Healthcare during pregnancy can be a minefield for many women, with confusing and often contradictory information emerging on a regular basis. Pharmacists can help explain, reassure and demystify.

With so much information available, it is important to help customers separate fact from fiction when it comes to keeping well during pregnancy and managing minor ailments once the baby is born.

Given the wide range of pregnancy-specific vitamins and minerals now available, expectant mothers may be forgiven for thinking that vitamin supplementation is key to a healthy pregnancy. However, a recent non-systematic review published in the Drug and Therapeutics Bulletin has cast considerable doubt on the whole construct of vitamin supplementation in pregnancy.1

The report looked at a number of systematic reviews and trials of vitamin use during pregnancy and concluded that supplements were “unlikely to be needed and are an unnecessary expense”. The evidence from the report backs up existing recommendations and official NHS advice on dietary supplementation during pregnancy, which is restricted to folic acid and vitamin D.

Current recommendations from NICE are that women should take 400mcg folic acid daily from before pregnancy until the end of the first trimester, and 10mcg vitamin D daily throughout pregnancy and while breastfeeding. Crucially, no other supplements are recommended for routine use.

The role of folic acid in reducing the risk of neural tube defects and the value of vitamin D supplements in building bone formation in babies is supported by robust clinical data2 but there is no evidence to suggest a need for vitamin A supplementation in well-nourished pregnant women. In fact, vitamin A supplements should be avoided during pregnancy due to the risk of birth defects, while there is no compelling data to support the routine supplementation of any other vitamins or iron.

Expectant mothers can therefore be reassured that it is not necessary to invest in expensive multivitamin supplements, and that eating a good balanced diet during pregnancy, along with folic acid and vitamin D supplements, should be all that is required to ensure the best possible health outcomes for both themselves and their unborn child.2

Key facts 

  • Folic acid and vitamin D are the only supplements required by most women during pregnancy 
  • Flu vaccination is advised for all pregnant women, with one in 11 maternal deaths during pregnancy in the UK directly linked to influenza infection 
  • Antenatal group B strep testing is not currently routine on the NHS but home testing kits are available

Medicines safety advice

Recent research has linked paracetamol use during pregnancy to a range of future health problems in children, including autism, ADHD, asthma and fertility issues. Suggestions of a link between paracetamol and asthma first surfaced several years ago and were re-energised in 2016 by a paper in the International Journal of Epidemiology by Norwegian public health researchers.3

This cohort study analysed data on over 110,000 children born between 1999 and 2008 and found a link between paracetamol and childhood asthma, both in cases when the drug was taken by the expectant mother and by the infant (if less than six months of age). Infant exposure to paracetamol was estimated to increase the asthma risk by 29 per cent and exposure in pregnancy by 13 per cent, although this latter estimate was only borderline significant.

 

Pregnancy and light bladder weakness

Light bladder weakness is a common occurrence during pregnancy or after childbirth due to the physical and hormonal changes that occur at this time, says Donna Wilson, TENA training and brand manager.

“The body produces more progesterone, a muscle relaxant that weakens the effect of the pelvic floor muscles making it more difficult to stop the flow of urine. The process of giving birth will also overstretch these muscles, while a caesarean section can cause the pelvic floor to weaken. This, teamed with a growing baby putting more pressure on the bladder, means that light bladder weakness can be a frequent occurrence – triggered by simple things like coughing, sneezing or laughing.”

Customers should be encouraged to practise pelvic floor exercises to strengthen the muscles in their pelvic floor. To help support and guide women through their pelvic floor training, lights by TENA has developed the ‘My PFF’ (my pelvic floor fitness) mobile app. My PFF comes with daily reminders, exercise settings and a personalised notes section.

“Women may still experience light bladder weakness when doing pelvic floor exercises, so it is advisable to recommend using lights by TENA products alongside the app,” says Wilson. TENA is currently running a ‘Feel Fresh or its Free’ money back guarantee on 2.2 million promotional packs to encourage trial.

 

Another recent paracetamol-focused paper, published in the same journal, found a strong association between paracetamol use during pregnancy and autism spectrum symptoms in boys, and attention-related and hyperactivity symptoms in both genders.4 This study enrolled over 2,500 mothers and children and compared children persistently exposed to paracetamol in the womb to non-exposed subjects.

“This is an important study and while most women should, if possible, avoid taking medications during pregnancy, paracetamol has previously been seen as a low-risk drug to take if necessary and needed,” says Royal College of Midwives director for midwifery, Louise Silverton.

“Paracetamol should be used during pregnancy on medical advice where women absolutely require something to, for example, help reduce fever. That said, it is important to remember most women who use paracetamol minimally and only when necessary during their pregnancy will deliver a healthy baby.”5

Further studies, notably conducted in animals only, have also hinted at a potential adverse impact of paracetamol use during pregnancy on hormone levels and fertility in subsequent generations.6 With such stories swirling in the media, pregnant women require both reassurance and evidence-based advice on how to safely manage pain and fever during pregnancy.

According to the NHS, paracetamol remains the preferred choice to treat mild to moderate pain and/or fever during pregnancy as there “is no clear evidence that it has any harmful effects on an unborn baby”.The caveat, as with all medicines taken during pregnancy, is that paracetamol should be used at the lowest effective dose for the shortest possible time.

Combination analgesics containing paracetamol and caffeine are not recommended during pregnancy due to the link between caffeine and miscarriage and low birth weight. Ibuprofen is also best avoided where possible during pregnancy and is strictly contraindicated for women of 30 weeks or more gestation due to the increased risk of cardiac complications and reduced amniotic fluid volume.

To treat heartburn, a common painful pregnancy ailment, both antacids and alginates are considered safe to use during pregnancy provided the recommended doses are adhered to. Pregnant women on iron supplements should be cautioned that antacids could prevent proper iron absorption, so should be taken at least two hours before or after the iron supplement.

Managing minor infant ailments7,10

Nappy rash

A form of irritant contact dermatitis, nappy rash affects up to one-third of babies and is characterised by red, sore areas of skin on the bottom and genitals. The skin may feel hot to the touch or look shiny and tight, and is sometimes accompanied by inflamed spots or pimples. Newborns rarely develop nappy rash but infants aged nine months and over are common sufferers. Preventing skin irritation is the cornerstone of care for any baby with nappy rash.

Key advice for parents should include:

  • Changing nappies regularly
  • Thoroughly cleaning the whole nappy area using water and cotton wool or fragrance and alcohol-free baby wipes (always wiping from front to back)
  • Encouraging nappy-free time to allow air to get to the skin and promote healing

Avoiding the use of talcum powder or soaps, lotions or bubble baths.

A number of different barrier creams are available which can be recommended for nappy rash. These are applied to the baby’s bottom at each nappy change and help to lock moisture into the skin and prevent nappy rash developing.

Colic

Colic is a common yet poorly understood condition that tends to affect mainly younger babies, resolving in most cases by six months of age. Key symptoms include frequent, intense bouts of excessive crying (especially in the late afternoon/evening), a red or flushed face, and fist clenching and back arching when crying. Comfort is crucial for a colicky baby and a variety of different comforting techniques can be recommended (see Crysis and the NCT for a comprehensive list).

It may also be useful for parents to rule out cow’s milk protein intolerance as the cause of their baby’s colic by removing dairy products from the diet (if breastfeeding) or switching to a hypoallergenic milk formula for one to two weeks. Several OTC colic treatments are also available, formulated as drops, which are added to the baby’s bottle or breast milk before a feed.

Simeticone drops are designed to help disperse small air bubbles trapped in the baby’s GI tract, while lactase drops catalyse the breakdown of the milk protein lactose, which may contribute to colic symptoms. A one-week trial of drops is generally recommended for babies with suspected colic and parents should be advised to stop treatment after this point if there is no improvement in symptoms. Products containing dicycloverine and the herbal remedy star anise tea are harmful for babies and should be avoided.

Teething

Easily recognisable symptoms of teething include sore red gums, flushed cheeks, excess dribbling, biting and chewing, ear rubbing and general irritability and fretfulness. Although there is no direct supportive evidence, it is also widely accepted anecdotally among parents that teething can cause additional symptoms, such as a raised temperature and diarrhoea in some babies.

Offering teething rings or healthy chewable foods (if the baby is over six months) can help encourage teething infants to bite and chew safely. Other treatment options include teething gels containing local anaesthetic and antiseptic ingredients, which are rubbed onto the gums with a clean finger or cotton wool pad to create a brief numbing effect, and homeopathic teething powders or granules that are poured directly into the mouth or mixed with cooled boiled water to create a drink.

Infant paracetamol or ibuprofen can also be recommended to ease the pain and distress associated with teething, but it is important to always check parents are fully aware of the correct dosing information.

Upset stomach

An upset stomach causing diarrhoea and vomiting is a common illness in babies and toddlers, usually the result of a viral gastrointestinal infection that will resolve on its own. The main risk for a baby with an upset stomach is dehydration, which can develop more rapidly than in adults.

Parents should be advised to continue offering the baby’s usual feeds and drinks, using oral rehydration salt (ORS) solutions if required to prevent dehydration and to remain vigilant for potential red flag symptoms that require urgent medical attention. These include:

  • A temperature >38oC if the infant is aged less than three months or >39oC if aged three to six months
  • Blood or mucus in the stools
  • Bile-stained vomit
  • Severe abdominal pain.

Where ORS solutions are used, infants should be offered small volumes regularly over a four-hour period in place of their usual food and drinks (breast-feeding can continue as normal). Anti-diarrhoeal drugs are not recommended for young children.

Colds

Due to their under-developed immune systems, young children may catch between eight and 12 colds a year. Symptoms mirror those typically seen in adults, although infants are at increased risk of developing accessory complications, such as ear infections.

Important self-care advice for parents includes encouraging the child to rest and giving plenty of fluids, taking steps to prevent over-heating (e.g. keeping the room at a comfortable temperature and using lightweight bedding), and raising the head end of the bed to ease breathing. Exposure to warm moist air (e.g. from a hot running shower or bath) can help clear a blocked nose, and nasal drops can also be used in young babies to thin and clear nasal secretions.

Age-appropriate versions of liquid paracetamol and ibuprofen can also be recommended to ease sore throat pain, reduce fever and alleviate any general cold-associated discomfort.

Influenza vaccination

All pregnant women are advised to have a NHS flu vaccination. This is available from October each year and can be given at any stage of pregnancy. For those customers reluctant to receive the vaccination, it is important to explain the risks of influenza during pregnancy, both for mother and baby.

Pregnant women are more likely to contract flu due to their suppressed immune response, and more likely to develop complications as a result of changes to the major organ systems that occur during pregnancy. Recent research has revealed that one in every 11 maternal deaths that occurs during pregnancy in the UK is directly attributable to influenza infection.8

The flu virus can also cause harm to the developing foetus and has been linked with premature labour, smaller birth size and even stillbirth. MBRRACE-UK, an initiative led by the national perinatal epidemiology unit at the University of Oxford, stresses that: “The importance of influenza immunisation for pregnant women cannot be over-emphasised…Increasing immunisation rates in pregnancy against seasonal influenza must remain a public health priority.”

Pharmacy’s role in flu vaccination has been strengthened in recent years with the launch of the community pharmacy-led national flu vaccination service.

With both the NHS and Public Health England highlighting significant room for improvement in flu vaccine uptake, pharmacy teams can help drive effective patient recruitment by proactively offering influenza vaccination to pregnant patients in tandem with key pregnancy-related advice and the dispensing of any medications.

Screening

Group B streptococcus (GBS) is a normal gut bacteria which one in every five pregnant women in the UK will carry either in their digestive tract or vagina.9 In these women, there is a small chance that GBS will pass to the baby during childbirth. To put the risk in perspective, around half of babies born to a woman with GBS will become colonised themselves at the time of delivery, but only one in 200 will develop GBS disease.9

 Nevertheless, GBS can be a worrying issue for pregnant women, as one in every 10 babies born with the bacteria will die from the infection, leading to calls for routine antenatal GBS testing to be introduced on the NHS. In contrast to several other European countries, the current NHS approach focuses on identifying patients at risk of GBS infection rather than a blanket screening approach. Pharmacy staff should be ready to offer advice and support to any pregnant customer with questions about GBS.

The ECM (Enriched Culture Medium) test, recognised by leading charities as the gold standard for detecting GBS, is now available as a home testing kit from several private organisations and can be purchased online. For pregnant women who opt to carry out home GBS testing, it is important to ensure the test instructions are followed carefully.

Samples can deteriorate over time, so should be posted to the laboratory on a working day for maximum expediency. It is also important customers are aware that current or recent antibiotic use can potentially interfere with their results.

Women who test positive for GBS on a home testing kit should seek advice from their GP or midwife about the potential implications for childbirth and delivery, in particular the possible need for intravenous antibiotic coverage during labour.

 

Learning objectives

After reading this feature you should:

  • Be familiar with current NHS recommendations for analgesic use and vitamin supplementation during pregnancy
  • Be able to explain the importance of influenza vaccination during pregnancy
  • Understand the concerns associated with group B strep in pregnancy
  • Know how to recognise and manage common minor ailments in babies and young infants

 

REFERENCES

  1. Drug and Therapeutics Bulletin 2016. doi:10.1136/dtb.2016.7.0414 
  2. NHS. Pregnancy supplements ‘don’t help, just take vit D and folic acid’. News article. July 12, 2016. Available at: nhs.uk/news/2016/07July/Pages/Pregnancy-supplements-donthelp- just-take-vit-D-and-folic-acid.aspx
  3. Magnus M et al. International Journal of Epidemiology 2016; 45(2): 295-303
  4. Avella-Garcia C et al. International Journal of Epidemiology 2016; 1-9
  5. Royal College of Midwives. Prenatal paracetamol use linked to autism symptoms, study claims. Press release: 1 July 2016. Available at: rcm.org.uk/news-views-and-analysis/ news/prenatal-paracetemol-use-linked-to-autism-symptoms-study-claims
  6. Dean A et al. Scientific Reports 2016; Article no 19789
  7. NHS Choices: nhs.uk/pages/home.aspx
  8. MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK). ‘Saving Lives, Improving Mothers’ Care’ Report. Published December 2014. Available at: npeu.ox.ac.uk/mbrrace-uk/reports
  9. Group B Strep Support: gbss.org.uk/information-and-support/about-gbs/what-is-gbs/ for-pregnant-women
  10. Babycentre: babycentre.co.uk

 

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