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Tag "pregnancy"

Tylenol (acetaminophen, or in Europe it is called paracetamol) is the go-to drug for pain, headaches, and fever during pregnancy. A new study just published in the journal JAMA Pediatrics indicates that this drug may not be as safe as previously thought.

Animal research has long suggested that acetaminophen is a so called hormone disruptor, a substance that changes the normal balance of hormones. It is a well-established fact that an abnormal hormonal exposures in pregnancy may influence fetal brain development.

Danish researchers decided to evaluate whether prenatal exposure to acetaminophen increases the risk for developing attention-deficit/hyperactivity disorder (ADHD) in children. They studied 64,322 live-born children and mothers enrolled in the Danish National Birth Cohort during 1996-2002.

The doctors used parental reports of behavioral problems in children 7 years of age using a specific questionnaire, retrieved diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry, and identified ADHD prescriptions (mainly Ritalin) for children from the Danish Prescription Registry.

More than half of all mothers reported acetaminophen use while pregnant. Children whose mothers used acetaminophen during pregnancy were at about 1.3 times higher risk for receiving a hospital diagnosis of ADHD, use of ADHD medications, or having ADHD-like behaviors at age 7 years. Stronger associations were observed with use in more than 1 trimester during pregnancy and with higher frequency of intake of acetaminophen.

The researchers concluded that maternal acetaminophen use during pregnancy is associated with a higher risk for ADHD-like behaviors in children.

This presents a difficult problem in treating headaches and pain in pregnant women. Aspirin and other non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can cause other problems in pregnancy and are particularly dangerous in the third trimester. In women with migraines, acetaminophen tends to be ineffective anyway, so these women should be given migraine-specific drugs, such as triptans (Imitrex or sumatriptan, Maxalt or rizatriptan, and other). They are much more effective than acetaminophen and the woman may need to take much less of these drugs than of acetaminophen. Triptans are also in category C in pregnancy, which means that we do not know how safe they are. Imitrex was introduced more than 20 years ago and we do not that it does not have any major risks for the fetus, but that does not mean that more subtle problems, such as ADHD are also not more common. Another headache drug that should be avoided in pregnancy is Fioricet. It is popular with some obstetricians because it has been on the market for 40 years. However, it contains not only acetaminophen, but also caffeine, which can make headaches worse, as well as a barbiturate drug butalbital, which can also have deleterious effect on the fetal brain.

Fortunately, two out of three women stop having migraines during pregnancy, especially in the second and third trimester. If they continue having headaches, treatment is directed at prevention. Regular aerobic exercise, getting enough sleep, regular meals, good hydration, avoiding caffeine, learning biofeedback, meditation or another form of relaxation, magnesium supplementation, are all safe and can be very effective. Acute treatments that do not involve drugs are often not very practical for a busy person. However, if the headache prevents normal functioning anyway, taking a hot bath with an ice pack on the head at the same time can help some women. Taking a nap, getting a massage, aromatherapy with peppermint and lavender essential oils are good options. For nausea, ginger and Sea Bands are sometimes very effective.

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During pregnancy, two thirds of women stop having migraine headaches.  However, one third continues to have them, and sometimes even worsen during pregnancy.   As a general rule, only acetaminophen (Tylenol) is considered safe, but for most migraine sufferers it is completely ineffective.  Codeine is also benign, but it also either does not work or causes side effects, such as nausea and sedation.  Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other are very effective for migraines, but are not proven to be as safe.  Pregnancy registries in the US have information on over 1,500 women who took a triptan during pregnancy and so far the drugs look safe for the baby.  A new study from Norway in the February issue of Headache reports on another 1,535 women who took triptans during pregnancy and compared them to 68,000 women who did not.  This study also found no increased risk of congenital malformation, even if triptans were taken in the first trimester.  Women who took triptans in the second and third trimester also had healthy babies, but they had a slightly increased risk of atonic uterus and bleeding during labor.

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The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study by Norwegian researchers published in Headache provides some additional details.  Women with headaches who are pregnant for the first time tend to have fewer headaches than non-pregnant women or women during subsequent pregnancies.  This is especially true in the third trimester.   Non-pregnant women who had never been pregnant were less likely to have headaches than women who had been.  If a woman does have headaches during pregnancy, the initial treatment should consist of non-drug therapies, such as biofeedback or meditation, magnesium and other supplements, acupuncture, and if headaches are frequent, Botox injections.

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Postpartum headaches are very common and are usually benign. A study presented at the meeting of the Society for Maternal-Fetal Medicine by Dr. Caroline Stella and her colleagues looked at 95 women with severe headaches that started 25 hours to 32 days after delivery and were not responsive to usual doses of pain medicines. Half of these women eventually were diagnosed to have migraine or tension-type headaches and they all responded to higher doses of pain drugs. In one quarter of patients headaches were due to preeclampsia or eclampsia and were relieved by intravenous magnesium or magnesium and high blood pressure medications. Fifteen women had spinal headaches due to complication of epidural analgesia and they responded to a “blood patch” procedure. Only one woman had a brain hemorrhage and one had thrombosis (occlusion) of a vein in the brain. The authors suggested that all these conditions should be considered when evaluating women with postpartum headaches and appropriate testing needs to be performed.

In another study presented at this meeting Dutch researchers found that women who suffered from an episode of eclampsia had persistent cognitive dysfunction 6-8 years later. This contradicts the widely held belief that women with eclampsia can expect full recovery. This study suggests that eclampsia needs to be treated early and aggressively (magnesium infusion is one of the main treatments) to prevent permanent brain injury. It is also important to understand that persistent cognitive dysfunction is not psychological in nature and that it should be treated with cognitive rehabilitation.

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