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Posts Tagged ‘pregnancy’

 

A Natural Approach to Preventing Gestational Diabetes

Monday, October 26th, 2015
image courtesy of freedigitalphotos.net

By Katie Woodward, PharmD Student

You are having a new baby! Congratulations! You’ve probably already had several opportunities to answer that age-old question, “What gender are you hoping for?” And it is likely you responded with something like, “I don’t care as long as my baby is healthy!” Thanks to new scientific research, your chances of delivering a healthy baby are constantly improving.

We are going to play a quick game of “Bad News/Good News.” The bad news: gestational diabetes may cause complications in your pregnancy. Several factors may put you at risk of developing gestational diabetes. If diabetes runs in your family, if you are overweight, not very active, or over the age of 40 you are at risk of developing gestational diabetes.1 Gestational diabetes can cause jaundice, high birth weight, trauma during birth, increase necessity for C-section, and increase likelihood of obesity or diabetes in the child.1,2 Gestational diabetes also puts a new mother at risk of developing Type 2 Diabetes, which can require insulin injections and other treatments to control.

Now, for the good news: new research has demonstrated that myo-inositol is a supplement you can take which significantly decreases your chances of developing gestational diabetes, even if you are at high-risk.3 For those already diagnosed with gestational diabetes, taking a myo-inositol supplement can help decrease your need for insulin, make you more likely to carry the baby to term, and decrease your infant’s chances of developing hypoglycemia.3 Standard treatment for gestational diabetes requires the patient to check blood sugar levels in the morning and after meals, which can require several needle sticks per day as well as the purchase of a glucometer, test strips, and lancets.4 Insulin injections are also used to help control the blood sugar in up to 20% of women with gestational diabetes.4

A research study published in the Journal of Maternal-Fetal and Neonatal Medicine was designed as a prospective, double-blind, randomized controlled clinical trial which compared a placebo group to a group of mothers who supplemented with myo-inositol twice daily.3 The myo-inositol group had significantly better outcomes including lower maternal BMI, longer gestation at the time of delivery, and decreased abnormal oral glucose tolerance test results. The oral glucose tolerance test is the standard screening measure for gestational diabetes.  One limitation was that the study was relatively small. Some of the data may have been statistically significant if there had been more women involved in the study; for instance, the myo-inositol group had a lower incidence of neonatal hypoglycemia, but the data was not quite strong enough to be statistically significant. Another interesting statistic is that 21% of women in the placebo group required insulin therapy, while only 3% of women in the myo-inositol group required insulin therapy. While larger studies may be needed to validate this data, this study demonstrated that at least 50% of women who take myo-inositol may benefit from the treatment.3 Since the current standard of care for prevention of gestation diabetes is diet change and monitoring blood sugar, myo-inositol may be an easy and beneficial way to minimize complications from gestational diabetes.  It also has a promising potential to minimize the requirement of insulin injections.

Since it is a compound naturally found in both your body and your baby’s body, you can safely consume myo-inositol supplements.5 The product may be a little bit difficult to find in grocery stores, but it can be found in combination products or ordered online. According to research, the supplement is best if taken 2000 mg twice daily (make sure you separate the doses by at least six hours.)One product can be purchased from Fairhaven Health6 where you can get a 60-day supply for less than $20.* Myo-inositol is often combined with another compound called D-chiro inositol, which has also been demonstrated to assist with gestational diabetes.7 The combination product is called Ovasitol and it can be purchased online from Theralogix Nutritional Science Company, but it must be ordered online and can cost up to $1 per day ($90 for a 90 day supply.)8 Another product to consider is called Sensitol, and it contains D-chrio inositol, myo-inositol, and alpha lipoic acid. The product can be ordered online and a thirty day supply is $52.9

Gestational diabetes can have some scary consequences for you and your baby. Based on the evidence, I would recommend that any mother who has increased risk of gestational diabetes should discuss supplementation with myo-inositol with their medical provider.   It could help prevent or minimize problems associated with gestational diabetes. Myo-inositol may be expensive and may not be easily accessible to all; since it is commonly used as a preventative supplement, do you think that pregnant women at high risk for developing gestational diabetes should consider it as an option?

*The manufacturer suggests that the drug be taken four times daily, but in studies, the 2000 mg dose was only recommended twice daily.3 Also, this will help decrease the cost of the drug.

**Note: The Cochrane Collaboration is working on a new study to further describe the dosing and efficacy of myo-inositol as a treatment/ prevention method for gestational diabetes and it should be released soon.

References

  1. Available at: http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014. Accessed October 14, 2015.
  2. Brown J. Myo-inositol for preventing gestational diabetes. Cochrane Database Of Systematic Reviews [serial online]. February 2, 2015;(2)Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed October 11, 2015.
  3. Matarrelli B, Vitacolonna E, Celentano C, et al. Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: a randomized controlled trial. The Journal Of Maternal-Fetal & Neonatal Medicine: The Official Journal Of The European Association Of Perinatal Medicine, The Federation Of Asia And Oceania Perinatal Societies, The International Society Of Perinatal Obstetricians [serial online]. July 2013;26(10):967-972. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 11, 2015
  4. Available at: http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/treatment/con-20014854. Accessed October 21, 2015.
  5. D’Anna R, Scilipoti A, Di Benedetto A, et al. myo-Inositol supplementation and onset of gestational diabetes mellitus in pregnant women with a family history of type 2 diabetes: a prospective, randomized, placebo-controlled study. Diabetes Care [serial online]. April 2013;36(4):854-857. Available from: MEDLINE, Ipswich, MA. Accessed October 11, 2015.
  6. Available at: http://www.fairhavenhealth.com/myo-inositol.html?cmp=bing&kw=myo-inositol&utm_source=BingShopping&utm_medium=CSE&utm_campaign=myo-inositol. Accessed October 14, 2015.
  7. Costantino D, Guaraldi C. [Role of D-chiro-inositol in glucidic metabolism alterations during pregnancy]. Minerva Ginecol. 2014;66(3):281-91.
  8. Available at: http://www.theralogix.com/index.cfm?fa=products.ovasitol.default&dvsn=reprohealth. Accessed October 14, 2015.
  9. Available at: http://catalog.designsforhealth.com/Sensitol?quantity=1. Accessed October 21, 2015.

Nicotine Patches Fail Most Pregnant Women

Friday, November 14th, 2014

By Kara Bobka, PharmD Student

In 2011, 10% of pregnant women reported smoking during the last trimester.1 Smoking during pregnancy can lead to miscarriages, premature births, placenta problems, birth defects, and infant death.1 The standard treatment for smoking cessation is behavioral therapy, like staying active or chewing gum, and support groups. Nicotine replacement therapy (NRT), such as over-the-counter nicotine patches, provides a way to help pregnant women achieve smoking cessation or stop smoking.2 Nicotine patches are applied directly to the skin, where they release a nicotine source that is then absorbed through the skin to decrease withdrawal symptoms for up to twenty-four hours.2,3 Yet, most recommend wearing the patch for sixteen-hours to give the body a break from nicotine and to decrease the potential for skin irritation.3

Patches fight symptoms of anxiety, cravings, irritability, restlessness, increased appetite, low mood, and poor concentration that are associated with smoking withdrawal. 3 However, two recent meta-analyses4,5 and one well-powered study6 showed that standard NRT doses (15 mg a day) are ineffective with pregnant women smokers when used for eight months or less. To address the effectiveness of NRT in pregnant smokers, a randomized, double blind, multicentre trial in the British Medical Journal (BMJ) confirms nicotine patches are no more effective than placebo at increasing either smoking cessation rates or birth weights even when nicotine doses are adjusted to individuals and given at higher doses. 7  

 What They Did

Berlin et al. randomized 402 pregnant women smokers (≥5 cigarettes per day) from 23 French maternity wards to receive either nicotine or placebo patches.7 All were ≥18 years of age and between 9 and 20 weeks gestation.7 All had to have health insurance. 7 More so, participants were motivated to stop smoking.7

Participants were given a two-week grace period between their initial and first follow-up visit for a chance to either stop smoking or to reduce cigarette consumption (<5 per day) on their own.7 This was necessary because people must be asked to quit smoking before using NRTs.7 Pregnant women can only be prescribed NRTs if they are unable to stop alone.7 Failing to either quit or reduce cigarette use, patients were eligible to continue, where they set a quit date and began the study.7 Smoking cessation was monitored via monthly measurements of saliva nicotine levels.7

Therapy lasted from quit date to the end of pregnancy, where women were either given 16-hour delivery nicotine patches (10-15 mg), similar to those produced in the US, or an identical placebo manufactured specifically for the study.7 For those who received active patches, daily doses ranged between 10-30 mg and were adjusted based on initial saliva nicotine levels.7 Behavioral support was provided at each visit.7

Primary outcomes were complete smoking cessation (self reported and confirmed via spirometry-confirmed carbon monoxide levels ≤8ppm) and birth weight.7 Secondary outcomes were self-reported smoking abstinence and birth characteristics.7

 What They Found

Results demonstrated that 11 of 96 (5.5%) and 10 of 76 (5.1%) women in the nicotine patch and placebo patch groups, respectively, achieved complete smoking cessation (P=0.87).7 42% in the nicotine patch group and 37% in the placebo patch group decreased their consumption of cigarettes by half.7 After two weeks, 62% had smoked again.7 More so, the nicotine patch did not decrease tobacco cravings or withdrawal symptoms or the number of cigarettes smoked.7 Average birth weights of groups did not differ significantly.7 Yet, newborns of mothers who were able to quit had a notably higher birth weight than those who were unable to stop smoking.7

Study limitations included that the subjects were women who smoked at least five cigarettes a day. So, results are hard to generalize to other expecting smokers. More so, the treatment began after the first trimester. It may be more effective to begin treatment earlier since smoking abstinence before 15 weeks gestation has yielded comparable birth outcomes to those of non-smokers.8 Another study conducted in England showed NRT combinations to be effective versus single or no NRT use.9 Despite other findings and its limitations, this study shows a lack of effectiveness of NRTs in pregnant women smokers and thereby a lack of birth characteristics’ improvements.

 What To Tell Patients

Although NRT has been shown to help others quit smoking, its effects on pregnant women remain unclear.   Earlier treatment with NRT during pregnancy may be more beneficial, although no evidence is to suggest that at this point. So, the best way to achieve smoking cessation is via behavioral therapy and support.7

To stop smoking, the Center for Disease Control and Prevention (CDC) recommends five great behavioral therapies. These include: asking family and friends for support; developing a quit plan or joining a quit program; staying busy (Get active. Chew gum. Drink water.); avoiding smoking triggers (Toss cigarettes, lighters, and ashtrays. Avoid caffeine.); and staying positive, yet vigilant.10 To successfully stop smoking, it takes time, but you can! So, reward yourself after the first 24 hours. You deserve it! Your baby will thank you!

If you smoked and wanted to quit, what actions would you take? Would you try a nicotine patch?

 

Bibliography and References Cited

 

  1. Tobacco use and pregnancy. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/. Published August 5, 2014. Updated 2014. Accessed October 26, 2014.
  2. American Society of Health-System Pharmacists, Inc. Nicotine Transdermal Patch. MedlinePlus: Trusted Health Information for You. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601084.html. Published June 13, 2013. Updated September 24, 2014. Accessed October 26, 2014.
  3. Nicorette® 16hr Invisipatch. Nicorette. http://www.nicorette.com.au/products/16hr-patch. Updated September 29, 2014. Accessed October 26, 2014.
  4. Coleman T, Chamberlain C, Cooper S, Leonardi-Bee J. Efficacy and safety of nicotine replacement therapy for smoking cessation in pregnancy: systemic review and meta-analysis. 2011;106(1): 52-61.
  5. Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J. Pharmacological Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2012;9:CD010078.
  6. Coleman T, Cooper S, Thornton JG, Grainge MJ, Watts K, Britton J, Lewis S. A Randomized Trial of Nicotine-Replacement Therapy Patches in Pregnancy. N Engl J Med. 2012;336:808-18.
  7. Berlin I, Grangé G, Jacob, N, Tanguy ML. Nicotine patches in pregnant smokers: randomized, placebo controlled, multicentre trial of efficacy. BMJ. 2014;348(1622):1-16.
  8. McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, et al; SCOPE consortium. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. 2009;338:b1081.
  9. Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug Alcohol Depend. 2013;132:660-664.
  10. Tips From Former Smokers. Centers for Disease Control and Prevention. http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/guide/steps-on-quit-day.html. Updated March 24, 2014. Accessed October 26, 2014.

 

How can you help your baby if you are smoking and pregnant?

Tuesday, October 28th, 2014

By Samantha Smolinski, PharmD Student

Approximately 50% of women who smoke before pregnancy continue to smoke after pregnancy. Smoking during pregnancy has been shown to cause some adverse effects on the baby. These adverse effects include lifelong decreases in lung function, an increased risk for asthma, low birth weight, shortened pregnancy terms, miscarriage, and infant mortality.1,2 The standard of care for pregnant women who smoke is to suggest that they quit.3

Many women have difficulty quitting smoking. Research has shown that when women join smoking cessation programs like Freedom From Smoking through the American Lung Association or FreshStart from the American Cancer Society to help them quit smoking, they are more likely to quit due to social support and encouragement.4,5 Women have reported that when they were living with another person who smoked, it was much harder for them to quit smoking and remain a non-smoker. In addition to this, many women claim that they found quitting easier when their significant other was supportive of their decision.6 Another common option to aid the mother in her journey to quit smoking is nicotine replacement therapy. Nicotine replacement therapy involves substituting cigarettes with pure nicotine, so that the patient maintains the same level of nicotine in the blood to reduce withdrawal symptoms. The amount of nicotine the patient receives is gradually reduced overtime until the patient can comfortably quit smoking. The forms for this replacement therapy can come in patches, gums, lozenges (dissolved in mouth), inhalators, nasal sprays, and microtabs. Nicotine replacement therapy increases the chances for someone to quit smoking by approximately 80%.4 However, this therapy may cause some adverse pregnancy outcomes and potential malformations. Although malformations may occur, studies have shown that this side effect may be less harmful than those adverse effects that result from smoking during pregnancy.3 In addition to the potential side effects, nicotine is absorbed faster in pregnant women than in non-pregnant women, which means that standard uses of this therapy may not be applicable to pregnant women.4

Recently, a randomized, double-blind trial was conducted with one hundred fifty-nine newborns of pregnant smokers and seventy-six newborns of pregnant non-smokers. Smoking pregnant women were randomly placed in groups where sixty-three received vitamin C 500 mg and eighty-three received a placebo.1 Vitamin C was chosen for this study because there have been multiple studies that have shown that it has a protective effect on lung function.7 After the women had their babies, pulmonary function tests were performed on the babies within seventy-two hours after birth and again a year later. The tests that were conducted a year later were only for the babies of the smoking pregnant due to institutional review board regulations. The first outcome included the measured pulmonary function tests within seventy-two hours of birth and the second outcome included pulmonary function tests at one year as well as the incidence of wheezing. Results suggested that women who smoked while they were pregnant and taking vitamin C 500 mg improved their newborn pulmonary function and decreased the chance of wheezing within one year when compared to the offspring of women who were pregnant and smoking in the placebo group. This study was conducted because of a prior study that had been done on pregnant rhesus monkeys.1 This study had shown that the offspring of the pregnant monkeys with nicotine treatment and vitamin C supplementation had increased pulmonary functions when compared to the offspring of the pregnant monkeys who were only treated with nictotine.7 Thus, vitamin C can be an inexpensive and simple approach to decrease the adverse effects smoking has on pregnancy.4

Vitamin C supplementation can bring additional benefit to women who are smoking and pregnant. This can help the adverse effects that smoking has on the baby’s lung function after birth. Although quitting is still the best choice for pregnant women and their babies, vitamin C supplementation can be useful by helping the baby if the mother smokes intermittently (through part of the pregnancy or through the entire pregnancy.) My recommendation to patients would be to quit smoking as soon as possible and that the best way to do this is through the support of others. In addition to quitting, they should take a daily 500 mg vitamin C supplement which has shown benefits for the babies of women who smoke during pregnancy. Vitamin C can be found over the counter at a relatively low price.

What changes are you willing to make to help your baby?

 

References:

  1. McEvoy CT, Schilling D, Clay N,et al. Vitamin c supplementation for pregnant smoking women and pulmonary function in their newborn infants: A randomized clinical trial.JAMA. 2014;311(20):2074-2082.
  2. Pollack H, Lantz PM, Frohna JG. Maternal smoking and adverse birth outcomes among singletons and twins.Am J Public Health. 2000;90(3):395-400.
  3. Forinash AB, Pitlick JM, Clark K, Alstat V. Nicotine replacement therapy effect on pregnancy outcomes.Ann Pharmacother. 2010;44(11):1817-1821.
  4. Coleman T. Recommendations for the use of pharmacological smoking cessation strategies in pregnant women.CNS Drugs. 2007;21(12):983-993.
  5. Lando HA, McGovern PG, Barrios FX, Etringer BD. Comparative evaluation of american cancer society and american lung association smoking cessation clinics.Am J Public Health. 1990;80(5):554-559.
  6. Flemming K, Graham H, Heirs M, Fox D, Sowden A. Smoking in pregnancy: A systematic review of qualitative research of women who commence pregnancy as smokers.J Adv Nurs. 2013;69(5):1023-1036.
  7. Proskocil BJ, Sekhon HS, Clark JA, Lupo SL,