Risks and Benefits Again

I have a benign heart arrhythmia. Before I got pregnant, I was taking 10mg/day of propranolol to control it. I stopped taking it as soon as I found out I was pregnant, thinking I'd rather deal with the arrhythmia than expose the baby to any unnecessary drugs. (Also, taking pills made me gag.)

When I called the OB's office to set up a first prenatal, my doctor's partner was worried about the propranolol. My doctor, on the other hand, said, "Oh, no, it's one of the safest things you can take to manage an arrhythmia in pregnancy." I knew that there were risks associated with taking the drug in late pregnancy, but I had thought that I could take it from the feeling-better stage until close to term.

I have been itching to start getting some exercise again, but I have to take the medication for that to work. If I try to go for an unmedicated run, I last about 300 yards. I can push myself to keep going, but after 10 minutes or so I'm going to throw up in somebody's yard. With the drug, I can chug along for half an hour or more -- or at least I could before I spent all that time lying on the couch.

Pregnancy is hard on my mental health -- it really cranks up my usual tendencies toward anxiety and hypersensitivity. Exercise is good for my mental health, and, obviously, my physical well-being too. I went for a couple of gentle runs in the past couple of weeks and was excited to get back in the groove.

So I was really bummed when I went to pick up my prescription refill and the pharmacist cautioned me sternly about propranolol in pregnancy. It's a category D medication in the second and third trimesters. It's associated with a whole lot more problems than I knew.

Some of the difference in her reaction and my doctor's reaction has to be related to dosage. In some of the research they were looking at women taking 16 times the dose that I take. But the pharmacist had that information in front of her -- if she was concerned, shouldn't I be concerned?

I guess if neither my OB nor my CNM is worried about my taking 10mg/day, I don't need to have a cow about the pharmacist's reaction. One possibility might be to take a pill only before exercising, maybe 3 days a week, and live with the arrhythmia the rest of the time. (It's been better than usual since I've been pregnant, which is the opposite of what I expected.) Maybe I could also request a referral to go back to the cardiologist for more information about the whole pregnancy/arrhythmia thing -- my OB said he wanted to talk to the cardiologist anyway.

I'm upset that something I thought was a great idea (getting more exercise, with a little pharmaceutical assistance) met with such a negative reaction. (See above re: pregnancy, mental health, adverse effects.) The list of potential side effects for the baby is troubling, but I don't have good information about incidence, dosage effects, etc. I'm not sure what to do. Any thoughts?

Comments

[bearing]

Does it matter what kind of exercise you're getting? Running for 10 minutes would make me throw up, and I don't even have a heart arrhythmia. What if it's yoga or weightlifting or swimming? Can you do it without the drugs then?

[bearing]

(BTW, it's just me, but I would tend to respect the pharmacists' opinion re: drug interactions with pregnancy more than the OB's. I still remember my cousin whose OB ordered her not to breastfeed because she took Claritin. Maybe get a second pharmacist's opinion?)

[giddy]

I like your idea to take the drug on the days you exercise, if you are pretty sure that the drug will have the necessary effect when taken on an as-needed basis instead of a constant basis allowing for a constant low level of medication to be in your system. It sounds to me from what I read in the PDR (Physician's Desk Reference; I'm not a pharmacist but I do work in the industry) that this is probably the case for arrhythmias. You might ask the pharmacist for specific info on the timing of peak concentration in your system (in pharma-speak, when is Tmax?) so if you DID do this you could time it right. Even if you just did it for a few months.... The other striking thing is that the dose you are suggesting is SO much less than for angina or hypertension (which is sometimes up to 640 mg/day!). This has got to make a difference. The rat studies cited in the PDR used doses 15X the max recommendedhuman doses, and if the max recommended human dose was 640 mg/day that is already 64X your dose....your risk would have to be pretty darn low compared to the rats.
(Caveat: This is an old edition of the PDR, still says Preg Category D, so there must be new information out there.) But I'm with "bearing" ; get another opinion! Your mental health is worth a lot!

[giddy]

Oops, I mean that the old PDR says Preg Categ C. YOu said it's D now. (Of course, I forget which direction is worse.... so either way I'm not helping.)

[Erin]

First, I don't know anything about the drug you're talking about. But I won't let that stop me!
I have been put in this position by pharmacists before, and I do have a take on that. After my youngest was born I took him to the pharmacy with me to have my Zoloft prescription refilled, and as I was picking it up, the pharmacist put on his stern face and told me that I should not be taking this drug while nursing.
I was fit. to. be. tied. That drug was prescribed to me by a clinician with many years of experience and pharmaceutical training. The risks and benefits was weighed by myself, and by the MD who had been treating me through 2 pregnancies. The decision was not taken lightly, the dose was not high, and a pharmacist is not a clinician, but only reads the warning label that comes with the drugs he puts in a bottle.
I think you should do what your CNM and MD have discussed with you. They are the ones with the clinical experience, they know you better than the pharmacist.

[Kris]

I would see the cardiologist and have him/her have a discussion with the OB, and take their advice from their. You could also mention to both of them the pharmacist's reaction, and let them take it into consideration.

Good luck!

[electriclady]

Try Motherisk (motherisk.org)--it's a project based at the Hospital for Sick Children in Toronto that looks at prenatal exposure to all kinds of medications and toxins and offers assistance to pregnant women and physicians in evaluating risk/benefit. (I think that's what they do--they have a database and a hotline, anyway.)

[Rebecca]

I had much the same experience with a pharmacist that Erin did. I was put on an antibiotic by two different doctors, both who knew I was nursing because the problem was related to nursing. I went to pick up my prescription refill and the pharmacist told me that I shouldn't be taking it while nursing. I flipped out because I had already been taking it for a week. I called my family doctor to ask him, and he told me that the antibiotic I was on was the best one for nursing mothers.

I'll copy Erin here and agree that the OB has better clinical experience than the pharmacist.

[Karen]

I am glad you're feeling well enough now to even consider exercise. As someone who has spent her entire adult life getting aerobic exercise via jogging, I admit that I did not jog one step while pregnant. I did walk a lot. I took a prenatal yoga class (which was awesome in many, many ways, mostly having to do with new friends and a whole other side of my city). I swam. I wonder, like the first commenter, if you can do some lower energy exercise and get a similar mental health benefit without the need for propanolol.

[CJ]

Hi, everybody, and thanks for the input.

Exertion triggers the arrhythmia, so I get it with swimming too. I've had this all my life, but it wasn't diagnosed until after Pete was born in 2005. I swam while pregnant with my first three boys, and always wondered why I had to stop so often to catch my breath, and why my pulse shot up out of the recommended zone so quickly.

I don't know about yoga -- my guess is that it would happen intermittently during the class, but not as consistently as with aerobic exercise.

If I can run without harming the baby, that's my first choice. Life is really busy, and running allows me to get 30 minutes of exercise in 30 minutes. Swimming is nice and will be my next choice if I decide to go unmedicated, but I have to drive to the pool, get changed, swim, get changed, drive home. Getting 30 minutes of exercise takes more like 60 minutes if I'm swimming.

Giddy, thanks for the inside POV. I believe it's rated differently for different trimesters -- category C for the first trimester and category D (which is worse, ugh) for the second and third.

I called my OB's office and am waiting to hear back...

[anon-anon]

I have a question: what did you do about the arrhythmia in your previous pregnancies?

[amy]

oops! i didn't mean to post as anon-anon. for some reason, typepad won't forget the information from a truly anonymous comment on another blog some time back. sorry!

[CJ]

what did you do about the arrhythmia in your previous pregnancies?

Nothing. Thought I was a lazy slouch when I had trouble swimming any distance. Wondered why my pulse was so fast when the books said it shouldn't be. I was floored to get the diagnosis. Slow learner -- what can I say?

As I've gotten older, it's triggered much more easily. It's almost never a big deal -- my heart starts to beat too fast in response to exertion or stress, and it calms down when the I slow down or calm down. But I had one persistent episode when I was 8.5 months pregnant with Pete that pushed me to get the testing done a few weeks after he was born.

Ever since I was diagnosed I have stumbled across memories of things that happened when I was younger -- like how I was the one in Girl Scouts who couldn't cope with the high altitude, or how I was the one on the family vacation (to Colorado -- altitude again) who struggled so miserably with the hike I could have handled just fine at home. I wish I could back and tell the younger me, "It's not a moral failing, silly; it's the wiring in your heart!"

[mary]

I have two pharmacists in the family and I had to go to a reproductive endocrinologist to get pregnant. The RE didn't have a problem with any of the allergy medications I was taking (nor did the OB), and my family pharmacists felt that my inhaled medication was probably safer than the ingested one because of its localized effect. When I delivered in the hospital, the nurses (via the hospital pharmacists) were all having a fit about my allergy medications, particularly the inhaled one. I think you just get different reactions from different people to some extent. If, as was discussed above, your dose is so much lower than the usual dose, I would think taking it on days you plan to exercise would be a reasonable compromise. The cardiologist may have other insight as well.

[bearing]

Wow, I guess YMMV when it comes to the relative risk-analysis skills of clinicians and pharmacists!

[Sarah]

well, your OB is the most familiar with your whole case history, and though I'd run it by the cardiologist first, but I'd go with the OBs opinion over the pharmacist.

THAT SAID, I think that if the medicine is optional, I'd opt to not take it if you find that a 30-45 min walk or yoga or some other exercise gives you the boost you get from running. Frankly, I find going down the stairs with two baskets of laundry a trill. But if you don't, and running is really what does it for you, then I'd take the meds and run. The benefits, both physically and emotionally, that you gain from the running are not small and if your doctor and specialist feel comfortable with it, I'd say it should be just fine, too.