have looked at ideal timing between pregnancies. 

1. What is optimal time to wait between pregnancies?  If you are <35 and healthy, the ideal time to wait before planning your next pregnancy is 18-24 months and less than five years.  If you are over the age of 35, as fertility decreases at this age, the ideal interval may be closer to 12 months.  Remember these numbers do not apply to a miscarriage.  Most people with a first trimester loss are safe to start trying during the menstrual cycle following their loss.  However, you should consult with your doctor as they would be aware of your medical and pregnancy history and would be able to help you plan accordingly. 
2. What are the risks of spacing a pregnancy closer than the recommended intervals?  Studies have shown that pregnancy within 6 months of a live birth increases the risk of premature birth, placental abruption, low birth weight, anemia, and congenital disorders.  Very closely spaced pregnancies often do not give mom enough time to recover from pregnancy and breastfeeding, as this can deplete your folate and iron stores, and which is why they are at higher risk of being anemic. 
3. What are the risks of waiting too long? Long intervals between pregnancies can affect fertility and can increase the chance of developing preeclampsia.  Moms over the age of 35 have increased risks of preeclampsia, hypertension, diabetes, problems with the placenta and stillbirth.  There is also a higher chance of having a baby with a chromosomal issue.
4. What is different if I had a c-section?  If you have had a c-section, waiting at least 6 months is preferred in order to allow the uterus to heal and decrease the chance of uterine rupture.  Most physicians also require a minimum of 6-12 months between pregnancies if you are considering a vaginal birth after cesarean (VBAC). 

Planning your family can be tough.  Even if you have the perfect plan in mind, there’s no guarantee that your body will cooperate, but by keeping the above guidelines in mind, then you can help make your pregnancy safer and more likely to result in the outcome you (and your provider) are hoping for:  healthy mom and healthy baby 😊

Dr. Pam