The world likes to get judgy when it comes to medications, particularly those that are viewed as addictive or otherwise “bad” in some way. The judginess grows exponentially when it comes to medication use in pregnancy.
Obviously, it’s a problem if a medication has a negative effect on a developing fetus. However, in the real world, things are seldom that simple. There may be a lot of nuances in determining what’s the best choice for an individual woman, and unfounded fears about medication use in pregnancy could end up interfering with that.
Opioid use in pregnancy
Opioids are one type of medication that definitely has a bad reputation. Yet when it comes to an individual weighing of pros and cons, regular opioid use during pregnancy could be a very good decision. While there are negative effects of opioid abuse during pregnancy, that’s primarily due to repeated withdrawal cycles. If women are instead put on opioid substitution therapy, it results in better outcomes for them and their babies.
For women who are already on opioids for chronic pain management, remaining on them may end up being the best choice, as it avoids the risks associated with withdrawal and also with untreated pain. Untreated chronic pain can have a number of negative effects on the in utero environment.
Will a baby born to a mother taking opioids go into withdrawal? Probably. This is referred to as neonatal abstinence syndrome, and there are protocols to manage it, including giving morphine short-term with a downward tapering of the dose and maximizing skin-to-skin contact between mom and baby. Would it be great to avoid this? Sure, but only if the alternatives are better. A baby going into withdrawal sounds horrible, but it’s unfair to weigh that against an imagined alternative of rainbows and unicorns.
Psychiatric medications in pregnancy
When it comes to mental health, untreated or undertreated serious mental illness is not good for mom or baby. That means that when weighing any medication option, the alternatives are not high-risk medication or no-risk alternative. If the illness can be managed without medication, that’s great, but with more severe illness, that may not be possible.
When it comes to antidepressants, generally, whatever is most effective for treating mom’s depression is the safest option. SSRI and SNRI antidepressants may lead to neonatal abstinence syndrome (NAS), which is usually mild and short-lived and can be improved by a low stimulation environment and increased skin-to-skin time.
Things get a little dicier when it comes to mood stabilizers. Lithium is associated with an increase in the risk of a rare heart defect called Ebstein’s anomaly. Carbamazepine is associated with a higher risk to cause birth defects, and the risk with valproic acid is substantially higher.
If I were to get pregnant, I would most likely choose to stay on lithium. Even a woman whose bipolar disorder was poorly controlled with anything over than valproic acid may decide that the risk of stopping the medication was greater than the risk of staying on it. It really comes down to the individual woman’s risk profile.
ECT as an option
Electroconvulsive therapy (ECT) has been shown to be safe and effective during pregnancy, although it is not often used. ECT has been helpful for me before, and I’d likely turn to it again if I got pregnant. I have to wonder, though, what level of stigma would go along with that. I would imagine that most people’s initial gut reaction would be that this must be dangerous for the fetus, and to be honest, I would probably have a hard time silencing that thought in my own mind.
Postpartum, I’d be concerned about my ability to care for a child if I was getting ECT, since I tend to have significant memory problems as a side effect.
The take-home message
I’m not trying to advocate for indiscriminate medication use in pregnancy. If there’s an effective alternative available, that’s ideal, no question. If you can find a way to stay well without medication, the choice is crystal-clear. What I’m trying to get at is that there are a lot of different factors that need to go into making an individual decision, and it’s unfair to criticize a woman’s decision without having a full understanding of all of those specific individual factors.
So if you are pregnant or thinking about getting pregnant, have these conversations with your health care providers. Don’t let other people’s judgments get in the way of what’s right for you and your family. Choose the option where the pros outweigh the cons in your individual situation, regardless of what that choice ends up being and what other people think about it.
- Anxiety and Depression Association of America: Pregnancy and medication
- Johns Hopkins Medicine: Antidepressants and pregnancy
- Massachusetts General Hospital Center for Women’s Mental Health
- US FDA list of pregnancy exposure registries
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.