19 From belly to baby: preparing for a healthy pregnancy

Introduction

Quality maternity care including pre-conception, pregnancy, and interconception care (care from one pregnancy to the next) has been shown to reduce rates of maternal and infant mortality and morbidity.¹ While rates of morbidity and mortality are lower in the United States than many other countries, there are numerous disparities that exist.

Sociodemographic and behavioral factors play into the maternal and fetal outcomes. Age, race, education, family income, nutritional status, and preconception health may affect mom and baby. Preterm births, low birthweight infants, and infant death are highest in teens under 18 years of age and women over 40. Women greater than 35 years old are also at risk for higher rates of maternal death or serious maternal outcomes. Interpregnancy intervals also affect the health of the baby with increased morbidity including neonatal intensive care or enhanced ventilation requirements in babies born within an interpregnancy interval less than 12 months or over 24 months. Mothers tended towards increasing risks of gestational hypertension or gestational diabetes when the interpregnancy interval increased beyond 24 months.² In addition, when compared with infants born to non-Hispanic white mothers, infants born to non-Hispanic black mothers and Native American mothers are more than twice as likely to die in the first year of life and to be at risk for preterm birth or other complications.³ While a small number of racial or ethnic disparities may be due to genetic factors, the majority are due to inequalities in income, housing, and education level.⁴ Women of lower socioeconomic status are more likely to have increased stress, poorer nutrition, and increased use of tobacco or other substances. This contributes to increases in preterm birth and small-for-gestational-age babies.^5-6 Women with lower levels of education have been associated with higher maternal mortality despite similar access to care.⁷ Finally, health-care system disparities in access or affordability and provider-level factors including culturally derived mistrust of the healthcare system may also contribute to differences in prenatal and perinatal outcomes.⁴ Improved maternal and infant health will likely require continued research and multidisciplinary approaches to understand these and other contributing factors.

Good nutritional status is essential in pregnancy. A prenatal vitamin in addition to a well-rounded diet is recommended prior to and during pregnancy to prevent adverse outcomes. Higher levels of folic acid and iron are needed in pregnancy.⁸ Folic acid should be started prior to conception at doses of 400-800 micrograms daily to prevent neural tube defects that can happen in the first few weeks of pregancy.^8-9 Iron requirements increase from 15-18 milligrams to 27 milligrams during pregnancy as the body makes more red blood cells to provide oxygen to the fetus.¹⁰ While the daily intake requirements do not change during pregnancy, calcium and vitamin D are essential for the development of the fetus’ bones and teeth.

Addressing prior health conditions is also a component of maternal care. Typically, hypertension and diabetes diagnosed prior to 20 weeks gestation are categorized as chronic health conditions while those diagnosed past 20 weeks gestation are categorized as gestational conditions. Both chronic conditions and gestational conditions have been shown to increase the risk of miscarriages, small for gestational age, macrosomia, preterm birth, and neonatal intensive care stays.^11-12 In addition, there are increased rates of maternal death and long-term complications.^11-13

Pharmacists should review a patient’s medications including prescriptions, over-the-counter and herbal medications, and vitamins at every visit to determine safety during pregnancy. This is incredibly important as nine out of 10 U.S. women take a medication at some point in their pregnancy.¹⁴ It is necessary to know how far along a patient is in the pregnancy to identify if a medication can be used as some adverse effects may only be seen in specific trimesters. Since 2015, medications have moved from the previous categorization system of A, B, C, D, and X to the more extensive risk summary and clinical considerations. This now involves three sections for pregnancy, lactation, and females and males of reproductive potential.¹⁵ Pharmacists can utilize a variety of drug resources, case reports, and studies to best recommend medications to use or not to use in pregnancy.

Case

CC: “I missed my period. I think I may be pregnant.”

Patient: TW is a 37-year-old African American female (68 in, 92 kg) coming in for evaluation of a new pregnancy.

HPI: TW is G2P2 with two healthy baby boys ages three and five. She reports her last period was 2.5 months ago. She has had some nausea throughout the day with vomiting two to three times daily for the last five weeks. In addition, she reports occasional dizziness. TW and her husband have not been using any contraception since her last pregnancy.

PMH: depression (four years); iron-deficiency anemia in last pregnancy

FH:

• Mother: alive (60 years) with HTN, T2DM, no prenatal complications (G4P4)
• Father: alive (58 years) with HTN

SH: Denies use of alcohol, nicotine, illicit substances, and non-prescribed medications

SDH: Medicaid insurance. Refugee status; moved to the US from Ethiopia 12 years ago

Medications:

• Sertraline 100 mg once daily
• One A Day® Vitacraves^® Women’s Gummy Multivitamin 2 gummies daily
• Ferrous sulfate 325 mg 1 tablet once daily (last took 2.5 years ago)

Allergies: NKDA

Vitals:

• BP 110/62 mmHg
• HR 72 bpm
• RR 16 rpm
• Temperature 98.6 ⁰F

Labs: Pregnancy test (positive)

Imaging: Ultrasound confirms singleton pregnancy at 11 weeks gestation

Case Questions

1. What socioeconomic factors may increase TW’s risk for maternal and infant morbidity and mortality?

2. TW is currently on a few medications. Where can pharmacists and healthcare providers look to determine safety of a medication in pregnancy? Can TW continue her current medications in pregnancy?

3. List the current published USPSTF recommendations for pregnant women. Which might be appropriate for the pharmacist to address?

4. Looking at TW’s chart, assess her need for supplementation of folic acid and iron

5. Using the USPSTF clinical risk assessment for preeclampsia, decide if TW should be recommended aspirin during this pregnancy.

Author Commentary

Pregnancy comes with many stressors, with medications being just one. Pharmacists can provide support and answers to questions regarding what products may or may not be safe for mom and baby during pregnancy, and later in lactation and nursing. Recognizing the benefits and risks of medications and being able to explain it to both physicians and patients can optimize care and allow for patient-centered care. While it is important to avoid certain medications, some medications especially folic acid should be recommended to all pregnant women and those of childbearing potential to minimize risks for neural tube defects. It is just as important to know what medications to recommend as it is to know what medications to avoid. Pharmacists in all practice settings should stay up-to-date on changes to prenatal guidelines and recommendations, including those for preventative care.

Pharmacists may engage the pregnant patient in regular care, providing education during pregnancy for acute or chronic issues. As a pharmacist, one may be asked to co-manage gestational concerns such as gestational hypertension, gestational diabetes, or gestational anemias with the provider. Patients may come to the pharmacy for regular blood pressure checks or to review use of diabetic supplies and blood glucoses during pregnancy. Recognizing times to for education and self-care and referral for serious symptoms is needed to ensure timely care. Working with the patient and provider to select the right contraception, whether hormonal or family planning methods, during the interpregnancy period can allow for optimal spacing if more children are planned to minimize complications from shortened or lengthened interpregnancy intervals. Finally, providing care in a culturally competent, health literate way can help patients feel comfortable and confident in the pharmacist’s knowledge and advice. Being aware of community resources can help patients to gain access to the care and provisions needed in pregnancy, hopefully minimizing disparities for a healthy pregnancy.

Ensuring the mom and baby are protected with the right medications, the right vaccinations, and the right education, pharmacists can prepare the patient for a healthy pregnancy and beyond.

Patient Approaches and Opportunities

Pregnancy is an important health condition affecting many women at some point in their lives. Pharmacists must be able to appropriately address prenatal concerns and know when patients should be referred to other healthcare providers. Providing patients and healthcare providers with up to date information addressing the risks and benefits of medications prior to pregnancy for women of childbearing age, during pregnancy, breastfeeding and postpartum, is a vital area for pharmacists to minimize teratogenic risks and concerns for mother and baby. It is important to assess social determinants of health and recognize their importance in healthcare decision-making. Pharmacists can make key interventions to minimize adverse outcomes by being knowledgeable in medication and nutrition recommendations for pregnant patients.

Pharmacists play a public health role in so many ways. Pharmacists recommend and may administer vaccinations. During pregnancy, non-live vaccines can be recommended. All pregnant women without complications should receive an inactivated influenza during influenza season and a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) between weeks 27 and 36. The Tdap vaccine improves protection and cocooning of young infants from pertussis. Additionally, pharmacists can provide recommendations for postpartum contraception depending on the needs of the patient. As durable medical equipment providers pharmacists may also counsel patients on breastfeeding and lactation support and supply breast pumps and supplies.

Despite being a time in which many patients are on few to no medications, pharmacists can truly provide outstanding care and support, contributing to the needs of the patients and healthcare team.