Jennifer Ball, PharmD, BCACP, BCGP
At the end of this case, students will be able to:
- Identify social determinants of health affecting infant and maternal morbidity and mortality
- List key preventative measures in pregnancy as recommended by the United States Preventative Services Task Force (USPSTF)
- Assess a patient in need of prenatal vitamin, iron, and aspirin for prevention of prenatal complications
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.
You are a pharmacist in a family medicine clinic.
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
- 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
- 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)
- 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
1. What socioeconomic factors may increase TW’s risk for maternal and infant morbidity and mortality?
TW is a non-Hispanic black woman of lower socioeconomic status which is likely to lead to poorer infant and maternal health. She is also advanced maternal age at 37 years old. In addition, she is a refugee which has been associated with later presentation to care and increased rates of postpartum depression.a
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?
Drug resources (Lexicomp, Micromedex, Facts & Comparisons, Epocrates, etc) all have a pregnancy section that includes information about use of the medication in pregnancy. This should be formatted to see the clinical considerations and risk summary.
All prenatal patients and their healthcare providers are asked to submit medications used in pregnancy and any concerns to the pregnancy registry. Case reports can be found on scholarly databases such as PubMed.
In reviewing the patient’s medications, sertraline, gummy multivitamins, and ferrous sulfate are all safe in pregnancy. In some cases, sertraline may be weaned towards the end of pregnancy as some babies may have increased jitteriness, vomiting, constant crying, increased muscle tone, irritability, altered sleep patterns, difficulty eating and regulating body temperature or problems with breathing.b Most cases these effects have been mild and the effects go away within two weeks of age.
3. List the current published USPSTF recommendations for pregnant women. Which might be appropriate for the pharmacist to address?
- >Bacterial vaginosis in pregnancy to prevent preterm delivery: screening
- Folic Acid for the prevention of neural tube defects: preventative medication
- Hepatitis B in pregnant women: screening
- Iron deficiency anemia in pregnant women: screening and supplementation
- Lead levels in childhood and pregnancy: screening
- Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: preventative medication
- Rh(D) incompatibility: screening
- Syphilis infection in pregnant women: screening
While the pharmacist is likely able to address all of the USPSTF recommendations, the three that are medication-related are folic acid for the prevention of neural tube defects, iron deficiency anemia: screening and supplementation, and low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia.
4. Looking at TW’s chart, assess her need for supplementation of folic acid and iron
Looking at her current multivitamin, she is only getting 400mcg of folic acid and no iron. Prenatal products will likely have 600-800mcg of folic acid. In addition, the calcium may also be too low based on her current multivitamin. She should be recommended to switch to a prenatal vitamin. As this patient has a history of iron deficiency anemia in pregnancy, a tablet or capsule formulation should be recommended as the gummy products do not contain iron.
5. Using the USPSTF clinical risk assessment for preeclampsia, decide if TW should be recommended aspirin during this pregnancy.
Following the USPSTF 2014 Recommendations on low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia:c
Patients with one or more high risk factors should be recommended to start aspirin 81mg at 12 weeks gestation to 36 weeks gestation. High risk factors include: history of preeclampsia, multifetal gestation, chronic hypertension, type 1 or 2 diabetes, renal disease, or autoimmune disease (I.e. systemic lupus erythematous, antiphospholipid syndrome.
Patients with two or more moderate risk factors should be recommended to start aspirin 81mg at 12 weeks gestation to 36 weeks gestation. Moderate risk factors include: nulliparity, obesity (BMI >30kg/m2), family history of preeclampsia (mother or sister), sociodemographic characteristics (African American race, low socioeconomic status), age ≥ 35 year-old, or personal history factors (e.g. low birthweight or small for gestational age, previous adverse pregnancy outcome, >10 year pregnancy interval).
Based on the patient’s chart, she has no high risk factors and three moderate risk factors
- >obesity with BMI 30.8
- sociodemographic characteristics (African American/ low socioeconomic status)
- age ≥ 35 year-old
Thus low-dose 81mg aspirin daily should be started at 12 weeks gestation and continued through 36 weeks gestation to prevent preterm preeclampsia.
a. Social Determinants of Maternal Health and Birth Outcomes. MCN Am J Matern Child Nurs. 2017 Jan/Feb;42(1):7.
b. Mother to Baby. Sertraline (Zoloft®) Factsheet [internet]. 2017 Sept 1. Accessed 2018 Nov 12. Available from: https://mothertobaby.org/fact-sheets/sertraline-zoloft-pregnancy/.
c. LeFevre ML; U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Dec 2;161(11):819-26.
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.
Related chapters of interest:
- Deciphering immunization codes: making evidence-based recommendations
- Getting to the point: importance of immunizations for public health
- An ounce of prevention: pharmacy applications of the USPSTF guidelines
- Hormonal contraception: from emergency coverage to long-term therapy
- Healthypeople.gov. https://www.healthypeople.gov/
- National Institutes of Health Office of Dietary Supplements. https://ods.od.nih.gov/
- American College of Obstetricians and Gynecologists (ACOG). https://www.acog.org/
- Centers for Disease Control and Prevention- Treating for Two. https://www.cdc.gov/pregnancy/meds/treatingfortwo/index.html
- Mother to Baby. https://mothertobaby.org/
- United States Preventative Services Task Force (USPSTF). https://www.uspreventiveservicestaskforce.org/
- Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR. 2006;55(RR-06):1–23.
- DeFranco EA, Seske LM, Greenberg JM, Muglia LJ. Influence of interpregnancy interval on neonatal morbidity. Am J Obstet Gynecol. 2015 Mar;212(3):386.e1-9.
- Berns S, ed. Toward Improving the Outcome of Pregnancy III: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives [Internet]. White Plains, NY: March of Dimes Foundation; 2010 Dec. Accessed 2018 Nov 12. Available from: http://www.marchofdimes.org/materials/toward-improving-the-outcome-of-pregnancy-iii.pdf.
- Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
- Blumenshine P, Egerter S, Barclay CJ, Cubbin C, Braveman PA. Socioeconomic disparities in adverse birth outcomes: a systematic review. Am J Prev Med. 2010 Sep;39(3):263-72.
- Strutz KL, Hogan VK, Siega-Riz AM, Suchindran CM, Halpern CT, Hussey JM. Preconception Stress, Birth Weight, and Birth Weight Disparities Among US Women. Am J Public Health. 2014 Aug; 104(8):e125-e132.
- Karlsen S, Say L, Souza J, Hogue CJ, Calles DL, Gülmezoglu AM, Raine R. The relationship between maternal education and mortality among women giving birth in health care institutions: Analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health. BMC Public Health. 2011; 11: 606.
- American College of Obstetricians and Gynecologists. Frequently asked questions: Nutrition During Pregnancy [Internet]. 2018 Jul. Accessed 2018 Nov 12. Available from: https://www.acog.org/Patients/FAQs/Nutrition-During-Pregnancy?IsMobileSet=false.
- US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, et al. Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Jan 10;317(2):183-189.
- National Institutes of Health Office of Dietary Supplements. Iron Fact Sheet for Health Professionals [internet]. 2018 Sept 20. Accessed 2018 Nov 12. Available from: https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/.
- Leeman L, Dresang LT, Fontaine P. Hypertensive Disorders of Pregnancy. Am Fam Physician. 2016 Jan 15;93(2):121-7.
- McCance DR. Diabetes in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2015 Jul;29(5):685-99.
- Neiger R. Long-Term Effects of Pregnancy Complications on Maternal Health: A Review. J Clin Med. 2017 Aug; 6(8): 76.
- Mitchell AA, Gilboa SM, Werler MM, et al. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol. 2011;205(1):51:e1-e8.
- Food and Drug Administration, HHS. Content and format of labeling for human prescription drug and biological products; requirements for pregnancy and lactation labeling. Final rule. Fed Regist. 2014 Dec 4;79(233):72063-103.