Environmental Exposures and Medications in Pregnancy

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season we are focusing on topics related to pregnancy and obstetric concerns. On this episode, I'd like to welcome Dr. Collins and Dr. Kshettry who will be talking to us about medications and exposures during pregnancy. Dr. Collins, Dr. Kshettry, thanks so much for joining me on the podcast.

Suchetha Kshettry, MD:

Thank you for having us.

Jacqueline Collins, MD:

Yes.

Erica Newlin, MD:

Can you each tell us a little about your role in the Cleveland Clinic and a little about your background? Dr. Collins, you can go first.

Jacqueline Collins, MD:

Hello everybody. I'm Dr. Collins. Jacqueline Collins. I am a generalist with Cleveland Clinic. That means that I see the whole gamut of OB GYN care from teenagers starting birth control and seeing their OB GYN for the first time up through labor, delivery and menopause care. I do have a special interest in LGBTQ+ care, in menopause and in women's sexual health. So I do focus on those areas, but I see a little bit of everything.

Suchetha Kshettry, MD:

Hi everyone. I'm Dr. Kshetty. Similar to Dr. Collins, I also am an OB GYN specialist, a generalist who sees a wide variety of patients obstetrical and gynecologic in nature, and also have an interest in actually early pregnancy complications and in part of our trauma-informed care program here at the clinic. So excited to be here.

Erica Newlin, MD:

I think when people get that first positive pregnancy test, they start getting a lot of recommendations from family members and friends and the internet about all the things they should avoid. So hopefully today we can kind of break up those myths and talk about the actual evidence about things. So let's start by talking about safe foods in pregnancy. What are the major foods to avoid?

Jacqueline Collins, MD:

Yeah, and as you said, as soon as people get that first positive pregnancy test, it is one of those things where it seems like every person has their opinion and every person has a little bit of advice to give and it can be hard to kind of wade through what friends and family say and what there's actual evidence behind.

When we talk about safe foods and pregnancy, there are a few things that we do encourage patients to avoid because of certain risks associated with them.

You know, one of the questions people often bring in is fish. The question of is fish okay to eat in pregnancy? How much is okay to eat in pregnancy? And they often talk to patients about the fact that fish have some great things in them that can be really helpful for babies' development in a pregnancy, some great omegas, some great fatty acids.

But you want to balance that with the risk of mercury in fish. And so we often recommend about two to three servings of fish per week maximum and avoiding certain types of fish, tile fish, swordfish, king mackerel, shark, those fish tend to have a much higher concentration of mercury in them and we sort of recommend avoiding those altogether.

But salmon, tuna, not bigeye tuna, but tuna are all things that can be part of a very good balanced healthy pregnancy diet.

We also talk to patients about avoiding certain types of cheeses, soft cheeses in particular. And really it comes down to cheeses that have been pasteurized or unpasteurized.

This is when I say if you're at a fancy restaurant and you order that salad with goat cheese and you don't see that, that goat cheese says pasteurized in front of you, best to avoid that one. But if you're making something at home and you're buying the cheese yourself and you know that it says pasteurized on it, go ahead and eat it.

I also recommend that everything be cooked. If you're going to eat eggs and you're going to eat them runny, probably err on the side of more cooked than uncooked when it comes to yolks and things as well. And that has more to do with just risks of gastroenteritis or stomach upsets as well and what that can do for dehydration when you're already nauseous and vomiting in early pregnancy as well.

When we talk about the soft cheeses and the lunch meats, the concern is actually bacteria called listeria. And while it can be found on other things and it's important to watch the news and the CDC website, the last couple listeria outbreaks have been in things other than lunch meats and soft unpasteurized cheeses, it is more common in those things and that particular bacteria can cause problems in pregnancy, can cause miscarriage in early pregnancy.

Erica Newlin, MD:

Yeah. I always encourage people to wash their fruits and vegetables super well, and I was joking with one of my colleagues about cantaloupe because it is notorious for hiding in those nooks and crannies of the cantaloupe rind. Like even though listeria is rare, I was very paranoid about it during my pregnancy.

Jacqueline Collins, MD:

Absolutely. Absolutely. I think and I think the last was avocado maybe as well.

Erica Newlin, MD:

I missed that one.

Jacqueline Collins, MD:

Yeah. Yeah.

Suchetha Kshettry, MD:

And lettuce it, it can be in a lot of spaces but, and also to that point, if there are any questions, I think calling your provider is the best move, cause at least you can talk through it and see what the risk is and if there is any additional testing or anything that needs to be done.

Erica Newlin, MD:

For sure. Yeah. And thanks for clarifying on the soft cheeses because I've definitely said soft cheeses before and people are like, so Kraft mac and cheese.

Jacqueline Collins, MD:

Right.

Erica Newlin, MD:

And it's really that unpasteurized and unpasteurized is basically raw milk. And that's hard to find. It's present but it's hard to find but it's not in your regular grocery store usually.

Jacqueline Collins, MD:

Right, right. But it is something to be aware of especially you know, if you are going to restaurants where you don't really know where that cheese came from, it is something to think about.

Suchetha Kshettry, MD:

Or visiting a farm.

Erica Newlin, MD:

Exactly. Or I think there's one raw milk, Swiss cheese at Costco. So you can look out for that too.

Suchetha Kshettry, MD:

I have not Tried it. Yes. I have to look it up.

Jacqueline Collins, MD:

Decide suddenly that pregnancy is the time you have to have that cheese. Right?

Suchetha Kshettry, MD:

I love gruyere so much.

Erica Newlin, MD:

Yeah. And the point of things being cooked, that's why we usually say to avoid sushi too. But if you really have that craving, like cooked sushi is usually okay.

What about caffeine? How much is too much?

Suchetha Kshettry, MD:

Yeah, that is such a good question because I personally love my caffeine and so that's one of the first things that we get asked quite frequently. And so you do not have to give up caffeine when you're pregnant. And so I think that is important to sort of keep in mind.

The recommendation actually is less than about 200 milligrams per day. So what that comes out to is about one cup of coffee. So that's a regular cup, so not your Starbucks like Venti cups of coffee. And that is generally considered safe in pregnancy.

I think the other thing that's important to keep in mind is caffeine is in a lot of different spaces in addition to coffee. So tea, I mean it certainly has less, but tea certainly has caffeine, different energy drinks, sodas as well as chocolate actually. So you want to make sure that you're sort of being mindful of what you're taking in through all of those spaces

Erica Newlin, MD:

For sure. But bottom line, don't let anyone shame you for this.

Suchetha Kshettry, MD:

Yes, yes. You can have some, yes.

Jacqueline Collins, MD:

Caffeine can be a point of survival for some of us.

Suchetha Kshettry, MD:

And sometimes I tell patients, right, if you want to have, if the multiple cups is what you're used to, then think about tea or think about decaf because it has less. And then you can continue with those habits that are important to you.

Jacqueline Collins, MD:

It's also something that I point out to patients who before pregnancy had a lot of caffeine intake and then complain of headaches during pregnancy that one of the reasons that patients can have headaches during pregnancy is also withdraw from caffeine when you're so used to having it.

And so there really is nothing wrong with having a little bit of caffeine, especially if you're used to having a lot of caffeine prior to pregnancy.

Erica Newlin, MD:

For sure. Another thing I often point out to patients who drink a lot of pop or soda is it's not just the caffeine, it's the sugar content too. So keeping mind that as well.

Erica Newlin, MD:

On the subject of beverages, is there a safe amount of alcohol consumption in pregnancy?

Jacqueline Collins, MD:

Yeah, so this is a tough one. I try to tell patients that, you know, the hard thing is it's just not ethical to study alcohol exposure and fetuses and in pregnancy. And so there is no study, there's not probably ever going to be a study and there's no way that I can tell you exactly how much alcohol it takes to cause fetal alcohol syndrome in your baby.

And so across the board the recommendation has to be no alcohol consumption in pregnancy. You know, that being said, I always get the question from patients about what I ingested before I knew I was pregnant.

And you know, we were sort of talking about this a little bit before, you know what happens before what happens, you know, before you know you're pregnant, it's done, it's over. You can't really do a whole lot about it. But again, I can't tell you how that will or will not affect the pregnancy moving forward.

Suchetha Kshettry, MD:

Exactly. I think the other thing that we were talking about that comes up quite frequently is what if you didn't know you were pregnant? Right? And so I think you were saying we just put that behind us and move forward from when you get that positive pregnancy test. And so yeah, agree.

Erica Newlin, MD:

And I think usually when I've looked at this in the past, most studies say if it's very early in pregnancy, particularly in those first eight weeks or so, that the effect is minimal when they've looked at that it's really more consistent use even low amount of consistent use through the later first, second, third trimester.

It's interesting, I went down a cultural Google rabbit hole looking at French women and because people will often be just like, well French women drink wine during pregnancy and they're fine. But actually culturally in the past 20 years that's really gone in the other direction, which I think is interesting. I think here in America we still have that urban legend, the French perceptions a glass of wine.

Erica Newlin, MD:

Yeah. But apparently that's no longer the case. And then how about smoking? What are the risks? Is it okay to substitute out for nicotine patches? What do you usually tell people about smoking?

Suchetha Kshettry, MD:

Yeah, so smoking does carry risks in pregnancy. And so specifically risk of growth restriction. So smaller fetus, smaller baby placental issues, early delivery, low birth weight. After you have a baby there's an increased risk of SIDS. Certainly, secondhand smoke also can be harmful.

And so the recommendation is to limit or stop smoking if possible. Right. And so one of the questions I do get, we do get frequently is about e-cigarettes and there really isn't a whole lot of data on it. And so it's best to avoid because we don't know.

And smoking cessation and stopping smoking is actually quite challenging, especially if you've been doing it for a while. Right. And so we know that it can take up to seven times of trying before you can fully stop smoking or give up any sort of anything really. And so our first line is always behavioral counseling.

So attempt like we have different therapies in different spaces and resources that we provide to patients to help in that. But certainly there are other options like gums and lozenges. So those certainly can be considered patches as well. Really it ends up being a shared decision between the provider and the patient themselves.

And so we try to go through risk and benefit discussion, close supervision because we want to make sure that they have indeed stopped smoking. Especially when we're using those tools.

The data's a little bit limited but there are other medications that can certainly have been used such as bupropion and so there isn't a whole lot of pregnancy data but it is reassuring. And so that might be an option as well to talk to your provider about.

Erica Newlin, MD:

And then with the rise of marijuana legalization across the US I have a lot of patients who are like, well I don't smoke tobacco but I, yeah I smoke marijuana. I like need it from is there a safe amount of marijuana in pregnancy?

Suchetha Kshettry, MD:

Yeah. There is no safe amount of marijuana in pregnancy either. And so the recommendation for that is also to stop smoking marijuana as well, which can be challenging as well.

I think a lot of patients, at least when they talk about hey, it might help with your nausea or it might help with these things as well. And so we have other ways that we can help with those symptoms, but we, you can work with us, you can work with your provider on all of these things.

Erica Newlin, MD:

And on the marijuana topic I always tell patients the point is not to shame you or call you out for your marijuana use or your tobacco smoking. It's always just a, to help you have a safe pregnancy and a healthy baby.

What are the most common questions you're getting from pregnant people about medications and taking medications?

Jacqueline Collins, MD:

Yeah, so a lot of patients will come into pregnancy already on some medications. And so a lot of time, one of the first visits is just reviewing medications that patients are already on and determining which ones are safe to continue and which ones need to be stopped or cut back on. And so that can be like an individual review with the patient in that initial visit.

A lot of over-the-counter medications we don't have a whole lot of research, a lot of data on. There's some common over-the-counter medications that we do recommend patients avoid in pregnancy. The main one being you know, different ibuprofen derivatives.

So talk to patients a lot about if you are going to use a medication for pain or fevers in pregnancy that acetaminophen should be your first line for those types of things.

Other questions that we get a lot of time are about different supplements and different vitamins that patients should take or should avoid during pregnancy.

You know, a lot of times I'll tell patients that their prenatal has a lot of what they need and really has most of what they need in it. I also talk to patients about the fact that the vast majority of vitamins are water soluble and that if you take it, it's just going to be really expensive pee.

And you know, with the exception of the fat-soluble vitamins, which there's really only a few of those and I talk about ADEK, the A, D, E, and K vitamins and that it is possible to overdose on some of those. I mean you can get too much of a good thing while every patient in Cleveland seems to have a vitamin D deficiency, and I don't know why that's the case.

More than any other city I've practiced in Cleveland seems to have issues with vitamin D, but you can actually overdose on vitamin D, you have to take a lot of it, a whole lot of it for that to be the case. But you can.

And so that's something to talk to your provider about and if you're concerned about it, you can always get a level drawn and see if you're deficient. You know that being that a little bit of an extra vitamin D is also usually fine and great in pregnancy even without getting tested to see if you're deficient.

Suchetha Kshettry, MD:

The thing that I do tell, especially when they're on multiple supplements is the vitamin A. So you can get excess vitamin A and that should be avoided. And the other thing, it's allergy season and so that's one of the things that comes up quite frequently. And so there are several antihistamines that are over the counter that can be used safely in pregnancy.

So the goal is, you know, we want all of our patients, our pregnant moms to be comfortable as well. And so that is fine. There's a couple like pseudoephedrine that sometimes might need to be avoided in particular situations or particular gestational ages, but certainly to talk to your provider about that. But otherwise really most things the antihistamines over the counter are fine to take.

Erica Newlin, MD:

You mentioned ibuprofen as being the one to avoid. Can you talk about why and if someone's listening to this today and they're like, oh shoot, I'm 16 weeks and I took ibuprofen last week.

Jacqueline Collins, MD:

Right.

Erica Newlin, MD:

What's the, what's the risk?

Jacqueline Collins, MD:

Right. So you know when we talk about the NSAIDs, one of the concerns that we have is repetitive exposure, especially you know, later in the pregnancy and what that could do potentially to the baby's kidneys. Also to the baby's heart.

Like one time taking is not as big a deal as, you know, repetitive exposure and certainly exposure early in pregnancy is not concerning as well. But that being said, if you're 25, 26 weeks pregnant and you have a fever grab for your acetaminophen instead.

Suchetha Kshettry, MD:

The other thing I tell patients quite honestly is there are times where we ask pregnant patients to take ibuprofen. Right. And so generally for specific indications, generally for like a shortened period of time. And so having one is certainly okay, but not the first line as a recommendation.

Erica Newlin, MD:

Can you touch a little on how we determine safety of medications during pregnancy? Like what kind of studies we're using, what evidence we have?

Suchetha Kshettry, MD:

Yeah, so generally speaking, when we assess for safety of medications, just overall it's through the FDA and the labeling and the testing done. And so the different categories that are associated with it.

It becomes a little bit more challenging in pregnancy because most of these studies are patients that take them, patients that don't and you're assessing for different outcomes. And so those types of studies would be unethical in a pregnant population to watch long-term to see did something happen or not happen.

And so in pregnancy many times it's actually based on seeing a large group of patients that have been taking it and seeing if there have been any adverse events or adverse outcomes. And so much of it is looking at gestational age dosing and sort of going from there. But they really aren't RCTs or randomized controlled trials that aren't necessarily done as the primary form in pregnancy just because that just wouldn't be ethical to do

Erica Newlin, MD:

For sure. And then also sometimes we'll make conclusions based off of animal studies or like you mentioned primarily retrospective, meaning we look back at people who maybe didn't know they were pregnant or so we're, we're really depending a lot on people's recall.

Suchetha Kshettry, MD:

Recall for things.

Erica Newlin, MD:

Yeah. So often I tell many patients that I don't think that this medication has an issue. I have no evidence that this medication has an issue. But yeah. But it's always, always tough.

Suchetha Kshettry, MD:

It's tough. Yeah. And that's why I think the conversation's really important because much of this, and that's why there may not be a lot of data per se, but that doesn't mean you can't have the medication. And so it does become a conversation on risk and benefit in making that decision together.

Jacqueline Collins, MD:

My line always for patients is, if you don't need it, don't take it. But if you do need it to be happy, healthy, connected to your pregnancy, connected to your life, then you need it.

Erica Newlin, MD:

On that topic. Let's shift to one of the hot topics right now, which is antidepressants in pregnancy. So can you talk about the safety of some of the most commonly prescribed antidepressants?

Jacqueline Collins, MD:

Absolutely. And this is in particular one where I am having this conversation relatively frequently with patients. You know, a lot of patients will come in and their first thought is, I do need to get off all these medications. I don't want to expose my baby to these medications.

And I think that that's a really important conversation to have with patients because you know, a lot of the antidepressants have actually, you know, some decent studies behind them that tell us that they have minimal to little effect in pregnancy and that the overall benefit to the mom is abundant.

When we talk about antidepressants, the most commonly prescribed antidepressants are the SSRIs, which is a group of medications that help with anxiety and depression and that patients are usually on for several weeks before they notice a lot of benefit.

So they're not a medication where you take, you know, one time where you're feeling anxious or one time where you're feeling depressed. There are medications that you really do have to be on for an extended period of time to get to the correct dose and to have the proper effect.

And when they've looked at these medications, there's one medication within the class that was shown to have a little bit of an increased risk in heart defects. And so if I have patients on that medication, sometimes we'll do some additional testing, we'll do a fetal echo, the rest of the medications in that category don't seem to have the same effect. And so that's unnecessary in those patients.

And the benefit to patients who suffer from anxiety and depression, especially when they're going through a time like pregnancy where there are so many changes in life and there are so many new life stressors coming in to come off of those medications can sometimes be a much bigger detriment to their pregnancy, to their baby, to their ability to bond with their baby than staying on those medications.

So more often than not, while it is a shared decision making, the recommendation is to stay on those medications in that sphere of life.

Suchetha Kshettry, MD:

The other thing, I mean I think this is such an important topic and Dr. Collins said this, but really untreated depression carries significant risk for obstetrically speaking for the mom, the baby.

And so it is incredibly important, our national organization for OBGYNs, ACOG and certainly many other national organizations very explicitly support treatment in pregnancy. And so, you know, it's really important to have that conversation if you are concerned is what I would say because I think continuing these medications is incredibly important.

The other question sometimes that does come up that I get asked is about being on any of these medications, these SSRIs later in pregnancy and sort of as the baby is born, are there any transient like neonatal risks to the baby?

And so there is some data, some literature about things that might happen transiently such as like some jitteriness or mild respiratory distress or anything like that. But that risk is incredibly low. And so we have to weigh that.

I mean certainly if there's any concern, you know we're there, we have pediatricians, we have NICU doctors there to assess as well. But we still recommend continuing the medication throughout the pregnancy and postpartum because these are really our highest risk times.

Jacqueline Collins, MD:

And as Dr. Kshettry said, those risks, you know in the, in the newborn period they're transient. Whereas you know, the risks of long-term untreated depression can go on and can reverberate for quite some time.

Erica Newlin, MD:

Shifting to another hot topic right now, vaccines, let's start by covering what vaccines are commonly given during pregnancy and how we determine the safety.

Suchetha Kshettry, MD:

Sure. Vaccines are incredibly important as well. Because especially for pregnant patients, you want to make sure that you want to do all of the things that you think is safe for yourself and the baby and a vaccines is one of them.

And really the biggest vaccines that are recommended in pregnancy, their safety profile has been assessed and they are the ones that are not the live vaccines. And so it's really the live vaccines that we do not recommend in pregnancy. So that's your MMR and Varicella, those are contraindicated but the others are recommended.

And so influenza, the flu vaccine is one that we do recommend during flu season, whenever that might be in your pregnancy. Certainly COVID-19 is a vaccine that is top of mind for everybody that is also recommended.

ACOG, which is our national body, continues to recommend the COVID-19 vaccine. So we do offer it to our patients. And so that is a conversation as well.

The maternal RSV vaccine that's newer is also recommended during RSV season, which is September through February. Yes. And so, and that's given at a particular gestational age. So it's around 32 weeks to 36 weeks and six days. Yes. And so that we do offer to patients also T-DAP and so that is usually in the third trimester. So these are the main vaccines that we do recommend and offer to our patients.

Erica Newlin, MD:

Yeah, and I think it's important to note too, and I tell patients this because I have a lot of people who are like, well I never get the flu vaccine and I never get the flu.

But with pregnancy it compromises your respiratory status because you have less lung volume, you have a much higher risk for severe disease from the flu or from COVID. So that's why these vaccines are really important.

Suchetha Kshettry, MD:

Yeah. And that's a really fair point. And so if you get the flu or you get any of these when you're pregnant, you get a lot sicker, a lot quicker and it can be much harder to recover. And so you're essentially protecting yourself and the pregnancy and your baby.

Jacqueline Collins, MD:

Yeah, I think patients sometimes think that if they get the vaccine and they still end up getting the disease, the vaccine didn't work. And I think that that's a misconception sort of across the board with vaccines.

And one of the important things to think about things like the flu vaccine and such in pregnancy is that if you do get the disease and you get sick that the vaccine may have helped you from having more severe disease. So really reducing that like risk of hospitalizations and deaths even more than just incidents.

Erica Newlin, MD:

Let's shift to another really important topic. Can you dye your hair?

Jacqueline Collins, MD:

This is an important topic. For some of us, this is a very important topic in pregnancy. Absolutely you can dye your hair in pregnancy.

Pregnancy is a time where your body is changing and it's a rapid change to your body and that that change is somewhat out of your control. And I think for a lot of us feeling good and looking good during pregnancy is more important to us than we necessarily let on to others.

But no, absolutely, this is the really common question that I get and I think that there's a misconception out there that it's not safe to dye your hair in pregnancy or to do a lot of other things during pregnancy that help you feel good or help you look good.

And I tell patients as long as you are in a well-ventilated space, I think that that's actually the bigger issue. If you walk into a salon and it's poorly ventilated and there's tons of fumes and you are not feeling great and you're getting a headache and you don't feel good, that's probably not a great environment for you to be in for you or the baby. But if you are in a space where that's not an issue, go ahead dye your hair, look your best, no issues there.

Erica Newlin, MD:

And then what about any skincare products or cosmetics that should be avoided?

Jacqueline Collins, MD:

Most cosmetics and most products that are out there will be safe to use in pregnancy. You know, one of the things I do tell patients is that you don't really absorb a whole lot through your skin, especially through the small areas of skin that are on the face.

And so some patients will actually, you know, bring in all of their, I don't know if this happens to you guys, but I will have patients who will bring in their makeup line, including their foundations and their concealers and things and ask me if the ingredients in them are safe to use.

And sometimes these ingredients are 50 things long and the bottom line is the vast majority of foundations, concealers, makeups, you know, products are perfectly fine, perfectly safe to use in pregnancy. Especially because you're using them on such a small area of the body, just using them on the face and such.

You know, we do have a conversation with patients about some of the more advanced things, you know, certainly things like your Botox and your fillers and you know, avoiding those during pregnancy. And you know, that is a conversation we have to have is sort of, you know, if you're on a schedule where you're keeping up with your every four-month Botox, that that is something that you're going to want to delay or you're going to want to hold off on until after pregnancy.

Erica Newlin, MD:

What do you tell people about the vitamin A derived skincare products? We talked about vitamin A before and risk of is there enough absorption in the like retinol and those sorts of products to make a difference?

Jacqueline Collins, MD:

Usually not. Obviously you want to be avoiding oral retinol and you know, oral vitamin A, but the amount that's in your skincare products, especially if you're using them appropriately, it's really not absorbed in a quantity that's going to be harmful to baby.

And that is another one of the ones though, patients will come in in the first trimester and be like, oh my goodness, you know, I've been using my every three day retinal pads and is that harmful? And you know, that is a conversation that I have with patients is that you're really not absorbing enough of that through the skin to have that much of an effect on the pregnancy or on the baby.

Erica Newlin, MD:

I learn so much about skincare regimes from what people ask if they can use.

Suchetha Kshettry, MD:

I’m like oh I need to do that. Yeah.

Erica Newlin, MD:

Like red light therapy, I should be doing that.

Suchetha Kshettry, MD:

What are these new trends? Right.

Erica Newlin, MD:

Another thing I get a lot of questions about are massages. Yay? Nay? Is it Okay? Prenatal massage.

Suchetha Kshettry, MD:

Yes. Yes. I one hundred percent I think prenatal massages, massages and for anybody but also for pregnant women is incredibly important. So if that is important to you, then safe to get.

There are specific locations that provide prenatal massages and what that really means is that the positioning is on the side and you know, avoiding specific pressure points or areas like the abdomen or something like that or being on your back for too long.

And so really those are the factors that I think when they advertise a hey we do prenatal massages, like that's what they're looking at. But overall massages are fine. Absolutely.

Jacqueline Collins, MD:

Yeah. I do tell patients that it's always important to share with your provider that you are pregnant. So you know, get your massages, enjoy it, but make sure that you share with your provider that you are pregnant because they will be able to provide you with safer, more comfortable positions to be in during the massage.

And same if you go the route of acupuncture or moxibustion, you know, that is something where you, you do want to be sharing with your provider that you're pregnant because there are some things that they would do or wouldn't do depending on whether or not you're pregnant and how far along you were in the pregnancy.

Erica Newlin, MD:

What is moxibustion?

Jacqueline Collins, MD:

So moxibustion is very specific sort of under the category of acupuncture, but where you know, heat and cupping is also used and it is something that we do to help flip breach babies. Were we not aware of that?

Erica Newlin, MD:

I knew I've always heard it called cupping.

Jacqueline Collins, MD:

You know it is a stress relief practice that some providers are very skilled in that can provide a great amount of muscle relaxation and stress relief for pregnant patients.

But it is done differently during pregnancy for stress relief and muscle relaxation versus at the end of pregnancy for patients who are seeking assistance with relaxation to encourage labor or to encourage changes in baby's position.

Erica Newlin, MD:

What about painting the nursery? Is it safe?

Suchetha Kshettry, MD:

Yes, that's the short answer. It is safe. I mean similar to what Dr. Collins was sharing about walking into a salon, when you want to get your hair dyed, it's really, you want to make sure that things are well ventilated and so painting the nursery is safe.

Trying to use maybe water-based paints or latex paints, but avoiding sort of older paint that might be lead-based is important. Maybe not sleeping in that room that first night and just giving some time for things to air out.

Erica Newlin, MD:

So you're saying if you find a paint can from the 1970s in your basement

Suchetha Kshettry, MD:

Probably avoid that. Probably the best one. Yeah, avoid that one. But however, whatever colors, whatever themes go for it. I think that's always really important, especially as you're nesting and as you're preparing.

Erica Newlin, MD:

How do you each counsel patients about travel and pregnancy?

Jacqueline Collins, MD:

So travel and pregnancy, you know, this is another hot topic and something that a lot of patients come in and ask about. You know, really air travel up through about 36 weeks is considered safe in pregnancy and part of the reason why we recommend not traveling beyond that has to do with risk of going into labor.

That being said, I think that each case needs to be a little bit individualized. I do talk to my patients about risks of international travel in the third trimester risks of things that can happen when you deliver a baby in another country. And issues with citizenship have been issues for patients in the past and so that's a consideration.

But the actual risk of getting on a plane and traveling, we recommend patients move around, they move their legs, they get up and walk around. Sometimes if it's a particularly long flight I will encourage like a layover just to kind of break the flight up for patients. But you know, up until about 36 weeks or so, flight travel is fine and you know, take that baby moon really, you may never have a chance to do it again, so go for it.

Suchetha Kshettry, MD:

Yeah one hundred percent and especially when you're thinking about international travel or just travel to any destination, really just checking the CDC website is also important just to see if there's any specific outbreaks or anything like that to make sure that you are prepared that you know ahead of time and if there's things that need to be done to mitigate any risk or talk to your provider, at least you can have that conversation before you go.

Jacqueline Collins, MD:

And if it is a situation where you know it's your sister's wedding or it's something important where you, you do need to travel and you know that risk benefit tips towards, I'm going to go.

You know, one of the things I always do encourage patients is figure out where the closest hospital that has a labor and delivery unit is to where you're going to be. I think that that's certainly a smart thing to do if you're in that situation. And you know, sometimes life calls for that.

Erica Newlin, MD:

Similarly I tell people like make sure you know where an OB hospital is and kind of look for the large academic centers if there is one there. And I often have people take a paper copy of their records to, or at least something that they can be like, all right this is my dating, this is for sure cause that's something that comes up when we have patients from out of town because we have no records. And so that can be helpful sometimes.

Jacqueline Collins, MD:

And getting records at three o'clock in the morning is not always as easy as it sounds. So yeah, that, that's a great idea and I think that that would be really helpful.

Erica Newlin, MD:

Shifting topics, is sex safe in pregnancy? Are there times in pregnancy or situations where it should be avoided?

Suchetha Kshettry, MD:

For uncomplicated pregnancies, yes, it is safe. It's safe for any time during the pregnancy. So really any trimester. Sometimes you can have a little bit of spotting actually and that can be worrisome. But generally speaking it can be, it's usually from the cervix and so it's not harmful to the baby or it's not harmful to the pregnancy.

Really the times that we recommend not having sex and no intercourse and nothing in the vagina, pelvic rest is really, what I was trying to think of is for the more high risk pregnancy. So if there's some concern with where your placenta is located or concern with your water breaking or preterm labor or something like that, then we have those conversations explicitly and say, “hey, please avoid sex.” But otherwise, yes.

And then the other thing to think about is using condoms if you're concerned for STI or decreasing risk of infection as well.

Erica Newlin, MD:

And then we have another episode on the pelvic floor and pelvic floor physical therapy. So I always tell people if sex is very painful, even outside of pregnancy our pelvic floor physical therapy friends are there to help.

Suchetha Kshettry, MD:

Yeah, actually I think that is fantastic and I would encourage everyone to listen to that episode. Pelvic floor physical therapy is something, it certainly isn't new but over the last goodness maybe 10 or so years has become more prominent and it's so incredibly important.

And one thing I talk to patients about now is you don't necessarily have to wait until after you deliver to meet with a pelvic floor therapist. Because I think that there's a lot of benefit in just learning different exercises but also learning your body and also in preparation for labor as well can be helpful too.

Jacqueline Collins, MD:

And if you have any like specific practices that you are concerned about, then absolutely that's something that you should feel comfortable discussing with your provider. That's what we're here for.

Erica Newlin, MD:

Great. Any final thoughts?

Suchetha Kshettry, MD:

I mean I think the biggest takeaway hopefully is that there's always a lot of questions out there and always feel comfortable coming to talk to your provider. But really there's a lot of things that you can still do in pregnancy.

Google does not have all the right answers, but you know, just make sure that you talk to someone and there's no shaming. And if, you know, if you have questions, please ask.

And, and pregnancy's a time of, you know, of joy.

Jacqueline Collins, MD:

It should be.

Suchetha Kshettry, MD:

It's not meant to be like restrictive, right? Like there's things you can do, there's things that you can do safely and there's things that you should continue to do.

Jacqueline Collins, MD:

I think you put it very well before when you said pregnancy's not torture or shouldn't be torture. Sometimes it feels like it but it shouldn't be.

Erica Newlin, MD:

Well, perfect. Well thank you both so much.

Suchetha Kshettry, MD:

Thank you.

Jacqueline Collins, MD:

Thanks for having us.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.