University Health System Blog

Dr. Paul Stumpf answers the question: “Are there general warnings on over the counter drugs for pregnant women?”

Pregnant women should not take any medication, including over the counter drugs and herbal supplements, without first checking with their obstetrician or health care provider. As an obstetrician I advise expectant moms on the possible risks of taking certain common over the counter drugs. When it comes to these medications, some are safer than others. There’s a lot of info out there and knowing what’s safe for you and your unborn child can be confusing. All medicine, from the common aspirin to prescription drugs, will affect your body.

Warnings

Again, its highly advisable to consult with your obstetrician before taking any type of drug. Here are some warnings on some common over the counter medicine you may not know:

• Nonsteroidal anti-inflammatory drugs like aspirin or ibuprofen (Advil, Motrin, Aleve) can cause serious blood flow problems in unborn children if used during the last third of pregnancy (after 28 weeks).
• Aspirin may increase the chance for bleeding problems in the mother and baby during pregnancy or delivery;
• Nicotine therapy drugs, like nicotine patches and lozenges, are thought to be safer than smoking, but risks are not fully known;
• Sudafed for allergy relief may not be recommended during the first trimester of pregnancy;
• Antibiotics like tetracycline and ciprofloxacin should be avoided if possible, particularly in the early stages of pregnancy;
• Isotretinoin (Accutane, Sotret, Claravis, Amnesteem), used to treat acne, can cause miscarriage or birth defects;
• Certain high blood pressure medications can cause kidney problems in the fetus;
• Some herbal remedies, like blue cohosh in particular, may be harmful;
• Common nutritional supplements like multivitamins may be harmful, as high levels of Vitamin A has been shown to cause severe birth defects if taken in large doses

If your doctor prescribed medicine for you before you got pregnant, should you continue taking them? You definitely need to discuss this with your doctor as soon as your pregnancy is confirmed. Some medications may be critically important to your health while others can be eliminated, changed or the dosage lowered to reduce any potential risk to your baby.

Guidelines

Certain remedies are usually safe for pregnant women, but of course, you should double check with your obstetrician. These include:

• Tylenol for headaches, muscle aches or mild pain pregnant, with two regular strength tablets every six hours until symptoms subside;
• Nasal sprays work well for some allergies, with two squirts in each nostril every six hours. Benadryl can be an alternative to Sudafed but use with caution as it may make you drowsy;
• Antacids like Tums, Rolaids, Maalox or Mylanta can usually be used as directed as some pregnant women experience heartburn or indigestion

How Medications are Tested

With so many medications on the market and more added each day, it’s more difficult for doctors and nurses to keep track of which drugs can be used during pregnancy. In addition to textbooks and research journals, the U.S. Food and Drug Administration (FDA) plays an important safety role. The FDA requires pharmaceutical companies to show that a specific medicine works for a certain problem and that it’s generally safe. Pharmaceutical companies must check whether birth defects or other problems occur in baby animals when the drug is given to pregnant test animals. If it causes problems, it may mean it can cause problems in human babies. Although the FDA requires these experiments and other criteria to be satisfied, drug testing and its affects is not an exact science. There’s a lot that researchers and doctors just don’t know about some medications used during pregnancy.

What are Pregnancy Exposure Registries?

Drugs are rarely tested for safety in pregnant women. However a pregnancy exposure registry can help doctors and researchers learn how medications affect pregnant mothers and their babies. A pregnancy exposure registry is a study that enrolls pregnant women who are using a certain medicine. Women sign up for the study while pregnant and their progress is followed for a length of time after the baby is born. Researchers compare the babies of mothers who used the medicine while pregnant to the babies of mothers who didn’t use the medicine. This type of study compares large groups of pregnant mothers and babies to look for possible effects. Obstetricians and their patients can use registry results to make more informed choices about using certain drugs. If you’re pregnant and using a medicine or you were using one when you got pregnant, check if there’s a pregnancy exposure registry for that medicine. The FDA has a list of pregnancy exposure registries that pregnant women can join. You can also find out more about pregnancy and medicine from the National Women’s Health Information Center at 800-994-9662.

Conclusion

My advice, and I can’t stress this enough, is to let your doctor or obstetrician know about any and all medications and drugs you’re taking while pregnant. Better yet, bring the bottles with you to your pre-pregnancy checkup. If you’re not pregnant yet but you’re planning to have a baby, it’s a great idea to discuss your health and your medications with your doctor before you conceive. That way both you and your baby will have the best chance of a smooth pregnancy, a happy birth and healthy life.

Paul Stumpf, M.D. heads the ob/gyn department at the University of Nevada School of Medicine. Dr. Stumpf is board certified in obstetrics, gynecology and reproductive endocrinology.

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Dr. John Gosche answers the question: “My child has continuous abdominal pain. How do I know if she needs surgery?”

Thankfully most children won’t need to meet me in my role as a pediatric surgeon. But unfortunately a small number of kids have a medical condition requiring surgical care. In today’s post, I’m going to cover the typical presentation and symptoms related to three abdominal conditions that may need surgery: appendicitis, volvulus and intussusception.

Appendicitis

The appendix is a non-essential structure attached to the part of the colon known as the cecum, usually located in the right lower portion of the abdomen. Inflammation of the appendix, or appendicitis, is the most common reason for emergency surgery in children. The lifetime risk of appendicitis is about nine percent for boys and seven percent for girls.

Appendicitis most commonly develops in children 12 to 18 years old but can develop at any age. Appendicitis happens when the lumen of the appendix becomes blocked, causing a build-up of secretions and pressure inside the appendix, which leads to bacterial growth, tissue swelling, inflammation and ultimately impairment of the blood supply to the appendix’s wall. Appendicitis commonly causes abdominal pain, nausea, vomiting, a loss of appetite and low-grade fever. The abdominal pain associated with appendicitis classically begins as a poorly localized mid-abdominal pain followed minutes or hours later by sharp pain that localizes to the right lower portion of the abdominal wall.

Unfortunately many experience less typical symptoms of appendicitis and as a result, appendicitis can be a difficult diagnosis to confirm. Early diagnosis and treatment is key to decreasing the risk of serious complications. In many cases findings during a physical exam and simple blood tests will help confirm a diagnosis, although some children may require x-rays as well.

Volvulus

Volvulus is twisting of the intestine that frequently impairs blood supply to the affected area of the intestine. Volvulus is commonly associated with malrotation, when the intestine doesn’t position normally in a child’s abdomen during development, causing the base of the intestine to be narrowed and making the intestine prone to twisting. Malrotation may not cause symptoms before twisting. Usually volvulus happens in the first weeks of life. Midgut volvulus however can happen at any age including before birth or later in life. Common symptoms include vomiting yellow or green discharge, abdominal pain in older children or irritability in infants.

Later symptoms include extreme sleepiness and blood in the stool. Early diagnosis and treatment are critical to prevent permanent injury or loss of the intestine. Unfortunately, the symptoms may be nonspecific and may be due to other less life threatening conditions. Prompt medical evaluation however should be sought when a child develops bilious emesis and severe abdominal pain. A special radiographic study called an upper gastrointestinal contrast series can help diagnose malrotation.

Intussusception

An intussusception is movement of one segment of the intestine into an adjacent segment. In intussusception the trapped bowel becomes swollen and its blood supply is compromised. This condition most commonly occurs in five to nine month old infants. Often an intussusception will follow gastroenteritis or an upper respiratory tract infection. The classic symptom of intussusception is episodic, severe abdominal pain. Affected infants frequently scream in pain and draw up their legs during an episode lasting a few minutes then seem normal between episodes.

Other symptoms include vomiting that may become bilious, passage of blood through the rectum and lethargy. The symptoms can be nonspecific but a history of severe, episodic abdominal pain should be a concern. Parents should seek medical advice. A special radiographic test called a contrast enema can confirm the diagnosis and in many cases can be used to push back or reduce the intussuscepted intestine, avoiding the need for surgery. The success rate with contrast enema reduction depends on early recognition and treatment.

Summary

Abdominal conditions requiring emergency surgical care are uncommon in children. Unfortunately many of these conditions may present with symptoms difficult to distinguish from less life-threatening illnesses. Severe or persistent abdominal pain, especially pain that has a unique pattern or associated with bilious vomiting, should raise concern about a potentially serious problem and should prompt immediate medical attention.

John Gosche, M.D., Ph.D. has practiced medicine for more than 20 years. He is professor and chief of the pediatric surgery division at the University of Nevada School of Medicine. Dr. Gosche is board certified in general surgery and pediatric surgery. He practices in Las Vegas.

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Dr. Ole Thienhaus answers the question: “How do I know if my teenage child is depressed?”

Depression in teenagers is a more common affliction than previously thought. In fact, years ago many would have denied its existence altogether: Adolescent turmoil and normal moodiness would have been held up as explanations for any young person in emotional distress. The troubling increase in teenage suicides and suicide attempts over the past few decades has brought the issue to the forefront and made mood disorders in adolescents a major public health concern. Recent statistics reveal that in girls aged 13 to 18, almost six percent are diagnosed as suffering from clinical depression. In boys of the same age, the percentage is about four and a half.

Clinical depression is the key term here. The old notion that adolescents tend to be emotionally labile is obviously accurate: As most of us recall, growing up is a distressingly tough job, and heartbreak and despair are part of that painful transition from childhood to adult independence. But episodes lasting four to six months when the expressed mood is continuously dejected or downcast, when crying spells are accompanied by withdrawal from activities usually enjoyed, when the young person no longer socializes with friends, school performance suffers, and the future is seen as bleak: This kind of sustained gloom should concern parents, teachers and friends.

Even long periods of emotional distress do not necessarily mean that someone suffers from major depressive disorder, but it should send a signal that something’s wrong. The teen may have gotten into drugs or there may be peer conflicts or school trouble that’s more than he or she can handle. But the possibility of a first episode of major depression should also be kept in mind. Failure to intervene can exact a high price: Suicidal behavior, school failure and substance abuse are common complications. And the probability of a chronic recurrent condition is of great concern: About 70 percent of kids with depression grow up to have major depression as adults.

Ideally parents have managed to maintain a level of communication with their teenagers that lets them find out about their daughter’s or son’s troubles. It is very common, and no cause for parental self-blame, that the adolescent prefers to conduct a more in-depth discussion with a professional. The professional, such as a child and adolescent psychiatrist, or a behavioral pediatrician, or a youth counselor, comes with less baggage than any family member, and offers teens a degree of confidentiality that makes it easier to share fears and embarrassing thoughts or fantasies.

If the discovery that their child suffers from major depressive disorder expectedly comes as a shock to the parents, it is worth emphasizing that depression is amenable to effective treatments. Although it is often a chronically recurrent illness, adequate clinical management is likely to lead to long-lasting or even permanent remission.

For the affected teen, the engagement in a therapeutic relationship with a mature and trained mental health professional can be a critical ingredient towards recovery. However, in itself it is not sufficient for recovery if the emerging illness is, indeed, major depressive disorder. Systematic psychotherapy with adjunctive antidepressant medication, is required. One of the effective psychotherapies is a technique called cognitive behavioral therapy, another is interpersonal therapy. In neither of these does the patient lie on a couch, spending years trying to recall childhood memories.

Rather, in cognitive behavioral therapy he or she learns to systematically shift his or her perspective on their predicament, so as to appreciate a sense of mastery of life’s challenges over time. This is called reframing: The patient is trained, consciously, to consider and then adopt an alternative view of the identified circumstances and emotions that underlie their despair. If the treatment is managed by a skilled clinician the gains can often be accomplished in as little as twelve to twenty sessions i.e. four months or less. In interpersonal therapy, the focus is on problems in relating to others – identifying misinterpretations of others’ behavioral cues, correcting the perceptions and practicing interactions based on the newly acquired skills at decoding those around the patient.

Psychotropic medication in kids is often feared by well-meaning parents and clinicians alike. None of us like the idea of our children being on medications, let alone drugs that work on the brain. Very specifically, concerns about increased suicidal thoughts in adolescents on certain antidepressants have been widely published over the past few years, causing even greater hesitancy to prescribe such medications in young patients. However, it’s well established by now that the advantages of a carefully tailored and monitored medication treatment improve the prognosis greatly, especially if the medication is used in conjunction with psychotherapy.

The psychotherapies, as outlined above, reduce the risk of a situation triggering a cascade of self-defeating emotional reactions. The medication realigns the imbalanced state of neurochemicals that bring the emotional pain into consciousness. The data base for the effectiveness of antidepressant medication is solid enough that the U.S. Food and Drug Administration has explicitly approved one particular antidepressant, fluoxetine, as an effective and safe medication in the treatment adolescent depression.

So, should your teen get on Prozac and into psychotherapy at this point? Not necessarily. The diagnosis of major depression takes more than a bedside glance. Just like other illnesses, psychiatric disorders have a better prognosis if they are caught early, before they become chronic or have led to complications.

Ole Thienhaus, M.D. is dean of the University of Nevada School of Medicine. He lives in Reno and Las Vegas, commuting every week between the medical school’s two campuses, treating patients in urban and rurual communities.

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