ABNORMAL BABIES: DRUGS AND PREGNANCY

drugs may act adversely at any time during the nine months, the period of greatest risk is usually the first trimester. That's when many of the fetus' organs are being formed. As a matter of fact, the first week of pregnancy, before most women even know they have conceived, is critical. So if you are working at getting pregnant, assume at all times that you have just succeeded, as far as drugs, radiation, infection and diet are concerned.

Suppose you're a diabetic and have been taking oral agents to keep your blood sugar down because diet alone wasn't enough. Now you become pregnant. Should you continue the medication or switch to insulin? In my opinion, you're best off stopping the oral drug, especially during the first three months. Although these medications are not teratogenic (injurious to the fetus), they can lower not only your blood sugar but that of the embryo as well. An abnormally low blood sugar is harmful to the embryo, and is difficult to correct. Insulin, on the other hand, does not seem to have this effect. So if your diabetes requires something other than mere attention, to what you eat, you’re better off with insulin for the "duration."

Also, if you're a diabetic, your risk of having a malformed baby is about three times that of the normal population. But you can reduce that likelihood by really focusing on your diabetic control. My last five or six diabetic patients who did so gave birth to babies who were perhaps slightly overweight but otherwise perfectly normal. According to experts at the famous Joslin Clinic, when diabetic mothers are carefully monitored throughout their pregnancy, and their blood sugars are controlled by diet and insulin, 96 percent of the babies born are normal.

Which antibiotics are safe during pregnancy? I don't normally advise their use by anyone for trivial upper-respiratory infections unless there is a compelling reason to do so, for example, when the patient is old, fragile and vulnerable to pneumonia, or is diabetic, or has chronic lung, heart or kidney disease. A healthy pregnant woman doesn't fall into any of those categories, as far as I'm concerned. But if you're pregnant and running a respectable fever—one in excess of 101°—for two or three days, you should take an antibiotic. Penicillin is safe (unless you're allergic to it), but avoid tetracycline, because it can interfere with the bone growth of the infant, may discolor its teeth later in life and may cause other bodily deformities. Avoid streptomycin, not often prescribed anymore. There is a whole group of antibiotics called aminoglycosides (these include kanamycin, gentamicin and vancomycin) that are very powerful and usually are used only in life-threatening situations. If no other drug will do the job, you may have to take one of them, but I'm not entirely convinced of their safety.

Sulfa drugs are frequently used for urinary and upper-respiratory-tract infections. They are considered safe but, from time to time, have been observed to cause bleeding abnormalities in the fetus. So take them if you must, but never casually or capriciously. Septra and Bactrim, excellent agents in the treatment of urinary infections, have been shown to cause cleft palate in animals. I'd avoid them during pregnancy.

Thyroid disorders are common in young women. The gland may be overactive, underactive, enlarged or have some nodules in it. If you are hypothyroid and require thyroid replacement, there is no reason not to supplement it when you're pregnant. After all, you're just replacing something that's missing—thyroid hormone. In fact, if you fail to take it, you may give birth to a cretin—a fetus that has been deprived of enough thyroid hormone during the critical weeks and months of its development in the uterus. But treatment of an overactive gland is another matter. The usual options include: (a) radioactive iodine to "wipe out" the toxic gland, (b) antithyroid drugs like propylthiouracil to "suppress" it, or (c) surgical removal. The pregnant female has only one choice—surgery. Radiation in any form is obviously out of the question. The various antithyroid drugs, which have an iodine base, cause the gland of the fetus to enlarge so much that it can compress the airway and interfere with respiration when the fetus's lungs begin to function. There have also been reports of mental retardation in the offspring following their use. Indeed, all pregnant women, even those with normal thyroid activity, should avoid iodine in any form, because it may interfere with the function of that gland. For example, if you're asthmatic or have a chronic cough, make sure your cough syrup or decongestant isn't loaded with iodine.

One of my patients called me a few weeks ago. She had just learned she was pregnant, and her husband was so delighted with the news he offered her a trip to Egypt, sailing down the Nile. She called me, not merely to say goodbye, but to check on the safety of the various drugs she was taking along, "just in case I need them." We had a lengthy discussion about each one, and I told her much of what I have written in this chapter. As I was about to hang up, I remembered malaria prophylaxis, a must for anyone going anywhere in Africa. "Oh, that's easy. We're old hands with malaria. We just take one chloroquine tablet a week for two weeks before we leave, then every week while we're there and for six weeks after we come back. That's all right, isn't it? I mean, it's only one pill a week."

Well, the fact is, chloroquine is great for preventing malaria but can cause deafness of the newborn—at least when it's used in the larger doses required to treat malaria. Whether the lesser concentration used for prophylaxis is dangerous, I'm not sure. It makes sense to avoid it during the first three months anyway. Do you know what I advised this young lady? To postpone her trip until the second trimester, or better still, to celebrate the happy event in a malaria-free environment. However, if you're pregnant and must go to a malaria zone, or if you actually come down with the disease and require treatment, your doctor may prescribe Primaquine or Pentaquine—alternatives to chloroquine—which may be less harmful to the fetus.

While we're on the subject of toxicity of quinine (of which chloroquine and related drugs are derivatives), don't forget some other common products in which this substance is found. Do you love cold, sparkling tonic water with or without gin or vodka? Avoid it during pregnancy. There is reason to believe that even in this pleasant form, quinine may cause congenital problems, mostly related to hearing and vision. Do you have leg cramps at night? Tried everything, and nothing works? Chances are your doctor will prescribe quinine at bedtime. It may help, but it too should be avoided during pregnancy.

Here's a practical problem that may confront a young woman with epilepsy who needs medication to control or prevent seizures. Most of the anticonvulsants like Dilantin, trimethadione and paramethadione are very likely to cause serious birth defects, everything ranging from growth deficiency and cardiac abnormalities to deformed genitals and mental retardation—the works. Even a drug as benign as phenobarbital, which is often used in conjunction with other anti-epileptic agents, is not without significant risk. The likelihood of trouble is so great that I advise epileptic women not to become pregnant if they require any of these drugs. What's more, if they unknowingly do conceive and have taken any of these agents in the first trimester, the risk is so great I offer them the option of abortion. Some patients, however, can have their minor, or petit mal, seizures controlled by a less toxic agent called Zarontin.

Aspirin is the most commonly used drug in our society, but it is unsafe during pregnancy, both at the beginning and at the very end. Recent studies have shown that infants born of mothers who treated their cold or flu symptoms with aspirin during the first trimester have twice the incidence of congenital heart defects. Aspirin also interferes with blood clotting. That's why it's used for the prevention of heart attacks and strokes. But this mechanism can cause bleeding in the infant, so avoid its use during the last week or two of pregnancy. If you don't, the baby may be born with internal hemorrhages.

Ergot is a drug widely prescribed in the treatment of migraine headaches. It is most effective when taken at the very first indication that a headache is about to strike (during the "aura" of flashing lights that the migraine patient experiences just before the onset of the headache itself). Taking an ergot preparation (the one I prescribe most is called Cafergot) at that time will often abort the headache. But ergot is an abortifacient, that is, it induces abortion. So if you have migraines and become pregnant, you'll have to stop the ergot if you want to have the baby.

There are various other drugs that, although they may not cause deformities in the newborn, do interfere with its adaptation to life outside the uterus. Some sleeping pills you've grown to depend on may not give your baby a hole in the heart, but it may make him or her awfully sleepy, with depressed respirations at birth. If you're hooked on any narcotic, your baby will be too. So don't take what you don't need.

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General health