The EngagED Midwife
The EngagED Midwife
Drug Dilemmas: Navigating Pharmacology for Expectant and Nursing Mothers
It’s easy for healthcare providers to feel overwhelmed by medication safety during pregnancy and breastfeeding. In this episode, Cara and Missi take this complex topic and make it simple.
They start by highlighting a common issue: many clinicians still use the outdated FDA risk categories (A, B, C, D, X), which were replaced in 2015 by the more detailed Pregnancy and Lactation Labeling Rule (PLLR). The hosts explain how pregnancy changes a person’s body and how this affects medication, from blood volume to heart rate. They also cover specific medications to be cautious with, like ACE inhibitors and statins. When it comes to breastfeeding, the discussion turns to lactation risk categories (L1–L5) and practical factors like timing and a baby’s age as well as what's really important for nursing moms.
This episode covers common clinical scenarios and provides clear guidance on safe medication options for both pregnant and breastfeeding patients while providing valuable resources for students and practicing midwives. This episode turns an intimidating topic into a manageable framework for confident prescribing.
#PrescribinginPregnancy #MedicationAndMotherhood #PerinatalPharmacology #PharmForWomensHealth #NoMoreABCDX #MidwiferyMatters #JusticeForTylenol #CallTheMidwife #OurFavePharmD
Welcome to the Engage Midwife Podcast. This is Missy and this is Kara. I'm so excited that it feels like fall.
Speaker 2:Yeah, I feel like we're going to have a second summer, but it has been feeling quite glorious and football season has started, so all is well in the Midwest.
Speaker 1:What happened to your Chiefs in Brazil?
Speaker 2:I don't want to talk about it.
Speaker 1:Well, I will just say that I watched the first half and I was like, ah, they're not on, they ain't got it. No.
Speaker 2:No, it's okay, it's early, it's early in the season, it's early, we're fine.
Speaker 1:Yes, we're fine. Do you know what happened with my Buckeyes this weekend? Did they win? Well, last week they beat Texas, which makes me so happy, and this week we won 70 to zero, but we did not cover our spread. We won seven zero, 70 to zero. You know what the spread was? No 70 and a half.
Speaker 2:Oh, that's funny. I don't even know exactly what that means. I've heard the terms before. But anywho, congratulations.
Speaker 1:I suppose that is quite a beating I mean hitting on all cylinders, I think, in football season. So now I'm insufferable to my family who doesn't want to listen to me talk about Ohio state and Heisman talk and all the things, but my son's to think that there's not going to be a wide receiver that's ever going to win the Heisman again. So now it's a, now it's a whole thing. So welcome to football season, welcome to fall weather. For me that's sweater weather, for you that's not a wilting flower weather.
Speaker 2:Yeah, it means that Kara is in her blissful era. You can find me on my deck, ideally in a very light sweatshirt or long sleeve t-shirt, covered up in a blanket. I want to be silly. I want my nose to feel cold. That's really bliss.
Speaker 1:I the. The very clear demarcation for me is when my coffee goes from iced to hot.
Speaker 2:I don't know. I really enjoy a hot coffee most of the time, but when out and about? Yeah, we're still in ice season for out and about, but I have hot coffee every day at home.
Speaker 1:Oh yeah, no. I can't do it In the summertime, it's cold all the time.
Speaker 2:No, it makes me feel cozy. I like it, and then I sweat for a couple of hours.
Speaker 1:But what's funny is is this this is a thing that happens in the fall, and I don't know if it's in the Midwest or if it's all over the country, but everybody gets all like oh, it's pumpkin spice season. I don't like pumpkin spice. We are probably the only two podcast girlies in the history of the world that are like no, thank you Pumpkin spice. Bring on mint season.
Speaker 2:Yeah, bring on peppermint season. We are two mint girlies.
Speaker 1:Yeah, I could totally skip over pumpkin spice in my life. Yeah, me too.
Speaker 2:Me too.
Speaker 1:I'll make some pumpkin bread like and my husband loves this pumpkin cookie that has this cinnamon buttercream situation on it. So those are like the two smallish things that I will do, but I don't want pumpkin in my coffee and I do want one slice of pumpkin pie on Thanksgiving day.
Speaker 2:That is acceptable. What else do I-? Are you a cool whip or a ready whip family?
Speaker 1:You know, what's wild is is that this is going to sound super bougie. You have to make your own. I do have to make my own.
Speaker 2:Okay, whatever I will, you can never convince me that Cool Whip is not the best topping for pie.
Speaker 1:Until you taste my homemade whipped cream, and then you'd be like okay, fine, maybe you should make me some. I also think, are we still in this era of Missy has never baked for Kara?
Speaker 2:Yeah, I mean, I think I tried your blueberry gluten-free bread and that was like the one thing that I've had and it may have been leftovers that you made for your family and I just happened to show up when there was still some available. But yes, you talk about being a baker. You post all these pictures about baking, but I don't know that that's true, okay.
Speaker 1:I don't know. I'm going to promise you that when I see you in October, I'm going to bring you the brown butter salted chocolate chip cookies, because I can travel on a plane with those. Okay, I do love me a chocolate chip cookie, so the other thing I will tell you about this pumpkin situation is Bob wants to burn like a pumpkin candle. Nope, don't need that either, don't need the pumpkin in my life.
Speaker 2:Yeah, I don't mind a pumpkin candle in the month of November.
Speaker 1:Yeah, it's still September, dude. The stores here have Christmas stuff out. I'm not game for that either. I'm like let me enjoy football season Like I don't want to think about Christmas.
Speaker 2:We actually in our house have football decor up, because that's how much we like football season.
Speaker 1:I think that is appropriate. Yeah Well, all right. Feel like is hard for midwives and WHNPs because it is so nuanced that without really good references it's just hard to commit to memory. And I'll tell you the topic and then I'm going to give you a little anecdote. The topic we're going to talk about is drugs and pharmacology in pregnancy and lactation. Topic we're going to talk about is drugs and pharmacology in pregnancy and lactation, which those references have changed a lot Even since when you and I were like baby midwives. The things that we used to use we don't use anymore and things have. There's like the.
Speaker 1:I think the barometer on this is changing about how we talk about pregnancy and like lactation, and I will also say there's lots of new drugs, right, that we don't have any idea how they affect pregnancy and lactation, and so I think when we talk about this, this will be a good reference point. Maybe you'll just learn like what should I download or where should I go if I'm looking for the things, because also, you can't just Google this, right, you can't be like is this drug safe in pregnancy? Because you might not get a reliable source. And I will say I work in triage a lot, you know this. I get a lot of phone calls from moms and some things we can treat over the counter right or over the phone. We don't need to see somebody to treat something. But also they'll call and they'll say my PCP prescribed me this Is. But also they'll call and they'll say my PCP prescribed me this.
Speaker 1:Is it safe while I'm breastfeeding? And I'll be like, well, shit, I don't know. Like let me put you on hold for one second. Okay, I'm going to check with a reference, right and like literally like, look something up, and that is very much acceptable. It's also something with pharmacology specifically that I have a huge pet peeve with testing about, because I don't care if you're a student, I don't care if you're taking a certification exam. When we talk about testing and topics like pharmacology and you and I have always said this why are we driving home the idea that you have to memorize all these things when we have fantastic references, that we just look them up In clinical practice? We just grab our phones and we go to our references and we look them up.
Speaker 2:And as super experienced providers. I'm still looking up stuff all the time and I know you do as well Like why, when we have really great resources readily available, we can access them online. We can access them in our pocket at any time. Like why are we testing people on some of these things? It's important to understand why some of the concepts are important and how do you interpret what you're reading. But I agree with you, I think this is an intimidating topic for people, so I really do hope that the takeaway is here's some great resources, here's where you go when you need help finding the answers, and let's make this less scary for prescribers.
Speaker 1:Yeah, so I think things that we should talk, like we need to talk about practical tips, right, things that we need to know as prescribers sort of the tenants or the pearls of prescribing in pregnancy and lactation and then for me, it's the references, and anybody who has picked up my phone or picked up my iPad knows that I'm so nerdy and that everything in my phone or iPad is color-coded, and I have one section in my phone that has babies on it. It's not color-coded, it just has babies on it, and for me, that's the suite of apps that I use when I know I need to do something work-related, and so that's where some of these things live for me. But I think, knowing what the right references are right and we talk about this all the time what are the primary references for where we look things up when we don't understand them? And so I think that's another thing that we're going to cover today.
Speaker 2:Yeah absolutely Absolutely. So I think we could break this up today to talk about pregnancy and prescribing and then talk about lactation, if that sounds okay to you, and we can start off with pregnancy and really understanding some of the changes that happen physiologically that can alter how we absorb our medications, how we excrete them all of those different things and what impact that can have on choosing medications, how the body handles some of that sort of thing.
Speaker 1:Yep, I think that's great Because they're different, right, right, the things that we worry about in pregnancy have to do with placental transfer, right.
Speaker 2:Things we worry about in lactation have to do with milk transfer and they're different, well, and I also think that during pregnancy so much we're worried about exposures early as organs are forming, as things are developing, that sort of thing where oftentimes in lactation it's more about like, what is the impact going to be on the newborn, like is it going to make them super sleepy, is it going to affect their respiratory effort, that sort of thing. So they're slightly different exposure concerns. But obviously, you know, whenever we give a medication to someone that is pregnant or lactating, it can have an impact on more than one person, and so we want to think about those things. Okay, so physiology during pregnancy, I think there's a couple of things to think about.
Speaker 2:We talk all the time about that increased blood volume. That happens physiologically. We get an increase in the plasma volume, increase in blood volume, and that changes how drugs are distributed throughout the body. So it's going to almost kind of dilute a bit. But it also means we've got increased cardiac output. We're delivering medications faster. We also have altered renal clearance, which means that we can eliminate some medications faster than we normally would. That's interesting. It's not slowing it down like what can happen in elderly people it's actually faster excretion through the liver. That metabolism has changed a bit. And then you know, we know there's the gastric emptying. That's why so many people have that lovely GERD kind of feeling and so forth. But that will alter how we absorb our medications as well during pregnancy, and so all of those physiologic changes affect the pharmacology, the pharmacokinetics, the pharmacodynamics, and should be something that we're thinking about as we choose medications. Yeah, and the other thing that, oh, go ahead.
Speaker 1:No, I was just going to say, like, as we talk about physiology too, I think one of the frameworks that we have to think about with pregnancy and lactation is where is safety included in the conversation, right? Where do we need to ensure that the risk benefit ratio is appropriate for mom and baby, right? And are there things where moms need to absolutely continue their medications, even though it's not the safest potentially thing in pregnancy and lactation, but they're necessary for maternal health?
Speaker 2:Yeah, absolutely Like. We need people to be well oxygenated, so we want them to use their medications for asthma, we want their high blood pressure to be managed, those kinds of things. But as we make those decisions about exposures and risks, we would like to choose things that are on the safer side or that we have more information about, so that we can make informed decisions. And then you know, shared decision-making is important too, so we can educate our patients and provide them lots of information, but really thinking about you know what are their values and what are some of their feelings about what we're offering to them, and thinking about that in the decision-making.
Speaker 1:So my first reference plug is going to go right here, because we were just talking about physiology and the physiologic changes in pregnancy, and so, especially for students or people who are studying for certification exam, I feel really strongly about and Kara is going to roll her eyes because she knows I talk about this book all the time the pharmacology for women's health text last published in 2018. However, there are things in this that do not change. So chapter 35 is specifically about pregnancy and if you don't feel great about pharmacologic changes in pregnancy, pharmacokinetics, drug distribution, et cetera and it also talks about teratogens and fetotoxicity and all of those things I think you should for sure hit this chapter In this particular text. We are going to put it with the reference to our show notes, but also it talks about why things change because of placental circulation, right, and how the fetus actually affects that transfer of medication. So chapter 35, pharmacology for women's health, is the place I would go for a very succinct, complete, I think reference for drugs and pregnancy.
Speaker 2:Awesome. So, if it's okay, I think one of the things that we should talk about a little bit because I still hear people mentioning them is the pregnancy risk categories for medications. But we're here to tell you it's a really old, outdated system and you guys, I think, might be a little bit shocked when I tell you the dates on these things, but If you remember, the FDA, food and Drug Administration had pregnancy risk categories that were A, b, c, d and X, and they, ideally, were supposed to give us information about. You know, obviously, a medications were considered the safest, x were considered absolutely not safe and everything in between there was a risk-benefit discussion about them. That started in 1979 with those risk categories A was there was no risk in human studies. B was there was no risk in animal studies. C risk could not be ruled out. D there was evidence of risk. And then category X was contraindicated.
Speaker 2:Well, all the way back in 2009, 2009, they started taking a look at this and was it the information that we needed to have? And basically, since 2015, we have been told we should not be using pregnancy risk categories. Instead, what replaced that was the pregnancy and lactation labeling rule, so PLLR, and that was again since 2015, and it was supposed to allow for informed clinical interpretation and medical management and every medication that is, you know, listed in the PDR, everything that's available and has an FDA indication, should have this PLLR, and that all information should be updated with it. So move away from those pregnancy categories. Now we're doing the PLLR and what was included in this was pregnancy information, pregnancy exposure registry, a risk summary, clinical considerations data, lactation information, clinical considerations for lactation. There was also information on females and males of reproductive potential, so even not necessarily currently pregnant or lactating, but have potential, pregnancy testing, contraception and infertility.
Speaker 2:So all of those things are included in this, and the pregnancy subsection had a registry that collects data on pregnant women and notes if there's any risks that have been noted, and you know it's a lot of information is what basically the takeaway is? I'm not sure that it's as easy for people to see a category and know exactly what it is, but there should be more information available to prescribers. And so, moving away again, no more A, b, c, d, x, but thinking more about what is the actual data, what is the registry information, this collection of, not only for pregnant people and those that are lactating, but also, if they have reproductive potential, what the exposure could mean for them. No, it's not like exciting and sexy, but I do think it's important for us to take note of that change.
Speaker 1:It was more than 10 years ago and we should be moving on with that. Can we talk for a minute about teratogens and how? Because I feel like that is a place where there are obviously certain things that we have been drilled into remembering that are teratogenic. But I think a quick review about teratogens, especially for you know providers who are seeing women either in the preconception period or an early pregnancy, so for me, like the review, is human development phases right Versus what's teratogenic. So, quick overview pre-embryonic right. Conception up to 17 days that's just two weeks post-conception.
Speaker 1:This is in that place where people don't even probably know that they're pregnant yet. Yeah, it's a zygote, yes, and so when you're in a zygotic zygote phase, you don't even know you're pregnant. This is why conversations about preconception are important when women may be on medications, because this could cause like issues with implantation, really early development, et cetera, and so this is like all or nothing, right, when they're this little. You also have to think how many cells big is a zygote? It's not very many cells, so you mess with one or two cells, you mess with them all.
Speaker 2:Yeah, yeah. So again, just to reiterate what you just said, that all or nothing principle is that it could either mean we have survival of the zygote and everything's fine, because we didn't have really like a placenta and circulation well establishedestablished and that sort of thing, but it could also mean that if enough cells are impacted, it is complete loss of the pregnancy, and so that's that all or nothing phenomenon.
Speaker 1:Next would be the embryonic phase. That's day 18 to day 55. This is where we go from being a zygote to being an embryo. But it's a period of really high vulnerability for the embryo because all of these cells are rapidly differentiating and so all of the major organ systems are being formed during that embryonic period. And if you have damage that happens in the embryonic period, then that can lead to big problems with organs, organ systems, malformations, et cetera. So great example of this is like cleft lip, cleft palate, right Yep.
Speaker 2:Absolutely.
Speaker 1:During that time and then when you get to the fetal phase, that's anything after eight weeks, again, brain formation, functional abnormalities. So think about senses, right, hearing loss, things like that will affect those kinds of like developmental systems. But again, anything that crosses the placenta in the fetal phase also can have an effect. So now that we have talked about those things, I just want to run a quick list of things that I think may be useful for people to hear me say like these are teratogenic.
Speaker 2:Yeah, absolutely.
Speaker 1:So, and these are drugs that I think a lot of, I guess high probability drugs you and I talk we like to use the word high probability but the things that I think we're going to encounter the most right and so clearly immunosuppressive things, people who are on things like methotrexate Methotrexate is actually the drug that we use for a common location, right Ectopic, when we're trying to, like you know, rid a body of an ectopic pregnancy. So clearly it's carotid genic Vitamin A. That's the one. I always remember, barbara Peterson, when I was in school and she was teaching this class, she'd be like vitamin A. If they're on vitamin A or any kind of retinoid for their skin, they need to be off of vitamin A. And I was like, okay, I got it. I'm never going to forget vitamin A. Ace inhibitors for people who are on cardiovascular drugs. We don't think much about ACE inhibitors for 50-year-old people, but if we have pregnant women on ACE inhibitors, we need to understand that those are teratogenic.
Speaker 2:Statins as well. Especially with pregnancy, we need our cholesterol to build a healthy fetus, but a statin can impact that development, and so statins are also teratogenic and we have a lot of young people on statins, so I think that's a really good point that you just made.
Speaker 1:I think antifungal drugs and antibiotics there's a couple of things that are kind of on this teratogen list that I think we should know about Ketoconazole and fluconazole, like if you have somebody who's potentially taking a medication for a fungal infection right. Or even like chronic yeast people who are taking like a diflucan once a week because of a yeast situation, that is teratogenic. Trimethoprim, that antibiotic class right. There are antibiotic classes that were like meh, first trimester, right with antibiotics, right right.
Speaker 1:We don't recommend NSAIDs in pregnancy. It really this is an interesting change, because when you and I were baby midwives, we were like no NSAIDs ever. Now we really know that there are some safe times that you can take NSAIDs, but honestly, for me it's one of those things that I'm like. I would rather tell my patients they can never have them than say, oh well, there's this limited amount of time that you can take NSAIDs in pregnancy and have it.
Speaker 2:Yeah Well, and I have found that if I want them to take it, I will say you know, we tell people not to because there's only this limited amount of time and you're in that safe period right now Because I certainly have recommended people take an NSAID before. But you're right, we just don't want willy-nilly use of them.
Speaker 1:Yeah, and the problem with NSAIDs is premature closure of the ductus, the ductus arteriosus Also.
Speaker 2:They can cause oligohydramnios, which is another thing that we don't want. So definitely not after 30 weeks gestation.
Speaker 1:Yes. Another one that I remember very clearly from being in school is like radioactive iodine. I don't know why I remembered that, but so people who need like have thyroid disorder and are on any of those drugs for endocrine disorders that have to do with radioactive iodine are also teratogenic. You know, the sex hormone stuff is stuff that we've really gotten away from. They're not drugs that we use frequently, but live vaccines clearly no MMR in pregnancy. And then you know there's mesoprostols on this list.
Speaker 1:I think for most of us who know what we use mesoprostol for, it's an abortifacient, like we use it when we manage medical abortion, so clearly teratogenic, so I mean. But I think that this is a good kind of high level list of things like oh, and for me, like thinking about what I do and the risk of people that I work with, I'm like the statins need to be like high on my you know list of things at the top of my head. Right, I'm not thinking as much about vitamin A and radioactive iodine. I'm thinking about statins and ACE inhibitors and potentially antifungals and antibiotics more than anything else.
Speaker 2:Well, and one of the things it's so interesting that you said this, because it was one of the things that I was always watching for. You know, people would come in for their well-woman visits. They'd come in for anything. I was checking to see what their medications were and were they desiring pregnancy? What were they doing to prevent pregnancy? And, especially now that we're doing so good with managing people's chronic conditions and thinking about how the GLPs are changing things. Certainly, when I would have patients that were put on metformin, all of a sudden they would start cycling again as they lost some weight and their insulin resistance was being treated and so forth. And so, yes, the exposure to that ACE inhibitor that they were on for their high blood pressure was something I needed to think about, because they hadn't gotten pregnant for years and years and years, but maybe they were going to start ovulating again or that sort of thing. So I'm really glad that you raised this issue because I think, as we think about, every visit with someone of reproductive potential is a preconception visit, especially when we know that half of pregnancies aren't planned. We need to be thinking about the medications that we prescribe and provide refills for, and everything even outside of pregnancy alone, thinking about what could an exposure be if someone did get pregnant. Yeah, good job, all right.
Speaker 2:Well, from there. What should we think about now? You know, thinking about, I guess, moving on to lactation. Does that sound good, yeah?
Speaker 1:I mean I think we've covered.
Speaker 1:I just want to put like a little disclaimer here about pregnancy, like there is no way in our podcast that we can talk about like every single drug and whether or not it's safe.
Speaker 1:I think if you are somebody who was like, oh, I prescribe these or I've seen patients on these 20 drugs and these 20 drugs are the things that I really need to know about, I would encourage you to figure out a way to have a quick reference for yourself, whether it's a reference that Kara and I talk about or whether it's, like you know, we are big fans of good notes.
Speaker 1:We handwrite a lot of notes that translate from our iPads into our phones. Maybe it's something that you need to write out a reference for yourself, or maybe it's a quick link to a website that you need to bookmark somewhere. But I think you know you as a prescriber and I think finding the right resource and the right reference that works for you or the right quick thumbnail or bookmark that's going to be helpful for you in pregnancy is where you need to kind of live with this. But there are tons and we're going to continue to give you resources through this podcast that I think will be helpful. But just figure out what it is that works. But we'll give you some ones that have, I think, the best, most accurate information.
Speaker 2:Yeah, and I think you know one of the things for medications is we used to have a little handbook that we would give our patients when they would come in pregnant and it was like here are the things that you can try over the counter or here you know, for all of the very common discomforts of pregnancy. I kept that handy so that I always knew. They called me, you know, and said I have such and such. I'm like, have you tried? And the things that were on that list and the consistency between what I was telling them matching up with what was on the list that we had provided them, is really helpful. It was also great for me to have that list so I could always remember what was good or what was safe. I think as you develop and you go along in your practice refining that list for yourself and putting things that you've heard good things from patients or as new medications come out, adding them to your list or removing some off as we have more information about it that can be really important.
Speaker 1:Yeah, so I think lactation is a whole nother ballgame and before we start to talk about lactation and lactation risk, I do think like a good physiology right Reminder about lactogenesis, lactogenesis one and two, If you're, if you're no good at lactogenesis, go back to the pharmacology book that I was talking about.
Speaker 1:Go to. Did I tell you Chapter 37? 38., 38, Chapter 38. Review that. Review Lactogenesis 1, Lactogenesis 2. It will also give you some good information about drugs that stimulate milk production, drugs that inhibit milk production, but also the idea of why drugs cross the blood-brain barrier. But it has to do with a lot of things, right. Whether or not we get drug that passes through milk during breastfeeding has to do with size of the molecules. Right, it has to do with protein binding. It has to do with fat solubility and then the half-life of the drug. There are some things we don't even think a thing about, right, in breastfeeding and things that we need to be really aware of, and a lot of the things that we think about with lactation and a lot of the things that we think about with lactation. They all have different reasons, right, as to why they cross the breast milk. But, again, the idea of risk versus benefit when we talk about whether or not moms need to be on medications.
Speaker 2:Yeah, and when we talk about the drug transfer into the breast milk, on a lot of medications you'll see something about the relative infant dose, RID, and generally a medication is considered safe if the RID is less than 10%. So that's something that's helpful to think about as you read through different medications and see what the relative infant dose is.
Speaker 1:Yeah, your book, that chapter in that book also gives you that calculation and a really really nice explanation like it will actually shows you the math. That makes my math art so happy. No, I know um, but it also gives you a really nice um, I think example and explanation of absolute and bendos and why we think about that.
Speaker 2:We're going to tell you some great resources at the end of the podcast of where we go to get information about all of these different things as well as just, you know, tools that you should have in your toolbox. But one of the things that is helpful is thinking about the lactation risk categories. So we said we moved away from the ABCDX and we went to more robust information from the FDA with the PLLR. But when we talk about lactation risk categories, these were developed by Dr Hale he's the author of Medications and Mother's Milk, really great researcher around lactation medicine and so forth and they are considered pretty standard categories. You'll see them listed in a lot of different drug references and so forth, but they go from L1, which is the safest, to L5, which is contraindicated, and so I just want to tell you these categories really quickly and then we can move on to like what are some common things that we use for different conditions in pregnancy and lactation. But L1 I mentioned was the safest. This is where controlled studies show that there is no risk. So that would be things like Tylenol or ibuprofen. Use those while lactating, no problem.
Speaker 2:L2 is a safer medication. There's limited studies and we think that there's very minimal risk and so a lot of antibiotics are going to be in that L2 category. L3 is moderately safe and there's no controlled studies. There is a potential risk. It's possible, but it may be acceptable if the benefit is greater than the risk. A classic case of this is the use of SSRIs for postpartum depression or mood and anxiety disorders. L4 is possibly hazardous. There is some evidence of risk. We could use this medication if there was no safer alternative, but in general we want to avoid these. But that could be things like maybe chemo drugs or something like that. And then L5 is contraindicated. There's significant risk. We should not use these at all in people that are breastfeeding. That's some of our radioactive isotopes. Cocaine, in case you were wondering, you shouldn't use cocaine while lactating. Glad to know that it's been given a risk category, but again, avoid those things that should be contraindicated during lactation.
Speaker 1:I think too, when we talk about breastfeeding, the other, for me, considerations are not just the drug, but some of it has to do with, like, the timing, not just the toxin, but like when they take it right. How much is bioavailable right? How much milk is a baby actually getting? So the volume of breast milk, that relative infant dose that we talked about, and then how old the baby is right. Newborns, so under eight weeks old, are at much more higher risk right For adverse effects from medications than, let's say, an older child. So I think that they're all. There are a lot of things to consider when we talk about lactation, but the message I'm getting is you shouldn't be on any kind of radioactive things when you're pregnant or breastfeeding.
Speaker 1:So, maybe not, you know they talk about like. I always kind of like look at it when I hear them say like, oh, you shouldn't be on chemo drugs or you shouldn't be getting radiation while you're pregnant or breastfeeding, and I'm like that seems very obvious until it's not, until you have a mom with breast cancer or you know some other kind of cancer where she needs to be on medications in order to prolong her life and protect her pregnancy, and that again is a risk benefit scenario that I think as midwives, we don't see ourselves in.
Speaker 2:So some of these things oh sorry, I was just going to say I'm going to guess cancer is not good for the pregnancy or lactation either, correct, correct.
Speaker 1:I think that we sometimes will like, oh duh, like, oh yeah, like that clearly is not something that they should be on. But you know, I feel like in health care for me, especially after being where I've worked for the last four years, it's not really an oh duh anymore, right, like nothing surprises me any longer. But I do think the understanding lactation risk categories these have not changed significantly, but there are some really good references. So can we talk some about like the things in pregnancy and lactation, like some like high level pharmacology for pregnancy and lactation, like clinical scenarios.
Speaker 2:Yeah, sure, I think that sounds like a good idea, yeah.
Speaker 1:So one of the most common things in pregnancy that we prescribe medications for is nausea and vomiting. You and I were not as good of friends as we are now when I was pregnant with Brooks, but I definitely had hyperemesis in the pre-zofran pump era of life. The funny thing about that is that I prayed and I swore that if God would give me a baby, I would stand on my head naked in the snow and vomit five times a day. And God said hold my beer, stand on my head naked in the snow and vomit five times a day. And God said hold my beer, because I did not have to stand on my head naked, but I did vomit five times a day. I was 151 pounds full term with Brooks, which is ridiculous because I'm so tall, but I was so sick and I would have loved a Zofran pump, which is like great now.
Speaker 1:But now we have things like Diclegis, right Um, which is what I always say. It's um, it's Unisom, right. And B12, b6 and B12 together in one um, like compounded drug, which is so um. But also we give a lot of Zofran. Let me say Zofran is a great drug. Sometimes when you feel like you're going to vomit. It is fantastic for keeping you from vomiting. It sometimes will take the nausea away, but sometimes, when you absolutely want to puke, it will still keep you from puking. So you know there's that, but also that can also be I was going to say significant diet or some significant constipation. That was it. Yes, and it can cause headache, yeah, and so I think that's another interesting thing that, like you, you know we give a medication that we think is going to help with something that's so debilitating in pregnancy, but also considering like risks and benefits.
Speaker 2:Yeah, you know, one of the things I would do a fair amount when I was in my early practice was get old fashioned Finnergan and it worked really well and people could take it orally but if they couldn't keep it down they could insert it rectally like a suppository and it also worked really well and it was very inexpensive. So I don't want to forget some of like our old classic medications. It also made people sleep, which you know in general, if you're sleeping, you're not nauseous.
Speaker 1:Yes, but not a great thing. If you've got to function during the day, agreed, agreed. If you have other little children, you have a job. If you've got to function during the day.
Speaker 2:Agreed, Agreed. If you have other little children, you have a job, you know those kinds of things it could be like functioning like a human.
Speaker 1:Yeah, yeah, Common complaint in pregnancy is heartburn. I did not suffer with heartburn as a pregnant person, but lots of people do and I am trying to like rule out do you have heartburn when you tell me you have epigastric pain? Are you preeclampsic or do you just have heartburn? So I always start with like, can I give you some Pepsid and some fluids and some Tums and see if this doesn't go away?
Speaker 2:right, yeah, yeah, in general, starting out with those Tums, that sort of thing, then going to our H2 blockers. Like you mentioned, pepsid, you can use a PPI if needed, but we try to avoid those if possible. Okay, you mentioned it Constipation.
Speaker 1:Constipation, and that has to do with a lot of things. Right, it can be, you know, slow GI motility, it can be medication use, it can be all the things. So bulk forming, fiber and stool, softness, dude water, just drink your water. Even as a non-pregnant person, I will tell you that on days when I don't drink enough water, I will feel constipated. You've got to drink the water.
Speaker 2:And move your body, like walking in water, can fix so many things.
Speaker 2:Yeah, so many things, but trying to avoid castor oil, I was just going to say, please don't take the castor oil unless you're like 40 weeks and desperate to have a baby, and then maybe talk with your midwife about it. If you are the pregnant person, if you're the midwife, think about if you want to talk to your patients about it. Yeah, to talk to your patients about it. Yeah. Pain relief we kind of already mentioned that in general. Acetaminophen, tylenol is our go-to for pain relief. We try to avoid NSAIDs. We have a lot of data on the use of Tylenol and it is probably the safest medication that we have that people can routinely use. It is not anti-inflammatory, though, so it's not always super effective at getting rid of the pain. It's definitely good at reducing fever, but it's what we have, it's what we can use.
Speaker 1:Yeah, I've been having a lot of conversations recently with patients, especially postpartum, about why we take Advil versus why we take Tylenol and I'm like Tylenol is always going to be best for a fever, Like Tylenol is the best for the fever, the Advil is best for the aches and pains and the muscly kinds of things, and they're different. They have different mechanisms of action. The reason that we prescribe them both is because they're different Absolutely. If you're postpartum rounding and you've got patients that have pain but also you're trying to think about fever and fever prevention and those kinds of things both yeah, absolutely Infections.
Speaker 2:And thinking about our antibiotics In general. Our penicillins are considered safe in pregnancy, our cephalosporins and some of our macrolides, but we want to avoid tetracyclines and fluoroquinolones as we think about prescribing different types of antibiotics. Yeah, the question I have a question for you, especially being in triage it always comes up of we're told to avoid macrobid in the last few weeks of pregnancy, but I have found in practice that most people talk about how that's a theoretical risk for like hyperbilirubinemia of the infant and that most people still feel like it's such a well-tolerated medication that they will still use macrobid for UTI in late pregnancy. I'm curious what you see in practice.
Speaker 1:I still like it and pharmacy will call me and they'll say do you really want to use this in the patient's 37 weeks? And I'll say yep, because they're going to only use it for five days and it's going to be fine.
Speaker 2:Yeah, and it's so much easier with just twice-day dosing. I find that it's really well tolerated.
Speaker 1:We just have so many patients who are allergic and we can have a whole conversation about allergies and what's really an allergy and what's a side effect, differences between side effects and allergies right, but we have a lot of patients who are allergic, have strange allergies. It's not a drug that you hear that people are allergic to. A lot of the time you also see the side effect profile, I think with Macrobid, that you would see with some of the other drugs and when we get urine cultures back. I mean I've seen a handful of urine cultures not be susceptible to Macrobid, but not very many. It's rare, I find.
Speaker 1:Yeah, susceptible to macrobid, but not very many. It's rare, I find. Yeah, I agree, I mean I have had, you know, I've had some weird urosepsis the last couple of years, like some patients with some weird urosepsis that had like Klebs UTI. You got a Klebs UTI. Macrobid's not going to do it, but rarely. And I think if I was not where I am working and if I was just like in what I would like to say, like normal world, I probably would always be like treating with Macrobid, because it's always susceptible to Macrobid.
Speaker 1:But, yeah, I do agree that we are still using it. It's not something that we are averse to and our pediatricians haven't said like no, you shouldn't use that.
Speaker 2:Yeah, agreed, agreed. I think the other thing in pregnancy that we want to talk about is for mental health, and, as the use of SSRIs are considered safe in pregnancy, zoloft is oftentimes preferred. I think you know Zoloft and Prozac. We have so much information over the years on those two in particular. They have the indications for anxiety as well as depression. In general is a risk benefit, and a treated mother's mental health condition is going to be safer for that pregnancy and that fetus than untreated. We do want to avoid Paxil, though.
Speaker 1:Yeah, I think when we talk about mental health things, it's like one of those things that I'm like I need you to be on your drugs.
Speaker 2:Yeah, exactly, and it's unfortunate. I think we're moving away from the time period where other prescribers would tell people to stop everything as soon as they had a positive pregnancy test. I hope we're moving away from that, because we do need to have really good conversations and shared decision-making with our patients.
Speaker 1:So let's switch to lactation. Yeah, how does this translate? I was going to say I think it's easier to talk about the things we should avoid in lactation because I think that list is shorter and easier to remember. So you know things that we shouldn't give, that we should stay away from in lactation. So codeine is one of them. That's mostly because we think about the metabolism of codeine bioavailable in breast milk that are okay for pain. People can be taking Percocet or some sort of oxycodone when they're breastfeeding. If they need it short term.
Speaker 2:That is better than codeine and codeine's kind of I think, an old drug anyway we gave so many T3s like so much Tylenol, number three working postpartum and it's fascinating to know what we know now about those super metabolizers and how it can convert the codeine. So I agree with you we have other options available. Probably going to be better without it.
Speaker 1:And other things I would avoid are like sulfa drugs, especially if a baby is jaundice or premature or has any kind of hyperbilirubinemia. I'd stay away from sulfa drugs. You know, we know about contraception in the postpartum period. We should avoid estrogen, although the US MET criteria will say at 21 days they can have things that have estrogen in them, fine. So you know, met is kind of the resource that we think about when we talk about contraception and so the MET criteria says 21 to 30 days that they can be back on estrogen.
Speaker 2:Yeah absolutely.
Speaker 1:And then I think I was going to say the only other thing is allergies and colds and that you know we're about to hit cold season and flu season, that you want to stay away from the pseudoephedrine, the drugs like Sudafed that can really it's not so much for the baby as much as it is for the mom If we think about how those drugs work to like dry everything up, it will also dry up the smoke.
Speaker 2:Yeah, but you can use, just like you had said, zyrtec, lirin, those kinds of things for allergies and they don't have that drying effect that Sudafed does.
Speaker 1:So I think over-the-counter medications is another thing that and I think we've covered a lot of the things that are safe in pregnancy in terms of pregnancy and lactation. In terms of over-the-counter, I would say that be careful. If you're like you have a lot of patients who like herbals versus you know traditional over the counters, because if you don't know exactly what's in it, you can't counsel your patients well and you know making sure that you have a. If you are in a population of patients who uses a lot of herbal remedies that you have a really good reference for, for being able to look that stuff up and make good recommendations, but for the most part over the counter things Tums, pepsin, metamucil Colace um, when you've got a cold, like saline spray, um, the the things that generally we can get over the counter.
Speaker 2:Yeah absolutely.
Speaker 1:You're going to tell somebody like we know, advil not safe in pregnancy. Don't do that. As an aside, did you know that some Advil has gluten in it?
Speaker 2:I did not know, but I do not have to be as gluten aware as some people.
Speaker 1:And it's not necessarily terrible for me who's just got a wild intolerance. But people who have celiac have to be careful about some of their over-the-counter drugs because some of their binders are gluten-y.
Speaker 2:It makes sense. Once you talk about it and think about, like how it like the coating on it or how it binds the medication into a tablet, it kind of makes sense.
Speaker 1:Yeah, so that's a very strange aside, but it just happened in my head that I was like did you know?
Speaker 2:Yeah, all right. So you mentioned having a good resource about herbals, but let's talk about resources in general. So things that we can do, places that we can go to, what are our things that we grab? You've already mentioned the Pharmacology and Women's Health book, so Koa King and Mary Brucker praises to you for such a great textbook over the years. It is wonderful. But then there's some other things that we should check out when we're thinking about prescribing.
Speaker 2:Something that's free is LactMed. It is from the NIH. It is an app that I have on my phone. It's also a website that you can go to and it's really quick for checking for breastfeeding safety. I like it a lot. And then we mentioned Dr Hale Medications in Mother's Milk. It's another great resource. There's some other ones like, I think, is it Briggs? That is, the drugs in pregnancy and lactation. That was a textbook I had to have when I was in school. It gets updated from time to time, but those are more books or apps that you could have on your phone. There are other things like Mother to Baby. That has fact sheets and a hotline, and then Mother Risk also has lactation and pregnancy information. Do you have any others, missy, that you like to use?
Speaker 1:I talked about Repro. What was it Repro? Oh, that's right, repro Talks, repro Talks, that's it. So people who are like in preconception, right, um, or who are in early pregnancy, is another like reputable source, um. But I do think, like hail you just talked about has an app. So, um, that's, hail is published by springer and so they have a companion app. Like you were saying, drugs and lactation the National Institute of Health also has an app that can go straight on your phone. And then you did talk about lactamide, which also has an app.
Speaker 1:So remember and if you don't remember this, go back to my article about, like, how you look at apps and determine whether or not I think it's important when you're putting apps on your phone, that you always look at who the source is and who the developer. It's the same thing we tell students If you're going to go and buy a question bank, you should know who writes the questions. It's the same thing for apps you should always know who the source is. So if it's the NIH or the CDC or it's Johns Hopkins or it's the Mayo Clinic, go for it. Those are all great resources. Just be careful if the app developer isn't something that you're like. Oh, I recognize this as a reputable source. That's the number one thing when we're looking at like apps.
Speaker 2:So another point of what you had mentioned. You get a phone call and you say let me put you on hold so I can check a reference. I vividly remember checking Kelly Mom, which is a website. It is really great for lactation, but it was. I had someone that had plugged ducts and I knew that I could recommend lecithin to them for that while they were lactating, but I couldn't remember the dose. Kelly Mom is another really good reference. It's a website that is available widely to the public, but I feel good about it and I feel like they really put out reputable information, and so that is another one that I routinely would use and I would let my patients know what references I was using. I remember someone being like you just looked it up on a website and I'm like, yeah, but that's like part of the important part of my job is knowing what I can look at and trust versus just anything that's available on the internet.
Speaker 1:Yeah, all of our references that we talked about will be in our show notes for you to be able to download and have and figure out what you like the best. So what advice do you have for people, new students, new prescribers what are you sending them away with, kara?
Speaker 2:Don't memorize everything. Know your references. That would be number one. No-transcript With everything. In prescribing, use the lowest effective dose for the shortest amount of duration as possible. I think that's just general good rules and so certainly during pregnancy lactation, that makes sense. And then think about who you can consult. Do you have colleagues that are really super knowledgeable? Sometimes I'm calling my lactation consultant friends, sometimes I'm calling the pharmacist I loved in my private practice that there was a pharmacy in the medical office building on the main floor and I would call down and have questions for them periodically. So, knowing who the people are, that you can physically pick up the phone and call versus what are your references that you have at your fingertips, that you can pull out whenever you need them, and then remember, your confidence is going to grow over time and as you have more experience and more exposure and you're going to be that colleague that someone else calls eventually, which is so fun.
Speaker 1:Yeah, I agree. I think I remember when I was brand new in practice and I would have people come in with dysmenorrhea and I'd be like I know I don't want to give them a narcotic, but I don't know what to do. Somebody like help, Like it seems so silly now, but I'm like I just didn't have a lot of experience with, like, how we treat those things and also 20 years ago the drugs weren't that great. Yeah, let's be clear. We didn't have good drugs for you know.
Speaker 2:Well, we still had ibuprofen, and it's one of my favorite medications. Correct, but nobody's dosing it appropriately.
Speaker 1:No, it is underutilized. Yeah and underdosed. I mean yeah, agreed. So yeah, like taking it once and being like it didn't work is not going to do it.
Speaker 2:Exactly, exactly Okay. Maybe that's our biggest takeaway from this episode.
Speaker 1:Let's not talk so bad about ibuprofen. Correct, all right. So things to remember about this whole idea of pregnancy and lactation is FDA has changed its tune, right, we're no longer talking about pregnancy category, we're talking about this PLOR guidelines. That has a lot more information. It's a little less straightforward but, I think, more appropriate.
Speaker 2:Yeah, really good clinical relevance.
Speaker 1:Lactation risk categories haven't changed, but it's a really nice guideline for breastfeeding, breastfeeding activity. When things are safe or not safe, it's a good point of reference.
Speaker 2:Yeah, absolutely.
Speaker 1:Um, I think the high, like the big tenant to of prescribing is balance, right, don't? You just said don't memorize everything, but it's like knowing who to ask or where to find the answers. Like you're not going to I'm holding this pharmacology book right now and like you're not going to memorize this book, like, even if you sleep on it, osmosis're not going to memorize this book. Like, even if you sleep on it, osmosis is not going to work. Okay, and so when you're in a position where you need to be able to look something up quickly, like just know where to go and know the balance, know the things that you're supposed to know, you should absolutely know that off the top of your head, dicloxacillin is the drug that you use as a gold standard to treat mastitis period. Yes, Agreed.
Speaker 2:You should also know that we don't use doxycycline in pregnancy Period.
Speaker 1:Yes, you should also know that Tylenol is the number one thing that we talk about in pregnancy for aches and pains. That's safe, so I think there is a short list of things in terms of pharmacology that you have to just know. Like we tell students all the time you're going to treat an STI, here's the first line for every STI, and you should be able to rattle those off right. There are nuances to everything, though, and so what I'm what I think you and I are trying to say in this podcast is is the nuances are where the balance is, and that's where you figure out where your references are and how to use them, but don't discount that. There are some things that you should just know right off the top of your head, and I will also tell you that my cycloxycelan has been a change since I've been in practice, because that was not the gold standard when I got out of school.
Speaker 2:I remember learning about it. Thankfully, I have not had to treat a ton of mastitis in my life.
Speaker 1:I'm just going to say we use Keflex because dosing four times a day for somebody stinks.
Speaker 2:It does, but it works really well.
Speaker 1:No, I know, but hey, you got got to get up. Not only do you have a brand new baby and you've got mastitis and you feel like trash, but now you've got to take this drug four times a day, like I mean, this is coming from somebody who breastfed 24 months out of her life.
Speaker 2:Like thank goodness we have smartphones with like timers and alarms and all of those things manage our lives, because back in the day, holy smokes.
Speaker 1:Right. So I got off track. But I have one more like closing. Oh, okay, yes, we should feel good and empowered as prescribers, we should feel confident. But if you don't feel confident, you have references and resources and you can phone a friend. Yeah, yeah, you sure can. I'm sure Teresa Ashe is so sick of me being like so what do you think of this thing in pregnancy? Like, who's your favorite PharmD? I know who mine is, who is yours Right, and so who are your references? So again, I'm going to make a plug to you know, jones and Bartlett, that they need to revise this book to have a third edition of pharmacology for women's health. I don't think it's in the works yet but honestly, I this is a big puffy heart, this book and I want there to be-, jones and Bartlett, do you hear us?
Speaker 2:All of us, as program directors and educators, would love an update of that textbook.
Speaker 1:Maybe you could just give it to me and that could be my life's work and I could be done doing it. So funny.
Speaker 2:Well, I hope this was helpful to everyone.
Speaker 1:I mean it was helpful to me.
Speaker 2:It was me too. It was a good review. I think it was really good.
Speaker 1:I also think is this episode coming out pre-ACNM.
Speaker 2:Yes, and we will have another episode soon about ACNM and our ACNM leaders. I'm really excited about that one as well.
Speaker 1:Yeah, with ACNM Vice President Lexi Dunn and the CEO, michelle Monroe, on our next episode, as a prelude to seeing everyone in Palm Springs. Also, I will put a little point in here. If you see Kara and I, please come up and say hello. We have swag the way we're going to have buttons and stickers and fun things at ACNM about the Engage Midwife. So, please, if you see us or you hear our voices because that's what you recognize please come say hello, like we want to talk to you. We want to hear your ideas for podcast episodes. And yes, we're huggers, it's okay, you can hug us. We get a lot of pleasure out of meeting people who want to talk to us, and so it's a lot of fun. It's fun for you guys, but it's fun for us too.
Speaker 2:It's really fun. Well, thanks, missy, this was great, great conversation.
Speaker 1:Well, thanks for joining us for the Engaged Midwife Podcast. We can't wait to talk to you again, take.