Episode 185 Medicines In Pregnancy

We talk frankly about why medicines in pregnancy and breastfeeding feel frightening, even though most women take something during pregnancy and many treatments are genuinely safe. We break down why the evidence is often patchy, how to think about benefit versus risk, and where to find clear information you can trust. 

• British Pharmacological Society statement and the scale of medicine use in pregnancy 
• why pregnant and breastfeeding women are often excluded from trials 
• how the BNF language can feel alarming and unhelpful 
• benefit versus risk and why untreated illness can be the bigger danger 
• common prescriptions in pregnancy such as antibiotics for UTIs, anti sickness drugs and reflux medicines 
• how pregnancy physiology can change dosing and drug clearance 
• women’s anxiety when advice is unclear or conflicting 
• practical resources: BUMPS for patients and UKTIS for health professionals 
• why considering research participation can improve care for future women

Want to know more:

https://www.medicinesinpregnancy.org/

https://uktis.org/

https://www.bps.ac.uk/fileadmin/uploads/bps/Policy_statements/BPS_Position_Statement-_Medications_in_Pregnancy_and_Breastfeeding__1_.pdf 

https://bmjopen.bmj.com/content/4/2/e004365

If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod on Instagram, and you can email me atobspod at gmail.com. If you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation. But if you'd like to contribute, you now can. 

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how...

Transcript

Welcome And Who It Helps

Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician, hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the obspod is for you. I've been prompted to record today's episode because of the recent publication from the British Pharmacological Society, a position statement on medicines in pregnancy and breastfeeding. This made me realise that I haven't actually explicitly discussed this topic on my podcast. In the position statement, it detailed that as many as eight out of ten women pregnant in the UK will take medication at some point during their pregnancy. And this was excluding common medications such as vitamins or iron supplementation. And in some ways I wasn't surprised because obviously all the prescribing I do, or the majority of it, is for women that are either pregnant or breastfeeding. But I was slightly surprised because often what I see in clinic is women that are really terrified of taking any kind of medication in pregnancy at all. As soon as you suggest you're going to prescribe any medication, a woman is concerned and worrying and asking me, Am I sure it's safe for her baby? And if it's in the postnatal period, she's saying to me, Are you sure it's okay for breastfeeding? And I find this slightly weird because obviously, as a doctor who treats women in pregnancy and postnatally only as my entire job, I find it slightly weird the idea that I might prescribe something that might be harmful. But equally, I can see from the woman's perspective, she's got to trust me and trust my judgment. And women are naturally very protective and concerned about the impact on their baby. So women are clearly very concerned about taking drugs in pregnancy and after birth, and that's with good reason. There have been some medications in the past that have been very detrimental in pregnancy, either to the development of the baby that has caused lifelong health problems, and which perhaps at the time doctors thought were safe and later were found not to be. So I can understand why there's this level of scepticism and distrust, perhaps, and reluctance to take things. And that's partly down to us as the medical profession or healthcare professionals in terms of how we research medication. And one of the reasons for this statement from the British Pharmacological Society is to point out that very few medications are trialled or include in trials about how they work, any research on pregnant and breastfeeding women. They often exclude that. So I've got a copy of the BNF in front of me, and I can literally turn randomly to pretty much any page. And so, for example, I've opened it on page 520 and it says cautions pregnancy appendix 4, breastfeeding appendix 5. Okay, that's 520. That's looking at treatments for gout. Okay, I'm now flicked uh randomly to anti-malarials. Let's see, cautions, pregnancy, see notes in appendix four. Manufacturer advises avoid in pregnancy during and for three months after breastfeeding. See appendix five. Okay, I'm gonna flick randomly on. Let's look at some anti-migraine drugs. I'm just randomly picking something, contraindications, pregnancy and breastfeeding, and it goes on and on. So I can pretty much open any page in the book and it'll tell me that. Really unhelpful. And then if I actually turn to appendix four, um, it says drugs can have harmful effects on the fetus at any time during pregnancy. It's important to bear this in mind when prescribing for a woman of childbearing age, blah blah blah, and then there's a list of medications. And usually what it says is manufacturer advises avoid. Not known to be harmful, manufacturers advise use only when potential benefit outweighs risk. No evidence of teratogenicity, that means causing abnormalities. Manufacturer advises use only when potential benefit outweighs risk. No evidence of harm. No evidence of harm, but manufacturers advise avoid, unless compelling reasons. I mean it goes on. So basically, for a lot of medications we have, there's literally no evidence, but because manufacturers and people are worried about the potential effects, they go avoid, avoid, avoid, avoid. And this causes problems because pregnant women have, or some pregnant women have chronic health conditions that we need to manage in pregnancy, and some pregnant women develop problems in pregnancy that need medication. So as an obstetrician, I get extremely used to prescribing things which I know are safe and I'm used to using, and also this key issue of benefit outweighs risk. If you have an untreated illness, whether that's a mental health problem or a physical health problem, if that's untreated and you are unwell, that is going to have more impact on your baby and the health of your baby potentially than leaving you untreated. So the tiny, tiny, tiny chance of a potential problem from that medication versus the much higher chance of a problem if you have something that's untreated, that's what we're talking about when we're talking about benefit outweighing risk. The benefit massively outweighs the risk. So as an obstetrician, I'm very used to prescribing things for women in pregnancy. And if we go back to the study that kind of started the supporting statement from the British Pharmacological Society, you know, they looked at what women were taking. Women were taking antibiotics for perhaps a urinary tract infection. That's actually really important to treat in pregnancy because potentially untreated, not only can it make the mother unwell, it could even trigger preterm birth. So that's a very important reason to treat something. Another common thing might be nausea, and surprisingly, women were not often taking medications for nausea, and that's something we see that often GPs are a bit reluctant to prescribe, particularly as women may be asking for anti-nausea and vomiting medication in the first trimester, which is when the baby's forming, so they're nervous about giving medication at that stage, but we often do need to prescribe that. So that's very common, and also antacid, so anti-acid medication or indigestion medications, such as omeprazole or rhinitidine, that sort of thing. Those were the commonest things. But I see lots of women who need to take their normal medication, and there are actually very few medications that are an absolute no-no in pregnancy, and usually doctors that are giving those treatments are well versed in the fact that actually women of a reproductive age, so women that could get pregnant or might get pregnant, even if they're not planning pregnancy, because we know many pregnancies are actually unplanned, women in that age bracket who may get pregnant shouldn't be on those medications. And the number of medications which are a complete no in pregnancy are actually really quite small. The other really important thing about the drugs in pregnancy and breastfeeding statement was the fact that actually, physiologically, how your body absorbs and clears and deals with that medication in pregnancy may change because your blood volume changes, and therefore your doses of your medication may actually need to be adjusted and changed because of pregnancy and breastfeeding. The fact that really we've let women down that there's not lots of good information on that either. How your circulating volume may have an effect on the dose that you need, and how doses might need to be adjusted and changed in pregnancy because of the way your metabolism and physiology changes. We really haven't researched that and sorted that out properly. So again, we've we've slightly let women down there. The statement referred to some research about women's experiences of taking medication in pregnancy and breastfeeding, and I'm going to include a link to that in the show notes because it's interesting what women say were they were anxious and they were reluctant to take medication, and part of that was because we as health professionals, whether that's midwives, obstetricians, GPs, weren't giving women good clear information, we were being unclear or uncertain, or giving them conflicting advice. And I've definitely seen this in my clinic: women coming along that have been told by perhaps their GP to stop medication when actually it really isn't necessary and we really would advise continuing it. So we're doing a disservice by giving unclear information, which is increasing women's anxiety about things. So the statement reported that it's it's critical for health professionals to be confident about prescribing in pregnancy and for us to be doing more research. So, how can we build that confidence? Well, there is a fantastic resource available. So for women, it's called BUMPS, standing for best use of medicines in pregnancy. It's a great website that I use a lot. So you can type in and there's kind of an A to Z search, and you can look up any sort of medication that your doctor might be suggesting you take or that you're already on, and you can see exactly the pros and cons as to what we think, whether or not it might cause problems, and if those if there are some potential downsides, what those might be, so that you can make a well-informed choice. If you're a health professional, you can look at the UK TIS website, which is the health professionals version. So it's run by the same organization, pharmacists, and it gives more in-depth, detailed information for health professionals again about any medication you want. And again, I will put a link to that in the show notes. So I guess what is my zesty bit? My zesty bit is if you're a woman taking medication or someone is suggesting that you need to take medication in pregnancy, don't be afraid. There is benefit, and a lot of things are safe in pregnancy and breastfeeding. And if you're not sure, ask your midwife or obstetrician because they're much more familiar with prescribing in pregnancy. And certainly I often see that perhaps GPs are less confident about prescribing, where obstetricians, because we do this day in and day out, we have a clearer idea about what can and can't be taken. But explore the website, the bumps website that I'm going to put in the show notes, and don't be worried if you're taking medication in pregnancy, you're in good company. At least 80% of women are taking some form of medication in pregnancy at some point. And in fact, in some of the countries in the study that they looked at, up to 95% of women were taking something at some stage. So it really is not the big scary problem that you think it might be, and definitely is better for you to be healthy and well. That is the best way to protect your baby as well as yourself. If you're a health professional, then again don't be worried about prescribing. Yes, of course, you've got to do that due diligence and check that the drug you're suggesting is suitable for pregnancy. And now you do have this amazing website resource. You don't have to go and hunt in the BNF and look up obscure appendices. You can look online really easily at this website, and you can give women the bumps version so that they can look at more user-friendly information. Again, you know, give them time to go away and think about what you're prescribing and why you're prescribing, and explain to the woman what it's for, why you think it's beneficial and why you think it's important she takes it. And then I guess the final thing is yeah, absolutely, it's great they've put out this consensus statement, and we need much more information about medicines in pregnancy. So I guess my final plea is if during your pregnancy you're asked to participate in a study, do be willing to think about and consider participating in research so that we can get this information so that women in the future don't have such a difficult time knowing how drugs behave in their system. So if you're asked to participate in research, then yeah, of course, it might not be for everybody, but do give it some serious thought. I very much hope you found this episode of the Obspod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician, and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient-identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod on Twitter and Instagram, and you can email me atobspod at gmail.com. Finally, it's very important to me to keep the Obspod free and accessible to as many people as possible. But it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation. But if you'd like to contribute, you now can. Thank you for listening.